Desarrollo de una herramienta de comunicación para la seguridad del paciente (Briefing). Experiencia en una unidad de cuidados intensivos de trauma y emergencias / Development of communication tool for patient safety (

Objetivo: Validar una herramienta de seguridad utilizada en sectores de alto riesgo (briefing de seguridad) en la medicina intensiva. Diseño: Estudio prospectivo, observacional y analítico. Ámbito: UCI de Trauma y Emergencias de un hospital terciario. Pacientes: Pacientes con trauma grave (Injury Severity Score-ISS>16). Intervención: Recogida de incidentes, relacionados con la seguridad del paciente (SP). Variables: Características de la población, estado de la unidad, incidentes de SP, aspectos de la herramienta e impacto sobre la cultura de seguridad. Resultados: Se incluyeron 441 pacientes (edad media 39,9±17,5 años), 75,15% hombres, 89% con trauma cerrado y un 10,5% de mortalidad. La herramienta se aplicó en 586 turnos de 798 posibles (73,4%) y se recogieron 942 incidentes (2,20 incidentes por paciente). Los incidentes más frecuentes se relacionaron con la medicación (20,7%), los dispositivos (colocación 4,03% y mantenimiento 17,8%) y la vía aérea y la ventilación mecánica (VM) (17,09%). Se estableció una correlación entre la presencia de incidentes y las características del enfermo (mayor Injury Severity Score, presencia de VM y terapias de reemplazo renal continuo) y con el estado de la unidad (más de 6 pacientes por turno sobre 8 posibles y el periodo vacacional). La herramienta influyó en diferentes aspectos de la cultura de seguridad de la unidad de manera significativa (frecuencia de comunicación, número de eventos, pérdida de carácter punitivo y trabajo de manera activa en SP). Conclusiones: El briefing es una herramienta para la recogida de los incidentes, simple, fácil de usar, útil para implantar mejoras e influir en la cultura de seguridad (AU)

Objective: To validate a safety tool used in high-risk sectors (safety briefing) in intensive care medicine. Design: A prospective, observational and analytical study was carried out. Setting: Trauma and emergency intensive care unit in a tertiary hospital. Patients: Patients with severe trauma (Injury Severity Score ISS>16). Intervention: Documentation of incidents related to patient safety (PS). Variables: Patients characteristics, state of the Unit, patient safety incidents, aspects of the tool (SP) and safety culture impact. Results: We included 441 patients (75.15% males, mean age 39.9±17.5 years), with blunt trauma in 89% and a 10.5% mortality rate. The tool was applied in 586 out of 798 possible shifts (73.4%), and documented 942 events (2.20 incidents per patient). The incidents were more frequently associated with medication (20.7%), devices (placement 4.03%, and maintenance 17.8%) and airway and mechanical ventilation (MV) (17.09%). A correlation was established between the occurrence of incidents and the characteristics of the patient (higher Injury Severity Score, presence of MV, and continuous renal replacement therapies) and the status of the Unit (more than 6 patients per shift out of 8 possible, and holiday period). The tool significantly influenced different aspects of the safety culture of the unit (communication frequency, number of events, punitive loss and active work in PS). Conclusions: Safety briefing is a tool for the documentation of incidents that is simple and easy to use, and is useful for implementing improvements and in influencing safety culture (AU)

[Development of communication tool for patient safety ("Briefing"). Experience in a trauma and emergency intensive care unit]. / Desarrollo de una herramienta de comunicación para la seguridad del paciente (Briefing). Experiencia en una unidad de cuidados intensivos de trauma y emergencias.

