Moral distress among healthcare professionals working in intensive care units in Spain.

OBJECTIVE: To assess moral distress (MD) among Spanish critical care healthcare professionals (HCPs). DESIGN: Cross-sectional, prospective study. SETTING: ICUs in Spain. PARTICIPANTS: HCPs currently working in Spanish ICUs. INTERVENTIONS: A 55-item questionnaire was electronically distributed. MAIN VARIABLES: The questionnaire included work-related and socio-demographic characteristics, the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA), and the Hospital Ethical Climate Survey (HECS). RESULTS: In total, 1065 intensive care providers completed the questionnaire. Three out of four validity hypotheses were supported. MD was significantly higher for physicians (80, IQR 40-135) than for nurses (61, IQR 35-133, p=0.026). MD was significantly higher for those clinicians considering leaving their position (78, IQR 46-163 vs. 61, IQR 32-117; p<0.001). The MMD-HP-SPA was inversely correlated with the HECS (r=-0.277, p<0.001). An exploratory factor analysis revealed a four-factor structure, evidencing the patient, team, and system levels of MD. CONCLUSIONS: In the study sample, Spanish intensivists report higher MD than nurses. Strategies to improve ICU ethical climate and to correct other related factors in order to mitigate MD at a patient, team, and system level should be implemented. Both groups of HCPs manifest a relevant intention to leave their position due to MD. Further studies are needed to determine the extent to which MD influences their desire to leave the job.

Moral distress among healthcare professionals working in intensive care units in Spain.

OBJECTIVE: To assess moral distress (MD) among Spanish critical care healthcare professionals (HCPs). DESIGN: Cross-sectional, prospective study. SETTING: ICUs in Spain. PARTICIPANTS: HCPs currently working in Spanish ICUs. INTERVENTIONS: A 55-item questionnaire was electronically distributed. MAIN VARIABLES: The questionnaire included work-related and socio-demographic characteristics, the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA), and the Hospital Ethical Climate Survey (HECS). RESULTS: In total, 1065 intensive care providers completed the questionnaire. Three out of four validity hypotheses were supported. MD was significantly higher for physicians (80, IQR 40-135) than for nurses (61, IQR 35-133, p=0.026). MD was significantly higher for those clinicians considering leaving their position (78, IQR 46-163 vs. 61, IQR 32-117; p<0.001). The MMD-HP-SPA was inversely correlated with the HECS (r=-0.277, p<0.001). An exploratory factor analysis revealed a four-factor structure, evidencing the patient, team, and system levels of MD. CONCLUSIONS: In the study sample, Spanish intensivists report higher MD than nurses. Strategies to improve ICU ethical climate and to correct other related factors in order to mitigate MD at a patient, team, and system level should be implemented. Both groups of HCPs manifest a relevant intention to leave their position due to MD. Further studies are needed to determine the extent to which MD influences their desire to leave the job.

Evaluation of the thoracic compression technique using APPs. Do they help or hinder cardiopulmonary resuscitation? / Evaluación sobre la técnica de compresiones torácicas usando APP. ¿Ayudan o entorpecen la reanimación cardiopulmonar?

OBJECTIVE: To evaluate the quality of cardiopulmonary resuscitation (CPR) by lay people when guided by a mobile phone application with real-time feedback, with the comparison of three different mobile phone applications (APPs). DESIGN: A cross-sectional quasi-experimental study was carried out. PARTICIPANTS: A sample of 113 nursing students participated in the study. INTERVENTIONS: Three hands-only CPR tests with continuous compressions were performed: (i)without external help; (ii)with the mobile phone turned off; and (iii)guided by APP. Three different APPs were randomly assigned (Pocket CPR®, CPR Pro®> and Massage cardiaque et DSA®). The mannequin Laerdal Resusci Anne QCPR (Stavanger, Norway) 2.0.0.14 software was used. VARIABLES OF PRIMARY INTEREST: APPs used. Demographic variables characterizing the study sample. INDEPENDENT VARIABLES: mean depth, mean rate, percentage of correct hand positioning, percentage of compressions with correct re-expansion, percentage of compressions with correct depth, percentage of compressions at the correct rate, and overall quality of CPR. RESULTS: Overall CPR quality was 33.3% ± 32.7 using Pocket CPR, 10.9% ± 22.72% using CPR Pro and 7.8% ± 9.2 using Massage cardiaque et DSA. None of the APPs produced a statistically significant improvement. The percentage of time that the resuscitator managed to maintain a correct compression rate improved when using all three APPs. CONCLUSIONS: Cardiopulmonary resuscitation guided by phone APPs did not improve the overall quality of compressions during resuscitation, though it improved the percentage of compressions performed at the correct rate.

