An outbreak of Multi-Drug Resistant Acinetobacter in the burn intensive care unit of a large tertiary care center

Risk factors for Multi-Drug Resistant Acinetobacter (MDRA) acquisition were studied in patients in a burn intensive care unit (ICU) where there was an outbreak of MDRA. Forty cases were matched with eighty controls based on length of stay in the Burn ICU and statistical analysis was performed on data for several different variables. Matched analysis showed that mechanical ventilation, transport ventilation, number of intubations, number of bronchoscopy procedures, total body surface area burn, and prior Methicillin Resistant Staphylococcus aureus colonization were all significant risk factors for MDRA acquisition. ^ MDRA remains a significant threat to the burn population. Treatment for burn patients with MDRA is challenging as resistance to antibiotics continues to increase. This study underlined the need to closely monitor the most critically ill ventilated patients during an outbreak of MDRA as they are the most at risk for MDRA acquisition.^

Circadian rhythm profiles in porcine ICU subjects

Purpose: To explore the natural trajectory of circadian rhythms of sedation requirement, core body temperature (CBT), pulmonary mechanics (PM), and gas exchange (GE) in mechanically ventilated swine, as these variables affect the duration of mechanical ventilation. ^ Design: A secondary analysis to describe and compare circadian rhythms of study variables in swine mechanically ventilated for ≤ 7 days. ^ Setting: Porcine Intensive Care Unit (ICU).^ Sample: Six male swine. ^ Methods: Sedation requirements were recorded hourly and the CBT, PM and GE variables were sampled every 1 s – 1 min for ≤ 7 days. The data sets for each pig with > 5 days ICU length of stay were divided into one section representing the first 3 days and one section representing subsequent days. The Lomb periodogram was used to estimate the circadian time period for each variable, and cosinor analysis with the estimated time period to obtain amplitude and mesor. Circadian to ultradian bandpower ratio to assess rhythm quality and stability over time and goodness-of-fit index to describe biological significance of a rhythm were used. Together, these two parameters were used to define rhythm robustness over time. The masking effect of sedation as a potential confounder of the circadian rhythms of CBT, PM, and GE was explored, and circadian rhythm profiles of CBT of pigs in the ICU setting were compared with those of the same pigs in the ambulatory setting. ^ Results: All pigs had significant rhythms in CBT, respiratory rate, and peripheral oxygen saturation across ICU data sets. Healthier pigs had more robust rhythms of study variables over time. Sedation did not appear to mask the circadian rhythms of CBT, PM, and GE. The circadian rhythm of CBT was less robust in the ICU setting than in the ambulatory setting. ^ Conclusions: Individual subject observations provided preliminary evidence that robustness of rhythms varies with subject acuity. Comparison of profiles of circadian rhythms among ICU subjects with similar acuity and disease processes is warranted to determine if the profiles in the present study are reproducible. Identification of consistent patterns may provide insight into subject morbidity and timing of such therapeutic interventions as weaning from mechanical ventilation. ^

An Intercomparison of Modelling Approaches for Simulating the Atmospheric Dispersion of Ammonia Emitted by Agricultural Sources

