Síndrome post-cuidados intensivos al mes del alta hospitalaria de pacientes críticos supervivientes a COVID-19 / Post-intensive care syndrome at one month after hospital discharge in critically ill patients surviving COVID-19

Objetivos: Incidencia del síndrome post-cuidados intensivos al mes del alta hospitalaria en pacientes críticos supervivientes de COVID-19 e identificar factores asociados. Diseño: Estudio de cohortes prospectivo. Ámbito: Dos unidades de críticos polivalentes del Hospital Universitario Araba. Pacientes ingresados en unidades de críticos por insuficiencia respiratoria aguda grave secundaria a COVID-19. Intervención: Ninguna. Variables de interés: Variables demográficas, estancias, índice de Charlson, APACHEII, SOFA, días de ventilación mecánica, traqueotomía, delirio, tetraparesia del paciente crítico, EuroQol 5D5L, Minimental Test. Resultados: Se objetiva un deterioro en el índice de salud (IS) del EuroQol, que pasa de 90,9 ±16,9 a 70,9 ±24,7 (p<0,001). La afectación de los cinco dominios del EuroQol es de: movilidad (46,1%), actividades habituales (44,7%), malestar/dolor (30,7%), dominio psicológico (27,3%) y autocuidado (20,3%). El 61,5% sufren un descenso significativo de su índice de salud. El análisis multivariante mediante regresión logística nos muestra que el delirio (OR=3,01; IC95%: 1,01-8,9; p=0,047) y la traqueotomía (OR=2,37; IC95%: 1,09-5,14; p=0,029) muestran asociación con la caída en el IS del EuroQol 5D5L. El área bajo la curva ROC del modelo es del 67,3%, con un intervalo de confianza entre el 58% y el 76%. Se calibra el modelo mediante el test de Hosmer-Lemeshow:(χ2=0,468; p=0,792). Solamente el 1,2% de los pacientes mostraban una puntuación ≤24, claramente patológica, en el Minimental Test de Folstein. Conclusiones: El delirio y la necesidad de traqueostomía se asocian a síndrome post-cuidados intensivos evaluado mediante EuroQol 5D5L. (AU)

Objectives: Incidence of post-intensive care syndrome at one month after hospital discharge in surviving critically ill COVID-19 patients and to identify associated factors. Design: Prospective cohort study. Setting: Two multipurpose critical care units of the Araba University Hospital. Patients admitted to critical care units for severe acute respiratory failure secondary to COVID-19. Intervention: None. Variables of interest: Demographic variables, length of stay, Charlson index, APACHEII, SOFA, days of mechanical ventilation, tracheotomy, delirium, tetraparesis of the critical patient, EuroQol 5D5L, Minimental Test. Results: A deterioration in the EuroQol health index (HI) from 90.9 ±16.9 to 70.9 ±24.7 (P<.001) was observed. The impairment of the five EuroQol domains is: mobility (46.1%), usual activities (44.7%), discomfort/pain (30.7%), psychological domain (27.3%) and self-care (20.3%). The 61.5% suffer a significant decrease in their health index. Multivariate analysis by logistic regression shows us that delirium (OR=3.01; 95%CI: 1.01-8.9; P=.047) and tracheostomy (OR=2.37; 95%CI: 1.09-5.14; P=.029) show association with drop in EuroQol 5D5L SI. The area under the ROC curve of the model is 67.3%, with a confidence interval between 58% and 76%. The model is calibrated using the Hosmer-Lemeshow test (χ2=0.468; P=.792). Only 1.2% of patients showed a score ≤24, clearly pathological, on the Folstein's Minimental Test. Conclusions: Delirium and need for tracheostomy are associated with post-intensive care syndrome assessed by EuroQol 5D5L. (AU)

Post-intensive care syndrome one month after discharge in surviving critically ill COVID-19 patients.

OBJECTIVES: Incidence of post-intensive care syndrome at one month after hospital discharge in surviving critically ill COVID 19 patients and to identify associated factors. DESIGN: Prospective cohort study. SETTING: Two multipurpose critical care units of the Araba University Hospital. Patients admitted to critical care units for severe acute respiratory failure secondary to COVID 19. INTERVENTION: None. VARIABLES OF INTEREST: Demographic variables, length of stay, Charlson index, APACHE II, SOFA, days of mechanical ventilation, tracheotomy, delirium, tetraparesis of the critical patient, EuroQol 5D5L, Minimental Test. RESULTS: A deterioration in the EuroQol health index (HI) from 90.9±16.9 to 70.9±24.7 (p<0.001) was observed. The impairment of the five EuroQol domains is: mobility (46.1%), usual activities (44.7%), discomfort/pain (30.7%), psychological domain (27.3%) and self-care (20.3%). The 61.5% suffer a significant decrease in their health index. Multivariate analysis by logistic regression shows us that delirium (OR=3.01; 95%CI: 1.01-8.9; p=0.047) and tracheostomy (OR=2.37; 95%CI: 1.09-5.14; p=0.029) show association with drop in EuroQoL 5D5L SI. The area under the ROC curve of the model is 67.3%, with a confidence interval between 58% and 76%. The model is calibrated using the Hosmer-Lemeshow test (χ2=0.468; p=0.792). Only 1.2% of patients showed a score ≤ 24, clearly pathological, on the Folstein's Minimental Test. CONCLUSIONS: Delirium and need for tracheostomy are associated with post-intensive care syndrome assessed by EuroQol 5D5L.

