Competency assessment of residents of Intensive Care Medicine through a simulation-based objective structured clinical evaluation (OSCE). A multicenter observational study.

OBJECTIVES: The current official model of training in Intensive Care Medicine (ICM) in Spain is based on exposure to experiences through clinical rotations. The main objective was to determine the level of competency (I novice to V independent practitioner) achieved by the residents at the end of the 3rd year of training (R3) in ICM through a simulation-based OSCE. Secondary objectives were: (1) To identify gaps in performance, and (2) To investigate the reliability and feasibility of conducting simulation-based assessment at multiple sites. DESIGN: Observational multicenter study. SETTING: Thirteen Spanish ICU Departments. PARTICIPANTS: Thirty six R3. INTERVENTION: The participants performed on five, 15-min, high-fidelity crisis scenarios in four simulation centers. The performances were video recorded for later scoring by trained raters. MAIN VARIABLES OF INTEREST: Via a Delphi technique, an independent panel of expert intensivists identified critical essential performance elements (CEPE) for each scenario to define the levels of competency. RESULTS: A total of 176 performances were analyzed. The internal consistency of the check-lists were adequate (KR-20 range 0.64-0.79). Inter-rater reliability was strong [median Intraclass Correlation Coefficient across scenarios: 0.89 (0.65-0.97)]. Competency levels achieved by R3 were: Level I (18.8%), II (35.2%), III (42.6%), IV/V (3.4%). Overall, a great heterogeneity in performance was observed. CONCLUSION: The expected level of competency after one year in the ICU was achieved only in half of the performances. A more evidence-based educational approach is needed. Multiple center simulation-based assessment showed feasibility and reliability as an evaluation method of competency. TRIAL REGISTRATION: COBALIDATION. NCT04278976. (https://register. CLINICALTRIALS: gov).

Postoperative management in the Intensive Care Unit of head and neck surgery patients. / Manejo postoperatorio en UCI de cirugía de cabeza y cuello.

Patient care after major head and neck surgery has changed in recent years. Tumors are the most common reasons for this type of surgery, though it is also used to treat benign conditions. Recent advances in equipment and surgical techniques have improved the postoperative course in this field, allowing early recovery, less pain and infection, a shorter hospital stay, and even better aesthetic results. This is due to the use of minimally invasive techniques, which are gaining relevance. Such techniques allow complex procedures in the head and neck region, through natural orifices or small incisions, with minimal damage and sequelae for the patients. Despite these advances, however, the complexity of the treatment intervention requires multidisciplinary patient management, mostly in the Intensive Care Unit, in order to monitor the possible occurrence of complications. Potential risk factors include previous comorbidity, the type of surgery involved (e.g., bilateral cervical lymphadenectomy), multiple transfusions, and the appearance of early complications requiring repeat surgery. Despite the existence of several studies, there are no standardized protocols for the postoperative period in surgeries of this kind. This causes many specialists to resort to accelerated recovery protocols (ERAS: "Enhanced Recovery After Surgery") that have already been established in other surgical specialties.

Physician staffing needs in critical care departments. / Estimación de las necesidades de profesionales médicos en los servicios de medicina intensiva.

Departments of Critical Care Medicine are characterized by high medical assistance costs and great complexity. Published recommendations on determining the needs of medical staff in the DCCM are based on low levels of evidence and attribute excessive significance to the structural/welfare approach (physician-to-beds ratio), thus generating incomplete and minimalistic information. The Spanish Society of Intensive Care Medicine and Coronary Units established a Technical Committee of experts, the purpose of which was to draft recommendations regarding requirements for medical professionals in the ICU. The Technical Committee defined the following categories: 1) Patient care-related aspects; 2) Activities outside the ICU; 3) Patient safety and clinical management aspects; 4) Teaching; and 5) Research. A subcommittee was established with experts pertaining to each activity category, defining criteria for quantifying the percentage time of the intensivists dedicated to each task, and taking into account occupational category. A quantitative method was applied, the parameters of which were the number of procedures or tasks and the respective estimated indicative times for patient care-related activities within or outside the context of the DCCM, as well as for teaching and research activities. Regarding non-instrumental activities, which are more difficult to evaluate in real time, a matrix of range versus productivity was applied, defining approximate percentages according to occupational category. All activities and indicative times were tabulated, and a spreadsheet was created that modified a previously designed model in order to perform calculations according to the total sum of hours worked and the hours stipulated in the respective work contract. The competencies needed and the tasks which a Department of Critical Care Medicine professional must perform far exceed those of a purely patient care-related character, and cannot be quantified using structural criteria. The method for describing the 5 types of activity, the quantification of specific tasks, the respective times needed for each task, and the generation of a spreadsheet led to the creation of a management instrument.

