[Is the critical patient competent for decision taking? Psychological and psychopathological reasons of cognitive impairment]. / ¿Es el paciente crítico competente para tomar decisiones? Razones psicológicas y psicopatológicas de la alteración cognitiva.

BACKGROUND: Emotional factors may lead to cognitive impairment that can adversely affect the capacity of patients to reason, and thereby, limit their participation in decision taking. PURPOSES: To analyze critical patient aptitude for decision taking, and to identify variables that may influence competence. DESIGN: An observational descriptive study was carried out. SETTING: Intensive care unit. PATIENTS: Participants were 29 critically ill patients. MAIN VARIABLES: Social, demographic and psychological variables were analyzed. Functional capacities and psychological reactions during stay in the ICU were assessed. RESULTS: The patients are of the firm opinion that they should have the last word in the taking of decisions; they prefer bad news to be given by the physician; and feel that the presence of a psychologist would make the process easier. Failure on the part of the professional to answer their questions is perceived as the greatest stress factor. Increased depression results in lesser cognitive capacity, and for patients with impaired cognitive capacity, participation in the decision taking process constitutes a burden. The variables anxiety and depression are significantly related to decision taking capacity.

[Study of post-ICU mortality during 4 years (2006-2009). Analysis of the factors related to death in the ward after discharge from the ICU]. / Estudio de la mortalidad post-UCI durante 4 años (2006-2009). Análisis de factores en relación con el fallecimiento en planta tras el alta de UCI.

OBJECTIVE: To detect possible reasons for mortality of critical patients transferred from the ICU to the hospital wards and to analyze the possible attributable causes for such mortality. DESIGN: An observational study of prospectively collected data, analyzed retrospectively. POPULATION: Cohort analysis of 5328 with consecutive admissions to our ICU, whose evolution was followed up to hospital discharge or death. PERIOD: From January 2006 to December 2009. METHOD: An analysis was made of differential significance of epidemiological, clinical-care, death risk estimate, coincidence between ICU admissions reasons and causes of death after ICU discharge, as well as limitation of health care effort incidence. Inappropriate ICU discharge was considered to exist if the death occurred during the first 48 hours after ICU transfer, without limitation of care effort. RESULTS: A total of 907 patients died (SMR=0.9; 95% CI, 0.87-0.93), 202 of whom died after ICU discharge (3.8% of total sample and 22.3% of all deceased patients), ward length of stay being 12.4±17.9 days. No significant differences were found between deaths in the ICU or post-ICU deaths regarding infective complications appearing after admission to the ICU. Greater mortality was also not found in those re-admitted to the ICU after having been transferred to the ward. It was verified that the cause of death in the ward did not significantly coincide with the cause of admission to the ICU. DISCUSSION: Some mortality after ICU discharge is to be expected. Our data do not allow us to attribute this mortality rate to care deficiencies (inappropriate ICU discharges or deceased care in the wards). The reasons for this mortality have a varied and variable explanation. It mostly corresponds to an evolution of the patients differing from that expected when they were discharged from ICU.

[Patient data management systems or unit data management systems. Two clinical management perspectives in Intensive Medicine]. / PDMS o UDMS. Dos perspectivas de gestión clínica en Medicina Intensiva.

The need of availability of information able to describe the activity performed in ICU has two different sides. The first related with the monitoring of the patient himself, his clinical situation changes and the checking of attitudes and reactions of the clinical team related to these changes. The other one focused on the possibility to describe appropriately the general activity of the unit, the epidemiological characteristics of the attended population and the indicators of efectitivity and efficiency that could be used for a continous quality improving. The first one has been named as patient level control, and the second one as unit level control. Industry tried to develop potent instruments (informatized) able to <> information from patient monitoring systems in order to cope with the first quoted need (the so called patient data management systems [PDMS]), but has not yet be able to cross the line between the individual patient and the global unit activity. Authors emphasize the need of having the unit data management systems (UDMS), a not solved problem, as a complement on real time on line information obtained from patients.

