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PURPOSE: Methylene blue (MB) has been tested as a rescue therapy for patients with refractory septic shock. However, there is a lack of evidence on MB as an adjuvant therapy, its' optimal timing, dosing and safety profile. We aimed to assess whether early adjunctive MB can reduce time to vasopressor discontinuation in patients with septic shock. METHODS: In this single-center randomized controlled trial, we assigned patients with septic shock according to Sepsis-3 criteria to MB or placebo. Primary outcome was time to vasopressor discontinuation at 28 days. Secondary outcomes included vasopressor-free days at 28 days, days on mechanical ventilator, length of stay in ICU and hospital, and mortality at 28 days. RESULTS: Among 91 randomized patients, forty-five were assigned to MB and 46 to placebo. The MB group had a shorter time to vasopressor discontinuation (69 h [IQR 59-83] vs 94 h [IQR 74-141]; p < 0.001), one more day of vasopressor-free days at day 28 (p = 0.008), a shorter ICU length of stay by 1.5 days (p = 0.039) and shorter hospital length of stay by 2.7 days (p = 0.027) compared to patients in the control group. Days on mechanical ventilator and mortality were similar. There were no serious adverse effects related to MB administration. CONCLUSION: In patients with septic shock, MB initiated within 24 h reduced time to vasopressor discontinuation and increased vasopressor-free days at 28 days. It also reduced length of stay in ICU and hospital without adverse effects. Our study supports further research regarding MB in larger randomized clinical trials. Trial registration ClinicalTrials.gov registration number NCT04446871 , June 25, 2020, retrospectively registered.
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Sepsis , Choque Séptico , Humanos , Azul de Metileno/farmacología , Azul de Metileno/uso terapéutico , Vasoconstrictores/uso terapéutico , Sepsis/complicacionesRESUMEN
BACKGROUND: Awake prone positioning (APP) improves oxygenation in coronavirus disease (COVID-19) patients and, when successful, may decrease the risk of intubation. However, factors associated with APP success remain unknown. In this secondary analysis, we aimed to assess whether APP can reduce intubation rate in patients with COVID-19 and to focus on the factors associated with success. METHODS: In this multicenter randomized controlled trial, conducted in three high-acuity units, we randomly assigned patients with COVID-19-induced acute hypoxemic respiratory failure (AHRF) requiring high-flow nasal cannula (HFNC) oxygen to APP or standard care. Primary outcome was intubation rate at 28 days. Multivariate analyses were performed to identify the predictors associated to treatment success (survival without intubation). RESULTS: Among 430 patients randomized, 216 were assigned to APP and 214 to standard care. The APP group had a lower intubation rate (30% vs 43%, relative risk [RR] 0.70; CI95 0.54-0.90, P = 0.006) and shorter hospital length of stay (11 interquartile range [IQR, 9-14] vs 13 [IQR, 10-17] days, P = 0.001). A respiratory rate ≤ 25 bpm at enrollment, an increase in ROX index > 1.25 after first APP session, APP duration > 8 h/day, and a decrease in lung ultrasound score ≥ 2 within the first 3 days were significantly associated with treatment success for APP. CONCLUSION: In patients with COVID-19-induced AHRF treated by HFNC, APP reduced intubation rate and improved treatment success. A longer APP duration is associated with APP success, while the increase in ROX index and decrease in lung ultrasound score after APP can also help identify patients most likely to benefit. TRIAL REGISTRATION: This study was retrospectively registered in ClinicalTrials.gov at July 20, 2021. Identification number NCT04477655. https://clinicaltrials.gov/ct2/show/NCT04477655?term=PRO-CARF&draw=2&rank=1.