Routine invasive strategy in acute coronary syndrome patients with renal dysfunction. Results of the ARIAM-SEMICYUC registry. / Estrategia invasiva de rutina en el síndrome coronario agudo sin elevación del segmento ST con disfunción renal. Resultados del registro ARIAM-SEMICYUC.

OBJECTIVE: To evaluate the use and effectiveness of a routine invasive strategy (RIS) in patients with acute coronary syndrome without persistent ST-segment elevation with renal dysfunction in the real world scenario. METHODS: A retrospective cohort study based on the ARIAM-SEMICYUC Registry (2011-2014) was carried out. Renal dysfunction was defined as GFR (Cockroft-Gault)<60ml/min (moderate dysfunction) or<30ml/min (severe dysfunction). Patients in which early angiography (<72h) was performed due to cardiogenic shock or recurrent myocardial ischemia were excluded. The primary endpoint was hospital mortality. Confounding factors were controlled using propensity score analysis. RESULTS: A total of 4,279 patients were analyzed, of which 26% had moderate renal dysfunction and 5% severe dysfunction. Patients with renal dysfunction had greater severity and comorbidity, higher hospital mortality (8.6 vs. 1.8%), and lesser use of the RIS (40 vs. 52%). The adjusted OR for mortality in patients without/with renal dysfunction were 0.38 (95% confidence interval [95%CI] 0.17 to 0.81) and 0.52 (95%CI 0.32 to 0.87), respectively (interaction P-value=.4779). The impact (adjusted risk difference) of RIS was higher in the group with renal dysfunction (-5.1%, 95%CI -8.1 to -2.1 vs. -1.6%, 95%CI -2.6 to -0.6; interaction P-value=.0335). No significant interaction was detected for the other endpoints considered (ICU mortality, 30-day mortality, myocardial infarction, acute renal failure or moderate/severe bleeding). CONCLUSIONS: The results suggest that the effectiveness of IRS is similar in patients with normal or abnormal renal function, and alert to the under-utilization of this strategy in such patients.

Predictive scoring systems in multiorgan failure: A cohort study.

OBJECTIVE: An evaluation is made of the hospital mortality predicting capacity of the main predictive scoring systems. DESIGN: A 2-year retrospective cohort study was carried out. SETTING: A third level ICU with surgical and medical patients. PATIENTS: All patients with multiorgan failure during the first day in the ICU. MAIN VARIABLES: APACHE II and IV, SAPS II and III, MPM II and hospital mortality. RESULTS: A total of 568 patients were included. Mortality rate: 39.8% (226 patients). Discrimination (area under the ROC curve; 95% CI): APACHE IV (0.805; 0.751-0.858), SAPS II (0.755; 0.697-0.814), MPM II (0.748; 0.688-0.809), SAPS III (0.737; 0.675-0.799) and APACHE II (0.699; 0.633-0.765). MPM II showed the best calibration, followed by SAPS III. APACHE II, SAPS II and APACHE IV showed very poor calibration. Standard mortality ratio (95% CI): APACHE IV 1.9 (1.78-2.02); APACHE II 1.1 (1.07-1.13); SAPS III 1.1 (1.06-1.14); SAPS II 1.03 (1.01-1.05); MPM 0.9 (0.86-0.94). CONCLUSIONS: APACHE IV showed the best discrimination, with poor calibration. MPM II showed good discrimination and the best calibration. SAPS II, in turn, showed the second best discrimination, with poor calibration. The APACHE II calibration and discrimination values currently disadvise its use. SAPS III showed good calibration with modest discrimination. Future studies at regional or national level and in certain critically ill populations are needed.

