Discussion
This is the first international survey that has aimed to evaluate perceptions of impact and self-reported practices in the diagnosis and treatment of VAT. We consider that the present survey is relevant to increase the current knowledge of VAT. There are several conflicting results regarding the clinical implications of VAT, and the present survey provides a path toward meaningful research questions for future clinical studies. The main conclusions of the present study are that VAT is perceived as a common complication of MV in ICU patients and is a diagnosis based not only on clinical criteria but also on non-invasive techniques and microbiological confirmation and that half of physicians surveyed use systemic ATBs to treat VAT as they believe that VAT is associated with a longer duration of MV and longer ICU length of stay.
The true incidence of VAT is not currently known. VAT is recognized by the Centers of Disease Control and Prevention (CDC)/National Healthcare Safety Network [
4] as an individual clinical entity. As the clinical relevance of VAT seems to be increasing, it is necessary to further delineate its incidence in a study that applies a widely accepted definition. A large multicenter international study is planned in order to answer some of the questions presented in this survey. The goal of the present survey was to determine the importance of VAT and physicians attitudes based on the answers taken from 288 ICUs in Europe and Latin America.
The majority of respondents (>90%) to the present survey agreed that patients under MV have a significant risk of developing VAT, and they perceived that this risk was even higher in medical patients. This finding is in opposition to that of the study by Malacarne and colleagues [
5], who in a prospective epidemiological study conducted in 71 Italian ICUs with 9,493 consecutive patients found that surgical patients were more likely to develop VAT than medical patients (odds ratio (OR) of 1.64). According to the current definition, as recently published by the CDC, a diagnosis of VAT is made if there is absence of pneumonia in the x-ray and at least two of the following findings: (1) fever (>38°C), (2) cough, (3) new or increased production of sputum, (4) rhonchi, and (5) wheezing, and at least one of the following: (a) positive culture obtained by deep tracheal aspirate or bronchoscopy and (b) positive laboratory test on respiratory secretions [
4].
Similarly, the European Respiratory Society, European Society of Clinical Microbiology and Infectious Diseases, and European Society of Intensive Care Medicine taskforce requires a positive culture of respiratory secretions as a mandatory item in the diagnosis of VAT [
6]. In the present survey, almost 80% of physicians routinely diagnosed VAT with the assistance of microbiological studies, and a minority (13.9%) relied solely on clinical assessment. As expected, non-invasive techniques were more frequently preferred to obtain samples and achieve microbiological confirmation. Although the use of quantitative cultures of respiratory secretions could be helpful to differentiate VAT from colonization, invasive techniques are not mandatory for VAT diagnosis. It was therefore surprising that invasive techniques are used by almost half of respondents. This finding is more frequent in the LA group than the SPF group.
The subjectivity and variability inherent in interpretation of CXRs in mechanically ventilated patients make chest imaging ill suited for inclusion in a definition algorithm to be used for the potential purposes of public reporting, inter-facility comparisons, and pay-for-reporting and pay-for-performance programs. Several authors [
7,
8] have proposed the use of CT lung scans and this recommendation is followed by half of the respondents to the survey. Nevertheless, it is important to consider whether a CT scan for this purpose is cost-effective and safe for critically ill patients. Ventilated patients are at high risk for complications en route, and in addition transport outside the ICU has been reported to be an independent risk factor for VAP (OR 2.9, 95% confidence interval 1.4 to 5.7) [
8,
9]. A recent observational cross-sectional study of adult patients in the emergency department found that CXRs demonstrated poor sensitivity and positive predictive value for detecting pulmonary opacities when compared with chest CT for routine clinical care [
10,
11]. It remains unclear whether the use of chest CT is cost-effective or even necessary for the management of suspected VAT.
The ATB treatment of VAT remains controversial [
12]. In the survey, half of the respondents reported that the duration of MV is an important factor to consider when deciding on administration of ATBs to patients with VAT. The use of ATBs in VAT has been evaluated in two recent randomized controlled trials. Palmer and colleagues [
13] found faster weaning and less use of systemic ATB when nebulized ATBs were administered. Nseir and colleagues [
14] found a lower mortality rate and more MV-free days. Although the administration of aerosolized ATB in patients with uncomplicated VAT is an attractive approach, it is reported by only the minority of the respondents. In our survey, this practice is more frequent in LA. Well-designed prospective studies are needed in order to further delineate the best therapeutic approach for suspected VAT.