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COVID-19 , Insuficiencia Respiratoria , COVID-19/complicaciones , COVID-19/terapia , Cánula , Humanos , Posición Prona , Insuficiencia Respiratoria/complicaciones , Insuficiencia Respiratoria/terapia , VigiliaRESUMEN
OBJECTIVES: Airway pressure release ventilation is a ventilatory mode characterized by a mandatory inverse inspiratory:expiratory ratio with a very short expiratory phase, aimed to avoid derecruitment and allow spontaneous breathing. Recent basic and clinical evidence suggests that this mode could be associated with improved outcomes in patients with acute respiratory distress syndrome. The aim of this study was to compare the outcomes between airway pressure release ventilation and traditional ventilation targeting low tidal volume, in patients with severe coronavirus disease 2019. DESIGN: Single-center randomized controlled trial. SETTING: ICU of a Mexican referral center dedicated to care of patients with confirmed diagnosis of coronavirus disease 2019. PATIENTS: Ninety adult intubated patients with acute respiratory distress syndrome associated with severe coronavirus disease 2019. INTERVENTIONS: Within 48 hours after intubation, patients were randomized to either receive ventilatory management with airway pressure release ventilation or continue low tidal volume ventilation. MEASUREMENTS AND MAIN RESULTS: Forty-five patients in airway pressure release ventilation group and 45 in the low tidal volume group were included. Ventilator-free days were 3.7 (0-15) and 5.2 (0-19) in the airway pressure release ventilation and low tidal volume groups, respectively (p = 0.28). During the first 7 days, patients in airway pressure release ventilation had a higher Pao2/Fio2 (mean difference, 26 [95%CI, 13-38]; p < 0.001) and static compliance (mean difference, 3.7 mL/cm H2O [95% CI, 0.2-7.2]; p = 0.03), higher mean airway pressure (mean difference, 3.1 cm H2O [95% CI, 2.1-4.1]; p < 0.001), and higher tidal volume (mean difference, 0.76 mL/kg/predicted body weight [95% CI, 0.5-1.0]; p < 0.001). More patients in airway pressure release ventilation had transient severe hypercapnia, defined as an elevation of Pco2 at greater than or equal to 55 along with a pH less than 7.15 (42% vs 15%; p = 0.009); other outcomes were similar. Overall mortality was 69%, with no difference between the groups (78% in airway pressure release ventilation vs 60% in low tidal volume; p = 0.07). CONCLUSIONS: In conclusion, when compared with low tidal volume, airway pressure release ventilation was not associated with more ventilator-free days or improvement in other relevant outcomes in patients with severe coronavirus disease 2019.
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COVID-19/complicaciones , Presión de las Vías Aéreas Positiva Contínua , Respiración Artificial/métodos , Síndrome de Dificultad Respiratoria/terapia , Adulto , Anciano , COVID-19/mortalidad , Femenino , Humanos , Masculino , México , Persona de Mediana Edad , Síndrome de Dificultad Respiratoria/etiología , Síndrome de Dificultad Respiratoria/mortalidad , Volumen de Ventilación PulmonarRESUMEN
Resumen: Introducción: preeclampsia, la complicación más común del embarazo, ocasiona más de 76,000 muertes maternas al año, principalmente por complicaciones neurológicas. La alteración en la vasorregulación cerebral es clave en la patogénesis de dichas complicaciones. La ecografía Doppler transcraneal (EDT) evalúa el flujo de las principales arterias cerebrales, pero se desconocen los cambios que presentan las pacientes con preeclampsia/eclampsia. Objetivo: descripción de los cambios en el flujo sanguíneo cerebral evaluados mediante EDT en pacientes con preeclampsia/eclampsia. Material y métodos: se realizó EDT a las pacientes con diagnóstico de preeclampsia y/o eclampsia atendidas de forma consecutiva en la Unidad de Cuidados Intensivos del Hospital Civil de Guadalajara, del 01 de marzo de 2019 al 01 de marzo de 2021 y grupo control de embarazadas sanas; describimos el patrón de flujo de las arterias cerebrales anterior, media, posterior y arteria basilar. Resultados: Ochenta pacientes, 50 con preeclampsia/eclampsia y 30 embarazadas sanas, edad 23 ± 6.7, 50% primigestas, 34.8 ± 4.3 semanas de gestación. La presión de perfusión cerebral de las arterias cerebrales media derecha > 74 mmHg (sensibilidad 0.88, especificidad 0.86, ABC 0.92) y anterior derecha > 69 mmHg (sensibilidad 0.89, especificidad 0.93, ABC 0.92) tuvieron la mayor asociación con preeclampsia/eclampsia. El índice de flujo sanguíneo de las arterias cerebrales posteriores tuvo asociación significativa con eclampsia (p = 0.02), ABC: 0.695 (p = 0.009), punto de corte ≥ 34.6 cm/s (sensibilidad 1.0, especificidad 0.43, OR 26). Conclusiones: un incremento generalizado de la presión de perfusión es el hallazgo más común en preeclampsia/eclampsia. Aumento en el índice de flujo sanguíneo en las arterias cerebrales posteriores se asocia a complicaciones neurológicas graves en pacientes con preeclampsia.
