A meta-analysis of Lactate Ringer's solution versus Normal Saline in the treatment of acute pancreatitis.

Fluid resuscitation is an important way in the treatment of acute pancreatitis (AP). This meta-analysis aimed to compare the safety and efficacy of Lactate Ringer's solution (LR) and Normal Saline (NS) in the treatment of patients with acute pancreatitis. Searched in PubMed, Web of Science Core Collection (Clarivate), Embase, Cochrane Library, CNKI, China Wanfang, and China VIP database. All randomized controlled clinical trials (RCTs) were identified. Six studies with 431 patients were included. Compared with NS, LR can significantly reduce the incidence of SIRS at 24h, reduce the length of hospitalization, moderate-severe AP, ICU admission and local complications, especially pancreatic necrosis. It is safe and effective to choose LR for fluid resuscitation in AP, but due to the small number of included studies, multi-center and large-sample RCTs are still needed for further verification. PROSPERO registration number: CRD42022322788.

Hydration with Lactated Ringer's solution combined with rectal diclofenac in the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography. / Hidratación con Ringer Lactato combinado con diclofenaco rectal en la prevención de pancreatitis poscolangiopancreatografía retrógrada endoscópica.

OBJECTIVE: Different measures are recommended to reduce pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). We conducted a study in patients with ERCP treated with rectal diclofenac or lactated Ringer's solution, or both interventions, to assess whether there is a decrease in the number of cases of post-ERCP pancreatitis. MATERIAL AND METHODS: A mixed cohort study involving 1,896 patients from 2009 to 2018. Up to June 2012 without treatment (Group I). Subsequently, 100mg of rectal diclofenac (Group II). Since 2016, lactated Ringer's solution 200ml/hour during the procedure and 4hours after it, in addition to 500ml over 30minutes when the pancreas was cannulated (Group III). Since 2017, lactated Ringer's solution plus Diclofenac (Group IV). There were 725 patients in group I, and 530, 227 and 414 patients in groups II, III and IV, respectively. Factors predisposing to post-ERCP pancreatitis and post-ERCP pancreatitis cases that were defined by consensus criteria have been collected. RESULTS: There were 65 cases of post-ERCP pancreatitis (3.4%); 2.9%, 3.4%, 3.1% and 4.3% in groups I, II, III and IV, respectively (P=.640). In group I, there was 4.2% of post-ERCP pancreatitis in naïve papillae and 4%, 4.9% and 6.3% in groups II, III and IV, respectively (P=.585). The severity of post-ERCP pancreatitis and adverse effects were similar in all groups. 38.4% were high-risk patients. There were also no differences in post-ERCP pancreatitis in this group (P=.501). CONCLUSION: In this work, no benefit was obtained with diclofenac plus hydration in reducing the number and severity of cases of post-ERCP pancreatitis nor with the other prophylactic measures.

Predictive factors of bacterial meningitis in the patients seen in emergency departments. / Factores predictores de meningitis bacteriana en los pacientes atendidos en urgencias.

OBJETIVES: To analyse and compare predictive factors of bacterial meningitis in the patients seen in the Emergency Departments (ED) due to an episode of acute meningitis (AM). METHODS: A prospective, observational study was carried out in patients aged 15 years and older seen in ED due to AM between August 2009 and November 2015. Thirty-two variables for predicting bacterial meningitis were assessed. They covered epidemiological, comorbidity, clinical and analytical factors. Multivariate logistic regression analysis was performed. RESULTS: The study included 154 patients. The diagnosis was bacterial meningitis in 53 (34.4%) patients. Four variables were significantly associated with bacterial aetiology: cerebrospinal fluid (CSF) lactate concentration ≥33mg/dl (odds ratio [OR] 50.84; 95% confidence interval [CI]: 21.63-119.47, P<.001), serum procalcitonin (PCT) ≥0.8ng/ml (OR 46.34; 95%CI: 19.71-108.89; P<.001), CSF glucose <60% of blood value (OR 20.82; 95%CI: 8.86-48.96; P=.001), CSF polymorphonuclears greater than 50% (OR 20.19; 95%CI: 8.31-49.09; P=.002]. The area under the curve for the model serum PCT≥0.8ng/ml plus CSF lactate ≥33mg/dl was 0.992 (95%CI: 0.979-1; P<.001), and achieved 99% sensitivity and 98% specificity for predicting bacterial meningitis. CONCLUSIONS: Serum PCT with CSF lactate, CSF glucose and CSF polymorphonuclears evaluated in an initial assessment in the ED for patients with AM, achieved an excellent diagnostic usefulness for predicting bacterial meningitis.

Short-term prognostic factors in the elderly patients seen in emergency departments due to infections. / Factores pronósticos a corto plazo en los ancianos atendidos en urgencias por infección.

