Revistas
Revista:
BMJ SUPPORTIVE & PALLIATIVE CARE
ISSN:
2045-435X
Año:
2022
Vol.:
12
N°:
2
Págs.:
198
Revista:
REVISTA ESPAÑOLA DE ANESTESIOLOGÍA Y REANIMACION
ISSN:
0034-9356
Año:
2021
Vol.:
68
N°:
8
Págs.:
437 - 442
Objectives: The disease COVID-19 produces serious complications that can lead to cardiorespiratory arrest. Quality cardiopulmonary resuscitation (CPR) can improve patient prognosis. The objective of this study was to evaluate the performance of the specialty of Anaesthesiology in the management of CPR during the pandemic. Methods: A survey was carried out with Google Forms consisting of 19 questions. The access link to the questionnaire was sent by email by the Spanish Society of Anesthesia (SEDAR) to all its members. Results: 225 responses were obtained. The regions with the highest participation were: Madrid, Catalonia, Valencia and Andalusia. 68.6%% of the participants work in public hospitals. 32% of the participants habitually work in intensive care units (ICU), however, 62.1% have attended critical COVID-19 in the ICU and 72.6% have anesthetized them in the operating room. 26.3% have attended some cardiac arrest, 16.8% of the participants admitted to lead the manoeuvres, 16.8% didn't participate in the CPR, and 66.2% was part of the team, but did not lead the assistance. Most of the CPR was performed in supine, only 5% was done in prone position. 54.6% of participants had not taken any course of Advance Life Support (ALS) in the last 2 years. 97.7% of respondents think that Anaesthesia should lead the in-hospital CPR. Conclusion: The specialty of Anesthesiology has actively participated in the care of the critically ill patient and in the management of CPR during the COVID-19 pandemic. However, training and/or updating in ALS is required. (C) 2020 Sociedad Espanola de Anestesiologia, Reanimacion y Terapeutica del Dolor. Published by Elsevier Espana, S.L.U. All rights reserved.
Revista:
CRITICAL CARE (PRINT)
ISSN:
1364-8535
Año:
2021
Vol.:
25
N°:
1
Págs.:
2
BackgroundCritically ill patients with coronavirus disease 19 (COVID-19) have a high fatality rate likely due to a dysregulated immune response. Corticosteroids could attenuate this inappropriate response, although there are still some concerns regarding its use, timing, and dose.MethodsThis is a nationwide, prospective, multicenter, observational, cohort study in critically ill adult patients with COVID-19 admitted into Intensive Care Units (ICU) in Spain from 12th March to 29th June 2020. Using a multivariable Cox model with inverse probability weighting, we compared relevant outcomes between patients treated with early corticosteroids (before or within the first 48 h of ICU admission) with those who did not receive early corticosteroids (delayed group) or any corticosteroids at all (never group). Primary endpoint was ICU mortality. Secondary endpoints included 7-day mortality, ventilator-free days, and complications.ResultsA total of 691 patients out of 882 (78.3%) received corticosteroid during their hospital stay. Patients treated with early-corticosteroids (n=485) had lower ICU mortality (30.3% vs. never 36.6% and delayed 44.2%) and lower 7-day mortality (7.2% vs. never 15.2%) compared to non-early treated patients. They also had higher number of ventilator-free days, less length of ICU stay, and less secondary infections than delayed treated patients. There were no differences in medical complications between groups. Of note, early use of moderate-to-high doses was associated with better outcomes than low dose regimens.ConclusionEarly use of corticosteroids in critically ill patients with COVID-19 is associated with lower mortality than no or delayed use, and fewer complications than delayed use.
