Predicting Mortality in Children With Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study / Byron Enrique Piñeres Olave    

Público ISBD Título : Predicting Mortality in Children With Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study Tipo de documento : documento electrónico Autores : Byron Enrique Piñeres Olave, Fecha de publicación : 2020 Títulos uniformes : Critical Care Medicine Idioma : Inglés (eng) Palabras clave : mortality  pediatric acute respiratory distress syndrome  prediction  risk stratification  ventilator-free days Resumen : Objectives: Pediatric acute respiratory distress syndrome is heterogeneous, with a paucity of risk stratification tools to assist with trial design. We aimed to develop and validate mortality prediction models for patients with pediatric acute respiratory distress syndrome. Design: Leveraging additional data collection from a preplanned ancillary study (Version 1) of the multinational Pediatric Acute Respiratory Distress syndrome Incidence and Epidemiology study, we identified predictors of mortality. Separate models were built for the entire Version 1 cohort, for the cohort excluding neurologic deaths, for intubated subjects, and for intubated subjects excluding neurologic deaths. Models were externally validated in a cohort of intubated pediatric acute respiratory distress syndrome patients from the Children's Hospital of Philadelphia. Setting: The derivation cohort represented 100 centers worldwide; the validation cohort was from Children's Hospital of Philadelphia. Patients: There were 624 and 640 subjects in the derivation and validation cohorts, respectively. Interventions: None. Measurements and main results: The model for the full cohort included immunocompromised status, Pediatric Logistic Organ Dysfunction 2 score, day 0 vasopressor-inotrope score and fluid balance, and PaO2/FIO2 6 hours after pediatric acute respiratory distress syndrome onset. This model had good discrimination (area under the receiver operating characteristic curve 0.82), calibration, and internal validation. Models excluding neurologic deaths, for intubated subjects, and for intubated subjects excluding neurologic deaths also demonstrated good discrimination (all area under the receiver operating characteristic curve ≥ 0.84) and calibration. In the validation cohort, models for intubated pediatric acute respiratory distress syndrome (including and excluding neurologic deaths) had excellent discrimination (both area under the receiver operating characteristic curve ≥ 0.85), but poor calibration. After revision, the model for all intubated subjects remained miscalibrated, whereas the model excluding neurologic deaths showed perfect calibration. Mortality models also stratified ventilator-free days at 28 days in both derivation and validation cohorts. Conclusions: We describe predictive models for mortality in pediatric acute respiratory distress syndrome using readily available variables from day 0 of pediatric acute respiratory distress syndrome which outperform severity of illness scores and which demonstrate utility for composite outcomes such as ventilator-free days. Models can assist with risk stratification for clinical trials. Mención de responsabilidad : Nadir Yehya, Michael O Harhay, Margaret J Klein, Steven L Shein, Byron E Piñeres-Olave, Ledys Izquierdo, Anil Sapru, Guillaume Emeriaud, Philip C Spinella, Heidi R Flori, Mary K Dahmer, Aline B Maddux, Yolanda M Lopez-Fernandez, Bereketeab Haileselassie, Deyin Doreen Hsing, Ranjit S Chima, Amanda B Hassinger, Stacey L Valentine, Courtney M Rowan, Martin C J Kneyber, Lincoln S Smith, Robinder G Khemani, Neal J Thomas, on behalf of the Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology (PARDIE) V1 Investigators and the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Referencia : Crit Care Med. 2020 Jun;48(6):e514-e522. DOI (Digital Object Identifier) : 10.1097/CCM.0000000000004345 PMID : 32271186 Derechos de uso : CC BY-NC-ND En línea : https://journals.lww.com/ccmjournal/FullText/2020/06000/Predicting_Mortality_in_ [...] Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=5113 Predicting Mortality in Children With Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study [documento electrónico] / Byron Enrique Piñeres Olave,  . - 2020. Obra : Critical Care Medicine Idioma : Inglés (eng) Palabras clave : mortality  pediatric acute respiratory distress syndrome  prediction  risk stratification  ventilator-free days Resumen : Objectives: Pediatric acute respiratory distress syndrome is heterogeneous, with a paucity of risk stratification tools to assist with trial design. We aimed to develop and validate mortality prediction models for patients with pediatric acute respiratory distress syndrome. Design: Leveraging additional data collection from a preplanned ancillary study (Version 1) of the multinational Pediatric Acute Respiratory Distress syndrome Incidence and Epidemiology study, we identified predictors of mortality. Separate models were built for the entire Version 1 cohort, for the cohort excluding neurologic deaths, for intubated subjects, and for intubated subjects excluding neurologic deaths. Models were externally validated in a cohort of intubated pediatric acute respiratory distress syndrome patients from the Children's Hospital of Philadelphia. Setting: The derivation cohort represented 100 centers worldwide; the validation cohort was from Children's Hospital of Philadelphia. Patients: There were 624 and 640 subjects in the derivation and validation cohorts, respectively. Interventions: None. Measurements and main results: The model for the full cohort included immunocompromised status, Pediatric Logistic Organ Dysfunction 2 score, day 0 vasopressor-inotrope score and fluid balance, and PaO2/FIO2 6 hours after pediatric acute respiratory distress syndrome onset. This model had good discrimination (area under the receiver operating characteristic curve 0.82), calibration, and internal validation. Models excluding neurologic deaths, for intubated subjects, and for intubated subjects excluding neurologic deaths also demonstrated good discrimination (all area under the receiver operating characteristic curve ≥ 0.84) and calibration. In the validation cohort, models for intubated pediatric acute respiratory distress syndrome (including and excluding neurologic deaths) had excellent discrimination (both area under the receiver operating characteristic curve ≥ 0.85), but poor calibration. After revision, the model for all intubated subjects remained miscalibrated, whereas the model excluding neurologic deaths showed perfect calibration. Mortality models also stratified ventilator-free days at 28 days in both derivation and validation cohorts. Conclusions: We describe predictive models for mortality in pediatric acute respiratory distress syndrome using readily available variables from day 0 of pediatric acute respiratory distress syndrome which outperform severity of illness scores and which demonstrate utility for composite outcomes such as ventilator-free days. Models can assist with risk stratification for clinical trials. Mención de responsabilidad : Nadir Yehya, Michael O Harhay, Margaret J Klein, Steven L Shein, Byron E Piñeres-Olave, Ledys Izquierdo, Anil Sapru, Guillaume Emeriaud, Philip C Spinella, Heidi R Flori, Mary K Dahmer, Aline B Maddux, Yolanda M Lopez-Fernandez, Bereketeab Haileselassie, Deyin Doreen Hsing, Ranjit S Chima, Amanda B Hassinger, Stacey L Valentine, Courtney M Rowan, Martin C J Kneyber, Lincoln S Smith, Robinder G Khemani, Neal J Thomas, on behalf of the Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology (PARDIE) V1 Investigators and the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Referencia : Crit Care Med. 2020 Jun;48(6):e514-e522. DOI (Digital Object Identifier) : 10.1097/CCM.0000000000004345 PMID : 32271186 Derechos de uso : CC BY-NC-ND En línea : https://journals.lww.com/ccmjournal/FullText/2020/06000/Predicting_Mortality_in_ [...] Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=5113

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Acute Kidney Injury in Pediatric Severe Sepsis: An Independent Risk Factor for Death and New Disability / Byron Enrique Piñeres Olave  

