Monitorización de la glucemia en el paciente crítico adulto: tipo de muestra y método de análisis. Revisión sistemática y metanálisis / Blood glucose monitoring in critically ill adult patients: Type of sample and method of analysis. Systematic review and meta-analysis

IntroducciónLa guía clínica para el manejo de la sepsis recomienda usar muestras de sangre arterial para el control glucémico. Un estudio multicéntrico en 86 unidades de cuidados intensivos españolas reveló que el 85,4% de estas utilizaban punción capilar.ObjetivoAnalizar la fiabilidad de la glucemia comparando diferentes muestras sanguíneas (arterial, venosa, capilar) e instrumentos (glucómetros, gasómetros, laboratorio central). Secundariamente, estimar el efecto de variables confusoras y el rendimiento de los instrumentos de medición determinados por las diferentes normas de calidad.MetodologíaRevisión sistemática y metanálisis con búsqueda en las bases de datos PubMed, CINAHL y Embase en septiembre-2021 y septiembre-2022, sin límites temporales ni idiomáticos. Fuentes de literatura gris: DART-Europe, OpenGrey y Google Académico. Resultados resumidos mediante síntesis cualitativa (descripción de resultados, características de los estudios) y cuantitativa (metanálisis para evaluar la diferencia de medias estandarizadas). Calidad metodológica de artículos evaluada con Quality Assessment of Diagnostic Accuracy Studies-2. Protocolo: https://osf.io/ DOI 10.17605/OSF.IO/T8KYP.ResultadosSe incluyeron un total de 32 artículos y 5.451 pacientes. No se obtuvieron discrepancias entre muestras arteriales con glucómetro vs. laboratorio (sesgo [IC95%]: 0,01 [−0,12 a 0,14] mg/dL). En cambio, muestras arteriales con gasómetro sí sobreestimaron de forma significativa (sesgo [IC95%]: 0,12 [0,01 a 0,24] mg/dL). La misma tendencia presentan capilares con glucómetro, aunque no de forma significativa (sesgo [IC95%]: 0,07 [−0,02 a 0,15] mg/dL). Hay discrepancia entre los estudios sobre el efecto del hematocrito y el equilibrio ácido-base. El mayor consenso se da en la poca concordancia del glucómetro con muestras capilares vs. laboratorio en presencia de shock y soporte vasopresor, situación de fallo renal o durante el tratamiento con vitamina C.Conclusiones... (AU)

IntroductionThe clinical guideline for the management of sepsis recommends using arterial blood samples for glycaemic control. A multicentre study in 86 Spanish intensive care units revealed that 85.4% of these used capillary puncture.ObjectiveTo analyse the reliability of glycaemia by comparing different blood samples (arterial, venous, capillary) and instruments (glucometers, gasometers, central laboratory). Secondarily, to estimate the effect of confounding variables and the performance of measuring instruments as determined by different quality standards.MethodologySystematic review and meta-analysis with search in PubMed, CINAHL and Embase databases in September-2021 and September-2022, with no time or language limits. Grey literature sources: DART-Europe, OpenGrey and Google Scholar. Results summarised by qualitative (description of results, study characteristics) and quantitative (meta-analysis to assess standardised mean difference) synthesis. Methodological quality of articles assessed with Quality Assessment of Diagnostic Accuracy Studies-2. Protocol: https://osf.io/ DOI 10.17605/OSF.IO/T8KYP.ResultsA total of 32 articles and 5451 patients were included. No discrepancies were obtained between arterial glucometer vs. laboratory samples (bias [95%CI]: 0.01 [−0.12 to 0.14] mg/dL). In contrast, arterial samples with a gasometer did significantly overestimate (bias [95%CI]: 0.12 [0.01 to 0.24] mg/dL). The same trend is seen in capillaries with a glucometer, although not significantly (bias [95%CI]: 0.07 [−0.02 to 0.15] mg/dL). There is discrepancy between studies on the effect of haematocrit and acid-base balance. The greatest consensus is on the poor agreement of glucometer with capillary vs. laboratory samples in the presence of shock and vasopressor support, renal failure or during vitamin C treatment.Conclusions... (AU)

Monitorización de la glucemia en el paciente crítico adulto: tipo de muestra y método de análisis. Revisión sistemática y metanálisis / Blood glucose monitoring in critically ill adult patients: Type of sample and method of analysis. Systematic review and meta-analysis

