Big data and machine learning in critical care: Opportunities for collaborative research.

The introduction of clinical information systems (CIS) in Intensive Care Units (ICUs) offers the possibility of storing a huge amount of machine-ready clinical data that can be used to improve patient outcomes and the allocation of resources, as well as suggest topics for randomized clinical trials. Clinicians, however, usually lack the necessary training for the analysis of large databases. In addition, there are issues referred to patient privacy and consent, and data quality. Multidisciplinary collaboration among clinicians, data engineers, machine-learning experts, statisticians, epidemiologists and other information scientists may overcome these problems. A multidisciplinary event (Critical Care Datathon) was held in Madrid (Spain) from 1 to 3 December 2017. Under the auspices of the Spanish Critical Care Society (SEMICYUC), the event was organized by the Massachusetts Institute of Technology (MIT) Critical Data Group (Cambridge, MA, USA), the Innovation Unit and Critical Care Department of San Carlos Clinic Hospital, and the Life Supporting Technologies group of Madrid Polytechnic University. After presentations referred to big data in the critical care environment, clinicians, data scientists and other health data science enthusiasts and lawyers worked in collaboration using an anonymized database (MIMIC III). Eight groups were formed to answer different clinical research questions elaborated prior to the meeting. The event produced analyses for the questions posed and outlined several future clinical research opportunities. Foundations were laid to enable future use of ICU databases in Spain, and a timeline was established for future meetings, as an example of how big data analysis tools have tremendous potential in our field.

Preliminary experience on the safety and tolerability of mechanical "insufflation-exsufflation" in subjects with artificial airway.

BACKGROUND: Catheter suctioning of respiratory secretions in intubated subjects is limited to the proximal airway and associated with traumatic lesions to the mucosa and poor tolerance. "Mechanical insufflation-exsufflation" exerts positive pressure, followed by an abrupt drop to negative pressure. Potential advantages of this technique are aspiration of distal airway secretions, avoiding trauma, and improving tolerance. METHODS: We applied insufflation of 50 cmH2O for 3 s and exsufflation of - 45 cmH2O for 4 s in patients with an endotracheal tube or tracheostomy cannula requiring secretion suctioning. Cycles of 10 to 12 insufflations-exsufflations were performed and repeated if secretions were aspirated and visible in the proximal artificial airway. Clinical and laboratory parameters were collected before and 5 and 60 min after the procedure. Subjects were followed during their ICU stay until discharge or death. RESULTS: Mechanical insufflation-exsufflation was applied 26 times to 7 male and 6 female subjects requiring suctioning. Mean age was 62.6 ± 20 years and mean Apache II score 23.3 ± 7.4 points. At each session, a median of 2 (IQR 1; 2) cycles on median day of intubation 11.5 (IQR 6.25; 25.75) were performed. Mean insufflation tidal volume was 1043.6 ± 649.9 ml. No statistically significant differences were identified between baseline and post-procedure time points. Barotrauma, desaturation, atelectasis, hemoptysis, or other airway complication and hemodynamic complications were not detected. All, except one, of the mechanical insufflation-exsufflation sessions were productive, showing secretions in the proximal artificial airway, and were well tolerated. CONCLUSIONS: Our preliminary data suggest that mechanical insufflation-exsufflation may be safe and effective in patients with artificial airway. Safety and efficacy need to be confirmed in larger studies with different patient populations. TRIAL REGISTRATION: EudraCT 2017-005201-13 (EU Clinical Trials Register).

Med-Score 24: A multivariable prediction model for poststernotomy mediastinitis 24 hours after admission to the intensive care unit.

