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.

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.

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.

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.

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

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.

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.

Síndrome de disfunción múltiple de órganos en neonatología. Comparación de dos períodos / Multiple organ dysfunction syndrome in neonatology. A comparison of two periods

Introducción. El síndrome de disfunción múltiple de órganos es una causa importante de morbimortalidad en la terapia intensiva pediátrica y neonatal. Se estudió la evolución clínica de esta entidad en una terapia intensiva neonatal de alta complejidad y que atiende sólo a pacientes derivados, con el objetivo de analizar los cambios ocurridos en esta grave afección en dos períodos (1997 y 2002).Población, material y métodos. Se estudiaron en forma prospectiva 100 neonatos sucesivos internados en la unidad de cuidados intensivos neonatal del Hospital de Pediatría Prof. Dr. J. P. Garrahan entre el 1 de julio y el 31 de diciembre de 1997 (período I) y el 1º de diciembre de 2001 al 31 de julio del 2002(período II).Se analizó el síndrome de disfunción múltiple de órganos en relación a la frecuencia global, las causas más frecuentes, su momento de aparición, el grado de compromiso de los diferentes órganos y la evolución final.Se definió al síndrome de disfunción múltiple de órganos como la presencia de disfunción de dos órganos o sistemas o más por más de 24 horas. Los criterios de disfunción para cada órgano se definieron según un trabajo previo a los fines de la comparación entre ambos períodos.Resultados. En el período II hubo mayor frecuencia de esta entidad (n= 60) (p mayor 0,05). La mortalidad fue menor en el período II en comparación con el período I (15 por ciento y 23,3 por ciento respectivamente) (p mayor 0,05).Hubo mayor progresión al síndrome de disfunción múltiple de órganos en el período II en los pacientes con malformaciones digestivas y cardiopatías congénitas.Se comprobó un patrón evolutivo en el período II similar al período I, con alta frecuencia de casos que se agravaron o desarrollaron la disfunción de órganos luego del ingreso. Se observó mayor mortalidad cuanto mayor era el número de órganos o sistemas involucrados en ambos períodos.Conclusiones. En los períodos analizados hubo cambios importantes en la evolución del síndrome de disfunción múltiple de órganos; esta condición fue más frecuente y menor su mortalidad en elperíodo II. Se observó la persistencia elevada de presentación de la disfunción de órganos después del ingreso y mayor mortalidad cuanto mayor era el número de órganos o sistemas afectados.

Utilização do sofa escore na avaliação da incidência de disfunção orgânica em apcientes portadores de patologia cardiovascular / Use of the sofa escore to assess the incidence of organ dysfunction in patients with cardiovascular pathology

Fundamento: O sofa escore pode ser utilizado para descreer o curso da disfunção orgânica, podendo ajudar a entender a fisiopatologia de situações clinicamente relevantes.Objetivo: Avaliar o uso do SOFA (Sequential Organ Failure Assessment) escore na determinação da incidência e gravidade da disfunção orgânica(DO) em cardiopatas.Métodos: Através de um estudo de corte observacional, foram analisados 201 pacientes portadores de cardiopatia, admitidos na Unidade Cardiointensiva Clínica(UCIC) entre Julho e Dezembro de 2003. Foram considerados o Total Maximum SOFA(TMS - soma dos piores valores dos seis componentes do escore) durente a permanência na UCIC e o Maximum SOFA(max SOFA) para cada um dos órgãos envolvidos no escore, para avaliação da DO.Resultaods: foram estudados 121 pacientes(61,2 por cento) do sexo masculino com idade média de 59,9 anos, com um tempo médio de permanência de 5,4 dias e taxa de mortalidade de 11,4 por cento. A DO múltipla, os altos valores no SOFA escore para cada órgão e o número de órgãos em falência(SOFA maior igual 3), foram associados à maior mortalidade. A presença de infecção à admissão esteve associada a maiores escores de DO. O TMS foi significativamente mais alto entre os não-sbreviventes; (10,6 x 2,3 p menor 0,001) e o Max SOFA também correlacionou-se com a evolução destes pacientes, com taxas de mortalidade que variaram de 1,3 por cento naqueles sem falência orgânica a 100 por cento. nos pacientes com falência de quatro ou mais órgãos (p menor 0,001). A disfunção respiratória apresentou a maior prevalência, no entanto as disfunções neurológica e cardiovascular correlacionaram-se com as mais elevadas taxas de mortalidade.Conclusão: O SOFA escore é um método simples e efetivo para a avaliação do grau e progressão da DO em cardiopatas, auxiliando na identificação de grupos de maior risco e que, portanto, merecem maior monitorização