IntroducciónLa guía clínica para el manejo de la sepsis recomienda usar muestras de sangre arterial para el control glucémico. Un estudio multicéntrico en 86 unidades de cuidados intensivos españolas reveló que el 85,4% de estas utilizaban punción capilar.ObjetivoAnalizar la fiabilidad de la glucemia comparando diferentes muestras sanguíneas (arterial, venosa, capilar) e instrumentos (glucómetros, gasómetros, laboratorio central). Secundariamente, estimar el efecto de variables confusoras y el rendimiento de los instrumentos de medición determinados por las diferentes normas de calidad.MetodologíaRevisión sistemática y metanálisis con búsqueda en las bases de datos PubMed, CINAHL y Embase en septiembre-2021 y septiembre-2022, sin límites temporales ni idiomáticos. Fuentes de literatura gris: DART-Europe, OpenGrey y Google Académico. Resultados resumidos mediante síntesis cualitativa (descripción de resultados, características de los estudios) y cuantitativa (metanálisis para evaluar la diferencia de medias estandarizadas). Calidad metodológica de artículos evaluada con Quality Assessment of Diagnostic Accuracy Studies-2. Protocolo: https://osf.io/ DOI 10.17605/OSF.IO/T8KYP.ResultadosSe incluyeron un total de 32 artículos y 5.451 pacientes. No se obtuvieron discrepancias entre muestras arteriales con glucómetro vs. laboratorio (sesgo [IC95%]: 0,01 [−0,12 a 0,14] mg/dL). En cambio, muestras arteriales con gasómetro sí sobreestimaron de forma significativa (sesgo [IC95%]: 0,12 [0,01 a 0,24] mg/dL). La misma tendencia presentan capilares con glucómetro, aunque no de forma significativa (sesgo [IC95%]: 0,07 [−0,02 a 0,15] mg/dL). Hay discrepancia entre los estudios sobre el efecto del hematocrito y el equilibrio ácido-base. El mayor consenso se da en la poca concordancia del glucómetro con muestras capilares vs. laboratorio en presencia de shock y soporte vasopresor, situación de fallo renal o durante el tratamiento con vitamina C.Conclusiones... (AU)

IntroductionThe clinical guideline for the management of sepsis recommends using arterial blood samples for glycaemic control. A multicentre study in 86 Spanish intensive care units revealed that 85.4% of these used capillary puncture.ObjectiveTo analyse the reliability of glycaemia by comparing different blood samples (arterial, venous, capillary) and instruments (glucometers, gasometers, central laboratory). Secondarily, to estimate the effect of confounding variables and the performance of measuring instruments as determined by different quality standards.MethodologySystematic review and meta-analysis with search in PubMed, CINAHL and Embase databases in September-2021 and September-2022, with no time or language limits. Grey literature sources: DART-Europe, OpenGrey and Google Scholar. Results summarised by qualitative (description of results, study characteristics) and quantitative (meta-analysis to assess standardised mean difference) synthesis. Methodological quality of articles assessed with Quality Assessment of Diagnostic Accuracy Studies-2. Protocol: https://osf.io/ DOI 10.17605/OSF.IO/T8KYP.ResultsA total of 32 articles and 5451 patients were included. No discrepancies were obtained between arterial glucometer vs. laboratory samples (bias [95%CI]: 0.01 [−0.12 to 0.14] mg/dL). In contrast, arterial samples with a gasometer did significantly overestimate (bias [95%CI]: 0.12 [0.01 to 0.24] mg/dL). The same trend is seen in capillaries with a glucometer, although not significantly (bias [95%CI]: 0.07 [−0.02 to 0.15] mg/dL). There is discrepancy between studies on the effect of haematocrit and acid-base balance. The greatest consensus is on the poor agreement of glucometer with capillary vs. laboratory samples in the presence of shock and vasopressor support, renal failure or during vitamin C treatment.Conclusions... (AU)

[Streamlining of patient discharge and intra-hospital transfer processes using Lean methodology]. / Resultados de la dinamización del proceso de alta y de traslados intrahospitalarios de los pacientes aplicando el método Lean.

INTRODUCTION: The application of Lean methodology in the hospital environment can help to improve interprofessional communication and reduce non-value adding activities (waste). OBJECTIVE: To determine the effectiveness of the implementation of a visual management tool, in the ability to reduce the number of trips, to determine the location of patients in real time in the process of intra-hospital transfers (ITH) and discharges in a hospital. MATERIAL AND METHODS: Before-after study in a hospital internal medicine unit. Several time wastes due to unnecessary transfers were detected. A multiprofessional group was formed to design a visual management tool for the resolution of these identified problems. The opinion of the professionals on the tool was evaluated and variables of staff displacement and completion of the tool were measured before and after its implementation. RESULTS: The personnel involved was trained. Completion of the tool improved over time, both in HIT and in discharges, reducing the number of trips. CONCLUSIONS: The application of a visual management tool in care processes, including all the personnel involved is effective and saves waste.

Blood glucose monitoring in critically ill adult patients: type of sample and method of analysis. Systematic review and meta-analysis.

