[Validation of the modified IMPROVE scale in patients undergoing primary total hip arthroplasty]. / Validación de la escala IMPROVE modificada en pacientes sometidos a artroplastía total de cadera primaria.

INTRODUCTION: Major orthopedic surgery such as total hip arthroplasty (THA) is associated with an increased risk of postoperative complications. Candidates for THA are often older adults, with comorbidities that increase the risk of major bleeding, the IMPROVE scale has independent actors on the risk of bleeding according to the characteristics of the patients at hospital admission. It foresees the possibility of hemorrhage and the need for blood transfusion, being support in decision-making in the planning of a safe THA with the provision of the necessary resources. OBJECTIVE: To evaluate the sensitivity, validity and reliability of the modified IMPROVE scale in patients undergoing primary total hip arthroplasty. MATERIAL AND METHODS: Study of processes with a sample of 131 patients undergoing primary THA, in the period from January 01, 2018 to July 01, 2018. RESULTS: The scale presents good reliability, as for the performance of the scale, a good sensitivity was obtained, classifying 96.9% of the patients correctly; which is suitable for the type of scale. CONCLUSIONS: The modified IMPROVE scale is a discretely adequate and useful tool for the prognosis of bleeding risk in patients who undergo THA, compared with other assessment scales developed in other geographical areas. It is recommended to continue with the study of risk factors for major bleeding in this specific population.

INTRODUCCIÓN: La cirugía ortopédica mayor, como la artroplastía total de cadera (ATC), se asocia con mayor riesgo de complicaciones postoperatorias. Los candidatos a ATC con frecuencia son adultos mayores, con comorbilidades que aumentan el riesgo de hemorragia mayor. La escala IMPROVE tiene factores independientes sobre el riesgo de sangrado según las características de los pacientes al ingreso hospitalario, prevé la posibilidad de hemorragia y la necesidad de transfusión sanguínea, siendo apoyo en la toma de decisiones en la planeación de ATC seguras con la probabilidad de prever los recursos necesarios. OBJETIVO: Evaluar la sensibilidad, validez y confiabilidad de la escala IMPROVE modificada en los pacientes sometidos a artroplastía total de cadera primaria. MATERIAL Y MÉTODOS: Estudio de procesos con una muestra de 131 pacientes sometidos a ATC primaria, en el período del 01 de Enero al 01 de Julio de 2018. RESULTADOS: La escala presenta una buena confiabilidad, en cuanto al rendimiento se obtuvo una buena sensibilidad, clasificando al 96.9% de los pacientes correctamente, lo cual es adecuado para el tipo de escala. CONCLUSIONES: La escala IMPROVE modificada es una herramienta discretamente adecuada y útil para el pronóstico del riesgo hemorrágico en pacientes que se someten a una ATC primaria comparada con otras escalas de valoración desarrolladas en otras zonas geográficas. Se recomienda seguir con el estudio de los factores de riesgo de sangrado mayor en esta población en específico.

Evaluating the Impact of Performance Improvement Initiatives on Transplant Center Reporting Compliance and Patient Follow-Up After Living Kidney Donation.

With the changing demographics of the living donor population and increased regulatory oversight, it is important that transplant centers report outcomes accurately. The aim of our retrospective cohort study of 312 living donors who underwent nephrectomy between 2008 and 2013 was to evaluate the impact of living donor program performance improvement initiatives on: (i) transplant center program reporting compliance; (ii) patient compliance with postdonation follow-up and its associated factors; and (iii) overall financial costs to the transplant center. The effect of the initiatives (donation eras 2008-2010 and 2011-2013) on compliance at key reporting points (6 months, 1 year, 2 years) was analyzed using correlation coefficients, χ(2) and Fisher's exact tests. Multivariable logistic regression models tested the initiatives' effect on the likelihood of patient follow-up. The initiatives were associated with significant improvement in form reporting compliance (r ≥ 0.862, p ≤ 0.027; 1 and 2 year Fisher's Exact p ≤ 0.002) and patient follow-up (χ(2) p ≤ 0.009) with acceptable transplant center costs. Multivariable analyses demonstrated that donation era was consistently and significantly (p < 0.001) associated with increased likelihood of postdonation patient follow-up. Institution of performance improvement initiatives with dedicated program resources is financially feasible and leads to more accurate and complete form reporting and improved patient follow-up after nephrectomy.