Revista:
THERAPEUTIC DRUG MONITORING
ISSN:
0163-4356
Año:
2021
Vol.:
43
N°:
2
Págs.:
256 - 263
Background: The proper dosage of antibiotics is a key element in the effective treatment of infection, especially in critically ill patients. This study aimed to evaluate the efficacy of optimized meropenem regimens based on pharmacokinetic/pharmacodynamic criteria in patients admitted to the intensive care unit. Methods: This observational, naturalistic, retrospective, unicentric cohort study was performed between May 2011 and December 2017. The clinical and bacteriologic responses of 77 control intensive care unit patients receiving meropenem were compared with those of 77 propensity score-balanced patients who received meropenem dose adjusted by therapeutic drug monitoring. The primary end point of clinical response was a reduction at the end of treatment of at least 80% of the maximum procalcitonin (PCT) value recorded during the meropenem treatment. Results: The primary end point was met by 55 patients (71.4%) in the adjusted group compared with 41 (53.3%) patients in the control group (mean difference 18.1%, P = 0.02). Fifty-one patients (66.2%) in the adjusted group required a meropenem dose adjustment, being necessary in 46 of them (90.2%) to decrease the dose. The reduction of PCT was the greatest in the adjusted group compared with the unadjusted group (93% versus 85%, P = 0.004); a greater percentage of patients reached a PCT level < 0.5 ng/mL (63.6% versus 41.6%, P = 0.006), and there was a trend toward an improved bacteriologic response (relative risk = 1.27; 95% confidence interval: 0.92-1.56). There were no differences in early mortality or safety between groups. Conclusions: Adjustment of meropenem therapy by monitoring is a useful strategy for improving meropenem effectiveness in the treatment of infection in critically ill patients, with no impact on safety.
Autores:
Nagore, D.; Candela, A.; Bürge, M.; et al.
Revista:
JOURNAL OF CLINICAL ANESTHESIA
ISSN:
0952-8180
Año:
2021
Vol.:
73
Págs.:
110367
Background: Hydroxyethyl starch (HES) solutions increase the risk of acute kidney injury (AKI) in critically ill patients admitted to intensive care unit (ICU) for medical indications. We conducted a cohort study to evaluate the renal safety of modern 6% HES solutions in high-risk patients having cardiac surgery. Method: In this multicentre prospective cohort study, we recruited 261 consecutive patients at high-risk for developing cardiac surgery-associated AKI, based on a Cleveland score >= 4 points, from July to December 2017th in 14 hospitals in Spain and the United Kingdom. Multivariable logistic regression modeling and propensity-score matched-pairs analysis were used to determine the adjusted association between administration of HES and AKI. Results: Of the cohort, 95 patients (36.4%) received 6% HES 130/0.4 either intraoperatively or postoperatively. Postoperative AKI occurred in 145 patients (55.5%). The unadjusted odds of AKI was significantly higher in the HES group, when compared to those not receiving HES (OR 2.22, 95% CI 1.30-3.80, p = 0.003). In multivariable logistic regression models, modern HES was not associated with significantly increased risk of AKI (adjusted OR 0.84, 95% CI 0.41-1.71, p = 0.63). In propensity score match-pairs analysis of 188 patients, the HES group experienced similar adjusted odds of AKI (OR 1.05, CI 95% 0.87-1.27, p = 0.57) and RRT (OR 1.06, CI 95% 0.92-1.22, p = 0.36). Conclusions: The use of modern hydroxyethyl starch 6% HES 130/0.4 was not associated with an increased risk of AKI nor dialysis in this cohort of patients at elevated risk for developing AKI after cardiac surgery.
Autores:
Granell Gil, M. ; Sanchis López, N. (Autor de correspondencia); Aldecoa Álvarez de Santulano, C.; et al.
Revista:
REVISTA ESPAÑOLA DE ANESTESIOLOGÍA Y REANIMACION
ISSN:
0034-9356
Año:
2021
Vol.:
69
N°:
1
Págs.:
12 - 24
Background: We explored the experience of clinicians from the Spanish Society of Anesthesiology in airway management of COVID-19 patients. Methods: An software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment. Results: 1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists. The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision. Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and physicians. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management. Conclusions: Most physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide. (C) 2021 Sociedad Espanola de Anestesiologia, Reanimacion y Terapeutica del Dolor. Published by Elsevier Espana, S.L.U. All rights reserved.
Revista:
REVISTA ESPAÑOLA DE ANESTESIOLOGÍA Y REANIMACION
ISSN:
0034-9356
Año:
2021
Vol.:
68
N°:
7
Págs.:
428 - 430
Revista:
REVISTA ESPAÑOLA DE ANESTESIOLOGÍA Y REANIMACION
ISSN:
0034-9356
Año:
2021
Vol.:
68
N°:
8
Págs.:
437 - 442
Objetivos: La enfermedad por COVID-19 produce graves complicaciones que pueden derivar en parada cardiorrespiratoria (PCR). Una resucitación cardiopulmonar (RCP) de calidad puede mejorar el pronóstico de los pacientes. El objetivo de este estudio fue evaluar el desempeño de la especialidad de Anestesiología y Reanimación en el manejo de la RCP durante la pandemia en España.