INTRODUCTION: The clinical guideline for the management of sepsis, recommends using arterial blood samples for glycaemic control. A multicentre study in 86 Spanish intensive care units (ICU) revealed that 85.4% of ICUs used capillary puncture. OBJECTIVE: To analyse the reliability of glycaemia by comparing different blood samples (arterial, venous, capillary) and instruments (glucometers, gasometers, central laboratory). Secondarily, to estimate the effect of confounding variables and the performance of measuring instruments as determined by different quality standards. METHODOLOGY: Systematic review and meta-analysis with search in PubMed, CINAHL and Embase databases in September-2021 and September-2022, with no time or language limits. Grey literature sources: DART-Europe, OpenGrey and Google Scholar. Results summarised by qualitative (description of results, study characteristics) and quantitative (meta-analysis to assess standardised mean difference) synthesis. Methodological quality of articles assessed with Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). PROTOCOL: https://osf.io/ DOI 10.17605/OSF.IO/T8KYP. RESULTS: A total of 32 articles and 5451 patients were included. No discrepancies were obtained between arterial glucometer vs laboratory samples [bias (95%CI): 0.01 (-0.12 to 0.14) mg/dL]. In contrast, arterial samples with a gasometer did significantly overestimate [bias (95%CI): 0.12 (0.01 to 0.24) mg/dL]. The same trend is seen in capillaries with a glucometer, although not significantly [bias (95%CI): 0.07 (--0.02 to 0.15) mg/dL]. There is discrepancy between studies on the effect of haematocrit and acid-base balance. The greatest consensus is on the poor agreement of glucometer with capillary vs laboratory samples in the presence of shock and vasopressor support, renal failure or during vitamin C treatment. CONCLUSIONS: The evidence to date recommends the use of arterial blood with a blood glucose meter for better reliability of glycaemic analysis and less effect of possible confounding variables, frequently present in the critically ill adult patient.

Workloads of intensive care nurses. Validity of their estimation using mobile applications and comparison with Nursing Activities Score. Systematised review of the literature.

INTRODUCTION: Adjusting human resources to intensive care units (ICU) workload is essential. The development of software for estimating nursing workload using mobile devices (smartphone, smartwatch and/or tablets) could be a useful tool and complement and/or improve the measurements made with the Nursing Activities Score (NAS), a validated scale. OBJECTIVES: To analyze the validity of devices and mobile applications for estimating ICU nurses' workloads and their comparison with NAS. METHODOLOGY: Systematised literature review from 2009 to 2021 informed by flowchart PRISMA-2020 and its extension PRISMA-S. Critical reading (CASPe). Steps:elaboration of the research question, concept identification (English and Spanish natural language and descriptors MesH, Emtree and CINAHL Headings), search strategy and data collection in MEDlars online (MEDLINE), OVID, Excerpta Medica dataBASE (EMBASE), Elsevier, Cumulative Index to Nursing & Allied Health Literature (CINAHL), EBSCO and Web of Science (WoS); data extraction and evaluation, analysis and synthesis of results. We included studies with abstracts published in English and Spanish conducted in ICU with workload measurement (preferably NAS) using mobile devices. RESULTS: 223 studies of which 84 in MEDLINE, 50 in CINAHL, 48 in EMBASE, 33 in WOS and 8 in other sources. 117 were eligible for screening, of which 95 did not meet the inclusion criteria. 22 studies were screened for eligibility, of which 17 were excluded. Five articles were selected for final review. None of the studies provided results on costs, acceptance testing, validity, reliability, system problems, advantages, disadvantages or resource estimation. DISCUSSION AND CONCLUSIONS: The use of mobile devices and applications to measure ICU workloads is not yet validated and has not been shown to be more accurate than traditional NAS assessment.

Ensayo clínico aleatorizado en pacientes COVID- 19 sobre el efecto de la fisioterapia precoz en su acondicionamiento físico / Randomized clinical trial in Covid-19 patients on the effect of early physiotherapy on their physical condition

Introducción La Organización Mundial de la Salud (OMS) recomienda las intervenciones tempranas de rehabilitación y movilización en pacientes hospitalizados por COVID-19. Los beneficios de la fisioterapia precoz, durante la estancia hospitalaria, no han sido probados en ensayos clínicos. Objetivo Evaluar los efectos de la fisioterapia precoz y educación para la salud en pacientes COVID-19 hospitalizados, en relación con los síntomas descritos en estudios previos, analizando diferencias entre grupos respecto a su acondicionamiento físico, necesidad de oxigenoterapia y estancia hospitalaria. Metodología Ensayo clínico aleatorizado con dos brazos, desarrollado en unidades de hospitalización y cuidados respiratorios intermedios (UCRI), con pacientes COVID-19. Se incluyeron 64 sujetos en el grupo experimental (implementación de un programa de fisioterapia precoz tras 48-72 horas de ingreso) y 62 en el grupo control (tratamiento habitual del centro). Variables sociodemográficas y clínicas: escala de disnea modified Medical Research Council (Mmrc), oxigenoterapia, Medical Research Council Scale sum score (MRC-SS), 30 segundos sit to stand test (30 s-STST), fuerza de prensión manual (FPM), Tinetti, escala de fragilidad (FRAIL-España) y escala Post-COVID-19 Functional Status (PCFS). Se evaluaron al ingreso, al alta y a los dos meses del alta. Resultados Los experimentales tuvieron menos días de ingreso y de oxigenoterapia convencional. Al alta, presentan menor riesgo de caída (72,9 vs. 95,8%) y menor debilidad en MRC-SS (2,1 vs. 14,6%). A los dos meses tenían menor fragilidad (5,0 vs. 14,5%), mayor fuerza de prensión manual, menos disnea, mejores resultados en 30s-STST y menos limitaciones post-COVID (86,5 vs. 96,4%) (AU)

