Infection control in long term care institutions for the elderly: A reflection document on the situation in Spain.

A progressively increasing percentage of the elderly live during the last years of their lives in nursing homes. Although these institutions are intended to mimic life at home as much as possible, they have characteristics that make them quite similar to a "nosocomiun", i.e. an establishment for the treatment of the sick. The very coexistence among the elderly, the fact of sharing caregivers and the very significant exposure to third parties, together with the frequent predisposing diseases to infection in this population, make infection frequent among residents and also easily transmissible. This leads us to ask what can be done to prevent infection in this environment and more specifically what is the state of the art of the matter in a Western European nation such as ours. The Board of Trustees of the Health Sciences Foundation has asked itself a series of questions on the subject of infection prevention in Nursing Homes, the structure of procedures, the legislation available, compliance with the measures indicated, the best indicators of the processes and therefore, the need to promote in Spain a document of recommendations to avoid infections in this poplation whose morbidity and mortality need not be highlighted. To this end, a multidisciplinary group of experts in different aspects of this problem has been convened and asked the proposed questions. The questions were discussed by the group as a whole and led to a series of conclusions agreed upon by the participants. The results of the meeting are reported below.

4 ª Mesa Redonda: Tuberculosis pulmonar: Estado actual / No disponible

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[Neurological complications in cardiac surgery post-operative period]. / Complicaciones neurológicas en el postoperatorio de cirugía cardíaca.

The incidence of neurological complications after cardiac surgery continues to be elevated, although this is variable in the different studies published, fundamentally because of the different populations studied and the different definitions of neurological dysfunction. The etiology of these alterations is attributed to a multifactorial origin, aortic artherosclerosis, cerebral hypoperfusion and inflammatory phenomenon secondary to the technique. This review arises from the recognition of the personal, economic, and socio-health care repercussion entailed by these complications, with high rates of mortality and morbidity recorded, and it tries to give an objective view of the current literature on the subject. Having knowledge of the risk markers and understanding the pathogenesis is important to try to plan strategies that may minimize the appearance and development of these complications and contribute to the decrease of their serious consequences. The data and the experience obtained by our group are shown at the end of the review.

Complicaciones neurológicas en el postoperatorio de cirugía cardíaca / Neurological complications in cardiac surgery post-operative period

La incidencia de complicaciones neurológicas tras cirugía cardíaca continúa siendo elevada, aunque ésta es variable en los diferentes estudios publicados, debido fundamentalmente a las diferentes poblaciones estudiadas y a las distintas definiciones de disfunción neurológica. La etiología de dichas alteraciones se atribuye a un origen multifactorial, destacando la aterosclerosis aórtica, la hipoperfusión cerebral y el fenómeno inflamatorio secundario a la propia técnica. Esta revisión surge del reconocimiento de la repercusión personal, económica y sociosanitaria que estas complicaciones representan, con altas tasas de morbilidad y de mortalidad registradas, y trata de dar una visión objetiva de la literatura actual sobre el tema. Es importante el conocimiento de los marcadores de riesgo y la comprensión de la patogénesis para intentar con ello plantear estrategias que puedan minimizar la aparición y desarrollo de estas complicaciones para así contribuir a la disminución de sus graves consecuencias. Los datos de la experiencia obtenidos por nuestro grupo se muestran al final de la revisión

The incidence of neurological complications after cardiac surgery continues to be elevated, although this is variable in the different studies published, fundamentally because of the different populations studied and the different definitions of neurological dysfunction. The etiology of these alterations is attributed to a multifactorial origin, aortic artherosclerosis, cerebral hypoperfusion and inflammatory phenomenon secondary to the technique. This review arises from the recognition of the personal, economic, and socio-health care repercussion entailed by these complications, with high rates of mortality and morbidity recorded, and it tries to give an objective view of the current literature on the subject. Having knowledge of the risk markers and understanding the pathogenesis is important to try to plan strategies that may minimize the appearance and development of these complications and contribute to the decrease of their serious consequences. The data and the experience obtained by our group are shown at the end of the review

Fármacos vasoactivos en la resucitación cardiopulmonar: ¿no? ¿sí? ¿cuáles? / Vasoactives agents in cardiopulmonary resuscitation: no? yes? which ones?