RESUMEN La dispersión del amoniaco (NH3) emitido por fuentes agrícolas en medias distancias, y su posterior deposición en el suelo y la vegetación, pueden llevar a la degradación de ecosistemas vulnerables y a la acidificación de los suelos. La deposición de NH3 suele ser mayor junto a la fuente emisora, por lo que los impactos negativos de dichas emisiones son generalmente mayores en esas zonas. Bajo la legislación comunitaria, varios estados miembros emplean modelos de dispersión inversa para estimar los impactos de las emisiones en las proximidades de las zonas naturales de especial conservación. Una revisión reciente de métodos para evaluar impactos de NH3 en distancias medias recomendaba la comparación de diferentes modelos para identificar diferencias importantes entre los métodos empleados por los distintos países de la UE. En base a esta recomendación, esta tesis doctoral compara y evalúa las predicciones de las concentraciones atmosféricas de NH3 de varios modelos bajo condiciones, tanto reales como hipotéticas, que plantean un potencial impacto sobre ecosistemas (incluidos aquellos bajo condiciones de clima Mediterráneo). En este sentido, se procedió además a la comparación y evaluación de varias técnicas de modelización inversa para inferir emisiones de NH3. Finalmente, se ha desarrollado un modelo matemático simple para calcular las concentraciones de NH3 y la velocidad de deposición de NH3 en ecosistemas vulnerables cercanos a una fuente emisora. La comparativa de modelos supuso la evaluación de cuatro modelos de dispersión (ADMS 4.1; AERMOD v07026; OPS-st v3.0.3 y LADD v2010) en un amplio rango de casos hipotéticos (dispersión de NH3 procedente de distintos tipos de fuentes agrícolas de emisión). La menor diferencia entre las concentraciones medias estimadas por los distintos modelos se obtuvo para escenarios simples. La convergencia entre las predicciones de los modelos fue mínima para el escenario relativo a la dispersión de NH3 procedente de un establo ventilado mecánicamente. En este caso, el modelo ADMS predijo concentraciones significativamente menores que los otros modelos. Una explicación de estas diferencias podríamos encontrarla en la interacción de diferentes “penachos” y “capas límite” durante el proceso de parametrización. Los cuatro modelos de dispersión fueron empleados para dos casos reales de dispersión de NH3: una granja de cerdos en Falster (Dinamarca) y otra en Carolina del Norte (EEUU). Las concentraciones medias anuales estimadas por los modelos fueron similares para el caso americano (emisión de granjas ventiladas de forma natural y balsa de purines). La comparación de las predicciones de los modelos con concentraciones medias anuales medidas in situ, así como la aplicación de los criterios establecidos para la aceptación estadística de los modelos, permitió concluir que los cuatro modelos se comportaron aceptablemente para este escenario. No ocurrió lo mismo en el caso danés (nave ventilada mecánicamente), en donde el modelo LADD no dio buenos resultados debido a la ausencia de procesos de “sobreelevacion de penacho” (plume-rise). Los modelos de dispersión dan a menudo pobres resultados en condiciones de baja velocidad de viento debido a que la teoría de dispersión en la que se basan no es aplicable en estas condiciones. En situaciones de frecuente descenso en la velocidad del viento, la actual guía de modelización propone usar un modelo que sea eficaz bajo dichas condiciones, máxime cuando se realice una valoración que tenga como objeto establecer una política de regularización. Esto puede no ser siempre posible debido a datos meteorológicos insuficientes, en cuyo caso la única opción sería utilizar un modelo más común, como la versión avanzada de los modelos Gausianos ADMS o AERMOD. Con el objetivo de evaluar la idoneidad de estos modelos para condiciones de bajas velocidades de viento, ambos modelos fueron utilizados en un caso con condiciones Mediterráneas. Lo que supone sucesivos periodos de baja velocidad del viento. El estudio se centró en la dispersión de NH3 procedente de una granja de cerdos en Segovia (España central). Para ello la concentración de NH3 media mensual fue medida en 21 localizaciones en torno a la granja. Se realizaron también medidas de concentración de alta resolución en una única localización durante una campaña de una semana. En este caso, se evaluaron dos estrategias para mejorar la respuesta del modelo ante bajas velocidades del viento. La primera se basó en “no zero wind” (NZW), que sustituyó periodos de calma con el mínimo límite de velocidad del viento y “accumulated calm emissions” (ACE), que forzaban al modelo a calcular las emisiones totales en un periodo de calma y la siguiente hora de no-calma. Debido a las importantes incertidumbres en los datos de entrada del modelo (inputs) (tasa de emisión de NH3, velocidad de salida de la fuente, parámetros de la capa límite, etc.), se utilizó el mismo caso para evaluar la incertidumbre en la predicción del modelo y valorar como dicha incertidumbre puede ser considerada en evaluaciones del modelo. Un modelo dinámico de emisión, modificado para el caso de clima Mediterráneo, fue empleado para estimar la variabilidad temporal en las emisiones de NH3. Así mismo, se realizó una comparativa utilizando las emisiones dinámicas y la tasa constante de emisión. La incertidumbre predicha asociada a la incertidumbre de los inputs fue de 67-98% del valor medio para el modelo ADMS y entre 53-83% del valor medio para AERMOD. La mayoría de esta incertidumbre se debió a la incertidumbre del ratio de emisión en la fuente (50%), seguida por la de las condiciones meteorológicas (10-20%) y aquella asociada a las velocidades de salida (5-10%). El modelo AERMOD predijo mayores concentraciones que ADMS y existieron más simulaciones que alcanzaron los criterios de aceptabilidad cuando se compararon las predicciones con las concentraciones medias anuales medidas. Sin embargo, las predicciones del modelo ADMS se correlacionaron espacialmente mejor con las mediciones. El uso de valores dinámicos de emisión estimados mejoró el comportamiento de ADMS, haciendo empeorar el de AERMOD. La aplicación de estrategias destinadas a mejorar el comportamiento de este último tuvo efectos contradictorios similares. Con el objeto de comparar distintas técnicas de modelización inversa, varios modelos (ADMS, LADD y WindTrax) fueron empleados para