Introduction The WHO recommends early rehabilitation and mobilization interventions in patients hospitalized for COVID-19. The benefits of early physiotherapy, during the hospital stay, have not been proven in clinical trials. Objective To evaluate the effects of early physiotherapy and health education in hospitalized COVID-19 patients, in relation to the symptoms described in previous studies, analyzing differences between groups regarding their physical conditioning, need for oxygen therapy and hospital stay. Methodology Randomized clinical trial with two arms, developed in hospitalization and intermediate respiratory care units, with COVID-19 patients. Sixty-four patients included in the experimental group (implementation of an early physiotherapy program after 48–72 h of admission) and 62 patients in the control group (usual treatment of the center). Sociodemographic and clinical variables: mMRC, oxygen therapy, MRC-SS, 30 s-STST, FPM, Tinetti, FRAIL-España and PCFS. They were evaluated on admission, discharge and two months after discharge. Results The experimental patients had fewer days of admission and conventional oxygen therapy. At discharge, they present a lower risk of falling (72.9% vs. 95.8%) and less weakness in MRC-SS (2.1% vs. 14.6%). At two months they had less frailty (5.0% vs. 14.5%), greater hand grip strength, less dyspnea, better results in 30s-STST and fewer post-COVID limitations (86.5% vs. 96.4%). Conclusión The intervention of early physiotherapy in COVID-19 patients and the health education received, prevents muscle weakness during admission, improves physical conditioning at discharge and two months later, and reduces the days of hospital stay (AU)

Predictive validity of the Clinical Frailty Scale-España on the increase in dependency after hospital discharge.

INTRODUCTION: The frailty present at hospital admission and the stressors to which patients are subjected during their stay may increase dependency at hospital discharge. OBJECTIVES: To assess the predictive validity of the Clinical Frailty Scale-España (CFS-Es) on increased dependency at 3 and 12 months (m) after hospital discharge. METHODOLOGY: Multicentre cohort study in 2020-2022. Including patients with >48 h stay in intensive care units (ICU) and non-COVID-19. VARIABLES: pre-admission frailty (CFS-Es). Sex, age, days of stay (ICU and hospital), dependency on admission and at 3 m and 12 m after discharge (Barthel index), muscle weakness (Medical Research Council Scale sum score <48), hospital readmissions. STATISTICS: descriptive and multivariate analysis. RESULTS: 254 cases were included. Thirty-nine per cent were women and the median [Q1-Q3] age was 67 [56-77] years. SAPS 3 on admission (median [Q1-Q3]): 62 [51-71] points. Frail patients on admission (CFS-Es 5-9): 58 (23%). Dependency on admission (n = 254) vs. 3 m after hospital discharge (n = 171) vs. 12 m after hospital discharge (n = 118): 1) Barthel 90-100: 82% vs. 68% vs. 65%. 2) Barthel 60-85: 15% vs. 15% vs. 20%. 3) Barthel 0-55: 3% vs. 17% vs. 15%. In the multivariate analysis, adjusted for the variables recorded, we observed that frail patients on admission (CFS-Es 5-9) are 2.8 times (95%CI: 1.03-7.58; p = 0.043) more likely to increase dependency (Barthel 90-100 to <90 or Barthel 85-60 to <60) at 3 m post-discharge (with respect to admission) and 3.5 times (95%CI: 1.18-10.30; p = 0.024) more likely to increase dependency at 12 m post-discharge. Furthermore, for each additional CFS-Es point there is a 1.6-fold (95%CI: 1.01-2.23; p = 0.016) greater chance of increased dependency in the 12 m following discharge. CONCLUSIONS: CFS-Es at admission can predict increased dependency at 3 m and 12 m after hospital discharge.

Effectiveness of closed blood sampling systems in intensive care patients: a scoping review.

