Systematic Review of Automated Diuresis Measurement in Critically Ill Patients.

The measurement of urinary flow is a vital medical indicator for critically ill patients in intensive care units. However, there is a clinical need to automate the real-time measurement of diuresis using Internet of Medical Things devices, allowing continuous monitoring of urine flow. A systematic review of scientific literature, patents, and available commercial products was conducted, leading to the conclusion that there is no suitable device to fulfill this need. We identified six characteristics that such a device should possess: minimizing contact with urine, detecting changes in flow patterns, the ability to record minute-by-minute data, capable of sending early alerts, not relying on exclusive disposable components, and being user-friendly for clinical professionals. Additionally, cost-effectiveness is crucial, encompassing the device, infrastructure, maintenance, and usage.

Development of a urinometer for automatic measurement of urine flow in catheterized patients.

Urinary flow measurement and colorimetry are vital medical indicators for critically ill patients in intensive care units. However, there is a clinical need for low-cost, continuous urinary flow monitoring devices that can automatically and in real-time measure urine flow. This need led to the development of a non-invasive device that is easy to use and does not require proprietary disposables. The device operates by detecting urine flow using an infrared barrier that returns an unequivocal pattern, and it is capable of measuring the volume of liquid in real-time, storing the history with a precise date, and returning alarms to detect critical trends. The device also has the ability to detect the color of urine, allowing for extended data and detecting problems in catheterized patients such as hematuria. The device is proposed as an automated clinical decision support system that utilizes the concept of the Internet of Medical Things. It works by using a LoRa communication method with the LoRaWAN protocol to maximize the distance to access points, reducing infrastructure costs in massive deployments. The device can send data wirelessly for remote monitoring and allows for the collection of data on a dashboard in a pseudonymous way. Tests conducted on the device using a gold standard medical grade infusion pump and fluid densities within the 1.005 g/ml to 1.030 g/ml urine density range showed that droplets were satisfactorily captured in the range of flows from less than 1 ml/h to 500 ml/h, which are acceptable ranges for urinary flow. Errors ranged below 15%, when compared to the values obtained by the hospital infusion pump used as gold standard. Such values are clinically adequate to detect changes in diuresis patterns, specially at low urine output ranges, related to renal disfunction. Additionally, tests carried out with different color patterns indicate that it detects different colors of urine with a precision in detecting RGB values <5%. In conclusion, the results suggest that the device can be useful in automatically monitoring diuresis and colorimetry in real-time, which can facilitate the work of nursing and provide automatic decision-making support to intensive care physicians.

Trombólisis intraarterial en paciente COVID-19 con isquemia aguda en extremidadinferior / Intraarterial thrombolysis in a COVID-19 patient with acute lower limb ischemia

La trombólisis dirigida por catéter es un procedimiento considerado de elección y aceptado, con muy buenos resultados en los casos de trombosis arteriales del lecho distal. Los pacientes con infección por COVID-19 y trombosisarteriales representan una subpoblación de pacientes críticos que condiciona el uso de determinadas técnicasquirúrgicas de revascularización.

Catheter-directed thrombolysis is an accepted procedure with very good results in cases of arterial thrombosis ofthe distal territory, being considered of choice. Patients with COVID-19 infection and arterial thrombosis representa subpopulation of critically ill patients that conditions the use of certain revascularization surgical techniques.

Trifecta Bioprosthesis Sudden-Onset Three-Leaflet Detachment.

Acute bioprosthesis failure is an uncommon event that may require urgent surgery. This is even less frequent when it is not associated with endocarditis, thrombus formation, or structural valve deterioration. We describe an acute complete detachment of the 3 leaflets of a Trifecta tissue valve 6 years after implantation in a patient who suddenly experienced strong chest pain with severe dyspnea. In the operating room, total detachment of the 3 leaflets from the scalloped cuff and from 1 of the cusps was observed. No signs of endocarditis or leaflet calcifications were found.

