Browsing by Author "Castro López, Ricardo"

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    A lactate-targeted resuscitation strategy may be associated with higher mortality in patients with septic shock and normal capillary refill time: a post hoc analysis of the ANDROMEDA-SHOCK study
    (2020) Kattan Tala, Eduardo José; Hernández P., Glenn; Ospina Tascón, Gustavo A.; Valenzuela, Emilio Daniel; Bakker, Jan; Castro López, Ricardo
    Abstract Background Capillary refill time (CRT) may improve more rapidly than lactate in response to increments in systemic flow. Therefore, it can be assessed more frequently during septic shock (SS) resuscitation. Hyperlactatemia, in contrast, exhibits a slower recovery in SS survivors, probably explained by the delayed resolution of non-hypoperfusion-related sources. Thus, targeting lactate normalization may be associated with impaired outcomes. The ANDROMEDA-SHOCK trial compared CRT- versus lactate-targeted resuscitation in early SS. CRT-targeted resuscitation associated with lower mortality and organ dysfunction; mechanisms were not investigated. CRT was assessed every 30 min and lactate every 2 h during the 8-h intervention period, allowing a first comparison between groups at 2 h (T2). Our primary aim was to determine if SS patients evolving with normal CRT at T2 after randomization (T0) exhibited a higher mortality and organ dysfunction when allocated to the LT arm than when randomized to the CRT arm. Our secondary aim was to determine if those patients with normal CRT at T2 had received more therapeutic interventions when randomized to the LT arm. To address these issues, we performed a post hoc analysis of the ANDROMEDA-SHOCK dataset. Results Patients randomized to the lactate arm at T0, evolving with normal CRT at T2 exhibited significantly higher mortality than patients with normal CRT at T2 initially allocated to CRT (40 vs 23%, p = 0.009). These results replicated at T8 and T24. LT arm received significantly more resuscitative interventions (fluid boluses: 1000[500–2000] vs. 500[0–1500], p = 0.004; norepinephrine test in previously hypertensive patients: 43 (35) vs. 19 (19), p = 0.001; and inodilators: 16 (13) vs. 3 (3), p = 0.003). A multivariate logistic regression of patients with normal CRT at T2, including APACHE-II, baseline lactate, cumulative fluids administered since emergency admission, source of infection, and randomization group) confirmed that allocation to LT group was a statistically significant determinant of 28-day mortality (OR 3.3; 95%CI[1.5–7.1]); p = 0.003). Conclusions Septic shock patients with normal CRT at baseline received more therapeutic interventions and presented more organ dysfunction when allocated to the lactate group. This could associate with worse outcomes.Abstract Background Capillary refill time (CRT) may improve more rapidly than lactate in response to increments in systemic flow. Therefore, it can be assessed more frequently during septic shock (SS) resuscitation. Hyperlactatemia, in contrast, exhibits a slower recovery in SS survivors, probably explained by the delayed resolution of non-hypoperfusion-related sources. Thus, targeting lactate normalization may be associated with impaired outcomes. The ANDROMEDA-SHOCK trial compared CRT- versus lactate-targeted resuscitation in early SS. CRT-targeted resuscitation associated with lower mortality and organ dysfunction; mechanisms were not investigated. CRT was assessed every 30 min and lactate every 2 h during the 8-h intervention period, allowing a first comparison between groups at 2 h (T2). Our primary aim was to determine if SS patients evolving with normal CRT at T2 after randomization (T0) exhibited a higher mortality and organ dysfunction when allocated to the LT arm than when randomized to the CRT arm. Our secondary aim was to determine if those patients with normal CRT at T2 had received more therapeutic interventions when randomized to the LT arm. To address these issues, we performed a post hoc analysis of the ANDROMEDA-SHOCK dataset. Results Patients randomized to the lactate arm at T0, evolving with normal CRT at T2 exhibited significantly higher mortality than patients with normal CRT at T2 initially allocated to CRT (40 vs 23%, p = 0.009). These results replicated at T8 and T24. LT arm received significantly more resuscitative interventions (fluid boluses: 1000[500–2000] vs. 500[0–1500], p = 0.004; norepinephrine test in previously hypertensive patients: 43 (35) vs. 19 (19), p = 0.001; and inodilators: 16 (13) vs. 3 (3), p = 0.003). A multivariate logistic regression of patients with normal CRT at T2, including APACHE-II, baseline lactate, cumulative fluids administered since emergency admission, source of infection, and randomization group) confirmed that allocation to LT group was a statistically significant determinant of 28-day mortality (OR 3.3; 95%CI[1.5–7.1]); p = 0.003). Conclusions Septic shock patients with normal CRT at baseline received more therapeutic interventions and presented more organ dysfunction when allocated to the lactate group. This could associate with worse outcomes.