Abstract: Introduction: preeclampsia, the most common complication of pregnancy, leads to > 76,000 maternal deaths annually, mainly due to neurological complications. An alteration in cerebral vasoregulation is key in the pathogenesis of these complications. Transcranial Doppler Ultrasound (TCD) evaluates the flow of the main cerebral arteries and could help to predict the development of preeclampsia/eclampsia and its complications. Objective: to determine the most frequent cerebral blood flow changes in preeclampsia/eclampsia. Material and methods: we prospectively analyzed by TCD patients with preeclampsia/eclampsia on admission to the ICU. Results: Eighty patients, 50 with preeclampsia/eclampsia and 30 healthy pregnant women, age 23 ± 6.7, 50% primigravida, 34.8 ± 4.3 weeks gestation. Cerebral perfusion pressure of right middle cerebral arteries > 74 mmHg (sensitivity 0.88, specificity 0.86, AUC 0.92) and right anterior cerebral arteries > 69 mmHg (sensitivity 0.89, specificity 0.93, AUC 0.92), had the highest association with preeclampsia/eclampsia. Posterior cerebral artery blood flow index had significant association with eclampsia (p = 0.02), AUC 0.695 (p = 0.009), with a cut-off ≥ 34.6 cm/s (sensitivity 1.0, specificity 0.43, OR 26). Conclusions: a generalized increase in perfusion pressure is the most common finding in preeclampsia/eclampsia. Hyper flow in the posterior cerebral arteries may predict severe neurological complications.
Resumo: Introdução: a pré-eclâmpsia, complicação mais comum da gravidez, causa mais de 76,000 mortes maternas anualmente, principalmente devido a complicações neurológicas. A vasorregulação cerebral alterada é fundamental na patogênese dessas complicações. A ultrassonografia Doppler transcraniana (DTC) avalia o fluxo das principais artérias cerebrais, as alterações que os pacientes com pré-eclâmpsia/eclâmpsia apresentam são desconhecidas. Objetivo: descrição das alterações do fluxo sanguíneo cerebral avaliados por DTC em pacientes com pré-eclâmpsia/eclâmpsia. Material e métodos: DTC foi realizado em pacientes com diagnóstico de pré-eclâmpsia e/ou eclâmpsia tratados consecutivamente na unidade de terapia intensiva do Hospital Civil de Guadalajara, de 1o de março de 2019 a 1o de março de 2021 e um grupo controle de gestantes saudáveis; descrevemos o padrão de fluxo das artérias cerebrais anterior, média, posterior e da artéria basilar. Resultados: 80 pacientes, 50 com pré-eclâmpsia/eclâmpsia e 30 gestantes saudáveis, idade 23 ± 6.7, 50% primíparas, 34.8 ± 4.3 semanas de gestação. A pressão de perfusão cerebral das artérias cerebrais médias direitas > 74 mmHg (sensibilidade 0.88, especificidade 0.86, AUC 0.92) e anterior direita > 69 mmHg (sensibilidade 0.89, especificidade 0.93, AUC 0.92), teve a maior associação com pré-eclâmpsia/eclâmpsia. O índice de fluxo sanguíneo das artérias cerebrais posteriores, teve associação significativa com eclâmpsia (p = 0.02), AUC: 0.695 (p = 0.009), ponto de corte ≥ 34.6 cm/s (sensibilidade 1.0, especificidade 0.43, OR 26). Conclusões: Um aumento generalizado da pressão de perfusão é o achado mais comum na pré-eclâmpsia/eclâmpsia. O aumento da taxa de fluxo sanguíneo nas artérias cerebrais posteriores está associado a complicações neurológicas graves em pacientes com pré-eclâmpsia.
