[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.

A medicalized hotel as a public health resource for the containment of Covid-19: more than a place for quarantining.

BACKGROUND: To describe the implementation of a medicalized hotel in the community of Madrid as a public health resource for the containment of coronavirus disease (COVID-19) and to describe the characteristics of population benefitted. METHODS: A descriptive study of the implementation of the Via Castellana Medicalised Hotel (VCMH) was conducted. The average monthly household income, educational level and occupational social class of the subjects admitted were obtained through a survey conducted during their stay. RESULTS: There was no guidance for launching; however the hotel was coordinated by a tertiary referral hospital and attended the preventive medicine regulations and the decrees of legal regimes and authorization of health services in Madrid. Between 19 March and the 9 May 2020, 399 patients were admitted; 59% (235) were migrant; the main reason for referral (58%) was a lack of house conditions for quarantining, including overcrowding, which when compared with the migrant status a positive correlation was found. Some other reasons for referral were homelessness and eviction. Most of the survey participants had low monthly household income, educational level and social class. CONCLUSIONS: This medicalized hotel provided medical care and offered housing to a subgroup of vulnerable population who could not afford a safe quarantine.

[Pharmacological treatment of COVID-19: Narrative review of the Working Group in Infectious Diseases and Sepsis (GTEIS) and the Working Groups in Transfusions and Blood Products (GTTH)]. / Tratamiento farmacológico de la COVID-19: revisión narrativa de los Grupos de Trabajo de Enfermedades Infecciosas y Sepsis (GTEIS) y del Grupo de Trabajo de Transfusiones Hemoderivados (GTTH).

Infection by the SARS-CoV-2 virus, known as COVID-19 (COronaVIrus Disease-19) was initially detected in China in December 2019, and has subsequently spread rapidly throughout the world, to the point that on March 11 the World Health Organization (WHO) reported that the outbreak could be defined as a pandemic. COVID-19 disease ranges from mild flu-like episodes to other serious and even life-threatening conditions, mainly due to acute respiratory failure. These patients are frequently admitted to our Intensive Care Units in relation to acute respiratory distress syndrome. The lack of a treatment based on scientific evidence has led to the use of different management guidelines, in many cases with rapid changes in the applied protocols. Recent reviews in reputed journals have underscored the lack of proven therapies and the need for clinical trials to establish clear and objective treatment guidelines. The present study provides an update on the currently applied treatment, and intends to offer help in relation to daily care, without seeking to replace the protocols adopted in each individual center.

Safety and effectiveness of a prothrombin complex concentrate in approved and off-label indications.

OBJECTIVE: To evaluate the effectiveness and safety of prothrombin complex concentrates (PCCs) in approved and off-label indications. BACKGROUND: PCCs are approved for the urgent reversal of vitamin K antagonists (VKAs). Data concerning the efficacy, safety and dosing for off-label indications are limited, but they are included in massive bleeding protocols. METHODS: This was a retrospective review of cases treated with four-factor PCCs (4F-PCCs) between January 2009 and 2016. Efficacy end-points include: (i) VKA reversal efficacy assessed by international normalised ratio (INR) normalisation (<1·5) and (ii) clinical efficacy as bleeding cessation and/or decreased number of transfused blood components and 24-h mortality in bleeding coagulopathy. The safety end-point is the incidence of thromboembolic events. RESULTS: A total of 328 patients were included (51·8% male, median age 78 years old). Indications were as follows: VKA reversal (66·6%), bleeding coagulopathy (30·5%) and direct anticoagulant (DOAC) reversal due to bleeding (2·5%). VKA reversal was effective in 97·1% of patients, and 76·5% demonstrated complete reversal (INR < 1·5); only 34·3% patients needed hemoderivatives. Prior to emergency procedures, PCCs achieved global responses in 83% of patients, with no bleeding complication during intervention. DOAC reversal was effective in 88·9% of patients. Bleeding cessation was associated with the dose administered (P = 0·002). In coagulopathy bleeding, haemorrhage cessation, established by the International Society of Thrombosis and Haemostais (ISTH) definition, occurred in 56·7% of massive bleeding events and in 42·5% of other coagulopathies; 24-h mortality was 30%, mainly related to active bleeding. Ten thrombotic episodes were observed (3·1%). CONCLUSION: 4F-PCC was effective as adjuvant treatment with an acceptable safety profile, not only for the emergent reversal of VKAs but also for refractory coagulopathy associated with major bleeding.

