Guidelines for inhaled sedation in the ICU.

INTRODUCTION AND OBJECTIVES: Sedation is used in intensive care units (ICU) to improve comfort and tolerance during mechanical ventilation, invasive interventions, and nursing care. In recent years, the use of inhalation anaesthetics for this purpose has increased. Our objective was to obtain and summarise the best evidence on inhaled sedation in adult patients in the ICU, and use this to help physicians choose the most appropriate approach in terms of the impact of sedation on clinical outcomes and the risk-benefit of the chosen strategy. METHODOLOGY: Given the overall lack of literature and scientific evidence on various aspects of inhaled sedation in the ICU, we decided to use a Delphi method to achieve consensus among a group of 17 expert panellists. The processes was conducted over a 12-month period between 2022 and 2023, and followed the recommendations of the CREDES guidelines. RESULTS: The results of the Delphi survey form the basis of these 39 recommendations - 23 with a strong consensus and 15 with a weak consensus. CONCLUSION: The use of inhaled sedation in the ICU is a reliable and appropriate option in a wide variety of clinical scenarios. However, there are numerous aspects of the technique that require further study.

Situación de los cuidados intensivos en España / Intensive care in Spain

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Estructura de las unidades de cuidados intensivos de anestesia: recomendaciones de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR) / Structure of the anesthesia intensive care units: recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology

ANTECEDENTES Y OBJETIVO: Los objetivos de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SCI-SEDAR) con el presente trabajo son: establecer nuevas recomendaciones adaptando los estándares publicados por el Ministerio de Sanidad y Política Social, y alineadas con las principales guías internacionales, y desarrollar una herramienta de mejora de la calidad y la eficiencia. MATERIALES Y MÉTODO: A lo largo de 2018, 3 miembros de la SCI-SEDAR definieron la metodología, desarrollaron las recomendaciones y seleccionaron al panel de expertos. Debido a la limitada evidencia de buena parte de las recomendaciones y a la importante variabilidad estructural de las unidades de cuidados intensivos de anestesia actuales, se optó por un abordaje Delphi modificado para determinar el grado de consenso. RESULTADOS: Un total de 24 expertos de 21 instituciones constituyeron el grupo de expertos del presente trabajo. Se establecieron 175 recomendaciones sobre 8 apartados, incluyendo 129 con consenso fuerte y 46 con consenso débil. CONCLUSIONES: La SCI-SEDAR estableció las recomendaciones estructurales de las unidades de cuidados intensivos de anestesia que deberán guiar la renovación o la creación de nuevas unidades

BACKGROUND AND OBJECTIVE: In this article, the Intensive Care Section of the Spanish Society of Anesthesiology (SCI-SEDAR) establishes new recommendations based on the standards published by the Ministry of Health, Consumer Affairs and Social Welfare and aligned with the principle international guidelines, and develops a tool to improve quality and efficiency. MATERIALS AND METHOD: Over a 12-month period (2018), 3 members of the SCI-SEDAR defined the methodology, developed the recommendations and selected the panel of experts. Due to the limited evidence available for many of the recommendations and the significant structural differences between existing anesthesia intensive care units, we chose a modified Delphi approach to determine the degree of consensus. RESULTS: The panel consisted of 24 experts from 21 institutions. The group put forward 175 recommendations on 8 sections, including 129 with strong consensus and 46 with weak consensus. CONCLUSIONS: The SCI-SEDAR has established a series of structural recommendations that should be used when renovating or creating new anesthesia intensive care units

Structure of the Anesthesia Intensive Care Units: Recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology. / Estructura de las unidades de cuidados intensivos de anestesia: recomendaciones de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR).

