In patients with spontaneous or traumatic intracranial hemorrhage, hematoma expansion is associated with poorer neurological outcomes and increased mortality. The administration of an antifibrinolytic agent like tranexamic acid (TXA) may potentially improve clinical outcomes in patients with acute brain injury by preventing such intracranial expansion. However, studies on the impact of TXA in these patients have yielded variable results, and its efficacy, appropriate dosing and optimal timing of administration remain unclear. The present review summarizes the clinical evidence regarding the proper use of tranexamic acid in the treatment of intracranial traumatic and non-traumatic hemorrhage, and its implications for clinical practice.

Temperature management has been used in patients with acute brain injury resulting from different conditions, such as post-cardiac arrest hypoxic-ischaemic insult, acute ischaemic stroke, and severe traumatic brain injury. However, current evidence offers inconsistent and often contradictory results regarding the clinical benefit of this therapeutic strategy on mortality and functional outcomes. Current guidelines have focused mainly on active prevention and treatment of fever, while therapeutic hypothermia (TH) has fallen into disuse, although doubts persist as to its effectiveness according to the method of application and appropriate patient selection. This narrative review presents the most relevant clinical evidence on the effects of TH in patients with acute neurological damage, and the pathophysiological concepts supporting its use.

El control de la temperatura corporal se ha utilizado en pacientes con daño cerebral agudo ocasionado por distintas enfermedades como daño hipóxico-isquémico posparada cardiaca, accidente cerebro vascular isquémico agudo y traumatismo craneoencefálico grave. Sin embargo, la evidencia actual ofrece resultados poco consistentes y a menudo contradictorios en cuanto al beneficio clínico de esta estrategia terapéutica sobre la mortalidad y los resultados funcionales. Las guías actuales han centrado su atención fundamentalmente en la prevención activa y el tratamiento de la fiebre, mientras que la hipotermia terapéutica (HT) ha caído en desuso, aun cuando persisten dudas sobre su efectividad de acuerdo con el modo de aplicación y la adecuada selección de pacientes. En esta revisión narrativa se presenta la evidencia clínica más relevante sobre los efectos de la HT en pacientes con daño neurológico agudo, así como de los conceptos fisiopatológicos en los que se fundamenta su uso.

La descontaminación digestiva selectiva (DDS) es una estrategia profiláctica cuyo objetivo es prevenir o erradicar el sobrecrecimiento bacteriano en la flora intestinal que precede al desarrollo de la mayoría de las infecciones en la UCI. La DDS previene infecciones graves, reduce la mortalidad, es coste-efectiva, no tiene efectos adversos, y su uso a corto o largo plazo no muestra un aumento significativo de la resistencia antimicrobiana. La DDS es una de las intervenciones más evaluadas en pacientes críticos, a pesar de lo cual su uso no se ha generalizado. El objetivo de este artículo es presentar una revisión narrativa de la evidencia más relevante y una actualización de los conceptos fisiopatológicos de control de la infección en los que se fundamenta el uso de la DDS.

Selective digestive decontamination (SDD) is a prophylactic strategy aimed at preventing or eradicating bacterial overgrowth in the intestinal flora that precedes the development of most infections in the Intensive Care Unit. SDD prevents serious infections, reduces mortality, is cost-effective, has no adverse effects, and its short- or long-term use is not associated with any significant increase in antimicrobial resistance. SDD is one of the most widely evaluated interventions in critically ill patients, yet its use is not widespread. The present article offers a narrative review of the most relevant evidence and an update of the pathophysiological concepts of infection control supporting the use of SDD.

Introduction: Critical patients, despite initial recovery in the intensive care unit (ICU), may require read-mission to the ICU or even die in the same hospital episode. The objectives are to determine the incidence and to identify risk factors for ICU readmission, and to determine hospital mortality. Methods: Observational cohort study of all patients admitted consecutively for more than 24 hours to the ICU of the University Hospital of Getafe between April 1, 2018 and September 30, 2018 and discharged alive from their first ICU admission. Results: Of the 164 patients alive at ICU discharge, 14 (8.5%) were readmitted to ICU (2.4% at < 48 hours). The adjusted risk of ICU readmission was higher in patients with disabling neurological deficits prior to ICU admission [odds ratio (OR) 7.96, 95% confidence interval (CI) 1.55-40.92] or who received vasoactive drugs (OR 5.07, 95% CI 1.41-18.29) during their ICU stay. Readmitted patients had higher hospital mor-tality (4 of 14 [29%] versus 5 of 150 [3%], P < .001) and longer hospital stay (74.5 [37.5-99.75] days versus 16 [9-34] days, median [interquartile range], P = .001). Conclusions: Patients with disabling neurological deficits prior to hospital admission or who received vasoactive drugs during their ICU stay have a higher risk of readmission to the ICU, which increases hospital stay and mortality. (c) 2020 Elsevier Espana, S.L.U. All rights reserved.

