Pacientes críticos COVID-19. ¿Han variado el manejo y los resultados en la UCI tras un año de pandemia? Estudio multicéntrico, prospectivo, observacional / Critical patients COVID-19 has changed the management and outcomes in the ICU after 1 year of the pandemic? A multicenter, prospective, observational study

Objetivo: Comparar las características clínicas, los tratamientos y la evolución de los pacientes críticos con neumonía por COVID-19 atendidos en unidades de cuidados intensivos (UCI) tras un año de pandemia. Metodología: Estudio multicéntrico, prospectivo, en el que se incluyó pacientes críticos COVID-19 en 9 UCI del noroeste de España. Se compararon las características clínicas, los tratamientos y la evolución de pacientes ingresados en UCI durante los meses de marzo-abril de 2020 (periodo1) con pacientes ingresados en enero-febrero de 2021 (periodo2). Resultados: Se incluyeron 337 pacientes (98 en el periodo1 y 239 en el periodo2). En el periodo2 menos pacientes requirieron ventilación mecánica invasiva (VMI) (65% vs 84%, p<0,001), utilizándose con mayor frecuencia cánulas nasales de alto flujo (CNAF) (70% vs 7%, p<0,001), ventilación mecánica no invasiva (VMNI) (40% vs 14%, p<0,001), corticoides (100% vs 96%, p=0,007) y posición de decúbito prono tanto en pacientes despiertos (42% vs 28%, p=0,012) como en pacientes intubados (67% vs 54%, p=0,034). Los días de VMI, de estancia en UCI y hospitalaria fueron inferiores en el periodo2. La mortalidad fue similar en los dos periodos estudiados (16% vs 17%). Conclusiones: Tras un año de pandemia, observamos que en los pacientes ingresados en UCI se ha utilizado con mayor frecuencia CNAF, VMNI, uso del decúbito prono y corticoides, disminuyendo los pacientes en VMI, así como los tiempos de estancia en UCI y de estancia hospitalaria. La mortalidad ha sido similar en los dos periodos a estudio.(AU)

Objective: To compare the clinical characteristics, treatments, and evolution of critical patients with COVID-19 pneumonia treated in intensive care units (ICU) after one year of pandemic. Methodology: Multicenter, prospective study, which included critical COVID-19 patients in 9 ICUs in northwestern Spain. The clinical characteristics, treatments, and evolution of patients admitted to the ICU during the months of March-April 2020 (period1) were compared with patients admitted in January-February 2021 (period2). Results: 337 patients were included (98 in period1 and 239 in period2). In period2, fewer patients required invasive mechanical ventilation (IMV) (65% vs. 84%, P<.001), using high-flow nasal cannulas (CNAF) more frequently (70% vs. 7%, P<.001), ventilation non-invasive mechanical (NIMV) (40% vs. 14%, P<.001), corticosteroids (100% vs. 96%, P=.007) and prone position in both awake (42% vs. 28%, P=.012), and intubated patients (67% vs. 54%, P=.034). The days of IMV, ICU stay and hospital stay were lower in period2. Mortality was similar in the two periods studied (16% vs. 17%). Conclusions: After one year of pandemic, we observed that in patients admitted to the ICU, CNAF, NIMV, use of the prone position, and corticosteroids have been used more frequently, reducing the number of patients in IMV, and the length of stay in the ICU and hospital stay. Mortality was similar in the two study periods.(AU)

Critical patients COVID-19 has changed the management and outcomes in the ICU after 1 year of the pandemic? A multicenter, prospective, observational study.

