[Mechanical restraint: its use in intensive cares]. / Contención mecánica: su uso en cuidados intensivos.

OBJECTIVE: To analyze the impact of the use of mechanical restraint (MR) or physical restraints in a Critical Care unit and to evaluate the procedure. BASIC PROCEDURES: A descriptive, prospective study. INCLUSION CRITERIA: patients who required MR from March to June 2010. VARIABLES: demographic, clinical presentation, indications, techniques and devices. A statistical analysis with mean, standard deviation and percentages using the program SPSS 14.0. RESULTS: A total of 85 cases were studied: 65.9% male, mean age 64.19 (±17.9), NEMS 29.3 (±8.2). Incidence of MR: 15.6%. Main indication for MR: Risk of serious disruption of treatment processes (80%). Decision nurse (94.1%). Urgent action: (85.9%). Registration procedure: 57.6%. Information to the family: 9.4%. Previous actions: verbal containment (100%), pharmacological (48.2%). CONCLUSIONS: There is a relevant incidence of MR. The principal reason is that of avoiding interruption of the therapeutic process. The nurse makes the initial decision. Necessary information/training of professionals for legal and ethical repercussions is needed.

NEMS: ¿nuevo predictor de mortalidad en el paciente crítico? / Nems: a new predictor of mortality in the critical patient?

En las unidades de cuidados intensivos se utilizan habitualmente escalas que predicen el riesgo de mortalidad hospitalaria y objetivan las necesidades terapéuticas y asistenciales que requieren los pacientes críticos. El objetivo de este trabajo fue estudiar si el NEMS podía ser utilizado como predictor de mortalidad, comparándolo con el APACHE II. Se realizó un estudio prospectivo en una unidad de cuidados intensivos polivalente de 24 camas. El APACHE II y NEMS se estratificaron en 3 niveles. Se recogieron datos demográficos y el valor en las primeras 24 horas del APACHE II y NEMS. Se incluyeron 1.257 pacientes; fallecieron el 16,4%. Fueron quirúrgicos el 69,6%; la mediana para estancia y edad fue de 2 días (1-4) y 66 años (50-77); el 59,3% fueron hombres. La mediana para vivos y muertos de APACHE II fue 10 (6-20) y 22,5 (17,25-29) respectivamente, (p<0,001) y para NEMS, 24 (18-29) y 34 (25-39,7), (p<0,001). La correlación entre ambas escalas fue rho=0,457, (p<0,01). La regresión logística controlada por edad, sexo y APACHE mostró solo para NEMS elevados un OR=3,1 (IC95%: 1,5-6,6), respecto al nivel mas inferior. Según los resultados no se debe utilizar el NEMS como predictor de mortalidad, aunque el riesgo de muerte aumenta tres veces con NEMS altos (AU)

Abstract Numerical scales are commonly used in intensive care units to predict hospital mortality and to assess the therapeutic effort and care that critically ill patients require. The aim of this work was to study whether the NEMS value can be used as a predictor of mortality, comparing it with the APACHE II. A prospective study in a 24 intensive care unit beds was conducted. The APACHE II and NEMS values were stratified into three levels. Demographic data and the first 24 hours values of APACHE II and NEMS scales were collected. A total of 1257 patients were included, 16.4% of whom died. 69.6% were surgical; median stay was 2 days (1-4). Medianage was 66 years (50-77), 59.3% were men. The median APACHE II and NEMS for the living and the dead in the subsequent course was 10 (6-20) versus 22.5 (17.25 to 29) (p <0.001) and 24(18-29) versus 34 (25 to 39.7) (p < 0.001) respectively. The correlation between both scales was rho = 0.457 (p < 0.01). Logistic regression controlled for age, sex and APACHE II showed an OR of3.1 (95% CI: 1.5-6.6) only for high NEMS, compared to the lowest level. According to the results NEMS should not be used as a predictor of mortality, although the risk of death increases by three times with high NEMS (AU)

[NEMS: a new predictor of mortality in the critical patient?]. / NEMS: ¿nuevo predictor de mortalidad en el paciente crítico?

