[Intermittent mandatory ventilation]. / Ventilación mandatoria intermitente.

Intermittent mandatory ventilation (IMV) is a mode of ventilation that allows the patient to make spontaneous breaths during the expiratory phase of mandatory ventilator breaths. There are two types of IMV according to whether respirator breaths are synchronized with the patient's respiratory efforts: Non-synchronized IMV and synchronized IMV (SIMV), and according to whether SIMV is volume- or pressure programmed. The main advantage of SIMV is that the respirator delivers the preset ventilator pressure and rate while allowing the patient to breath spontaneously, thus facilitating progressive weaning from mechanical ventilation. It diminishes the risk of barotrauma, produces less hemodynamic com-promise than control ventilation, reduces atrophy of respiratory muscles and the need for sedation and muscle relaxation and can be associated with pressure support ventilation.

[Mortality and quality of life of patients beyond 65 years one year after ICU discharge]. / Mortalidad y calidad de vida al año del alta de una unidad de cuidados intensivos en pacientes mayores de 65 años.

BACKGROUND: Intensive care in elderly patients is a subject of controversy, because they generally present a high rate of mortality and short expectation of life. Due to the increasing life expectancy, more elderly patients will be treated in Intensive Care Unit (ICU) with an increasing consume of resources. The present study considers the mortality and quality of life (QOL) of patients beyond 65 years after ICU, and theirs predictors. PATIENTS AND METHOD: Retrospective study of patients >= 65 years admitted in multidisciplinaire ICU. Mortality and QOL (with modified EuroQOL Instrument) one year after discharge were studied. To determine mortality and QOL one year independent predicting factors, multiple logistic regression models were used. RESULTS: Of 313 patients studied, 95 (30%) died in ICU, 32 (10%) in hospital and 34 (11%) died after discharge. The independent predicting factors of mortality one year after ICU discharge were: organ failure (p < 0.000; odds ratio [OR], 2.9), cardiac surgery (p < 0.0000; OR, 0.15) and respiratory disease (p < 0.01; OR, 2.8). Of the 152 surviving patients, 21% got worse their previous QOL and only 17% were severely discapitated. The independent predicting factors of QOL one year after ICU discharge were: prior QOL (p < 0.0002; OR, 10.2) and age (p < 0.002; OR, 0.09). CONCLUSION: Despite the high one year after ICU discharge mortality rate (51%), 83% of the survivors were able to live independently. Due to dependence between mortality and multiorganic failure during ICU stay and not age, this latter cannot be the determining factor of the care level.

Factores predictores de mortalidad tras el alta de la unidad de medicina intensiva / Predictive factors for mortality after discharge from the intensive care unit

Fundamento. La mortalidad tras el alta de la unidad de medicina intensiva (UMI) es también el resultado de su actividad y calidad asistencial. El objetivo de este estudio fue analizar la mortalidad durante un año tras el alta de la unidad y estimar un sistema predictivo que nos permita calcular el riesgo de morir en ese período. Método. Estudio retrospectivo de 1.000 pacientes ingresados sucesivamente en una UMI polivalente. Se recogieron datos demográficos, antecedentes personales, diagnóstico, fracaso orgánico, supervivencia en la UMI, hospitalaria y al año. Se utilizó el test de Kruskal-Wallis para variables numéricas y el test de la 2 para las cualitativas. Con objeto de conocer las variables predictivas independientes de mortalidad postUCI se estimó un modelo de regresión logística múltiple. Resultados. De los 843 pacientes incluidos en el estudio, 212 (25 por ciento) fallecieron en la unidad, 64 (7,5 por ciento) en el hospital y 64 (7,5 por ciento) durante el año de seguimiento. Los factores predictores independientes de mortalidad al año del alta de la UMI fueron: la edad (p < 0,01; OR: 1,02; intervalo de confianza [IC] del 95 por ciento: 1,01-1,04), la cirugía cardíaca (p < 0,01; OR: 0,26; IC del 95 por ciento: 0,130,53), el fracaso orgánico (p < 0,01; OR: 1,34; IC del 95 por ciento: 1,09-1,63), la patología crónica previa (p < 0,01; OR: 1,48; IC del 95 por ciento: 1,15-1,88), la enfermedad digestiva (p < 0,01; OR: 3,14; IC del 95 por ciento: 1,44-6,83), la parada cardiorrespiratoria (p < 0,05; OR: 3,86; IC del 95 por ciento: 1,21-12,31) y la enfermedad respiratoria (p < 0,05; OR: 2,14; IC del 95 por ciento: 1,114,13). Conclusión. La mortalidad de los pacientes supervivientes tras el alta de la UMI fue del 20 por ciento. El modelo de regresión logística nos permite estimar la supervivencia al año a partir de los factores predictores. Aunque estos sistemas no puedan aplicarse en pacientes individuales, nos ayudan a elaborar un juicio clínico y tomar decisiones importantes (AU)

