Metaanálisis de los efectos del suero salino en la mortalidad en cuidados intensivos / Meta-analysis of the effects of normal saline on mortality in intensive care

Introducción y objetivo: Evaluar, mediante un metaanálisis, el efecto del suero salino sobre la mortalidad en los pacientes de cuidados intensivos, cuando se compara su uso con el de cristaloides balanceados. Material y método: Se ha realizado un metaanálisis de ensayos clínicos controlados, aleatorizados y estudios prospectivos secuenciales en el tiempo, publicados, que evaluaron la mortalidad del suero salino en enfermos ingresados en unidades de cuidados intensivos. Se llevó a cabo una búsqueda electrónica en Medline, Embase, biblioteca Cochrane, ISI Proceedings y Web of Science y una búsqueda manual sobre las referencias seleccionadas. La extracción de datos fue realizada de forma independiente por 2 investigadores. Las discrepancias se resolvieron por consenso en el grupo de trabajo. El cálculo de la OR y su intervalo de confianza se realizó ponderando por el inverso de la varianza. La heterogeneidad se evaluó mediante I2. El sesgo de publicación se valoró mediante funnel plot y test de Egger. Resultados: Se seleccionaron 8 artículos para el metaanálisis de mortalidad, que incluían un total de 20.684 pacientes. Se objetivó una asociación entre el uso de suero salino y la mortalidad en los enfermos de cuidados intensivos (OR 1,0972; IC 95%:1,0049-1,1979) cuando se comparaba con el uso de cristaloides balanceados. No se encontró evidencia de sesgo de publicación (prueba de Egger p=0,5349). En el análisis de sensibilidad ninguno de los estudios modificó sustancialmente el resultado global si se eliminaba del metaanálisis. Conclusiones: Es posible que exista un aumento de la mortalidad asociada al empleo de suero salino en los pacientes ingresados en cuidados intensivos cuando se compara con el empleo de cristaloides balanceados

Introduction and objective: To evaluate, by means of a meta-analysis, the effect of normal saline on mortality in intensive care patients, when compared with the use of balanced crystalloids. Material and method: Published controlled clinical trials, randomised and sequential prospective studies in time, evaluating the mortality when physiological saline was used in patients admitted to intensive care units. Electronic search was performed in Medline, Embase, Cochrane Library, ISI Proceedings, and Web of Science, as well as a manual search of selected references. An independent evaluation was performed by 2 investigators. Discrepancies were resolved by consensus in the working group. Contingency tables were performed, and the OR with confidence intervals of each study were obtained. Heterogeneity was assessed by I2. Publication bias was assessed using funnel plot and Egger test. Results: A total of 8 articles were selected for the meta-analysis of mortality, which included a total of 20,684 patients. A significant association was observed between the use of saline and mortality in intensive care patients (OR 1.0972; 95% CI 1.0049-1.1979), when compared to the use of balanced crystalloids. No statistical evidence of publication bias (Egger, P=.5349) was found. In the sensitivity analysis, none of the studies substantially modified the overall outcome if it was eliminated from the meta-analysis. Conclusions: There may be an increase in mortality associated with the use of saline in patients admitted to intensive care when comparing with the use of balanced crystalloids

Meta-analysis of the effects of normal saline on mortality in intensive care. / Metaanálisis de los efectos del suero salino en la mortalidad en cuidados intensivos.

INTRODUCTION AND OBJECTIVE: To evaluate, by means of a meta-analysis, the effect of normal saline on mortality in intensive care patients, when compared with the use of balanced crystalloids. MATERIAL AND METHOD: Published controlled clinical trials, randomised and sequential prospective studies in time, evaluating the mortality when physiological saline was used in patients admitted to intensive care units. Electronic search was performed in Medline, Embase, Cochrane Library, ISI Proceedings, and Web of Science, as well as a manual search of selected references. An independent evaluation was performed by 2 investigators. Discrepancies were resolved by consensus in the working group. Contingency tables were performed, and the OR with confidence intervals of each study were obtained. Heterogeneity was assessed by I2. Publication bias was assessed using funnel plot and Egger test. RESULTS: A total of 8 articles were selected for the meta-analysis of mortality, which included a total of 20,684 patients. A significant association was observed between the use of saline and mortality in intensive care patients (OR 1.0972; 95% CI 1.0049-1.1979), when compared to the use of balanced crystalloids. No statistical evidence of publication bias (Egger, P=.5349) was found. In the sensitivity analysis, none of the studies substantially modified the overall outcome if it was eliminated from the meta-analysis. CONCLUSIONS: There may be an increase in mortality associated with the use of saline in patients admitted to intensive care when comparing with the use of balanced crystalloids.