Numerical scales are commonly used in intensive care units to predict hospital mortality and to assess the therapeutic effort and care that critically ill patients require. The aim of this work was to study whether the NEMS value can be used as a predictor of mortality, comparing it with the APACHE II. A prospective study in a 24 intensive care unit beds was conducted. The APACHE II and NEMS values were stratified into three levels. Demographic data and the first 24 hours values of APACHE II and NEMS scales were collected. A total of 1257 patients were included, 16.4% of whom died. 69.6% were surgical; median stay was 2 days (1-4). Median age was 66 years (50-77), 59.3% were men. The median APACHE II and NEMS for the living and the dead in the subsequent course was 10 (6-20) versus 22.5 (17.25 to 29) (p <0.001) and 24 (18-29) versus 34 (25 to 39.7) (p<0.001) respectively. The correlation between both scales was rho=0.457 (p<0.01). Logistic regression controlled for age, sex and APACHE II showed an OR of 3.1 (95% CI: 1.5-6.6) only for high NEMS, compared to the lowest level. According to the results NEMS should not be used as a predictor of mortality, although the risk of death increases by three times with high NEMS.

Centring ability and apical transportation after overinstrumentation with ProTaper Universal and ProFile Vortex instruments.

AIM: To evaluate morphological changes to the major foramen after overinstrumentation with ProTaper Universal and ProFile Vortex Ni-Ti rotary instruments. METHODOLOGY: Twenty-eight mesiobuccal canals of maxillary and mandibular first molars were divided into two groups of 14 canals each. The root canals were prepared with ProTaper Universal or ProFile Vortex instruments. ProTaper and Vortex instruments were used until the file tip protruded 1 mm beyond the working length (0.5 mm beyond the major foramen). The major foramen was photographed before and after overinstrumentation with each file of the two systems used. The images were superimposed and evaluated using Adobe Photoshop. The parameters evaluated were canal transportation, centring ability and shape of the major foramen. Transportation and centring ability were calculated in two directions: the direction of maximum curvature (MC) and a direction vertical to the maximum curvature (VC). Measurements of canal transportation and centring ability were analysed by anova followed by post hoc least significance difference (LSD) multiple comparisons. RESULTS: No significant differences were observed amongst the different instruments with respect to centring ability in either direction (P > 0.05). The F3 ProTaper Universal instrument was associated with a higher mean values for transportation in the direction of MC (P < 0.05) than the S1, S2 and F1 ProTaper Universal instruments and the size 15, 0.06 taper, size 20, 0.06 taper, and size 25, 0.06 taper ProFile Vortex instruments. The size 30, 0.06 taper ProFile Vortex instrument had a larger mean value for transportation in the direction of MC (P < 0.05) than the S1 ProTaper Universal and size 15, 0.06 taper ProFile Vortex instruments. The S1, S2, F1, F2 and F3 ProTaper Universal files and the size 15, 0.06 taper, size 20, 0.06 taper, size 25, 0.06 taper, and size 30, 0.06 taper ProFile Vortex files produced an oval foramen in 71%, 71%, 85%, 85%, 71%, 71%, 85%, 85% and 89% of the cases, respectively. CONCLUSIONS: In most samples, the ProTaper Universal and ProFile Vortex files produced transportation of the major foramen and created an oval-shaped major foramen after overinstrumentation.

[Technical and functional standards and implementation of a clinical information system in intensive care units]. / Estándares técnicos y funcionales, y proceso de implantación, de un sistema de información clínica en unidades de cuidados intensivos.

