Minimización de costos de sedación usando anestesia inhalada. Análisis en la UTI durante la pandemia por COVID-19 / Minimization of sedation costs using inhaled anesthesia. Analysis in the ICU during the COVID-19 pandemic / Minimização dos custos de sedação usando anestesia inalatória. Análise na UTI durante a pandemia de COVID-19

Resumen: Introducción: los sedantes de uso no convencional y aquéllos fuera de recomendación como los anestésicos inhalados se usaron ante la escasez de medicamentos durante la pandemia por SARS-CoV-2. Objetivos: comparar el costo y resultados obtenidos con el uso de anestésicos inhalados versus sedantes intravenosos en COVID-19. Material y métodos: estudio retrospectivo en una unidad de terapia intensiva (UTI) de un hospital público de referencia. Se hizo un cálculo de costos de sedación de los dos primeros días de estancia en la UTI. Las dosis de fármacos fueron tomadas del expediente clínico y los costos de adquisición directamente de CompraNet. Se comparan medias de costos por medicamento y por grupo. Resultados: de 151 pacientes, 81 recibieron sedación intravenosa y 70 anestesia inhalada con o sin sedantes intravenosos. No hubo diferencia en mortalidad, días de ventilación mecánica, estancia en la UTI y estancia hospitalaria entre grupos. Se observó una reducción significativa de costos derivados del menor uso de midazolam, propofol y dexmedetomidina (p < 0.0001) cuando se usó anestesia inhalada y una diferencia entre medias de costos totales de sedación de $4,108.42 M.N. por día por paciente. Conclusiones: la anestesia inhalada durante la pandemia por COVID-19 permitió una reducción de costos comparada con sedación intravenosa en los primeros dos días de estancia en la UTI.

Abstract: Introduction: non-conventional sedatives and those off-label, such as inhaled anesthetics, were used due to the shortage of medicines during the SARS-CoV-2 pandemic. Objectives: to compare the cost and results obtained with the use of inhaled anesthetics versus intravenous sedatives in COVID-19. Material and methods: retrospective study in a public reference hospital ICU. A calculation of sedation costs was made of the first two days of ICU stay. Drug doses were taken from the clinical records and acquisition costs directly from CompraNet. Mean costs per medication and per group are compared. Results: of 151 patients, 81 received intravenous sedation and 70 received inhaled anesthesia with or without intravenous sedatives. There was no difference in mortality, days of mechanical ventilation, ICU stay, and hospital stay between groups. A significant reduction in costs derived from the less use of midazolam, propofol and dexmedetomidine (p < 0.0001), and a difference between means of total sedation costs of $4,108.42 Mexican pesos per patient per day was observed with inhaled anesthesia. Conclusions: inhaled anesthesia during the COVID-19 pandemic compared to intravenous sedation allowed a cost reduction in the first two days of ICU stay.

Resumo: Introdução: sedativos de uso não convencional e não recomendados, como anestésicos inalatórios, foram utilizados devido à escassez de medicamentos durante a pandemia de SARS-CoV-2. Objetivos: comparar o custo e os resultados obtidos com o uso de anestésicos inalatórios versus sedativos intravenosos na COVID-19. Material e métodos: estudo retrospectivo em uma UTI de um hospital público de referência. Foi feito um cálculo dos custos de sedação para os dois primeiros dias de internação na UTI. As doses dos medicamentos foram retiradas do prontuário clínico e os custos de aquisição diretamente do CompraNet. Os custos médios por medicamento e por grupo são comparados. Resultados: dos 151 pacientes, 81 receberam sedação intravenosa e 70 anestesia inalatória com ou sem sedativos intravenosos. Não houve diferença na mortalidade, dias em ventilação mecânica, permanência na UTI e internação entre os grupos. Uma redução significativa nos custos derivados do menor uso de midazolam, propofol e dexmedetomidina (p < 0.0001) foi observada quando a anestesia inalatória foi usada e uma diferença entre as médias dos custos totais de sedação de $4,108.42 M.N. por dia por paciente. Conclusões: a anestesia inalatória durante a pandemia de COVID-19 permitiu redução de custos em comparação com a sedação endovenosa nos primeiros dois dias de internação na UTI.

Clinical performance and resource utilization in the start of a totally new Intensive Care Unit. Same staff, new area.

