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array:24 [ "pii" => "S2173572719300943" "issn" => "21735727" "doi" => "10.1016/j.medine.2019.05.002" "estado" => "S300" "fechaPublicacion" => "2019-08-01" "aid" => "1110" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "copyrightAnyo" => "2017" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Intensiva. 2019;43:382-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 292 "formatos" => array:3 [ "EPUB" => 62 "HTML" => 169 "PDF" => 61 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0210569117302395" "issn" => "02105691" "doi" => "10.1016/j.medin.2017.09.002" "estado" => "S300" "fechaPublicacion" => "2019-08-01" "aid" => "1110" "copyright" => "Elsevier España, S.L.U. y SEMICYUC" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Intensiva. 2019;43:382-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 753 "formatos" => array:3 [ "EPUB" => 53 "HTML" => 467 "PDF" => 233 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta científica</span>" "titulo" => "¿Se debe restringir el ingreso en cuidados intensivos solo a los pacientes más graves?" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "382" "paginaFinal" => "384" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Should intensive care admission be restricted to the most severely ill patients?" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1284 "Ancho" => 2077 "Tamanyo" => 105494 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Distribución de los pacientes por deciles de riesgo al ingreso SAPS3.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. Fernandez, J.M. Alcoverro, I. Catalán, O. Rubio, S. 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Roldán-Reina, J.J. Egea-Guerrero, N. Palomo-López, D.X. Cuenca-Apolo, M. Adriaensens-Pérez, L. Martín-Villén" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A.J." "apellidos" => "Roldán-Reina" ] 1 => array:2 [ "nombre" => "J.J." "apellidos" => "Egea-Guerrero" ] 2 => array:2 [ "nombre" => "N." "apellidos" => "Palomo-López" ] 3 => array:2 [ "nombre" => "D.X." "apellidos" => "Cuenca-Apolo" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Adriaensens-Pérez" ] 5 => array:2 [ "nombre" => "L." "apellidos" => "Martín-Villén" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210569117302383" "doi" => "10.1016/j.medin.2017.09.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569117302383?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572719300992?idApp=WMIE" "url" => "/21735727/0000004300000006/v1_201907250825/S2173572719300992/v1_201907250825/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2173572718302248" "issn" => "21735727" "doi" => "10.1016/j.medine.2018.06.005" "estado" => "S300" "fechaPublicacion" => "2019-08-01" "aid" => "1231" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Intensiva. 2019;43:373-81" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 239 "formatos" => array:3 [ "EPUB" => 44 "HTML" => 107 "PDF" => 88 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Point of view</span>" "titulo" => "Clinical implications of the rheological theory in the prevention of ventilator-induced lung injury. Is mechanical power the solution?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "373" "paginaFinal" => "381" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Implicaciones clínicas de la teoría reológica en la prevención de la lesión pulmonar inducida por el ventilador. ¿Es la potencia mecánica la solución?" ] ] "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" => 1737 "Ancho" => 3333 "Tamanyo" => 248088 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mechanical power calculation. From a practical point of view, the elastic triangle (green triangle) is not included in the energy calculation because this energy is only used in the first inspiration. The key point is the energy which is delivered in the following consecutive breaths. PEEP: positive end-expiratory pressure; <span class="elsevierStyleItalic">E</span><span class="elsevierStyleInf">breath</span>: energy supplied in each breath; <span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">T</span>: tidal volume; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">plat</span>: plateau pressure; PIP: peak inspiratory pressure; DP: driving pressure.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "V. Modesto i Alapont, M. Aguar Carrascosa, A. Medina Villanueva" "autores" => array:3 [ 0 => array:2 [ "nombre" => "V." "apellidos" => "Modesto i Alapont" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Aguar Carrascosa" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Medina Villanueva" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210569118301864" "doi" => "10.1016/j.medin.2018.06.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569118301864?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572718302248?idApp=WMIE" "url" => "/21735727/0000004300000006/v1_201907250825/S2173572718302248/v1_201907250825/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Should intensive care admission be restricted to the most severely ill patients?" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "382" "paginaFinal" => "384" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "R. Fernandez, J.M. Alcoverro, I. Catalán, O. Rubio, S. Cano, C. Subirà" "autores" => array:6 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Fernandez" "email" => array:1 [ 0 => "rfernandezf@althaia.cat" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.M." "apellidos" => "Alcoverro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "I." "apellidos" => "Catalán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "O." "apellidos" => "Rubio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "S." "apellidos" => "Cano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "C." "apellidos" => "Subirà" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Sant Joan de Déu-Fundació Althaia, Manresa, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universitat Internacional de Catalunya, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "CIBERES, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Se debe restringir el ingreso en cuidados intensivos solo a los pacientes más graves?" ] ] "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" => 1284 "Ancho" => 2077 "Tamanyo" => 106496 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Stratification of patients into risk deciles at SAPS3 admission.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The clinical practice guidelines on the management of intensive care unit (ICU) admissions recommend that the selection of patients should be based on a potential benefit,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> assigning the lowest priority to those patients who are “too well” or “too serious” to be able to benefit from the healthcare provided at the ICU.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> However, Chen et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> showed that the percentages of high and low risk of patients admitted to ICUs varied among different hospitals showing a lack of consensus on what patients benefit the most from their ICU admission.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The lack of beds at the ICU is another factor that justifies the refusal to hospitalize low-risk patients. Partly it is because of this that intermediate care units have been created to provide healthcare to low-risk patients in a more cost-effective scenario. However, a recent study suggests that critically ill patients may fare worse at low-intensity ICUs compared to high-intensity ICUs.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">During an ICU admission, the risk of a patient is usually defined by his severity scores.