Docencia de la Medicina Intensiva. Aspectos bioéticos / Teaching Intensive Care Medicine. Bioethical aspects / La docència de la Medicina Intensiva. Aspectes bioètic

Cualquier acto médico presenta siempre una doble vertiente, técnica y moral. La bioética, surge como herramienta clave para poder conjugar ambos aspectos en la toma diaria de decisiones médicas. Además, docencia y aprendizaje estarán presentes de forma patente durante toda la vida profesional de la mayoría de los médicos. En la actualidad, los avances obtenidos por la comunidad universitaria en cuanto a la docencia de la bioética son notables. No han sido tan claro, sin embargo, para la formación durante la residencia ni tras la especialidad. El contexto de la Medicina Intensiva, dedicada a pacientes con enfermedades críticas, ofrece una serie de particularidades que pueden ser beneficiosas para el aprendizaje de muchos aspectos bioéticos. Estos incluyen, entre otros, el respeto a la autonomía del paciente, la búsqueda de la beneficencia, incluso durante los cuidados al final de la vida, o la toma de decisiones en equipo o en situaciones de extrema urgencia. En cuanto al modo de enseñanza de la bioética existen diferentes aproximaciones, desde la clásica clase magistral a la clase invertida o el método del caso, que tiene su mayor exponente en la simulación. Nuestra propuesta particular consiste en la integración de la práctica y la discusión en grupo como elemento fundamental de la enseñanza de la bioética, ayudada de las metodologías más recientes, fundamentalmente, de la simulación. Cualquier acto médico presenta siempre una doble vertiente, técnica y moral. La bioética, surge como herramienta clave para poder conjugar ambos aspectos en la toma diaria de decisiones médicas. Además, docencia y aprendizaje estarán presentes de forma patente durante toda la vida profesional de la mayoría de los médicos. En la actualidad, los avances obtenidos por la comunidad universitaria en cuanto a la docencia de la bioética son notables. No han sido tan claro, sin embargo, para la formación durante la residencia ni tras la especialidad. El contexto de la Medicina Intensiva, dedicada a pacientes con enfermedades críticas, ofrece una serie de particularidades que pueden ser beneficiosas para el aprendizaje de muchos aspectos bioéticos. Estos incluyen, entre otros, el respeto a la autonomía del paciente, la búsqueda de la beneficencia, incluso durante los cuidados al final de la vida, o la toma de decisiones en equipo o en situaciones de extrema urgencia. En cuanto al modo de enseñanza de la bioética existen diferentes aproximaciones, desde la clásica clase magistral a la clase invertida o el método del caso, que tiene su mayor exponente en la simulación. Nuestra propuesta particular consiste en la integración de la práctica y la discusión en grupo como elemento fundamental de la enseñanza de la bioética, ayudada de las metodologías más recientes, fundamentalmente, de la simulación

All medical action always includes a double perspective: technical and moral. Bioethics emerges as a key tool to combine both aspects when medical decisions are taken in the daily work of a physician. In addition, teaching and learning are always clearly present in the working life of the majority of the practitioners. Currently, the advances of teaching Bioethics reached by the university community are remarkable. However, it was not so clear the level to the training during the medical residency and after the specialty. The context of Intensive Care Medicine dedicated to patients with critical diseases offers some characteristics which might be beneficial to the learning of a wide variety of bioethical aspects. These include, among others, the respect of the patient’s autonomy, the search of beneficence, also during end-oflife care, decision making in groups or in extreme emergency cases. Related to the way of teaching Bioethics, there are different approaches, from the master class to the flipped class or the case method whose greatest exponent is simulation. Our particular proposal consists in the integration of practice and discussion in groups as essential element in teaching Bioethics, helped by some recent methodologies like simulation

Qualsevol acte mèdic presenta sempre un doble vessant, a la vegada tècnic i moral. La bioètica sorgeix com a eina clau per poder conjugar tots dos aspectes en la presa diària de decisions mèdiques. A més, docència i aprenentatge estaran presents de forma palesa durant tota la vida professional de la majoria dels metges. En l'actualitat, els avanços obtinguts per la comunitat universitària quant a la docència de la bioètica són notables. No ha estat tan clar, no obstant això, per a la formació durant la residència ni després de l'especialitat. El context de la Medicina Intensiva, dedicada a pacients amb malalties crítiques, ofereix una sèrie de particularitats que poden ser beneficioses per a l'aprenentatge de molts aspectes bioètics, que inclouen, entre altres, el respecte a l'autonomia del pacient, la recerca de la beneficència, fins i tot durant les cures al final de la vida, o la presa de decisions en equip o en situacions d'extrema urgència. Quant a la manera d'ensenyar la bioètica, existeixen diferents aproximacions, des de la clàssica classe magistral a la classe invertida o el mètode del cas, que té el seu major exponent en la simulació. La nostra proposta particular consisteix en la integració de la pràctica i la discussió en grup com a element fonamental de l'ensenyament de la bioètica, ajudada per les metodologies més recents, i fonamentalment de la simulació

Relationship between volume and survival in closed intensive care units is weak and apparent only in mechanically ventilated patients.