We studied the impact of age on survival and functional recovery in brain-injured patients. We performed an observational cohort study of all consecutive adult patients with brain injury admitted to ICU in 8 years. To estimate the optimal cut-off point of the age associated with unfavorable outcomes (mRS 3–6), receiver operating characteristic (ROC) curve analyses were used. Multivariate logistic regression analyses were performed to identify prognostic factors for unfavorable outcomes. We included 619 brain-injured patients. We identified 60 years as the cut-off point at which the probability of unfavorable outcomes increases. Patients ≥ 60 years had higher severity scores at ICU admission, longer duration of mechanical ventilation, longer ICU and hospital stays, and higher mortality. Factors identified as associated with unfavorable outcomes (mRS 3–6) were an advanced age (≥ 60 years) [Odds ratio (OR) 4.59, 95

Despite the need for specific weaning strategies in neurological patients, evidence is generally insufficient or lacking. We aimed to describe the evolution over time of weaning and extubation practices in patients with acute brain injury compared with patients who are mechanically ventilated (MV) due to other reasons. We performed a secondary analysis of three prospective, observational, multicenter international studies conducted in 2004, 2010, and 2016 in adults who had need of invasive MV for more than 12 h. We collected data on baseline characteristics, variables related to management ventilator settings, and complications while patients were ventilated or until day 28. Among the 20,929 patients enrolled, we included 12,618 (60

Critical patients, despite initial recovery in the intensive care unit (ICU), may require readmission to the ICU or even die in the same hospital episode. The objectives are to determine the incidence and to identify risk factors for ICU readmission, and to determine hospital mortality.Observational cohort study of all patients admitted consecutively for more than 24hours to the ICU of the University Hospital of Getafe between April 1, 2018 and September 30, 2018 and discharged alive from their first ICU admission.Of the 164 patients alive at ICU discharge, 14 (8.5%) were readmitted to ICU (2.4% at≤48hours). The adjusted risk of ICU readmission was higher in patients with disabling neurological deficits prior to ICU admission [odds ratio (OR) 7.96, 95% confidence interval (CI) 1.55-40.92] or who received vasoactive drugs (OR 5.07, 95% CI 1.41-18.29) during their ICU stay. Readmitted patients had higher hospital mortality (4 of 14 [29%] versus 5 of 150 [3%], P<.001) and longer hospital stay (74.5 [37.5-99.75] days versus 16 [9-34] days, median [interquartile range], P=.001).Patients with disabling neurological deficits prior to hospital admission or who received vasoactive drugs during their ICU stay have a higher risk of readmission to the ICU, which increases hospital stay and mortality.

OBJECTIVES:To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality.DESIGN:Secondary analysis of three prospective, observational, multicenter studies.SETTING:Cohort studies conducted in 2004, 2010, and 2016.PATIENTS:Adult patients who received mechanical ventilation for more than 12 hours.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma.CONCLUSIONS:More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease.

SummaryAutopsy studies show that IA is among the most commonly missed diagnoses in critically ill patients. And, because of lack of unequivocal diagnostic criteria, a timely diagnosis remains challenging. We investigate the epidemiology of and the clinical risk factors for IA in critically ill patients. We conducted a retrospective, observational study of all consecutive ICU patients with evidence of IA in the postmortem examination. During the period of the study (25 years), 893 postmortem examinations were performed in the ICU. Twenty‐five patients (2.8%) were diagnosed with IA in autopsy. Only ten (40%) were classified as IA ante‐mortem, based on the initiation of antifungal treatment. The most common comorbid conditions were corticosteroid treatment (n = 14, 56%), chronic obstructive pulmonary disease (COPD) (n = 11, 44%), immunosuppression (n = 6, 24%) and haematological malignancy (n = 5, 20%). Twenty‐three patients (92%) had three or more risk factors for IA. Critically ill patients with pulmonary infiltrates, treated with high doses intravenous corticosteroids (even for a short period of time), particularly COPD patients who developed worsening respiratory insufficiency despite appropriate treatment were at the highest risk of IA.

We evaluate the evolution over time of discrepancies between clinical diagnoses and postmortem findings in critically ill patients and assess the factors associated with these discrepancies. We conducted a prospective study of all consecutive patients who underwent autopsy in a medical-surgical intensive care unit (ICU) between January 2008 and December 2015. Among 7655 patients admitted to our ICU, 671 (8.8%) died. Clinical autopsy was performed in 215 (32%) patients. Major missed diagnoses were noted in 38 patients (17.7%). Eighteen patients (8.4%) had class I discrepancies, and 20 patients (9.3%) had class II discrepancies. The most frequently missed diagnoses were invasive aspergillosis, intestinal ischemia, myocardial infarction, cancer, and intra-abdominal abscesses. We did not find a statistically significant correlation between any premortem factor, including age, sex, severity of illness, length of hospital stay before ICU admission, length of ICU stay before death, duration of mechanical ventilation, or admitting unit, and the level of agreement between clinical and pathological diagnosis. In the last decades, the discrepancies between clinical and autopsy diagnoses persisted despite advances in medical skills and technology. Specific clinical entities such as invasive aspergillosis, mesenteric ischemia, myocardial infarction, intra-abdominal abscesses, and neoplastic diseases remain a diagnostic challenge in critically ill patients. Clinical level of diagnostic certainty does not increase with specific premortem characteristics.

