[Intensive care during the 2019-coronavirus epidemic]. / Cuidados intensivos durante la epidemia de coronavirus 2019.

On 31 December 2019, the Health Commission of Hubei Province of China first unveiled a group of unexplained cases of pneumonia, which WHO subsequently defined as the new coronavirus of 2019 (SARS-CoV-2). SARS-CoV-2 has presented rapid person-to-person transmission and is currently a global pandemic. In the largest number of cases described to date of hospitalized patients with SARS-CoV-2 disease (2019-nCoViD), 26% required care in an intensive care unit (ICU). This pandemic is causing an unprecedented mobilization of the scientific community, which has been associated with an exponentially growing number of publications in relation to it. This narrative literature review aims to gather the main contributions in the area of intensive care to date in relation to the epidemiology, clinic, diagnosis and management of 2019-nCoViD.

Comparative Population Plasma and Tissue Pharmacokinetics of Micafungin in Critically Ill Patients with Severe Burn Injuries and Patients with Complicated Intra-Abdominal Infection.

Severely burned patients have altered drug pharmacokinetics (PKs), but it is unclear how different they are from those in other critically ill patient groups. The aim of the present study was to compare the population pharmacokinetics of micafungin in the plasma and burn eschar of severely burned patients with those of micafungin in the plasma and peritoneal fluid of postsurgical critically ill patients with intra-abdominal infection. Fifteen burn patients were compared with 10 patients with intra-abdominal infection; all patients were treated with 100 to 150 mg/day of micafungin. Micafungin concentrations in serial blood, peritoneal fluid, and burn tissue samples were determined and were subjected to a population pharmacokinetic analysis. The probability of target attainment was calculated using area under the concentration-time curve from 0 to 24 h/MIC cutoffs of 285 for Candida parapsilosis and 3,000 for non-parapsilosis Candida spp. by Monte Carlo simulations. Twenty-five patients (18 males; median age, 50 years; age range, 38 to 67 years; median total body surface area burned, 50%; range of total body surface area burned, 35 to 65%) were included. A three-compartment model described the data, and only the rate constant for the drug distribution from the tissue fluid to the central compartment was statistically significantly different between the burn and intra-abdominal infection patients (0.47 ± 0.47 versus 0.15 ± 0.06 h(-1), respectively; P < 0.05). Most patients would achieve plasma PK/pharmacodynamic (PD) targets of 90% for non-parapsilosis Candida spp. and C. parapsilosis with MICs of 0.008 and 0.064 mg/liter, respectively, for doses of 100 mg daily and 150 mg daily. The PKs of micafungin were not significantly different between burn patients and intra-abdominal infection patients. After the first dose, micafungin at 100 mg/day achieved the PK/PD targets in plasma for MIC values of ≤0.008 mg/liter and ≤0.064 mg/liter for non-parapsilosis Candida spp. and Candida parapsilosis species, respectively.

First resuscitation of critical burn patients: progresses and problems.

Currently, the aim of the resuscitation of burn patients is to maintain end-organ perfusion with fluid intake as minimal as possible. To avoid excess intake, we can improve the estimation using computer methods. Parkland and Brooke are the commonly used formulas, and recently, a new, an easy formula is been used, i.e. the 'Rule of TEN'. Fluid resuscitation should be titrated to maintain the urine output of approximately 30-35 mL/h for an average-sized adult. The most commonly used fluids are crystalloid, but the phenomenon of creep flow has renewed interest in albumin. In severely burn patients, monitoring with transpulmonary thermodilution together with lactate, ScvO2 and intraabdominal pressures is a good option. Nurse-driven protocols or computer-based resuscitation algorithms reduce the dependence on clinical decision making and decrease fluid resuscitation intake. High-dose vitamin C, propranolol, the avoidance of excessive use of morphine and mechanical ventilation are other useful resources.

Systematic review of the effect of propanolol on hypermetabolism in burn injuries.