BACKGROUND AND OBJECTIVE: In this article, the Intensive Care Section of the Spanish Society of Anesthesiology (SCI-SEDAR) establishes new recommendations based on the standards published by the Ministry of Health, Consumer Affairs and Social Welfare and aligned with the principle international guidelines, and develops a tool to improve quality and efficiency. MATERIALS AND METHOD: Over a 12-month period (2018), 3 members of the SCI-SEDAR defined the methodology, developed the recommendations and selected the panel of experts. Due to the limited evidence available for many of the recommendations and the significant structural differences between existing anesthesia intensive care units, we chose a modified Delphi approach to determine the degree of consensus. RESULTS: The panel consisted of 24 experts from 21 institutions. The group put forward 175 recommendations on 8 sections, including 129 with strong consensus and 46 with weak consensus. CONCLUSIONS: The SCI-SEDAR has established a series of structural recommendations that should be used when renovating or creating new anesthesia intensive care units.

Cuidados Intensivos de Anestesia: recomendaciones de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología / Intensive Care of Anaesthesia: recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology

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Mortalidad hospitalaria en pacientes críticos postquirúrgicos mayores de 80 años. ¿Podemos predecirla de forma precoz? / Hospital mortality in postoperative critically ill patients older than 80 years. Can we predict it at an early stage?

Objetivos. Conocer la incidencia de mortalidad hospitalaria en el postoperatorio de los pacientes con edad igual o mayor de 80 años que ingresan en la Unidad de Reanimación (UR), así como evaluar la capacidad predictiva de las variables presentes en las primeras 48 h de ingreso sobre la mortalidad hospitalaria. Material y métodos. Estudio retrospectivo observacional de cohortes. Se incluyeron todos los pacientes de edad igual o mayor de 80 años ingresados en la UR tras intervenirse quirúrgicamente durante junio del 2011 a diciembre del 2013. Se realizó un modelo de regresión logística en base a un análisis uni y bivariado para conocer la posible asociación entre la mortalidad y las variables independientes. Resultados. De los 186 pacientes recogidos en el estudio, 9 (4,8%) fallecieron en la UR y 22 (11,8%) fallecieron una vez trasladados a planta de hospitalización, lo que se traduce en una mortalidad hospitalaria total de 31 (16,7%). De los 78 pacientes (42%) intervenidos de urgencia y de los 108 de forma programada se observó una mortalidad de 19 (10,2%) y 12 (6,5), respectivamente. Las únicas variables presentes en las primeras 48 h de ingreso en la UR que demostraron ser factor de riesgo para mortalidad hospitalaria fueron ventilación mecánica de más de 48 h (OR; 7,146; IC 95%: 1,563-32,664; p = 0,011) y el grado de severidad en la escala APACHE II en las primeras 24 h (OR: 1,102; IC 95%: 1,005-1,208; p = 0,039). Conclusión. La incidencia de mortalidad hospitalaria en pacientes ancianos encontrada en nuestro centro es equiparable a la de otras series publicadas. La ventilación mecánica prolongada de más de 48 h y el grado de severidad en la escala APACHE II identificarían aquellos pacientes con mayor riesgo de fallecer durante el ingreso hospitalario (AU)

Objectives. To determine the incidence of in-hospital mortality throughout the post-surgical period of patients aged 80 or over who were admitted to the post-surgical critical care unit, as well as to assess the predictive capacity of those variables existing in the first 48 hours on the in-hospital mortality. Material and methods. An observational retrospective cohort study conducted on postsurgical patients up to 80 years old who were admitted to the unit between June 2011 and December 2013. Univariate and multivariate binary logistic regression was used to determine the association between mortality and the independent variables. Results. Of the 186 patients included, 9 (4.8%) died in the critical care unit, and 22 (11.8%) died in wards during hospital admission, giving a hospital mortality of 31 (16.7%). Among the 78 patients (42%) that underwent acute surgery, and the 108 who underwent elective surgery, there was a mortality rate of 19 (10.2%) and 12 (6.5%), respectively. As regards the variables analysed during the first 48 hours of admission that showed to be hospital mortality risk factor were the need for mechanical ventilation over 48 h, with an OR: 7.146 (95% CI: 1.563-32.664, P = .011) and the degree of the severity score on the APACHE II scale in the first 24 hours, with an OR: 1.102 (95% CI: 1.005-1.208, P = .039). Conclusion. The incidence of hospital mortality in very old patients found in our study is comparable to that reported by other authors. Patients who need mechanical ventilation over 48 h, and with higher scores in the APACHE II scale could be at a higher risk of in-hospital mortality (AU)