OBJECTIVES: To analyse factors associated with short-term mortality in elderly patients seen in emergency departments (ED) for an episode of infectious disease. MATERIALS AND METHODS: A prospective, observational, multicentre, analytical study was carried out on patients aged 75years and older who were treated in the ED of one of the eight participating hospitals. An assessment was made of 26 independent variables that could influence mortality at 30days. They covered epidemiological, comorbidity, functional, clinical and analytical factors. Multivariate logistic regression analysis was performed. RESULTS: The study included 488 consecutive patients, 92 (18.9%) of whom died within 30days of visiting the ED. Three variables were significantly associated with higher mortality: severe functional dependence, with Barthel index ≤60 [odds ratio (OR) 8,92; 95% confidence interval (CI): 4.98-15.98, P=.003], systolic blood pressure <90mmHg [OR 7.34; 95%CI: 4.39-12.26, P=.005] and serum lactate >4mmol/l [OR 21.14; 95%CI: 8.94-49.97, P=.001]. The area under the curve for the model was 0.971 (95%CI: 0.951-0.991; P<.001). CONCLUSIONS: Several factors evaluated in an initial assessment in the ED, including the level of functional dependence, systolic blood pressure and, especially, serum lactate, were found to determine a poor short-term prognosis in the elderly patients who presented with an episode of an infectious disease.

Venous-to-arterial carbon dioxide difference in the resuscitation of patients with severe sepsis and septic shock: A systematic review. / La diferencia venoarterial de dióxido de carbono en la reanimación de pacientes con sepsis grave y shock séptico: una revisión sistemática.

INTRODUCTION: The way to assess tissue perfusion during the resuscitation of patients with severe sepsis and septic shock is a current subject of research and debate. Venous oxygen saturation and lactate concentration have been the most frequently used criteria, though they involve known limitations. The venous-to-arterial difference of carbon dioxide (pCO2 delta) is a parameter than can be used to indicate tissue perfusion, and its determination therefore may be useful in these patients. METHODS: A qualitative systematic review of the literature was made, comprising studies that assessed pCO2 delta in adult patients with severe sepsis or septic shock, and published between January 1966 and November 2016 in the Medline-PubMed, Embase-Elsevier, Cochrane Library, and LILACS databases. There was no language restriction. The PRISMA statement was followed, and methodological quality was evaluated. RESULTS: Twelve articles were included, all of an observational nature, and including 10 prospective studies (9 published since 2010). Five documented greater mortality among patients with high pCO2 delta values, in 3 cases even when achieving venous oxygen saturation targets. In 4 studies, a high pCO2 delta was related to lower venous oxygen saturation and higher lactate levels, and another 3 documented lesser percentage lactate reductions. CONCLUSION: The parameter pCO2 delta has been more frequently assessed in the management of patients with severe sepsis during the last few years. The studies demonstrate its correlation to mortality and other clinical outcomes, defining pCO2 delta as a useful tool in the management of these patients.

[Half-molar sodium-lactate: The osmotic agent we are looking for?]. / Lactato de sodio 0,5 molar: ¿el agente osmótico que buscamos?

Intracranial hypertension (ICH) is the most important modifiable factor with predictive negative value in brain injury patients. Osmotherapy is the most important first level specific measure in the treatment of ICH. Mannitol 20%, and 3, 7.5, 10, and 23% hypertonic sodium chloride are the most commonly used osmotic agents in the neurocritical care setting. Currently, controversy about the best osmotic agent remains elusive. Therefore, over the past few years, half-molar sodium lactate has been introduced as a new osmotic agent to be administered in the critically ill. Lactate is able to prevent hyperchloremia, as well as its adverse effects such as hyperchloremic acidosis, systemic inflammation, and acute kidney injury. Furthermore, lactate may also be used by glia as energy substrate in brain injury patients. Half-molar sodium lactate would also have a more potent and long-lasting effect decreasing intracellular osmolarity and by inhibiting neuronal volume control mechanisms. Pioneering researches in patients with traumatic brain injury have shown a more significant effect than mannitol on the control of ICH. In addition, in this group of patients this solution appears to be beneficial in preventing episodes of ICH. However, future research is necessary to corroborate or not these promising results.

Prognostic factors associated with mortality in patients with severe trauma: from prehospital care to the Intensive Care Unit.

OBJECTIVE: To identify factors related to mortality in adult trauma patients, analyzing the clinical, epidemiological and therapeutic characteristics at the pre-hospital levels, in the Emergency Care Department and in Intensive Care. DESIGN: A retrospective, longitudinal descriptive study was carried out. Statistical analysis was performed using SPSS, MultBiplot and data mining methodology. SETTING: Adult multiple trauma patients admitted to the Salamanca Hospital Complex (Spain) from 2006 to 2011. MAIN VARIABLES OF INTEREST: Demographic variables, clinical, therapeutic and analytical data from the injury site to ICU admission. Evolution from ICU admission to hospital discharge. RESULTS: A total of 497 patients with a median age of 45.5 years were included. Males predominated (76.7%). The main causes of injury were traffic accidents (56.1%), precipitation (18.4%) and falls (11%). The factors with the strongest association to increased mortality risk (P<.05) were age > 65 years (OR 3.15), head injuries (OR 3.1), pupillary abnormalities (OR 113.88), level of consciousness according to the Glasgow Coma Scale ≤ 8 (OR 12.97), and serum lactate levels > 4 mmol/L (OR 9.7). CONCLUSIONS: The main risk factors identified in relation to the prognosis of trauma patients are referred to the presence of head injuries. Less widely known statistical techniques such as data mining or MultBiplot also underscore the importance of other factors such as lactate concentration. Trauma registries help assess the healthcare provided, with a view to adopting measures for improvement.