BACKGROUND: The use of propranolol has been proposed to reduce the hypermetabolic response of patients with burn injuries. OBJECTIVES: To review the studies published up to December 2013 on the effects of propranolol in burn patients. METHODS: A PubMed search was conducted using the terms "burns", "thermal injury", "beta-blocker" and "propranolol", with the filters "human" and "English" and "Spanish". A total of 42 citations were retrieved, 15 of which were randomized clinical trials. The main results are summarized. MAIN RESULTS: Propranolol at doses adjusted to decrease the heart rate by 20% of the baseline value (4­6 mg/kg/day p.o.) reduces supraphysiological thermogenesis, cardiac work, resting energy expenditure and peripheral lipolysis. It likewise increases the efficiency of muscular protein synthesis and reduces central mass accretion. Most studies have been conducted in pediatric burn patients. CONCLUSIONS: Propranolol reduces the hypermetabolic response in pediatric burn patients. More studies on its effects in adult burn patients are needed.

[Percutaneous tracheostomy through dilatation with the Ciaglia Blue Dolphin(®) method]. / Traqueotomía percutánea por dilatación con el método Ciaglia Blue Dolphin(®)

OBJECTIVE: To describe the perioperative and postoperative complications in critically ill patients requiring percutaneous tracheostomy using the Ciaglia Blue Dolphin(®) technique. DESIGN: A prospective, observational, cohort study was carried out. SCOPE: Two medical-surgical Intensive Care Units. PATIENTS: Adult patients subjected to prolonged mechanical ventilation. INTERVENTION: Percutaneous tracheostomy using Ciaglia Blue Dolphin(®) with an endoscopic guide. VARIABLES: Demographic variables, intraoperative and postoperative complications, and Intensive Care Unit and ward mortality were recorded. RESULTS: Seventy patients were included. Age: 68.6 ± 12 years (68.6% males). APACHE II score: 23.5±8.7. Duration of mechanical ventilation prior to percutaneous tracheostomy: 14.3 ± 5.5 days. Perioperative complications were recorded in 25 patients. In 23 of them the complications were mild: difficulty inserting the tracheostomy cannula (n=10), mild bleeding (n=7), partial atelectasis (n=3), cuff leak (n=2), and technical inability to complete the procedure (switch to Ciaglia Blue Rhino(®)) (n=1). Severe complications were recorded in 2 patients: severe bleeding that forced completion of the procedure via surgical tracheostomy (n=1), and false passage with desaturation (n=1). None of the complications proved life-threatening. Eleven complications occurred in the learning curve. As postoperative complications, mild peri-cannula bleeding was seen in 2 patients. CONCLUSIONS: Percutaneous tracheostomy using the Ciaglia Blue Dolphin(®) technique with an endoscopic guide is a safe procedure. As with other procedures, the learning curve contributes to increase the incidence of complications. Potential benefits versus other percutaneous tracheostomy techniques should be explored by randomized trials.

Prognosis of elderly patients subjected to mechanical ventilation in the ICU.

