Atención integral por cuidados paliativos para pacientes con ventilación mecánica asistida SARS-CoV-2 severos y sus beneficios / Comprehensive care for palliative care for patients with severe SARS-CoV-2 assisted mechanical ventilation and its benefits

Resumen Objetivo. Esta investigación tiene como objetivo describir la población atendida y los beneficios del programa "Lineamiento de atención integral por Cuidados Paliativos en el Área de Salud de Palmares, para pacientes con SARS-CoV-2 severo" con ventilación mecánica asistida, hospitalizados en unidades de cuidados intensivos de la Caja Costarricense del Seguro Social durante la pandemia en Costa Rica, del 10 de junio al 31 de octubre del 2021. Métodos. Estudio descriptivo mixto de la población y los beneficios del programa por medio de indicadores cuantitativos obtenidos del informe de aplicación y cualitativos a través de la realización de una encuesta de satisfacción a usuarios en el período de estudio. Resultados. El programa atendió a 13 pacientes, brindó apoyo en manejo del duelo a los familiares de cinco pacientes que ya habían fallecido y a los cuidadores de ocho pacientes hospitalizados, también ofreció 70 consultas médicas en un período promedio de 62 días. La edad promedio de los pacientes fue de 55 años; doce pacientes presentaban algún factor de riesgo, siendo la obesidad y la falta de esquema de vacunación completo (dos dosis) los más frecuentes. Durante la implementación del programa fallecieron cinco pacientes más, obteniendo una tasa de mortalidad del 78%. A los pacientes que sobrevivieron se les atendió en promedio por 135 días. Con el apoyo del equipo, los pacientes lograron la recuperación clínica de las complicaciones respiratorias y funcionales. Lograron independencia total de actividades básicas de la vida diaria y reinserción social en menos de tres meses después del alta hospitalaria. En general, se documentó una percepción positiva del programa en el 100% de los usuarios, con cambios en el nivel de sufrimiento manifestado por las familias y el apoyo en el manejo del duelo. Conclusión. Con la optimización de uso de los recursos ya existentes en la Caja Costarricense del Seguro Social y la participación social, este programa abordó aspectos no atendidos previamente para los pacientes que sufrieron COVID 19 severo, como el manejo del sufrimiento y/o duelo durante la hospitalización y al egreso. Además, el programa colaboró en la recuperación clínica y funcional de los usuarios sobrevivientes y documentó múltiples beneficios percibidos por el paciente, sus familias, la institución y la sociedad, como el abordaje del sufrimiento, la adecuada atención al duelo, la organización de los recursos asistenciales y la pronta recuperación física, emocional y social del paciente sobreviviente.

Abstract Aim. This research aims to describe the population served and the benefits of the program "Guidelines for integral care for patients with severe SARS-CoV-2 by Palliative Care at the Area de Salud de Palmares " to patients with assisted mechanical ventilation, hospitalized in intensive care units of the Caja Costarricense del Seguro Social during the pandemic in Costa Rica, from June 10 to October 31, 2021. Methods. This study is a mixed descriptive investigation that analyzes quantitative indicators from the report on the program's application and qualitative indicators from a satisfaction survey for the users in the study period. Results. The program treated 13 patients, provided grief management support to the relatives of five patients who had already died and to the caregivers of eight hospitalized patients, and offered 70 medical consultations in an average period of 62 days. The average age of the patients was 55 years; twelve patients had some risk factors, and obesity and lack of a complete vaccination schedule (two doses) were the most frequent. During the program implementation, five more patients died, obtaining a mortality rate of 78%. The average treatment day for surviving patients was 135 days. Through the team's support, patients accomplished clinical recovery from respiratory and functional complications. They got independent basics activities of daily living and social reintegration in less tan three months after discharge. A positive perception of the program was documented in 100% of the program's users, with changes in the level of suffering manifested by the families and the support in grief management. Conclusion. With the optimization of the use of existing resources in the the Caja Costarricense del Seguro Social and the social participation, this program addressed aspects not previously attended to patients who suffered severe COVID 19, such as the management of suffering and/or grief during hospitalization and upon discharge. In addition, the program helped in the clinical and functional recovery of the surviving users, and documented multiple benefits perceived by the patient, their families, the institution, and society, such as the approach to suffering, adequate bereavement care, organization of care resources, and early physical, emotional and social recovery of the survivor patient.

