Síndrome de disfunción orgánica múltiple progresiva en embarazo adolescente: reporte de caso clínico / Progressive multiple organ dysfunction syndrome in adolescent pregnancy: case report

INTRODUCCIÓN: El embarazo adolescente es un proceso fisiológico, pero puede evolucionar con parto prematuro, patologías obstétricas o médicas graves, mortalidad o secuelas para madre e hijo/a. Nuestro objetivo es reportar el síndrome de disfunción orgánica múltiple progresiva secundario a pielonefritis y sepsis ocurrido durante el preparto, parto y puerperio de embarazo adolescente y sus secuelas. CASO CLÍNIO: Adolescente de 14 años, con embarazo de 27 semanas de gestación controlado desde las 8 hasta 25 semanas. Ingresó de urgencia en unidad de alto riesgo obstétrico por signos de parto prematuro, pielonefritis e injuria renal aguda. Se inició tratamiento con cefazolina intravenosa y betametasona para maduración pulmonar, nifedipino oral y sulfato de magnesio para prevención del parto prematuro y protección neuronal fetal, evolucionando con hipotensión sostenida y shock séptico. A las 13 horas después del ingreso, fue trasladada a unidad de paciente crítico donde evolucionó con falla orgánica múltiple persistente y progresiva durante 28 días, afectando sucesivamente los sistemas cardiovascular, hematológico, respiratorio y gastrointestinal. Se trató con drogas vasoactivas, antibióticos, ventilación mecánica invasiva, ultrafiltración, hemodiálisis, drenaje pleural y colecistectomía. A las 24 horas de ingreso a cuidado intensivo, ocurrió el parto prematuro vaginal. La embarazada desarrolló enfermedad renal crónica etapa KDIGO 5 ( V) y se encuentra en espera de trasplante renal. Por su parte, la recién nacida prematura viva presentó asfixia neonatal severa, displasia broncopulmonar y encefalopatía hipóxico-isquémica. CONCLUSIONES: El embarazo adolescente complicado es una emergencia sanitaria. El diagnóstico y manejo oportuno de la pielonefritis, shock séptico y disfunción orgánica asociada a la sepsis pueden evitar mortalidad y secuelas permanentes materna y/o neonatal.

INTRODUCTION: Adolescent pregnancy is a physiological process, but it can evolve with premature delivery, severe obstetric or clinical pathologies, mortality, or sequelae for mother and child. We aim to report the progressive multiple organ dysfunction syndrome secondary to pyelonephritis and sepsis during prepartum, delivery, and puerperium of adolescent pregnancy and its sequelae. CASE REPORT: A 14-year-old adolescent with a pregnancy of 27 weeks of gestation controlled from 8 to 25 weeks. She was urgently admitted to the high-risk obstetric unit due to signs of preterm labor, pyelonephritis, and acute renal injury. Treatment was started with intravenous cefazolin and betamethasone for lung maturation, oral nifedipine, and magnesium sulfate to prevent preterm labor and fetal neuronal protection, evolving with sustained hypotension and septic shock. At 13 hours after admission, she was transferred to the intensive care unit, where she evolved with persistent and progressive multiple organ failure for 28 days, progressively affecting the cardiovascular, hematologic, respiratory, and gastrointestinal systems. She was treated with vasoactive drugs, antibiotics, invasive mechanical ventilation, ultrafiltration, hemodialysis, pleural drainage, and cholecystectomy. Twenty-four hours after admission to intensive care, preterm vaginal delivery occurred. She developed chronic kidney disease stage KDIGO 5 (Kidney Disease Improving Global Outcomes V) and is awaiting renal transplantation. On the other hand, the preterm newborn presented severe neonatal asphyxia, bronchopulmonary dysplasia, and hypoxic-ischemic encephalopathy. CONCLUSION: Complicated adolescent pregnancy is a health emergency. Avoiding delays in the diagnosis and treatment of pyelonephritis, septic shock and the progressive multiple organ dysfunction syndrome can prevent mortality and permanent sequelae, both maternal and neonatal.

Mortalidad de la sepsis en la unidad de cuidados intensivos / Mortality from sepsis in intensive care unit

INTRODUCCIÓN. La sepsis es un estado de disfunción multisistémica, que se produce por una respuesta desregulada del huésped a la infección. Diversos factores influyen en la gravedad, manifestaciones clínicas y progresión de la sepsis, tales como, heterogeneidad inmunológica y regulación dinámica de las vías de señalización celular. La evolución de los pacientes depende del tratamiento oportuno, las escalas de puntuación clínica permiten saber la mortalidad estimada. OBJETIVO. Evaluar la mortalidad en la unidad de cuidados intensivos; establecer el manejo y la utilidad de aplicar paquetes de medidas o "bundlers" para evitar la progresión a disfunción, fallo multiorgánico y muerte. METODOLOGÍA. Modalidad de investigación tipo revisión sistemática. Se realizó una búsqueda bibliográfica en bases de datos como Google académico, Mendeley, ScienceDirect, Pubmed, revistas como New England Journal Medicine, Critical Care, Journal of the American Medical Association, British Medical Journal. Se obtuvo las guías "Sobreviviendo a la sepsis" actualización 2021, 3 guías internacionales, 10 estudios observacionales, 2 estudios multicéntricos, 5 ensayos aleatorizados, 6 revisiones sistémicas, 5 metaanálisis, 1 reporte de caso clínico, 4 artículos con opiniones de expertos y actualizaciones con el tema mortalidad de la sepsis en UCI con un total de 36 artículos científicos. RESULTADOS. La mortalidad de la sepsis en la unidad de cuidados intensivos, fue menor en el hospital oncológico de Guayaquil, seguido de Australia, Alemania, Quito, Francia, Estados Unidos de Norteamérica y Vietnan, La mortalidad más alta se observa en pacientes con enfermedades del tejido conectivo. DISCUSIÓN. La aplicación de los paquetes de medidas o "bundlers" en la sepsis, se asocia con una mejor supervivencia y menores días de estancia hospitalaria. CONCLUSIÓN. Las escalas SOFA, APACHE II y SAPS II ayudan a predecir la mortalidad de forma eficiente, en la detección y el tratamiento temprano en pacientes con enfermedades agudas y de alto riesgo.

