Intensive Care Units In Spain Research Articles

Rescue treatment with terlipressin in children with refractory septic shock: a clinical study

IntroductionRefractory septic shock has dismal prognosis despite aggressive therapy. The purpose of the present study is to report the effects of terlipressin (TP) as a rescue treatment in children with catecholamine refractory hypotensive septic shock.MethodsWe prospectively registered the children with severe septic shock and hypotension resistant to standard intensive care, including a high dose of catecholamines, who received compassionate therapy with TP in nine pediatric intensive care units in Spain, over a 12-month period. The TP dose was 0.02 mg/kg every four hours.ResultsSixteen children (age range, 1 month–13 years) were included. The cause of sepsis was meningococcal in eight cases, Staphylococcus aureus in two cases, and unknown in six cases. At inclusion the median (range) Pediatric Logistic Organ Dysfunction score was 23.5 (12–52) and the median (range) Pediatric Risk of Mortality score was 24.5 (16–43). All children had been treated with a combination of at least two catecholamines at high dose rates. TP treatment induced a rapid and sustained improvement in the mean arterial blood pressure that allowed reduction of the catecholamine infusion rate after one hour in 14 out of 16 patients. The mean (range) arterial blood pressure 30 minutes after TP administration increased from 50.5 (37–93) to 77 (42–100) mmHg (P < 0.05). The noradrenaline infusion rate 24 hours after TP treatment decreased from 2 (1–4) to 1 (0–2.5) µg/kg/min (P < 0.05). Seven patients survived to the sepsis episode. The causes of death were refractory shock in three cases, withdrawal of therapy in two cases, refractory arrhythmia in three cases, and multiorgan failure in one case. Four of the survivors had sequelae: major amputations (lower limbs and hands) in one case, minor amputations (finger) in two cases, and minor neurological deficit in one case.ConclusionTP is an effective vasopressor agent that could be an alternative or complementary therapy in children with refractory vasodilatory septic shock. The addition of TP to high doses of catecholamines, however, can induce excessive vasoconstriction. Additional studies are needed to define the safety profile and the clinical effectiveness of TP in children with septic shock.

Use of percutaneous tracheostomy in intensive care units in Spain. Results of a national survey.

To assess the use of percutaneous tracheostomy in Intensive Care Units (ICU) in Spain, its practice, and current opinions on the technique. An e-mail or post survey was sent to 239 Spanish ICU directors. Pediatric ICUs and coronary units were excluded. One hundred ICUs (41.8%) replied. The 44% ( n=44) of the ICUs that answered belonged to university hospitals and 53% ( n=53) had postgraduate teaching. Eighty-two percent ( n=82) used percutaneous tracheostomy. Griggs' Guide Wire Dilating Forceps and Ciaglia Blue Rhino were the most frequent techniques employed. In 30.5% of ICUs ( n=25) endoscopic guidance was used, in 15.7% ( n= 13) it was routine. In 24.4% ( n=20) some kind of long-term follow-up was carried out, but only in 12.2% ( n=10) was follow-up done routinely. In 58.5% of ICUs ( n=48) in which percutaneous tracheostomy is performed is this technique considered safer than surgical tracheostomy and in 86.4% ( n=70) percutaneous tracheostomy is the first choice for tracheostomy in the critically ill patient. Percutaneous tracheostomy is a well-established technique in ICUs in Spain, and is considered the technique of choice for tracheostomy in critically ill patients. It is mainly performed without endoscopic guidance and follow-up is not usually carried out.

Comparison of a high-protein disease-specific enteral formula with a high-protein enteral formula in hyperglycemic critically ill patients

Aims: To determine whether a specific high-protein enteral formula with a similar caloric percentage of fat and carbohydrates achieves greater control over glycemic levels and reduces insulin requirements in hyperglycemic critically ill patients when compared to a control high-protein enteral formula. Design: A prospective, randomized, controlled, single-blind trial in two University Hospital Intensive Care Units in Spain. Methods: We enrolled 50 patients with diabetes mellitus or stress hyperglycemia with basal glycemia ≥160 mg/dl and indication for enteral nutrition ≥5 days. Patients with severe kidney failure, liver failure or obesity were excluded from the study. In the first 48 h of admission, after randomization, 26 patients received the study diet and 24 patients received the control diet. The variables were monitored for 14 days. The Harris–Benedict formula with a fixed stress factor of 1.2 was used to calculate caloric needs. Insulin was administered by continuous infusion. An intention-to-treat analysis was performed. Results: On admission, there were no differences between the study and control group in plasma glucose levels (mg/dl) (190.9±45 vs 210.3±63) and capillary glucose levels (mg/dl) (226.1±73 vs 213.8±67). After the feeding trial, there were differences between the study and control group in plasma glucose levels (mg/dl) (176.8±44 vs 222.8±47, P=0.001), capillary glucose levels (mg/dl) (163.1±45 vs 216.4±56, P=0.001), insulin requirements/day (IU) 8.73 (2.3–27.5) vs 30.2 (21.5–57.1) ( P=0.001), insulin/received carbohydrates (UI/g) 0.07 (0.02–0.22) vs 0.18 (0.11–0.35) ( P=0.02) and insulin/received carbohydrates/kg 0.98 (0.26–3.59) vs 2.13 (1.44–4.58) ( P=0.04). These differences remain in a day-to-day comparison. There were no differences in the analytical tests, or in digestive or infectious complications. Intensive Care Unit length of stay, mechanical ventilation and mortality were similar in both groups. Conclusions: Hyperglycemic critically ill patients fed with a high-protein diet with a similar caloric percentage of fat and carbohydrates show a significant reduction in plasma glucose levels, capillary glucose levels and insulin requirements in comparison to patients on a conventional high-protein diet. This better glycemic control do not modify Intensive Care Unit length of stay, infectious complications, mechanical ventilation and mortality.

