'Learning by doing', a model for improving the promotion of healthy lifestyles by student nurses.

BACKGROUND: 'Learning by doing' is a learning model based on performing actions and gaining experience. The 'nursing process' is a systematic, rational method for providing nursing care. During their university education, nursing students need to acquire the ability to promote healthy lifestyles. OBJECTIVE: To determine the effectiveness of a learning strategy based on learning by doing and grounded in the use of the nursing process, on the lifestyle of nursing students. METHODS: This quasi-experimental intervention (before-after), performed over 2011-2022, involved 2300 nursing students at a university nursing school in Spain. The risk factors for chronic diseases-being a smoker, being overweight, or having high blood pressure-to which each student was exposed were recorded. Those positive for at least one risk factor selected companion students as 'support nursing students' who became responsible for designing an individualised care plan to reduce the risk(s) faced. To ensure the correct use of the nursing process, teachers approved and monitored the implementation of the care plans. Whether risk-reduction objectives were met was determined three months later. RESULTS: The students with risk factors largely improved their lifestyles (targets for reducing smoking/body weight were met) with the help of their supporting peers. CONCLUSIONS: The learning by doing method demonstrated its effectiveness, improving the lifestyle of at-risk students via the use of the nursing process.

Implementation of Evidence-Based Practice in Peripheral Intravenous Catheter Care.

BACKGROUND: Inserting a peripheral intravenous (PIV) catheter is a common health care procedure; however, risks include phlebitis, extravasation, and accidental dislodgement. Using evidence-based practices (EBPs) can reduce these risks. PURPOSE: The purpose of this study was to implement an evidence-based PIV catheter care bundle and a decision-making algorithm. METHODS: A quasi-experimental study design was used. A care bundle and an evidence-based decision-making algorithm were implemented on a medical unit. Outcomes included length of PIV catheter dwell time, phlebitis and other complications, and health professionals' adherence to the interventions. RESULTS: A total of 364 PIV catheters were assessed. PIV catheter dwell time decreased from 3.6 to 2.9 days ( P < .001), and phlebitis rates decreased from 14.8% to 4.9% ( P < .05). Health professionals' adherence increased from 84.3% to 91.8%. CONCLUSIONS: Implementing EBPs can improve care provided to patients with PIV catheters.

Pain Behaviors Analyzed by Videorecording in Brain-Injured Patients Admitted to the Intensive Care Unit.

AIM: To describe and classify pain behaviors (facial and body) in brain-injured patients with a low level of consciousness before, during, and after the performance of painful and non-painful care procedures. METHODS: Facial behaviors and body movements in brain-injured patients were videotaped at rest, during the application of three care procedures (two painful and one non-painful), and 15 minutes after completion of these procedures. Each video recording was evaluated by expert evaluators blinded to each other. For each of the behaviors observed, all possible combinations between the three procedures and/or time were compared using the McNemar test. Effect size was measured by the difference in proportions using the Wilson score 95% confidence intervals. RESULTS: Twenty-seven patients were included. The mean (standard deviation) Glasgow Coma Score was 5.4 (1.9). A total of 33 behaviors (29 active, four neutral) were registered. Expression of behaviors was more common during the painful procedures compared with the other time points (non-painful procedures, baseline, and final evaluation). Inter-evaluator agreement was substantial (Kappa index >0.7) in more than 50% of the observed behaviors. CONCLUSIONS: In this study involving brain-injured patients with a low level of consciousness, facial, body, and ventilation-related behaviors were more common during painful procedures. Agreement between evaluators to detect the presence or absence of these behaviors was substantial. These findings underscore the need to develop pain assessment measures specific to this patient population.

[Lean Six Sigma in the implementation of automated dispensing systems: improving the safe use of medications in thoracic surgery.] / Lean Seis Sigma en la implantación de sistemas automatizados de dispensación: mejora del uso seguro del medicamento en cirugía torácica.

OBJECTIVE: Medications errors are a major problem that can cause a harm to inpatients. The main objective of the study was to compared medication errors in pharmacotherapeutic process before and after to carried out an intervention: to implant an automated dispensing cabine with to use Lean Six Sigma methodology. The secondary objective was to assess process performance, sigma level and defects per one million opportunities for medication error. METHODS: Quasi-experimental and randomized study carried out in a Thoracic Surgery Unit of a Spanish Hospital. A pharmaceutic recorded and assesed the medication errors detected during pre-intervention period (july-august 2017) and post-intervention period (march-april 2018). The steps analyzed were dispensing, storage and compounding/administration. The pharmacist observed a third of the medication dispensed, stored and compounded/administered during the study period. The observed medication was randomly selected using AleatorMetod.xls software. To perform the statistical analysis, Student's t test and Mann-Whitney U test were used to compare quantitative variables, and Chi-square test for qualitative variables. A significance level of p<0.05 was considered. RESULTS: The pharmaceutic recorded 4,538 drugs. After intervention, medication errors were decreased a 49% in total pharmacotherapeutic process (12.06% vs 6.15%; p<0.001). In addition, errors were decreased a 91.6% (4.27% vs 0.36%; p=0.004) in the step of medication storage; and a 75.8% (22.52% vs 5.46%; p<0.001) in the step of drugs compounding/administration. However, medication errors were increased in the step of medication dispensing (4.51% vs 15.29%; p<0.001). The process performance increased a 6% (87.9% vs 93.9%), sigma level increased from 2.67 to 3.04 and defects per one million opportunities for medication error decreased a 49%. CONCLUSIONS: To implant an automated dispensing cabinet with Lean Six Sigma methodology helps create a safer environment for the inpatient, reducing medication errors in the steps of storage and preparation/administration, as well as improving the total process performance and sigma level.

