Identificación de un brote de SARSCoV-2 (Covid-19) en un centro gerontológico de la Ciudad de México.

OBJECTIVE: To describe a Covid-19 outbreak in a gerontological center in Mexico City. MATERIAL AND METHODS: Cross-sectional study in older adults. The association of risk factors for dying from Covid-19 was analyzed using a multiple logistic regression model. RESULTS: One hundred and two elders with an average age of 82.5 ± 8.8 years were included. Fifty-five (54%) tested positive and 47 (46%) were negative for the new coronavirus. Using the multiple logistic regression model, people with frailty had an OR of 11.6 of dying from Covid-19 compared to robust people (p-value = 0.024). CONCLUSION: The Covid-19 outbreak was initially caused by a resident of the center and spread by cross infection. In vulnerable populations, early detection, isolation, and follow-up of contacts should be carried out, as well as the identification of risk factors in order to reduce the spread and mortality caused by SARSCoV-2.

Characteristics and mortality of Mexican patients with COVID-19 and mechanical ventilation.

INTRODUCTION: COVID-19-associated mortality in patients who require mechanical ventilation is unknown in the Mexican population. OBJECTIVE: To describe the characteristics of Mexican patients with COVID-19 who required mechanical ventilation. METHODS: Observational cohort study carried out in an intensive care unit from March 25 to July 17, 2020. Data were obtained from a prospective database and electronic medical records, and were analyzed with the chi-square test, Fisher's exact test or Mann-Whitney's U-test. RESULTS: One hundred patients required mechanical ventilation; median age was 56 years, 31 % were females and 97 % were Latin American. Most common comorbidities were obesity (36 %), diabetes (26 %), hypertension (20 %), and chronic or end-stage kidney disease (10 %). At the end of the analysis, 11 patients remained in the ICU, 31 had been discharged alive and 58 (65.2 %) died; survivors were younger, had lower scores on severity and organ dysfunction scales, lower levels of C-reactive protein at ICU admission, were less likely to receive hemodialysis and vasopressors, and had longer hospital and ICU stays. CONCLUSIONS: This study adds information on the presentation and results of SARS-CoV-2-infected patients who require mechanical ventilation.

INTRODUCCIÓN: La mortalidad por COVID-19 en quienes requieren ventilación mecánica se desconoce en la población mexicana. OBJETIVO: Describir las características de pacientes mexicanos con COVID-19 que requirieron ventilación mecánica. MÉTODOS: Estudio de cohorte observacional en una unidad de terapia intensiva, del 25 de marzo al 17 de julio de 2020. Los datos se obtuvieron de una base de datos prospectiva y de registros clínicos electrónicos; fueron analizados con c2, prueba exacta de Fisher o prueba U de Mann-Whitney. RESULTADOS: Cien pacientes recibieron ventilación mecánica, la edad media fue de 56 años, 31 % era del sexo femenino y 97 %, latinoamericano. Las comorbilidades más comunes fueron obesidad (36 %), diabetes (26 %), hipertensión (20 %) y enfermedad renal crónica o renal terminal (10 %). Al término del análisis, 11 pacientes permanecían en la UCI, 31 egresaron vivos y 58 (65.2 %) fallecieron; los sobrevivientes fueron más jóvenes, con menores puntuación en las escalas de gravedad y disfunción orgánica, menores niveles de proteína C reactiva al ingreso a la UCI, menor propensión a hemodiálisis, necesidad de, necesidad de vasopresores y con mayor estancia hospitalaria y en la UCI. CONCLUSIONES: Este estudio agrega información sobre la presentación y resultados de pacientes con ventilación mecánica infectados con SARS-CoV-2.

Impact of strategic planning, organizational culture imprint and care bundles to reduce adverse events in the ICU.