Métodos: Se realizó una encuesta con Google Forms que constaba de 19 preguntas. El link de acceso al cuestionario fue enviado vía correo electrónico por la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR) a todos sus miembros.
Resultados: Se obtuvieron 225 respuestas. Las provincias con mayor participación fueron: Madrid, Cataluña, Valencia y Andalucía. ...
Autores:
Sanchez-Guijo, F.; Garcia-Arranz, M.; Lopez-Parra, M.; et al.
Revista:
ECLINICALMEDICINE
ISSN:
2589-5370
Año:
2020
Vol.:
25
Págs.:
100454
Background: Identification of effective treatments in severe cases of COVID-19 requiring mechanical ventilation represents an unmet medical need. Our aim was to determine whether the administration of adipose-tissue derived mesenchymal stromal cells (AT-MSC) is safe and potentially useful in these patients.
Methods: Thirteen COVID-19 adult patients under invasive mechanical ventilation who had received previous antiviral and/or anti-inflammatory treatments (including steroids, lopinavir/ritonavir, hydroxychloroquine and/or tocilizumab, among others) were treated with allogeneic AT-MSC. Ten patients received two doses, with the second dose administered a median of 3 days (interquartile range-IQR- 1 day) after the first one. Two patients received a single dose and another patient received 3 doses. Median number of cells per dose was 0.98 × 106 (IQR 0.50 × 106) AT-MSC/kg of recipient's body weight. Potential adverse effects related to cell infusion and clinical outcome were assessed. Additional parameters analyzed included changes in imaging, analytical and inflammatory parameters.
Findings: First dose of AT-MSC was administered at a median of 7 days (IQR 12 days) after mechanical ventilation. No adverse events were related to cell therapy. With a median follow-up of 16 days (IQR 9 days) after the first dose, clinical improvement was observed in nine patients (70%). Seven patients were extubated and discharged from ICU while four patients remained intubated (two with an improvement in their ventilatory and radiological parameters and two in stable condition). Two patients died (one due to massive gastrointestinal bleeding unrelated to MSC therapy). Treatment with AT-MSC was followed by a decrease in inflammatory parameters (reduction in C-reactive protein, IL-6, ferritin, LDH and d-dimer) as well as an increase in lymphocytes, particularly in those patients with clinical improvement.
Interpretation: Treatment with intravenous administration of AT-MSC in 13 severe COVID-19 pneumonia under mechanical ventilation in a small case series did not induce significant adverse events and was followed by clinical and biological improvement in most subjects.
Autores:
Ferrando, C. (Autor de correspondencia); Mellado-Artigas, R.; Gea, Alfredo; et al.
Revista:
CRITICAL CARE
ISSN:
1466-609X
BackgroundAwake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone.MethodsProspective, multicenter, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory Sequential Organ Failure Assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate, and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP.ResultsA total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53-1.43), p=0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0-2.5) vs 2 IQR 1.0-3.0] days (p=0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40-2.72), p=0.92].ConclusionIn patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.
Autores:
Ferrando, C. (Autor de correspondencia); Mellado-Artigas, R.; Gea, Alfredo; et al.
Revista:
REVISTA ESPAÑOLA DE ANESTESIOLOGÍA Y REANIMACION
ISSN:
0034-9356
Año:
2020
Vol.:
67
N°:
8
Págs.:
425 - 437
Background: The clinical course of COVID-19 critically ill patients, during their admission in the intensive care unit (UCI), including medical and infectious complications and support therapies, as well as their association with in-ICU mortality has not been fully reported. Objective: This study aimed to describe clinical characteristics and clinical course of ICU COVID-19 patients, and to determine risk factors for ICU mortality of COVID-19 patients. Methods Prospective, multicentre, cohort study that enrolled critically ill COVID-19 patients admitted into 30 ICUs from Spain and Andorra. Consecutive patients from March 12th to May 26th, 2020 were enrolled if they had died or were discharged from ICU during the study period. Demographics, symptoms, vital signs, laboratory markers, supportive therapies, pharmacological treatments, medical and infectious complications were reported and compared between deceased and discharged patients. Results: A total of 663 patients were included. Overall ICU mortality was 31% (203 patients). At ICU admission non-survivors were more hypoxemic [SpO2 with non-rebreather mask, 90 (IQR 83 to 93) vs. 91 (IQR 87 to 94); P<.001] and with higher sequential organ failure assessment score [SOFA, 7 (IQR 5 to 9) vs. 4 (IQR 3 to 7); P<.001]. Complications were more frequent in non-survivors: acute respiratory distress syndrome (ARDS) (95% vs. 89%; P=.009), acute kidney injury (AKI) (58% vs. 24%; P<10-16), shock (42% vs. 14%; P<10-13), and arrhythmias (24% vs. 11%; P<10-4). Respiratory super-infection, bloodstream infection and septic shock were higher in non-survivors (33% vs. 25%; P=.03, 33% vs. 23%; P=.01 and 15% vs. 3%, P=10-7), respectively. The multivariable regression model showed that age was associated with mortality, with every year increasing risk-of-death by 1% (95%CI: 1 to 10, P=.014). Each 5-point increase in APACHE II independently predicted mortality [OR: 1.508 (1.081, 2.104), P=.015]. Patients with AKI [OR: 2.468 (1.628, 3.741), P<10-4)], cardiac arrest [OR: 11.099 (3.389, 36.353), P=.0001], and septic shock [OR: 3.224 (1.486, 6.994), P=.002] had an increased risk-of-death. Conclusions: Older COVID-19 patients with higher APACHE II scores on admission, those who developed AKI grades ii or iii and/or septic shock during ICU stay had an increased risk-of-death. ICU mortality was 31%.