OBJETIVO: Los errores de medicación son un problema importante que pueden provocar un daño en los pacientes hospitalizados. El objetivo principal del estudio fue evaluar los errores de medicación en el circuito farmacoterapéutico antes y después de realizar una intervención: implantación de un Sistema Automatizado de Dispensación con la utilización de metodología Lean Seis Sigma. El objetivo secundario fue evaluar el rendimiento del proceso, el nivel sigma y los defectos por millón de oportunidades de error en la medicación. METODOS: Estudio cuasi-experimental y aleatorizado realizado en la Unidad de Cirugía Torácica de un Hospital Español. Un farmacéutico registró y evaluó los errores detectados durante las fases pre-intervención (julio-agosto 2017) y post-intervención (marzo-abril 2018). Las etapas analizadas fueron dispensación, almacenaje y preparación/administración. El farmacéutico observó un tercio de la medicación dispensada, almacenada y preparada/administrada durante el periodo de estudio. La medicación observada fue seleccionada de forma aleatoria utilizando el software AleatorMetod.xls. Para realizar el análisis estadístico se utilizó la prueba t de Student y el test U de Mann-Whitney para comparar variables cuantitativas y la prueba Chi-cuadrado para variables categóricas. Se consideró un nivel de significación de p<0,05. RESULTADOS: Se observaron 4.538 fármacos. Tras realizar la intervención, se redujeron un 49% los errores detectados durante el circuito farmacoterapéutico global (12,06% vs 6,15%; p<0,001). Además, se redujo un 91,6% (4,27% vs 0,36%; p=0,004) los errores en la etapa de almacenaje y un 75,8% (22,52% vs 5,46%; p<0,001) en la etapa de preparación/administración. Sin embargo, hubo un aumento en la etapa de dispensación (4,51% vs 15,29%; p<0,001). El rendimiento global se incrementó un 6% (87,9% vs 93,9%), el nivel de sigma aumentó de 2,67 a 3,04 y se redujeron un 49% de defectos por millón de oportunidades de error en la medicación. CONCLUSIONES: La implantación de Sistemas Automatizados de Dispensación con metodología Lean Seis Sigma ayuda a la creación de un entorno más seguro para el paciente, disminuyendo los errores de medicación en las etapas de almacenaje y preparación/administración, además de mejorar el rendimiento global del circuito.

Lean Seis Sigma en la implantación de sistemas automatizados de dispensación: mejora del uso seguro del medicamento en cirugía torácica / Lean Six Sigma in the implementation of automated dispensing systems: improving the safe use of medications in thoracic surgery

Fundamentos: Los errores de medicación son un problema importante que pueden provocar un daño en los pacientes hospitalizados. El objetivo principal del estudio fueevaluar los errores de medicación en el circuito farmacote rapéutico antes y después de realizar una intervención: implantación de un Sistema Automatizado de Dispensación conla utilización de metodología Lean Seis Sigma. El objetivosecundario fue evaluar el rendimiento del proceso, el nivelsigma y los defectos por millón de oportunidades de error enla medicación.Métodos: Estudio cuasi-experimental y aleatorizadorealizado en la Unidad de Cirugía Torácica de un HospitalEspañol. Un farmacéutico registró y evaluó los errores detectados durante las fases prentervención (julio-agosto 2017)y post-intervención (marzo-abril 2018). Las etapas analizadas fueron dispensación, almacenaje y preparación/administración. El farmacéutico observó un tercio de la medicacióndispensada, almacenada y preparada/administrada durante elperiodo de estudio. La medicación observada fue seleccionada de forma aleatoria utilizando el software AleatorMetod.xls.Para realizar el análisis estadístico se utilizó la prueba t deStudent y el test U de Mann-Whitney para comparar variablescuantitativas y la prueba Chi-cuadrado para variables categóricas. Se consideró un nivel de significación de p<0,05.Resultados: Se observaron 4.538 fármacos. Tras realizar la intervención, se redujeron un 49% los errores detectados durante el circuito farmacoterapéutico global (12,06%vs 6,15%; p<0,001). Además, se redujo un 91,6% (4,27% vs0,36%; p=0,004) los errores en la etapa de almacenaje y un75,8% (22,52% vs 5,46%; p<0,001) en la etapa de preparación/administración. Sin embargo, hubo un aumento en la etapa dedispensación (4,51% vs 15,29%; p<0,001).(AU)