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    An evidence-based resuscitation algorithm applied from the emergency room to the ICU improves survival of severe septic shock
    (2008) Castro López, Ricardo; Regueira Heskia, Tomás; Aguirre Zúniga, Marcia Lorena; Llanos Valdés, Osvaldo Pablo; Bruhn, Alejandro; Bugedo Tarraza, Guillermo; Dougnac Labatut, Alberto; Castillo Fuenzalida, Luis Benito; Andresen Hernández, Max; Hernández P., Glenn
    Background. Septic shock is highly lethal. We recently implemented an algorithm (advanced resuscitation algorithm for septic shock, ARAS 1) with a global survival of 67%, but with a very high mortality (72%) in severe cases [norepinephrine (NE) requirements >0.3 µg/kg/min for mean arterial pressure ≥70 mmHg]. As new therapies with different levels of evidence were proposed [steroids, drotrecogin alpha, high-volume hemofiltration (HVHF)], we incorporated them according to severity (NE requirements; algorithm ARAS-2), and constructed a multidisciplinary team to manage these patients from the emergency room (ER) to the ICU. The aim of this study was to compare the outcome of severe septic shock patients under both protocols. Methods. Adult patients with severe septic shock were enrolled consecutively and managed prospectively with ARAS1 (1999-2001), and ARAS-2 (2002-05). ARAS-2 incorporates HVHF for intractable shock. Results. Thirty-three patients were managed with each protocol, without statistical differences in baseline demographics, APACHE II (22.2 vs 23.8), SOFA (11.4 vs 12.7) and NE peak levels (0.62 vs 0.8 µg/kg/min). The 28-day mortality and epinephrine use were higher with ARAS-1 (72.7% vs 48.5%; 87.9% vs 18.2 %); and low-dose steroids (35.9% vs 72.7%), drotrecogin (0 vs 15 %) and HVHF use (3.0% vs 39.4%) were higher for ARAS-2 (P<0.05 for all). Conclusion. Management of severe septic shock with a multidisciplinary team and an updated protocol (according to the best current evidence), with precise entry criteria for every intervention at different stages of severity, may improve survival in these patients. Multidisciplinary management, rationalization of the use of vasoactives and rescue therapy based on HVHF instead of epinephrine may have contributed to these results. Management of severe septic shock with these kinds of algorithms is feasible and should be encouraged.
