Nos toca el cuidado en tiempos de covid-19 / Turn for care/caring touch in times of COVID-19

No disponible

Contención mecánica en cuidados críticos: mapeo situacional, conceptualización profesional y recomendaciones para la práctica / Mechanical restraints in Critical Care: situational mapping, professional conceptualization and recommendations for practice

Objetivo: objetivo principal: diseñar estrategias y algoritmos de decisión que minimicen el uso y los riesgos derivados de las contenciones mecánicas (CM) en unidades de cuidados críticos (UCC). Objetivos secundarios: a) conocer la experiencia de los profesionales al manejar pacientes críticos con CM y en función del medio en el que están inmersos respecto al uso de CM; b) explorar el significado que los profesionales dan a los conceptos "riesgo" y "seguridad"; c) analizar la prevalencia de uso de CM en pacientes críticos, los factores asociados a su uso y los eventos adversos relacionados; d) conocer la actitud de los profesionales de UCC acerca del uso de CM. Método: estudio multicéntrico en dos fases secuenciales: fase I para la generación de conocimiento amplio e integral acerca del uso de CM en pacientes críticos a través de diferentes metodologías: investigación cualitativa fenomenológica interpretativa, audit clínico (revisión de la práctica clínica) y estudio transversal para explorar las actitudes de los profesionales. En la fase II, mediante método Delphi a partir de los conocimientos generados, se procederá al desarrollo de estrategias, recomendaciones y algoritmos de decisión que minimicen los riesgos derivados del uso inadecuado de las CM en pacientes críticos. Conclusiones: para lograr el objetivo de la minimización del uso de CM en las UCC y en los casos que sean necesarias se haga ajustado a las recomendaciones, se plantea como necesaria la generación de conocimiento amplio, específico y adaptado a la realidad de los pacientes críticos

Objectives: primary objective: to design strategies and algorithms for decision that will minimize the use of mechanical restraints (MRs) and the risks derived in Critical Care Units (CCUs). Secondary Objectives: a) To learn about the experience of professionals when managing critical patients with MRs, and based on their current setting in terms of the use of MRs; b) To explore the meaning given by professionals to the terms "risk" and "safety"; c) To analyze the prevalence of the use of MRs in critical patients, those factors associated with their use, and any related adverse events; d) To understand the attitude of CCU professionals regarding the use of MRs. Method: a multicenter study in two sequential stages: Stage I for the generation of a wide and comprehensive knowledge about the use of MRs in critical patients through different methodologies: interpretative phenomenological qualitative research, clinical audit (review of clinical practice) and cross-sectional study to explore the attitudes by professionals. In Stage II, through the Delphi method, and based on the knowledge generated, there will be a development of strategies, recommendations and decision algorithms that will minimize the risks derived of an inadequate use of MRs in critical patients. Conclusions: in order to achieve the objective of minimizing the use of MRs in CCUs and, in those cases necessary, using them according to recommendations, it is considered necessary to generate wide and specific knowledge, adapted to the reality of critical patients

Bioimpedancia vectorial y espectroscópica: valoración del estado de hidratación con ambos métodos en hemodiálisis / Bioimpedance vector and spectroscopic analysis: assessing hydration status using both methods in haemodialysis

El análisis de bioimpedancia es una herramienta útil para determinar el estado nutricional y de hidratación del enfermo en hemodiálisis. Los dos sistemas más utilizados son la bioimpedancia de monofrecuencia vectorial y la bioimpedancia multifrecuencia espectroscópica que utilizan diferentes criterios para clasifi car el estado de hidratación del enfermo dializado. El sistema de bioimpedancia de monofrecuencia vectorial utiliza una escala ordinal de 7 puntos que va desde el valor 3 (mayor hidratación) hasta el valor -3 (mayor deshidratación) definiendo la hiperhidratación cuando el vector está en el eje de hidratación por debajo de la elipse de tolerancia del 75% (valores 3 y 2 de la escala ordinal). El sistema de bioimpedancia multifrecuencia espectroscópica emplea dos criterios para defi nir el estado de hiperhidratación prediálisis: OH superior a 2,5 litros o mayor del 15% del volumen de agua extracelular. El objetivo del presente trabajo fue analizar el grado de concordancia entre ambos sistemas de bioimpedancia para defi nir el estado de hiperhidratación en enfermos tratados con hemodiálisis. Se llevó a cabo un estudio transversal en 54 enfermos tratados con hemodiálisis a los que se les realizó un análisis de bioimpedancia con monitores de monofrecuencia vectorial y multifrecuencia espectroscópica inmediatamente antes de una sesión de hemodiálisis. El grado de equivalencia en la defi nición de hiperhidratación entre ambos monitores fue mejor cuando se utilizó, en el monitor de multifrecuencia, el criterio de OH>15% del agua extracelular (índice kappa 0.81, concordancia excelente) que cuando se utilizó el criterio de OH>2,5 litros (índice kappa 0.71, concordancia aceptable). Conclusiones: Hay una buena relación entre la escala vectorial de hidratación y el valor OH (exceso de hidratación). Los criterios utilizados por los monitores de monofrecuencia vectorial y multifrecuencia espectroscópica para defi nir los estados de hiperhidratación prediálisis tienen una equivalencia aceptable y sus resultados pueden ser intercambiables(AU)