Tratamientos de soporte vital al final de la vida: costos y aspectos éticos. Punto de vista en una unidad de cuidados intensivos basado en la metodología Q / Life-support treatments at end of life: Costs and ethical aspects. Point of view in an intensive care unit based on Q methodology

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Epidemiología del traumatismo craneoencefálico en la población mayor de 65 años a lo largo de 25 años / Epidemiology of traumatic brain injury in the elderly over a 25 year period

Objetivo: Conocer los cambios en la epidemiología del traumatismo craneoencefálico (TCE) en una cohorte de enfermos mayores de 65 años ingresados en UCI de un hospital de tercer nivel a lo largo de 25 años. Material y métodos: Estudio de cohortes retrospectivo realizado en una unidad de cuidados intensivos de un hospital universitario de tercer nivel español. Se recogieron variables demográficas, clínicas en el momento del ingreso, comorbilidades, mecanismos de lesión y lesiones presentadas, días de estancia en UCI y hospitalaria de los pacientes mayores de 65 años que ingresaron con el diagnóstico de TCE. Se realizó un análisis estadístico por lustros. Resultados: Se analizaron un total de 446 TCE en mayores de 65 años. En el análisis por lustros, se observó un aumento de la proporción de enfermos que presentan hematoma epidural (1,39% en el periodo 1990-1995 vs. 9,46% en 2010-2015), con tendencia lineal significativa (p=0,018). En la actualidad las caídas desde la propia altura han pasado de representar un 8,33% (1991-1995) a más de un 70% (2011-2015), p<0,001. El porcentaje de accidentes de tráfico ha descendido desde un 26,39% hasta un 3,95% en el último periodo, p<0,001. Conclusiones: En los últimos 25 años parece evidenciarse un cambio en la etiología del TCE en la población mayor de 65 años en nuestro ámbito

Objective: To identify the changes in the epidemiology of traumatic brain injury (TBI) in a cohort of patients older than 65 years old admitted in the Intensive care unit of a third-level hospital over a 25 year period. Material and methods: A retrospective cohort study conducted on patients over 65 years-old admitted with the diagnosis of TBI into an intensive care unit of a Spanish university hospital. The demographic, clinical variables were collected at the time of admission, including comorbidities, injury mechanisms, and injuries presented, and days of stay in ICU. A statistical analysis was carried out by five-year periods. Results: A total of 446 TBI in patients over 65 years were included. In the analysis, an increase was observed in the proportion of patients presenting with epidural haematoma (1.39% in the period 1990-1995 vs. 9.46% in 2010-2015), with a significant linear tendency (P=.018). Falls from own height have increased from 8.33% (1991-1995) to currently more than 70% (2011-2015), P<.001. The percentage of traffic accidents declined from 26.39% to 3.95% in the last period, P<.001. Conclusions: In the last 25 years there seems to be evidence of a change in the origins of TBI in the elderly in our field

Epidemiology of traumatic brain injury in the elderly over a 25 year period. / Epidemiología del traumatismo craneoencefálico en la población mayor de 65 años a lo largo de 25 años.

OBJECTIVE: To identify the changes in the epidemiology of traumatic brain injury (TBI) in a cohort of patients older than 65 years old admitted in the Intensive care unit of a third-level hospital over a 25 year period. MATERIAL AND METHODS: A retrospective cohort study conducted on patients over 65 years-old admitted with the diagnosis of TBI into an intensive care unit of a Spanish university hospital. The demographic, clinical variables were collected at the time of admission, including comorbidities, injury mechanisms, and injuries presented, and days of stay in ICU. A statistical analysis was carried out by five-year periods. RESULTS: A total of 446 TBI in patients over 65 years were included. In the analysis, an increase was observed in the proportion of patients presenting with epidural haematoma (1.39% in the period 1990-1995 vs. 9.46% in 2010-2015), with a significant linear tendency (P=.018). Falls from own height have increased from 8.33% (1991-1995) to currently more than 70% (2011-2015), P<.001. The percentage of traffic accidents declined from 26.39% to 3.95% in the last period, P<.001. CONCLUSIONS: In the last 25 years there seems to be evidence of a change in the origins of TBI in the elderly in our field.