Evaluación de la relajación neuromuscular y predictores de vía aérea difícil en pacientes programados para cirugía general Hospital Central Universitario Dr. Antonio María Pineda / Evaluation of muscle relaxation and predictors of difficult airway in patients programmed for general surgery Hospital Central Universitario Dr. Antonio María Pineda

Se realizó una investigación experimental tipo ensayo clínico controlado simple ciego con el fin de evaluar la relajación muscular y los predictores de vía aérea difícil en pacientes programados para cirugía general en el Hospital Central Universitario Dr. Antonio María Pineda. La muestra estuvo conformada por 100 pacientes distribuidos aleatoriamente en cuatro grupos de 25 pacientes cada uno. En los grupos Experimental-1 (E-1) y Control-1 (C-1) se utilizó una dosis del bloqueante neuromuscular Bromuro de Rocuronio de 0,6 mg/kg y en los grupos Experimental-2 (E-2) y Control-2 (C-2) de 1 mg/kg. La edad promedio de los pacientes fue de 34,8 ± 9,8 años; en los grupos E-1 y E-2, los predictores de vía aérea difícil predominantes fueron distancia esternomentoniana (32% y 42%), distancia tiromentoniana (24% y 40%), distancia interincisivos clase I (88% y 92 %), circunferencia de cuello  40 cm (16% y 8 %), Mallampati (88% y 40%), extensión atlanto-occipital (28% y 20%) y protrusión mandibular (28% y 20%). En el 72% y 80% de los pacientes de los grupos experimentales y control no hubo intento adicional de intubación orotraqueal (IOT); el tiempo invertido para alcanzar la IOT fue < 1 minuto en el grupo C-2 (64%) y E-2 (72%). Existen diferencias estadísticamente significativas entre el número de intentos para alcanzar la IOT, la presencia de predictores de vía aérea difícil y la dosis de bloqueante neuromuscular utilizada lo que evidencia de que a medida que se aumenta la dosis del medicamento hay mayor posibilidad de éxitos en la IOT, aun cuando estén presentes predictores de vía aérea difícil(AU)

An experimental simple blind controlled clinical trial was carried out to evaluate muscle relaxation and predictors of difficult airway in patients scheduled for general surgery at the Hospital Central Universitario Dr. Antonio María Pineda. The sample consisted of 100 patients randomly distributed into four groups of 25 patients each. Patients from the Experimental-1 (E-1) and Control-1 (C-1) groups received 0.6 mg/kg of the neuromuscular blocking agent Rocuronium Bromide while Experimetal-2 (E-2) and Control-2 (C-2) patients received a dosage of 1 mg/kg. Average age of participants was 34.8 ± 9.8 years. Predictors of difficult airway in E-1 and E-2 were sternomental distance (32% and 42%, thyromental distance (24% and 40%), interincisive distance class 1 (88% and 92%), neck circumference  40 cm (16% and 8%), Mallampati (88% and 40%), atlanto-occipital extension (28% and 20%) and mandibular protrusion (28% and 20%). In 72% and 80% of patients from the E and C groups there was not an additional attempt of orotracheal intubation (OTI); the time invested to reach the OTI was less than one minute in 64% of patients from the C-2 and 72% of the E-2. There are statistically significant differences between the number of attempts to reach the OTI, presence of predictors of difficult airway and the dose of Rocuronium Bromide which means that as the drug dosage increases, there is a greater possibility of success in the OTI, even when predictors of difficult airway are present(AU)

Risk Factors for Deliberate Self-extubation

PURPOSE: This study was conducted to analyze intubation survival rates according to characteristics and to identify the risk factors affecting deliberate self-extubation. METHODS: Data were collected from patients' electronic medical reports from one hospital in B city. Participants were 450 patients with endotracheal intubation being treated in intensive care units. The collected data were analyzed using Kaplan-Meier estimation, Log rank test, and Cox's proportional hazards model. RESULTS: Over 15 months thirty-two (7.1%) of the 450 intubation patients intentionally extubated themselves. The patients who had experienced high level of consciousness, agitation. use of sedative, application of restraints, and day and night shift had significantly lower intubation survival rates. Risk factors for deliberate self-extubation were age (60 years and over), unit (neurological intensive care), level of consciousness (higher), agitation, application of restraints, shift (night), and nurse-to-patient ratio (one nurse caring for two or more patients). CONCLUSION: Appropriate use of sedative drugs, effective treatment to reduce agitation, sufficient nurse-to-patient ratio, and no restraints for patients should be the focus to diminish the number of deliberate self-extubations.

