Slide Presentations

SEVERE PULMONARY HYPERTENSION IN IDIOPATHIC PULMONARY FIBROSIS

Para Colombia, es importante adoptar un sistema estandarizado y estructurado de gestión de la calidad para el mejoramiento continuo de la atención en salud en las unidades de cuidados intensivos (UCI). La Asociación Colombiana de Medicina Crítica y Cuidados Intensivos (AMCI) desarrolló este documento consenso para ofrecer recomendaciones en los distintos pilares de calidad en salud que son necesarios para la práctica dentro de las unidades. Fue construido con un enfoque integral, teniendo en cuenta la experiencia acumulada de los actores que ejercen la disciplina de la medicina crítica junto con el análisis de la mejor evidencia científica disponible, pero contextualizada a la perspectiva nacional. Este consenso busca garantizar y priorizar las condiciones de seguridad y calidad para los pacientes críticamente enfermos en las unidades. En respuesta a la variabilidad en procesos, sistemas, estructura y complejidad en las UCI de todo el territorio nacional, la AMCI convocó un equipo multidisciplinario de expertos en medicina crítica, clínicos y metodólogos para hacer un pronunciamiento científico mediante la metodología de consenso formal, principalmente por el método Delphi, acerca de los estándares de calidad necesarios para garantizar la eficiencia y calidad en los servicios de cuidados intensivos y que se puedan reflejar en los desenlaces de los pacientes. Se pretende impactar positivamente en los distintos niveles del sistema de salud, prestadores, administradores y aseguradores. También se pretende establecer canales de trabajo con el gobierno nacional y sus entes reguladores, para brindar argumentos desde la sociedad científica que puedan facilitar la formulación de políticas en normatividad de control y auditoría. El consenso invita a todas las UCI del país a realizar una autoevaluación de sus condiciones específicas, teniendo en cuenta los contenidos de este consenso, aclarando que fue desarrollado en un contexto científico, académico y no comercial, centrado en la búsqueda continua del beneficio para los pacientes, pero también del talento humano que labora en las unidades. Cada institución de salud debe ser garante mediante el liderazgo de la coordinación asistencial de las UCI de contar con las mejores condiciones para poder desarrollar la práctica de la medicina crítica. Este documento consenso se constituye una fuente para los procesos de mejoramiento. Este documento tiene un alcance nacional y su contenido está previsto de actualización en un tiempo no mayor a cuatro años.

For Colombia, it is important to adopt a standardized and structured quality management system for the continuous improvement of health care in intensive care units (ICU). The Colombian Association of Critical Medicine and Intensive Care (AMCI) developed this consensus document to offer recommendations on the different pillars of health quality that are necessary for practice within the units. It was built with a comprehensive approach, taking into account the accumulated experience of the actors who practice the discipline of critical medicine together with the analysis of the best available scientific evidence, but contextualized to the national perspective. This consensus seeks to guarantee and prioritize safety and quality conditions for critically ill patients in the units. In response to the variability in processes, systems, structure, and complexity in ICU throughout the national territory, the AMCI convened a multidisciplinary team of experts in critical medicine, clinicians, and methodologists to make a scientific statement using the consensus methodology. formally, mainly through the DELPHI method, about the quality standards necessary to guarantee efficiency and quality in intensive care services and that can be reflected in patient outcomes. It is intended to have a positive impact on the different levels of the health system, providers, administrators and insurers. It is also intended to establish work channels with the national government and its regulatory bodies, to provide arguments from the scientific society that can facilitate the formulation of policies in control and audit regulations. The consensus invites all intensive care units in the country to carry out a self-assessment of their specific conditions, taking into account the contents of this consensus, clarifying that it was developed in a scientific, academic and non-commercial context, focused on the continuous search for benefit for patients, but also for the human talent that works in the units. Each health institution must be a guarantor, through the leadership of the care coordination of the ICU, of having the best conditions to be able to develop the practice of critical medicine. This consensus document constitutes a source for improvement processes. This document has a national scope and its content is expected to be updated in no more than 4 years.