BACKGROUND: There is little information of intensive care unit (ICU) performance when it's relocated to a totally new and equipped area. OBJECTIVE: To analyze the clinical performance and use of resources of a new respiratory-ICU (nRICU) in a large third-level care hospital. METHOD: Cross-sectional, comparative study using prospective data of patients admitted from July 17, 2017 to July 17, 2018. The Rapoport adjusted method was used to obtain the standardized clinical performance index (SCPI) and the standardized resource use index (SRUI). RESULTS: Out of 354 patients, those who were readmissions or remained hospitalized and those whose treatment was withheld or withdrawn where excluded from the analysis. In 301 patients, the observed survival at hospital discharge was 63% while the expected survival was 67.7%. Values of SCPI and SRUI were -1.03 and 0.05 respectively, placing results in coordinates within two standard deviations when plotted in the Rapoport chart. There was a statistically significant difference in survival when comparing the study period with outcomes obtained in the RICU before its relocation (63% vs. 55%, p = 0.01). CONCLUSIONS: In its 1st year of operation, the nRICU had better clinical performance compared to the former RICU, with no change in the use of resources.

ANTECEDENTES: Existe poca información acerca del desempeño de una unidad de cuidados intensivos (UCI) cuando es reubicada en un área totalmente nueva y equipada. OBJETIVO: Analizar el rendimiento clínico y el uso de recursos de la nueva UCI respiratoria (UCIR) de un hospital grande de tercer nivel. MÉTODO: Estudio transversal, comparativo, con datos prospectivos de pacientes ingresados del 17 de julio de 2017 al 17 de julio de 2018. Se usa el método ajustado de Rapoport para obtener el índice de rendimiento clínico estandarizado (IRCE) y el índice de uso de recursos estandarizado (IRURE). RESULTADOS: De 354 pacientes fueron excluidos los reingresos, los pacientes aún hospitalizados y aquellos a quienes se limitó o retiró el tratamiento. En 301 pacientes la sobrevida hospitalaria fue del 63%, mientras que la sobrevida esperada fue del 67.7%. El IRCE fue −1.03 y el IRURE fue 0.05, situando el resultado en coordenadas dentro de dos desviaciones estándar en el gráfico de Rapoport. Hubo una diferencia estadísticamente significativa en la sobrevida comparando el periodo de estudio con resultados de la UCIR obtenidos antes de su reubicación (63 vs. 55%, p = 0.01). CONCLUSIONES: En su primer año de funcionamiento, la nueva UCIR tuvo mejor rendimiento clínico que la antigua, sin modificación en el uso de recursos.

Mortality in Patients With Chronic Renal Disease Without Health Insurance in Mexico: Opportunities for a National Renal Health Policy.

INTRODUCTION: Despite a systematic increase in the coverage of patients with end-stage renal disease (ESRD) who have received dialytic therapies and transplantation over the past 2 decades, the Mexican health system currently still does not have a program to provide full coverage of ESRD. Our aim was to analyze mortality in patients with ESRD without health insurance. METHODS: This was a prospective cohort study of 850 patients with advanced chronic kidney disease (CKD). Risk factors associated with death were calculated using a Cox's proportional hazards model. We used the statistical package SPSS version 22.0 for data analysis. RESULTS: The mean age of patients was 44.8 ± 17.2 years old. At the time of hospital admission, 87.6% of the population did not have a social security program to cover the cost of renal replacement treatment, and 91.3% of families had an income below US$300 per month. During the 3 years of the study, 28.8% of the cohort patients were enrolled in 1 of Mexico's social security programs. The 3-year mortality rate was of 56.7% among patients without access to health insurance, in contrast to 38.2% of patients who had access to a social security program that provided access to renal replacement therapy (P < 0.001). Risk factor analysis revealed that not having health insurance increased mortality (risk ratio: 2.64, 95% confidence intervals: 1.84-3.79; P = 0.001). CONCLUSION: Mexico needs a coordinated National Kidney Health and Treatment Program. A program of this nature should provide the basis for an appropriate educational and intervention strategy for early detection, prevention, and treatment of patients with advanced chronic kidney disease.