OBJECTIVE: To evaluate the occurrence of adverse events during a multifaceted program implementation. DESIGN: Cross-sectional secondary analysis. SETTING: The respiratory-ICU of a large tertiary care center. PARTICIPANTS: Retrospectively collected data of patients admitted from 1 March 2010 to 28 February 2014 (usual care period) and from 1 March 2014 to 1 March 2017 (multifaceted program period) were used. INTERVENTIONS: The program integrated three components: (1) strategic planning and organizational culture imprint; (2) training and practice and (3) implementation of care bundles. Strategic planning redefined the respiratory-ICU Mission and Vision, its SWOT matrix (strengths, weaknesses, opportunities, threats) as well as its medium to long-term aims and planned actions. A 'Wear the Institution's T-shirt' monthly conference was given in order to foster organizational culture in healthcare personnel. Training was conducted on hand hygiene and projects 'Pneumonia Zero' and 'Bacteremia Zero'. Finally, actions of both projects were implemented. MAIN OUTCOME MEASURES: Rates of adverse events (episodes per 1000 patient/days). RESULTS: Out of 1662 patients (usual care, n = 981; multifaceted program, n = 681) there was a statistically significant reduction during the multifaceted program in episodes of accidental extubation ([Rate ratio, 95% CI] 0.31, 0.17-0.55), pneumothorax (0.48, 0.26-0.87), change of endotracheal tube (0.17, 0.07-0.44), atelectasis (0.37, 0.20-0.68) and death in the ICU (0.82, 0.69-0.97). CONCLUSIONS: A multifaceted program including strategic planning, organizational culture imprint and care protocols was associated with a significant reduction of adverse events in the respiratory-ICU.

Eventos adversos en una nueva unidad de cuidados intensivos. Influencia del diseño y la tecnología de las instalaciones en las tasas de incidencia.

INTRODUCTION: New hospitals are replacing old facilities. There is little information on the performance of an intensive care unit (ICU) when it is relocated in a new and equipped area. OBJECTIVE: To analyze the impact of the change of ICU facilities from a shared environment to individual beds on the occurrence of adverse events. METHOD: Cross-sectional, comparative study, with prospectively collected data from patients admitted from March 01, 2014 to February 28, 2017 to the former ICU (f-ICU) and from July 17, 2017 to January 17, 2019 to the new ICU (n-ICU) of a public teaching hospital. The rate of adverse events was measured in events per 1,000 patient-days. RESULTS: Among 1,188 patients (f-ICU, n = 681 vs. n-ICU, n = 507), a reduction in the rate of unforeseen cardiac arrest (rate ratio: 0.31; 95% confidence interval [CI] = 0.12-0.80) and an increase in the rate of unplanned extubation (rate ratio: 2.49; 95% CI = 1.24-5.01) were observed, with both being statistically significant. The other nine monitored adverse events showed no changes. CONCLUSIONS: In comparison with the f-ICU, most of the monitored adverse events did not significantly change within the first 18 months of activities at the n-ICU.

INTRODUCCIÓN: Nuevos hospitales están reemplazando a instalaciones antiguas. Existe poca información del desempeño de una unidad de cuidados intensivos (UCI) cuando es reubicada en un área nueva y equipada. OBJETIVO: Analizar el impacto del cambio de instalaciones de un ambiente compartido a camas individuales en la ocurrencia de eventos adversos en la UCI. MÉTODO: Estudio transversal, comparativo, con datos prospectivos de pacientes ingresados del 1 de marzo de 2014 al 28 de febrero de 2017 a la antigua UCI (aUCI) y del 17 de julio de 2017 al 17 de enero de 2019 a la nueva UCI (nUCI) de un hospital-escuela público. La tasa de eventos adversos se midió en eventos por 1000 días-paciente. RESULTADOS: En 1188 pacientes (aUCI, n = 681 versus nUCI, n = 507) se observó reducción en la tasa de paro cardiaco no previsto (razón de tasas 0.31, IC 95 % = 0.12-0.80) e incremento en la tasa de extubación no planeada (razón de tasas 2.49, IC 95 % = 1.24-5.01), estadísticamente significativos; los otros nueve eventos adversos monitoreados no mostraron cambios. CONCLUSIONES: Comparada con la aUCI, la mayor parte de eventos adversos monitoreados no se modificaron significativamente en los 18 meses de inicio de actividades de la nUCI.