Factores de riesgo y factores pronósticos de las bacteriemias por Pseudomonas aeruginosa en pacientes ingresados en servicios de cuidados intensivos

To determine risk and prognostic factors in patients admitted to the intensive care unit (ICU) in which an episode of bacteremia caused by Pseudomonas aeruginosa has been diagnosed. Cohort, observational, prospective, multicenter study. Patients admitted to 30 ICUs in Spain in whom one or more pathogens were isolated from blood cultures were included. In a total of 16,216 patients admitted to the participating ICUs during the study period, 949 episodes of bacteremia were diagnosed In 77 cases (8.11%), P. aeruginosa was the causative pathogen, with an infection rate of 4.7 episodes per 1000 patients. Independent risk factors associated with P. aeruginosa bacteremia were as follows: respiratory infection focus (OR 3.92; 95% IC 2.33-6.59; p </= 0.0001), previous use of antibiotics (OR 2.13; 95% IC 1.18-3.81; p </= 0.0078), arterial catheter (OR 4.09; 95% IC 2.26-7.38; p </= 0.0001), and previous longer ICU stay (days) (OR 1.02; 95% IC 1.003-1.033; p = 0.0274). Crude mortality rate in patients with bacteremia caused by P. aeruginosa was 50.6% (39/77), whereas mortality rate of bacteremia caused by other pathogens was 38.6% (337/872) (p = 0.039). This difference was also found for attributed mortality (31.2% [24/77] vs. 20.4% [178/872], (p = 0.027). In the multivariate analysis adjusted by respiratory infection focus, previous ICU stay, and age, crude mortality (OR 1.55; 95% CI 0.96-2.51; p = 0.071) and attributed mortality (OR 1.63; 95% CI 0.96-2.78; p = 0.0709) of P. aeruginosa bacteremia were higher than in bacteremia caused by other pathogens. In the multivariate analysis, risk factors significantly associated with crude mortality were respiratory infection focus (OR 4.13; 95% IC 1.15-14.76; p = 0.0293) and severe sepsis or septic shock (OR 4.96; 95% IC 1.23-20.09; p = 0.0248). Bacteremia caused by P. aeruginosa admitted to the ICU have a higher crude and attributed mortality than bacteremias caused by other pathogens. Prognosis is associated with the presence of severe sepsis or septic shock and respiratory infection focus.

Donor Action: A Quality Assurance Program for Intensive Care Units That Increases Organ Donation

Donor Action (DA) is an international initiative that helps intensive care units (ICUs) improve donation. Existing best practices from around the world have been incorporated into this quality assurance program. Following a validated diagnostic review, areas of weakness in donation practices are identified and the appropriate changes introduced. Corrective measures have been developed in the form of five “core” program modules which correspond to critical steps in the donation process and can be used together or alone according to specific identified needs. Medical records review (MRR) and hospital attitude surveys (HAS) were performed in 11 ICUs in Spain (2), The Netherlands (2), the United Kingdom (1), and Canada (6). Baseline data were gathered on the units potential for donation, staff attitudes toward donation, and self-reported skills/confidence in performing a range of donation roles. Analysis of these data were used to customize the program to individual ICU requirements. MRR data from 579 cases showed a 69% (398) potential for donation from which only 31% (124) were realized. Detection and management failures (166; 42%) and refusal to donate (104; 26%) were the major reasons for loss of potential donors. The HAS returns from staff (2,129) showed consistently strong perceptions that organ donation saves lives (97%). Support for donation (94%) and willingness to donate their own organs (79%) were high in all country samples. Ratings of skills/confidence were highest for comforting the family (70%), with much lower comfort levels reported on explaining brain death (44%), introducing organ donation (38%), and presenting a family with the option for donation (31%). Following introduction of the appropriate program modules, a sustained (2–year) effect of a 33% increase in donation rates is demonstrated. The Donor Action HAS and MRR are useful tools in identifying problems within the donation process and lead to the introduction of improvement strategies integral to the Donor Action program that result in an increase in organ donation.

