Since March, Chile experienced an exponential increase in SARS-CoV2 cases, which led to an almost full occupancy of the intensive care units (ICU).
To characterize patients with SARS-CoV2 disease who ...required hospitalization in the ICU and invasive mechanical ventilation (IMV) in our hospital.
A prospective observational study was performed, which included the first 50 patients, aged 54 ± 13 years (58% men), with SARS-CoV2 disease, with ICU and IMV requirements between March 23 and June 2, 2020. Demographics, comorbidities, symptoms, laboratory and imaging, therapies performed and IMV characteristics were registered. The most relevant outcomes observed were lethality, number of days in the ICU and connection to an IMV.
Ninety percent of patients were overweight or obese, 46% had hypertension and many had diabetes mellitus. They had elevated inflammatory parameters and typical patterns of COVID-19 in computed tomography. Most of the patients got protective lung ventilation with a high rate of use of neuromuscular blockade (NMB) and prone position. Antibiotics, hydroxychloroquine, and lopinavir/ritonavir were administered according to the protocol of the institution. Lethality was 16% (8 cases) at the end of this study.
The information obtained in this study provides characteristics and early outcomes of hospitalized patients with confirmed COVID-19 and IMV, admitted to the ICU of our center.
We present the case of a 22-year-old patient with no morbid history who developed a brain abscess secondary to endocarditis due to Eikenella corrodens. The diagnosis was established by detecting the ...microorganism by universal polymerase chain reaction in fluid from the brain collection. Trans-esophageal echocardiogram study confirmed vegetations in the mitral valve. External ventricular shunt placement was required due to emptying of abscess to brain ventricles and secondary hydrocephalus. He received 80 days of effective antibiotic treatment and his evolution was favorable with complete resolution of his infection verified with images and echocardiogram. Follow-up at seven months later due to ventricule-peritoneal drainage valve dysfunction did not confirmed infection.
Trauma is the main cause of death among people aged 5 to 44 years.
To describe features, treatment and evolution of trauma patients admitted to an emergency room.
Adult patients admitted in the ...emergency department of a public hospital due to severe trauma were studied and followed during their hospital stay.
We included 114 patients aged 40 ± 17 years (78%men) with an injury severity score of 21 ± 11. Trauma was penetrating in 43%. Traumatic brain injury (TBI) was the most common diagnosis in 46%. In the emergency room, 8% had hypotension, 5% required vasopressors and 23% required mechanical ventilation. The initial lactate was 3.6 ± 2.9 mmol/L. Sixty-five patients (57%) required emergency surgery. The intraoperative lactate was 3 ± 1.7 mmol/L and 20% required vasopressors. Sixty-four patients (56%) were admitted to the ICU, with APACHEII and SOFA scores of 16 ± 8 and 5 ± 3, respectively. ICU lactate was 3.2±1.5 mmol/L. In the ICU 40% required vasopressors and 63% mechanical ventilation. Thirty two percent had coagulopathy, 43% received transfusions and 10% required massive transfusions. The hospital stay was 13 (6-32) days, being significantly longer in patients with TBI. ICU and hospital mortalities were 12.5 and 18.4% respectively. The only predictor for mortality was the APACHEII score (Hazard Ratio 1.18, 95% confidence intervals 1.03-1.36).
APACHE score was a predictor of mortality in this group of patients.
The spontaneous breathing trial (SBT) assesses the risk of weaning failure by evaluating some physiological responses to the massive venous return increase imposed by discontinuing positive pressure ...ventilation. This trial can be very demanding for some critically ill patients, inducing excessive physical and cardiovascular stress, including muscle fatigue, heart ischemia and eventually cardiac dysfunction. Extubation failure with emergency reintubation is a serious adverse consequence of a failed weaning process. Some data suggest that as many as 50% of patients that fail weaning do so because of cardiac dysfunction. Unfortunately, monitoring cardiovascular function at the time of the SBT is complex. The aim of our study was to explore if central venous pressure (CVP) changes were related to weaning failure after starting an SBT. We hypothesized that an early rise on CVP could signal a cardiac failure when handling a massive increase on venous return following a discontinuation of positive pressure ventilation. This CVP rise could identify a subset of patients at high risk for extubation failure.
Two-hundred and four mechanically ventilated patients in whom an SBT was decided were subjected to a monitoring protocol that included blinded assessment of CVP at baseline, and at 2 minutes after starting the trial (CVP-test). Weaning failure was defined as reintubation within 48-hours following extubation. Comparisons between two parametric or non-parametric variables were performed with student T test or Mann Whitney U test, respectively. A logistic multivariate regression was performed to determine the predictive value on extubation failure of usual clinical variables and CVP at 2-min after starting the SBT.
One-hundred and sixty-five patients were extubated after the SBT, 11 of whom were reintubated within 48h. Absolute CVP values at 2-minutes, and the change from baseline (dCVP) were significantly higher in patients with extubation failure as compared to those successfully weaned. dCVP was an early predictor for reintubation (OR: 1.70 1.31,2.19, p<0.001).
An early rise in CVP after starting an SBT was associated with an increased risk of extubation failure. This might represent a warning signal not captured by usual SBT monitoring and could have relevant clinical implications.
Purpose
The role of dobutamine during septic shock resuscitation is still controversial since most clinical studies have been uncontrolled and no physiological study has unequivocally demonstrated a ...beneficial effect on tissue perfusion. Our objective was to determine the potential benefits of dobutamine on hemodynamic, metabolic, peripheral, hepatosplanchnic and microcirculatory perfusion parameters during early septic shock resuscitation.