Prognosis of elderly patients subjected to mechanical ventilation in the ICU.

OBJECTIVE: To analyze the prognosis of mechanically ventilated elderly patients in the Intensive Care Unit (ICU). DESIGN AND SCOPE: Sub-analysis of a prospective multicenter observational cohort study conducted over a period of two years in 13 medical-surgical ICUs in Spain. PATIENTS: Adult patients who required mechanical ventilation (MV) for longer than 24 hours. INTERVENTIONS: None. STUDY VARIABLES: Demographic data, APACHE II, SOFA, reason for MV, comorbidity, functional condition, reintubation, duration of MV, tracheotomy, ICU mortality, in-hospital mortality. RESULTS: A total of 1661 patients were recruited. Males accounted for 67.9% (n=1127), with a mean age of 62.1 ± 16.2 years. APACHE II: 20.3 ± 7.5. Total SOFA: 8.4 ± 3.5. Four hundred and twenty-three patients (25.4%) were ≥ 75 years of age. Comorbidity and functional condition rates were poorer in these patients (p<0.001 for both variables). Mortality in the ICU was higher in the elderly patients (33.6%) than in the younger subjects (25.9%) (p=0.002). Also, in-hospital mortality was higher in those ≥ 75 years of age. No differences in duration of MV, prevalence of tracheostomy or reintubation incidence were found. Regarding the indication for MV, only the patient ≥ 75 years of age with pneumonia, sepsis or trauma had a higher in-ICU mortality than the younger patients (46.3% vs 33.1%, p=0.006; 55% vs 25.8%, p=0.002; 63.6% vs 4.5%, p<0,001, respectively). No differences were found referred to other reasons for MV. CONCLUSION: Older patients (≥ 75 years) have significantly higher in-ICU and in-hospital mortality than younger patients without differences in the duration of mechanical ventilation. Differences in mortality were at the expense of pneumonia, sepsis and trauma.

[Prolonged mechanical ventilation probability model]. / Modelo de probabilidad de ventilación mecánica prolongada.

OBJECTIVE: To design a probability model for prolonged mechanical ventilation (PMV) using variables obtained during the first 24 hours of the start of MV. DESIGN: An observational, prospective, multicenter cohort study. SCOPE: Thirteen Spanish medical-surgical intensive care units. PATIENTS: Adult patients requiring mechanical ventilation for more than 24 hours. INTERVENTIONS: None. STUDY VARIABLES: APACHE II, SOFA, demographic data, clinical data, reason for mechanical ventilation, comorbidity, and functional condition. A multivariate risk model was constructed. The model contemplated a dependent variable with three possible conditions: 1. Early mortality; 2. Early extubation; and 3. PMV. RESULTS: Of the 1661 included patients, 67.9% (n=1127) were men. Age: 62.1±16.2 years. APACHE II: 20.3±7.5. Total SOFA: 8.4±3.5. The APACHE II and SOFA scores were higher in patients ventilated for 7 or more days (p=0.04 and p=0.0001, respectively). Noninvasive ventilation failure was related to PMV (p=0.005). A multivariate model for the three above exposed outcomes was generated. The overall accuracy of the model in the training and validation sample was 0.763 (95%IC: 0.729-0.804) and 0.751 (95%IC: 0.672-0.816), respectively. The likelihood ratios (LRs) for early extubation, involving a cutoff point of 0.65, in the training sample were LR (+): 2.37 (95%CI: 1.77-3.19) and LR (-): 0.47 (95%CI: 0.41-0.55). The LRs for the early mortality model, for a cutoff point of 0.73, in the training sample, were LR (+): 2.64 (95%CI: 2.01-3.4) and LR (-): 0.39 (95%CI: 0.30-0.51). CONCLUSIONS: The proposed model could be a helpful tool in decision making. However, because of its moderate accuracy, it should be considered as a first approach, and the results should be corroborated by further studies involving larger samples and the use of standardized criteria.