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    Capillary refill time during fluid resuscitation in patients with sepsis-related hyperlactatemia at the emergency department is related to mortality
    (2017) Lara Hernández, Bárbara Alejandra; Enberg, L.; Ortega Gutiérrez, Marcos Eduardo; León, P.; Kripper, Cristóbal; Aguilera Fuenzalida, Pablo René; Kattan Tala, Eduardo José; Castro López, Ricardo; Bakker, Jan; Hernández P., Glenn
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    Características y evolución de los pacientes que ingresan a una unidad de cuidados intensivos de un hospital público
    (2016) Ruiz, C.; Díaz, Marco A.; Zapata, J.; Bravo Morales, Sebastián; Panay, S.; Escobar, C.; Godoy, J.; Andresen Hernández, Max; Castro López, Ricardo
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    Corticosteroids use and risk of respiratory coinfections in mechanically ventilated patients with COVID-19
    (2021) Ceballos, María Elena; Núñez Palma, Carolina Verónica; Uribe, Javier; Vera Alarcón, María Magdalena; Castro López, Ricardo; García C., Patricia; Arriata, Gabriel; Gándara, Vicente; Vargas, Camila; Domínguez De Landa, María Angélica; Cerón, Inés; Born, Pablo; Espíndola, Eduardo
    Background: To describe respiratory coinfections, predictive factors and outcomes in patients requiring mechanical ventilation (MV) with COVID-19. Methods: Cohort study, carried out in a Chilean single tertiary Hospital. All patients with COVID-19 admitted to ICU that required MV were included between 1 June and 31 July 2020 Results: 175 patients were admitted to ICU and required MV. Of these, 71 patients developed at least one respiratory coinfection (40.6 %). Early coinfections and late coinfections were diagnosed in 1.7% and 31.4% of all patients admitted to ICU respectively. Within late coinfections, 88% were bacterial, 10% were fungal, and 2% were viral coinfections. One third of isolated bacteria were multidrug-resistant. Multivariate analysis showed that the risk for coinfection was 7.7 times higher for patients with history of corticosteroids (adOR = 7.65, CI 95%: 1.04-56.2, p=0,046) and 2.7 times higher for patients that received dexamethasone during hospitalization (adOR=2.69; CI 95%: 1.14-6.35, p=0,024) than patients that were not exposed. For each additional day in MV, the risk of coinfection increases 1.1 times (adOR=1.06; CI 95%: 1.01-1.11, p=0,025)
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    ¿Cuál es el rol de la proteína C activada en el tratamiento de la sepsis?
    (2016) Alvarado, Juan; Castro López, Ricardo
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    ¿Cuál es el rol de los corticoides en el manejo de la sepsis?
    (2016) Jérez, Joaquín; Castro López, Ricardo
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    Dynamic changes of hepatic vein Doppler velocities predict preload responsiveness in mechanically ventilated critically ill patients
    (2024) Bruna, Mario; Alfaro, Sebastián; Muñoz Ferrada, Felipe Ignacio; Cisternas, Liliana; González, Cecilia; Conlledo, Rodrigo; Ulloa Morrison, Rodrigo; Huilcaman, Marcos; Retamal, Jaime; Castro López, Ricardo; Rola, Philippe; Wong, Adrian; Argaiz, Eduardo R.; Contreras, Roberto; Hernández P., Glenn; Kattan Tala, Eduardo José
    Background: Assessment of dynamic parameters to guide fluid administration is one of the mainstays of current resuscitation strategies. Each test has its own limitations, but passive leg raising (PLR) has emerged as one of the most versatile preload responsiveness tests. However, it requires real-time cardiac output (CO) measurement either through advanced monitoring devices, which are not routinely available, or echocardiography, which is not always feasible. Analysis of the hepatic vein Doppler waveform change, a simpler ultrasound-based assessment, during a dynamic test such as PLR could be useful in predicting preload responsiveness. The objective of this study was to assess the diagnostic accuracy of hepatic vein Doppler S and D-wave velocities during PLR as a predictor of preload responsiveness. Methods: Prospective observational study conducted in two medical–surgical ICUs in Chile. Patients in circulatory failure and connected to controlled mechanical ventilation were included from August to December 2023. A baseline ultrasound assessment of cardiac function was performed. Then, simultaneously, ultrasound measurements of hepatic vein Doppler S and D waves and cardiac output by continuous pulse contour analysis device were performed during a PLR maneuver. Results: Thirty-seven patients were analyzed. 63% of the patients were preload responsive defined by a 10% increase in CO after passive leg raising. A 20% increase in the maximum S wave velocity after PLR showed the best diagnostic accuracy with a sensitivity of 69.6% (49.1–84.4) and specificity of 92.8 (68.5–99.6) to detect preload responsiveness, with an area under curve of receiving operator characteristic (AUC–ROC) of 0.82 ± 0.07 (p = 0.001 vs. AUC–ROC of 0.5). D-wave velocities showed worse diagnostic accuracy. Conclusions: Hepatic vein Doppler assessment emerges as a novel complementary technique with adequate predictive capacity to identify preload responsiveness in patients in mechanical ventilation and circulatory failure. This technique could become valuable in scenarios of basic hemodynamic monitoring and when echocardiography is not feasible. Future studies should confirm these results.