[Recommendations on cardiopulmonary resuscitation in patients with suspected or confirmed SARS-CoV-2 infection (COVID-19). Executive summary]. / Recomendaciones sobre reanimación cardiopulmonar en pacientes con sospecha o infección confirmada por SARS-CoV-2 (COVID-19). Resumen ejecutivo.

The SARS-CoV-2 pandemic has created new scenarios that require modifications to the usual cardiopulmonary resuscitation protocols. The current clinical guidelines on the management of cardiorespiratory arrest do not include recommendations for situations that apply to this context. Therefore, the National Cardiopulmonary Resuscitation Plan of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), in collaboration with the Spanish Group of Pediatric and Neonatal CPR and with the Teaching Life Support in Primary Care program of the Spanish Society of Family and Community Medicine (SEMFyC), have written these recommendations, which are divided into 5 parts that address the main aspects for each healthcare setting. This article consists of an executive summary of them.

[Preliminary clinical experience with PiCCO system in children with shock]. / Experiencia clínica de monitorización hemodinámica del shock mediante el sistema PiCCO.

PURPOSE: To evaluate the PiCCO hemodynamics monitor in terms of clinical usefulness in children with shock. METHODS: Prospective multicenter analytical study in children aged from one month to 18 years with shock admitted to five pediatric intensive care units. Measurements were made before and after three interventions: a) volume load; b) increases in vasoactive drugs; c) dosage changes of drugs that could lessen vascular resistance. Recorded parameters included thermodilution data, along with the usual hemodynamic parameters. RESULTS: A total of 120 measurements were performed on 35 patients: mean age 36 (2.6-156) months, mean weight 15 (5.8-72) kg. Shock etiology was septic in 37% of cases, cardiogenic in 26%, hypovolemic in 20% and neurogenic in 17%. No procedure related complication was noticed. Twenty-two volume challenges in 17 patients were registered. Volume load induced a significant intrathoracic blood volume index (ITBI) increase from 501(235-763) to 584 (418-810) ml/m(2), cardiac index (CI) 4.04 (2.58-6.25) to 4.48 (2.86-8.71) lmin-1m(2), and mean blood pressure from 74 (53-99) to 87 (59-112) mmHg. CI changes correlated with ITBI increase (r = 0.678, p = 0.001). 13 interventions to increase vasomotor tone were associated with an increase in contractility of 18% in systemic vascular resistance index (SVRI). CONCLUSIONS: Hemodynamic monitoring with the PiCCO system is feasible and seems safe in children with shock. PiCCO derived parameters could add clinically important information to assess preload state and its modifications with therapy.

[Serious accidents caused by horses. Warnings and prevention rules]. / Accidentes graves provocados por caballos. Alertas y pautas de prevención.

INTRODUCTION: Children's equestrian activities in the domestic, play activities, sports and educational areas are relatively frequent, and are not exempt from risks. Nevertheless, there is a lack of data on horse-related injuries, their circumstances and the key points for their prevention. METHOD: Retrospective and descriptive study of pediatric equestrian injuries admitted to Hospital between July 1997 and September 2008. RESULTS: A total of 17 patients with ages between 4 and 17 years were analyzed. There were 14 accidental falls, 2 kicks and 1 bite, and 8 patients had lost consciousness after the accident. Only 1 patient used a protective helmet. There were 3 skull fractures, 4 intracranial haemorrhages, 1 pneumoencephalus and 2 diffuse axonal injuries. There were also 4 long bone fractures, 1 jaw fracture, 1 vertebral wedging and 1 partial ear avulsion were recorded. A total of 8 patients required intensive care, 2 underwent neurosurgery due to an intracranial haematoma and 4 surgical fracture reduction. CONCLUSIONS: Horse handling by children and teenagers can be a high risk activity. In our cases brain trauma was the most common and severe injury. Due to the poor use of protection devices by our patients, we believe it is now necessary to take measures to increase safety in equestrian activities.

