Utilidad de la diferencia venoarterial de PCO2 como predictor de complicaciones en el postoperatorio inmediato del trasplante hepático / Utility of the central venous-to-arterial CO2 difference to predict adverse outcomes after liver transplantation

Objetivo: Evaluar la relación de la diferencia venoarterial de PCO2 (ΔPCO2) con la aparición de complicaciones en el manejo postoperatorio precoz del trasplante hepático. Materiales y métodos: Estudio observacional y prospectivo realizado en una unidad de cuidados intensivos médico-quirúrgica de un hospital universitario. Se incluyó a 150 pacientes adultos que recibieron un trasplante de hígado ortotópico entre enero de 2015 y noviembre de 2018. Los pacientes fueron clasificados en 4grupos predefinidos de acuerdo con la evolución de la ΔPCO2 durante las primeras 6 h del postoperatorio en la unidad de cuidados intensivos, al considerar ese periodo como el de mayor riesgo de alteraciones hemodinámicas: 1) ΔPCO2 persistentemente normal (normal en T0 y T6); 2) ΔPCO2 descendente (alta en T0, normal en T6); 3) ΔPCO2 ascendente (normal en T0, alta en T6) y 4) ΔPCO2 persistentemente alta (alta en T0 y T6). Se comparó la relación de dichos grupos con la aparición de disfunción multiorgánica a las 72 h y las probabilidades de supervivencia globales y en el día 30 se describieron mediante curvas de Kaplan-Meier; las diferencias se calcularon mediante un test log-rank. Para el estudio de la correlación entre índice cardiaco y ΔPCO2 se utilizó el coeficiente de correlación de Spearman. Resultados: La disfunción multiorgánica representada mediante el SOFA a las 72 h (p=0,86) y el Δ-SOFA (p=0,088) no presentó diferencias significativas entre los 4grupos a estudio, de la misma forma que ocurrió con la mortalidad hospitalaria (χ2=5,72; p=0,126) y a los 30 días (χ2=2,23; p=0,5252). Con respecto a la relación entre índice cardiaco y ΔPCO2, se demostró una correlación inversa estadísticamente significativa de valor bajo (rho de Spearman: −0,17; p=0,002). Conclusiones: En pacientes críticos admitidos tras un trasplante hepático, la diferencia venoarterial de PCO2 no predice la mortalidad ni la incidencia de complicaciones en el periodo postoperatorio inmediato.(AU)

Objective: Test whether the development of abnormal venous-to arterial CO2 difference (ΔPCO2) during the early phases of postoperative care after a liver transplantation is related to multi-organ dysfunction and outcomes. Materials and methods: Prospective cohort study accomplished in a mixed intensive care unit at a university hospital. We included 150 eligible patients after a liver transplantation between 2015 and 2018. Patients were classified in 4predefined groups according to the ΔPCO2 evolution during the first 6h of resuscitation: 1) persistently normal ΔPCO2 (normal at T0 and T6); 2) decreasing ΔPCO2 (high at T0, normal at T6); 3) increasing ΔPCO2 (normal at T0, high at T6); and 4) persistently high ΔPCO2 (high at T0 and T6). Multiorgan dysfunction at day-3 was compared for predefined groups and a Kaplan Meier curve was constructed to show the survival probabilities using a log-rank test to evaluate differences between groups. A Spearman-rho was used to test the agreement between cardiac output and ΔPCO2. Results: There were no significant differences between the study groups regarding higher SOFA scores at day-3 (P=0.86), Δ-SOFA (P=0.088), as well as global mortality rates (χ2=5.72; P=0.126) and mortality rates at day-30 (χ2=2.23; P=0.5252). A significantly poor inverse agreement between cardiac output and ΔPCO2 was observed (rho de Spearman −0,17; P=0,002) at different points of resuscitation. Conclusions: After a liver transplantation, central venous-to-arterial CO2 difference was not associated with survival or postoperative adverse outcomes in a critical care patients population.(AU)

Utility of the central venous-to-arterial CO2 difference to predict adverse outcomes after liver transplantation.

