Resultados de la modificación de un protocolo de manejo para la pancreatitis aguda en Medicina Intensiva / Results of the modification of an acute pancreatitis management protocol in Intensive Care medicine

Objetivo: Conocer si la implantación de un protocolo para el manejo de la pancreatitis aguda (PA) en Medicina Intensiva (MI) redundó en la mejora de los resultados clínicos. Diseño: Serie de casos, observacional, retrospectivo, con un diseño antes-después. Periodo de estudio: 1/01/2001-31/12/2016, dividido en 2 periodos (preprotocolo 2001-2007; posprotocolo 2008-2016). Ámbito: Un servicio de MI con 48 camas y población de 700.000 habitantes. Participantes: Pacientes ingresados en MI con PA. No hubo criterios de exclusión. Intervenciones: Se aplicaron las recomendaciones propuestas en la 7.a Conferencia de Consenso (2007) de la SEMICYUC sobre la PA en el segundo periodo. Variables de interés principales: Edad, sexo, APACHE II, SOFA, periodo a estudio, días previos al ingreso en MI, tipo de nutrición, cirugía, profilaxis antibiótica, mortalidad hospitalaria, estancia en MI, estancia hospitalaria, clasificación basada en determinantes. Resultados: Doscientos ochenta y seis pacientes (94 preprotocolo, 192 posprotocolo), mortalidad hospitalaria de 66 casos (23,1%). La aplicación del protocolo supuso una disminución de la estancia hospitalaria previa al ingreso en MI, y de la profilaxis antibiótica, con un aumento del uso de nutrición enteral. Se evidenció un descenso de la mortalidad hospitalaria en el segundo periodo (35,1 vs. 17,18%, p=0,001), sin cambios significativos en la estancia en MI ni en la hospitalaria. En el análisis multivariante, la variable «periodo de tratamiento» mantuvo significación estadística respecto a la mortalidad hospitalaria (OR 0,34 en 2008-2016, IC 95% 0,15-0,74). Conclusiones: El establecimiento de un protocolo podría estar relacionado con un descenso de la mortalidad de los pacientes ingresados en MI por PA

Objective: To determine whether the implementation of a protocol for the management of patients with acute pancreatitis (AP) in an Intensive Care Unit (ICU) improves the clinical outcomes. Design: A retrospective, before-after observational case series study was carried out. Study period: 1 January 2001 to 31 December 2016, divided in 2 periods (pre-protocol 2001-2007, post-protocol 2008-2016). Scope: An ICU with 48 beds and a recruitment population of 700,000 inhabitants. Participants: AP patients admitted to the ICU, with no exclusion criteria. Interventions: The recommendations proposed in the 7th Consensus Conference of the SEMICYUC on AP (5 September 2007) were applied in the second period. Main variables of interest: Patient age, sex, APACHE II, SOFA, study period, pre-ICU hospital stay, nutrition, surgery, antibiotic prophylaxis, hospital mortality, ICU length of stay, hospital length of stay, determinant-based classification. Results: The study comprised 286 patients (94 in the pre-protocol period, 192 in the post-protocol period), with a global in-hospital mortality rate of 23.1% (n=66). Application of the protocol decreased the pre-ICU hospital stay and the use of antibiotic prophylaxis, and increased the use of enteral nutrition. Hospital mortality decreased in the second period (35.1 vs. 17.18%; P=.001), with no significant changes in ICU and hospital stays. In the multivariate logistic regression analysis, the variable period of treatment remained as a variable of statistical significance in terms of hospital mortality (OR 0.34 for the period 2008-2016, 95% CI 0.15-0.74). Conclusions: The implementation of a protocol could result in decreased mortality among AP patients admitted to the ICU

Results of the modification of an acute pancreatitis management protocol in Intensive Care medicine. / Resultados de la modificación de un protocolo de manejo para la pancreatitis aguda en Medicina Intensiva.