OBJECTIVE: To validate a safety tool used in high-risk sectors (safety briefing) in intensive care medicine. DESIGN: A prospective, observational and analytical study was carried out. SETTING: Trauma and emergency intensive care unit in a tertiary hospital. PATIENTS: Patients with severe trauma (Injury Severity Score ISS≥16). INTERVENTION: Documentation of incidents related to patient safety (PS). VARIABLES: Patients characteristics, state of the Unit, patient safety incidents, aspects of the tool (SP) and safety culture impact. RESULTS: We included 441 patients (75.15% males, mean age 39.9±17.5 years), with blunt trauma in 89% and a 10.5% mortality rate. The tool was applied in 586 out of 798 possible shifts (73.4%), and documented 942 events (2.20 incidents per patient). The incidents were more frequently associated with medication (20.7%), devices (placement 4.03%, and maintenance 17.8%) and airway and mechanical ventilation (MV) (17.09%). A correlation was established between the occurrence of incidents and the characteristics of the patient (higher Injury Severity Score, presence of MV, and continuous renal replacement therapies) and the status of the Unit (more than 6 patients per shift out of 8 possible, and holiday period). The tool significantly influenced different aspects of the safety culture of the unit (communication frequency, number of events, punitive loss and active work in PS). CONCLUSIONS: Safety briefing is a tool for the documentation of incidents that is simple and easy to use, and is useful for implementing improvements and in influencing safety culture.

Escalas predictivas de transfusión masiva en trauma. Experiencia de un registro de transfusiones / Massive transfusion predictive scores in trauma. Experience of a transfusion registry

Objetivo: Valorar la utilidad de diferentes escalas previamente descritas, en la predicción de transfusión masiva (TM) con un registro de transfusiones en trauma grave. Diseño: Estudio retrospectivo de cohortes. Ámbito: Unidad de Cuidados Intensivos de Trauma de un hospital terciario. Pacientes: Se incluyeron pacientes adultos con trauma grave (Injury Severity Score >15), admitidos desde octubre de 2006 hasta julio de 2009.Intervención: Ninguna. Variables: Se evaluaron las siguientes escalas y puntos de corte (PC): Trauma Associated Severe Haemorrhage (TASH) PC: ≥ 16 y ≥ 18; Assessment Blood Consumption (ABC) PC: ≥ 2 y Emergency Transfusion Score (ETS) PC: ≥ 3, ≥ 4 y ≥ 6. TM fue definida como la transfusión de 10 o más unidades de concentrados de hematíes (CH) en las primeras 24 horas del ingreso. Estudiamosla sensibilidad (S), especificidad (E), valor predictivo positivo y negativo (VPP y VPN), razones de verosimilitud positiva y negativa (RVP y RVN) y las curvas receiver-operating characteristics (ROC) y el área bajo las mismas (AUROC).Resultados: Se estudiaron 568 pacientes, el 77,6% hombres, con una edad media de 41,16 ± 18 años e ISS de 30 ± 13. El 93,8% con trauma cerrado. La frecuencia global de TM fue del 18,8%. La mejor S se obtuvo para el ETS ≥ 3 y la mejor especificidad con el TASH ≥ 18. El AUROC para los diferentes escalas fue: ABC: 0,779, ETS: 0,784 y el TASH: 0,889.Conclusiones: Estas escalas pueden ser útiles para caracterizar la población con TM, la exclusión de población de bajo riesgo, intentar ser objetivos en la resucitación con control de daños y apoyar las decisiones clínicas, con pocos datos y fáciles de obtener. (AU)

Objectives: Our purpose is to validate previously described massive transfusion (MT) scoring in our Transfusion Trauma Registry. Design: A retrospective cohort of adult trauma patients. Setting: Trauma and Emergency Intensive Care Unit of a tertiary hospital. Patients: Patients with severe trauma (injury severity score > 15) admitted from October 2006to July 2009.Interventions: None. Variables: The following MT scoring and cutoff points (CP) were evaluated: Trauma-Associated Severe Hemorrhage (TASH) CP: ≥ 16 and ≥ 18; Assessment Blood Consumption (ABC) CP: ≥ 2and Emergency Transfusion Score (ETS) CP: ≥ 3, ≥ 4, ≥ 6. MT was defined as the transfusion of10 units or more of packed red blood cells in the first 24 hours. We studied the sensivity (S),specifity (SP), and positive and negative predictive values (PPV, NPV), the positive and negative likehood ratios (LHR +, LHR-) and area under the receiver operating characteristic curve (ROC).Results: A total of 568 patients were available for analysis; 77.6% were men, with a mean age of 41.16 ± 18 years and an ISS of 30 ± 13. 93.8% with blunt trauma. The overall MT rate was18.8%. The best S was obtained with ETS ≥3 and best SP was obtained with TASH ≥18. ROC for different scores was: ABC: 0.779, ETS: 0. 784, TASH: 0.889.Conclusion: These scales can be useful for characterizing the TM population, for excluding low risk populations, and for attempting to be objective in hematological damage control and in supporting clinical decisions, based on fe1w and easily obtainable data (AU)

[Massive transfusion predictive scores in trauma. Experience of a transfusion registry]. / Escalas predictivas de transfusión masiva en trauma. Experiencia de un registro de transfusiones.