[Changes observed in three quality indicators after the implementation of improvement strategies in the respiratory intensive care unit]. / Cambios en tres indicadores de calidad después de la implementación de estrategias de mejora en la unidad de cuidados intensivos respiratorios.

OBJECTIVE: To compare the results of quality monitoring after the implementation of improvement strategies in the respiratory intensive care unit (RICU). DESIGN: A prospective, comparative, longitudinal and interventional study was carried out. SETTING: The RICU of Hospital General de México (Mexico). PATIENTS: All patients admitted to the RICU from March 2012 to March 2013. INTERVENTIONS: An evidence-based bundle of interventions was implemented in order to reduce the ratios of three quality indicators: non-planned extubation (NPE), reintubation, and ventilator-associated pneumonia (VAP). VARIABLES OF INTEREST: NPE, reintubation and VAP ratios. RESULTS: A total of 232 patients were admitted, with a mean age of 49.5±17.8years; 119 (50.5%) were woman. The mean Simplified Acute Physiology Score (SAPS-3) was 49.8±17, and the mean Sequential Organ Failure Assessment (SOFA) score was 5.3±4.1. The mortality rate in the RICU was 38.7%. The standardized mortality ratio was 1.50 (95%CI: 1.20-1.84). An improved ratio was observed for reintubation and NPE indicators compared to the ratios of the previous 2011 cohort: 1.6% vs. 7% (P=.02) and 8.1 vs. 17 episodes per 1000 days of mechanical ventilation (P=.04), respectively. A worsened VAP ratio was observed: 18.4 vs. 15.1 episodes per 1000 days of mechanical ventilation (P=.5). CONCLUSIONS: Quality improvement is feasible with the identification of areas of opportunity and the implementation of strategies. Nevertheless, the implementation of a bundle of preventive measures in itself does not guarantee improvements.

Tracheal resection and anastomosis in postintubation tracheal stenosis: a systematic review.

Surgical resection of the stenotic segment with end-to-end anastomosis is considered the gold standard in postintubation tracheal stenosis. However, outcomes of this concrete aetiology are not well described. With the aim to examine the extent, range and characteristics of the existing evidence, a scoping review was performed. Data sources included MEDLINE, Scopus, Ovid and the Cochrane databases. Inclusion criteria consisted of studies in adult patients with postintubation tracheal stenosis that reported characteristics, surgical management and outcomes. A total of 125 articles were identified, of which 10 were included in the final analysis. All studies were case reports or case series (level 4 evidence) grouping 110 patients, 75 males and 35 females. The age ranged from 15 to 71 years. Cotton-Myer stenosis grade was 1 [1 (0.9%)], 2 [25 (22.7%)], 3 [70 (63.6%)] and 4 [14 (12.7%)]. Stenosis location was in the tracheal upper-third in 108 (98.2%), in the middle-third in 1 (0.9%) and in the lower-third in 1 (0.9%). Stenosis length ranged from 1 to 5.6 cm. Follow-up ranged from 1 to 60 months (2 years for the most). Most frequent complications were transitory dysphagia in 13 (11.3%), granuloma formation in 8 (7.3%), dehiscence or air leak in 5 (4.5%) and wound infection in 4 (3.6%). Restenosis rate ranged from 2% to 25%. There was no perioperative mortality. Tracheal resection and primary anastomosis in postintubation tracheal stenosis appear to be safe and effective in the short and mid-terms; however, the very low level of evidence found prevents definitive conclusions.

Tuberculosis extrapulmonar: un problema de salud pública.

Extrapulmonary tuberculosis is defined as that case of tuberculosis clinically diagnosed and confirmed by bacteriological studies that affects tissues and organs outside the lung parenchyma. Mexico is in third place among Latin American countries in terms of the incidence of pulmonary and extrapulmonary tuberculosis. Culture methods are still the gold standard for the diagnosis of extrapulmonary tuberculosis since they identify the species and susceptibility to drugs.

La tuberculosis extrapulmonar es aquella tuberculosis diagnosticada clínicamente y confirmada por estudios bacteriológicos que afecta a tejidos y órganos fuera del parénquima pulmonar. México es el tercer lugar en América Latina en incidencia de tuberculosis pulmonar y extrapulmonar. Los métodos de cultivo siguen siendo el método de referencia para el diagnóstico de tuberculosis extrapulmonar, ya que identifican la especie y la sensibilidad a los fármacos.