BACKGROUND: Anemia associated with blood extraction for diagnostic purposes is a highly prevalent entity in intensive care units (ICU) for adults. The evidence recommends its prevention through different strategies, among which we can find the use of closed blood sampling systems (CBSS). Different experimental studies support the use of these devices. OBJECTIVE: To identify knowledge gaps regarding the effectiveness of CBSS in ICU patients. METHODS: Scoping review with search in PubMed, CINAHL, Embase, Cochrane Library and Joanna Briggs Institute databases, between September-2021 and September-2022. No time, language, or other limits were applied to ensure the recovery of all relevant studies. Gray literature sources: DART-Europe, OpenGrey and Google Scholar. Two researchers independently reviewed titles and abstracts and assessed full texts against the inclusion criteria. The following data was extracted for each study: design and sample, inclusion and exclusion criteria, variables, type of CBSS, results and conclusions. RESULTS: 18 articles were included in the final review, 11 clinical trials (RCTs) published between 1992 and 2014. Three systematic reviews were found, but they only analyzed the effect of CBSS in reducing blood loss, hemoglobin stabilization, and the need for transfusion. Five of the RCTs analyzed the risk of infection, one catheter complications, and two alterations in blood pressure readings. CONCLUSIONS: The use of CBSS is recommended to reduce blood loss in ICUs. However, there are discrepancies about their ability to prevent anemia and/or the need for blood transfusion. Its use does not increase catheter-related infection rates or alter the measurement of mean arterial pressure.

Decúbito prono en pacientes COVID-19 con síndrome de distrés respiratorio agudo y ventilación mecánica invasiva / Prone positioning in Covid-19 patients with acute respiratory distress syndrome and invasive mechanical ventilation

Objetivos: Identificar eventos adversos secundarios al decúbito prono (DP) en pacientes con COVID-19 con síndrome de distrés respiratorio agudo (SDRA) moderado/severo, analizar los factores de riesgo para el desarrollo de úlceras por presión (UPP) en DP y describir la evolución oximétrica de estos pacientes durante el DP. Método: Estudio descriptivo retrospectivo realizado sobre 63 pacientes ingresados en la UCI de un hospital de segundo nivel, con neumonía por SARS-CoV-2, SDRA moderado/severo, ventilación mecánica invasiva, que precisaron maniobras de DP, durante marzo y abril de 2020. Se usó un muestreo no probabilístico consecutivo y se analizaron las variables seleccionadas a través de una regresión logística. Resultados: Se realizaron un total de 139 sesiones de pronación. La mediana de sesiones fue de 2 [1-3] y la duración de 22 h [15-24] por sesión. La aparición de eventos adversos ocurrió en 84,9% de los casos, siendo los fisiológicos (por ejemplo, hiper/hipotensión) los más frecuentes. Al comparar pacientes pronados que mantuvieron la integridad cutánea (34 de 63 pacientes, 54%) vs. los que desarrollaron UPP (29 de 63, 46%), estos últimos presentaron los siguientes factores de riesgo: mayor edad, ser hipertensos, prealbúmina < 21 mg/dL, mayor número de sesiones de prono y mayor gravedad al ingreso. Se observó un incremento significativo entre la PaO2/FiO2 previa al DP y en los diferentes cortes temporales durante el prono, además de una caída significativa tras despronar. Conclusiones: Existe una alta incidencia de eventos adversos debidos al DP, siendo los de tipo fisiológico los más frecuentes. La identificación de varios factores de riesgo para el desarrollo de UPP ayudará a prevenir la aparición de estas lesiones durante la pronación. La terapia de DP en pacientes COVID-19 con SDRA moderado/severo ha demostrado una mejora en los parámetros de oxigenación.(AU)

Objective: To identify adverse events related to prone positioning in COVID-19 patients with severe disease and acute respiratory distress syndrome, to analyze the risk factors associated with the development of anterior pressure ulcers, to determine whether the recommendation of prone positioning is associated with improved clinical outcomes. Methods: Retrospective study performed in 63 consecutive patients with COVID-19 pneumonia admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning between March and April 2020. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression. Results: A total of 139 proning cycles were performed. The mean number of cycles were 2 [1-3] and the mean duration per cycle was of 22 hours [15-24]. The prevalence of adverse events this population was 84.9%, being the physiologic ones (i.e., hypo/hypertension) the most prevalent. 29 out of 63 patients (46%) developed prone-related pressure ulcers. The risk factors for prone-related pressure ulcers were older age, hypertension, levels of pre-albumin < 21 mg/dL, the number of proning cycles and severe disease. We observed a significant increase in the PaO2/FiO2 at different time points during the prone positioning, and a significant decrease after it. Conclusions: There is a high incidence of adverse events due to PD, with the physiological type being the most frequent. The identification of the main risk factors for the development of prone-related pressure ulcers will help to prevent the occurrence of these lesions during the prone positioning. Prone positioning offered an improvement in the oxygenation in these patients.(AU)

Prone positioning in COVID-19 patients with acute respiratory distress syndrome and invasive mechanical ventilation.

