Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por covid-19: revisión rápida y consenso de expertos / Ethical recommendations for a difficult decision-making in intensive care units due to the exceptional situation of crisis by the covid-19 pandemia: a rapid review & consensus of experts

Ante la situación excepcional de salud pública provocada por la pandemia por COVID-19, desde el grupo de ética de la Sociedad Española de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) se ha promovido un trabajo de consenso, con el objetivo de encontrar algunas respuestas desde la ética a la encrucijada entre el incremento de personas con necesidades de atención intensiva y la disponibilidad efectiva de medios. En un periodo muy corto de tiempo, se ha cambiado el marco de ejercicio de la medicina hacia un escenario de "medicina de catástrofe", con el consecuente cambio en los parámetros de toma de decisiones. En este contexto la asignación de recursos o la priorización de tratamiento pasan a ser elementos cruciales, y es importante contar con un marco de referencia ético para poder tomar las decisiones clínicas necesarias. Para ello, se ha realizado un proceso de revisión narrativa de la evidencia, seguida de u. consenso de expertos no sistematizado, que ha tenido como resultado tanto la publicación de un documento de posicionamiento y recomendaciones de la propia SEMICYUC, como el consenso entre 18 sociedades científicas y 5 institutos/cátedras de bioética y cuidados paliativos de un documento marco de referencia de recomendaciones éticas generales en este contexto de crisis

In view of the exceptional public health situation caused by the COVID-19 pandemic, a consensus work has been promoted from the ethics group of the Spanish Society of the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC), with the objective of finding some answers from ethics to the crossroads between the increase of people with intensive care needs and the effective availability of means. In a very short period, the medical practice framework has been changed to a "catastrophe medicine" scenario, with the consequent change in the decision-making parameters. In this context, the allocation ofresources or the prioritization of treatment become crucial elements, and it is important to have an ethical reference framework to be able to make the necessary clinical decisions.For this, a process of narrative review of the evidence has been carried out, followed by u. Unsystematic consensus of experts, which has resulted in both the publication of a position paper and recommendations from SEMICYUC itself, and the consensus between 18 scientific societies and 5 institutes / chairs of bioethics and palliative care of a framework document of reference for general ethical recommendations in this context of crisis

Dexmedetomidine for the Treatment of Hyperactive Delirium Refractory to Haloperidol in Nonintubated ICU Patients: A Nonrandomized Controlled Trial.

OBJECTIVES: To evaluate the clinical effectiveness, safety, and cost of dexmedetomidine for the treatment of agitated delirium refractory to haloperidol in nonintubated critically ill patients. DESIGN: Nonrandomized, controlled trial. SETTING: Intensive care department of a tertiary care nonprofit hospital. PATIENTS: All consecutive admissions to a medical-surgical ICU with a diagnosis of agitated delirium. INTERVENTIONS: Initial haloperidol titration: all patients received IV bolus doses of haloperidol until agitation was controlled (Richmond Agitation Sedation Scale scoring range, 0 to -2) or reaching the maximum daily dose. Group comparison: patient responders to haloperidol (control group) were compared with nonresponders (dexmedetomidine group). MEASUREMENTS AND MAIN RESULTS: A total of 132 nonintubated patients were treated with haloperidol in the initial haloperidol titration phase. Forty-six patients (34.8%; 95% CI, 26.0-43.1%) did not respond to haloperidol, and 86 patients (65.2%; 95% CI, 56.3-73.0%) were responders. During the group comparison phase, dexmedetomidine achieved a higher percentage of time in satisfactory sedation levels than did haloperidol (92.7% [95% CI, 84.5-99.8%] vs 59.3% [95% CI, 48.6-69.3%], respectively; p = 0.0001). Haloperidol was associated with 10 cases (11.6% [95% CI, 6.5-21.2%]) of oversedation and two (2.0% [0.4-8%]) of corrected QT lengthening. Direct cost of dexmedetomidine was 17 times greater than haloperidol, but it achieved a mean savings of $4,370 per patient due to the reduction in length of ICU stay. CONCLUSIONS: In the study conditions, dexmedetomidine shows to be useful as a rescue drug for treating agitation due to delirium in nonintubated patients in whom haloperidol has failed, and it seems to have a better effectiveness, safety, and cost-benefit profile than does haloperidol.

Relationship between volume and survival in closed intensive care units is weak and apparent only in mechanically ventilated patients.

BACKGROUND: Recent studies have found an association between increased volume and increased intensive care unit (ICU) survival; however, this association might not hold true in ICUs with permanent intensivist coverage. Our objective was to determine whether ICU volume correlates with survival in the Spanish healthcare system. METHODS: Post hoc analysis of a prospective study of all patients admitted to 29 ICUs during 3 months. At ICU discharge, the authors recorded demographic variables, severity score, and specific ICU treatments. Follow-up variables included ICU readmission and hospital mortality. Statistics include logistic multivariate analyses for hospital mortality according to quartiles of volume of patients. RESULTS: The authors studied 4,001 patients with a mean predicted risk of death of 23% (range at hospital level: 14-46%). Observed hospital mortality was 19% (range at hospital level: 11-35%), resulting in a standardized mortality ratio of 0.81 (range: 0.5-1.3). Among the 1,923 patients needing mechanical ventilation, the predicted risk of death was 32% (14-60%) and observed hospital mortality was 30% (12-61%), resulting in a standardized mortality ratio of 0.96 (0.5-1.7). The authors found no correlation between standardized mortality ratio and ICU volume in the entire population or in mechanically ventilated patients. Only mechanically ventilated patients in very low-volume ICUs had slightly worse outcome. CONCLUSION: In the currently studied healthcare system characterized by 24/7 intensivist coverage, the authors found wide variability in outcome among ICUs even after adjusting for severity of illness but no relationship between ICU volume and outcome. Only mechanically ventilated patients in very low-volume centers had slightly worse outcomes.

