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Background: During the first wave of the COVID-19 pandemic, different clinical phenotypes were published. However, none of them have been validated in subsequent waves, so their current validity is unknown. The aim of the study is to validate the unsupervised cluster model developed during the first pandemic wave in a cohort of critically ill patients from the second and third pandemic waves. Methods: Retrospective, multicentre, observational study of critically ill patients with confirmed COVID-19 disease and acute respiratory failure admitted from 74 Intensive Care Units (ICU) in Spain. To validate our original phenotypes model, we assigned a phenotype to each patient of the validation cohort using the same medoids, the same number of clusters (n= 3), the same number of variables (n= 25) and the same discretisation used in the development cohort. The performance of the classification was determined by Silhouette analysis and general linear modelling. The prognostic models were validated, and their performance was measured using accuracy test and area under curve (AUC)ROC. Results: The database included a total of 2,033 patients (mean age 63[53-92] years, 1643(70.5%) male, median APACHE II score (12[9-16]) and SOFA score (4[3-6]) points. The ICU mortality rate was 27.2%. Although the application of unsupervised cluster analysis classified patients in the validation population into 3 clinical phenotypes. Phenotype A (n=1,206 patients, 59.3%), phenotype B (n=618 patients, 30.4%) and phenotype C (n=506 patients, 24.3%), the characteristics of patients within each phenotype were significantly different from the original population. Furthermore, the silhouette coefficients were close to or below zero and the inclusion of phenotype classification in a regression model did not improve the model performance (accuracy =0.78, AUC=0.78) with respect to a standard model (accuracy = 0.79, AUC=0.79) or even worsened when the model was applied to patients within each phenotype (accuracy = 0.80, AUC 0.77 for Phenotype A, accuracy=0.73, AUC= 0.67 for phenotype B and accuracy= 0.66 , AUC= 0.76 for phenotype C ) Conclusion: Models developed using machine learning techniques during the first pandemic wave cannot be applied with adequate performance to patients admitted in subsequent waves without prior validation. Trial Registration: The study was retrospectively registered (NCT 04948242) on June 30, 2021

Graphical abstract Fx1, Objetivo: Evaluar si el uso de corticoesteroides (Cs) se asocia con la mortalidad en la unidad de cuidados intensivos (UCI) en la población global y dentro de los fenotipos clínicos predeterminados Diseño: Análisis secundario de estudio multicéntrico observacional Ámbito: UCI Pacientes: Pacientes adultos con COVID-19 confirmado ingresados en 63 UCIs de España Intervención: Corticoides vs. no Corticoides Variables de interés principales: A partir del análisis no supervisado de grupos, 3 fenotipos clínicos fueron derivados y clasificados como: A: grave, B: critico and C: potencialmente mortal. Se efectuó un análisis multivariado después de un propensity optimal full matching (PS) y una regresión ponderada de Cox (HR) y análisis de Fine-Gray (sHR) para evaluar el impacto del tratamiento con Cs sobre la mortalidad en la población general y en cada fenotipo clínico. Resultados: Un total de 2.017 pacientes fueron analizados, 1.171(58%) con Cs. Después del PS, el uso de Cs no se relacionó significativamente con la mortalidad en UCI (OR:1.0,95%CI:0.98-1.15). Cs fueron administrados en 298/537(55.5%) pacientes del fenotipo “A” y no se observó asociación significativa con la mortalidad (HR=0.85[0.55-1.33]). Un total de 338/623(54.2%) pacientes del fenotipo “B” recibieron Cs sin efecto significativo sobre la mortalidad (HR=0.72[0.49-1.05]). Finalmente, 535/857(62.4%) pacientes del fenotipo “C” recibieron Cs. En este fenotipo, se evidenció un efecto protector de los Cs sobre la mortalidad HR (0.75[0.58-0.98]). Conclusión: Nuestros hallazgos alertan sobre el uso indiscriminado de Cs a dosis moderadas en todos los pacientes críticos con COVID-19. Solamente pacientes con elevado estado de inflamación podrían beneficiarse con el tratamiento con Cs.