OBJECTIVES: Our purpose is to validate previously described massive transfusion (MT) scoring in our Transfusion Trauma Registry. DESIGN: A retrospective cohort of adult trauma patients. SETTING: Trauma and Emergency Intensive Care Unit of a tertiary hospital. PATIENTS: Patients with severe trauma (injury severity score>15) admitted from October 2006 to July 2009. INTERVENTIONS: None. VARIABLES: The following MT scoring and cutoff points (CP) were evaluated: Trauma-Associated Severe Hemorrhage (TASH) CP: ≥16 and ≥18; Assessment Blood Consumption (ABC) CP: ≥2 and Emergency Transfusion Score (ETS) CP: ≥3, ≥4, ≥6. MT was defined as the transfusion of 10 units or more of packed red blood cells in the first 24 hours. We studied the sensivity (S), specifity (SP), and positive and negative predictive values (PPV, NPV), the positive and negative likehood ratios (LHR +, LHR-) and area under the receiver operating characteristic curve (ROC). RESULTS: A total of 568 patients were available for analysis; 77.6% were men, with a mean age of 41.16 ± 18 years and an ISS of 30 ± 13. 93.8% with blunt trauma. The overall MT rate was 18.8%. The best S was obtained with ETS ≥3 and best SP was obtained with TASH ≥18. ROC for different scores was: ABC: 0.779, ETS: 0. 784, TASH: 0.889. CONCLUSION: These scales can be useful for characterizing the TM population, for excluding low-risk populations, and for attempting to be objective in hematological damage control and in supporting clinical decisions, based on fe1w and easily obtainable data.

[Prolonged sedation in Intensive Care Units]. / Sedación prolongada en Unidades de Cuidados Intensivos.

Sedation and analgesia constitute one of the cornerstones in the management of the critically ill patients. Most patients admitted to an Intensive Care Unit require prolonged sedation and analgesia. It has been demonstrated that adequate sedo- analgesia lessens stress-related events in the critically ill patients, facilitating their management and improving their outcomes. However, the use of sedatives and analgesics, especially when administered in continuous intravenous infusion, may have its complications derived from its infra or over utilization with proved impact on the outcome of critically ill patients. A proper monitoring and the implementation of sedation and analgesia protocols warrant the adequate management of existing sedatives aiding to avoid tolerance and dependency events. Strategies such as "sequential sedation", "dynamic sedation" or "daily sedation interruption" have been proposed as efficacious tools for the avoidance of complications related to prolonged sedation. In the present chapter, concepts related to prolonged sedation (meaning sedation for more than 72 hours) are reviewed; available agents are evaluated and strategies aimed to assure quality in its application are described.

[Loco-regional analgesia]. / Analgesia locorregional.

The epidural analgesia is one of the most effective techniques for pain relief when it is indicated, but it can present potentially serious complications that must precociously be diagnosed and be treated. In the Critical Care setting, epidural analgesia is used for pain control after surgery or major trauma. The technique is simple, a catheter is placed into a virtual cavity, so the administered drugs are absorbed through the epidural space into nerve roots. The administration of local anesthetics, opioids or the combination of both by epidural route (administered in continuous infusion or bolus), provides better analgesia. Also the clonidine can be used. In order to diagnose and to treat suitably the possible complications (pain, urinary retention, nauseas and vomits, itching, motor block, infection, respiratory depression, hypotension) a series of safety measures must be adopted (respiratory and heart rate, blood pressure, sedation score, sensory and motor level assessment, rate of diuresis, temperature and signs of infection).