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    Effects of capillary refill time-vs. lactate-targeted fluid resuscitation on regional, microcirculatory and hypoxia-related perfusion parameters in septic shock: a randomized controlled trial
    (2020) Castro López, Ricardo; Kattan Tala, Eduardo José; Valenzuela, Emilio Daniel; Alegría, Leyla; Oviedo, Vanessa; Soto, Dagoberto; Vera Alarcón, María Magdalena; Bravo Morales, Sebastián; Bakker, Jan; Hernández P., Glenn
    Abstract Background Persistent hyperlactatemia has been considered as a signal of tissue hypoperfusion in septic shock patients, but multiple non-hypoperfusion-related pathogenic mechanisms could be involved. Therefore, pursuing lactate normalization may lead to the risk of fluid overload. Peripheral perfusion, assessed by the capillary refill time (CRT), could be an effective alternative resuscitation target as recently demonstrated by the ANDROMEDA-SHOCK trial. We designed the present randomized controlled trial to address the impact of a CRT-targeted (CRT-T) vs. a lactate-targeted (LAC-T) fluid resuscitation strategy on fluid balances within 24 h of septic shock diagnosis. In addition, we compared the effects of both strategies on organ dysfunction, regional and microcirculatory flow, and tissue hypoxia surrogates. Results Forty-two fluid-responsive septic shock patients were randomized into CRT-T or LAC-T groups. Fluids were administered until target achievement during the 6 h intervention period, or until safety criteria were met. CRT-T was aimed at CRT normalization (≤ 3 s), whereas in LAC-T the goal was lactate normalization (≤ 2 mmol/L) or a 20% decrease every 2 h. Multimodal perfusion monitoring included sublingual microcirculatory assessment; plasma-disappearance rate of indocyanine green; muscle oxygen saturation; central venous-arterial pCO2 gradient/ arterial-venous O2 content difference ratio; and lactate/pyruvate ratio. There was no difference between CRT-T vs. LAC-T in 6 h-fluid boluses (875 [375–2625] vs. 1500 [1000–2000], p = 0.3), or balances (982[249–2833] vs. 15,800 [740–6587, p = 0.2]). CRT-T was associated with a higher achievement of the predefined perfusion target (62 vs. 24, p = 0.03). No significant differences in perfusion-related variables or hypoxia surrogates were observed. Conclusions CRT-targeted fluid resuscitation was not superior to a lactate-targeted one on fluid administration or balances. However, it was associated with comparable effects on regional and microcirculatory flow parameters and hypoxia surrogates, and a faster achievement of the predefined resuscitation target. Our data suggest that stopping fluids in patients with CRT ≤ 3 s appears as safe in terms of tissue perfusion. Clinical Trials: ClinicalTrials.gov Identifier: NCT03762005 (Retrospectively registered on December 3rd 2018)
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    Effects of dobutamine on systemic, regional and microcirculatory perfusion parameters in septic shock: a randomized, placebo-controlled, double-blind, crossover study
    (2013) Hernández P., Glenn; Bruhn, Alejandro; Luengo Messen, Cecilia; Regueira Heskia, Tomás; Kattan Tala, Eduardo José; Fuentealba, Andrea; Florez, Jorge; Castro López, Ricardo; Aquevedo Salazar, Andrés Fernando; Pairumani, Ronald; Mc-Nab Martin, Paul Andrew; Ince, Can
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    ESICM LIVES 2016: part three
    (2016) Hernández P., Glenn; Carpio Cordero, David; Labra Abrigo, Carla Alejandra; Castro López, Ricardo; Alegría Aguirre, Luz Katiushka; Bakker, Jan; Velasquez, T.; Mackey, G.; Lusk, J.; Kyle, U.G.