New oral anticoagulants in severe trauma patients: enemy at the gates?

The high incidence of trauma, especially in elderly people anticoagulated with new oral anticoagulants (NOAs), has become a major challenge, particularly in critical situations with life-threatening bleeding. Under these circumstances, urgent NOA reversion becomes mandatory. Prothrombin complex has become a frequent indication in critical situations in which rapid reversal of anticoagulation is needed and where the use of fresh frozen plasma is limited. This study offers our point of view regarding the usefulness of NOAs, not only in the prevention of cardioembolic events but also as regards their emergent reversion in cases of severe bleeding associated to trauma.

Forum for debate: Safety of allogeneic blood transfusion alternatives in the surgical/critically ill patient.

In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues.

Resuscitative goals and new strategies in severe trauma patient resuscitation.

Traumatic injuries represent a major health problem all over the world. In recent years we have witnessed profound changes in the paradigm of severe trauma patient resuscitation, new concepts regarding acute coagulopathy in trauma have been proposed, and there has been an expansion of specific commercial products related to hemostasis, among other aspects. New strategies in severe trauma management include the early identification of those injuries that are life threatening and require surgical hemostasis, tolerance of moderate hypotension, rational intravascular volume replacement, prevention of hypothermia, correction of acidosis, optimization of oxygen carriers, and identification of those factors required by the patient (fresh frozen plasma, platelets, tranexamic acid, fibrinogen, cryoprecipitates and prothrombin complex). However, despite such advances, further evidence is required to improve survival rates in severe trauma patients.

Results of a survey on albumin use in clinical practice in intensive care units.

BACKGROUND: Human albumin solutions are used in a number of disorders, though their indications are not clear in all circumstances. These solutions are costly, and their benefit has not been established in all settings. It is therefore interesting to assess the presence of albumin solutions in the daily clinical practice of critical care professionals. OBJECTIVES: To report the standard clinical practices and to describe the variability of albumin solutions use in critically ill patients. DESIGN: A survey sent by e-mail to Spanish and South American Intensive Care Units (ICUs) PERIOD: Planning and execution during the year 2012. METHODS: A questionnaire comprising 35 questions. RESULTS: Fifty-seven surveys were analyzed. The use of albumin solutions was sporadic or negligible in critically ill patients (96.5%). The exceptions were patients with liver disease (87.7% of the responders administered albumin to these patients). A high percentage of professionals claimed to know the available scientific evidence on the use of albumin in patients with liver disease (82.5%) and in patients without liver disease (77.2%). Only 5.3% of the responders preferred to rely on their own experience to establish the indications of albumin use. CONCLUSIONS: The use of albumin solutions is infrequent in ICUs, except in patients with liver disease. Evidence-based knowledge on albumin use is declared to be extensive in ICUs. As a rule, opinions on the use of albumin solutions are based on the scientific recommendations, especially in patients with liver disease. Professional experience rarely prevails over the published clinical guidelines.

Is minimising waste volume for drawing blood samples in critically ill patients feasible?