Público ISBD Título : Acute Kidney Injury in Pediatric Severe Sepsis: An Independent Risk Factor for Death and New Disability Tipo de documento : documento electrónico Autores : Byron Enrique Piñeres Olave, Fecha de publicación : 2016 Títulos uniformes : Critical Care Medicine Idioma : Inglés (eng) Palabras clave : Acute kidney injury  critical care outcomes  epidemiology  pediatric intensive care units  renal replacement therapy  sepsis Resumen : Objectives: The prevalence of septic acute kidney injury and impact on functional status of PICU survivors are unknown. We used data from an international prospective severe sepsis study to elucidate functional outcomes of children suffering septic acute kidney injury. Design: Secondary analysis of patients in the Sepsis PRevalence, OUtcomes, and Therapies point prevalence study: acute kidney injury was defined on the study day using Kidney Disease Improving Global Outcomes definitions. Patients with no acute kidney injury or stage 1 acute kidney injury (“no/mild acute kidney injury”) were compared with those with stage 2 or 3 acute kidney injury (“severe acute kidney injury”). The primary outcome was a composite of death or new moderate disability at discharge defined as a Pediatric Overall Performance Category score of 3 or higher and increased by 1 from baseline. Setting: One hundred twenty-eight PICUs in 26 countries. Patients: Children with severe sepsis in the Sepsis PRevalence, OUtcomes, and Therapies study. Interventions: None. Measurements and Main Results: One hundred two (21%) of 493 patients had severe acute kidney injury. More than twice as many patients with severe acute kidney injury died or developed new moderate disability compared with those with no/mild acute kidney injury (64% vs 30%; p Mención de responsabilidad : Julie C Fitzgerald, Rajit K Basu, Ayse Akcan-Arikan, Ledys M Izquierdo, Byron E Piñeres Olave, Amanda B Hassinger, Maria Szczepanska, Akash Deep, Duane Williams, Anil Sapru, Jason A Roy, Vinay M Nadkarni, Neal J Thomas, Scott L Weiss, Susan Furth, Sepsis PRevalence, OUtcomes, and Therapies Study Investigators and Pediatric Acute Lung Injury and Sepsis Investigators Network Referencia : Crit Care Med. 2016 Dec;44(12):2241-2250. DOI (Digital Object Identifier) : 10.1097/CCM.0000000000002007 PMID : 27513354 En línea : https://journals.lww.com/ccmjournal/Abstract/2016/12000/Acute_Kidney_Injury_in_P [...] Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=3952 Acute Kidney Injury in Pediatric Severe Sepsis: An Independent Risk Factor for Death and New Disability [documento electrónico] / Byron Enrique Piñeres Olave,  . - 2016. Obra : Critical Care Medicine Idioma : Inglés (eng) Palabras clave : Acute kidney injury  critical care outcomes  epidemiology  pediatric intensive care units  renal replacement therapy  sepsis Resumen : Objectives: The prevalence of septic acute kidney injury and impact on functional status of PICU survivors are unknown. We used data from an international prospective severe sepsis study to elucidate functional outcomes of children suffering septic acute kidney injury. Design: Secondary analysis of patients in the Sepsis PRevalence, OUtcomes, and Therapies point prevalence study: acute kidney injury was defined on the study day using Kidney Disease Improving Global Outcomes definitions. Patients with no acute kidney injury or stage 1 acute kidney injury (“no/mild acute kidney injury”) were compared with those with stage 2 or 3 acute kidney injury (“severe acute kidney injury”). The primary outcome was a composite of death or new moderate disability at discharge defined as a Pediatric Overall Performance Category score of 3 or higher and increased by 1 from baseline. Setting: One hundred twenty-eight PICUs in 26 countries. Patients: Children with severe sepsis in the Sepsis PRevalence, OUtcomes, and Therapies study. Interventions: None. Measurements and Main Results: One hundred two (21%) of 493 patients had severe acute kidney injury. More than twice as many patients with severe acute kidney injury died or developed new moderate disability compared with those with no/mild acute kidney injury (64% vs 30%; p Mención de responsabilidad : Julie C Fitzgerald, Rajit K Basu, Ayse Akcan-Arikan, Ledys M Izquierdo, Byron E Piñeres Olave, Amanda B Hassinger, Maria Szczepanska, Akash Deep, Duane Williams, Anil Sapru, Jason A Roy, Vinay M Nadkarni, Neal J Thomas, Scott L Weiss, Susan Furth, Sepsis PRevalence, OUtcomes, and Therapies Study Investigators and Pediatric Acute Lung Injury and Sepsis Investigators Network Referencia : Crit Care Med. 2016 Dec;44(12):2241-2250. DOI (Digital Object Identifier) : 10.1097/CCM.0000000000002007 PMID : 27513354 En línea : https://journals.lww.com/ccmjournal/Abstract/2016/12000/Acute_Kidney_Injury_in_P [...] Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=3952