[Survival and quality of life of patients with multiple organ failure one year after leaving an intensive care unit]. / Supervivencia y calidad de vida de los pacientes con fracaso multiorgánico al año del alta de una unidad de medicina intensiva.

BACKGROUND: The patients' mortality with multiple organ failure (MOF) is very high and patients who consume the most resources are those with uncertain prognosis. In order to use the limited resources adequately, it is necessary to know the cost-benefit relationship of their treatment and in this study cost, mortality, quality of life (QOL) of survivors who developed MOF has been investigated. PATIENTS AND METHODS: Mortality in the Intensive Care Unit (ICU) and mortality QOL (with modified EuroQOL Instrument) one year after discharge were studied in 239 admitted patients who developed MOF. Cost was estimated from administrative dats of cost patients-day. To determine mortality independent predicting factors, a logistic regression model was used. RESULTS: Of the 239 patients studied, 144 (60%) died in ICU and 29 (12%) died after discharge. The independent predicting factors of mortality one year after discharge from ICU were: age (p < 0.1, odds ratio [OR] = 1.02), cardiac surgery (p < 0.0000, OR = 0.1899) and trauma (p < 0.05, OR = 0.2287). Of the 66 surviving patients, 18% were severely discapacitated. Forty one percent recovered their previous QOL, 18% improved it and 39% got worse. Patients with MOF consumed 64% of ICU total resources and of these, 77% was consumed by patients who died and by severely discapacitated. CONCLUSION: A high proportion of resources were used by MOF patients, but patients who died and who remained with worst QOL consumed the highest part. Although the mortality after one year was high (72%), 80% of the survivors achieved an acceptable QOL and for this reason, treatment of these patients should not be limited if survival and QOL predictions are not 100% correct.

Eficacia y eficiencia de una Unidad de Medicina Intensiva Polivalente / Effectiveness and efficiency in a multidisciplinary ICU

Fundamento. Al médico se le exige continuamente mejorar los cuidados de salud y contener el gasto. Por ello necesitamos conocer nuestros resultados (de mortalidad y calidad de vida [CDV]) así como los recursos invertidos para poder mejorar la eficacia y la eficiencia de nuestra Unidad de Medicina Intensiva (UMI) en el futuro. Método. Estudio retrospectivo de 1.000 pacientes ingresados sucesivamente en una UMI polivalente. Se excluyen menores de 15 años, extranjeros y reingresos. Se recogieron datos demográficos, antecedentes personales, diagnóstico, fracaso orgánico, supervivencia en UMI, hospitalaria y al año, CDV previa y al año (con el EuroQOL modificado) y los costes según los días de estancia en el hospital y en la UMI. Se utilizó el test de Kruskal-Wallis para variables numéricas. Resultados. De los 843 pacientes incluidos en el estudio, 212 (25 por ciento) fallecieron en la unidad, 64 (7,5 por ciento) en el hospital y 64 (7,5 por ciento) durante el año de seguimiento. De los 503 supervivientes al año, el 58 por ciento gozaban de buen estado de salud, el 30 por ciento presentaban alguna discapacidad pero vivían independientemente y sólo un 11 por ciento tenían discapacidades severas. Los pacientes que costaron significativamente menos fueron los que se recuperaron totalmente. El 23 por ciento de los pacientes consumió el 70 por ciento de todos los recursos, y éstos fueron los pacientes que fallecieron y los que quedaron con peor CDV. Conclusión. El 60 por ciento de los pacientes sobrevivían al año, y de ellos el 89 por ciento tenían una CDV aceptable, lo cual demuestra la eficacia de las UMI y justifica su existencia. Los pacientes que fallecieron o quedaron con una CDV más limitada consumieron la mayor parte de los recursos. Sólo cuando nuestra capacidad predictiva de mortalidad y CDV sea correcta en el 100 por ciento de los casos y podamos limitar el tratamiento, mejoraremos la eficiencia. Mientras tanto sólo la sociedad puede marcar la directriz en la distribución y contención del gasto. (AU)

Comparative efficacy of bronchoalveolar lavage and telescoping plugged catheter in the diagnosis of pneumonia in mechanically ventilated patients.