[Usefulness of inflammation and infection biomarkers in the Emergency Department]. / Utilidad de los biomarcadores de inflamación e infección en los servicios de urgencias.

Infectious processes account for 10% of patient seen in the emergency department. To administer antibiotics early, and before any other therapeutic-diagnostic decisions (complementary tests, microbiological samples, intensity of hemodynamic support, need for admission, etc.) have direct repercussions on the survival of patients with severe bacterial infections (bacteremia, severe sepsis or septic shock). In this context, the emergency department represents a critical level where the suspicion of infection and it diagnosis is made and treatment is started, and the progression and prognosis will be determined by the speed of this action. However, the clinical manifestations of infectious diseases are often non-specific and variable which makes early recognition of these patients and situations difficult. Inflammation and infection biomarkers have been around for years as helpful tools for improving emergency medical diagnoses and management of infection in the emergency department. The aim of this review is to summarize the published scientific evidence, in order to clarify the existing controversies, comparing the usefulness of the major biomarkers of inflammation and infection. It will alas suggest recommendations for their use in order to improve diagnosis, prognostic evaluation and management of infected patients in the emergency department.

[Diagnostic and prognostic power of biomarkers to improve the management of community acquired pneumonia in the emergency department]. / Poder diagnóstico y pronóstico de los biomarcadores para mejorar el manejo de la neumonía adquirida en la comunidad en los servicios de urgencias.

OBJECTIVES: To analyse the usefulness and performance of several biomarkers [C-reactive protein (CRP), mid-regional pro-adrenomedullin (MR-proADM), procalcitonin (PCT)] and lactate in predicting short- and medium-term mortality compared with the prognostic severity scales (PSS) usually employed for community-acquired pneumonia (CAP) and in assessing the aetiological suspicion of infection by Streptococcus pneumoniae and bacteraemia. METHODS: Observational, prospective and analytical study was conducted on patients who were diagnosed with CAP in our emergency department (ED). The data collected included socio-demographic and comorbidity variables, Charlson index, priority level according to the Spanish Triage System (STS), stage in the Pneumonia Severity Index (PSI) and in the CURB-65 (confusion, urea, respiratory rate, blood pressure and age ≥65years), criteria of severe CAP, microbiological studies, and biomarkers determinations. The patients were followed-up for 180days to calculate the prognostic power and the diagnostic performance for bacteraemia and aetiology. RESULTS: A total of 127patients were finally enrolled in the study. The 30-day mortality was 10.3% (13), and 22.6% (28) at 180 days. Blood cultures were positive in 29 patients (23%) and S.pneumoniae was identified as the responsible pathogen in 28 cases (22.2%). The area under the ROC curve (AUC-ROC) for lactate and MR-proADM to predict 30-day mortality was 0.898 (95%CI: 0.824-0.973; P<.0001) and 0.892 (95%CI: 0.811-0.974; P<.0001), respectively, and for MR-proADM at 180 days it was 0.921 (95%CI: 0.874-0.968; P<.0001). The AUC-ROC for PCT to predict bacteraemia was 0.952 (95%CI: 0.898-1.000; P<.0001) and, considering a cut-off value ≥0.95ng/ml, the negative predictive value (NPV) and the likelihood ratio (LR+) were 97.8% and 9.03, respectively. Using a PCT cut-off value >0.85ng/ml, the NPV and the LR+ were 96.6% and 5.89%, respectively, to predict a S.pneumoniae infection. CONCLUSIONS: MR-proADM and lactate showed a similar or even better performance for 30-day intra-hospital mortality than PSI, CURB-65, STS and CAP severity criteria in patients diagnosed with CAP (P>.05). Furthermore, the MR-proADM capacity to predict 180-day mortality was higher than PSS and the rest of biomarkers (P>.05), and its AUC-ROC increased if it was used in combination with PSI, CURB65 and STS. The determination of PCT has a remarkable diagnostic performance to rule out bacteraemia and to orientate the aetiology towards a S.pneumoniae infection.

Assessment of the shock index in septic shock: A systematic review.

