Enrique Piacentini

Peripheral arterial blood pressure monitoring adequately tracks central arterial blood pressure in critically ill patients: an observational study

IntroductionInvasive arterial blood pressure monitoring is a common practice in intensive care units (ICUs). Accuracy of invasive blood pressure monitoring is crucial in evaluating the cardiocirculatory system and adjusting drug therapy for hemodynamic support. However, the best site for catheter insertion is controversial. Lack of definitive information in critically ill patients makes it difficult to establish guidelines for daily practice in intensive care. We hypothesize that peripheral and central mean arterial blood pressures are interchangeable in critically ill patients.MethodsThis is a prospective, observational study carried out in a surgical-medical ICU in a teaching hospital. Fifty-five critically ill patients with clinical indication of invasive arterial pressure monitoring were included in the study. No interventions were made. Simultaneous measurements were registered in central (femoral) and peripheral (radial) arteries. Bias and precision between both measurements were calculated with Bland-Altman analysis for the whole group. Bias and precision were compared between patients receiving high doses of vasoactive drugs (norepinephrine or epinephrine >0.1 μg/kg/minute or dopamine >10 μg/kg/minute) and those receiving low doses (norepinephrine or epinephrine <0.1 μg/kg/minute or dopamine <10 μg/kg/minute).ResultsCentral mean arterial pressure was 3 ± 4 mmHg higher than peripheral mean arterial pressure for the whole population and there were no differences between groups (3 ± 4 mmHg for both groups).ConclusionMeasurement of mean arterial blood pressure in radial or femoral arteries is clinically interchangeable. It is not mandatory to cannulate the femoral artery, even in critically ill patients receiving high doses of vasoactive drugs.

Antibiotic prescription patterns in the empiric therapy of severe sepsis: combination of antimicrobials with different mechanisms of action reduces mortality

IntroductionAlthough early institution of adequate antimicrobial therapy is lifesaving in sepsis patients, optimal antimicrobial strategy has not been established. Moreover, the benefit of combination therapy over monotherapy remains to be determined. Our aims are to describe patterns of empiric antimicrobial therapy in severe sepsis, assessing the impact of combination therapy, including antimicrobials with different mechanisms of action, on mortality.MethodsThis is a Spanish national multicenter study, analyzing all patients admitted to ICUs who received antibiotics within the first 6 hours of diagnosis of severe sepsis or septic shock. Antibiotic-prescription patterns in community-acquired infections and nosocomial infections were analyzed separately and compared. We compared the impact on mortality of empiric antibiotic treatment, including antibiotics with different mechanisms of action, termed different-class combination therapy (DCCT), with that of monotherapy and any other combination therapy possibilities (non-DCCT).ResultsWe included 1,372 patients, 1,022 (74.5%) of whom had community-acquired sepsis and 350 (25.5%) of whom had nosocomial sepsis. The most frequently prescribed antibiotic agents were β-lactams (902, 65.7%) and carbapenems (345, 25.1%). DCCT was administered to 388 patients (28.3%), whereas non-DCCT was administered to 984 (71.7%). The mortality rate was significantly lower in patients administered DCCTs than in those who were administered non-DCCTs (34% versus 40%; P = 0.042). The variables independently associated with mortality were age, male sex, APACHE II score, and community origin of the infection. DCCT was a protective factor against in-hospital mortality (odds ratio (OR), 0.699; 95% confidence interval (CI), 0.522 to 0.936; P = 0.016), as was urologic focus of infection (OR, 0.241; 95% CI, 0.102 to 0.569; P = 0.001).Conclusionsβ-Lactams, including carbapenems, are the most frequently prescribed antibiotics in empiric therapy in patients with severe sepsis and septic shock. Administering a combination of antimicrobials with different mechanisms of action is associated with decreased mortality.