Consensus conference on best practices in live kidney donation: recommendations to optimize education, access, and care.

Live donor kidney transplantation is the best treatment option for most patients with late-stage chronic kidney disease; however, the rate of living kidney donation has declined in the United States. A consensus conference was held June 5-6, 2014 to identify best practices and knowledge gaps pertaining to live donor kidney transplantation and living kidney donation. Transplant professionals, patients, and other key stakeholders discussed processes for educating transplant candidates and potential living donors about living kidney donation; efficiencies in the living donor evaluation process; disparities in living donation; and financial and systemic barriers to living donation. We summarize the consensus recommendations for best practices in these educational and clinical domains, future research priorities, and possible public policy initiatives to remove barriers to living kidney donation.

Factores clínicos asociados al éxito de la ventilación asistida proporcional en la fase aguda del paciente crítico: estudio piloto / Clinical factors associated with success of proportional assist ventilation in the acute phase of critical illness: Pilot study

RAZÓN: La ventilación asistida proporcional (PAV) + genera una presión en la vía aérea que depende del esfuerzo inspiratorio del paciente, ajustando automáticamente el flujo y volumen generados según los cambios en la mecánica respiratoria. Pretendimos analizar los factores clínicos asociados al éxito de la PAV+ como primera línea de tratamiento en la fase aguda del paciente crítico. MÉTODOS: Estudio prospectivo, de cohortes. En todo paciente con ventilación mecánica estimada > 24h se sustituía la ventilación asistida controlada por PAV+ en cuanto recuperaban la actividad respiratoria espontánea. La PAV+ se programó para generar una asistencia elevada. Se compararon los pacientes en que la PAV+ se aplicó con éxito frente a aquellos en los que fracasó. RESULTADOS: PAV+ fue un éxito en 12 pacientes (63%) y fracasó en 7 (37%) debido a taquipnea (n = 4), hipercapnia (n = 2) y acidosis metabólica (n=1), aunque no llegó a demostrarse estadísticamente. Los parámetros clínicos fueron similares para ambos grupos. El día de ingreso, el trabajo total respiratorio (WOBTOT) fue inferior en el grupo de éxito (WOBTOT: 0,95 [0,8-1,35] vs. 1,6 [1,4-1,8] J/L; p < 0,007). El área bajo la curva ROC fue 0,89 ± 0,08 para WOBTOT. El mejor punto de corte para predecir el éxito de la PAV+ fue un WOBTOT < 1,4 J/L (sensibilidad: 1 [0,7-1], especificidad: 0,6 [0,4-0,6], VPP: 0,7 [0,5-0,7], y VPN: 1 [0,6-1]). CONCLUSIÓN: PAV+ fue una técnica aplicable como primera línea de tratamiento en el 63% de los pacientes, fundamentalmente en aquellos sin deterioro excesivo del trabajo respiratorio. Las variables clínicas asociadas al fracaso fueron la taquipnea y la hipercapnia, aunque sin significación estadística

REASON: Proportional assist ventilation plus (PAV+) applies pressure depending on the patient's inspiratory effort, automatically adjusting flow and volume assist to changes in respiratory mechanics. We aimed to assess the clinical factors associated with the success of PAV+ as first-line support in the acute phase of critical illness. METHODS: A prospective cohort study was carried out. Mechanically ventilated patients > 24h were switched from assist-control ventilation to PAV+ as soon as they regained spontaneous breathing activity. PAV+ was set to deliver the highest assistance. We compared patients in whom PAV+ succeeded versus those in whom it failed. RESULTS: PAV+ succeeded in 12 (63%) patients, but failed in 7 (37%) due to tachypnea (n = 4), hypercapnia (n = 2), and metabolic acidosis (n = 1), but without statistical significance. Both groups had similar clinical parameters. On the day of inclusion, total work of breathing per breath was lower in the successful PAV+ group (WOBTOT: 0.95 [0.8-1.35] vs. 1.6 [1.4-1.8] J/L; P < .007). The area under the ROC curve was 0.89 ± 0.08 for WOBTOT. The best cut-off for predicting PAV+ success was WOBTOT < 1.4J/L (sensitivity: 1 [0.7-1], specificity: 0.6 [0.4-0.6], PPV: 0.7 [0.5-0.7], and NPV: 1 [0.6-1]). CONCLUSION: PAV+ proved feasible as first-line ventilatory support in 63% of the patients, mostly in individuals without extreme derangements in WOBTOT. Tachypnea and hypercapnia were the clinical factors associated with failure, though statistical significance was not reached

