Papers by Gustavo Ospina-tascón
Annals of Intensive Care, Aug 26, 2020
Background: Capillary refill time (CRT) may improve more rapidly than lactate in response to incr... more 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).
Intensive Care Medicine, Feb 12, 2016
Academic Emergency Medicine, Jan 27, 2023
BackgroundReported risk of bleeding complications after central catheter access in patients with ... more BackgroundReported risk of bleeding complications after central catheter access in patients with thrombocytopenia is highly variable. Current guidelines recommend routine prophylactic platelet (PLT) transfusion before central venous catheter placement in patients with severe thrombocytopenia. Nevertheless, the strength of such recommendations is weak and supported by observational studies including few patients with very low PLT counts (<20 × 109/L). This study aims to assess the risk of bleeding complications related to using or not using prophylactic PLT transfusion before ultrasound‐guided central venous access in patients with very low PLT counts.MethodsThis was a retrospective cohort study of patients with very low PLT counts (<20 × 109/L) subjected to ultrasound‐guided central venous catheterization between January 2011 and November 2019 in a university hospital. Bleeding complications were graded according to the Common Terminology Criteria for Adverse Events. A multivariate logistic regression was conducted to assess the risk of major and minor bleeding complications comparing patients who did or did not receive prophylactic PLT transfusion for the procedure. Multiple imputation by chained equations was used to handle missing data. A two‐tailed p < 0.05 was considered statistically significant.ResultsAmong 221 patients with very low PLT counts, 72 received prophylactic PLT transfusions while 149 did not. Baseline characteristics were similar between transfused and nontransfused patients. No major bleeding events were identified, while minor bleeding events were recognized in 35.7% of patients. Multivariate logistic regression analysis showed no significant differences in bleeding complications between patients who received prophylactic PLT transfusions and those who did not (odds ratio 0.83, 95% confidence interval 0.45–1.55, p = 0.567). Additional complete case and sensitivity analyses yielded results similar to those of the main analysis.ConclusionsIn this single‐center retrospective cohort study of ultrasound‐guided central venous access in patients with very low PLT counts, no major bleeding was identified, and prophylactic PLT transfusions did not significantly decrease minor bleeding events.
Critical Care Medicine, May 30, 2023
OBJECTIVES: To investigate the effects of immediate start of norepinephrine versus initial fluid ... more OBJECTIVES: To investigate the effects of immediate start of norepinephrine versus initial fluid loading followed by norepinephrine on macro hemodynamics, regional splanchnic and intestinal microcirculatory flows in endotoxic shock. DESIGN: Animal experimental study. SETTING: University translational research laboratory. SUBJECTS: Fifteen Landrace pigs. INTERVENTIONS: Shock was induced by escalating dose of lipopolysaccharide. Animals were allocated to immediate start of norepinephrine (i-NE) (n = 6) versus mandatory 1-hour fluid loading (30 mL/kg) followed by norepinephrine (i-FL) (n = 6). Once mean arterial pressure greater than or equal to 75 mm Hg was, respectively, achieved, successive mini-fluid boluses of 4 mL/kg of Ringer Lactate were given whenever: a) arterial lactate greater than 2.0 mmol/L or decrease less than 10% per 30 min and b) fluid responsiveness was judged to be positive. Three additional animals were used as controls (Sham) (n = 3). Time × group interactions were evaluated by repeated-measures analysis of variance. MEASUREMENTS AND MAIN RESULTS: Hypotension was significantly shorter in i-NE group (7.5 min [5.5–22.0 min] vs 49.3 min [29.5–60.0 min]; p < 0.001). Regional mesenteric and microcirculatory flows at jejunal mucosa and serosa were significantly higher in i-NE group at 4 and 6 hours after initiation of therapy (p = 0.011, p = 0.032, and p = 0.017, respectively). Misdistribution of intestinal microcirculatory blood flow at the onset of shock was significantly reversed in i-NE group (p < 0.001), which agreed with dynamic changes in mesenteric-lactate levels (p = 0.01) and venous-to-arterial carbon dioxide differences (p = 0.001). Animals allocated to i-NE showed significantly higher global end-diastolic volumes (p = 0.015) and required significantly less resuscitation fluids (p < 0.001) and lower doses of norepinephrine (p = 0.001) at the end of the experiment. Pulmonary vascular permeability and extravascular lung water indexes were significantly lower in i-NE group (p = 0.021 and p = 0.004, respectively). CONCLUSIONS: In endotoxemic shock, immediate start of norepinephrine significantly improved regional splanchnic and intestinal microcirculatory flows when compared with mandatory fixed-dose fluid loading preceding norepinephrine. Immediate norepinephrine strategy was related with less resuscitation fluids and lower vasopressor doses at the end of the experiment.
