Successful Use of Propofol After Failed Palliative Sedation in Patients With Refractory Symptoms.

Context: Propofol is a general anesthetic used in multiple clinical scenarios. Despite growing evidence supporting its use in palliative care, propofol is rarely used in palliative sedation. Reluctance toward the adoption of propofol as a sedative agent is often associated with fear of adverse events such as respiratory arrest. Objectives: We aimed to describe efficacy and safety of palliative sedation in refractory sedation with propofol using a protocol based on low, incremental dosing. Methods: A retrospective observational study featuring inpatients receiving sedative treatment with propofol in our palliative care unit in Madrid (Spain) between March 1, 2018 and February 28, 2023, following a newly developed protocol. Results: During the study period, 22 patients underwent sedation with propofol. Propofol was used successfully to control different refractory symptoms, mainly psychoexistential suffering and delirium. All patients had undergone previous failed attempts at sedation with other medications (midazolam or lemovepromazine) and presented risk factors for complicated sedation. All patients achieved satisfactory (profound) levels of sedation measured with the Ramsay Sedation Scale, but total doses varied greatly between patients. Most patients (17, 77%) received combined therapy with propofol and other sedative medications to harness synergies. The median time between start of sedation with propofol and death was 26.0 hours. No cases of apnea or death during induction were recorded. Conclusion: A protocol for palliative sedation with propofol based on low, incremental dosing, with the option of administering an initial induction bolus, shows excellent results regarding adequate levels of sedation, without observing apnea or respiratory depression. Our results promote the use of propofol to achieve palliative sedation in patients with refractory symptoms and risk factors for complicated sedation at the end of life.

Risk Factors for Therapeutic Failure and One-Year Mortality in Patients with Intramedullary Nail-Associated Infection after Trochanteric and Subtrochanteric Hip Fracture Repair.

Despite the implications of trochanteric and subtrochanteric intramedullary (IM) nail infection for patients with hip fracture, little is known about risk factors for therapeutic failure and mortality in this population. We performed a retrospective observational analysis including patients diagnosed with trochanteric and subtrochanteric IM nail infection at a Spanish academic hospital during a 10-year period, with a minimum follow-up of 22 months. Of 4044 trochanteric and subtrochanteric IM nail implants, we identified 35 cases of infection during the study period (0.87%), 17 of which were chronic infections. Patients with therapeutic failure (n = 10) presented a higher average Charlson Comorbidity Index (CCI) (5.40 vs. 4.21, p 0.015, CI 0.26-2.13) and higher rates of polymicrobial (OR 5.70, p 0.033, CI 1.14-28.33) and multidrug-resistant (OR 7.00, p 0.027, CI 1.24-39.57) infections. Upon multivariate analysis, polymicrobial infection and the presence of multidrug-resistant pathogens were identified as independent risk factors for therapeutic failure. Implant retention was associated with an increased risk of failure in chronic infection and was found to be an independent risk factor for overall one-year mortality in the multivariate analysis. Our study highlights the importance of broad-spectrum empirical antibiotics as initial treatment of trochanteric and subtrochanteric IM nail-associated infection while awaiting microbiological results. It also provides initial evidence for the importance of implant removal in chronic IM-nail infection.

Effect of an algorithm for automatic placing of standardised test order sets on low-value appointments and attendance rates at four Spanish teaching hospitals: an interrupted time series analysis.