Reflexiones sobre el Consejo de Redacción de Medicina Intensiva / Considerations on the Editorial Board of MEDICINA INTENSIVA

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Trombólisis en el ictus: la accesibilidad sin garantía de seguridad es insostenible. Réplica / Thrombolysis in stroke: accessibility without safety guarantees is untenable. Reply

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Costes de la calidad en medicina intensiva. Guía para gestores clínicos / Quality costs in critical care medicine. A guide for hospital managers

Objetivo: En este artículo se revisa la utilidad y aplicabilidad de los sistemas disponibles para calcular los costes generales y los costes de la calidad de los servicios clínicos hospitalarios, se analiza la estructura de costes de un servicio clínico tipo y se evalúa el impacto económico de un programa de mejora de la calidad. Material y método: Revisión de técnicas para calcular los costes en las unidades de cuidados intensivos (UCI) mediante diferentes enfoques de la contabilidad analítica para tal fin. Resultados: Se describen los métodos de análisis descendente y ascendente para el cálculo de los costes hospitalarios por servicios. Este desarrollo metodológico se complementa con los resultados de aplicación en la UCI del Hospital del Milagro y se presentan su estructura de costes y los datos obtenidos con esta metodología al analizar los costes resultantes de las actividades de mejora de la calidad, que permitieron ahorrar 28.582 D anuales. Conclusiones: El esfuerzo para implementar sistemas de análisis de los costes en general y de los costes de la calidad en particular redundará en beneficio de los actores del sistema sanitario: ciudadanos, profesionales, gestores y financiadores, ya que lo que hoy día sólo son legítimas demandas más o menos en ciernes, mañana será un compromiso ineludible de los profesionales asistenciales ante la sociedad

Objective: This article reviews the utility and applicability of available systems for calculating general and quality costs in clinical service settings by analyzing the costs structure of a clinical service and evaluating the financial impact of a quality improvement program. Material and method: The techniques to calculate costs in intensive care units (ICUs) were reviewed using the main analytical accounting approaches for this purpose. Results: Methods of top-down and bottom-up analysis for hospital costs calculation are described. This methodological development is complemented with the results of the application of these analyses in the ICU of the Hospital del Milagro. Costs structure and the results obtained with this methodology when the costs of activities related to quality improvement, which achieved a cost-saving of 28,582 D, are presented. Conclusions: Efforts to implement systems designed to analyze general and quality costs will benefit all actors of the healthcare system: citizens, professionals, managers, and financial providers since what are only legitimate demands today, more or less in the making, tomorrow will be an unavoidable commitment of healthcare professionals to society

Expresión conjunta de las relaciones entre efectividad y eficiencia asistenciales en pacientes críticos / Combined measure of effectiveness and efficiency in critically-ill patients

Objetivo: Diseñar una expresión conjunta de efectividad y eficiencia en el ámbito de actuación de la medicina intensiva y la asistencia a los pacientes críticos. Material y método: El estudio utiliza los datos de actividad de los años 1998 a 2000 de un servicio de medicina intensiva de 15 camas que incluye 2.627 registros de ingresos consecutivos. Se ha utilizado un conjunto mínimo básico de datos (CMBD) de diseño propio que incorpora datos demográficos, registro de la causa de ingreso, estancia en la unidad de cuidados intensivos (UCI), carga asistencial NEMS (Nine Equivalents of Nursing Manpower Used Score), datos de estimación pronostica mediante SAPS II (Simplified Acute Physiology Score) y mortalidad durante la estancia hospitalaria. La efectividad asistencial se establece mediante la relación entre mortalidad real y predicha (tasa estandarizada de mortalidad [SMR]) y la eficiencia, mediante el índice de eficiencia normalizado, resultante de dividir (para cada causa de ingreso) el promedio del sumatorio de la carga asistencial durante la estancia por la estancia media y referirlo a la del global de la muestra (carga asistencial total dividida por promedio de estancia global) Resultados: La expresión conjunta de efectividad/eficiencia, así establecidas, según una distribución alrededor del eje de coordenadas, permite identificar los grupos de pacientes de alta efectividad y alta eficiencia frente a los grupos cuya asistencia se traduce en baja efectividad y baja eficiencia. Conclusión: El método descrito permite establecer una evaluación secuencial de la calidad de los resultados asistenciales conseguidos tanto en las comparaciones longitudinales (a lo largo del tiempo) como en comparaciones transversales entre distintas UCI o con relación a un estándar. (AU)