Burnout symptoms among physicians and nurses before, during and after COVID-19 care. / Síntomas de Burnout entre médicos y enfermeros antes, durante y después de atender pacientes con COVID-19.

OBJECTIVE: this study evaluated burnout symptoms among physicians and nurses before, during and after COVID-19 care. METHOD: a cross-sectional comparative study in the Pulmonary Care unit of a tertiary-level public hospital. The Maslach Burnout Inventory was used. RESULTS: 280 surveys were distributed across three periods: before (n=80), during (n=105) and after (n=95) COVID-19 care; 172 surveys were returned. The response rates were 57.5%, 64.8% and 61.1%, respectively. The prevalence of severe burnout was 30.4%, 63.2% and 34.5% before, during and after COVID-19 care (p<0.001). Emotional exhaustion (p<0.001) and depersonalization (p=0.002) symptoms were more prevalent among nurses than among physicians. Severe burnout was more prevalent in women, nurses and night shift staff. CONCLUSION: the high prevalence of burnout doubled in the first peak of hospital admissions and returned to pre-pandemic levels one month after COVID-19 care ended. Burnout varied by gender, shift and occupation, with nurses among the most vulnerable groups. Focus on early assessment and mitigation strategies are required to support nurses not only during crisis but permanently.

The Prevalence of Depression and Anxiety Symptoms and Their Association With Respiratory Diseases.

INTRODUCTION: Patients with respiratory diseases face adverse situations such as symptom management, general condition deterioration, and a hostile perception of the hospital environment, favoring the appearance of anxiety and depression. METHODS: A total of 317 patients hospitalized for a disease of pulmonary origin were analyzed and divided into the following subgroups: infectious, oncological, acute, and chronic diseases. Patients over 18 years of age with preserved cognitive capacity were included in the study. The Hospital Anxiety and Depression Scale (HADS) was applied to them on the second or fourth day of their hospital stay and five days after the first evaluation. Multiple linear regression models were carried out to analyze the association between anxiety and depression measured over two different periods. The models present the statistically significant variables with a 95% confidence level. RESULTS: The patients presented with anxiety in 74.4% of cases, mainly those with acute respiratory diseases (42.4%) and neoplastic diseases (27.5%). A total of 69.5% presented with depression, with symptoms more significant in those with chronic and oncological pulmonary diseases and those with no job. Patients with at least one comorbidity presented with anxiety in 53.9% of cases and depression in 52.1% of cases. Linear regression models were carried out and showed that anxiety was 1.75 and 1.84 times more frequent in patients with chronic diseases compared to those with infectious pathologies in the first and second reviews, respectively. The linear regression model also showed a higher frequency of depressive symptoms in patients with chronic conditions (1.62 times) compared to the group with infectious and contagious pathologies, and prolonged hospital stays were associated with depressive symptoms 1.37 times more than short stays. CONCLUSIONS: Anxiety and depression are frequent disorders in patients with respiratory diseases, negatively affecting the prognosis. Routine mental health screening and multidisciplinary management are essential in this population.

Pulmonary aspergilloma in immunocompromised patients in a Respiratory Care Unit.

INTRODUCTION: Pulmonary aspergilloma is commonly associated with comorbidities that cause immunodeficiency such as diabetes mellitus, tuberculosis, human immunodeficiency virus/acquired immunodeficiency syndrome and/or a pre-existing parenchymal lung disease such as chronic obstructive pulmonary disease. Predisposing factors can further increase the risk of acquiring this mycosis. Our objective was to determine the frequency, clinical and microbiological characteristics of pulmonary aspergilloma in immunocompromised patients. METHODOLOGY: Retrospective case series of patients diagnosed with pulmonary aspergilloma in a respiratory care unit in Mexico City from 2000 to 2019 was studied. Bronchoalveolar lavage cultures on Sabouraud-dextrose agar and serum galactomannan determination were performed on each patient. RESULTS: We identified twenty-four patients with pulmonary aspergilloma (sixteen male and eight female), thirteen had a history of tuberculosis (54%), seven of diabetes mellitus (29%), three of human immunodeficiency virus/acquired immunodeficiency syndrome (13%) and one of chronic obstructive pulmonary disease (4%). The most commonly reported symptoms were hemoptysis in eighteen patients (75%), dyspnea in sixteen patients (67%) and chest pain in thirteen patients (54%). Aspergillus fumigatus was identified in all cultures and galactomannan was positive in 21 serum samples (87%). CONCLUSIONS: Coexistence of diseases that could suppress the immune system predispose to pulmonary aspergilloma; clinical presentation is often confused with other systemic diseases. A high degree of clinical suspicion is important for early detection.

