Frailty in patients over 65 years of age admitted to Intensive Care Units (FRAIL-ICU). / Fragilidad en pacientes mayores de 65 años ingresados en cuidados intensivos (FRAIL-ICU).

OBJECTIVE: To estimate the prevalence of frailty in patients admitted to the Intensive Care Unit (ICU) and its impact upon ICU mortality at 1 and 6 months. DESIGN: A prospective observational cohort study was carried out. SETTING: Spanish ICU. INTERVENTION: None. PATIENTS AND METHODS: Patients≥65 years of age admitted to the ICU for>24hours. Variables were registered upon admission, and functional status was assessed by telephone calls 1 and 6 months after discharge from the ICU. MAIN STUDY VARIABLES: Age, gender, frailty (FRAIL scale), functional status (Barthel, Lawton, Clinical Dementia Rating and NUTRIC score), days of mechanical ventilation (MV), functional score (APACHE II and SOFA), ICU mortality, and mortality 1 and 6 months after ICU discharge. RESULTS: A total of 132 patients were evaluated, of which 46 were frail (34.9%). Age of the frail versus non-frail patients: 78.8±7.2 and 78.6±6.4 years, respectively (P=.43); male gender: 43.8% versus 56.3% (P=.10); SOFA score: 4.7±2.9 versus 4.6±2.9 (P=.75); MV: 33.3% versus 66.7% (P=.75); days of MV: 5.6±15 versus 4.3±8.1 (P=.57); ICU mortality 13% versus 6% (P = .14), mortality at 1 month 24% versus 8% (P = .01), mortality 6 months 32% versus 15% (P = .03). Frailty is associated with mortality at one month (OR = 3.5, P <.05, 95% CI (1.22-10.03) and at 6 months after discharge from the ICU (OR = 2.62, P <.05, 95% CI (1.04-6.56). CONCLUSIONS: Frailty was present in 35% of the patients admitted to the ICU, and was associated with mortality.

Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients. / Recomendaciones para el tratamiento de los pacientes críticos de los Grupos de Trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC).

The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.

Estudio multicéntrico sobre la asociación entre variables relacionadas con la resucitación y la mortalidad en la sepsis grave / Multicenter study on the association between variables related to resuscitation and mortality in severe sepsis

Objetivo. Estimar la asociación entre parámetros indicativos de retraso y fracaso en la resucitación con la mortalidad en pacientes con sepsis grave, y describir el patrón de uso de fármacos vasoactivos en pacientes con shock séptico. Diseño. Estudio prospectivo de cohortes. Ámbito. Siete Unidades de Cuidados Intensivos (UCI) polivalentes en España. Pacientes y método. Enfermos diagnosticados de sepsis grave ingresados de forma consecutiva en las UCI participantes durante un período de un mes. Variables de interés principales. Se recogieron variables relacionadas con intervenciones de resucitación, persistencia de un estado de resucitación insuficiente, disfunción de órganos, uso de fármacos vasoactivos y mortalidad en UCI. Resultados. La mortalidad global fue del 40%. En comparación con los enfermos que sobreviven, los que fallecen presentan mayor puntuación Simplified Acute Physiology Score II (SAPS II) (p = 0,02), mayor número de órganos disfuncionantes (p = 0,01), y menor escala de coma de Glasgow (GCS) en el momento del ingreso (p = 0,001). La duración de la oliguria y de la hipotensión, así como la duración de la necesidad de administración de fármacos presores, se relacionaron de forma univariante con el pronóstico. El patrón de uso de fármacos vasoactivos más prevalente fue noradrenalina sola (60% de los enfermos con hipotensión) o en combinación con dopamina a dosis inferiores a 5 µg/kg/min (32% de los enfermos con hipotensión).Conclusión. No sólo parámetros indicativos de hipoperfusión tisular presentes al ingreso, sino también la duración de la hipoperfusión tisular y del shock, son variables que se relacionan con la mortalidad en la sepsis grave. Estos resultados apoyan el concepto de que la resucitación y la aplicación de medidas terapéuticas de forma precoz que eviten o disminuyan la duración de la hipoperfusión tisular pueden mejorar el pronóstico de la sepsis grave