INTRODUCTION: Clinical Information Systems (CIS) are becoming a useful tool for managing patients and data in the ICU. However, the existing CIS differ in their capabilities and technical requirements. It is therefore essential for intensivists, as the end clients of these applications, to define the suitable minimum specifications required in order to be operative and helpful. OBJECTIVES: The Spanish Society of Intensive Care Medicine and Coronary Units, through its Organization and Management Workgroup, has designated a group of clinical and software experts to draft a document with the recommendable technical and operating requirements of these systems. METHODS: The group was formed by ten people supported by managers or engineers from the five principal industries producing CIS in Spain. The project involved the following phases: a) Completion of a check list. This step was considered necessary in order to establish the precise current situation of CIS applications. b) Discussion of the results by the group of experts in a meeting and in online format. RESULTS: The requirements were grouped into four sections: technical, functional, safety and data management. All requirements were classified as basic and optional in order to allow the end user to choose among different options according to the existing budget, though ensuring a minimal set of useful characteristics. A chronogram for the installation process was also proposed.

[Evaluation of the effect of a cleaning/disinfection intervention on the rate of multiresistant microorganism infections in the Intensive Care Unit]. / Evaluación del efecto de una intervención de limpieza/desinfección sobre la incidencia de infecciones por microorganismos multirresistentes en una Unidad de Cuidados Intensivos.

AIM: Evaluate the effect of an intervention on the rate of nosocomial infections (NI) produced by multiresistant microorganisms in the Intensive Care Units. MATERIAL AND METHODS: A study was conducted before and after an intervention in two ICUs to control an outbreak of multiresistant Acinetobacter baumanii (MRAB). During the outbreak (from 22-12-06 to 12-2-07) the wards were closed and both the wards and the equipment of both ICUs were cleaned and disinfected. A microbiological sampling was also made. The nosocomial infection rate density of the multiresistant microorganisms was compared between hospitalized patients: preintervention (1-3-2006 to 15-12-2006) and postintervention (1-3-2007 to 15-12-2007). To certify if there were any statistically significant differences between them, a rate ratio (RT) was calculated with a 95% confidence interval. The level of statistical significance was established at p < 0.05. We stratified per unit, per type of microorganism and location of the infection. RESULTS: The global NI incidence rate for multiresistant microorganisms significantly declined after the interventions in both units (RT: 1.83, 95% CI: 1.34-2.50), p < 0.005. A significant decrease was also observed on the NI incidence rate for the following microorganisms: P. aeruginosa (RT: 2.36, 95% CI: 1.41-3.96), Enterobacter BLEE (RT: 2.31, 95% CI: 1.11-4.82) and S. maltophilia (RT: 2.77, 95% CI: 1.10-6.99). In regards to the infection location, a significant decrease in respiratory infection rates was observed (RT: 1.96, 95% CI: 1.29-2.99). CONCLUSION: The intervention conducted to control the MRAB outbreak was effective in reducing the NI incidence of multiresistant microorganisms.

Evaluación del efecto de una intervención de limpieza/ desinfección sobre la incidencia de infecciones por microorganismos multirresistentes en una Unidad de Cuidados Intensivos / Evaluation of the effect of a cleaning/disinfection intervention on the rate of multiresistant microorganism infections in the Intensive Care Unit

Objetivo. Evaluar el efecto de una intervención sobre la incidencia de infecciones nosocomiales(IN) por microorganismos multirresistentes en las Unidades de Cuidados Intensivos (UCI).Material y métodos. Se realizó un estudio antes-después de una intervención para el controlde un brote de Acinetobacter baumannii multirresistente (ABMR) en dos UCI. Durante el brote(del 22-12-06 al 12-2-07) se procedió al cierre y limpieza/desinfección de las salas y equipamientode las dos UCI, con muestreo microbiológico antes y después. Se comparó la densidadde incidencia de IN por microorganismos multirresistentes entre los pacientes ingresados: preintervención(del 1-3-2006 al 15-12-2006) y posintervención (del 1-3-2007 al 15-12-2007). Paracomprobar si existían diferencias estadísticamente signifi cativas se calculó la razón de tasas(RT) y su intervalo de confi anza (IC) al 95%. El nivel de signifi cación estadística se estableció enp < 0,05. Se estratifi có por unidad, tipo de microorganismo y localización de la infección.Resultados. La tasa de incidencia global de IN por microorganismos multirresistentes disminuyósignifi cativamente tras la intervención en ambas unidades (RT: 1,83, IC 95% 1,34-2,50), p < 0,005.También existió disminución signifi cativa en la tasa de incidencia de IN para los microorganismos:P. aeruginosa (RT: 2,36, IC 95% 1,41-3,96), enterobacterias BLEE (RT: 2,31, IC 95% 1,11-4,82) y S.maltophilia (RT: 2,77, IC 95% 1,10-6,99). Con respecto a la localización de la infección resultósignifi cativa la disminución en la tasa de infecciones respiratorias (RT: 1,96, IC 95% 1,29-2,99).Conclusión. La intervención realizada para el control del brote de ABMR fue efectiva paradisminuir la incidencia de IN por otros microorganismos multirresistentes(AU)