un caso no agrícola, una colonia de pingüinos en la Antártida. Este caso fue empleado para el estudio debido a que suponía la oportunidad de obtener el primer factor de emisión experimental para una colonia de pingüinos antárticos. Además las condiciones eran propicias desde el punto de vista de la casi total ausencia de concentraciones ambiente (background). Tras el trabajo de modelización existió una concordancia suficiente entre las estimaciones obtenidas por los tres modelos. De este modo se pudo definir un factor de emisión de para la colonia de 1.23 g NH3 por pareja criadora por día (con un rango de incertidumbre de 0.8-2.54 g NH3 por pareja criadora por día). Posteriores aplicaciones de técnicas de modelización inversa para casos agrícolas mostraron también un buen compromiso estadístico entre las emisiones estimadas por los distintos modelos. Con todo ello, es posible concluir que la modelización inversa es una técnica robusta para estimar tasas de emisión de NH3. Modelos de selección (screening) permiten obtener una rápida y aproximada estimación de los impactos medioambientales, siendo una herramienta útil para evaluaciones de impactos en tanto que permite eliminar casos que presentan un riesgo potencial de daño bajo. De esta forma, lo recursos del modelo pueden Resumen (Castellano) destinarse a casos en donde la posibilidad de daño es mayor. El modelo de Cálculo Simple de los Límites de Impacto de Amoniaco (SCAIL) se desarrolló para obtener una estimación de la concentración media de NH3 y de la tasa de deposición seca asociadas a una fuente agrícola. Está técnica de selección, basada en el modelo LADD, fue evaluada y calibrada con diferentes bases de datos y, finalmente, validada utilizando medidas independientes de concentraciones realizadas cerca de las fuentes. En general SCAIL dio buenos resultados de acuerdo a los criterios estadísticos establecidos. Este trabajo ha permitido definir situaciones en las que las concentraciones predichas por modelos de dispersión son similares, frente a otras en las que las predicciones difieren notablemente entre modelos. Algunos modelos nos están diseñados para simular determinados escenarios en tanto que no incluyen procesos relevantes o están más allá de los límites de su aplicabilidad. Un ejemplo es el modelo LADD que no es aplicable en fuentes con velocidad de salida significativa debido a que no incluye una parametrización de sobreelevacion del penacho. La evaluación de un esquema simple combinando la sobreelevacion del penacho y una turbulencia aumentada en la fuente mejoró el comportamiento del modelo. Sin embargo más pruebas son necesarias para avanzar en este sentido. Incluso modelos que son aplicables y que incluyen los procesos relevantes no siempre dan similares predicciones. Siendo las razones de esto aún desconocidas. Por ejemplo, AERMOD predice mayores concentraciones que ADMS para dispersión de NH3 procedente de naves de ganado ventiladas mecánicamente. Existe evidencia que sugiere que el modelo ADMS infraestima concentraciones en estas situaciones debido a un elevado límite de velocidad de viento. Por el contrario, existen evidencias de que AERMOD sobreestima concentraciones debido a sobreestimaciones a bajas Resumen (Castellano) velocidades de viento. Sin embrago, una modificación simple del pre-procesador meteorológico parece mejorar notablemente el comportamiento del modelo. Es de gran importancia que estas diferencias entre las predicciones de los modelos sean consideradas en los procesos de evaluación regulada por los organismos competentes. Esto puede ser realizado mediante la aplicación del modelo más útil para cada caso o, mejor aún, mediante modelos múltiples o híbridos. ABSTRACT Short-range atmospheric dispersion of ammonia (NH3) emitted by agricultural sources and its subsequent deposition to soil and vegetation can lead to the degradation of sensitive ecosystems and acidification of the soil. Atmospheric concentrations and dry deposition rates of NH3 are generally highest near the emission source and so environmental impacts to sensitive ecosystems are often largest at these locations. Under European legislation, several member states use short-range atmospheric dispersion models to estimate the impact of ammonia emissions on nearby designated nature conservation sites. A recent review of assessment methods for short-range impacts of NH3 recommended an intercomparison of the different models to identify whether there are notable differences to the assessment approaches used in different European countries. Based on this recommendation, this thesis compares and evaluates the atmospheric concentration predictions of several models used in these impact assessments for various real and hypothetical scenarios, including Mediterranean meteorological conditions. In addition, various inverse dispersion modelling techniques for the estimation of NH3 emissions rates are also compared and evaluated and a simple screening model to calculate the NH3 concentration and dry deposition rate at a sensitive ecosystem located close to an NH3 source was developed. The model intercomparison evaluated four atmospheric dispersion models (ADMS 4.1; AERMOD v07026; OPS-st v3.0.3 and LADD v2010) for a range of hypothetical case studies representing the atmospheric dispersion from several agricultural NH3 source types. The best agreement between the mean annual concentration predictions of the models was found for simple scenarios with area and volume sources. The agreement between the predictions of the models was worst for the scenario representing the dispersion from a mechanically ventilated livestock house, for which ADMS predicted significantly smaller concentrations than the other models. The reason for these differences appears to be due to the interaction of different plume-rise and boundary layer parameterisations. All four dispersion models were applied to two real case studies of dispersion of NH3 from pig farms in Falster (Denmark) and North Carolina (USA). The mean annual concentration predictions of the models were similar for the USA case study (emissions from naturally ventilated pig houses and a slurry lagoon). The comparison of model predictions with mean annual measured concentrations and the application of established statistical model acceptability criteria concluded that all four models performed acceptably for this case study. This was not