Donor referral from outside the intensive care unit: A multidisciplinary cooperation model using communication apps and redefining refereal criteria.

OBJECTIVE: We evaluate the impact of a web-based collaborative system on the referral of possible organ donors from outside of the intensive care unit (ICU). STUDY DESIGN: Cohort prospective study. SETTINGS: University hospital. PATIENTS AND INTERVENTION: In 2015 a virtual collaborative system using a cross-platform instant messaging application replaced the previous 2014 protocol for the referral of patients outside of the ICU with a severe brain injury in whom all treatment options were deemed futile by the attending team to the donor coordination (DC). Once the DC evaluated the medical suitability and likelihood of progression to brain death (BD), the option of intensive care to facilitate organ donation (ICOD) was offered to the patient's relatives. This included admission to the ICU and elective non-therapeutic ventilation (ENTV), where appropriate. RESULTS: A two-fold increase of referrals was noted in 2015 [n=46/74; (62%)] compared to 2014 [n=13/40; (32%)]; p<0.05. Patients were mostly referred from the stroke unit (58.6%) in 2015 and from the emergency department (69.2%) in 2014 (p<0.01). Twenty (2015: 42.5%) and 4 (2014: 30.7%) patients were discarded as donors mostly due to medical unsuitability. Family accepted donation in 16 (2015: 62%) and 6 (2014: 66%) cases, all admitted to the ICU and 10 (2015: 62.5%) and 3 (50%) being subject to ENTV. Ten (2015: 66.6%) and 5 (2014: 83.3%) patients progressed to BD, 60.5±20.2 and 44.4±12.2h after referral respectively. Nine (2015) and 4 (2014) of these patients became utilized donors, representing 29.0% (2015) and 13.0% (2014) of the BD donors in the hospital during the study period (p<0.05). CONCLUSION: The implementation of a virtual community doubled the number of patients whose families were presented with the option of donation prior to their death.

"Non-Touch" Vena Cava Technique as an Improvement in Combined Lung and Liver Procurement in Controlled Donation After Circulatory Death.

The number of organs retrieved from donation after circulatory death (DCD) donors has continued to rise in recent years. The functional superiority of DCD organs is achieved when the lungs are perfused with cold perfusion and livers with normothermic regional perfusion (NRP). Thus, a precise surgical technique is required to combine thoracic and abdominal organ procurement. The technique used at our center consists of a rapid laparotomy and middle sternotomy, then the abdominal aorta (Ao) and abdominal inferior vena cava (VC) are cannulated and the descending thoracic Ao is cross-clamped. NRP is started at that point. As a variation of previously described techniques, the thoracic vena cava is not initially clamped in order to improve the return of blood volume to the NRP circuit. The pulmonary artery is cannulated to flush the lungs and the left atrial appendage is opened for drainage. After 120 minutes, NRP perfusion is stopped and the organs are flushed with cold preservation solution. In 2016, 3 livers and 6 lungs were harvested at our center using the technique described. After a minimum follow-up of 1 year, no evidence of biliary complications was observed. The combined procurement of lungs after room temperature perfusion and liver after NRP without initial clamping of the thoracic VC is feasible, with excellent function post-transplantation.

Factors related to limitation of life support within 48h of intensive care unit admission: A multicenter study.

OBJECTIVE: To determine factors related to limitations on life support within 48h of intensive care unit (ICU) admission. STUDY DESIGN: Prospective multicenter study. SETTING: Eleven ICUs. PATIENTS: All patients who died and/or had limitations on life support after ICU admission during a four-month period. VARIABLES: Patient characteristics, hospital characteristics, characteristics of limitations on life support. Time-to-first-limitation was classified as early (<48h of admission) or late (≥48h). We performed univariate, multivariate analyses and CHAID (chi-square automatic interaction detection) analysis of variables associated with limitation of life support within 48h of ICU admission. RESULTS: 3335 patients were admitted; 326 (9.8%) had limitations on life support. A total of 344 patients died; 247 (71.8%) had limitations on life support (range among centers, 58.6%-84.2%). The median (p25-p75) time from admission to initial limitation was 2 (0-7) days. CHAID analysis found that the modified Rankin score was the variable most closely related with early limitations. Among patients with Rankin >2, early limitations were implemented in 71.7% (OR=2.5; 95% CI: 1.5-4.4) and lung disease was the variable most strongly associated with early limitations (OR=12.29; 95% CI: 1.63-255.91). Among patients with Rankin ≤2, 48.8% had early limitations; patients admitted after emergency surgery had the highest rate of early limitations (66.7%; OR=2.4; 95% CI: 1.1-5.5). CONCLUSION: Limitations on life support are common, but the practice varies. Quality of life has the greatest impact on decisions to limit life support within 48h of admission.