INTRODUCTION. Sepsis is a state of multisystem dysfunction, which is caused by a dysregulated host response to infection. Several factors influence the severity, clinical manifestations and progression of sepsis, such as immunological heterogeneity and dynamic regulation of cell signaling pathways. The evolution of patients depends on timely treatment, clinical scoring scales allow to know the estimated mortality. OBJECTIVE. To evaluate mortality in the intensive care unit; to establish the management and usefulness of applying bundlers to prevent progression to dysfunction, multiorgan failure and death. METHODOLOGY. Systematic review type research modality. A bibliographic search was carried out in databases such as Google Scholar, Mendeley, ScienceDirect, Pubmed, journals such as New England Journal Medicine, Critical Care, Journal of the American Medical Association, British Medical Journal. We obtained the guidelines "Surviving Sepsis" update 2021, 3 international guidelines, 10 observational studies, 2 multicenter studies, 5 randomized trials, 6 systemic reviews, 5 meta-analyses, 1 clinical case report, 4 articles with expert opinions and updates on the subject of sepsis mortality in ICU with a total of 36 scientific articles. RESULTS. The mortality of sepsis in the intensive care unit, was lower in the oncological hospital of Guayaquil, followed by Australia, Germany, Quito, France, United States of America and Vietnam, The highest mortality is observed in patients with connective tissue diseases. DISCUSSION. The application of bundlers in sepsis is associated with better survival and shorter days of hospital stay. CONCLUSIONS. The SOFA, APACHE II and SAPS II scales help to predict mortality efficiently in the early detection and treatment of patients with acute and high-risk disease.

Factores clínicos pronósticos de enfermedad grave y mortalidad en pacientes con COVID-19. Síntesis rápida / Clinical factors for the prognosis of severe illness and death in patients with COVID-19

Los hallazgos de esta síntesis rápida están organizados de tal manera que responden las 4 preguntas planteadas. Cada subsección presenta los hallazgos relevantes de las revisiones sistemáticas, y los resultados del metaanálisis realizado con 20 estudios observacionales específicos para COVID-19 no incluidos en las revisiones sistemáticas. Los factores clínicos y paraclínicos considerados en el metaanálisis de efectos aleatorios fueron la edad, comorbilidades como la hipertensión arterial, diabetes mellitus, enfermedad cardiovascular, malignidad, y enfermedad renal crónica; y los paraclínicos dímero D, proteína C reactiva (PCR), interleuquina 6 (IL-6), procalcitonina, deshidrogenasa láctica (LDH), y recuento linfocitario.

Incidence and risk factors for major infections in hospitalized children with nephrotic syndrome / Incidência e fatores de risco para infecções graves em crianças hospitalizadas com síndrome nefróticas

ABSTRACT Introduction: Children with nephrotic syndrome are at increased risk of infections because of disease status itself and use of various immunosuppressive agents. In majority, infections trigger relapses requiring hospitalization with increased risk of morbidity and mortality. This study aimed to determine the incidence, spectrum, and risk factors for major infections in hospitalized children with nephrotic syndrome. Methods: All consecutive hospitalized children between 1-12 years of age with nephrotic syndrome were enrolled in the study. Children with acute nephritis, secondary nephrotic syndrome as well as those admitted for diagnostic renal biopsy and intravenous cyclophosphamide or rituximab infusion were excluded. Results: A total of 148 children with 162 admissions were enrolled. Incidence of major infections in hospitalized children with nephrotic syndrome was 43.8%. Peritonitis was the commonest infection (24%), followed by pneumonia (18%), urinary tract infection (15%), and cellulitis (14%), contributing with two thirds of major infections. Streptococcus pneumoniae (n = 9) was the predominant organism isolated in children with peritonitis and pneumonia. On logistic regression analysis, serum albumin < 1.5gm/dL was the only independent risk factor for all infections (OR 2.6; 95% CI, 1.2-6; p = 0.01), especially for peritonitis (OR 29; 95% CI, 3-270; p = 0.003). There were four deaths (2.5%) in our study, all due to sepsis and multiorgan failure. Conclusions: Infection remains an important cause of morbidity and mortality in children with nephrotic syndrome. As Pneumococcus was the most prevalent cause of infection in those children, attention should be paid to the pneumococcal immunization in children with nephrotic syndrome.

RESUMO Introdução: Crianças com síndrome nefrótica apresentam maior risco de infecções devido ao próprio status da doença e ao uso de vários agentes imunossupressores. Em grande parte, as infecções desencadeiam recidivas que exigem hospitalização, com risco aumentado de morbidade e mortalidade. Este estudo teve como objetivo determinar a incidência, o espectro e os fatores de risco para infecções graves em crianças hospitalizadas com síndrome nefrótica. Métodos: Todas as crianças hospitalizadas consecutivamente entre 1 e 12 anos de idade com síndrome nefrótica foram incluídas no estudo. Crianças com nefrite aguda, síndrome nefrótica secundária, bem como aquelas admitidas para biópsia renal diagnóstica e infusão intravenosa de ciclofosfamida ou rituximabe foram excluídas. Resultados: Foram cadastradas 148 crianças com 162 internações. A incidência de infecções graves em crianças hospitalizadas com síndrome nefrótica foi de 43,8%. A peritonite foi a infecção mais comum (24%), seguida por pneumonia (18%), infecção do trato urinário (15%) e celulite (14%), contribuindo com dois terços das principais infecções. Streptococcus pneumoniae (n = 9) foi o organismo predominantemente isolado em crianças com peritonite e pneumonia. Na análise de regressão logística, a albumina sérica < 1,5gm / dL foi o único fator de risco independente para todas as infecções (OR 2,6; 95% CI, 1,2-6; p = 0,01), especialmente para peritonite (OR 29; IC95% 3 -270, p = 0,003). Houve quatro mortes (2,5%) em nosso estudo, todas devido a sepse e falência de múltiplos órgãos. Conclusões: A infecção continua sendo uma importante causa de morbimortalidade em crianças com síndrome nefrótica. Como o Pneumococo foi a causa mais prevalente de infecção nessas crianças, deve-se atentar para a imunização pneumocócica em crianças com síndrome nefrótica.