[Technical and functional standards and implementation of a clinical information system in intensive care units]. / Estándares técnicos y funcionales, y proceso de implantación, de un sistema de información clínica en unidades de cuidados intensivos.

INTRODUCTION: Clinical Information Systems (CIS) are becoming a useful tool for managing patients and data in the ICU. However, the existing CIS differ in their capabilities and technical requirements. It is therefore essential for intensivists, as the end clients of these applications, to define the suitable minimum specifications required in order to be operative and helpful. OBJECTIVES: The Spanish Society of Intensive Care Medicine and Coronary Units, through its Organization and Management Workgroup, has designated a group of clinical and software experts to draft a document with the recommendable technical and operating requirements of these systems. METHODS: The group was formed by ten people supported by managers or engineers from the five principal industries producing CIS in Spain. The project involved the following phases: a) Completion of a check list. This step was considered necessary in order to establish the precise current situation of CIS applications. b) Discussion of the results by the group of experts in a meeting and in online format. RESULTS: The requirements were grouped into four sections: technical, functional, safety and data management. All requirements were classified as basic and optional in order to allow the end user to choose among different options according to the existing budget, though ensuring a minimal set of useful characteristics. A chronogram for the installation process was also proposed.

Intensity of continuous renal replacement therapies in patients with severe sepsis and septic shock: a systematic review and meta-analysis.

The purpose of this study was to assess the efficacy of continuous renal replacement therapies in patients with severe sepsis or septic shock, with or without acute kidney injury. We performed a systematic search in Medline, Embase, Web of Knowledge, Cochrane Library and Clinicaltrials.gov and a hand search of the retrieved studies. We included both randomised controlled clinical trials and subgroups of randomised trials that assessed the effect of continuous renal replacement therapies (at traditional or high doses) and reported clinical outcomes in adult patients with severe sepsis or septic shock. The study selection and data extraction were performed by duplicate. Analysis of heterogeneity and meta-analysis was performed according to the Cochrane Collaboration guidelines for conducting systematic reviews of interventions. Twelve studies (1895 patients) met the inclusion criteria. Pooling of all studies resulted in a mortality risk ratio of 0.96 (95% confidence interval 0.83 to 1.12). The studies showed moderate statistical heterogeneity (I2 statistic 52%, P = 0.02). The effect on mortality was not modified (interaction P values non significant) by the dose of continuous renal replacement therapies, the severity of illness or the risk of bias. The available evidence suggests that these therapies in patients with severe sepsis or septic shock are not associated with an improvement in other outcomes such as haemodynamics, pulmonary gas exchange, multiple organ dysfunction syndrome or length of stay. The best available evidence does not support the routine use of continuous renal replacement therapies (at traditional or high doses) in patients with severe sepsis or septic shock.

[High PEEP vs. conventional PEEP in the acute respiratory distress syndrome: a systematic review and meta-analysis]. / PEEP alta frente a PEEP convencional en el síndrome de distrés respiratorio agudo. Revisión sistemática y metaanálisis.

