RESUMEN
La identificación de pacientes en situación de enfermedad crónica avanzada y complejidad, y la fragmentación de cuidados hacia el final de la vida aconsejan trazar un plan terapéutico a largo plazo, congruente con los valores y preferencias de los pacientes, a la vez que con un pronóstico vital y funcional razonables. Disponer de una herramienta de ajuste en la adecuación de la intensidad diagnóstica y terapéutica sería de ayuda en la continuidad de cuidados y podría ser facilitadora de la toma de decisiones en las transiciones y en los cambios dinámicos que presentan los pacientes a medida que se acercan al final del proceso vital
The identification of patients with advanced and complex chronic diseases, and the fragmentation of care towards the end of life, requires the drawing up a long-term therapeutic plan. This should take into account the values and preferences of the patients, as well as the vital and functional prognosis. Having an adjustment tool for determining the diagnostic and therapeutic effort is helpful in the continuity of care, as well as in decision-making in the transitions and dynamic changes of patients as they approach the end of life process
Asunto(s)
Humanos , Masculino , Femenino , Anciano , Cuidados Paliativos al Final de la Vida/métodos , Afecciones Crónicas Múltiples/epidemiología , Planificación Anticipada de Atención/organización & administración , Administración y Planificación de Tierras , Diagnóstico de la Situación de Salud , Técnicas de Apoyo para la Decisión , Hospitalización/estadística & datos numéricos , Trasplante de Órganos/estadística & datos numéricos , Evaluación Geriátrica/métodosRESUMEN
PURPOSE: To determine the frequency of limitations on life support techniques (LLSTs) on admission to intensive care units (ICU), factors associated, and 30-day survival in patients with LLST on ICU admission. METHODS: This prospective observational study included all patients admitted to 39 ICUs in a 45-day period in 2011. We recorded hospitals' characteristics (availability of intermediate care units, usual availability of ICU beds, and financial model) and patients' characteristics (demographics, reason for admission, functional status, risk of death, and LLST on ICU admission (withholding/withdrawing; specific techniques affected)). The primary outcome was 30-day survival for patients with LLST on ICU admission. Statistical analysis included multilevel logistic regression models. RESULTS: We recruited 3042 patients (age 62.5 ± 16.1 years). Most ICUs (94.8%) admitted patients with LLST, but only 238 (7.8% [95% CI 7.0-8.8]) patients had LLST on ICU admission; this group had higher ICU mortality (44.5 vs. 9.4% in patients without LLST; p < 0.001). Multilevel logistic regression showed a contextual effect of the hospital in LLST on ICU admission (median OR = 2.30 [95% CI 1.59-2.96]) and identified the following patient-related variables as independent factors associated with LLST on ICU admission: age, reason for admission, risk of death, and functional status. In patients with LLST on ICU admission, 30-day survival was 38% (95% CI 31.7-44.5). Factors associated with survival were age, reason for admission, risk of death, and number of reasons for LLST on ICU admission. CONCLUSIONS: The frequency of ICU admission with LLST is low but probably increasing; nearly one third of these patients survive for ≥ 30 days.
RESUMEN
The identification of patients with advanced and complex chronic diseases, and the fragmentation of care towards the end of life, requires the drawing up a long-term therapeutic plan. This should take into account the values and preferences of the patients, as well as the vital and functional prognosis. Having an adjustment tool for determining the diagnostic and therapeutic effort is helpful in the continuity of care, as well as in decision-making in the transitions and dynamic changes of patients as they approach the end of life process.
Asunto(s)
Planificación Anticipada de Atención/normas , Cuidado Terminal/normas , Conferencias de Consenso como Asunto , Humanos , Cuidados para Prolongación de la Vida/normas , España , Salud UrbanaAsunto(s)
Embolia Aérea/diagnóstico por imagen , Venas Mesentéricas/diagnóstico por imagen , Vena Porta/diagnóstico por imagen , Anciano , Embolia Aérea/etiología , Resultado Fatal , Humanos , Isquemia/complicaciones , Yeyuno/irrigación sanguínea , Masculino , Arteria Mesentérica Superior/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
The second most important infectious complication in hospitalised patients is pneumonia, and it hits first place in the Intensive Care Unit (ICU). Almost 80% of the episodes of health-care pneumonia happens when patient is under mechanical ventilation, causing ventilator-associated pneumonia (VAP). VAP is associated with the highest rates of mortality in ICU infections, mainly if due to Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA). It also increases days under mechanical ventilation and the length of stay in ICU and hospital. Although all the diagnostic procedures, the diagnosis of VAP is based basically in the clinics: X-ray infiltrates and purulent endotracheal secretions are the cornerstone of the diagnosis. We should evaluate and screen any risk factor for multiresistant pathogens. If we have an early VAP and no risk factors, the majority of empiric antibiotic strategies are useful, but if we have a patient with more than one week under mechanical ventilation, previous antibiotic use, and risk factors for multiresistant pathogens, we should then individualize empiric antibiotic treatment.
