[Nurses' role in cases of total pain]. / Enfermería ante el dolor total.

Health professional daily confront the pain and suffering persons who need our help undergo. From a nurse's methodology this article describes a new perspective about nurses' role regarding total pain, employing as a tool to deal with this topic the AREA holistic pain model, a model which centers on the person and his/her family permanently seeking results derived from a plan which joins together all treatments and based on the creation of a reasoning network that will provide prioritized nursing diagnoses.

Experience in the management of ECMO therapy as a mortality risk factor. / Experiencia en el manejo de terapia ECMO como factor de riesgo de mortalidad.

INTRODUCTION: The extracorporeal oxygenation membrane (ECMO) is a system that provides circulatory and respiratory assistance to patients in cardiac or respiratory failure refractory to conventional treatment. It is a therapy with numerous associated complications and high mortality. Multidisciplinary management and experienced teams increase survival. OBJECTIVE: Our purpose is to evaluate and analyse the effect of the learning curve on mortality. METHODS: Retrospective and observational study of 31 patients, from January 2012 to December 2015. Patients were separated into 2periods. These periods were divided by the establishment of an ECMO protocol. We compared the quantitative variables by performing the Mann-Whitney U test. For the categorical qualitative variables we performed the chi-square test or Fisher exact statistic as appropriate. The survival curve was computed using the Kaplan-Meier method, and the analysis of statistical significance using the Log-rank test. Data analysis was performed with the STATA programme 14. RESULTS: Survival curves show the tendency to lower mortality in the subsequent period (P=0.0601). The overall mortality rate in the initial period was higher than in the subsequent period (P=0.042). In another analysis, we compared the characteristics of the 2groups and concluded that they were homogeneous. CONCLUSION: The degree of experience is an independent factor for mortality. The application of a care protocol is fundamental to facilitate the management of ECMO therapy.

[Diaphragmatic paralysis after the catheterization of the internal jugular vein]. / Parálisis diafragmática post cateterización de la vena yugular interna.

The complications derived from the puncture and catheterization of the veins of the neck, cause symptoms and signs on physical examination which facilitate their diagnosis. The phrenic paralysis which we present, is characterized by few accompanying symptoms, with the elevation of the hemidiaphragm being a radiological finding. The suspicion is confirmed by fluoroscopy. We reviewed the mechanisms, the cases described in the literature, and the possible risk factors.

[Magnesium: metabolism and requirements]. / Magnesio: metabolismo y requerimientos.

Magnesium is an important element in health and in disease, it is the organism's second most abundant intracellular cation, after potassium, and it is the main divalent intracellular cation. Its metabolic importance is well known, as it has been identified as a cofactor in more than 300 enzymatic reactions which affect the energetic metabolism, and the synthesis of proteins and nucleic acids, Hypomagnesemia is a frequent finding in hospitalized patients, even more so when the patients are critical (+/-65%). Although low serum levels of magnesium imply the presence of intracellular depletion, normal serum magnesium levels may be present in situations of intracellular magnesium depletion, with important clinical repercussions. Keeping in mind that only 1% of the body's magnesium is in the extracellular fluid, the serum magnesium levels may not adequately reflect the situation, which is why techniques have been proposed which determine the intracellular concentración. The identification of the patients who may potentially present a magnesium depletion, requires a clear knowledge of the risk factors associated with magnesium deficiency: poorly controlled diabetes mellitus, excessive alcohol intake, severe diarrhea, important steatorrhea, and the use of drugs which favor their renal excretion. The present review gives an up date of the most frequent causes of magnesium deficits, giving a series of practical recommendations to prevent this situation, and to undertake a correct replacement therapy. Finally, and although hypermagnesemia appears in a reduced number of circumstances, the presence of kidney failure of diverse etiology, as well as the broadening of the indications of magnesium salts, have increased its incidence, which is why special emphasis is made in this section.

[New prospects in the treatment of acute kidney failure]. / Nuevas perspectivas en el tratamiento del fracaso renal agudo.