OBJECTIVE: To compare the clinical characteristics, treatments, and evolution of critical patients with COVID-19 pneumonia treated in Intensive Care Units (ICU) after one year of pandemic. METHODOLOGY: Multicenter, prospective study, which included critical COVID-19 patients in 9 ICUs in northwestern Spain. The clinical characteristics, treatments, and evolution of patients admitted to the ICU during the months of March-April 2020 (period 1) were compared with patients admitted in January-February 2021 (period 2). RESULTS: 337 patients were included (98 in period 1 and 239 in period 2). In period 2, fewer patients required invasive mechanical ventilation (IMV) (65% vs 84%, p < 0.001), using high-flow nasal cannulas (CNAF) more frequently (70% vs 7%, p < 0.001), ventilation non-invasive mechanical (NIMV) (40% vs 14%, p < 0.001), corticosteroids (100% vs 96%, p = 0.007) and prone position in both awake (42% vs 28%, p = 0.012), and intubated patients (67% vs 54%, p = 0.034). The days of IMV, ICU stay and hospital stay were lower in period 2. Mortality was similar in the two periods studied (16% vs 17%). CONCLUSIONS: After 1 year of pandemic, we observed that in patients admitted to the ICU, CNAF, NIMV, use of the prone position, and corticosteroids have been used more frequently, reducing the number of patients in IMV, and the length of stay in the ICU and hospital stay. Mortality was similar in the two study periods.

[Critical patients COVID-19 has changed the management and outcomes in the ICU after 1 year of the pandemic? A multicenter, prospective, observational study]. / Pacientes críticos COVID-19. ¿Han variado el manejo y los resultados en la UCI tras un año de pandemia? Estudio multicéntrico, prospectivo, observacional.

Objective: To compare the clinical characteristics, treatments, and evolution of critical patients with COVID-19 pneumonia treated in intensive care units (ICU) after one year of pandemic. Methodology: Multicenter, prospective study, which included critical COVID-19 patients in 9 ICUs in northwestern Spain. The clinical characteristics, treatments, and evolution of patients admitted to the ICU during the months of March-April 2020 (period 1) were compared with patients admitted in January-February 2021 (period 2). Results: 337 patients were included (98 in period 1 and 239 in period 2). In period 2, fewer patients required invasive mechanical ventilation (IMV) (65% vs. 84%, P < .001), using high-flow nasal cannulas (CNAF) more frequently (70% vs. 7%, P < .001), ventilation non-invasive mechanical (NIMV) (40% vs. 14%, P < .001), corticosteroids (100% vs. 96%, P = .007) and prone position in both awake (42% vs. 28%, P = .012), and intubated patients (67% vs. 54%, P = .034). The days of IMV, ICU stay and hospital stay were lower in period 2. Mortality was similar in the two periods studied (16% vs. 17%). Conclusions: After one year of pandemic, we observed that in patients admitted to the ICU, CNAF, NIMV, use of the prone position, and corticosteroids have been used more frequently, reducing the number of patients in IMV, and the length of stay in the ICU and hospital stay. Mortality was similar in the two study periods.

Stress and burnout in anaesthesia: a real world problem?

PURPOSE OF REVIEW: Stress and burnout have arisen as relevant problems to the healthcare workers and the health systems themselves. As anaesthesiologists work in stressful areas of the hospitals, we are exposed to these problems. In this review, we summarize recent studies regarding stress and burnout, exploring possible solutions. RECENT FINDINGS: Almost 50% of anaesthesiologists scored positive for some of the burnout domains in different surveys, with one-third reporting high levels. The management of this problem not only needs an institutional but also an individual approach. Some recent randomized clinical trials and longitudinal studies suggest that there is some benefit of using several techniques to control stress, although benefits are still modest and most of the studies are based on transversal surveys and self-reported questionnaires. SUMMARY: There is a lack of definitive evidence to guide the management of stress and burnout in medical professions in general and in anaesthesiology in particular. Longitudinal and interventional studies are needed to better determine ways of action. In the meantime, creating a positive work climate and institutional support as well as promoting control over one's job and the autonomy of employees are the most recommended strategies. Workers should also learn how to cope with stressors and practice personal strategies of wellness and resilience to fight against burnout.

Job satisfaction, stress and burnout in anaesthesia: relevant topics for anaesthesiologists and healthcare managers?

