Impacto clínico de cumplimentar un protocolo de tratamiento nutricional en pacientes críticos afectados por SARS-CoV-2 / The clinical impact of implementation of a nutritional treatment protocol in critically ill adults with SARS-CoV-2 infection

Introducción: El paciente crítico afectado por SARS-CoV-2 tiene riesgo de desnutrición. La necesidad de evitar la sobrecarga de volumen y las maniobras que retrasan el logro de los requerimientos nutricionales como la pronación hacen que el abordaje nutricional de estos sujetos sea complejo. Para asegurar un tratamiento adecuado, se desarrolló un protocolo de soporte nutricional como guía de práctica clínica adaptado al paciente con COVID-19. Objetivo: Describir el protocolo de soporte nutricional creado en nuestro centro, el cumplimiento del mismo y analizar los resultados de su aplicación en los pacientes con SARS-CoV-2, ingresados en la unidad de cuidados intensivos (UCI) del Consorcio Hospital General Universitario de Valencia (CHGUV) de marzo a mayo del 2020. Material y métodos: Diseño observacional, descriptivo, retrospectivo y longitudinal para evaluar el cumplimiento de un protocolo de soporte nutricional. Resultados: Se incluyeron 31 pacientes. No se pudo establecer un seguimiento nutricional en ocho de ellos. De los 23 restantes, ocho alcanzaron 80% de los requerimientos calóricos antes del décimo día tras el inicio del tratamiento (grupo buen cumplimiento) y 15 a partir del undécimo día (grupo mal cumplimiento). El grupo con buen cumplimiento obtuvo 75% (n = 6) de curación y 25% de éxitus (n = 2), en comparación con el grupo con «mal cumplimiento» donde 53% (n = 8) fueron dados de alta a planta vs. 47% (n = 7) que fallecieron (prueba X2, valor p = 0,019). Aquellos pacientes que alcanzaron 80% de las necesidades calóricas en algún momento del ingreso en UCI tuvieron menor duración de la hospitalización frente a los que no lo obtuvieron (mediana de días de ingreso = 14, rango intercuartílico [IQR] = 10-16 y mediana de días de ingreso = 22, IQR = 13-39, valor p = 0,025)...(AU)

Introduction: The critical patient affected by SARS-CoV-2 is at risk of malnutrition. The need to avoid volume overload and manoeuvres that delay reaching nutritional requirements such as pronation make the nutritional approach to these patients complex. To ensure adequate treatment, a nutritional support protocol was developed as a clinical practice guideline adapted to the COVID-19 patient. Objective: To describe and analyse the results of introducing a nutritional support protocol aimed at SARS-CoV-2 patients admitted to the intensive care unit (ICU) of the Consorcio Hospital General Universitario de Valencia (CHGUV) from March to May 2020. Material and methods: Observational, descriptive, retrospective and longitudinal design to evaluate compliance with a nutritional support protocol. Results: Thirty-one consecutive patients were included but nutritional follow-up could not be performed in eight. Of the remaining 23 patients, only eight reached 80% of caloric requirements before the tenth day after starting treatment (good compliance group) and 15 after the eleventh day (poor compliance group). In the group with «good compliance» 75% (n = 6) were discharged and 25% died (n = 2), compared to the group with «bad compliance» where 53% (n = 8) were discharged and 47% (n = 7) died (Chi square test, p-value = 0.019). Those patients who reached 80% of caloric needs during ICU stay had a shorter length of stay compared to those who did not (median days of admission = 14, IQR = 10-16 and median days of admission = 22, IQR = 13-39, p-value = 0.025). Conclusions: Introducing a nutritional protocol during the first weeks of the SARS-CoV-2 pandemic could improve clinical outcomes by promoting healing and reducing associated complications. (AU)

The clinical impact of implementation of a nutritional treatment protocol in critically ill adults with SARS-CoV-2 infection.