INTRODUCTION: Drawing blood samples through a central venous catheter (CVC) is a customary practice in Intensive Care Units (ICUs). It is indicated to discard a volume of waste blood to avoid interference in the results. AIM: To determine whether a lower discard volume for obtaining blood samples from temporary CVCs placed into the internal jugular, femoral or subclavian vein offers valid results. METHOD: A quasi-experimental prospective cross-sectional study for which sixty-five patients of over 18 years of age in ICUs, who had been fitted with a triple lumen central venous catheter, were recruited over a period of eight months. Two consecutive blood samples were extracted with tubes for biochemistry, coagulation and hemogram from each patient from the distal lumen. The first sample was obtained with a discarded waste of 1.5 ml from a total extracted volume of 10.2 ml, similar to the usual waste in our ambit (10 ml). Subsequently the second sample was obtained. The paired t-test was used to analyse the data. The Bland-Altman plot and intraclass correlation coefficient (ICC) were used to measure the agreement between methods. The reference change value (RCV) was established as the admissible limit of variation between the pairs of samples. RESULTS: A total of 65 sample pairs were drawn (intervention-control). The paired t-test found statistically significant differences with a significance level of α = .05 for chlorine (-.536; .012); prothrombin time (-.092; .019) and prothrombin activity (.284; 1.375).The ICC was greater than .9 in all the variables and the limit determined for the RCV was not surpassed by any value. CONCLUSIONS: The results show the reliability of the blood samples drawn with a discard volume of 1.5 ml.

Ultrasound diagnosis of Terson syndrome as an indicator of extreme severity in neurocritical care patients.

INTRODUCTION: Terson syndrome (TS) is defined as any intraocular haemorrhage identified in patients with acute intracranial pathology. TS appears to be associated with clinical severity in patients with subarachnoid haemorrhage (SAH), but the association is yet to be defined in patients with traumatic brain injury (TBI) and intracerebral haemorrhage (ICH). This study aimed to evaluate the diagnostic performance of ocular ultrasound (OU) and its usefulness in clinical practice. MATERIAL AND METHODS: We performed an observational, prospective, single-centre study of neurocritical care patients. We analysed cases and controls, defined according to indirect ophthalmoscopy (IO) and OU findings. We determined the diagnostic characteristics of OU. A multivariate analysis was performed to identify clinically relevant associations. RESULTS: The sample included 91 patients diagnosed with ICH (41.76%), SAH (29.67%), and TBI (28.57%). TS was identified by OU in 8 patients (8.79%) and by IO in 24 (24.37%). The adjusted mortality rate in patients with TS showed an odds ratio (OR) of 4.15 (95% confidence interval [CI], 1.52-11.33). All patients with TS detected by OU presented Glasgow Coma Scale scores < 9, with an elevated risk of needing decompressive craniectomy (OR: 9.84; 95% CI, 1.64-59). OU presented an overall sensitivity of 30.43%, specificity of 98.53%, and diagnostic accuracy of 81.32%. For the detection of vitreous haemorrhage, sensitivity and specificity were 87.5% and 98.5%, respectively. CONCLUSIONS: OU diagnosis of TS identifies extremely critical patients, who may require the highest level of care; TS is an independent risk factor for in-hospital mortality.

[Severe thrombocytopenia on admission to the intensive care unit in patients with multiple organ failure]. / Trombocitopenia grave al ingreso en una unidad de cuidados intensivos en pacientes con disfunción multiorgánica.

OBJECTIVE: To evaluate the frequency of severe thrombocytopenia (STCP) (≤ 50,000/µl) in the first 24 hours in patients with multiple organ dysfunction syndrome, and the factors that influence its occurrence. DESIGN: A retrospective, observational study. AREA: Medical-surgical intensive care unit (ICU). Tertiary hospital. PATIENTS: Those with failure of at least two organs, according to SOFA criteria, with the exclusion of neurological and traumatologic critical cases. VARIABLES: Medical history, regular medication, baseline functional status, demographic variables, severity scores in ICU, multiple-organ failure data, course in ICU and main hospital data. RESULTS: A total of 587 patients were included; 6.3% (37 patients) presented with STCP during the first day of admission; 64.6% were men; SOFA 8 (5-10); APACHE II 18 (13-24); APACHE IV 59 (46-73); 32.5% were surgical patients. A total of 79.9% subsequently needed mechanical ventilation, and 71.4% required vasoactive drugs. Overall stay in ICU: 4 (2-10) days, main hospital stay 18 (9-35) days. A total of 29.2% died in the ICU; 11.7% developed STCP during admission to the ICU. Multivariate analysis found the main determining factors in the occurrence of thrombocytopenia on admission to be: history of hospitalization in the last year, albumin and bilirubin levels, and sepsis. CONCLUSION: The prevalence of STCP among critical patients was 6.3%. Its occurrence was associated with albumin and bilirubin levels, sepsis, and with patient admittance in the last year.