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Immunological characterization of compensatory anti-inflammatory response syndrome in patients with severe sepsis : a longitudinal study / Fabián Alberto Jaimes Barragán  

Público ISBD Título : Immunological characterization of compensatory anti-inflammatory response syndrome in patients with severe sepsis : a longitudinal study Tipo de documento : documento electrónico Autores : Fabián Alberto Jaimes Barragán, Fecha de publicación : 2014 Títulos uniformes : Critical Care Medicine Idioma : Inglés (eng) Palabras clave : Immunosuppression  longitudinal studies  physio pathology  secondary infection  sepsis  survival Resumen : Objectives: To perform a complete immunological characterization of compensatory anti-inflammatory response syndrome in patients with sepsis and to explore the relationship between these changes and clinical outcomes of 28-day mortality and secondary infections. Design: Prospective single-center study conducted between April 2011 and December 2012. Setting: ICUs from Hospital Universitario San Vicente Fundación at Medellin, Colombia. Patients: One hundred forty-eight patients with severe sepsis. Interventions: None. Measurements and Main Results: At days 0, 1, 3, 5, 10, and 28, we determined the expression of HLA-DR in monocytes and the apoptosis and the proliferation index in T lymphocytes, as well as the levels of tumor necrosis factor-α, interleukin-6, interleukin-1β, interleukin-10, and transforming growth factor-β in both plasma and cell culture supernatants of peripheral blood mononuclear cells. The mean percentage of HLA-DR+ was 60.7 at enrollment and increased by 0.9% (95% CI, 0.7–1.2%) per day. The mean percentage of CD4 T cells and CD8 T cells AV+/7-AAD– at enrollment was 37.2% and 20.4%, respectively, but it diminished at a rate of –0.5% (95% CI, –0.7% to –0.3%) and –0.3% (95% CI, –0.4% to –0.2%) per day, respectively. Plasma levels of interleukin-6 and interleukin-10 were 290 and 166 pg/mL and decreased at a rate of –7.8 pg/mL (95% CI, –9.5 to –6.1 pg/mL) and –4 pg/mL (95% CI, –5.1 to –2.8 pg/mL) per day, respectively. After controlling for confounders, only sustained plasma levels of interleukin-6 increase the risk of death (hazard ratio 1.003; 95% CI, 1.001–1.006). Conclusions: We found no evidence to support a two-phase model of sepsis pathophysiology. However, immunological variables did behave in a mixed and time-dependent manner. Further studies should evaluate changes over time of interleukin-6 plasma levels as a prognostic biomarker for critically ill patients. Mención de responsabilidad : Henry G Gomez, Sandra M Gonzalez, Jessica M Londoño, Natalia A Hoyos, Cesar D Niño, Alba L Leon, Paula A Velilla, Maria T Rugeles, Fabián A Jaimes Referencia : Crit Care Med. 2014 Apr;42(4):771-80. DOI (Digital Object Identifier) : 10.1097/CCM.0000000000000100 PMID : 24365860 En línea : https://journals.lww.com/ccmjournal/Abstract/2014/04000/Immunological_Characteri [...] Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=3798 Immunological characterization of compensatory anti-inflammatory response syndrome in patients with severe sepsis : a longitudinal study [documento electrónico] / Fabián Alberto Jaimes Barragán,  . - 2014. Obra : Critical Care Medicine Idioma : Inglés (eng) Palabras clave : Immunosuppression  longitudinal studies  physio pathology  secondary infection  sepsis  survival Resumen : Objectives: To perform a complete immunological characterization of compensatory anti-inflammatory response syndrome in patients with sepsis and to explore the relationship between these changes and clinical outcomes of 28-day mortality and secondary infections. Design: Prospective single-center study conducted between April 2011 and December 2012. Setting: ICUs from Hospital