IL-6, IL-10, sFas, granulysin and indicators of intestinal permeability as early biomarkers for a fatal outcome in COVID-19.

The clinical presentation of coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), ranges between mild respiratory symptoms and a severe disease that shares many of the features of sepsis. Sepsis is a deregulated response to infection that causes life-threatening organ failure. During sepsis, the intestinal epithelial cells are affected, causing an increase in intestinal permeability and allowing microbial translocation from the intestine to the circulation, which exacerbates the inflammatory response. Here we studied patients with moderate, severe and critical COVID-19 by measuring a panel of molecules representative of the innate and adaptive immune responses to SARS-CoV-2, which also reflect the presence of systemic inflammation and the state of the intestinal barrier. We found that non-surviving COVID-19 patients had higher levels of low-affinity anti-RBD IgA antibodies than surviving patients, which may be a response to increased microbial translocation. We identified sFas and granulysin, in addition to IL-6 and IL-10, as possible early biomarkers with high sensitivity (>73 %) and specificity (>51 %) to discriminate between surviving and non-surviving COVID-19 patients. Finally, we found that the microbial metabolite d-lactate and the tight junction regulator zonulin were increased in the serum of patients with severe COVID-19 and in COVID-19 patients with secondary infections, suggesting that increased intestinal permeability may be a source of secondary infections in these patients. COVID-19 patients with secondary infections had higher disease severity and mortality than patients without these infections, indicating that intestinal permeability markers could provide complementary information to the serum cytokines for the early identification of COVID-19 patients with a high risk of a fatal outcome.

Association between Postmortem Kidney Biopsy Findings and Acute Kidney Injury from Patients with SARS-CoV-2 (COVID-19).

BACKGROUND AND OBJECTIVES: AKI in coronavirus disease 2019 (COVID-19) is associated with higher morbidity and mortality. The objective of this study was to identify the kidney histopathologic characteristics of deceased patients with diagnosis of COVID-19 and evaluate the association between biopsy findings and clinical variables, including AKI severity. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Our multicenter, observational study of deceased patients with COVID-19 in three third-level centers in Mexico City evaluated postmortem kidney biopsy by light and electron microscopy analysis in all cases. Descriptive and association statistics were performed between the clinical and histologic variables. RESULTS: A total of 85 patients were included. Median age was 57 (49-66) years, 69% were men, body mass index was 29 (26-35) kg/m2, 51% had history of diabetes, 46% had history of hypertension, 98% received anticoagulation, 66% were on steroids, and 35% received at least one potential nephrotoxic medication. Severe AKI was present in 54% of patients. Biopsy findings included FSGS in 29%, diabetic nephropathy in 27%, and arteriosclerosis in 81%. Acute tubular injury grades 2-3 were observed in 49%. Histopathologic characteristics were not associated with severe AKI; however, pigment casts on the biopsy were associated with significantly lower probability of kidney function recovery (odds ratio, 0.07; 95% confidence interval, 0.01 to 0.77). The use of aminoglycosides/colistin, levels of C-reactive protein and serum albumin, previous use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, antivirals, nonsteroid anti-inflammatory drugs, and anticoagulants were associated with specific histopathologic findings. CONCLUSIONS: A high prevalence of chronic comorbidities was found on kidney biopsies. Nonrecovery from severe AKI was associated with the presence of pigmented casts. Inflammatory markers and medications were associated with specific histopathologic findings in patients dying from COVID-19.