OBJECTIVE: Test whether the development of abnormal venous-to arterial CO2 difference (ΔPCO2) during the early phases of postoperative care after a liver transplantation (LT) is related to multi-organ dysfunction and outcomes. MATERIALS AND METHODS: Prospective cohort study accomplished in a mixed intensive care unit (ICU) at a university hospital. We included 150 eligible patients after a LT between 2015 and 2018. Patients were classified in four predefined groups according to the ΔPCO2 evolution during the first 6 h of resuscitation: (1) persistently normal ΔPCO2 (normal at T0 and T6); (2) decreasing ΔPCO2 (high at T0, normal at T6); (3) increasing ΔPCO2 (normal at T0, high at T6); and (4) persistently high ΔPCO2 (high at T0 and T6). Multiorgan dysfunction at day-3 was compared for predefined groups and a Kaplan Meier curve was constructed to show the survival probabilities using a log-rank test to evaluate differences between groups. A Spearman-Rho was used to test the agreement between cardiac output and ΔPCO2. RESULTS: There were no significant differences between the study groups regarding higher SOFA scores at day-3 (P = .86), Δ-SOFA (P = .088), as well as global mortality rates (χ²â€¯= 5.72; P = .126) and mortality rates at day-30 (χ²â€¯= 2.23; P = .5252). A significantly poor inverse agreement between cardiac output and ΔPCO2 was observed (r2 -0,17; P = ,002) at different points of resuscitation. CONCLUSIONS: After a LT, central venous-to-arterial CO2 difference was not associated with survival or postoperative adverse outcomes in a critical care patients population.

Recomendaciones para el tratamiento nutrometabólico especializado del paciente crítico: respuesta metabólica al estrés. Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) / Recommendations for specialized nutritional-metabolic treatment of the critical patient: Metabolic response to stress. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)

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Ventilación mecánica en el paciente quemado crítico con inhalación: ¿podemos evitarla? / Mechanical ventilation in critically ill burn patient with inhalation injury: Can we avoid it?

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Documento práctico del manejo de la hiponatremia en pacientes críticos / Practical document on the management of hyponatremia in critically ill patients

La hiponatremia es el trastorno electrolítico más prevalente en las Unidades de Cuidados Intensivos. Se asocia a un aumento de la morbilidad, mortalidad y estancia hospitalaria. La mayoría de los estudios publicados hasta el momento son observacionales, retrospectivos y no incluyen pacientes críticos, lo que dificulta la extracción de conclusiones sólidas. Además, debido a la escasa evidencia científica de calidad, incluso las recomendaciones realizadas por distintas sociedades científicas recientemente publicadas difieren en aspectos importantes como son el diagnóstico o el tratamiento de la hiponatremia. Los mecanismos etiopatogénicos en los pacientes críticos suelen ser complejos. Sin embargo, hay que profundizar en ellos para llegar al diagnóstico más probable y a la pauta de tratamiento más adecuada. Todo ello, ha motivado la realización de esta revisión práctica sobre aspectos útiles en el abordaje de la hiponatremia en las Unidades de Cuidados intensivos, con el objetivo de homogeneizar el manejo de esta entidad y disponer de un algoritmo diagnóstico a nivel nacional

Hyponatremia is the most prevalent electrolyte disorder in Intensive Care Units. It is associated with an increase in morbidity, mortality and hospital stay. The majority of the published studies are observational, retrospective and do not include critical patients; hence it is difficult to draw definitive conclusions. Moreover, the lack of clinical evidence has led to important dissimilarities in the recommendations coming from different scientific societies. Finally, etiopathogenic mechanisms leading to hyponatremia in the critical care patient are complex and often combined, and an intensive analysis is clearly needed. A study was therefore made to review all clinical aspects about hyponatremia management in the critical care setting. The aim was to develop a Spanish nationwide algorithm to standardize hyponatremia diagnosis and treatment in the critical care patient

Documento sobre la situación del modelo español de Medicina Intensiva. Plan estratégico SEMICYUC 2018-2022 / Document on the state of affairs of the Spanish model of Intensive Care Medicine. SEMICYUC Strategic Plan 2018-2022