We acknowledge limitations to the present survey. First, the present study may have a bias selection as VAT may represent an important clinical entity for respondents. Second, although we sought to survey the ICU physician most involved in the decision-making process related to ICU infections, it may represent the personal opinion of the respondents and may not reflect hospital or country-wide policies. Third, we could not be completely sure that respondents were not using VAT and VAP answers in an interchangeable fashion. However, questions about VAT were formulated with closed answers, and questions related to VAP were made in order to avoid confusion and misinterpretation between these two entities. Fourth, we recognize that self-reported practices in a survey may not reflect actual practice of the respondents, a limitation inherent in the nature of all surveys. Finally, this survey comes from only three European and 13 LA countries and thus cannot represent the opinions of these entire communities.
Acknowledgments
We thank Alexis Tcach (ClinicalRec, Buenos Aires, Argentina) for the informatics support to carry out the survey, Luciano Rodriguez for assistance in data entry, and Craig Dunlop for English editing. This study is a collaboration of Sociedad Española de Medicina Intensiva, Critica y Unidades Coronarias (SEMICYUC) and Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva (FEPIMCTI). The writing committee of the study takes responsibility for the content and integrity of this article. Writing Committee: Alejandro Rodríguez (Hospital Joan XXIII Critical Care Department/IISPV/URV/CIBERES, Tarragona, Spain); Ignacio Martín-Loeches (Critical Care Centre Corporació Sanitària I Universitaria Parc Taulí/UAB/CIBERES, Sabadell, Spain); Pedro Póvoa (Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Lisboa, Portugal); Saad Nseir (Pôle de Réanimation, CHU de Lille, France); Jorge Salluh (associate researcher - D’OR Institute for Research and Education Postgraduate Program - Instituto Nacional de Câncer Rio de Janeiro, Brazil); and Daniel Curcio (Hospital de Chivilcoy, Buenos Aires, Argentina).
TAVeM group
Study Coordinators: Ignacio Martín-Loeches (Corporació Sanitaria Parc Taulí Sabadell, Spain) and Alejandro Rodriguez (Hospital Universitario Joan XXIII - URV - IISPV, Tarragona, Spain); Steering Committee: José Cuñat (Hospital Universitario La Fe - Valencia, Spain - SEMICYUC); F. Álvarez-Lerma (Hospital del Mar- Barcelona, Spain - SEMICYUC) Sebastián Ugarte (Chile - FEPIMCTI); Carmelo Dueñas (Colombia- FEPIMCTI); Jorge Sinclair (Panamá - FEPIMCTI); Daniel Curcio (Hospital Municipal Chivilcoy - Buenos Aires, Argentina); Pedro Povoa (Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Lisboa, Portugal); Saad Nseir (Pôle de Réanimation, CHU de Lille, France); Jorge Salluh (Associate reseacher - D’OR Institute for Research and Education Postgraduate Program - Instituto Nacional de Câncer Rio de Janeiro, Brazil). Andorra: Antonio Margarit Ribas (Hospital Nostra Senyora de Meritxell - Escaldes-Engordany); Argentina: Daniel Curcio, Fernando San Rome, Alexis Tcach (Hospital Municipal Chivilcoy - Chivilcoy), Christian Dellera, Darío Barrios, Ernesto Illiovich (Hospital Dr. Julio C. Perrando - Resistencia); María Gabriela Rodríguez Álvarez, Alex Tamayo, Marcos Wilches, Lorena Molocznik (Hospital Municipal Eva Perón - Merlo), Rubén O. Fernández, Mónica Grilli, Natalia Moyano (Hospital Español - Mendoza); Graciela