BACKGROUND: Recent studies have found an association between increased volume and increased intensive care unit (ICU) survival; however, this association might not hold true in ICUs with permanent intensivist coverage. Our objective was to determine whether ICU volume correlates with survival in the Spanish healthcare system. METHODS: Post hoc analysis of a prospective study of all patients admitted to 29 ICUs during 3 months. At ICU discharge, the authors recorded demographic variables, severity score, and specific ICU treatments. Follow-up variables included ICU readmission and hospital mortality. Statistics include logistic multivariate analyses for hospital mortality according to quartiles of volume of patients. RESULTS: The authors studied 4,001 patients with a mean predicted risk of death of 23% (range at hospital level: 14-46%). Observed hospital mortality was 19% (range at hospital level: 11-35%), resulting in a standardized mortality ratio of 0.81 (range: 0.5-1.3). Among the 1,923 patients needing mechanical ventilation, the predicted risk of death was 32% (14-60%) and observed hospital mortality was 30% (12-61%), resulting in a standardized mortality ratio of 0.96 (0.5-1.7). The authors found no correlation between standardized mortality ratio and ICU volume in the entire population or in mechanically ventilated patients. Only mechanically ventilated patients in very low-volume ICUs had slightly worse outcome. CONCLUSION: In the currently studied healthcare system characterized by 24/7 intensivist coverage, the authors found wide variability in outcome among ICUs even after adjusting for severity of illness but no relationship between ICU volume and outcome. Only mechanically ventilated patients in very low-volume centers had slightly worse outcomes.

Mortalidad tras el alta de la Unidad de Cuidados Intensivos y factores pronósticos relacionados en una cohorte de pacientes críticos con disfunción multiorgánica / Post-Intensive Care Unit mortality and related prognostic factors in a cohort of critically ill patients with multi-organ dysfunction

Fundamento y objetivo: Evaluar la mortalidad tras el alta de la Unidad de Cuidados Intensivos –post-UCI– (hospitalaria y seguimiento a un año) y los factores asociados. Pacientes y método: Diseño de cohortes en enfermos medicoquirúrgicos con síndrome de disfunción multiorgánica (SDMO) durante sus primeras 24h de ingreso. Se registraron antecedentes personales, situación basal, datos generales de ingreso en UCI, estancia hospitalaria y datos de supervivencia mediante contacto telefónico al año. Se evaluó la mortalidad en cualquier momento del seguimiento, relizando una regresión de Cox para valorar factores de mortalidad. Resultados: Se reclutaron 545 pacientes. En el total del período de estudio fallecieron 256 pacientes (52,9%); de los ingresados en UCI fallecieron el 29,5%, mientras que de los 384 enfermos que pasaron a planta falleció el 14,8%. De los 327 enfermos dados de alta hospitalaria se ha contactado con el 81,3% (266 pacientes), de los que han fallecido el 14,3%. Los factores relacionados con la muerte hospitalaria fueron la edad (odds ratio [OR] 1,04; intervalo de confianza del 95% [IC 95%] 1,02-1,06; p<0,01) y una situación basal funcional disminuida (OR 1,7; IC 95% 1,1-2,9; p<0,05). Las variables relacionadas con la mortalidad posthospitalaria fueron: una situación basal funcional disminuida (OR 2,42; IC 95% 1,23-4,75; p<0,01) y el reingreso tras el alta hospitalaria (OR 1,45; IC 95% 1,19-1,76; p<0,001). Conclusiones: Los pacientes ingresados por un SDMO medicoquirúrgico presentan una mortalidad al año de seguimiento del 52,9%. Los factores que más influyen en la mortalidad hospitalaria son la edad y una situación funcional basal disminuida, ambos factores no modificables. Tras el alta hospitalaria, la situación funcional basal disminuida sigue siendo transcendental, junto con el reingreso hospitalario (AU)