Clinical and experimental emergency medicine, Dec 8, 2022
Current Opinion in Anesthesiology, Feb 10, 2021
Purpose of review The aim of this study was to discuss the implication of microvascular dysfuncti... more Purpose of review The aim of this study was to discuss the implication of microvascular dysfunction in septic shock. Recent findings Resuscitation of sepsis has focused on systemic haemodynamics and, more recently, on peripheral perfusion indices. However, central microvascular perfusion is altered in sepsis and these alterations often persist despite normalization of various macro haemodynamic resuscitative goals. Endothelial dysfunction is a key element in sepsis pathophysiology. It is responsible for the sepsis-induced hypotension. In addition, endothelial dysfunction is also implicated involved in the activation of inflammation and coagulation processes leading to amplification of the septic response and development of organ dysfunction. It also promotes an increase in permeability, mostly at venular side, and impairs microvascular perfusion and hence tissue oxygenation. Microvascular alterations are characterized by heterogeneity in blood flow distribution, with adequately perfused areas in close vicinity to not perfused areas, thus characterizing the distributive nature of septic shock. Such microvascular alterations have profound implications, as these are associated with organ dysfunction and unfavourable outcomes. Also, the response to therapy is highly variable and cannot be predicted by systemic hemodynamic assessment and hence cannot be detected by classical haemodynamic tools. Summary Microcirculation is a key element in the pathophysiology of sepsis. Even if microcirculation-targeted therapy is not yet ready for the prime time, understanding the processes implicated in microvascular dysfunction is important to prevent chasing systemic hemodynamic variables when this does not contribute to improve tissue perfusion.
Current Opinion in Critical Care, Apr 7, 2023
Purpose of review To discuss the different techniques used to assess tissue oxygenation in critic... more Purpose of review To discuss the different techniques used to assess tissue oxygenation in critically ill patients. Recent findings While historically the analysis of oxygen consumption (VO2)/oxygen delivery (DO2) relationships has provided important information, methodological limitations prevent its use at bedside. PO2 measurements, while attractive, are unfortunately of limited value in the presence of microvascular blood flow heterogeneity which is observed in many critically ill conditions including sepsis. Surrogates of tissue oxygenation are hence used. Elevated lactate levels may suggest inadequate tissue oxygenation, but other sources than tissue hypoxia can also contribute to hyperlactatemia so that lactate measurements should be used in combination with other measurements of tissue oxygenation. Venous O2 saturation can be used to evaluate the adequacy of DO2 in respect to VO2, but it can be misleading normal or even high in sepsis. Measurements of Pv-aCO2 and computation of Pv-aCO2/CavO2 are very promising as physiologically sound, easy to measure, rapidly respond to therapy, and are associated with outcome. An elevated Pv-aCO2 reflects an impaired tissue perfusion while an increased Pv-aCO2/CavO2 ratio reflects tissue dysoxia. Summary Recent studies have highlighted the interest of surrogate measurements of tissue oxygenation and in particular PCO2 gradients.
Annals of Translational Medicine, Jun 1, 2020
Septic shock involves a complex interaction between abnormal vasodilation, relative and/or absolu... more Septic shock involves a complex interaction between abnormal vasodilation, relative and/or absolute hypovolemia, myocardial dysfunction, and altered blood flow distribution to the tissues. Fluid administration, vasopressor support and inotropes, represent fundamental pieces of quantitative resuscitation protocols directed to assist the restoration of impaired tissue perfusion during septic shock. Indeed, current recommendations on sepsis management include the use of inotropes in the case of myocardial dysfunction, as suggested by a low cardiac output, increased filling pressures, or persisting signals of tissue hypoperfusion despite an adequate correction of intravascular volume and mean arterial pressure by fluid administration and vasopressor support. Evidence supporting the use of inotropes in sepsis and septic shock is mainly based on physiological studies. Most of them suggest a beneficial effect of inotropes on macro hemodynamics especially when sepsis coexists with myocardial dysfunction; others, however, have demonstrated variable results on regional splanchnic circulation, while others suggest favorable effects on microvascular distribution independently of its impact on cardiac output. Conversely, impact of inodilators on clinical outcomes in this context has been more controversial. Use of dobutamine has not been consistently related with more favorable clinical results, while systematic administration of levosimendan in sepsis do not prevent the development of multiorgan dysfunction, even in patients with evidence of myocardial dysfunction. Nevertheless, a recent metanalysis of clinical studies suggests that cardiovascular support regimens based on inodilators in sepsis and septic shock could provide some beneficial effect on mortality, while other one corroborated such effect on mortality specially in patients with proved lower cardiac output. Thus, using or not inotropes during sepsis and septic shock remains as controversy matter that deserves more research efforts.