Clinical factors associated with success of proportional assist ventilation in the acute phase of critical illness: pilot study.

REASON: Proportional assist ventilation plus (PAV+) applies pressure depending on the patient's inspiratory effort, automatically adjusting flow and volume assist to changes in respiratory mechanics. We aimed to assess the clinical factors associated with the success of PAV+ as first-line support in the acute phase of critical illness. METHODS: A prospective cohort study was carried out. Mechanically ventilated patients>24h were switched from assist-control ventilation to PAV+ as soon as they regained spontaneous breathing activity. PAV+ was set to deliver the highest assistance. We compared patients in whom PAV+ succeeded versus those in whom it failed. RESULTS: PAV+ succeeded in 12 (63%) patients, but failed in 7 (37%) due to tachypnea (n=4), hypercapnia (n=2), and metabolic acidosis (n=1), but without statistical significance. Both groups had similar clinical parameters. On the day of inclusion, total work of breathing per breath was lower in the successful PAV+ group (WOBTOT: 0.95 [0.8-1.35] vs. 1.6 [1.4-1.8] J/L; P<.007). The area under the ROC curve was 0.89 ± 0.08 for WOBTOT. The best cut-off for predicting PAV+ success was WOBTOT<1.4 J/L (sensitivity: 1 [0.7-1], specificity: 0.6 [0.4-0.6], PPV: 0.7 [0.5-0.7], and NPV: 1 [0.6-1]). CONCLUSION: PAV+ proved feasible as first-line ventilatory support in 63% of the patients, mostly in individuals without extreme derangements in WOBTOT. Tachypnea and hypercapnia were the clinical factors associated with failure, though statistical significance was not reached.

Dynamic challenges inhibiting optimal adoption of kidney paired donation: findings of a consensus conference.

While kidney paired donation (KPD) enables the utilization of living donor kidneys from healthy and willing donors incompatible with their intended recipients, the strategy poses complex challenges that have limited its adoption in United States and Canada. A consensus conference was convened March 29-30, 2012 to address the dynamic challenges and complexities of KPD that inhibit optimal implementation. Stakeholders considered donor evaluation and care, histocompatibility testing, allocation algorithms, financing, geographic challenges and implementation strategies with the goal to safely maximize KPD at every transplant center. Best practices, knowledge gaps and research goals were identified and summarized in this document.

A web-based application for initial screening of living kidney donors: development, implementation and evaluation.

Most centers utilize phone or written surveys to screen candidates who self-refer to be living kidney donors. To increase efficiency and reduce resource utilization, we developed a web-based application to screen kidney donor candidates. The aim of this study was to evaluate the use of this web-based application. Method and time of referral were tabulated and descriptive statistics summarized demographic characteristics. Time series analyses evaluated use over time. Between January 1, 2011 and March 31, 2012, 1200 candidates self-referred to be living kidney donors at our center. Eight hundred one candidates (67%) completed the web-based survey and 399 (33%) completed a phone survey. Thirty-nine percent of donors accessed the application on nights and weekends. Postimplementation of the web-based application, there was a statistically significant increase (p < 0.001) in the number of self-referrals via the web-based application as opposed to telephone contact. Also, there was a significant increase (p = 0.025) in the total number of self-referrals post-implementation from 61 to 116 per month. An interactive web-based application is an effective strategy for the initial screening of donor candidates. The web-based application increased the ability to interface with donors, process them efficiently and ultimately increased donor self-referral at our center.

