Respiratory quotient estimations as additional prognostic tools in early septic shock.

Central venous-to-arterial carbon dioxide difference (PcvaCO2), and its correction by the arterial-to-venous oxygen content difference (PcvaCO2/CavO2) have been proposed as additional tools to evaluate tissue hypoxia. Since the relationship between pressure and content of CO2 (CCO2) might be affected by several factors, some authors advocate for the use of CcvaCO2/CavO2. The aim of the present study was to explore the factors that might intervene in the difference between PcvaCO2/CavO2 and CcvaCO2/CavO2, and to analyze their association with mortality. Observational study in a 30-bed mixed ICU. Fifty-two septic shock patients within the first 24 h of ICU admission were studied. After restoration of mean arterial pressure, hemodynamic and metabolic parameters were evaluated. A total of 110 sets of measurements were performed. Simultaneous PcvaCO2/CavO2 and CcvaCO2/CavO2 values were correlated, but agreement analysis showed a significant proportional bias. The difference between PcvaCO2/CavO2 and CcvaCO2/CavO2 was independently associated with pH, ScvO2, baseline CcvaCO2/CavO2 and hemoglobin. A stepwise regression analysis showed that pH was the single best predictor for the magnitude of such difference, with very limited effect of other variables. At inclusion, variables associated with ICU-mortality were lactate, pH, PcvaCO2/CavO2, and the difference between PcvaCO2/CavO2 and CcvaCO2/CavO2. Initial ScvO2, PcvaCO2, CcvaCO2/CavO2, and cardiac index were not different in survivors and non-survivors. In a population of early septic shock patients, simultaneous values of PcvaCO2/CavO2 and CcvaCO2/CavO2 were not equivalent, and the main determinant of the magnitude of the difference between these two parameters was pH. The PcvaCO2/CavO2 ratio was associated with ICU mortality, whereas CcvaCO2/CavO2 was not.

Central venous-to-arterial carbon dioxide difference and the effect of venous hyperoxia: A limiting factor, or an additional marker of severity in shock?

Central venous-to-arterial carbon dioxide difference (PcvaCO2) has demonstrated its prognostic value in critically ill patients suffering from shock, and current expert recommendations advocate for further resuscitation interventions when PcvaCO2 is elevated. PcvaCO2 combination with arterial-venous oxygen content difference (PcvaCO2/CavO2) seems to enhance its performance when assessing anaerobic metabolism. However, the fact that PCO2 values might be altered by changes in blood O2 content (the Haldane effect), has been presented as a limitation of PCO2-derived variables. The present study aimed at exploring the impact of hyperoxia on PcvaCO2 and PcvaCO2/CavO2 during the early phase of shock. Prospective interventional study. Ventilated patients suffering from shock within the first 24 h of ICU admission. Patients requiring FiO2 ≥ 0.5 were excluded. At inclusion, simultaneous arterial and central venous blood samples were collected. Patients underwent a hyperoxygenation test (5 min of FiO2 100%), and arterial and central venous blood samples were repeated. Oxygenation and CO2 variables were calculated at both time points. Twenty patients were studied. The main cause of shock was septic shock (70%). The hyperoxygenation trial increased oxygenation parameters in arterial and venous blood, whereas PCO2 only changed at the venous site. Resulting PcvaCO2 and PcvaCO2/CavO2 significantly increased [6.8 (4.9, 8.1) vs. 7.6 (6.7, 8.5) mmHg, p 0.001; and 1.9 (1.4, 2.2) vs. 2.3 (1.8, 3), p < 0.001, respectively]. Baseline PcvaCO2, PcvaCO2/CavO2 and ScvO2 correlated with the magnitude of PO2 augmentation at the venous site within the trial (ρ -0.46, p 0.04; ρ 0.6, p < 0.01; and ρ 0.7, p < 0.001, respectively). Increased PcvaCO2/CavO2 values were associated with higher mortality in our sample [1.46 (1.21, 1.89) survivors vs. 2.23 (1.86, 2.8) non-survivors, p < 0.01]. PcvaCO2 and PcvaCO2/CavO2 are influenced by oxygenation changes not related to flow. Elevated PcvaCO2 and PcvaCO2/CavO2 values might not only derive from cardiac output inadequacy, but also from venous hyperoxia. Elevated PcvaCO2/CavO2 values were associated with higher PO2 transmission to the venous compartment, suggesting higher shunting phenomena.