Aim. Evaluate the effect of an intervention on the rate of nosocomial infections (NI)produced by multiresistant microorganisms in the Intensive Care Units.Material and methods. A study was conducted before and after an intervention in two ICUsto control an outbreak of multiresistant Acinetobacter baumanii (MRAB). During theoutbreak (from 22-12-06 to 12-2-07) the wards were closed and both the wards and theequipment of both ICUs were cleaned and disinfected. A microbiological sampling was alsomade. The nosocomial infection rate density of the multiresistant microorganisms wascompared between hospitalized patients: preintervention (1-3-2006 to 15-12-2006) andpostintervention (1-3-2007 to 15-12-2007). To certify if there were any statisticallysignifi cant differences between them, a rate ratio (RT) was calculated with a 95% confi denceinterval. The level of statistical signifi cance was established at p < 0.05. We stratifi ed perunit, per type of microorganism and location of the infection.Results. The global NI incidence rate for multiresistant microorganisms signifi cantlydeclined after the interventions in both units (RT: 1.83, 95% CI: 1.34-2.50), p < 0.005. Asignifi cant decrease was also observed on the NI incidence rate for the followingmicroorganisms: P. aeruginosa (RT: 2.36, 95% CI: 1.41-3.96), Enterobacter BLEE (RT: 2.31,95% CI: 1.11-4.82) and S. maltophilia (RT: 2.77, 95% CI: 1.10-6.99). In regards to theinfection location, a signifi cant decrease in respiratory infection rates was observed (RT:1.96, 95% CI: 1.29-2.99).Conclusion. The intervention conducted to control the MRAB outbreak was effective inreducing the NI incidence of multiresistant microorganisms(AU)

University of Puerto Rico Emergency Medicine Program: impact throughout the country

OBJECTIVES: Determine distribution, job description, and board certification status of the University of Puerto Rico Emergency Medicine Program (UPREMP) graduates. METHODS: A telephone survey was performed of all UPREMP graduates from 1995 to 2007, asking for the following information: practitioner or non practitioner, working place, job description (e.g. Fellow, Staff or Emergency Room Directors), and board certification status. In cases in which the person could not be reached by phone, the last information available at the UPREMRP department was used to fill the survey. The board certification was verified using The American Board of Medical Specialties web site. Worksheets were used to organize data and then analyzed statistically with Excel 2003. RESULTS: Of the 102 graduates, 59% are males and 41% are women, 50% are board certified, 30% are not and 20% are pending certification. Of the female graduates, 77% are board certified, while only 60% of male graduates are board certified. Sixty percent (60%) of the graduates stayed in Puerto Rico and 40% moved to the United States. The distribution of graduates among PR senatorial districts (counties) was as follows: San Juan 22%, Bayamón 17%, Arecibo 0%, Mayagüez 5%, Ponce, 23%, Guayama 6%, Humacao 12% and Carolina 20%. The job description among graduates was: 54% full time Emergency Department (ED) Staff, 3% part time ED staff, 23% academic faculty, 10% directors, 5% fellows and 5% other. CONCLUSION: From our study, we can conclude that although the vast majority of UPREMP graduates stay in PR after graduation, most of them practice in four of the eight PR senatorial districts. Further studies are needed to determine: the reasons why graduates have moved to the mainland US and for working mostly in four PR senatorial districts.