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BACKGROUND: Awake prone positioning has been reported to improve oxygenation for patients with COVID-19 in retrospective and observational studies, but whether it improves patient-centred outcomes is unknown. We aimed to evaluate the efficacy of awake prone positioning to prevent intubation or death in patients with severe COVID-19 in a large-scale randomised trial. METHODS: In this prospective, a priori set up and defined, collaborative meta-trial of six randomised controlled open-label superiority trials, adults who required respiratory support with high-flow nasal cannula for acute hypoxaemic respiratory failure due to COVID-19 were randomly assigned to awake prone positioning or standard care. Hospitals from six countries were involved: Canada, France, Ireland, Mexico, USA, Spain. Patients or their care providers were not masked to allocated treatment. The primary composite outcome was treatment failure, defined as the proportion of patients intubated or dying within 28 days of enrolment. The six trials are registered with ClinicalTrials.gov, NCT04325906, NCT04347941, NCT04358939, NCT04395144, NCT04391140, and NCT04477655. FINDINGS: Between April 2, 2020 and Jan 26, 2021, 1126 patients were enrolled and randomly assigned to awake prone positioning (n=567) or standard care (n=559). 1121 patients (excluding five who withdrew from the study) were included in the intention-to-treat analysis. Treatment failure occurred in 223 (40%) of 564 patients assigned to awake prone positioning and in 257 (46%) of 557 patients assigned to standard care (relative risk 0·86 [95% CI 0·75-0·98]). The hazard ratio (HR) for intubation was 0·75 (0·62-0·91), and the HR for mortality was 0·87 (0·68-1·11) with awake prone positioning compared with standard care within 28 days of enrolment. The incidence of prespecified adverse events was low and similar in both groups. INTERPRETATION: Awake prone positioning of patients with hypoxaemic respiratory failure due to COVID-19 reduces the incidence of treatment failure and the need for intubation without any signal of harm. These results support routine awake prone positioning of patients with COVID-19 who require support with high-flow nasal cannula. FUNDING: Open AI inc, Rice Foundation, Projet Hospitalier de Recherche Clinique Interrégional, Appel d'Offre 2020, Groupement Interrégional de Recherche Clinique et d'Innovation Grand Ouest, Association pour la Promotion à Tours de la Réanimation Médicale, Fond de dotation du CHRU de Tours, Fisher & Paykel Healthcare Ltd.
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COVID-19 , Posicionamiento del Paciente , Posición Prona , Insuficiencia Respiratoria , Adulto , COVID-19/terapia , Canadá , Francia , Humanos , Irlanda , México , Estudios Prospectivos , Insuficiencia Respiratoria/terapia , SARS-CoV-2 , España , Resultado del Tratamiento , Estados Unidos , VigiliaRESUMEN
BACKGROUND: Data on short-term peripheral intravenous catheter-related bloodstream infections per 1,000 peripheral venous catheter days (PIVCR BSIs per 1,000 PVC days) rates from Latin America are not available, so they have not been thoroughly studied. METHODS: International Nosocomial Infection Control Consortium (INICC) members conducted a prospective, surveillance study on PIVCR BSIs from January 2010 to March 2018 in 100 intensive care units (ICUs) among 41 hospitals, in 26 cities of 9 countries in Latin America (Argentina, Brazil, Colombia, Costa Rica, Dominican-Republic, Ecuador, Mexico, Panama, and Venezuela). The Centers for Disease Control and Prevention (CDC) National Health Safety Network (NHSN) definitions were applied, and INICC methodology and INICC Surveillance Online System software were used. RESULTS: In total, 10,120 ICU patients were followed for 40,078 bed days and 38,262 PVC days. In addition, 79 PIVCR BSIs were identified, with a rate of 2.06 per 1,000 PVC days (95% confidence interval [CI], 1.635-2.257). The average length of stay (ALOS) of patients without a PIVCR BSI was 3.95 days, and the ALOS was 5.29 days for patients with a PIVCR BSI. The crude extra ALOS was 1.34 days (RR, 1.33; 95% CI, 1.0975-1.6351; P = .040).The mortality rate in patients without PIVCR BSI was 3.67%, and this rate was 6.33% in patients with a PIVCR BSI. The crude extra mortality was 1.70 times higher. The microorganism profile showed 48.5% gram-positive bacteria (coagulase-negative Staphylococci 25.7%) and 48.5% gram-negative bacteria: Acinetobacter spp, Escherichia coli, and Klebsiella spp (8.5% each one), Pseudomonas aeruginosa (5.7%), and Candida spp (2.8%). The resistances of Pseudomonas aeruginosa were 0% to amikacin and 50% to meropenem. The resistance of Acinetobacter baumanii to amikacin was 0%, and the resistance of coagulase-negative Staphylococcus to oxacillin was 75%. CONCLUSIONS: Our PIVCR BSI rates were higher than rates from more economically developed countries and were similar to those of countries with limited resources.