the case for the Danish case study (mechanically ventilated pig house) for which the LADD model did not perform acceptably due to the lack of plume-rise processes in the model. Regulatory dispersion models often perform poorly in low wind speed conditions due to the model dispersion theory being inapplicable at low wind speeds. For situations with frequent low wind speed periods, current modelling guidance for regulatory assessments is to use a model that can handle these conditions in an acceptable way. This may not always be possible due to insufficient meteorological data and so the only option may be to carry out the assessment using a more common regulatory model, such as the advanced Gaussian models ADMS or AERMOD. In order to assess the suitability of these models for low wind conditions, they were applied to a Mediterranean case study that included many periods of low wind speed. The case study was the dispersion of NH3 emitted by a pig farm in Segovia, Central Spain, for which mean monthly atmospheric NH3 concentration measurements were made at 21 locations surrounding the farm as well as high-temporal-resolution concentration measurements at one location during a one-week campaign. Two strategies to improve the model performance for low wind speed conditions were tested. These were ‘no zero wind’ (NZW), which replaced calm periods with the minimum threshold wind speed of the model and ‘accumulated calm emissions’ (ACE), which forced the model to emit the total emissions during a calm period during the first subsequent non-calm hour. Due to large uncertainties in the model input data (NH3 emission rates, source exit velocities, boundary layer parameters), the case study was also used to assess model prediction uncertainty and assess how this uncertainty can be taken into account in model evaluations. A dynamic emission model modified for the Mediterranean climate was used to estimate the temporal variability in NH3 emission rates and a comparison was made between the simulations using the dynamic emissions and a constant emission rate. Prediction uncertainty due to model input uncertainty was 67-98% of the mean value for ADMS and between 53-83% of the mean value for AERMOD. Most of this uncertainty was due to source emission rate uncertainty (~50%), followed by uncertainty in the meteorological conditions (~10-20%) and uncertainty in exit velocities (~5-10%). AERMOD predicted higher concentrations than ADMS and more of the simulations met the model acceptability criteria when compared with the annual mean measured concentrations. However, the ADMS predictions were better correlated spatially with the measurements. The use of dynamic emission estimates improved the performance of ADMS but worsened the performance of AERMOD and the application of strategies to improved model performance had similar contradictory effects. In order to compare different inverse modelling techniques, several models (ADMS, LADD and WindTrax) were applied to a non-agricultural case study of a penguin colony in Antarctica. This case study was used since it gave the opportunity to provide the first experimentally-derived emission factor for an Antarctic penguin colony and also had the advantage of negligible background concentrations. There was sufficient agreement between the emission estimates obtained from the three models to define an emission factor for the penguin colony (1.23 g NH3 per breeding pair per day with an uncertainty range of 0.8-2.54 g NH3 per breeding pair per day). This emission estimate compared favourably to the value obtained using a simple micrometeorological technique (aerodynamic gradient) of 0.98 g ammonia per breeding pair per day (95% confidence interval: 0.2-2.4 g ammonia per breeding pair per day). Further application of the inverse modelling techniques for a range of agricultural case studies also demonstrated good agreement between the emission estimates. It is concluded, therefore, that inverse dispersion modelling is a robust technique for estimating NH3 emission rates. Screening models that can provide a quick and approximate estimate of environmental impacts are a useful tool for impact assessments because they can be used to filter out cases that potentially have a minimal environmental impact allowing resources to be focussed on more potentially damaging cases. The Simple Calculation of Ammonia Impact Limits (SCAIL) model was developed as a screening model to provide an estimate of the mean NH3 concentration and dry deposition rate downwind of an agricultural source. This screening tool, based on the LADD model, was evaluated and calibrated with several experimental datasets and then validated using independent concentration measurements made near sources. Overall SCAIL performed acceptably according to established statistical criteria. This work has identified situations where the concentration predictions of dispersion models are similar and other situations where the predictions are significantly different. Some models are simply not designed to simulate certain scenarios since they do not include the relevant processes or are beyond the limits of their applicability. An example is the LADD model that is not applicable to sources with significant exit velocity since the model does not include a plume-rise parameterisation. The testing of a simple scheme combining a momentum-driven plume rise and increased turbulence at the source improved model performance, but more testing is required. Even models that are applicable and include the relevant process do not always give similar predictions and the reasons for this need to be investigated. AERMOD for example predicts higher concentrations than ADMS for dispersion from mechanically ventilated livestock housing. There is evidence to suggest that ADMS underestimates concentrations in these situations due to a high wind speed threshold. Conversely, there is also evidence that AERMOD overestimates concentrations in these situations due to overestimation at low wind speeds. However, a simple modification to the meteorological pre-processor appears to improve the performance of the model. It is important that these differences between the predictions of these models are taken into account in regulatory assessments. This can be done by applying the most suitable model for the assessment in question or, better still, using multiple or hybrid models.