Call to develop a standard acquisition charge model for kidney paired donation.

We propose a Medicare Demonstration Project to develop a standard acquisition charge for kidney paired donation. A new payment strategy is required because Medicare and commercial insurance companies may not directly pay living donor costs intended to lead to transplantation of a beneficiary of a different insurance provider. Until the 1970s, when organ procurement organizations were empowered to serve as financial intermediaries to pay the upfront recovery expenses for deceased donor kidneys before knowing the identity of the recipient, there existed similar limitations in the recovery and placement of deceased donor organs. Analogous to the recovery of deceased donor kidneys, kidney paired donation requires the evaluation of living donors before identifying their recipient. Tissue typing, crossmatching and transportation of living donors or their kidneys represent additional financial barriers. Finally, the administrative expenses of the organizations that identify and coordinate kidney paired donation transplantation require reimbursement akin to that necessary for organ procurement organizations. To expand access to kidney paired donation for more patients, we propose a model to reimburse paired donation expenses analogous to the proven strategy used for over 30 years to pay for deceased donor solid organ transplantation in America.

Acute physiologic effects of a stepwise recruitment maneuver in acute respiratory distress syndrome.

BACKGROUND: Stepwise recruitment maneuvers (RM) applied with high airway pressures may optimize lung recruitment, but this kind of intervention may lead to widely heterogeneous responses with possible side effects. To assess the clinical impact of these maneuvers, we performed a stepwise maximal-recruitment strategy superimposed on routine mechanical ventilation. METHODS: We studied 13 adults with early-phase acute lung injury/acute respiratory distress syndrome (ALI/ARDS). We used pressure-control ventilation at an FiO(2) of 1. Starting from a Pplat/positive end-expiratory pressure (PEEP) of 40/25, we sequentially increased airway pressure in 5 cmH(2)O steps until a PaO(2)/FiO(2) of 350 mmHg or a Pplat/PEEP of 60/40 cmH(2)O was reached. The PEEP was then progressively reduced until the PaO(2) decreased by more than 10% of the maximum PaO(2); the PEEP was subsequently set to 2 cmH(2)O above this level. An intra-arterial catheter continuously displayed blood gas measures. The respiratory mechanics and hemodynamics were monitored at each phase and during the two-hour follow-up. RESULTS: Two hours after the RM, the PaO(2)/FiO(2) was higher than at baseline (187±102 versus 339±136 mmHg, P<0.001). In 8 patients, the PEEP increased from 12±3 cmH(2)O to 15±4 cmH(2)O after the RM (P<0.001). In the other five, it closely mirrored the basal PEEP. Seven patients did not reach the 350-mmHg PaO(2) target. The respiratory system compliance decreased in seven patients. The RM was discontinued due to severe complications in four patients. CONCLUSION: Although stepwise-RM improves oxygenation, it has a heterogeneous impact on respiratory mechanics and may cause adverse hemodynamic effects and transient hypoxemia. If the use of this kind of RM is considered, it should be adapted to individual patient needs, applied carefully and closely monitored.

¿Influyen los antecedentes de consumo de sustancias adictivas en la necesidad de sedación del paciente crítico? / Does a history of substance abuse influence sedation requirements incritically-illpatients?

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[Near-infrared spectroscopy in the postanesthesia recovery care unit: noninvasive monitoring of peripheral perfusion]. / Espectroscopia cercana al infrarrojo en la reanimación: medición no invasiva de la perfusión periférica.

Clinical signs of recovery, such as blood pressure or heart rate, do not accurately reflect the perfusion of organs and tissues in patients in critical condition. Of the various means for monitoring perfusion, regional monitors are the most sensitive. Near-infrared spectroscopy (NIRS), which analyzes infrared light detected after it has passed through red blood cells in tissues, provides a measure of oxygen saturation that is the most appropriate method for clinical situations. In patients with sepsis or multiple injuries, tissue oxygen saturation can be useful as an early indicator of shock, as a marker of recovery or need for transfusion, or as a prognostic factor. In spite of widespread interest in NIRS, however, there are gaps to fill in our understanding of clinical signs and physiology in relation to this technique before peripheral tissue monitoring can become routine in postanesthesia recovery care units.