Factores de riesgo y evaluación del riesgo de muerte hospitalaria en la sustitución valvular mitral con prótesis mecánica / Risk factors and evaluation of hospital death risk in valvular mitral replacement with a mechanical prosthesis

Se realizó un estudio prospectivo en 1301 pacientes sometidos a sustitución valvular mitral, en el Instituto de Cardiología y Cirugía Cardiovascular entre enero de 1996 y mayo de 2001. Los objetivos fueron conocer la mortalidad operatoria y establecer las bases de un sistema de puntaje de riesgo de mortalidad. Se determinó el riesgo relativo y las probabilidades de muerte. La mortalidad hospitalaria fue de 9,0 (por ciento) (27 pacientes). La causa de muerte más frecuente fue el fallo multiorgánico (14 pacientes,51,8 (por ciento). Los factores de riesgo más importantes fueron: en el preoperatorio, la cardiomegalia severa (RR 6,1) y la urgencia de la operación (RR 5,1); en el transoperatorio, el bajo gasto cardíaco (RR 6,0) y en el posoperatorio la disfunción neurológica (RR ,33,6) y el fallo multiorgánico (RR 26,9). La mortalidad operatoria es aceptable. El sistema de puntaje de riesgo de muerte es factible y debe ser automatizado y validado(AU)

A prospective study was conducted among 1 301 patients who underwent valvular mitral replacement at the Institute of Cardiology and Cardiovascular Surgery from January, 1996, to May, 2001, aimed at knowing the operative mortality and to establish the bases of a mortality risk scoring system. The relative risk and the death probabilities were determined. The hospital mortality was 9.0 percent (27 patients). The most frequent cause of death was multiple organ failure (14 patients, 51.8 percent) The most important risk factors were: in the preoperative, severe cardiomegaly (RR 6.1) and emergency surgery (RR 5.1); in the transoperative, low cardiac output (RR 6.0); and in the postoperative, neurological dysfunction (RR 33.6) and multiple organ failure (RR 26.9). Operative mortality was acceptable. The death risk scoring system is feasible and it should be automated and validated(AU)

Multiple organ failure in septic patient

Multiple organ failure (MOF) is the main cause of death in ICUs, especially affecting septic patients.It is strongly related to number of systems with failure, type of system involved, risk factors such as age, previous chronic diseases, delayed or inadequate resuscitation, persistent infection, immune supression, and others. The prognoses is worse for patients rather than in elective or emergency surgical patients. The objective of this article is to provide data from our university teaching hospital ICU related to the incidence of septic patients, the distribution of MOF, and distribution of failure among each of the organs. The mortality rate, relationhip between mortality and age, and mortality and types of organs affected were evaluated. The main bacterial causes of septis were also identified. A retrospective evaluation was done of 249 patients admitted to the ICU in a 4 month period during 1999. Fifty four patients had sepsis diagnosed by ACCS/SCCM criteria. There were 37 men and 17 women; 24 medical and 30 post-surgical patients (9 after elective surgery and 21 emergency patients). APACHE II score was calculated on admission and MOF, measured for the first five days, was diagnosed using Marshall and Meakins criteria. The statistical method used was non-parametric Mann-Whitney test, p<0.05 was considered significant. The incidence of sepis was recorded in 52/249 patients (22 percent). Thirty of these 54 patients (56 percent) died. Death occurred in 2 of 11 patients with one organ failure (18 percent), in 14/27 with 2 or 3 organ failures (52 percent), and 14/16 with 4 or more organ failures (88 percent). None of the three patients 15 to 20 years years old died, 17/32 (55 percent) patients age 21-60 years, and >61 years 13/19 (68 percent), died. There were 23 patients with positive bacterial culture. The most frequent bacteria found were: Pseudomonas aeruginosa (5), multiresistant Acinetobacter baumanii (3), Streptococcus epidermidis (3), Enterobacter aerogenes (3), Klebsiella pneumoniae (2) and multiresistant Staphylococcus aureus (2). The mean value ñ SD of APACHE II (mortality risk) for survivors was 21 ñ 18 and non-survivors 42 ñ 26 (p<0.001). We conclude that MOF due to septis in an ICU is frequent, with high mortality related to the number of failing organs, age and high APACHE II.