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Infección Hospitalaria , Sepsis , Argentina , Brasil , Catéteres , Colombia , Costa Rica , Infección Hospitalaria/epidemiología , República Dominicana/epidemiología , Ecuador/epidemiología , Humanos , Unidades de Cuidados Intensivos , América Latina/epidemiología , México , Panamá , Estudios Prospectivos , VenezuelaRESUMEN
OBJECTIVES: To assess the effect of prone positioning therapy on intubation rate in awake patients with COVID-19 and acute respiratory failure. TRIAL DESIGN: This is a two-center parallel group, superiority, randomized (1:1 allocation ratio) controlled trial. PARTICIPANTS: All patients admitted to the Hospital Civil de Guadalajara and Hospital General de Occidente in Mexico for COVID-19 associated acute respiratory failure and in need of supplementary oxygen through high-flow nasal cannula are screened for eligibility. INCLUSION CRITERIA: all adult patients admitted to the COVID-19 unit who test positive for COVID-19 by PCR-test and in need for oxygen are eligible for inclusion. Randomization starts upon identification of requirement of a fraction of inspired oxygen ≥30% for an oxygen capillary saturation of ≥90% Exclusion criteria: less than 18 years-old, pregnancy, patients with immediate need of invasive mechanical ventilation (altered mental status, fatigue), vasopressor requirement to maintain median arterial pressure >65 mmHg, contraindications for prone positioning therapy (recent abdominal or thoracic surgery or trauma, facial, pelvic or spine fracture, untreated pneumothorax, do-not-resuscitate or do-not-intubate order, refusal or inability of the patient to enroll in the study. INTERVENTION AND COMPARATOR: Patients of the intervention group will be asked to remain in a prone position throughout the day as long as possible, with breaks according to tolerance. Pillows will be offered for maximizing comfort at chest, pelvis and knees. Monitoring of vital signs will not be suspended. Inspired fraction of oxygen will be titrated to maintain a capillary saturation of 92%-95%. For patients in the control group, prone positioning will be allowed as a rescue therapy. Staff intensivists will monitor the patient's status in both groups on a 24/7 basis. All other treatment will be unchanged and left to the attending physicians. MAIN OUTCOMES: Endotracheal intubation rate for mechanical ventilation at 28 days. RANDOMISATION: Patients will be randomly allocated to either prone positioning or control group at 1:1 ratio. Such randomization will be computer generated and stratified by center with permuted blocks and length of 4. BLINDING (MASKING): Due to logistical reasons, only principal investigators and the data analyst will be blinded to group assignment. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): With an intubation rate of 60% according to recent reports from some American centers, and assuming a decrease to 40% to be clinically relevant, we calculated a total of 96 patients per group, for a beta error of 0.2, and alpha of 0.5. Therefore, we plan to recruit 200 patients, accounting for minimal losses to follow up, with 100 non-intubated patients in the prone position group and a 100 in the control group. TRIAL STATUS: The local registration number is 048-20, with the protocol version number 2.0. The date of approval is 3rd May 2020. Recruitment started on 3rd May and is expected to end in December 2020. TRIAL REGISTRATION: The protocol was retrospectively registered under the title: "Prone Positioning in Non-intubated Patients With COVID-19 Associated Acute Respiratory Failure. The PRO-CARF trial" in ClinicalTrials.gov with the registration number: NCT04477655. Registered on 20 July 2020. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).
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Infecciones por Coronavirus/complicaciones , Intubación Intratraqueal/instrumentación , Oxígeno/uso terapéutico , Neumonía Viral/complicaciones , Posición Prona/fisiología , Insuficiencia Respiratoria/etiología , Enfermedad Aguda , Adulto , Betacoronavirus/genética , COVID-19 , Cánula/efectos adversos , Cánula/provisión & distribución , Estudios de Casos y Controles , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/virología , Femenino , Hospitalización , Humanos , Intubación Intratraqueal/estadística & datos numéricos , Masculino , México/epidemiología , Oxígeno/administración & dosificación , Oxígeno/sangre , Oxígeno/provisión & distribución , Pandemias , Posicionamiento del Paciente/métodos , Neumonía Viral/epidemiología , Neumonía Viral/virología , Insuficiencia Respiratoria/fisiopatología , Insuficiencia Respiratoria/terapia , SARS-CoV-2RESUMEN