La tomografía computarizada corporal como factor asociado a menor mortalidad en el traumatismo geriátrico grave con afectación toracoabdominopélvica / Whole-body computed tomography as a factor associated with lower mortality in severe geriatric trauma with thoracic-abdominal-pelvic injury

Objetivo: Analizar la asociación de la realización de una tomografía computarizada (TC) corporal con la mortalidad intrahospitalaria en pacientes de edad avanzada con afectación toracoabdominopélvica que precisa ingreso en una unidad de cuidados intensivos. Pacientes y método: Estudio observacional, descriptivo y retrospectivo realizado sobre 140 pacientes con edad igual o mayor de 65 años ingresados en una unidad de cuidados intensivos tras un traumatismo con afectación toracoabdominopélvica. Se establecen 2 grupos, según se haya realizado TC corporal como parte rutinaria del estudio o el diagnóstico se estableciera mediante radiografía convencional o ecografía. Análisis comparativo de ambos grupos y análisis de la mortalidad mediante regresión logística. Resultados: La edad media fue de 75,16±8,89 años. La puntuación media en la escala APACHE II fue de 16,25±8,4 puntos, y en la escala Injury Severity Score, de 22,38±15,45 puntos. Se realizó TC corporal en 102 pacientes (72,9%). En estos se observó una menor mortalidad (15,7 frente a 52,6%; p¿0,001), una menor necesidad de ventilación mecánica (47,1 frente a 65,8%; p=0,049) y una menor puntuación en la escala APACHE II (14,75±7,19 frente a 20,26±10,06 puntos; p=0,003). El análisis multivariante mostró una menor mortalidad en los pacientes en los que se realizó TC corporal, con una OR de 0,21 (IC 95% 0,07-0,68; p=0,010), tras ajustar por puntuación en la escala APACHE II y en el Injury Severity Score. Conclusiones: La realización de TC corporal como parte del estudio del traumatismo podría mejorar el manejo de los pacientes de edad avanzada con afectación toracoabdominopélvica que ingresan en una unidad de cuidados intensivos

Objective: To determine the relationship between the use of whole-body computed tomography (WB-CT) and hospital mortality in elderly patients with thoracic-abdominal-pelvic injury requiring admission to an intensive care unit. Patients and method: An observational, descriptive and retrospective study was conducted on 140 patients aged 65 years and older admitted to the intensive care unit after a thoracic-abdominal-pelvic injury. Two groups were established, depending on whether a WB-CT was performed as a routine part of the study or the diagnosis was established by conventional radiography or ultrasound. A comparative analysis was performed on both groups, as well as an analysis of mortality through logistic regression. Results: The mean age of the patients was 75.16±8.89 years. The mean score on the APACHE II scale was 16.25±8.4 points, and on the Injury Severity Score scale, 22.38±15.45 points. WB-CT was performed on 102 patients (72.9%). In these patients, there was a lower mortality rate (15.7 vs. 52.6%, P¿.001), a lower need for mechanical ventilation (47.1 vs. 65.8%, P=.049), and a lower score on the APACHE II scale (14.75±7.19 vs. 20.26±10.06 points, P=.003). The multivariate analysis showed a lower mortality in the patients in whom WB-CT was performed, with an OR of 0.21 (95% CI 0.07-0.68; (P=.010), after adjusting for the APACHE II and ISS scores. Conclusions: Performing a WB-CT scan as part of the trauma study could improve the management of elderly patients with thoracic-abdominal-pelvic involvement admitted to the intensive care unit

Influence of Proportion of Normal Saline Administered in the Perioperative Period of Renal Transplantation on Kalemia Levels.