Bioimpedance analysis is a useful tool for determining the nutritional and hydration status of haemodialysis patients. The two most commonly used systems are bioimpedance vector single frequency analysis and bioimpedance spectroscopic multiple frequency analysis, which use different criteria to classify the hydration status of the dialysed patient. The single frequency bioimpedance vector system uses a scale of 7 points ranging from a value of 3 (most hydration) to a value of -3 (most dehydration), defi ning hyperhydration when the vector is on the hydration axis below the tolerance ellipse of 75% (values 3 and 2 on the scale). Multi-frequency spectroscopy uses two criteria to defi ne the pre-dialysis state of hyperhydration: OH more than 2.5 litres or more than 15% of the extracellular water volume. The aim of this study was to analyse the degree of concordance between the two systems of bioimpedance in defi ning the state of hyperhydration of haemodialysis patients. A transversal study was carried out on 54 patients undergoing haemodialysis, performing a bioimpedance analysis with single frequency vector and multi- frequency spectroscopic monitors immediately before a haemodialysis session. The degree of equivalence in the defi nition of hyperhydration between the two monitors was greater when the criterion of OH>15% of extracellular water was used in the multi-frequency monitor (kappa index 0.81, excellent concordance) than when the criterion of OH>2.5 litres was used (kappa index 0.71, acceptable concordance). Conclusions: There is a good relationship between the hydration vector scale and OH value (excess hydration). The criteria used by the single-frequency vector and multi-frequency spectroscopic monitors show acceptable equivalence and their results can be interchangeable(AU)

Predicted end-tidal sevoflurane concentration for insertion of a Laryngeal Mask Supreme: a prospective observational study.

CONTEXT: The single-use Laryngeal Mask Airway (LMA) Supreme is a new supraglottic airway device. It has been reported to be reliable and easy-to-use in clinical practice; however, the anaesthetic techniques for its insertion are not standardised. OBJECTIVES: The purpose of this study was to determine the ED50 of end-tidal sevoflurane concentration for successful LMA Supreme insertion without the use of neuromuscular blockade. DESIGN: A prospective observational study. SETTING: A single tertiary care surgical centre. PATIENTS: Thirty-one consecutive elective patients scheduled for minor elective surgery under general anaesthesia. INTERVENTION: Patients were preoxygenated with 100% oxygen and anaesthetised using normal tidal volume inhalation of sevoflurane. The target sevoflurane concentration was determined using a modified Dixon's 'up-and-down' method (starting at 2.5% with 0.5% as the step size). After the predetermined end-tidal concentration had been established and maintained for 10 min, LMA Supreme insertion was attempted. MAIN OUTCOME MEASURE: The main outcome measure was the patient's response to LMA Supreme insertion, classified as either 'movement' or 'no movement'. The mean of the concentrations of seven cross-overs from 'movement' to 'no movement' was used to estimate the ED50. RESULTS: The estimated sevoflurane concentration for successful LMA Supreme insertion in 50% of adults was 3.03 ± 0.75% (95% confidence interval 2.3 to 3.7%). The values of the ET50 and ET95 obtained by logistic regression were 2.83 and 5.30%, respectively. CONCLUSION: Sevoflurane alone can provide acceptable conditions for insertion of the LMA Supreme in adults, at an estimated minimum alveolar anaesthetic concentration of 3% with minimal adverse effects.

