[Recommendations for the management of critically ill patients with COVID-19 in Intensive Care Units]. / Recomendaciones para el manejo de los pacientes críticos con COVID-19 en las Unidades de Cuidados Intensivos.

The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.

Association between exposure to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers prior to septic shock and acute kidney injury.

OBJECTIVE: To evaluate the association between angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) use prior to a septic shock episode and the development, prognosis and long-term recovery from acute kidney injury (AKI). DESIGN: A single-centre, prospective observational study was carried out between September 2005 and August 2010. SCOPE: Patients admitted to the ICU of a third level hospital. PATIENTS: A total of 386 septic shock patients were studied. INTERVENTIONS: None. VARIABLES OF INTEREST: Use of ACEIs/ARBs, AKI development, recovery of previous creatinine levels and time to recovery. RESULTS: A total of 386 patients were included, of which 312 (80.8%) developed AKI during ICU stay and 23% were receiving ACEIs/ARBs. The percentage of patients on ACEIs/ARBs increased significantly in relation to more severe stages of AKI irrespective of the kind of AKI score. After adjusting for confounders, the development of AKI was independently associated to the use of ACEIs/ARBs (OR 2.19; 95%CI 1.21-3.84; p=.04). With respect to the recovery of kidney function, the group of patients on ACEIs/ARBs had significantly higher creatinine levels at ICU discharge and needed hemodialysis more frequently thereafter. However, use of ACEIs/ARBs affected neither recovery of previous creatinine levels nor significantly delayed recovery. CONCLUSIONS: The use of ACEIs/ARBs before septic shock episodes was correlated to AKI development and severity, but did not affect the recovery of kidney function after sepsis resolution.

Effects of antibiotic administration delay and inadequacy upon the survival of septic shock patients.

OBJECTIVE: To assess how antibiotic administration delay and inadequacy influence survival in septic shock patients. DESIGN: A prospective, observational cohort study was carried out between September 2005 and September 2010. SCOPE: Patients admitted to the ICU of a third level hospital. PATIENTS: A total of 342 septic shock patients INTERVENTIONS: None VARIABLES OF INTEREST: The time to antibiotic administration (difference between septic shock presentation and first administered dose of antibiotic) and its adequacy (in vitro susceptibility testing of isolated pathogens) were determined. RESULTS: ICU and hospital mortality were 26.4% and 33.5%, respectively. The median delay to administration of the first antibiotic dose was 1.7h. Deceased patients received antibiotics significantly later than survivors (1.3±14.5h vs. 5.8±18.02h; P=.001). Percentage drug inadequacy was 12%. Those patients who received inadequate antibiotics had significantly higher mortality rates (33.8% vs. 51.2%; P=.03). The coexistence of treatment delay and inadequacy was associated to lower survival rates. CONCLUSIONS: Both antibiotic administration delay and inadequacy exert deleterious effects upon the survival of septic shock patients, independently of their characteristics or severity.

[Measuring the satisfaction of patients admitted to the intensive care unit and of their families]. / Medición de la satisfacción de los pacientes ingresados en unidad de cuidados intensivos y sus familiares.

OBJECTIVE: To determine the level of satisfaction of family members with the care and decision making process, and to know the level of satisfaction of patients discharged from ICU. DESIGN: A prospective, observational and descriptive study with a duration of 5 months was carried out. SETTING: The ICU of Marqués de Valdecilla University Hospital, Santander (Spain). SUBJECTS: Family members of adult patients admitted to the ICU and patients discharged to the ward. INSTRUMENT: Family Satisfaction Intensive Care Survey (FS-ICU 34) of family members of patients discharged to the ward. We adapted the FS-ICU 34 in relation to care for application to the patients. RESULTS: A total of 385 questionnaires were obtained: 192 from families of survivors and 162 from patients, and 31 from relatives of non-survivors. The majority of relatives were satisfied with overall care and overall decision making (survivors: 83.46 ± 11.83 and 79.42 ± 13.58, respectively; non-survivors: 80.41 ± 17.27 and 79.61 ± 16.93, respectively). Patients were very satisfied with the care received (84.71 ± 12.85). CONCLUSIONS: The level of satisfaction of the relatives of patients admitted to the ICU is high, in the same way as the degree of patient satisfaction. Still, there are several points that should be improved, such as the waiting room environment and the atmosphere of the ICU in terms of noise, privacy and lighting. In relation to the decision making process, there are also some aspects that may be improved, such as the provision of hope regarding recovery of the critically ill relative.