AIM: To characterize the prescribing patterns for hydrocortisone for patients with septic shock and perform an exploratory analysis in order to identify the variables associated with better outcomes. METHODS: This prospective cohort study included 59 patients with septic shock who received stress-dose hydrocortisone. It was performed at 2 critical care units in academic hospitals from June 1st, 2015, to July 31st, 2016. Demographic data, comorbidities, medical management details, adverse effects related to corticosteroids, and outcomes were collected after the critical care physician indicated initiation of hydrocortisone. Univariate comparison between continuous and bolus administration of hydrocortisone was performed, including multivariate analysis, as well as Kaplan-Meier analysis to compare the proportion of shock reversal at 7 d after presentation. Receiver operating characteristic (ROC) curves determined the best cut-off criteria for initiation of hydrocortisone associated with the highest probability of shock reversal. We addressed the effects of the taper strategy for discontinuation of hydrocortisone, noting risk of shock relapse and adverse effects. RESULTS: All-cause 30-d mortality was 42%. Hydrocortisone was administered as a continuous infusion in 54.2% of patients; time to reversal of shock was 49 h longer in patients who were given a bolus administration [59 h (range, 47.5-90.5) vs 108 h (range, 63.2-189); P = 0.001]. The maximal dose of norepinephrine after initiation of hydrocortisone was lower in patients on continuous infusion [0.19 µg/kg per minute (range, 0.11-0.28 µg)] compared with patients who were given bolus [0.34 µg/kg per minute (range, 0.16-0.49); P = 0.004]. Kaplan-Meier analysis revealed a higher proportion of shock reversal at 7 d in patients with continuous infusion compared to those given bolus (83% vs 63%; P = 0.004). There was a good correlation between time to initiation of hydrocortisone and time to reversal of shock (r = 0.80; P < 0.0001); ROC curve analysis revealed that the best criteria for prediction of shock reversal was a time to initiation of hydrocortisone of ≤ 13 h after administration of norepinephrine, with an area under the curve of 0.81 (P < 0.001). The maximal dose of norepinephrine at initiation of hydrocortisone with the highest association with shock reversal was ≤ 0.28 µg/kg per minute, with an area under the curve of 0.75 (P = 0.0002). On a logistic regression model, hydrocortisone taper was not associated with a lower risk of shock relapse (RR = 1.29; P = 0.17) but was related to a higher probability of hyperglycemia [odds ratio (OR), 5.3; P = 0.04] and hypokalemia (OR = 10.6; P = 0.01). CONCLUSION: Continuous infusion of hydrocortisone could hasten the resolution of septic shock compared to bolus administration. Earlier initiation corresponds with a higher probability of shock reversal. Tapering strategy is unnecessary.
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BACKGROUND The retropharyngeal abscess is a rare presentation of head and neck tuberculosis. The pathogenesis of the abscess formation in the retropharyngeal space in the adult is controversial. CASE REPORT We report a case of large retropharyngeal abscesses in a 46-year-old man with disseminated tuberculosis. The patient had severe progressive dysphagia, weight loss, and a slowly enlarging bilateral cervical mass during a period of three months. His posterior pharynx wall was bulging and red, and both tonsils were enlarged and congested. The neck had an abscess of 5 cm in diameter that was firm, tender, and warm along the left sternocleidomastoid muscle. Palpable bilateral lymphadenitis was detected in the submandibular, cervical, axillary, and inguinal regions. A computed tomographic (CT) scan of the neck revealed large bilobulated retropharyngeal abscesses. A liver ultrasound showed multiple hypoechoic lesions. A Ziehl-Neelsen smear for acid-fast bacilli was positive from different abscess samples, and mycobacterial cultures subsequently yielded Mycobacterium tuberculosis. Antituberculous therapy was begun and the retropharyngeal abscesses were aspirated by external incision with complete drainage and relief of symptoms. CONCLUSIONS Large retropharyngeal abscess is a rare entity in which Mycobacterium tuberculosis etiology should be considered, especially in endemic countries, and the diagnosis may be difficult because symptoms and signs are influenced by abscess size and time of onset, or if the etiology is not suspected.
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OBJECTIVE: The aim of this study was to review clinical data and outcomes of patients with burns in a Mexican non-burn intensive care unit (ICU). METHODS: We did a retrospective analysis of our single-centre database of burn patients admitted to the ICU in the Hospital Civil Fray Antonio Alcalde (University Hospital). The sample was divided for analysis into two groups according to the outcome 'death' or 'discharge' from ICU. RESULTS: Overall mortality was 58.2%, without a decreasing trend in mortality rates through the years. We identified the presence of third-degree burns (odds ratio (OR) 1.5, p=0.003), and >49% total burned surface area (TBSA; OR 3.3, p≤0.001) was associated with mortality. Mean age was higher in deceased patients (38.2 years vs. 31.3 years, p=0.003) as was the TBSA (62.8% vs. 36.4%, p≤0.001). At multivariate analysis, inhalation injury was not associated with increased mortality, but it was with more mechanical ventilation days. Early surgical debridement/cleansing was performed in most patients; however, the mean of the procedures was 1.7 per patient in both groups. CONCLUSION: We identified significant factors associated with mortality. These variables and prognosis from non-burn ICUs differ broadly compared with burn intensive care units (BICUs); thus, more structured, multidisciplinary and specialised treatment strategies are still needed.