Las infecciones se han convertido en una de las principales complicaciones de los pacientes con neumonía grave por SARS-CoV-2 que ingresan en UCI. El deficiente estado inmunitario, el desarrollo frecuente de fracaso orgánico con necesidad de tratamientos de soporte invasivos y las estancias prolongadas en áreas estructurales en gran medida saturadas de enfermos son factores de riesgo para el desarrollo de infecciones. El Grupo de Trabajo de Enfermedades Infecciosas y Sepsis GTEIS de la Sociedad Española de Medicina Intensiva y Unidades Coronarias SEMICYUC enfatiza la importancia de las medidas de prevención de infecciones relacionadas con los cuidados sanitarios, y de la detección y tratamiento precoz de las principales infecciones en el paciente con infección por SARS-CoV-2. La coinfección bacteriana, las infecciones respiratorias relacionadas con la ventilación mecánica, bacteriemia relacionada con el catéter, infección del tracto urinario asociado a dispositivo e infecciones oportunistas son desarrolladas. Infections have become one of the main complications of patients with severe SARS-CoV-2 pneumonia admitted in ICU. Poor immune status, frequent development of organic failure requiring invasive supportive treatments, and prolonged ICU length of stay in saturated structural areas of patients are risk factors for infection development. The Working Group on Infectious Diseases and Sepsis GTEIS of the Spanish Society of Intensive Medicine and Coronary Units SEMICYUC emphasizes the importance of infection prevention measures related to health care, the detection and early treatment of major infections in the patient with SARS-CoV-2 infections. Bacterial co-infection, respiratory infections related to mechanical ventilation, catheter-related bacteremia, device-associated urinary tract infection and opportunistic infections are review in the document.

Background More than 20% of hospitalized patients with COVID-19 demonstrate ARDS requiring ICU admission. The long-term respiratory sequelae in such patients remain unclear. Research Question What are the major long-term pulmonary sequelae in critical patients who survive COVID-19? Study Design and Methods Consecutive patients with COVID-19 requiring ICU admission were recruited and evaluated 3 months after hospitalization discharge. The follow-up comprised symptom and quality of life, anxiety and depression questionnaires, pulmonary function tests, exercise test (6-min walking test [6MWT]), and chest CT imaging. Results One hundred twenty-five patients admitted to the ICU with ARDS secondary to COVID-19 were recruited between March and June 2020. At the 3-month follow-up, 62 patients were available for pulmonary evaluation. The most frequent symptoms were dyspnea (46.7%) and cough (34.4%). Eighty-two percent of patients showed a lung diffusing capacity of less than 80%. The median distance in the 6MWT was 400 m (interquartile range, 362-440 m). CT scans showed abnormal results in 70.2% of patients, demonstrating reticular lesions in 49.1% and fibrotic patterns in 21.1%. Patients with more severe alterations on chest CT scan showed worse pulmonary function and presented more degrees of desaturation in the 6MWT. Factors associated with the severity of lung damage on chest CT scan were age and length of invasive mechanical ventilation during the ICU stay. Interpretation Three months after hospital discharge, pulmonary structural abnormalities and functional impairment are highly prevalent in patients with ARDS secondary to COVID-19 who required an ICU stay. Pulmonary evaluation should be considered for all critical COVID-19 survivors 3 months after discharge.

Resumen Ante la situacion excepcional de salud publica provocada por la pandemia por COVID-19, desde el grupo de etica de la Sociedad Espanola de Medicina Intensiva, Critica y Unidades Coronarias (SEMICYUC) se ha promovido un trabajo de consenso con el objetivo de encontrar algunas respuestas desde la etica a la encrucijada entre el incremento de personas con necesidades de atencion intensiva y la disponibilidad efectiva de medios. En un periodo muy corto de tiempo se ha cambiado el marco de ejercicio de la medicina hacia un escenario de «medicina de catastrofe», con el consecuente cambio en los parametros de toma de decisiones. En este contexto la asignacion de recursos o la priorizacion de tratamiento pasan a ser elementos cruciales, y es importante contar con un marco de referencia etico para poder tomar las decisiones clinicas necesarias. Para ello, se ha realizado un proceso de revision narrativa de la evidencia, seguida de un consenso de expertos no sistematizado, que ha tenido como resultado tanto la publicacion de un documento de posicionamiento y recomendaciones de la propia SEMICYUC, como el consenso entre 18 sociedades cientificas y 5 institutos/catedras de bioetica y cuidados paliativos de un documento marco de referencia de recomendaciones eticas generales en este contexto de crisis.