OBJECTIVE: To identify published research on the Shock Index (SI) in patients with septic shock or severe sepsis and to describe its main findings and conclusions. DESIGN: Systematic review of the literature following the recommendations of the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). SETTINGS: The following databases were consulted: Pubmed, Embase, Library Cochrane and Lilacs. PATIENTS: Patients older than 14 years with septic shock. Pregnant women and population with COVID-19 were excluded. INTERVENTIONS: Studies reporting measurement of the shock index or its modified variants. MAIN VARIABLES OF INTEREST: Absolute frequencies and relative frequencies were assessed with measures of central tendency and dispersion. Effect estimators (OR, RR and HR) were extracted according to the context of each study. RESULTS: Seventeen articles were included, of which 11 investigated the SI as a predictor of mortality. Seven of them found significant differences in the SI when comparing survivors to non-survivors and observed a relationship between the SI evolution and clinical outcomes. Additional research evidenced a relation between the Modified Shock Index and myocardial depression, as well as mortality. Furthermore, they identified a relationship between the Diastolic Shock Index, the dose of administered dobutamine, and mortality. CONCLUSIONS: The results suggest that both the SI and its modified versions, particularly in serial assessments, can be considered for evaluating patient prognosis. The SI can also aid in determining fluid management for patients.

Mortality prediction model from combined serial lactate, procalcitonin and calprotectin levels in critically ill patients with sepsis: A retrospective study according to Sepsis-3 definition.

OBJECTIVE: 1) To evaluate the ability of baseline and on 24 h serum calprotectin, in comparison to canonical biomarkers (lactate and procalcitonin), for prognosis of 28-day mortality in critically ill septic patients; and 2) To develop a predictive model combining the three biomarkers. DESIGN: A single-center, retrospective study. SETTING: Intensive Care Unit of a university hospital. PATIENTS OR PARTICIPANTS: One hundred and seventy three septic pacientes were included. INTERVENTIONS: Measurement of baseline lactate, procalcitonin and calprotectin level and procalcitonin and calprotectin levels on 24 h. MAIN VARIABLES OF INTEREST: Demographics and comorbidities, SOFA score on ICU admission, baseline lactate, procalcitonin and calprotectin on admission and on 24 h and 28-day mortality. RESULTS: 1) On ICU admission, lactate was the only biomarker achieving a significant accuracy (AUC: 0.698); 2) On 24 h, no differences were found on procalcitonin and calprotectin levels. Procalcitonin and calprotectin clearances were significantly lower in non-survivors and both achieved a moderate performance (AUCs: 0.668 and 0.664, respectively); 3) A biomarker based-model achieved a significant accuracy (AUC: 0.766), trending to increase (AUC: 0.829) to SOFA score alone; y 4) Baseline lactate levels and procalcitonin and calprotectin clearance were independent predictors for the outcome. CONCLUSIONS: 1) Baseline and on 24 h calprotectina and procalcitonin levels lacked ability in predicting 28-day mortality; 2) Accuracy of clearance of both biomarkers was moderate; and 3) Combination of SOFA score and the predictive biomarker based-model showed a high prognostic accuracy.

Use of fluid therapy in perioperative adult patients: A narrative review.

The administration of intravenous fluids is the most common intervention in hospitalised patients in the perioperative setting and critical care units. The aim of this narrative review is to provide an overview of balanced solutions for fluid therapy in the perioperative period in adult patients, and to review new trends and solutions in fluid therapy. The evidence was grouped into 3 areas: intraoperative fluid administration, fluid administration in critically ill patients, and the importance / benefit of balanced crystalloid solutions. Although a number of high-quality studies have been published in recent years, the scientific evidence regarding the type of fluid, the dose, and rate of administration is still limited. The choice of fluid therapy during the perioperative period must be tailored to patient-specific factors, the nature of the surgery, expected fluid loss, and other relevant factors. Finally, more robust clinical evidence and physician training is of the utmost importance.

Relationship between Lactate Dehydrogenase and survival in patients with non-small cell lung cancer receiving immunotherapy. / Relación entre el lactato deshidrogenasa y la supervivencia en pacientes con cáncer de pulmón no microcítico que reciben tratamiento con inmunoterapia.

OBJECTIVE: The expression level of programmed death ligand 1 (PD-L1) is the only approved biomarker for predicting response to immunotherapy, yet its efficacy is not always consistent. Lactate dehydrogenase (LDH) has been associated with tumor aggressiveness and poorer prognosis across various cancer types and may serve as a useful biomarker for monitoring treatment response. The objective of this study is to analyze the relationship between LDH levels prior to the start of treatment with immune checkpoint inhibitors (ICIs) and clinical outcomes in patients with non-small cell lung cancer (NSCLC). METHOD: A retrospective study was conducted including patients diagnosed with NSCLC who were treated with at least three cycles of immunotherapy. Data on demographics, clinical and pathological characteristics, treatment received, pre-treatment LDH levels, and clinical outcomes such as treatment response and overall survival (OS) were analyzed. RESULTS: A total of 181 patients diagnosed with NSCLC were included. Elevated pre-treatment LDH levels (more than 244 U/l) were associated with significantly reduced OS. The median survival was 548 days in patients with LDH less than 244 U/l, compared to 332 days in those with LDH more than 244 U/l (p = 0.037). Among men, OS was greater in the LDH less than 244 U/l group (623 days) versus 332 days in the LDH more than 244 U/l group (p = 0.043). In patients with metastatic disease, OS was higher in those with LDH less than 244 U/l (474 days) compared to 249 days in those with LDH more than 244 U/l (p = 0.023). In patients receiving both immunotherapy and chemotherapy, OS was greater in those with LDH less than 244 U/l (623 days) compared to 281 days in the LDH more than 244 U/l group (p = 0.042). CONCLUSIONS: High levels of LDH prior to the start of treatment with ICIs are associated with lower treatment efficacy and a worse prognosis of the disease, especially in male, metastatic patients with a PD-L1 expression level less than 1%.

