Clindamycin but not Intravenous Immunoglobulins reduces mortality in a retrospective cohort of critically ill patients with bacteremic Group A Streptococcal infections.

OBJECTIVE: Mortality of patients requiring Intensive Care Unit (ICU) admission for an invasive group A streptococcal (GAS) infection continues being high. In critically ill patients with bacteremic GAS infection we aimed at determining risk factors for mortality. METHODS: Retrospective multicentre study carried out in nine ICU in Southern Spain. All adult patients admitted to the participant ICUs from January 2014 to June 2019 with one positive blood culture for S. pyogenes were included in this study. Patient characteristics, infection-related variables, therapeutic interventions, failure of organs, and outcomes were registered. Risk factors independently associated with ICU and in-hospital mortalities were determined by multivariate regression analyses. RESULTS: Fifty-seven patients were included: median age was 63 (45-73) years, median SOFA score at admission was 11 (7-13). The most frequent source was skin and soft tissue infection (n=32) followed by unknown origin of bacteremia (n=12). In the multivariate analysis, age (OR 1.079; 95% CI 1.016-1.145), SOFA score (OR 2.129; 95% CI 1.339-3.383) were the risk factors for ICU mortality and the use of clindamycin was identified as a protective factor (OR 0.049; 95% CI 0.003-0.737). Age and SOFA were the independent factors associated with hospital mortality however the use of clindamycin showed a strong trend but without reaching statistical significance (OR 0.085; 95% CI 0.007-1.095). CONCLUSIONS: In this cohort of critically ill patients the use of intravenous immunoglobulin was not identified as a protective factor for ICU or hospital mortality treatment with clindamycin significantly reduced mortality after controlling for confounders.

Expanded criteria donors for kidney transplantation: quality control and results.

Although the number of kidneys from expanded criteria deceased donors (ECDs) is growing in most transplant centers, the limits for acceptance of these kidneys and the safety standards have still not been fully established. We evaluated 342 kidney transplants performed between January 1999 and December 2004. In 77 (22.5%) of these, the kidneys were from ECDs, that is, donors age >60 years and with one of the following characteristics: hypertension, death due to cerebrovascular accident (CVA) or glomerular filtration rate (GFR) <70 mL/min. The results of the ECD transplants were compared with 265 transplants during the same period from standard donors (SDs), that is, donors age <60 years and GFR > 70 mL/min. All the ECD kidneys underwent biopsy and were accepted for transplantation only if the score was <7. The ECDs (66.5 +/- 4.3 years) in comparison with the SDs (48.0 +/- 16.0 years) had a greater frequency of death due to CVA (94.8% vs 49.8%) and a lower GFR (80.4 +/- 25.0 vs 111 +/- 41.6 mL/min; P < .05). Of the ECDs, 97.4% had a history of hypertension versus 24.3% of the SDs. Kidney biopsies were performed in 116 SD kidneys because the donor age was >55 years or there was a history of hypertension. The median score for the kidney biopsies of the ECD kidneys was 3 versus 2 for the SD kidneys. Graft survival was not significantly different until the fifth year. The GFR at 12 months was significantly different (SDs, 58.0 +/- 22.7 vs ECDs, 48.9 +/- 16.5 mL/min; P < .05). Although the GFR in the ECD kidneys was lower than that of the SD kidneys, it could still be adequate for recipients older than 50 years of age. Accordingly, the acceptance criteria for ECD kidneys based mainly on the kidney biopsy score and donor GFR benefit the recipients.

Expanded donor criteria due to age: an effort rewarded.