Job satisfaction is defined as an employee's positive reaction towards his/her work. Changes in health policies, which are seen as a threat to the autonomy of health workers, are associated with a decrease in satisfaction levels, increase burnout among physicians, and may impair the quality and safety of care. The work environment of anaesthesiologists include stressful areas such as the operating theatre, the ICU, and the emergency setting, and this has been linked to higher levels of stress and lower satisfaction. We frequently lack feedback from patients and even our colleagues despite usually working within a team. Nevertheless, job satisfaction and burnout rates in anaesthesia are similar to other specialties. The most relevant factors in job satisfaction are worker autonomy, control of the working environment, recognition of our value, professional relationships, leadership and organisational justice. Although these can be manipulated for good or otherwise, there are additional, less malleable factors such as personality, expectations and motivation of the employee, that play a part. Within organisations there needs to be the will to evaluate employees' satisfaction, to improve their work environment and to develop strategies and coping mechanisms for professional stress. Personal wellness should also be nurtured, as a satisfactory work-life balance and an adequate social support network might act as a buffer for dissatisfaction and burnout. Improvement in satisfaction might create a positive work climate that would benefit both the safety of our patients and our profession.

Unplanned surgical reoperations in a tertiary hospital: perioperative mortality and associated risk factors.

BACKGROUND AND OBJECTIVES: The aim of the study was to estimate the rate of unplanned surgical reoperations in a tertiary hospital and the mortality in reoperated patients and to determine factors associated with risk of mortality in these patients. METHODS: Unplanned surgical reoperations in our hospital were recorded from 1 May 2006 to 31 March 2008. Unplanned reoperation was defined as any surgical procedure required to treat a complication of a prior procedure within the first 30 days of the initial operation. Patients were followed until hospital discharge. RESULTS: Of 11,468 patients who underwent surgery, 381 (3.3%) required reoperation. The main indications for the second or subsequent procedure were postsurgical bleeding (26.3%) and infection (31.2%). Mortality was higher in reoperated patients (21.7 vs. 2.9% in nonreoperated patients, P<0.05). Age, number of reoperations, reoperation of patients before discharge from the postoperative care unit, acute abdomen as the indication for reoperation and reoperation in the thoracic cavity were independently associated with mortality. CONCLUSION: Unplanned reoperations have important implications for patient outcomes and are related to high mortality. Certain patient-related and procedure-related factors increase risk.

Atelectasias perioperatorias y maniobras de reclutamiento alveolar / Peri-Operative Atelectasis and Alveolar Recruitment Manoeuvres

Las complicaciones respiratorias postoperatorias constituyen una causa importante de morbimortalidad. Las atelectasias perioperatorias, en concreto, afectan hasta al 90% de los pacientes quirúrgicos y su repercusión puede prolongarse en el tiempo en forma de alteraciones de la mecánica respiratoria, de la circulación pulmonar y de hipoxemia. El colapso alveolar se produce en presencia de ciertos factores predisponentes, fundamentalmente por mecanismos de compresión y absorción. Para prevenir o tratar estas atelectasias, se han propuesto diversas estrategias terapéuticas, como las maniobras de reclutamiento alveolar, cuyo uso se ha popularizado en los últimos años. Su aplicación en pacientes con colapso alveolar, pero sin lesión pulmonar aguda previa relevante, presenta ciertas particularidades, por lo que su empleo no está exento de incertidumbres y complicaciones. Esta revisión describe la frecuencia, la fisiopatología, la relevancia y el tratamiento de las atelectasias perioperatorias, y hace especial incidencia en el tratamiento con maniobras de reclutamiento con el objetivo de proporcionar las bases para un empleo racional y adecuado de éstas(AU)