[Bias in time delay in ICU admission as a mortality risk factor or "lead time bias"]. / Sesgo de retraso en el ingreso en la Unidad de Cuidados Intensivos como causa de mal pronóstico o lead time bias.

OBJECTIVE: To assess if delay in admission to the Intensive Care Unit (ICU), measured according to the prognostic estimation of survival in critical patients (EPEC) system, influences the final outcome of patients admitted to our ICU. DESIGN: Retrospective and systematic analysis of data collected during six months in 2003. SETTING: Nineteen-bed ICU (15 from Standard intensive care and 4 from intermediate care) in a referral teaching hospital. PATIENTS: Four hundred and eighty one patients consecutively admitted to our ICU and followedup to hospital discharge. MAIN INTEREST VARIABLES: Risk of death was estimated with the EPEC, SAPS II and MPM II 0. Variables collected were gender, age, origin of admission, risk of death by means of the 3 methods mentioned, admission time delay (lead time bias) as measured by EPEC and life status on ICU and hospital discharge (alive or dead). RESULTS: A total of 44 out of 481 patients died during the hospital stay, overall admission delay being 0.7 +/- 1.98 hours (2.96 +/- 3.28, range 0.25-20 hours, for those with delay > 0). No differences were found when comparing delay in admission among those surviving and the deceased, and there was very bad correlation between the prognosis made considering delay time for admission and that established without considering it (SAPS II or MPM II 0). CONCLUSIONS: Our study does not make it possible to relate lead time bias with patient survival. Due to the EPEC design, it is possible to differentiate "physiopathological delay" (inappropriate detection of the critical situation) and "logistic delay" (conditioned by factors such as lack of available beds). Our study as well as the EPEC only considers the latter. It cannot be ruled out that the increase in mortality regarding prognosis is directly related with first type of delay and not with the overall lead time bias.

[Information strategies in a polyvalent Intensive Care Unit]. / Estrategias de información en una Unidad de Cuidados Intensivos polivalente.

INTRODUCTION: Understanding the information provided to families and surrogates of the critically ill patients admitted to ICUs and its adequate communication without contradictions, is a fundamental aspect related with the possible participation of these persons in the treatment decision making and with the quality perceived regarding the care process. Our aim in this study is to assess these two aspects (information and communication of information). DESIGN: Opinion study elaborated by the medical team and nursing staff of a multidisciplinary ICU. METHOD: Observational qualitative study performed through an open answers questionnaire. Search for agreement on terminology and concepts that should be included in the information and estimation of the different contents of information provided by the main health care professional groups (physicians and nurses). Using the Delphi technique to elaborate an information communication sheet between different staff members in order to homogenize the information process. RESULTS: The analysis of the questionnaire reveals the great heterogeneity of the contents and modes of information provided. This may cause difficulties in understanding and the integration of families and relatives in the care process. The agreement achieved among the different between physicians to facilitate the information and avoid subjective interpretations by the informed people is presented.

[Percutaneous tracheostomy in ventilated patients]. / Traqueostomía percutánea en pacientes ventilados.