A new chest compression technique in infants. / Nueva técnica de masaje cardíaco en lactantes.

OBJECTIVE: To compare the quality of chest compressions performed according to the classical technique (MT) versus a new technique (NM) (compression with 2thumbs with closed fists) in an infant manikin. DESIGN: A controlled, randomized cross-over study was carried out in professionals assisting pediatric patients. SETTING: A University Hospital with a Pediatric ICU in the north of Spain. PARTICIPANTS: Residents and nurses in Pediatrics who had completed a basic and an advanced pediatric cardiopulmonary resuscitation course. INTERVENTIONS: Quantitative analysis of the variables referred to chest compression quality in a 2-minute cardiopulmonary resuscitation scenario in infants. Laerdal's SimPad® with SkillReporter™ system was used. MAIN VARIABLES OF INTEREST: Mean rate and percentage of compressions in the recommended rate range, mean depth and percentage of compressions within the depth range of recommendations, percentage of compressions with adequate decompression, and percentage of compressions performed with the fingers in the center of the chest. RESULTS: Global quality of the compressions (NM: 84.2±23.7% vs. MT: 80.1±25.4% [p=0.25; p=ns]), percentage of compressions with correct depth (NM: 59.9±35.8% vs. MT: 59.5±35.7% [p=0.76; p=ns]), mean depth reached (NM: 37.3±3.8mm vs. MT: 36±5.3mm [p=0.06; p=ns]), percentage of complete re-expansion of the chest (NM: 94.4±9.3% vs. MT: 92.4±18.3% [p=0.58; p=ns]), and percentage of compressions with the recommended rate (NM: 62.2±34.6% vs. MT: 51±37.2% [p=0.13; p=ns]) proved similar with both methods. CONCLUSIONS: The quality of chest compressions with the new method (thumbs with closed fists) is similar to that afforded by the traditional method.

Therapeutic criteria in communicating childhood hydrocephalus.

AIM: The aim of this study was to evaluate the usefulness of cerebral blood flow velocity in the middle cerebral artery measured by transcranial Doppler as criteria to therapeutic action in communicating hydrocephalic children. METHODS: In eight non-tumoral communicating hydrocephalic infants, ranging from five to 18 months of age, monitored from 18 to 36 months (mean time of follow-up: 24.25 months), cerebrospinal fluid (CSF) oxypurines (hypoxanthine and xanthine) and uric acid levels were compared by means of the Evans' index, the mean weekly increase in cranial circumference, and the transcranial Doppler measurements. RESULTS: Results indicate that clinical (mean weekly increase in head circumference), radiological (Evans' index), biochemical (oxypurines and uric acid in the CSF), and hemodynamic (transcranial Doppler) criteria have the same role in monitoring infantile hydrocephalus. CONCLUSION: In conclusion the transcranial Doppler measurement can be done noninvasively and examinations can be repeated when needed, obtaining immediate RESULTS: Hence, it is the most adequate monitoring technique in clinical practice.

[Glossary of bioethic terms and expressions frequently used in pediatric intensive care practice]. / Glosario de términos y expresiones frecuentes de bioética en la práctica de cuidados intensivos pediátricos.

Ethical issues are of increasing interest in current medicine, and pediatrics is no exception. In critical care, the relevance of these considerations becomes even greater. Commonly used expressions in bioethics, frequently lead to terminological confusion and misunderstandings, as reported by several publications, revealing a lack of clear concepts in many cases. As an attempt to clarify or facilitate the comprehension of the most relevant terms in this field, the Spanish Society of Pediatric Intensive Care has prepared a Glossary of the most commonly used terms and expressions.

[Ethics and pediatric cardiopulmonary resuscitation]. / Etica y reanimación cardiopulmonar pediátrica.

