Care and treatments related to intensive care unit-acquired muscle weakness: A cohort study.

BACKGROUND: Intensive care unit-acquired muscle weakness (ICUAW) has an incidence of 40-46%. Early mobilisation is known to be a protective factor. OBJECTIVE: The aim of the study was to identify the incidence of ICUAW in Spain and to evaluate variables likely to contribute to the development of ICUAW. METHODS: A 4-month, prospective observational multicentre cohort study was conducted on patients receiving invasive mechanical ventilation for at least 48 h. Data were collected from ICU day 3 until ICU discharge. The primary outcome was presence of ICUAW (diagnosed using the Medical Research Council [MRC] scale). The secondary outcome was nurse-patient ratio, physiotherapist availability, analgesia, sedation and delirium management, glycaemic control, and daily level of mobility during the ICU stay as per the ICU Mobility Scale. A logistic regression model was constructed based exclusively on days 3-5 of the ICU stay. RESULTS: The data of 642 patients were analysed from 80 ICUs, accounting for 35% of all ICUs in Spain. The incidence of ICUAW was 58% (275 of 474 patients; 95% confidence interval [CI] [53-62]). The predictors for ICUAW were older age (odds ratio [OR] = 1.01; 95% CI [1.00-1.03]) and more days with renal replacement therapy (OR = 1.01; 95% CI [1.00-1.02]). The protective factors for ICUAW were male gender (OR = 0.58; 95% CI [0.38-0.89]), higher Barthel Index (showing prehospital functional independence) (OR = 0.97; 95% CI [0.95-0.99]), more days of being awake and cooperative (defined by a feasible MRC assessment) (OR = 0.98; 95% CI [0.97-0.99]), presence of delirium (OR = 0.98; 95% CI [0.97-0.99]), and more days with active mobilisation (ICU Mobility Scale ≥ 4) (OR = 0.98; 95% CI [0.97-0.99]). CONCLUSIONS: The risk factors for ICUAW were functional dependence before admission, female gender, older age, and more days on renal replacement therapy. The protective factors for ICUAW were feasibility of MRC assessment, the presence of delirium, and being actively mobilised during the first 5 days in the ICU.

[A first step towards safer sedation and analgesia: A systematic evaluation of outcomes and level of sedation and analgesia in the mechanically ventilated critically ill patient]. / Un primer paso hacia una analgosedación más segura: evaluación sistemática de objetivos y grado de analgesia y sedación en el paciente crítico con ventilación mecánica.

INTRODUCTION: Safe analgesia and sedation strategies are necessary in order to avoid under or over sedation, as well as improving the comfort and safety of critical care patients. OBJECTIVES: To compare and contrast a multidisciplinary protocol of systematic evaluation and management of analgesia and sedation in a group of critical care patients on mechanical ventilation with the usual procedures. MATERIALS AND METHODS: A cohort study with contemporary series was conducted in a tertiary care medical-surgical ICU February to November during 2013 and 2014. The inclusion criteria were mechanical ventilation ≥ 24h and use of sedation by continuous infusion. Sedation was monitored using the Richmond agitation-sedation scale or bispectral index, and analgesia were measured using the numeric rating scale, or behavioural indicators of pain scale. The study variables included; mechanical ventilation time, weaning time, ventilation support time, artificial airway time, continuous sedative infusion time, daily dose and frequency of analgesic and sedative drug use, hospital stay, and ICU and hospital mortality, Richmond agitation-sedation scale, bispectral index, numeric rating scale, and behavioural indicators of pain scale measurements. Kruskal Wallis and Chi2, and a significance of p<.05 were used. RESULTS: The study included 153 admissions, 75 pre-intervention and 78 post-intervention, with a mean age of 55.7±13 years old, and 67% men. Both groups showed similarities in age, reason for admission, and APACHE. There were non-significant decreases in mechanical ventilation time 4 (1.4-9.2) and 3.2 (1.4-8.1) days, respectively; p= 0.7, continuous sedative infusion time 6 (3-11) and 5 (3-11) days; p= 0.9, length of hospital stay 29 (18-52); 25 (14-41) days; p= 0.1, ICU mortality (8 vs. 5%; p= 0.4), and hospital mortality (10.6 vs. 9.4%: p= 0.8). Daily doses of midazolam and remifentanil decreased 347 (227-479) mg/day; 261 (159-358) mg/day; p= 0.02 and 2175 (1427-3285) mcg/day; 1500 (715-2740) mcg/day; p= 0.02, respectively. There were increases in the use of remifentanil (32% vs. 51%; p= 0.01), dexmedetomidine (0 vs.6%; p= 0.02), dexketoprofen (60 vs. 76%; p= 0.03), and haloperidol (15 vs.28%; p= 0.04). The use of morphine decreased (71 vs. 54%; p= 0.03). There was an increase in the number of measurements and Richmond agitation-sedation scale scores 6 (3-17); 21 (9-39); p< 0.0001, behavioural indicators of pain scale 6 (3-18); 19(8-33); p< 0.001 and numeric rating scale 4 (2-6); 8 (6-17); p< 0.0001. CONCLUSIONS: The implementation of a multidisciplinary protocol of systematic evaluation of analgesia and sedation management achieved an improvement in monitoring and adequacy of dose to patient needs, leading to improved outcomes.

Psychometric validation of the behavioral indicators of pain scale for the assessment of pain in mechanically ventilated and unable to self-report critical care patients.