INTRODUCTION: The critical patient affected by SARS-CoV-2 is at risk of malnutrition. The need to avoid volume overload and manoeuvres that delay reaching nutritional requirements such as pronation make the nutritional approach to these patients complex. To ensure adequate treatment, a nutritional support protocol was developed as a clinical practice guideline adapted to the COVID-19 patient. OBJECTIVE: To describe and analyse the results of introducing a nutritional support protocol aimed at SARS-CoV-2 patients admitted to the intensive care unit (ICU) of the Consorcio Hospital General Universitario de Valencia (CHGUV) from March to May 2020. MATERIAL AND METHODS: Observational, descriptive, retrospective and longitudinal design to evaluate compliance with a nutritional support protocol. RESULTS: Thirty-one consecutive patients were included but nutritional follow-up could not be performed in eight. Of the remaining 23 patients, only eight reached 80% of caloric requirements before the tenth day after starting treatment (good compliance group) and 15 after the eleventh day (poor compliance group). In the group with «good compliance¼ 75% (n=6) were discharged and 25% died (n=2), compared to the group with «bad compliance¼ where 53% (n=8) were discharged and 47% (n=7) died (Chi square test, p-value=0.019). Those patients who reached 80% of caloric needs during ICU stay had a shorter length of stay compared to those who did not (median days of admission=14, IQR=10-16 and median days of admission=22, IQR=13-39, p-value=0.025). CONCLUSIONS: Introducing a nutritional protocol during the first weeks of the SARS-CoV-2 pandemic could improve clinical outcomes by promoting healing and reducing associated complications.

[The clinical impact of implementation of a nutritional treatment protocol in critically ill adults with SARS-CoV-2 infection]. / Impacto clínico de cumplimentar un protocolo de tratamiento nutricional en pacientes críticos afectados por SARS-CoV-2.

Introduction: The critical patient affected by SARS-CoV-2 is at risk of malnutrition. The need to avoid volume overload and manoeuvres that delay reaching nutritional requirements such as pronation make the nutritional approach to these patients complex. To ensure adequate treatment, a nutritional support protocol was developed as a clinical practice guideline adapted to the COVID-19 patient. Objective: To describe and analyse the results of introducing a nutritional support protocol aimed at SARS-CoV-2 patients admitted to the intensive care unit (ICU) of the Consorcio Hospital General Universitario de Valencia (CHGUV) from March to May 2020. Material and methods: Observational, descriptive, retrospective and longitudinal design to evaluate compliance with a nutritional support protocol. Results: Thirty-one consecutive patients were included but nutritional follow-up could not be performed in eight. Of the remaining 23 patients, only eight reached 80% of caloric requirements before the tenth day after starting treatment (good compliance group) and 15 after the eleventh day (poor compliance group). In the group with «good compliance¼ 75% (n = 6) were discharged and 25% died (n = 2), compared to the group with «bad compliance¼ where 53% (n = 8) were discharged and 47% (n = 7) died (Chi square test, p-value = 0.019). Those patients who reached 80% of caloric needs during ICU stay had a shorter length of stay compared to those who did not (median days of admission = 14, IQR = 10-16 and median days of admission = 22, IQR = 13-39, p-value = 0.025). Conclusions: Introducing a nutritional protocol during the first weeks of the SARS-CoV-2 pandemic could improve clinical outcomes by promoting healing and reducing associated complications.

SARS-CoV-2 infection. Descriptive analysis of a selected case series.

OBJECTIVES: COVID-19 was declared pandemic by March 2020. Clinical, analytical, and radiological findings have been reported. Detailed different evolution of patients of the same local outbreak has been scarcely reported. We report 6 selected cases of such an evolution. CLINICAL CASES: The clinical, radiological, analytical evolution of 6 patients is reported. Patients were selected as it were epidemiological close contacts, and showed particular different clinical evolution. RESULTS: The clinical course at the start of infection (first week) was similar among patients. In relationship with clinical evolution, middle to severe course were related with inflammation markers levels evolution (D-dimer, IL-6, ferritin, lymphocytes count, etc.). Specially lung alterations were observed, but neurological/neuropsychiatric findings are still common. In evolution, 2 patients showed middle symptoms, but the 2 most severely affected died. CONCLUSIONS: It remains to be elucidated the different evolutive pathways and outcomes of COVD-19. In our 6 patients of the same local outbreak, clinical, laboratory and radiological features were different. We discuss some aspects of the pathophysiology of the disease, other than the widely described of the respiratory system.