El modelo español de Medicina Intensiva requiere una revisión y reflexión continuas. Tenemos valores y fortalezas que se concretan en nuestra actividad y en el importante papel que realizamos a diario a nivel hospitalario. Otras especialidades pugnan por compartir actividades de cuidados del paciente crítico y otras circunstancias pueden hacer mermar esa actividad. Este artículo es el reflejo de la reflexión de un importante número de miembros del Grupo de Trabajo de Planificación, Organización y Gestión de nuestra Sociedad (GTPOG-SEMICYUC). Se afrontan las acciones que se deben llevar a cabo para la actualización del modelo de Medicina Intensiva, hacia un modelo más abierto de UCI sin paredes o UCI extendida. Se aborda desde tres puntos de vista que deben ser complementarios: las acciones a nivel de la Administración, las acciones a nivel de nuestra Sociedad Científica y las llevadas a cabo por cada uno de los Servicios (liderados por sus representantes), tanto a nivel hospitalario como a nivel de las autoridades sanitarias en cada comunidad autónoma

The role of Critical Care Medicine in Spain requires continuous revision and reflection. We have values and strengths that are evidenced in our daily work and by their important effects in routine hospital activity. Other medical specialties seeking to assume activities referred to critical patient care, as well as a number of other circumstances, may have a negative impact upon our routine duties. This article reflects the impressions of an important number of members of the Planning, Organization and Management Task Force of the Spanish Society of Critical Medicine Society (Grupo de Trabajo de Planificación, Organización y Gestión; GTPOG-SEMICYUC). The actions required to upgrade our Critical Care Medicine model are presented, evolving towards a broader view such as the 'ICU without walls' or 'Expanded ICU'. The subject is addressed from three complementary standpoints: actions involving the administrative authorities; actions required on the part of our scientific Society; and initiatives to be implemented locally in each Intensive Care Unit (led by the corresponding Unit representatives) at both hospital level and involving the regional authorities

Practical document on the management of hyponatremia in critically ill patients. / Documento práctico del manejo de la hiponatremia en pacientes críticos.

Hyponatremia is the most prevalent electrolyte disorder in Intensive Care Units. It is associated with an increase in morbidity, mortality and hospital stay. The majority of the published studies are observational, retrospective and do not include critical patients; hence it is difficult to draw definitive conclusions. Moreover, the lack of clinical evidence has led to important dissimilarities in the recommendations coming from different scientific societies. Finally, etiopathogenic mechanisms leading to hyponatremia in the critical care patient are complex and often combined, and an intensive analysis is clearly needed. A study was therefore made to review all clinical aspects about hyponatremia management in the critical care setting. The aim was to develop a Spanish nationwide algorithm to standardize hyponatremia diagnosis and treatment in the critical care patient.

Document on the state of affairs of the Spanish model of Intensive Care Medicine. SEMICYUC Strategic Plan 2018-2022. / Documento sobre la situación del modelo español de Medicina Intensiva. Plan estratégico SEMICYUC 2018-2022.

The role of Critical Care Medicine in Spain requires continuous revision and reflection. We have values and strengths that are evidenced in our daily work and by their important effects in routine hospital activity. Other medical specialties seeking to assume activities referred to critical patient care, as well as a number of other circumstances, may have a negative impact upon our routine duties. This article reflects the impressions of an important number of members of the Planning, Organization and Management Task Force of the Spanish Society of Critical Medicine Society (Grupo de Trabajo de Planificación, Organización y Gestión; GTPOG-SEMICYUC). The actions required to upgrade our Critical Care Medicine model are presented, evolving towards a broader view such as the 'ICU without walls' or 'Expanded ICU'. The subject is addressed from three complementary standpoints: actions involving the administrative authorities; actions required on the part of our scientific Society; and initiatives to be implemented locally in each Intensive Care Unit (led by the corresponding Unit representatives) at both hospital level and involving the regional authorities.

Traspaso de información en Medicina Intensiva / Handover in Intensive Care

El traspaso de información (TI) es una tarea frecuente y compleja que lleva implícito el traspaso de la responsabilidad del cuidado del paciente. Las deficiencias en este proceso se asocian a importantes brechas en la seguridad clínica e insatisfacción de pacientes y profesionales. Los esfuerzos por estandarizar el TI se han incrementado en los últimos años, dando pie a la aparición de herramientas mnemotécnicas. Globalmente las prácticas locales del TI son heterogéneas y el nivel de formación, bajo. El objetivo de esta revisión es enfatizar la importancia del TI y proporcionar una estructura metodológica que favorezca el TI efectivo en las UCI, reduciendo el riesgo asociado a este proceso. Específicamente, se hace referencia al TI durante los cambios de guardia y los turnos de enfermería, durante el traslado de los pacientes a otras áreas diagnósticas y terapéuticas y en el momento del alta de UCI. También se contemplan las situaciones de urgencia y se señala la potencial participación de pacientes y familiares. Por último, se proponen fórmulas para la medición de la calidad y se mencionan posibles mejoras en este proceso, especialmente en el ámbito de la formación