OBJECTIVE: To assess the psychometric properties of the behavioral indicators of pain scale (ESCID) when applied to a wide range of medical and surgical critical patients. DESIGN: A multicentre, prospective observational study was designed to validate a scale measuring instrument. SETTING: Twenty Intensive Care Units of 14 hospitals belonging to the Spanish National Health System. PARTICIPANTS: A total of 286 mechanically ventilated, unable to self-report critically ill medical and surgical adult patients. PROCEDURE: Pain levels were measured by two independent evaluators simultaneously, using two scales: ESCID and the behavioral pain scale (BPS). Pain was observed before, during, and after two painful procedures (turning, tracheal suctioning) and one non-painful procedure. MAIN VARIABLES: ESCID reliability was measured on the basis of internal consistency using the Cronbach-α coefficient. Inter-rater and intra-rater agreement were measured. The Spearman correlation coefficient was used to assess the correlation between ESCID and BPS. RESULTS: A total of 4386 observations were made in 286 patients (62% medical and 38% surgical). High correlation was found between ESCID and BPS (r=0.94-0.99; p<0.001), together with high intra-rater and inter-rater concordance. ESCID was internally reliable, with a Cronbach-α value of 0.85 (95%CI 0.81-0.88). Cronbach-α coefficients for ESCID domains were high: facial expression 0.87 (95%CI 0.84-0.89), calmness 0.84 (95%CI 0.81-0.87), muscle tone 0.80 (95%CI 0.75-0.84), compliance with mechanical ventilation 0.70 (95%CI 0.63-0.75) and consolability 0.85 (95%CI 0.81-0.88). CONCLUSION: ESCID is valid and reliable for measuring pain in mechanically ventilated unable to self-report medical and surgical critical care patients. CLINICALTRIALS.GOV: NCT01744717.

[To go in-depth in the knowledge of the device to control fecal elimination in the critical patient]. / Profundizando en el conocimiento sobre el manejo del dispositivo para control de la eliminación fecal en el paciente crítico.

OBJECTIVE: To describe the general characteristics of the patient and device use. To know retention balloon pressure (RBP) and related factors. To identify rate of leakage incidence, relocation and perineal damage due to the device (PSD) and related risk factors. MATERIAL AND METHODS: An analytical observational, cross-sectional study conducted in a polyvalent ICU from June-December 2010 was performed. The sample included Flexi-Seal(®) carriers. Variables evaluated were patient and device use characteristics, RBP, leakage and quantity, relocation and reason, PSD, sedoanalgesia infusion, neuromuscular block, patient position, Flexi-Seal type catheter, ventilatory mode (VM), intra-abdominal pressure (IAP), mean intrathoracic pressure (MITP), PEEP, Glasgow, color-aspect, fecal consistency and volume. Significance P<.05. RESULTS: Twenty-one patients were included, 52% male, aged 54±17 with 30 insertion episodes, Flexi-Seal-Signal(®) 33%, 10±8 days permanency, main indication 33% «diarrhea and injured skin¼," 30% device removal «intolerance and/or spontaneous expulsion¼. Median (Me) PGR =40; RI (61-19) cmH2O. Factors associated to higher PGR: SCI absence, prone-decubitus position, leakage, relocation, conventional Flexi-Seal(®), MV, lower PEEP and IMP, Color-aspect, higher MITP. Leakage, relocation and PSD incidence density 43, 30 and 2 cases/100 days of catheter, respectively. Leakage and relocation risk factors: higher PGR, Glasgow and fecal volume, lower MITP, MV, assisted-spontaneous mode OR 2.5 CI (1.6-3.8) and OR 1.7(1.1-2.7), absence SCI OR 3.3 (2.2-5.1) and OR 2.4(1.5-3.8), absence neuromuscular block OR 2.4 (1.4-3.9) and OR 1.8 (1.1-3.1), Flexi-Seal(®) conventional OR 2.7(1.7-4.1) and OR 2 (1.2-3.3), respectively. Leakage risk factors: color-aspect, supine position, lower IMP and PEEP. CONCLUSIONS: Monitoring RBP may alert us about leakage presence and relocation need. Knowing associated risk factors to RBP, leakage and relocation would help to develop strategies to reduce their high incidence rate such as decreasing RBP by reducing inflated volume.

[Decubitus prone position in patient with extracorporeal CO2 removal device Novalung(®)]. / Decúbito prono en paciente portador de dispositivo de extracción extracorpórea de CO(2) Novalung(®).

OBJECTIVE: To describe the course of a patient with the extracorporeal CO2 removal device and discover the effect of Novalung on ventilation, considering the patient's prone position and its influence on the device's blood flow. To develop a protocol of managing and specific care of a patient with Novalung. MATERIAL AND METHODS: A case report of a patient with Novalung in a tertiary hospital ICU unit is reported. Parameters considered are hemodynamic, respiratory, pharmacological, analytical, neuromonitoring, managing of the Novalung and length of decubitus prone cycles. Anova Test, Student's T test, Wilcoxon-Mann Whitney and Spearman correlation. Significance p <0.05. RESULTS: A 46-year old women with nosocomial pneumonia and acute respiratory failure with indication of Novalung to decrease hypercapnia and optimize ventilatory management of refractory hypoxemia. ICU Stay 26 days, MBP 82 ± 9 mmHg, HR 110 ± 6l pm during the admission, monitoring PICCO 5 days CI 3.2 ± 0.8 l/min/m2, ELWI 33 ± 4 ml, continuous hemofiltration 13.2 days with a median removal 50 cc/h. Norepinephrine dose 0.68 ± 0.79 µ/kg/min for 15 days. Respiratory parameters during the admission: PO2 59 ± 13 mmHg, PCO2 68 ± 35 mmHg, SatO2 85 ± 12%, PO2/FIO2 69 ± 35, tidal volume 389 ± 141 cc. Novalung® 13 days, heparin dose 181.42 ± 145 mIU/Kg/min, Cephalin time 57.56 ± 16.41 sec, O2 flow 7 ± 3 l/min, median blood flow 1030 cc/h, interquartile range 1447-612 cc/h. Prone cycles 4, duration 53 ± 27 hours. With Novalung® PCO2 decreased regardless of position 66 ± 21:56 ± 9, p=0.005. Tidal volume 512 ± 67:267 ± 72, p=0.0001. Blood flow on supine-prone position 1053 ± 82:113 ± 112, p=0.001. There was no link between blood flow and PCO2 (p=0.2) and between O2 and PO2 flow (p=0.05). Specific care: pedal and tibial pulse monitoring, keep circuit safe to prevent and detect signs of bleeding, femoral arterial and venous catheter care, coagulation monitoring. COMMENTS: During the use of Novalung protective, ventilation, low tidal volumes, decreased pressure plateau, PEEP and hypercapnia were achieved. Blood flow decreased in prone position, but the PCO2 did not increase. The device did not coagulate.