Procalcitonin levels are lower in intensive care unit patients with H1N1 influenza A virus pneumonia than in those with community-acquired bacterial pneumonia. A pilot study

PURPOSE The purpose of the study was to know the kinetics of procalcitonin (PCT), C-reactive protein (CRP), and white blood cell (WBC) in critically ill patients with H1N1 influenza A virus pneumonia and to compare levels of these inflammatory mediators with patients with acute community-acquired bacterial pneumonia. MATERIALS AND METHODS An observational study in a mixed intensive care unit (ICU) at a general university hospital was performed. All consecutive patients admitted to the ICU with a diagnosis of severe acute community-acquired pneumonia from September 2009 to December 2009 were included. Viral (H1N1 influenza A) and bacterial microbiological diagnoses were done in every patient. At admission, demographics, comorbidities, Simplified Acute Physiology Score, Sequential Organ Failure Assessment, Lung Injury Score, and Pao(2)/Fio(2) were recorded. At admission and after 24, 48, and 120 hours, WBC, CRP, and PCT levels were obtained. Finally, hospital and ICU length of stay and mortality were recorded. RESULTS No differences in CRP or WBC were found between H1N1-positive patients and H1N1-negative patients (patients with acute community-acquired bacterial pneumonia). Procalcitonin levels at admission were lower in H1N1-positive patients (PCT = 0.4 [0.1-6.1] ng/mL) than in the H1N1-negative patients (24.8 [13.1-34.5] ng/mL). Procalcitonin significantly decreased with time but remained lower in the H1N1-positive group at all measurements (P < .05 for all comparisons). CONCLUSIONS Among patients admitted to the ICU with pneumonia, the PCT level could help identify H1N1 influenza A virus pneumonia and thus enable earlier antiviral therapy.

Hemodynamic effects of recombinant human activated protein C in patients with septic shock

PURPOSE The aim of this study is to examine the effects of recombinant human activated protein C (rhAPC) on hemodynamic parameters in patients with septic shock. METHODS This is a retrospective study of 2 university-hospital critical care units. Patients with septic shock with pulmonary artery catheterization or transthoracic thermodilution monitoring were studied. We matched patients with septic shock with at least 2 organ failures (18 treated with rhAPC and 18 controls) on sex, age, sequential organ failure assessment (SOFA), Acute Physiology and Chronic Health Evaluation (APACHE) II, and sepsis etiology. We recorded norepinephrine dose and hemodynamic parameters at baseline and 24, 36, and 48 hours after the real or theoretical start of rhAPC treatment. RESULTS Mean arterial pressure remained stable in both groups. In rhAPC patients, norepinephrine requirements, initially higher than in controls, were significantly lower at 48 hours, and stroke volume at 24 and 48 hours improved (P < .05). CONCLUSION Recombinant human activated protein C use correlated with improved hemodynamic parameters and decreased norepinephrine requirements. The retrospective nature of the study limits the strength of these findings.

Assessing practical skills in cardiopulmonary resuscitation: Discrepancy between standard visual evaluation and a mechanical feedback device

Abstract This paper aims to analyze agreement in the assessment of external chest compressions (ECC) by 3 human raters and dedicated feedback software. While 54 volunteer health workers (medical transport technicians), trained and experienced in cardiopulmonary resuscitation (CPR), performed a complete sequence of basic CPR maneuvers on a manikin incorporating feedback software (Laerdal PC v 4.2.1 Skill Reporting Software) (L), 3 expert CPR instructors (A, B, and C) visually assessed ECC, evaluating hand placement, compression depth, chest decompression, and rate. We analyzed the concordance among the raters (A, B, and C) and between the raters and L with Cohens kappa coefficient (K), intraclass correlation coefficients (ICC), Bland–Altman plots, and survival–agreement plots. The agreement (expressed as Cohens K and ICC) was ≥0.54 in only 3 instances and was ⩽0.45 in more than half. Bland–Altman plots showed significant dispersion of the data. The survival–agreement plot showed a high degree of discordance between pairs of raters (A–L, B–L, and C–L) when the level of tolerance was set low. In visual assessment of ECC, there is a significant lack of agreement among accredited raters and significant dispersion and inconsistency in data, bringing into question the reliability and validity of this method of measurement.