The use of therapeutic hypothermia after cardiopulmonary arrest

Actually recommended by the International Liaison Committee on Resuscitation (ILCOR), therapeutic hypothermia has been the only modality shown to improve neurological outcomes after cardiac arrest. This article provides the background for such recommendations as well as: pathophysiology, review of brain injury during cardiac arrest, discussion of beneficial effects of therapeutic hypothermia, different mechanisms used to induce it and the latest clinical trials results.

Descriptive study of cerebrovascular accidents among Hispanic population

BACKGROUND AND PURPOSE: Data characterizing stroke patients among Hispanic population are scant. The aim of this study was to describe this population and to assess baseline knowledge of stroke type, risk factors, and family history, among others. METHODS: A retrospective chart review of 253 stroke patients admitted to the University of Puerto Rico Hospital during the fiscal year July 2002 to June 2003 was done. A standardized data collection form was used to obtain the following information from patient records: patient age, gender, stroke type, time of symptom onset, patient risk factors, family risk factors, and patient outcome. RESULTS: We enrolled 253 patients, 120 (47%) males and 133 (53%) females. Patient age distribution was as follows: 18 (7%) were < 44 years, 79 (31%) were bwtween 45-64 years, 156 (62%) were > 65 years. Stroke type distribution was: ischemic 174 (69%), hemorrhagic 49 (19%), and transformation from ischemic to hemorrhagic 13 (5%). Ischemic stroke subtypes distribution was: large-artery occlusion 113 (65%), small-artery occlusion 60 (34%), cardio-embolism 1 (0.6%), 17 (7%) information was not recorded. Time of symptom onset: 153 (60%) > 3 hours, 14 (6%) < 3 hours, and 86 (34%) was unknown. Family history of risk factors was present in 103 (41%), not present 29 (11%) and 121 (49%) was unknown. Most common patient risk factors were: hypertension 212 (84%), > 65 years 156 (62%), male gender 120 (47%), diabetes mellitus 105 (42%), previous history of stroke 91 (36%), hyper-cholesterolemia 44 (17%), history of smoking 51 (20%), alcoholism 43 (17%). CONCLUSION: The data obtained from this Hispanic population is similar to that reported in the literature for the general population. The prevalence of ischemic strokes out numbered by far the occurrence of hemorrhagic strokes in the study group. Both men and women demonstrated an increasing tendency of stroke incidence with increasing age. Among death outcome, a difference was evident in the...

Bariatric surgery patients: reasons to visit emergency department after surgery

STUDY OBJECTIVE: Morbid obesity prevalence is reaching epidemic proportions in Western society. Long-term weight loss can be achieved by bariatric surgery. This surgery also has a positive impact in the reduction of obesity related co-morbid conditions. The purpose of this study is to determine the reasons that bariatric surgery patients had to visit the emergency department within a three month period after surgery. METHODS: A retrospective chart review study was performed at the UPR Hospital in Carolina. Patients with the diagnosis of morbid obesity who had bariatric surgery were identified. Of the 283 patients who met the criteria, the following information was obtained: gender, age, height, weight, pre-operative BMI, obesity-related comorbid conditions, post operative length of stay (LOS), and reasons and length of stay of Emergency Department (ED) visits within a 3 month period after surgery. Statistical analysis was done with Statistical Package for Social Sciences (SPSS) Program. RESULTS: The same profile of gender and BMI was obtained between the population that had the surgery and the sample that visited the ED, the group of patients between 20-29 years old was more likely to visit the ED. No correlation was found between a longer post operative length of stay and an increased probability of visiting the ED. Of the population, 5% had to visit ED within a three month period. The most common post operative complications were: Abdominal Pain (46.2%), Emesis (38.5%), and Dehydration (30.8%). Other less frequent complications were nausea, DVT, pneumonia, dizziness, gastritis, infected wound and upper GI bleeding. CONCLUSION: The most common reasons that bariatric surgery patients had to visit the emergency department within a three month period after surgery were: abdominal pain, emesis, dehydration and nausea. These complications could most likely be attributed to patient poor compliance with diet, resulting in the classical symptoms of the dumping...