[Evaluation of the compliance of semirecumbent position between 30-45° in intubated patients]. / Evaluación del cumplimiento de cabeceros elevados entre 30-45° en pacientes intubados.

AIMS: To determine compliance of the standard "semirecumbent position between 30-45° in patients with artificial airway (AA)". To know the opinion of the professionals on this issue. MATERIAL AND METHODS: An observational, prospective study was carried out in December 2009 in the ICU department of a tertiary hospital that excluded the limitation of therapeutic effort, prone position and antitrendelemburg. DATA COLLECTED: headrest angle, professional experience of the nurse, shift, perception of the auditor, diagnostic, type of AA (tracheostomy or endotracheal tube), mechanical ventilation (MV) (yes/no) and enteral nutrition (EN). Nurses were surveyed to verify if they knew the standard, if they complied with it, the method used and their suggestions. We used the Student's t test and ANOVA for multivariable analysis, and Fisher's χ2; p<0.05=significant. RESULTS: A total of 546 valid measurements were obtained from 53 patients, of which 40.9% had the correct semirecumbent position (30-45°). Professionals with <1 year of experience were those who raised the headrest the least, with only 26.4% of these measurements over 30°. The standard was met in only 34.8% of the neurocritical patients (NC) vs non NC (46.7%) (p<0.05). It was <30° in 29.2% of patients with tracheostomy vs 44% measurements performed on patients with TOT (p<0.05). There were no differences between shifts, the use of MV or EN. Diagnostic accuracy of the auditor: sensitivity: 91.6%; specificity: 72.5%; positive predictive value: 70.2%; negative predictive value (NPV): 92.4%. 97.9% of responders know the standard. Visual judgment was used in 97.2% of the cases. CONCLUSIONS: Measured compliance was less than 50% although the standard is well known by the nursing team. Even though the subjective perception has a high NPV, it does not achieve the standard.

Reflections arising from the COVID-19 pandemic. / Reflexiones derivadas de la pandemia COVID-19.

While we were drafting the recommendations for the joint contingency plan between the Spanish Society of Intensive Care and Coronary Unit Nursing (SEEIUC) and the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), predictions were overtaken by events with regard to the magnitude of the COVID-19 pandemic. Members informed us of the lack of personal protection equipment (PPE), the rapid provision of improvised ICUs in various hospital areas and the recruitment of nurses to cover shifts. The failure to recognise the specialty of critical care nursing, included in the macro-specialty of medical-surgical nursing and not yet developed, has highlighted the urgent need to learn from our mistakes: specialisation, increase the number of nurses in teams and protect the public health system.

Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD. / Valoración de la analgesia, sedación, contenciones y delirio en los pacientes ingresados en unidades de cuidados intensivos españolas. Proyecto ASCyD.

AIMS: Main aim: To determine the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. Secondary aims: To determine the use of validated assessment tools and to explore patients' levels of pain and sedation/agitation, the prevalence of delirium, and the use of PR. METHOD: An observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit's characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units. RESULTS: One hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). There was recorded use of PR in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium. CONCLUSIONS: The assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC. (ClinicalTrials.gov Identifier: NCT03773874).

[Contingency plan for the intensive care services for the COVID-19 pandemic]. / Plan de contingencia para los servicios de medicina intensiva frente a la pandemia COVID-19.

In January 2020, the Chinese authorities identified a new virus of the Coronaviridae family as the cause of several cases of pneumonia of unknown aetiology. The outbreak was initially confined to Wuhan City, but then spread outside Chinese borders. On 31 January 2020, the first case was declared in Spain. On 11 March 2020, The World Health Organization (WHO) declared the coronavirus outbreak a pandemic. On 16 March 2020, there were 139 countries affected. In this situation, the Scientific Societies SEMICYUC and SEEIUC have decided to draw up this Contingency Plan to guide the response of the Intensive Care Services. The objectives of this plan are to estimate the magnitude of the problem and identify the necessary human and material resources. This is to provide the Spanish Intensive Medicine Services with a tool to programme optimal response strategies.

Degree of implementation of preventive strategies for post-ICU syndrome: Multi-centre, observational study in Spain. / Grado de implementación de las estrategias preventivas del síndrome post-UCI: estudio observacional multicéntrico en España.