The relative efficacy of telescoping plugged catheter (TPC) and bronchoalveolar lavage (BAL) in the diagnosis of pneumonia in mechanically ventilated patients has been compared in 45 subjects suspected of having pneumonia because of the presence of clinical and radiographic criteria. Diagnosis of pneumonia was strongly suggested in 25 of the 45 patients, and definitely confirmed in 10 of them. The diagnostic threshold to assess a quantitative bacterial culture as positive was a growth on BAL of > or = 10(5) cfu/ml and on TPC of > or = 10(3) cfu/ml. The BAL specimen cultures established the diagnosis in 19 cases (76 percent). In the remaining six patients, this technique did not permit the assessment of the diagnosis, which was established by other procedures (TPC, blood cultures, clinical outcome, or autopsy). False-positive results were not found. Sensitivity and specificity for BAL cultures were 76 percent and 100 percent, respectively. Telescoping plugged catheter established the presence of pneumonia in 16 patients (64 percent). Combining both techniques, the sensitivity increased up to 88 percent, maintaining specificity of 100 percent. In summary, BAL has a greater sensitivity than TPC in the diagnosis of pneumonias in mechanically ventilated patients. However, they are procedures that can complement each other.

Reliability of the bronchoscopic protected catheter brush in the diagnosis of pneumonia in mechanically ventilated patients.

OBJECTIVE: To assess the usefulness of the telescoping plugged catheter in the diagnosis of nosocomial pneumonia. DESIGN: Prospective study. PATIENTS: A total of 103 ventilated patients with suspected pneumonia were prospectively studied over 20 months. RESULTS: The quantitative cultures of the protected brush specimen detected pulmonary bacterial infection (greater than 10(3) cfu/mL) in 49 (47.5%) patients. Subsequent follow-up confirmed pneumonia in 41 patients; in only one patient was a positive protected brush specimen culture established as a false-positive result. There were 54 patients with less than 10(3) cfu/mL and the diagnosis was excluded in 36 of them. We identified eight patients with false-negative protected brush specimen cultures. The results obtained by this technique allowed us to modify treatment in 49 (47.5%) patients. CONCLUSIONS: The telescoping plugged catheter demonstrated significant bacterial infection in a relatively small proportion of patients in whom bacterial lung infection was suspected. This technique can be safely performed and is a sensitive and specific method to establish the cause of pneumonia, thus allowing specific treatment and the avoidance of inappropriate antibiotic therapy.

[The usefulness of the double-light telescopic catheter in the diagnosis of bacterial pneumonia in patients under mechanical ventilation]. / Utilidad del catéter telescópico de doble luz en el diagnóstico de la neumonía bacteriana en pacientes bajo ventilación mecánica.

Fifty-eight patients who presented clinical criteria of pneumonia (fever, leukocytosis, purulent tracheo-bronchial secretions, and lung infiltrate of recent appearance in X-ray) were prospectively studied in order to determine the cost effectiveness [correction of rentability] of quantitative culture of bronchial secretions by means of a telescopic catheter (TC) in the diagnosis of bacterial pneumonia in patients under mechanical ventilation. In 25 patients (43%) a positive culture was obtained above 10(3) UFC/ml, confirming the pneumonia diagnosis in 17 cases and detecting a false positive result in one patient. In no case with a count less than 10(3) UFC/ml pneumonia diagnosis could be confirmed, being this diagnosis excluded in 24 of 33 patients with a count lower than 10(3) UFC/ml. These results suggest that the presence of fever, purulent tracheobronchial secretions and lung infiltrate in an intubated patient under mechanical ventilation does not indicate the presence of pneumonia in a high percentage of cases and that CT scan can identify those patients who require antimicrobial treatment, and this avoiding its use in patients who do not need it, with the resulting decrease in morbidity and high cost.