OBJECTIVE: Reducing backlogs for elective care is a priority for healthcare systems. We conducted an interrupted time series analysis demonstrating the effect of an algorithm for placing automatic test order sets prior to first specialist appointment on avoidable follow-up appointments and attendance rates. DESIGN: Interrupted time series analysis. SETTING: 4 academic hospitals from Madrid, Spain. PARTICIPANTS: Patients referred from primary care attending 10 033 470 outpatient appointments from 16 clinical specialties during a 6-year period (1 January 2018 to 30 June 2023). INTERVENTION: An algorithm using natural language processing was launched in May 2021. Test order sets developed for 257 presenting complaints from 16 clinical specialties were placed automatically before first specialist appointments to increase rates of diagnosis and initiation of treatment with discharge back to primary care. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes included rate of diagnosis and discharge to primary care and follow-up to first appointment index. The secondary outcome was trend in 'did not attend' rates. RESULTS: Since May 2021, a total of 1 175 814 automatic test orders have been placed. Significant changes in trend of diagnosis and discharge to primary care at first appointment (p=0.005, 95% CI 0.5 to 2.9) and 'did not attend' rates (p=0.006, 95% CI -0.1 to -0.8) and an estimated attributable reduction of 11 306 avoidable follow-up appointments per month were observed. CONCLUSION: An algorithm for placing automatic standardised test order sets can reduce low-value follow-up appointments by allowing specialists to confirm diagnoses and initiate treatment at first appointment, also leading to early discharge to primary care and a reduction in 'did not attend' rates. This initiative points to an improved process for outpatient diagnosis and treatment, delivering healthcare more effectively and efficiently.

Sedación paliativa en una unidad de cuidados paliativos de un hospital de tercer nivel: ¿es habitual el sufrimiento emocional o existencial? / Palliative sedation in a palliative care unit at a tertiary hospital: is emotional or existential suffering frequent?

ANTECEDENTES Y OBJETIVOS: Hoy en día la mayor difusión de los cuidados paliativos deriva en más pacientes atendidos y, por tanto, mayor complejidad en la sintomatología a tratar. En una situación de agonía puede haber síntomas refractarios que precisan sedación. El sufrimiento emocional, psicológico o existencial como causa de sedación no está muy claro entre los diferentes profesionales. Los objetivos de este estudio son: a) conocer la frecuencia de sedación en la agonía en una unidad de cuidados paliativos (UCP), la relación con el tipo de enfermedad del paciente y el motivo que la justificaba; b) revisar los fármacos y dosis empleadas, y el tiempo hasta el fallecimiento; c) valorar la necesidad de opioides en el momento del fallecimiento; d) analizar los pacientes que precisaron sedación por sufrimiento emocional o existencial. Material y método: Estudio retrospectivo de pacientes fallecidos en la Unidad de Cuidados Paliativos del Hospital Fundación Jiménez Díaz entre el 1 diciembre de 2015 y el 30 de septiembre de 2016. Se registraron: edad, tipo de enfermedad, necesidad de sedación en la agonía, síntoma principal que justificaba la sedación, fármacos empleados, dosis empleadas en el momento del fallecimiento, tiempo entre el inicio de la sedación y el fallecimiento, tipo de opioide y dosis en el momento del fallecimiento. Se registraron comentarios de la historia clínica de los pacientes con sufrimiento emocional o existencial refractarios que precisaron una sedación, y se revisó si habían precisado valoración por psicología o psiquiatría, y quién tomaba la decisión para iniciar la sedación. Se aplicó el test exacto de Fisher para las variables dicotómicas, y la t de Student para comparar las medias en grupos independientes. Resultados: Se incluyeron 299 pacientes (edad media 75,8 años, DS 11,2). Se registraron 234 pacientes con enfermedad oncológica (78 %), y 63 pacientes (21 %) con enfermedad no oncológica. Dos pacientes presentaban criterios de ambas. Precisaron sedación en la agonía 92 pacientes (31 %): 84 oncológicos y 8 no oncológicos. Hubo diferencias estadísticamente significativas (p < 0,001) entre la necesidad de sedación en los pacientes oncológicos y no oncológicos. Los principales motivos que justificaron una sedación fueron: delirium (34 pacientes, 37 %), sufrimiento espiritual (15 pacientes, 16 %) y multifactorial (14 pacientes, 15 %). Los principales fármacos empleados en la sedación fueron midazolam (93 %) y de forma combinada midazolam con un neuroléptico (67 %). La dosis en el momento del fallecimiento fueron 40,6 mg de midazolam y 90,5 mg levomepromazina. El tiempo entre el inicio de la sedación y el fallecimiento fue de 2,4 días (DS 1,7). El 95 % de los pacientes sedados recibían opioides en el momento del fallecimiento, principalmente cloruro mórfico parenteral, con una dosis media de 41,7 mg. La edad media de los pacientes que precisaron sedación por sufrimiento emocional o existencial fue 67,07 años (DS 10,20). El 87 % de estos pacientes recibieron valoración por psicología o psiquiatría, lo que facilitó que la mayoría de ellos (80 %) dieran su consentimiento para el inicio de la sedación. CONCLUSIONES: Casi un tercio de los pacientes que fallecieron en la UCP precisaron sedación. Los pacientes oncológicos precisaron sedación con mayor frecuencia que los pacientes no oncológicos, siendo esta diferencia estadísticamente significativa. El delirium y el sufrimiento emocional fueron las causas más frecuentes que justificaron una sedación en la agonía. Es frecuente el uso combinado de benzodiacepinas y neurolépticos en una sedación en la agonía. Las dosis medias de midazolam y levomepromazina en el momento del fallecimiento en pacientes sedados fueron similares a las registradas en otros estudios. El tiempo entre el inicio de la sedación y el fallecimiento fue de pocos días. El opioide más utilizado en el momento del fallecimiento de los pacientes sedados fue cloruro mórfico parenteral, aunque no todos los pacientes los precisaron. La sedación por sufrimiento emocional o existencial refractario es habitual en las UCP, aunque genera controversia entre los diferentes profesionales. Se recomienda hacer un abordaje multidisciplinar en cuidados paliativos para mejorar la atención a los pacientes con sufrimiento psicoexistencial