Revista:
RESEARCH IN SOCIAL AND ADMINISTRATIVE PHARMACY
ISSN:
1551-7411
Año:
2020
Vol.:
16
N°:
9
Págs.:
1285 - 1289
Background: Incorporating in the Intensive Care Unit (ICU) a clinical pharmacist who performs interventions on antimicrobials may be cost-effective.
Objectives: To evaluate the clinical and economic impact of clinical pharmacist interventions on antimicrobials in an ICU. To identify drug related problems and medication errors detected by the pharmacist.
Methods: A retrospective observational study was performed to analyze drug related problems, medication errors and clinical pharmacist interventions related to antimicrobials in adults admitted to an ICU in a 5-month period. The economic impact of pharmacist interventions was estimated considering difference in cost derived from antimicrobial treatment, adverse drug events and clinical pharmacist time.
Results: A total of 212 drug related problems were detected in 114 patients, 18 being medication errors. Clinical pharmacist developed one intervention for each problem identified. 204 interventions (96.2%) were considered important with improved patient care and 7 (3.3%) very important. No negative impact of any intervention was identified. Physicians accepted 97.6% of the interventions. A potential saving of 10,905 € was estimated as a result of pharmacist interventions and 4.8 € were avoided per euro invested in a clinical pharmacist.
Conclusions: A clinical pharmacist performing interventions on antimicrobials in the ICU has a positive impact on patient care and decreases costs.
Autores:
Delgado, M. C M.; Aviles-Jurado, F. X.; Escudero, J. A.; et al.
Revista:
MEDICINA INTENSIVA
ISSN:
0210-5691
Año:
2020
Vol.:
44
N°:
8
Págs.:
493 - 499
The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures. (c) 2020 Published by Elsevier Espana, S.L.U.
Autores:
Villalonga Vadell, R. (Autor de correspondencia); Martín Delgado, M. C.; Avilés-Jurado, F. X.; et al.
Revista:
REVISTA ESPAÑOLA DE ANESTESIOLOGÍA Y REANIMACION
ISSN:
0034-9356
Año:
2020
Vol.:
67
N°:
9
Págs.:
504 - 510
The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.
Revista:
EUROPEAN JOURNAL OF CLINICAL MICROBIOLOGY AND INFECTIOUS DISEASES
ISSN:
0934-9723
Año:
2020
Vol.:
39
N°:
2
Págs.:
361 - 368
Autores:
Ferrando, C. (Autor de correspondencia); Aldecoa, C.; Unzueta, C.; et al.