The life expectancy of the current Spanish population is 78 years, with some 20% of the population aged over 65 years. The continuing increase in the demand for transplants has led to widening of the criteria for acceptance of donors without worsening the results, but without reducing transplant waiting lists or mortality. This has resulted in the need to include the concept of the expanded criteria donor (ECD). We undertook a retrospective study of 77 donors from a hospital with no neurosurgery service from January 2000 to December 2005. Four of the donors younger than 60 years of age (n = 38) were not appropriate (10.5%), whereas five of the donors older than 60 years of age (n = 39) were not appropriate (12.8%; P = NS). The older donors provided 47 used kidneys (60.2%) and 22 livers (56.4%), slightly fewer than those obtained from the younger donors, though the difference was not significant. Thus, ECDs, those older than 60 years of age, did not result in a significant loss of kidneys or livers available for transplantation. Other factors associated with systemic vascular disease and accompanying disorders could be determinant when predicting the usefulness of organs for transplantation.

[MARS (Molecular Absorbent Recirculating System) as hepatic extracorporeal care in serious acute liver failure of alcoholic etiology]. / MARS (molecular adsorbent recirculating system) como asistencia extracorporea hepatica en el fracaso hepatica en el fracaso hepatico agudo grave de etiologia enolica.

Acute liver failure with criteria of seriousness and alcoholic etiology is a picture of worldwide distribution, with an elevated mortality, of approximately 50%, that requires admission to the ICU. Acute serious alcoholic hepatitis is defined by a Maddrey score value > 32 and/or spontaneous encephalopathy. Together with the classical treatment with corticosteroids and nutritional supplements, alcoholic abstinence and others such as anti-TNF therapy, we introduce MARS (Molecular Adsorbent recirculating System) as a extracorporeal liver assistance system with detoxification function, that is presented as a support measure that makes it possible to maintain the patient in good conditions until an organ becomes available or until the functional recovery of the native liver. In our case, MARS has shown some spectacular results and above all, results maintained over time, associated to the rest of the therapeutic measures characteristic of this disease.

MARS (molecular adsorbent recirculating system) como asistencia extracorpórea hepática en el fracaso hepático agudo grave de etiología enólica / MARS (molecular absorbent recirculatingsystem) as hepatic extracorporeal carein serious acute liver failure of alcoholicetiology

La insuficiencia hepática aguda con criterios de gravedad y etiología enólica es un cuadro de amplia distribución mundial, con una elevada mortalidad, aproximadamente el 50%, y requiere ingreso en la Unidad de Cuidados Intensivos (UCI). La hepatitis alcohólica aguda grave está definida por un valor de Maddrey score > 32 y/o encefalopatía espontánea. Junto al tratamiento clásico con corticoides y suplementos nutricionales, abstinencia alcohólica y otros, como las terapias anti-factor de necrosis tumoral (anti-TNF) introducimos el MARS (molecular adsorbent recirculating system) como sistema de asistencia extracorpórea hepática con función de detoxificación, que se presenta como una medida de soporte que permite mantener al paciente en buenas condiciones hasta la disponibilidad de un órgano o hasta la recuperación funcional del hígado nativo. En nuestro caso, el MARS ha mostrado unos resultados espectaculares y, sobre todo, mantenidos en el tiempo, asociado al resto de las medidas terapéuticas propias a esta patología

Acute liver failure with criteria of seriousness and alcoholic etiology is a picture of worldwide distribution, with an elevated mortality, of approximately 50%, that requires admission to the ICU. Acute serious alcoholic hepatitis is defined by a Maddrey score value > 32 and/or spontaneous encephalopathy. Together with the classical treatment with corticosteroids and nutritional supplements, alcoholic abstinence and others such as anti-TNF therapy, we introduce MARS (Molecular Adsorbent recirculating System) as a extracorporeal liver assistance system with detoxification function, that is presented as a support measure that makes it possible to maintain the patient in good conditions until an organ becomes available or until the functional recovery of the native liver. In our case, MARS has shown some spectacular results and above all, results maintained over time, associated to the rest of the therapeutic measures characteristic of this disease

Multifactorial snowball effect in the reduction of refusals for organ procurement.

