Limitación de tratamientos de soporte vital en Unidades de Cuidados Intensivos españolas: análisis del estudio ETHICUS II / Limitation of life support treatments in Spanish Intensive Care Units: Analysis of the ETHICUS II study

Objetiv Describir los resultados obtenidos en UCI españolas en el estudio ETHICUS II. Diseño Subestudio planificado de pacientes del ETHICUS II. Ámbito 12 UCI españolas. Pacientes o participantes Pacientes que fallecieron o en los que se decidió una limitación de tratamiento de soporte vital (LTSV) durante un periodo de reclutamiento de 6 meses. Intervenciones Se realizó seguimiento hasta el alta de la UCI y 2 meses tras la decisión de LTSV o fallecimiento. Variables de interés principales Características demográficas, clínicas, tipo de decisión de LTSV. Se clasificaron en 4 categorías: omisión o retirada de tratamientos de soporte, acortar el proceso de morir, resucitación cardiopulmonar ineficaz y muerte cerebral. Resultados Un total de 12 UCI participaron en el ETHICUS II. Incluyeron 795 pacientes; 129 fallecieron tras realizarse RCP, 129 desarrollaron muerte encefálica. Se decidió LTSV en 537, fallecieron en UCI 485, el 90,3%. La edad media fue 66,19 años±14,36, el 63,8% fueron hombres. En un 41% se decidió retirada de tratamientos de soporte total y en un 59% se procedió a no iniciar medidas. Diecinueve pacientes (2,38%) disponían de documento de voluntades vitales anticipadas. Conclusiones El perfil clínico predominante cuando se estableció una LTSV fue el de pacientes varones mayores de 65 años con comorbilidad mayoritariamente cardiovascular. La supervivencia fue mayor en las decisiones de LTSV que comprendían la omisión de tratamientos respecto a aquellas en las que se decidió la retirada. España ha ocupado un papel destacado en este estudio multicéntrico de ámbito mundial. (AU)

Objective The aim of this study is to describe the results of Spanish ICUs in ETHICUS II study. Design Planned substudy of patients from ETHICUS II study. Setting 12 Spanish ICU. Patients or participants Patients admitted to Spanish ICU who died or in whom a limitation of life-sustaining treatment (LLST) was decided during a recruitment period of 6 months. Interventions Follow-up of patients was performed until discharge from the ICU and 2 months after the decision of LLST or death. Main variables of interest Demographic characteristics, clinical profile, type of decision of LLST, time and form in which it was adopted. Patients were classified into 4 categories according to the ETHICUS II study protocol: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, failed cardiopulmonary resuscitation and patients with brain death. Results A total of 795 patients were analyzed; 129 patients died after CPR, 129 developed brain death. LLST was decided in 537 patients, 485 died in the ICU, 90.3%. The mean age was 66.19 years±14.36, 63.8% of male patients. In 221 (41%) it was decided to withdraw life-sustaining treatments and in 316(59%) withholding life-sustaining treatments. Nineteen patients (2.38%) had advance living directives. Conclusions The predominant clinical profile when LTSV was established was male patients over 65 years with mostly cardiovascular comorbidity. We observed that survival was higher in LLST decisions involving withholding of treatments compared to those in which withdrawal was decided. Spain has played a leading role in both patient and ICU recruitment participating in this worldwide multicenter study. (AU)

Limitation of life support treatments in Spanish Intensive Care Units: Analysis of the ETHICUS II study.

OBJECTIVE: The aim of this study is to describe the results of Spanish ICUs in ETHICUS II study. DESIGN: Planned substudy of patients from ETHICUS II study. SETTING: 12 Spanish ICU. PATIENTS OR PARTICIPANTS: Patients admitted to Spanish ICU who died or in whom a limitation of life-sustaining treatment (LLST) was decided during a recruitment period of 6 months. INTERVENTIONS: Follow-up of patients was performed until discharge from the ICU and 2 months after the decision of LLST or death. MAIN VARIABLES OF INTEREST: Demographic characteristics, clinical profile, type of decision of LLST, time and form in which it was adopted. Patients were classified into 4 categories according to the ETHICUS II study protocol: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, failed cardiopulmonary resuscitation and patients with brain death. RESULTS: A total of 795 patients were analyzed; 129 patients died after CPR, 129 developed brain death. LLST was decided in 537 patients, 485 died in the ICU, 90.3%. The mean age was 66.19 years ± 14.36, 63.8% of male patients. In 221 (41%) it was decided to withdraw life-sustaining treatments and in 316 (59%) withholding life-sustaining treatments. Nineteen patients (2.38%) had advance living directives. CONCLUSIONS: The predominant clinical profile when LTSV was established was male patients over 65 years with mostly cardiovascular comorbidity. We observed that survival was higher in LLST decisions involving withholding of treatments compared to those in which withdrawal was decided. Spain has played a leading role in both patient and ICU recruitment participating in this worldwide multicenter study.

Réplica al Dr. Palencia Herrejón / Reply to Dr. Palencia Herrejón

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VLAD. Un sistema gráfico de expresión continua de efectividad asistencial aplicado en medicina intensiva / The variable life adjusted display (VLAD). A graphical technique of continuous expression of healthcare effectiveness applied to intensive care medicine

Introducción: Se describen distintos métodos para estimar y expresar la efectividad en la asistencia a pacientes críticos. De entre ellos, se hace especial hincapié en el método VLAD (Variable Life Adjusted Display), que permite una descripción secuencial y continua, con expresión gráfica, fácilmente comprensible y utilizable. El objetivo del trabajo no es hacer una descripción de un nuevo método, sino la difusión de uno poco conocido y su aplicación a pacientes críticos. Material y método: Se describe la metodología de cálculo del método VLAD como resultado de la resta acumulada entre supervivientes reales y predichos supervivientes, por cualquiera de los métodos al uso utilizados para predecir mortalidad en pacientes críticos. Los autores utilizan el Simplified Acute Physiology Score 2. Resultados: El método se aplica a 7.448 pacientes, ingresados consecutivamente en una unidad de cuidados intensivos polivalente desde 1999 a 2004, incluido. Se ofrecen distintos gráficos según que la expresión VLAD se realice sobre la totalidad de la muestra, o sobre submuestras homogéneas (tipo de ingreso, o determinadas causas de ingreso). Discusión: Se ofrece una visión crítica de los medios de expresión de efectividad, desde una perspectiva de gestión clínica, y de sus potenciales aplicaciones: instrumento de gestión, revisión de la asistencia prestada, docencia e investigación

Introduction: Different methods for estimating and expressing effectiveness of the care of critically ill patients are described. Among them, especial interest is placed on VLAD methodology, which allows continuous and sequential expression of the variable under study through a graphic display that is easy to use and understand. The aim of this article was not to describe a new methodology, but rather to present a little-known method not previously used in critically-ill patients in Spain. Material and method: We describe the procedure for calculating VLAD as the result of the cumulative subtraction of real mortality from predicted mortality, irrespective of the methodology used for prediction. In the present article, SAPS 2 was used. Results: The method was applied in 7,448 patients consecutively admitted to a medical­surgical ICU from 1999 to 2004 (inclusive). Graphs depicting the use of VLAD in the whole sample and in homogeneous subgroups (type of admission or certain admission diagnoses) were obtained. Discussion: We provide a critical view of techniques for expressing effectiveness, from the perspective of clinical management, as well as of the possible uses of these techniques in healthcare management, quality evaluation, teaching, and research