Guillermo Ortiz Ruiz

Introducción: la ventilación no invasiva (VNI) ha demostrado ser un método eficaz, simple y de bajo costo para el tratamiento de la falla respiratoria hipercápnica crónica. Sin embargo, su evidencia clínica ha sido descrita principalmente en pacientes con enfermedad pulmonar obstructiva crónica (EPOC), hipoventilación, obesidad y edema pulmonar cardiogénico, con limitaciones importantes reportadas en las publicaciones de pacientes con enfermedad neuromuscular (ENM). Aunque existe la necesidad de realizar grandes estudios aleatorizados en este grupo de pacientes, la literatura y la experiencia clínica actual soportan de manera inequívoca el beneficio de la VNI en mejorar la calidad de vida, disminuir el riesgo de infecciones respiratorias e impactar la mortalidad en algunos grupos de pacientes. El objetivo de este consenso es realizar recomendaciones de expertos, basadas en la evidencia científica disponible y la experiencia adquirida en los pacientes con ENM. Metodología: se realizó una búsqueda estructurada basada en preguntas PICOT en diferentes bases de datos, incluyendo literatura publicada entre enero de 1992 y febrero de 2025. La selección de estudios fue realizada por revisores independientes y las recomendaciones se elaboraron con base en la estrategia GRADE. El acuerdo entre expertos se definió mediante metodología Delphi, considerando consenso con más del 75 % de los votos y recomendación muy fuerte con más del 90 %. Resultados: a partir de la evidencia identificada y del consenso de expertos, se formularon 57 recomendaciones para el uso de VNI en pacientes con falla ventilatoria crónica secundaria a ENM. Conclusiones: este consenso proporciona recomendaciones basadas en evidencia y en la experiencia de expertos para el uso de VNI en pacientes con ENM. A pesar de la limitada disponibilidad de estudios aleatorizados de gran tamaño, la evidencia actual apoya su beneficio en pacientes seleccionados y respalda su incorporación en la práctica clínica.

La neumonía adquirida en la comunidad (NAC) sigue siendo una causa principal de morbilidad y mortalidad en adultos. Su abordaje se centra en el reconocimiento temprano de la gravedad, la identificación de factores de riesgo para patógenos resistentes y la administración oportuna de antibióticos. Su diagnóstico es clínico, sin embargo, se apoya en imagen de tórax y en pruebas microbiológicas dirigidas según la severidad. La formulación de una Guía de Práctica Clínica (GPC) basada en evidencia resulta esencial para enfrentar las múltiples brechas en el diagnóstico, tratamiento y prevención de la NAC. Por tanto, la GPC tiene como propósito orientar la toma de decisiones clínicas sobre el diagnóstico, la evaluación, el tratamiento empírico, el seguimiento y la prevención de la NAC en adultos inmunocompetentes, con el fin de mejorar los desenlaces en salud, estandarizar la atención, reducir la variabilidad no justificada y optimizar el uso de los recursos disponibles en el sistema de salud colombiano.

Background: The ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO₂/FiO₂) is central to the classification of acute respiratory distress syndrome (ARDS). However, its assessment requires arterial blood gas analysis, which may be limited by availability, cost, and invasiveness. Consequently, the ratio of peripheral oxygen saturation to fraction of inspired oxygen (SpO₂/FiO₂) has been proposed as a non-invasive surrogate for estimating the degree of oxygenation impairment. Methods: A retrospective cross-sectional study was conducted in adult patients with COVID-19 admitted to the intensive care unit at an altitude of 2600 m above sea level (m.a.s.l.). Spearman correlation coefficients were calculated to assess the association between the SpO₂/FiO₂ and PaO₂/FiO₂ ratios and their corresponding imputation models. A generalized linear model was applied, and the diagnostic performance of the SpO₂/FiO₂ ratio and the imputation models for detecting severe and non-severe hypoxemia (PaO₂/FiO₂ cutoff value of 150) was evaluated using the area under the receiver operating characteristic curve (AUC). Results: A total of 473 patients receiving invasive mechanical ventilation were included, with a mean age of 62.4 years (SD 14.1), and a predominance of males (67.2%). An SpO₂/FiO₂ ratio cutoff value of ≥206 demonstrated excellent diagnostic performance, with an AUC of 0.983 (95% CI 0.97–0.99), high sensitivity (90.6%), high specificity (96.7%), and an overall correct classification rate of 93.9%. This performance remained consistent across multiple clinical scenarios. In patients with positive end-expiratory pressure > 10 cmH₂O, the AUC was 0.982, with a specificity of 97.7%. In the presence of hyperbilirubinemia (total bilirubin ≥ 3 mg/dL), the AUC was 0.951. Among patients with hemoglobin levels < 10 g/dL, sensitivity reached 100%, although specificity was reduced. In the subgroup with arterial partial pressure of carbon dioxide > 35 mmHg, an SpO₂/FiO₂ ratio ≥ 206 showed near-perfect specificity (99.4%) and a positive likelihood ratio of 120.9. Conclusions: The SpO₂/FiO₂ ratio is a reliable and non-invasive surrogate of the PaO₂/FiO₂ ratio in mechanically ventilated patients with COVID-19 living at high altitude, particularly for the identification of non-severe hypoxemia.