Revista:
BRITISH JOURNAL OF ANAESTHESIA
ISSN:
0007-0912
Año:
2020
Vol.:
124
N°:
1
Págs.:
110 - 120
Background: We aimed to examine whether using a high fraction of inspired oxygen (FIO2) in the context of an individualised intra- and postoperative open-lung ventilation approach could decrease surgical site infection (SSI) in patients scheduled for abdominal surgery. Methods: We performed a multicentre, randomised controlled clinical trial in a network of 21 university hospitals from June 6, 2017 to July 19, 2018. Patients undergoing abdominal surgery were randomly assigned to receive a high (0.80) or conventional (0.3) FIO2 during the intraoperative period and during the first 3 postoperative hours. All patients were mechanically ventilated with an open-lung strategy, which included recruitment manoeuvres and individualised positive end-expiratory pressure for the best respiratory-system compliance, and individualised continuous postoperative airway pressure for adequate peripheral oxyhaemoglobin saturation. The primary outcome was the prevalence of SSI within the first 7 postoperative days. The secondary outcomes were composites of systemic complications, length of intensive care and hospital stay, and 6-month mortality. Results: We enrolled 740 subjects: 371 in the high FIO2 group and 369 in the low FIO2 group. Data from 717 subjects were available for final analysis. The rate of SSI during the first postoperative week did not differ between high (8.9%) and low (9.4%) FIO2 groups (relative risk [RR]: 0.94; 95% confidence interval [CI]: 0.59-1.50; P=0.90]). Secondary outcomes, such as atelectasis (7.7% vs 9.8%; RR: 0.77; 95% CI: 0.48-1.25; P=0.38) and myocardial ischaemia (0.6% [n=2] vs 0% [n=0]; P=0.47) did not differ between groups. Conclusions: An oxygenation strategy using high FIO2 compared with conventional FIO2 did not reduce postoperative SSIs in abdominal surgery. No differences in secondary outcomes or adverse events were found.
Revista:
JOURNAL OF INTENSIVE CARE MEDICINE
ISSN:
0885-0666
Año:
2019
Vol.:
34
N°:
9
Págs.:
732 - 739
Background:
The main objective was to determine whether the administration of chemotherapy (CT) during the month before intensive care unit (ICU) admission of medical patients with cancer influences the survival rate. The design was a single-institution observational cohort study in an ICU of a tertiary university hospital.
Methods:
Our cohort included 248 oncology patients admitted to the ICU from 2005 to 2014 due to nonsurgical problems. Seventy-six (30.6%) patients had received CT in the month before admission (CT group) and 172 did not receive CT (control group). The main outcome measures were ICU, hospital, 30-day, 90-day, and 1-year mortalities. We performed survival analysis using the Kaplan-Meier estimator, comparing both groups using the log-rank test, and multivariate analysis using Cox regression adjusted for gender, age, maximum Sequential Organ Failure Assessment (SOFA), and delta maximum SOFA to calculate the hazard ratios (HRs) and their respective 95% confidence intervals. This association was also evaluated by a graphic representation of survival.
Results:
The CT group presented an ICU mortality rate of 27.6% versus 25.5% in the control group. The multivariate analysis adjusted for age, sex, and delta maximum SOFA showed significant differences between the groups (HR: 2.12; P = .009). The hospital mortality rate was 55.3% in the CT group compared to 45.4% in the control group (adjusted HR: 1.81; P = .003). At 30 days, the mortality rate was 56.6% in the CT group compared to 46.5% in the control group (adjusted HR: 1.69; P = .008). Mortality at 90 days was 65.8% in the CT group versus 59.9% in the control group (adjusted HR: 1.47; P = .03). One-year mortality was also higher in the CT group (79% vs 72.7%, adjusted HR: 1.44; P = .02).
Conclusion:
The administration of CT in the month before ICU admission in patients with cancer was associated with higher mortality in the ICU, in the hospital, and 30 and 90 days after admission when adjusted for the increase in organ failure measured by delta maximum SOFA. We provide useful new information for decision-making about ICU management of patients with cancer.
Revista:
MINERVA ANESTESIOLOGICA
ISSN:
0375-9393
Año:
2019
Vol.:
85
N°:
1
Págs.:
34 - 44
Background: Predictive models of acute kidney injury after cardiac surgery (CS-AKI) include emergency surgery and patients with hemodynamic instability. Our objective was to evaluate the performance of validated predictive models (Thakar and Demirjian) in elective cardiac surgery and to propose a better score in the case of poor performance.
Methods: A prospective, multicenter, observational study was designed. Data were collected from 942 patients undergoing cardiac surgery, after excluding emergency surgery and patients with an intra-aortic balloon pump. The main outcome measure was CS-AKI defined by the composite of requiring dialysis or doubling baseline creatinine values.