Interviewing the family of a possible organ donor is a legal requirement in Spain, but it is the stage at which most potential donors are lost. Multiple factors influence the family's acceptance or rejection of this option, including awareness of the wishes of the deceased, personal preconceived attitudes of family members, as well as issues related to the hospital and its health care personnel, whose attitudes are a key factor in obtaining permission. We examined all 651 donation situations in a single hospital that included a family interview over the last 15 years. Among these 651 cases, 191 families refused donation (29.3%). The rate of donation refusal has fallen from 46.3% to 12.5% over these 15 years. To better understand the evolution of donor characteristics, interviewees, and the setting, we divided the sample into three 5-year periods to analyze key variables collected from the family interviews. The results showed that at the same time as the donor profile has changed, namely, fewer brain trauma cases and more victims of stroke as well as older mean age and more coexistent diseases, these has been an improvement in the factors related to the information and opinion of both the families and the donor about this process. The main reasons for refusal of donation have changed from negation of brain death, religious factors, and the desire to maintain the body intact during the 1990s, to sociocultural reasons in minority ethnic groups, to presumed refusal during life, and to family disagreements during the more recent years.

Soporte hepático extracorpóreo: situación actual y expectativas de futuro / Extracorporeal liver support: current situation and future prospects

Dada la mortalidad del fracaso hepático grave y la ausencia de opciones terapéuticas, necesitamos un sistema de suplencia como puente a la recuperación o al trasplante. El hígado tiene funciones de depuración y metabólicas, por lo que hay 2 opciones al reemplazo: detoxificación (sistemas artificiales) o síntesis (bioartificiales). La detoxificación se realiza mediante el uso de membranas biocompatibles. Dado el elevado número de moléculas implicadas en la fisiopatología de este fracaso, los sistemas disponibles no han mostrado su eficacia, pero los sistemas combinados de plasmaféresis con hemofiltración o adsorción parecen prometedores. La diálisis con albúmina es otra opción eficaz y el sistema MARS® (reutilización de albúmina) es el sistema de suplencia más usado que ha demostrado mejoría clínica e incluso disminución de la mortalidad (síndrome hepatorrenal y descompensación grave de la hepatopatía crónica). Los sistemas bioartificiales (hepatocitos funcionantes) deberían presentar ventajas claras, pero no han demostrado aún efectos beneficiosos en la clínica y presentan una elevada complejidad y coste, lo que los aleja por el momento de la práctica clínica habitual. La falta de resultados significativos sobre el pronóstico con ambas aproximaciones pone de manifiesto la necesidad de buscar sistemas que integren ambos conceptos de reemplazo (AU)

Hemofiltración en la pancreatitis aguda / Hemofiltration in acute pancreatitis

Introducción. La pancreatitis aguda (PA) es una enfermedad frecuente pero, en general, benigna, aunque existe un número significativo de pacientes que desarrollan una pancreatitis necrosante (PAN) que se acompaña de una elevada morbimortalidad. El fracaso renal agudo (FRA) es una complicación frecuente y una de las que revisten mayor gravedad. El tratamiento actual de la PAN debería haber supuesto un descenso en la aparición de FRA; sin embargo, esta expectativa no se ha cumplido. Método. Revisión de la bibliografía mediante búsqueda en Medline con las palabras clave "acute pancreatitis" y "acute renal failure".Resultados. Aunque la aparición aislada de FRA es infrecuente en la PAN, se detecta una frecuencia elevada cuando ésta evoluciona a la aparición de disfunción orgánica múltiple con elevada mortalidad (el 75-80 por ciento que ante la necesidad de tratamiento de reemplazo se eleva hasta el 95 por ciento). No se han definido factores de riesgo que permitan predecir su desarrollo salvo los referidos a la gravedad del cuadro de PAN. La PAN determina la producción de mediadores inflamatorios que determinan el fracaso de órganos a distancia, entre ellos el riñón, aunque se ha descrito un efecto patogénico directo sobre el árbol vascular renal, fenómenos de apoptosis en células tubulares renales y otros factores como hipovolemia o cuadros de rabdomiólisis y mioglobinuria acompañantes. Se trata de pacientes con frecuente inestabilidad hemodinámica, hipoxia y alteraciones de la coagulación, lo que imposibilita tanto la diálisis peritoneal como la hemodiálisis intermitente, por lo que la hemofiltración, al no provocar alteraciones hemodinámicas ni afectar la oxigenación, se puede considerar el tratamiento de reemplazo de elección. Por otra parte, la hemofiltración presenta algunas características que la hacen susceptible de ser usada para la eliminación de sustancias proinflamatorias (mediante eliminación por convección o por adsorción), lo que podría justificar su uso como tratamiento de la PAN incluso en pacientes sin FRA. Se revisan los datos de la bibliografía que sustentan este criterio. Conclusión. No se puede indicar el tratamiento de la PAN con hemofiltración en el momento actual, aunque existen argumentos en favor del uso de esta técnica son necesarios datos más concluyentes. Sin embargo, sí debemos considerar que la hemofiltración es el tratamiento de elección para los pacientes con PAN que presentan FRA y requieren tratamiento de sustitución renal. En estos pacientes se deberían usar membranas biocompatibles, dar preferencia a los tratamientos de hemofiltración con elevado volumen y hacer recambios frecuentes de los filtros para optimizar el efecto de adsorción de la membrana (AU)

