Handover in Intensive Care. / Traspaso de información en Medicina Intensiva.

Handover is a frequent and complex task that also implies the transfer of the responsibility of the care. The deficiencies in this process are associated with important gaps in clinical safety and also in patient and professional dissatisfaction, as well as increasing health cost. Efforts to standardize this process have increased in recent years, appearing numerous mnemonic tools. Despite this, local are heterogeneous and the level of training in this area is low. The purpose of this review is to highlight the importance of IT while providing a methodological structure that favors effective IT in ICU, reducing the risk associated with this process. Specifically, this document refers to the handover that is established during shift changes or nursing shifts, during the transfer of patients to other diagnostic and therapeutic areas, and to discharge from the ICU. Emergency situations and the potential participation of patients and relatives are also considered. Formulas for measuring quality are finally proposed and potential improvements are mentioned especially in the field of training.

Valor pronóstico de la proteína fijadora de lipopolisácaridos y la procalcitonina en pacientes consepsis grave y shock séptico ingresados en una unidad de cuidados intensivos / Prognostic value of lipopolysaccharide binding protein and procalcitonin in patients with severe sepsis and septic shock admitted to intensive care

OBJETIVOS: 1) Valorar la utilidad pronóstica de la determinación inicial y seriada de la proteína fijadora de lipopolisacáridos (LBP) y de la procalcitonina (PCT) y 2) evaluar si su adicción a los scores de gravedad mejoraría su valor pronóstico. DISEÑO: Estudio prospectivo observacional. ÁMBITO: Unidad de Cuidados Intensivos de un hospital general universitario. PACIENTES: Se incluyó a 100 pacientes ingresados por sepsis grave/shock séptico. Variables de interés Datos demográficos, APACHE II y SOFA, concentración de PCT y LBP inicial y a las 48 h y mortalidad hospitalaria. RESULTADOS: Los scores APACHE II al ingreso y SOFA a las 48 h presentaron el mayor rendimiento como predictores de mortalidad hospitalaria (AUC ROC: 0,75 para ambos). La concentración inicial de PCT y LBP y el aclaramiento de LBP fueron similares en pacientes supervivientes y fallecidos. Solo el aclaramiento de PCT fue superior en supervivientes respecto a los fallecidos (AUC ROC: 0,66). La combinación de los scores de gravedad con el aclaramiento de PCT no mejoró su valor pronóstico. CONCLUSIONES: La concentración inicial de LBP y de PCT y el aclaramiento de LBP no presentaron valor pronóstico en pacientes con sepsis grave/shock séptico. Solo el aclaramiento de PCT se comportó como predictor de mortalidad hospitalaria. El rendimiento de los scores APACHE II al ingreso y SOFA a las 48 h fue superior al de los biomarcadores analizados y la adición del aclaramiento de PCT no aumentó su valor pronóstico

AIMS: 1) To assess the prognostic value of levels on admission and serial measurements of lipopolysaccharide binding protein (LBP) and procalcitonin (PCT) in relation to in-hospital mortality; and 2) to determine whether the addition of these parameters to severity scores (APACHE II and SOFA) is able to improve prognostic accuracy. DESIGN: A single-center, prospective observational study was carried out. Setting Intensive Care unit of a university hospital. PATIENTS: One hundred severe sepsis and septic shock patients were included. Data collected Demographic data, APACHE II and SOFA scores, PCT and LBP levels on admission and after 48hours, and in-hospital mortality. RESULTS: The best area under the curve for predicting in-hospital mortality corresponded to APACHE II on admission and SOFA after 48h (AUC ROC: 0.75 for both). PCT and LBP levels on admission and LBP clearance were not statistically different between in-hospital survivors and non-survivors. Only PCT clearance was higher among in-hospital survivors than in non-survivors (AUC ROC: 0.66). The combination of severity scores and PCT clearance did not result in superior areas under the curve. CONCLUSIONS: LBP and PCT levels on admission and LBP clearance showed no prognostic value in severe sepsis and septic shock patients. Only PCT clearance was predictive of in-hospital mortality. The prognostic accuracy was significantly better for APACHE on admission and SOFA after 48h than for any of the analyzed biomarkers, and the addition of PCT clearance did not improve their prognostic value

[Prognostic value of lipopolysaccharide binding protein and procalcitonin in patients with severe sepsis and septic shock admitted to intensive care]. / Valor pronóstico de la proteína fijadora de lipopolisácaridos y la procalcitonina en pacientes con sepsis grave y shock séptico ingresados en una unidad de cuidados intensivos.