Preeclampsia severa síndrome HELLP e Insuficiencia renal / Severe preeclampsia, Hellp's syndrome and renal failure

Se presenta un estudio retrospectivo realizado en la unidad de cuidados intensivos del nuevo Hospital Civil de Guadalajara con paciente que desarrolló preeclampsia severa y síndrome HELLP, 70 pacientes de las cuales 30 desarrollaron insuficiencia renal aguda, de éstas 25 fueron catalogadas como necrosis tubular aguda y cinco con necrosis cortical bilateral. Todas las pacientes (30) con insuficiencia renal aguda presentaron hipertensión arterial severa, además de depleción de volumen plasmático circulante con un promedio de PVC de 6 cm de agua (en 20 pacientes), los promedios de urea de 64.2 mg/dl y creatinina 4.2 mg/dl. Seis pacientes del grupo fallecieron, tres por hemorragia cerebral, dos choque hipovolémico y una paciente por falla multisistémica. La causa del desarrollo de insuficiencia renal aguda se debe a disminución del volumen circulante, endoteliosis glomerular y vasoconstricción severa

S.R.I.S y D.M.O.: aplicación de un nuevo score de evaluación temprana y seguimiento de disfunción multiorgánica / S.R.I.S and D.M.O.: application at a new score of early evaluation and pursuit of multiorganic dysfunction

Se siguieron prospectivamente durante el período comprendido entre marzo a diciembre de 1993, a 86 pacientes injuriados severos (PIS) que ingresaron con respuesta inflamatoria sistémica (SRIS) y disfunción de 2 o más sistemas orgánicos (DMO), con el objeto de evaluar la aplicación en la 1ra. sem. de evolución de un nuevo score, que monitorea 8 órganos (SNC, Respirat, Cardiov, Renal, Hepat, Digest, Hemat y Hemost.), con bases clínicas y de laboratorio. El score divide la respuesta de cada órgano en disfunción leve y severa, asignándole 1 y 2 puntos respectivamente a cada nivel. Los ptes. sobrevivientes (OSV) representaron el 37,2 por ciento (n=32) con una edad 44ñ14 y un Apache II 11ñ3; los no sobrevivientes (PNS) fueron el 62,8 por ciento (n=54), con una edad 56ñ16 (p< 0.007) y Apache II 19ñ6.7 pts. (p<0.0001). La patología médica representó el 36 por ciento (n=31), los postoperatorios el 50 por ciento (n=43) y el trauma múltiple 14 por ciento (n=12); (NS); la incidencia de sepsis fue del 52.3 por ciento (n=45), (NS). El análisis estadístico permitió comprobar que no existían diferencias en el score día 1 (S1) [PSV 4.44ñ1.87 - PNS 4.42ñ1.93], ni en el número de org. severos (OS1) [PSV 1.20ñ0.9 - PNS 1.32ñ0.9]. Las diferencias se comportaron como significativas a partir del 3er. día de evolución, S3-PSV 3.8ñ1.5 y S3-PNS 6.4ñ2.4/(p<0.005); 0S3-PSV 0.9ñ0.6 y OS3-PNS 2.5ñ1.2/(p<0.005), estas diferencias se mantuvieron hasta el 7mo. día. La correlación entre S y OS fue R2=0.81 [p<0.001]. La comparación predictiva demostró mayor riesgo de mortalidad ante el incremento del Apache (p<0.02) y del score a partir de S3 (p<0.005). Asimismo se detectó que el compromiso del SNC [p<0.01] y Ap. Resp. [p<0.04] en el día 1 y del Ap. Cardiovasc. [p<0.05] en el día 3, poseen un impacto importante en la mortalidad. De lo expuesto hasta aquí deducimos que el score de DMO se comportó tempranamente como predictor de la evolución de nuestros PIS, permitiendo seguir su evolución diaria, siendo pasible su evaluación en una población mayor. La estrecha correlación entre OS y Score, remarca que la falla severa impacta directamente en la evolución de la DMO. Además el SNC, Ap. Resp. y Ap. Cardiov. son los órganos que más contribuyen en la mortalidad. Esto sugerirá que el soporte intensivo en las primeras 48 hs. de evolución en PIS con SRIS y DMO, podría limitar el número y grado de fallas mejorando así su pronóstico