Cardiopulmonary resuscitation (CPR) is a medical activity that involves major ethical issues. As in other areas of clinical ethics, CPR decisions must be based on the principles of autonomy, beneficence, nonmaleficence, and justice. The decision-making process is more difficult in emergency situations, and when the patient is a minor, the parents and the child's best interests must be taken into consideration. There are specific situations in which starting CPR is clearly indicated and others in which ceasing resuscitation maneuvers is justified. Do not attempt resuscitation orders must be respected by health staff. Other ethical issues involved in CPR include resuscitation of potential organ donors, learning CPR procedures, research in CPR, and the information given to the parents of children with cardiorespiratory arrest.

[Usefulness of Heliox in the management of a serious airway obstruction caused by a subglottic hemangioma]. / Utilidad del Heliox en el manejo de una obstrucción grave de la vía aérea por un hemangioma subglótico.

Heliox therapy, alone or combined with noninvasive ventilation, has successfully been used in the treatment of infants and children with respiratory disease such as airway obstruction. We describe the case of a 1-month-old infant with severe upper respiratory airway obstruction (approximately 80 %) secondary to multiple cervical hemangiomatosis effectively treated with either Heliox alone or combined with nasal continuous positive airway pressure. This treatment provided symptomatic relief and facilitated diagnosis and subsequent application of specific treatment; the patient was free of signs of respiratory distress and the use of aggressive treatments such as endotracheal intubation or tracheal cannulation was avoided. Heliox can constitute a multipurpose, safe and useful tool in the noninvasive management of infants and children with serious obstructive respiratory disease.

[Long-term consequences of pediatric trauma requiring intensive care]. / Consecuencias a largo plazo de los traumatismos pediátricos que precisaron cuidados intensivos.

INTRODUCTION: Trauma is a major cause of pediatric morbidity. The aim of the present study was to determine the long-term effects of severe trauma in children and their families. PATIENTS AND METHODS: We performed an observational, cross sectional study of 209 children admitted to our pediatric intensive care unit due to trauma between 1999 and 2003. Family members and/or children were interviewed at least 2 years after the event. Functional situation was assessed by means of the Pediatric Overall Performance Category (POPC) scale and neurological status by means of the Pediatric Cerebral Performance Category (PCPC) scale. Subjective perception of quality of life was also evaluated. RESULTS: At assessment, patient age was 13+/-4 years. The causes of trauma were traffic accidents (42.6%), falls (30.1%), bicycle accidents (15.3%) and other causes (12%). The trauma affected the brain and cranium in 78.9%, skeleton in 20.2%, abdomen in 16.3% and other body regions in 15.3% of the patients. At assessment, 1.5 % of the patients were in a persistent vegetative state, 0.5% had severe disability, and 1% had moderate disability. A total of 9.5% had some type of persistent psychological disorder and 3.8 % needed some kind of help to perform daily activities. The median (range) score for self-estimated quality of life by the family was 3 (0-6) for the group of children with moderate or severe disability, while 12.9% of parents reported serious alterations of family dynamics related to the trauma event. CONCLUSIONS: Most children who survive after severe trauma achieve a good functional situation in the long term. Although the number of children with severe sequelae is small, these children have serious difficulties in achieving normal social adaptation and their quality of life is clearly impaired.

[Reversible posterior leukoencephalopathy syndrome: an infrequent complication in the course of haemolytic-uremic syndrome]. / Leucoencefalopatía posterior reversible: una complicación infrecuente en el curso del síndrome hemolítico urémico.