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> These severity scores are updated on a regular basis in order to achieve a better calibration of his response to therapy. However, even in the most recent models, the relation between predicted mortality and observed mortality are evenly distributed along the degree of severity.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A study of 150,000 patients with medical diagnoses of low risk associated the ICU admission of these patients to more invasive procedures and higher costs with no significant differences of mortality.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Given the tendency towards lower ICU-acquired complication rates, basically catheter-related infections and pneumonia, our hypothesis is that low-risk patients can benefit from ICU admissions similar to high-risk patients.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We retrospectively reviewed the 2009–2015 clinical database from the 14-bed mixed medical–surgical ICU at our university hospital. Our ICU accepts patients who require complete ICU therapies, but it also accepts intermediate-level patients. Also, our ICU is a coronary unit and stroke unit. However, our hospital is not accredited to do neurosurgery, cardiac surgery, or transplants.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The ICU clinical database includes data collected at admission (administrative data, comorbidities and severity score [SAPS3]), during the ICU stay (procedures, complications and limitation of life support treatment – LLST) and at ICU discharge (length of the ICU the stay and patient's state at discharge). The length of the hospital stay, and the patient's state at hospital discharge were obtained from the hospital database.</p><p id="par0040" class="elsevierStylePara elsevierViewall">For statistical analysis purposes, the categorical variables were expressed as frequencies and percentages and compared using the <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span> test. Continuous variables were expressed as mean and standard deviation and compared using the Student's <span class="elsevierStyleItalic">t</span> test. We stratified the population into deciles of mortality risk at admission and then compared it to the actual hospital mortality rate.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The study spans through a period of seven years and is characterized by a homogeneous case-mix in hospital admissions where the ICU admission criteria remained invariable. Four thousand nine hundred and seventeen (4917) patients were admitted (average age 65.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>16.5 years; 64% males). The average length of the ICU stay was 4.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.1 days and the average length of the hospital stay was 14.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>18.8 days. Mortality risk (SAPS3) at admission was 27.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>23.9% and 810 (16.5%) patients died at the ICU or at the ward after being discharged from the ICU which led to a standardized mortality ratio of 0.59<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.04.</p><p id="par0050" class="elsevierStylePara elsevierViewall">When patients were stratified into deciles of SAPS3 risk, a biased population was seen with a higher percentage of low-risk patients (risk<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>10%) compared to high-risk patients (risk<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>50%) (1499 [30.5%] vs 929 [18.9%]) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The length of the ICU stay was not homogeneous either (low risk: 2.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.2 days vs high risk: 6.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.7 days, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows that the standardized mortality ratio was also distributed non-homogeneously dropping gradually with respect to lower deciles of the SAPS3, from 0.87 for SAPS3<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>90% to 0.30 for SAPS3<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>10%.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">This study found that low-risk patients not only were not hurt by their ICU admission, but that the survival benefit of low-risk patients was proportionally greater compared to high-risk patients.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Our analyses are based on the predictive value of SAPS3 at admission. The original SAPS3 was adapted to predict mortality in every level of risk while taking into consideration the geographical and developing area of the world where the patient received healthcare.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> For this reason, part of our population's survival advantage compared to the predicted mortality rate may be due to the cumulative effects of not calibrating this tool across the years as it has already been proven.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> However, none of the studies that evaluated this problem found that this error in the calibration affects differently based on the level of predicted risk.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Our period of observation was not long enough to be able to show time-dependent effects over the standardized mortality ratio. On the other hand, some patients spent one or more days at the ICU waiting to be hospitalized, meaning that the survival benefit may be associated with the improvement reported and with admissions at semi-intensive care units,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> yet former studies do not suggest a greater benefit for low-risk patients.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Another problem here is the economic burden involved when admitting low-risk patients to an ICU. We do not have direct data on costs, but most studies suggest that the key factor here is the much shorter length of the ICU stay<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a> of low-risk patients. We can only speculate whether there would be an equivalent survival advantage for low-risk patients in less expensive ICUs, such as semi-intensive or “low intensity” units.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Our study suggests that ICU admissions involve survival benefits for low-risk patients as well, which makes them eligible for admission too.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors</span><p id="par0085" class="elsevierStylePara elsevierViewall">Person responsible for this paper, its concept and design: RF.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Analysis and interpretation: RF, JMA, IC, OR, SC, and CS.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Manuscript writing: RF.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernandez R, Alcoverro JM, Catalán I, Rubio O, Cano S, Subirà C. ¿Se debe restringir el ingreso en cuidados intensivos solo a los pacientes más graves? Med Intensiva. 2019;43:382–384.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1284 "Ancho" => 2077 "Tamanyo" => 106496 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Stratification of patients into risk deciles at SAPS3 admission.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1326 "Ancho" => 2097 "Tamanyo" => 131703 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Stratification of the standardized mortality ratio into SAPS3 mortality risk deciles.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Critical care delivery: the importance of process of care and ICU structure to improved outcomes: an update from the American College of Critical Care Medicine Task Force on models of critical care" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.J. 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