OBJECTIVE: To identify adverse events related to prone positioning in COVID-19 patients with severe disease and acute respiratory distress syndrome, to analyze the risk factors associated with the development of anterior pressure ulcers, to determine whether the recommendation of prone positioning is associated with improved clinical outcomes. METHODS: Retrospective study performed in 63 consecutive patients with COVID-19 pneumonia admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning between March and April 2020. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression. RESULTS: A total of 139 proning cycles were performed. The mean number of cycles were 2 [1-3] and the mean duration per cycle was of 22h [15-24]. The prevalence of adverse events this population was 84.9 %, being the physiologic ones (i.e., hypo/hypertension) the most prevalent. 29 out of 63 patients (46%) developed prone-related pressure ulcers. The risk factors for prone-related pressure ulcers were older age, hypertension, levels of pre-albumin <21mg/dl, the number of proning cycles and severe disease. We observed a significant increase in the PaO2/FiO2 at different time points during the prone positioning, and a significant decrease after it. CONCLUSIONS: There is a high incidence of adverse events due to PD, with the physiological type being the most frequent. The identification of the main risk factors for the development of prone-related pressure ulcers will help to prevent the occurrence of these lesions during the prone positioning. Prone positioning offered an improvement in the oxygenation in these patients.

[Prone positioning in Covid-19 patients with acute respiratory distress syndrome and invasive mechanical ventilation]. / Decúbito prono en pacientes COVID-19 con síndrome de distrés respiratorio agudo y ventilación mecánica invasiva.

Objective: To identify adverse events related to prone positioning in COVID-19 patients with severe disease and acute respiratory distress syndrome, to analyze the risk factors associated with the development of anterior pressure ulcers, to determine whether the recommendation of prone positioning is associated with improved clinical outcomes. Methods: Retrospective study performed in 63 consecutive patients with COVID-19 pneumonia admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning between March and April 2020. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression. Results: A total of 139 proning cycles were performed. The mean number of cycles were 2 [1-3] and the mean duration per cycle was of 22 hours [15-24]. The prevalence of adverse events this population was 84.9%, being the physiologic ones (i.e., hypo/hypertension) the most prevalent. 29 out of 63 patients (46%) developed prone-related pressure ulcers. The risk factors for prone-related pressure ulcers were older age, hypertension, levels of pre-albumin < 21 mg/dL, the number of proning cycles and severe disease. We observed a significant increase in the PaO2/FiO2 at different time points during the prone positioning, and a significant decrease after it. Conclusions: There is a high incidence of adverse events due to PD, with the physiological type being the most frequent. The identification of the main risk factors for the development of prone-related pressure ulcers will help to prevent the occurrence of these lesions during the prone positioning. Prone positioning offered an improvement in the oxygenation in these patients.

The use of mechanical restraint in critical care units: Characterisation, application standards and related factors. Results of a multicentre study.

OBJECTIVES: To describe and characterise the use of mechanical restraint (MR) in critical care units (CCU) in terms of frequency and quality of application and to study its relationship with pain/agitation-sedation/delirium, nurse:patient ratio and institutional involvement. METHOD: Multicentre observational study conducted in 17 CCUs between February and May 2016. The observation time per CCU was 96 h. The main variables were the prevalence of restraint, the degree of adherence to MR recommendations, pain/agitation-sedation/delirium monitoring and institutional involvement (protocols and training of professionals). RESULTS: A total of 1070 patients were included. The overall prevalence of restraint was 19.11%, in patients with endotracheal tube (ETT) 42.10% and in patients without ETT or artificial airway it was 13.92%. Adherence rates between 0% and 40% were obtained for recommendations related to non-pharmacological management and between 0% and 100% for those related to monitoring of ethical-legal aspects. The lower prevalence of restraint was correlated with adequate pain monitoring in non-communicative patients (P < .001) and with the provision of training for professionals (P = .020). An inverse correlation was found between the quality of the use of MR and its prevalence, both in the general group of patients admitted to CCU (r = -.431) and in the subgroup of patients with ETT (r = -.521). CONCLUSIONS: Restraint is especially frequently used in patients with ETT/artificial airway, but is also used in other patients who may not meet the use profile. There is wide room for improvement in non-pharmacological alternatives to the use of MC, ethical and legal vigilance, and institutional involvement. Better interpretation of patient behaviour with validated tools may help limit use of MR.

