Influence of n-3 polyunsaturated fatty acids enriched lipid emulsions on nosocomial infections and clinical outcomes in critically ill patients: ICU lipids study.

OBJECTIVE: n-3 polyunsaturated fatty acids (contained in fish oil) have been shown to beneficially influence infection rate and clinical outcomes in surgical patients probably due to their immunomodulatory action. In contrast, study results of fish oil administration in critically ill patients are controversial. The aim of this study was to investigate the effects of n-3 polyunsaturated fatty acids on the prevalence of nosocomial infections and clinical outcomes in medical and surgical critically ill patients. DESIGN: Prospective, multicenter, randomized, comparative, double-blind study. SETTING: Seventeen Spanish ICUs during 4 years. SUBJECTS: A total of 159 medical and surgical intensive care patients with Acute Physiology and Chronic Health Evaluation II score more than or equal to 13, expected to require total parenteral nutrition for at least 5 days. INTERVENTIONS: Patients received total parenteral nutrition prepared either with a lipid emulsion containing 10% fish oil or a fish oil-free lipid emulsion. The prevalence of nosocomial infections was detected during 28 days of ICU stay. Patients were followed 6 months after discharge from the ICU for length of hospital stay, hospital mortality, and 6-month mortality. MEASUREMENTS AND MAIN RESULTS: The number of patients with nosocomial infections was significantly reduced in the fish oil-receiving group (21.0% vs 37.2%, p = 0.035) and the predicted time free of infection was prolonged (21 ± 2 vs 16 ± 2 d, p = 0.03). No significant differences were detected for ICU, hospital, and 6-month mortality. CONCLUSIONS: The results show that administration of n-3 polyunsaturated fatty acids reduces the risk of nosocomial infections and increases the predicted time free of infections in critically ill medical and surgical patients. The administration of n-3 polyunsaturated fatty acids was safe and well tolerated.

Stratification of the severity of critically ill patients with classification trees.

BACKGROUND: Development of three classification trees (CT) based on the CART (Classification and Regression Trees), CHAID (Chi-Square Automatic Interaction Detection) and C4.5 methodologies for the calculation of probability of hospital mortality; the comparison of the results with the APACHE II, SAPS II and MPM II-24 scores, and with a model based on multiple logistic regression (LR). METHODS: Retrospective study of 2864 patients. Random partition (70:30) into a Development Set (DS) n = 1808 and Validation Set (VS) n = 808. Their properties of discrimination are compared with the ROC curve (AUC CI 95%), Percent of correct classification (PCC CI 95%); and the calibration with the Calibration Curve and the Standardized Mortality Ratio (SMR CI 95%). RESULTS: CTs are produced with a different selection of variables and decision rules: CART (5 variables and 8 decision rules), CHAID (7 variables and 15 rules) and C4.5 (6 variables and 10 rules). The common variables were: inotropic therapy, Glasgow, age, (A-a)O2 gradient and antecedent of chronic illness. In VS: all the models achieved acceptable discrimination with AUC above 0.7. CT: CART (0.75(0.71-0.81)), CHAID (0.76(0.72-0.79)) and C4.5 (0.76(0.73-0.80)). PCC: CART (72(69-75)), CHAID (72(69-75)) and C4.5 (76(73-79)). Calibration (SMR) better in the CT: CART (1.04(0.95-1.31)), CHAID (1.06(0.97-1.15) and C4.5 (1.08(0.98-1.16)). CONCLUSION: With different methodologies of CTs, trees are generated with different selection of variables and decision rules. The CTs are easy to interpret, and they stratify the risk of hospital mortality. The CTs should be taken into account for the classification of the prognosis of critically ill patients.

[Risk factors of the hepatic dysfunction associated with parenteral nutrition]. / Factores de riesgo de la disfunción hepática asociada a la nutrición parenteral.

BACKGROUND AND OBJECTIVE: The objective of this study is to describe the incidence of hepatic dysfunction (HD) in our hospital and evaluate the possible risk factors associated with HD development as an improvement of the caring process received by patients treated with parenteral nutrition (PN). PATIENTS AND METHOD: A prospective study of patients (n=994) who required PN during the period 2000-2004. HD is the identification of an increase above 1,5 of the top reference value of alkaline phosphatase (40-450U/l) and gamma glutamyl transpeptidase (11-49U/l) associated with an increase of transaminases (5-32U/l) and a total bilirrubin higher than 1,2mg/dl. RESULTS: The incidence of HD was 4,9% (n=49). Days with PN were significantly higher in the HD group: median (interquartile range): 30 (20-59) vs 15 (8-25) days (p<0.001). In the univariated HD analysis, the variables that reached significant odds ratio were: the critical patient condition, the PN duration, the total calorie contribution higher than 25kcal/kg, to exceed 3g of carbohydrates/kg, to administer more than 0.8g/kg of lipids and to exceed 0.16g of nitrogen/kg. In the multivariated analysis, the variables selected as independent risk factors were: to exceed 3 weeks of PN, to be a critical patient and a contribution over 0.16g of nitrogen/kg. CONCLUSIONS: The present profiles of the patients who will develop HD are those with prolonged PN. These patients undergo processes and critical therapy, where the specialists must monitor, not only calorie contribution, carbohydrates or lipids, but proteins as well.