Omisiones detectadas en 150 casos de muerte materna en la Ciudad de México / Omissions detected in 150 cases of maternal death in Mexico City

Resumen OBJETIVO: Identificar y describir, en una muestra poblacional acotada, las omisiones en el proceso de atención a la salud en casos de muerte materna. MATERIALES Y MÉTODOS: Estudio descriptivo y retrospectivo para el que se seleccionaron cuatro hospitales federales de referencia, ubicados en la Ciudad de México, para revisión de los casos de muerte materna ocurridos entre enero de 2010 y diciembre de 2017. Para la identificación de las omisiones en el proceso de atención, se estudiaron 11 variables del dictamen de muerte materna: oportunidad del diagnóstico clínico, tratamiento otorgado, atención de complicaciones, atención prenatal, oportunidad de la atención médica, registro de datos en el expediente, previsibilidad de la muerte materna y muertes susceptibles de evitarse por el hospital. RESULTADOS: Se analizaron 150 casos de muerte materna. El 36% de los casos se dictaminaron como muertes que pudieron evitarse por el hospital y 71% como muertes susceptibles de prevención mediante diagnóstico. No recibieron atención prenatal 92 pacientes (61%); en 52 casos (35%) los registros médicos en el expediente clínico estaban incompletos. CONCLUSIONES: Los dictámenes elaborados por los comités señalan las acciones que no se llevaron a cabo durante el proceso de atención. El subregistro de datos en los expedientes clínicos es una omisión que afecta negativamente el análisis de los casos y la integración de los dictámenes por parte de los comités. El porcentaje elevado de evitabilidad y previsibilidad de los casos refleja probables deficiencias durante la atención en diferentes áreas y permite definir acciones correctivas para disminuir su ocurrencia.

Abstract OBJECTIVE: Identify and describe, in a limited population sample, the omissions in the health care process in cases of maternal death. MATERIALS AND METHODS: This is a descriptive and retrospective study. Four federal referral hospitals were selected, located in Mexico City and the cases of maternal death occurred between January 2010 and December 2017. For the identification of the omissions in the care process, 11 variables of the opinion were studied. of maternal death: opportunity of clinical diagnosis, treatment granted, care of complications, prenatal care, opportunity for medical attention, record of data in the file, predictability of maternal death and avoidable deaths by the hospital. RESULTS: 150 cases of maternal death were reviewed. 36% of the cases were ruled as preventable deaths by the hospital and 71% as preventable deaths by diagnosis. Ninety-two patients (61%) did not receive prenatal care; in 52 cases (35%), the medical records in the clinical file were incomplete. CONCLUSIONS: The opinions drawn up by the Committees indicate the actions that were not carried out during the care process. The underreporting of data in the clinical files is an omission that negatively affects the analysis of the cases and the integration of the opinions by the committees. The high percentage of preventability and predictability of the cases, reflects probable deficiencies during the attention in different areas and allows to define corrective actions to reduce their occurrence.

Ascending necrotizing mediastinitis secondary to emphysematous pyelonephritis.

Mediastinal infections usually originate from postoperative complications or in a descending manner from a cervical infectious process; few reports have emerged describing an ascending trajectory. A 56-year-old woman with a Huang class 1 left emphysematous pyelonephritis was referred due to a progression of an ascending necrotizing mediastinitis. A left posterolateral thoracotomy was performed, drainage and thorough lavage were carried out with a successful outcome. We believe this is the first reported case of ascending necrotizing mediastinitis secondary to an emphysematous renal infection.

Systematic review of spontaneous pneumomediastinum: a survey of 22 years' data.

OBJECTIVE: To describe and clarify management protocols in relation to spontaneous pneumomediastinum, and try to integrate criteria on this subject. BACKGROUND: Thoracic physicians are faced with patients who present with gas in the mediastinum, frequently without an obvious etiologic factor. Published material contains heterogeneous information from which different conclusions can be drawn. METHODS: In a Medline search from 1990 to 2012, we collected data on mortality, morbidity, signs, symptoms, etiologic factors, and diagnostic methods. Standardized mean differences were calculated. RESULTS: We identified 600 patients in 27 papers with series of >5 patients without precipitating or etiologic factors previous to the clinical presentation, but athletic activity, drug abuse, and history of asthma played an apparent role in the disease process. Most patients complained of thoracic pain and dyspnea, with subcutaneous emphysema and Hamman's sign. The most common complication was tension pneumothorax. Morbidity was seen in 2.8%; no mortality has been reported so far. CONCLUSION: Spontaneous pneumomediastinum is a rare disease with a benign course, which should be treated conservatively unless a complication mandates an invasive procedure. An algorithm for diagnosis and treatment is offered, based on the available evidence.

Descending necrotizing mediastinitis below the tracheal carina.