Lactate and pH values in newborns with a history of acute fetal distress.

BACKGROUND: Acute fetal distress (AFD) is a condition that requires timely diagnosis because it generates hypoxia, acidosis, and even intrauterine death. This study aimed to determine lactate and pH values in the umbilical cord in full-term newborns (NBs) with a history of AFD. METHODS: We conducted a cross-sectional study in full-term NBs of mothers with at least one perinatal, neonatal, or gasometric AFD antecedent. Neonatal morbidity was considered: if 1-min Apgar ≤ 6, or advanced neonatal maneuvers, or neonatal intensive care unit (NICU) admissions were necessary. The cutoff points were lactate > 4mmol/L and pH < 7.2. RESULTS: Of 66 NBs, 33.3% of mothers presented at least one antecedent for developing AFD; 22.7% presented hypertensive pregnancy disease, 13.6% oligohydramnios, and 63.6% other factors. Perinatally, 28.7% required advanced neonatal resuscitation maneuvers and 7.5% admission to the NICU. In the gasometry, the lactate and pH values for the neonatal morbidity of the NBs' group were 4.726 ± 1.401 and 7.293 ± 0.056, respectively, versus 2.240 ± 0.318 and 7.359 ± 0.022 (p < 0.05) for the group without associated neonatal morbidity. CONCLUSIONS: Lactate values in the umbilical cord increased by 25%, and pH decreased by one percent in NBs with a history of AFD and associated morbidity.

INTRODUCCIÓN: El sufrimiento fetal agudo (SFA) es una condición que amerita un diagnóstico oportuno debido a que genera hipoxia, acidosis e incluso la muerte intrauterina. El objetivo de este estudio fue determinar los valores de lactato y pH en cordón umbilical en recién nacidos de término con antecedente SFA. MÉTODOS: Se llevó a cabo un estudio transversal, en recién nacidos a término, de madres que tuvieron al menos un antecedente para SFA de tipo perinatal, neonatal o gasométrico. Se consideró morbilidad neonatal cuando presentaron Apgar al minuto ≤ 6, o requirieron maniobras avanzadas de reanimación neonatal, o ingreso a Unidad de Cuidados Intensivos Neonatales (UCIN). El punto de corte fue > 4 mmol/L para los valores de lactato y pH < 7.2. RESULTADOS: De un total de 66 recién nacidos, el 33.3% de las madres presentaron al menos un antecedente para desarrollar SFA; el 22.7% presentó enfermedad hipertensiva del embarazo, el 13.6%, oligohidramnios, y el 63.6%, otros factores. El 28.7% requirieron maniobras avanzadas de la reanimación neonatal y el 7.5%, el ingreso a la UCIN. En la gasometría, el valor de lactato y pH para el grupo de recién nacidos con morbilidad neonatal fue de 4.726 ± 1.401 y 7.293 ± 0.056 respectivamente, versus 2.240 ± 0.318 y 7.359 ± 0.022 (p < 0.05) para el grupo sin morbilidad neonatal asociada. CONCLUSIONES: Se observó un incremento del 25% de los valores de lactato en cordón umbilical y una disminución del 1% del pH en los recién nacidos con antecedente de SFA y morbilidad asociada.

A possible role for the venous-to-arterial CO2 difference in cardiogenic shock: an exploratory study. / Estudio exploratorio del rol de la diferencia venoarterial de dióxido de carbono en el shock cardiogénico.

OBJECTIVES: The venous-to-arterial CO2 partial pressure difference (CO2) is a marker of how adequately capillary blood flow is able to remove CO2 from tissues, but evidence regarding its usefulness in patients with cardiogenic shock (CS) is scarce The main objective of this study was to describe the changes in CO2 in patients with cardiogenic shock during the 48 hours after hospital admission. A secondary objective was to analyze the association between CO2 and in-hospital mortality due to cardiovascular disease (CVD) and cardiogenic shock refractory to treatment. MATERIAL AND METHODS: Prospective observational exploratory study in a single hospital. Patients in cardiogenic shock who were admitted to a cardiology critical care unit were included. We measured CO2 on inclusion and 6, 12, 24, and 48 hours after admission to the unit. Variables were explored with logistic regression analysis and areas under the receiver operating characteristic curves were calculated. RESULTS: A total of 50 patients were included. In-hospital mortality due to CVD was 20%. CO2 peaked initially and decreased gradually over the first 48 hours of care. In-hospital mortality tended to be higher in patients with the highest CO2 values, but the difference was not significant. High CO2 values at 24 hours were associated with refractory cardiogenic shock. The negative predictive value of a CO2 value lower than 6 mmHg at 12 hours was 87% for mortality due to CVD. CONCLUSION: This exploratory study suggests that CO2 could be a helpful additional marker to measure when managing cardiogenic shock. CO2 lower than 6 mmHg between 12 and 24 hours after admission may identify patients at low risk of death due to CVD or refractory cardiogenic shock.

