Incidencia del trastorno por duelo prolongado en los allegados de pacientes fallecidos durante o tras ingreso en la Unidad de Cuidados Intensivos / Incidence of prolonged grief disorder in relatives of patients who die during or after admission in Intensive Care Unit

Objetivos. Estudiar la incidencia del «trastorno por duelo prolongado» desde un año después del fallecimiento de un familiar ingresado en la Unidad de Cuidados Intensivos (UCI). Material y métodos. Estudio de seguimiento longitudinal con corte transversal en una UCI polivalente de un hospital de referencia. Se evaluó a los allegados alrededor de un año después del fallecimiento, usando como herramientas los «criterios de consenso para el diagnóstico del trastorno por duelo prolongado» (CCTDP). Se determinó la prevalencia entre el primero y segundo años. Resultados. Se incluyeron 151 familiares de fallecidos en la UCI. El seguimiento se realizó 22,1±5,3 meses tras el fallecimiento. Once familiares (10,3%) cumplieron los CCTDP. De todos los allegados en duelo, aquellos identificados con trastorno por duelo prolongado son los que con más frecuencia precisaron apoyo psicológico/psiquiátrico. Conclusiones. En una muestra de allegados de pacientes fallecidos tras un ingreso en la UCI, una minoría significativa cumplió los CCTDP al cabo de 1-2 años tras el fallecimiento. Hay que tener en consideración este hecho que es frecuentemente pasado por alto, y que podría precisar algún tipo de intervención psicológica(AU)

Objectives. To determine the incidence of «Prolonged Grief Disorder» from one year after the death of a relative admitted to the Intensive Care Unit. Material and methods. A cross-sectional, longitudinal follow-up study was conducted in a general ICU of a reference hospital. The relatives were evaluated approximately one year after the death using the «Consensus Criteria for Prolonged Grief Disorder» as a tool. The prevalence between the first and second years was determined. Results. A total of 151 relatives of patients who died in ICU were included. The follow-up was carried out 22.1±5.3 months after the death. Eleven relatives (10.3%) fulfilled the «Consensus Criteria for Prolonged Grief Disorder». Of all the grieving relatives, those identified with prolonged grief disorder are the ones who most often require psychological/psychiatric support. Conclusions. In a sample of close relatives of patients who died in ICU, a significant minority fulfilled the criteria for «Prolonged Grief Disorder» 1-2 years after the death. This condition, which is often overlooked, and could require some kind of psychological treatment, should be taken into consideration(AU)

[Incidence of prolonged grief disorder in relatives of patients who die during or after admission in Intensive Care Unit]. / Incidencia del trastorno por duelo prolongado en los allegados de pacientes fallecidos durante o tras ingreso en la Unidad de Cuidados Intensivos.

OBJECTIVES: To determine the incidence of «Prolonged Grief Disorder¼ from one year after the death of a relative admitted to the Intensive Care Unit. MATERIAL AND METHODS: A cross-sectional, longitudinal follow-up study was conducted in a general ICU of a reference hospital. The relatives were evaluated approximately one year after the death using the «Consensus Criteria for Prolonged Grief Disorder¼ as a tool. The prevalence between the first and second years was determined. RESULTS: A total of 151 relatives of patients who died in ICU were included. The follow-up was carried out 22.1±5.3 months after the death. Eleven relatives (10.3%) fulfilled the «Consensus Criteria for Prolonged Grief Disorder¼. Of all the grieving relatives, those identified with prolonged grief disorder are the ones who most often require psychological/psychiatric support. CONCLUSIONS: In a sample of close relatives of patients who died in ICU, a significant minority fulfilled the criteria for «Prolonged Grief Disorder¼ 1-2 years after the death. This condition, which is often overlooked, and could require some kind of psychological treatment, should be taken into consideration.