Training in intensive care medicine. A challenge within reach.

The medical training model is currently immersed in a process of change. The new paradigm is intended to be more effective, more integrated within the healthcare system, and strongly oriented towards the direct application of knowledge to clinical practice. Compared with the established training system based on certification of the completion of a series or rotations and stays in certain healthcare units, the new model proposes a more structured training process based on the gradual acquisition of specific competences, in which residents must play an active role in designing their own training program. Training based on competences guarantees more transparent, updated and homogeneous learning of objective quality, and which can be homologated internationally. The tutors play a key role as the main directors of the process, and institutional commitment to their work is crucial. In this context, tutors should receive time and specific formation to allow the evaluation of training as the cornerstone of the new model. New forms of objective summative and training evaluation should be introduced to guarantee that the predefined competences and skills are effectively acquired. The free movement of specialists within Europe is very desirable and implies that training quality must be high and amenable to homologation among the different countries. The Competency Based training in Intensive Care Medicine in Europe program is our main reference for achieving this goal. Scientific societies in turn must impulse and facilitate all those initiatives destined to improve healthcare quality and therefore specialist training. They have the mission of designing strategies and processes that favor training, accreditation and advisory activities with the government authorities.

Early identification of infectious complications in lung transplant recipients using procalcitonin.

OBJECTIVES: The purpose of this study was to determine how sequential measurements of procalcitonin (PCT) could improve the diagnosis of early infectious complications after lung transplantation, and to compare this molecule with other commonly used markers (serum C-reactive protein [CRP] and leukocyte count). METHODS: Prospective observational study in a 34-bed university hospital intensive care unit (ICU). All lung transplant (LT) recipients between January and November 2010 were included. Biomarkers were measured just before surgery, on ICU admission, and daily on postoperative days 2, 3, 4, and 7. RESULTS: A total of 25 patients were included. Those patients with infectious complications presented with significantly higher levels of PCT as early as the first day after transplantation and during subsequent days. The area under receiver operating characteristic curve for PCT as a predictor of infection ranged between 0.83 and 0.97. PCT cutoff of 8.18 ng/mL on day 2 had a sensitivity of 80% and specificity of 100% for prediction of infection development. Neither CRP levels nor leukocyte count could discriminate between the patients with and without infections at any time. CONCLUSIONS: In contrast with CRP levels and leukocyte counts, measurement of PCT appears to be a useful diagnostic tool in detecting early infectious complications in LT patients.

[Prognostic value of procalcitonin, C-reactive protein and leukocytes in septic shock]. / Valor pronóstico del aclaramiento de procalcitonina, PCR y leucocitos en el shock séptico.

OBJECTIVES: This study evaluates the potential prognostic value of serial measurements of different biomarkers (procalcitonin [PCT], C-reactive protein and leukocytes [CRP]) in septic shock patients. DESIGN: Prospective observational study. SETTING: Intensive care unit of a third-level University Hospital. PATIENTS: The study comprised a total of 88 septic shock patients defined using the 2001 Consensus Conference SCCM/ESICM/ACCP/ATS/SIS criteria. The PCT, CRP and leukocytes were recorded on admission to the ICU and again 72 hours after admission. INTERVENTIONS: None. RESULTS: Those patients with increasing procalcitonin levels showed higher hospital mortality than those with a decreasing levels (58.8% vs. 15.4%, P<0.01). No such effect was observed in relation to C-reactive protein or leukocytes. The best area under the curve for prognosis was for procalcitonin clearance (0.79). A procalcitonin clearance of 70% or higher offered a sensitivity and specificity of 94.7% and 53%, respectively. CONCLUSIONS: Serial procalcitonin measurements are more predictive of the prognosis of septic shock patients than single measurements of this parameter. The prognostic reliability of the latter is also better than in the case of C-reactive protein and leukocytes. The application of serial procalcitonin measurements may allow the identification of those septic patients at increased mortality risk, and help improve their treatment.

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).

Recommendations for the management of critically ill patients with COVID-19 in Intensive Care Units.

