Recomendaciones de consenso sobre el transporte de pacientes en ECMO de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) y la Sociedad Española de Cuidados Intensivos Pediátricos (SECIP) / Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Spanish Society of Pediatric Intensive Care (SECIP) consensus recommendations for ECMO transport

La evolución del tratamiento de oxigenación por membrana extracorpórea (ECMO) y en particular del transporte de los pacientes sometidos a él, ha cambiado de forma significativa en la última década y lo ha hecho de manera desigual en diferentes regiones. Se ha demostrado que la creación de centros de referencia especializados mejora los resultados. Por todo ello ha sido necesario crear redes de equipos especializados y el número de transportes secundarios de pacientes con este tratamiento está en aumento. Con el fin de mejorar la calidad del tratamiento y ofrecer una guía para los servicios que intervienen en estos transportes, los grupos de trabajo de transporte crítico de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) y la Sociedad Española de Cuidados Intensivos Pediátricos (SECIP) han realizado un trabajo conjunto de elaboración de estas recomendaciones, enfocadas a los siguientes aspectos: indicaciones, sistemas de centros de referencia, medios de transporte, características y equipamiento, equipos humanos, formación y seguridad clínica (AU)

The evolution of extracorporeal membrane oxygenation treatment and the transport of patients receiving this treatment has changed dramatically in the last decade unevenly in different regions. The creation of specialized referral centers has been shown to improve outcomes. For all these reasons, it has been necessary to create networks of specialized teams and the number of secondary transports of patients with this treatment is increasing. In order to improve the quality of treatment and offer a guide to the services involved in these transports, the critical transport working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Spanish Society of Pediatric Intensive Care (SECIP) have carried out a joint effort to prepare these recommendations, focused on the following aspects: indications, reference center systems, means of transport, characteristics and equipment, human teams, training and clinical safety (AU)

Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Spanish Society of Pediatric Intensive Care (SECIP) consensus recommendations for ECMO transport.

The evolution of extracorporeal membrane oxygenation treatment and the transport of patients receiving this treatment has changed dramatically in the last decade unevenly in different regions. The creation of specialized referral centers has been shown to improve outcomes. For all these reasons, it has been necessary to create networks of specialized teams and the number of secondary transports of patients with this treatment is increasing. In order to improve the quality of treatment and offer a guide to the services involved in these transports, the critical transport working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Spanish Society of Pediatric Intensive Care (SECIP) have carried out a joint effort to prepare these recommendations, focused on the following aspects: indications, reference center systems, means of transport, characteristics and equipment, human teams, training and clinical safety.

Transporte interhospitalario con membrana de oxigenación extracorpórea: cuestiones a resolver / Issues to resolve with the use of extracorporeal membrane oxygenation during interfacility transportation

El soporte extracorpóreo con membrana de oxigenación extracorpórea (ECMO) está indicado en pacientes resistentes al tratamiento, con shock cardiogénico o insuficiencia respiratoria y en aquellos pacientes reagudizados subsidiarios de trasplante cardiaco y pulmonar. La experiencia profesional y la cantidad de recursos necesarios son causas por las que se cree que la regionalización podría beneficiar a este tipo de pacientes a través del establecimiento de centros de referencia en ECMO y de la integración de una red de transporte especializado en ECMO. Debido a su mayor complejidad, este tipo de transporte supone un reto para los sistemas sanitarios y para los propios médicos, y requiere un abordaje multidisciplinar e interterritorial. El transporte en ECMO es más seguro que sin soporte mecánico, sin existir por el momento criterios de iniciación de la terapia en pacientes a trasladar, pudiendo ser necesarios criterios de menor gravedad en ellos. La formación y la especialización del equipo tanto en terapias de soporte extracorpóreo como en transporte interhospitalario, así como la sistematización de los traslados, pueden favorecer los resultados. No existen estudios acerca de las condiciones que deben cumplir los medios de transporte, siendo el espacio y la estabilidad características importantes. El traslado aéreo en ECMO supone una posibilidad cada vez más frecuente, existiendo datos sobre su seguridad, pero no sobre la fisiología del paciente en ECMO en altura, lo cual podría ayudar a la indicación y gestión de este tipo de transporte

Extracorporeal membrane oxygenation (ECMO) support is indicated in patients who are refractory to treatment, those with cardiogenic shock or respiratory failure and those with exacerbations eligible for heart and lung transplantation. Physician experience and quantity of necessary resources are reasons why regionalization could benefit patients of this kind, establishing ECMO reference centers and integrating a transportation network specialized in ECMO. This type of transportation is a challenge for healthcare systems and physicians, given its greater complexity, requiring a multidisciplinary and inter-territorial approach. ECMO transportation is safer than without mechanical support, though there are currently no criteria for starting such therapy in patients being transferred. Criteria of lesser severity might be necessary for these patients. The training and specialization of the team in extracorporeal support therapies, interfacility transport and the systemization of transfer can improve the outcomes. There are no studies on the conditions that must be met by the transportation media, although space and stability are important characteristics. Air transfer with ECMO is an increasingly frequent option. Although there are data on its safety, there are none on the physiology of patients undergoing ECMO at high altitudes. Such information could be of help in the indication and management of this type of transportation

Issues to resolve with the use of extracorporeal membrane oxygenation during interfacility transportation. / Transporte interhospitalario con membrana de oxigenación extracorpórea: cuestiones a resolver.