Decúbito ventral em doentes com ARDS

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Crystalloid strong ion difference determines metabolic acid-base change during acute normovolaemic haemodilution

Objective. To study the acid-base effects of crystalloid strong ion difference (SID) during haemodilution. Design. Prospective in vivo study. Setting. University laboratory. Subjects. Anaesthetised, mechanically ventilated Sprague-Dawley rats. Interventions. Rats were studied in seven groups of three. Each group underwent normovolaemic haemodilution with one of seven crystalloids, with SID values from 0 to 40 mEq/l. Six exchanges of 9 ml crystalloid for 3 ml blood were performed. Measurements and main results. [Hb] fell from 142+/-17 to 44+/-10 g/l (p

Neuropsychiatric manifestations in inflammatory neuropathies:a systematic review

We conducted a systematic literature review on psychological and behavioral comorbidities in patients with inflammatory neuropathies. In Guillain-Barré syndrome (GBS), psychotic symptoms are reported during early stages in 30% of patients. Typical associations include mechanical ventilation, autonomic dysfunction, inability to communicate, and severe weakness. Anxiety and depression are frequent comorbidities. Anxiety may increase post-hospital admissions and be a predictor of mechanical ventilation. Post-traumatic stress disorder may affect up to 20% of ventilated patients. Sleep disturbances are common in early-stage GBS, affecting up to 50% of patients. In chronic inflammatory demyelinating polyradiculoneuropathy, memory and quality of sleep may be impaired. An independent link between depression and pre-treatment upper limb disability and ascites was reported in POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, M-protein, Skin) syndrome, with an association with early death. Hematological treatment of POEMS appears effective on depression. Published literature on psychological/behavioral manifestations in inflammatory neuropathies remains scarce, and further research is needed. This article is protected by copyright. All rights reserved.

Embolisation of Vertebral Artery Damaged Following Cervical Disc Removal

Introduction: The incidence of vertebral artery (VA) injury during cervical spine surgery is rare. Even though tamponade is effective in many cases, early consultation of an endovascular team is recommended if bleeding cannot be controlled. We report a case of emergent endovascular embolisation of left VA due to iatrogenic injury during anterior cervical disc removal and fusion. Case: A 47-year-old woman was admitted to our emergency department with serious arterial bleeding from the neck only hours after undergoing anterior cervical disc removal and fusion surgery. She was intubated and mechanically ventilated, however hemorrhage could not be successfully controlled by packing with surgical hemostatic agents. Cranial computed tomography, computed tomography of the cervical spine and CT angiography confirmed the suspected diagnosis of injury to the VA. Emergent endovascular embolisation successfully stopped the bleeding. Occlusion of the vessel was achieved by vascular plugging. The patient was discharged from our hospital 14 days after the intervention, receiving a revision surgery of the cervical spine on the day of embolisation. At the date of discharge she presented without any focal neurological deficit. Conclusion: Pre-operative radiographic imaging of the cervical spine should be used routinely to identify anatomic abnormalities of the vertebral arteries. Endovascular embolisation appears to be effective in treating acute iatrogenic dissection of the vertebral arteries.

