Estrés laboral en los intensivistas de Uruguay / Work stress among intensivists in Uruguay / Estresse ocupacional em médicos intensivistas no Uruguai

Resumen: Introducción: el estrés laboral (EL) se genera por experiencias en el ambiente laboral y por el relacionamiento con otros individuos. En la medicina intensiva, el desarrollo de los factores de estrés se ha vinculado principalmente a la relación del médico con el paciente en estado crítico, su familia, el equipo de trabajo así como con la realización de maniobras invasivas. El presente estudio tiene como objetivo conocer el nivel de estrés, así como determinar los factores asociados al desarrollo de estrés laboral. Metodología: en 2018 se realizó una encuesta a los intensivistas. Los niveles de estrés se midieron con el Inventario de Estrés para Profesionales de la Salud de Wolfgang y la Escala de Síntomas de Estrés. Resultados: se analizaron 96 respuestas de médicos intensivistas. La experiencia de estos en medicina intensiva es de 11 (6-22,75) años. La carga laboral semanal en UCI es de 48 (36-60) horas, correspondiendo a trabajo nocturno 24 (12-24) horas. El nivel de estrés total fue de 53 (44-65) puntos. Al discriminar de acuerdo al nivel de severidad encontramos que 5% presenta estrés mínimo, 63% estrés moderado y 32% estrés severo. Una carga laboral semanal mayor de 40 horas se asoció con el desarrollo de EL severo. Asimismo se evidenciaron mayores puntajes de EL en los intensivistas más jóvenes. Conclusiones: los médicos intensivistas presentan frecuentemente niveles elevados de estrés. Identificamos factores asociados al desarrollo del mismo. Es fundamental diseñar estrategias tendientes a reducir el impacto del EL en la UCI.

Abstract: Introduction: Work Stress (WS) is generated by interactions and experiences with other people in the work environment. In the Intensive Care Unit (ICU), the physician´s relationship with critical patients, and with their families, the work team and performing invasive procedures, have been identified as stress development factors. This study aims to explore stress levels, and to define the factors associated to work stress. Methods: in 2018, an online survey was sent to physicians working in the ICU. Stress levels were assessed using Wolfgang's Health Professionals Stress Inventory (HPSI) and the Stress Symptom Scale. Results: 96 responses by intensive care physicians were analysed. Average work experience was 11 (6-22.75) years. Intensivists workload is 48 hours a week at the ICU (36-60), 24 (12-24) of which were night shift hours. The total stress level was 53 (44-65) points. Stress levels found were: 5% minimal, 63% moderate and 32% high. A weekly workload greater than 40 hours was associated to the development of severe WS. Higher WS scores were seen in younger physicians. Conclusions: physicians working in the ICU frequently showed high levels of WS. This study identified the factors associated to its development. A recommendation is made to design strategies and policies that reduce the impact of WS on ICU physicians.

Resumo: Introdução: o estresse ocupacional (EO) é gerado por experiências no ambiente de trabalho e pelo relacionamento com outras pessoas. Na Medicina Intensiva, o desenvolvimento dos fatores de estresse tem estado vinculado principalmente à relação do médico com o paciente crítico, sua família, a equipe de trabalho, bem como a realização de manobras invasivas. O objetivo deste estudo é conhecer o nível de estresse, bem como determinar os fatores associados ao desenvolvimento do estresse ocupacional. Metodologia: em 2018, foi realizada uma pesquisa com médicos intensivistas. Os níveis de estresse foram medidos com o Inventário de Estresse de Profissionais da Saúde de Wolfgang e o Inventário de Sintomas de Estresse. Resultados: foram analisadas 96 respostas de médicos intensivistas. A experiência dos entrevistados como intensivistas é de 11 (6 a 22,75) anos. A carga horária semanal de trabalho em UTI é de 48 (36-60) horas, correspondendo a 24 (12-24) horas de trabalho noturno. O nível de estresse total foi de 53 (44-65) pontos. Ao discriminar de acordo com o nível de gravidade, encontramos que 5% apresentam estresse mínimo, 63% estresse moderado e 32% estresse severo. Uma carga de trabalho semanal superior a 40 horas foi associada ao desenvolvimento de EO grave. Da mesma forma, maiores escores de EO foram observados nos intensivistas mais jovens. Conclusões: os médicos intensivistas frequentemente apresentam altos níveis de estresse. Identificamos fatores associados ao seu desenvolvimento. É fundamental traçar estratégias para reduzir o impacto do EO na UTI.

