Pandemic 2009 influenza A in Argentina: a study of 337 patients on mechanical ventilation.

RATIONALE: The rapid spread of the 2009 Influenza A (H1N1) around the world underscores the need for a better knowledge of epidemiology, clinical features, outcomes, and mortality predictors, especially in the most severe presentations. OBJECTIVES: To describe these characteristics in patients with confirmed, probable, and suspected viral pneumonia caused by 2009 influenza A (H1N1) admitted to 35 intensive care units with acute respiratory failure requiring mechanical ventilation in Argentina, between June 3 and September 7. METHODS: Inception-cohort study including 337 consecutive adult patients. Data were collected in a form posted on the Argentinian Society of Intensive Care website. MEASUREMENTS AND MAIN RESULTS: Proportions of confirmed, probable, or suspected cases were 39%, 8%, and 53% and had similar outcomes. APACHE II was 18 +/- 7; age 47 +/- 17 years; 56% were male; and 64% had underlying conditions, with obesity (24%), chronic obstructive respiratory disease (18%), and immunosupression (15%) being the most common. Seven percent were pregnant. On admission, patients had severe hypoxemia (Pa(O(2))/Fi(O(2)) 140 [87-200]), extensive lung radiologic infiltrates (2.87 +/- 1.03 quadrants) and bacterial coinfection, (25%; mostly with Streptococcus pneumoniae). Use of adjuvants such as recruitment maneuvers (40%) and prone positioning (13%), and shock (72%) and acute kidney injury requiring hemodialysis (17%), were frequent. Mortality was 46%, and was similar across all ages. APACHE II, lowest Pa(O(2))/Fi(O(2)), shock, hemodialysis, prone positioning, and S. pneumoniae coinfection independently predicted death. CONCLUSIONS: Patients with 2009 influenza A (H1N1) requiring mechanical ventilation were mostly middle-aged adults, often with comorbidities, and frequently developed severe acute respiratory distress syndrome and multiorgan failure requiring advanced organ support. Case fatality rate was accordingly high.

Delirium epidemiology in critical care (DECCA): an international study.

INTRODUCTION: Delirium is a frequent source of morbidity in intensive care units (ICUs). Most data on its epidemiology is from single-center studies. Our aim was to conduct a multicenter study to evaluate the epidemiology of delirium in the ICU. METHODS: A 1-day point-prevalence study was undertaken in 104 ICUs from 11 countries in South and North America and Spain. RESULTS: In total, 975 patients were screened, and 497 fulfilled inclusion criteria and were enrolled (median age, 62 years; 52.5% men; 16.7% and 19.9% for ICU and hospital mortality); 64% were admitted to the ICU because of medical causes, and sepsis was the main diagnosis (n = 76; 15.3%). In total, 265 patients were sedated with the Richmond agitation and sedation scale (RASS) deeper than -3, and only 232 (46.6%) patients could be evaluated with the confusion-assessment method for the ICU. The prevalence of delirium was 32.3%. Compared with patients without delirium, those with the diagnosis of delirium had a greater severity of illness at admission, demonstrated by higher sequential organ-failure assessment (SOFA (P = 0.004)) and simplified acute physiology score 3 (SAPS3) scores (P < 0.0001). Delirium was associated with increased ICU (20% versus 5.7%; P = 0.002) and hospital mortality (24 versus 8.3%; P = 0.0017), and longer ICU (P < 0.0001) and hospital length of stay (LOS) (22 (11 to 40) versus 7 (4 to 18) days; P < 0.0001). Previous use of midazolam (P = 0.009) was more frequent in patients with delirium. On multivariate analysis, delirium was independently associated with increased ICU mortality (OR = 3.14 (1.26 to 7.86); CI, 95%) and hospital mortality (OR = 2.5 (1.1 to 5.7); CI, 95%). CONCLUSIONS: In this 1-day international study, delirium was frequent and associated with increased mortality and ICU LOS. The main modifiable risk factors associated with the diagnosis of delirium were the use of invasive devices and sedatives (midazolam).

Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial.