OBJECTIVE: To determine whether the implementation of a protocol for the management of patients with acute pancreatitis (AP) in an Intensive Care Unit (ICU) improves the clinical outcomes. DESIGN: A retrospective, before-after observational case series study was carried out. STUDY PERIOD: 1 January 2001 to 31 December 2016, divided in 2 periods (pre-protocol 2001-2007, post-protocol 2008-2016). SCOPE: An ICU with 48 beds and a recruitment population of 700,000 inhabitants. PARTICIPANTS: AP patients admitted to the ICU, with no exclusion criteria. INTERVENTIONS: The recommendations proposed in the 7th Consensus Conference of the SEMICYUC on AP (5 September 2007) were applied in the second period. MAIN VARIABLES OF INTEREST: Patient age, sex, APACHE II, SOFA, study period, pre-ICU hospital stay, nutrition, surgery, antibiotic prophylaxis, hospital mortality, ICU length of stay, hospital length of stay, determinant-based classification. RESULTS: The study comprised 286 patients (94 in the pre-protocol period, 192 in the post-protocol period), with a global in-hospital mortality rate of 23.1% (n=66). Application of the protocol decreased the pre-ICU hospital stay and the use of antibiotic prophylaxis, and increased the use of enteral nutrition. Hospital mortality decreased in the second period (35.1 vs. 17.18%; P=.001), with no significant changes in ICU and hospital stays. In the multivariate logistic regression analysis, the variable period of treatment remained as a variable of statistical significance in terms of hospital mortality (OR 0.34 for the period 2008-2016, 95% CI 0.15-0.74). CONCLUSIONS: The implementation of a protocol could result in decreased mortality among AP patients admitted to the ICU.

Relationship between intra-abdominal hypertension, outcome and the revised Atlanta and determinant-based classifications in acute pancreatitis.

BACKGROUND: The aim of this study was to analyse the relationship between intra-abdominal hypertension (IAH) and severity of acute pancreatitis (AP) measured by the revised Atlanta classification (RAC) and determinant-based classification (DBC). Secondary objectives were to assess IAH as a predictor of morbidity and mortality in the ICU. METHODS: This prospective international observational study included patients admitted to the ICU with AP and at least one organ failure. Information was collected on demographics, severity scores at admission using RAC and DBC, organ failure, mechanical ventilation, continuous renal replacement therapy (CRRT), surgery and mortality. Maximum intra-abdominal pressure (IAP) during ICU stay was used for analysis. RESULTS: Some 374 patients were included. The hospital mortality rate was 28·9 per cent. IAP was measured in 301 patients (80·5 per cent), of whom 274 (91·0 per cent) had IAH and 103 (34·2 per cent) acute compartment syndrome. A higher IAH grade was more likely in patients with severe AP (42 per cent for grade I versus 84 per cent for grade IV) and acute critical pancreatitis (9 versus 25 per cent; P = 0·001). Compared with grade I IAH, patients with grade IV had more infected necrosis (16 versus 28 per cent; P = 0·005), need for surgery (27 versus 50 per cent; P = 0·006), mechanical ventilation (53 versus 84 per cent; P = 0·007) and requirement for CRRT (22 versus 66 per cent; P < 0·001). IAH predicted shock (area under receiver operating characteristic (ROC) curve (AUC) 0·79, 95 per cent c.i. 0·73 to 0·84), respiratory failure (AUC 0·82, 0·77 to 0·87), renal failure (AUC 0·93, 0·89 to 0·96) and mortality (AUC 0·89, 0·86 to 0·93). CONCLUSION: IAH was associated with severity of AP classified according to both RAC and DBC systems. IAP grade can predict outcome of AP during ICU stay.