Tolerancia aguda e hiperalgesia inducida por remifentanilo durante la anestesia con sevofluorano en el perro

Se ha relacionado el remifentanilo con la hiperalgesia inducida por opioides (HIO) y tolerancia en ratas, lo cual produce una disminución en la reducción de sevofluorano. Esta disminución en la CAM de sevofluorano sugiere tolerancia aguda a opioides (TAO). El objetivo de este estudio es determinar si se puede desarrollar tolerancia aguda a opioides que limite la reducción de concentración alveolar mínima (CAM) de sevofluorano. La respuesta a estímulos nociceptivos mecánicos es evaluada y relacionada a HIO. Se evalúan mediante estímulos nociceptivos mecánicos (NMT) perros beagles, tras lo que se realiza anestesia con sevofluorano y 50% O2, se monitorizan y ventilan mecánicamente. Se determina la CAM de sevofluorano (CAMb1), tras lo que se administra remifentanilo (N=9) o salino (N=9) intravenoso. Veinte minutos después se determina de nuevo la CAM de sevofluorano (CAMpostfarm1) y treinta minutos después de la CAMpostfarm1 se determina la CAMpostfarm2. Una semana después, se determina la CAMb2. El NMT se determina a los 3 y 7 días de la primera anestesia para evaluar la HIO. Se considera TAO un aumento estadísticamente significativo de la CAMpostfarm2 respecto a la CAMpostfarm1 de sevofluorano. Hiperalgesia es considerada si hay una disminución del NMT a los días 3 y 7 y/o un aumento en la CAMb2 respecto a la CAMb1. La infusión continua de remifentanilo reduce la CAMpostfarm1 a 1.54±0.23% (43.7%). No se encuentran diferencias significativas entre la CAMpostfarm2 respecto a la CAMpostfarm1 ni en el grupo de salino (p 0.104) ni en el de remifentanilo (p 0.389). Tampoco se hallan entre la CAMb1 y CAMb2 (p 0.818) o entre RSb, RS3 y RS7 en ambos grupos. El remifentanilo induce tolerancia aguda en ratas; pero, en perros, la eficacia en reducir la CAM de sevofluorano no disminuye, sugiriendo que no se induce TAO. Ni produciéndose hiperalgesia en una semana.

Desenlaces de la escala Omaha+ en los pacientes en cuidado intensivo en la fundación santa fe de Bogotá

Introducción La ventilación mecánica es fundamental en el manejo de la falla respiratoria aguda, actualmente no existe consenso sobre el momento exacto de extubación. Este estudio describe el comportamiento de la escala OMAHA+ en nuestra institución. Objetivo Principal Describir los desenlaces clínicos relacionados con la escala OMAHA+ durante la extubación de los pacientes de las unidades de cuidado intensivo del hospital universitario. Métodos Estudio descriptivo, retrospectivo, basado en el registro de la escala OMAHA+ de 68 pacientes durante el proceso de extubación en las Unidades de cuidado intensivo adulto de la Fundación Santa Fe de Bogotá durante Agosto de 2014 a Mayo de 2015. Resultados Se encontraron valores gasométricos cercanos a la normalidad, con una PaO2/FiO2 media de 261 (DS 60,6), SaO2 media de 96% (DS 2%), media de lactato sérico de 1.5 mmol/L (DS 1,2 mmol/L), con signos vitales normales. La causa más común de ingreso a UCI fue Neumonía, seguida por cirugía cardiaca y abdominal. Las medias de parámetros ventilatorios al momento de extubación fueron; PEEP de 6 (DS 0,8), volumen corriente de 8ml/Kg (DS 1,4 ml/Kg), índice de Tobín de 34 (DS 11,9), test de fuga positivo 94%, y sólo una extubación fallida. Conclusiones La escala OMAHA+ puede ser una herramienta útil, aplicable y fácilmente reproducible en los pacientes con soporte ventilatorio mecánico invasivo previo al proceso de extubación, con baja proporción de fallo. Estos resultados deben ser evaluados en estudios prospectivos.