[Post-intensive care syndrome one month after hospital discharge of critical patients surviving COVID 19.] / Síndrome post-cuidados intensivos al mes del alta hospitalaria de pacientes críticos supervivientes a COVID 19.

OBJECTIVES: incidence of post-intensive care syndrome at one month after hospital discharge in surviving critically ill COVID 19 patients and to identify associated factors. DESIGN: prospective cohort study. SETTING: two multipurpose critical care units of the Araba University Hospital.Patients admitted to critical care units for severe acute respiratory failure secondary to COVID 19. INTERVENTION: none. VARIABLES OF INTEREST: demographic variables, length of stay, Charlson index, APACHE II, SOFA, days of mechanical ventilation, tracheotomy, delirium, tetraparesis of the critical patient, EuroQol 5D5L, Minimental Test. RESULTS: a deterioration in the EuroQol health index (HI) from 90.9 ± 16.9 to 70.9 ± 24.7 (p < 0.001) was observed. The impairment of the five EuroQol domains is: mobility (46.1%), usual activities (44.7%), discomfort/pain (30.7%), psychological domain (27.3%) and self-care (20.3%). The 61.5% suffer a significant decrease in their health index. Multivariate analysis by logistic regression shows us that delirium (OR= 3.01; 95%CI: 1.01-8.9; p= 0.047) and tracheostomy (OR= 2.37; 95%CI: 1.09-5.14; p= 0.029) show association with drop in EuroQoL 5D5L SI. The area under the ROC curve of the model is 67.3%, with a confidence interval between 58% and 76%. The model is calibrated using the Hosmer-Lemeshow test:(χ2=0.468; p=0.792). Only 1.2% of patients showed a score ≤ 24, clearly pathological, on the Folstein's Minimental Test. CONCLUSIONS: delirium and need for tracheostomy are associated with post-intensive care syndrome assessed by EuroQol 5D5L.

Estudio aleatorizado sobre la posición de electrodos en la cardioversión eléctrica electiva de la fibrilación auricular / Electrode position in elective electrical cardioversion of atrial fibrillation. A randomized study

Objetivo: Este estudio pretende averiguar cuál de las 2 posiciones de electrodos, anteroposterior (A-P) izquierda o anteroapical (A-A), se muestra más eficaz en la cardioversión eléctrica (CVE) de la fibrilación auricular (FA). Diseño: Ensayo clínico con asignación aleatorizada. Ámbito: UCI de un hospital de segundo nivel. Pacientes y métodos: Pacientes ambulatorios en FA remitidos a la UCI para CVE mediante choques bifásicos. Se comienza con la posición correspondiente según números aleatorizados y se administran hasta 3 choques (150-200-200J), y se cambia a la posición alternativa de no haberse conseguido el ritmo sinusal (RS) (hasta 2 choques más de 200J). Se analizan y se comparan ambas posiciones asignadas, y se determina cuál consigue restaurar el RS con menor número de choques y menor energía aplicada. Resultados: Se incluyen 46 pacientes en el grupo A-A y 45 pacientes en el grupo A-P, y se consigue RS en el 92% de los casos, si bien los pacientes del grupo A-A precisaron significativamente menor número de choques y menor energía: 1 frente a 2 choques (p=0,003) y 150 frente a 350J (p=0,017). Solamente un paciente de los 5 en los que falló la posición A-A se revirtió a RS con la posición A-P, mientras que 10 de los 13 pacientes no revertidos con electrodos A-P lo fueron al cambiar a posición A-A (p=0,038). Conclusiones: La posición A-A se muestra más eficaz en la CVE electiva de la FA, y se recomienda como de primera elección (AU)

Aim: To compare the effectiveness of left anteroposterior (A-P) and apex-anterior (A-A) electrode position in the electrical cardioversion (ECV) of patients with atrial fibrillation (AF). Design: Randomized clinical trial. Location: ICU of a second-level hospital. Patients and methods: Ambulatory AF patients admitted to ICU for ECV with biphasic shocks. Up to a maximum of 3 shocks (150-200-200J) are given in the electrode position determined by random numbers, and if sinus rhythm (SR) is not restored, electrode position is changed and 2 additional 200J shocks are allowed. Both electrode positions are analyzed and compared to determine which one allows restoration of SR with the lowest number of shocks and least energy. Results: Forty-six patients were included in the A-A group, and 45 in the A-P group. Sinus rhythm was restored in 92% of cases, although patients in the A-A group needed a lower number of shocks and less energy: 1 versus 2 shocks (p=0,003) and 150 versus 350J (p=0.017). Only one out of 5 patients in whom the A-A position had failed was reverted to RS with the A-P position, whereas 10 out of 13 patients in which A-P position had failed were reverted in the A-A position (p=0.038). Conclusions: The A-A position is more effective in the elective electrical cardioversion of atrial fibrillation, so we recommend this position as the first choice (AU)

[Electrode position in elective electrical cardioversion of atrial fibrillation. A randomized study]. / Estudio aleatorizado sobre la posición de electrodos en la cardioversión eléctrica electiva de la fibrilación auricular.