Extracorporeal membrane oxygenation (ECMO) support is indicated in patients who are refractory to treatment, those with cardiogenic shock or respiratory failure and those with exacerbations eligible for heart and lung transplantation. Physician experience and quantity of necessary resources are reasons why regionalization could benefit patients of this kind, establishing ECMO reference centers and integrating a transportation network specialized in ECMO. This type of transportation is a challenge for healthcare systems and physicians, given its greater complexity, requiring a multidisciplinary and inter-territorial approach. ECMO transportation is safer than without mechanical support, though there are currently no criteria for starting such therapy in patients being transferred. Criteria of lesser severity might be necessary for these patients. The training and specialization of the team in extracorporeal support therapies, interfacility transport and the systemization of transfer can improve the outcomes. There are no studies on the conditions that must be met by the transportation media, although space and stability are important characteristics. Air transfer with ECMO is an increasingly frequent option. Although there are data on its safety, there are none on the physiology of patients undergoing ECMO at high altitudes. Such information could be of help in the indication and management of this type of transportation.

Health care costs of complex perianal fistula in Crohn's disease.

AIM: To evaluate the use of health care resources and the associated costs of complex perianal Crohn's disease (CD) from the National Health System perspective. METHODS: We conducted a multicenter, retrospective, observational study in which gastroenterologists from 11 hospitals in the Community of Madrid took part. Data was collected on the direct healthcare resources (pharmacological treatments, surgical procedures, laboratory/diagnostic tests, visits to specialists and emergency departments, and hospitalizations) consumed by 97 adult patients with complex perianal CD which was active at some point between January 1, 2005, and case history review. RESULTS: We recorded 527 treatments: 73.1% pharmacological (32.3% antibiotic, 20.5% immunomodulator, 20.3% biological) and 26.9% surgical. Mean annual global cost was €8,289/patient, 75.3% (€6,242) of which was accounted for by pharmacological treatments (€13.44 antibiotics; €1,136 immunomodulators; €5,093 biological agents), 12.4% (€1,027) by hospitalizations and surgery, 7.7% (€640) by medical visits, 4.2% (€350) by laboratory/diagnostic tests, and 0.4% (€30) by emergency department visits. CONCLUSIONS: Pharmacological therapies, and in particular biological agents, are the main cost driver in complex perianal CD; costs due to surgery and hospitalizations are much lower.

Infliximab salvage therapy after failure of ciclosporin in corticosteroid-refractory ulcerative colitis: a multicentre study.

BACKGROUND: Ciclosporin has proven to be effective in patients with corticosteroid-refractory ulcerative colitis (UC). When therapy with this drug fails, infliximab can be considered to avoid colectomy. The efficacy and safety of this sequential approach remain unknown. AIM: To assess the efficacy and safety profile of treatment with infliximab after failure of ciclosporin in patients with a corticosteroid-refractory flare of UC. METHODS: Retrospective review of medical records of patients with a corticosteroid-refractory flare of UC who did not respond to ciclosporin and received salvage therapy with infliximab within a month of discontinuing ciclosporin. The severity of the flare and response to the treatment were graded using the Lichtiger index. Cumulative rates of colectomy were calculated using Kaplan-Meier analysis. Cox regression analysis was performed to identify predictors of colectomy. To evaluate the safety profile of this treatment strategy, any adverse event occurring after the first infusion of infliximab was considered. RESULTS: The study population comprised 47 patients with corticosteroid-refractory UC treated with infliximab after failure of ciclosporin. The median baseline Lichtiger index was 13. The mean time from the last ciclosporin dose to the first infliximab infusion was 6 days. After the first infliximab infusion, 13% of patients achieved remission, and 74% partial response. Of the 35 patients who received the third infliximab infusion, 60% achieved remission, and 37% partial response. Fourteen patients (30%) underwent colectomy. The rate of adverse events was 23%. One death occurred in a 40-year-old man who failed ciclosporin and infliximab and underwent surgery 10 days after the first infliximab infusion; he died of nosocomial pneumonia. CONCLUSIONS: Treatment with infliximab makes it possible to avoid colectomy in two-thirds of corticosteroid-refractory UC patients in whom ciclosporin fails. However, the rates of adverse events and mortality mean that the decision to administer sequential therapy (ciclosporin-infliximab) should be taken on an individual basis.