BACKGROUND: The hyperchloremic metabolic acidosis triggered by the infusion of normal saline (NS) significantly increases the level of extracellular potassium. In this study we assessed the influence of proportion of NS administered in the perioperative period of renal transplantation on potassium levels in usual clinical practice. METHODS: This study was a retrospective cohort analysis of patients undergoing renal transplantation during a 24-month period (2015-2016). To determine the influence of NS on K+ levels, simple linear regression and multiple linear regression analyses were performed, adjusted for the total volume of fluids administered, establishing the difference in serum K+ levels for each 20% increase in the proportion of NS. RESULTS: As the proportion of NS administered increased, K+ levels at 24 hours were significantly increased (P = .026) (0.69 mEq/L K+ increase per 20% increase in NS ratio). Mean K+ values at 24 hours (adjusted for total volume of fluids administered) ranged from 4.17 mEq/L (95% confidence interval [CI] 3.7-4.56) in patients who did not receive NS to 4.85 mEq/L (95% CI 4.56-5.15) in those administered exclusively NS. CONCLUSION: The risk of developing hyperkalemia in patients who receive a balanced solution with potassium in its formulation compared with NS in the perioperative period of renal transplantation is not increased, but the volume of NS administered is significantly associated with increases in K+ levels at 24 hours.

Whole-body computed tomography as a factor associated with lower mortality in severe geriatric trauma with thoracic-abdominal-pelvic injury. / La tomografía computarizada corporal como factor asociado a menor mortalidad en el traumatismo geriátrico grave con afectación toracoabdominopélvica.

OBJECTIVE: To determine the relationship between the use of whole-body computed tomography (WB-CT) and hospital mortality in elderly patients with thoracic-abdominal-pelvic injury requiring admission to an intensive care unit. PATIENTS AND METHOD: An observational, descriptive and retrospective study was conducted on 140 patients aged 65 years and older admitted to the intensive care unit after a thoracic-abdominal-pelvic injury. Two groups were established, depending on whether a WB-CT was performed as a routine part of the study or the diagnosis was established by conventional radiography or ultrasound. A comparative analysis was performed on both groups, as well as an analysis of mortality through logistic regression. RESULTS: The mean age of the patients was 75.16±8.89 years. The mean score on the APACHE II scale was 16.25±8.4 points, and on the Injury Severity Score scale, 22.38±15.45 points. WB-CT was performed on 102 patients (72.9%). In these patients, there was a lower mortality rate (15.7 vs. 52.6%, P˂.001), a lower need for mechanical ventilation (47.1 vs. 65.8%, P=.049), and a lower score on the APACHE II scale (14.75±7.19 vs. 20.26±10.06 points, P=.003). The multivariate analysis showed a lower mortality in the patients in whom WB-CT was performed, with an OR of 0.21 (95% CI 0.07-0.68; (P=.010), after adjusting for the APACHE II and ISS scores. CONCLUSIONS: Performing a WB-CT scan as part of the trauma study could improve the management of elderly patients with thoracic-abdominal-pelvic involvement admitted to the intensive care unit.

Limitación del tratamiento de soporte vital en el traumatismo grave en edades avanzadas tras el ingreso en una unidad de cuidados intensivos / Limitation of life-sustaining treatment in severe trauma in the elderly after admission to an intensive care unit

Objetivo: Analizar los factores asociados al proceso de limitación del tratamiento de soporte vital (LTSV) en los pacientes de edad avanzada que ingresan en una unidad de cuidados intensivos (UCI) tras un traumatismo. Diseño: Estudio observacional, descriptivo, retrospectivo. Ámbito: UCI. Pacientes: Ciento cuarenta y nueve pacientes con una edad igual o mayor de 65 años ingresados en UCI tras un traumatismo. Se analizó la mortalidad intrahospitalaria, la decisión de LTSV y los factores asociados a dicho proceso. Intervenciones: Ninguna. Resultados: La edad media fue de 76,3±6,36 años. La puntuación media en la escala APACHE II fue de 15,9±7,4 puntos, y en la escala ISS, de 19,6±11,4 puntos. Se decidió LTSV en 37 pacientes (24,8%). Los factores asociados a este proceso fueron la edad (OR 1,16; IC 95% 1,08-1,25), la puntuación en el APACHE II (OR 1,11; IC 95%1,05-1,67), la puntuación en el ISS (OR 1,03; IC 95% 1,01-1,06), el ingreso como consecuencia de un deterioro neurológico (OR 19,17; IC 95% 2,33-157,83) y el traumatismo craneoencefálico (OR 2,89; IC 95% 1,05-7,96). Conclusiones: La LTSV se establece con frecuencia en los pacientes de edad avanzada que ingresan en la UCI tras un traumatismo, y se asocia con la mortalidad intrahospitalaria. Los factores asociados al proceso de LTSV son una mayor edad, una mayor puntuación en las escalas APACHE II e ISS, el ingreso como consecuencia de un deterioro neurológico y la presencia de traumatismo craneoencefálico (AU)