Resumen La pandemia por COVID-19 ha provocado el ingreso de un elevado numero de pacientes en UCI, generalmente por insuficiencia respiratoria severa. Desde la aparicion de los primeros casos de infeccion por SARS-CoV-2, a finales de 2019, en China, se ha publicado una cantidad ingente de recomendaciones de tratamiento de esta entidad, no siempre respaldadas por evidencia cientifica suficiente ni con el rigor metodologico necesario. Gracias al esfuerzo de distintos grupos de investigadores, actualmente disponemos de resultados de ensayos clinicos, y otro tipo de estudios, de mayor calidad. Consideramos necesario realizar un documento que incluya recomendaciones que recojan estas evidencias en cuanto al diagnostico y tratamiento de la COVID-19, pero tambien aspectos que otras guias no han contemplado y que consideramos fundamentales en el manejo del paciente critico con COVID-19. Para ello se ha creado un comite redactor, conformado por miembros de los Grupos de Trabajo de SEMICYUC mas directamente relacionados con diferentes aspectos especificos del manejo de estos pacientes.

PURPOSE: Ventilator associated-lower respiratory tract infections (VA-LRTIs), either ventilator-associated pneumonia (VAP) or tracheobronchitis (VAT), accounts for most nosocomial infections in intensive care units (ICU) including. Our aim was to determine if appropriate antibiotic treatment in patients with VA-LRTI will effectively reduce mortality in patients who had cardiovascular failure.METHODS: This was a pre-planned subanalysis of a large prospective cohort of mechanically ventilated patients for at least 48 h in eight countries in two continents. Patients with a modified Sequential Organ Failure Assessment (mSOFA) cardiovascular score of 4 (at the time of VA-LRTI diagnosis and needed be present for at least 12 h) were defined as having cardiovascular failure.RESULTS: VA-LRTI occurred in 689 (23.2%) out of 2960 patients and 174 (25.3%) developed cardiovascular failure. Patients with cardiovascular failure had significantly higher ICU mortality than those without (58% vs. 26.8%; p CONCLUSIONS: Patients with VA-LRTI and cardiovascular failure did not show an association to a higher ICU survival with appropriate antibiotic treatment. Additionally, we found that in patients without cardiovascular failure, appropriate antibiotic treatment conferred a survival benefit for patients only with VAP.TRIAL REGISTRY: ClinicalTrials.gov, number NCT01791530.

espanolLa infeccion grave y su evolucion a sepsis son cada vez mas frecuentes y se encuentran entre las principales causas de enfermedad critica y mortalidad. El manejo adecuado es crucial para mejorar el pronostico. Este documento desarrolla tres puntos esenciales que tienen un impacto significativo en este objetivo: a) el reconocimiento temprano de los pacientes que cumplen los criterios de sepsis, b) la identificacion de aquellos pacientes que sufren una infeccion y tienen un alto riesgo de progresar a sepsis, y c) realizar una correcta eleccion y optimizacion del tratamiento antimicrobiano inicial. EnglishSevere infection and its evolution to sepsis are becoming more prevalent every day and are among the leading causes of critical illness and mortality. Proper management is crucial to improve prognosis. This document addresses three essential points that have a significant impact on this objective: a) early recognition of patients with sepsis criteria, b) identification of those patients who suffer from an infection and have a high risk of progressing to sepsis, and c) adequate selection and optimization of the initial antimicrobial treatment.

BACKGROUND: Mortality rates for patients with ARDS remain high. We assessed temporal changes in the epidemiology and management of ARDS patients requiring invasive mechanical ventilation in European ICUs. We also investigated the association between ventilatory settings and outcome in these patients. METHODS: This was a post hoc analysis of two cohorts of adult ICU patients admitted between May 1-15, 2002 (SOAP study, n = 3147), and May 8-18, 2012 (ICON audit, n = 4601 admitted to ICUs in the same 24 countries as the SOAP study). ARDS was defined retrospectively using the Berlin definitions. Values of tidal volume, PEEP, plateau pressure, and FiO2 corresponding to the most abnormal value of arterial PO2 were recorded prospectively every 24 h. In both studies, patients were followed for outcome until death, hospital discharge or for 60 days. RESULTS: The frequency of ARDS requiring mechanical ventilation during the ICU stay was similar in SOAP and ICON (327[10.4%] vs. 494[10.7%], p = 0.793). The diagnosis of ARDS was established at a median of 3 (IQ: 1-7) days after admission in SOAP and 2 (1-6) days in ICON. Within 24 h of diagnosis, ARDS was mild in 244 (29.7%), moderate in 388 (47.3%), and severe in 189 (23.0%) patients. In patients with ARDS, tidal volumes were lower in the later (ICON) than in the earlier (SOAP) cohort. Plateau and driving pressures were also lower in ICON than in SOAP. ICU (134[41.1%] vs 179[36.9%]) and hospital (151[46.2%] vs 212[44.4%]) mortality rates in patients with ARDS were similar in SOAP and ICON. High plateau pressure (> 29 cmH2O) and driving pressure (> 14 cmH2O) on the first day of mechanical ventilation but not tidal volume (> 8 ml/kg predicted body weight [PBW]) were independently associated with a higher risk of in-hospital death. CONCLUSION: The frequency of and outcome from ARDS remained relatively stable between 2002 and 2012. Plateau pressure > 29 cmH2O and driving pressure > 14 cmH2O on the first day of mechanical ventilation but not tidal volume > 8 ml/kg PBW were independently associated with a higher risk of death. These data highlight the continued burden of ARDS and provide hypothesis-generating data for the design of future studies., SCOPUS: ar.j, info:eu-repo/semantics/published