Study of paediatric intensive care units in Spain

To describe the organisation of paediatric intensive care units in Spain and the medical assistance provided during 1996. A written questionnaire was sent to all the paediatric ICUs linked to or within the Spanish public health system. Thirty-one of the 34 paediatric ICUs replied. All are medico-surgical units. Eighteen treat only paediatric patients, 12 paediatric and neonatal patients, and one paediatric and adult patients. Fifteen units have fewer than seven beds, eight have between 7 and 12 beds, and eight between 13 and 18 beds. Of the paediatric ICUs, 83.8 % are staffed by paediatricians specialised in paediatric intensive care. The mean number of on-call on site periods of duty for each member of the medical staff was 5.1 +/- 1.7 per month. Thirty of the 31 units undertake paediatric resident training, 13 train residents specialising in paediatric intensive care and 12 participate in medical student training. In 1996 there were 9,585 admissions (309 +/- 182 patients per ICU) signifying 35.3 +/- 14 patients/bed. Of the patients, 65.9 % were medical and 34.1 % surgical. The mean duration of stay was 5.6 +/- 2.1 days. The mortality rate was 5.4 +/- 3.2 %. The main causes of death were multiple organ failure and brain death. In Spain, paediatric intensive care is principally performed by specialised paediatricians. Although the general results for 1996 are similar to those of other European countries, efficiency studies are necessary to plan and re-organise the paediatric intensive care units in Spain.

Artificial nutrition support in intensive care units in Spain. Nutritional and Metabolic Working Group of the Spanish Society of Intensive Care Medicine and Coronary Units (SEMIUC).

A multicenter survey to study the use of nutritional support in patients admitted to the ICU in Spain. The survey was announced during the annual Spanish Society of Intensive Care Medicine and Coronary Units (SEMIUC) congress meeting. Questionnaires designed to determine current clinical practice concerning artificial nutrition were sent to the 27 ICU who accepted to participate. In each center the 235-question form was filled out individually for each patient admitted to the ICU during the month of March, 1992. To validate the study a preliminary pilot surveys were conducted to ensure that there was a correct interpretation of the questions. The replies were entered into a database for analysis. A total of 1261 patients were studied; 33.9% received artificial nutrition (AN). The administration of AN was significantly higher in the medical group (44%), than in the surgical (37%) and the trauma group (19%). AN was significantly lower in patients admitted to private clinic than public institutions (26.7% versus 34.7%). Among the patients who received AN, enteral nutrition (EN) was administered to 59.7% of the patients, total parenteral nutrition (TPN) to 38.5%, and peripheral parenteral nutrition (PPN) to 18.2%. Medical patients received significantly more EN than surgical and trauma patients. Surgical patients received more PN than medical and trauma groups. Nutritional support is a common practice in the treatment of ICU patients in our country. All information concerning its use is necessary to optimize it.

Modes of Mechanical Ventilation and Weaning

Little information exists regarding the proportion of patients treated with mechanical ventilation in intensive care units (ICUs), their underlying disease states, the modes of ventilation used, duration of ventilator support, methods and time required for weaning, and mortality in these patients. We carried out a cross-sectional multicenter study in 47 medical-surgical ICUs in Spain to investigate these issues in 290 patients who required mechanical ventilation for at least 24 hs. Relative frequency of different modes was as follows: assist-control ventilation (AC), 55%; synchronized intermittent mandatory ventilation (SIMV), 26%; pressure support ventilation (PSV), 8%; SIMV plus PSV, 8%; pressure-controlled ventilation (PCV), 1%; and continuous positive airway pressure (CPAP), 2%. Overall duration of mechanical ventilation was 27.1±1.1 (SE). A variety of techniques were used for weaning: T-tube trials, 24%; SIMV, 18%; PSV, 15%; SIMV plus PSV, 9%; and some combination of two or more methods in succession in 33% of the patients. Time required for weaning using a combination of SIMV and PSV was longer (17.8 days) than with other techniques (about 5 days, p<0.01). Time between initiation of weaning and removal of mechanical ventilation accounted for 41% of total ventilator time and was particularly high (59%) in patients with chronic obstructive pulmonary disease. Overall mortality rate was 34%, and it was higher in patients who were ventilated for 1 to 10 days than in those ventilated for a longer time. Despite the availability of several new modes of ventilator support, older modes such as AC and SIMV were more commonly used. Weaning constitutes a large portion of total ventilator time, and thus, measures that expedite the weaning process should markedly decrease the duration of mechanical ventilation.