Clinical performance and resource utilization in the start of a totally new Intensive Care Unit. Same staff, new area.

BACKGROUND: There is little information of intensive care unit (ICU) performance when it's relocated to a totally new and equipped area. OBJECTIVE: To analyze the clinical performance and use of resources of a new respiratory-ICU (nRICU) in a large third-level care hospital. METHOD: Cross-sectional, comparative study using prospective data of patients admitted from July 17, 2017 to July 17, 2018. The Rapoport adjusted method was used to obtain the standardized clinical performance index (SCPI) and the standardized resource use index (SRUI). RESULTS: Out of 354 patients, those who were readmissions or remained hospitalized and those whose treatment was withheld or withdrawn where excluded from the analysis. In 301 patients, the observed survival at hospital discharge was 63% while the expected survival was 67.7%. Values of SCPI and SRUI were -1.03 and 0.05 respectively, placing results in coordinates within two standard deviations when plotted in the Rapoport chart. There was a statistically significant difference in survival when comparing the study period with outcomes obtained in the RICU before its relocation (63% vs. 55%, p = 0.01). CONCLUSIONS: In its 1st year of operation, the nRICU had better clinical performance compared to the former RICU, with no change in the use of resources.

ANTECEDENTES: Existe poca información acerca del desempeño de una unidad de cuidados intensivos (UCI) cuando es reubicada en un área totalmente nueva y equipada. OBJETIVO: Analizar el rendimiento clínico y el uso de recursos de la nueva UCI respiratoria (UCIR) de un hospital grande de tercer nivel. MÉTODO: Estudio transversal, comparativo, con datos prospectivos de pacientes ingresados del 17 de julio de 2017 al 17 de julio de 2018. Se usa el método ajustado de Rapoport para obtener el índice de rendimiento clínico estandarizado (IRCE) y el índice de uso de recursos estandarizado (IRURE). RESULTADOS: De 354 pacientes fueron excluidos los reingresos, los pacientes aún hospitalizados y aquellos a quienes se limitó o retiró el tratamiento. En 301 pacientes la sobrevida hospitalaria fue del 63%, mientras que la sobrevida esperada fue del 67.7%. El IRCE fue −1.03 y el IRURE fue 0.05, situando el resultado en coordenadas dentro de dos desviaciones estándar en el gráfico de Rapoport. Hubo una diferencia estadísticamente significativa en la sobrevida comparando el periodo de estudio con resultados de la UCIR obtenidos antes de su reubicación (63 vs. 55%, p = 0.01). CONCLUSIONES: En su primer año de funcionamiento, la nueva UCIR tuvo mejor rendimiento clínico que la antigua, sin modificación en el uso de recursos.

Síntomas de Burnout entre médicos y enfermeros antes, durante y después de atender pacientes con COVID-19 / Burnout symptoms among physicians and nurses before, during and after COVID-19 care / Sintomas de burnout entre médicos e enfermeiros antes, durante e depois do cuidado de pacientes com COVID-19

Objetivo: este estudio evaluó síntomas de Burnout entre médicos y enfermeros antes, durante y después de la atención provista a pacientes con la enfermedad COVID-19. Método: estudio comparativo y transversal realizado en la unidad de Atención Respiratoria de un hospital público de nivel terciario. Se empleó el Inventario de Burnout Maslach. Resultados: se distribuyeron 280 encuestas entre los tres períodos: antes (n=80), durante (n=105) y después (n=95) de la atención a pacientes con COVID-19; se obtuvieron 172 encuestas respondidas. Las tasas de respuesta fueron 57,5%, 64,8% y 61,1%, respectivamente. Los valores de prevalencia de Burnout grave fueron 30,4%, 63,2% y 34,5% antes, durante y después de la atención a pacientes por la enfermedad del coronavirus 2019 (p<0,001). Los síntomas de agotamiento emocional (p<0,001) y despersonalización (p=0,002) fueron más prevalentes entre los enfermeros que entre los médicos. El Síndrome de Burnout grave fue más prevalente en las mujeres, los enfermeros y el personal del turno noche. Conclusión: la elevada prevalencia de Burnout se duplicó en el primer pico de internaciones y regresó a niveles previos a la pandemia un mes después de finalizada la atención a pacientes por la enfermedad del coronavirus 2019. El Síndrome de Burnout varió por sexo, turno de trabajo y ocupación, y los enfermeros representaron los grupos más vulnerables. Es necesario enfocarse en estrategias de evaluación y mitigación tempranas para asistir a los enfermeros, no solo durante la crisis sino permanentemente.