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Quemaduras/mortalidad , Unidades de Cuidados Intensivos/estadística & datos numéricos , Adulto , Distribución por Edad , Enfermedad Crítica , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , México/epidemiología , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Distribución por Sexo , Análisis de Supervivencia , Índices de Gravedad del TraumaRESUMEN
Acinetobacter baumannii has emerged as an important nosocomial pathogen. It is difficult to control and treat. The most seriously ill patients and those previously infected are more likely than others to be infected or colonized by A. baumannii. The epidemiology of A. baumannii infection is complex, with the coexistence of epidemic and endemic infections. The A. baumannii are the species isolated in 90% of the nosocomial infections and in 92% of the nosocomial bacteremias. The intensive care units presented the greater number of nosocomial bacteremias by A. baumannii. The most common sources of A. baumannii are respiratory tract, surgical wound, catheter, urinary tract and others. The most frequently clinical manifestation is sepsis and a fulminating course is observed when the patient presents septic shock. Progressive resistance of A. baumannii to antimicrobial limits the therapeutic options. The patients with A. baumannii multidrug-resistant present an excessive rate of attributed mortality, length of stay and costs.
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Infecciones por Acinetobacter/complicaciones , Acinetobacter baumannii , Bacteriemia/microbiología , Infecciones por Acinetobacter/epidemiología , Infecciones por Acinetobacter/terapia , Bacteriemia/epidemiología , Bacteriemia/terapia , HumanosRESUMEN
OBJECTIVE: Determine the severity and the course of Acinetobacter baumannii blood infections (AbBI). METHODS: We carried out a prospective review of all Acinetobacter baumannii (A. baumannii) isolated from the Intensive Care Unit (ICU) of a medical facility. RESULTS: During the study period, 46 patients were identified with AbBI. The rate of AbBI was 14 per 1,000 admissions. A. baumannii was ICU acquired in 85% of cases studied. The median time frame between ICU admission and acquisition of AbBI was 9 +/- 7 days. 31 patients displayed blood infection (BI) by A. baumannii alone and 15 with polymicrobial BI. The clinical manifestation of the 31 patients with AbBI included the following symptoms: 42% presented with septic shock, 42% had severe sepsis and 16% had sepsis. Two or more episodes of AbBI were observed among 13% of patients. Of A. baumannii isolates, 17% were resistant to imipenem. Patient mortality with AbBI alone was 45% and 40% for polymicrobial BI. Patient mortality for septic shock was 60%, 70% died during the first 72 hrs after AbBI. CONCLUSIONS: AbBI displayed an endemic pattern during the study period. Severe sepsis and septic shock were the most common clinical presentations of AbBI. AbBI are associated with a significant increase in the death rate of patient in the ICU studied.
Asunto(s)
Infecciones por Acinetobacter/complicaciones , Acinetobacter baumannii , Bacteriemia/diagnóstico , Bacteriemia/microbiología , Adulto , Cuidados Críticos , Femenino , Humanos , Masculino , Estudios Prospectivos , Índice de Severidad de la EnfermedadRESUMEN
Objetivo: Determinar la severidad y el comportamiento de las bacteremias por Acinetobacter baumannii (BAb). Métodos: Se revisaron de manera prospectiva todos los Acinetobacter baumannii aislados en una unidad de cuidados intensivos. Resultados: Se identificaron 46 pacientes con BAb y una tasa de BAb de 14 por mil ingresos. A. baumannii se adquirió en la unidad de cuidados intensivos en 85%. El periodo entre el ingreso y la BAb fue de 9±7 días. La BAb se presentó en 31 pacientes y bacteremia polimicrobiana en 15. Las manifestaciones clínicas de los 31 pacientes: choque séptico en 42%, sepsis severa en 42% y sepsis en 16%. Dos o más episodios de BAb ocurrieron en 13%. Se presentó resistencia a imipenem en 17% de los A. baumannii. La mortalidad para los pacientes con BAb fue de 45% y para bacteremia polimicrobiana de 40%. La mortalidad para los pacientes con choque séptico fue de 60%; 70% de los pacientes murió durante las primeras 72 horas seguidas a la BAb. Conclusiones: La distribución de los casos de BAb se presentó en forma continua con un patrón endémico. Sepsis severa y choque séptico fueron las principales manifestaciones de BAb. Las BAb se asocian con una tasa de mortalidad significativa.