The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.

[EICS (Extended Intensive Care Service): looking outside the ICU]. / SECI (Servicio Extendido de Cuidados Intensivos): mirando fuera de la UCI.

Early warning systems (EWS) identify patients at risk with a view to improving morbidity and mortality rates using early therapeutic and transfer actions. We have recently implemented an EWS that focuses on two main aspects: the guidance of care after discharge from the ICU, and recognition of the onset of deteriorating health among adult patients in general wards through physiologically based early warning scores.

Acceptance and validity of the methods used to implement a competency based medical education programme in an Intensive Care Department of a teaching referral center.

OBJECTIVES: 1. To determine the satisfaction of tutors and residents with a specific methodology used to implement CoBaTrICE. 2. To determine the reliability and validity of the global rating scales designed ad hoc to assess the performance of the residents for training purposes. DESIGN: Prospective cohort study. PARTICIPANTS: All the residents and tutors of the ICU Department of the Hospital Universitario y Politécnico la Fe de Valencia. INTERVENTION: CoBaTrICE implementation started in March 2016, it was based on: (1) Training the tutors in feedback techniques; (2) Performing multiple objective and structured work based assessments to achieve the competences of the program; and (3) The use of an electronic portfolio to promote learning reflection and to collect the evidence that learning was taking place. METHODS: The acceptance of CoBaTrICE was explored through a satisfaction survey conducted after 9 months of implementation of the training program. The 15 residents and 5 tutors of the ICU Department were asked about the methodology of the formative assessments, the quality of the feedback, self-learning regulation and the electronic portfolio usefulness. The validity of the global rating scales was assessed through the tests alfa de Cronbach, reliability and generalizability indexes, and intraclass correlation coefficient. RESULTS: The implementation of CoBaTrICE was satisfactory in all the dimensions studied. The global rating scales used for formative purposes showed reliability and validity. CONCLUSIONS: The methodology used to implement CoBaTrICE was highly valued by tutors and residents. The global rating scales used for formative purposes showed reliability and validity.

[Contingency plan for the intensive care services for the COVID-19 pandemic]. / Plan de contingencia para los servicios de medicina intensiva frente a la pandemia COVID-19.

In January 2020, the Chinese authorities identified a new virus of the Coronaviridae family as the cause of several cases of pneumonia of unknown aetiology. The outbreak was initially confined to Wuhan City, but then spread outside Chinese borders. On 31 January 2020, the first case was declared in Spain. On 11 March 2020, The World Health Organization (WHO) declared the coronavirus outbreak a pandemic. On 16 March 2020, there were 139 countries affected. In this situation, the Scientific Societies SEMICYUC and SEEIUC have decided to draw up this Contingency Plan to guide the response of the Intensive Care Services. The objectives of this plan are to estimate the magnitude of the problem and identify the necessary human and material resources. This is to provide the Spanish Intensive Medicine Services with a tool to programme optimal response strategies.

[Pediatric advanced life support]. / Reanimación cardiopulmonar avanzada en pediatría.

Advanced life support (ALS) includes all the procedures and maneuvers used to restore spontaneous circulation and breathing, thus minimizing brain injury. The fundamental steps of ALS are airway control with adjuncts, ventilation with 100% oxygen, vascular access and fluid and drug administration, and monitoring to diagnose and treat arrhythmias. Airway control can be achieved by means of oropharyngeal airway, endotracheal intubation, and alternative methods (laryngeal mask and cricothyroidotomy). Vascular access can be achieved by the peripheral venous, intraosseous, central venous, and tracheal routes. The most frequent rhythms found in children with cardiorespiratory arrest are nonshockable (asystole, severe bradycardia, pulseless electrical activity, and complete atrioventricular block). In these cases, adrenaline continues to be the essential drug. Currently, low adrenaline doses (0.01 mg/kg IV and 0.1 mg/kg intratracheal administration) are recommended throughout the resuscitation period. Amiodarone (5 mg/kg) is the drug of choice in cases of ventricular fibrillation refractory to electric shock. The treatment sequence for shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia) is one 4 J/kg electric shock, followed by cardiopulmonary resuscitation (chest compressions and ventilation) for 2 minutes with subsequent reassessment of the electrocardiographic rhythm. Adrenaline must be administered immediately before the third electric shock and subsequently every 3-5 minutes. Amiodarone must be administered immediately before the fourth shock.