Impact of harmful use of alcohol on the sedation of critical patients on mechanical ventilation: A multicentre prospective, observational study in 8 Spanish intensive care units.

PURPOSE: To evaluate the impact of a history of harmful use of alcohol (HUA) on sedoanalgesia practices and outcomes in patients on mechanical ventilation (MV). METHODS: A prospective, observational multicentre study was made of all adults consecutively admitted during 30 days to 8 Spanish ICUs. Patients on MV >24h were followed-up on until discharge from the ICU or death. Data on HUA, smoking, the use of illegal (IP) and medically prescribed psychotropics (MPP), sedoanalgesia practices and their related complications (sedative failure [SF] and sedative withdrawal [SW]), as well as outcome, were prospectively recorded. RESULTS: A total of 23.4% (119/509) of the admitted patients received MV >24h; 68.9% were males; age 57.0 (17.9) years; APACHE II score 18.8 (7.2); with a medical cause of admission in 53.9%. Half of them consumed at least one psychotropic agent (smoking 27.7%, HUA 25.2%; MPP 9.2%; and IP 7.6%). HUA patients more frequently required PS (86.7% vs. 64%; p<0.02) and the use of >2 sedatives (56.7% vs. 28.1%; p<0.02). HUA was associated to an eightfold (p<0.001) and fourfold (p<0.02) increase in SF and SW, respectively. In turn, the duration of MV and the stay in the ICU was increased by 151h (p<0.02) and 4.4 days (p<0.02), respectively, when compared with the non-HUA group. No differences were found in terms of mortality. CONCLUSIONS: HUA may be associated to a higher risk of SF and WS, and can prolong MV and the duration of stay in the ICU in critical patients. Early identification could allow the implementation of specific sedation strategies aimed at preventing these complications.

Medical Students for Tissue Procurement, a 10-Year Experience in a Large University Hospital: An Exportable Model?

OBJECTIVE: The objective of this study was to describe tissue procurement activity performed during 10 years (2004-2014) by trained medical students in a large university hospital. METHODS: In this study, third to sixth year medical students were trained as in-hospital Tissue Coordinators (Tc) to perform tissue procurement activity on a 24/7 schedule supervised by an on-call senior Transplant Coordinator (sTC) in a large university hospital. Tc duty consisted of detection, initial evaluation of all hospital deaths, donor's family approach for tissue donation, and retrieval logistics organization, including corneal tissue retrieval after training and certification. They also assist sTC in organ procurement activity. RESULTS: A total of 18,931 deaths were prospectively evaluated, 79% of whom (n = 14,879) presented medical contraindications for tissue donation. Of the remaining 4052 (21%) potential tissue donors (PTD), 2522 (62%) were not converted into real donors, mostly due to family refusal (66%; n = 1650) followed by detection system failure and other logistical issues (34%; n = 872). A total of 2814 corneal units, 225 skin donations, 327 muscleskeletal tissue donations, 91 blood vessels donations, and 177 heart valve donations were obtained from the remaining 1530 (38%) real donors. Tissue potentiality increased from 19% to 43% throughout the study period as a consequence of the fluctuating acceptance criteria used by tissue banks depending on tissue demand. CONCLUSIONS: The tissue donation program performed by trained students was successful in achieving a high and sustainable tissue donation rate in a large university hospital.

[Factors associated with compliance to the semi-recumbent position in the patient on mechanical ventilation: CAPCRI-Q questionnaire]. / Factores relacionados con el cumplimiento de la posición semiincorporada en el paciente con ventilación mecánica según los profesionales: cuestionario CAPCRI-Q.

AIM: To create a questionnaire (CAPCRI-Q) to determine the factors associated with the compliance of the semi-recumbent position in patients under mechanical ventilation. METHODS: A closed questionnaire was created using a literature review and clinical practice. The initial version consisted of 61 items placed into 5 categories: patient factors, team and professionals factors, activity, educational and training factors, and equipment and resources. A Delphi method was used to prepare the questionnaire. Comprehension, relevance and importance of each item were evaluated, as well as the recommendations of experts. A qualitative pilot test with 9 healthcare professionals was performed, followed by a quantitative pilot test with 67 nurses from 6 intensive care units to test the internal consistency of the instrument. RESULTS: Three rounds with 15 experts were required to reach a consensus. The final version of the questionnaire consisted of 36 items enclosed in the same categories as the initial version. The internal consistency analysis showed values greater than 0.800 for each independent item, each category, and for the global questionnaire (0.873; 95%CI: 0.825-0.913). The analysis of the nurses' responses emphasised the importance of the patient factors, as well as organisational and infra-structural factors, for the compliance of the recommendation. CONCLUSIONS: The questionnaire created is reliable and appears to have content validity. The most influential factors for compliance are those related to the patient and the internal organisation. The results of the questionnaire can be used to evaluate the factors influencing the compliance and to establish improvement strategies.