Background and objective: To assess the post-Intensive Care Unit (ICU) mortality (in-hospital and one year after hospital discharge) and the associated factors. Patients and method: Cohort design in medical-surgical patients with multi-organ dysfunction syndrome (MODS) during the first 24h of admission to ICU. We recorded the following data: personal background, functional general situation, general information about admission to ICU, hospital stay and contact by phone after one year of hospital discharge. We registered mortality at the follow-up at anytime. Cox regression was performed to evaluate mortality factors. Results: Five hundred and forty five patients were recruited. During the study period 256 patients (52.9%) died; out of them 29.5% in ICU; 14.8% of 384 patients transferred to the ward died. Of 327 discharged patients, 266 (81.3%) were contacted; 14.3% of those had died. In-hospital death-related factors were age (odds ratio [OR] 1.04; 95% confidence interval [95% CI] 1.02-1.06; P<.01) and a decreased functional general status (OR 1.7; 95% CI 1.1-2.9; P<.05). Post-hospitalisation mortality-related variables were: diminished functional general status (OR 2.42; 95% CI 1.23-4.75; P<.01) and readmission after discharge from hospital (1.45 OR; 95% CI 1.19-1.76; P<.001). Conclusions: Patients admitted for a medical-surgical MODS presented a mortality of 52.9% within one year. The factors influencing hospital mortality are age and a generally diminished functional status, both being not modifiable factors. After discharge, the decreased general functional status remained central along with the re-hospitalisation (AU)

Clinical presentation of acute coronary syndrome in patients previously treated with nitrates.

AIMS: Several reports have suggested that nitrates limit acute ischaemic damage by a mechanism similar to preconditioning. This study aims to evaluate the effect of chronic oral nitrates on the clinical presentation and short-term outcomes of patients admitted with acute coronary syndrome (ACS). METHODS: A retrospective cohort study was conducted in patients with ACS admitted to 62 acute care units from 2010 to 2011. A propensity score-matched samples analysis was performed. RESULTS: We analysed 3171 consecutive patients, of whom 298 (9.4%) were chronically treated with nitrates. Patients previously treated with nitrates had higher comorbidity and disease severity at admission, lower prevalence of ACS with ST elevation, lower troponin elevation, higher prevalence of initial Killip class 2-4 and higher hospital mortality. The propensity score-matched analysis confirmed that previous use of nitrates is independently associated with a lower prevalence of ST-elevation ACS [odds ratio (OR) 0.53, 95% confidence interval (CI) 0.36-0.78; P = 0.0014] and a lower troponin elevation (OR 0.61, 95% CI 0.41-0.92) but not with Killip class on admission (OR 1.18, 95% CI 0.83-1.67, P = 0.3697) or mortality (OR 0.71, 95% CI 0.37-1.38, P = 0.3196). CONCLUSION: The results support the hypothesis that nitrates have a protective effect on acute ischaemic injury.

[Post-Intensive Care Unit mortality and related prognostic factors in a cohort of critically ill patients with multi-organ dysfunction]. / Mortalidad tras el alta de la Unidad de Cuidados Intensivos y factores pronósticos relacionados en una cohorte de pacientes críticos con disfunción multiorgánica.

BACKGROUND AND OBJECTIVE: To assess the post-Intensive Care Unit (ICU) mortality (in-hospital and one year after hospital discharge) and the associated factors. PATIENTS AND METHOD: Cohort design in medical-surgical patients with multi-organ dysfunction syndrome (MODS) during the first 24h of admission to ICU. We recorded the following data: personal background, functional general situation, general information about admission to ICU, hospital stay and contact by phone after one year of hospital discharge. We registered mortality at the follow-up at anytime. Cox regression was performed to evaluate mortality factors. RESULTS: Five hundred and forty five patients were recruited. During the study period 256 patients (52.9%) died; out of them 29.5% in ICU; 14.8% of 384 patients transferred to the ward died. Of 327 discharged patients, 266 (81.3%) were contacted; 14.3% of those had died. In-hospital death-related factors were age (odds ratio [OR] 1.04; 95% confidence interval [95% CI] 1.02-1.06; P<.01) and a decreased functional general status (OR 1.7; 95% CI 1.1-2.9; P<.05). Post-hospitalisation mortality-related variables were: diminished functional general status (OR 2.42; 95% CI 1.23-4.75; P<.01) and readmission after discharge from hospital (1.45 OR; 95% CI 1.19-1.76; P<.001). CONCLUSIONS: Patients admitted for a medical-surgical MODS presented a mortality of 52.9% within one year. The factors influencing hospital mortality are age and a generally diminished functional status, both being not modifiable factors. After discharge, the decreased general functional status remained central along with the re-hospitalisation.