CONHECIMENTO DO ENFERMEIRO SOBRE O CHOQUE SÉPTICO / NURSES' KNOWLEDGE ON SEPTIC SHOCK / CONOCIMIENTO DELENFERMERO SOBREELSHOCK SÉPTICO

O choque séptico é uma condição clínica decorrente do agravamento da resposta orgânica à sepse, associado à alta mortalidade. A equipe de enfermagem tem sido alvo de estudos sobre identificação precoce dos sinais e sintomas de sepse e choque séptico a fim de modificar estes índices. Objetivou-se identificar o conhecimento dos enfermeiros que atuam em um hospital, acercado choque séptico. Método: estudo descritivo, transversal com tratamento quantitativo dos dados, realizado em um hospital público de grande porte localizado no sul do estado de São Paulo. Um instrumento contendo as variáveis relativas ao choque séptico foi aplicado para o atendimento do objetivo. Quarenta e um enfermeiros responderam ao instrumento, entre os quais mais de 80% conheciam os sinais e sintomas: infecção documentada, febre, elevação da frequência cardíaca. Entre as respostas negativas: 31,7% não sabiam sobre a suspeita de infecção; 26,8% sobre a hiperglicemia; e 34,1% sobre a elevação da saturação de oxigênio no sangue venoso misto. Observaram-se fragilidades no conhecimento dos enfermeiros sobre algumas variáveis relativas ao choque séptico. É necessário encorajar o desenvolvimento de programas de educação destinados à atualização do profissional, visando à melhoria da qualidade da assistência e, consequentemente, nas condições de saúde do paciente.[AU]

Septic shock is a clinical condition caused by the worsening of the organic response to sepsis associated with high mortality. Nursing teams have been the target of studies on early identification of signs and symptoms of sepsis and septic shock in order to modify these indices. To identify the knowledge of nurses working in a hospital about septic shock. Descriptive method, cross-sectional study with quantitative treatment of data, performed in a large public hospital located in the south of the state of São Paulo. An instrument containing variables related to septic shock was applied to meet the objective. Forty-one nurses answered the instrument. More than 80% knew the signs and symptoms: documented infection, fever, increased heart rate. Among the negative responses: 31.7% did not have knowledge of suspected infection; 26.8% of hyperglycemia; and 34.1% of increased oxygen saturation in mixed venous blood. There were flaws in the knowledge of nurses about some variables related to septic shock. It is necessary to encourage the development of education programs aimed at updating the knowledge of professionals, and improving the quality of care and, consequently, the patient's health conditions.[AU]

El shock séptico es una condición clínica resultante del agravio de la respuesta orgánica a la sepsis, asociado a la alta mortalidad. El equipo de enfermería ha sido objeto de estudios sobre identificación precoz de las señales y síntomas de sepsis y shock séptico a fin de modificar estos índices. El Objetivo fue identificar el conocimiento de los enfermeros que actúan en un hospital, acerca del shock séptico. Estudio descriptivo, transversal con tratamiento cuantitativo de los datos, realizado en un hospital público de gran tamaño ubicado en el sur del estado de São Paulo-Brasil. Un instrumento conteniendo las variables relativas al shock séptico fue aplicado para el cumplimiento del objetivo. Cuarenta y uno enfermeros respondieron al instrumento, entre los que más de 80% conocían las señales y los síntomas: infección documentada, fiebre, elevación de la frecuencia cardíaca. Entre las respuestas negativas: 31,7% no sabían sobre la sospecha de infección; 26,8% sobre la hiperglucemia; y 34,1% sobre la elevación de la saturación venosa mixta de oxígeno en la sangre. Se observaron fragilidades en el conocimiento de los enfermeros sobre algunas variables relativas al shock séptico. Es necesario fomentar el desarrollo de programas de educación dirigidos a la actualización del profesional, con vistas a la mejoría de la calidad de la asistencia y, consecuentemente, en las condiciones de salud del paciente.[AU]

Safety and efficacy of regional citrate anticoagulation in continuous blood purification treatment of patients with multiple organ dysfunction syndrome

The aim of this study was to discuss the safety and efficacy of regional citrate anticoagulation (RCA) on continuous blood purification (CBP) during the treatment of multiple organ dysfunction syndrome (MODS). Thirty-five patients with MODS were divided into two groups: the local citrate anticoagulation (RCA) group, and the heparin-free blood purification (hfBP) group. The MODS severity was assessed according to Marshall's MODS score criteria. Blood coagulation indicators, blood pressure, filter lifespan, filter replacement frequency, anticoagulation indicators, and main metabolic and electrolyte indicators were analyzed and compared between RCA and hfBP groups. RCA resulted in lower blood pressure than hfBP. The filter efficacy in RCA treatment was longer than in the hfBP group. The blood clearance of creatine, blood urea nitrogen and uric acid was better in the RCA group. RCA also led to higher pH than hfBP. Neither treatment resulted in severe bleeding events. In addition, MODS score was positively correlated with prothrombin time and activated partial thromboplastin time but negatively correlated with platelet concentration. RCA is a safer and more effective method in CBP treatment; however, it could also lead to low blood pressure and blood alkalosis.