Uso de contenciones mecánicas en unidades de cuidados críticos: caracterización, estándares de aplicación y factores relacionados. Resultados de un estudio multicéntrico / The use of mechanical restraint in critical care units: Characterisation, application standards and related factors. Results of a multicentre study

Objetivos: Describir y caracterizar el uso de contenciones mecánicas (CM) en unidades de cuidados críticos (UCC) en términos de frecuencia y calidad de aplicación y analizar su relación con la monitorización del dolor/agitación-sedación/delirio, la ratio enfermera:paciente y la implicación institucional. Método: Estudio observacional multicéntrico realizado en 17 UCC entre febrero y mayo del año 2016. El tiempo de observación por UCC fue de 96h. Las principales variables fueron la prevalencia de contenciones, el grado de adherencia a las recomendaciones de uso de CM, la monitorización del dolor/agitación-sedación/delirio y la implicación institucional (protocolos y formación de los profesionales). Resultados: Se incluyeron 1.070 pacientes. La prevalencia general de contenciones fue del 19,11%, en pacientes con tubo endotraqueal (TET) del 42,10% y en pacientes sin TET ni vía aérea artificial del 13,92%. Se obtuvieron valores de adherencia entre el 0 y el 40% para las recomendaciones relacionadas con manejo no farmacológico y entre el 0 y el 100% para las relacionadas con la vigilancia de aspectos ético-legales. La menor prevalencia de contenciones se correlacionó con una adecuada monitorización del dolor en pacientes no comunicativos (p<0,001) y con la impartición de formación a los profesionales (p=0,020). Se halló correlación inversa entre la calidad de aplicación de CM y su prevalencia, tanto en el grupo general de pacientes ingresados en las UCC (r=−0,431) como en el subgrupo de pacientes con TET (r=−0,521). Conclusiones: Las contenciones son especialmente frecuentes en pacientes con TET/vía aérea artificial, pero también están presentes en otros pacientes que a priori no responden al perfil de uso atribuido. Las alternativas no farmacológicas al uso de CM, la vigilancia de aspectos éticos y legales y la implicación institucional presentan un amplio margen de mejora.(AU)

Objectives: To describe and characterise the use of mechanical restraint (MR) in critical care units (CCU) in terms of frequency and quality of application and to study its relationship with pain/agitation-sedation/delirium, nurse:patient ratio and institutional involvement. Method: Multicentre observational study conducted in 17 CCUs between February and May 2016. The observation time per CCU was 96h. The main variables were the prevalence of restraint, the degree of adherence to MR recommendations, pain/agitation-sedation/delirium monitoring and institutional involvement (protocols and training of professionals). Results: A total of 1070 patients were included. The overall prevalence of restraint was 19.11%, in patients with endotracheal tube (ETT) 42.10% and in patients without ETT or artificial airway it was 13.92%. Adherence rates between 0% and 40% were obtained for recommendations related to non-pharmacological management and between 0% and 100% for those related to monitoring of ethical-legal aspects. The lower prevalence of restraint was correlated with adequate pain monitoring in non-communicative patients (P<.001) and with the provision of training for professionals (P=.020). An inverse correlation was found between the quality of the use of MR and its prevalence, both in the general group of patients admitted to CCU (r=−.431) and in the subgroup of patients with ETT (r=−.521). Conclusions: Restraint is especially frequently used in patients with ETT/artificial airway, but is also used in other patients who may not meet the use profile. There is wide room for improvement in non-pharmacological alternatives to the use of MC, ethical and legal vigilance, and institutional involvement. Better interpretation of patient behaviour with validated tools may help limit use of MR.(AU)

[Update of the recommendations of the Pneumonia Zero project]. / Actualización de las recomendaciones del proyecto Neumonía Zero.

The SARS-Cov-2 pandemic has had a negative impact on the implementation of the Zero Pneumonia recommendations and has been accompanied by an increase in rates of ventilator- associated pneumonia (VAP) in intensive care units in Spain. With the aim of reducing the current rates to 7 episodes per 1000 days of MV, the recommendations of the initial project have been updated.Twenty-seven measures were identified and classified into 12 functional measures (semi- sitting position, strict hand hygiene, airway manipulation training, daily assessment of possible extubation, protocolisation of weaning, early tracheostomy, non-invasive ventilation, microbiological surveillance, tubing change, humidification, respiratory physiotherapy, post- pyloric enteral nutrition), 7 mechanical measures (pneumotap pressure control, subglottic suction tubes, subglottic suctioning of tubes, subglottic suctioning of tubes, post-pyloric enteral nutrition, subglottic suction tubes, small-bore/small-bowel tube nutrition, closed/open circuit secretion suctioning, respiratory filters, tooth brushing, negative pressure techniques for secretion suctioning) and 8 pharmacological (selective digestive decontamination, oropharyngeal decontamination, short course of antibiotics, chlorhexidine mouth hygiene, inhaled antibiotics, antibiotic rotation, probiotics, monoclonal antibodies).Each measure was analysed independently, by at least two members of the working group, through a systematic review of the literature and an iterative review of recommendations from scientific societies and/or expert groups.For the classification of the quality of the evidence and strength of the recommendations, the GRADE group proposal was followed. To determine the level of recommendation, each measure was scored by all members of the working group in relation to its effectiveness, tolerability and applicability in Spanish ICUs in the short term. The support of external experts was requested for some of the measures reviewed. Those measures that achieved the highest score were selected.