OBJECTIVE: To analyze the prognosis of mechanically ventilated elderly patients in the Intensive Care Unit (ICU). DESIGN AND SCOPE: Sub-analysis of a prospective multicenter observational cohort study conducted over a period of two years in 13 medical-surgical ICUs in Spain. PATIENTS: Adult patients who required mechanical ventilation (MV) for longer than 24 hours. INTERVENTIONS: None. STUDY VARIABLES: Demographic data, APACHE II, SOFA, reason for MV, comorbidity, functional condition, reintubation, duration of MV, tracheotomy, ICU mortality, in-hospital mortality. RESULTS: A total of 1661 patients were recruited. Males accounted for 67.9% (n=1127), with a mean age of 62.1 ± 16.2 years. APACHE II: 20.3 ± 7.5. Total SOFA: 8.4 ± 3.5. Four hundred and twenty-three patients (25.4%) were ≥ 75 years of age. Comorbidity and functional condition rates were poorer in these patients (p<0.001 for both variables). Mortality in the ICU was higher in the elderly patients (33.6%) than in the younger subjects (25.9%) (p=0.002). Also, in-hospital mortality was higher in those ≥ 75 years of age. No differences in duration of MV, prevalence of tracheostomy or reintubation incidence were found. Regarding the indication for MV, only the patient ≥ 75 years of age with pneumonia, sepsis or trauma had a higher in-ICU mortality than the younger patients (46.3% vs 33.1%, p=0.006; 55% vs 25.8%, p=0.002; 63.6% vs 4.5%, p<0,001, respectively). No differences were found referred to other reasons for MV. CONCLUSION: Older patients (≥ 75 years) have significantly higher in-ICU and in-hospital mortality than younger patients without differences in the duration of mechanical ventilation. Differences in mortality were at the expense of pneumonia, sepsis and trauma.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]. / 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla.

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: « Does this particular AABT reduce the transfusion rate or not?¼ All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

[Intensive care during the 2019-coronavirus epidemic]. / Cuidados intensivos durante la epidemia de coronavirus 2019.

On 31 December 2019, the Health Commission of Hubei Province of China first unveiled a group of unexplained cases of pneumonia, which WHO subsequently defined as the new coronavirus of 2019 (SARS-CoV-2). SARS-CoV-2 has presented rapid person-to-person transmission and is currently a global pandemic. In the largest number of cases described to date of hospitalized patients with SARS-CoV-2 disease (2019-nCoViD), 26% required care in an intensive care unit (ICU). This pandemic is causing an unprecedented mobilization of the scientific community, which has been associated with an exponentially growing number of publications in relation to it. This narrative literature review aims to gather the main contributions in the area of intensive care to date in relation to the epidemiology, clinic, diagnosis and management of 2019-nCoViD.

[The impact factor of Nutrición Hospitalaria is 1.096]. / El factor de impacto de Nutrición Hospitalaria es 1,096.

The editors of Nutrición Hospitalaria (Nutr Hosp) analyze the journal from its foundation in 1979 to the present time, on occasion of the first publication of its impact factorby Journal Citation Reports (JCR). The actions taken along this thirty year period are described, including its incorporation to multiple web databases, the Open Access policy of the journal, its progressive internationality, and the bibliometric analysis made in 1999. A figure with the journal citation trends is included. Nutr Hosp, included in the "Nutrition & Dietetics" group of JCR, is in the position 42/59, i.e. in the third quartile. Among the Spanish journals included in JCR,Nutr Hosp is located in the 14/37 position. A few considerations are made related to the economical aspects of the journal, the number of articles received so far, the articles expected in the future, the rejection rate and the language (Spanish or English) in which Nutr Hosp should be published.

[Micronutrients in parenteral nutrition]. / Micronutrientes en nutrición parenteral.

At a multidisciplinary debate, and after reviewing the evidence available as well as experts' opinion, the IV Baxter-SENPE Working Panel established the indications and managemente guidelines for micronutrients (water-soluble and fat-soluble vitamins, and oligoelements or trace elements) in parenteral nutrition. It was concluded about the convenience of daily intake of micronutrients with diferent options regarding deficiente or excessive dosages, administration systems, interactions, monitoring, and cots-effectiveness.

[Reason and emotion: integration of cognitive-behavioural and experiential interventions in the treatment of long evolution food disorders]. / La razón y la emoción: integración de las intervenciones cognitivo-conductuales y experenciales en el tratamiento de los trastornos de alimentación de larga evolución.