Objective: To analyze the factors associated to limitation of life-sustaining treatment (LLST) measures in elderly patients admitted to an intensive care unit (ICU) due to trauma. Design: A retrospective, descriptive, observational study was carried out. Setting: ICU. Patients: A total of 149 patients aged 65 years or older admitted to the ICU due to trauma. Hospital mortality, the decision to limit life-sustaining treatment and the factors associated to these measures were analyzed. Interventions: None. Results: The mean patient age was 76.3±6.36 years. The average APACHE II and ISS scores were 15.9±7.4 and 19.6±11.4 points, respectively. LLST were used in 37 patients (24.8%). Factors associated to the use of these measures were patient age (OR 1.16; 95% CI 1.08 to 1.25], APACHE II score (OR 1.11; 95% CI 1.05-1.67), ISS score (OR 1.03; 95% CI 1.01 to 1.06), admission due to neurological impairment (OR 19.17; 95% CI 2.33 to 157.83) and traumatic brain injury (OR 2.89; 95% CI 1.05 to 7.96). Conclusions: LLST is frequently established in elderly patients admitted to the ICU due to trauma, and is associated to hospital mortality. Factors associated with the use of these measures are patient age, higher APACHE II and ISS scores, admission due to neurological impairment, and the presence of head injuries (AU)

Limitation of life-sustaining treatment in severe trauma in the elderly after admission to an intensive care unit. / Limitación del tratamiento de soporte vital en el traumatismo grave en edades avanzadas tras el ingreso en una unidad de cuidados intensivos.

OBJECTIVE: To analyze the factors associated to limitation of life-sustaining treatment (LLST) measures in elderly patients admitted to an intensive care unit (ICU) due to trauma. DESIGN: A retrospective, descriptive, observational study was carried out. SETTING: ICU. PATIENTS: A total of 149 patients aged 65 years or older admitted to the ICU due to trauma. Hospital mortality, the decision to limit life-sustaining treatment and the factors associated to these measures were analyzed. INTERVENTIONS: None. RESULTS: The mean patient age was 76.3±6.36 years. The average APACHE II and ISS scores were 15.9±7.4 and 19.6±11.4 points, respectively. LLST were used in 37 patients (24.8%). Factors associated to the use of these measures were patient age (OR 1.16; 95% CI 1.08 to 1.25], APACHE II score (OR 1.11; 95% CI 1.05-1.67), ISS score (OR 1.03; 95% CI 1.01 to 1.06), admission due to neurological impairment (OR 19.17; 95% CI 2.33 to 157.83) and traumatic brain injury (OR 2.89; 95% CI 1.05 to 7.96). CONCLUSIONS: LLST is frequently established in elderly patients admitted to the ICU due to trauma, and is associated to hospital mortality. Factors associated with the use of these measures are patient age, higher APACHE II and ISS scores, admission due to neurological impairment, and the presence of head injuries.

Balance hídrico y carga de cloro en las primeras 24h de ingreso en UCI y su relación con las terapias de reemplazo renal mediante un estudio multicéntrico, retrospectivo, de casos y controles emparejados por APACHE-II / Fluid balance and chloride load in the first 24h of ICU admission and its relation with renal replacement therapies through a multicentre, retrospective, case-control study paired by APACHE-II