Sedación prolongada en Unidades de Cuidados Intensivos / Prolonged sedation in intensive care units

La sedoanalgesia es uno de los pilares básicos del manejo del paciente crítico. La mayoría de los pacientes ingresados en una Unidad de Cuidados Intensivos requiere sedoanalgesia de forma prolongada. Una adecuada sedoanalgesia disminuye el grado de estrés del paciente crítico, facilitando su manejo y tratamiento y mejorando su pronóstico. Sin embargo, la sedoanalgesia, sobre todo en perfusión continua, es una práctica que no está exenta de complicaciones derivadas tanto de su infra-como de su sobre-utilización, que pueden empeorar el pronóstico de los pacientes críticos. Una adecuada monitorización y la aplicación de protocolos consensuados en sedoanalgesia garantizan la utilización adecuada de los sedantes evitando fenómenos de tolerancia y dependencia. Estrategias como la sedación secuencial, la sedación dinámica o la interrupción diaria de la sedación se han propuesto como herramientas útiles para evitar complicaciones asociadas a la sedación prolongada. En el presente capítulo se revisan conceptos relacionados con la sedación prolongada, entendida ésta como aquélla cuya duración es mayor de 72 horas; se evalúan los agentes disponibles y se proponen estrategias para garantizar la calidad de su aplicación (AU)

Sedation and analgesia constitute one of the cornerstones in the management of the critically ill patients. Most patients admitted to an Intensive Care Unit require prolonged sedation and analgesia. It has been demonstrated that adequate sedo-analgesia lessens stress-related events in the critically ill patients, facilitating their management and improving their outcomes. However, the use of sedatives and analgesics, especially when administered in continuous intravenous infusion, may have its complications derived from its infra or over utilization with proved impact on the outcome of critically ill patients. A proper monitoring and the implementation of sedation and analgesia protocols warrant the adequate management of existing sedatives aiding to avoid tolerance and dependency events. Strategies such as “sequential sedation”, “dynamic sedation” or “daily sedation interruption” have been proposed as efficacious tools for the avoidance of complications related to prolonged sedation. In the present chapter, concepts related to prolonged sedation (meaning sedation for more than 72 hours) are reviewed; available agents are evaluated and strategies aimed to assure quality in its application are described (AU)

Analgesia locorregional / Loco-regional analgesia

La analgesia epidural es una de las técnicas más eficaces para el alivio del dolor cuando está indicada, pero puede presentar complicaciones potencialmente graves que deben ser diagnosticadas y tratadas precozmente. Se emplea en Medicina Intensiva en el control del dolor posoperatorio y tras traumatismo grave. La técnica es sencilla: se coloca un catéter en una cavidad virtual permitiendo que los anestésicos locales difundan hasta las raíces nerviosas raquídeas. La administración de anestésicos locales, opiáceos o la combinación de ambos por vía epidural (ad- ministrados de forma intermitente o en infusión continua) proporciona una mejor analgesia. También puede emplearse la clonidina. Para diagnosticar y tratar adecuadamente las posibles complicaciones (dolor, retención urinaria, náuseas y vómitos, prurito, bloqueo motor, infección, depresión respiratoria e hipotensión) deben adoptarse una serie de medidas de seguridad (monitorización respiratoria y hemodinámica, nivel de consciencia, nivel sensitivo, ritmo de diuresis y signos de infección) (AU)

The epidural analgesia is one of the most effective techniques for pain relief when it is indicated, but it can present potentially serious complications that must precociously be diagnosed and be treated. In the Critical Care setting, epidural analgesia is used for pain control after surgery or major trauma. The technique is simple, a catheter is placed into a virtual cavity, so the administered drugs are absorbed through the epidural space into nerve roots. The administration of local anesthetics, opioids or the combination of both by epidural route (administered in continuous infusion or bolus), provides better analgesia. Also the clonidine can be used. In order to diagnose and to treat suitably the possible complications (pain, urinary retention, nauseas and vomits, itching, motor block, infection, respiratory depression, hypotension) a series of safety measures must be adopted (respiratory and heart rate, blood pressure, sedation score, sensory and motor level assessment, rate of diuresis, temperature and signs of infection) (AU)

[Characteristics of lung cancer in a region in northern Spain]. / Características del carcinoma broncopulmonar en una región del norte de España.