Actualmente aún existen importantes cuestiones y controversias por resolver en el campo de la resucitación cardiopulmonar. Una de estas cuestiones que se plantean es el uso de fármacos en el manejo avanzado de la parada cardiorrespiratoria. En el siguiente trabajo nos proponemos revisar, a la luz de la bibliografía existente sobre recomendaciones en soporte vital y resucitación de las diferentes sociedades científicas, la indicación, dosis óptima y fármaco vasoactivo de elección en el tratamiento de la parada cardiorrespiratoria. En primer lugar, la indicación de agentes vasoactivos como una intervención dentro de la resucitación cardiopulmonar humana carece de evidencia científica concluyente, debido a la ausencia de estudios clínicos bien diseñados que lo confirmen. En cuanto al segundo aspecto, también se desconoce la dosis óptima de vasopresor en resucitación cardiopulmonar, si bien se descarta la utilización inicial de altas dosis de adrenalina debido a que la mayoría de los trabajos no encuentran beneficios significativos con respecto a dosis estándar, pudiendo incluso asociarse a una mayor incidencia de efectos adversos durante los cuidados posresucitación. La tercera cuestión pendiente de dilucidar es la elección del fármaco vasoactivo en la resucitación cardiopulmonar. Los múltiples estudios comparativos con diferentes fármacos adrenérgicos no han demostrado que se asocien a mayor supervivencia a largo plazo que la adrenalina. Recientes aunque escasos trabajos con vasopresina, agente vasopresor no adrenérgico, revelan resultados prometedores no concluyentes con similar eficacia a la adrenalina y posiblemente con menos efectos secundarios cardiológicos. Recientemente, la International Guidelines 2000 Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, en agosto de 2000, y el European Resuscitation Council, en marzo de 2001, han publicado sus recomendaciones, en las que queda reflejado cómo ambas sociedades científicas coinciden en lo referente a la primera cuestión, pero no con respecto a las otras dos, en donde existen pequeñas diferencias de matiz entre ambas conferencias internacionales. (AU)

Incapacidad funcional en una población de ancianos en el medio comunitario / Functional impairment in elderly comunity dweling

Objetivos: Conocer la prevalencia de incapacidad funcional en actividades básicas e instrumentales de la vida diaria en una población de ancianos residentes en el medio comunitario, determinar aquellas actividades para las que se incapacitan un mayor número de sujetos e identificar aquellas variables que pudieran estar asociadas a la incapacidad funcional. Método: Diseño; estudio epidemiológico transversal. Sujetos: mayores de 74 años registrados en el padrón municipal del Concejo de Gozón del año 1996. La población de estudio se obtuvo del total de sujetos mayores de 74 años empadronados (n =1.227), extrayendo una muestra de 348 sujetos mediante un muestreo aleatorio simple. Variables de estudio: sociodemográficas (edad, sexo, estado civil, convivientes, nivel de estudios y puntuación en la escala sociofamiliar de Gijón), clínicas (existencia de enfermedades potencialmente incapacitantes y número de enfermedades y fármacos), asistenciales (utilización de ayuda a domicilio formal, teleasistencia y centro de día), funcionales (evaluadas mediante los índices de Barthel y Lawton) y mentales (puntuaciones en la escala de Pfeiffer y la escala de depresión geriátrica).Resultados: 275 ancianos fueron incluidos en el estudio (81,4 años, 62,5 por ciento mujeres). La prevalencia de incapacidad funcional en actividades básicas de la vida diaria (ABVD) fue de 22,9 por ciento y en actividades instrumentales de la vida diaria (AIVD) del 73,5 por ciento, siendo las actividades más afectadas las relacionadas con la movilidad y las labores de la casa. En el análisis de regresión logística se mostraron como predictoras de incapacidad funcional en ABVD las variables: edad (OR 1,14), sexo femenino (OR 5,51), número de enfermedades (OR 1,42) y puntuación en el índice de Lawton (0,52). Asimismo, permanecieron como predictoras de incapacidad en AIVD las variables: edad (OR 1,2), sexo femenino (OR 0,03), número de enfermedades (OR 1,38) y puntuación en el Pfeiffer (1,53). Conclusiones: Para nuestra población de estudio, las variables edad, sexo, número de enfermedades y puntuaciones en el índice de Lawton y la escala de Pfeiffer, parecen comportarse como variables independientes capaces de predecir el riesgo de incapacidad funcional en ABVD y AIVD. Estas variables podrían ser útiles para seleccionar grupos de ancianos con riesgo, que pudieran beneficiarse de intervenciones especializadas dirigidas a prevenir/reducir la incapacidad funcional (AU)

[Functional deterioration of basic daily living activities after an emergency service consultation]. / Deterioro funcional en actividades básicas de la vida diaria tras la consulta en un servicio de urgencias.

OBJECTIVE: To determine the incidence of functional decline of elderly patients discharged from an emergency department and to analized functional impairment as a risk of readmission. METHODS: A prospective cohort aged 75 or older were followed up after discharge from an emergency department between 01-02-95 and 01-04-95. The study protocol included sociodemografics, clinicals, functionals and mentalsoutcomes. We studied the incidence of functional decline in basic activities of daily living, with Barthel Index, and association with the risk of readmission. RESULTS: The sample was composed by 125 elders (mean aged 81.9 +/- 4.6 years and 60.8% were women). The incidence of functional decline in basic activities of daily living at the visit to emergency department was 20.8% and one moth after discharge was 18.4%. Both activities with more functional impairment were bathing, dressing and movility activities. Functional decline was associated with the risk of readmission at emergency department (Odds Ratio = 4.1 [1.4-11.8]) CONCLUSIONS: 20% of patients who are discharged of emergency department present a new functional impairment in basics activities of daily living. Functional decline is associated with the risk of readmission one moth after discharged.