Evaluación del bienestar espiritual en pacientes en hemodiálisis / Evaluation of spiritual well-being in haemodialysis patients

Introducción: Se define la espiritualidad como la búsqueda personal de propósito y significado en la vida, pudiendo incorporar o no la religión. En este artículo se presenta el desarrollo y la aplicación de una medida de bienestar espiritual a una muestra de pacientes en hemodiálisis. Material y métodos: El instrumento básico empleado se denomina Cuestionario del Sentido de la Vida (Meaning in Life Scale , MiLS), con 21 ítems y cuatro escalas: Propósito, Falta de significado, Paz y Beneficios de la espiritualidad. También se proporciona una puntuación global de espiritualidad. Además, se registraron variables de tipo clínico (tiempo en hemodiálisis, índice de comorbilidad de Charlson) y sociodemográfico (edad, género), así como estimaciones del estado de salud, calidad de vida (general y actual), felicidad personal, el grado de religiosidad y la creencia en la existencia de vida ultraterrena. Se ha utilizado un diseño transversal con 94 pacientes en hemodiálisis. Resultados: Los resultados muestran que la versión española de este instrumento (MiLS-Sp) es una medida de (..) (AU)

Introduction: Spirituality can be defined as a personal search for meaning and purpose in life that may or may not encompass religion. In this article we report on the development and testing of an instrument for measuring spiritual well-being within a sample of haemodialysis patients. Material and Method: The main instrument, a 21-item Meaning in Life Scale (MiLS), comprises four scales: Life Perspective, Purpose and Goals, Confusion and Lessened Meaning, Harmony and Peace, and Benefits of Spirituality. A total score for spiritual well-being is also produced. We also used the following variables: clinical (time on haemodialysis, modified Charlson comorbidity index), sociodemographic (age, gender), and self-assessments of health, quality of life (general and recent), personal happiness, religiosity, and belief in the (..) (AU)

Evaluation of spiritual well-being in haemodialysis patients.

INTRODUCTION: Spirituality can be defined as a personal search for meaning and purpose in life that may or may not encompass religion. In this article we report on the development and testing of an instrument for measuring spiritual well-being within a sample of haemodialysis patients. MATERIAL AND METHOD: The main instrument, a 21-item Meaning in Life Scale (MiLS), comprises four scales: Life Perspective, Purpose and Goals, Confusion and Lessened Meaning, Harmony and Peace, and Benefits of Spirituality. A total score for spiritual well-being is also produced. We also used the following variables: clinical (time on haemodialysis, modified Charlson comorbidity index), sociodemographic (age, gender), and self-assessments of health, quality of life (general and recent), personal happiness, religiosity, and belief in the afterlife. A cross-sectional study was carried out on 94 haemodialysis patients. RESULTS: This study demonstrates that the MiLS-Sp is a psychometrically sound measure of spiritual well-being for dialysis patients (reliability, validity) as they manage the complex demands of a chronic illness. Spiritual well-being was significantly associated with various quality of life variables, health status, personal happiness, or religiosity in patients on dialysis. There was no relationship between spirituality scores and comorbidity, HD duration, gender, or age. Spiritual well-being is relatively low in dialysis patients. CONCLUSION: Spirituality may play an important role on psychological well-being, quality of life, and self-rated health for patients on haemodialysis. Spiritual well-being in these patients is relatively low. Results suggest that assessing and addressing spiritual well-being in dialysis patients may be helpful in clinical practice.

A comparative study of 2 new phosphate binders (sevelamer and lanthanum carbonate) in routine clinical practice.

INTRODUCTION: Lack of adherence may influence the efficiency of phosphate binders. Our clinical hypothesis was that if lanthanum carbonate (LC) might offer some advantage over sevelamer (S), that that would be in those patients in whom serum phosphate (P) levels were not controlled by S or in those requiring high doses of it, presuming that therapeutic compliance with S could be inadequate. The aim of this study was to compare the cost-consequences of changing from S to LC. METHODS: This was a prospective comparative before-after interventional study. Fifty-one hemodialysis patients prescribed a large number of tablets of S (≥ 9 tablets/day) and/or had serum phosphorus (P) levels >5.5 mg/dL were changed from S to LC; 68 patients who did not meet those criteria served as controls. RESULTS: Mean daily number of total phosphate binder tablets was reduced after the introduction of LC (13.9 ± 5.5 at time 0 vs. 7.7 ± 4.6 at 12 months; p<0.001). LC was suspended in 14 patients (31.1%), due to a wish to return to the previous medication (S). Percentage compliance with the objectives recommended by the NFK-KDOQI guidelines improved after the change (patients with P <5.5 mg/dL: 46.9% at month 0 and 72.5% at month 12; p<0.01). The incremental cost of changing from S (month 0) to LC (month 12) was -107.8 monthly, considering only the costs of phosphate binders. LC reached the P objective at a lower cost (euro 582.2 vs. euro 1,038.5; -44%; p<0.01). CONCLUSIONS: A complete change from S to LC in these particular kinds of patients significantly decreased the cost of treatment while also improving the achievement of NFK-KDOQI guideline objectives for mineral metabolism.