In the last 25 years, the mortality of renal failure, far from decreasing, has shown a slight tendency towards increasing, despite continuously more sophisticated and expensive therapeutic measures. As an explanation, the greater frequency of intrahospital renal failures, as past of the systemic inflammatory response syndrome which covers dysfunction of various organs and systems, is brought into this. This relative treatment inefficiency leads to the need of investigating new lines of treatment. After reviewing the conservative treatment of acute renal failure, the main alternatives which exist at present, are reviewed, some of which are in the experimental phase. As prognostically poor renal failure appears in relation to the inflammatory response syndrome, the possibility of eliminating mediators there of by means of continuous hemofiltration systems, is being considered. Despite some positive effects, the majority of authors have not managed to achieve a significant reduction of acute renal failure. The theoretical possibility of improving renal function by administration of certain amino acids (Arginine and Glycine), is not confirmed in practice, possibly due to the incidence of oxidative stress. This stress may be a determining factor in the evolution of renal failure, as it induces many risk factors in these patients. However, carefully, the bases for the anti-oxidant therapy are being established. Finally, the treatment with hormones and growth factors, with the aim of stimulating the rapid regeneration of the renal tubule, represents a very attractive therapeutic alternative, though still in the experimental phase.

[The usefulness of cholesterol as a nutritional-metabolic marker in the septic patient]. / Utilidad del colesterol como marcador nutrometabólico en el paciente séptico.

We studied the behavior of the cholesterol of 118 septic patients on entering Intensive Care and on receiving parenteral nutritional support, to establish its utility as malnutrition and/or monitoring marker. On admission, there was more intensive hypocholesterolemia (104 +/- 39 mg/dl) in those who had developed multi-organ failure (87 +/- 34 mg/dl, p < 0.001). There was no correlation between cholesterol and gravity (APACHE II). Basal cholesterol values were correlated with transferrin (r = 0.58), prealbumin (r = 0.43), retinol-linked protein (r = 0.32) and albumin (r = 0.32) and albumin (r = 0.54). During twelve days' parenteral nutrition, cholesterol and visceral protein levels recovered, and the good correlation was maintained between cholesterol and transferrin while that between cholesterol and prealbumin increased and that between cholesterol and retinol-linked virtually disappeared. There ceased to be a relation between albumin and cholesterol as from day six. In cases where the septic situation was maintained, with clinical deterioration, cholesterol levels did not rise. This, along with the close correlation with transferrin, led us to think that cholesterol is influenced by inflammation mediators, acting as a marker for this more as nutritional parameter. However, in practice, it provides the same information as short-life visceral proteins, and its determination is more accessible.(ABSTRACT TRUNCATED AT 250 WORDS)

[Non-glucose carbohydrates in the parenteral nutrition of patients with systemic inflammatory response syndrome]. / Hidratos de carbono no-glucosa en la nutrición parenteral de pacientes con síndrome de respuesta inflamatoria sistémica.

OBJECTIVE: To compare tolerance of two sources of isocaloric intake (fructose-glucose-xylitol mixture [FGX] versus glucose) in parenteral nutrition for patients with systemic inflammatory response syndrome (SIRS). DESIGN: Open, prospective, cohort and randomized study. SETTING: Intensive Care Unit. SUBJECTS AND METHODS: Two groups of patients admitted in ICU: acute pneumonia with sepsis, and necro-hemorrhagic pancreatitis. Criteria of exclusion were: diabetes, previous hypertriglyceridemia, renal failure with serum creatinine > 3 mg/dL on admission in ICU, or hyperbilirrubinemia > 2.5 mg/dL. Parenteral nutrition (TPN), consisting of 1.4 g AA + Lipids 1.3 g + carbohydrates 4 g/kg/d, (either glucose or FGX at random) was administered. Basal levels and days 1st, 4th and 10th plasma glucose, triglycerides, cholesterol, uric acid were determined, and blood venous gases as well. Capillary glycemia was measured every 6 hours and insulin given if glucose levels rose above 180 mg/dL. STATISTICS: Fisher's exact test; Student t-test; Mann-Whitney test. Data as mean and SD. RESULTS AND CONCLUSIONS: During 48 months, 119 patients admitted in the ICU (72 with pneumonia and 47 with pancreatitis) were included. In pneumonia, tolerance was similar with both intakes; glycemia was kept at the same level in both, but the amount of insulin given was significantly more in those patients fed on glucose (p < 0.05). Nevertheless, resting blood glucose and triglyceride levels were higher in pancreatitic patients, and more insulin was required. Those on FGX had lower triglyceride plasma levels (p < 0.05) and less insulin was given throughout the study. Glycemia was kept lower though no statistical significance was reached (p < 0.1). No hyperuricemia nor lactic acidosis was found.

[Anesthesia in two patients with motor neuron disease]. / Anestesia en dos pacientes con enfermedad de la motoneurona.