Factores asociados a la mortalidad en las reintervenciones quirúrgicas / Mortality-associated factors in surgical resurgeries

Introducción: las reintervenciones constituyen un serio problema de origen multifactorial que inquieta a los cirujanos y empeora el pronóstico del enfermo operado. Objetivo: identificar los niveles de mortalidad según variables seleccionadas y sus causas. Método: se realizó un estudio observacional y descriptivo de 110 pacientes admitidos en el Servicio de Cirugía General del Hospital Provincial Docente Saturnino Lora de Santiago de Cuba durante el trienio 2013-2015 y que fueron reintervenidos durante los primeros 30 días posteriores a la operación inicial, de los cuales fallecieron 19 (17,2 por ciento). Resultados: el mayor porcentaje de decesos correspondió a los mayores de 60 años, en los operados inicialmente con diagnósticos de oclusión intestinal, apendicitis aguda y neoplasia de colon, que habían sido reintervenidos en tres y cuatro ocasiones. Las causas de muerte más frecuentes fueron el choque séptico y el fallo múltiple de órganos. Conclusiones: entre los principales factores asociados a la mortalidad en las reintervenciones figuran: la edad mayor de 60 años, el diagnóstico operatorio inicial de oclusión intestinal, el mayor número de reoperaciones, el choque séptico y el fallo múltiple de órganos(AU)

Introduction: resurgery is a serious problem of multifactorial origin that worries surgeons and worsens the prognosis of the surgical patients. Objective: to determine the levels of mortality according to the selected variables and their causes. Method: observational and descriptive study conducted in 110 patients admitted to the general surgery services of Saturnino Lora provincial teaching hospital in Santiago de Cuba during the 2013-2015 period. They had been reoperated on within the first 30 days after the initial surgery and 19 died (17.2 percent). Results: highest percentage of deaths occurred in over 60 years-old persons among those initially operated on for intestinal occlusion, acute appendicitis and colon neoplasia, who had been reoperated on three and four times. The most frequent causes of death were septic shock and multi-organ failure. Conclusions: among the main mortality-associated factors in resurgeries are over 60 years-old age, initial surgical diagnosis of intestinal occlusion, higher number of resurgeries, septic shock and multi-organ failure(AU)

Septic Pulmonary Embolism Requiring Critical Care: Clinicoradiological Spectrum, Causative Pathogens and Outcomes

OBJECTIVES: Septic pulmonary embolism is an uncommon but life-threatening disorder. However, data on patients with septic pulmonary embolism who require critical care have not been well reported. This study elucidated the clinicoradiological spectrum, causative pathogens and outcomes of septic pulmonary embolism in patients requiring critical care. METHODS: The electronic medical records of 20 patients with septic pulmonary embolism who required intensive care unit admission between January 2005 and December 2013 were reviewed. RESULTS: Multiple organ dysfunction syndrome developed in 85% of the patients, and acute respiratory failure was the most common organ failure (75%). The most common computed tomographic findings included a feeding vessel sign (90%), peripheral nodules without cavities (80%) or with cavities (65%), and peripheral wedge-shaped opacities (75%). The most common primary source of infection was liver abscess (40%), followed by pneumonia (25%). The two most frequent causative pathogens were Klebsiella pneumoniae (50%) and Staphylococcus aureus (35%). Compared with survivors, nonsurvivors had significantly higher serum creatinine, arterial partial pressure of carbon dioxide, and Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and they were significantly more likely to have acute kidney injury, disseminated intravascular coagulation and lung abscesses. The in-hospital mortality rate was 30%. Pneumonia was the most common cause of death, followed by liver abscess. CONCLUSIONS: Patients with septic pulmonary embolism who require critical care, especially those with pneumonia and liver abscess, are associated with high mortality. Early diagnosis, appropriate antibiotic therapy, surgical intervention and respiratory support are essential.

Falência hepática aguda em crianças e adolescentes / Acute liver failure in children and adolescents

A halência hepática aguda (FHA) é uma condição rara, mas devastadora, que evolui para falência de múltiplos órgãos e óbito como seu curso natural. A assistência intensiva e o transplante hepático possibilitaram a modificação da história natural e aumento da sobrevida. A FHA, geralmente, se apresenta em uma criança ou adolescente previamente hígido que inicia com sintomas inespecíficos de duração variada e com a evolução do quadro surgem outros sintomas como icterícia, vômitos, hipoglicemia e convulsões, tornando a síndrome clínica evidente. O diagnóstico etiológico é importante, uma vez que algumas doenças de base possuem tratamentos específicos. Contudo, em até 50% dos casos, um diagnóstico específico não é estabelecido. Sua presença será estabelecida se há evidência bioquímica de falência hepática aguda, na ausência de doença hepática crônica e associada à coagulopatia de origem hepática não corrigível pela vitamina K (RNI > 1,5 em paciente com encefalopatia hepática ou RNI ? 2 na ausência de encefalopatia hepática). O tempo entre o início do quadro clínico e o desenvolvimento da encefalopatia deve ser inferior a oito semanas. O reconhecimento e o encaminhamento para centro especializado devem ser o mais precoce possível. A indicação de transplante hepático deve ser avaliada periodicamente. O tratamento intensivo e multidisciplinar é essencial para sobrevida.

The Acute Liver Failure (ALF) is a rare but devastating condition that can lead to multiple organ failure and death as its natural course. Intensive therapy and liver transplantation have changed its natural history and raised survival rates. ALF usually presents in a previously healthy child who initiates with unspecific symptoms of variable duration and then evolve with jaundice, vomiting, hypoglycemia and seizures, when the clinical syndrome becomes evident. The etiologic diagnosis is importantbecause some diseases have specific treatments. However in 50% of the cases a specific diagnosis is not estabilished. The criteria for diagnosing ALF is biochemical evidence of acute hepatic failure without signs of chronic liver disease associated with coagulopathy non responsive to vitamin K (INR>1,5 with encephalopathy or INR>2 regardless the presence of encephalopathy signs). The time between the initial symptoms and the development of encephalopathy must be less than 8 weeks. Recognizing and referring the patient for a reference center must be a priority. The need for liver transplantation should be periodically assessed. Intensive multidisciplinary care is essential for survival.