Zakalik, Angela M. Sánchez, Adrian A. Marín (Hospital Luis Lagomaggiore - Mendoza), Roberto Santa Cruz, Mario Araujo; Hugo Culaccioni (Hospital Regional Rio Gallegos - Río Gallegos), Jorge Arroyo, Fernando Fernández, Guillermo Soria (Hospital Central - Mendoza); Daniel Duarte, Héctor Herrera, Romina Nicastro (CEMEP - Rio Grande); Fernando Lipovestky, Diego Pereyra, Sandra Arcieri (Hospital Universitario UAI - Buenos Aires); Marcelino Javier Díaz, Luís JJ Ranieri, Roberto Giménez (Sanatorio Santa Fe - Santa Fe); Fabian M Galeano (Hospital Saturnino Unzue - 25 de Mayo); Alex Tamayo Reyes, Luís González, Julia Sakugawa (Hospital Provincial de Moreno - Moreno); Cesar J Pucci, Sonia Farías, Diego Pereyra (SOIF SRL - Villa Mercedes); Christian Dellera, Darío Barrios (Hospital Dr. Julio C Perrando - Resistencia); Abel Cahuana, Ivan Vite Acosta (Sanatorio San José - Buenos Aires); Daniel U Castro, Luis A Bustamante, Marcia C Nonino (Hospital Delicia Concepción Masvernat - Concordia); Bolivia: Gustavo La Fuente Zerain, Sergio Peca Charocsi, Rubén Casanova (Hospital Universitario Japonés - Santa Cruz de la Sierra); Carlos Ibáñez Guzmán (Hospital Obrero Nº 1 - La Paz); Brazil: Péricles Almeida Delfino Duarte ( Hospital U. do Oeste do Paraná / Hospital do Câncer /UOPECCAN/ Hospital São Lucas-FAG - Cascavel); Ricardo Goulart (Hospital Vitoria - Sao Paulo); Carlos Nassif (Hospital Nove de Julho - Sao Paulo); Céu Cordeiro Gonçalves Moura (Hospital Alvorada Moema - UTI 1 - São Paulo), Sylas Bezerra Cappi (Hospital Alvorada Moema - UTI 2 - Sao Paulo); Thiago Lisboa (Hospital de Clinicas / Hospital Santa Rita -Complexo Hospitalar Santa Casa - Porto Alegre); Joa Geraldo Simoes Houly (Hospital Santa Paula - Sao Paulo); Isabela Miranda Lopes (Hospital de Clinicas Caieiras - Sao Paulo); Luciane Marques Bertoldo Viñas (Hospital ABC - Sao Bernardo do Campo); Thiago Domingos Correa, Eliezer Silva (Hospital Israelita Albert Einstein); Pedro Azambuja, Marcos Freitas Knibel (Hospial Sao Lucas - Rio de Janeiro); Alessandro Nascimento Araújo Souza (Hospital Portuges - Salvador); Bruno Toldo, Octavio Ranzani (Hospital da Luz - Santo Amaro); Cauê Matte (Hospital Santa Izabel - Salvador); Israel Pinheiro Campos (Hospital Paulistano - Sao Paulo); Felipe Dal Pizzol (Hospital São José - Criciúma); Laura Darriba W.Camargo, Eduardo de Souza Pacheco (Hospital da Luz - Sao Paulo); Antonio Paulo Nassar Junior (Hospital São Camilo - Santana); Sandro Oliveira (Hospital Bangu - Rio de Janeiro); Elmo Pereira Jr. (Hospital Norte Dor - Rio de Janeiro); Jair Biatto (Hospital Santa Rita - Maringá); Marcellus Gazola Grillo (Hospital Evangelico - Cachoeiro de Itapemirim); Ricardo Lima, Daniel Cutrim (Hospital Samaritano - Rio de Janeiro); Ludhmila Hajjar (Instituto do Cancer / InCor - Sao Paulo); Vicente Cés de Souza Dantas (Hospital Pasteur - Rio de Janeiro); Cesar Biselli Ferreira, Luiz Marcelo Sá (HCFMUSP - UTI Emergencias Cirúrgicas e Trauma - Sao Paulo); Antonio Carlos Babo Rodrigues (Hospital Estadual Getulio Vargas - Rio de Janeiro); Edison Moraes Rodrigues Filho (Hospital Nossa Senhora da Conceição - Porto Alegre); Jose Roberto Aldrighi (Hospital São Cristovão - Sao Paulo); Suzana Lobo (Hospital de Base - São José do Rio Preto); Lígia Rabello, Rodrigo Serafim (Hospital Copa Dor - Rio de Janeiro); Amadeu Martinez (Hospital Espanhol - Salvador); Jose Jorge Soares Netto (Instituto Nacional de Câncer II - Rio de Janeiro); Fernando Colombari (Hospital Alemão