Guidelines for inhaled sedation in the ICU.

INTRODUCTION AND OBJECTIVES: Sedation is used in intensive care units (ICU) to improve comfort and tolerance during mechanical ventilation, invasive interventions, and nursing care. In recent years, the use of inhalation anaesthetics for this purpose has increased. Our objective was to obtain and summarise the best evidence on inhaled sedation in adult patients in the ICU, and use this to help physicians choose the most appropriate approach in terms of the impact of sedation on clinical outcomes and the risk-benefit of the chosen strategy. METHODOLOGY: Given the overall lack of literature and scientific evidence on various aspects of inhaled sedation in the ICU, we decided to use a Delphi method to achieve consensus among a group of 17 expert panellists. The processes was conducted over a 12-month period between 2022 and 2023, and followed the recommendations of the CREDES guidelines. RESULTS: The results of the Delphi survey form the basis of these 39 recommendations - 23 with a strong consensus and 15 with a weak consensus. CONCLUSION: The use of inhaled sedation in the ICU is a reliable and appropriate option in a wide variety of clinical scenarios. However, there are numerous aspects of the technique that require further study.

Postoperative arterial hypotension: the unnoticed enemy.

Postoperative hypotension is a frequently underestimated health problem associated with high morbidity and mortality and increased use of health care resources. It also poses significant clinical, technological, and human challenges for healthcare. As it is a modifiable and avoidable risk factor, this document aims to increase its visibility, defining its clinical impact and the technological challenges involved in optimizing its management, taking clinical-technological, humanistic, and economic aspects into account.

[Recommendations for thromboembolic disease in oncological processes. A view from primary care]. / Recomendaciones sobre enfermedad tromboembólica venosa en procesos oncológicos. Una visión desde la medicina de familia.

Venous thromboembolic disease (VTE) is a frequent complication in patients diagnosed with cancer and a cause of morbidity and mortality. Approximately 20% of thromboembolic episodes develop in association with active cancer. On the other hand, it is estimated that about 2-12% of cases, the thromboembolic episode is the first manifestation of an occult cancer, diagnosed at that time or subsequently, which offers an opportunity for early diagnosis and treatment. There are multiple factors that contribute to increase the risk of VTE in oncological patients in relation to specific characteristics of the patient, the tumor and the treatments. Knowledge of these risk factors will contribute to early diagnosis when signs of VTE appear, as well as the assessment of thromboprophylaxis if indicated. The diagnosis of VTE in patients with cancer does not differ of those who do not suffer from it. Regarding the treatment of VTE in these patients, low molecular weight heparin (LMWH), direct acting anticoagulants (DACs) and antivitamin K (VKA) are the most commonly used, although the dosing regimen and length are not clear yet. The management of these patients should be interdisciplinary and early, so the primary care physician plays a key role in this process as he/she is liaise with his/her patients. It is also necessary to update knowledge in order to improve the care of these patients. For these reasons, this document has been prepared by the Working Group on Vasculopathies of the Spanish Society of Primary Care Physicians (SEMERGEN) whose objective is to present the available information regarding the management of VTE that may appear in oncological patients, as well as the assessment of thromboprophylaxis and treatment, if appropriate, from an approach focused on a primary care field.

Result of the implementation of a quality management system based on the ISO 9001:2015 standard in a surgical intensive care unit.