Nuestra experiencia con los grupos relacionados por el diagnóstico en una unidad de cuidados intensivos / Our experience with diagnosis-related groups in an intensive care unit

Objetivo. Para definir los productos y costes hospitalarios, la administración sanitaria recurre al sistema de grupos relacionados por el diagnóstico (GRD), cada día más universalizado, el cual agrupa en un case mix diversos diagnósticos que tienen un consumo similar de recursos. Cada caso o enfermo tiene un solo GRD, que se le asigna en el momento del alta hospitalaria. En un 80 por ciento de los enfermos de cuidados intensivos, el alta se realiza desde otro servicio hospitalario, lo cual puede facilitar una pérdida de información del producto generado en las UCI. Nos plantemos atribuir los GRD a todos los enfermos directamente en el momento del alta de la UCI. Pacientes y método. Se asignó un conjunto mínimo básico de datos (CMBD) a 500 casos consecutivos de una UCI polivalente y, posteriormente, se les agrupó por GRD (AP-DRG versión 14.0). Estos resultados se compararon con los GRD obtenidos por estos mismos enfermos en el momento del alta hospitalaria. Resultados. Sólo coincidía el 28,36 por ciento de los GRD en la primera confrontación entre ambas series. Tras un nuevo análisis se comprobó que un 19,99 por ciento de los GRD tenían errores de codificación y un 27,17 por ciento se había codificado con informaciones deficientes. Además, el sistema definía de forma insatisfactoria los procesos agrupados del 22,78 por ciento restante. Discusión. Como herramienta de gestión no habría inconveniente en atribuir directamente los GRD en el momento del alta de la UCI, ya que 98,30 por ciento de los diagnósticos y procedimientos de estos enfermos se generan en la UCI, o antes de ingresar en intensivos. Pero el sistema no es útil para definir a los enfermos de la UCI porque: a) globalmente, define mal los casos complejos; b) salvo excepciones, el sistema no valora los procedimientos de UCI que podían definir los GRD atendidos, y c) los pesos o costes asignados a los case mix resultan muy inferiores, salvo excepciones, al consumo real de los enfermos de la UCI (AU)

Pharmacoeconomic assessment of propofol 2% used for prolonged sedation.

OBJECTIVE: To demonstrate that the use of propofol 2% is comparable to propofol 1% in effectiveness and in the wake-up time used for prolonged sedation. DESIGN: Open-label, case cohort study with a cohort of historical controls, phase IV clinical trial. SETTING: Medical and surgical intensive care unit (ICU) in a community hospital. PATIENTS: Fifty-one consecutive patients (medical, surgical, and trauma) admitted to our ICU requiring mechanical ventilation for >24 hrs. METHODS: All patients received propofol 2% (1-6 mg.kg-1.hr-1, starting with the lowest dose) and morphine chloride (0.5 mg.kg-1.24 hrs-1). A 4-5 level of sedation (Ramsay scale) was recommended. When weaning was indicated clinically, sedation and analgesia were interrupted abruptly, mechanical ventilation was discontinued, and the patient was connected to a T-bridge. OUTCOME MEASUREMENTS: Inability to attain the desired level of sedation with the highest dose rate of proposal, and hypertriglyceridemia >500 mg/dL, were considered therapeutic failure. The time between discontinuation of mechanical ventilation and extubation was measured. Those variables, as well as different items related to ICU cost, were compared between the study group and two historical groups sedated with propofol 1% and midazolam. RESULTS: The duration of sedation was 122.4 +/- 89.2 (sd) hrs for the propofol 2% group. The frequency of hypertriglyceridemia was 3.9% and 20.4% for the propofol 2% and the propofol 1% groups, respectively (p =.016). Therapeutic failure rates were 19.6% and 33.4% for the propofol 2% and propofol 1% groups, respectively (p =.127). The lower frequency of hypertriglyceridemia was associated with a higher number of patients reaching weaning. Weaning time was similar in the two propofol groups, 32.3 hrs ($1,744) for the propofol 2% group vs. 97.9 hrs ($5,287) for the midazolam group. Cost of sedation was $2.68 per hour for the midazolam group and $7.69 per hour for the propofol group. There was a favorable cost-benefit ratio for the propofol group, attributable to the shorter weaning time, although benefit was less than expected because higher doses of propofol 2% than propofol 1% were required during the first 48 hrs (p <.05). CONCLUSIONS: The new propofol 2% preparation is an effective sedative agent and is safe because of the low frequency of associated hypertriglyceridemia. The shorter weaning time associated with the use of propofol 2% as compared with midazolam compensates for its elevated cost. The economic benefit of propofol 2% is less than expected because higher doses of propofol 2% than propofol 1% are required over the first 48 hrs.