[Relationship between the alveolar-arterial oxygen gradient and PaO2/FiO2-introducing PEEP into the model]. / Relación entre el gradiente alveolo-arterial de oxígeno y la PaO2/FiO2 introduciendo la PEEP en el modelo.

OBJECTIVES: To determine whether the alveolar-arterial oxygen gradient (Grad[A-a]O2) helps confirm the influence of PEEP on PaFi (PaO2/FiO2). DESIGN: Observational study; we used linear regression to perform a multivariate study to improve the PaFi formula by taking PEEP into account. SETTING: Tertiary hospital. PATIENTS: We included all patients who were admitted to the intensive care unit, regardless of pulmonary damage. VARIABLES: We recorded personal history, clinical judgment, intensive care data, severity scores on the first day and progression. Two calculated variables: PaFi and Grad(A-a)O2. RESULTS: A total of 956 patients were included: 63.9% men; median age 68 years. On the first day, 31.8% did not have mechanical ventilation (MV), 13.1% had non-invasive MV and 55.1% had invasive MV. PaFi values: 32.9% 0-200, 32.2% 201-300, and 34.8% >300. PEEP values: 0-5 69.8%, 6-10 27.5% and >10 2.6%. We observed a correlation (Pearson) between Grad(A-a)O2 and PaFi of -0.84 (p<0.001). On performing multiple regression (dependent variable: Grad[A-a]O2), the following variables were included in the model: PaFi, PEEP, APACHE IV and SOFA; coefficient of determination (R²) of 0.62 without PEEP and 0.72 with PEEP. We changed the PaFi formula, referring to it as PaFip (PaFi plus PEEP): Ln (PaFi/[PEEP+12]). Correlation index between PaFip and Grad(A-a)O2: -0.9 (p<0.001). We performed linear regression (dependent variable: Grad[A-a]O2) and used PaFip instead of PaFi. Only PaFi remained in the model, and was discretely complemented by APACHE IV; R²=0.8. CONCLUSIONS: By adding PEEP to the PaFi model (PaFip), we clearly improve the latter, as reflected by a better goodness of fit.

Epidemiology of blood transfusion in the Spanish Critical Care Units: «Transfusion Day¼.

OBJECTIVE: To describe the transfusion practice in the ICUs in Spain, according to national and international recommendations (guidelines). DESIGN: Prospective, cross-sectional, multi-centre study. SCOPE: Data collection was carried out by means of a questionnaire sent electronically to the Heads of Service of 111 ICUs in Spain. PARTICIPANTS: 1,448 patients were included, aged 61.8 (SD 15.7) years, 66.2% male, with an SOFA of 4.7 ±â€¯3.8 and average stay of 10.62 ±â€¯17.49 days. VARIABLES: Demographic and clinical variables of the patients were collected, as well as variables related to the transfusion act. RESULTS: Of the 1,448 patients, 9.9% received al least one transfusion of any blood product, 3.7% fresh plasma, 3.9% platelets and 8.9% red blood cell concentrate, mainly by analytical criteria (36.2%). Hemoglobin had a mean of 7.8 g/dL (95% CI: 6-9-8.5) and 9.8 g/dL (95% CI: 8.5-11.2) before and after the transfusion, respectively, p < 0.001. The transfusion units had a mean of 2.5 ±â€¯2.4 per patient. The most commonly used blood product was red blood cell concentrate (CH) (90.2%). Patients admitted for surgery had a higher transfusion rate (14.4%) than those admitted for medical pathology (8.9%) (p = 0.006). 5.4% (7/129) of patients who received CH died compared to 2.4% (31/1302) who did not (p = 0.04). Mortality of transfused patients was higher. The transfusion rate in most of hospitals was 5% to 20%, with 18 hospitals (16.21%) having transfusion rates between 20% and 50%. Hospitals with PBM programs and mass transfusion programs had a lower transfusion rate, although not statistically significant. CONCLUSIONS: In this multicenter cross-sectional study, a transfusion prevalence of 9.9% was observed in Spanish Critical Care Units. The most frequent blood product transfused was red blood cells and the main reasons for transfusion were acute anemia with hemodynamic impact and analytical criteria. Mortality of transfused patients was higher.