Espectroscopia cercana al infrarrojo en la reanimación: medición no invasiva de la perfusión periférica / Near-infrared spectroscopy in the postanesthesia recovery care unit: noninvasive monitoring of peripheral perfusion

Los parámetros clínicos de reanimación como la presiónarterial, la frecuencia cardíaca etc. son insuficientespara garantizar la correcta perfusión de los tejidos yórganos del paciente en estado crítico. Diferentes monitoresevalúan la correcta perfusión, de ellos los más sensiblesson los monitores de perfusión regional. Las tecnologíaNIRS (Near Infrared Spectroscopy), basada en elanálisis de la luz infrarroja recaptada tras incidir sobrelas moléculas de hemoglobina del tejido y así determinarsu saturación, destaca por ser la técnica regional másadecuada para uso clínico. En el paciente politraumatizadoy séptico la saturación tisular de O2 puede resultarútil en la detección precoz del shock, como parámetrodiana de la reanimación, como marcador transfusional ycomo factor pronóstico. A pesar del interés por la tecnologíaNIRS se deberán realizar estudios que llenenlagunas existentes a nivel clínico y fisiológico para quela monitorización de la perfusión tisular se convierta enmonitor rutinario en nuestras áreas de reanimación(AU)

Clinical signs of recovery, such as blood pressure orheart rate, do not accurately reflect the perfusion oforgans and tissues in patients in critical condition. Of thevarious means for monitoring perfusion, regionalmonitors are the most sensitive. Near-infraredspectroscopy (NIRS), which analyzes infrared lightdetected after it has passed through red blood cells intissues, provides a measure of oxygen saturation that isthe most appropriate method for clinical situations. Inpatients with sepsis or multiple injuries, tissue oxygensaturation can be useful as an early indicator of shock, asa marker of recovery or need for transfusion, or as aprognostic factor. In spite of widespread interest in NIRS,however, there are gaps to fill in our understanding ofclinical signs and physiology in relation to this techniquebefore peripheral tissue monitoring can become routinein postanesthesia recovery care units(AU)

Effects of hydroxyethyl starch administration on renal function in critically ill patients.

BACKGROUND: The influence of hydroxyethyl starch (HES) solutions on renal function is controversial. We investigated the effect of HES administration on renal function in critically ill patients enrolled in a large multicentre observational European study. METHODS: All adult patients admitted to the 198 participating intensive care units (ICUs) during a 15-day period were enrolled. Prospectively collected data included daily fluid administration, urine output, sequential organ failure assessment (SOFA) score, serum creatinine levels, and the need for renal replacement therapy (RRT) during the ICU stay. RESULTS: Of 3147 patients, 1075 (34%) received HES. Patients who received HES were older [mean (SD): 62 (SD 17) vs 60 (18) years, P = 0.022], more likely to be surgical admissions, had a higher incidence of haematological malignancy and heart failure, higher SAPS II [40.0 (17.0) vs 34.7 (16.9), P < 0.001] and SOFA [6.2 (3.7) vs 5.0 (3.9), P < 0.001] scores, and less likely to be receiving RRT (2 vs 4%, P < 0.001) than those who did not receive HES. The renal SOFA score increased significantly over the ICU stay independent of the type of fluid administered. Although more patients who received HES needed RRT than non-HES patients (11 vs 9%, P = 0.006), HES administration was not associated with an increased risk for subsequent RRT in a multivariable analysis [odds ratio (OR): 0.417, 95% confidence interval (CI): 0.05-3.27, P = 0.406]. Sepsis (OR: 2.03, 95% CI: 1.37-3.02, P < 0.001), cardiovascular failure (OR: 6.88, 95% CI: 4.49-10.56, P < 0.001), haematological cancer (OR: 2.83, 95% CI: 1.28-6.25, P = 0.01), and baseline renal SOFA scores > 1 (P < 0.01 for renal SOFA 2, 3, and 4 with renal SOFA = 0 as a reference) were all associated with a higher need for RRT. CONCLUSIONS: In this observational study, haematological cancer, the presence of sepsis, cardiovascular failure, and baseline renal function as assessed by the SOFA score were independent risk factors for the subsequent need for RRT in the ICU. The administration of HES had no influence on renal function or the need for RRT in the ICU.