OBJECTIVE: To perform a systematic review and meta-analysis of the literature to evaluate the effects of high PEEP versus conventional PEEP on mortality and on the risk of barotrauma in patients with the acute respiratory distress syndrome (ARDS). SOURCE OF DATA: Computer search of Medline, Embase, CINAHL, CANCERLIT, Pascal-Biomed, ACP Journal Club, Cochrane library (CDSR, DARE, CCTR), ISI Proceedings, Current Contents, and Web of Science, as well as manual search of selected references. SELECTION OF STUDIES: Controlled random clinical trials published after NAECC (1994) that evaluated the effect of two levels of PEEP and that reported the mortality and incidence of barotrauma in the series. DATA EXTRACTION: By two investigators working independently, with discrepancies resolved by group consensus. Contingency tables were elaborated and the RRs with corresponding confidence intervals were obtained for each study. RESULTS: Four articles were selected for the meta-analysis of mortality and three for the meta-analysis of barotrauma. No effects of PEEP level on mortality were found (RR 0.73, 95% CI: 0.49 to 1.10) or on the incidence of barotrauma (RR 0.50, 95% CI: 0.14 to 1.73). However, an analysis of the studies in which PEEP was individualized in function of Pflex showed a significant decrease in mortality (RR 0.59, 95% CI: 0.43 to 0.82) (p=0.001) CONCLUSIONS: The use of high or conventional PEEP in function of oxygenation does not affect mortality or the incidence of barotrauma in patients with ARDS. However, there might be a decrease in mortality associated to high PEEP individualized in function of the pulmonary mechanics of each patient.

[Use of internet and electronic resources among Spanish intensivist physicians. First national survey]. / Uso de Internet y recursos electrónicos entre médicos intensivistas españoles. Primera encuesta nacional.

OBJECTIVE: Estimate knowledge and use habits of different electronic resources in a sample of Spanish intensivists: Internet, E-mail, distribution lists, and use of portable electronic devices. DESIGN: Self-applied questionnaire. METHODS: A 50-question questionnaire was distributed among Spanish intensivists through the hospital marketing delegates of a pharmaceutical company and of electronic forums. RESULTS: A total of 682 questionnaires were analyzed (participation: 74%). Ninety six percent of those surveyed used Internet individually: 67% admitted training gap. Internet was the second source of clinical consultations most used (61%), slightly behind consultation to colleagues (65%). The pages consulted most were bibliographic databases (65%) and electronic professional journals (63%), with limited use of Evidence Based Medicine pages (19%). Ninety percent of those surveyed used e-mail regularly in the practice of their profession, although 25% admitted that were not aware of its possibilities. The use of E-mail decreased significantly with increase in age. A total of 62% of the intensivists used distribution lists. Of the rest, 42% were not aware of its existence and 32% admitted they had insufficient training to handle them. Twenty percent of those surveyed had portable electronic devices and 64% considered it useful, basically due to its rapid consultation at bedside. Female gender was a negative predictive factor of its use (OR 0.35; 95% CI 0.2-0.63; p=0.0002). CONCLUSIONS: A large majority of the Spanish intensivists use Internet and E-mail. E-mail lists and use of portable devices are still underused resources. There are important gaps in training and infrequent use of essential pages. There are specific groups that require directed educational policies.

[Nutritional assessment of the severely ill patient]. / Valoración del estado nutricional en el paciente grave.

There are different parameters aimed at assessing nutritional status. These parameters may be of some help to assess nutritional status prior to patients' admission. However, their application in the critically ill patient is troublesome since results interpretation is interfered by changes originated by the acute disease or treatment measures. This is particularly true in relation to anthropometrical variables that are severely affected by changes in water distribution in the critical patient. Biochemical markers (creatinine/height index, serum albumin, etc.) are also interfered as a result of the metabolic changes that modify the synthesis and degradation processes. Short half-life proteins (prealbumin, retinol-bound protein) are not indicative of the nutritional status although they do inform about an appropriate response to nutrients intake and concurrence of new conditions of metabolic stress. Functional assessment parameters, such as muscular function test, are also difficult to apply in a great number of patients. Subjective global assessment, although it requires some degree of expertise, may be an appropriate tool. Some theoretically more accurate methods, such as bioelectrical impedance, need further investigation in these patients before being recommended.

[Requeriments of macronutrients and micronutrients]. / Requerimientos de macronutrientes y micronutrientes.