OBJETIVO: La diferencia venoarterial de dióxido de carbono (CO2) representa la adecuación del flujo capilar para eliminar CO2 tisular, sin embargo, su evidencia en pacientes con shock cardiogénico (SC) es escasa. El objetivo primario fue caracterizar la cinética de la diferencia venoarterial de CO2 en pacientes con SC durante las primeras 48 horas de ingreso. El objetivo secundario fue analizar la asociación de la CO2 con la mortalidad intrahospitalaria de causa cardiovascular y el SC refractario. METODO: Estudio exploratorio, observacional, prospectivo y unicéntrico. Se incluyeron pacientes en SC ingresados en una unidad de cuidados críticos cardiológicos. Se determinó la CO2 a la inclusión, a las 6, 12, 24 y 48 horas y se realizó un análisis de regresión logística y curvas de la característica operativa del receptor. RESULTADOS: Se incluyeron 50 pacientes. La mortalidad cardiovascular intrahospitalaria fue del 20%. La cinética de la CO2 mostró un pico inicial y un progresivo descenso durante las primeras 48 horas. Los pacientes con valores más altos de CO2 tuvieron una mayor mortalidad cardiovascular intrahospitalaria, pero esta diferencia no fue significativa. A las 24 horas, valores elevados de CO2 se asociaron significativamente con SC refractario. Un valor inferior a 6 mmHg a las 12 horas mostró un valor predictivo negativo del 87% para mortalidad cardiovascular. CONCLUSIONES: Este estudio exploratorio sugiere la potencial utilidad de la CO2 como biomarcador adicional en el manejo del SC. La CO2 permite identificar pacientes con bajo riesgo de mortalidad cardiovascular y SC refractario cuando sus valores son inferiores a 6 mmHg a las 12-24 horas de evolución.

The Guadalajara Declaration on sepsis: emergency physicians' constructive comments on the Surviving Sepsis Campaign's 2021 updated guidelines. / Declaración de Guadalajara: una visión constructiva desde el servicio de urgencias a partir de la Surviving Sepsis Campaign 2021.

TEXT: The Surviving Sepsis Campaign (SSC) published a 2021 update of its 2016 recommendations. The update was awaited with great anticipation the world over, especially by emergency physicians. Under the framework of the CIMU 2022 (33rd World Emergency Medicine Conference) in Guadalajara, Mexico in March, emergency physiciansreviewed and analyzed the 2021 SSC guidelines from our specialty's point of view. In this article, the expert reviewers present their consensus on certain key points of most interest in emergency settings at this time. The main aims of the review are to present constructive comments on 10 key points and/or recommendations in the SSC 2021 update and to offer emergency physicians' experience- and evidence-based proposals. Secondarily, the review's recommendations are a starting point for guidelines to detect severe sepsis in emergency department patients and prevent progression, which is ultimate goal of what has become known as the Guadalajara Declaration on sepsis.

TEXTO: En noviembre del año 2021, la Surviving Sepsis Campaign (SSC) publicó una actualización de sus recomendaciones y directrices de 2016. Estas fueron recibidas con una enorme expectativa en todo el mundo, especialmente entre los médicos de urgencias y emergencias (MUE). Recientemente, en el marco del CIMU 2022 (33 Congreso Mundial de Medicina de Urgencias celebrado en marzo de 2022 en Guadalajara ­ México) se ha revisado y analizado, desde la perspectiva del MUE, la Guía SSC de 2021. Los expertos que realizaron esa tarea y también consensuaron algunos de los puntos clave que más interesan y preocupan a los MUE en la actualidad han elaborado este documento. Su objetivo principal es analizar de forma constructiva diez de los puntos clave y recomendaciones de la SSC 2021 para complementarlas con argumentos y propuestas desde la experiencia, evidencia y perspectiva del urgenciólogo. Además, de forma secundaria, pretende ser el punto de partida de la elaboración de las guías para detectar, prevenir la progresión y atender a los pacientes con infección grave y sepsis en urgencias, que supone la meta final de lo que desde la MUE ya se conoce como "la Declaración de Guadalajara".

Lactate levels as a prognostic predict in cardiogenic shock under venoarterial extracorporeal membrane oxygenation support.