CONTEXT: Gamma-aminobutyric acid receptor agonist medications are the most commonly used sedatives for intensive care unit (ICU) patients, yet preliminary evidence indicates that the alpha(2) agonist dexmedetomidine may have distinct advantages. OBJECTIVE: To compare the efficacy and safety of prolonged sedation with dexmedetomidine vs midazolam for mechanically ventilated patients. DESIGN, SETTING, AND PATIENTS: Prospective, double-blind, randomized trial conducted in 68 centers in 5 countries between March 2005 and August 2007 among 375 medical/surgical ICU patients with expected mechanical ventilation for more than 24 hours. Sedation level and delirium were assessed using the Richmond Agitation-Sedation Scale (RASS) and the Confusion Assessment Method for the ICU. INTERVENTIONS: Dexmedetomidine (0.2-1.4 microg/kg per hour [n = 244]) or midazolam (0.02-0.1 mg/kg per hour [n = 122]) titrated to achieve light sedation (RASS scores between -2 and +1) from enrollment until extubation or 30 days. MAIN OUTCOME MEASURES: Percentage of time within target RASS range. Secondary end points included prevalence and duration of delirium, use of fentanyl and open-label midazolam, and nursing assessments. Additional outcomes included duration of mechanical ventilation, ICU length of stay, and adverse events. RESULTS: There was no difference in percentage of time within the target RASS range (77.3% for dexmedetomidine group vs 75.1% for midazolam group; difference, 2.2% [95% confidence interval {CI}, -3.2% to 7.5%]; P = .18). The prevalence of delirium during treatment was 54% (n = 132/244) in dexmedetomidine-treated patients vs 76.6% (n = 93/122) in midazolam-treated patients (difference, 22.6% [95% CI, 14% to 33%]; P < .001). Median time to extubation was 1.9 days shorter in dexmedetomidine-treated patients (3.7 days [95% CI, 3.1 to 4.0] vs 5.6 days [95% CI, 4.6 to 5.9]; P = .01), and ICU length of stay was similar (5.9 days [95% CI, 5.7 to 7.0] vs 7.6 days [95% CI, 6.7 to 8.6]; P = .24). Dexmedetomidine-treated patients were more likely to develop bradycardia (42.2% [103/244] vs 18.9% [23/122]; P < .001), with a nonsignificant increase in the proportion requiring treatment (4.9% [12/244] vs 0.8% [1/122]; P = .07), but had a lower likelihood of tachycardia (25.4% [62/244] vs 44.3% [54/122]; P < .001) or hypertension requiring treatment (18.9% [46/244] vs 29.5% [36/122]; P = .02). CONCLUSIONS: There was no difference between dexmedetomidine and midazolam in time at targeted sedation level in mechanically ventilated ICU patients. At comparable sedation levels, dexmedetomidine-treated patients spent less time on the ventilator, experienced less delirium, and developed less tachycardia and hypertension. The most notable adverse effect of dexmedetomidine was bradycardia. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00216190 Published online February 2, 2009 (doi:10.1001/jama.2009.56).

Improving quality in the intensive care unit setting.

Summarizing the mission of the ICU, the institution directive board and the unit director must generate a structure, proceedings criteria, management, and analysis of results capable of providing satisfactory care. Furthermore, they must take into account each organizational aspect that is necessary to offer an appropriate service for the patient. Medicine in general and intensive care in particular require that precautions be taken to avoid the patient and family feeling uncertain and fearful about the quality of the attention and care they receive.

Effects of high-dose of intravenous immunoglobulin and antibiotics on survival for severe sepsis undergoing surgery.

The objective of this study was to assess the impact on outcome of adjuvant therapy (high-dose of immunoglobulin [Ig] M-enriched intravenous Ig, IVIG) in intensive care unit (ICU) patients who underwent surgery by abdominal sepsis. This was a prospective, randomized, double-blind, controlled study set in the medical/surgical ICUs of seven teaching hospitals. Patients with severe sepsis and septic shock of intra-abdominal origin admitted to the ICU within 24 h after the onset of symptoms were included in the study. Polyvalent IgM-enriched Ig (Pentaglobin; IVIG group) at a dosage of 7 mL/kg/day for 5 days or an equal amount of 5% human albumin (control group) was randomized. Fifty-six patients were enrolled. The overall mortality rate was 37.5.%. Twenty patients had shock and 36 had severe sepsis (the mortality rate was 55.0% and 25.0%, respectively). In the intent-to-treat analysis, the mortality rate was reduced from 48.1% in patients treated with antibiotic (ATB) plus albumin to 27.5% (P = 0.06) for patients with ATB plus IVIG. The organ failure score (1.0 +/- 0.6 vs. 1.2 +/- 0.9), organ dysfunction score (1.7 +/- 1.1 vs. 1.8 +/- 1.0), and reoperation rate (17.2% vs. 29.6%) were not different between IVIG and control groups, respectively. Eight patients (14.3%) received inappropriate ATB initial therapy (IAT), and seven died (87.5%). IAT was the only variable independently associated with death (odds ratio, 19.4) in a logistic regression model. We conclude that IVIG administration, when used in combination with adequate antibiotics, improved the survival of surgical ICU patients with intra-abdominal sepsis. The initial choice of antibiotic has a dramatic impact on outcome.