AIM: To compare the effectiveness of left anteroposterior (A-P) and apex-anterior (A-A) electrode position in the electrical cardioversion (ECV) of patients with atrial fibrillation (AF). DESIGN: Randomized clinical trial. LOCATION: ICU of a second-level hospital. PATIENTS AND METHODS: Ambulatory AF patients admitted to ICU for ECV with biphasic shocks. Up to a maximum of 3 shocks (150-200-200 J) are given in the electrode position determined by random numbers, and if sinus rhythm (SR) is not restored, electrode position is changed and 2 additional 200 J shocks are allowed. Both electrode positions are analyzed and compared to determine which one allows restoration of SR with the lowest number of shocks and least energy. RESULTS: Forty-six patients were included in the A-A group, and 45 in the A-P group. Sinus rhythm was restored in 92% of cases, although patients in the A-A group needed a lower number of shocks and less energy: 1 versus 2 shocks (p=0,003) and 150 versus 350 J (p=0.017). Only one out of 5 patients in whom the A-A position had failed was reverted to RS with the A-P position, whereas 10 out of 13 patients in which A-P position had failed were reverted in the A-A position (p=0.038). CONCLUSIONS: The A-A position is more effective in the elective electrical cardioversion of atrial fibrillation, so we recommend this position as the first choice.

[Variations in health-related quality of life in critical patients]. / Variaciones en la calidad de vida relacionada con la salud en los pacientes críticos.

OBJECTIVE: To determine the changes in the health-related quality of life (hRQOL) six months after discharge from the ICU and the conditions associated to them. DESIGN: A prospective cohort study. SETTING: 14 beds medical-surgical intensive care unit (ICU). PATIENTS: A total of 247 patients admitted to our ICU for more than 24 hours with a follow-up of 6 months were study. Those admitted with acute coronary syndrome or for monitoring purposes were excluded. INTERVENTION: A quality of life survey was conducted using the score developed by the PAEEC group (project of the epidemiological analysis of critical illness) to assess hRQOL before ICU admission and 6 months after discharge. RESULTS: The hRQOL deteriorated, going from a median value of 3 to 6 (p < 0.001). The multivariate analysis showed less deterioration of hRQOL in patients with chronic health conditions registered on the APAChE-II score (regression coefficient [RC] = -1.4; 95% CI, -2.5 to -0.2; p < 0.02) and in those with a hRQOL > or = 10 points (RC = -4,4; 95% CI, -5.9 to -2.8; p < 0.001). There was more deterioration in polytraumatized patients (RC = 1.9; 95% CI, 0.6-3.3; p = 0.01) or with renal failure (RC = 3.9; 95% CI, 1.9-5.9; p < 0.001) or in those with a stay duration longer than 10 days (RC = 1.9; 95% CI, 0.6-3.2; p < 0.001). CONCLUSIONS: Most patients experience deterioration of hRQOL. Patients with chronic diseases or with worst previous hRQOL who survive 6 months experience less deterioration of hRQOL than those who are polytraumatized or have renal failure or a longer ICU stay.

Variaciones en la calidad de vida relacionada con la salud en los pacientes críticos / Variations in health-related quality of life in critical patients

Objetivo. Analizar las variaciones de la calidad de vida relacionada con la salud (CVRS) a los 6 meses del alta de la unidad de medicina intensiva (UMI)y los factores que se asocian a estas variaciones. Diseño. Estudio prospectivo de cohortes. Ámbito. UMI médico-quirúrgica de 14 camas. Pacientes. Fueron 247 pacientes ingresados en UMI más de 24 h, con un seguimiento de 6 meses. Se excluyó a los pacientes con síndrome coronario agudo y los que ingresaban solamente para seguimiento. Intervención. Se realizó una encuesta de CVRS desarrollada por el grupo Proyecto para el Análisis Epidemiológico del Enfermo Crítico sobre su estado previo y a los 6 meses del alta de la UMI. Resultados. La CVRS se deteriora pasando de una mediana de 3 puntos a 6 (p < 0,001). El análisis multivariable muestra menor deterioro en la CVRS en pacientes con antecedentes registrados por el APAChE II (coeficiente de regresión [CR] = -1,4; intervalo de confianza [IC] del 95%, -2,5 a -0,2; p = 0,02) o una CVRS ≥ 10 puntos (CR = -4,4; IC del 95%, -5,9 a -2,8; p < 0,001) y mayor deterioro en pacientes politraumatizados (CR = 1,9; IC del 95%, 0,6-3,3; p < 0,01), con insuficiencia renal (CR = 3,9; IC del 95%, 1,9-5,9; p < 0,001) o estancia en UMI > 10 días (CR = 1,9; IC del 95%, 0,6-3,2; p = 0,004). Conclusiones. La mayoría de los pacientes muestran un deterioro de la CVRS. Los pacientes con enfermedades crónicas o con peor CVRS previa que han sobrevivido a los 6 meses muestran menor deterioro que los politraumatizados o con insuficiencia renal o estancias prolongadas en UMI (AU)