Objective: this study evaluated burnout symptoms among physicians and nurses before, during and after COVID-19 care. Method: a cross-sectional comparative study in the Pulmonary Care unit of a tertiary-level public hospital. The Maslach Burnout Inventory was used. Results: 280 surveys were distributed across three periods: before (n=80), during (n=105) and after (n=95) COVID-19 care; 172 surveys were returned. The response rates were 57.5%, 64.8% and 61.1%, respectively. The prevalence of severe burnout was 30.4%, 63.2% and 34.5% before, during and after COVID-19 care (p<0.001). Emotional exhaustion (p<0.001) and depersonalization (p=0.002) symptoms were more prevalent among nurses than among physicians. Severe burnout was more prevalent in women, nurses and night shift staff. Conclusion: the high prevalence of burnout doubled in the first peak of hospital admissions and returned to pre-pandemic levels one month after COVID-19 care ended. Burnout varied by gender, shift and occupation, with nurses among the most vulnerable groups. Focus on early assessment and mitigation strategies are required to support nurses not only during crisis but permanently.

Objetivo: este estudo avaliou os sintomas de burnout entre médicos e enfermeiros antes, durante e após o cuidado dos pacientes contaminados com o COVID-19. Método: estudo transversal comparativo realizado na unidade de Atenção Pulmonar de um hospital público de nível terciário. Foi utilizado o Inventário de Burnout de Maslach. Resultados: 280 formulários de pesquisa foram distribuídos em três períodos: antes (n=80), durante (n=105) e após (n=95) os cuidados dos pacientes contaminados com COVID-19; 172 formulários foram respondidos. As taxas de resposta foram de 57,5%, 64,8% e 61,1%, respectivamente. A prevalência de burnout grave foi de 30,4%, 63,2% e 34,5% antes, durante e após o atendimento dos pacientes (p<0,001). Os sintomas de exaustão emocional (p<0,001) e despersonalização (p=0,002) foram mais prevalentes entre os enfermeiros do que entre os médicos. O burnout grave foi mais prevalente em mulheres, enfermeiros e funcionários do turno da noite. Conclusão: a alta prevalência de burnout dobrou no primeiro pico de internações hospitalares e voltou aos níveis pré-pandemia um mês após o término dos cuidados dos pacientes contaminados com COVID-19. O burnout variou de acordo com o sexo, turno e profissão, encontrando-se os enfermeiros entre os grupos mais vulneráveis. O foco na avaliação precoce e nas estratégias de mitigação é necessário para apoiar os enfermeiros não apenas durante a crise, mas de forma permanente.

Minimización de costos de sedación usando anestesia inhalada. Análisis en la UTI durante la pandemia por COVID-19 / Minimization of sedation costs using inhaled anesthesia. Analysis in the ICU during the COVID-19 pandemic / Minimização dos custos de sedação usando anestesia inalatória. Análise na UTI durante a pandemia de COVID-19