Community-acquired pneumonia (CAP) has high morbidity and mortality among adults. Several clinical guidelines recommend prompt administration of combined antimicrobial therapy. However, the association between guidelines concordance and mortality in patients with severe pneumonia remains unclear. The present study aimed to examine the impact of guidelines-concordant empiric antimicrobial therapy on 7-day mortality in patients with extremely severe pneumonia who required mechanical ventilation at admission, using a nationwide inpatient database in Japan.

Data of CAP patients aged over 20 years who required mechanical ventilation at admission between April 2012 and March 2014 were retrospectively analyzed. Multivariable logistic regression analysis was performed to examine the association between guidelines-concordant empiric antimicrobial therapy and all-cause 7-day mortality, with adjustment for patient backgrounds and pneumonia severity.

There were a total of 3719 eligible patients, 836 (22.5%) of whom received guidelines-concordant combination therapy. Overall, 7-day mortality was 29.5%. Higher 7-day mortality was associated with advanced age, confusion, lower systolic blood pressure, malignant tumor or immunocompromised state, and C-reactive protein ≥20 mg/dl or infiltration occupying two-thirds of one lung on chest radiography. After adjustment for these variables, guidelines-concordant combined antimicrobial therapy was associated with significantly lower 7-day mortality (odds ratio: 0.78; 95% confidence interval: 0.65–0.95; P=0.013).

Adherence to initial empiric treatment as recommended by the guidelines was associated with better short-term prognosis in patients with extremely severe pneumonia who required mechanical ventilation on hospital admission.

Severe community-acquired pneumonia (SCAP) is a fatal disease. This study was conducted to describe an outcome analysis of the intensive care units (ICUs) of Turkey.

This study evaluated SCAP cases hospitalized in the ICUs of 19 different hospitals between October 2008 and January 2011. The cases of 413 patients admitted to the ICUs were retrospectively analyzed.

Overall 413 patients were included in the study and 129 (31.2%) died. It was found that bilateral pulmonary involvement (odds ratio (OR) 2.5, 95% confidence interval (CI) 1.1–5.7) and CAP PIRO score (OR 2, 95% CI 1.3–2.9) were independent risk factors for a higher in-ICU mortality, while arterial hypertension (OR 0.3, 95% CI 0.1–0.9) and the application of non-invasive ventilation (OR 0.2, 95% CI 0.1–0.5) decreased mortality. No culture of any kind was obtained for 90 (22%) patients during the entire course of the hospitalization. Blood, bronchoalveolar lavage, and non-bronchoscopic lavage cultures yielded enteric Gram-negatives (n = 12), followed by Staphylococcus aureus (n = 10), pneumococci (n = 6), and Pseudomonas aeruginosa (n = 6). For 22% of the patients, none of the culture methods were applied.

SCAP requiring ICU admission is associated with considerable mortality for ICU patients. Increased awareness appears essential for the microbiological diagnosis of this disease.

Despite remarkable advances in its management, community-acquired pneumonia (CAP) remains an important cause of morbidity and mortality leading to significant consumption of health, social and economic resources.

The assessment of CAP severity is a cornerstone in its management, facilitating selection of the most appropriate site of care and empirical antibiotic therapy. Several clinical scoring systems based on 30-day mortality have been developed to identify those patients with the highest risk of death. Although well validated in appropriate patient groups, each system has its own limitations and each exhibits different sensitivity and specificity values. These problems have increased interest in the use of biomarkers to predict CAP severity. Although so far no ideal solution has been identified, recent advances in bacterial genomic load quantification have made this tool very attractive.

Early antibiotic therapy is essential to the reduction of CAP mortality and the selection of antibiotic treatment according to clinical guidelines is also associated with an improved outcome. In addition, the addition of a macrolide to standard empirical therapy seems to improve outcome in severe CAP although the mechanism of this is unclear. Finally, the role of adjuvant therapy has not yet been satisfactorily established.

In this review we will present our opinion on current best practice in the assessment of severity and treatment of severe CAP.