Annals of Intensive Care, Jul 19, 2011
Multiple experimental and human trials have shown that microcirculatory alterations are frequent ... more Multiple experimental and human trials have shown that microcirculatory alterations are frequent in sepsis. In this review, we discuss the characteristics of these alterations, the various mechanisms potentially involved, and the implications for therapy. Sepsis-induced microvascular alterations are characterized by a decrease in capillary density with an increased number of stopped-flow and intermittent-flow capillaries, in close vicinity to wellperfused capillaries. Accordingly, the surface available for exchange is decreased but also is highly heterogeneous. Multiple mechanisms may contribute to these alterations, including endothelial dysfunction, impaired inter-cell communication, altered glycocalyx, adhesion and rolling of white blood cells and platelets, and altered red blood cell deformability. Given the heterogeneous nature of these alterations and the mechanisms potentially involved, classical hemodynamic interventions, such as fluids, red blood cell transfusions, vasopressors, and inotropic agents, have only a limited impact, and the microcirculatory changes often persist after resuscitation. Nevertheless, fluids seem to improve the microcirculation in the early phase of sepsis and dobutamine also can improve the microcirculation, although the magnitude of this effect varies considerably among patients. Finally, maintaining a sufficient perfusion pressure seems to positively influence the microcirculation; however, which mean arterial pressure levels should be targeted remains controversial. Some trials using vasodilating agents, especially nitroglycerin, showed promising initial results but they were challenged in other trials, so it is difficult to recommend the use of these agents in current practice. Other agents can markedly improve the microcirculation, including activated protein C and antithrombin, vitamin C, or steroids. In conclusion, microcirculatory alterations may play an important role in the development of sepsis-related organ dysfunction. At this stage, therapies to target microcirculation specifically are still being investigated.
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Value in Health, Jun 1, 2023
Critical Care Medicine, Dec 16, 2021
Although infection with COVID-19 frequently presents with sepsis-like symptoms and changes in blo... more Although infection with COVID-19 frequently presents with sepsis-like symptoms and changes in blood pressure, the role of the DSI in these patients has not been studied. Our study sought to explore if the DSI may be similarly used in patients with COVID-19 to identify individuals with an elevated mortality risk. B Introduction: b In patients with septic shock, the diastolic shock index (DSI), defined as the ratio of heart rate to diastolic blood pressure, has been shown to correlate with mortality. [Extracted from the article] Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)
Archivos De Bronconeumologia, Feb 1, 2014
Es probable que la disfunción de los músculos respiratorios, principalmente del diafragma, consti... more Es probable que la disfunción de los músculos respiratorios, principalmente del diafragma, constituya una pieza clave dentro de los mecanismos fisiopatológicos que conducen a la dificultad del destete de la ventilación mecánica. La limitada movilidad del paciente crítico-y en especial del diafragma-cuando se requiere soporte prolongado con ventilación mecánica favorece el inicio temprano de la disfunción muscular respiratoria, la cual puede originarse también o hacerse mayor en presencia de factores frecuentes en el paciente críticamente enfermo, tales como sepsis, desnutrición, edad avanzada, duración y modo ventilatorio, uso de algunos medicamentos como glucocorticoides y bloqueadores neuromusculares. En esta revisión haremos énfasis en este origen multicausal, en el que la alteración del metabolismo de las proteínas es un mecanismo común involucrado, de acuerdo con los hallazgos reportados en diferentes modelos. El entendimiento de esta multicausalidad integrada por un mismo mecanismo fisiopatológico podría favorecer el manejo y la monitorización de los pacientes sometidos a ventilación mecánica.