Objetivo. Analizar la asociación entre el balance hídrico durante las primeras 24h de ingreso en UCI y las variables relacionadas con los valores de cloro (carga de cloro, tipo de fluido administrado, hipercloremia), con el empleo de técnicas de reemplazo renal secundarias a insuficiencia renal aguda (IRA-TRR) durante el posterior ingreso en UCI de los enfermos. Pacientes y métodos. Estudio multicéntrico de casos y controles, de base hospitalaria y ámbito nacional, llevado a cabo en 6 UCI. Los casos fueron pacientes mayores de 18 años que desarrollaron una IRA-TRR. Los controles fueron pacientes mayores de 18 años, ingresados en el mismo periodo y centro que los casos, que no desarrollaron IRA-TRR durante su ingreso en UCI. Se realizó emparejamiento por APACHE-II. Se llevó a cabo un análisis de regresión logística no condicional ajustada por edad, sexo, APACHE-II. Las variables de interés principales fueron: balance hídrico, carga de cloro administrada, e IRA-TRR. Resultados. Se han analizado las variables de 310 enfermos. Se evidenció un aumento del 10% en la posibilidad de desarrollar IRA-TRR por cada 500ml de balance hídrico positivo (OR: 1,09 [IC 95%:1,05-1,14]; p<0,001). El estudio de los valores medios de carga administrada no evidenció diferencias entre el grupo de casos y de controles (299,35±254,91 frente a 301,67±234,63; p=0,92). Conclusiones. El balance hídrico en las primeras 24h de ingreso en UCI se relaciona con el desarrollo de IRA-TRR, independientemente de la cloremia (AU)

Objective. To analyse the association between water balance during the first 24h of admission to ICU and the variables related to chloride levels (chloride loading, type of fluid administered, hyperchloraemia), with the development of acute kidney injury renal replacement therapy (AKI-RRT) during patients’ admission to ICU. Patients and methods. Multicentre case-control study. Hospital-based, national, carried out in 6 ICUs. Cases were patients older than 18 years who developed an AKI-RRT. Controls were patients older than 18 years admitted to the same institutions during the study period, who did not develop AKI-RRT during ICU admission. Pairing was done by APACHE-II. An analysis of unconditional logistic regression adjusted for age, sex, APACHE-II and water balance (in evaluating the type of fluid). Results. We analysed the variables of 430 patients: 215 cases and 215 controls. An increase of 10% of the possibility of developing AKI-RRT per 500ml of positive water balance was evident (OR: 1.09 [95% CI: 1.05 to 1.14]; P<.001). The study of mean values of chloride load administered did not show differences between the group of cases and controls (299.35±254.91 vs. 301.67±234.63; P=.92). Conclusions. The water balance in the first 24h of ICU admission relates to the development of IRA-TRR, regardless of chloraemia (AU)

Evaluación del conocimiento en la composición de fluidos de resucitación del personal médico en formación / Evaluation of knowledge in the composition of fluids of resuscitation of the personnel medical intraining

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Fluid balance and chloride load in the first 24h of ICU admission and its relation with renal replacement therapies through a multicentre, retrospective, case-control study paired by APACHE-II. / Balance hídrico y carga de cloro en las primeras 24h de ingreso en UCI y su relación con las terapias de reemplazo renal mediante un estudio multicéntrico, retrospectivo, de casos y controles emparejados por APACHE-II.

OBJECTIVE: To analyse the association between water balance during the first 24h of admission to ICU and the variables related to chloride levels (chloride loading, type of fluid administered, hyperchloraemia), with the development of acute kidney injury renal replacement therapy (AKI-RRT) during patients' admission to ICU. PATIENTS AND METHODS: Multicentre case-control study. Hospital-based, national, carried out in 6 ICUs. Cases were patients older than 18 years who developed an AKI-RRT. Controls were patients older than 18 years admitted to the same institutions during the study period, who did not develop AKI-RRT during ICU admission. Pairing was done by APACHE-II. An analysis of unconditional logistic regression adjusted for age, sex, APACHE-II and water balance (in evaluating the type of fluid). RESULTS: We analysed the variables of 430 patients: 215 cases and 215 controls. An increase of 10% of the possibility of developing AKI-RRT per 500ml of positive water balance was evident (OR: 1.09 [95% CI: 1.05 to 1.14]; P<.001). The study of mean values of chloride load administered did not show differences between the group of cases and controls (299.35±254.91 vs. 301.67±234.63; P=.92). CONCLUSIONS: The water balance in the first 24h of ICU admission relates to the development of IRA-TRR, regardless of chloraemia.

SPLIT trial: ¿algo nuevo en fluidoterapia del crítico? / The SPLIT trial: Anything new in critical care fluid therapy?

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