Efecto del tratamiento antibiótico inicial adecuado sobre la mortalidad en pacientes en estado crítico con bacteriemia por Pseudomonas aeruginosa / Effect of adequate initial antimicrobi al therapy on mortality in critical patients with Pseudomonas aeruginosa bacteremia

Introducción. La bacteriemia es una de las infecciones hospitalarias de mayor mortalidad, especialmente en las unidades de cuidados intensivos, donde es más frecuente. Pseudomonas aeruginosa es uno de los causantes de bacteriemia más agresivos. Objetivo. Evaluar la asociación entre el tratamiento antibiótico inicial y la mortalidad hospitalaria en estos pacientes. Materiales y métodos. Se trata de un estudio de cohorte retrospectivo multicéntrico realizado entre 2005 y 2008. Se consideró tratamiento adecuado aquel iniciado en las primeras 48 horas del diagnóstico que incluyera, al menos, una dosis de antibiótico intravenoso al que P. aeruginosa fuera sensible y hubiera sido suministrado en la dosis y frecuencia recomendadas. El desenlace principal fue la mortalidad hospitalaria en un lapso de 30 días. Se hizo pareo según grado de exposición usando índices de propensión y, posteriormente, análisis paramétrico de supervivencia. Resultados. Se incluyeron 164 pacientes. La mediana de edad y la clasificación del APACHE II ( Acute Physiology and Chronic Health Evaluation II ) fue de 56 y 13, respectivamente. Se identificó la fuente de la bacteriemia en 68,3 % de los casos, y la más frecuente fue el tracto respiratorio; 44 % de los pacientes recibió tratamiento inadecuado, y la resistencia bacteriana fue la principal variable asociada. La proporción de incidencia de sepsis grave, choque séptico, falla orgánica múltiple y muerte en el lapso de 30 días fue de 67,7, 50, 41,5 y 43,9 %, respectivamente. El tratamiento adecuado se asoció a una prolongación del tiempo hasta el evento (razón de tiempo ajustada, 2,95, IC 95%, 1,63 a 5,33). Conclusión. El tratamiento antibiótico inicial adecuado es un factor protector contra la mortalidad hospitalaria en pacientes con bacteriemia por P. aeruginosa .

Introduction: Among hospital-acquired infections, bacteremia is one of the leading causes of mortality worldwide, especially among intensive care unit patients, where it is more frequent. Pseudomonas aeruginosa is one of the most aggressive agents causing bacteremia. Objective: To evaluate the association between initial antimicrobial therapy and hospital mortality in these patients. Materials and methods: A multicenter and retrospective cohort study was conducted between 2005 and 2008. Antimicrobial therapy was considered adequate if it included at least one intravenous antibiotic to which the P. aeruginosa isolate was susceptible in vitro, was administered at the recommended dose and frequency for bacteremia, and initiated within the first 48 hours from diagnosis. The main outcome was 30-day hospital mortality. Patients were paired according to exposure level using propensity score matching, and then a parametric survival model was fitted. Results: One hundred and sixty four patients were included. Median age and the APACHE II score were 56 and 13, respectively. The source of bacteremia was identified in 68.3 % of cases, the respiratory tract being the most frequent. Forty-four percent of patients received inadequate therapy, with bacterial resistance as the main associated variable. The incidence of severe sepsis, septic shock, multiple organ failure and death within the first 30 days was 67.7, 50, 41.5 and 43.9%, respectively. Adequate therapy was associated with a longer time to the event (adjusted time ratio, 2.95, 95% CI, 1.63 to 5.33). Conclusion: Adequate initial antimicrobial therapy is a protective factor against hospital mortality in patients with P. aeruginosa bacteremia.

Red blood cell transfusions worsen the outcomes even in critically ill patients undergoing a restrictive transfusion strategy / Transfusões de concentrados de hemácias pioram os resultados mesmo em pacientes graves, submetidos a estratégia restritiva de transfusão

CONTEXT AND OBJECTIVE: Anemia and blood transfusions are common in intensive care. This study aimed to evaluate epidemiology and outcomes among critically ill patients under a restrictive transfusion strategy. DESIGN AND SETTING: Prospective observational cohort study in an intensive care unit (ICU) at a tertiary hospital. METHODS: All adults admitted to the ICU over a one-year period who remained there for more than 72 hours were included, except those with acute coronary syndrome, ischemic stroke, acute hemorrhage, prior transfusion, pregnant women and Jehovah's Witnesses. The restrictive strategy consisted of transfusion indicated when hemoglobin levels were less than or equal to 7.0 g/dl. RESULTS: The study enrolled 167 patients; the acute physiology and chronic health evaluation II (APACHE II) score was 28.9 ± 6.5. The baseline hemoglobin level was 10.6 ± 2.2 g/dl and on day 28, it was 8.2 ± 1.3 g/dl (P < 0.001). Transfusions were administered to 35% of the patients. In the transfusion group, 61.1% did not survive, versus 48.6% in the non-transfusion group (P = 0.03). Transfusion was an independent risk factor for mortality (P = 0.011; odds ratio, OR = 2.67; 95% confidence interval, CI = 1.25 to 5.69). ICU stay and hospital stay were longer in the transfusion group: 20.0 (3.0-83.0) versus 8.0 (3.0-63.0) days (P < 0,001); and 24.0 (3.0-140.0) versus 14.0 (3.0-80.0) days (P = 0.002), respectively. CONCLUSIONS: In critically ill patients, there was a reduction in hemoglobin with increasing length of ICU stay. Moreover, transfusion was associated with worse prognoses.