Objective. To determine the changes in the health-related quality of life (hRQOL) six months after discharge from the ICU and the conditions associated to them. Design. A prospective cohort study. Setting. 14 beds medical-surgical intensive care unit (ICU). Patients. A total of 247 patients admitted to our ICU for more than 24 hours with a follow-up of 6 months were study. Those admitted with acute coronary syndrome or for monitoring purposes were excluded. Intervention. A quality of life survey was conducted using the score developed by the PAEEC group (project of the epidemiological analysis of critical illness) to assess hRQOL before ICU admission and 6 months after discharge. Results. The hRQOL deteriorated, going from a median value of 3 to 6 (p < 0.001). The multivariate analysis showed less deterioration of hRQOL in patients with chronic health conditions registered on the APAChE-II score (regression coefficient [RC] = -1.4; 95% CI, -2.5 to -0.2; p < 0.02) and in those with a hRQOL ≥ 10 points (RC = -4,4; 95% CI, -5.9 to -2.8; p < 0.001). There was more deterioration in polytraumatized patients (RC = 1.9; 95% CI, 0.6-3.3; p = 0.01) or with renal failure (RC = 3.9; 95% CI, 1.9-5.9; p < 0.001) or in those with a stay duration longer than 10 days (RC = 1.9; 95% CI, 0.6-3.2; p < 0.001). Conclusions. Most patients experience deterioration of hRQOL. Patients with chronic diseases or with worst previous hRQOL who survive 6 months experience less deterioration of hRQOL than those who are polytraumatized or have renal failure or a longer ICU stay (AU)

[Treatment recommendations at the end of the life of the critical patient]. / Recomendaciones de tratamiento al final de la vida del paciente crítico.

Admission of a patient in the Intensive Care Unit (ICU) is justified when the critical situation can be reverted or relieved. In spite of this, there is high mortality in the ICU in regard to other hospital departments. End-of-life treatment of critical patients and attention to the needs of their relatives is far from being adequate for several reasons: society denies or hides the death, it is very difficult to predict it accurately, treatment is frequently fragmented between different specialists and there is insufficient palliative medicine training, including communication skills. There are frequent conflicts related to the decisions made regarding the critical patients who are in the end of their life, above all, with the limitation of life-sustaining treatments. Most are conflicts of values between the different parties involved: the patient, his relatives and/or representatives, health professionals, and the institution. The SEMICYUC Working Group of Bioethics elaborates these Recommendations of treatment at the end of the life of the critical patient in order to contribute to the improvement of our daily practice in such a difficult field. After analyzing the role of the agents involved in decision making (patient, familiar, professional, and health care institutions), of the ethical and legal foundations of withholding and withdrawal of treatments, guidelines regarding sedation in the end of the life and withdrawal of mechanical ventilation are recommended. The role of advance directives in intensive medicine is clarified and a written form that reflects the decisions made is proposed.

Recomendaciones de tratamiento al final de la vida del paciente crítico / Treatment recommendations at the end of the life of the critical patient

El ingreso de un paciente en la Unidad de Medicina Intensiva (UMI) está justificado cuando es posible revertir o paliar su situación crítica; a pesar de ello, en las UMI se produce una alta mortalidad con respecto a otros servicios hospitalarios. El tratamiento al final de la vida de los pacientes críticos y la atención a las necesidades de sus familiares están lejos de ser adecuados, por diversos motivos: la sociedad niega u oculta la muerte, es muy difícil predecirla con exactitud, con frecuencia el tratamiento está fragmentado entre diferentes especialistas y hay una insuficiente formación en medicina paliativa, incluyendo habilidades de comunicación. Se producen frecuentes conflictos relacionados con las decisiones que se toman en torno a los enfermos críticos que están en el final de su vida, especialmente con la limitación de tratamientos de soporte vital (LTSV). La mayoría son conflictos de valores entre las diversas partes implicadas: el paciente, sus familiares y/o representantes, los profesionales sanitarios y la institución. El Grupo de trabajo de Bioética de la SEMICYUC elabora estas Recomendaciones de tratamiento al final de la vida del paciente crítico con el propósito de contribuir a la mejora de nuestra práctica diaria en tan difícil campo. Tras el análisis del papel de los agentes implicados en la toma de decisiones (pacientes, familiares, profesionales e instituciones sanitarias) y de los fundamentos éticos y legales de la omisión y retirada de tratamientos, se aconsejan unas pautas de actuación en lo referente a la sedación en el final de la vida y la retirada de la ventilación mecánica, se matiza el papel de las instrucciones previas en medicina intensiva y se propone un formulario que refleje de forma escrita las decisiones adoptadas