INTRODUCTION: The implementation of Quality Management Systems (QMS) is one of the fundamental and future-oriented elements for the improvement of modern health systems. The objective of implementing a QMS in accordance with the requirements of the ISO 9001: 2015 Standard is to effectively carry out its activities, covering both technical and management aspects, guaranteeing the satisfaction of the needs and expectations of all its stakeholders, as well as compliance with legal and regulatory requirements. It must contemplate all those aspects that have an impact on the final quality of the product or service provided by the organization. OBJECTIVE: The main objective is to describe the process of implementing a QMS under the ISO 9001: 2015 Standard in the Surgical Intensive Care Unit of the General University Hospital of Elche and evaluate its results. METHODOLOGY: Carrying out and implementing a QMS in the Surgical Intensive Care Unit of the General University Hospital of Elche applying the points of the ISO 9001: 2015 Standard. The SGC has followed the benchmark of management by processes, identifying from its strategic core of mission, vision and values, the different processes involved and their interrelation reflected in the process map. Based on it, the necessary documents have been developed to describe the operation of the Unit both at an operational level through the key processes (admission and initial assessment of the patient, stabilization, follow-up, complementary tests, interconsultations, transfers and discharge) as well as which refers to procedures of a strategic or support type. RESULTS: The strategic lines that marked the beginning of the deployment of our QMS were defined with the drafting of 7 objectives, achieving 100% compliance. The key processes (7) that described the functioning of our organization were elaborated, as well as those of a strategic type (14) and support or support (5), complemented with 55 medical and nursing protocols. 20 monitoring indicators were analyzed: 6 organizational and planning type, and 14 clinical. 46 incidents were detected in the first year of implementation of the QMS that were analyzed by the Quality Commission, emerging 7 corrective actions. 14 improvement actions were developed after the application of the AMFE methodology for key processes, achieving an average of greater than 70% effectiveness after reassessment. From the analysis of patient and family satisfaction through SAIP case management, 41 of a total of 52 cases were acknowledgments in writing. CONCLUSIONS: Implementing a QMS in our Surgical Intensive Care Unit has made it possible to define the strategic lines of our organization, develop objectives, establish monitoring indicators, standardize the work of the Unit through procedures and protocols, increase safety at work through the use of lists of verification, initiate improvement actions to strengthen the weak points of the QMS itself, as well as know the degree of satisfaction and needs of our patients and the personnel who work in it.

Home blood pressure self-measurement: "Current situation and new perspectives".

The method typically used to diagnose and monitor hypertensive patients has been to measure blood pressure in the physician's surgery; however, it is a well-known fact that this approach poses certain drawbacks, such as observer bias, failure to detect an alert reaction in the clinic, etc., difficulties that affect its accuracy as a diagnostic method. In recent years, the varying international scientific societies have persistently recommended the use of blood pressure measurements outside the clinic (at home or in the outpatient setting), using validated automatic devices. Data from some studies suggest that if we rely solely on in-office measurements, approximately 15-20% of the time we may be wrong when making decisions, both in terms of diagnosis and patient follow-up. Home blood pressure measurements are a simple and very affordable method that has a similar reproducibility and prognostic value as ambulatory blood pressure monitoring, the availability of which is currently very limited. Moreover, ambulatory self-measurements have the significant benefit of being able to improve control of hypertensive individuals. Healthcare professionals and patients should be aware of the methodology of home blood pressure measurement, its usefulness and limitations.

Evaluation of prophylaxis in primary prevention with acetylsalicylic acid in people with diabetes: A scoping review.

BACKGROUND: The efficacy and safety of acetylsalicylic acid (ASA) prophylaxis for the primary prevention of atherosclerotic cardiovascular disease (ACVD) remain controversial in people with diabetes (DM) without ACVD, because the possible increased risk of major bleeding could outweigh the potential reduction in the risk of mortality and of major adverse cardiovascular events (MACE) considered individually or together. OBJECTIVE: To evaluate the overall risk-benefit of ASA prophylaxis in primary prevention in people with DM and to compare the recommendations of the guidelines with the results of the meta-analyses (MA) and systematic reviews (SR). MATERIAL AND METHODS: We searched Medline, Google Scholar, Embase, and the Cochrane Library for SR and MA published from 2009 to 2020 which compared the effects of ASA prophylaxis versus placebo or control followed up for at least one year in people with DM without ACVD. Heterogeneity among the randomized clinical trials (RCT) included in the SR and MA was assessed. Cardiovascular outcomes of efficacy (all-cause mortality [ACM], cardiovascular mortality [CVM], myocardial infarction [MI], stroke and MACE) and of safety (major bleeding events [MBE], major gastrointestinal bleeding events [MGIBE], and intracranial and extracranial bleeding) were shown. RESULTS: The recommendations of 12 guidelines were evaluated. The results of 25 SR and MA that included a total of 20 RCT were assessed. None of the MA or SR showed that ASA prophylaxis decreased the risk of ACM, CVM or MI. Only two of the 19 SR and MA that evaluated ischemic stroke showed a decrease in the stroke risk (mean 20.0% [SD±5.7]), bordering on statistical significance. Almost half of the MA and SR showed, bordering on statistical significance, a risk reduction for the MACE composite endpoint (mean 10.5% [SD±3.3]). The significant increases in MGIBE risk ranged from 35% to 55%. The significant increases in the risk of MBE and extracraneal bleeding were 33.4% (SD±14.9) and 54.5% (SD±0.7) respectively. CONCLUSION: The overall risk-benefit assessment of ASA prophylaxis in primary prevention suggests that it should not be applied in people with DM.