We report two cases of patients diagnosed of motoneuron disease. First patient had amyotrophic lateral sclerosis with bulbar involvement and developed prolonged apnea after general anesthesia for elective hemorrhoidectomy. Second patient had Kugelberg-Welander disease or type III hereditary mononeuron disease, underwent laparotomy and had no anesthetic complications. Patients with motoneuron disease should be considered as high anesthetic risk patients because they may develop respiratory complications accordingly to their previous muscle involvement so neurologic and respiratory assessment is basic. The use of succinylcholine should be limited to cases in whom external denervation and muscle atrophy may be ruled out. Short half-life muscle relaxants such as atracurium and vecuronium are advised with monitoring of neuromuscular function. Currently, local-regional techniques are not contraindicated.

Experiencia en el manejo de terapia ECMO como factor de riesgo de mortalidad / Experience in the management of ECMO therapy as a mortality risk factor

Introducción. La membrana de oxigenación extracorpórea (ECMO) es un sistema que proporciona asistencia circulatoria y respiratoria a pacientes en fallo cardiaco o respiratorio refractarios al tratamiento convencional. Es una terapia con numerosas complicaciones asociadas y alta mortalidad. El manejo por equipos multidisciplinares y con experiencia aumenta la probabilidad de supervivencia. Objetivos. Evaluar y analizar el efecto de la curva de aprendizaje sobre la mortalidad. Métodos. Estudio retrospectivo y observacional de 31 pacientes, realizado desde enero de 2012 hasta diciembre de 2015. Los pacientes se agruparon en 2periodos que están divididos por la instauración de un protocolo ECMO. Comparamos las variables cuantitativas realizando la prueba U de Mann-Whitney; para las variables cualitativas categóricas empleamos la prueba Chi-cuadrado o el estadístico exacto de Fisher, según correspondiera. La curva de supervivencia se elaboró mediante el método de Kaplan-Meier y el análisis de la significación estadística mediante el test Log-rank. El análisis de los datos se realizó con el programa STATA 14. Resultados. En las curvas de supervivencia se muestra la tendencia a menor mortalidad en los pacientes del periodo posterior (p=0,0601). La tasa de mortalidad general en el periodo inicial fue mayor que en el periodo posterior (p=0,042). En otro análisis comparamos características de los 2grupos y concluimos que eran homogéneos. Conclusión. El grado de experiencia es un factor independiente para la mortalidad. La aplicación de un protocolo asistencial es fundamental para facilitar el manejo de la terapia ECMO (AU)

Introduction. The extracorporeal oxygenation membrane (ECMO) is a system that provides circulatory and respiratory assistance to patients in cardiac or respiratory failure refractory to conventional treatment. It is a therapy with numerous associated complications and high mortality. Multidisciplinary management and experienced teams increase survival. Objective. Our purpose is to evaluate and analyse the effect of the learning curve on mortality. Methods. Retrospective and observational study of 31 patients, from January 2012 to December 2015. Patients were separated into 2periods. These periods were divided by the establishment of an ECMO protocol. We compared the quantitative variables by performing the Mann-Whitney U test. For the categorical qualitative variables we performed the chi-square test or Fisher exact statistic as appropriate. The survival curve was computed using the Kaplan-Meier method, and the analysis of statistical significance using the Log-rank test. Data analysis was performed with the STATA programme 14. Results. Survival curves show the tendency to lower mortality in the subsequent period (P=0.0601). The overall mortality rate in the initial period was higher than in the subsequent period (P=0.042). In another analysis, we compared the characteristics of the 2groups and concluded that they were homogeneous. Conclusion. The degree of experience is an independent factor for mortality. The application of a care protocol is fundamental to facilitate the management of ECMO therapy (AU)

Cuidados integrales de los últimos días y horas de vida / Comprehensive care in the last days and hours of life

Este artículo identifica los elementos más significativos del proceso de atención enfermera a los últimos días y horas de vida en el contexto de una enfermedad en situación terminal previamente diagnosticada. Para ello se revisan las principales guías clínica de cuidados integrales y, en especial, la diseñada por el Hospital San Juan de Dios de Sevilla. Se concluye que es necesario saber identificar la fase de agonía para aplicar, en consecuencia, un plan asistencial predeterminado capaz de responder de forma personalizada a las necesidades específicas que se presentan en las últimas horas de la vida de un paciente en situación terminal. La actuación interprofesional continuada y coordinada sobre el paciente y la familia siguiendo estándares normalizados permite el logro de una muerte en paz y libre de un sufrimiento evitable (AU)