Pacientes hematológicos admitidos en cuidados intensivos: análisis de supervivencia / Hematological patients admitted to the intensive care unit: survival analysis

Introducción. El pronóstico de las enfermedades hematológicas malignas ha experimentado un importante avance en las últimas décadas, lo que ha propiciado que muchos de estos pacientes sean admitidos en unidades de cuidados intensivos; pero aún sigue existiendo controversia sobre el beneficio real del tratamiento en estas unidades. El objetivo de este trabajo es determinar factores pronósticos y mortalidad a corto y medio plazo. Material y métodos. Estudio prospectivo de los pacientes con enfermedades hematológicas admitidos en nuestra unidad (UCI polivalente en un hospital de tercer nivel) durante los años 19941997 con seguimiento de los enfermos dados de alta hasta mayo de 2000. Resultados. Estudiamos a 29 pacientes (34 por ciento con leucemia mieloide aguda, 17,2 por ciento con linfoma no hodgkiniano, 13,8 por ciento con leucemia linfoblástica aguda y 10,3 por ciento con linfoma hodgkiniano); el 24,1 por ciento recibió un trasplante de médula ósea. Estos pacientes contabilizaron 33 ingresos con una mediana de estancia de 10 días (65,5 por ciento con ventilación mecánica), un índice APACHE II al ingreso de 23,8 (6,5) y fracasos al ingreso de 2,7 (1,1) órganos. La mortalidad hospitalaria fue del 89,7 por ciento (72,4 por ciento en un primer ingreso en la UCI). La supervivencia global de los pacientes a los 10 días tras el ingreso en la UCI fue del 50 por ciento, al mes del 25 por ciento y a los 2 meses del 17 por ciento; tras 2 años de seguimiento, la supervivencia fue del 3,3 por ciento. Sólo el APACHE II y el número de disfunciones de órganos al ingreso se relacionan con la mortalidad intra-UCI (aunque sobrestiman el porcentaje de supervivencia de los pacientes); ninguna variable ha demostrado relación con la supervivencia a largo plazo. Conclusiones. Los índices pronóstico habituales son predictores de mortalidad intra-UCI pero podrían estar sobreestimando las expectativas de supervivencia (AU)

Endogenous endotoxemia of intestinal origin during cardiopulmonary bypass. Role of type of flow and protective effect of selective digestive decontamination.