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    ESICM LIVES 2016: part two
    (2016) Alegría Aguirre, Luz Katiushka; Soto, D.; Jarufe Cassis, Nicolás; Bruhn, Alejandro; Castro López, Ricardo; Kattan Tala, Eduardo José; Rebolledo Acevedo, Rolando Arturo; Achurra Tirado, Pablo; Bakker, Jan; Hernández P., Glenn
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    High-volume hemofiltration as salvage therapy in severe hyperdynamic septic shock
    (2006) Cornejo, Rodrigo; Downey Concha, Patricio; Castro López, Ricardo; Romero, Carlos; Regueira Heskia, Tomás Emilio; Vega Stieb, Jorge Enrique; Castillo Fuenzalida, Luis Benito; Andresen Hernández, Max Alfonso; Dougnac Labatut, Alberto; Bugedo Tarraza, Guillermo; Hernández Poblete, Glenn Wilson
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    Intubation timing as determinant of outcome in patients with acute respiratory distress syndrome by SARS-CoV-2 infection
    (2021) Vera Alarcón, María Magdalena; Kattan Tala, Eduardo José; Born, Pablo; Rivas, E.; Amthauer, M.; Nesvadba, A.; Lara, Bárbara; Rao, I.; Espíndola, Eduardo; Rojas Orellana, Luis; Hernández Poblete, Glenn; Bugedo Tarraza, Guillermo; Castro López, Ricardo
    Background: SARS-CoV-2 infection presents in many cases with pneumonia and respiratory failure. It is not clear whether the time of intubation and connection to mechanical ventilation (MV) in this condition is associated with an increase in mortality or represents the natural course of the disease. We conducted an observational, prospective, single-center study to describe the characteristics and outcomes of acute respiratory distress syndrome (ARDS) patients with confirmed COVID-19 and treated with invasive MV to determine whether the time-to-intubation following hospital admission is associated with worse outcomes. Methods: We prospectively included consecutive patients with SARS-CoV-2 infection and moderate to severe ARDS, admitted to an intensive care unit (ICU) and connected to MV between March 17 and July 31, 2020. We examined their general characteristics, ventilatory management, and clinical outcomes. Time of intubation was defined as the time from hospital admission to endotracheal intubation and was categorized as early (<72 hours) or late (≥72 hours). Mann-Whitney U, Kruskal Wallis, chi-square, and Fisher’s exact, were used when appropriate. Uni and multivariate analyses between main outcome and explanatory variables were performed. Results: A total of 183 consecutive patients were included, 28% (51/183) were female, and their median age was 62 years [54-70]. One hundred (55%) patients were subjected to early and 83 (45%) to late intubation. Patients intubated after 72 hours were older and presented more comorbidities. Mortality was higher in the group of patients with late intubation (41% versus 21%; p= 0.002), a PaO2/FiO2 ratio <100 mmHg at admission (p= 0.029), and that were older than 60 years (p= 0.008). Conclusions: In acute COVID-19 patients with moderate to severe ARDS, intubation after 72 hours following hospital admission, age >60 years-old and a PaO2/FiO2 ratio <100 at admission may appear to be associated with increased ICU mortality. Further studies are required to confirm our findings and establish the best timing for intubation in COVID-19 patients admitted to the ICU with respiratory failure.
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    Light and the outcome of the critically ill: an observational cohort study
    (2012) Castro López, Ricardo; Angus, Derek C.; Hong, Seo Y.; Lee, Chingwen.; Weissfeld, Lisa A.; Clermont, Gilles.; Rosengart, Matthew R.