This article identifies the most significant elements of the process of nurse attention to the last days and hours of life in the context of a disease previously diagnosed like a terminal situation. For this object, we have reviewed the main clinical guidelines on comprehensive care and, especially, the guideline that was designed by the Saint John of God Hospital in Seville. We conclude that it is necessary to know how to identify the phase of agony to apply, therefore a default care plan that allows to respond customized to the specific needs that occur in the last hours of the life of a terminal patient. A continued and coordinated interprofessional assistance to patient and family following standardized standards allows achieving a peaceful death and free from avoidable suffering (AU)

Enfermería ante el dolor total / Nurses’ role in cases of total pain

Los profesionales de la salud a diario nos enfrentamos con el dolor y el sufrimiento de personas que necesitan de nuestra ayuda. Este artículo realiza, desde la metodología enfermera, un nuevo planteamiento sobre el rol de la enfermería en el dolor total, utilizando como herramienta para un abordaje holístico del dolor el modelo AREA (Análisis del Resultado del Estado Actual), modelo centrado en la persona y su familia, con la búsqueda permanente de resultados derivados de la planificación conjunta de los cuidados y basado en la creación de la red de razonamiento que darán lugar a los diagnósticos enfermeros prioritarios(AU)

Health professional daily confront the pain and suffering persons who need our help undergo. From a nurse’s methodology, this article describes a new perspective about nurses’ role regarding total pain, employing as a tool to deal with this topic the AREA holistic pain model, a model which centers on the person and his/her family, permanently seeking results derived from a plan which joins together all treatments and based on the creation of a reasoning network that will provide prioritized nursing diagnoses(AU)

Respuesta inflamatoria sistémica: fisiopatología y mediadores / Systemic inflammatory response: pathophysiology and mediators

Introducción. Se efectúa una revisión de las características y significado de la respuesta inflamatoria. Se describen las reacciones programadas que se desencadenan cuando la respuesta inflamatoria se generaliza y se analizan los mecanismos de puesta en marcha y finalización del proceso. Material. Revisión bibliográfica de los estudios recogidos en Medline. Resumen de la revisión. Tras la agresión se desencadena una serie de respuestas orgánicas programadas que tienden a limitar el cuadro inflamatorio. La pérdida del control local induce una respuesta inflamatoria generalizada, rápida y ampliada, controlada humoral y celularmente (complemento, cininas, coagulación y cascada fibrinolítica) y desencadenada por la activación conjunta de fagocitos y células endoteliales. Si esta respuesta inflamatoria no es adecuadamente modulada, se origina un síndrome inflamatorio sistémico, que puede alterar el metabolismo intermediario y el funcionalismo de los diferentes órganos. Se describe el complejo entramado de los mediadores de la inflamación, así como sus relaciones con la respuesta neuroendocrina y con la respuesta de fase aguda. Se pasa revista a los mecanismos que ponen en marcha la respuesta inflamatoria y a los sistemas orgánicos establecidos para su modulación o contrarregulación. Se concluye en la necesidad de sistematizar el estudio de las diferentes respuestas a la inflamación, con fines pronósticos y terapéuticos (AU)

Respuesta inflamatoria sistémica: definiciones, marcadores inflamatorios y posibilidades terapéuticas / Systemic inflammatory response: definitions, inflammatory markers and therapeutic possibilities

Introducción. Se analizan las definiciones y las teorías fisiopatológicas que se han elaborado para explicar la evolución del síndrome inflamatorio hacia la disfunción multisistémica, analizando el valor predictivo de los diferentes mediadores y de los cambios metabólicos. Tras revisar las características del síndrome inflamatorio se recogen los diferentes intentos terapéuticos para modular el SIRS. Material. Se ha revisado la bibliografía recogida en Medline, fundamentalmente estudios clínicos realizados en pacientes críticos. Resumen. Se describen tres síndromes (SIRS, CARS y MARS) que pueden configurar la respuesta inflamatoria. La evolución hacia la disfunción multisistémica es explicada por diversas teorías, pero queda por estudiar los mecanismos que permiten la modulación y supresión de la respuesta inflamatoria. A pesar de su importancia fisiopatológica, las citocinas de inicio no son buenos marcadores pronósticos. Los marcadores de fase aguda, así como los cambios en el metabolismo lipídico y del hierro, muestran una mejor correlación con la evolución. Tras comentar que la respuesta inflamatoria no es proporcional, estructural ni universal, se revisan los diversos intentos terapéuticos que pretenden antagonizar dicha respuesta. Se comentan las tres líneas que deben regir para las investigaciones futuras (AU)