[Nutritional evaluation in patients with total gastrectomy]. / Evaluación nutricional en pacientes con gastrectomía total.

Gastric cancer continues to be the second cause of cancer-related mortality in the world. Surgery is the only potentially curative therapy, although the adverse effects of surgery are considerable and include digestive symptoms, loss of appetite and malnutrition. Our study included 45 patients subjected to gastrectomy who were under treatment at our unit during 2000. The data given here refer to their first visit following surgery. The most frequent complications were diarrhoea (31%), pain (29%) and early dumping (24%). Other complications found were late dumping, nausea/vomiting and dysphagia. Anorexia appeared in 49% and 29% presented a negative attitude towards food. These complications give rise to insufficient food intake, leading to malnutrition, mainly marasmic in nature. Only 7% of the patients were normonourished, with 86% presenting slight or moderate malnutrition and 7% severe malnutrition. The mean Body Mass Index (BMI) of these patients was 20 +/- 3 kg/m2. The most frequent analytical alterations were anaemia with ferropenia and b12 deficit, and a reduction in the levels of zinc and retinol transporting protein. Many patients had impaired quality of life; 43% did not leave home and only 13% were able to work. Three groups were established depending on the time that had passed since the gastrectomy was performed before the first nutritional assessment (less than 3 months, from three months to a year, and over one year), without significant differences being found in any of the parameters studied. In this article we include recommendations for the nutritional handling and treatment of patients following gastrectomy.

[Carcinoma of the Vater's ampulla and colonic carcinoma with synchronous onset]. / Carcinoma de ampolla de Vater y carcinoma colónico de aparición sincrónica.

We report the case of a female patient who presented with a very unusual association: an early invasive adenocarcinoma of the ampulla of Vater and a synchronous carcinoma of the right colon, in the absence of familial polyposis coli. Six years before a hysterectomy was performed because of uterine leiomyomata. The treatment was a Whipple's resection and, after three months, a right colectomy.

[Hepatic actinomycosis]. / Actinomicosis hepática.

We present a case of primary liver actinomycosis in a patient who was operated on for a duodenal ulcus seven years before. A gastrectomy was performed. His gallbladder was also removed two years before. After the surgical treatment, followed by antibiotic and chemotherapeutic treatment, with the result of a pretended success, the patient developed a liver pyogenic abscess and portal hypertension. Authors emphasise the seriousness of the illness as well as its rarity even with an accurate treatment.

[Massive lower digestive hemorrhage caused by jejunal cavernous hemangioma detected with scintigraphy]. / Hemorragia digestiva baja masiva debida a hemangioma cavernoso yeyunal no detectado por escintigrafía.

We report the case of a patient who needed urgent surgical assistance because of massive lower gastrointestinal hemorrhage secondary to a jejunal angiodysplasia (cavernous hemangioma). These lesions are a rare cause of gastrointestinal bleeding of obscure origin. The use of preoperative diagnostic techniques such as oral fiber-optic endoscopy, barium intestinal studies and scintigraphy have little value when the origin of lower gastrointestinal bleeding is in the small bowel. The best yield is obtained with celiac or superior mesenteric angiography. There are some cases in which only an exploratory surgical laparotomy is useful for the diagnostic supported by intraoperative enteroscopy guided by the surgeon.

[Intraoperative echography of hepatic metastases]. / Ecografía intraoperatoria de las metástasis hepáticas.

In order to evaluate the usefulness of intraoperative echography in the study of liver metastases, two groups of patients were submitted to study: A consecutive series of 25 patients operated on for digestive tumours. Before operation, echography was performed to all of them. Four patients operated on for liver metastases. In the patients who were operated for digestive tumors, the authors found 8.6% of metastasis which neither the preoperative echography nor liver palpation had detected. The usefulness of the examination in the patients to whom resective hepatic surgery was going to be performed was based on: The finding of a portal thrombosis which had not been detected in the preoperative study. The possibility of connecting the intrahepatic vascularity with the lesions, in order to decide which technique to choose. The demonstration of the non-existence of other metastases.