INTRODUCTION: Percutaneous tracheostomy is an alternative to conventional surgical tracheostomy. It is associated to a more feasible procedure, that is less invasive and linked to a lower degree of complications. Herein, we review our experience since the implementation of this technique in our Department. DESIGN: Retrospective observational. SETTING: Nineteen-bed intensive care department, in a general reference teaching hospital. PATIENTS AND METHOD: A total of 115 of 130 tracheostomies performed from 2001 to 2003 were retrospectively analyzed. Collected data include epidemiological information, reason for performing the procedure, maintenance time of artificial airway before the tracheostomy and type of ventilatory support or oxygen supplementation before and after the procedure. The modified PEEP (PEEP-mod = FiO2 x PEEP) was calculated, sedation level received before and 4-6 hours after the technique and also 24 hours later, were reviewed. Subsequent patient evolution was collected. INTERVENTIONS: Observational study on the results of routine procedures. VARIABLES OF INTEREST: Blood gases indicators of effectiveness in oxygen supply and the need of mechanical ventilation support. RESULTS: Median age of the 115 reviewed patients was 65 years. The most common admission reasons were: brain vascular accident in 25 cases, head and neck injury in 21, cancer in 11 and sepsis in 10 patients. Tracheostomy was indicated because prolonged mechanical ventilation in 52 patients, coma in 28 and emergency or scheduled surgery in 10 cases. Median length of stay in the ICU before tracheostomy was 14 days. Ninety-two patients were discharged from the ICU, and 52 from the Hospital. The remaining patients died during their hospital stay. Serious complications appeared in 5 patients (4%); 3 of them were the development of fistulae and all of them occurred in patients in whom the tracheostomy was performed in the ICU at bedside. Before the procedure, 72 patients were under mechanical ventilation, but only 56 received ventilatory support 24 hours after tracheostomy. When PEEP-mod values were analyzed, first monitoring of median value was 1.6 (range 0 to 2), 4-6 hours time median value was 2 (1.4-2.45), and 24 hours later median value was 1.2 (0-2) (global variation, p < 0.001). CONCLUSIONS: In our experience, percutaneous tracheostomy performed at bedside in the ICU is an adequate solution with a low complication rate and its makes it possible to reduce the level of ventilatory support.

Quality of life before intensive care unit admission and its influence on resource utilization and mortality rate.

OBJECTIVE: To analyze the quality of life of critically ill patients before their intensive care admission and its relation to age, variables measured in the intensive care unit (ICU; severity of illness, therapeutic effort, resource utilization, and length of stay), and in-hospital mortality rate. DESIGN: Observational prospective multicenter study. SETTING: Eighty-six medical-surgical ICUs in Spain, including coronary patients. PATIENTS: We studied 8,685 patients between 1992 and 1993. Patients <16 yrs old and those dying within the first 6 hrs were excluded. MEASUREMENTS AND MAIN RESULTS: Data collection included age, gender, admission diagnosis, severity level by Acute Physiology and Chronic Health Evaluation (APACHE) III, quality of life survey score, therapeutic activity level by Therapeutic Intervention Scoring System (TISS), and ICU and hospital mortality rate. Pre-ICU quality-of-life score was 3.74 +/- 4.42 points; 33.24% of patients had a normal quality of life (0 points), and numbers of patients declined logarithmically in relationship to increasing quality-of-life scores, with only 189 patients having a score >15 points. Pre-ICU quality-of-life score correlated with age (r =.289, p <.001), with severity level by APACHE III score (r =.217, p <.001), and weakly with TISS (r =.067, p <.001). There was no correlation between quality of life and length of ICU stay. Patients dying in hospital after ICU discharge (n = 429) had worse quality of life (5.88 +/- 5.38 points) than those dying in the ICU (n = 1,453, 4.8 +/- 4.94), who themselves had a worse quality of life than hospital survivors (n = 6,803, 5.05 +/- 5.07; p <.0001 by analysis of variance), with significant differences between all three groups. In the multivariate analysis, pre-ICU quality-of-life was related to age, APACHE III score, and hospital mortality rate but not to TISS or ICU length of stay. Pre-ICU quality of life was introduced as a variable in the APACHE III prediction model and entered the model after acute physiology score, diagnosis, and age and before prior patient location and comorbidities. The area under the receiver operating characteristics curve was 0.834 when quality-of-life was included and 0.83 when not. CONCLUSIONS: In Spain, the quality of life of critically ill patients before their ICU admission is good, and only a small proportion of patients have a low quality of life before admission. Previous quality of life is related to hospital mortality rate but contributes very little to the discriminatory ability of the APACHE III prediction model and has little influence on ICU resource utilization as measured by length of stay and therapeutic activity.

Initial international use of APACHE. An acute severity of disease measure.