AIM: To evaluate the degree of implementation of protocols associated with the prevention of intensive-care-unit (ICU) acquired muscle weakness, and the presence of the physiotherapist in various ICU in Spain. METHOD: A descriptive, cross-sectional study performed in 86 adult ICU in Spain between March and June 2017. Neurosurgical and major burns ICU were excluded. A multiple-choice survey was used that included questions on protocols for glycaemia control, sedation, pain assessment, delirium prevention, delirium management and early mobilisation. The survey was completed using a user-protected application and password. The Student's t-test or Mann-Whitney U test and Pearson's correlation or Spearman's Rho test were used for the inferential analysis. RESULTS: Eighty-nine point five percent of the ICU had a glycaemia control protocol, with a predominating range of 110-140mg/dl. Seventy-four point four percent evaluated sedation levels, although only 36% had sedation protocols. Pain assessment was carried out on communicative patients in 73.7%, and on uncommunicative patients in only 47.5%. Only 37.2% performed daily screening to detect delirium and 31.4% of the ICU had delirium prevention protocols, 26.7% had delirium management protocols and 14% had protocols for early mobilisation. Thirty-four point nine percent requested cross consultation with the rehabilitation department. CONCLUSIONS: The implementation of the different protocols associated with the prevention of ICU-acquired muscle weakness was high in relation to glycaemia control protocols, sedation level and pain assessment in communicative patients, and was low for early mobilisation and delirium screening and prevention. Similarly, the physiotherapist was seldom present in the ICU.

[Pressure monitoring in continuous renal replacement therapy]. / Monitorización de presiones en técnicas continuas de depuración extrarrenal.

INTRODUCTION: Continuous renal replacement therapy (CRRT) has experienced significant advances that have lead to an increase of its indications and improved the technology used in continued pressures monitoring. AIM: This study has aimed to discover if there are any associations between the increase of the circuit pressures and their duration. MATERIALS AND METHODS: A prospective, longitudinal analytic pilot study was conducted in an Intensive Care Unit of a university hospital from October 2008 to April 2009. The study analyzed the patient's information with CRRT and the hourly values of entry pressure (EP), comeback pressure (CP), transmembrane pressure (TMP) and pre-filter pressure (PFP). The Spearman correlation and the Student's T test were used. RESULTS: The study analyzed 44 sets corresponding to 11 patients (45.5% men and 54.5% women) with a life expectancy of 62 years. The same light catheter GamCath (11 French) and Continuous Venovenous Hemodiafiltration (CVVHDF) therapy were used in all patients. The mean duration of the circuits was 39 h. Mean, median, maximum and minimum values of the sample pressures were: EP:-52.17; -52.57; 160; -256 (millimeters of mercury) mmHg]; CP: (98.6; 95.3; 323; -2 mmHg); TMP: (58.57; 58.52; 245; -20 mmHg) and PFP: (161.76; 159.42; 375; -13 mmHg), respectively. CONCLUSIONS: A negative correlation was demonstrated between the duration of the sets and the mean CP and PFP. The sample obtained circuits withdrawn due to finished treatment (72 h), and by coagulation or changes in pressures.

[Burnout syndrome in different intensive care units]. / Síndrome de burnout en distintas Unidades de Cuidados Intensivos.

OBJECTIVES: To determine the prevalence of the professional burnout syndrome in health care personnel of different Intensive Care Units (ICUs). To know the association between burnout, its dimensions and sociodemographic-laboral variables. To compare the dimensions of burnout, characteristics of the personnel and of the patients of the different ICUs. MATERIAL AND METHODS: Analytic, comparative, cross-sectional study performed in the ICU of a tertiary hospital in November 2006 performed in a sample of 289 professionals. The Maslach Burnout Inventory questionnaire and sociodemographic-laboral variables were provided. The following were evaluated in the ICUs: Therapeutic Intervention Scoring System (TISS), Nine Equivalents of Nursing Manpower Use Score (NEMS), mortality, stay, isolations and travel of third parties. The chi2 test, Fischer test, Kruskall-Wallis test and multivariate logistic regression analysis were used. RESULTS: A total of 73% of the workers answered. Ages ranged from 37 +/- 9 and 81% were women. The prevalence of burnout was 14%, this affecting 16% of the nurses, 14% of residents, 13% physicians and 10% auxiliary workers. Burnout was associated to low professional satisfactions, relationship with regular colleagues, low work recognition and time worked and experience in the ICU to high emotional tiredness, with a p < 0.05. In a polyvalent ICU, higher values of the following were obtained: TISS 42 +/- 11, NEMS 35 +/- 10, mortality 18%, stay 5 +/- 9, isolation 21%, burnout syndrome 17%, elevated emotional tiredness 49%, elevated depersonalization 63% and low professional performance 44%. CONCLUSIONS: The prevalence of the burnout syndrome in our sample was 14%, those being affected most being the nursing professionals. We detected elevated levels of depersonalization and middle levels of emotional tiredness and professional performance. The variables related with professional burnout syndrome were low professional satisfaction, relationship with regular colleagues, low work recognition, and elevated emotional tiredness in the more expert personnel. The ICU with the greatest prevalence of burnout during the month studied attended patients with greater TISS, NEMS, mortality, stay and isolations.

[Analysis of 4 sedation rating scales in the critical patient]. / Análisis de 4 escalas de valoración de la sedación en el paciente crítico.