In view of the exceptional public health situation caused by the COVID-19 pandemic, a consensus work has been promoted from the ethics group of the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC), with the objective of finding some answers from ethics to the crossroads between the increase of people with intensive care needs and the effective availability of means. In a very short period, the medical practice framework has been changed to a 'catastrophe medicine' scenario, with the consequent change in the decision-making parameters. In this context, the allocation of resources or the prioritization of treatment become crucial elements, and it is important to have an ethical reference framework to be able to make the necessary clinical decisions. For this, a process of narrative review of the evidence has been carried out, followed by a unsystematic consensus of experts, which has resulted in both the publication of a position paper and recommendations from SEMICYUC itself, and the consensus between 18 scientific societies and 5 institutes/chairs of bioethics and palliative care of a framework document of reference for general ethical recommendations in this context of crisis. (C) 2020 Published by Elsevier Espana, S.L.U.

PURPOSE: To determine clinical predictors associated with corticosteroid administration and its association with ICU mortality in critically ill patients with severe influenza pneumonia. METHODS: Secondary analysis of a prospective cohort study of critically ill patients with confirmed influenza pneumonia admitted to 148 ICUs in Spain between June 2009 and April 2014. Patients who received corticosteroid treatment for causes other than viral pneumonia (e.g., refractory septic shock and asthma or chronic obstructive pulmonary disease [COPD] exacerbation) were excluded. Patients with corticosteroid therapy were compared with those without corticosteroid therapy. We use a propensity score (PS) matching analysis to reduce confounding factors. The primary outcome was ICU mortality. Cox proportional hazards and competing risks analysis was performed to assess the impact of corticosteroids on ICU mortality. RESULTS: A total of 1846 patients with primary influenza pneumonia were enrolled. Corticosteroids were administered in 604 (32.7%) patients, with methylprednisolone the most frequently used corticosteroid (578/604 [95.7%]). The median daily dose was equivalent to 80 mg of methylprednisolone (IQR 60-120) for a median duration of 7 days (IQR 5-10). Asthma, COPD, hematological disease, and the need for mechanical ventilation were independently associated with corticosteroid use. Crude ICU mortality was higher in patients who received corticosteroids (27.5%) than in patients who did not receive corticosteroids (18.8%, p

Importance End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time.Objective To determine the changes in end-of-life practices in European ICUs after 16 years.Design, Setting, and Participants Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision.Exposures Comparison between the 1999-2000 cohort vs 2015-2016 cohort.Main Outcomes and Measures End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists.Results Of 13 625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P Conclusions and Relevance Among patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations. Importance: End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time. Objective: To determine the changes in end-of-life practices in European ICUs after 16 years. Design, Setting, and Participants: Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision. Exposures: Comparison between the 1999-2000 cohort vs 2015-2016 cohort. Main Outcomes and Measures: End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists. Results: Of 13625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P

Objective: The objective of this study was to evaluate the impact of the empirical therapy with fluconazole or an echinocandin on 30- and 90-day mortality in critically ill patients with candidemia. The outcome of patients in whom the empirical echinocandin was deescalated to fluconazole was also assessed. Design: Retrospective, observational multicenter study. Setting: Medical and surgical ICUs in nine Spanish hospitals. Patients: Adult patients ( 18 yr) with an episode of Candida bloodstream infection during ICU admission from January 2011 to April 2016. Interventions: Patient characteristics, infection-related variables, therapeutic interventions, and metastatic complications were reviewed. A propensity score-adjusted multivariable analysis was performed to identify the risk factors significantly associated with 30-day and 90-day mortality. Measurements and Main Results: A total of 294 patients were diagnosed of candidemia in the participant ICUs. Sixty patients were excluded (other antifungals in the primary therapy or the patient died without empirical antifungal therapy). The study group comprised 115 patients who received fluconazole (30-day mortality, 37.4%) and 119 patients treated empirically with an echinocandin (30-day mortality, 31.9%). The use of an echinocandin in the empirical therapy was a protective factor for 30-day (odds ratio, 0.32; 95% CI, 0.16-0.66; p = 0.002) and 90-day mortality (odds ratio, 0.50; 95% CI, 0.27-0.93; p = 0.014) in the propensity score- adjusted multivariable analysis. Deescalation of the empirical echinocandin to fluconazole was not associated with a higher mortality or the occurrence of long-term complications. Conclusions: Empirical use of an echinocandin in critically ill patients with documented candidemia reduces mortality at 30 and 90 days significantly. Deescalation of the empirical echinocandin to fluconazole is safe and effective in fluconazole-susceptible infections.