Background: Medications errors are a major problemthat can cause a harm to inpatients. The main objective of thestudy was to compared medication errors in pharmacotherapeutic process before and after to carried out an intervention:to implant an automated dispensing cabine with to use LeanSix Sigma methodology. The secondary objective was to assess process performance, sigma level and defects per one million opportunities for medication error.Methods: Quasi-experimental and randomized studycarried out in a Thoracic Surgery Unit of a Spanish Hospital.A pharmaceutic recorded and assesed the medication errorsdetected during pre-intervention period (july-august 2017)and post-intervention period (march-april 2018). The stepsanalyzed were dispensing, storage and compounding/administration. The pharmacist observed a third of the medicationdispensed, stored and compounded/administered during thestudy period. The observed medication was randomly selected using AleatorMetod.xls software. To perform the statistical analysis, Student’s t test and Mann-Whitney U test wereused to compare quantitative variables, and Chi-square testfor qualitative variables. A significance level of p<0.05 wasconsidered.Results: The pharmaceutic recorded 4,538 drugs. Afterintervention, medication errors were decreased a 49% in totalpharmacotherapeutic process (12.06% vs 6.15%; p<0.001). Inaddition, errors were decreased a 91.6% (4.27% vs 0.36%;p=0.004) in the step of medication storage; and a 75.8%(22.52% vs 5.46%; p<0.001) in the step of drugs compounding/administration. However, medication errors were increased in the step of medication dispensing (4.51% vs 15.29%;p<0.001). The process performance increased a 6% (87.9%vs 93.9%), sigma level increased from 2.67 to 3.04 and defects per one million opportunities for medication error decreased a 49%.(AU)

Flu Vaccination Coverage and Predictors of Non-Vaccination in Military Health Corps Personnel 2016-2017 and 2019-2021.

(1) Background: Vaccination is the most effective intervention to control seasonal influenza morbidity and mortality. The present study aimed to determine the influenza vaccination coverage in the Military Health Corps personnel in the 2020−2021 season, as well as the time trend and the possible influence of the pandemic on coverage, in order to study the reasons that led to the non-vaccination of health professionals and to analyze adverse drug reactions (ADRs). (2) Methods: A descriptive, cross-sectional study was conducted from February to May 2021. All FAS CMS personnel were included. A self-administered questionnaire was sent by e-mail to the selected personnel. (3) Results: Vaccination coverage in the 2016−2017 season was 15.8% (n = 276), in the 2019−2020 season it was 17.41% (n = 424), and in the 2020−2021 season it was 24.22% (n = 590). The percentage of vaccinated men was higher than the percentage of women. In 2019 and 2020 the most vaccinated group was 31−40 years old. Lieutenants had the highest vaccination uptake in 2019 and 2020. The personnel with the highest uptake of vaccines were those in the specialty of nursing in each of 2016, 2019 and 2020, with >30 years of time worked in 2016. In terms of factors leading to refusal of vaccination, the most reported was "not considered a risk group" (23.0%), and the least reported was "avoidance of vaccine administration" (2.2%). Eighty individuals presented adverse reactions after vaccine administration (9.6%). (4) Conclusions: The rate of influenza vaccination among healthcare professionals was lower during the 2020 season compared to the previous season, but was expected to increase in the upcoming 2021 season.

Vaccine Coverage against Influenza and SARS-CoV-2 in Health Sciences Students during COVID-19 Pandemic in Spain.

Vaccination against influenza and SARS-CoV-2 is recommended in health sciences students to reduce the risk of acquiring these diseases and transmitting them to patients. The aim of the study was to evaluate how the pandemic influenced the modification of influenza vaccination coverage during the 2019/2020 and 2021/2022 campaigns and to analyze the vaccination coverage against SARS-CoV-2 in health sciences students. A cross-sectional study was conducted among students of the Faculty of Nursing, Physiotherapy and Podiatry of the Complutense University of Madrid. A questionnaire was administered in two stages, the first, Q1, before the start of the pandemic, where we analyzed influenza coverage during the 2019/2020 campaign and a second, Q2, 18 months after the start of the pandemic where we analyzed influenza coverage during the 2021/2022 campaign and coverage against SARS-CoV-2. A total of 1894 students (58.78% of the total of those enrolled) participated. Flu vaccination coverage increased from 26.7% in Q1 to 35.0% in Q2 (p < 0.05), being higher in the age group older than 21 years, who studied nursing, were in their fourth year and lived with people at risk. Vaccination coverage against SARS-CoV-2 was very high (97.8%), especially in students vaccinated against influenza. Coverage of the influenza vaccine in health sciences students increased from 2019-2020 to 2021-2022, being higher in the age group older than 21 years, who studied nursing, were in their first and fourth year and lived with people at risk. Coverage of the SARS-CoV-2 vaccine in health sciences students was very high, especially in those vaccinated against influenza.

The Attitude towards Vaccination of Health Sciences Students at a Spanish University Improved over the First 18 Months of the COVID-19 Pandemic.