BACKGROUND: This study aimed to verify the relationship between different Sedation Rating Scales (SRSs) for critical patients on mechanical ventilation and to know the relationship between the SRSs, clinical information and the dose of sedative and analgesia drugs (SAD). MATERIAL AND METHODS: A longitudinal, prospective analytic pilot study conducted in a Medical-Surgical Intensive Care Unit of a tertiary hospital from October-December 2006. The sample included patients who required administration of SAP and mechanical ventilation. The following biological parameters and scales were evaluated: patient's demographics, RAMSAY, Sedation Agitation Scale (SAS), Richmond Agitation Sedation Scale (RASS), Motor Activity Assessment Scale (MASS), SAD dose, mean blood pressure, cardiac rate, pupil diameter and respiratory frequency. Spearman coefficient of interrelation was used to compare the relationship between the different scales. RESULTS: A total of 2.412 measurements were made for each variable: SRS, clinical information and SAD dose in 30 patients with different diseases, 63 % males, age 52 +/- 19 years, APACHEII 24 +/- 8, SAPSII 44 +/- 16, with an ICU mortality UCI 34 %. Median and IQ range of stay in ICU 15.5 and 20 days, of mechanical ventilation 9 and 14 days, of SAD 6 and 5.5 days and of paralyzing drugs (PD) 2 and 5 days, respectively. Interrelation was detected between all the SRSs, with p < 0.0001. The relationship between SAS, RASS and MASS was direct, whereas these were related inversely to RAMSAY. No evidence of interrelation was found between the SRSs, the clinical information and the SAD doses. CONCLUSION: The RAMSAY scale that has not been validated in ICU patients has a strong interrelation with the other already validated SRSs. SRSs are subjective and do not correlate with the clinical information and the SAD doses, probably due to the sample's small size and heterogeneity.

[Course and cares of intestinal transplant in immediate post-operative period]. / Evolución y cuidados del trasplante intestinal en el postoperatorio inmediato.

OBJECTIVE: Describe the course and immediate post-operative care in patients with intestinal transplant. MATERIAL AND METHODS: Descriptive, prospective study conducted in the Polyvalent Intensive Care Unit of a tertiary hospital for one year. Variables analyzed during the first 48 hours of the post-operative period: vital signs, O2 saturation, weaning time, diuresis, glycemia, catheters, drains, ileostomy, gastrostomy, TISS, NEMS, nursing cares, APACHE II and SAPS II on admission. Statistical analysis with SPSS 11.0. RESULTS: Four patients, 50% women, mean age 42 +/- 8 years. Reason for intestinal transplant: 75% familial adenomatous polyposis with desmoid tumor and 25% mesenteric artery obstruction. They were administered alemtuzumab and tacrolimus. All the patients were carrier of central and arterial venous catheters, and Jackson Pratt abdominal drains (50% two, 50% three). Intubation time (median) 15 hours. APACHE II 10 +/- 6 y SAPS II 16 +/- 4. Means on first and second day of: systolic/diastolic blood pressure 132 +/- 23/73 +/- 11; 130 +/- 25/74 +/- 13 mmHg; glycemia 136 +/- 26/119 +/- 25 mg/dl; diuresis 95 +/- 34/125 +/- 30 cc/hour; TISS28 49 +/- 4/38 +/- 11 and NEMS 27 +/- 0/25 +/- 10, respectively. One re-operation due to hemorrhagic shock. Median study in Intensive Care Unit of 4 days. CONCLUSIONS: 1) They are hemodynamically stable patients with short weaning. They do not have many catheters, functioning ileostomy since the first day and TISS28 and NEMS in the middle of the range. 2) The most specific cares of the intestinal transplant are: surgical wound, drains, ileostomy, gastrostomy. 3) The need for intense immunosuppression implies strict isolation and nursing:patient ratio of 1:1.

Evaluación del cumplimiento de cabeceros elevados entre 30–45 o en pacientes intubados / Evaluation of the compliance of semirecumbent position between 30–45 o in intubated patients

ObjetivoDeterminar cumplimiento del estándar “cabecero de la cama entre 30–45o en pacientes con vía aérea (VA) artificial”. Conocer la opinión de los profesionales respecto a él.Material y métodosEstudio observacional prospectivo, realizado en diciembre de 2009 en el servicio de medicina intensiva de un hospital terciario. Excluidos: con limitación del esfuerzo terapéutico, decúbito prono y anti-Trendelemburg. Se registró: altura del cabecero, experiencia del enfermero, turno, percepción del auditor, diagnóstico, tipo de VA artificial (traqueostomía o tubo endotraqueal [TOT]), ventilación mecánica (VM), sí/no, y nutrición enteral (NE). Se realizó una encuesta a los enfermeros para saber si conocían el estándar, lo cumplían, método utilizado y sugerencias. Se utilizó la t de Student, ANOVA para análisis multivariable y la χ2, Test de Fisher; se consideró significativo p<0,05.ResultadosSe obtuvieron 546 mediciones válidas, de 53 pacientes. El 40,9% tenía el cabecero correcto (30–45o). Los profesionales con menos de 1 año de experiencia son los que elevan menos el cabecero; sólo el 26,4% de estas determinaciones estaba por encima de 30o. El 34,8% de los pacientes neurocríticos (NC) cumplían el estándar en relación con no NC (46,7%) (p<0,05). El 29,2% de los pacientes con traqueostomía estaban con más de 30o frente al 44% de las mediciones realizadas en pacientes con TOT (p<0,05). No hubo diferencias entre turnos, VM o NE. Capacidad diagnóstica de la percepción del auditor: sensibilidad, 91,6%; especificidad, 72,5%; valor predictivo positivo, 70,2%; valor predictivo negativo (VPN), 92,4%. El 97,9% de los profesionales encuestados conoce el estándar. La estimación visual se utiliza en el 97,2% de los casos.ConclusionesEl cumplimiento del estándar es<50% aunque se conoce bien. A pesar de que la percepción subjetiva tiene un elevado VPN, parece insuficiente para cumplir el estándar(AU)