Nursing workload and adherence to non-pharmacological measures in the prevention of ventilator-associated pneumonia. A pilot study. / Carga de trabajo y cumplimiento por parte de las enfermeras de las medidas no farmacológicas para la prevención de la neumonía asociada a la ventilación mecánica. Estudio piloto.

OBJECTIVE: To analyse whether adherence to non-pharmacological measures in the prevention of ventilator-associated pneumonia (VAP) is associated with nursing workload. METHODS: A prospective observational study performed in a single medical-surgical ICU. Nurses in charge of patients under ventilator support were assessed. VARIABLES: knowledge questionnaire, application of non-pharmacological VAP prevention measures, and workload (Nine Equivalents of Nursing Manpower Use Score). Phases: 1) the nurses carried out a educational programme, consisting of 60-minute lectures on non-pharmacological measures for VAP prevention, and at the end completed a questionnaire knowledge; 2) observation period; 3) knowledge questionnaire. RESULTS: Among 67 ICU-staff nurses, 54 completed the educational programme and were observed. A total of 160 observations of 49 nurses were made. Adequate knowledge was confirmed in both the initial and final questionnaires. Application of preventive measures ranged from 11% for hand washing pre-aspiration to 97% for the use of a sterile aspiration probe. The Nine Equivalents of Nursing Manpower Use Score was 50±13. No significant differences were observed between the association of the nurses' knowledge and the application of preventive measures or between workload and the application of preventive measures. CONCLUSIONS: Nurses' knowledge of VAP prevention measures is not necessarily applied in daily practice. Failure to follow these measures is not subject to lack of knowledge or to increased workload, but presumably to contextual factors.

Microcirculatory monitoring in septic patients: Where do we stand?

Microcirculatory alterations play a pivotal role in sepsis-related morbidity and mortality. However, since the microcirculation has been a "black box", current hemodynamic management of septic patients is still guided by macrocirculatory parameters. In the last decades, the development of several technologies has shed some light on microcirculatory evaluation and monitoring, and the possibility of incorporating microcirculatory variables to clinical practice no longer seems to be beyond reach. The present review provides a brief summary of the current technologies for microcirculatory evaluation, and attempts to explore the potential role and benefits of their integration to the resuscitation process in critically ill septic patients.

Fluid therapy and the hypovolemic microcirculation.

PURPOSE OF REVIEW: In shock states, optimizing intravascular volume is crucial to promote an adequate oxygen delivery to the tissues. Our current practice in fluid management pivots on the Frank-Starling law of the heart, and the effects of fluids are measured according to the induced changes on stroke volume. The purpose of this review is to evaluate the boundaries of current macrohemodynamic approach to fluid administration, and to introduce the microcirculatory integration as a fundamental part of tissue perfusion monitoring. RECENT FINDINGS: Macrocirculatory changes induced by volume expansion are not always coupled to proportional changes in microcirculatory perfusion. Loss of hemodynamic coherence limits the value of guiding fluid therapy according to macrohemodynamics, and highlights the importance of evaluating the ultimate target of volume administration, the microcirculation. SUMMARY: Current approach to intravascular volume optimization is made from a macrohemodynamic perspective. However, several situations wherein macrocirculatory and microcirculatory coherence is lost have been described. Future clinical trials should explore the usefulness of integrating the microcirculatory evaluation in fluid optimization.

[Tissue oxygen saturation in the critically ill patient]. / Saturación tisular de oxígeno en el paciente crítico.

Hemodynamic resuscitation seeks to correct global macrocirculatory parameters of pressure and flow. However, current evidence has shown that despite the normalization of these global parameters, microcirculatory and regional perfusion alterations can persist, and these alterations have been independently associated with a poorer patient prognosis. This in turn has lead to growing interest in new technologies for exploring regional circulation and microcirculation. Near infra-red spectroscopy allows us to monitor tissue oxygen saturation, and has been proposed as a noninvasive, continuous and easy-to-obtain measure of regional circulation. The present review aims to summarize the existing evidence on near infra-red spectroscopy and its potential clinical role in the resuscitation of critically ill patients in shock.

[Hemodynamic monitoring in the critically patient. Recomendations of the Cardiological Intensive Care and CPR Working Group of the Spanish Society of Intensive Care and Coronary Units]. / Monitorización hemodinámica en el paciente crítico. Recomendaciones del Grupo de Trabajo de Cuidados Intensivos Cardiológicos y RCP de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias.