We need objective and reliable ways of measuring the severity of disease of hospitalized patients. This paper demonstrates the international predictive accuracy of a severity of disease measure on 1504 consecutive, unscheduled intensive care admissions to 14 hospitals in the United States, France, Spain, and Finland. Using laboratory data gathered within 24 hours of ICU admission, the Acute Physiology Score of APACHE (Acute Physiology and Chronic Health Evaluation) was a strong and stable predictor of hospital survival and concurrent therapeutic effort. In ordinary least squares and logistic multiple regression analysis, the impact of the Acute Physiology Score (APS) was highly significant (p less than 0.001) and of virtually identical magnitude in the United States and European hospitals. The use of this severity of disease measure should help researchers gain insights concerning the efficacy of medical services and the characteristics of physician decision making by permitting more precise prognostic stratification of severely ill patients.

[Correlation between the Morris' index and pulmonary capillary pressure in patients with acute myocardial infarction]. / Correlación entre índice de Morris y presión capilar pulmonar en pacientes con infarto agudo de miocardio.

The authors study the usefulness of the measurement of the negative area of P in V1 (Morris' index) in patients with acute myocardial infarction. The study was carried out prospectively in 70 patients, 31 of them having a Swan-Ganz catheter inserted permitting simultaneous hemodynamic and electrocardiographic measurements. No overall correlation was found between pulmonary capillary pressure (PCP) and Morris' index (Mlx), but a correlation existed in the subgroup of patients that showed evident variations of Mlx values during the study. On admission a relationship between PCP and Mlx was evident in 68% of the cases, without statistical significance. No PCP-Mlx correlation was found in the patients in whom the Mlx was always normal or abnormal during the study, nor in those with a prior history of arterial hypertension or left heart failure. An intraatrial conduction defect was found in 13% of the cases, no PCP-Mlx correlation being present in those. The fact that the PCP-Mlx correlation is best in patients with changing Mlx values in successive measurements that in patients with a prior history of hypertension or left ventricular failure suggests that Mlx values may vary with changes of left atrial pressure. The measurement of the Mlx to estimate left atrial pressure has little value in patients with conditions that may cause left atrial enlargement and intraatrial conduction defects.

[Study of 51 cases of disseminated intravascular coagulation with reference to the association with acute renal failure. Results in severely ill patients (author's transl)]. / Estudio de 51 casos de coagulación intravascular diseminada con referencia a la asociación con insuficiencia renal aguda. Resultados en pacientes gravemente enfermos.

During the years 1977 to 1979 51 patients admitted to a general Intensive Care Unit were diagnosed of disseminated intravascular coagulation (DIC); their clinical histories were reviewed and they form the basis of this report. The diagnosis was made independently of the eventual clinical manifestations and it was based on the platelet count, serum fibrinogen levels, alteration of the prothrombin time and the cephalin-kaolin time, elevation of fibrin degradation products, and positivity of the ethanol test. An attempt was made to elucidate the precipitating cause of the coagulopathy, and to see if there was one or more of them. Particular emphasis is made on the association with Gram negative sepsis. Survival was evaluated in relation to heparin therapy, massive doses of corticosteroids, and association to acute renal failure. In conclusion, severe DIC with or without bleeding appears to be a manifestation of multiorgan failure seen in severely ill patients; the prognosis and mortality of this form of DIC is worse than the usual DIC and treatment with heparin or corticosteroids do not increase survival, while its association to acute renal failure implies a higher mortality (p less than 0.02).

[Usefulness of creatine phosphokinase isoenzyme, CK-MB, in the diagnosis of myocardial necrosis (author's transl)]. / Utilidad de la isoenzima de la creatinfosfocinasa, CK-MB, en el diagnóstico de la necrosis miocárdica.