Brain death organ donation potential and life support therapy limitation in neurocritical patients.

OBJECTIVE: To analyze the profile, incidence of life support therapy limitation (LSTL) and donation potential in neurocritical patients. STUDY DESIGN: A multicenter prospective study was carried out. SETTING: Nine hospitals authorized for organ harvesting for transplantation. PATIENTS: All patients consecutively admitted to the hospital with GCS < 8 during a 6-month period were followed-up until discharge or day 30 of hospital stay. STUDY VARIABLES: Demographic data, cause of coma, clinical status upon admission and outcome were analyzed. LSTL, brain death (BD) and organ donation incidence were recorded. RESULTS: A total of 549 patients were included, with a mean age of 59.0 ± 14.5 years. The cause of coma was cerebral hemorrhage in 27.0% of the cases.LSTL was applied in 176 patients (32.1%). In 78 cases LSTL consisted of avoiding ICU admission. Age, the presence of contraindications, and specific causes of coma were associated to LSTL. A total of 58.1% of the patients died (n=319). One-hundred and thirty-three developed BD (24.2%), and 56.4% of these became organ donors (n=75). The presence of edema and mid-line shift on the CT scan, and transplant coordinator evaluation were associated to BD. LSTL was associated to a no-BD outcome. Early LSTL (first 4 days) was applied in 9 patients under 80 years of age, with no medical contraindications for donation and a GCS ≤ 4 who finally died in asystole. CONCLUSIONS: LSTL is a frequent practice in neurocritical patients. In almost one-half of the cases, LSTL consisted of avoiding admission to the ICU, and on several occasions the donation potential was not evaluated by the transplant coordinator.

Potencialidad de donación de órganos en muerte encefálica y limitación del tratamiento de soporte vital en los pacientes neurocríticos / Potential of organ donation in brain death and limitation of life support treatment in neurocritical patients

Objetivo. Analizar el perfil, la incidencia de limitaciónde tratamiento de soporte vital (LTSV) y la potencialidad de donación de órganos enpacientes neurocríticos. Diseño Multicéntrico prospectivo. Ámbito Nueve centros autorizados para extracción de órganos para trasplante...

[Prolonged sedation in Intensive Care Units]. / Sedación prolongada en Unidades de Cuidados Intensivos.

Sedation and analgesia constitute one of the cornerstones in the management of the critically ill patients. Most patients admitted to an Intensive Care Unit require prolonged sedation and analgesia. It has been demonstrated that adequate sedo- analgesia lessens stress-related events in the critically ill patients, facilitating their management and improving their outcomes. However, the use of sedatives and analgesics, especially when administered in continuous intravenous infusion, may have its complications derived from its infra or over utilization with proved impact on the outcome of critically ill patients. A proper monitoring and the implementation of sedation and analgesia protocols warrant the adequate management of existing sedatives aiding to avoid tolerance and dependency events. Strategies such as "sequential sedation", "dynamic sedation" or "daily sedation interruption" have been proposed as efficacious tools for the avoidance of complications related to prolonged sedation. In the present chapter, concepts related to prolonged sedation (meaning sedation for more than 72 hours) are reviewed; available agents are evaluated and strategies aimed to assure quality in its application are described.

[Use of neuromuscular blockers in the critical patient]. / Utilización de bloqueantes neuromusculares en el paciente crítico.

The use of neuromuscular blockers (NMB) is a frequent practice in Intensive Care Units. However most of the experience with the use of these agents come from the operating room used to deal with patients with different characteristics from those admitted in the ICU. Recent advances on neuromonitoring and the commercialization of newer agents make necessary the update in the management of NMB in the ICU. The NMB agent should be chosen attending to its pharmacokinetics and the physiopathology of the critically ill patient. Those NMB with organ-independent metabolism as well as those with rapid onset of action are the preferred ones for the use in the critically ill patient substituting older depolarizing agents and those whose metabolism is dependent on the liver and/or kidney, organs frequently impaired in the critically ill patients. Neuromuscular blocking in the critically ill patient should be done according to protocols and monitor its effects in order to avoid complications related to its prolonged use.

[Depression and use of antidepressants in the critical patient]. / Depresión y uso de antidepresivos en el paciente crítico.