This paper intends to show the combination of therapeutical strategies in the treatment of long evolution food disorders. This fashion of work entitled "Modelo Santa Cristina" is based on several theoretical paradigms: Enabling Model, Action Control Model, Change Process Transtheoretical Model and Cognitive-Behavioural Model (Cognitive Restructuring and Learning Theories). Furthermore, Gestalt, Systemic and Psychodrama Orientation Techniques. The purpose of the treatment is both the normalization of food patterns and the increase in self-knowledge, self-acceptance and self-efficacy of patients. The exploration of ambivalence to change, the discovery of the functions of symptoms and the search for alternative behaviours, the normalization of food patterns, bodily image, cognitive restructuring, decision taking, communication skills and elaboration of traumatic experiences are among the main areas of intervention.

[Management models in clinical nutrition: weaknesses and strengths]. / Modelos de gestión en nutrición clínica: Puntos débiles y puntos fuertes.

At the 6th Abbott-SENPE Debate Forum a multidisciplinary and multiprofessional discussion was established in order to seek for the model or the models of clinical management most appropriate for Clinical Nutrition and Dietetics Units (CNAD) in Spain. The weaknesses and strengths as well as opportunities for the current systems were assessed concluding that a certain degree of disparity was observed not only due to regional differences but also to different hospital types. It was proposed, from SENPE, the creation of a working group helping to standardize the models and promote the culture of Integral Control and Change Management.

[Careful! Your bibliographic references may be examined]. / Cuidado!, sus referencias bibliográficas pueden ser estudiadas.

Reference to previous work represents a conceptual association of recognized scientific ideas that are beneficial for the citing author. I.e., a reference is an express recognition of an intellectual compromise towards a previous source of information. After all, advancement of science is supported by previous research. At present, the way to know and to measure the importance of a published item comes through its posterior citations, circumstance that obliges scientific journals to control the pertinence and relevance of the cited work. Therefore, when submitting a manuscript for consideration to a scientific journal, it must be beard in mind that the included references will be examined.

[V debate forum of the SENPE. Current issues on home-based and ambulatory artificial nutrition]. / V Foro de Debate SENPE: Problemática actual de la nutrición artificial domiciliaria y ambulatoria.

A multidisciplinary and multiprofessional debate is established trying to detect and find plausible solutions regarding Home-based and Ambulatory Enteral Nutrition (HBAEN) in Spain, due to the little attention paid by the Administration to the global problem of hyponutrition, the little interest showed by the collectivity of health care professionals, and the lack of a regulation differentiating the patient at his/her home and the patient at a nursing home. It was concluded that the current legislation on Home Based Enteral Nutrition (HBEN) has been variedly applied and does not contemplate the real clinical health care, with some pathologies subsidiary of this kind of therapy being excluded. Proposals to improve both financing and pathologies irrespective of the kind of nutritional therapy are made.

Effect of the route of nutrition and L-alanyl-L-glutamine supplementation in amino acids' concentration in trauma patients.

PURPOSE: Our purpose was to assess the amino acids' (AAs) profile in trauma patients and to assess the effect of the route of nutrition and the exogenous ALA-GLN dipeptide supplementation on plasma AAs' concentration. METHODS: This is a secondary analysis of a previous randomized controlled trial. On day 1 and day 6 after trauma, plasma concentration of 25 AAs was measured using reverse phase high-performance liquid chromatography. Results were analyzed in relation to the route of nutrition and supplementation of ALA-GLN dipeptide. Differences between plasma AAs' concentrations at day 1 and day 6 were evaluated using the Student's t test or Mann-Whitney-Wilcoxon test. One-way ANOVA and the Kruskal-Wallis test were used to compare groups. A two-sided p value less than 0.05 was considered statistically significant. RESULTS: Ninety-eight patients were analyzed. Mean plasma concentrations at day 1 were close to the lower normal level for most AAs. At day 6 we found an increase in the eight essential AAs' concentrations and in 9 out of 17 measured non-essential AAs. At day 6 we found no differences in plasma concentrations for the sum of all AAs (p = .72), glutamine (p = .31) and arginine (p = .23) distributed by the route of nutrition. Administration of ALA-GLN dipeptide increased the plasma concentration of alanine (p = .004), glutamine (p < .001) and citrulline (p = .006). CONCLUSIONS: We found an early depletion of plasma AAs' concentration which partially recovered at day 6, which was unaffected by the route of nutrition. ALA-GLN dipeptide supplementation produced a small increase in plasma levels of glutamine and citrulline.