INTRODUCTION AND OBJECTIVES: Lactate and its evolution are associated with the prognosis of patients in shock, although there is little evidence in those assisted with an extracorporeal venoarterial oxygenation membrane (VA-ECMO). Our objective was to evaluate its prognostic value in cardiogenic shock assisted with VA-ECMO. METHODS: Study of patients with cardiogenic shock treated with VA-ECMO for medical indication between July 2013 and April 2021. Lactate clearance was calculated: [(initial lactate - 6 h lactate) / initial lactate × exact time between both determinations]. RESULTS: From 121 patients, 44 had acute myocardial infarction (36.4%), 42 implant during cardiopulmonary resuscitation (34.7%), 14 pulmonary embolism (11.6%), 14 arrhythmic storm (11.6%), and 6 fulminant myocarditis (5.0%). After 30 days, 60 patients (49.6%) died, mortality was higher for implant during cardiopulmonary resuscitation than for implant in spontaneous circulation (30 of 42 [71.4%] vs 30 of 79 [38.0%], P=.030). Preimplantation GPT and lactate (both baseline, at 6hours, and clearance) were independently associated with 30-day mortality. The regression models that included lactate clearance had a better predictive capacity for survival than the ENCOURAGE and ECMO-ACCEPTS scores, with the area under the ROC curve being greater in the model with lactate at 6 h. CONCLUSIONS: Lactate (at baseline, 6h, and clearance) is an independent predictor of prognosis in patients in cardiogenic shock supported by VA-ECMO, allowing better risk stratification and predictive capacity.

Experience in Spain with the first patients in home hemodialysis treated with low-flow dialysate monitors.

Home hemodialysis (HHD) with low-flow dialysate devices has gained popularity in recent years due to its simple design, portability, and ability to provide greater freedom of movement for our patients. However, there are doubts about the adequacy that this technology offers, since it uses monitors with low-flow bath and lactate. The aim of this study was to demonstrate the clinical benefits of low-flow HHD with the NxStage System One® recently introduced in Spain. We present the results of an observational, retrospective cohort study that included the first patients who started short daily HHD with this device in 12 Spanish centers. We analyzed the evolution of 86 patients at 0, 6 and 12 months, including data related to prescription, and evolution of biochemical parameters related to dialysis dose, anemia, mineral-bone metabolism; evolution of residual renal function, medication usage, and causes of withdrawal during the followup. We were able to demonstrate that this NxStage System One® monitor, in patients with HHD, have provided an adequate dialysis dose, with optimal ultrafiltration rate, with improvement of main biochemical markers of dialysis adequacy. The usage of this technique was associated to a decrease of antihypertensive drugs, phosphate binders and erythropoietin agents, with very good results both patient and technique survival. The simplicity of the technique, together with its good clinical outcomes, should facilitate the growth and utilization of HHD, both in incident and prevalent patients.

Venous-arterial oxygen saturation and serum lactate in the postoperative period of cardiac surgery.

INTRODUCTION: Oxygen saturation and lactate are markers of tissue hypoxia; they are obtained from central venous and mixed venous sample of the pulmonary artery. The simultaneous behavior of these parameters in the postoperative period of cardiac surgery is unknown. OBJECTIVE: To characterize the lactate and oxygen saturation of the venous-arterial circuit of the postoperative patient from cardiac surgery. METHODS: Design: Analytical cross-sectional. In consecutive patients after cardiac surgery, serum lactate and oxygen saturation of the venous-arterial circuit were obtained. The variables were reported with median (25.75 percentiles). They were analyzed with Kruskal-Wallis ANOVA and respective adjustment, Spearman correlation, the descriptive Bland-Altman statistic and intraclass correlation coefficient (95% confidence interval). A p < 0.05 was considered significant. RESULTS: 244 blood samples from 61 patients were studied. Women 30 (49%). (Oxygen saturation) [lactate] were: arterial 98 (95.3, 99.4%) and 1.7 (1.1, 2.1); peripheral venous 85 (75.4, 94%) and [1.9 (1.35, 2.3)]; central venous 68.8 (58.74, 70.2%) and 1.8 (1.3, 2.3); mixed central venous 66.8 (61.2, 73.1%) and 1.8 (1.3, 2.2), p < 0.05. The best intraclass correlation coefficient for oxygen saturation were from central vein to mixed central vein 0.856 (0.760,0.914); and lactate: 0.954 (0.923, 0.972). CONCLUSIONS: The oxygen saturation differs in the venous-arterial circuit unlike lactate where they are similar. The best values of the intraclass correlation coefficient for lactate and oxygen saturation were those obtained in central vein and mixed central vein.

INTRODUCCIÓN: La saturación de oxígeno y el lactato son marcadores de hipoxia tisular, se obtienen de muestra venosa mezclada en arteria pulmonar o venosa central. Se desconoce el comportamiento simultáneo de estos parámetros en el postoperatorio de cirugía cardiaca. OBJETIVO: Caracterizar la saturación de oxígeno y lactato del circuito venoso-arterial del paciente postoperado de cirugía cardiaca. MÉTODOS: Diseño transversal analítico. En pacientes consecutivos postoperados de cirugía cardiaca se obtuvieron lactato sérico y saturación de oxígeno del circuito venoso-arterial. Las variables se informaron con mediana (percentiles 25 y 75). Se analizaron con ANOVA de Kruskal-Wallis y ajuste respectivo, correlación de Spearman, el estadístico descriptivo de Bland-Altman y coeficiente de correlación intraclase (intervalo de confianza al 95%). Una p < 0.05 se consideró significativa. RESULTADOS: Se estudiaron 244 muestras sanguíneas de 61 pacientes. Mujeres 30 (49%). Saturación de oxígeno y lactato fueron: arterial 98 (95.3, 99.4)% y 1.7 (1,1, 2.1); venosa periférica 85 (75.4, 94)% y 1.9 (1.35, 2.3); venosa central 68.8 (58.74, 70.2)% y 1.8 (1.3, 2.3); venosa central mezclada 66.8 (61.2, 73.1)% y 1.8 (1.3, 2.2), p < 0.05. El mejor coeficiente de correlación intraclase para la saturación de oxígeno fue de vena central a vena central mezclada: 0.856 (0.760, 0.914); del lactato: 0.954 (0.923, 0.972). CONCLUSIONES: La saturación de oxígeno difiere en el circuito venoso-arterial a diferencia del lactato, donde son similares. Los mejores valores del coeficiente de correlación intraclase para el lactato y la saturación de oxígeno fueron los obtenidos en vena central y vena central mezclada.