Admission of a patient in the Intensive Care Unit (ICU) is justified when the critical situation can be reverted or relieved. In spite of this, there is high mortality in the ICU in regard to other hospital departments. End-of-life treatment of critical patients and attention to the needs of their relatives is far from being adequate for several reasons: society denies or hides the death, it is very difficult to predict it accurately, treatment is frequently fragmented between different specialists and there is insufficient palliative medicine training, including communication skills. There are frequent conflicts related to the decisions made regarding the critical patients who are in the end of their life, above all, with the limitation of life-sustaining treatments. Most are conflicts of values between the different parties involved: the patient, his relatives and/or representatives, health professionals, and the institution. The SEMICYUC Working Group of Bioethics elaborates these Recommendations of treatment at the end of the life of the critical patient in order to contribute to the improvement of our daily practice in such a difficult field. After analyzing the role of the agents involved in decision making (patient, familiar, professional, and health care institutions), of the ethical and legal foundations of withholding and withdrawal of treatments, guidelines regarding sedation in the end of the life and withdrawal of mechanical ventilation are recommended. The role of advance directives in intensive medicine is clarified and a written form that reflects the decisions made is proposed

[Limitation of therapeutic effort after ICU admission. Analysis of related factors]. / Limitación del esfuerzo terapéutico tras el ingreso en una Unidad de Medicina Intensiva. Análisis de factores asociados.

OBJECTIVE: To analyze the limitation of therapeutic effort (LTE) in our Intensive Care Unit (ICU) and the variables associated with that decision. DESIGN: Prospective cohort study with a follow up of one year after discharge. SETTING: ICU of a second level hospital. PATIENTS: Four hundred and nine patients admitted during a two-year period. MAIN VARIABLES: APACHE II, NEMS, SOFA, quality of life (PAEEC) and mortality. RESULTS: LTE was performed in 49 (12%) patients. This decision was made by general agreement among the care team in 88% of cases and with the family in 73.5%. It was made on day 8 (4-20) with a SOFA score of 9 (4-13). Mortality in the LTE group was 69.4% in ICU, 92% in hospital, and 96% at 6 and 12 months. A logistic regression model showed that the variables associated with LTE were the following: NEMS score >or=30.7 (OR 12; 95% CI 3.7-39, p < 0.001), NEMS 26.6-30.6 (OR 8; 95% CI 2.5-25.6, p = 0.001), APACHE II > 30 (OR 7.6; 95% CI 2-29, p = 0.003), quality of life >or= 7 (OR 4.2; 95% CI 1.1-15, p = 0.03), age >or= 80 (OR 3.7, 95% CI 1.4-9.5, p = 0.007) and medical patient condition (OR 3.5; 95% CI 1.5-8, p = 0.003). CONCLUSIONS: LTE is a common practice and is usually performed among the care team and the patient's surrogates. The main variables associated with LSC are those related to the severity of illness, previous quality of life, medical disease and patient's age.

Limitación del esfuerzo terapéutico tras el ingreso en una Unidad de Medicina Intensiva. Análisis de factores asociados / Limitation of therapeutic effort after ICU admission. Analysis of related factors

Objetivo. Analizar la limitación del esfuerzo terapéutico (LET) en una Unidad de Medicina Intensiva (UMI) y las variables consideradas en la toma de decisiones. Diseño. Estudio de cohortes prospectivo con seguimiento durante un año tras el alta. Ámbito. UMI de un Hospital de Nivel II. Pacientes. Cuatrocientos nueve pacientes ingresados durante un período de dos años. Variables de interés. APACHE II, Nine Equivalents of Nursing Manpower Use Score (NEMS), Sequential Organ Failure Assessment Score (SOFA), calidad de vida (PAEEC) y mortalidad. Resultados. Se realizó LET en 49 (12%) pacientes. Hubo consenso del equipo asistencial en el 88% de los casos y en el 73,5% con la familia. La decisión se tomó el día 8 (4-20) de estancia y con un SOFA de 9 (4-13) puntos. Entre los pacientes con LET la mortalidad en la UMI fue del 69,4%, la hospitalaria del 92% y a 6 y 12 meses del 96%. Un modelo de regresión logística mostró que las variables asociadas a la decisión de LET fueron las siguientes: NEMS ≥ 30,7 (odds ratio [OR] 12; intervalo de confianza [IC] 95% 3,7-39, p 30 (OR 7,6; IC 95% 2-29, p = 0,003), la calidad de vida previa ≥ 7 (OR 4,2; IC 95% 1,1-15, p = 0,03), edad ≥ 80 años (OR 3,7; IC 95% 1,4-9,5, p = 0,007), paciente médico (OR 3,5; IC 95% 1,5-8, p = 0,003). Conclusiones. La LET es una práctica frecuente y que se realiza generalmente con acuerdo del equipo asistencial y los representantes del paciente. Las variables asociadas a la decisión de LET son las relacionadas con la gravedad, la calidad de vida previa, la patología médica y la edad del paciente