La administración precoz y adecuada de la antibioticoterapia empírica en la sepsis salva vidas; pero ¿cómo hacerlo?

As is classically mentioned, sepsis constitutes a global health problem, with a high incidence, highly variable presentation, and important mortality and morbidity in its advanced stages (severe sepsis/septic shock). In the last decade, the mortality rate due to sepsis treated in Intensive Care Units has progressively decreased thanks to the application of a series of measures in the first hours of the disorder and to the organizational adaptation of hospitals with a view to ensuring early care of patients with sepsis. At present, initial management of the disorder is based on three principles: (1) early and aggressive resuscitation measures; (2) the early introduction of empirical antibiotic treatment; and (3) drainage of the septic focus. Regarding empirical antibiotic treatment, it has been repeatedly pointed out that a delay in administering the first dose in patients with septic shock and in individuals with severe sepsis is correlated to increased mortality. On the other hand, the administration of inadequate empirical antibiotic treatment is also associated to increased mortality. As demonstrated by the excellent work of

El espacio muerto de los catéteres venosos centrales como fuente de errores que pueden afectar a la seguridad de los pacientes en la unidad de cuidados intensivos

Algunos autores han apuntado a que los opiáceos y benzodiacepinas podrían estar sobreutilizados en el período postoperatorio inmediato de cirugía cardíaca pediátrica, como consecuencia de su fácil disponibilidad y la actual preocupación por el control del dolor en países desarrollados. Su uso está profundamente integrado en nuestros hábitos de tratamiento y forma parte de los protocolos de muchos centros. En marzo de 2008 durante una misión de colaboración en Irak, en la región del Kurdistán, 14 niños fueron sometidos a reconstrucción de sus cardiopatías bajo circulación extracorpórea y otros 13, a cateterismo cardíaco intervencionista. La escasez de fármacos motivó que tuviésemos que controlar rigurosamente el uso de opiáceos, de modo que después de la salida de quirófano éstos se retiraron, y se controló el dolor solamente con ketoprofeno. Se reconstruyeron cardiopatías de baja y media complejidad, comunicación interauricular, comunicación interventricular y tetralogía de Fallot, en niños con edades entre 8 meses y 11 años y pesos de entre 6 y 23 kg, mientras que las intervenciones mediante cateterismo se realizaron a pacientes con estenosis pulmonar y persistencia del ductus arterioso. Como ha sido referido en una experiencia similar, los niños no mostraron signos de dolor y se necesitó en sólo una ocasión una dosis de fentanilo en bolo por irritabilidad del paciente. La rápida recuperación de la vigilia, debido a la ausencia de hipnosedación, favoreció el fast-track, con una considerable reducción de los tiempos de ventilación mecánica en comparación con los habituales. Las cada vez más frecuentes misiones humanitarias en el tercer mundo han causado que se apliquen variaciones a los tratamientos postoperatorios habituales. Los intensivistas debemos enfrentarnos al problema de la limitación de recursos, lo que nos fuerza a buscar soluciones alternativas para el control del dolor. Estos cambios ponen en duda la idoneidad del uso que hacemos actualmente de opiáceos y benzodiacepinas en perfusión continua durante las primeras horas del postoperatorio y nos alertan a reconsiderarlo. La complejidad de los procedimientos en neonatos y lactantes pequeños, así como su delicada fisiología, con frecuencia conduce a que requieran de mayores tiempos de ventilación mecánica, de modo que la hipnosedación es indispensable para su manejo adecuado. La restitución de la vigilia trae consigo la recuperación de concentraciones óptimas de catecolaminas endógenas, lo que ayuda al paciente a restablecer un funcionamiento respiratorio fisiológico. En niños mayores, debería restaurarse ese estado en cuanto la hemodinámica lo permita, y así acortar los tiempos de ventilación y los derivados del procedimiento.