Combined Diaphragm and Limb Muscle Atrophy Is Associated With Increased Mortality in Mechanically Ventilated Patients: A Pilot Study / La combinación de atrofia del diafragma y atrofia de los músculos de las extremidades se asocia a un aumento de la mortalidad en los pacientes con ventilación mecánica: un estudio piloto

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Evaluación muscular respiratoria y periférica en la Unidad de Cuidados Intensivos / Respiratory and Peripheral Muscle Assessment in the Intensive Care Unit

La atrofia y la debilidad de los músculos respiratorios y periféricos son un problema frecuente en las Unidades de Cuidados Intensivos (UCI). Su diagnóstico es dificultoso, especialmente en las primeras etapas de la enfermedad crítica. Esto determina que en muchos casos no sea detectada hasta etapas avanzadas, por ejemplo, frente a dificultad para la desvinculación de la asistencia ventilatoria mecánica. El objetivo de esta revisión es describir las principales herramientas con las que contamos actualmente para la evaluación muscular en la UCI, tanto periférica como respiratoria. Se mencionan técnicas con distinto grado de complejidad y especificidad, haciendo particular hincapié en aquellas con mayor aplicabilidad en la práctica clínica diaria, como la ecografía

Atrophy and weakness of the respiratory and peripheral muscles is a common problem in the intensive care unit (ICU). It is difficult to diagnose, particularly in the early stages of critical disease. Consequently, many cases are detected only in advanced stages, for example, when difficulties in mechanical ventilation weaning are encountered. The aim of this review is to describe the main tools that are currently available for evaluation of peripheral and respiratory muscles in the ICU. Techniques of varying complexity and specificity are discussed, and particular emphasis is placed on those with greater relevance in daily clinical practice, such as ultrasound

Evolución histórica de la mortalidad de los pacientes internados en el Centro Nacional de Quemados entre 1995 y 2017 / Historical evolution of the mortality in burned patient at the Centro Nacional de Quemados (National Burns Center) between 1995 and 2017 / Evolução histórica da mortalidade dos pacientes queimados atendidos no Centro Nacional de Quemados entre 1995 e 2017

Introducción: la mortalidad de los pacientes con injuria térmica ha descendido a nivel mundial. Este hecho se ha relacionado en parte con la creación de centros especializados en el tratamiento de esta patología. En nuestro medio no existen estudios recientes que evalúen la evolución de la mortalidad en este tipo de centros. Objetivo: describir las características de la población asistida y la evolución de la mortalidad en el Centro Nacional de Quemados. Material y método: estudio transversal, observacional, descriptivo. Se incluyeron todos los pacientes ingresados con diagnóstico de quemadura cutánea o de injuria inhalatoria desde la inauguración del centro en 1995 hasta el 31 de diciembre de 2017. Resultados: ingresaron en el período de estudio 3.050 pacientes quemados, 25% presentaron una superficie corporal quemada superior o igual a 20%. Existió un predominio de pacientes jóvenes (más de 60% menores de 50 años) y de sexo masculino (62%). El agente causal más frecuente fue el fuego directo (71%), seguido por líquidos calientes (9%) y electricidad (5%). El 43% de los pacientes requirió asistencia ventilatoria mecánica, y la estadía media en el centro fue de 17 días. La mortalidad global fue de 19,7%, similar a la esperada de acuerdo a scores de severidad específicos. La mortalidad de los pacientes más graves ha descendido desde la apertura del centro. Conclusiones: nuestro centro asiste predominantemente a pacientes jóvenes, con siniestros que involucran al fuego como el principal agente causal. La mortalidad es acorde a la esperada de acuerdo a los scores de severidad, destacándose un descenso continuo de la misma a lo largo de los años. (AU)