Asunto(s)
Infección Hospitalaria/etiología , Neumonía Bacteriana/etiología , Ventiladores Mecánicos/microbiología , Algoritmos , Antibacterianos/uso terapéutico , Comorbilidad , Cuidados Críticos/métodos , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/epidemiología , Infección Hospitalaria/microbiología , Infección Hospitalaria/prevención & control , Manejo de la Enfermedad , Farmacorresistencia Bacteriana Múltiple , Contaminación de Equipos , Humanos , Tiempo de Internación , Neumonía Bacteriana/tratamiento farmacológico , Neumonía Bacteriana/epidemiología , Neumonía Bacteriana/microbiología , Neumonía Bacteriana/prevención & control , Factores de Riesgo , España/epidemiología , Ventiladores Mecánicos/efectos adversosRESUMEN
La neumonía es la segunda complicación infecciosa en frecuencia en el medio hospitalario, y ocupa el primer lugar en los servicios de medicina intensiva (unidades de cuidados intensivos [UCI]). El 80% de los episodios de neumonía nosocomial se produce en pacientes con vía aérea artifical y se denomina neumonía asociada a la ventilación mecánica (NAV). La NAV es la causa más frecuente de mortalidad entre las infecciones nosocomiales en las UCI, principalmente si son debidas a Pseudomonas aeruginosa y Staphylococcus aureus resistente a meticilina (MRSA). Además, incrementa los días de ventilación mecánica y la estancia media en la UCIy el hospital. A pesar de las pruebas disponibles, el diagnóstico de una NAV sigue siendo clínico. La presencia de una opacidad en la radiografía de tórax y secreciones traqueales purulentas son condiciones imprescindibles para su diagnóstico. Además, deberemos evaluar su estado y los factores de riesgo para patógenos de difícil tratamiento. Si la NAV es temprana y no existen estos factores de riesgo, la mayoría de las pautas empíricas presentan una cobertura correcta de la flora que nos encontraremos. Sin embargo, si el diagnóstico de NAV se realiza en un paciente con más de 1 semana de ventilación mecánica, en tratamiento antibiótico o con factores de riesgo, deberemos individualizar la pauta (AU)
The second most important infectious complication in hospitalised patients is pneumonia, and it hits first place in the Intensive Care Unit (ICU). Almost 80% of the episodes of health-care pneumonia happens when patient is under mechanical ventilation, causing ventilator-associated pneumonia (VAP). VAP is associated with the highest rates of mortality in ICU infections, mainly if due to Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA). It also increases days under mechanical ventilation and the length of stay in ICU and hospital. Although all the diagnostic procedures, the diagnosis of VAP is based basically in the clinics: X-ray infiltrates and purulent endotracheal secretions are the cornerstone of the diagnosis. We should evaluate and screen any risk factor for multirresistant pathogens. If wehave an early VAP and no risk factors, the majority ofempiric antibiotic strategies are useful, but if we have apatient with more than one week under mechanical ventilation, previous antibiotic use, and risk factors for multirresistant pathogens, we should then individualize empiric antibiotic treatment (AU)
Asunto(s)
Humanos , Respiración Artificial/efectos adversos , Neumonía/epidemiología , Infección Hospitalaria/epidemiología , Neumonía/tratamiento farmacológico , Neumonía/microbiología , Antibacterianos/uso terapéuticoRESUMEN
BACKGROUND: Clinical resolution of ventilator-associated pneumonia (VAP) determines the duration of treatment and mechanical ventilation. The aim of this study was to evaluate the influence of organisms and their susceptibility to treatment on outcomes. METHODS: Prospective observational study in three teaching ICUs. Sixty episodes of VAP with appropriate therapy (Haemophilus influenzae, 15 episodes; methicillin-sensitive Staphylococcus aureus [MSSA], 15 episodes; Pseudomonas aeruginosa, 15 episodes; and methicillin-resistant S aureus [MRSA], 15 episodes), and 30 episodes with initial inappropriate therapy, all due to P aeruginosa, were compared. The main outcome measures were clinical resolution variables and, in survivors, length of mechanical ventilation after VAP onset. RESULTS: A significant delay in the resolution of hypoxemia was observed in VAP episodes due to MRSA and P aeruginosa with inappropriate antibiotic therapy (IAT) (median time to resolution, 10 and 8 days, respectively) when compared with the remaining pathogens (median time to resolution, 2 days). A multiple regression model, adjusted for disease severity, confirmed the delayed clinical resolution for MRSA and P aeruginosa with IAT. Similar associations were documented for defervescence. Among survivors, the median duration of mechanical ventilation after VAP onset was significantly longer for MRSA (17 days) and P aeruginosa IAT (11 days) when compared with episodes due to H influenzae or MSSA (6 days). Multiple regression analysis, adjusted for disease severity, confirmed that MRSA required significantly (R(2) = 0.132; p < 0.01) longer respiratory support than other organisms. CONCLUSIONS: When treated promptly, the resolution of VAP due to MSSA, H influenzae, and P aeruginosa was comparable. The resolution of MRSA VAP, regardless of the appropriateness of initial antibiotic therapy, was associated with longer respiratory support.