[Knowledge of thromboprophylaxis-COVID-19 in healthcare professionals in Spain]. / Conocimiento de la tromboprofilaxis-COVID-19 en los profesionales sanitarios en España.

INTRODUCTION: Patients suffering from coronavirus infection have an increased risk of venous thromboembolic disease (VTE) associated with COVID-19, which confers a higher risk of mortality. For this reason, it is necessary to analyze the knowledge and the different actions in the management of thromboprophylaxis in work environments. MATERIAL AND METHODS: Observational, descriptive and cross-sectional study with data collection through a Google® form with 19 questions for professionals involved in the care of COVID-19. 414 surveys were received. The quantitative variables were represented with means and standard deviation and the qualitative variables with percentages and confidence intervals. RESULTS: 414 surveys analyzed. 58.2% were women. The most participatory age group was 56-65 years. 95.2% stated that COVID-19 patients had a higher risk of VTE and peripheral arterial microthrombosis. 93.6% considered that outpatient COVID-19 patients should receive thromboprophylaxis. 60.5% of the physicians did not know any protocol for the evaluation of thrombotic risk in these patients. Low molecular weight heparin was considered the main treatment for thromboprophylaxis. CONCLUSIONS: The majority of doctors consider that COVID-19 patients have a higher risk of suffering VTE and peripheral arterial microthrombosis than the general population, however more than a third do not assess the thrombotic risk and a significant percentage claim not to know protocols to evaluate said risk. The survey highlights the training needs of our professionals in thromboprophylaxis so that our patients receive healthcare with the highest possible quality.

Critical view of robotic-assisted transverse abdominal release (r-TAR).

INTRODUCTION: Establishing straightforward and reproducible steps to describe the technique performed with the aid of the robotic system for complex hernia surgery is key for good outcomes. Even using the description of open surgery as a parameter for performing the robotic technique, it is important to stress the particularities of this access. To describe the steps to perform robotic-assisted TAR (r-TAR) in a standardized technique, with a critical and safe view of all the anatomical structures. DESCRIPTION OF THE TECHNIQUE: We defined 8 landmarks for the critical view of safety in r-TAR which include: (1) patient position, trocar and docking; (2) posterior rectus sheath mobilization; (3) transversus abdominis release (TAR)-Top-down technique; (4) transversus abdominis release (TAR)-bottom-up technique and mesh insertion; (5) contralateral trocar insertion and redocking, 6) posterior sheath closure; (7) final mesh positioning; and (8) anterior defect closure and drains. DISCUSSION: Complex hernia surgery using a robotic-assisted posterior component separation requires well-established steps so the procedure can be reproducible and achieve better results.

Primary thoracoabdominal hernias.