CONTEXTO E OBJETIVO: Anemia e transfusões sanguíneas são comuns em terapia intensiva. O objetivo deste estudo foi investigar a epidemiologia e resultados em pacientes críticos sob o regime de transfusão restritiva. TIPO DE ESTUDO E LOCAL: Estudo de coorte, prospectivo e observacional em unidade de terapia intensiva de um hospital terciário. MÉTODOS: Foram incluídos todos adultos admitidos na unidade durante um ano e que permaneceram internados por mais de 72 horas, exceto pacientes com lesão coronariana aguda, isquemia cerebral aguda, hemorragia aguda, transfusão anterior, mulheres grávidas e testemunhas de Jeová. A estratégia restritiva consiste na transfusão indicada com a hemoglobina inferior ou igual a 7.0 g/dl. RESULTADOS: Totalizando 167 pacientes incluídos, APACHE II (Acute Physiology and Chronic Health disease II) foi de 28,9 ± 6,5. O valor da hemoglobina basal foi de 10,6 ± 2.2 g/dl e no 28º dia foi de 8,2 ± 1.3 g/dl (P < 0,001). 35% dos pacientes receberam transfusões. No grupo de transfusão 61,1% não sobreviveram versus 48,6% do grupo não transfusão (P = 0,03). A transfusão foi fator de risco independente de mortalidade (P = 0,011; odds ratio, OR = 2,67; intervalo de confiança, IC 95% = 1,25-5,69). A internação na unidade de terapia intensiva e hospitalar foi maior no grupo de transfusão: 20,0 (3,0-83,0) versus 8,0 (3,0-63,0) dias (P < 0,001); e 24,0 (3,0-140,0) versus 14,0 (3,0-80,0) dias (P = 0,002). CONCLUSÕES: Em pacientes graves, observou-se redução da hemoglobina com a progressão da permanência na UTI. Além disso, a transfusão foi associada com piores prognósticos.

Efecto de la oración de intercesión sobre la evolución de pacientes críticamente enfermos / The effect of intercessory prayer on critically-ill patient outcome

Objetivo. Evaluar el efecto de la oración intercesora remota sobre la evolución clínica y la mortalidad de los pacientes críticamente enfermos. Materiales y métodos. Se condujo un experimento controlado de asignación aleatoria, doblemente enmascarado. Un grupo de pacientes admitidos a la unidad de cuidados intensivos de la Clínica de los Andes de Tunja (n=100), fue asignado aleatoriamente y pareado por gravedad a uno de dos grupos. El primer grupo (n=50) recibió intervención con oración intercesora remota adicional al manejo convencional según las guías de la unidad de cuidados intensivos. El segundo grupo no recibió la intervención de la oración. Se analizaron las variables basales demográficas y de creencia en la oración, y las de resultado clínico como índice de disfunción orgánica múltiple, días de estancia y mortalidad. Resultados. No hubo diferencias estadísticamente significativas en las variables basales entre los dos grupos. En el grupo de oración, en comparación con el de control, la estancia fue significativamente mayor (p<0,02), el número de muertes fue menor (9 Vs. 15, p<0,05), y la mortalidad estandarizada fue menor (0,67 % Vs. 0,89 %, p<0,05). Por último, el índice de disfunción orgánica múltiple fue significativamente menor en el grupo de oración (3,24 Vs. 5,6, p=0,1). Conclusiones. La oración intercesora remota demostró capacidad para disminuir la mortalidad y los índices de disfunción orgánica múltiple, a expensas de un aumento de los días de estancia.

Objective: To evaluate the effect of remote intercessory prayer on clinical outcomes and mortality in critically-ill patients. Materials and methods: A randomized controlled double-blind trial was conducted. One hundred patients admitted to the intensive care unit (ICU) of Clínica de los Andes de Tunja was randomly allocated and pair-matched by severity of the illness. All patients received conventional ICU treatment according to clinical guidelines. The treatment group had intercessory prayers whereas control group did not. Baseline demographic and belief-related variables were analyzed as well as clinical outcome variables such as multiple organ dysfunction, length of stay and mortality. Results: No differences were found between groups regarding baseline variables. Length of stay was significantly increased in the treatment group (p<0.02), mortality rate was lower in prayer group (9 versus 15, p<0.05) as well as standardized mortality rate (0.67 versus 0.89, p<0.05). Finally, the multiple organ dysfunction score was significantly lower in the treatment group (3.24 versus 5.6, p=0.1). Conclusions: Remote intercessory prayer was shown to decrease mortality and multiple organ dysfunction scores, at the expense of the length of stay.

Outcomes and organ dysfunctions of critically ill patients with systemic lupus erythematosus and other systemic rheumatic diseases

Our objective was to compare the pattern of organ dysfunctions and outcomes of critically ill patients with systemic lupus erythematosus (SLE) with patients with other systemic rheumatic diseases (SRD). We studied 116 critically ill SRD patients, 59 SLE and 57 other-SRD patients. The SLE group was younger and included more women. Respiratory failure (61 percent) and shock (39 percent) were the most common causes of ICU admission for other-SRD and SLE groups, respectively. ICU length-of-stay was similar for the two groups. The 60-day survival adjusted for the groups’ baseline imbalances was not different (P = 0.792). Total SOFA scores were equal for the two groups at admission and during ICU stay, although respiratory function was worse in the other-SRD group at admission and renal and hematological functions were worse in the SLE group at admission. The incidence of severe respiratory dysfunction (respiratory SOFA >2) at admission was higher in the other-SRD group, whereas severe hematological dysfunction (hematological SOFA >2) during ICU stay was higher in the SLE group. SLE patients were younger and displayed a decreased incidence of respiratory failure compared to patients with other-SRDs. However, the incidences of renal and hematological failure and the presence of shock at admission were higher in the SLE group. The 60-day survival rates were similar.