Oswaldo Cruz- Sao Paulo); Marcio Andrade Martins (Hospital do Coração - Camboriú); Rodrigo Hatum (Hospital Total Cor - Rio de Janeiro); Mirna Matsui (Hospital UFGD - Dourados); Leandro Utino Taniguchi (HC-FMUSP - UTI Pronto-Socorro da Clínica Médica - Sao Paulo); Luciano Azevedo (Hospital Sirio-Libanes - Sao Paulo); Otavio Ranzani (HCFMUSP - UTI Respiratoria/Pneumologia) Sergio Kiffer Macedo (Hospital São José da Avaí - Itaperuna); Marcio Osório Guerreiro (Hospital Universitario São Francisco de Paula - Pelotas); Jorge Luis dos Santos Valiatti (Hospital Padre Albino - Catanduva); Ludhmila Hajjar (InCor), Dyanne Moyses Dalcomune (Hospital Meridional - Cariacica); Ulysses Vasconcellos de Andrade e Silva (Hospital Fundação Pio XII/Hospital de Câncer - Barretos); Eraldo de Azevedo Lucio (Hospital São Francisco/Santa Casa de Porto Alegre - Porto Alegre); Celina Acra (Casa de Saúde Santa Lúcia - Rio de Janeiro); Felipe Hernriques Alves da Silva (Instituto Nacional de Câncer I - Rio de Janeiro); André M Japiassu (IPEC/FioCruz - Rio de Janeiro); Fabio Ferreira Amorim (Hospital Regional de Samambaia - Brasília); Rubens Costa Filho, Dominique Thielmann (Hospital Procardíaco - Rio de Janeiro); Danielle (Hospital Municipal São José - Joinville); Marcelo de Oliveira Maia (Hospital Santa Luzia - Brasília); Jorge Hoher (Santa Casa Porto Alegre - Porto Alegre); Marcelo Park (Hospital das Clinicas - Sao Paulo); Walter Homena (Hospital Barra Dor - UTI Pós-operatória - Rio de Janeiro); Chile: Ronald Pairumani Medrano, Jorge Silva Sepulveda, Ruth Rosales Chacón (Hospital Barros Luco Trudeau - Santiago); Eduardo Tobar, Ricardo Gálvez, Cecilia Luengo, Nivia Estuardo (Hospital Clínico Universidad de Chile - Santiago); Eduardo Labarca, Ana M Donoso, Elizabeth Barthel (Hospital Naval Almirante Nef - Viña del Mar); Alejandro Bruhn (Hospital Clínico Pontificia Universidad Católica de Chile - Santiago); Juan E Sánchez Valenzuela, José M Arancibia Henriquez, David Gallardo Pérez (Hospital San Juan de Dios - Santiago); Hernán Figueroa Riquelme, Jorge Becerra, José Pinto (Hospital Juan Noe - Arica); Ricardo Morales Inzunza, Vinko Tomicic Flores (Clínica Las Lilas - Santiago); Francisco Arancibia, María Paz Saavedra (Instituto Nacional del Tórax - Santiago); Colombia: Carmelo Dueñas (Gestión Salud - Cartagena); Juan C Fernández Mercado, Orlando Girón Florez, Mauricio Castro Vivero (Clínica CRECER - Cartagena); David Yepes, Jorge Bejarano, Juan Carlos Arango (Clínica CES - Medellín); Edwin Chapeta Parada, Andrés Minidiola Rochel, Richard Granados Chaparro (Hospital San Vicente de Arauca - Arauca); Francisco Molina, Madelyne Aristizábal, Marcela Cortés (Clínica Universitaria Bolivariana - Medellín); Erick de Jesús Valencia, Cristian Eduardo Moreno Niño, Julián David Paniagua (Clínica SaludCoop - Medellín); Daniel Molano Franco, José Rojas Gambasica, Albert Valencia (Clínica Universitaria Colombia Colsanitas - Bogotá); Guillermo Ortiz Ruíz, Manuel Garay Fernández, Antonio Lara Garkcia, Rafael A. Meza Matallana, Mario A. Mercado Díaz (Hospital Santa Clara - Bogotá); Juan Arias, Carlos Carvajal (Hospital Pablo Tobón Uribe - Medellín); Felipe Reyes, Carlos Bustamante, Ricardo Buitrago (Fundación Clínica Shaio - Bogotá); Juan C Arango (Instituto Neurológico de Colombia - Medellín); Erick de Jesús Valencia, Cristina E Moreno, Julián D Paniagua (Clínica SaludCoop - Medellín); Rubén D Camargo Rubio, José Jaraba, Ricardo Romero (Clínica General del Norte - Barranquilla); Carlos A. Pacheco Melo (Clínica El Rosario Sede Tesoro - Medellín); Abraham Ali Munive, Ángela Hernández, Fabio Varón Vega (Fundación Cardioinfantil - Bogotá); José A. Rojas Suárez, Jennifer González, Laura Loaiza (Gestión Salud SAS - Cartagena); Alejandro Rey (Clínica Centro - Barranquilla); Mario Gómez Duque, Mario Villabón González, Daniel Molano (Hospital San José - Grupo Investigación CIMCA - Bogotá); César Enciso Olivera, Ronald Medina Lombo (Hospital Infantil Universitario de San José - Bogotá); Edwin G. Chapeta Parada, Andrés Mindiola, Andrés Corchuelo (Hospital San Vicente - Arauca); Luis A. Muñoz, Miguel Coral Pabón (Clínica Fundadores - Bogotá); Costa Rica: Juan Villalobos Vindas, María C. Peláez Gil, Sergio Calderón Bejarano (Caja Costarricense del Seguro Social, Hospital México - San José); Ecuador: Diego Barahona Pinto, Leonardo Pazmiño Narvaéz, Nelson Remache Vargas, Mijayl Jativa (Hospital de los Valles - Quito); Fernando Paredes Oña, Cristian Peláez, Pedro Torres, (Hospital San Francisco - Quito); Diego Morocho Tutillo, María Fernanda García, Edgar Espinosa (Hospital Eugenio Espejo - Quito); Estuardo Salgado Yepez, Diego Morocho, Santiago Parraga (Clínica La Merced - Quito); Freddy Morales Álava, Blanchy Macías Romero, Juan F. Morales Moreira (Hospital Oncológico Dr. Julio Villacreses Colmont - Portoviejo); Gleinner J. Cañarte Bermúdez, Verónica Llerena, José Mora (Hospital IESS - Portoviejo); Luis Herrera, Ana M. Díaz, Roberto González (Hospital Instituto Ecuatoriano Seguridad Social Ibarra - Ibarra); José Vergara Centeno, Luis González Zambrano, Gonzalo Sánchez Sánchez (Hospital Luis Vernaza - Guayaquil); Fausto Guerrero, Guillermo Falconi (Hospital Carlos Andrade Marín - Quito); Mijail Jativa, Tatiana Moreno, Patricio Acosta (Hospital San Francisco - Quito); Virginia Intriago Cedeño, Luís Bermudez Zambrano (Hospital Verdi Cevallos Baldo - Portoviejo): Spain: Alejandro Rodríguez, María Bodí, Sandra Trefler, Mónica Magret, Judith Marín, Laura Claverias, Candela Solé (Hospital Joan XXIII - Tarragona) Ignacio Martín-Loeches, Emili Díaz, Jordi Vallés, Antonio Artigas, Craig Dunlop, Eva Torrents (Hospital Parc Taulí - Sabadell ); Francisco Álvarez Lerma, María P Gracia Amilla, Marta Bassas (Hospital del Mar - Barcelona); Pedro Cobos Castellano (Hospital Punta de Europa - Algeciras); Sergio Ruíz-Santana; Catalina Sánchez Ramírez; Liliana Caipe Balcázar; Silvia Hípola Escalada (Hospital Dr. Negrín - Canarias); Adrià Albis, Estel Güell, Jordi Almirall, Mari de la Torre (Hospital de Mataró); Miguel Angel Blasco Navalpotro, Mónica Fuentes Ponte, Laura Sanz Sanz (Hospital Severo Ochoa- Madrid); Patricia Albert del Cruz, Esther García Sánchez, Manuel Cruz Tejedor (Hospital Universitario del Sureste - Madrid); Xavier Nuvials Casals; Mercedes Palomar, Montserrat Valverdú Vidal, Begoña Balsera Garrido (Hospital Arnau de Vilanova- Lleida); María Del Valle Ortiz, Esther Martínez Barrio, Sergio Ossa Echeverri (Hospital de Burgos); Susana Sancho Chinesta, Rafael Zaragoza, Nerea Buceta, Mar Criado (Hospital Dr. Peset - Valencia); Joaquim Amador Amerigo, Mª Teresa Jurado Castro, Alfons Arizmendi Demay (Hospital de Terrassa); Abelardo García de Lorenzo y Mateos, María Antonia Arce Mendiburo, Eva Perales Ferrera (Hospital La Paz - Madrid); Ignacio Javier Catalán Gómez, Claudia Domínguez Curell, Silvia Cano Hernández (Hospital de Manresa - Manresa); Nieves Cruza Leganes, Ruth Corpas Fernández, María