Handover is a frequent and complex task that also implies the transfer of the responsibility of the care. The deficiencies in this process are associated with important gaps in clinical safety and also in patient and professional dissatisfaction, as well as increasing health cost. Efforts to standardize this process have increased in recent years, appearing numerous mnemonic tools. Despite this, local are heterogeneous and the level of training in this area is low. The purpose of this review is to highlight the importance of IT while providing a methodological structure that favors effective IT in ICU, reducing the risk associated with this process. Specifically, this document refers to the handover that is established during shift changes or nursing shifts, during the transfer of patients to other diagnostic and therapeutic areas, and to discharge from the ICU. Emergency situations and the potential participation of patients and relatives are also considered. Formulas for measuring quality are finally proposed and potential improvements are mentioned especially in the field of training

Handover in Intensive Care. / Traspaso de información en Medicina Intensiva.

Handover is a frequent and complex task that also implies the transfer of the responsibility of the care. The deficiencies in this process are associated with important gaps in clinical safety and also in patient and professional dissatisfaction, as well as increasing health cost. Efforts to standardize this process have increased in recent years, appearing numerous mnemonic tools. Despite this, local are heterogeneous and the level of training in this area is low. The purpose of this review is to highlight the importance of IT while providing a methodological structure that favors effective IT in ICU, reducing the risk associated with this process. Specifically, this document refers to the handover that is established during shift changes or nursing shifts, during the transfer of patients to other diagnostic and therapeutic areas, and to discharge from the ICU. Emergency situations and the potential participation of patients and relatives are also considered. Formulas for measuring quality are finally proposed and potential improvements are mentioned especially in the field of training.

Sobrevivir a las unidades de cuidados intensivos mirando a través de los ojos de la familia / Surviving the intensive care units looking through the family's eyes

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Foro de debate: seguridad de las alternativas a la transfusión alogénica en el paciente quirúrgico y/o crítico / Forum for debate: Safety of allogeneic blood transfusion alternatives in the surgical/critically ill patient

Estos últimos años han aparecido alertas de seguridad, no siempre bien sustentadas, que cuestionan el uso de algunas alternativas farmacológicas a la transfusión de sangre alogénica y/o lo restringen en indicaciones establecidas. Asistimos también a la preconización de otras alternativas, incluyendo productos hemáticos y fármacos antifibrinolíticos, sin que haya una base científica sólida que lo justifique. Por iniciativa del Grupo de Estudios Multidisciplinares sobre Autotransfusión y del Anemia Working Group España se reunió a un panel multidisciplinar de 23 expertos del área de cuidados de la salud en un foro de debate para: 1) analizar las diferentes alertas de seguridad en torno a ciertas alternativas a la transfusión; 2) estudiar los antecedentes que las han propiciado, la evidencia que las sustentan y las consecuencias que conllevan para la práctica clínica, y 3) emitir una valoración argumentada de la seguridad de cada alternativa a la transfusión cuestionada, según el uso clínico de la misma. Los integrantes del foro mantuvieron contactos por vía telemática y una reunión presencial en la que presentaron y discutieron las conclusiones sobre cada uno de los elementos examinados. Se elaboró un primer documento que fue sometido a 4 rondas de revisión y actualización hasta alcanzar un consenso, unánime en la mayoría de los casos. Presentamos la versión final del documento, aprobada por todos los miembros del panel, esperando sea de utilidad para nuestros colegas

In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues

Forum for debate: Safety of allogeneic blood transfusion alternatives in the surgical/critically ill patient.

In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues.