Prolonged sedation of critically ill patients with midazolam or propofol: impact on weaning and costs.

OBJECTIVE: To compare the effectiveness of sedation, the time required for weaning, and the costs of prolonged sedation of critically ill mechanically ventilated patients with midazolam and propofol. DESIGN: Open-label, randomized, prospective, phase IV clinical trial. SETTING: Medical and surgical intensive care unit (ICU) in a community hospital. PATIENTS: All ICU admissions (medical, surgical and trauma) requiring mechanical ventilation for > 24 hrs. A total of 108 patients were included in the study. INTERVENTIONS: Patients were randomized to receive midazolam or propofol. The dose range allowed for each drug was 0.1 to 0.5 mg/kg/hr for midazolam and 1 to 6 mg/kg/hr for propofol. The lowest dose that achieved an adequate patient-ventilator synchrony was infused. All patients received 0.5 mg/kg/24 hrs of morphine chloride. MEASUREMENTS AND MAIN RESULTS: The level of sedation was quantified by the Ramsay scale every 2 hrs until weaning from mechanical ventilation was started. If sedation could not be achieved by infusing the highest dose of midazolam or propofol, the case was recorded as a therapeutic failure. In the propofol group, serum triglycerides were determined every 72 hrs. Concentrations of > 500 mg/dL were also recorded as a therapeutic failure. When the patient was ready for weaning according to defined criteria, sedation was interrupted abruptly and the time from interruption of sedation to the first T-bridge trial and to extubation was measured. Cost analysis was performed based on the cost of intensive care in our unit ($54/hr). In the midazolam group (n = 54), 15 (27.8%) patients died; 11 (20.4%) patients had therapeutic failure; and 28 (51.8%) patients were subjected to a T-bridge trial. In the propofol group (n = 54), these proportions were 11 (20.4%), 18 (33.4% [including seven due to inadequate sedation, and 11 due to hypertriglyceridemia]), and 25 (46.2%), respectively. None of these values was significantly different between the two groups. Duration of sedation was 141.7 +/- 89.4 (SD) hrs and 139.7 +/- 84.7 hrs (p = NS), and cost (US dollars) attributed to sedation was $378 +/- 342 and $1,047 +/- 794 (p = .0001) for the midazolam and propofol groups, respectively. In the midazolam group, time from discontinuation of the drug infusion to extubation was 97.9 +/- 54.6 hrs (48.9 +/- 47.2 hrs to the first disconnection, and 49.0 +/- 23.7 hrs to extubation). In the propofol group, time from discontinuation of the drug infusion to extubation was 34.8 +/- 29.4 hrs (4.0 +/- 3.9 hrs to the first disconnection, and 30.8 +/- 29.2 hrs to extubation). The difference between the two groups in the weaning time was 63.1 +/- 12.5 (SEM) hrs (p < .0001). Cost per patient in the midazolam group (including ICU therapy and sedation with midazolam) was $10,828 +/- 5,734. Cost per patient in the propofol group was $9,466 +/- 5,820, $1,362 less than in the midazolam group. CONCLUSIONS: In our population of critically ill patients sedated with midazolam or propofol over prolonged periods, midazolam and propofol were equally effective as sedative agents. However, despite remarkable differences in the cost of sedation with these two agents, the economic profile is more favorable for propofol than for midazolam due to a shorter weaning time associated with propofol administration.