    Abstract Introduction Light before and during acute illness has been associated with both benefit and harm in animal models and small human studies. Our objective was to determine the associations of light duration (photoperiod) and intensity (insolation) before and during critical illness with hospital mortality in ICU patients. Based on the 'winter immunoenhancement' theory, we tested the hypothesis that a shorter photoperiod before critical illness is associated with improved survival. Methods We analyzed data from 11,439 patients admitted to 8 ICUs at the University of Pittsburgh Medical Center between June 30, 1999 and July 31, 2004. Daily photoperiod and insolation prior to and after ICU admission were estimated for each patient by using data provided by the United States Naval Observatory and National Aeronautics and Space Administration and direct measurement of light gradient from outside to bedside for each ICU room. Our primary outcome was hospital mortality. The association between light and risk of death was analyzed using multivariate analyses, adjusting for potential confounders, including severity of illness, case mix, and ICU type. Results The cohort had an average APACHE III of 52.9 and a hospital mortality of 10.7%. In total, 128 ICU beds were analyzed; 108 (84%) had windows. Pre-illness photoperiod ranged from 259 to 421 hours in the prior month. A shorter photoperiod was associated with a reduced risk of death: for each 1-hour decrease, the adjusted OR was 0.997 (0.994 to 0.999, p = 0.03). In the ICU, there was near complete (99.6%) degradation of natural light from outside to the ICU bed. Thus, light exposure once in the ICU approached zero; the 24-hour insolation was 0.005 ± 0.003 kWh/m2 with little diurnal variation. There was no association between ICU photoperiod or insolation and mortality. Conclusions Consistent with the winter immunoenhancement theory, a shorter photoperiod in the month before critical illness is associated with a reduced risk of death. Once in the ICU, patients are exposed to near negligible natural light despite the presence of windows. Further studies are warranted to determine the underlying mechanisms and whether manipulating light exposure, before or during ICU admission, can enhance survival.
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    Manejo del potencial donante cadáver
    (2014) Bugedo Tarraza, Guillermo; Bravo Morales, Sebastián; Romero, C.; Castro López, Ricardo
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    Medicina de urgencia y unidades de cuidados intensivos. Una alianza necesaria en busca de la mejoría de la atención de pacientes críticos
    (2016) Lara, Bárbara; Cataldo Cornejo, Alejandro; Castro López, Ricardo; Aguilera Fuenzalida, Pablo René; Ruiz Balart, Carolina; Andresen Hernández, Max
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    Metodología de adaptación de una guía clínica para el manejo de pacientes adultos con neumonía adquirida en la comunidad en una red de salud privada
    (2011) Pantoja Calderón, Tomás; Ferdinand Olivares, Constanza; Saldías Peñafiel, Fernando; Rojas Orellana, Luis; Balcells Marty, María Elvira; Castro López, Ricardo; Poblete Umanzor, Rodrigo Eduardo
    Background: Clinical practice guidelines (CPG) are widely used as tools for improving quality of health care. Guidelines developed elsewhere, can be adapted using a valid and systematic process. Aim: To describe the methodology used in the process of adaptation of a guideline for the management of adults with community-acquired pneumonia (CAP) in a private health care organization. Material and Methods: We used the ADAPTE framework involving three main phases. At the set-up phase a guideline adaptation group integrated by medical specialists from different disciplines, a methodologist and a nurse coordinator was formed. At the adaptation phase, the specific clinical questions to be addressed by the guidelines were identified. Results: Twenty five guidelines were initially retrieved. After their assessment, the number was reduced to only three. Recommendations from these guidelines were 'mapped' and focused searches were carried out where 'evidence gaps' were identified. An initial draft was written and revised by the adaptation group. At the finalization phase, the external review of the guideline was carried out and a process for the regular review and update of the adapted guideline was defined. Conclusions: We developed a guideline for the management of adults with CAP, adapted to the local context of our health care system, using guidelines developed elsewhere. This guideline creation method can be an efficient means of saving professional resources.
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    Organizational Issues, structure and processes of care in 257 ICUs in Latin America: a study from the latin America Intensiva Care Network
    (2017) Estenssoro, Elisa; Alegría, Leyla; Murias, Gastón; Friedman, Gilberto; Castro López, Ricardo; Nin Vaeza, Nicolas; Loudet, Cecilia; Bruhn, Alejandro; Jibaja, Manuel; Ospina Tascon, Gustavo; Ríos, Fernando; Machado, Flavia R.; Biasi Cavalcanti, Alexandre; Dubin, Arnaldo; Hurtado, F. Javier; Briva, Arturo; Romero, Carlos; Bugedo Tarraza, Guillermo; Bakker, Jan; Cecconi, Maurizio; Azevedo, Luciano; Hernández P., Glenn