AIMS: 1) To assess the prognostic value of levels on admission and serial measurements of lipopolysaccharide binding protein (LBP) and procalcitonin (PCT) in relation to in-hospital mortality; and 2) to determine whether the addition of these parameters to severity scores (APACHE II and SOFA) is able to improve prognostic accuracy. DESIGN: A single-center, prospective observational study was carried out. SETTING: Intensive Care unit of a university hospital. PATIENTS: One hundred severe sepsis and septic shock patients were included. DATA COLLECTED: Demographic data, APACHE II and SOFA scores, PCT and LBP levels on admission and after 48 hours, and in-hospital mortality. RESULTS: The best area under the curve for predicting in-hospital mortality corresponded to APACHE II on admission and SOFA after 48 h (AUC ROC: 0.75 for both). PCT and LBP levels on admission and LBP clearance were not statistically different between in-hospital survivors and non-survivors. Only PCT clearance was higher among in-hospital survivors than in non-survivors (AUC ROC: 0.66). The combination of severity scores and PCT clearance did not result in superior areas under the curve. CONCLUSIONS: LBP and PCT levels on admission and LBP clearance showed no prognostic value in severe sepsis and septic shock patients. Only PCT clearance was predictive of in-hospital mortality. The prognostic accuracy was significantly better for APACHE on admission and SOFA after 48 h than for any of the analyzed biomarkers, and the addition of PCT clearance did not improve their prognostic value.

Incidence, clinical characteristics, and prognostic significance of right bundle-branch block in acute myocardial infarction: a study in the thrombolytic era.

BACKGROUND: Whereas the significance of right bundle-branch block (RBBB) in acute myocardial infarction was extensively studied in the prethrombolytic era, a possible change in the overall incidence and meaning of RBBB as a consequence of thrombolytic therapy is not well known. METHODS AND RESULTS: A multicenter, prospective study of 1238 patients consecutively diagnosed with acute myocardial infarction and admitted to three coronary care units was conducted. ECGs during the acute phase and clinical events until discharge and 1-year follow-up were monitored. In the 135 (10.9%) patients in whom RBBB was found, there were 51 (37.8%) new cases, 46 (34.1%) old cases, and 38 (28.1%) cases with an indeterminate time of origin. New RBBB was permanent in 26 and transient in 25 patients. RBBB was isolated in 76 (56%) and bifascicular in the remaining 59 (44%) patients. The following complications were more frequently associated with RBBB than non-RBBB patients: heart failure, 24% versus 46% (P<.001); use of pacemaker because of atrioventricular block, 3.6% versus 11% (P<.001); and 1-year mortality, 17.6% versus 40.7% (P<.001). Early mortality was significantly higher for new RBBB (43.1%, P<.001) than for old (15.5%) and indeterminate (15.3%) RBBB. These figures for 1-year mortality were 58.8% (P<.001), 35.5 (P<.01), and 23% (NS), respectively. Permanent and transient RBBB had different mortality rates: early mortality, 76% versus 8%, and 1-year mortality, 84% versus 32% (P<.001 for both). For isolated RBBB versus bifascicular block, early mortality was 14.4% versus 40.6%, and 1-year mortality was 30.2% versus 54.2% (P<.05 for both). Multivariate analysis showed an independent prognostic value of RBBB for early and 1-year mortality. CONCLUSIONS: The overall meaning of RBBB in acute myocardial infarction has not changed in the thrombolytic era, although a higher rate of new and transient RBBB and a lower rate of bifascicular block may represent a beneficial effect of thrombolytic therapy.