Objective. To analyze the limitation of therapeutic effort (LTE) in our Intensive Care Unit (ICU) and the variables associated with that decision. Design. Prospective cohort study with a follow up of one year after discharge. Setting. ICU of a second level hospital. Patients. Four hundred and nine patients admitted during a two-year period. Main variables. APACHE II, NEMS, SOFA, quality of life (PAEEC) and mortality. Results. LTE was performed in 49 (12%) patients. This decision was made by general agreement among the care team in 88% of cases and with the family in 73.5%. It was made on day 8 (4-20) with a SOFA score of 9 (4-13). Mortality in the LTE group was 69.4% in ICU, 92% in hospital, and 96% at 6 and 12 months. A logistic regression model showed that the variables associated with LTE were the following: NEMS score ≥30.7 (OR 12; 95% CI 3.7-39, p 30 (OR 7.6; 95% CI 2-29, p = 0.003), quality of life ≥ 7 (OR 4.2; 95% CI 1.1-15, p = 0.03), age ≥ 80 (OR 3.7, 95% CI 1.4-9.5, p = 0.007) and medical patient condition (OR 3.5; 95% CI 1.5-8, p = 0.003). Conclusions. LTE is a common practice and is usually performed among the care team and the patient's surrogates. The main variables associated with LSC are those related to the severity of illness, previous quality of life, medical disease and patient's age

[Comparison of two electrode positions in electrical cardioversion of atrial fibrillation]. / Comparación de dos posiciones de electrodos en la cardioversión eléctrica de la fibrilación auricular.

OBJECTIVE: This study aims to compare effectiveness of electrical cardioversion (ECV) in patients with chronic atrial fibrillation (AF) according to the electrode positions: anteroapical (A-A) or anteroposterior (A-P). That which restores the sinus rhythm (SR) using the least energy is considered superior. DESIGN: Observational study comparing two consecutive series of patients. SCOPE. Intensive Care Unit (ICU) of second level hospital. PATIENTS AND METHODS: Out-patients in AF referred to the ICU for biphasic ECV. The first series began with position A-A and the second one with A-P, administering up to 3 shocks (150-200-200J), changing to the alternative position if SR was not achieved and administering 2 more shocks of 200J. Age, gender, weight, baseline heart disease, ejection fraction, left atrial size, AF time, baseline vital signs, antiarrhythmic medication, reversion to SR, number of shocks, energy used and side effects were analyzed and compared between both series. RESULTS. A total of 50 patients were treated in each group. The baseline characteristics were similar except for a greater percentage of women in group A-A. The anteroapical electrode position achieved SR with significantly fewer numbers of shocks and less energy, more frequently achieving reversion on the first shock. CONCLUSIONS: We found greater effectiveness in the electrical cardioversion of the AF with the electrodes in the anteroapical position, that we recommend as first choice. If it is not effective, the A-P position should be attempted.

Comparación de dos posiciones de electrodos en la cardioversión eléctrica de la fibrilación auricular / Comparison of two electrode positions in electrical cardioversion of atrial fibrillation

Objetivo. El objetivo de este estudio es comparar la efectividad de la cardioversión eléctrica (CVE) en pacientes con fibrilación auricular (FA) crónica según la posición de los electrodos: anteroapical (A-A) o anteroposterior (A-P). Se considera superior la que restaura el ritmo sinusal (RS) empleando menor energía. Diseño. Estudio observacional comparando dos series consecutivas de pacientes. Ámbito. Unidad de Cuidados Intensivos (UCI) de un hospital de segundo nivel. Pacientes y métodos. Pacientes ambulatorios en FA remitidos a la UCI para CVE bifásica. En la primera serie se comenzaba con la posición A-A, y en la segunda con la A-P, administrándose hasta 3 choques (150-200-200J); de no haberse conseguido RS, se cambiaba a la posición alternativa y se administraban otros 2 choques más de 200J. Se analizaron y compararon entre ambas series la edad, sexo, peso, cardiopatía de base, fracción de eyección, tamaño auricular izquierdo, tiempo en FA, constantes basales, medicación antiarrítmica, reversión a RS, número de choques, energía empleada y efectos secundarios. Resultados. Se trataron 50 pacientes en cada grupo, cuyas características basales eran similares salvo un porcentaje superior de mujeres en el grupo A-A. La posición de electrodos A-A consiguió RS con significativamente menor número de choques y menor energía, lográndose con más frecuencia la reversión al primer choque. Conclusiones. Encontramos mayor efectividad en la CVE de la FA con los electrodos en posición A-A, que recomendamos como primera elección. De no ser eficaz, debe intentarse la posición A-P