Introduction: burned patients mortality has decreased because of a better understanding of initial shock pathophysiology, early surgical interventions, antibiotic therapy optimization and appropriate nutritional support. Mortality reduction has also been related to the creation of specialized burn centers. There are no recent reports of burn injury patients in our country. Objective: to describe characteristics and evolution of patients assisted at the national burned center (Centro Nacional de Quemados, Uruguay). Methods: transversal, observational, descriptive study. All patients admitted in the center with diagnosis of skin burns or inhalation injury, from the center's opening in 1995 through December 31, 2017. Results: during the study period 3,050-burned patients were admitted, 25% of which had a total body surface area burnt of at least 20%. There was a predominance of male sex (62%) and young patients (more than 60% had less than 50 years old). The most frequent responsible agent was direct fire (71%), followed by hot liquids (9%) and electricity (5%). Mechanical ventilation was needed in 43% of the patients, and mean length of stay in the center was 17 days. Overall mortality rate was 19.7%, accordingly to that predicted by specific severity scores. In the sub-group of more severe patients, mortality has progressively decreased since the center opening. Conclusions: our center assists young patients with burn injuries mostly caused by direct fire. Overall mortality is in line with the expected according to severity scores, having decreased progressively since the center inauguration.

Introduction: burned patients mortality has decreased because of a better understanding of initial shock pathophysiology, early surgical interventions, antibiotic therapy optimization and appropriate nutritional support. Mortality reduction has also been related to the creation of specialized burn centers. There are no recent reports of burn injury patients in our country. Objective: to describe characteristics and evolution of patients assisted at the national burned center (Centro Nacional de Quemados, Uruguay). Methods: transversal, observational, descriptive study. All patients admitted in the center with diagnosis of skin burns or inhalation injury, from the center's opening in 1995 through December 31, 2017. Results: during the study period 3,050-burned patients were admitted, 25% of which had a total body surface area burnt of at least 20%. There was a predominance of male sex (62%) and young patients (more than 60% had less than 50 years old). The most frequent responsible agent was direct fire (71%), followed by hot liquids (9%) and electricity (5%). Mechanical ventilation was needed in 43% of the patients, and mean length of stay in the center was 17 days. Overall mortality rate was 19.7%, accordingly to that predicted by specific severity scores. In the sub-group of more severe patients, mortality has progressively decreased since the center opening. Conclusions: our center assists young patients with burn injuries mostly caused by direct fire. Overall mortality is in line with the expected according to severity scores, having decreased progressively since the center inauguration.

Respiratory and Peripheral Muscle Assessment in the Intensive Care Unit. / Evaluación muscular respiratoria y periférica en la Unidad de Cuidados Intensivos.

Atrophy and weakness of the respiratory and peripheral muscles is a common problem in the intensive care unit (ICU). It is difficult to diagnose, particularly in the early stages of critical disease. Consequently, many cases are detected only in advanced stages, for example, when difficulties in mechanical ventilation weaning are encountered. The aim of this review is to describe the main tools that are currently available for evaluation of peripheral and respiratory muscles in the ICU. Techniques of varying complexity and specificity are discussed, and particular emphasis is placed on those with greater relevance in daily clinical practice, such as ultrasound.

Características de la limitación de terapia de soporte vital en pacientes fallecidos en unidades de medicina intensiva / Characteristics of limiting life support therapies in patients who died in the ICU

Introducción: la limitación de terapias de soporte vital (LTSV) es una práctica habitual y éticamente aceptada. La misma se enmarca en el concepto de adecuación del esfuerzo terapéutico. Objetivo: determinar la frecuencia, las directivas de implementación y los factores asociados a LSTV en los pacientes fallecidos en unidades de cuidados intensivos (UCI). Conocer la frecuencia y características del registro de este proceso en la historia clínica. Diseño: estudio observacional multicéntrico de corte transversal. Ámbito: se analizaron las historias clínicas de ocho UCI polivalentes públicas y privadas de Uruguay. Pacientes: se incluyeron todos los pacientes mayores de 18 años fallecidos en un período de seis meses consecutivos en el año 2011. Intervenciones: análisis de las características de los pacientes mediante revisión de historias clínicas. Resultados: analizamos 210 pacientes fallecidos. Se identificó LSTV en 63 (30%). El 75% de las decisiones consistió en la retirada de medidas terapéuticas. Los factores independientemente asociados a LTSV fueron: mayor edad (OR 1,04 (IC 95% 1,01-1,07), p = 0,001), mayor estadía en UCI (OR 1,06 (IC 95% 1,02 - 1,11), p = 0,001) y limitación para las actividades de la vida diaria (OR 4,65 (IC 95% 1,1-19,6), p=0,035). El 70% de las directivas LTSV fueron registradas en la historia clínica. Los soportes vitales más frecuentemente retirados fueron: nutrición parenteral (100%), vasopresores (79%), nutrición enteral (64%) y antimicrobianos (52%). La asistencia ventilatoria mecánica invasiva se retiró en el 33% de los casos. Conclusiones: un tercio de los pacientes fallece con LTSV. Este tipo de decisiones se asocian a mala calidad de vida previa, mayor edad y mayor estadía en UCI. Un tercio de las decisiones de LTSV no son registradas. (AU)