The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients. (C) 2017 Elsevier Espana, S.L.U. y SEMICYUC. All rights reserved.

Introduction: Pandemic Influenza A (H 1 N 1 )v pneumonia has led to a notable increase of admissions to intensive care units. A cytokine-mediated inflammatory response has been well documented in pneumonia and acute respiratory distress syndrome. However, few studies have focused on the role of these inflammatory mediators in infections caused by the Influenza A (H 1 N 1 )v. In this study, we assess the inflammatory response mediated by cytokines at the local and systemic levels in three cases of severe pneumonia caused by Influenza A (H 1 N 1 ) virus. Methodology: Serum and bronchoalveolar lavage samples were obtained from three mechanically ventilated patients diagnosed with Influenza A (H1N1) virus pneumonia by bronchoscopic bronchoalveolar lavage. Levels of interleukin 6 (IL-6), interleukin 8 (IL-8), tumour necrosis factor alpha (TNFα) and interleukin 1 beta (IL-1s) were meassured in these samples by enzyme-linked immunosorbent assay (ELISA). Results: High levels of C Reactive Protein, Procalcitonin below 1 ng/ml and absence of leukocytosis were common findings in all patients. TNF α and IL-1s were not detected in the serum. IL-6 levels in serum were (94, pg/ml, 77 pg/ml and 84 pg/ml) respectively in the three patients, while IL-8 levels were (30,2 pg/ml, 128 pg/ml and 40,5 pg/ml). In the BAL samples, only one of the analysed cytokines, IL-1s was present at detectable levels in two patients (21 pg/ml and 11 pg/ml respectively). Conclusions: Our results support previous findings which suggest that high levels of IL-6 and IL-8 in serum somehow participate in the inflammatory response in severe cases of pandemic influenza pneumonia.

Resumen Objetivo Evaluar la relacion entre el resultado microbiologico y la concentracion de citoquinas en el lavado broncoalveolar (LBA). Diseno Estudio prospectivo observacional. Ambito Unidad de cuidados intensivos (UCI) medicoquirurgica de 17 camas. Pacientes Enfermos consecutivos en ventilacion mecanica con sospecha clinica de neumonia ingresados en UCI durante un periodo de 27 meses. Intervenciones Se realizo LBA con 150 ml de suero salino fisiologico repartidos en 3 alicuotas de 50 ml, durante el procedimiento no se utilizaron anestesicos locales. Una muestra del LBA fue procesada para su estudio microbiologico, otra cantidad de LBA se envio a laboratorio para medicion de las siguientes citoquinas: interleuquina (IL) 6, IL 8, factor de necrosis tumoral alfa (TNF-α), factor estimulante de crecimiento de granulocitos (G-CSF) y factor estimulante de crecimiento de granulocitos y monocitos. Principales variables de interes Edad, APACHE II al ingreso, dias en ventilacion mecanica, estancia en UCI, mortalidad, antibioterapia previa, resultado microbiologico y concentracion de citoquinas en el LBA. Resultados 59 enfermos fueron incluidos, la mayoria se encontraban con antibioterapia previa (79,7%). En el analisis microbiologico 22 pacientes (37,2%) presentaron LBA positivo. En el grupo de enfermos con LBA positivo la concentracion de TNF-α fue mas alta de forma significativa con respecto al grupo con LBA negativo. Conclusiones Hay una correlacion significativa entre el resultado microbiologico y la concentracion de TNF-α en el LBA. En enfermos en ventilacion mecanica, la concentracion de TNF-α en el LBA se ha asociado al resultado positivo del cultivo a pesar de antibioterapia previa.