Reemplazo de válvula mitral consecutivo a endocarditis micótica / Mitral valve replacement due to mycotic endocarditis

Se presenta el caso clí­nico de un niño de 15 meses de edad, el cual experimentó varias infecciones en la etapa neonatal (entre ellas por Candida albicans) y otras complicaciones; sin embargo, no pudo recibir el esquema terapéutico completo contra la candidiasis sistémica por habérsele diagnosticado un daño funcional hepático. Posteriormente, al detectársele una endocarditis micótica, se le reemplazó la válvula mitral. En su último ingreso padecía, además, broncoespasmo asociado a neumonía bacteriana, anemia carencial, deshidratación isotónica moderada, acidosis metabólica e inmunodeficiencia mixta, causantes de una insuficiencia multiorgánica que le produjo la muerte al dí­a siguiente de su admisión hospitalaria.

A case report of a child aged 15 months who underwent several infections (i.e. due to Candida albicans) and other complications during the neonatal stage is presented. However, he could not receive the complete treatment against systemic candidiasis because of an impairment of liver function. Subsequently, mitral valve was replaced when detecting mycotic endocarditis. In addition, while being hospitalized for the last time, he underwent bronchial spasm associated with bacterial pneumonia, deficiency anemia, mild isotonic dehydration, non-respiratory acidosis, and mixed immunodeficiency which caused multiple organ failure and death the day after his hospital admisión.

TNF -308G > a promoter polymorphism (rs1800629) and outcome from critical illness

BACKGROUND: The susceptibility to adverse outcome from critical illness (occurrence of sepsis, septic shock, organ dysfunction/failure, and mortality) varies dramatically due to different degrees of inflammatory response. An over expression of tumor necrosis factor alpha (TNF-α) can lead to the progression of the inflammatory condition. OBJECTIVE: We assessed the relationship of the genotype distribution of -308G >A TNF-α polymorphism with regard to the development of sepsis, septic shock, higher organ dysfunction or mortality in critically ill patients. METHODS: Observational, hospital-based cohort study of 520 critically ill Caucasian patients from southern Brazil admitted to the general ICU of São Lucas Hospital, Porto Alegre, Brazil. Patients were monitored daily from the ICU admission day to hospital discharge or death, measuring SOFA score, sepsis, and septic shock occurrences. The -308G >A TNF-α SNP effect was analyzed in the entire patient group, in patients with sepsis (349/520), and in those who developed septic shock (248/520). RESULTS: The genotypic and allelic frequencies were -308GG = 0.72; -308GA = 0.27; -308AA = 0.01; -308G = 0.85; -308A = 0.15. No associations were found with sepsis, septic shock, organ dysfunction, and/or mortality rates among the TNF-α genotypes. Our results reveal that the -308G >A TNF-α SNP alone was not predictive of severe outcomes in critically ill patients. CONCLUSION: The principal novel input of this study was the larger sample size in an investigation with -308G > A TNF-α SNP. The presence of -308A allele is not associated with sepsis, septic shock, higher organ dysfunction or mortality in critically ill patients.

Validación de dos escalas de valor pronóstico en niños que ingresan a UCI / Validation of two prediction value scores in children admitted to the intensive care unit

Las escalas PIM (Índice de Mortalidad Pediátrica) y PELOD (Índice Pediátrico de Disfunción Orgánica) son sistemas de evaluación que permiten la estimación de la severidad de la enfermedad y el ajuste del riesgo de mortalidad en grupos heterogéneos de pacientes. El objetivo del presente trabajo fue el de validar las escalas PIM y PELOD en una Unidad de Cuidados Intensivos pediátrica (UCIP). Metodología. Fueron incluidos 97 niños con edad menor o igual a 12 años; las variables estudiadas fueron la mortalidad o sobrevida durante la estancia en UCI. PIM incluye 7 variables medidas durante la primera hora de admisión a UCI; PELOD incluye disfunción de seis sistemas orgánicos en 12 variables. Para estimar discriminación, se utilizó el área bajo la curva de rendimiento diagnóstico, y para evaluar calibración, la bondad de ajuste de Hosmer-Lemeshow. Resultados. Edad media 4,0 años (rango intercuartil 1,0-8,1); estancia 6,0 días; (rango 3,0 a 17,0); las principales causas de ingreso a UCIP fueron accidentes 30, sepsis 19, neurológicas 14. Desarrollaron disfunción orgánica múltiple 58 (59,8%) de 97. La mortalidad observada fue de 17,5%. La predicción de riesgo de mortalidad por PIM fue significativamente más alta en no sobrevivientes (0,48±0,35) que sobrevivientes (0,18±0,23; t test 3,40 p<0,003); calibración (p=0,025) y discriminación (área bajo la curva = 0,79 ± 0,057; p<0,001) de PIM fue buena. Conclusión: PIM es una medida válida de predicción de riesgo de mortalidad en UCIP en nuestro medio

The Pediatric Index of Mortality (PIM) and Pediatric Logistic Organ Dysfunction (PLOD) scale are scoring systems that allow assessment of the severity of illness and mortality risk adjustment in heterogeneous groups of patients. The aim of this study was to validate the accuracy and reliability of PIM and PELOD scoring in a pediatric Intensive Care Unit (ICU) Methods: 97 children under 12 years of age were included. Survival and mortality during the stay in the ICU were studied. PIM scale includes 7 parameters measured during the first hour of admission to the ICU; PELOD includes dysfunction of 6 organs and systems in 12 variables. The area under the curve was used to assess discrimination and calibration was assessed with the Hosmer-Lemeshow goodness of fit test. Results: The median patient age was 4,0 years (inter-quartile range 1,0-8,1), median length of stay was 6 days (range 3-17). Main causes for admission to the ICU were accidents 30, sepsis 19, neurological 14. Fifty eight patients (59,8%) developed multiple organic dysfunction. Observed mortality was 17,5%. Prediction of risk of mortality with PIM was significantly higher in non survivors (0,48 ± 0,35) than in survivors (0,18 ± 0,23); t test 3,40 p<0,003; calibration (p=0,025) and discrimination (area under the curve = 0,79±0,057; p<0,001) for PIM was good. Conclusions: PIM is a valid prediction index for mortality risk in pediatric ICU in our hospitals