[Recurrent ARDS in varicella pneumonia complicated by disseminated candidiasis in a pregnant woman]. / SDRA recurrente tras neumonía varicelosa complicado con candidiasis diseminada en mujer gestante.

Adult respiratory distress syndrome (ARDS) seems to be the common way from different etiologies. We describe the clinical evolution of an ARDS in a pregnant woman, initially due to Varicella Pneumonia which was complicated with Disseminated Candidiasis and recurrent ARDS. We review the nosocomial infection with Candida in ICU patients: the growing incidence, the diagnostic problems and the new standards for treatment.

Hospital mortality prognostication in sepsis using the new biomarkers suPAR and proADM in a single determination on ICU admission.

PURPOSE: The soluble form of the urokinase-type plasminogen activator receptor (suPAR) and proadrenomedullin (proADM) are two new and promising sepsis biomarkers. We assessed the prognostic value of a single determination of proADM and suPAR, comparing them with C-reactive protein (CRP) and procalcitonin (PCT), and evaluating whether their addition to severity scores (APACHE II and SOFA) could improve their prognostic accuracy. METHODS: A single-centre prospective observational study conducted in an adult intensive care department at Marques de Valdecilla University Hospital in Spain. APACHE II and SOFA scores, CRP, PCT, suPAR and proADM levels on the day of ICU admission were collected. RESULTS: A total of 137 consecutive septic patients were studied. The best area under the curve (AUC) for the prediction of in-hospital mortality was for APACHE II (0.82) and SOFA (0.75) scores. The ROC curve for suPAR yielded an AUC of 0.67, higher than proADM (0.62), CRP (0.50) and PCT (0.44). Significant dose-response trends were found between hospital mortality and suPAR (OR Q4 = 4.83, 95% CI 1.60-14.62) and pro-ADM (OR Q4 = 3.00, 95% CI 1.06-8.46) quartiles. Non-significant associations were found for PCT and CRP. The combination of severity scores and each biomarker did not provide superior AUCs. CONCLUSIONS: SuPAR and, to a lesser extent, proADM levels on ICU admission were better tools in prognosticating in-hospital mortality than CRP or PCT. However, neither of the two new biomarkers has been demonstrated to be excessively useful in the current setting. The prognostic accuracy was better for severity scores than for any of the biomarkers.

[Training in the care of the critical and multiple-injured patient: role of clinical simulation]. / Formación en la asistencia al paciente crítico y politraumatizado: papel de la simulación clínica.

Clinical simulation is suggested as a new educational instrument to learn and train in different medical skills. It is conceived as a new method that integrates scientific knowledge and human factors. Experience with these systems has been limited up to now, but it is now being widely accepted since it seems to accelerate acquisition of skills and knowledge in a safe setting, that is, without risk for the patient. However, its effect on clinical performance has not been validated yet. They are two types of simulators for intensive cares: screen based and human patient simulator (HPS). These systems make it possible to simulate different situations that require the application of action protocols or the management of new drugs in the clinical practice, promoting the rational use of resources in urgent care of the critical and multiple-injured patients. The limiting factors that prevent the expansion of the simulation for clinical training are its high cost, human resources needed, and the difficulties to assess the effectiveness of the training in real situations.

Comparison of the performance of two general and three specific scoring systems for meningococcal septic shock in children.