It is important to know the attitudes of students of health sciences (SHSs) towards vaccination since they will be tomorrow's health professionals. Vaccination is a powerful tool in the fight against COVID-19. The aim of the present, cross-sectional study was to examine how the COVID-19 pandemic has influenced the attitude of SHSs towards vaccination. Data were collected in the form of a questionnaire from all students of nursing, physiotherapy and chiropody matriculated at a Madrid University for the academic year 2019/2020 (i.e., before the start of the pandemic [Q1]), and from all those matriculated for the year 2021/22 (i.e., c18 months after the pandemic was declared [Q2]). A multivariate analysis was performed to identify the influence of sex, degree being studied, course year and the time of answering (Q1 or Q2), on the dimensions Beliefs, Behaviours and General Attitude. Overall, 1894 questionnaires were returned (934 [49.3%] for Q1, and 960 [50.7%] for Q2), of which 70.5% were completed by students of nursing, 14% by students of physiotherapy and 15.4% by those studying chiropody. In Q2, the results for all three dimensions were significantly better (p < 0.05). The most important influencing factors were being a student of nursing, being in the final years of training (years 3 or 4), female gender and answering at the time of Q2. The results obtained are encouraging since student nurses (who showed Q1 and Q2 General Attitude scores of 3.34 and 3.47 (maximum possible 4), respectively [p < 0.05]) are the health professionals of tomorrow most likely to be involved in vaccination programmes.

Futuras líneas de investigación en cuidados sobre dolor, sedación, contenciones y delirium en el paciente crítico / Future lines of research on pain care, sedation, restraints and delirium in the critically ill patient

La valoración y manejo del dolor-analgesia, agitación-sedación, contenciones mecánicas (CM) y delirium en el paciente critico ha ido evolucionando en los últimos años, tal y como recogen las recomendaciones de las Guías de Práctica Clínica (GPC) 1. Sin embargo, todavía quedan cuestiones pendientes, en las que las enfermeras pueden investigar destacando el efecto que los cuidados pueden tener en los resultados de salud sensibles a la práctica enfermera. A continuación, se proponen doce líneas de investigación en cuidados para la orientación de futuros proyectos sobre dolor, sedación, CM y delirium. (AU)

Use of topical sevoflurane in pressure ulcer treatment in a double-lung transplant patient.

Pain caused by wounds of different etiology is usually treated with oral analgesics. New topical use of products such as the ether anesthetic sevoflurane shows good results for pain control and has additional benefits. Pressure ulcers are painful and patients may benefit from the use of sevoflurane. We present the case of a double-lung transplant patient with a long-standing sacral pressure ulcer with poor pain control, for which sevoflurane dressings were used. The number of pain-free hours after application, the amount of daily analgesics and the size of the wound were monitored with the mobile wound application MOWA. After several days of sevoflurane application, the patient reduced analgesic consumption, remained longer free of pain, and the size of the wound decreased. Unfortunately, the patient had serious complications due to multiple comorbidities and died before the wound healed completely. Topical use of sevoflurane in pressure ulcers may be a good option to treat pain and improve patient quality of life.

Lateral Kangaroo Care in Hemodynamic Stability of Extremely Preterm Infants: Protocol Study for a Non-Inferiority Randomized Controlled Trial CANGULAT.

INTRODUCTION: This study aims to assess the efficacy of the modified kangaroo care lateral position on the thermal stability of preterm neonates versus conventional kangaroo care prone position. MATERIAL AND METHODS: A non-inferiority randomized parallel clinical trial. Kangaroo care will be performed in a lateral position for the experimental group and in a prone position for the control group preterm. The study will take place at the neonatal intensive care unit (NICU) of a University Hospital. The participants will be extremely premature infants (under 28 weeks of gestational age) along the first five days of life, hemodynamically stable, with mother or father willing to do kangaroo care and give their written consent to participate in the study. The sample size calculated was 35 participants in each group. When the premature infant is hemodynamically stable and one of the parents stays in the NICU, the patient will be randomized into two groups: an experimental group or a control group. The primary outcome is premature infant axillary temperature. Neonatal pain level and intraventricular hemorrhage are secondary outcomes. DISCUSSION: There is no scientific evidence on modified kangaroo care lateral position. Furthermore, there is little evidence of increased intraventricular hemorrhage association with the lateral head position necessary in conventional or prone kangaroo care in extremely premature newborns. Kangaroo care is a priority intervention in neonatal units increasing the time of use more and more, making postural changes necessary to optimize comfort and minimize risks with kangaroo care lateral position as an alternative to conventional prone position kangaroo care. Meanwhile, it is essential to ensure that the conventional kangaroo care prone position, which requires the head to lay sideways, is a safe position in terms of preventing intraventricular hemorrhage in the first five days of life of children under 28 weeks of gestational age. Trial registration at clinicaltrials.gov: NCT03990116.

Application of the Behavioural Indicators of Pain Scale in patients with traumatic brain injury.