Universitario San Vicente Fundación at Medellin, Colombia. Patients: One hundred forty-eight patients with severe sepsis. Interventions: None. Measurements and Main Results: At days 0, 1, 3, 5, 10, and 28, we determined the expression of HLA-DR in monocytes and the apoptosis and the proliferation index in T lymphocytes, as well as the levels of tumor necrosis factor-α, interleukin-6, interleukin-1β, interleukin-10, and transforming growth factor-β in both plasma and cell culture supernatants of peripheral blood mononuclear cells. The mean percentage of HLA-DR+ was 60.7 at enrollment and increased by 0.9% (95% CI, 0.7–1.2%) per day. The mean percentage of CD4 T cells and CD8 T cells AV+/7-AAD– at enrollment was 37.2% and 20.4%, respectively, but it diminished at a rate of –0.5% (95% CI, –0.7% to –0.3%) and –0.3% (95% CI, –0.4% to –0.2%) per day, respectively. Plasma levels of interleukin-6 and interleukin-10 were 290 and 166 pg/mL and decreased at a rate of –7.8 pg/mL (95% CI, –9.5 to –6.1 pg/mL) and –4 pg/mL (95% CI, –5.1 to –2.8 pg/mL) per day, respectively. After controlling for confounders, only sustained plasma levels of interleukin-6 increase the risk of death (hazard ratio 1.003; 95% CI, 1.001–1.006). Conclusions: We found no evidence to support a two-phase model of sepsis pathophysiology. However, immunological variables did behave in a mixed and time-dependent manner. Further studies should evaluate changes over time of interleukin-6 plasma levels as a prognostic biomarker for critically ill patients. Mención de responsabilidad : Henry G Gomez, Sandra M Gonzalez, Jessica M Londoño, Natalia A Hoyos, Cesar D Niño, Alba L Leon, Paula A Velilla, Maria T Rugeles, Fabián A Jaimes Referencia : Crit Care Med. 2014 Apr;42(4):771-80. DOI (Digital Object Identifier) : 10.1097/CCM.0000000000000100 PMID : 24365860 En línea : https://journals.lww.com/ccmjournal/Abstract/2014/04000/Immunological_Characteri [...] Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=3798

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The epidemiology of sepsis in Colombia: a prospective multicenter cohort study in ten university hospitals / Gisela de la Rosa Echavez  

Público ISBD Título : The epidemiology of sepsis in Colombia: a prospective multicenter cohort study in ten university hospitals Tipo de documento : documento electrónico Autores : Gisela de la Rosa Echavez, Fecha de publicación : 2011 Títulos uniformes : Critical Care Medicine Idioma : Inglés (eng) Resumen : Objective: Our aim was to determine the frequency and the clinical and epidemiologic characteristics of sepsis in a hospital based population in Colombia. Design: Prospective cohort. Setting: Ten general hospitals in the four main cities of Colombia. Patients: Consecutive patients admitted in emergency rooms, intensive care units, and general wards from September 1, 2007, to February 29, 2008, with confirmation of infection according to the Centers for Disease Control and Prevention definitions. Interventions: None. Measurements and Main Results: The following information was recorded: demographic, clinical, and microbiologic characteristics; Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores; requirement for intensive care unit; length of stay; and 28-day all-cause mortality. During a period of 6 months, 2,681 patients were recruited: 69% and 31% with community-acquired and hospital-acquired infections, respectively. The mean age was 55 yrs (sd = 21), 51% were female, and the median length of stay was 10 days (interquartile range, 5–19). The mean Acute Physiology and Chronic Health Evaluation score was 11.5 (sd = 7) and the mean Sequential Organ Failure Assessment score was 3.8 (sd = 3). A total of 422 patients with community-acquired infections (16%) were admitted to the intensive care unit as a consequence of their infection and the median length of stay was 4.5 days in the intensive care unit. At admission, 2516 patients (94%) met at least one sepsis criterion and 1,658 (62%) met at least one criterion for severe sepsis. Overall, the 28-day mortality rates of patients with infection without sepsis, sepsis without organ dysfunction, severe sepsis without shock, and septic shock were 3%, 7.3%, 21.9%, and 