A large percentage of critically ill patients suffer from depression while admitted in an Intensive Care Unit (ICU). This pathology, often underdiagnosed by intensive care professionals has a proved negative impact on median-large outcome, which makes early detection and management a key issue. However diagnosing depression in ICU is a complicated task since there are no validated tools for its detection. The cornerstone intervention for the treatment of depression are antidepressant medication. All antidepressants have similar efficacy profiles. The prescription of a particular agent should be done based in its collateral effects. Unfortunately the efficacy and safety of antidepressant agents has not been evaluated in the critically ill patient. The implementation of simple measures like guaranteeing comfort during its admission to the ICU and the early reintroduction of any psychotropic medication that the patient could be taking before ICU could improve the emotional adaptation to their new situation.

Endotracheal tube intraluminal diameter narrowing after mechanical ventilation: use of acoustic reflectometry.

OBJECTIVE: To quantify the incidence and degree of endotracheal tube intraluminal obstruction after mechanical ventilation and its relation to time of intubation. DESIGN: Prospective observational study. SETTING: A 14-bed medical-surgical intensive care unit at a university-affiliated teaching hospital. PATIENTS: Ninety-four endotracheal tubes used in 80 patients requiring mechanical ventilation for more than 12 h. INTERVENTIONS AND RESULTS: Acoustic reflectometry was performed in every endotracheal tube after patient extubation to measure its volume reduction. The intraluminal volumes of used endotracheal tubes in mechanically ventilated patients were significantly lower than those of unused tubes of the same size (5.52+/-0.92 ml(3) versus 6.54+/-0.79 ml(3), p<0.05). The mean difference in endotracheal tube segment volumes was 15.2% (range 0-66%). Volume reduction was above 10% in 60.8% of the tubes. In 22% of endotracheal tubes the remaining inner diameter was less than 7 mm. Reduction below this figure was less frequent (9.3%) in tubes 8 mm or more (p<0.05). The percentage of endotracheal tube volume reduction was not associated with the duration of intubation (r=-0.09, p= n.s.) Peak pressure measured before extubation did not predict obstruction (r=0.11, p= n.s.). CONCLUSIONS: Inadvertent endotracheal tube obstruction was common in patients requiring mechanical ventilation and may be significant as early as at 24 h. Moderate obstruction in endotracheal tube lumens should be suspected in cases of difficulties in weaning, even in patients who were ventilated for less than 1 day.

[Sinusitis in immunocompromised patients. A multicenter study]. / Sinusitis en inmunodeprimidos. Un estudio multicéntrico.

This paper evaluates different aspects of sinusitis in patients with a decreased immunological system, such as its prevalence and clinical evolution, its peculiar bacteriology and the altered response to treatment, and the prognosis, especially in patients with AIDS. There seems to be an increased prevalence of sinusitis in these patients, with a relationship between their immunological status and the severity and aggressiveness of the sinusitis. Bacteriological studies reveal the pressure of more aggressive species, such as P. aeruginosa, and specific sinusitis are more frequent, which may explain why the treatment with common antibiotics often remains uneffective. The simultaneous therapy of concomitant infections leads to a higher resistance towards common drugs. A standard treatment is therefore needed. The results of three studies, retrospective and prospective, on HIV-infected patients reveal a high incidence of acute sinusitis with aggressive bacteria.

Percutaneous endoscopic gastrostomy in head and neck cancer patients.

OBJECTIVE: To present our experience with the indications and complications of percutaneous endoscopic gastrostomy (PEG) in head and neck cancer patients. MATERIALS AND METHODS: In a retrospective study of the patients treated, we reviewed the records of 43 patients diagnosed with head and neck cancer at the Otorhinolaryngology Department, in which a PEG was performed by the Unit of Digestive Endoscopy. RESULTS: All cases had squamous cell carcinoma. Larynx was the most frequent primary site, with 21 cases (49%), followed by hypopharynx, 12 patients (28%). Indications for PEG were: dysphagia (53.5%) and pharyngocutaneous fistula (43.5%). The most frequent complication was a local infection. CONCLUSION: PEG is a good choice for long-term enteral feeding in head and neck cancer patients due to its low complication rate and easy handling.

[Pansinusitis secondary to inflammatory myofibroblastic tumor]. / Pansinusitis secundaria a tumor miofibroblástico inflamatorio.

Inflammatory myofibroblastic tumors are aetiologically enigmatic and biologically unpredictable lesions. The lungs are the organs of apparent predilection. These tumors have also been documented in a number of extrapulmonary sites including head and neck. Paranasal location is rare. We report a case of a maxillary location in a 10 years and 10 months old girl initiated as an acute pansinusitis.