Age, invasive ventilatory support and outcomes in elderly patients admitted to intensive care units

Objective: to determine the relationship between age and in-hospital mortality of elderly patients, admitted to ICU, requiring and not requiring invasive ventilatory support. Design: prospective observational cohort study conducted over a period of 11 months. Setting: medical-surgical ICU at a Brazilian university hospital. Subjects: a total of 840 patients aged 55 years and older were admitted to ICU. Methods: in-hospital death rates for patients requiring and not requiring invasive ventilatory support were compared across three successive age intervals (55-64; 65-74 and 75 or more years), adjusting for severity of illness using the Acute Physiologic Score. Results: age was strongly correlated with mortality among the invasively ventilated subgroup of patients and the multivariate adjusted odds ratios increased progressively with every age increment (OR = 1.60, 95% CI = 1.01-2.54 for 65-74 years old and OR = 2.68, 95% CI = 1.58-4.56 for >= 75 years). For the patients not submitted to invasive ventilatory support, age was not independently associated with in-hospital mortality (OR = 2.28, 95% CI = 0.99-5.25 for 65-74 years old and OR = 1.95, 95% CI = 0.82-4.62 for >= 75 years old). Conclusions: the combination of age and invasive mechanical ventilation is strongly associated with in-hospital mortality. Age should not be considered as a factor related to in-hospital mortality of elderly patients not requiring invasive ventilatory support in ICU.

Energy balance in elderly patients after surgery for a femoral neck fracture.

To study energy and protein balances in elderly patients after surgery, spontaneous energy and protein intake and resting energy expenditure (REE) were measured in 20 elderly female patients with a femoral neck fracture (mean age 81 +/- 4, SD, range 74-87 years; weight 53 +/- 8, range 42-68 kg) during a 5-6 day period following surgery. REE, measured over 20-40 min by indirect calorimetry using a ventilated canopy, averaged 0.98 +/- 0.15 kcal/min on day 3 and decreased to 0.93 +/- 0.15 kcal/min on day 8-9 postsurgery (p less than 0.02). REE was positively correlated with body weight (r = 0.69, p less than 0.005). Mean REE extrapolated to 24 hr (24-REE) was 1283 +/- 194 kcal/day. Mean daily food energy intake measured over the 5-day follow-up period was 1097 +/- 333 kcal/day and was positively correlated with 24-REE (r = 0.50, p less than 0.05). Daily energy balance was -235 +/- 351 kcal/day on day 3 (p less than 0.01 vs zero) and -13 +/- 392 kcal/day on day 8-9 postsurgery (NS vs zero) with a mean over the study period of -185 +/- 289 kcal/day (p less than 0.01 vs zero). When an extra 100 kcal/day was allowed for the energy cost of physical activity, mean daily energy balance over the 5-day study period was calculated to be -285 +/- 289 kcal/day (p less than 0.01 vs zero). Measurements of total 24-hr urinary nitrogen (N) excretion were obtained in a subgroup of 14 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Progression rate of self-propelled feeding tubes in critically ill patients.

OBJECTIVE: Gaining postpyloric access in ventilated, sedated ICU patients usually requires time-consuming procedures such as endoscopy. Recently, a feeding tube has been introduced that migrates spontaneously into the jejunum in surgical patients. The study aimed at assessing the rate of migration of this tube in critically ill patients. DESIGN: Prospective descriptive trial. SETTING: Surgical ICU in a tertiary University Hospital. PATIENTS: One hundred and five consecutive surgical ICU patients requiring enteral feeding were enrolled, resulting in 128 feeding-tube placement attempts. METHODS: A self-propelled tube was used and followed up for 3 days: progression was assessed by daily contrast-injected X-ray. Severity of illness was assessed with SAPS II and organ failure assessed with SOFA score. RESULTS: The patients were aged 55+/-19 years (mean+/-SD) with SAPS II score of 45+/-18. Of the 128 tube placement attempts, 12 could not be placed in the stomach; eight were accidentally pulled out while in gastric position due to the necessity to avoid fixation during the progression phase. Among organ failures, respiratory failure predominated, followed by cardiovascular. By day 3, the postpyloric progression rate was 63/128 tubes (49%). There was no association between migration and age, or SAPS II score, but the progression rate was significantly poorer in patients with hemodynamic failure. Use of norepinephrine and morphine were negatively associated with tube progression (P<0.001), while abdominal surgery was not. In ten patients, jejunal tubes were placed by endoscopy. CONCLUSION: Self-propelled feeding tubes progressed from the stomach to the postpyloric position in 49% of patients, reducing the number of endoscopic placements: these tubes may facilitate enteral nutrient delivery in the ICU.

Automatic selection of tidal volume, respiratory frequency and minute ventilation in intubated ICU patients as start up procedure for closed-loop controlled ventilation.

