Introduction: The use of high-flow nasal cannulas (HFNC) in patients with hypoxemic ventilatory failure reduces the need for mechanical ventilation and does not increase mortality when intubation is promptly applied. The aim of the study is to describe the behavior of HFNC in patients who live at high altitudes, and the performance of predictors of success/failure of this strategy. Methods: Prospective multicenter cohort study, with patients aged over 18 years recruited for 12 months in 2020 to 21. All had a diagnosis of hypoxemic respiratory failure secondary to pneumonia, were admitted to intensive care units, and were receiving initial management with a high-flow nasal cannula. The variables assessed included need for intubation, mortality in ICU, and the validation of SaO2, respiratory rate (RR) and ROX index (IROX) as predictors of HFNC success / failure. Results: One hundred and six patients were recruited, with a mean age of 59 years and a success rate of 74.5%. Patients with treatment failure were more likely to be obese (BMI 27.2 vs 25.5; OR: 1.03; 95% CI: .95-1.1) and had higher severity scores at admission (APACHE II 12 vs 20; OR 1.15; 95% CI: 1.06-1.24). Respiratory rates after 12 (AUC .81 CI: .70-.92) and 18 h (AUC .85 CI: .72-0.90) of HFNC use were the best predictors of failure, performing better than those that included oxygenation. ICU mortality was higher in the failure group (6% vs 29%; OR 8.8; 95% CI:1.75-44.7). Conclusions: High-flow oxygen cannula therapy in patients with hypoxemic respiratory failure living at altitudes above 2600 m is associated with low rates of therapy failure and a reduced need for mechanical ventilation in the ICU. The geographical conditions and secondary physiological changes influence the performance of the traditionally validated predictors of therapy success. Respiratory rate <30 proved to be the best indicator of early success of the device at 12 h of use.

BACKGROUND: Sedation in intensive care is fundamental for optimizing clinical outcomes. For many years the world has been facing high rates of opioid use, and to combat the increasing opioid addiction plans at both national and international level have been implemented. 1 The COVID-19 pandemic posed a major challenge for health systems and also increased the use of sedatives and opioid analgesia for prolonged periods of time, and at high doses, in a significant proportion of patients. In our institutions, the shortage of many drugs for intravenous (IV) analgosedation forces us to alternatives to replace out-of-stock drugs or to seek sedation goals, which are difficult to obtain with traditional drugs at high doses. 2 METHODS: This was an analytical retrospective cohort study evaluating the follow-up of subjects with inclusion criteria from ICU admission to discharge (alive or dead). Five end points were measured: need for high-dose opioids (6 200 lg/h), comparison of inhaled versus IV sedation of opioid analgesic doses, midazolam dose, need for muscle relaxant, and risk of delirium. RESULTS: A total of 283 subjects were included in the study, of whom 230 were administered IV sedation and 53 inhaled sedation. In the inhaled sedation group, the relative risks (RRs) were 0.5 (95% CI 0.4-0.8, P 5 .045) for need of high-dose fentanyl, 0.3 (95% CI 0.20-0.45, P < .001) for need of muscle relaxant, and 0.8 (95% CI 0.61-1.15, P 5 .25) for risk of delirium. The median difference of fentanyl dose between the inhaled sedation and IV sedation groups was 61 lg/h or 1,200 lg/d (2.2 ampules/d, P < .001), and that of midazolam dose was 5.7 mg/h. CONCLUSIONS: Inhaled sedation was associated with lower doses of opioids, benzodiazepines, and muscle relaxants compared to IV sedation. This therapy should be considered as an alternative in critically ill patients requiring prolonged ventilatory support and where IV sedation is not possible, always under adequate supervision of ICU staff.

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Introducción: las infecciones causadas por Enterococcus resistente a Vancomicina (EVR) presentan mayor mortalidad en pacientes críticos, asociado a un aumento gradual en este patrón de resistencia, especialmente en el continente americano, por lo cual la adecuada terapia antimicrobiana empírica es fundamental para mejorar los desenlaces. Objetivo: determinar los factores de riesgo asociados al desarrollo de infección por EVR en pacientes sépticos en la Unidad de Cuidados Intensivos (UCI) del Hospital San José en Bogotá, Colombia. Métodos: Estudio descriptivo de casos y controles en pacientes sépticos ingresados a la UCI durante 2016 y 2017. Los casos se definieron como pacientes con infección por EVR y los controles los pacientes con infección por otro germen. Resultados: se incluyeron 32 pacientes con aislamiento de EVR y 96 controles. Los factores de riesgo asociados a infección por EVR fueron: nutrición parenteral(OR 15,7 IC 4,2-71,4), lavado peritoneal (OR 8,9 IC 3,2-24,8), cultivo polimicrobiano (OR 19,9 IC 6,0-83,4). La mortalidad fue 56,2% en casos y 33,3% en controles. Conclusiones: Los factores de riesgo hallados con mayor frecuencia fueron: múltiples lavados peritoneales, nutrición parenteral y cultivos polimicrobianos. Encontramos una correlación significativa en el uso de antibiótico empírico adecuado y la reducción en la mortalidad.

Background. COVID-19 patients in intensive care units suffer from bacterial/fungal superinfections. However, the incidence and cause of such superinfections in high-altitude hospitals remain poorly investigated. Objectives. The aim of this study was to evaluate the frequency of bacterial/fungal superinfection in patients with COVID-19 hospitalized in the intensive care unit (ICU) of the Hospital Universitario San José de Bogotá, Colombia, located at an altitude of 2,651 meters above sea level (high altitude). The impact of corticosteroids on the development of infection was also evaluated. Methods. The cohort included 279 patients, of which 188 (67.4%) were male, 116 (42.3%) were treated with dexamethasone, and 48 (17.2%) were diagnosed with superinfection. A retrospective descriptive cohort study was performed to evaluate the association between bacterial/fungal superinfection frequency, corticosteroid treatment, mechanical ventilation, and mortality rate. Results. Our results showed that bacteremia was the most frequent diagnosis (n=20; 41.6%) of patients with superinfection, followed by pulmonary superinfection (n=17; 35.4%). The most frequently identified causative agents of superinfection were K. pneumoniae (n=23; 26.1%), C. albicans (n=10; 11.4%) and P. aeruginosa (n=8; 9.1%). Moreover, our results showed no association between corticosteroid treatment (or the use of empiric antibiotic treatment) and mortality. However, we found a significant association between bacterial/fungal superinfection and the number of days on mechanical ventilation. However, bacterial/fungal superinfection showed no impact on the mortality rate. Conclusions. We conclude that bacterial/fungal superinfection in ICU highland patients with SARS-CoV-2 treated at Hospital Universitario San José in Bogotá, Colombia, increases mainly in proportion to the time required for mechanical ventilation.