Airway management of COVID-19 patients: A survey on the experience of 1125 physicians in Spain.

BACKGROUND: We explored the experience of clinicians from the Spanish Society of Anesthesiology (SEDAR) in airway management of COVID-19 patients. METHODS: An software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment. RESULTS: 1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists. The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision. Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and healthcare workers. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management. CONCLUSIONS: Most physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide.

Infección por SARS-CoV-2. Análisis descriptivo de una serie de casos seleccionada / SARS-CoV-2 infection. Descriptive analysis of a selected case series

Objetivos: La COVID-19 fue declarada pandemia en marzo del 2020. Han sido comunicados los hallazgos clínicos, analíticos y radiológicos. Sin embargo, la diversa evolución de pacientes del mismo brote local lo ha sido escasamente. Comunicamos en este trabajo 6 casos seleccionados de tal evolución. Casos clínicos: Se expone la evolución clínica, radiológica y analítica de 6 pacientes. Estos fueron seleccionados ya que fueron epidemiológicamente contactos estrechos y mostraron una evolución clínica particularmente diferente. Resultados: El curso clínico al inicio de la infección (primera semana) fue similar entre los pacientes. En relación con la evolución clínica, un curso moderado a severo se relacionó evolutivamente con marcadores elevados de inflamación (dímero D, IL-6, ferritina, linfopenia, etc.). Fueron observadas alteraciones pulmonares típicas, pero fueron comunes también hallazgos neurológicos y neuropsiquiátricos. En la evolución 2pacientes mostraron síntomas moderados, pero los 2 más gravemente afectados murieron. Conclusiones: Está por elucidar las diferentes vías evolutivas y resultados finales de los pacientes con COVID-19. En nuestros 6 pacientes del mismo brote local, las características clínicas, de laboratorio y radiológicas fueron diferentes. Discutimos aspectos de la fisiopatología de la enfermedad distintos de los ampliamente descritos del sistema respiratorio.(AU)

Objectives: COVID-19 was declared pandemic by March 2020. Clinical, analytical, and radiological findings have been reported. Detailed different evolution of patients of the same local outbreak has been scarcely reported. We report 6 selected cases of such an evolution. Clinical cases: The clinical, radiological, analytical evolution of 6patients is reported. Patients were selected as it were epidemiological close contacts, and showed particular different clinical evolution. Results: The clinical course at the start of infection (first week) was similar among patients. In relationship with clinical evolution, middle to severe course were related with inflammation markers levels evolution (D-dimer, IL-6, ferritin, lymphocytes count, etc.). Specially lung alterations were observed, but neurological/neuropsychiatric findings are still common. In evolution, 2patients showed middle symptoms, but the 2most severely affected died. Conclusions: It remains to be elucidated the different evolutive pathways and outcomes of COVD-19. In our 6 patients of the same local outbreak, clinical, laboratory and radiological features were different. We discuss some aspects of the pathophysiology of the disease, other than the widely described of the respiratory system.(AU)

[Airway management of COVID-19 patients: a survey on the experience of 1125 physicians in Spain]. / Manejo de vía aérea en pacientes COVID-19: una encuesta sobre la experiencia de 1125 médicos en España.

BACKGROUND: We explored the experience of clinicians from the Spanish Society of Anesthesiology in airway management of COVID-19 patients. METHODS: An software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment. RESULTS: 1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists.The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision.Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and physicians. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management. CONCLUSIONS: Most physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide.