Validez de los criterios clínicos en el diagnóstico del síndrome de distrés respiratorio del adulto / Validity of clinical criteria in the diagnosis of the adult respiratory distress syndrome

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Liver transplantation in high-risk patients: hepatopulmonary syndrome and portopulmonary hypertension.

Two pulmonary vascular disorders, considered mutually exclusive, may be present in candidates for orthotopic liver transplantation (OLT). On the one hand, hepatopulmonary syndrome (HPS), with a prevalence about 20% in end-stage liver disease, is characterized by pulmonary vascular dilatation and abnormal gas exchange. On the other hand, portopulmonary hypertension (POPH), a process defined by pulmonary hypertension associated with portal hypertension, is less common than HPS (4%). These entities have very distinct clinical implications; whereas HPS is clinically characterized by respiratory symptoms that evolve to severe hypoxemia, patients with POPH are commonly asymptomatic, frequently diagnosed in the setting of OLT, and the symptoms appear when there is hemodynamic compromise. The pathogenesis of both entities is a putative mechanism, the imbalance of vasoactive substances in pulmonary vessels. The role of OLT to reverse these vascular disorders is controversial, although complete resolution of HPS and, less frequently, POPH following OLT has been reported. The recognition that the presence of both HPS and POPH is an important cause of morbidity and mortality among recipients of OLT has resulted in a change in the policy to select OLT candidates. Accurate identification of patients with pulmonary vascular disorders associated with liver disease should be the first step in the management of OLT candidates. Because the determinants of the prognosis of OLT in the setting of these pulmonary vascular changes have not been well established, an accurate cardiopulmonary evaluation with careful assessment of pulmonary gas exchange (in HPS) and right ventricular function (in POPH) of potential OLT recipients is mandatory before the procedure.

Recruitment manoeuvres in acute lung injury/acute respiratory distress syndrome.

Acute respiratory distress syndrome/acute lung injury is characterised by profound hypoxaemia due to a permeability pulmonary oedema. In this setting, recruitment manoeuvres (RMs) can be a useful tool as adjuncts to lung protective ventilatory strategies to prevent cyclic alveolar stress and avoid alveolar collapse. Many experimental and physiological studies have discussed the use of RMs but only a few heterogeneous clinical experiences have demonstrated the beneficial and deleterious effects that can occur using these manoeuvres. Besides, a lot of questions remain to be answered to find the best way to perform optimal RMs. Further experimental and clinical trials are needed to understand the potential beneficial effects of recruitment manoeuvres when using a protective mechanical ventilation strategy. This paper is a general review of experimental works that support application of recruitment manoeuvres emphasising the clinical studies that have been published to date in acute respiratory distress syndrome patients.

Mechanisms of pulmonary gas exchange improvement during a protective ventilatory strategy in acute respiratory distress syndrome.

To investigate the mechanisms underlying improvement of arterial oxygenation during a protective ventilatory strategy (PVS) in early acute respiratory distress syndrome (ARDS), we studied eight patients during volume-controlled mechanical ventilation, keeping respiratory rate and fraction of inspired oxygen (FI(O(2))) (0.82 +/- 0.20) unchanged: (1) at baseline (tidal volume [VT] 10 to 12 ml x kg(-1); positive end-expiratory pressure [PEEP] 8 to 10 cm H(2)O); (2) during PVS (PEEP 2 cm H(2)O above the low inflexion point (P(FLEX)) and VT of 5 to 7 ml x kg(-1)); and (3) post-PVS, back to baseline conditions. Inert gas measurements were done after 30 min in each ventilatory modality. During PVS, Pa(O(2)) increased significantly from 93 +/- 27 to 166 +/- 77 mm Hg (p < 0.008) and Pa(CO(2)) rose from 39 +/- 7 to 57 +/- 11 mm Hg (p < 0.0002) because of the decrease in minute ventilation (V E) (-3.6 L x min(-1)) (p < 0.005). Both heart rate (HR, +13 min(-1)) (p < 0.002) and cardiac output (Q, +1.2 L x min(-1)) (p < 0.05) increased. Static respiratory system linear compliance increased from 36 +/- 14 to 44 +/- 16 ml. cm H(2)O(-1) (p < 0.0002). PVS provoked recruitment of previously collapsed alveoli and redistribution of pulmonary blood flow from nonventilated alveoli to normal lung. Despite the increase in Q, intrapulmonary shunt fell from 39 +/- 15% to 31 +/- 11% (p < 0.04). We conclude that the decrease in intrapulmonary shunt owing to alveolar recruitment remains the pivotal mechanism to explain improvement of arterial oxygenation during this PVS.