Results: Both models showed poor discrimination in elective surgery (Thakar's model, AUC=0.57, 95% CI: 0.50-0.64 and Demirjian's model, AUC=0.64, 95% CI: 0.58-0.71). We generated a new model whose significant independent predictors were: anemia, age, hypertension, obesity, congestive heart failure, previous cardiac surgery and type of surgery. It classifies patients with scores 0-3 as at low risk (<5%), patients with scores 4-7 as at medium risk (up to 15%), and patients with scores >8 as at high risk (>30%) of developing CS-AKI with a statistically significant correlation (P<0.001). Our model reflects acceptable discriminatory ability (AUC=0.72, 95% CI: 0.66-0.78) which is significantly better than Thakar and Demirjian's models (P<0.01).
Conclusions: We developed a new simple predictive model of CS-AKI in elective surgery based on available preoperative information. Our new model is easy to calculate and can be an effective tool for communicating risk to patients and guiding decision-making in the perioperative period. The study requires external validation.
Autores:
Rubio, O. (Autor de correspondencia); Arnau, A.; Cano, S.; et al.
Revista:
JOURNAL OF INTENSIVE CARE
ISSN:
2052-0492
Año:
2018
Vol.:
6
Págs.:
24
Purpose: To determine the frequency of limitations on life support techniques (LLSTs) on admission to intensive care units (ICU), factors associated, and 30-day survival in patients with LLST on ICU admission. Methods: This prospective observational study included all patients admitted to 39 ICUs in a 45-day period in 2011. We recorded hospitals' characteristics (availability of intermediate care units, usual availability of ICU beds, and financial model) and patients' characteristics (demographics, reason for admission, functional status, risk of death, and LLST on ICU admission (withholding/withdrawing; specific techniques affected)). The primary outcome was 30-day survival for patients with LLST on ICU admission. Statistical analysis included multilevel logistic regression models. Results: We recruited 3042 patients (age 62.5 +/- 16.1 years). Most ICUs (94.8%) admitted patients with LLST, but only 238 (7.8% [95% CI 7.0-8.8]) patients had LLST on ICU admission; this group had higher ICU mortality (44.5 vs. 9.4% in patients without LLST; p < 0.001). Multilevel logistic regression showed a contextual effect of the hospital in LLST on ICU admission (median OR = 2.30 [95% CI 1.59-2.96]) and identified the following patient-related variables as independent factors associated with LLST on ICU admission: age, reason for admission, risk of death, and functional status. In patients with LLST on ICU admission, 30-day survival was 38% (95% CI 31.7-44.5). Factors associated with survival were age, reason for admission, risk of death, and number of reasons for LLST on ICU admission. Conclusions: The frequency of ICU admission with LLST is low but probably increasing; nearly one third of these patients survive for >= 30 days.
Revista:
EUROPEAN JOURNAL OF ANAESTHESIOLOGY
ISSN:
0265-0215
Año:
2018
Vol.:
35
N°:
1
Págs.:
65 - 66
BACKGROUND Four predictive models for acute kidney injury associated with cardiac surgery were developed by Demirjian in the United States in 2012. However, the usefulness of these models in clinical practice needs to be established in different populations independent of that used to develop the models. OBJECTIVES Our aim was to evaluate the predictive performance of these models in a Spanish population. DESIGN A multicentre, prospective observational study. DATA SOURCES Twenty-three Spanish hospitals in 2012 and 2013. ELIGIBILITY CRITERIA Of 1067 consecutive cardiac patients recruited for the study, 1014 patients remained suitable for the final analysis. MAIN OUTCOME MEASURES Dialysis therapy, and a composite outcome of either a doubling of the serum creatinine level or dialysis therapy, in the 2 weeks (or until discharge, if sooner) after cardiac surgery. RESULTS Of the 1014 patients analysed, 34 (3.4%) required dialysis and 95 (9.4%) had either dialysis or doubled their serum creatinine level. The areas under the receiver operating characteristic curves of the two predictive models for dialysis therapy, which include either presurgical variables only, or combined presurgical and intrasurgical variables, were 0.79 and 0.80, respectively. The model for the composite endpoint that combined presurgical and intrasurgical variables showed better discriminatory ability than the model that included only presurgical variables: the areas under the receiver operating characteristic
Revista:
ANALES DEL SISTEMA SANITARIO DE NAVARRA
ISSN:
1137-6627
Año:
2018
Vol.:
41
N°:
2
Págs.:
283 - 284
Revista:
EUROPEAN JOURNAL OF ANAESTHESIOLOGY
ISSN:
0265-0215
Año:
2017
Vol.:
34
N°:
2
Págs.:
81 - 88