OBJECTIVE: To gather information on the disease characteristics and survival rate of patients diagnosed with bronchogenic carcinoma in the respiratory medicine departments of hospitals in Asturias, Spain. PATIENTS AND METHODS: This was a retrospective observational study carried out using a standardized data collection protocol. All cases of lung cancer diagnosed during 2001 were included provided there was cytologic or histologic confirmation or they fulfilled a series of clinical, radiological, and/or endoscopic criteria consistent with such a diagnosis. RESULTS: Standard incidence rates adjusted to the world population were 22.4, 42.6, and 4.6 per 100,000 population for the whole population, men, and women respectively. The mean (SD) age was 67 (10.9) years, and 92% of the patients were men. Overall, 98% of the men and 44% of the women were smokers. Diagnosis was confirmed by cytologic or histologic findings in 92% of patients, and the majority were non-small cell tumors (81.4%). At the time of diagnosis, 65% of the patients had advanced disease, with distant metastasis in 26.6% of the non-small cell cancers and 52.8% of the small cell cancers. Patients received surgical treatment in 21.3% of cases, chemotherapy alone or combined with radiation therapy in 43.1%, and radiation therapy alone in 9.3%. In 26.2% of patients only palliative care was given. Overall, median survival in weeks was 36.4 (95% confidence interval [CI], 29.4-43.4). Median survival by treatment type was as follows: 69.3 (95% CI, 49-9.5) for surgery; 39.6 (95% CI, 31.2-48) for chemotherapy alone or with radiation therapy; 30 (95% CI, 15.4-44.6) for radiation therapy alone; and 13.3 (95% CI, 5.9-20.6) for patients who received palliative care alone (P< .05). CONCLUSIONS: The findings with respect to age, sex, incidence, histology, extent of tumor, and smoking status of patients with bronchogenic carcinoma in our region does not differ significantly from those reported for other areas of Spain. Current smoking is the primary cause of the high prevalence of this disease. Twenty-six percent of patients received only palliative care. The percentage of patients treated with surgery was low.

Vancomicina en perfusión continua, una nueva pauta posológica en las Unidades de Cuidados Intensivos / Continuous Vancomycin Infusion, a new posological scheme for Intensive Care Units

Objetivo. Valorar la eficacia clínica y la incidencia de efectos adversos con la nueva pauta posológica de vancomicina en perfusión continua. Diseño. Estudio prospectivo, descriptivo durante 17 semanas, desde el 1 de septiembre hasta el 31 de diciembre de 2002. Ámbito. Unidad de Cuidados Intensivos (UCI) Polivalente del Hospital Universitario Doce de Octubre de Madrid. Pacientes. Se incluyeron todos los pacientes ingresados en la UCI mayores de 18 años de edad, con sospecha clínica o diagnóstico de infección por cocos grampositivos que fueron tratados con vancomicina en perfusión continua. Durante el período de estudio fueron ingresados 110 pacientes, de los cuales 18 fueron incluidos. Intervención. Se pautó una dosis inicial de carga de 15 mg/kg de peso administrada en 60 minutos, seguida de dosis de mantenimiento de 30 mg/kg de peso cada 12 horas en perfusión continua. Variables de interés principales. Monitorización de los niveles séricos de vancomicina cada 48 horas y de la función renal mediante la determinación de creatinina sérica diaria y el cálculo de aclaramiento de creatinina basal previa al inicio de la perfusión de vancomicina y semanalmente. Resultados. Fueron incluidos en el estudio 18 pacientes de los cuales 14 fueron mujeres. La edad media fue de 61,9 años. El APACHE II medio al ingreso fue de 16,7. Los motivos de ingreso más frecuentes fueron: shock séptico de distintas etiologías, 7 enfermos; insuficiencia respiratoria en 6. El antibiótico se pautó de forma empírica en 4 pacientes. El microorganismo más frecuentemente aislado en los cultivos microbiológicos fue el Staphylococcus epidermidis, 7. La dosis media de vancomicina administrada fue de 25,8 mg/kg/día. Los niveles plasmáticos medios de vancomicina fueron 18,15 µg/ml. La duración media del tratamiento fue de 13,8 días. Se asociaron antibióticos ß-lactámicos en todos los pacientes y aminoglucósidos en 11. En 2 pacientes se suspendió el tratamiento por deterioro de la función renal. Once pacientes presentaron mejoría, en 4 hubo fracaso terapéutico y 3 fallecieron. Conclusiones. La administración de vancomicina en perfusión continua se asocia a una eficacia clínica ligeramente mayor y menores efectos adversos que los descritos con la administración de dosis múltiples. Asimismo supone mayor comodidad de administración, disminución de las cargas de trabajo de enfermería y menor manipulación de los catéteres intravasculares