Respiratory complications are a significant cause of post-operative morbidity and mortality. Peri-operative atelectasis, in particular, affects 90% of surgical patients and its effects can be prolonged, due to changes in respiratory mechanics, pulmonary circulation and hypoxaemia. Alveolar collapse is caused by certain predisposing factors, mainly by compression and absorption mechanisms. To prevent or treat these atelectasis several therapeutic strategies have been proposed, such as alveolar recruitment manoeuvres, which has become popular in the last few years. Its application in patients with alveolar collapse, but without a previous significant acute lung lesion, has some special features, therefore its use is not free of uncertainties and complications. This review describes the frequency, pathophysiology, importance and treatment of peri-operative atelectasis. Special attention is paid to treatment with recruitment manoeuvres, with the purpose of providing a basis for the their rational and appropriate use(AU)

[Peri-operative atelectasis and alveolar recruitment manoeuvres]. / Atelectasias perioperatorias y maniobras de reclutamiento alveolar.

Respiratory complications are a significant cause of post-operative morbidity and mortality. Peri-operative atelectasis, in particular, affects 90% of surgical patients and its effects can be prolonged, due to changes in respiratory mechanics, pulmonary circulation and hypoxaemia. Alveolar collapse is caused by certain predisposing factors, mainly by compression and absorption mechanisms. To prevent or treat these atelectasis several therapeutic strategies have been proposed, such as alveolar recruitment manoeuvres, which has become popular in the last few years. Its application in patients with alveolar collapse, but without a previous significant acute lung lesion, has some special features, therefore its use is not free of uncertainties and complications. This review describes the frequency, pathophysiology, importance and treatment of peri-operative atelectasis. Special attention is paid to treatment with recruitment manoeuvres, with the purpose of providing a basis for the their rational and appropriate use.

The effects of isoflurane and desflurane on intracranial pressure, cerebral perfusion pressure, and cerebral arteriovenous oxygen content difference in normocapnic patients with supratentorial brain tumors.

BACKGROUND: Desflurane is a volatile anesthetic agent with low solubility whose use in neurosurgery has been debated because of its effect on intracranial pressure and cerebral blood flow. The purpose of this study was to determine the variations on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) as well as on cerebral arteriovenous oxygen content difference (AVDo(2)) in normocapnic patients scheduled to undergo removal of supratentorial brain tumors with no evidence of mass effect during anesthesia with isoflurane or desflurane. METHODS: In 60 patients scheduled to undergo craniotomy and removal of supratentorial brain tumors with no evidence of midline shift, anesthesia was induced with intravenous fentanyl, thiopental, and vecuronium and was maintained with 60% nitrous oxide in oxygen. Patients were assigned to two groups randomized to receive 1 minimum alveolar concentration isoflurane or desflurane for 30 min. Heart rate, mean arterial pressure, intraparenchymal ICP, and CPP were monitored continuously. Before and after 30 min of continuous administration of the inhaled agents, AVDo(2) was calculated. RESULTS: There were no significant differences between groups in heart rate, mean arterial pressure, ICP, and CPP. ICP measurements throughout the study did not change within each group compared to baseline values. Mean arterial pressure decreased significantly in all patients compared to baseline values, changing from 105 +/- 14 mmHg (mean +/- SD) to 85 +/- 10 mmHg in the isoflurane group and from 107 +/- 11 mmHg to 86 +/- 10 mmHg in the desflurane group (P < 0.05 in both groups). CPP also decreased within each group compared with baseline values, changing from 95 +/- 15 mmHg to 74 +/- 11 mmHg in the isoflurane group and from 95 +/- 16 mmHg to 74 +/- 10 mmHg in the desflurane group (P < 0.05 in both groups). Cerebral AVDo(2) decreased significantly in both groups throughout the study, changing from 2.35 +/- 0.77 mm to 1.82 +/- 0.61 mm (mmol/l) in the isoflurane group (P < 0.05) and from 2.23 +/- 0.72 mm to 1.94 +/- 0.76 mm in the desflurane group (P < 0.05), without differences between groups. CONCLUSIONS: The results of this study indicate that there are no variations on ICP in normocapnic patients undergoing removal of supratentorial brain tumors without midline shift, as they were anesthetized with isoflurane or desflurane. CPP and cerebral AVDo(2) decreased with both agents.