Objective. This study aims to compare effectiveness of electrical cardioversion (ECV) in patients with chronic atrial fibrillation (AF) according to the electrode positions: anteroapical (A-A) or anteroposterior (A-P). That which restores the sinus rhythm (SR) using the least energy is considered superior. Design. Observational study comparing two consecutive series of patients. Scope. Intensive Care Unit (ICU) of second level hospital. Patients and methods. Out-patients in AF referred to the ICU for biphasic ECV. The first series began with position A-A and the second one with A-P, administering up to 3 shocks (150-200-200J), changing to the alternative position if SR was not achieved and administering 2 more shocks of 200J. Age, gender, weight, baseline heart disease, ejection fraction, left atrial size, AF time, baseline vital signs, antiarrhythmic medication, reversion to SR, number of shocks, energy used and side effects were analyzed and compared between both series. Results. A total of 50 patients were treated in each group. The baseline characteristics were similar except for a greater percentage of women in group A-A. The anteroapical electrode position achieved SR with significantly fewer numbers of shocks and less energy, more frequently achieving reversion on the first shock. Conclusions. We found greater effectiveness in the electrical cardioversion of the AF with the electrodes in the anteroapical position, that we recommend as first choice. If it is not effective, the A-P position should be attempted

Código ético de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) / Code of ethics of the Spanish Society of Intensive Care, Critical and Coronary Units (SEMICYUC)

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Factores pronósticos de mortalidad en pacientes con enfermedad pulmonar obstructiva crónica tras su ingreso en una Unidad de Medicina Intensiva. El papel de la calidad de vida / Mortality prognostic factors in patients with chronic obstructive pulmonary disease after their admission in an Intensive Care Unit The role of quality of life

Objetivo. Analizar la asociación entre calidad de vida y mortalidad de los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) ingresados en una Unidad de Medicina Intensiva (UMI) y las modificaciones de la calidad de vida a los 6 meses del alta. Diseño. Estudio de cohortes prospectivo de dos años con seguimiento durante un año tras el alta hospitalaria. Ámbito. Una Unidad de Medicina Intensiva. Pacientes. Pacientes con EPOC que ingresan por insuficiencia respiratoria aguda.Intervenciones. Se realizó una encuesta de calidad de vida al ingreso y a los 6 meses del alta. Variables de interés principales. Calidad de vida medida mediante una encuesta validada para enfermos críticos (PAEEC). Mortalidad en UMI, en hospital, a los 6 meses y al año. Resultados. Se incluyeron 91 pacientes. La mortalidad hospitalaria fue del 25,3%, a los 6 meses del 37,4% y al año del 45,5%. El análisis multivariante mostró que la mortalidad hospitalaria se asociaba con APACHE II > 18 (odds ratio 3,7; IC 95%: 1,1-12,2), calidad de vida previa al ingreso > 6 puntos (odds ratio 7,1; IC 95%: 2,1-24,1), y edad > 70 años (odds ratio 4,3; IC 95%: 1,3-14,2). A los 6 meses y al año sólo se asocia de forma independiente con la mortalidad la calidad de vida previa al ingreso. A los 6 meses, la calidad de vida de los supervivientes empeoraba de manera global (8,02 ± 4,85 frente a 5,57 ± 3,39, p = 0,001), así como en las actividades fisiológicas básicas, las actividades de la vida diaria y el estado emocional. Conclusiones. La calidad de vida previa se asocia a la mortalidad hospitalaria, a los 6 meses y al año del alta. La mitad de los pacientes sobrevive al año y son autónomos para sus necesidades básicas

Objective. To analyze the association between quality of life and mortality in patients with chronic obstructive pulmonary disease (COPD) cared in an Intensive Care Unit (ICU), and to determine the modifications of the quality of life at 6 months of discharge. Design. Prospective cohort study with 2 years duration and 1 year follow-up after hospital discharge. Context. An Intensive Care Unit. Patients. Patients with COPD admitted because of respiratory insufficiency. Interventions. A survey of quality of life was conducted at admission and at 6 months of discharge. Primary endpoints. Quality of life measured through a survey validated for critically ill patients (PAEEC). Mortality in ICU, in hospital, at 6 months, and per year. Results. Ninety one patients were included. Hospital mortality was 25.3%, at 6 months was 37.4%, and annual mortality 45.5%. Multivariate analysis showed that hospital mortality was associated with APACHE II scoring > 18 (odds ratio 3.7; CI 95%: 1.1-12.2), quality of life prior to admission > 6 points (odds ratio 7.1; CI 95%: 2.1-24.1), and age > 70 years (odds ratio 4.3; CI 95%: 1.3-14.2). At 6 months and annually only quality of life is independently associated with mortality prior to admission. At 6 months, the quality of life of survivors worsened globally (8.02 ± 4.85 versus 5.57 ± 3.39, p = 0.001), as well as in with regard to basic physiological activities, daily life activities, and emotional stress. Conclusions. Previous quality of life is associated with hospital mortality, with mortality at 6 months after discharge, and with mortality at 1 year after discharge. Half of patients survive at 1 year and can carry out autonomously their daily life activities