Factores de riesgo de la disfunción hepática asociada a la nutrición parenteral / Risk factors of the hepatic dysfunction associated with parenteral nutrition

Fundamento y objetivo: el objetivo de este trabajo es describir la incidencia de disfunción hepática (DH) en nuestro hospital y evaluar los posibles factores de riesgo asociados al desarrollo de DH como mejora del proceso asistencial de los pacientes con nutrición parenteral (NP). Pacientes y método: se ha realizado un estudio prospectivo de los pacientes (n=994) que requirieron NP durante el período 2000-2004. Se definió la DH como un aumento mayor de 1,5 veces el valor superior de referencia de la fosfatasa alcalina (40-450U/l) y la gammaglutamil transpeptidasa (11-49U/l), asociado a un aumento de las transaminasas (5-31U/l) y de la bilirrubina total superior a 1,2mg/dl. Resultados: la incidencia de DH fue del 4,9% (n=49). Los días de NP fueron significativamente mayores en el grupo de DH, con una mediana (intervalo intercuartílico) de 30 (20-59) frente a 15 (8-25) días (p<0,001). En el análisis univariado las variables que alcanzaron una odds ratio significativa fueron el estado de paciente crítico, la duración de la NP, el aporte de calorías superior a 25kcal/kg, superar los 3g de aporte de hidratos de carbono por kilogramo, administrar más de 0,8g/kg de lípidos y superar los 0,16g de nitrógeno por kilogramo. El modelo multivariante sólo seleccionó como factores de riesgo independientes: superar las 3 semanas de NP, ser un paciente crítico y un aporte mayor de 0,16g de nitrógeno por kilogramo. Conclusiones: el perfil actual de los pacientes que desarrollarán DH crítico con NP prolongada, en el que hay que controlar no sólo el aporte de calorías, hidratos de carbono o lípidos, sino también el de proteínas (AU)

Background and objective: The objective of this study is to describe the incidence of hepatic dysfunction (HD) in our hospital and evaluate the possible risk factors associated with HD development as an improvement of the caring process received by patients treated with parenteral nutrition (PN). Patients and method: A prospective study of patients (n=994) who required PN during the period 2000¿2004. HD is the identification of an increase above 1,5 of the top reference value of alkaline phosphatase (40-450U/l) and gamma glutamyl transpeptidase (11¿49U/l) associated with an increase of transaminases (5¿32U/l) and a total bilirrubin higher than 1,2mg/dl. Results: The incidence of HD was 4,9% (n=49). Days with PN were significantly higher in the HD group: median (interquartile range): 30 (20-59) vs 15 (8-25) days (p<0.001). In the univariated HD analysis, the variables that reached significant odds ratio were: the critical patient condition, the PN duration, the total calorie contribution higher than 25kcal/kg, to exceed 3g of carbohydrates/kg, to administer more than 0.8g/kg of lipids and to exceed 0.16g of nitrogen/kg. In the multivariated analysis, the variables selected as independent risk factors were: to exceed 3 weeks of PN, to be a critical patient and a contribution over 0.16g of nitrogen/kg. Conclusions: The present profiles of the patients who will develop HD are those with prolonged PN. These patients undergo processes and critical therapy, where the specialists must monitor, not only calorie contribution, carbohydrates or lipids, but proteins as well (AU)

Skin lesions after intensive care procedures: results of a prospective study.

PURPOSE: To define the skin lesions produced by procedures used in the intensive care unit (ICU) and to examine patients 12 months after discharge from the ICU. MATERIAL AND METHODS: This was a prospective clinical study in the 14-bed multidisciplinary ICU of a university hospital. Iatrogenic skin lesions (ISL) were examined in 316 patients after ICU discharge. RESULTS: A total of 189 patients were interviewed 12 months after ICU discharge. More than 85% of the patients had ISL after being discharged from the ICU. The patients with the highest Acute Physiology and Chronic Health Evaluation II score and longest average stay presented the highest number of ISLs. A total of 93 patients (49%) reported some skin lesions after 12 months. All patients who had undergone surgical tracheostomy reported the presence of a scar, but 4 of 24 patients who had undergone percutaneous tracheostomy reported no tracheostomy scar. Only 22% of all patients reported scars caused by vascular catheter access. About half (54.5%) of the patients reported secondary lesions caused by chest draining, and these were predominantly caused by the large-bore tube drainage. All patients reported the presence of a laparatomy scar. CONCLUSIONS: Most patients had identified skin lesions resulting from ICU procedures. Half of all patients were aware of their lesions and reported them at 12 months. Future research is needed to understand whether these lesions cause problems to survivor's quality of life and whether the lesions lead to increased health care utilization.