AimsTo determine compliance of the standard “semirecumbent position between 30–45o in patients with artificial airway (AA)”. To know the opinion of the professionals on this issue.Material and methodsAn observational, prospective study was carried out in December 2009 in the ICU department of a tertiary hospital that excluded the limitation of therapeutic effort, prone position and antitrendelemburg. Data collected: headrest angle, professional experience of the nurse, shift, perception of the auditor, diagnostic, type of AA (tracheostomy or endotracheal tube), mechanical ventilation (MV) (yes/no) and enteral nutrition (EN). Nurses were surveyed to verify if they knew the standard, if they complied with it, the method used and their suggestions. We used the Student's t test and ANOVA for multivariable analysis, and Fisher's χ2; p<0.05=significant.ResultsA total of 546 valid measurements were obtained from 53 patients, of which 40.9% had the correct semirecumbent position (30–45o). Professionals with<1 year of experience were those who raised the headrest the least, with only 26.4% of these measurements over 30o. The standard was met in only 34.8% of the neurocritical patients (NC) vs non NC (46.7%) (p<0.05). It was < 30o in 29.2% of patients with tracheostomy vs 44% measurements performed on patients with TOT (p<0.05). There were no differences between shifts, the use of MV or EN. Diagnostic accuracy of the auditor: sensitivity: 91.6%; specificity: 72.5%; positive predictive value: 70.2%; negative predictive value (NPV): 92.4%. 97.9% of responders know the standard. Visual judgment was used in 97.2% of the cases.ConclusionsMeasured compliance was less than 50% although the standard is well known by the nursing team. Even though the subjective perception has a high NPV, it does not achieve the standard(AU)

Monitorización de presiones en técnicas continuas de depuración extrarrenal / Pressure monitoring in continuous renal replacement therapy

IntroducciónLas técnicas de depuración extrarrenal han obtenido grandes avances que han conseguido una ampliación de las indicaciones y una mejora en la tecnología de la monitorización continua de las presiones.ObjetivoEl objetivo del estudio es conocer si existe asociación entre el aumento de las presiones de los circuitos y la duración de éstos.Material y métodosEstudio analítico longitudinal prospectivo, realizado en una unidad de cuidados intensivos polivalente de un hospital terciario, desde octubre de 2008 hasta abril de 2009. Se recogieron datos de filiación de pacientes con técnicas de depuración extrarrenal y valores horarios de: presión de entrada (PE), presión de retorno (PR), presión transmembrana (PTM) y presión prefiltro (PPF). Se utilizó la correlación de Spearman y T de Student.ResultadosSe analizaron 44 sets correspondientes a 11 pacientes (el 45,5% eran hombres y el 54,5% eran mujeres) con un media de edad de 62 años. Se utilizó el mismo catéter de doble luz: GamCath (11 Fr) y la misma terapia: hemodiafiltración venovenosa continua. La media de duración de los circuitos fue de 39h. Los valores de media, mediana, máximo y mínimo de las presiones de la muestra fueron: (-52,17; -52,57; 160 y -256 [milímetros de mercurio] mmHg), PR (98,6; 95,3; 323 y -2mmHg), PTM (58,57; 58,52; 245 y -20mmHg) y PPF (161,76; 159,42; 375 y -13mmHg), respectivamente. Conclusiones: Se demuestra correlación negativa entre la duración de los sets y la media de PR y de PPF. Conclusiones: La muestra obtenida incluía tanto circuitos retirados por tratamiento completo (72h) como por coagulación o cambio en presiones

IntroductionContinuous renal replacement therapy (CRRT) has experienced significant advances that have lead to an increase of its indications and improved the technology used in continued pressures monitoring.AimThis study has aimed to discover if there are any associations between the increase of the circuit pressures and their duration.Materials and methodsA prospective, longitudinal analytic pilot study was conducted in an Intensive Care Unit of a university hospital from October 2008 to April 2009. The study analyzed the patient's information with CRRT and the hourly values of entry pressure (EP), comeback pressure (CP), transmembrane pressure (TMP) and pre-filter pressure (PFP). The Spearman correlation and the Student's T test were used.ResultsThe study analyzed 44 sets corresponding to 11 patients (45.5% men and 54.5% women) with a life expectancy of 62 years. The same light catheter GamCath (11 French) and Continuous Venovenous Hemodiafiltration (CVVHDF) therapy were used in all patients. The mean duration of the circuits was 39h. Mean, median, maximum and minimum values of the sample pressures were: EP:−52.17; −52.57; 160; −256 (millimeters of mercury) mmHg]; CP: (98.6; 95.3; 323; −2mmHg); TMP: (58.57; 58.52; 245; −20mmHg) and PFP: (161.76; 159.42; 375; −13mmHg), respectively.ConclusionsA negative correlation was demonstrated between the duration of the sets and the mean CP and PFP. The sample obtained circuits withdrawn due to finished treatment (72h), and by coagulation or changes in pressures(AU)

Síndrome de burnout en distintas Unidades de Cuidados Intensivos / Burnout syndrome in different Intensive Care Units