Hemodynamic monitoring offers valuable information on cardiovascular performance in the critically ill, and has become a fundamental tool in the diagnostic approach and in the therapy guidance of those patients presenting with tissue hypoperfusion. From introduction of the pulmonary artery catheter to the latest less invasive technologies, hemodynamic monitoring has been surrounded by many questions regarding its usefulness and its ultimate impact on patient prognosis. The Cardiological Intensive Care and CPR Working Group (GTCIC-RCP) of the Spanish Society of Intensive Care and Coronary Units (SEMICYUC) has recently impulsed the development of an updating series in hemodynamic monitoring. Now, a final series of recommendations are presented in order to analyze essential issues in hemodynamics, with the purpose of becoming a useful tool for residents and critical care practitioners involved in the daily management of critically ill patients.

Research priorities in perioperative fluid therapy and hemodynamic monitoring: A Delphi Consensus Survey from the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR).

BACKGROUND: Research in fluid therapy and perioperative hemodynamic monitoring is difficult and expensive. The objectives of this study were to summarize these topics and to prioritize these topics in order of research importance. METHODS: Electronic structured Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care. RESULTS: 77 topics were identified and ranked in order of prioritization. Topics were categorized into themes of crystalloids, colloids, hemodynamic monitoring and others. 31 topics were ranked as essential research priority. To determine whether intraoperative hemodynamic optimization algorithms based on the invasive or noninvasive Hypotension Prediction Index versus other management strategies could decrease the incidence of postoperative complications. As well as whether the use of renal stress biomarkers together with a goal-directed fluid therapy protocol could reduce hospital stay and the incidence of acute kidney injury in adult patients undergoing non-cardiac surgery, reached the highest consensus. CONCLUSIONS: The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care will use these results to carry out the research.

[Limiting and facilitating factors of changes in the care of families of the critically ill patient]. / Elementos facilitadores y limitadores del cambio en la atención a los familiares del paciente crítico.

INTRODUCTION: Participatory action research (PAR) was conducted in an intensive care unit (UCI), with the general purpose of fostering change in clinical practice so as to improve the care offered to families of critically ill patients. As a result of this process, four change-related initiatives were introduced. One specific additional objective was to explore how the unit's background context limited or facilitated change. This paper presents findings based on this objective. MATERIALS AND METHODS: Qualitative methodology. DESIGN: Participatory-action research (PAR). DATA GATHERING TECHNIQUES: 11 discussion groups incorporating professionals, 5 in-depth interviews with professionals, field diaries kept by the participants, and field diary kept by the lead researcher. Eleven professionals took part in the discussion groups (each one conveyed information made known to them by 3-5 colleagues), 5 professionals were involved in the interviews, and 11 professionals filled in a field diary. A content analysis was performed. RESULTS: Factors limiting change included: 1) Not acknowledging the legitimacy of scientific evidence regarding the families of critically ill patients; 2) Imbalanced power relationships among the members of multi-disciplinary teams; 3) Nurses' lack of involvement in information flow; 4) The organization of time and physical space in the unit. Factors facilitating change: 1) A sense of individual and shared commitment; 2) Leadership in day-to-day matters; 3) A process based on reflection. CONCLUSIONS: A process of participatory action research can lead to change in clinical practice, although this is complex and requires substantial input in terms of personal energy. Contextual factors limiting this change are related to the actual structure of the unit, while factors facilitating it are circumstantial ones and are dependent upon individual people. In this sense, professionals working at the bedside are capable of introducing changes to the context in which they work.

[Objectives of hemodynamic resuscitation]. / Objetivos de la reanimación hemodinámica.