[Use of the electroencephalographic spectral edge frequency 90 to monitor sedation of chronically ill patients]. / Utilización del límite espectral 90% (LE90) del electroencefalograma como sistema de control de la sedación en los pacientes críticos.

INTRODUCTION: The depth of sedation required for patients in critical care units varies over time and should be subject to control. The clinical assessment scales used at present are inadequate, and several electroencephalographic variables have been investigated in recent years with the aim of quantifying depth of sedation. One such variable is the spectral edge frequency 90 (SEF90). OBJECTIVES: To establish the correlation between SEF90 and the Ramsay score as indicators of depth of sedation. To estimate the ability of SEF90 to predict sedation and a patient's hemodynamic response during aspiration of secretions through the orotracheal tube. PATIENTS AND METHODS: Patients in a surgical intensive care unit. The ability of SEF90 to predict a certain Ramsay score was assessed by logistic regression. We also calculated the predictive probability (Pk) of SEF90 for the appearance of hemodynamic change and of movement in the event of endotracheal aspiration. RESULTS: When SEF90 was < 16 Hz, the probability of a Ramsay score >= 4 was >= 90% (Pk = 0.91). Neither SEF90 nor the Ramsay score predicted hemodynamic response to orotracheal aspiration. CONCLUSIONS: SEF90 distinguishes superficial from deep sedation but does not differentiate further degrees of depth or the likelihood of hemodynamic instability or movement in response to aspiration.

Utilización del límite espectral 90 por ciento (le90) del electroencefalograma como sistema de control de la sedación en los pacientes críticos / Use of the electroencephalographic spectral edge frequency 90 to monitor sedation of chronically ill patients

INTRODUCCIÓN. La profundidad de la sedación requerida en los pacientes ingresados en unidades de cuidados críticos varía a lo largo del tiempo y debe ser controlable. Actualmente utilizamos escalas de valoración clínica que son insuficientes. En los últimos años se han empleado diferentes parámetros extraídos del electroencefalograma con la finalidad de cuantificar el nivel de sedación. Uno de estos parámetros es el 90 por ciento del límite de la frecuencia del espectro (LE90). OBJETIVOS. Establecer la correlación entre nivel de sedación según escala de Ramsay y LE90. Averiguar el poder discriminante del LE90 en predecir la profundidad de la sedación y también en prever la respuesta hemodinámica del paciente ante la maniobra de aspiración de secreciones a través del tubo orotraqueal. PACIENTES Y MÉTODOS. Pacientes ingresados en la unidad de cuidados intensivos quirúrgica. Mediante regresión logística buscamos la probabilidad de estar a un determinado nivel de la escala de sedación de Ramsay según el valor del LE90. También calculamos la probabilidad de predicción (Pk), según el valor del LE90, de aparición de respuestas hemodinámicas o de movimiento frente a la aspiración endotraqueal. RESULTADOS. A un valor de LE90 inferior a 16 Hz, la probabilidad de estar en un nivel igual o superior a 4 de la escala de Ramsay es igual o mayor al 90 por ciento (Pk = 0,91). Ni el LE90 ni la escala de Ramsay no predicen ninguna respuesta hemodinámica tras la aspiración orotraqueal. CONCLUSIONES. El LE90 permite discriminar entre sedación superficial y sedación profunda. El LE90 no permite precisar los diferentes grados de sedación ni la posibilidad de respuesta hemodinámica o movimiento frente a la aspiración (AU)

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