Aim. To evaluate the clinical effectiveness and incidence of adverse effects related to the new posological scheme of continous vancomycin infusion. Design. Prospective, descriptive 17-week study realized September 1, 2002 to December 31, 2002. Location. Multipurpose Intensive Care Unit of University Hospital Doce de Octubre in Madrid. Patients. There were included all over-18-year-old patients admitted to the Intensive Care Unit for clinically suspected or diagnosed gram-positive cocci infection, and who were receiving treatment with continuous vancomycin infusion. There were 110 patients admitted during the period of study, of which 18 were included. Intervention. There was ordered an initial dose of 15 mg/kg administered over 60 minutes, followed by a maintenance dose in continuous infusion of 30 mg/kg every 12 hours. Main variables of interest. Monitoring of vancomycin serum levels every 48 hours, and of renal function through the daily determination of serum creatinine levels and calculation of basal creatinine clearance at the beginning of vancomycin infusion and weekly thereafter. Results. There were included in the study 18 patients, of whom 14 were women. Average age was 61.9 years old. Average APACHE II scores at time of admittance was 16.7. Most common reasons for admittance were: septic shock of varying ethiology (7 patients), and respiratory failure (6 patients). Antibiotics were empirically prescribed in 4 patients. The microorganism more commonly isolated in microbiological cultures was Staphylococcus epidermidis (7 patients). The average dose of vancomycin administered was 25.8 mg/kg/day. Average plasma levels of vancomycin were 18.15 µg/ml. Average duration of the treatment was 13.8 days. Also included were the use of ß-lactamic antibiotics in all patients, and aminoglycoside antibiotics in 11. Treatment was suspended in 2 patients due to deterioration in renal function. Eleven patients showed improvement, in 4 there was therapeutic failure and 3 patients expired. Conclusions. The administration of continuous vancomycin infusion is associated with slightly greater clinical effectiveness and fewer adverse effects than those described for multiple-dose administrations. It is also easier to administer, requires less work on the part of nursing staff and reduces manipulation of intravenous catheters

[Sarcoidosis in a sanitary area at Leon (Spain). Epidemiology and clinical features]. / Sarcoidosis en el área sanitaria de León. Epidemiología y clínica.

BACKGROUND: The incidence of sarcoidosis is different among distincts geographic areas, probably due to climate variations. At present, there is in Spain few studies that correlate the observed cases with a concrete population. The aim of this study is to investigate the epidemiology of sarcoidosis in Leon"s sanitary area, in comparison with others spanish geographic areas. Moreover, we present a description of the clinic and radiologic characteristics of the studied cases. METHOD: We analyzed the cases of sarcoidosis attended in the area from 1993 until 2001. The incidence, age, sex, place of residence and clinic-radiologic characteristics are described. The population data of the sanitary area to calculate the incidence were obtain from the Insalud"s data base. The climatology values were collected from the National Institute of Meteorology. RESULTS: The incidence of sarcoidosis in Leon"s sanitary area was 1,37/100.000 habitants/year, and was similar to that founded in Catalonia, Galizia and others provinces of the Castilla and Leon community. We observed a higher incidence of sarcoidosis in female patients, because of predominance of cases among women aged forty years or more. No differences between rural and urban populations were founded. The clinical characteristics were similar those described in other geographics areas of our country. CONCLUSION: Although there are climate differences between the geographics areas of Spain, these aren"t enough to explain his influence in the incidence of sarcoidosis, which is similar in all of them, at least in the middle north of the country.