INTRODUCTION: Posterior reversible leukoencephalopathy syndrome (PRLS) is characterised by the sudden and usually transient onset of headaches, visual disorders, decreased awareness and convulsions associated with cerebral oedema in the posterior areas of the brain. Different reports have associated it with numerous processes and possibly with haemolytic-uremic syndrome (HUS). We describe a new case of PRLS within the context of HUS. CASE REPORT: We describe the case of a 4-year-old child with HUS who developed arterial hypertension that did not respond well to treatment and kidney failure that required renal replacement therapy. During the course of the disease the patient presented several transient episodes of headache, a lowered level of consciousness and seizures. Magnetic resonance imaging revealed multiple lesions in the white matter and the cortex that were hyperintense in T2 and hypointense in T1 situated in the bilateral occipital and right frontotemporoparietal regions. The patient made a full clinical recovery in a few days, although an magnetic resonance imaging scan performed at six weeks after the last episode showed partial remission of the lesions and a small cerebral infarction. CONCLUSIONS: The pathogenesis of PRLS is still not fully understood. Its multifactorial origin suggests that several different mechanisms may be involved. In the case reported here, it is possible that the arterial hypertension, retention of fluids and even the sessions of dialysis played a role in its development.

Utility of a simple lighting device to improve chest compressions learning. / Utilidad de un dispositivo luminoso simple para mejorar el aprendizaje del masaje cardiaco.

INTRODUCTION: The recommendations on cardiopulmonary resuscitation (CPR) emphasize the quality of the manoeuvres, especially chest compressions (CC). Audiovisual feedback devices could improve the quality of the CC during CPR. The aim of this study was to evaluate the usefulness of a simple lighting device as a visual aid during CPR on a mannequin. MATERIAL AND METHODS: Twenty-two paediatricians who attended an accredited paediatric CPR course performed, in random order, 2min of CPR on a mannequin without and with the help of a simple lighting device, which flashes at a frequency of 100 cycles per minute. The following CC variables were analyzed using a validated compression quality meter (CPRmeter®): depth, decompression, rate, CPR time and percentage of compressions. RESULTS: With the lighting device, participants increased average quality (60.23±54.50 vs. 79.24±9.80%; P=.005), percentage in target depth (48.86±42.67 vs. 72.95±20.25%; P=.036) and rate (35.82±37.54 vs. 67.09±31.95%; P=.024). CONCLUSIONS: A simple light device that flashes at the recommended frequency improves the quality of CC performed by paediatric residents on a mannequin. The usefulness of this CPR aid system should be assessed in real patients.

[Automated external defibrillation in children]. / Desfibrilación semiautomática en niños.

Ventricular fibrillation is an infrequent arrhythmia in cardiac arrest occurring in the out-of-hospital setting in infants and small children. However, outcome is good provided early defibrillation is performed; consequently, this procedure is one of the main links in the chain of survival in children with a shockable rhythm. Automated external defibrillators are small devices that can analyze heart rhythm and deliver a dose of electric energy when considered timely by the operator. Automated external defibrillators are easy to use and can be operated, if necessary, by anyone. Therefore, all pediatricians should be aware of how these devices work and be able to use them safely and effectively, following the current defibrillation protocol.

[Basic life support in pediatrics]. / Reanimación cardiopulmonar básica en Pediatría

Basic life support (BLS) is the combination of maneuvers that identifies the child in cardiopulmonary arrest and initiates the substitution of respiratory and circulatory function, without the use of technical adjuncts, until the child can receive more advanced treatment. BLS includes a sequence of steps or maneuvers that should be performed sequentially: ensuring the safety of rescuer and child, assessing unconsciousness, calling for help, positioning the victim, opening the airway, assessing breathing, ventilating, assessing signs of circulation and/or central arterial pulse, performing chest compressions, activating the emergency medical service system, and checking the results of resuscitation. The most important changes in the new guidelines are the compression: ventilation ratio and the algorithm for relieving foreign body airway obstruction. A compression/ ventilation ratio of 30:2 will be recommended for lay rescuers of infants, children and adults. Health professionals will use a compression: ventilation ratio of 15:2 for infants and children. If the health professional is alone, he/she may also use a ratio of 30:2 to avoid fatigue. In the algorithm for relieving foreign body airway obstruction, when the child becomes unconscious, the maneuvers will be similar to the BLS sequence with chest compressions (functioning as a deobstruction procedure) and ventilation, with reassessment of the mouth every 2 min to check for a foreign body, and evaluation of breathing and the presence of vital signs. BLS maneuvers are easy to learn and can be performed by anyone with adequate training. Therefore, BLS should be taught to all citizens.