Carmelo Dueñas

Delirium epidemiology in critical care (DECCA): an international study

IntroductionDelirium is a frequent source of morbidity in intensive care units (ICUs). Most data on its epidemiology is from single-center studies. Our aim was to conduct a multicenter study to evaluate the epidemiology of delirium in the ICU.MethodsA 1-day point-prevalence study was undertaken in 104 ICUs from 11 countries in South and North America and Spain.ResultsIn total, 975 patients were screened, and 497 fulfilled inclusion criteria and were enrolled (median age, 62 years; 52.5% men; 16.7% and 19.9% for ICU and hospital mortality); 64% were admitted to the ICU because of medical causes, and sepsis was the main diagnosis (n = 76; 15.3%). In total, 265 patients were sedated with the Richmond agitation and sedation scale (RASS) deeper than -3, and only 232 (46.6%) patients could be evaluated with the confusion-assessment method for the ICU. The prevalence of delirium was 32.3%. Compared with patients without delirium, those with the diagnosis of delirium had a greater severity of illness at admission, demonstrated by higher sequential organ-failure assessment (SOFA (P = 0.004)) and simplified acute physiology score 3 (SAPS3) scores (P < 0.0001). Delirium was associated with increased ICU (20% versus 5.7%; P = 0.002) and hospital mortality (24 versus 8.3%; P = 0.0017), and longer ICU (P < 0.0001) and hospital length of stay (LOS) (22 (11 to 40) versus 7 (4 to 18) days; P < 0.0001). Previous use of midazolam (P = 0.009) was more frequent in patients with delirium. On multivariate analysis, delirium was independently associated with increased ICU mortality (OR = 3.14 (1.26 to 7.86); CI, 95%) and hospital mortality (OR = 2.5 (1.1 to 5.7); CI, 95%).ConclusionsIn this 1-day international study, delirium was frequent and associated with increased mortality and ICU LOS. The main modifiable risk factors associated with the diagnosis of delirium were the use of invasive devices and sedatives (midazolam).

The epidemiology of sepsis in Colombia: a prospective multicenter cohort study in ten university hospitals.

Objective:Our aim was to determine the frequency and the clinical and epidemiologic characteristics of sepsis in a hospital-based population in Colombia. Design:Prospective cohort. Setting:Ten general hospitals in the four main cities of Colombia. Patients:Consecutive patients admitted in emergency rooms, intensive care units, and general wards from September 1, 2007, to February 29, 2008, with confirmation of infection according to the Centers for Disease Control and Prevention definitions. Interventions:None. Measurements and Main Results:The following information was recorded: demographic, clinical, and microbiologic characteristics; Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores; requirement for intensive care unit; length of stay; and 28-day all-cause mortality. During a period of 6 months, 2,681 patients were recruited: 69% and 31% with community-acquired and hospital-acquired infections, respectively. The mean age was 55 yrs (sd = 21), 51% were female, and the median length of stay was 10 days (interquartile range, 5–19). The mean Acute Physiology and Chronic Health Evaluation score was 11.5 (sd = 7) and the mean Sequential Organ Failure Assessment score was 3.8 (sd = 3). A total of 422 patients with community-acquired infections (16%) were admitted to the intensive care unit as a consequence of their infection and the median length of stay was 4.5 days in the intensive care unit. At admission, 2516 patients (94%) met at least one sepsis criterion and 1,658 (62%) met at least one criterion for severe sepsis. Overall, the 28-day mortality rates of patients with infection without sepsis, sepsis without organ dysfunction, severe sepsis without shock, and septic shock were 3%, 7.3%, 21.9%, and 45.6%, respectively. In community-acquired infections, the most frequent diagnosis was urinary tract infection in 28.6% followed by pneumonia in 22.8% and soft tissue infections in 21.8%. Within hospital-acquired infections, pneumonia was the most frequent diagnosis in 26.6% followed by urinary tract infection in 20.4% and soft tissue infections in 17.4%. Conclusions:In a general inpatient population of Colombia, the rates of severe sepsis and septic shock are higher than those reported in the literature. The observed mortality is higher than the predicted by the Acute Physiology and Chronic Health Evaluation II score.