Objective. To establish the association between parameters indicative of delay and failure in the resuscitation and mortality in patients with severe sepsis, and to describe the pattern of use of vasoactive drugs in patients with septic shock. Design. Prospective cohorts study. Context. Seven polyvalent Intensive Care Units (ICU) in Spain. Patients and method. Patients with severe sepsis admitted consecutively in the participating UCIs over 1 month. Primary endpoints. Variables related to resuscitation interventions, persistence of a state of insufficient resuscitation, organs dysfunction, use of vasoactive drugs, and mortality in ICU were evaluated. Results. Global mortality was 40%. In comparison with patients who survive, those which die show greater SAPS II scoring (p = 0.02), greater number of organs with failure (p = 0.01), and lower GCS scores at admission (p = 0.001). Oliguria and hypotension lenght, as well as the period of vasopressor drugs administration were univariately related to prognosis. The more prevalent pattern of vasoactive drugs use was that of norepinephrine alone (60% of patients with hypotension) or that of norepinephrine in combination with dopamine with doses lower than 5 µg/kg/ min (32% of patients with hypotension). Conclusion. In severe sepsis not only indicative parameters of tissue hypoperfusion at admission are variables related to mortality, but also the lenght of tissue hypoperfusion and shock. These results support the concept that early application of resuscitation and therapeutic measures that avoid or diminish the lenght of tissue hypoperfusion can improve the prognosis of severe sepsis

Actualización en sepsis. Introducción / Sepsis update. Introduction

No disponible

Oxigenación tisular y sepsis / Tissue oxygenation and sepsis

La función del sistema cardiovascular es proporcionar continuamente nutrientes y oxígeno a los tejidos para el mantenimiento de la función celular normal. La disfunción celular en condiciones de shock se explica, al menos en parte, por la presencia de hipoperfusión e hipoxia tisulares (hipoxia por bajo flujo, disminución de la disponibilidad de oxígeno a nivel mitocondrial). En condiciones de shock resucitado, el efecto de ciertos compuestos (como el peroxinitrito, formado a partir del anión superóxido y del óxido nítrico, ambos formados en exceso en el shock y la sepsis) sobre la respiración mitocondrial explica la disfunción celular (hipoxia citopática, causada por un empeoramiento en la capacidad de utilizar el oxígeno más que por una disminución en su disponibilidad). La monitorización de la oxigenación tisular sistémica puede hacerse mediante el estudio de la relación entre el consumo (VO2) y el transporte (TO2) de oxígeno. Una relación dependiente entre ambas variables (aumento del VO2 cuando se eleva el TO2) indica, asumiendo que la demanda tisular de oxígeno no varía, una situación de hipoxia tisular. La monitorización del lactato y de la acidosis durante las fases agudas del shock también permite determinar la persistencia de hipoxia tisular. La hiperlactatemia en el shock resucitado se debe a una fisiopatología más compleja (por ejemplo, aumento de la producción de lactato en ausencia de anaerobiosis y disminución del metabolismo hepático). Estudios en modelos animales y en pacientes con sepsis han demostrado que pueden observarse signos de hipoxia tisular regional en ausencia de signos sistémicos. La elevación de la pCO2 tisular o venosa permite un abordaje del diagnóstico de hipoxia a nivel tisular. Modelos teóricos apoyan el concepto de que la hipercarbia tisular (medida, por ejemplo, mediante tonometría intragástrica) se explica mejor por disminución del flujo sanguíneo que por hipoxia (disminución de la disponibilidad de oxígeno a nivel mitocondrial). Diversos metaanálisis han demostrado que el tratamiento del enfermo con shock dirigido a aumentar el gasto cardíaco mejora la supervivencia en enfermos quirúrgicos y traumatizados (aquellos enfermos en los que el tratamiento se puede iniciar de forma precoz tras el insulto), mientras que no cambia el pronóstico en enfermos médicos (aquellos en los que la duración del insulto es desconocida, y el tratamiento se inicia probablemente transcurrido largo tiempo desde el momento del insulto). Un ensayo clínico reciente ha demostrado que la atención precoz a la restauración del balance entre el consumo y el transporte de oxígeno como criterio terapéutico, simplemente midiendo la saturación venosa central de oxígeno, mejora marcadamente la supervivencia de enfermos con shock grave

The function of cardiovascular system is to provide continually nutrients and oxygen to tissues for normal cellular function maintenance. Cellular dysfunction in shock conditions is explained, at least partly, by the presence of tissue hypoperfusion and hypoxia (low flow hypoxia, reduction of oxygen availability in mitochondria). In recurrent shock conditions, the effect of certain compounds (as peroxynitrite, formed from anion superoxide and nitric oxide, both formed in excess in shock and sepsis) on mitochondrial breathing explains the cellular dysfunction (cytopathic hypoxia, due to a worsening in the capacity for oxygen utilization not to a reduction in its availability). Monitoring of systemic tissue oxygenation can be carried out through the study of the relationship between oxygen consumption (VO2) and transportation (TO2). Assuming that tissue oxygen demands does not show variations, the existence of a dependency relationship between two variables (increment of VO2 when TO2 increases) represents a situation of tissue hypoxia. Monitoring of lactate and acidosis during shock acute phases also makes possible establish the persistence of tissue hypoxia. Hyperlactacidemia in recurrent shock has more complex physiopathology (e.g., increase of lactate production in absence of anaerobiosis and reduction of liver metabolism). Studies in animal models and in patients with sepsis have showed that signs of regional tissue hypoxia can be observed in the absence of systemic signs of hypoxia. The elevation of tissue or venous pCO2 makes possible an approach of hypoxia diagnosis at tissue level. Theoretical models support the concept that tissue hypercarbia (measured, for example, through intragastric tonometry) is explained better by reduction of the blood flow than by hypoxia (reduction of oxygen availability at mitochondrial level). Some meta-analyses have demonstrated that treatment of shock patient to increase cardiac output improves the survival in surgical and injured patients (those patients in which the treatment can be initiated early after the injury), while the increase of cardiac output does not improve the prognosis of patients with medical conditions (those in which the duration of the injury is unknown, and the treatment probably begins long time since the moment of the injury). A recent clinical trial has showed that early restoration of balance between oxygen consumption and transport as therapeutic criterion (simply measuring central venous oxygen saturation) improves markedly the survival in patients with severe shock