Cardiovascular failure or shock, of any etiology, is characterized by ineffective perfusion of body tissues, inducing derangements in the balance between oxygen delivery and consumption. Impairment in oxygen availability on the cellular level causes a shift to anaerobic metabolism, with an increase in lactate and hydrogen ion production that leads to lactic acidosis. The degree of hyperlactatemia and metabolic acidosis will be directly correlated to the development of organ failure and poor outcome of the individuals. The amount of oxygen available at the tissues will depend fundamentally on an adequate level of perfusion pressure and oxygen delivery. The optimization of these two physiologic parameters can re-establish the balance between oxygen delivery and consumption on the cellular level, thus, restoring the metabolism to its aerobic paths. Monitoring variables such as lactate and oxygen venous saturations (either central or mixed) during the initial resuscitation of shock will be helpful to determine whether tissue hypoxia is still present or not. Recently, some new technologies have been developed in order to evaluate local perfusion and microcirculation, such as gastric tonometry, near-infrared spectroscopy and videomicroscopy. Although monitoring these regional parameters has demonstrated its prognostic value, there is a lack of evidence regarding to its usefulness during the resuscitation process. In conclusion, hemodynamic resuscitation is still based on the rapid achievement of adequate levels of perfusion pressure, and then on the modification of oxygen delivery variables, in order to restore physiologic values of ScvO(2)/SvO(2) and resolve lactic acidosis and/or hyperlactatemia.

Clinical risk factors for early mortality in patients with community-acquired septic shock. The importance of adequate source control.

OBJECTIVE: To evaluate the incidence and risk factors for early mortality (EM) in the ICU in patients with community-acquired septic shock (CASS). DESIGN: A retrospective cohort study of patients with CASS admitted to the ICU (2003-2016). SETTING: ICU at a University Hospital in Spain. PATIENTS: All consecutive patients admitted to the ICU with CASS. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: CASS was defined according to the Sepsis-3 definitions. EM were defined as occurring within of 72h following ICU admission. A multinomial logistic regression analysis was performed to identify the risk factors associated with early deaths. RESULTS: During the study period, 625 patients met the Sepsis-3 criteria and admitted with CASS. 14.4% of all patients died within the first 72h. Of 161 patients who died in the ICU, 90 (55.9%) died within the first 72h. The percentage of early and late mortality did not vary significantly during the study period. The need and adequacy of source control were significantly lower in patients with EM. In the multivariate analysis, ARDS, non-respiratory infections, bacteremia and severity at admission were variables independently associated with EM. The only factor that decreased EM was adequate source control in patients with infections amenable to source control. CONCLUSIONS: The incidence of EM has remained stable over time, which means that more than half of the patients who die from CASS do so within the first 72h. Infections where adequate source control can be performed have lower EM.

Clinical risk factors for early mortality in patients with community-acquired septic shock. The importance of adequate source control.

OBJECTIVE: To evaluate the incidence and risk factors for early mortality (EM) in the ICU in patients with community-acquired septic shock (CASS). DESIGN: A retrospective cohort study of patients with CASS admitted to the ICU (2003-2016). SETTING: ICU at a University Hospital in Spain. PATIENTS: All consecutive patients admitted to the ICU with CASS. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: CASS was defined according to the Sepsis-3 definitions. EM were defined as occurring within of 72h following ICU admission. A multinomial logistic regression analysis was performed to identify the risk factors associated with early deaths. RESULTS: During the study period, 625 patients met the Sepsis-3 criteria and admitted with CASS. 14.4% of all patients died within the first 72h. Of 161 patients who died in the ICU, 90 (55.9%) died within the first 72h. The percentage of early and late mortality did not vary significantly during the study period. The need and adequacy of source control were significantly lower in patients with EM. In the multivariate analysis, ARDS, non-respiratory infections, bacteremia and severity at admission were variables independently associated with EM. The only factor that decreased EM was adequate source control in patients with infections amenable to source control. CONCLUSIONS: The incidence of EM has remained stable over time, which means that more than half of the patients who die from CASS do so within the first 72h. Infections where adequate source control can be performed have lower EM.

Central venous-to-arterial carbon dioxide difference combined with arterial-to-venous oxygen content difference (PcvaCO2/CavO2) reflects microcirculatory oxygenation alterations in early septic shock.