Objetivo Evaluar la utilidad diagnostica del lavado broncoalveolar (LBA) en enfermos en ventilacion mecanica con sospecha de neumonia y describir los resultados clinicos de los diferentes tipos de neumonia en enfermos criticos. Diseno Estudio descriptivo. Ambito Unidad de cuidados intensivos (UCI) medico-quirurgica de 17 camas. Pacientes Enfermos ingresados en UCI desde noviembre de 2003 a marzo de 2006 con ventilacion mecanica y sospecha clinica de neumonia a quienes se realizo LBA. Intervenciones Se realizo LBA a traves de tubo orotraqueal con 150 ml de suero salino fisiologico, repartidos en tres alicuotas de 50 ml; la muestra se proceso para estudio microbiologico. Principales variables de interes Edad, APACHE II al ingreso, dias en ventilacion mecanica, estancia en UCI, mortalidad y agentes etiologicos aislados en el LBA. Resultados Se incluyo a 96 pacientes a quienes se realizo LBA; se distinguieron 4 grupos: neumonia adquirida en la comunidad (NAC), 12 casos; neumonia asociada a ventilacion mecanica (NAVM) precoz, 26 casos. NAVM tardia, 43 casos, y neumonia en enfermos inmunodeficientes, 15 casos. El LBA fue positivo (> 10.000 ufc/ml) en 40 (41,7%) pacientes (2 con NAC, 16 con NAVM precoz, 17 con NAVM tardia, 5 con neumonia e inmunodeficiencia). La mortalidad fue del 33,3, el 26,9, el 25,6 y el 73,3% en NAC, NAVM precoz, NAVM tardia e inmunodeficientes, respectivamente. Conclusiones La escasa sensibilidad del LBA en la NAC corrobora la actitud de limitar su indicacion solo a casos seleccionados. En el grupo de enfermos inmunodeficientes la mortalidad fue muy elevada. El LBA, segun nuestra limitada experiencia, tiene su mayor utilidad en el diagnostico de NAVM.

La monitorización hemodinámica es un elemento clave en el cuidado de los pacientes críticos, proporcionando una ayuda incuestionable en la asistencia al diagnóstico y en la elección de un tratamiento adecuado. Los dispositivos mínimamente invasivos han ido emergiendo durante los últimos años como una alternativa eficaz frente a las herramientas clásicas de monitorización. Entre ellos el eco-doppler esofágico, que permite, mediante la medición de la velocidad del flujo sanguíneo y el diámetro de la aorta torácica descendente, una monitorización continua y mínimamente invasiva del gasto cardíaco, además de otros parámetros igualmente útiles, proporcionando una visión suficientemente amplia del estado hemodinámico del paciente y facilitando la detección precoz de los cambios producidos por un deterioro clínico brusco. Aunque varios estudios han demostrado la utilidad del doppler esofágico en el ámbito quirúrgico, existe una evidencia escasa y dispersa en la literatura sobre el beneficio de esta herramienta en los pacientes críticos. Sin embargo, sus ventajas lo convierten en un atractivo elemento a tener en consideración dentro del arsenal diagnóstico de cuidados intensivos. El propósito del siguiente artículo es describir el funcionamiento, el grado de validación con otros métodos de monitorización y el papel del eco-doppler esofágico en la práctica clínica como herramienta de monitorización mínimamente invasiva del gasto cardíaco, aportando nuestra experiencia en el paciente crítico.

400,000 incidents of sea drowning take place every year. We report the case of a woman, 34 years old, attended on the beach by external hospital emergency services after suffering immersion in seawater resulting in drowning due to acute respiratory failure. She was admitted to the critical care unit and an emergency fiberoptic bronchoscopy was performed, extracting a large quantity of sand and algae. The respiratory function improved and FiO2 requirements were gradually reduced following the procedure. After 8 days of mechanical ventilation the patient was extubated, with good clinical tolerance and was transferred to a ward.

Little is known on the participation of immunoglobulin isotypes and subclasses in the pathogenesis of the severe disease caused by the pandemic influenza virus (influenza A(H1N1)pdm09).(1) To evaluate the association between plasma levels of IgG1, IgG2, IgG3, IgG4, IgA, IgM, IgE and outcome in patients with severe pandemic influenza. (2) To evaluate the association between immunoglobulin and cytokine levels in these patients.40 critically ill patients with community acquired pneumonia and influenza A(H1N1)pdm09 infection were recruited from November 2010 to February 2011. Plasma samples were collected during the first 24h following admission to the ICU. Immunoglobulins and 17 major cytokines were profiled in plasma.15 patients died (37.5%). When the association between clinical variables and prognosis was assessed, prior immunosuppression, APACHE II score, levels of IgG2 and levels of IgM were associated with outcome in a univariate Cox regression analysis. Kaplan Meier analysis showed that patients with levels of IgG2 and IgM59 and58 mg/dl respectively died earlier. Multivariate Cox regression analysis showed that APACHE II score and levels of IgM were the best predictors of outcome, being levels of IgM a protective factor against mortality. IgM was the immunoglobulin showing the largest number of negative correlations with cytokine levels.Our results support a central role of IgM in preventing uncontrolled inflammatory response and mortality in severe pandemic influenza. Early assessment of IgM could contribute to guide clinical decisions in these patients.