Ability of lactate, procalcitonin, and criteria defining sepsis to predict 30-day mortality, bacteremia, and microbiologically confirmed infection in patients with infection suspicion treated in emergency departments. / Capacidad del lactato, procalcitonina y de los criterios definitorios de sepsis para predecir mortalidad a 30 días, bacteriemia o infección confirmada microbiológicamente en los pacientes atendidos por sospecha de infección en urgencias.

OBJECTIVES: To evaluate lactate, procalcitonin, criteria defining systemic inflammatory response syndrome (SIRS), and the Quick Sepsis-Related Organ Failure Assessment (qSOFA) and compare their ability to predict 30-day mortality, infection with microbiologic confirmation, and true bacteremia in patients treated for infection in hospital emergency departments. MATERIAL AND METHODS: Prospective multicenter observational cohort study. We enrolled a convenience sample of patients aged 18 years or older attended in 71 Spanish emergency departments from October 1, 2019, to March 31, 2020. Each model's predictive power was analyzed with the area under the receiver operating characteristic curve (AUC), and predetermined decision points were assessed. RESULTS: A total of 4439 patients with a mean (SD) age of 18 years were studied; 2648 (59.7%) were men and 459 (10.3%) died within 30 days. True bacteremia was detected in 899 (20.25%), and microbiologic confirmation was on record for 2057 (46.3%). The model that included the qSOFA score (2) and lactate concentration (0.738 mmol/L; 95% CI, 0.711-0.765 mmol/L) proved to be the best predictor of 30-day mortality, with an AUC of 0.890 (95% CI, 0.880-0.901). The model that included the SIRS score (2) and procalcitonin concentration (0.51 ng/mL) proved to be the best predictor of true bacteremia and microbiologic confirmation, with an AUC of 0.713 (95% CI, 0.698-0.728). CONCLUSION: A qSOFA score of 2 or more plus lactate concentration (0.738 mmol/L) predict 30-day mortality better than the combination of a SIRS score of 2 or more and procalcitonin concentration. A SIRS score of 2 or more plus procalcitonin concentration (0.51 ng/mL) predict true bacteremia and microbiologic confirmation.

OBJETIVO: Evaluar y comparar la capacidad del lactato, la procalcitonina (PCT) y de los criterios definitorios de sepsis (síndrome de respuesta inflamatoria sistémica ­SRIS­ y del quick Sepsis-related Organ Failure Assessment ­qSOFA­) para predecir mortalidad a 30 días, o infección ­con confirmación microbiológica o bacteriemia verdadera (BV)­ en los pacientes que acuden al servicio de urgencias hospitalario (SUH) por un episodio de sospecha de infección. METODO: Estudio observacional de cohortes, multicéntrico, prospectivo. Se incluyó por oportunidad a pacientes 18 años atendidos por sospecha de infección en 71 SUH españoles desde el 01/10/2019 al 31/03/2020. Se analizó la capacidad predictiva con el área bajo la curva (ABC) de la característica operativa del receptor (COR) y puntos de decisión predeterminados. RESULTADOS: Se incluyeron 4.439 pacientes con edad media de 67 (18) años, 2.648 (59,7%) fueron hombres, fallecieron a los 30 días 459 (10,3%), se consideraron BV 899 (20,2%) y se consiguió confirmación microbiológica en 2.057 (46,3%). Para la mortalidad a 30 días la mejor ABC-COR fue la obtenida con el modelo qSOFA 2 más lactato 2 mmol/l con un ABC-COR de 0,738 (0,711-0,765). Para predecir BV y confirmación microbiológica el mejor rendimiento se obtuvo con el modelo de SRIS 2 más PCT 0,51 ng/ml, con un ABC-COR de 0,890 (0,880-0,901) y 0,713 (0,698-0,728), respectivamente. CONCLUSIONES: Para la predicción de mortalidad a 30 días, el qSOFA 2 es superior al SRIS 2 y el mejor rendimiento lo consigue el modelo qSOFA 2 más lactato 2 mmol/l. Para predecir BV y confirmación microbiológica, la PCT es superior al lactato y el mejor rendimiento lo obtiene el modelo SRIS 2 más PCT 0,51 ng/ml.