With the objective of evaluating the clinical usefulness of a new immunologic method (Merck-1-Test CK-MB), in the determination of the CK-MB activity, 48 patients admitted to the Coronary Unit for angina pectoris were studied. Samples of blood were gathered upon admission and every 4 hours for 48-72 hours, determining in each one of them the total CPK, SGOT, LDH, and CK-MB; electrocardiograms (ECG) were taken and all possible causes for the increase in the enzymatic activity were recorded. Results were analyzed in order to study the following aspects: in the patients in which an acute myocardial infarction was diagnosed the CK-MB activity was studied, also the relation of CK-MB to the remaining parameters, each parameter's sensitivity and specificity and the relationship of the CK-MB to the prognosis of the patients. The usefulness of CF-MB in the differential diagnosis of myocardial necrosis and variations in the total CKP curve in the clinical course of acute myocardial infarction unrelated to myocardial necrosis were evaluated too. The following conclusions were drawn from the analysis of the data. The immunological method has the advantages of its sensitivity and easily and quickly performance (15 minutes), but it has the disadvantage that it detects CK-BB (elevated in cebrovascular disorders). Twenty-four hours after the onset of symptoms, the negativity of CK-MB does not exclude the diagnosis of a myocardial necrosis. CK-MB is more sensitive than total CPK in diagnosing the extent of the area of necrosis. CK-MB is very specific for myocardial necrosis but less sensitive than other parameters. A positive CK-MB upon the patient's admission confirmed the diagnosis of necrosis in 60 percent of the cases, but in 18 percent error was induced because of false positives. CK-MB permitted confirmations of the diagnosis of myocardial infarction in 33 percent of cases in which there was only a suggestion of necrosis by the ECG. The variation in the curve of total CPK in the course of an acute myocardial infarction is subjected to such a great number of factors intercurrent with time, that caution should be exercised in trying to relate a specific elevation of total CPK to an unsuccessful maneuver or to a possible extension of the area of necrosis.

[The behaviour of fibrinogen and fibrinogen degradation products in myocardial infarction. Justification of a prognostic index (author's transl)]. / Comportamiento del fibrinógeno y sus productos de degradación en el infarto agudo de miocardio. Justificación de un indice pronóstico.

The behaviour of fibrinogen and fibrinogen degradation products in 52 patients with myocardial infarction was analyzed with the aim of finding an evolutive prognostic index for these patients. According to the clinical course the patients who developed complications were separated from those who did not develop them; a special distinction was made of those complications classified as being of thromboembolic type. In the same way those patients who died were analyzed differentially from those who did not. When these facts were related to the behaviour of fibrinogen and of fibrinogen degradation products the following facts were observed: 1) There was an increase of fibrinogen which reached its maximum on the 5th and 6th days and which returned to normal limits on approximately the 9th day. The greatest increase was reached in those patients who developed thromboembolic complications, although the study did not allow to establish significant differences between this group and the rest of the cases. A reactive and nonspecific behaviour was suggested. 2) Fibrinogen degradation productes reached its maximum increase during the 48 hours after the myocardial infarction, without significant differences between both groups. Therefore it does not seem that a prognostic and evolutive assessment can be derived from the study of the changes in the fibrinogen time and fibrinogen degradation products in patients with myocardial infarction.

[Pulmonary function differences in healthy subjects according to postural changes (author's transl)]. / Diferencias en la función pulmonar de sujetos sanos secundarias al cambio postural

The total lung capacity (TLC) and its subdivisions along with the forced spirometric values (FEF25-75 and FEV1) were determined in a group of 44 healthy subjects, composed of 29 women and 15 men. The determinations were carried out in a sitting position and in supine position, breathing air. All the pulmonary volumes diminished when the subject lay down, but the functional residual capacity (FRC) was that which underwent a greater reduction. The residual volume decrease was the only one which did not reach statistically significant levels. Women always showed smaller pulmonary volumes than men. It has been demonstrated that FRC can be exactly measured by means of the closed helium technique. The regression figures of FRC in supine position were determinted for both sexes, with a r = 0,33 (p less than 0,1) in women and r = 0,95 (p less than 0.001) in men. The forced spirometric tests did not undergo any important changes although the reduction of the FEV1 was significant in both sexes. The results obtained were compared with those published by other authors.