BACKGROUND AND OBJECTIVES: Nowadays palliative care treatments are well recognized, and many patients are referred with intractable symptoms. Patients in agony with refractory symptoms require sedation. The use of sedation for purely emotional or existential suffering is controversial. The objectives of this study are: a) to report the frequency of sedation in agony in a Palliative Care Unit (PCU), the relationship with the underlying disease, and the symptoms motivating sedation; b) to review the medications and dosage used to implement sedation, and to quantify the time from sedation to death; c) to describe the use and dosage of opioids at the end of life; d) to analyze the cases of patients undergoing sedation due to emotional or existential suffering. MATERIAL AND METHODS: A retrospective study of deceased patients at the PCU at Fundación Jiménez Díaz Hospital between December 1, 2015 and September 30, 2016 was performed. Registered variables included age, type of underlying disease, need of sedation during agony, main symptoms motivating sedation, medication used for sedation, dosage at the time of death, time between beginning of sedation and death, use of opioids and dosage of opioids at the time of death. The medical records of patients sedated due to emotional or existential suffering were reviewed, and the psychiatric and psychological assessment, as well as the decision-making process for sedation, were described. We used data query in Access XP, and the statistical analysis software package SPSS v15.0 in order to analyze results. Fisher's exact test and Student's t-test were used to prove statistical significance

The strengths and difficulties questionnaire - dysregulation profile, non-suicidal self-injury behaviors and the mediating role of stressful life events

Non-suicidal self-injury (NSSI) behaviors are self-injurious behaviors inflicted without intending death. Literature has shown the relationship between stressful life events (SLE) and NSSI behaviors. The Strengths and Difficulties Questionnaire-Dysregulation Profile (SDQ-DP) is defined as an index of self-regulatory problems, related to higher risk for suicidal ideation and attempts in adolescents. In this study the relationship between SDQ-DP and NSSI behaviors, mediated by SLE in a clinical sample of children and adolescents is analyzed. A cross-sectional study was conducted on 239 subjects (aged from 11 to 17) to test the mediation model. SDQ-DP significantly correlates with NSSI behaviors (Wald = 6.5477, p = .0105); SDQ-DP significantly correlates with SLE (T = 5.7229, p < .001); SLE significantly correlates NSSI behaviors, and the relation remains significant whilst controlling for SDQ-DP (Wald = 4.1715, p = .041); the relation between SDQ-DP and NSSI behaviors stops being significant whilst controlling for the potential mediator (SLE) (Wald = 2.9951, p = .0835). Study of indirect effect supports the mediation model (.0585 CI [.0016, .1266]). Findings are compatible with the complete mediation scenario. These results point out the importance of self-regulatory problems in coping strategies with regards to SLE and the development of NSSI behaviors

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