Protein kinase activity in Cucumis sativus cotyledons: effect of calcium and light.

Light signals received by phytochromes in plants may be transduced through protein phosphorylation. Ca(2+) as second messenger was involved in phytochrome-mediated cellular events. Our experiments with Cucumis sativus cotyledons, treated with red (R) and far-red (FR) light, showed a stimulatory effect on in vitro protein phosphorylation of histone, added as exogenous substrate to the cotyledon extracts, and also modified the phosphorylation of endogenous polypeptides. The effect of light treatments was mimicked by the addition of Ca(2+) to the phosphorylation buffer, indicating phytochrome- and Ca(2+)-dependence on activity of some protein kinases (PKs). In-gel kinase assays were performed to characterize the PKs involved at the cotyledon stage of cucumber plants. Three proteins of about 75, 57 and 47kDa with PK activity were detected between M(r) markers of 94 and 45kDa. All three were able to phosphorylate histone and undergo autophosphorylation. However, only the 75 and 57kDa proteins autophosphorylated and phosphorylated the substrate in a Ca(2+)-dependent manner, and were inhibited when calmodulin (CaM) antagonists were added to the incubation buffer. Western-blot analysis with polyclonal antibodies directed against calcium-dependent protein kinase of rice (OsCDPK11) or Arabidopsis (AtCPK2) recognised 57 and 75kDa polypeptides, respectively. These results indicate the presence in cucumber cotyledons of at least two proteins (ca. 75 and 57kDa) with activity of PKs that could be calcium-dependent protein kinases (CDPKs). Both CDPKs could be modulated by phytochromes throughout FR-HIR and VLFR responses.

Application of NKF-K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease: changes of clinical practices and their effects on outcomes and quality standards in three haemodialysis units.

BACKGROUND: The K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease was published in October 2003. The objective of this study was to analyse the effect of the application of those guidelines on clinical practices and on the achievement of bone disease targets and quality standards. METHODS: We included in the study 342 patients dialysed in our three HD units during 2003 and 2004. Starting October 2003, the K-DOQI recommendations were introduced into practice. Parathyroid hormone (PTH) was measured every 3 months and the serum Ca and P levels, monthly. In patients whose medications were modified, PTH was measured monthly and Ca and P levels, weekly or biweekly. RESULTS: The following are the main findings for 2004 (post-K/DOQI): an increased use of dialysates with a Ca concentration of 2.5 mEq/l (27.2-50.9%, P<0.001) and a reduced use of a dialysate calcium of 3.0 mEq/l (44.6-39.6%, P: NS) and 3.5 mEq/l (28-9.4%, P<0.001); a reduced use of calcium-based phosphate binders (891.9-565.5 mg Ca/day, P<0.001) and increased use of sevelamer hydrochloride (800 mg) (from 4.86 to 7.51 mg, tablets/day, P<0.001) lower serum Ca levels (9.7-9.4 mg/dl, P<0.01), and higher intact PTH levels (201.4-311.8 pg/ml, P<0.001), without changes in serum P levels; an increased proportion of patients with serum Ca levels within the K/DOQI target range (38.7-46.6%, P<0.01), resulting mainly from the reduced percentage of patients with hypercalcaemia (55-44.4%, P<0.01); a decreased proportion of patients with PTH<150 pg/ml (53.8-31.4%, P<0.001) but an increased proportion of patients with PTH>300 pg/ml, with no change in the proportion of patients with PTHs within the K/DOQI target range. Phosphorus levels and targets did not show significant differences between 2003 and 2004 (56.9-56.2%, P: NS). CONCLUSIONS: The only way to ensure that K/DOQI guidelines actually improve medical outcomes is to emphasize implementation strategies and also the scientific evaluation of their effectiveness in clinical settings. In spite of the application of the K-DOQI recommendations, a large proportion of our patients stayed outside the proposed targets, which points to the need for more effective therapeutic options.