Resumen: Introducción: los sedantes de uso no convencional y aquéllos fuera de recomendación como los anestésicos inhalados se usaron ante la escasez de medicamentos durante la pandemia por SARS-CoV-2. Objetivos: comparar el costo y resultados obtenidos con el uso de anestésicos inhalados versus sedantes intravenosos en COVID-19. Material y métodos: estudio retrospectivo en una unidad de terapia intensiva (UTI) de un hospital público de referencia. Se hizo un cálculo de costos de sedación de los dos primeros días de estancia en la UTI. Las dosis de fármacos fueron tomadas del expediente clínico y los costos de adquisición directamente de CompraNet. Se comparan medias de costos por medicamento y por grupo. Resultados: de 151 pacientes, 81 recibieron sedación intravenosa y 70 anestesia inhalada con o sin sedantes intravenosos. No hubo diferencia en mortalidad, días de ventilación mecánica, estancia en la UTI y estancia hospitalaria entre grupos. Se observó una reducción significativa de costos derivados del menor uso de midazolam, propofol y dexmedetomidina (p < 0.0001) cuando se usó anestesia inhalada y una diferencia entre medias de costos totales de sedación de $4,108.42 M.N. por día por paciente. Conclusiones: la anestesia inhalada durante la pandemia por COVID-19 permitió una reducción de costos comparada con sedación intravenosa en los primeros dos días de estancia en la UTI.

Abstract: Introduction: non-conventional sedatives and those off-label, such as inhaled anesthetics, were used due to the shortage of medicines during the SARS-CoV-2 pandemic. Objectives: to compare the cost and results obtained with the use of inhaled anesthetics versus intravenous sedatives in COVID-19. Material and methods: retrospective study in a public reference hospital ICU. A calculation of sedation costs was made of the first two days of ICU stay. Drug doses were taken from the clinical records and acquisition costs directly from CompraNet. Mean costs per medication and per group are compared. Results: of 151 patients, 81 received intravenous sedation and 70 received inhaled anesthesia with or without intravenous sedatives. There was no difference in mortality, days of mechanical ventilation, ICU stay, and hospital stay between groups. A significant reduction in costs derived from the less use of midazolam, propofol and dexmedetomidine (p < 0.0001), and a difference between means of total sedation costs of $4,108.42 Mexican pesos per patient per day was observed with inhaled anesthesia. Conclusions: inhaled anesthesia during the COVID-19 pandemic compared to intravenous sedation allowed a cost reduction in the first two days of ICU stay.

Resumo: Introdução: sedativos de uso não convencional e não recomendados, como anestésicos inalatórios, foram utilizados devido à escassez de medicamentos durante a pandemia de SARS-CoV-2. Objetivos: comparar o custo e os resultados obtidos com o uso de anestésicos inalatórios versus sedativos intravenosos na COVID-19. Material e métodos: estudo retrospectivo em uma UTI de um hospital público de referência. Foi feito um cálculo dos custos de sedação para os dois primeiros dias de internação na UTI. As doses dos medicamentos foram retiradas do prontuário clínico e os custos de aquisição diretamente do CompraNet. Os custos médios por medicamento e por grupo são comparados. Resultados: dos 151 pacientes, 81 receberam sedação intravenosa e 70 anestesia inalatória com ou sem sedativos intravenosos. Não houve diferença na mortalidade, dias em ventilação mecânica, permanência na UTI e internação entre os grupos. Uma redução significativa nos custos derivados do menor uso de midazolam, propofol e dexmedetomidina (p < 0.0001) foi observada quando a anestesia inalatória foi usada e uma diferença entre as médias dos custos totais de sedação de $4,108.42 M.N. por dia por paciente. Conclusões: a anestesia inalatória durante a pandemia de COVID-19 permitiu redução de custos em comparação com a sedação endovenosa nos primeiros dois dias de internação na UTI.

Falla respiratoria aguda: Hace 50 años, Hoy y Dentro de 50 años. Una revisión narrativa / Acute respiratory failure: 50 years ago, today and 50 years from now. A narrative review

The management of acute respiratory failure may require, among other measures, airway control, mechanical ventilation, and hemodynamic stabilization. About 60% of critically ill patients will require some type of respiratory support. For these reasons, an understanding of respiratory pathophysiology is important. The aim of this review is to establish an up-to-date of the concepts and fundamentals for acute respiratory failure.

El manejo de la falla respiratoria aguda puede requerir, entre otras medidas, control de la vía aérea, ventilación mecánica y estabilización hemodinámica. Alrededor del 60% de los pacientes graves requerirán de algún tipo de soporte respiratorio. Por estas razones es importante el entendimiento de la fisiopatología respiratoria. El objetivo de esta revisión es establecer conceptos y fundamentos actualizados sobre la falla respiratoria aguda.