Comparación de onda monofásica y bifásica en la cardioversión eléctrica de la fibrilación auricular / Comparison of monophasic versus biphasic waveform in electrical cardioversion of auricular fibrilation

Objetivo. Comparar la eficacia de los choques bifásicos (CB) frente a los monofásicos (CM) en revertir a ritmo sinusal (RS) pacientes con fibrilación auricular (FA) crónica. Diseño. Estudio observacional comparando dos series consecutivas de pacientes. Ámbito. Unidad de Cuidados Intensivos (UCI) de un hospital de segundo nivel. Pacientes y métodos. Pacientes ambulatorios en FA remitidos a la UCI para cardioversión eléctrica (CVE) con CM, la primera serie, y con CB, la segunda. Se analizaron y compararon entre ambas series la edad, sexo, peso, cardiopatía de base, fracción de eyección (FE), tamaño auricular izquierdo (AI), constantes basales, medicación antiarrítmica, reversión a RS, número de choques, máxima energía empleada y efectos secundarios. Resultados. Se trataron 58 pacientes en el grupo CM y 50 en el CB, cuyas características basales eran similares salvo en el tamaño AI (46 ± 5 y 43 ± 4 mm; p = 0,05) y en un mayor porcentaje de mujeres en el grupo CM (38% frente al 10%; p = 0,001). Se encontró diferencia significativa en la reversión a RS (84% y 96%; p = 0,04) y en el empleo de menor energía (200 y 150 J; p < 0,001) a favor del grupo CB. Conclusiones. Encontramos mayor eficacia en recuperación del RS con choques bifásicos, empleando menor energía. Aunque existe diferencia en el tamaño AI y la distribución de sexos entre ambas series, como al menos la cardioversión bifásica no fue menos eficaz, recomendamos su utilización en pacientes con FA

Aim. To compare the effectiveness of biphasic (BS) and monophasic (MS) shocks in reverting chronic auricular fibrillation (AF) patients to sinus rhythm (SR). Design. Observational study comparing two consecutive series of patients. Location. ICU of a second-level hospital. Patients and methods. Ambulatory AF patients sent to ICU for electrical cardioversion (ECV) with BS (first series) and MS (second series). The following were analyzed between the two series: age, sex, weight, basal cardiopathy, ejection fraction, left atrial size, basal constants, antiarrhythmic medication, reversion to SR, number of shocks, maximum utilized energy level and secondary effects. Results. There were treated 58 and 50 patients in groups MS and BS, respectively, and whose basal characteristics were similar except for atrial size (46 ± 5 mm and 43 ± 4 mm; p = 0.05) and the fact that there was a greater percentage of women in group MS (38% as opposed to 10%; p = 0.001). There was a significant difference in reversion to RS (84% and 96%; p = 0.04) and utilization of lower energy levels (200 and 150 J; p < 0.001) in favor of group MB. Conclusions. We found greater effectiveness in recovery to SR with biphasic shocks and while utilizing lower energy levels. Although there did exist some differences in left atrial size and sex distribution between the two series, since the biphasic cardioversion was no less effective it is recommended that it be utilized in patients with AF

Sedación para cardioversión eléctrica. Comparación de dosis bajas de propofol y etomidato / Sedation for electrical cardioversion. A comparison of low doses of propofol and etomidate

Fundamento. La cardioversión eléctrica es altamente efectiva para revertir arritmias, y todavía está sin establecer la mejor pauta de sedación para este procedimiento. Nuestro grupo intentó evitar problemas respiratorios o hemodinámicos minimizando la dosis de fármaco sedante, para poder recomendar esta pauta a médicos con menor entrenamiento en soporte vital avanzado.Método. En este estudio, prospectivo, aleatorizado y no ciego, asignamos 50 pacientes a recibir 1 mg-kg-1 de propofol o 0,15 mg-kg-1 de etomidato. Se administraron hasta tres choques eléctricos sincronizados (100 a 360 J para fibrilación auricular, 50 a 200 para flúter auricular). Se estudiaron diferencias en tiempo de inducción, de despertar, apnea, parámetros hemodinámicos y efectos secundarios.Resultados. No encontramos diferencias en el tiempo de inducción, aunque sí en el de despertar: 518 (DE 137) segundos con propofol, 651 (211) segundos con etomidato (p < 0,05). Los parámetros hemodinámicos permanecieron dentro de límites normales en ambos grupos.Observamos apnea en 3 pacientes del grupo de propofol y en cuatro del grupo de etomidato.Presentaron efectos secundarios 10 pacientes del grupo de propofol y 11 del grupo de etomidato, entre los que destacaron movimiento y mioclonías.Conclusión. Dado que no se garantiza la estabilidad respiratoria (7 pacientes de la serie presentan apnea) y aparecen otros efectos secundarios, no recomendamos esta pauta de sedación para cardioversión eléctrica (AU)