PURPOSE: To explore the relationship between central venous-to-arterial carbon dioxide difference (PcvaCO2), PcvaCO2/arterial-venous oxygen content difference ratio (PcvaCO2/CavO2) and the microcirculatory status, evaluated by using near-infrared spectroscopy, in septic shock patients. METHODS: Observational study in a 30-bed mixed ICU. Fifty septic shock patients within the first 24 h of ICU admission were studied. After restoration of mean arterial pressure, hemodynamic, metabolic and microcirculatory parameters were simultaneously evaluated. Local tissue oxygen saturation (StO2), and local hemoglobin index (THI) were measured on the thenar eminence by means of near-infrared spectroscopy. A transient vascular occlusion test was performed in order to obtain StO2 deoxygenation rate (DeO2), local oxygen consumption (nirVO2), and reoxgenation rate (ReO2). RESULTS: At inclusion, increased PcvaCO2 values were associated with lower StO2 and THI, whereas increased PcvaCO2/CavO2 values were associated with lower DeO2, nirVO2, and ReO2. Multiple regression models confirmed the association between PcvaCO2/CavO2 and nirVO2, while PcvaCO2 was only related to CI, and not to microcirculatory parameters. CONCLUSIONS: In a population of early septic shock patients, increases in PcvaCO2 and PcvaCO2/CavO2 reflected different alterations at the microcirculatory level. While PcvaCO2 was related to global flow, the PcvaCO2/CavO2 ratio was associated to impaired local oxygen utilization and diminished microvascular reactivity.

[Congenital neck mass. Diagnosis and treatment]. / Malformaciones congénitas del cuello. Diagnóstico y tratamiento.

Congenital neck masses are a challenge for general practitioners and specialists. Although some of them are diagnosed in utero, most of them remain silent until complications appear in the adult age. The anatomical location, consistency and age are determinants in guiding the possible diagnosis. A midline infrahyoid mass may be a thyroglossal cyst, however a lateral neck mass is more possible to result in a brachial cyst. Complementary imaging studies are essential such as pathological tests like needle aspiration fine needle aspiration (FNA).

Skeletal muscle oxygen saturation (StO2) measured by near-infrared spectroscopy in the critically ill patients.

According to current critical care management guidelines, the overall hemodynamic optimization process seeks to restore macrocirculatory oxygenation, pressure, and flow variables. However, there is increasing evidence demonstrating that, despite normalization of these global parameters, microcirculatory and regional perfusion alterations might occur, and persistence of these alterations has been associated with worse prognosis. Such observations have led to great interest in testing new technologies capable of evaluating the microcirculation. Near-infrared spectroscopy (NIRS) measures tissue oxygen saturation (StO2) and has been proposed as a noninvasive system for monitoring regional circulation. The present review aims to summarize the existing evidence on NIRS and its potential clinical utility in different scenarios of critically ill patients.

[Giant enchondroma of the thumb distal phalanx. Presentation of a case and review of the literature]. / Encondroma gigante falange distal del pulgar. A propósito de un caso y revisión de la bibliografía.

We report on a case of giant enchondroma of the distal phalanx of the thumb, with a significant degree of clinical and radiographic deformity. It is extremely rare in this location and its treatment should be surgical, with curettage of the lesional cavity and filling with autologous bone graft. In this case, we performed a differential diagnosis of a giant cell tumour and aneurysmatic bone cyst (X-ray and nuclear magnetic resonance [NMR]).

Prognostic implications of tissue oxygen saturation in human septic shock.

PURPOSE: To analyze the prognostic value of tissue oxygen saturation (StO(2)) in septic shock patients with restored mean arterial pressure (MAP). METHODS: This was a prospective observational study of patients admitted to the ICU in the early phase of septic shock, after restoration of MAP. Demographic data, severity score, hemodynamics, blood lactate, acid-base status, and StO(2) were measured at inclusion followed by a transient vascular occlusion test (VOT) to obtain the StO(2)-deoxygenation (DeOx) and StO(2)-reoxygenation (ReOx) rates. Sequential organ failure assessment (SOFA) score was measured at inclusion and after 24 h. RESULTS: Thirty-three patients were studied. StO(2) was 76 ± 10%, DeOx -12.2 ± 4.2%/min, and ReOx 3.02 ± 1.70%/s. MAP showed a significant correlation with VOT-derived slopes (r = -0.4, p = 0.04 for DeOx; and r = 0.55, p < 0.01 for ReOx). After 24 h, 17 patients (52%) had improved SOFA scores. Patients who did not improve their SOFA showed less negative DeOx values at inclusion. The association between DeOx and SOFA evolution was not affected by MAP. Both DeOx and ReOx impairment correlated with longer ICU stay (r = 0.44, p = 0.05; and r = -0.43, p = 0.05, respectively). CONCLUSIONS: In a population of septic shock patients with restored MAP, impaired DeOx was associated with no improvement in organ failures after 24 h. Decrements in DeOx and ReOx were associated with longer ICU stay. DeOx and ReOx were linked to MAP, and thus, their interpretation needs to be made relative to MAP.