BACKGROUND Four predictive models for acute kidney injury associated with cardiac surgery were developed by Demirjian in the United States in 2012. However, the usefulness of these models in clinical practice needs to be established in different populations independent of that used to develop the models. OBJECTIVES Our aim was to evaluate the predictive performance of these models in a Spanish population. DESIGN A multicentre, prospective observational study. DATA SOURCES Twenty-three Spanish hospitals in 2012 and 2013. ELIGIBILITY CRITERIA Of 1067 consecutive cardiac patients recruited for the study, 1014 patients remained suitable for the final analysis. MAIN OUTCOME MEASURES Dialysis therapy, and a composite outcome of either a doubling of the serum creatinine level or dialysis therapy, in the 2 weeks (or until discharge, if sooner) after cardiac surgery. RESULTS Of the 1014 patients analysed, 34 (3.4%) required dialysis and 95 (9.4%) had either dialysis or doubled their serum creatinine level. The areas under the receiver operating characteristic curves of the two predictive models for dialysis therapy, which include either presurgical variables only, or combined presurgical and intrasurgical variables, were 0.79 and 0.80, respectively. The model for the composite endpoint that combined presurgical and intrasurgical variables showed better discriminatory ability than the model that included only presurgical variables: the areas under the receiver operating characteristic curves were 0.76 and 0.70, respectively. All four models lacked calibration for their respective outcomes in our Spanish population. CONCLUSION Overall, the lack of calibration of these models and the difficulty in using the models clinically because of the large number of variables limit their applicability.
Revista:
ANALES DEL SISTEMA SANITARIO DE NAVARRA
ISSN:
1137-6627
Año:
2017
Vol.:
40
N°:
3
Págs.:
339-349
The quality of end-of-life care in the participating ICU needs to be improved. The study identifies shortcomings and indicates existing resources in clinical practice from which a gradual improvement plan, adapted to the situation in each hospital, can be designed. The analysis, inexpensive in its implementation, offers an opportunity for improvement, a goal recommended by most professional societies of intensive care medicine. Key words. End-of-life care. Intensive care. Critical care. Palliative care. Quality improvement.
Revista:
PLOS ONE
ISSN:
1932-6203
Año:
2017
Vol.:
12
N°:
2
Págs.:
e0172021
Perioperative anemia is an important risk factor for cardiac surgery-associated acute kidney injury (CSA-AKI). Nonetheless, the severity of the anemia and the time in the perioperative period in which the hemoglobin level should be considered as a risk factor is conflicting. The present study introduces the concept of perioperative hemoglobin area under the curve (pHb-AUC) as a surrogate marker of the evolution of perioperative hemoglobin concentration. Through a retrospective analysis of prospectively collected data, we assessed this new variable as a risk factor for the development of acute kidney injury after cardiac surgery in 966 adult patients who underwent cardiac surgery with cardiopulmonary bypass, at twenty-three academic hospitals in Spain. Exclusion criteria were patients on renal replacement therapy, who needed a reoperation because of bleeding and/or with missing perioperative hemoglobin or creatinine values. Using a multivariate regression analysis, we found that a pHb-AUC < 19 g/dL was an independent risk factor for CSA-AKI even after adjustment for intraoperative red blood cell transfusion (OR 1.41, p < 0.05). It was also associated with mortality (OR 2.48, p < 0.01) and prolonged hospital length of stay (4.67 +/- 0.99 days, p < 0.001).
Revista:
CUADERNOS DE BIOETICA
ISSN:
1132-1989
Año:
2016
Vol.:
27
N°:
90
Págs.:
175 - 184
En la literatura científica se constata un reciente interés por integrar los principios de la medicina palia
-
tiva en el trabajo cotidiano de la unidad de cuidados intensivos (UCI). El artículo revisa este planteamiento
con la idea de fondo de que su aplicación pueda aportar luz en la resolución de ciertos problemas éticos
presentes. Los pacientes con procesos avanzados y en situación de final de vida ingresados en cuidados
intensivos se encuentran con un nivel de sufrimiento y vulnerabilidad que sólo una atención comprensiva
y holística puede dar un alivio adecuado. Sin embargo, la realidad clínica del cuidado de estos pacientes
en UCI, por el momento, está lejana a ese ideal. La mejora de la atención clínica en este sentido, especial
-
mente en el fallecimiento, es el punto de interés que nos ocupa. Avanzar en este aspecto es complejo pero
se hace necesario un esfuerzo. La propuesta es recurrir a la medicina paliativa como modelo de referencia
en los cuidados del final de vida y en la atención holística, e introducir sus principios de tratamiento en la
UCI. El objetivo del artículo es exponer una estrategia práctica para llevarlo a cabo y que pueda ser útil en
la mejora de la atención clínica y ética de los pacientes.