Methods
We designed a randomized, controlled, double-blind, crossover study comparing the effects of 2.5-h infusion of dobutamine (5 mcg/kg/min fixed-dose) or placebo in 20 septic shock patients with cardiac index ≥2.5 l/min/m
2
and hyperlactatemia. Primary outcome was sublingual perfused microvascular density.
Results
Despite an increasing cardiac index, heart rate and left ventricular ejection fraction, dobutamine had no effect on sublingual perfused vessel density 9.0 (7.9–10.1) vs. 9.1 n/mm (7.9–9.9);
p
= 0.24 or microvascular flow index 2.1 (1.8–2.5) vs. 2.1 (1.9–2.5);
p
= 0.73 compared to placebo. No differences between dobutamine and placebo were found for the lactate levels, mixed venous-arterial pCO
2
gradient, thenar muscle oxygen saturation, capillary refill time or gastric-to-arterial pCO
2
gradient. The indocyanine green plasma disappearance rate 14.4 (9.5–25.6) vs. 18.8 %/min (11.7–24.6);
p
= 0.03 and the recovery slope of thenar muscle oxygen saturation after a vascular occlusion test 2.1 (1.1–3.1) vs. 2.5 %/s (1.2–3.4);
p
= 0.01 were worse with dobutamine compared to placebo.
Conclusions
Dobutamine failed to improve sublingual microcirculatory, metabolic, hepatosplanchnic or peripheral perfusion parameters despite inducing a significant increase in systemic hemodynamic variables in septic shock patients without low cardiac output but with persistent hypoperfusion.
Abnormal peripheral perfusion after septic shock resuscitation has been associated with organ dysfunction and mortality. The potential role of the clinical assessment of peripheral perfusion as a ...target during resuscitation in early septic shock has not been established.
To determine if a peripheral perfusion-targeted resuscitation during early septic shock in adults is more effective than a lactate level-targeted resuscitation for reducing mortality.
Multicenter, randomized trial conducted at 28 intensive care units in 5 countries. Four-hundred twenty-four patients with septic shock were included between March 2017 and March 2018. The last date of follow-up was June 12, 2018.
Patients were randomized to a step-by-step resuscitation protocol aimed at either normalizing capillary refill time (n = 212) or normalizing or decreasing lactate levels at rates greater than 20% per 2 hours (n = 212), during an 8-hour intervention period.
The primary outcome was all-cause mortality at 28 days. Secondary outcomes were organ dysfunction at 72 hours after randomization, as assessed by Sequential Organ Failure Assessment (SOFA) score (range, 0 best to 24 worst); death within 90 days; mechanical ventilation-, renal replacement therapy-, and vasopressor-free days within 28 days; intensive care unit and hospital length of stay.
Among 424 patients randomized (mean age, 63 years; 226 53% women), 416 (98%) completed the trial. By day 28, 74 patients (34.9%) in the peripheral perfusion group and 92 patients (43.4%) in the lactate group had died (hazard ratio, 0.75 95% CI, 0.55 to 1.02; P = .06; risk difference, -8.5% 95% CI, -18.2% to 1.2%). Peripheral perfusion-targeted resuscitation was associated with less organ dysfunction at 72 hours (mean SOFA score, 5.6 SD, 4.3 vs 6.6 SD, 4.7; mean difference, -1.00 95% CI, -1.97 to -0.02; P = .045). There were no significant differences in the other 6 secondary outcomes. No protocol-related serious adverse reactions were confirmed.
Among patients with septic shock, a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality.
ClinicalTrials.gov Identifier: NCT03078712.
Invasive candidiasis (IC) epidemiology has changed in critically ill patients and limited data are available in Chile.
To describe the epidemiological and microbiological profile of IC in critically ...ill patients.
Observational prospective study conducted from October 2001 to August 2003 in critically ill adults with suspected or confirmed IC.
53 patients met criteria for IC, finding 18 (33.9%) candidemias, 22 (41.5%) disseminated IC, and 13 (24.5%) local IC. We identified 8 (44.4%) C. albicans and 10 (55.6%) non-albicans Candida in candidemias. C. tropicalis was the predominant non-albicans species (27.7%). An 88.8 % of Candidas sp recovered in candidemias were fluconazole susceptible. Overall hospital mortality was 24.5%. Mortality in candidemia was significantly lower than in disseminated IC (16.6 vs 31.8%, p = 0.02).
A higher proportion of non-albicans Candida was observed in candidemias from critically ill patients. However, most of these strains were fluconazole susceptible. A lower overall mortality was observed in candidemias.
COVID-19 upsurge in orotracheal intubation (OTI) has opened a new opportunity for studying associated complications. Vocal fold motion impairment (VFMI) is a known complication of OTI. The present ...study sought to determine the impact of OTI and prolonged OTI on the risk of developing VFMI; to identify both risk and protective factors associated with it.
Retrospective cohort study.
Multicenter.
Medical charts were reviewed for all patients that received invasive mechanical ventilation with a subsequent flexible laryngoscopic assessment between March 2020 and March 2022. The main outcomes were the presence of VFMI, including immobility (VFI) and hypomobility (VFH).
A total of 155 patients were included, 119 (76.8%) COVID-19 and 36 (23.2%) non-COVID-19 patients; overall 82 (52.9%) were diagnosed with VFMI. Eighty (52.3%) patients underwent a tracheostomy. The median (IQR) intubation duration was 18 (11–24.25) days, while the median (IQR) time to tracheostomy was 22 (16–29). In the adjusted model, we observed there was a 68% increased risk for VFMI from day 21 of intubation (RR: 1.68; 95% CI 1.07–2.65; P = 0.025).
VFMI is a frequent complication in severely ill patients that undergo intubation. A prolonged OTI was associated with an increased risk of VFMI, highlighting the importance of timely tracheostomy. Further research is needed to confirm these findings in other subsets of critically ill patients.
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