45.6%, respectively. In community-acquired infections, the most frequent diagnosis was urinary tract infection in 28.6% followed by pneumonia in 22.8% and soft tissue infections in 21.8%. Within hospital-acquired infections, pneumonia was the most frequent diagnosis in 26.6% followed by urinary tract infection in 20.4% and soft tissue infections in 17.4%. Conclusions: In a general inpatient population of Colombia, the rates of severe sepsis and septic shock are higher than those reported in the literature. The observed mortality is higher than the predicted by the Acute Physiology and Chronic Health Evaluation II score Mención de responsabilidad : Ferney Rodríguez, Lena Barrera, Gisela De La Rosa, Rodolfo Dennis, Carmelo Dueñas, Marcela Granados, Dario Londoño, Francisco Molina, Guillermo Ortiz, Fabián Jaimes Referencia : Crit Care Med. 2011 Jul;39(7):1675-82. DOI (Digital Object Identifier) : 10.1097/CCM.0b013e318218a35e PMID : 21685740 En línea : https://journals.lww.com/ccmjournal/Abstract/2011/07000/The_epidemiology_of_seps [...] Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=3552 The epidemiology of sepsis in Colombia: a prospective multicenter cohort study in ten university hospitals [documento electrónico] / Gisela de la Rosa Echavez,  . - 2011. Obra : Critical Care Medicine Idioma : Inglés (eng) Resumen : Objective: Our aim was to determine the frequency and the clinical and epidemiologic characteristics of sepsis in a hospital based population in Colombia. Design: Prospective cohort. Setting: Ten general hospitals in the four main cities of Colombia. Patients: Consecutive patients admitted in emergency rooms, intensive care units, and general wards from September 1, 2007, to February 29, 2008, with confirmation of infection according to the Centers for Disease Control and Prevention definitions. Interventions: None. Measurements and Main Results: The following information was recorded: demographic, clinical, and microbiologic characteristics; Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores; requirement for intensive care unit; length of stay; and 28-day all-cause mortality. During a period of 6 months, 2,681 patients were recruited: 69% and 31% with community-acquired and hospital-acquired infections, respectively. The mean age was 55 yrs (sd = 21), 51% were female, and the median length of stay was 10 days (interquartile range, 5–19). The mean Acute Physiology and Chronic Health Evaluation score was 11.5 (sd = 7) and the mean Sequential Organ Failure Assessment score was 3.8 (sd = 3). A total of 422 patients with community-acquired infections (16%) were admitted to the intensive care unit as a consequence of their infection and the median length of stay was 4.5 days in the intensive care unit. At admission, 2516 patients (94%) met at least one sepsis criterion and 1,658 (62%) met at least one criterion for severe sepsis. Overall, the 28-day mortality rates of patients with infection without sepsis, sepsis without organ dysfunction, severe sepsis without shock, and septic shock were 3%, 7.3%, 21.9%, and 45.6%, respectively. In community-acquired infections, the most frequent diagnosis was urinary tract infection in 28.6% followed by pneumonia in 22.8% and soft tissue infections in 21.8%. Within hospital-acquired infections, pneumonia was the most frequent diagnosis in 26.6% followed by urinary tract infection in 20.4% and soft tissue infections in 17.4%. Conclusions: In a general inpatient population of Colombia, the rates of severe sepsis and septic shock are higher than those reported in the literature. The observed mortality is higher than the predicted by the Acute Physiology and Chronic Health Evaluation II score Mención de responsabilidad : Ferney Rodríguez, Lena Barrera, Gisela De La Rosa, Rodolfo Dennis, Carmelo Dueñas, Marcela Granados, Dario Londoño, Francisco Molina, Guillermo Ortiz, Fabián Jaimes Referencia : Crit Care Med. 2011 Jul;39(7):1675-82. DOI (Digital Object Identifier) : 10.1097/CCM.0b013e318218a35e PMID : 21685740 En línea : https://journals.lww.com/ccmjournal/Abstract/2011/07000/The_epidemiology_of_seps [...] Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=3552

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