[SARS-CoV-2 infection. Descriptive analysis of a selected case series]. / Infección por SARS-CoV-2. Análisis descriptivo de una serie de casos seleccionada.

OBJECTIVES: COVID-19 was declared pandemic by March 2020. Clinical, analytical, and radiological findings have been reported. Detailed different evolution of patients of the same local outbreak has been scarcely reported. We report 6 selected cases of such an evolution. CLINICAL CASES: The clinical, radiological, analytical evolution of 6 patients is reported. Patients were selected as it were epidemiological close contacts, and showed particular different clinical evolution. RESULTS: The clinical course at the start of infection (first week) was similar among patients. In relationship with clinical evolution, middle to severe course were related with inflammation markers levels evolution (D-dimer, IL-6, ferritin, lymphocytes count, etc.). Specially lung alterations were observed, but neurological/neuropsychiatric findings are still common. In evolution, 2 patients showed middle symptoms, but the 2 most severely affected died. CONCLUSIONS: It remains to be elucidated the different evolutive pathways and outcomes of COVD-19. In our 6 patients of the same local outbreak, clinical, laboratory and radiological features were different. We discuss some aspects of the pathophysiology of the disease, other than the widely described of the respiratory system.

SARS-CoV-2 infection. Descriptive analysis of a selected case series. / Infección por SARS-CoV-2. Análisis descriptivo de una serie de casos seleccionada.

OBJECTIVES: COVID-19 was declared pandemic by March 2020. Clinical, analytical, and radiological findings have been reported. Detailed different evolution of patients of the same local outbreak has been scarcely reported. We report 6 selected cases of such an evolution. CLINICAL CASES: The clinical, radiological, analytical evolution of 6patients is reported. Patients were selected as it were epidemiological close contacts, and showed particular different clinical evolution. RESULTS: The clinical course at the start of infection (first week) was similar among patients. In relationship with clinical evolution, middle to severe course were related with inflammation markers levels evolution (D-dimer, IL-6, ferritin, lymphocytes count, etc.). Specially lung alterations were observed, but neurological/neuropsychiatric findings are still common. In evolution, 2patients showed middle symptoms, but the 2most severely affected died. CONCLUSIONS: It remains to be elucidated the different evolutive pathways and outcomes of COVD-19. In our 6patients of the same local outbreak, clinical, laboratory and radiological features were different. We discuss some aspects of the pathophysiology of the disease, other than the widely described of the respiratory system.

Pulsed-Doppler evaluation of renal perfusion during pulsatile extracorporeal circulation. A pilot study. / Evaluación del flujo renal con Doppler pulsado durante la circulación extracorpórea pulsátil. Estudio piloto.

INTRODUCTION: Acute renal failure (ARF) after cardiac surgery is a risk factor associated with mortality and use of resources. Some studies have reported beneficial effects of pulsatile flow on cardiopulmonary bypass (CPB) on renal function. The aim of this study is to describe the echographic morphology of the renal arterial wave modifying the parameters of pulsatile CPB. MATERIAL AND METHOD: Descriptive study was performed on 10 patients without previous AFR and undergoing cardiac surgery with CPB. Pre-, intra- and post-surgery renal ultrasound was performed. During pulsatile CPB, the amplitude and the baseline flow were modified. Recordings of pulsed Doppler in intrarenal arteries were obtained by measuring maximum systolic velocity, minimum diastolic velocity, resistance index (RI) and acceleration time (AT). RESULTS: Statistical differences were found in ultrasounds pre-CPB between A50F50 modality (P=.013), A50F30 (P=.013) and A60F50 (P=.003). No statistically significance was found with A30F30 modality (P=.125). CONCLUSIONS: The decrease in the amplitude and the baseline flow of pulsatility during CPB shows a renal ultrasound morphology that is more similar to the physiological one. Subsequent studies using these characteristics during pulsatile CPB could thus show perfusion over the ARF that occurs after cardiac surgery.