AIM: To develop and psychometrically test the Behavioural Indicators of Pain Scale (ESCID) in patients with traumatic brain injury (TBI). DESIGN: A prospective observational study to test the psychometric properties of the Behavioural Indicators of Pain Scale in patients with TBI. METHOD: A convenience sample of patients with TBI, who were non-communicative and using invasive mechanical ventilation was selected. Pain was evaluated by two observers who were blinded from each other. Assessments were performed at baseline via the performance of a painful procedure (aspiration of secretions) and a non-painful procedure (rubbing with a gauze). Assessments were repeated after application of procedures on days 1 and 6 of hospitalization in an intensive care unit. Data were collected between January-December 2016. RESULTS: About 134 patients were included in the study. Of these, 76.1% were men. The mean age of participants was 45.2 (SD 17.5) years. The pain score significantly increased during the painful procedure when compared with the baseline measure and non-painful procedure (p < .001). Patients displayed a greater number of pain-indicating behaviours during the painful procedure on day 6, compared with day 1 (p < .05). This finding coincided with a reduced level of sedation and a greater level of consciousness. CONCLUSION: The ESCID scale detects pain behaviours and discriminates among the different types of stimulation in patients with brain injury, who are uncommunicative and with mechanical ventilation, with good reliability. The ability for patients with brain injury to express behaviours is limited because of the low level of consciousness and the deep level of sedation. IMPACT: This research will have an impact on the practice of pain assessment in patients with brain injury, representing a first step to adapt the content of the ESCID.

Equilibrio emocional, capacidad de autocuidado e integridad cutánea en la persona ostomizada / Emotional balance, self-care ability and skin integrity in ostomized persons

Objetivo: explorar la relación entre equilibrio emocional, autocuidado e integridad cutánea en personas ostomizadas mediante criterios de resultado NOC. Método: estudio observacional prospectivo. Se incluyeron pacientes ostomizados en seguimiento en "Consulta de Ostomía" a los siete días del alta, a los dos, seis y 12 meses. Se estudiaron variables sociodemográficas, clínicas y de resultado, basadas en ocho indicadores relacionados con los NOC (1101) Integridad tisular: piel y membranas mucosas, (1615) Autocuidado de la ostomía y (1204) Equilibrio emocional. Se realizó análisis descriptivo, usando frecuencias, medias y desviaciones estándar (DE). Se estudiaron las correlaciones entre los indicadores derivados de los NOC. Resultados: se incluyeron 55 pacientes. El 65,45% (n= 36) era hombre, con una edad media (DE) de 67,45 (13,4) años, siendo el 58,2% mayores de 65 años. Se restableció la continuidad intestinal en el 50,90% (n= 28) de los participantes. La integridad de la piel la consiguió el 10,90% (n= 6) (visita 1), llegando al 100% (n= 20) (visita 4). Logró un autocuidado adecuado el 18,18% (n= 10) (visita 1), llegando al 100% (n= 20) (visita 4). No consiguió equilibrio emocional ningún paciente en la visita 1, obteniéndolo el 34% (n= 17) (visita 2), el 59,5% (n= 21) (visita 3) y el 70% (n= 14) (visita 4). Las correlaciones entre variables se presentan de forma directa y positiva, con niveles de asociación moderado-bueno. Todas son estadísticamente significativas. Conclusiones: el porcentaje de pacientes con problemas en la piel periestomal mejora a lo largo del seguimiento. El autocuidado aumenta gradualmente así como el equilibrio emocional. Hay relación directa y positiva entre integridad cutánea y autocuidado, calidad del sueño, apetito, mantenimiento del arreglo e higiene personal y manifestación de un estado de ánimo sereno

Objective: to explore the relationship between emotional balance, self-care and skin integrity in ostomized persons through the NOC Outcomes Criteria. Method: a prospective observational study, including ostomized patients under follow-up in the Ostomy Unit at seven days after discharge, and at two, six and 12 months. Sociodemographical, clinical and outcome variables were studied, based on eight indicators associated with the NOC (1101) Tissue Integrity: Skin & Mucous Membranes, (1615) Ostomy Self-Care and (1204) Emotional Balance. A descriptive analysis was conducted, using frequencies, means and standard deviations (SD). Correlations between NOC-derived indicators were studied. Results: the study included 55 patients; 65.45% (n= 36) were male, with 67.45 (13.4) years as mean age (SD), and 58.2% were >65-year-old. Intestinal continuity was restored in 50.90% (n= 28) of the participants; 10.90% (n= 6) achieved skin integrity (visit 1), reaching 100% (n= 20) (visit 4). An adequate self-care was achieved by 18.18% (n= 10) (visit 1), reaching 100% (n= 20) (visit 4). No patient achieved emotional balance at Visit 1; 34% (n= 17) had achieved it at Visit 2, 59.5% (n= 21) at Visit 3, and 70% (n= 14) at Visit 4. Correlations between variables were presented in a direct and positive manner, with Moderate-Good association levels; all of them were statistically significant. Conclusions: the proportion of patients with problems in peristomal skin improved throughout follow-up. Self-care was gradually increased, as well as emotional balance. There was a direct and positive relationship between skin integrity and self-care, quality of sleep, appetite, maintaining personal hygiene and care, and reporting a serene mood

Guía de práctica clínica del American College of Critical Care Medicine sobre prevención y manejo del dolor, agitación/sedación, contenciones mecánicas, delirio, inmovilidad y alteraciones del sueño del paciente adulto / Clinical Practice Guidelines of the American College of Critical Care Medicine for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients

Objetivo: Actualizar y ampliar la Guía de Práctica Clínica de 2013 para el manejo del dolor, agitación y delirio en pacientes adultos de la UCI. Diseño: Treinta y dos expertos internacionales, cuatro expertos en metodología, y cuatro supervivientes de enfermedades críticas se reunieron virtualmente, al menos una vez al mes. Todos los grupos de sección se reunieron personalmente en los congresos anuales de la Sociedad de Medicina de Cuidados Críticos; las conexiones virtuales incluyeron a aquellas personas que no pudieron asistir. A priori, se desarrolló una política formal de conflicto de intereses, que se hizo cumplir a lo largo del proceso. Las teleconferencias y debates electrónicos entre los subgrupos, así como el panel al completo, formaron parte del desarrollo de la guía. Todos los miembros del panel realizaron personalmente una revisión general del contenido en enero de 2017. Métodos: Los expertos contenidos, los expertos en metodología, y los supervivientes de la UCI estuvieron representados en cada una de las cinco secciones de la guía: Dolor, Agitación/sedación, Delirio, Inmovilidad (movilización/rehabilitación), y Sueño (interrupción). Cada sección creó preguntas descriptivas y no procesables sobre Población, Intervención, Comparación, y Resultados, basadas en la relevancia clínica percibida. A continuación, el grupo responsable de la guía votó su clasificación, y los pacientes priorizaron su importancia. Para cada pregunta sobre Población, Intervención, Comparación, y Resultados, las distintas secciones buscaron la evidencia mejor disponible, determinaron su calidad, y formularon recomendaciones del tipo declaraciones sobre prácticas "sólidas," "condicionales," o "buenas" basándose en los principios de calificación de valoración, desarrollo y evaluación de recomendaciones. Además, se identificaron explícitamente las brechas de la evidencia y las salvedades clínicas. Resultados: El panel sobre dolor, agitación/sedación, delirio, inmovilidad (movilización/rehabilitación), y sueño (interrupción) emitió 37 recomendaciones (3 sólidas y 34 condicionales), dos declaraciones de prácticas buenas, y 32 declaraciones no calificables y no procesables. Tres preguntas procedentes de la lista de preguntas priorizadas centradas en el paciente carecieron de recomendación. Conclusiones: Concluimos un acuerdo sustancial entre una gran cohorte interdisciplinaria de expertos internacionales en cuanto a la evidencia que respalda las recomendaciones y las brechas en la literatura pendientes en cuanto a evaluación, prevención y tratamiento del dolor, agitación/sedación, delirio, inmovilidad (movilización/rehabilitación), y sueño (interrupción) en adultos críticos. Subrayar dicha evidencia y las necesidades de investigación mejorarán el manejo del dolor, agitación/sedación, delirio, inmovilidad (movilización/rehabilitación), y sueño (interrupción), y aportarán las bases para mejorar los resultados y la ciencia en esta población vulnerable

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[The efficacy of caloric intake in critically ill patients with traumatic pathology]. / Eficacia del aporte calórico en pacientes con patología traumática.

BACKGROUND: the effective contribution of enteral nutrition (EN) in intensive care units (ICU) is due to multiple factors. OBJECTIVES: to determine the efficacy of caloric intake in critically ill patients with traumatic pathology receiving enteral nutrition, and to analyze cause and time of interruption of EN. METHOD: prospective observational study (November 2015 - August 2016). INCLUSION CRITERIA: patient with EN ≥ 48 hours and age ≥ 18 years. EXCLUSION CRITERIA: patient with oral and/or parenteral nutrition. VARIABLES: demographic, day of EN, prescribed and administered kilocalories (kcal), caloric difference, caloric objective and variables related to the interruptions of the EN. The handling of EN and interruptions are made according to the unit's internal protocol. Kcal/patient are calculated according to the Harris-Benedict equation and multiplied by a stress factor depending on the type of trauma of the patient. RESULTS: sixty-nine patients were included, 79.71% were men, with a median age of 46 (34-58) years. A total of 1,112 days of EN were monitored. As of the third day of admission to the ICU (979 days monitored), the nutritional efficacy was optimal (caloric intake > 80%): 92.43% (72.8-97.5). The optimal caloric goal was maintained in 67.9% of these days. The most frequent causes of interruption of NE were procedures unrelated to airway, with holding time of three (1-7.25) hours. CONCLUSIONS at the third day, the patients with traumatic pathology received at least 80% of the prescribed caloric intake. Among the most frequent causes of interruption of EN were the procedures unrelated to airway.