Resultados de una encuesta sobre la práctica clínica habitual en el empleo de albúmina en UCI / Results of a survey on albumin use in clinical practice in intensive care units

INTRODUCCIÓN: Las soluciones de albúmina humana se emplean en diversas enfermedades, aunque su indicación no es clara en todas. Presentan un coste elevado y su beneficio no se encuentra plenamente establecido. Resulta interesante conocer cuál es la presencia de las soluciones de albúmina en la práctica clínica diaria de los intensivistas. OBJETIVO: Documentar prácticas clínicas habituales y describir la variabilidad de las mismas en cuanto al empleo de soluciones de albúmina en enfermos críticos. DISEÑO: Encuesta enviada mediante correo electrónico a unidades de cuidados intensivos (UCI) españolas y sudamericanas. Periodo: Planificación y realización durante el año 2012. Ámbito: UCI españolas y sudamericanas. MÉTODOS: Cuestionario de 35 preguntas. RESULTADOS: Se han analizado 57 encuestas. El empleo de las soluciones de albúmina fue esporádico o no se empleaba en el paciente crítico (96,5%). La excepción fueron los pacientes hepatópatas (un 87,7% de los encuestados la administraba). Un elevado porcentaje declaró conocer la evidencia científica disponible sobre el empleo de albúmina en pacientes hepatópatas (82,5%) y no hepatópatas (77,2%). El 5,3% de los encuestados prefería basarse en su experiencia para establecer las indicaciones del empleo de albúmina. CONCLUSIONES: El empleo de soluciones de albúmina no es frecuente en las UCI, salvo en pacientes hepatópatas. Los profesionales del enfermo crítico manifiestan tener un amplio conocimiento de la evidencia científica. Las opiniones emitidas, acerca del empleo de albúmina, son acordes con las recomendaciones establecidas, sobre todo, en pacientes hepatópatas. La experiencia profesional prevalece en escasas ocasiones sobre las recomendaciones publicadas

BACKGROUND: Human albumin solutions are used in a number of disorders, though their indications are not clear in all circumstances. These solutions are costly, and their benefit has not been established in all settings. It is therefore interesting to assess the presence of albumin solutions in the daily clinical practice of critical care professionals. OBJECTIVES: To report the standard clinical practices and to describe the variability of albumin solutions use in critically ill patients. DESIGN: A survey sent by e-mail to Spanish and South American Intensive Care Units (ICUs) Period: Planning and execution during the year 2012. METHODS: A questionnaire comprising 35 questions. RESULTS: Fifty-seven surveys were analyzed. The use of albumin solutions was sporadic or negligible in critically ill patients (96.5%). The exceptions were patients with liver disease (87.7% of the responders administered albumin to these patients). A high percentage of professionals claimed to know the available scientific evidence on the use of albumin in patients with liver disease (82.5%) and in patients without liver disease (77.2%). Only 5.3% of the responders preferred to rely on their own experience to establish the indications of albumin use. CONCLUSIONS: The use of albumin solutions is infrequent in ICUs, except in patients with liver disease. Evidence-based knowledge on albumin use is declared to be extensive in ICUs. As a rule, opinions on the use of albumin solutions are based on the scientific recommendations, especially in patients with liver disease. Professional experience rarely prevails over the published clinical guidelines

Results of a survey on albumin use in clinical practice in intensive care units.

BACKGROUND: Human albumin solutions are used in a number of disorders, though their indications are not clear in all circumstances. These solutions are costly, and their benefit has not been established in all settings. It is therefore interesting to assess the presence of albumin solutions in the daily clinical practice of critical care professionals. OBJECTIVES: To report the standard clinical practices and to describe the variability of albumin solutions use in critically ill patients. DESIGN: A survey sent by e-mail to Spanish and South American Intensive Care Units (ICUs) PERIOD: Planning and execution during the year 2012. METHODS: A questionnaire comprising 35 questions. RESULTS: Fifty-seven surveys were analyzed. The use of albumin solutions was sporadic or negligible in critically ill patients (96.5%). The exceptions were patients with liver disease (87.7% of the responders administered albumin to these patients). A high percentage of professionals claimed to know the available scientific evidence on the use of albumin in patients with liver disease (82.5%) and in patients without liver disease (77.2%). Only 5.3% of the responders preferred to rely on their own experience to establish the indications of albumin use. CONCLUSIONS: The use of albumin solutions is infrequent in ICUs, except in patients with liver disease. Evidence-based knowledge on albumin use is declared to be extensive in ICUs. As a rule, opinions on the use of albumin solutions are based on the scientific recommendations, especially in patients with liver disease. Professional experience rarely prevails over the published clinical guidelines.