OBJECTIVE: Before a patient can be connected to a mechanical ventilator, the controls of the apparatus need to be set up appropriately. Today, this is done by the intensive care professional. With the advent of closed loop controlled mechanical ventilation, methods will be needed to select appropriate start up settings automatically. The objective of our study was to test such a computerized method which could eventually be used as a start-up procedure (first 5-10 minutes of ventilation) for closed-loop controlled ventilation. DESIGN: Prospective Study. SETTINGS: ICU's in two adult and one children's hospital. PATIENTS: 25 critically ill adult patients (age > or = 15 y) and 17 critically ill children selected at random were studied. INTERVENTIONS: To stimulate 'initial connection', the patients were disconnected from their ventilator and transiently connected to a modified Hamilton AMADEUS ventilator for maximally one minute. During that time they were ventilated with a fixed and standardized breath pattern (Test Breaths) based on pressure controlled synchronized intermittent mandatory ventilation (PCSIMV). MEASUREMENTS AND MAIN RESULTS: Measurements of airway flow, airway pressure and instantaneous CO2 concentration using a mainstream CO2 analyzer were made at the mouth during application of the Test-Breaths. Test-Breaths were analyzed in terms of tidal volume, expiratory time constant and series dead space. Using this data an initial ventilation pattern consisting of respiratory frequency and tidal volume was calculated. This ventilation pattern was compared to the one measured prior to the onset of the study using a two-tailed paired t-test. Additionally, it was compared to a conventional method for setting up ventilators. The computer-proposed ventilation pattern did not differ significantly from the actual pattern (p > 0.05), while the conventional method did. However the scatter was large and in 6 cases deviations in the minute ventilation of more than 50% were observed. CONCLUSIONS: The analysis of standardized Test Breaths allows automatic determination of an initial ventilation pattern for intubated ICU patients. While this pattern does not seem to be superior to the one chosen by the conventional method, it is derived fully automatically and without need for manual patient data entry such as weight or height. This makes the method potentially useful as a start up procedure for closed-loop controlled ventilation.

TNF-a and IL-10 levels in tracheobronchial lavage of ventilated preterm infants and subsequent lung function

The role of airway inflammation in ventilated preterm newborns and the risk factors associated with the development of chronic lung disease are not well understood. Our objective was to analyze the association of the airway inflammatory response in ventilated preterm infants by serial measurements of TNF-a and IL-10 in tracheobronchial lavage (TBL) with perinatal factors and lung function measured early in life. A series of TBL samples were collected from ventilated preterm infants (less than 32 weeks of gestational age) and concentrations of TNF-a and IL-10 were measured by ELISA. Pulmonary function tests were performed after discharge by the raised volume rapid compression technique. Twenty-five subjects were recruited and 70 TBL samples were obtained. There was a significant positive association between TNF-a and IL-10 levels and length of time between the rupture of the amniotic membranes and delivery (r = 0.65, P = 0.002, and r = 0.57, P < 0.001, respectively). Lung function was measured between 1 and 22 weeks of corrected age in 10 patients. Multivariable analysis with adjustment for differences in lung volume showed a significant negative association between TNF-a levels and forced expiratory flow (FEF50; r = -0.6; P = 0.04), FEF75 (r = -0.76; P = 0.02), FEF85 (r = -0.75; P = 0.03), FEF25-75 (-0.71; P = 0.02), and FEV0.5 (r = -0.39; P = 0.03). These data suggest that TNF-a levels in the airways during the first days of life were associated with subsequent lung function abnormalities measured weeks or months later.

The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multicenter randomized controlled trial

Objective: Evaluation of selective decontamination of the digestive tract (SDD) on late mortality in ventilated trauma patients in an intensive care unit (ICU). Methods: A multicenter, randomized controlled trial was undertaken in 401 trauma patients with Hospital Trauma Index-Injury Severity Score of 16 or higher. Patients were randomized to control (n = 200) or SDD (n = 201), using polymyxin E, tobramycin, and amphotericin B in throat and gut throughout ICU treatment combined with cefotaxime for 4 days. Primary endpoint was late mortality excluding early death from hemorrhage or craniocerebral injury. Secondary endpoints were infection and organ dysfunction. Results: Mortality was 20.9% with SDD and 22.0% in controls. Overall late mortality was 15.3% (57/372) as 29 patients died from cerebral injury, 16 SDD and 13 control. The odds ratio (95% confidence intervals) of late mortality for SDD relative to control was 0.75 (0.40-1.37), corresponding to estimates of 13.4% SDD and 17.2% control. The overall infection rate was reduced in the test group (48.8% vs. 61.0%). SDD reduced lower airway infections (30.9% vs. 50.0%) and bloodstream infections due to aerobic Gram-negative bacilli (2.5% vs. 7.5%). No difference in organ dysfunction was found. Concluson: This study demonstrates that SDD significantly reduces infection in multiple trauma, although this RCT in 401 patients was underpowered to detect a mortality benefit.