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"apellidos" => "Añón" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173572715000648" "doi" => "10.1016/j.medine.2015.06.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572715000648?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569115001667?idApp=WMIE" "url" => "/02105691/0000003900000009/v2_201512050123/S0210569115001667/v2_201512050123/es/main.assets" ] ] "itemAnterior" => array:18 [ "pii" => "S2173572715000727" "issn" => "21735727" "doi" => "10.1016/j.medine.2015.07.001" "estado" => "S300" "fechaPublicacion" => "2015-12-01" "aid" => "827" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Med Intensiva. 2015;39:563-72" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 5850 "formatos" => array:3 [ "EPUB" => 189 "HTML" => 3477 "PDF" => 2184 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Antibiotic dose optimization in critically ill patients" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "563" "paginaFinal" => "572" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Optimización de la dosis de antibióticos en pacientes críticamente enfermos" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1532 "Ancho" => 2257 "Tamanyo" => 181514 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Initial pathophysiology of severe sepsis/septic shock and its impact on antibiotic pharmacokinetics.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.O. Cotta, J.A. Roberts, J. Lipman" "autores" => array:3 [ 0 => array:2 [ "nombre" => "M.O." "apellidos" => "Cotta" ] 1 => array:2 [ "nombre" => "J.A." "apellidos" => "Roberts" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Lipman" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572715000727?idApp=WMIE" "url" => "/21735727/0000003900000009/v2_201703210124/S2173572715000727/v2_201703210124/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Point of view</span>" "titulo" => "Does early versus late tracheotomy afford benefits in ventilated patients?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "573" "paginaFinal" => "574" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "J.M. Añón" "autores" => array:1 [ 0 => array:3 [ "nombre" => "J.M." "apellidos" => "Añón" "email" => array:2 [ 0 => "jmaelizalde@gmail.com" 1 => "jmanon@sescam.jccm.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Virgen de la Luz, Cuenca, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Aporta beneficios la traqueotomía precoz frente a la tardía en el enfermo ventilado?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Since the 1970s,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> different comparative studies have tried to answer this question. The two randomized, prospective multicenter trials with the largest sample size to date have been published during the last 5 years. In the first of them, Terragni et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> included 419 patients, of which 209 were randomized to early tracheotomy (after 6–8 days of translaryngeal intubation [TI]) and 210 to late tracheotomy (after 13–15 days of TI). The primary endpoint was the incidence of ventilator-associated pneumonia (VAP). The authors found no differences between the two groups in terms of either the primary endpoint or mortality after 28 days (secondary endpoint). The overall complications rate was 39%, though the majority were only minor problems. The second and most recent study was published by Young et al. (The TracMan randomized trial),<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> and included 909 patients, of which 455 were randomized to early tracheotomy (during the first 4 days of TI) and 454 to late tracheotomy (after 10 days of TI). There were no differences between the two groups in terms of mortality 30 days after randomization (primary endpoint) or as regards in-hospital mortality or mortality after one and two years of follow-up.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the study published by Terragni et al.,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> 17% (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>36) of the patients randomized to early tracheotomy and 20% (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>42) of those randomized to late tracheotomy were finally not subjected to tracheotomy, due to blood gas improvement and resolution of the acute disease process that led them to require mechanical ventilation in the first place. The authors underscored that the anticipation of tracheotomy increased the number of patients who were finally tracheotomized. In the study published by Young et al.,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> 14% (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>66) of the patients in the early tracheotomy group were not tracheotomized (15 because of recovery), while a full 55% (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>244) of the patients in the late tracheotomy arm were not tracheotomized–fundamentally due to extubation and discharge from the Intensive Care Unit. As commented by the authors, this situation questions the capacity of clinicians to establish an early prediction of the duration of mechanical ventilation beyond a period of 7 days. Both studies conclude that early tracheotomy should be avoided.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The results of these two large studies are in contrast to the data published in 2004 by Rumbak et al.,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> who in a randomized, prospective analysis of a smaller patient sample (120 medical critical patients: 60 in each arm) with screening criteria that do not allow generalization of the results, found early tracheotomy (performed after 48<span class="elsevierStyleHsp" style=""></span>h of ventilation) to be associated to lesser mortality and VAP than tracheotomy performed beyond 14 days of ventilation. Eight of the 60 patients (13%) randomized to late tracheotomy were finally not tracheotomized due to extubation before day 14.