Objetivos. Determinar la prevalencia del síndrome de desgaste profesional (burnout) enel personal sanitario de distintas Unidades de Cuidados Intensivos (UCI).Conocer la asociaciónentre el burnout, sus dimensiones y variables sociodemográficas-laborales. Comparardimensiones del burnout, características del personal y de los pacientes de distintas UCI.Material y métodos. Estudio analítico comparativo transversal, realizado en UCI de un hospitalterciario, en noviembre de 2006. La muestra fue 289 profesionales. Se entregó el cuestionarioMaslach Burnout Inventory y variables sociodemográficas-laborales. Se valoró en UCI:Therapeutic Intervention Scoring System (TISS), Nine Equivalents of Nursing Manpower UseScore (NEMS), mortalidad, estancia, aislamientos y desplazamientos terciarios. Se empleó laprueba de la χ2, Fischer, Kruskall-Wallis y análisis multivariable de regresión logística.Resultados. Contestaron el 73% de los trabajadores, edad 37 ± 9 y un 81% eran mujeres.Prevalencia de burnout 14%, afectados el 16% de enfermeros, 14% de residentes, 13% demédicos y 10% de auxiliares. El burnout se asoció a satisfacción profesional baja, relacióncon compañeros regular, reconocimiento laboral bajo, y tiempo trabajado y experienciaen UCI a un cansancio emocional elevado, con una p < 0,05. En la UCI Polivalente se obtuvieronvalores más elevados de: TISS 42 ± 11, NEMS 35 ± 10, mortalidad 18%, estancia5 ± 9, aislamientos 21%, síndrome burnout 17%, cansancio emocional elevado 49%, despersonalizaciónelevada 63% y realización profesional baja 44%.Conclusiones. La prevalencia del síndrome de burnout en nuestra muestra fue del 14%,siendo los profesionales de enfermería los más afectados. Detectamos niveles elevadosde despersonalización y niveles medios de cansancio emocional y de realización profesional.Las variables relacionadas con el (..) (AU)

Objectives. To determine the prevalence of the professional burnout syndrome inhealth care personnel of different Intensive Care Units (ICUs). To know the associationbetween burnout, its dimensions and sociodemographic-laboral variables. To comparethe dimensions of burnout, characteristics of the personnel and of the patients of thedifferent ICUs.Material and methods. Analytic, comparative, cross-sectional study performed in the ICUof a tertiary hospital in November 2006 performed in a sample of 289 professionals. TheMaslach Burnout Inventory questionnaire and sociodemographic-laboral variables wereprovided. The following were evaluated in the ICUs: Therapeutic Intervention ScoringSystem (TISS), Nine Equivalents of Nursing Manpower Use Score (NEMS), mortality, stay,isolations and travel of third parties. The χ2 test, Fischer test, Kruskall-Wallis test andmultivariate logistic regression analysis were used.Results. A total of 73% of the workers answered. Ages ranged from 37 ± 9 and 81% werewomen. The prevalence of burnout was 14%, this affecting 16% of the nurses, 14% ofresidents, 13% physicians and 10% auxiliary workers. Burnout was associated to lowprofessional satisfactions, relationship with regular colleagues, low work recognition andtime worked and experience in the ICU to high emotional tiredness, with a p < 0.05. In apolyvalent ICU, higher values of the following were obtained: TISS 42 ± 11, NEMS 35 ± 10,mortality 18%, stay 5 ± 9, isolation 21%, burnout syndrome 17%, elevated emotionaltiredness 49%, elevated depersonalization 63% and low professional performance 44%.Conclusions. The prevalence of the burnout syndrome in our sample was 14%, those beingaffected most being the nursing professionals. We detected elevated levels ofdepersonalization and middle levels of emotional tiredness and professional performance. (..) (AU)

Análisis de 4 escalas de valoración de la sedación en el paciente crítico / Analysis of 4 sedation rating scales in the critical patient

Introducción. Los objetivos del estudio fueron comprobar la correlación entre distintasescalas de valoración de la sedación (EVS) del paciente crítico con ventilación mecánica,así como conocer la asociación entre las EVS, datos clínicos y dosis de sedoanalgesia enperfusión (SAP).Material y métodos. Estudio analítico longitudinal prospectivo, realizado en una Unidadde Cuidados Intensivos Polivalente de un hospital terciario, desde octubre a diciembre de2006. La muestra incluyó a pacientes que precisaron administración de SAP y ventilaciónmecánica. Se valoraron: características de los pacientes, escala de Ramsay, escala desedación-agitación (SAS), escala de agitación-sedación de Richmond (RASS), escala deevaluación de la actividad motora (MAAS), dosis de SAP, tensión arterial media, frecuenciacardiaca, tamaño pupilar y frecuencia respiratoria. Se empleó el coeficiente de correlaciónde Spearman para valorar la relación entre las diferentes escalas.Resultados. Se realizaron 2.412 mediciones de cada variable: EVS, datos clínicos y dosisde SAP, en 30 pacientes con distintas patologías, 63% varones, edad 53 ± 19 años, APACHEII 23,8 ± 8,54, SAPS II 44,93 ± 16,52, mortalidad al alta en Unidad de Cuidados Intensivos(UCI) 34%. Mediana y rango intercuartílico de estancia en UCI 15,5 y 20 días, de ventilaciónmecánica 9 y 14 días, de SAP 6 y 5,5 días y de relajación en perfusión (RP) 2 y 5 días,respectivamente. Se detectó correlación entre todas las EVS, con una p < 0,0001. La relaciónentre SAS, RASS y MASS fue directa, mientras que estas se relacionaron inversamentecon el Ramsay. No se observó correlación entre las EVS, los datos clínicos y lasdosis de SAP.Conclusión. La escala de Ramsay, no validada, tiene una fuerte correlación con el restode las EVS estudiadas, ya validadas. Las EVS son subjetivas y no se correlacionan con losdatos clínicos y las dosis de SAP, probablemente por el reducido tamaño y heterogeneidadmuestral(AU)