PURPOSE:In neurologically critically ill patients with mechanical ventilation (MV), the development of acute respiratory distress syndrome (ARDS) is a major contributor to morbidity and mortality, but the role of ventilatory management has been scarcely evaluated. We evaluate the association of tidal volume, level of PEEP and driving pressure with the development of ARDS in a population of patients with brain injury.MATERIALS AND METHODS:We performed a secondary analysis of a prospective, observational study on mechanical ventilation.RESULTS:We included 986 patients mechanically ventilated due to an acute brain injury (hemorrhagic stroke, ischemic stroke or brain trauma). Incidence of ARDS in this cohort was 3%. Multivariate analysis suggested that driving pressure could be associated with the development of ARDS (odds ratio for unit increment of driving pressure 1.12; confidence interval for 95%: 1.01 to 1.23) whereas we did not observe association for tidal volume (in ml per kg of predicted body weight) or level of PEEP. ARDS was associated with an increase in mortality, longer duration of mechanical ventilation, and longer ICU length of stay.CONCLUSIONS:In a cohort of brain-injured patients the development of ARDS was not common. Driving pressure was associated with the development of this disease.

Autopsy has long been regarded as a valuable and reliable tool to improve quality of medical care by monitoring diagnostic accuracy and treatment of the critically-ill patients. However, post-mortem examination rates have fallen worldwide during the past decades. Unexpected findings at autopsy contribute to the increasing pool of medical knowledge and may allow the development of strategies for the early detection of diagnoses, leading to better patient care. Several studies have shown that major discrepancies are frequent, and in 5–40% of all hospitalized patients, and in 7–32% of adult intensive care patients a treatable condition that might have altered outcome, had it been recognized, is identified at post-mortem examination. Despite technological improvements in medicine, the percentage of missed diagnoses had not changed over time. Autopsy provides a ‘gold standard’ to assess the accuracy of diagnostic tests and also offers relevant information for the advance of medical knowledge and the description of new disease entities. The health care system as a whole can benefit enormously from autopsy data, the autopsy providing information unavailable by any other method, and should be considered in every patient who dies in the intensive care unit.

The objective of this study was to analyze the spatial and temporal dynamics of Chironomidae larvae assemblages in a subtropical mountain river basin of northwestern Argentina. We hypothesized that they would respond to (1) environmental changes along the altitudinal gradient in the Yungas forests; (2) environmental changes caused by spates (e.g., increased discharge or sediment transportation). We sampled five sites along an altitudinal gradient of ca. 1,500 m (from 680 to 2,170 m) during low-water and high-water period for 2 years. The Chironomidae larvae assemblages varied along the altitudinal gradient and between sampling periods based on an indicator species analyses and an ordination analyses (NMDS). The best indicator for high altitude sites was “Genus X” followed by Onconeura sp.2, “Genus 9”, “Genus 10”, and Rheotanytarsus sp.2; while Rheotanytarsus lamellatus , Oliveiriella sanjavieri , and Thienemanniella sp. were good indicators for low altitude sites. O. sanjavieri and R. lamellatus were the best indicators for high-water period. The most relevant environmental variables influencing their spatial and temporal distribution were altitude, water temperature, conductivity, and pH. This study is the first to analyze and describe in detail the spatial and temporal distribution of Chironomidae larvae assemblages in northwestern Argentina, and most of the taxa reported here are new records for the region.

The South American genus Oliveiriella is reported for the first time from Argentina. Description and diagnosis of all stages of a new species as well as the larva of O. almeidai are given.

Immature stages and adult female of Rheotanytarsus lamellatus Reiss are described for the first time, and the male is redescribed, diagnosed and compared with R. meridionalis (Johannsen). Both species are reported for the first time from Argentina. Keys to South American male adults and pupae are given.

METHODS:We studied patients requiring mechanical ventilation for more than 48 hours who died in the intensive care unit and whose bodies were autopsied. We evaluated 3 clinical definitions of ventilator-associated pneumonia: loose definition, defined as chest radiograph infiltrates and 2 of 3 clinical criteria (leukocytosis, fever, purulent respiratory secretions); rigorous definition, defined as chest radiograph infiltrates and all of the clinical criteria; and a clinical pulmonary infection score higher than 6 points. Sensitivity, specificity, and likelihood ratios were calculated by using pathology pattern as criterion standard.RESULTS:One hundred forty-two (56%) of the 253 patients included had histological criteria of pneumonia. Patients who met the clinical criteria of ventilator-associated pneumonia were 163 (64%) for the loose definition, 32 (13%) for the rigorous definition, and 109 (43%) for the clinical pulmonary infection score. The operative indexes (sensitivity and specificity) of each definition were as follows: loose definition, 64.8% and 36%; rigorous definition, 91% and 15.5%; and clinical pulmonary infection score higher than 6, 45.8% and 60.4%. The addition of microbiological data to the clinical definitions increased the specificity and decreased the sensitivity but not significantly.CONCLUSIONS:Accuracy of 3 commonly used clinical definitions of ventilator-associated pneumonia was poor taking the autopsy findings as reference standard.