Academic Emergency Medicine, Mar 21, 2023
Archivos De Bronconeumologia, Aug 1, 2020
Scientific Reports, Feb 16, 2022
Several limitations regarding pulse pressure variation (PPV) use have been reported. Our aim was ... more Several limitations regarding pulse pressure variation (PPV) use have been reported. Our aim was to describe changes in the PPV operative performance as a predictor of fluid responsiveness during the development of a swine endotoxin shock model and to assess hemodynamic variables associated with PPV changes. A swine porcine endotoxin shock model was established (Escherichia Coli 055:B5 endotoxin) in 7 pigs, and 3 pigs were included in the control group. The endotoxin was infused until the mean arterial pressure (MAP) dropped below 50 mmHg (TH0); then, the model animal was reanimated with fluids and vasopressors. We performed fluid challenges every hour for 6 h. ROC curve analysis and a linear mixed model were performed. The area under the curve of PPV decreased from 0.95 (0.81-1.00) to 0.60 (0.17-1.00) at TH0. Its cutoff increased from 10.5 to 22.00% at TH0. PPV showed an inverse relationship with stroke volume, mean systemic filling pressure, MAP, and systemic vascular resistance (SVR) (p < 0.001, AIC = 111.85). The PPV operative performance as a predictor of fluid responsiveness decreased with the progression of shock. This could lead to an inverse association between PPV and the following variables: MAP and SVR.
Revista Brasileira De Terapia Intensiva, 2022
Lessons from the ICU, 2019
Carbon dioxide is a catabolic product generated during the Krebs cycle under normoxic conditions.... more Carbon dioxide is a catabolic product generated during the Krebs cycle under normoxic conditions. As a final product of cellular respiration, carbon dioxide-derived variables could be potentially used to monitor tissue perfusion and to detect the appearance of anaerobic metabolism during shock states.
Scientific Reports
Around one-third of patients diagnosed with COVID-19 develop a severe illness that requires admis... more Around one-third of patients diagnosed with COVID-19 develop a severe illness that requires admission to the Intensive Care Unit (ICU). In clinical practice, clinicians have learned that patients admitted to the ICU due to severe COVID-19 frequently develop ventilator-associated lower respiratory tract infections (VA-LRTI). This study aims to describe the clinical characteristics, the factors associated with VA-LRTI, and its impact on clinical outcomes in patients with severe COVID-19. This was a multicentre, observational cohort study conducted in ten countries in Latin America and Europe. We included patients with confirmed rtPCR for SARS-CoV-2 requiring ICU admission and endotracheal intubation. Only patients with a microbiological and clinical diagnosis of VA-LRTI were included. Multivariate Logistic regression analyses and Random Forest were conducted to determine the risk factors for VA-LRTI and its clinical impact in patients with severe COVID-19. In our study cohort of 3287 ...
Open Forum Infectious Diseases, Oct 1, 2019
Background. Crimean-Congo hemorrhagic fever (CCHF) is a widespread, tickborne disease of humans. ... more Background. Crimean-Congo hemorrhagic fever (CCHF) is a widespread, tickborne disease of humans. CCHF is an endemic in Turkey, and since 2004 many cases have been reported from different regions in the country. CCHF infection in humans can lead to antibody responses that can be protective but there is limited data about the immunity of CCHF. The aim of this study was to investigate the possibility of recurrence of CCHF in people who previously had this disease. Methods. The patients who were diagnosed with CCHF between 2005 and 2018 were followed up and contacted via phone in order to answer several survey questions about CCHF. Patients who still live in the same places, who have high risks of disease transmission because of husbandry or farming and high potential of contact with ticks were included in this study. Those who changed their living place and stopped husbandry or farming were excluded from this study. The questions in the survey are the following: Have you had CCHF after your discharge from the hospital?; Has there been any tick contact?; Did you ever get a tick removed from your body? Did you or your family members have CCHF at the same time or at different periods of time? Has anyone had CCHF in the area you live? Do your animals have ticks? Do you live in the same place? Have you changed your job? Results. Ninety-nine out of 351 patients who were contacted via phone had data eligible to be included in the criteria. The amount of time elapsed after the discharge of the patients was between 1 and 14 years in average. None of the patients had experienced CCHF disease again. Also, 6 of these patients were bitten by ticks repeatedly (2-5 times). An average of 7-10 years had passed since the transmission of the disease by the patients. Conclusion. The results show that the CCHF disease creates an immune response and this response continues for a long time. The findings will be more enlightening with the measurement of the serum antibody levels of patients. Disclosures. All authors: No reported disclosures.
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Papers by Gustavo Ospina-tascón