Critically ill patients have important modifications in their energetic requirements, in which the clinical situation, treatment applied and the time course take part. Thus, the most appropriate method to calculate the caloric intake is indirect calorimetry. When this test is not available, calculations such as Harris-Benedict's may be used, although not using the so high correction factors as previously recommended in order to avoid hypercaloric intakes. The intake of a fixed caloric amount (comprised between 25-30 KcalKg/min) is adequate for most critically ill patients. Carbohydrates intake must be of 5 g/kg/day) maximum. Glucose plasma levels must be controlled in order to avoid hyperglycemia. With regards to fat intake, the maximum limit should be 1.5 g/kg/day. The recommended protein intake is 1.0-1.5 g/kg/day, according to the clinical situation characteristics. Special care must be taken with micronutrients intake, an issue that is many times undervalued. In this sense, there are data to consider some micronutrients such as Zn, CU, Mn, Cr, Se, Mo and some vitamins (A, B, C, and E) of great importance for patients in a critical condition, although specific requirements for each one of them have not been established.

Mechanical ventilation of patients on long-term oxygen therapy with acute exacerbations of chronic obstructive pulmonary disease: prognosis and cost-utility analysis.

OBJECTIVE: To analyze the prognosis and costs of mechanical ventilation in patients with exacerbations of chronic obstructive pulmonary disease (COPD) treated with long-term oxygen therapy. DESIGN: A prospective cohort study. Follow-up at 1 and 5 years. Cost utility analysis. SETTING: A medical-surgical intensive care unit (ICU) in a university hospital. PATIENTS: 20 patients with previous COPD treated with long-term oxygen therapy and needing mechanical ventilation due to acute respiratory failure. MEASUREMENTS AND MAIN RESULTS: Mortality in the ICU, in-hospital mortality (ICU plus ward), and mortality at 1 and 5 years, and factors associated with prognosis and cost-utility were assessed. The mean Acute Physiology and Chronic Health Evaluation II score was 20 (median 20 range 12-36). Cumulative mortality was 35% in the ICU, 50% in hospital, 75% at 1 year, and 85% at 5 years. Factors significantly associated with mortality in the ICU were low levels of albumin (p = 0.05) and sodium (p = 0.01) at admission. Patients who died in hospital and in the first year after discharge had a lower forced expiratory volume in 1 s (FEV1) than survivors (p = 0.03 and p = 0.05, respectively). The cost per Quality Adjusted Life Year (QALY) was U.S. $26283 and U.S. $44602 in a "best" (cost/QALY calculated for the life expectancy in Spain) and a "worst case scenario" (cost/QALY calculated for a 68-year life expectancy), respectively. CONCLUSIONS: Applying mechanical ventilation to COPD patients treated with long-term oxygen therapy carries a high mortality and cost. Factors significantly associated with mortality in the ICU were albumin and sodium concentrations and FEV1 in hospital and in the first year after discharge.

Diffuse recidivant alveolar hemorrhage in a patient with hepatitis C virus-related mixed cryoglobulinemia.

A case of diffuse and recidivant alveolar hemorrhage is presented in a patient with hepatitis C virus-related type II mixed cryoglobulinemia with membranoproliferative glomerulonephritis. The patient was a 48-year-old white woman who suffered several outbreaks of pulmonary hemorrhage refractory to treatment with steroids, cyclophosphamide, azathioprine, plasmapheresis and interferon-alpha. The patient also presented persistent increased titers of immune complexes and rheumatoid factor with no histological hepatic alterations. Some considerations about evolution and treatment are given according to the updated physiopathology of this disease.

[Micronutrients in severe septic aggression. Their usefulness as prognostic markers]. / Micronutrientes en la agresión séptica severa. Utilidad como marcadores pronósticos.

The object of this is to evaluate the influence of several micronutrients on the survival rate of septic patients following abdominal surgery. A retrospective assessment was done of sixty-one patients suffering from neoplastic or non-neoplastic pathology associated to septicemia. On admission the following parameters were determined: number of total lymphocytes, serum albumin, transferrin, zinc, copper, magnesium, iron, calcium, phosphorus, and copper/zinc levels. The differences obtained between surviving and non-surviving patients were analyzed. The most relevant findings revealed statistically significant lower serum albumin, zinc and transferrin values in the latter group. We conclude by stating that such parameters may be of prognostic value in this type of patients, and that supplemental micronutrients must be administered in order to improve prognosis.