Introduction: The objective of this study was to compare the continuous infusion of cefepime with the intermittent infusion in patients with sepsis caused by Gram-negative bacilli (GNB). Methods: Randomized 1:1 multicenter double-blinded placebo-controlled study with allocation concealment; multicenter study in the intensive care units of Colombia. Patients with sepsis, severe sepsis or septic shock, and GNB-suspected bacteremia. Cefepime was administered for 7 to 14 days over 30 m intermittently every 8 h over 24 h plus continuous saline solution (0.9%) (G1) or 3 g administered continuously plus saline solution every 8 h (0.9%) (G2). The percentage of clinical response at 3, 7, and 14 days, relapse at 28 days, and mortality at discharge were measured. Results: The recruitment was stopped at the suggestion of the Institutional Review Board (IRB) following an FDA alert about cefepime. Thirty-two patients were randomized; 25 received the intervention, and GNB bacteremia was confirmed in 16 (9 G1 and 7 G2). Favorable clinical response in days 3, 7, and 14 was 88.8%, 88.8%, and 77.8% (G1) and was similar for G2 (85.7%). There were no relapses or deaths in G2, while in G1, one relapse and two deaths were observed. Conclusions: The results of this study support the use of cefepime for the treatment of Gram-negative infections in critically ill patients, but we could not demonstrate differences between continuous or intermittent administration because of the small sample size, given the early suspension of the study.

Introduction: The objective of this study was: compare the continuous infusion of cefepime with the intermittent infusion in patients with sepsis caused by Gram negative bacilli (GNB). Methods: Randomized 1:1 multicenter double-blinded placebo-controlled study with allocation concealment. Multicenter study in Intensive Care Units of Colombia. Patients with sepsis, severe sepsis or septic shock and GNB suspected bacteraemia. Cefepime was administered for 7 to 14 days over 30 m intermittently every 8 h over 24 h plus continuous saline solution (0.9%) (G1) or 3 g administered continuously plus saline solution every 8 h (0.9%) (G2). Percentage of clinical response at 3, 7, 14 days, relapse at 28 days and mortality at discharge were measured. Results: The recruitment was stopped by suggestion of the Institutional Review Board (IRB), following an FDA alert about cefepime. Thirty-two patients were randomized, 25 received the intervention and GNB bacteremia was confirmed in 16 (9 G1 and 7 G 2). Favourable clinical response in days 3,7,14 was 88.8%, 88.8%, 77.8 % (G 1) and was similar for G 2 (85.7%). There were not relapses and deaths in G2 while in G1 one relapse and 2 deaths were observed. Conclusions: The results of this study support the use of cefepime for the treatment of Gram-negative infections in critically ill patients but we could not demonstrate differences between continuous or intermittent administration, because of the small sample size, given the early suspension of the study.