Herreros Gonzalo (Hospital Nuestra Señora del Prado, Talavera de la Reina - Toledo); Carmen J. Fernández González, María José Castro Orjales, Francisco Javier Rodríguez Fariñas (Complejo Hospitalario de Ferrol - Ferrol), Paula Ramírez Galleymore, José Ricardo Gimeno Costa, Mónica Gordón Sahuquillo Cristina López Ferraz (Hospital La Fe - Valencia); Pablo Vidal Cortés, Víctor J. López Ciudad, Paula Fernández Ugidos (Complejo Hospitalario de Ourense - Ourense); Leonardo Lorente Ramos, Oswaldo González Hernández (Hospital U de Canarias - Tenerife), Lourdes cordero lorenzana, Abel Vázquez González, María Matachana Martínez (Complejo Hospitalario A Coruña - A Coruña); José María Bonell Goytisolo, Ignacio Jara Zozaya, Isabel Ceniceros Rozalén (Hospital Quirón Palmaplanas - Palma de Mallorca); Jordi Solé Violán, José María Ferrer Agüero, Ana Marrero (Hospital Dr. Negrín - Canarias); María del Mar Martín Velasco, José Sánchez Godoy (Hospital de la Candelaria - Tenerife ); Pedro Mª Olaechea Astigarraga, Celia Sañudo Ugarte, Eneritz Gamboa Azpiazu (Hospital de Galdakao-Usansolo - Vizcaya); José Blanquer, Gerardo Aguilar, Carlos Delgado, F. Javier Belda (Hospital Clínico - Valencia); Emma Muñoz Quiñones, Yolanda del Castillo Durán, Raquel Alcega Estivill (Hospital Sant Pau i Santa Tecla - Tarragona); Javier Blanco Pérez, Rebeca Álvarez Lata, Vanesa María Camba Dopazo (Hospital Lucus Augusti (HULA) - Lugo); Luis Cabré Pericas, Milagros Calizaya, Eugenia Portillo, David Manzanedo (Hospital de Barcelona-SCIAS); Vicent López Camps, Miguel Ángel García García, David Arizo León, Manuel Palomo Navarro (Hospital de Sagunto - Valencia); María Pilar Posada González, María José Rodríguez Fernández, Juan Ignacio Chico Carballas (Hospital Xeral - Vigo); Vanesa Gómez Casal, Sabela Vara Adrio, Guillermo Lago Preciado (Hospital Xeral Cies - Vigo) Antonia Socias Mir, Llorenç Socias Crespí, María Romero Carratalá (Hospital Son Llatzer - Palma de Mallorca); Juan Carlos Ballesteros Herráez, Pilar Vázquez Paredes, Laura Sánchez Montori (Hospital Universitario Salamanca); Antonio L. Ruíz Aguilar, Alejandra Morón Giménez, Agustín Carlos Nebra Puertas, Marta Gurpegui Puente, Pilar Araujo Aguilar, Fernando Barra Quilez (Hospital Universitario Miguel Servet - Zaragoza); Mercedes Nieto, José M. Campos, Francisco J Romero, Mónica Requesens, Carmen Sánchez, Beatriz Busto (Hospital Clínico San Carlos - Madrid); Mª Concepción Valdovinos Mahave, José Mª Montón Dito, Mª Jesús Santed Andrés (Hospital Obispo Polanco - Teruel); Alfredo Marcos Gutiérrez, Ana Carolina Caballero Zirena (Hospital Virgen de la Concha - Zamora); Belén Jiménez, Pilar Luque, Raquel Bustamante, Carlos M. Sánchez Polo (Hospital Clínico - Zaragoza); Rafael Carrasco, Ainhoa Menéndez, Antonio Sangio (Hospital del Vinalopó - Elche); Adoración Alcalá López, Carmen Abad Terrado, Diana Martínez (Hospital General Universitario - Elche); Carlos Castillo Arenal, Juan Castedo González (Hospital Taxorritxu - Vitoria); Concha Moragues, Rubén González (Hospital Universitario La Plana - Vila-real - Castellón); Noemí M. Gil Pérez, Isabel M. Peña Luna, David F. López Hormiga (Hospital de Mérida - Mérida); Francisco José Fuentes Morillas, Pablo Nieto Sánchez, José Alfonso Rubio Mateo-Sidrón (Hospital U. Infanta Cristina - Badajoz); José Manuel Allegue Gallego, Roberto Jiménez Sánchez, Sergio Rebollo, Roberto Jiménez Sánchez (Hospital Santa Lucía - Cartagena); Esperanza Molero Silvero, Alberto González