INTRODUCCIÓN: el aporte efectivo de la nutrición enteral (NE) en las unidades de cuidados intensivos (UCI) se ve afectado por múltiples factores. OBJETIVOS: determinar la eficacia en el aporte calórico a los pacientes críticos con patología traumática que reciben nutrición enteral. Analizar causa y tiempo de interrupción de NE. MÉTODO: estudio observacional prospectivo (de noviembre de 2015 a agosto de 2016). Criterios de inclusión: paciente con NE ≥ 48 horas y edad ≥ 18 años. Criterios de exclusión: paciente con dieta oral y/o parenteral. Variables: demográficas, día de NE, kilocalorías (kcal) prescritas, administradas, diferencia calórica, objetivo calórico y relacionadas con las interrupciones de la NE. El manejo de NE e interrupciones se realiza según protocolo interno de la unidad. Las kcal/paciente se calculan según la ecuación de Harris-Benedict y multiplicando por un factor de estrés en función del tipo de trauma del paciente. RESULTADOS: se incluyeron 69 pacientes (el 79,71% eran hombres) con una mediana de edad de 46 (34-58) años. Se monitorizaron un total de 1.112 días de NE. A partir del tercer día de ingreso en UCI (979 días monitorizados) la eficacia nutricional fue óptima (aporte calórico > 80%): 92,43% (72,8-97,5). Mantenemos el objetivo calórico óptimo en el 67,9% de estos días. Observamos como causa más frecuente de interrupción de la NE los procedimientos no relacionados con la vía aérea, con un tiempo de parada de tres (1-7,25) horas. CONCLUSIÓN: el aporte calórico del paciente crítico con patología traumática se logra de forma óptima a partir del día 3. Entre las causas de interrupción de la NE más frecuentes se encuentran los procedimientos no relacionados con la vía aérea.

Eficacia del aporte calórico en pacientes con patología traumática / The efficacy of caloric intake in critically ill patients with traumatic pathology

Introducción: el aporte efectivo de la nutrición enteral (NE) en las unidades de cuidados intensivos (UCI) se ve afectado por múltiples factores. Objetivos: determinar la eficacia en el aporte calórico a los pacientes críticos con patología traumática que reciben nutrición enteral. Analizar causa y tiempo de interrupción de NE. Método: estudio observacional prospectivo (de noviembre de 2015 a agosto de 2016). Criterios de inclusión: paciente con NE ≥ 48 horas y edad ≥ 18 años. Criterios de exclusión: paciente con dieta oral y/o parenteral. Variables: demográficas, día de NE, kilocalorías (kcal) prescritas, administradas, diferencia calórica, objetivo calórico y relacionadas con las interrupciones de la NE. El manejo de NE e interrupciones se realiza según protocolo interno de la unidad. Las kcal/paciente se calculan según la ecuación de Harris-Benedict y multiplicando por un factor de estrés en función del tipo de trauma del paciente. Resultados: se incluyeron 69 pacientes (el 79,71% eran hombres) con una mediana de edad de 46 (34-58) años. Se monitorizaron un total de 1.112 días de NE. A partir del tercer día de ingreso en UCI (979 días monitorizados) la eficacia nutricional fue óptima (aporte calórico > 80%): 92,43% (72,8-97,5). Mantenemos el objetivo calórico óptimo en el 67,9% de estos días. Observamos como causa más frecuente de interrupción de la NE los procedimientos no relacionados con la vía aérea, con un tiempo de parada de tres (1-7,25) horas. Conclusión: el aporte calórico del paciente crítico con patología traumática se logra de forma óptima a partir del día 3. Entre las causas de interrupción de la NE más frecuentes se encuentran los procedimientos no relacionados con la vía aérea

Background: the effective contribution of enteral nutrition (EN) in intensive care units (ICU) is due to multiple factors. Objectives: to determine the efficacy of caloric intake in critically ill patients with traumatic pathology receiving enteral nutrition, and to analyze cause and time of interruption of EN. Method: prospective observational study (November 2015 - August 2016). Inclusion criteria: patient with EN ≥ 48 hours and age ≥ 18 years. Exclusion criteria: patient with oral and/or parenteral nutrition. Variables: demographic, day of EN, prescribed and administered kilocalories (kcal), caloric difference, caloric objective and variables related to the interruptions of the EN. The handling of EN and interruptions are made according to the unit’s internal protocol. Kcal/patient are calculated according to the Harris-Benedict equation and multiplied by a stress factor depending on the type of trauma of the patient. Results: sixty-nine patients were included, 79.71% were men, with a median age of 46 (34-58) years. A total of 1,112 days of EN were monitored. As of the third day of admission to the ICU (979 days monitored), the nutritional efficacy was optimal (caloric intake > 80%): 92.43% (72.8-97.5). The optimal caloric goal was maintained in 67.9% of these days. The most frequent causes of interruption of NE were procedures unrelated to airway, with holding time of three (1-7.25) hours. Conclusions: at the third day, the patients with traumatic pathology received at least 80% of the prescribed caloric intake. Among the most frequent causes of interruption of EN were the procedures unrelated to airway

Adaptación de la escala ESCID para medir el dolor en pacientes críticos con daño cerebral / Adaptation of the ESCID scale to measure pain in critical patients with brain damage