Late complications of percutaneous tracheostomy using the balloon dilation technique. / Complicaciones tardías de la traqueotomía percutánea con la modalidad de dilatación con balón.

OBJECTIVE: The purpose of this study was to determine the late complications in critically ill patients requiring percutaneous tracheostomy (PT) using the balloon dilation technique. DESIGN: A prospective, observational cohort study was carried out. SCOPE: Two medical-surgical intensive care units (ICU). PATIENTS: All mechanically ventilated adult patients consecutively admitted to the ICU with an indication of tracheostomy. INTERVENTIONS: All patients underwent PT according to the Ciaglia Blue Dolphin® method, with endoscopic guidance. Survivors were interviewed and evaluated by fiberoptic laryngotracheoscopy and tracheal computed tomography at least 6 months after decannulation. VARIABLES: Intraoperative, postoperative and long-term complications and mortality (in-ICU, in-hospital) were recorded. RESULTS: A total of 114 patients were included. The most frequent perioperative complication was minor bleeding (n=20) and difficult cannula insertion (n=19). Two patients had severe perioperative complications (1.7%) (major bleeding and inability to complete de procedure in one case and false passage and desaturation in the other). All survivors (n=52) were evaluated 211±28 days after decannulation. None of the patients had symptoms. Fiberoptic laryngotracheoscopy and computed tomography showed severe tracheal stenosis (>50%) in 2patients (3.7%), both with a cannulation period of over 100 days. CONCLUSIONS: Percutaneous tracheostomy using the Ciaglia Blue Dolphin® technique with an endoscopic guide is a safe procedure. Severe tracheal stenosis is a late complication which although infrequent, must be taken into account due to its lack of clinical expressiveness. Evaluation should be considered in those tracheostomized critical patients who have been cannulated for a long time.

[II BAXTER-SENPE workshop: peripheral parenteral nutrition]. / II Mesa de Trabajo Baxter-SENPE: Nutrición Parenteral Periférica.

During the II BAXTER-SENPE workshop, a multidisciplinary nutrition expert committee discusses on indications, advantages and drawbacks of Peripheral Parenteral Nutrition (PPN), being defined as PN compounded by the three essential elements, vitamins, and minerals. Its composition implies a CH: lipids ratio of 60:40, a limited lipid daily intake (1.3 g/kg of body weight/day) and no more than 30% of total calories), and a nitrogen load not higher than 10 g of nitrogen in a maximum volume of 2500 mL. PPN can be administered by the peripheral route since its osmolarity is lower than 800 mOsm/L and pH is 6.0-7.4; in this way, possible adverse affects of central venous accesses are prevented. Currently, PPN by represent up to 50% of all PNs prescribed at a hospital Studies on efficacy, safety and pharmacoeconomic show that PPN is very useful therapeutic resource in certain clinical situations, both medical and surgical, to prevent metabolic-nutritional worsening of the patient, thus having an impact on significant reduction of complications, the number of interventions, and hospital stay.

[IV Debate Forum of the SENPE: questions on nutrition research]. / IV Foro de Debate SENPE: problemática de la investigación en nutrición.

The IV Debate Forum of the SENPE values from a multidisciplinary and multi-professional perspective the questions on clinical research in nutrition in Spain, focusing on enteral nutrition due to the lack of legislation on this issue. The concluding remarks point out the SENPE commitment with promoting quality, education and facilitation of research, greater help to emergent groups, looking for financial support, and timely information on the several summons from public systems and reference centers