Informe del registro MAMI (base de datos de marcapasos definitivos en Medicina Intensiva) 1996-2003 / Report of MAMI (Data base on definitive pacemakers in Intensive Medicine) registry 1996-2003

Objetivo. Comunicar los resultados de la Base de datos de Marcapasos en Medicina Intensiva (MAMI), y compararlos con la bibliografía nacional e internacional. Diseño. Estudio observacional, prospectivo, multicéntrico, en el que participan 43 Servicios de Medicina Intensiva. Período: 01/04/1996 a 11/11/2003. Variables: demográficas, sintomatología, etiología y electrocardiograma (ECG) que motivan la implantación, tipo de intervención, mediciones durante la implantación, modelo y número de generador y electrodo y complicaciones precoces. Resultados. Quince mil novecientos noventa y cuatro implantes, 12.655 primoimplantes, 3.339 recambios. Edad media: 75,59 años, 57,46% hombres. Razones principales para el primoimplante: síncopes (39,76%), mareos (28,16%); para el recambio: agotamiento del generador (59,75%). ECG de los primoimplantes: BAV (49,91%), ACxFA + (21,60%). Modo de estimulación en el primoimplante: VVI(R) (49,99%), DDD(R) (25,07%), VDD(R) (23,48%), AAI(R) (1,43%). Modo de estimulación en el recambio: VVI(R) (71,45%). Modo de estimulación según ECG: ACxFA+: VVI(R) (97%); ENS: DDD(R) (56,24%) y VVI(R) (35,91%); BAV: VDD(R) (43,19%) y VVI(R) (36,87%); BR: VVI(R) (38,72%) y DDD(R) (36,11%). La utilización de dispositivos con detector capaz de autovariar su frecuencia es del 48,51%. La tasa de complicaciones precoces es del 6,86% en el primoimplante, con una mortalidad del 0,071%; y en el recambio del 2,84%, con una mortalidad del 0,089%. Desde 1996 hasta 2003, se observa una reducción del modo VVI (47,14% al 27,08%), con un aumento de los modos VDD(R) (del 18,84% al 28,73%) y DDD(R) (del 22,82% al 27,17%). El uso del modo AAI(R) no se ha modificado. Conclusiones. El registro MAMI es una herramienta válida para conocer las características de los implantes de marcapasos en Medicina Intensiva. Se ha producido un aumento de los modos de estimulación VDD y DDD, con una reducción del modo VVI

Objective. Report the results of the pacemaker data base in Intensive Medicine (MAMI) and compare them with the national and international bibliography.Design. Observational, prospective, multicenter study in which 43 Intensive Medicine Services participate. Period: 01/04/1996 to 11/11/2003. Variables: demographic, symptoms, etiology and electrocardiogram (ECG) that motivate implantation, type of intervention, measurements during implantation, model and number of generator and electrode and early complications. Results. 15,994 implants, 12,655 first implants, 3,339 replacements. Mean age: 75.59 years, 57.46% men. Main reasons for first implant: syncopes (39.76%), dizziness (28.16%); for replacement: wearing out of the generator (59.75%). ECG of the first implants: Auricular ventricular block (VAB) (49.91%), Complete arrhythmia caused by auricular fibrillation (CAxAF) + (21.60%). Pacing mode in first implant: VVI(R) (49.99%), DDD(R) (25.07%), VDD(R) (23.48%), AAI(R) (1.43%). Pacing mode in replacement: VVI(R) (71.45%). Pacing mode according to ECG: CAxAF+: VVI(R) (97%); Sinus node dysfunction (SND(R)) (56.24%) and VVI(R) (35.91%); VAB: VDD(R) (43.19%) and VVI(R) (36.87%); Bundle branch block (BBB): VVI(R) (38.72%) and DDD(R) (36.11%). The use of the devices with detector capable of varying their frequency automatically is 48.51%. The early complications rate is 6.86% in the first implant, with a 0.071% mortality and 2.84% replacement, with an 0.089% mortality. From 1996 to 2003, a reduction in the VVI mode (47.14% to 27.08%), with an increase in the VDD(R) modes (from 18.84% to 28.73%) and DDD(R) (from 22.82% to 27.17%). Use of the AAI(R) mode has not changed. Conclusions. The MAMI registry is a valid tool to know the characteristics of the pacemaker implants in Intensive Medicine. An increase has occurred in the stimulation modes VDD and DDD, with a reduction in the VVI mode