Background. This study aimed to verify the relationship between different SedationRating Scales (SRSs) for critical patients on mechanical ventilation and to know therelationship between the SRSs, clinical information and the dose of sedative and analgesiadrugs (SAD).Material and methods. A longitudinal, prospective analytic pilot study conducted in aMedical-Surgical Intensive Care Unit of a tertiary hospital from October-December 2006.The sample included patients who required administration of SAP and mechanicalventilation. The following biological parameters and scales were evaluated: patient’sdemographics, RAMSAY, Sedation Agitation Scale (SAS), Richmond Agitation SedationScale (RASS), Motor Activity Assessment Scale (MASS), SAD dose, mean blood pressure,cardiac rate, pupil diameter and respiratory frequency. Spearman coefficient ofinterrelation was used to compare the relationship between the different scales.Results. A total of 2.412 measurements were made for each variable: SRS, clinicalinformation and SAD dose in 30 patients with different diseases, 63 % males, age 52 ± 19years, APACHEII 24 ± 8, SAPSII 44 ± 16, with an ICU mortality UCI 34 %. Median and IQrange of stay in ICU 15.5 and 20 days, of mechanical ventilation 9 and 14 days, of SAD 6and 5.5 days and of paralyzing drugs (PD) 2 and 5 days, respectively. Interrelation wasdetected between all the SRSs, with p < 0.0001. The relationship between SAS, RASS andMASS was direct, whereas these were related inversely to RAMSAY. No evidence ofinterrelation was found between the SRSs, the clinical information and the SAD doses.Conclusion. The RAMSAY scale that has not been validated in ICU patients has a stronginterrelation with the other already validated SRSs. SRSs are subjective and do notcorrelate with the clinical information and the SAD doses, probably due to the sample’ssmall size and heterogeneity(AU)

Evolución y cuidados del trasplante intestinal en el postoperatorio inmediato / Course and cares of intestinal transplant in immediate post-operative period

Objetivo. Describir la evolución y cuidados del postoperatorio inmediato en pacientes con trasplante intestinal. Material y métodos. Estudio descriptivo prospectivo realizado en la Unidad de Cuidados Intensivos Polivalente de un hospital terciario durante un año. Variables analizadas durante las primeras 48 horas del postoperatorio: constantes vitales, saturación O2, tiempo de destete, diuresis, glucemia, catéteres, drenajes, ileostomía, gastrostomía, TISS, NEMS, cuidados de enfermería, APACHE II y SAPS II al ingreso. Análisis estadístico con SPSS 11.0. Resultados. Cuatro pacientes. Mujeres 50%, edad media 42 ± 8 años. Motivo trasplante intestinal: 75% poliposis adenomatosa familiar con tumor desmoides y 25% obstrucción arteria mesentérica. Recibieron alemtuzumab y tacrólimus. Todos los pacientes eran portadores de catéter venoso central, arterial y drenajes abdominales Jackson Pratt (50% dos, 50% tres). Tiempo intubación (mediana) 15 horas. APACHE II 10 ± 6 y SAPS II 16 ± 4. Medias primer y segundo día de: tensión arterial sistólica/diastólica 132 ± 23/73 ± 11; 130 ± 25/74 ± 13 mmHg; glucemia 136 ± 26/119 ± 25 mg/dl; diuresis 95 ± 34/125 ± 30 cc/hora; TISS28 49 ± 4/38 ± 11 y NEMS 27 ± 0/25 ± 10, respectivamente. Una reintervención por shock hemorrágico. Mediana de estancia en Unidad de Cuidados Intensivos 4 días. Conclusiones. 1) Son pacientes hemodinámicamente estables; con destete corto; no portan muchos catéteres; ileostomía funcionante desde el primer día y con TISS28 y NEMS en la media del rango. 2) Los cuidados más específicos del trasplante intestinal son: herida quirúrgica, drenajes, ileostomía, gastrostomía. 3) La necesidad de intensa inmunosupresión implica aislamiento estricto y una ratio de enfermería:paciente 1:1

Objective. Describe the course and immediate post-operative care in patients with intestinal transplant. Material and methods. Descriptive, prospective study conducted in the Polyvalent Intensive Care Unit of a tertiary hospital for one year. Variables analyzed during the first 48 hours of the post-operative period: vital signs, O2 saturation, weaning time, diuresis, glycemia, catheters, drains, ileostomy, gastrostomy, TISS, NEMS, nursing cares, APACHE II and SAPS II on admission. Statistical analysis with SPSS 11.0. Results. Four patients, 50% women, mean age 42 ± 8 years. Reason for intestinal transplant: 75% familial adenomatous polyposis with desmoid tumor and 25% mesenteric artery obstruction. They were administered alemtuzumab and tacrolimus. All the patients were carrier of central and arterial venous catheters, and Jackson Pratt abdominal drains (50% two, 50% three). Intubation time (median) 15 hours. APACHE II 10 ± 6 y SAPS II 16 ± 4. Means on first and second day of: systolic/diastolic blood pressure 132 ± 23/73 ± 11; 130 ± 25/74 ± 13 mmHg; glycemia 136 ± 26/119 ± 25 mg/dl; diuresis 95 ± 34/125 ± 30 cc/hour; TISS28 49 ± 4/38 ± 11 and NEMS 27 ± 0/25 ± 10, respectively. One re-operation due to hemorrhagic shock. Median study in Intensive Care Unit of 4 days. Conclusions. 1) They are hemodynamically stable patients with short weaning. They do not have many catheters, functioning ileostomy since the first day and TISS28 and NEMS in the middle of the range. 2) The most specific cares of the intestinal transplant are: surgical wound, drains, ileostomy, gastrostomy. 3) The need for intense immunosuppression implies strict isolation and nursing:patient ratio of 1:1