Usefulness of CURB-65 and pneumonia severity index for influenza A H1N1v pneumonia. A. Estella.Different prognostic scales have been documented to assess the severity and indications for hospitalization and ICU admissions of community acquired pneumonia. During the past two years Influenza A H1N1v infections have been commonly attended to in emergency departments. The aim of the study was to analyse the usefulness of the application of the Pneumonia Severity Index (PSI) and CURB-65 prognostic scales in patients with primary viral pneumonia caused by influenza A H1N1v.A retrospective study was performed at a community hospital with a 17 bed-intensive care unit. Patients admitted in hospital with influenza A H1N1v pneumonia over a two year period were analysed. CURB 65 and PSI scales were applied in the emergency department and outcome and destination of admission were analysed.24 patients were registered, 19 required ICU admission and 5 patients were admitted in medical wards. Most of the patients admitted to the intensive care unit (78.9%) required mechanical ventilation. Mortality was 21.1%. Most patients admitted to the ICU had CURB 65 scale of 1 (60%), 13.3% obtained 0 and 26.7% 2. PSI scale resulted class I in a 20%, class II 40%, 26.7% class IV and 13.3% class V. The scales CURB 65 and PSI showed no differences in scores according to the destination of admission and mortality.Use of CURB-65 and PSI in the emergency department may underestimate the risk of patients with Influenza A H1N1v pneumonia. Based in our results, the ability of these scales to predict ICU admissions for Influenza A H1N1v pneumonia is questioned.

A 25-year-old woman with a personal history of a recent epidural anaesthesia for vaginal delivery. Four days later was attended in the emergency department by persistent headache. In the physical examination there was not nuchal rigidity nor neurological abnormalities. Initially hydration, analgesic drugs and lying down with bed rest were the treatment for a suspected postdural puncture headache. Due to a lack of relieve with this treatment an urgent brain CT scan was performed because of MRI was not …

The origins of bronchoscopy date back to 1897 when Gustav Killian, considered “the father of bronchoscopy”, performed the first airway examination with a rigid esophagoscope to a farmer extracting a piece of bone that had lodged in the main stem bronchus. Shigeto Ikeda in 1964 revolutionized the field of bronchoscopy with the introduction of a flexible instrument that could be introduced to sub-segmental bronchi and allowed the extraction of samples for cytological examination. Endoscopy Machida Company Ltd and Olympus Optical Company Ltd in 1966 built the first prototype of a fiberoptic bronchoscope. Since its introduction in routine clinical practice in the decade of 60 has been improved, increasing its indications. 30 years ago, rigid bronchoscope was the main instrument for the direct examination of the tracheobronchial tree; and even today is considered the choice procedure in two emergencies, haemoptysis and removal of foreign bodies.

Resumen Objetivo Describir las principales indicaciones, resultados clinicos y complicaciones de la fibrobroncoscopia en enfermos criticos. Diseno Estudio retrospectivo, observacional, de un solo centro. Ambito Unidad de Cuidados Intensivos (UCI) medico-quirurgica de 17 camas. Pacientes Pacientes consecutivos a los que se les realizo una fibrobroncoscopia durante un periodo de cinco anos. Intervenciones Fibrobroncoscopia realizada por medicos especialistas en Medicina Intensiva con fines diagnosticos y/o terapeuticos. Principales variables de interes Indicaciones y complicaciones derivadas de la fibrobroncoscopia. Resultados Se han realizado 208 fibrobroncoscopias en 192 pacientes; en el momento del procedimiento 193 (92,8%) recibian ventilacion mecanica invasiva. La edad media de los pacientes incluidos fue de 58 ± 16 anos y el APACHE II al ingreso en UCI de 19 ± 7. La mortalidad global fue del 31,3%. Las indicaciones mas frecuente fueron en 148 (71,2%) casos por sospecha clinica de neumonia y en 28 (13,5%) para resolucion de atelectasias. La fibrobroncospia fue eficaz en 120 (57,7%) casos, con resolucion de la atelectasia en 20 casos, 71,4% y obteniendo resultados positivos del LBA en 68 (46%) de los casos con sospecha de neumonia. Se han detectado 27 complicaciones menores en 208 (13%) pacientes. Las complicaciones mas frecuentes han sido: taquicardia supraventricular (3,8%), hipoxemia transitoria (6,7%) y hemorragia leve de la mucosa bronquial (2,4%). Conclusiones El diagnostico microbiologico de neumonias y la resolucion de atelectasias fueron las indicaciones mas frecuentes. La fibrobroncoscopia realizada por especialistas de Medicina Intensiva es un procedimiento eficaz y seguro.