Hospital mortality in postoperative critically ill patients older than 80 years. Can we predict it at an early stage? / Mortalidad hospitalaria en pacientes críticos postquirúrgicos mayores de 80 años. ¿Podemos predecirla de forma precoz?

OBJECTIVES: To determine the incidence of in-hospital mortality throughout the post-surgical period of patients aged 80 or over who were admitted to the post-surgical critical care unit, as well as to assess the predictive capacity of those variables existing in the first 48hours on the in-hospital mortality. MATERIAL AND METHODS: An observational retrospective cohort study conducted on postsurgical patients up to 80years old who were admitted to the unit between June 2011 and December 2013. Univariate and multivariate binary logistic regression was used to determine the association between mortality and the independent variables. RESULTS: Of the 186 patients included, 9 (4.8%) died in the critical care unit, and 22 (11.8%) died in wards during hospital admission, giving a hospital mortality of 31 (16.7%). Among the 78 patients (42%) that underwent acute surgery, and the 108 who underwent elective surgery, there was a mortality rate of 19 (10.2%) and 12 (6.5%), respectively. As regards the variables analysed during the first 48hours of admission that showed to be hospital mortality risk factor were the need for mechanical ventilation over 48h, with an OR: 7.146 (95%CI: 1.563-32.664, P=.011) and the degree of the severity score on the APACHE II scale in the first 24hours, with an OR: 1.102 (95%CI: 1.005-1.208, P=.039). CONCLUSION: The incidence of hospital mortality in very old patients found in our study is comparable to that reported by other authors. Patients who need mechanical ventilation over 48h, and with higher scores in the APACHE II scale could be at a higher risk of in-hospital mortality.

Fascitis necrotizante causada por Vibrio vulnificus / Necrotising fasciitis caused by Vibrio vulnificus

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[Perioperative anesthetic management of 300 morbidly obese patients undergoing laparoscopic bariatric surgery and a brief review of relevant pathophysiology]. / Tratamiento anestésico perioperatorio de 300 pacientes con obesidad mórbida sometidos a cirugía bariátrica laparoscópica y breve revisión fisiopatológica.

OBJECTIVES: Laparoscopic bariatric surgery is a challenge for anesthesiologists because morbidly obese patients are at high risk and laparoscopy may complicate respiratory and hemodynamic management. The aim of this study was to analyze the perioperative anesthetic management of morbidly obese patents undergoing laparoscopic bariatric surgery. MATERIAL AND METHODS: Prospective study of 300 consecutive patients diagnosed with morbid obesity and scheduled for laparoscopic bariatric surgery. Patients were positioned with a wedge cushion under the head and shoulders. A rapid sequence induction of anesthesia was carried out. A short-handled, articulated-blade McCoy laryngoscope was used for intubation; an intubation laryngeal mask airway (Fastrach) was on hand as a rescue device. Propofol and remifentanil were used for maintenance of anesthesia and morphine was administered at the end of surgery. Incentive spirometry was initiated in the postanesthetic recovery unit. RESULTS: Eighty percent of the patients were women with a mean (SD) body mass index (kg/m2) of 46 (5). The first choice of direct laryngoscopic intubation was successful in 98.6% of cases. All patients were successfully intubated. Only 5 patients required intensive care. Postoperative complications (mainly respiratory problems, bleeding, and infections) were observed in 17%. No patient died. CONCLUSIONS: Perianesthetic management of morbidly obese patients who undergo laparoscopic surgery is safe. To minimize pulmonary complications, preoxygenation and rapid sequence induction should be performed correctly and incentive spirometry should be initiated in the immediate postoperative period. The McCoy laryngoscope ensures intubation in most cases.