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The last article published in relation to this controversial issue is a recent metaanalysis<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> including 11 randomized, prospective trials. The conclusions were that tracheostomy performed in the first 7 days of ventilation is associated to a shorter stay in the Intensive Care Unit, though without differences in terms of in-hospital mortality. Consequently, there is no evidence in support of an early tracheotomy strategy. Accuracy in predicting the duration of mechanical ventilation was cited as an important limitation of all the studies evaluated.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In effect, all the published comparative studies present the same limitation, for which no solution is currently available: the lack of a validated instrument for predicting prolonged mechanical ventilation. As a result, patient screening for inclusion has been based on subjective criteria. This situation in turn has led to recruitment problems in some studies, due to difficulties in anticipating the duration of ventilation, or because of clinician reluctance to follow the randomization protocols.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In 2014, Figueroa-Casas et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> published the results of a prospective study designed to evaluate the capacity to establish an early prediction of the duration of mechanical ventilation based on clinical judgment. The analysis of the accuracy of clinical prediction during the first 48<span class="elsevierStyleHsp" style=""></span>h of intubation revealed a sensitivity of 40% for mechanical ventilation lasting over 7 days, versus 29% for mechanical ventilation lasting over 14 days.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In 2007 we started a project designed to develop a predictive model capable of offering help in the clinical decision making process, fundamentally as regards the timing of tracheotomy in ventilated patients, and which was published in this journal in 2012.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The study, completed before the estimated sample size was reached, and lacking the required statistical power, was unable to meet the expectations. Other studies in this same line have likewise been unable to define a model applicable to the clinical setting. There is only a predictive equation validated for burn patients,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> but not applicable to other critical patients.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In view of the current state of this topic, the latest publications<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2–4</span></a> represent (or should represent) the end of comparative “early versus late tracheostomy” analyses. Future evaluations in this same line cannot draw solid conclusions if no validated predictive instrument is available. The lack of such an instrument results in methodological weaknesses that invalidate the findings of the studies. Furthermore, considering the poor clinical predictive capacity and the lack of a helping instrument, would it be reasonable to plan new projects a priori assuming that a number of patients are very likely to undergo needless surgery, with the sole justification of having been randomized to a given study arm?</p><p id="par0045" class="elsevierStylePara elsevierViewall">The time has come for a change in direction. If we want to obtain a solid answer to the question of this “Point of view”, we first will have to spend years of research in predictive models. This is no easy task. In the meantime, the individualization of decisions remains the best strategy in routine clinical practice.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Añón JM. ¿Aporta beneficios la traqueotomía precoz frente a la tardía en el enfermo ventilado? 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2022 April | 36 | 35 | 71 |
2022 March | 42 | 50 | 92 |
2022 February | 42 | 35 | 77 |
2022 January | 46 | 30 | 76 |
2021 December | 35 | 39 | 74 |
2021 November | 40 | 35 | 75 |
2021 October | 54 | 70 | 124 |
2021 September | 29 | 33 | 62 |
2021 August | 33 | 48 | 81 |
2021 July | 26 | 44 | 70 |
2021 June | 32 | 35 | 67 |
2021 May | 60 | 56 | 116 |
2021 April | 148 | 75 | 223 |
2021 March | 88 | 31 | 119 |
2021 February | 65 | 31 | 96 |
2021 January | 54 | 22 | 76 |
2020 December | 46 | 20 | 66 |
2020 November | 25 | 16 | 41 |
2020 October | 35 | 32 | 67 |
2020 September | 46 | 22 | 68 |
2020 August | 32 | 21 | 53 |
2020 July | 34 | 24 | 58 |
2020 June | 39 | 13 | 52 |
2020 May | 29 | 9 | 38 |
2020 April | 45 | 14 | 59 |
2020 March | 27 | 9 | 36 |
2020 February | 45 | 30 | 75 |
2020 January | 33 | 26 | 59 |
2019 December | 33 | 16 | 49 |
2019 November | 29 | 20 | 49 |
2019 October | 39 | 25 | 64 |
2019 September | 30 | 19 | 49 |
2019 August | 28 | 21 | 49 |
2019 July | 41 | 21 | 62 |
2019 June | 19 | 5 | 24 |
2019 May | 56 | 26 | 82 |
2019 April | 31 | 13 | 44 |
2019 March | 35 | 22 | 57 |
2019 February | 46 | 22 | 68 |
2019 January | 42 | 33 | 75 |
2018 December | 37 | 21 | 58 |
2018 November | 51 | 71 | 122 |
2018 October | 79 | 30 | 109 |
2018 September | 26 | 7 | 33 |
2018 August | 9 | 7 | 16 |
2018 July | 21 | 8 | 29 |
2018 June | 29 | 12 | 41 |
2018 May | 17 | 5 | 22 |
2018 April | 22 | 9 | 31 |
2018 March | 54 | 7 | 61 |
2018 February | 22 | 7 | 29 |
2018 January | 27 | 7 | 34 |
2017 December | 16 | 6 | 22 |
2017 November | 28 | 13 | 41 |
2017 October | 37 | 7 | 44 |
2017 September | 26 | 7 | 33 |
2017 August | 24 | 8 | 32 |
2017 July | 26 | 10 | 36 |
2017 June | 31 | 14 | 45 |
2017 May | 39 | 9 | 48 |
2017 April | 50 | 12 | 62 |
2017 March | 20 | 41 | 61 |
2017 February | 19 | 11 | 30 |
2017 January | 14 | 5 | 19 |
2016 December | 53 | 22 | 75 |
2016 November | 54 | 27 | 81 |
2016 October | 46 | 38 | 84 |
2016 September | 48 | 12 | 60 |
2016 August | 35 | 3 | 38 |
2016 July | 18 | 7 | 25 |
2016 June | 1 | 0 | 1 |