Traqueostomia na UTI: vale a pena realizá-la? / Tracheostomy in the ICU: is it worthwhile?

OBJETIVO: Analisar a viabilidade, as complicações e a mortalidade da traqueostomia realizada em ambiente de unidade de terapia intensiva (UTI). MÉTODOS: Análise retrospectiva dos prontuários médicos dos 73 pacientes que foram submetidos à traqueostomia nos leitos das UTIs do Hospital São Paulo da Universidade Federal de São Paulo no período de janeiro a novembro de 2003. Os procedimentos foram realizados sempre por um residente de cirurgia, sob a orientação de um cirurgião torácico, utilizando a técnica aberta sistematizada no serviço. RESULTADOS: A idade média dos pacientes foi de 55,2 anos, sendo que 47 eram do sexo masculino (64,4 por cento) e 26 eram do sexo feminino (35,6 por cento). A indicação mais freqüente foi a intubação orotraqueal prolongada (76,7 por cento). Não houve mortalidade relacionada ao procedimento, e em todos os pacientes o procedimento pôde ser realizado na UTI. As complicações imediatas ocorreram em 2 pacientes (2,7 por cento), nos quais houve sangramento local aumentado que cessou com compressão local. A complicação tardia foi a infecção ao redor da ferida operatória, a qual ocorreu em 2 pacientes (2,7 por cento) e foi tratada com curativos locais, sem maiores repercussões clínicas. CONCLUSÕES: Com base nos resultados de nossa análise, os quais são comparáveis aos resultados sobre traqueostomias realizadas no centro cirúrgico encontrados na literatura, concluímos que a traqueostomia na UTI é viável e apresenta baixo índice de complicações, mesmo quando realizada em pacientes graves por cirurgiões em treinamento. Portanto, a nosso ver, é possível afirmar que vale a pena realizar a traqueostomia na UTI.

OBJECTIVE: To determine the feasibility of performing tracheostomy in the intensive care unit (ICU) environment and to assess procedure-related complications and mortality. METHODS: The medical records of the 73 patients submitted to tracheostomy in the ICU of the Federal University of São Paulo Hospital São Paulo between January and November of 2003 were evaluated retrospectively. All operations were performed by surgical residents, under the supervision of a thoracic surgeon, using the open technique standardized at the facility. RESULTS: The mean age of the patients was 55.2 years. Of the 73 patients evaluated, 47 (64.4 percent) were male and 26 (35.6 percent) were female. The most common indication was prolonged orotracheal intubation (76.7 percent). There was no procedure-related mortality, and, in all patients, the procedure was successfully performed in the ICU. Early complications occurred in 2 patients (2.7 percent), who presented increased local bleeding, which was controlled using compression. The late complication was infection at the incision site, which occurred in 2 patients (2.7 percent) and was treated by applying local dressings, without further clinical repercussions. CONCLUSIONS: Based on the results of our analysis, which are comparable to those found in the literature regarding tracheostomy performed in the operating room, we concluded that tracheostomy in the ICU is feasible and presents a low rate of complications, even when performed in critically ill patients and by surgeons in training. Therefore, in our view, it is possible to state that performing tracheostomy in the ICU is worthwhile.

Uso del introductor de Eschmann o Gum elastic bougie en intubación dificultosa prevista: presentación de dos casos clínicos / Use of Eschmann introducer or Gum elastic bougie

La intubación dificultosa prevista o inadvertida continúa siendo un problema en la práctica anestesiológica actual, dada las graves consecuencias que se pueden derivar del manejo inadecuado de la vía aérea. En este trabajo se presentan dos casos clínicos en los cuales se utilizó un recurso novedoso en nuestro medio para el manejo de una vía aérea dificultosa prevista: el introductior de Eschmann o "gum elastic bougie", que en ambos casos permitió realizar una intubación exitosa.

Manejo de la vía aérea difícil en anestesia pediátrica

Se revisan las principales características anatómicas y funcionales de la vía aérea en niños y se discuten algunas propuestas en su manejo defícil, haciendo énfasis en la epiglotitis aguda