BACKGROUND: Primary thoracoabdominal hernias involve the triad of an intercostal hernia, abdominal wall hernia, and diaphragmatic hernia. We report a case series of this rare entity and describe the evolution and outcomes. METHODS: We completed a retrospective analysis of thoracoabdominal hernia repairs performed January 2010-April 2019 at Prisma Health-Upstate and Carolinas Medical Center. This includes all patients with spontaneous defects, excluding incisional hernias or those resulting from external trauma. RESULTS: Of 16 patients with thoracoabdominal hernias, 15 patients developed hernias after forceful coughing and one patient developed a hernia after strenuous physical activity. Seven patients required at least one additional intervention; two for recurrence; two for recurrence of original intercostal repairs done elsewhere; two for wound complications; and one had a missed abdominal wall component. CONCLUSIONS: Primary thoracoabdominal hernias require a high index of suspicion. Durable repair involves complex reconstruction of the thoracoabdominal wall including the diaphragm, intercostal space, rib fracture fixation, and mesh reinforcement of the abdominal wall with permanent fixation constructs.

Computed tomography imaging in ventral hernia repair: can we predict the need for myofascial release?

INTRODUCTION: Currently, the need for additional myofascial release (AMR) in addition to retromuscular dissection during open Rives-Stoppa hernia repair is determined intraoperatively based on the discretion of the surgeon. We developed a novel method to objectively predict the need for AMR preoperatively using computed tomography (CT)-measured rectus width to hernia width ratio (RDR). METHODS: A retrospective chart review of all patients who underwent open retro-muscular mesh repair of midline ventral hernia between August 1, 2007 and February 1, 2018, who had a preoperative CT scan within 1 year prior to their operation. The primary endpoint was the ability of the defect ratio to predict the need for AMR in pursuit of fascial closure. The secondary endpoint was the ability of Component Separation Index (CSI) to predict the need for AMR to obtain fascial closure. RESULTS: Of 342 patients, 208 repaired with rectus abdominis release alone (RM group), while 134 required AMR (RM + group). An RDR of > 1.34 on area under the curve analysis predicted the need for AMR with 77.6% accuracy. There was a linear decrease in the need for AMR with increasing RDR: RDR < 1 required AMR in 78.8% of cases, RDR 1.1-1.49 in 52%, RDR 1.5-1.99 in 32.1%, and RDR > 2 in just 10.8%. Similarly, CSI > 0.146 predicted the need for AMR with 76.3% accuracy on area under the curve analysis. CONCLUSION: The RDR is a practical and reliable tool to predict the ability to close the defect during open Rives-Stoppa ventral hernia repair without AMR. An RDR of > 2 portends fascial closure with rectus abdominis myofascial release alone in 90% of cases.

Prophylactic mesh augmentation using permanent synthetic mesh: outcomes of keyhole and Stapled Ostomy Reinforcement with Retromuscular Mesh techniques.

INTRODUCTION: Parastomal hernias (PSH) are the most common complication of stoma creation and can cause significant morbidity. We present a consecutive series of patients receiving prophylactic mesh augmentation (PMA) for prevention of PSH. METHODS: This retrospective review evaluates the efficacy and outcomes of PMA for PSH prevention, and retrospectively compares traditional keyhole PMA (tPMA) (n = 28) with a prophylactic Stapled Ostomy Reinforcement with Retromuscular Mesh technique (pSTORRM) (n = 24). RESULTS: PMA was performed in 52 cases between January 2015 and July 2018. All cases used a large-pore, non-coated, mid-weight polypropylene mesh placed in the retrorectus space. With a median follow-up of 16 mos, parastomal hernia was confirmed in 11.5% (n = 6), 5 of whom were symptomatic. patient-reported outcomes (PRO) indicated 6 additional patients with symptoms associated with PSH without clinical or radiographic confirmation. Patients had similar comorbidities and operative characteristics between tPMA and pSTORRM techniques, and no difference in a median follow-up. pSTORRM patients had fewer surgical site infections (8.3 vs 32.1%; p = 0.046) and occurrences (12.5 vs 46.4%; p = 0.015), and lower rate of PSH, though not statistically significant (4.2 vs 17.9%; p = 0.195). CONCLUSION: Permanent synthetic mesh placed as a sublay in the retromuscular space is safe and appears to decrease the risk of PSH formation after the creation of permanent stomas. A stapled technique may provide advantages over a traditional keyhole technique.