OBJECTIVE: To evaluate the performance at admission to the pediatric intensive care unit (PICU) of five severity scores, two general (the Pediatric Risk of Mortality [PRISM] II and III scores) and three specific for meningococcal septic shock (Leclerc, Glasgow Meningococcal Septicemia Prognostic Score [GMSPS], and Gedde-Dahl's MOC score) in children with this condition. DESIGN: Multicenter, retrospective, cohort study. SETTING: The PICUs from four tertiary centers. PATIENTS: Patients were 192 children ranging in age from 1 month to 14 yrs consecutively admitted to the participating PICUs during a period of 12 yrs and 6 months (January 1983 to June 1995), who were diagnosed with presumed or confirmed meningococcal septic shock. Patients with a length of stay <2 hrs were excluded from the study. INTERVENTIONS: Clinical and laboratory data gathered during the first 2 hrs after admission were used to compute the scoring systems tested. MEASUREMENTS AND MAIN RESULTS: There were 66 deaths (34%). Neisseria meningitidis was cultured from 142 (74%) children. GMSPS and PRISM II provided the best discriminative capability, as measured by the area under the receiver operating characteristic curve (SEM): 0.816 (0.036) and 0.803 (0.041), respectively. The other three scores gave lower receiver operating characteristic areas: PRISM III = 0.777 (0.043), MOC = 0.775 (0.037), and Leclerc = 0.661 (0.045). There was a statistically significant difference between the areas under the receiver operating characteristic curve of GMSPS and Leclerc (p < .01) but not between the GMSPS and the remaining three scores. All five scores presented good calibration with no significant differences between observed and predicted mortality (Hosmer-Lemeshow goodness-of-fit test). CONCLUSIONS: The specific GMSPS and the general pediatric severity system PRISM II performed better than the other three scores, being appropriate tools to assess severity of illness at admission to the PICU in children with presumed meningococcal septic shock.

[The evaluation of autopsy in the pediatric intensive unit]. / Evaluación de la autopsia en la Unidad de Cuidados Intensivos Pediátricos.

OBJECTIVE: Because of concerns about the declining autopsy rate, an attempt was made to evaluate the contributions from the postmortem examination in children. PATIENTS AND METHODS: We carried out a retrospective comparison analysis between clinical and pathological diagnosis of 56 consecutive autopsies performed on children who died in the PICU during the period 1983-1995. RESULTS: The autopsy rate was 60%. Autopsy provided valuable clinical information in 50% of the cases. There were major diagnostic errors in three patients (5%), that if detected before death would probably have improved survival. Another 14 cases (25%) showed missed clinical diagnoses related to the basic illness and the cause of death, whose premortem diagnosis would not have prolonged survival. There were no diagnostic discrepancies in 28 cases (50%). The most unexpected findings revealed by the autopsies were iatrogenics (10 cases), metabolic diseases (4 cases), congenital immunodeficiency syndromes (4 cases) and pulmonary opportunistic infections (3 cases). Eight of these diseases were genetic. An age < 12 months or and ICU stay < 24 hours were not predicting factors of a higher incidence of major diagnostic errors. CONCLUSIONS: The value of the autopsy as quality assurance and to detect iatrogenics and occult genetic diseases is unquestionable. New strategies have to be designed to increase the rate of autopsies.

[Definitions of sepsis in severe juvenile meningococcal infection. A review of 80 cases]. / Definiciones de sepsis en la infección meningocócica infantil grave. Una revisión de 80 casos.

OBJECTIVE: To describe the definitions for sepsis proposed by ACCP/SCCM Consensus Conference and to evaluate its capacity to classify children with severe meningococcal infection in homogeneous risk groups. METHODS: Eighty children with acute meningococcal infection and severe sepsis or septic shock, admitted to the pediatric ICU during a ten years period were reviewed. Mean age: 38 months (1,3 mo-14 yrs). RESULTS: N. meningitidis was isolated in 84%. Sixty-four percent of the patients were bacteremic and 39% showed a positive culture in CSF. Overall mortality was 19%. Fifty-two patients (65%) were in severe sepsis on admission, fifteen of them (29%) developed shock, mortality for this group was 4%. Twenty-eight patients (35%) were in septic shock on admission, mortality was 44%. Overall mortality of the shock group was 35%, mortality of shock on admission was higher than mortality of shock postadmission (44% vs 13%, p = 0.0001). Major complications were: DIC (28%), ARDS (26%), purpura fulminans (21%). There were not major complications or deaths in patients who did not develop shock. Bacteremia was not significant associated with shock or death. Meningitis was more frequent in severe sepsis group but 62% of deaths got it. Univariant analysis showed significant differences between both groups relative to tissular perfusion variables, coagulation and meningeal involvement. Multivariate analysis allowed us to establish a predictive model of survival feasible on admission to the ICU. For its determination three parameters are used: blood pressure, platelets and base excess. CONCLUSION: Definitions proposed for severe sepsis and septic shock are a valuable tool to classify children with acute meningococcal infection in homogeneous risk groups.