[Functional deterioration secondary to hospitalization for an acute disease in the elderly. An analysis of its incidence and the associated risk factors]. / Deterioro funcional secundario a la hospitalización por enfermedad aguda en el anciano. Análisis de la incidencia y los factores de riesgo asociados.

OBJECTIVE: To determine the incidence of functional impairment at hospital admission and after hospital discharge, and to identify those factors that could be predictors of such impairment in a cohort of elderly people with high level of independence in the basic activities of daily living (BADL). DESIGN: Epidemiologic, longitudinal and prospective study. SETTING: Acute unit in a geriatric department. SUBJECTS: The follow-up population was made up by 150 subjects older than 65 years, admitted on account of acute medical conditions from December, 15th, 1995, to December, 15th, 1996, who were independent for walking and independent or with slight dependence for BADL. STUDY PARAMETERS: All patients were evaluated at 48 hours after admission and one month after discharge by means of a protocol including sociodemographic, clinical, attending, functional and mental parameters. RESULTS: The incidence of functional impairment at hospital admission was 70.66%; such impairment persisted one month after discharge in 29.3% of subjects. The most involved activities related to motility. In the analysis of crude data, the following parameters showed association with functional impairment risk one month after discharge: female sex (OR: 2.5), sensorial organ pathology (OR: 2.6), hospital stay longer than 15 days (OR: 7.2), and Lawton Index score (3.8 +/- 2.6 in impaired patients vs. 4.9 +/- 2 in non-impaired patients; p < 0.01). Barthel Index score at admission lower than 60 (OR: 9.5), Cognitive Miniexam score lower than 28 (OR: 4.1), Informant Test score higher than 84 (OR: 2.5) and Geriatric Depression Scale score 9 (OR: 3.1). In the logistic regression model, the following parameters remained as predictors of impairment: sex (OR: 3.3), days of hospital stay (OR: 2.3) and Barthel Index score at admission (OR: 6.1) and Cognitive Miniexam score (OR: 2.7). CONCLUSIONS: For our population, sex, hospital stay days, functional impairment in Barthel Index at admission and Cognitive Miniexam score parameters seem to behave as independent variables that can predict functional impairment risk for BADL one month after discharge. These parameters could be useful to select groups of elderly people with impairment risk, who could benefit from specialized interventions leading to prevent/decrease functional impairment secondary to acute disease and hospitalization.

[Analysis and handling of the jugular catheter in the determination of cerebral anoxia]. / Análisis y manejo del catéter yugular en la determinación de la extracción de oxígeno.

The increase in the incidence of Craneoencephalic Trauma takes us to the search of new techniques such as the calculus of the Fraction of Oxygen Brain Extraction, determined by the channelling of the jugular bulb and later extraction of cerebral venous gasometries simultaneously to peripheric arterial gasometries. The aim of our work is to let Nursing know its handling as well as the diagnostic and therapeutical advantages and their associated complications. We conclude that this technique shows important advantages in the handling of endocraneal hypertension without being a work overload for Nursing. We suggest a performing guide to avoid the most common complications during its maintainance.

[An evaluation of a protocol of postoperative nutritional support in patients who have had a liver transplant]. / Valoración de un protocolo de soporte nutricional postoperatorio en pacientes sometidos a trasplante hepático (TxH).

Despite the fact that the incidence of malnutrition in patients subjected to liver transplants is high, there are no definite criteria on the most appropriate postoperative nutritional support characteristics. The present study is a review of our experience with the administering of a diet base on: 1) proteic saving techniques up to enteral nutrition tolerance, and 2) total parenteral nutrition in the event of intolerance (foreseen or proven) to enteral nutrition. The type of nutritional support used and nutritional evaluation data, both during hospitalization in intensive care, were studied over a period of 557 days, in a series of 70 patients subjected to liver transplants. In 61.9% of the study days, parenteral nutritional support techniques had to be used. Enteral nutrition was possible during 18.9% of the study period in patients who had been discharged, compared to 1.8% in patients who needed further transplants or died (p less than 0.001). The elimination of nitrogen gradually increased up to day 9, and then fell. No positive nitrogenated balance was observed until day 13. Glucemia levels remained high during the whole evolutive phase. Seric albumin and transferrin levels were normal at first, and fell during week two. Seric prealbumin levels were within normal limits. Seric Mg and Cu were lower that the reference values during the first 15 days of evolution, where as Zn reached normal levels on day 15. Normal cholesterol values were only observed on day 8. Our results show the level of intolerance to enteral nutrition during the evolution of the patients and the need for using a more aggressive nutritional support.