Recepción del politraumatizado: conferencia del curso de medicina intensiva y reanimación / Reception of the patients with multiple injuries: conference of the intensive medicine and resuscitation course

1. Exámen Primario ABCDE 2. Resucitación - Primero las lesiones mortales - Monitoreo 3.Exámen secundario 4.Tratamiento Definitivo - Estabilización y transporte. Prevenir siempre las lesion Secundarias

Nuestra experiencia en el manejo del traumatizado torácico en un servicio de terapia intensiva / Results in management of patients with trauma in an intensive care unit

Se analizan 62 traumatismos torácicos de los cuales 40 (64,5%) fueron cerrados y 22 (35,5%) penetrantes. De la heridas penetrantes, l9 (86%) fueron por arma de fuego y 3 (l4%) por arma blanca. Las contusiones fueron por accidentes de tránsito en 29 casos (72,5%) y por caída de altura en ll (27,5%). Los pacientes fueron clasificados de acuerdo al trauma score, a la escala de severidad lesional, al valor de dicha escala con 50% de mortalidad, a su condición al ingreso y de acuerdo a nuestra clasificación de grados, de gravedad para cada aparato o sistema lesionado. Se determinaron también los valores del gradiente arterioalveolar de oxígeno al ingreso y el peor registro obtenido. La mortalidad global fue de l5 pacientes (24%), l3 contusiones y 2 heridas penetrantes. De los estables al ingreso no falleció ninguno y de los inestables 9. El empleo de índices de gravedad lesional y funcional demostró tener valor predictivo pronóstico respecto a la morbimortalidad y servir de guía para el control del manejo de los traumatizados. (AU)

Nuestra experiencia en el manejo del traumatizado torácico en un servicio de terapia intensiva / Results in management of patients with trauma in an intensive care unit

Se analizan 62 traumatismos torácicos de los cuales 40 (64,5%) fueron cerrados y 22 (35,5%) penetrantes. De la heridas penetrantes, l9 (86%) fueron por arma de fuego y 3 (l4%) por arma blanca. Las contusiones fueron por accidentes de tránsito en 29 casos (72,5%) y por caída de altura en ll (27,5%). Los pacientes fueron clasificados de acuerdo al trauma score, a la escala de severidad lesional, al valor de dicha escala con 50% de mortalidad, a su condición al ingreso y de acuerdo a nuestra clasificación de grados, de gravedad para cada aparato o sistema lesionado. Se determinaron también los valores del gradiente arterioalveolar de oxígeno al ingreso y el peor registro obtenido. La mortalidad global fue de l5 pacientes (24%), l3 contusiones y 2 heridas penetrantes. De los estables al ingreso no falleció ninguno y de los inestables 9. El empleo de índices de gravedad lesional y funcional demostró tener valor predictivo pronóstico respecto a la morbimortalidad y servir de guía para el control del manejo de los traumatizados.

I Consenso nacional sobre estrategias en prevención primaria y secundaria de las enfermedades cardiovasculares a través de la aplicación de la vacuna antigripal / I National Consensus on primary and secondary prevention of cardiovascular diseases and anti-flu vaccination

Durante el mes de marzo de 2004, un panel de expertos y diversas autoridades nacionales de la salud pública, reunidos en la Patagonia argentina, generaron este primer documento sobre la utilización de la vacunación antigripal como parte de la estrategia médica en la prevención de las enfermedades cardiovasculares. Este grupo analizó el cuerpo de evidencia actual sobre el tema, así como las recomendaciones internacionales, tanto de la Asociación Panamericana de la Salud como de la Organización Mundial de la Salud, para la indicación de esta estrategia farmacológica. Este testimonio refleja la posición actual de todas estas partes, así como una interesante sugerencia a la comunidad médica en referencia a la actitud que se debe seguir en un futuro próximo (AU)

In March 2004, in the Patagonia, Argentina, a group of experts including national authorities, analysed the body of evidence related to anti-flu vaccination in the framework of primary and secondary prevention in ischemic heart disease. The rationale for using this pharmacological strategy, including the recommendation and suggestions given by the Pan-American Health Organization and the World Heart Organization, were deeply discussed during the meeting. The testimony is written in the present manuscript, including a critical suggestion to the medical community for the up-coming future (AU)