OBJECTIVE: Determine the severity and the course of Acinetobacter baumannii blood infections (AbBI). METHODS: We carried out a prospective review of all Acinetobacter baumannii (A. baumannii) isolated from the Intensive Care Unit (ICU) of a medical facility. RESULTS: During the study period, 46 patients were identified with AbBI. The rate of AbBI was 14 per 1,000 admissions. A. baumannii was ICU acquired in 85% of cases studied. The median time frame between ICU admission and acquisition of AbBI was 9 +/- 7 days. 31 patients displayed blood infection (BI) by A. baumannii alone and 15 with polymicrobial BI. The clinical manifestation of the 31 patients with AbBI included the following symptoms: 42% presented with septic shock, 42% had severe sepsis and 16% had sepsis. Two or more episodes of AbBI were observed among 13% of patients. Of A. baumannii isolates, 17% were resistant to imipenem. Patient mortality with AbBI alone was 45% and 40% for polymicrobial BI. Patient mortality for septic shock was 60%, 70% died during the first 72 hrs after AbBI. CONCLUSIONS: AbBI displayed an endemic pattern during the study period. Severe sepsis and septic shock were the most common clinical presentations of AbBI. AbBI are associated with a significant increase in the death rate of patient in the ICU studied.
Asunto(s)
Humanos , Masculino , Femenino , Adulto , Acinetobacter baumannii , Bacteriemia/diagnóstico , Bacteriemia/microbiología , Infecciones por Acinetobacter/complicaciones , Cuidados Críticos , Estudios Prospectivos , Índice de Severidad de la EnfermedadRESUMEN
Background. Bacteriuria = 10 to fifth CFU/ml is evidence of urinary tract infection in the absence of associated signs or symptoms. The presence of pyuria with asymptomatic bacteriuria established the response of elderly women against microorganisms capable of causing invasiveness or tissue injury of the urinary tract. Methods. The association between bacteriuria and pyuria was determined in 178 elderly, ambulatory women without symptoms of urinary tract infection in seven nursing homes. Urine culture results were subsequently analyzed in conjunction with absolute leukocyte count in urine. In this cross-sectional study, asymptomatic bacteriuria in elderly women was classified with and without pyuria. Results. The prevalence of asymptomatic bacteriuria was found in 44 (24.7 percent) elderly women. The presence of pyuria had a sensitivity of 63.6 percent for bacteriuria and a specificity of 91 percent. The positive predictive value for the presence of pyuria predicting those with bacteriuria was 70 percent, and the negative predictive value for the absence of pyuria predicting those without bacteriuria was 88.4 percent. Escherichia coli was the most common organism isolated in 81.8 percent of the women. Conclusions. bacteriuria = 10 to fifth CFU/ml associated with pyuria was detected in 77 percent of elderly women with asymptomatic urinary tract infections bacteriuria of < 10 to fifth CFU/ml with pyuria proves less sensitive as an indicator of urinary tract infection. Elderly women with pyuria but without bacteriuria should be studied for other causes of urinary tractinflammation
Asunto(s)
Humanos , Femenino , Anciano , Bacteriuria/epidemiología , Piuria/epidemiología , Infecciones Urinarias/diagnóstico , Bacteriuria/etiología , Bacteriuria/microbiología , Infecciones por Enterobacteriaceae/diagnóstico , Infecciones por Enterobacteriaceae/epidemiología , Infecciones por Escherichia coli/diagnóstico , Infecciones por Escherichia coli/epidemiología , Casas de Salud , Piuria/microbiología , Estudios Transversales Seriados , Infecciones Urinarias/complicacionesRESUMEN
Se describen tres mujeres diabéticas que desarrollaron mucormicosis cutánea en la espalda, pierna derecha y pierna izquierda, respectivamente. Las lesiones fueron únicas, entre 12 a 18 cm de diámetro, sin secreciones, con edema, eritema, calor, induración, necrosis importante y zonas isquémicas a su alrededor. Los exámenes histológicos mostraron extensa necrosis y numerosas hifas no septadas; en los cultivos creció Mucor spp. Todas las pacientes recibieron tratamiento con anfotericina B. En la primer paciente la enfermedad no se reconoció tempranamente y la paciente falleció; la segunda paciente requirió amputación de su pierna y la tercer paciente tuvo una buena respuesta. El diagnóstico temprano es primordial para evitar morbilidad y mortalidad por esta rara infección oportunista