[Analysis of costs and cost per diagnostic group of critically burned patients in the Spanish public health care system]. / Análisis de la financiación y del coste por proceso de los enfermos quemados críticos en el sistema público de salud español.

The financing of the National Institute of Health (INSALUD) of Spain will soon be based on Diagnosis-Related Groups (DRGs). Knowledge of the real cost of different DRGs is fundamental to ensure adequate financing and to establish criteria for comparisons between centers. Our public health system has no data on the real cost of critically burned patients and their DRGs. This retrospective descriptive study was carried out in a Major Burns Unit (MBU) and included all patients admitted between January and December 1996. Real total cost of the care of critical burned patients, cost per patient, and cost per DRG related with critical burn patients were calculated for the study period. Financing by Weighed Care Units (WCU) was compared with real costs. The total cost of the care of critical burn patients was 346,298,872 Spanish pesetas and the cost per patient was 4,439,729 ptas. WCU financing was 322,021,616 ptas and 4,128,482 ptas, respectively. The DRG with the highest total cost was 458 (non-extensive burns with skin grafts, 106,372,016 ptas). The DRG with the highest average cost was 472 (extensive burns with surgical procedure, 5,401,119 ptas). The DRG with the highest cost per stay was 457 (extensive burns without surgical procedure, 404,683 ptas). For the first time in Spain, the cost of DRGs related with critical burn patients is described. This information is necessary for DRG-based allocation of funds and for establishing criteria to compare centers. The real cost of critical burn patients exceeded WCU financing.

[Nursing care for patients with toxic epidermal necrolysis]. / Cuidados de enfermería en el paciente con necrólisis epidérmica tóxica.

Toxic Epidermal Necrolysis (TEN) is a severe skin disorder characterised by separation of the dermal-epidermal junction, as it is observed in second degree superficial burns, and it may also involve any mucosal surface area (otic, buccal, conjunctival, respiratory, genital). This condition is generally induced by the ingestion of drugs, particularly certain antibiotics, nonsteroidal antiinflammatory drugs, and antiepileptic drugs. Mortality has decreased over the last decades, from 80% to about 25% in recent series. This improvement in survival rate has been related to early diagnosis, management in specialized burn units, proper immunosuppressive treatment and intensive specialised nursing care. The main nursing diagnosis include abnormalities in the skin and mucose membranes integrity, risk of infection, loss of blood volume, risk of hypothermia, acute pain, upper airway insufficiency and anxiety. We here review the nursing care of patients with TEN. We emphasize the daily skin and mucose membranes care, and the prevention of conjunctival sinequiae, including daily conjunctival cleaning and debridement of necrotic tissue and fibrin debris using a handle needle.

[Changes in tissue oxygen extraction in patients with acute respiratory insufficiency]. / Alteraciones en la extracción hística de oxígeno en pacientes con insuficiencia respiratoria aguda.

We analyzed the tissue oxygen extraction in 25 patients with acute respiratory failure. Fourteen met the clinical criteria for the adult respiratory distress syndrome (ARDS). The 11 remaining patients had acute respiratory failure with causes different from ARDS. In all cases the changes in the oxygen extraction ratio (O2ER) and in the oxygen consumption (VO2) were evaluated after changing oxygen availability (O2A) with positive end-expiratory pressure (PEEP) and dobutamine infusion. The patients with ARDS showed a change in VO2 parallel to O2A changes, with a significant correlation (r = 0.85); however, no changes were found in O2ER (r = 18). In the patients without ARDS, the changes in O2A did not modify the VO2 (r = 0.02) but there was a significant inverse relationship between DO2 and O2ER (r = -0.70). These findings suggest an abnormal regulation of tissue oxygen extraction and an abnormal dependence of VO2 on O2A in cases with ARDS. Dobutamine therapy, in addition to inotropic effects, could improve a situation of hidden hypoxia, as it is a vasodilator that might act on microvasculature.