OBJECTIVES: Mediastinitis is a serious complication of heart surgery. In this study, we developed a bedside risk score for poststernotomy mediastinitis. METHODS: Data were prospectively collected from 4625 patients admitted to our intensive care unit after heart surgery (January 2005-June 2011). Mediastinitis was defined according to Centers for Disease Control and Prevention criteria. A logistic model was constructed in a randomly selected subgroup of 2618 patients and validated in a second cohort of 1352, as well as in a prospective cohort of 2615 (June 2011-December 2015). Model discriminatory power was assessed according to the area under the receiver operating characteristic curve (AUROC). The ß coefficients of the model were used to define 3 levels of mediastinitis risk as a score designated Med-Score 24. Its performance to predict mediastinitis was compared with that of the logistic EuroSCORE and Society of Thoracic Surgeons score. RESULTS: Ninety-four (2.36%) patients developed mediastinitis. The risk factors identified as predictive of mediastinitis (AUROC 0.80) were 4 preoperative variables (age >70 years, chronic obstructive lung disease, obesity, and antiplatelet therapy) and 3 perioperative variables (prolonged ischemia, emergency reoperation, and prolonged intubation). AUROCs for the Society of Thoracic Surgeons score and logistic EuroSCORE were 0.63 and 0.55, respectively, both differing significantly from the area calculated for Med-Score 24 (P < .001). CONCLUSIONS: The score developed showed excellent predictive power 24 hours after admission to the intensive care unit for mediastinitis risk. This simple tool helps stratify patients according to this risk, thus identifying high-risk patients for preventive measures. In our patient cohort, Med-Score 24 performed better than other scores used for this purpose.

[Invasive fungal infection in critically ill patient: role of micafungin]. / Infección fúngica en el paciente crítico: papel de micafungina.

The invasive fungal infections (IFIs) have increased in critically ill patients in recent years and are a serious complication that determine the evolution and prognosis of critically ill patients, especially invasive candidiasis (IC)and candidemia. Fortunately, treatment options for these infections have increased and there is a large arsenal of antifungal agents. This review of the literature, using PubMed and Cochrane databases, assesses the situation of the IFIs in critically ill patients and discusses the role of micafungin in this context. The broader spectrum of this candin, which gets the antifungal effect with lower MICs and that translates into greater clinical efficacy with a lower rate of adverse effects and easier to use, with proven cost-effectiveness compared with other antifungal, position micafungin as a useful therapeutic option for the management of invasive candidiasis / candidemia in critically ill patients.

Infección fúngica en el paciente crítico: papel de micafungina / Invasive fungal infection in critically ill patient: role of micafungin

Las infecciones fúngicas invasoras (IFI) han aumentado en los pacientes críticos (PC) en los últimos años y constituyen una complicación grave que condiciona la evolución y el pronóstico de estos pacientes, especialmente la candidiasis invasiva (CI) y la candidemia (CA). Afortunadamente existen más opciones terapéuticas y se dispone de un amplio arsenal de antifúngicos para optimizar el tratamiento de estas infecciones. En esta revisión de la literatura, utilizando las bases de PubMed y Cochrane, se evalúa la situación de las IFIs en el paciente crítico y se analiza el papel de micafungina en este contexto. El espectro más amplio de esta candina, y su efecto antifúngico con CMIs menores, que se traduce en gran eficacia clínica con una tasa menor de efectos adversos y de más fácil manejo, con coste-efectividad demostrada frente a otros antifúngicos, hacen de micafungina una opción terapéutica óptima para el manejo de la candidiasis invasiva/ candidemia en el paciente crítico(AU)

The invasive fungal infections (IFIs) have increased in critically ill patients in recent years and are a serious complication that determine the evolution and prognosis of critically ill patients, especially invasive candidiasis (IC) and candidemia. Fortunately, treatment options for these infections have increased and there is a large arsenal of antifungal agents. This review of the literature, using PubMed and Cochrane databases, assesses the situation of the IFIs in critically ill patients and discusses the role of micafungin in this context. The broader spectrum of this candin, which gets the antifungal effect with lower MICs and that translates into greater clinical efficacy with a lower rate of adverse effects and easier to use, with proven cost-effectiveness compared with other antifungal, position micafungin as a useful therapeutic option for the management of invasive candidiasis / candidemia in critically ill patients(AU)