Estebanez, Manuel Pérez Ale (HCD Gómez Ulla - Madrid); Mauricio Valencia, Sonia Piug (Hospital Clinic - Barcelona); Ana Abella Álvarez, Cecilia Hermosa Gelbard, Inés Torrejón Pérez (Hospital Universitario del Henares- Coslada); Ramón Fernández-Cid, Otilia Pons (Hospital Mateu Orfila - Mahón); Hasania Abdel-Hadi Álvarez, Alfonso Ambros Checa (Hospital General de Ciudad real - Ciudad real); Bernardo gil, Lola del Baño Aledo (Hospital Morales Meseguer - Murcia); Inés Navarrete Sánchez (Hospital Virgen de las Nieves - Granada); Pedro Rascado Sedes, Caridad Martín López (Hospital de Conxo - Santiago de Compostela); Antonio Rivera Fernández, Ana L. Balán Mariño, Marta Martín Cuadrado (Hospital San Agustín - Aviles); Noemí Llamas Fernández, José H. de Gea García, Iván Keituqwa Yáñez (Hospital Universitario Rafael Méndez de Lorca - Murcia); César Bocanegra Abarca, Carlos Ramírez González, Chiara Caciano Reategui (Hospital Universitario Gregorio Marañón - Madrid); Fernando García López (Hospital General de Albacete - Albacete); Antonio Albaya (Hospital de Guadalajara - Guadalajara); Carmen Fernández (Hospital Marcide - Ferrol); Antonio Martínez Pellus (Hospital Virgen de la Arrixaca - Murcia); Belén Jiménez (Hospital Lozano Blesa - Zaragoza); Rafael Sierra (Hospital Puerta del Mar - Cádiz); César Aragón (Hospital de Málaga - Málaga); Iratxe Seijas Betolaza (Hospital de Barakaldo - Barakaldo); Felipe Bobillo (Hospital Clínico - Valladolid); Paula Vera Artacoz (Hospital Sant Pau - Barcelona); Ana C. Caballero Zirena (Hospital Virgen de la Concha - Zamora); Teresa Recio Gómez (Hospital San Pedro Alcántara - Cáceres); Ricard Jordá Marcos (Clínica Rotger - Palma de Mallorca); César Palazón, África López, Bernardo Gil Rueda (Hospital Universitario Reina Sofía - Murcia); Cancha Moragues Ribes (Hospital La Plana - Vila Real de Castellón); José M, Bonell Goytisolo (USP Clínica Palma Planas - Palma de Mallorca); César Pérez Calvo (Hospital Fundación Jiménez Díaz Capio - Madrid); Luis Tamayo (Hospital Universitario Río Hortega - Valladolid); Laura Macaya Redin, Jorge Echevarria Guibo, Lourdes Fisac Cuadrado (Complejo Hospitalario de Navarra UCIB - Pamplona); Sara Benito, María Pilar Anguiano, Joaquin lobo (Complejo Hospitalari Navarra UCI A - Pamplona); María Victoria de la Torre Prados, Carmen Trujillano Fernández, Jonathan Pérez Vacas (Hospital Universitario Virgen de la Victoria - Málaga); Mónica Zamora Elson, Tomas Mallor Bonet, Lorenzo Labarta Monzón (Hospital San Jorge - Huesca); Enrique Alemparte Pardavila, José Luís Martínez Melgar, Ana Ortega Montes (Complejo Hospitalario de Pontevedra - Pontevedra); Sandra Rodríguez Bolaños, José Luis Bellot Iglesias, Francisco González Martínez (Hospital General Básico de Baza - Granada); France: Nicolas Weiss (Hôpital Pitié-Salpêtrière - Paris); Benoit Voisin (Centre Hospitalier de Bethune -Bethune); Nicolas Van Grundenbeerck (Centre Hospitalier de Lens - Lens); Laurent Robriquet (CHRU de Lille - Lille); Philippe Seguin (Hôpital Pontchaillou - Rennes); Philippe Cabaret (Hôpital St. Phillibert - Lille); Guillaume Brunin (CH Duchêne - Boulogne Sur Mer); Frédéric Brun (Hôspital Pierre Oudot - Bourgoin -Jallieu); Caroline Blazejewski (CHRU de Lille - Lille); Pascale Beuret (CH de Roanne - Roanne); Sébastien Béague (Hôpital de Dunckerque - Dunckerque); Elie Azoulay (Hôpital St. Louis - Paris); Laurent Argaud (Hôpital Edouard Herriot - Lyon); Jean-Paul Mira, Julián Charpentier (Hôpital Cochin - Paris); Martine Nyunga (CH de Roubaix - Roubaix); Pablo Massanet (CH de Montpellier - Montpellier); Florent Dewavrin; Isabelle Alves (CH de Valenciennes - Valenciennes); Sébastien Préau (CHRU de Lille - Lille); Erika Parmentier-Decrucq (CHRU de Lille - Lille); Saad Nseir (CHRU de Lille - Lille); Miguel Montanes Romain (Hôpital Beanjan APHP - Clichy); Stéphane Mérat (Hôpital d’Instruction des Armés Begin - Saint Mandé); Bruno Mégarbane (Hôpital Lariboisiere - Paris); Olivier Leroy (Hôpital Chatiliez - Tourcoing); Bernard Just (CH de Charleville-Mezieres - Charleville-Mezieres); Claude Guérin (Hôpital Croix-Rousse - Lyon); Christophe Girault (Hôpital Charles Nicolle - CHU de Rouen - Rouen); Jean-Yves Fagon (Hôpital Européen Georges-Pompidou -Paris ); Joel Cousson (Hôpital Robert Debré - Reims); Marc Clavel (CHU Dupuytren - Limoges); Benoit Misset (Groupe Hospitalier Paris St. Joseph - Paris Guatemala: Jorge L. Ranero Meneses, Rudy M. López (Instituto Guatemalteco de Seguridad Social - Guatemala); Luis D. González Patzan, César Cortez (Centro Médico Militar - Guatemala); Mexico: Luis D. Sánchez Velázquez, Marco A. Díaz Riveros, Araceli Muñoz Carrillo (Hospital General de México - México DF); Peru: Iván Ramos Palomino, Percy Cancina Prosopio (Clínica San Gabriel - Lima); Martín Oyanguren Miranda (Hospital Nacional E. Rebagliati Martins - Lima ); Luis Castillo Bravo, Pedro Fajardo Luna, Indira Oyanguren Miranda (Instituto de Enfermedades Neoplásicas - Lima); Indira Oyanguren Miranda, Luis Castillo Bravo, Vladimir M. Trelles (Clínica Angloamericana - Lima); Manuel Mayorga, Luis Martín Santivañez, Myriam Yaringano (Hospital Central de la FAP - Lima); Juan Salas (Hospital Regional Trujillo - Trujillo); Manuel Jesús Mayorga Espichan, Myriam Yaringano, Luis Martín Santivañez Monge, Christian Manuel Rivera Heredia (Hospital Central de la Fuerza Aérea del Perú - Lima); Portugal: Rui Araújo, Ernestina Gomes, Elena Molinos (Hospital Pedro Hispano - Matosinhos); Estâvão Lafuente (Hospital Vale Sousa - Penafiel); Celeste Dias, José Artur Paiva, António Sarmento, Maria Santos (Hospital S. João - Porto); Paula Castelões, Ana Josefina (CHVNG - Gaia); Aurora Cadeco (Hospital Viana Castelo - Viana do Castelo); Francisco Esteves (CHTMAD - Vila Real); Nuno Catorze (Centro Hospitalar Medio tejo - Abrantes); Paulo Freitas, Isabel Serra (HFF - Amadora); Pedro Póvoa, Carolina Paulino (HSFX - Lisboa); José Andrade Gomes (Hospital Luz - Lisboa); Luis Bagulho, (CHLC - Lisboa); Carlos Candeias, Luís Coelho, Raquel Marques (CHLN - Lisboa); Antero Fernandes (Hospital Gracia d’Orta - Almada); Paulo André (Hospital Barreiro - Barreiro); José Vaz, António Mendes (Hospital Beja - Beja); Fernando Pádua (Hospital Portalegre - Portalegre); José Júlio Nóbrega (CHF - Funchal). USA: Marcos I. Restrepo, Antonio Anzueto (UTHSCSA/STVHCS-ALM - San Antonio); Uruguay: Alberto Deicas, Mario Torales, Fabio Grill (CASMU - Montevideo); Mario Jesús Silva Castilla, María F. Alonso Silva, Jorge Modemel Ingold; Gino Limongi, Darwin Tejera, Rodolfo González (Asociación Española Primera en Socorros Mutuos - Montevideo); Venezuela: Flor Giannina Balbo Martínez, Selene M Espina Pacheco, Rosa D’Oliveira Tavares (Hospital Dr. Patrocinio Peñuela Ruíz, San Cristóbal - Tachira); Norma Ruíz, Néstor Brito, Yrene Vázquez (Hospital Militar Dr. Carlos Arvelos - Caracas); Stevens Salva (Hospital de Clínicas - Caracas); Francys Moreno (Hospital Central Universitario - San Cristóbal).