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.

[Emergency radiology: what clinicians expect from radiologists]. / Radiología urgente: lo que el clínico espera del radiólogo.

We review the relations between the radiology department and the clinicians that attend emergency patients, complementing our opinions with a survey conducted in the emergency departments of hospitals in the autonomous region of Madrid. A dedicated emergency radiology section is present in 63.2% of hospitals. Radiologists are readily available to consult in the emergency department in 100%. Radiologists are involved in the initial workup in 61% of hospitals, in follow-up in 22.3%, and in both the initial workup and follow-up in 16.7%. At least one common protocol is shared by radiologists and emergency clinicians in 73.7% of hospitals. Radiologists participate in deciding which imaging tests to perform in 78.9% of hospitals. Radiologists provide a written report of the examination in 83.3% of cases. Continual assessment of the relations between the emergency department and the radiology department will enable us to understand their dynamics and to know what aspects can be improved.

[Is H1N1 flu different from seasonal flu on initial plain chest films?]. / Gripe A ¿diferente de la gripe estacional?

OBJECTIVES: To determine whether there are differences in the findings on the initial plain chest films of patients with H1N1 influenza and those of patients with flu symptoms during the flu season. MATERIAL AND METHODS: All patients underwent plain-film chest radiography in the Emergency Department for flu symptoms; 95 patients had H1N1 influenza confirmed between July 2009 and December 2009 and 95 patients were attended for symptoms of seasonal flu in January 2009. We analyzed the views obtained, the distribution and location of the radiologic findings, and patients' age, sex, and previous disease. RESULTS: Patients with H1N1 influenza were younger than those with seasonal flu symptoms (mean 40.2 vs 50.9 years; p<0.001) and fewer had prior disease (48 vs. 63; p<0.001). Plain films were acquired with patients in the standing position in 75 patients in the H1N1 group and in 77 in the seasonal flu group; pathological findings were present in nearly 50% of the patients in each group. The most common findings in the H1N1 group were multifocal patchy consolidations (41.2%; p<0.001) and peribronchial-vascular opacities (16.3%), whereas in the seasonal flu group the most common finding was consolidation in a single lobe (43.9%). CONCLUSION: We found significant differences between the radiologic findings of patients with H1N1 influenza (severe) and those of patients with symptoms of flu during the flu season: the incidence of multifocal patchy consolidation was greater in H1N1 patients and H1N1 patients were younger.

[Pharmacological treatment of COVID-19: Narrative review of the Working Group in Infectious Diseases and Sepsis (GTEIS) and the Working Groups in Transfusions and Blood Products (GTTH)]. / Tratamiento farmacológico de la COVID-19: revisión narrativa de los Grupos de Trabajo de Enfermedades Infecciosas y Sepsis (GTEIS) y del Grupo de Trabajo de Transfusiones Hemoderivados (GTTH).

Infection by the SARS-CoV-2 virus, known as COVID-19 (COronaVIrus Disease-19) was initially detected in China in December 2019, and has subsequently spread rapidly throughout the world, to the point that on March 11 the World Health Organization (WHO) reported that the outbreak could be defined as a pandemic. COVID-19 disease ranges from mild flu-like episodes to other serious and even life-threatening conditions, mainly due to acute respiratory failure. These patients are frequently admitted to our Intensive Care Units in relation to acute respiratory distress syndrome. The lack of a treatment based on scientific evidence has led to the use of different management guidelines, in many cases with rapid changes in the applied protocols. Recent reviews in reputed journals have underscored the lack of proven therapies and the need for clinical trials to establish clear and objective treatment guidelines. The present study provides an update on the currently applied treatment, and intends to offer help in relation to daily care, without seeking to replace the protocols adopted in each individual center.