Guía de práctica clínica basada en la evidencia para el manejo de la sedo-analgesia en el paciente adulto críticamente enfermo

Dada la importancia del manejo de la sedacion, analgesia y delirium en las unidades de cuidados intensivos, y con el fin de actualizar las guias publicadas anteriormente, se decidio elaborar una nueva guia de practica clinica con los soportes, manejos e intervenciones mas relevantes acordes con las publicaciones recientes. Para elaborar esta guia, se reunio un grupo de 24 intensivistas procedentes de 9 paises de la Federacion Panamericana e Iberica de Sociedades de Medicina Critica y Terapia Intensiva. Se acogio la propuesta del Grading of Recommendations Assessment, Development and Evaluation Working Group para emitir el grado de recomendacion y evaluar la calidad de la evidencia. Se realizo una busqueda sistematica de la literatura utilizandose: MEDLINE, las siguientes bases de datos de la biblioteca Cochrane: Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects, National Health Service Economic Evaluation Database, y la base de datos de Literatura Latinoamericana y del Caribe en Ciencias de la Salud (LILACS). Finalmente, se seleccionaron 438 referencias, permitiendo realizar 47 recomendaciones fuertes con evidencia alta y moderada, 14 recomendaciones condicionales con evidencia moderada y 65 recomendaciones condicionales con evidencia baja. Se confirma la importancia del manejo inicial y multimodal del dolor, se hace enfasis en la disminucion de los niveles de sedacion y la utilizacion de sedacion profunda solo en casos especificos. Aumenta la evidencia y recomendaciones para el uso de medicamentos como dexmedetomidina, remifentanil, ketamina, entre otros.

Clinical course of sepsis, severe sepsis, and septic shock in a cohort of infected patients from ten Colombian hospitals

BackgroundSepsis has several clinical stages, and mortality rates are different for each stage. Our goal was to establish the evolution and the determinants of the progression of clinical stages, from infection to septic shock, over the first week, as well as their relationship to 7-day and 28-day mortality.MethodsThis is a secondary analysis of a multicenter cohort of inpatients hospitalized in general wards or intensive care units (ICUs). The general estimating equations (GEE) model was used to estimate the risk of progression and the determinants of stages of infection over the first week. Cox regression with time-dependent covariates and fixed covariates was used to determine the factors related with 7-day and 28-day mortality, respectively.ResultsIn 2681 patients we show that progression to severe sepsis and septic shock increases with intraabdominal and respiratory sources of infection [OR = 1,32; 95%IC = 1,20-1,46 and OR = 1.21, 95%CI = 1,11-1,33 respectively], as well as according to Acute Physiology and Chronic Health Evaluation II (APACHE II) [OR = 1,03; 95%CI = 1,02-1,03] and Sequential Organ Failure Assessment (SOFA) [OR = 1,16; 95%CI = 1,14-1,17] scores. The variables related with first-week mortality were progression to severe sepsis [HR = 2,13; 95%CI = 1,13-4,03] and septic shock [HR = 3,00; 95%CI = 1,50-5.98], respiratory source of infection [HR = 1,76; 95%IC = 1,12-2,77], APACHE II [HR = 1,07; 95% CI = 1,04-1,10] and SOFA [HR = 1,09; 95%IC = 1,04-1,15] scores.ConclusionsIntraabdominal and respiratory sources of infection, independently of SOFA and APACHE II scores, increase the risk of clinical progression to more severe stages of sepsis; and these factors, together with progression of the infection itself, are the main determinants of 7-day and 28-day mortality.