Care and treatments related to intensive care unit-acquired muscle weakness: A cohort study.

BACKGROUND: Intensive care unit-acquired muscle weakness (ICUAW) has an incidence of 40-46%. Early mobilisation is known to be a protective factor. OBJECTIVE: The aim of the study was to identify the incidence of ICUAW in Spain and to evaluate variables likely to contribute to the development of ICUAW. METHODS: A 4-month, prospective observational multicentre cohort study was conducted on patients receiving invasive mechanical ventilation for at least 48 h. Data were collected from ICU day 3 until ICU discharge. The primary outcome was presence of ICUAW (diagnosed using the Medical Research Council [MRC] scale). The secondary outcome was nurse-patient ratio, physiotherapist availability, analgesia, sedation and delirium management, glycaemic control, and daily level of mobility during the ICU stay as per the ICU Mobility Scale. A logistic regression model was constructed based exclusively on days 3-5 of the ICU stay. RESULTS: The data of 642 patients were analysed from 80 ICUs, accounting for 35% of all ICUs in Spain. The incidence of ICUAW was 58% (275 of 474 patients; 95% confidence interval [CI] [53-62]). The predictors for ICUAW were older age (odds ratio [OR] = 1.01; 95% CI [1.00-1.03]) and more days with renal replacement therapy (OR = 1.01; 95% CI [1.00-1.02]). The protective factors for ICUAW were male gender (OR = 0.58; 95% CI [0.38-0.89]), higher Barthel Index (showing prehospital functional independence) (OR = 0.97; 95% CI [0.95-0.99]), more days of being awake and cooperative (defined by a feasible MRC assessment) (OR = 0.98; 95% CI [0.97-0.99]), presence of delirium (OR = 0.98; 95% CI [0.97-0.99]), and more days with active mobilisation (ICU Mobility Scale ≥ 4) (OR = 0.98; 95% CI [0.97-0.99]). CONCLUSIONS: The risk factors for ICUAW were functional dependence before admission, female gender, older age, and more days on renal replacement therapy. The protective factors for ICUAW were feasibility of MRC assessment, the presence of delirium, and being actively mobilised during the first 5 days in the ICU.

Adaptation and validation of the ICU Mobility Scale in Spain. / Adaptación y validación de la ICU Mobility Scale en España.

OBJECTIVE: To adapt the ICU Mobility Scale (IMS) to the area of intensive care units (ICU) in Spain and to evaluate the metric properties of the Spanish version of the IMS (IMS-Es). METHOD: Descriptive metric study developed in two phases. Phase 1, adaptation to Spanish of the IMS by a team of nurses and physiotherapists (translation, pilot, backtranslation and agreement). Phase 2, analysis of metric properties (convergent, divergent and predictive validity, interobserver reliability, sensitivity and minimum important difference) of the IMS-Es. Patient characteristics (Barthel, Charlson, BMI, sex), sedation/agitation level (RASS), ICU and hospital stays, survival, quality of life (SF-12), muscle weakness (MRC-SS) and mobility (IMS-Es) were recorded in the patients of the MOviPre national multicentre study. RESULTS: After obtaining the IMS-Es, it was implemented in 645 patients from 80 Spanish ICUs between April and June 2017. Convergent validity: moderate correlation between IMS-Es and MRC-SS (r=.389; P<.001) and significant comparison between groups with and without ICU-acquired weakness (P<.001). Divergent validity: no correlation between IMS-Es and BMI [r (95%CI): -.112 (-.232 to .011)], weight [r (95%CI): -.098 (-.219 to .026)], Charlson [r (95%CI): -.122 (-.242 to .001)] and Barthel [r(95%CI): -.037 (-.160 to .087)] and no differences between sexes (P=.587) or BMI categories (P=.412). Predictive validity: moderate and significant correlations with post-ICU hospital stay [r (95%CI): -.442 (-.502 to -.377)] and physical component of SF-12 (PCS) [r (95%CI): .318 (.063 to .534)]; patients without active mobilisation in ICU increased risk of hospital mortality [OR (95%CI): 3.769 (1.428 to 9.947)]. Interobserver reliability: very good concordance between nurses [CCI (95%CI): .987 (.983 to .990)] and nurse-physiotherapist [CCI (95%CI): .963 (.948 to .974)]. Sensitivity to change: small effect on discharge from ICU (d=.273) and moderate effect at 3months after hospital discharge (d=.709). Minimal important difference: 2-point difference cut-off point, 91.1% sensitivity and 100.0% specificity. CONCLUSIONS: The IMS-Es is useful, valid and reliable for implementation by ICU nurses and physiotherapists in assessing the mobility of critical patients.