BACKGROUND: Descending necrotizing mediastinitis is a dreadful disease with a high mortality rate, particularly when below the tracheal carina. This study describes the epidemiologic, clinical, and paraclinical features of patients treated for this condition. METHODS: We performed a single-center retrospective descriptive review of 60 patients with descending necrotizing mediastinitis below the tracheal carina, who were treated during a 7-year period, the largest study in the last 50 years. Demographic, clinical, paraclinical, and therapeutic variables were analyzed. RESULTS: 43 (71.7%) patients were male. The mean age was 41.2 ± 14.7 years. Mean hospital length of stay was 25.0 ± 19.8 days. Comorbidities were present in 46.7% of patients, diabetes mellitus being the most common. Odontogenic infections (45%) were the most frequent source of descending necrotizing mediastinitis. Cultures showed Gram-negative bacilli in 68.3%, Gram-positive cocci in 38.3%, and fungi in 6.7%. Mortality was 35% (21 patients); risk factors for mortality were age (>35 years), diabetes mellitus among other comorbidities, and associated complications. CONCLUSIONS: In this low socioeconomic status patient population, descending necrotizing mediastinitis below the carina causes high morbidity and mortality, the latter particularly associated with age, complications, diabetes mellitus and other comorbidities.

Pleomorphic adenoma of the trachea: A case report.

We present the case of a 33-year-old woman who was being treated for bronchial asthma for 4 years. A tracheal tumor was evident on a computed tomography of the thorax and removed with argon plasma coagulation. It was diagnosed as pleomorphic adenoma of the trachea. It is a rare tracheal tumor without definite treatment guidelines. Our endoscopic approach to this rare lesion is discussed.

[Bronchoscopy-guided percutaneous tracheostomy. A safe technique in intensive care]. / Traqueostomía percutánea guiada por broncoscopia. Una técnica segura en cuidados intensivos.

INTRODUCTION: When compared with conventional surgery, bronchoscopy-guided percutaneous tracheostomy has demonstrated some advantages. We compare the results obtained with bronchoscopy-guided percutaneous tracheostomy performed by Intensive Care Unit personnel with those of conventional surgery. METHODS: Prospective and descriptive cohort of patients admitted to a respiratory intensive care unit from March 2010 to March 2012. RESULTS: A total of 510 patients were admitted to the respiratory Intensive Care Unit. Tracheostomy was performed in 51 (10%); of which, 27 (53%) underwent bronchoscopy-guided percutaneous tracheostomy, and 24(47%) underwent tracheostomy by conventional surgery. There were no differences between bronchoscopy-guided percutaneous tracheostomy and conventional surgery groups in age (52 ± 16 vs 53 ± 18 years, p = 0.83). Simplified Acute Physiology Score-3 differed among groups (59.4 ± 11.2 vs 51.5 ± 14.3, p = 0.03). Indications for performing tracheostomy were prolonged intubation (74.1% vs 62.5%, p = 0.55), neurologic impairment (22.2% vs 16.6%, p = 0.88), and laryngeal disease (3.7% vs 20.8%, p 0.14). Mean time between intubation and tracheostomy was 13.3 days (range 4-45) vs 13.4 days (range 2-40). There were three minor complications in bronchoscopy-guided percutaneous tracheostomy patients, transient bigeminism in one, and moderate bleeding in two, and one minor complication of moderate bleeding in one patient in the conventional surgery group, p = 0.68. CONCLUSION: Bronchoscopy-guided percutaneous tracheostomy is a versatile and safe alternative for conventional tracheostomy when performed in Intensive Care Unit by personnel with expertise and appropriate training.

Descending necrotizing mediastinitis associated with spinal cord abscess.

A 58-year-old man with a history of Ludwig's angina was admitted with a spinal cord abscess at the level of C2-T1 and associated osteomyelitic destruction of vertebral bodies, spinal cord compression, and secondary quadriparesis, followed by descending mediastinitis. A right posterolateral thoracotomy and a cervicotomy drained purulent exudates. A tracheostomy was performed, and the patient was discharged after 84 days.

Descending necrotizing mediastinitis and sternoclavicular joint osteomyelitis.

Descending necrotizing mediastinitis is usually associated with cervical or odontogenic infections. We describe a patient with blunt trauma to the chest 2 years earlier, and a slowly developing chest wall hematoma 18 months prior to admission, complicated by chronic sternoclavicular joint osteomyelitis, eventually leading to descending mediastinitis. Thoracotomy with drainage of the mediastinal spaces and multiple procedures for the sternoclavicular joint infection were successful. The rarity of this association and undefined optimal management prompted this report.