Perfil microbiológico de la Infecciones en Unidades de Cuidados Intensivos de Colombia (EPISEPSIS Colombia)

BACKGROUND AND OBJECTIVE Valid and reliable data regarding sepsis is lacking in Colombia. Our aim was to determine the prevalence of the microorganisms in the main infections treated in Intensive Care Units (ICUs) in our country. METHODS This is a sub-study of a prospective cohort with 10 general hospitals in Colombia during a 6-month period. The inclusion criteria were hospitalization in ICU and confirmation of infection according to the CDC definitions. Patients were classified into three groups, that is, community, hospital and intensive care, according to the site where the infection was acquired. RESULTS A total of 826 patients were included in this analysis. Of these, 51% developed infections in the community, 5.33% in the hospital and 43.7% in intensive care unit. Overall, the most common diagnoses were pneumonia (29.54%), intra-abdominal infection (18.16%) and urinary tract infection (11.62%). The most frequent germ in community-acquired infections was E. coli -lung (16. 4%), peritoneum (57.7%), urine (55.5%), blood (22.4%)-. E. coli -peritoneum (29.3%), urine (52.9%)- also predominated in the ICU-acquired infections, except for lung and blood in which Staphylococcus aureus (32.4%) and Klebsiella pneumoniae (15.7%) were the most prevalent. Cultures were requested from 655 patients, 40% of them having received antibiotics before cultures were taken, although this did not affected the percentages of positive cultures (P=0.583). CONCLUSIONS Pneumonia was the main cause of infection regardless of the site of acquisition. E. coli was the most prevalent germ, except in the pulmonary infections acquired in UCI in which S. aureus was the most prevalent.

Evidence-based guidelines for the use of tracheostomy in critically ill patients.

Objectives: To provide evidence‐based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. Methods: A taskforce composed of representatives of 10 member countries of the Pan‐American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. Results: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified, of which 226 publications were chosen. The taskforce generated a total of 19 recommendations, 10 positive (1B, 3; 2C, 3; 2D, 4) and 9 negative (1B, 8; 2C, 1). A recommendation was not possible in 6 questions. Conclusions: Percutaneous techniques are associated with a lower risk of infections compared with surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long‐term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Guías basadas en la evidencia para el uso de traqueostomía en el paciente crítico

OBJECTIVES Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions. CONCLUSION Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Biomarcadores cardíacos: Presente y futuro

En la actualidad, las enfermedades cardiovasculares se consideran la pandemia mas significativa del siglo XXI. Dentro de ellas, la enfermedad coronaria es la mas prevalente y la que mas morbi-mortalidad genera; en el caso particular de Colombia, es la principal causa de muerte en individuos mayores de 45 anos. La caracteristica silenciosa de esta enfermedad ha impulsado la investigacion de moleculas que permitan su diagnostico precoz y sirvan como predictores pronostico tanto en la fase cronica como en la aguda. Fruto de estas investigaciones, en los ultimos treinta anos se ha producido un avance importante en el desarrollo de biomarcadores cardiacos. Entre ellos estan los recien desarrollados ensayos de troponinas ultrasensibles para diagnostico temprano, la medicion de la albumina modificada por isquemia que cuenta con alto valor predictivo negativo para la deteccion de isquemia miocardica, el ligando de CD40 soluble para la clasificacion e individualizacion del tratamiento, la utilidad de la proteina C reactiva como marcador de riesgo de enfermedad coronaria y las diversas tecnicas de alto rendimiento como la proteomica, que permite la deteccion de multiples biomarcadores potenciales. A pesar de ello, aun no se dispone de evidencia suficiente para sustituir los marcadores que recomiendan las asociaciones cientificas por los nuevos marcadores que se han ido desarrollando, y continua el debate sobre que combinacion utilizar para alcanzar mayor rendimiento diagnostico, pronostico y terapeutico. A continuacion se revisan los avances actuales en biomarcadores cardiacos y su potencial integracion a la practica clinica habitual.