La neumonía asociada a ventilación mecánica (NAVM) es la principal infección nosocomial acontecida en cuidados intensivos, se asocia a un aumento de la estancia en la unidad de cuidados intensivos (UCI) y hospitalaria, a un mayor consumo de antibióticos, y del coste hospitalario. El proyecto Neumonía Zero (NZ), recientemente iniciado, es sin duda un reto para los profesionales de las UCI dirigido a disminuir las altas tasas de incidencia descritas. Es necesario aclarar de qué incidencia real partimos y si el método diagnóstico utilizado influye en esta. La falta de un patrón de referencia para el diagnóstico microbiológico de NAVM ha suscitado una controversia respecto a los algoritmos diagnósticos a seguir, distinguiéndose dos estrategias que coexisten: la «no invasiva» o «clínica», basada en cultivos de vías respiratorias altas y la «invasiva», fundamentada en el uso de cultivos cuantitativos de muestras obtenidas del tracto respiratorio inferior mediante técnicas broncoscópicas. A pesar de las recomendaciones de las sociedades científicas, que no justifican la utilización del aspirado traqueal cualitativo para el diagnóstico microbiológico de la NAVM, este sigue siendo un método habitualmente utilizado. El presente artículo incide en la necesidad de que el aspirado traqueal cualitativo deje de ser un método de diagnóstico rutinario para la NAVM recomendando el uso de técnicas broncoscópicas o el aspirado traqueal cuantitativo. Ventilator associated pneumonia (VAP) is the leading nosocomial infection in intensive care. It is associated with increased ICU and hospital stay, an increased use of antibiotics, and greater hospital costs. The recently launched Pneumonia Zero project (NZ) undoubtedly constitutes a challenge for professionals in the ICU, and has been designed to reduce the high incidence rates described. It is necessary to establish the true incidence, and whether the latter is influenced by the diagnostic method employed. The lack of a reference standard for the microbiological diagnosis of VAP has generated controversy over the diagnostic algorithms to be used, with the distinction of two strategies: a noninvasive or clinical strategy based on upper respiratory tract cultures, and an invasive method based on the use of quantitative cultures of samples from the lower respiratory tract obtained by bronchoscopic techniques. Despite the recommendations of scientific societies, which do not justify the use of qualitative tracheal aspirates in the microbiological diagnosis of VAP, this method is still routinely used. This study underscores the need to stop using qualitative tracheal aspirates as a routine diagnostic method for VAP, recommending the use of bronchoscopic techniques or quantitative tracheal aspirates.

Background Diffuse alveolar haemorrhage (DAH) is a serious pulmonary complication characterised by a high mortality rate and the absence of specific treatment. The intrapulmonary administration of activated recombinant factor VII (rFVIIa) in DAH was recently published in six patients by Heslet et al with an efficient hemostatic effect. We describe two cases of DAH treated with intrapulmonary rFVIIa. Methods Two cases of DAH were admitted to the ICU after presenting abrupt desaturation, tachypnea, cough and haemoptysis, requiring orotracheal intubation and mechanical ventilation. The diagnosis was achieved by the bloody return during the bronchoalveolar lavage, during the procedure rFVIIa (50 μg/Kg in 50 ml of isotonic saline) was administered via the bronchoscope. Results Immediate cessation of bleeding was observed. Prior to intrapulmonary administration of rFVIIa, the FiO2 was 1, which was reduced to 0.4 24 hours later. Following the procedure, the haemostatic effect made blood transfusion superfluous. No thrombotic complications associated with administration of the drug were observed. After the intervention both cases progressed fast and was discharged from the ICU with no further episodes of bleeding. Conclusion 1. Local intrabronchial deposition of DAH with rFVIIa has been shown to be effective in controlling life-threatening DAH. 2. In the case described above, no thrombotic complications were observed following the intrapulmonary administration of rFVIIa.