Introduction: withdraw and withhold life support therapies is an usual and ethically accepted practice. Objectives: to determine the frequency, the directives and factors associated with withdrawing and withholding life support therapies in patients who died in ICU. Determine the frequency and characteristics of the record of this process in clinical history. Design: multicentric observational study of cross section. Setting: clinical histories of 8 public and private mixed ICUs in Uruguay were analyzed. Patients: all patients over 18 years who died in a period of 6 consecutive months in 2011 were included. Interventions: analysis of the characteristics of patients through review of clinical histories. Results: we analyzed 210 patients who died. Withdrawing or withholding was identified in 63 (30%). 75% of the decisions consisted in withdraw therapeutic measures. Factors independently associated to withdrowing or withholding therapies were: an older age (OR 1.04 (95% CI 1.01-1.07), p = 0.001), a longer stay in ICU (OR 1.06 (95% CI 1, 02 - 1.11), p = 0.001), and the limitation for activities of daily living (OR 4.65 (95% CI 1.1 -19.6), p = 0.035). 70% of the decisions were recorded in the clinical history. The most frequently removed vital supports were: parenteral nutrition (100%), vasopressors (79%), enteral nutrition (64%) and antimicrobials (52%). Invasive mechanical ventilatory assistance was removed in 33% of the cases. Conclusions: one third of patients die with LSTL. These types of decisions are associated with a poor quality of life, an older age and a longer stay in the ICU. One third of LTSV decisions are not registered.

Introdução: a limitação do emprego de terapias de suporte vital (LTSV) é uma prática habitual e eticamente aceitada. Esta decisão está compreendida no conceito de adequação do esforço terapêutico. Objetivos: determinar a frequência, as normas de implementação e os fatores associados à LSTV nos pacientes falecidos em unidades de cuidados intensivos (UCI). Conhecer a frequência e as características do registro deste processo no prontuário do paciente. Tipo de estudo: estudo observacional multicêntrico de corte transversal. Escopo: foram analisados os prontuários dos pacientes de 8 UCIs polivalentes públicas e privadas do Uruguai. Pacientes: foram incluídos todos os pacientes maiores de 18 anos falecidos em um período de 6 meses consecutivos em 2011. Intervenções: análise das características dos pacientes pela revisão dos prontuários dos pacientes. Resultados: analisamos 210 pacientes falecidos. Em 63 (30%) pacientes foi registrada a LTSV. 75% das decisões consistiam na retirada de medidas terapêuticas. Os fatores independentemente associados a LTSV foram: idade mais avançada (OR 1,04 (IC 95 % 1,01-1,07), p = 0,001), maior permanência na UCI (OR 1,06 (IC 95% 1,02 - 1,11), p = 0,001), e limitação para as atividades da vida diária (OR 4,65 (IC 95% 1,1 -19,6), p=0,035). 70% das diretivas LTSV foram registradas no prontuário do paciente. Os suportes vitais mais frequentemente retirados foram: nutrição parenteral (100%), vasopressores (79%), nutrição enteral (64%) e antimicrobianos (52%). A assistência ventilatória mecânica invasiva foi retirada em 33% dos casos. Conclusões: um terço dos pacientes falece com LTSV. Este tipo de decisão está associada à má qualidade de vida previa, idade mais avançada e maior permanência em UCI. Um terço das decisões de LTSV não é registrado.