[Recall and memory after intensive care unit stay. Development of posttraumatic stress disorder]. / Recuerdos y memoria del paciente crítico a largo plazo. Desarrollo de estrés postraumático.

BACKGROUND AND OBJECTIVE: The intensive care unit (ICU) confers a stress on patients and may affect the memory. The aim of the study was to examine the memory after critical care and the relationship with therapy and the development of posttraumatic stress disorder. PATIENTS AND METHOD: Prospectively study conducted between December 2001 and June 2003. Patients were excluded if language difficulties or had a neurologic or psychiatric disease. We collected data on gender and age, length of stay in the ICU, severity of acute illness, diagnoses and medical treatment with mechanical ventilation, propofol, midazolam and dopamine during the ICU stay. 12 months after ICU eligible patients were contacted to assess memory. The ICUM (Intensive Care Memory) tool and IES (Impact Event Scale) were used to assess memory and posttraumatic stress disorder. RESULTS: A total of 169 patients were included. The incidence of memory was 77.6%. 41 patients recalled delusional memories and these patients had higher IES after discharge. The logistic regression suggested a relationship with propofol, dopamine and length of stay. CONCLUSIONS: ICU treatment may be related more to recall of delusions. The delusional memory is associated with posttraumatic stress disorder symptoms after ICU.

Recuerdos y memoria del paciente crítico a largo plazo. Desarrollo de estrés postraumático / Recall and memory after intensive care unit stay. Development of posttraumatic stress disorder

Fundamento y objetivo: Ingresar en una unidad de cuidados intensivos (UCI) provoca estrés que afecta a la memoria del paciente. El objetivo del presente estudio ha sido evaluar la memoria de los pacientes tras su estancia en la UCI y la influencia del tratamiento, además de examinar la relación entre memoria y síntomas de estrés postraumático. Pacientes y método: Se ha realizado un estudio prospectivo, que incluyó consecutivamente a los pacientes ingresados en la UCI del Hospital Universitario Arnau de Vilanova de Lleida entre diciembre de 2001 y junio de 2003. Se excluyó a los pacientes de nacionalidades distintas de la española y a los que presentaban alteraciones neurológicas o psiquiátricas. Se recogieron datos de filiación, estancia en UCI y hospitalaria, gravedad, diagnóstico principal y variables clínicas como ventilación mecánica, uso de dopamina y sedantes. A los 12 meses se realizó una entrevista programada en la que se recogieron las vivencias experimentadas en UCI según la herramienta ICUM (Intensive Care Unit Memory) y la escala de impacto del estresor (EIE) para evaluación de estrés postraumático. Resultados: Se incluyó a 169 pacientes. El 77,6% tenía algún recuerdo. Un total de 41 pacientes refirieron memoria ilusoria con EIE significativamente más alto que el resto de pacientes. El modelo de regresión logística múltiple demostró como factores predictores independientes de memoria ilusoria el tratamiento con propofol o con dopamina y la estancia hospitalaria. Conclusiones: El tratamiento recibido en la UCI puede favorecer la memoria ilusoria. La alteración de los recuerdos con aumento de la memoria ilusoria puede tener consecuencias psicológicas a largo plazo

Background and objective: The intensive care unit (ICU) confers a stress on patients and may affect the memory. The aim of the study was to examine the memory after critical care and the relationship with therapy and the development of posttraumatic stress disorder. Patients and method: Prospectively study conducted between December 2001 and June 2003. Patients were excluded if language difficulties or had a neurologic or psychiatric disease. We collected data on gender and age, length of stay in the ICU, severity of acute illness, diagnoses and medical treatment with mechanical ventilation, propofol, midazolam and dopamine during the ICU stay. 12 months after ICU eligible patients were contacted to assess memory. The ICUM (Intensive Care Memory) tool and IES (Impact Event Scale) were used to assess memory and posttraumatic stress disorder. Results: A total of 169 patients were included. The incidence of memory was 77.6%. 41 patients recalled delusional memories and these patients had higher IES after discharge. The logistic regression suggested a relationship with propofol, dopamine and length of stay. Conclusions: ICU treatment may be related more to recall of delusions. The delusional memory is associated with posttraumatic stress disorder symptoms after ICU

Intoxicación aguda por organofosforados tras ingestión de fruta fresca: ¿síndrome intermedio? / Acute orgonophosphate poisoning after fruit intake: an intermediate syndrome?

No disponible