Revista:
BRITISH JOURNAL OF ANAESTHESIA
ISSN:
0007-0912
Año:
2016
Vol.:
117
N°:
4
Págs.:
458 - 463
Background: Recent trials have shown hydroxyethyl starch (HES) solutions increase the risk of acute kidney injury (AKI) in critically ill patients. It is uncertain whether these adverse effects also affect surgical patients. We sought to determine the renal safety of modern tetrastarch (6% HES 130/0.4) use in cardiac surgical patients.
Methods: In this multicentre prospective cohort study, 1058 consecutive patients who underwent cardiac surgery from 15th September 2012 to 15th December 2012 were recruited in 23 Spanish hospitals.
Results: We identified 350 patients (33%) administered 6% HES 130/0.4 intraoperatively and postoperatively, and 377 (36%) experienced postoperative AKI (AKI Network criteria). In-hospital death occurred in 45 (4.2%) patients. Patients in the non-HES group had higher Euroscore and more comorbidities including unstable angina, preoperative cardiogenic shock, preoperative intra-aortic balloon pump use, peripheral arterial disease, and pulmonary hypertension. The non-HES group received more intraoperative vasopressors and had longer cardiopulmonary bypass times. After multivariable risk-adjustment, 6% HES 130/0.4 use was not associated with significantly increased risks of AKI (adjusted odds ratio 1.01, 95% CI 0.71-1.46, P=0.91). These results were confirmed by propensity score-matched pairs analyses.
Conclusions: The intraoperative and postoperative use of modern hydroxyethyl starch 6% HES 130/0.4 was not associated with increased risks of AKI and dialysis after cardiac surgery in our multicentre cohort.
Revista:
REVISTA ESPAÑOLA DE ANESTESIOLOGIA Y REANIMACION
ISSN:
0034-9356
Año:
2013
Vol.:
60
N°:
2
Págs.:
79-86.
To assess the correlation between intraoperative packed red blood cells transfusion and adverse outcome in a Spanish cohort of cardiac surgery patients. METHODS: Retrospective observational multicentre study. An analysis was performed on the data from 927 cardiac surgery patients treated in 24 Spanish hospitals in 2007. Patients who received intraoperative transfusions were compared with non-transfused patients. Multivariate analyses were performed (including, among others, several items from the Euroscore, surgery type, basal renal status and haemoglobin levels, and Thakar score).
RESULTS: Every transfusion of packed red cells was associated with increased postoperative risk of acute kidney damage at 72 hours after surgery, prolonged mechanical ventilation, and need for haemodynamic support. Moreover, transfused patients showed an increased in-hospital mortality rates (Adjusted OR: 1.30; 95% CI: 1.19-1.42), as well as longer hospital stays (almost 4 days).
CONCLUSIONS: In this cohort of patients, intraoperative transfusion might independently predict higher risk of early acute kidney damage, prolonged postoperative mechanical ventilation, and a need for haemodynamic support, and reduced short term survival (adjusted OR for mortality: 1.30; 95% CI: 1.19-1.42), and longer hospital stays (4 days longer).
Revista:
INTERNATIONAL JOURNAL OF ARTIFICIAL ORGANS
ISSN:
0391-3988
Año:
2011
Vol.:
34
N°:
4
Págs.:
329 - 338
Revista:
REVISTA ESPAÑOLA DE ANESTESIOLOGIA Y REANIMACION
ISSN:
0034-9356
Año:
2011
Vol.:
58
N°:
6
Págs.:
365 - 374
Early detection of AKI is necessary for preventing progression and starting renal replacement therapy at adjusted doses that reflect metabolic requirements..
Revista:
BLOOD PURIFICATION
ISSN:
0253-5068
Año:
2011
Vol.:
32
N°:
2
Págs.:
104 - 111
Patients who undergo early initiation of RRT after CSA-AKI have improved survival rates and renal function at discharge and decreased lengths of hospital stay
Revista:
Revista Espanola de Anestesiologia y Reanimacion
ISSN:
0034-9356
Año:
2011
Vol.:
58
N°:
2
Págs.:
132 - 133