Sepsis en una unidad de terapia intensiva polivalente: revisión de 2 años / Sepsis in a unit of multipurpose intensive therapy: revision of 2 years

Se analizaron retrospectivamente todas las historias clínicas de los pacientes ingresados al Servicio de Terapia Intensiva del Hospital Escuela desde enero de 2006 a diciembre de 2007, con el objetivo de evaluar incidencia, factores de riesgo, foco infeccioso, fallos orgánicos, esquemas antibióticos y mortalidad relacionados a la sepsis. Ingresaron al estudio 531 pacientes, 156 tuvieron sepsis, de los cuáles 108 pacientes ( 69,2%) tuvieron sepsis a la admisión y 48 pacientes (30,7%) desarrollaron el cuadro en UTI, con edad promedio de 45 años. Los focos infecciosos más frecuentes fueron pulmón (53,2%) abdomen (48%) y sistema nervioso central (SNC), (12,8%). En 51 pacientes (32,5%) se aislaron gérmenes Gram positivos (32,5%), siendo el Staphylococco aureus oxacilino resistente ( SAOR) y el neumococo los más frecuentes. Los Gram negativos se aislaron en 48 pacientes (29,3%), siendo los más frecuentes Pseudomona sp y Klebsiella sp. Los esquemas antibióticos empíricos más utilizados fueron vancomicina/ imipenem (27%) y ciprofloxacina/clindamicina (16%). La antibióticoterapia dirigida más usada fue vancomicina/imipenem (14,1%) y ceftriaxona/metronidazol (13,4%). Los factores de riesgo asociados fueron injuria cerebral, edad mayor a 60 años, hipertensión arterial y diabetes. Los fallos orgánicos, fueron en orden de frecuencia: pulmonar, neurológico, cardiovascular, renal, hepático y hematológico. El SOFA(secuential organ failure assessments) promedio fue 6,78, el APACHE II (acute physiology and chronic health evaluation) promedio fue 20, con una mortalidad de 51%.

Effects of early changes in organ dysfunctions on the outcomes of critically ill patients in need of renal replacement therapy

INTRODUCTION: Acute kidney injury usually develops in critically ill patients in the context of multiple organ dysfunctions. OBJECTIVE: To evaluate the effect of changes in associated organ dysfunctions over the first three days of renal replacement therapy on the outcomes of patients with acute kidney injury. METHODS: Over a 19-month period, we evaluated 260 patients admitted to the intensive care units of three tertiary-care hospitals who required renal replacement therapy for > 48 h. Organ dysfunctions were evaluated by SOFA score (excluding renal points) on the first (D1) and third (D3) days of renal replacement therapy. Absolute (A-SOFA) and relative (D-SOFA) changes in SOFA scores were also calculated. RESULTS: Hospital mortality rate was 75 percent. Organ dysfunctions worsened (A-SOFA>0) in 53 percent, remained unchanged (A-SOFA=0) in 17 percent and improved (A-SOFA<0) in 30 percent of patients; and mortality was lower in the last group (80 percent vs. 84 percent vs. 61 percent, p=0.003). SOFA on D1 (p<0.001), SOFA on D3 (p<0.001), A-SOFA (p=0.019) and D-SOFA (p=0.016) were higher in non-survivors. However, neither A-SOFA nor D-SOFA discriminated survivors from non-survivors on an individual basis. Adjusting for other covariates (including SOFA on D1), A-SOFA and D-SOFA were associated with increased mortality, and patients in whom SOFA scores worsened or remained unchanged had poorer outcomes. CONCLUSIONS: In addition to baseline values, early changes in SOFA score after the start of renal replacement therapy were associated with hospital mortality. However, no prognostic score should be used as the only parameter to predict individual outcomes.

The impact of duration of organ dysfunction on the outcome of patients with severe sepsis and septic shock

OBJECTIVES: This study aimed to assess the impact of the duration of organ dysfunction on the outcome of patients with severe sepsis or septic shock. METHODS: Clinical data were collected from hospital charts of patients with severe sepsis and septic shock admitted to a mixed intensive care unit from November 2003 to February 2004. The duration of organ dysfunction prior to diagnosis was correlated with mortality. Results were considered significant if p<0.05. RESULTS: Fifty-six patients were enrolled. Mean age was 55.6 ± 20.7 years, mean APACHE II score was 20.6 ± 6.9, and mean SOFA score was 7.9 ± 3.7. Thirty-six patients (64.3 percent) had septic shock. The mean duration of organ dysfunction was 1.9 ± 1.9 days. Within the univariate analysis, the variables correlated with hospital mortality were: age (p=0.015), APACHE II (p=0.008), onset outside the intensive care unit (p=0.05), blood glucose control (p=0.05) and duration of organ dysfunction (p=0.0004). In the multivariate analysis, only a duration of organ dysfunction persisting longer than 48 hours correlated with mortality (p=0.004, OR: 8.73 (2.37-32.14)), whereas the APACHE II score remained only a slightly significant factor (p=0.049, OR: 1.11 (1.00-1.23)). Patients who received therapeutic interventions within the first 48 hours after the onset of organ dysfunction exhibited lower mortality (32.1 percent vs. 82.1 percent, p=0.0001). CONCLUSIONS: These findings suggest that the diagnosis of organ dysfunction is not being made in a timely manner. The time elapsed between the onset of organ dysfunction and initiation of therapeutic intervention can be quite long, and this represents an important determinant of survival in cases of severe sepsis and septic shock.