Tratamiento anestésico perioperatorio de 300 pacientes con obesidad mórbida sometidos a cirugía bariátrica laparoscópica y breve revisión fisiopatológica / Perioperative anesthetic management of 300 morbidly obese patients

Objetivos: La cirugía bariátrica laparoscópica supone un reto para el anestesiólogo, ya que el obeso mórbido es un paciente de alto riesgo y la laparoscopia puede dificultar el tratamiento ventilatorio y hemodinámico del paciente. El objetivo de este estudio es analizar el tratamiento perioperatorio anestésico de pacientes obesos mórbidos sometidos a cirugía bariátrica laparoscópica. Material y métodos: Estudio prospectivo de 300 pacientes consecutivos diagnosticados de obesidad mórbida, programados para cirugía bariátrica por laparoscopia. Los pacientes se posicionaron con almohadillado en cuña bajo cabeza y hombros. Se llevó a cabo una inducción anestésica de secuencia rápida. Para la intubación se utilizó un laringoscopio de mango corto y pala articulada (McCoy), utilizando de rescate la ILMA (intubation laryngeal mask airway) o Fastrach. El mantenimiento anestésico se realizó con propofol y remifentanilo, administrando cloruro mórfico al final de la cirugía. En la unidad de reanimación postanestésica se inició espirometría incentivada. Resultados: El 80% fueron mujeres, con un índice de masa corporal de 46 ± 5 Kg/m2. Se utilizó de primera elección laringoscopia directa para intubar en el 98,6% de los casos. Ningún paciente fue imposible de intubar. Sólo 5 pacientes precisaron cuidados intensivos. Hubo un 17% de complicaciones postoperatorias, destacando las respiratorias, hemorrágicas e infecciosas. No hubo ningún caso de mortalidad. Conclusión: El manejo perianestésico de pacientes con obesidad mórbida operados mediante abordaje laparoscópico es seguro. Para minimizar las complicaciones respiratorias, conviene: preoxigenar adecuadamente, realizar inducción de secuencia rápida y comenzar la espirometría incentivada en el postoperatorio inmediato. El laringoscopio de McCoy garantiza la intubación en la mayoría de los casos(AU)

Objectives: Laparoscopic bariatric surgery is a challenge for anesthesiologists because morbidly obese patients are at high risk and laparoscopy may complicate respiratory and hemodynamic management. The aim of this study was to analyze the perioperative anesthetic management of morbidly obese patients undergoing laparoscopic bariatric surgery. Material and methods: Prospective study of 300 consecutive patients diagnosed with morbid obesity and scheduled for laparoscopic bariatric surgery. Patients were positioned with a wedge cushion under the head and shoulders. A rapid sequence induction of anesthesia was carried out. A short-handled, articulated-blade McCoy laryngoscope was used for intubation; an intubation laryngeal mask airway (Fastrach) was on hand as a rescue device. Propofol and remifentanil were used for maintenance of anesthesia and morphine was administered at the end of surgery. Incentive spirometry was initiated in the postanesthetic recovery unit. Results: Eighty percent of the patients were women with a mean (SD) body mass index (kg/m2) of 46 (5). The first choice of direct laryngoscopic intubation was successful in 98.6% of cases. All patients were successfully intubated. Only 5 patients required intensive care. Postoperative complications (mainly respiratory problems, bleeding, and infections) were observed in 17%. No patient died. Conclusions: Perianesthetic management of morbidly obese patients who undergo laparoscopic surgery is safe. To minimize pulmonary complications, preoxygenation and rapid sequence induction should be performed correctly and incentive spirometry should be initiated in the immediate postoperative period. The McCoy laryngoscope ensures intubation in most cases(AU)