OBJECTIVE: To evaluate the possible related factors to endotoxemia and cytokine activation during the ischemic phase of extracorporeal surgery, and the effect of selective digestive decontamination (SDD) as a preventive measure. DESIGN: Prospective, open, randomized trial. SETTING: Two multidisciplinary ICUs (tertiary care hospitals). PATIENTS: One hundred consecutive patients undergoing cardiopulmonary bypass (CPB), randomly allocated to two groups; gut decontamination (group I = 50 cases) and controls (group II = 50 cases). INTERVENTIONS: Preoperative administration of oral non-absorbable antibiotics (polymyxin E, tobramycin and amphotericin B) versus no administration. MEASUREMENTS AND RESULTS: The assessment of decontamination by means of the bacteriologic control of rectal swabs. Determinations of gastric intramucosal pH (gastric pHi) and plasma endotoxin, tumor necrosis factor (TNF) aNd interleukin-6 (IL-6) before surgery and during the ischemic and reperfusion phases of bypass. Rectal aerobic Gram-negative bacilli (AGNB) were significantly reduced in the treated patients and in 56% total eradication was achieved. Endotoxin, TNF and IL-6 plasma levels were significantly lower in this group. By contrast, both endotoxin and TNF/IL-6 levels and gastric pHi correlated with the type of surgical flow (pulsatile versus non-pulsatile). CONCLUSIONS: SDD reduces the gut content of enterobacteria. This may explain the lower endotoxin and cytokine levels detected in decontaminated patients. In addition to SDD, the type of flow employed during bypass seems to influence endotoxemia and cytokine levels.

Can selective digestive decontamination avoid the endotoxemia and cytokine activation promoted by cardiopulmonary bypass?

OBJECTIVE: To evaluate the effect of selective digestive decontamination on endotoxemia and cytokine activation during the ischemic phase of cardiopulmonary bypass surgery. DESIGN: Prospective, open, randomized, controlled trial. SETTING: Two multidisciplinary intensive care units in tertiary care hospitals. PATIENTS: Eighty consecutive patients randomly allocated to two groups: selective digestive decontamination (group 1, n = 40) and controls (group 2, n = 40). INTERVENTIONS: Preoperative administration of oral antibiotics (polymyxin E, tobramycin, and amphotericin B) vs. untreated controls. MEASUREMENTS AND MAIN RESULTS: Assessment of decontamination by bacteriologic evaluation of rectal swabs (colony-forming units [cfu]/mL) were made in each group, along with circulating endotoxin, tumor necrosis factor and interleukin-6 (IL-6) determinations before surgery, during ischemic and reperfusion phases of bypass, and at 4 hrs and at 24 hrs after surgery. Group 1 patients showed that rectal bacteria decreased ten-fold after treatment for 24 hrs, thousand-fold after 48 hrs, and registered 0 cfu/mL after digestive decontamination was administered for > 72 hrs. Endotoxin and IL-6 assays showed significantly lower values in this latter group vs. those circulating concentrations of control patients. On the other hand, both endotoxin and IL-6 concentrations correlated positively with the duration of surgical ischemia. CONCLUSIONS: Selective digestive decontamination reduces the gut content of enterobacteria, with complete elimination after 3 days of treatment. This fact could explain the lower endotoxin and cytokine concentrations found in the blood samples of patients who had been fully decontaminated. Duration of aortic cross-clamping is an important factor in generating endotoxemia and in the activation of cytokines.

Role of selective digestive decontamination (SDD) in the prevention of nosocomial pneumonia (NP): is gastric decontamination necessary?

In the course of a prospective selective digestive decontamination (SDD) trial to prevent nosocomial pneumonia (NP) during mechanical ventilation (MV), we carried out serial cultures of gastric aspirate to assess the importance of gastric colonization for potential respiratory pathogens and its relationship to the simultaneous gastric pH, to whether the patients were receiving Sucralfate or Ranitidine and to the nutritional biochemical parameters. If NP developed, a bronchial sample was taken by fibreoptic bronchoscopy to determine the causal organisms and its relationship to the previous gastric isolated. Results show: 1) Increase in aerobic Gram negative bacilli colonization during hospitalization. 2) Direct relationship between colonization level and gastric pH. 3) Greater pH in ranitidine vs sucralfate group. 4) Low incidence of NP (11%), the majority of these (66%) being early. 5) No bacteriological correlation between gastric colonization and aetiological agents of NP. 6) Close relationship between pharyngeal colonization and causative germs of pulmonary infection (40%).