[COVID-19 and thromboprophylaxis: Recommendations for our clinical practice in Primary Care]. / COVID-19 y tromboprofilaxis: recomendaciones para nuestra práctica clínica en Atención Primaria.

The new coronavirus (SARS-CoV-2) is responsible for a severe acute respiratory syndrome. Among its manifestations, it can develop a thrombotic disease, both venous and arterial, due to excessive inflammation that affects the vascular system, with platelet activation and endothelial dysfunction, among other mechanisms. Thrombosis is associated with SARS-CoV-2 infection, increasing its severity and conferring a worse prognosis. Our performance as Family Physicians can contribute important actions in the management and control of this severe complication. Considering that many of our patients already receive antithrombotic or anticoagulant therapy, the fact that they may develop a COVID-19 infection will have implications for the choice, dosage and control of their treatment. In this document we review, with the information currently available, the relationship between disease caused by SARS-CoV-2 and thrombosis, as well as its management with a focus on Primary Care.

Lessons learned from an intercalibration exercise on the quantification and characterisation of microplastic particles in sediment and water samples.

An intercalibration exercise on the characterisation of microplastics in marine sediment and water samples was carried out among five laboratories involved in the implementation of the Marine Strategy Framework Directive (MSFD) in their country. The samples were prepared by mixing cleaned natural sediment and sea water with microplastics sets made of particles of various polymers, shapes and colours. Overall, the errors on total counts were under 25% in absolute value. The risk of non-detection and loss of particles is greater than the risk of contamination during sample analysis. Significant differences are observed among particle types. It appears difficult to obtain reliable and comparable data on the colour of microplastics. A comparison of the errors with regards to the protocols used led to recommend NaCl [1.2 g/cm3] density separation for sediment and one filtering step (200 µm). The operators' experience appears as a key factor for the quality of the results.

[Management of type 2 diabetes mellitus in adolescents and young adults in primary care]. / Manejo de la diabetes mellitus tipo 2 en adolescentes y adultos jóvenes en atención primaria.

The prevalence of type 2 diabetes (DM2) diagnosed in childhood and adolescence is currently increasing, and is characterised by a rapidly progressive decline in beta-cells and insulin resistance. Physical inactivity and obesity are the main risk factors for its development. Diagnostic criteria are similar to those used in adults, although HbA1c as a diagnostic method is questioned. Diabetes-related complications are more aggressive than in adults. Diabetic nephropathy is the most frequent complication in the young population and macrovascular complications appear early, leading to high mortality rates. Healthy lifestyles are the basis of the treatment, and metformin, insulin and liraglutide (approved by FDA for its use in the United States) are the pharmacological options indicated in this population. It is important to establish models of health care transition from paediatric to adult care to ensure continuity of care and avoid patient disengagements.

Risk factors associated with the family care of people with serious mental illness.

BACKGROUND: The aim of the present study is to analyse the variables associated with the family care of people diagnosed with serious mental illness. MATERIAL AND METHODS: A cross-sectional study was carried out involving caregivers of people with serious mental illness (SMI) who were known to the mental health services in Valencia (España) and associations for those with SMI. The sample comprised 417 caregivers who completed a sociodemographic questionnaire and the Zarit Burden Interview. Bivariate analyses (t-test, analysis of variance and Pearson correlation) were performed, as was a multiple linear regression model. Values of p < .05 were considered significant. The study was carried out in accordance with the recommendations of the ethics committees of the participating institutions. RESULTS: The statistical analyses showed significant associations between the sociodemographic and clinical variables of the caregivers and patients and the burden felt by caregivers of people with SMI. The importance of both formal and informal social support stands out as a protective factor against the consequences of the illness's impact on the main caregiver. CONCLUSIONS: The role of spaces of mutual support is crucial. The results suggest that family psychoeducational programmes should be created, applied and evaluated in all mental healthcare services so as to reinforce training in mental health matters and provide support and assessment to caregivers in order to ease their burden.