Background & Objective: The COVID-19 mortality varies from country to country. The pandemic has enriched our knowledge about the pathogenesis of the viral diseases in the human race. We aimed to establish survival curves based on a population of patients with confirmed diagnosis of COVID-19 who received mechanical ventilation in ICU of our level-III hospital. Methodology: It is an observational study with a prospective cohort. All patients with a positive RT-PCR test for SARS-CoV-2 after the nasopharyngeal swab and who needed mechanical ventilation were identified. Kaplan–Meier survival estimates were calculated until the follow-up date of September 26, 2020. Results: We included 62 patients in the study. The bivariate analysis found that congestive heart failure, kidney injury, dysnatremia, acid-base disorders, delta CO2, and lactate levels were associated with higher mortality. When performing backward-type Cox regression, it was observed that the CO2 delta [Hazard Ratio (HR) = 14.78, 95% CI: 2.1-100.5, P = 0.00] and lactate levels (HR = 6.15, 95% CI: 1.1-34.2, P = 0.038), were associated with an increase in mortality, for the admission variables. And only dysnatremia (HR = 5.28, 95% CI: 1.8-15.3, P = 0.00) and acid-base disorders (HR = 12.04: 95% CI: 4.1-35.3, P = 0.00) for the follow-up variables. Conclusions: Among the factors associated with increased mortality in COVID-19 patients on mechanical ventilation in the first 24 h, parameters related to tissue hypoperfusion were identified. For the variables associated with mortality at 14 days, dysnatremia and acid-base disorders were identified. Abbreviations: ng - Nanogram; FiO2 - Inspired Oxygen Fraction, PEEP - Positive End-Expiratory Pressure; PAFI - Index of PaO2/FiO2; Delta CO2 - Venous-to-Arterial Carbon Dioxide Difference; SIC - Sepsis-Induced Coagulopathy; SOFA - Sequential Organ Failure Assessment; NEW2 - National Early Warning Score 2 Key words: COVID-19; Critical Care; Mortality; Pulmonary Ventilation; Respiratory Distress Syndrome, Adult Citation: Ortiz G, Garay M, Lara A, Llinas E, Betancur J, Mahecha J, Gomez D, Celemín C, Maiguel J, Murillo M. Survival of a cohort of COVID-19 patients on mechanical ventilation in the ICU of a Level III hospital in Bogotá, Colombia. Anaesth. pain intensive care 2023;27(5):458−463; DOI: 10.35975/apic.v27i5.2295 Received: September 28, 2022; Reviewed: June 12, 2023; Accepted: June 12, 2023

The aim of this retrospective and international study is to identify those clinical variables associated with diffuse alveolar damage (DAD), and to explore the impact of DAD on hospital mortality risk. Inclusion criteria were: adult patients with acute respiratory distress syndrome (ARDS) undergoing open lung biopsy (OLB) during their intensive care unit (ICU) management. The main end-points were: DAD and hospital mortality. In the training (n = 193) and validation cohorts (n = 65), the respiratory rate (odd ratio (OR) 0.956; confidence interval (CI) 95% 0.918; 0.995) and coronary ischemia (OR 5.974; CI95% 1.668; 21.399) on the day of ARDS had an average area under the receiver operating characteristic curve (AUROC) of 0.660 (CI95% 0.585; 0.736) and 0.562 (0.417; 0.706), respectively. PEEP (OR 1.131; CI95% 1.051; 1.218) and coronary ischemia (OR 6.820; CI95% 1.856; 25.061) on the day of OLB had an average AUROC of 0.696 (CI95% 0.621; 0.769) and 0.534 (CI95% 0.391; 0.678), respectively, to predict DAD. DAD (OR 2.296; CI95% 1.228; 4.294), diabetes mellitus requiring insulin (OR 0.081; CI95% 0.009; 0.710) and the respiratory rate (OR 1.045; CI95% 1.001; 1.091) on the day of ARDS had an average AUROC of 0.659 (CI95% 0.583; 0.737) and 0.513 (CI95% 0.361; 0.664) to predict hospital mortality and DAD (OR 2.081; CI95% 1.053; 4.114), diabetes mellitus requiring insulin (OR 0.093; CI95% 0.009; 0.956), PaCO₂ (OR 1.051; CI95% 1.019; 1.084), and platelets count (OR 0.999; CI95% 0.999; 0.999) the day of OLB had an average AUROC of 0.778 (CI95% 0.710; 0.843) and 0.634 (CI95%0.481; 0.787) to predict hospital mortalty in the training and validation cohorts, respectively. In conclusion, DAD could not to be predicted clinically and was significantly associated with hospital mortality.