OBJETIVO: evaluar la validez de constructo y la fiabilidadde la adaptación de la escala de conductas indicadoras de dolor (ESCID), para valorar el dolor en pacientes críticos con daño cerebral, no comunicativos y sometidos a ventilación mecánica. MÉTODO: sujetos: estudio multicéntrico, observacional. Se llevará a cabo en pacientes críticos con lesión cerebral adquirida, mayores de edad, sometidos a ventilación mecánica invasiva y sin capacidad de comunicación, ingresados en unidades de cuidados intensivos de cuatro hospitales universitarios de tercer nivel de la Comunidad de Madrid. En todos los sujetos se evaluará el dolor con dos instrumentos simultáneamente (ESCID-DC y videograbación). La evaluación del dolor con ESCID-DC se realizará por dos observadores independientes con resultado ciego entre ellos, ante la aplicación de dos procedimientos dolorosos (aspiración de secreciones traqueales y presión en lecho ungueal), y un procedimiento no doloroso. La medición se efectuará únicamente una vez por cada paciente y procedimiento. La medición del dolor se hará en tres momentos: cinco minutos antes, durante y 15 minutos después de cada procedimiento. Cinco minutos antes de iniciar los procedimientos y hasta diez minutos después, dos videocámaras (una enfoca el cuerpo completo, otra solo la cara) captarán imágenes y audio, para posteriormente analizar los cambios gestuales y corporales del sujeto en cada momento, y poder correlacionarlos con los ocho indicadores conductuales de la escala ESCID-DC. CONCLUSIONES: contar con una escala de este tipo con buenas propiedades psicométricas mejorará el manejo del dolor de los pacientes con daño cerebral y, por tanto, la eficacia del tratamiento

OBJECTIVE: to evaluate the validity of the concept and the reliability of the adaptation of the Scale of Behavior Indicators of Pain (ESCID) in order to assess pain in critical patients with brain damage, who are non-communicative and undergoing mechanical ventilation. METHOD: subjects: a multicenter observational study. It will be conducted on critical patients with acquired brain damage, of age, undergoing invasive mechanical ventilation, and unable to communicate, who have been admitted to intensive care units from four 3rd level University Hospitals from the Community of Madrid. Pain will be evaluated in all subjects with two instruments simultaneously (ESCID-DC and video recording). Pain evaluation through ESCID-DC will be conducted by two independent observers with blind results between them, with the application of two painful procedures (aspiration of tracheal secretions and pressure on the nail bed) and a non-painful procedure. Measurement will only be conducted once per patient and procedure. Pain measurement will be conducted at three time points: fiveminutes before, during, and fifteenminutes after each procedure. Five minutes before initiating the procedure and up to ten minutes afterwards, two video cameras will capture images and audio (one will focus on the entire body, the other one only on the face), in order to capture and subsequently analyze the gestural and body changes of the subject at each moment, and to be able to correlate them with the eight behavior indicators of the ESCID-DC scale. CONCLUSIONS: the availability of this type of scale, with good psychometric properties, will improve pain management for patients with brain damage and, therefore, treatment efficacy

Pain Assessment in Mechanically Ventilated, Noncommunicative Severe Trauma Patients.

The aim of this study was to measure pain levels in noncommunicative patients with severe trauma who required tracheal suctioning and mobilization and to determine the utility of the Behavioral Indicators of Pain Scale (ESCID) in these cases. The pain scores for the procedures were recorded on Days 1, 3, and 6 of the patients' stay in the intensive care unit. These assessments were performed at 3 moments: before, during, and after the application of the procedures. Because of the longitudinal character of the study, data were fitted into a multivariate model using the Generalized Estimating Equations method. The sample of 124 patients comprised 77.4% males and 22.6% females with an average age of 45.93 (SD = 16.43) years. A significant increase (p < .01) in the ESCID score was observed during the application of the procedures that produced similar pain levels. Kappa coefficient value obtained for interobserver agreement of ESCID scale scores during the application of care procedures at the intervals being evaluated was greater than 0.84, which should be interpreted as almost perfect. The ESCID scores increased during 2 care procedures that are frequently carried out in intensive care units and indicated that they produced similar pain levels.

Validation of the Behavioural Indicators of Pain Scale ESCID for pain assessment in non-communicative and mechanically ventilated critically ill patients: a research protocol.

AIM: To investigate the validity and reliability of the Behavioural Indicators of Pain Scale (ESCID) in medically and surgically non-communicative and mechanically ventilated critical patients. BACKGROUND: Scales based on behavioural indicators of pain are suggested to measure pain in non-communicative critically ill patients. Scales proposed thus far have a range not comparable to those used with patients who can report their pain. A scale with a 0-10 range and more behavioural indicators is proposed to improve the detection and measurement of pain. DESIGN: A multicentre prospective observational design to validate a scale-measuring instrument. METHODS: Three hundred non-communicative and mechanically ventilated critical patients from 20 different intensive care units will be observed for 5 minutes before, during and 15 minutes after three procedures: turning, tracheal suctioning and soft friction with gauze on healthy tissue. Two independent observers will assess the pain of subjects with the Behavioural Pain Scale and the ESCID scale simultaneously. Descriptive and inferential statistics will be used. Student's t-test will be used to compare components of the twos scales. Inter-rater and intrarater agreement will be investigated. The reliability scale will be measured using Cronbach's alpha. Approval date for this protocol was January 2012. DISCUSSION: A greater number of behavioural indicators in the ESCID scale than in previously validated scales, with a 0-10 score range, can improve the detection and measurement of pain in non-communicative and mechanically ventilated critical patients. Funding granted in 2011 by the Spanish Health Research Fund (PI 11/00766, Health Ministry). TRIAL REGISTRATION: Study registered with www.clinicaltrials.gov (NCT01744717).