Recomendaciones de "no hacer" en el tratamiento de los pacientes críticos de los grupos de trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) / "Do not do" recommendations of the working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of critically ill patients

El proyecto denominado «Compromiso por la calidad de las sociedades científicas» impulsado desde el año 2013 por el Ministerio de Sanidad, Servicios Sociales e Igualdad tiene como objetivo disminuir las intervenciones sanitarias innecesarias que no han demostrado eficacia, tienen escasa o dudosa efectividad o no son eficientes. El objetivo de este trabajo es elaborar las recomendaciones de «qué no hacer» seleccionadas para el tratamiento de los pacientes críticos. Se designó un panel de expertos de los 13grupos de trabajo (GT) de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC), elegido por su experiencia clínica o científica para la realización de las recomendaciones. Se analizó la literatura publicada entre los años 2000 y 2017 sobre diferentes cuestiones asociadas a los pacientes críticos. En reuniones de cada GT, los expertos debatieron las propuestas y sintetizaron las conclusiones, que fueron finalmente aprobadas por los GT después de un amplio proceso de revisión interna, realizado durante el primer semestre de 2017. Finalmente, se elaboraron un total de 65 recomendaciones, 5 por cada uno de los 13 GT. Estas recomendaciones se basan en la opinión de expertos y en el conocimiento científico, y pretenden reducir aquellos tratamientos o procedimientos que no aporten valor al proceso asistencial, evitar la exposición de los pacientes críticos a potenciales riesgos y mejorar la adecuación de los recursos sanitarios

The project "Commitment to Quality of Scientific Societies", promoted since 2013 by the Spanish Ministry of Health, seeks to reduce unnecessary health interventions that have not proven effective, have little or doubtful effectiveness, or are not cost-effective. The objective is to establish the "do not do" recommendations for the management of critically ill patients. A panel of experts from the 13 working groups (WGs) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2000 to 2017 was extracted. The clinical evidence was discussed and summarized by the experts in the course of consensus finding of each WG, and was finally approved by the WGs after an extensive internal review process carried out during the first semester of 2017. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and aim to reduce those treatments or procedures that do not add value to the care process; avoid the exposure of critical patients to potential risks; and improve the adequacy of health resources

"Do not do" recommendations of the working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of critically ill patients. / Recomendaciones de "no hacer" en el tratamiento de los pacientes críticos de los grupos de trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC).

The project "Commitment to Quality of Scientific Societies", promoted since 2013 by the Spanish Ministry of Health, seeks to reduce unnecessary health interventions that have not proven effective, have little or doubtful effectiveness, or are not cost-effective. The objective is to establish the "do not do" recommendations for the management of critically ill patients. A panel of experts from the 13 working groups (WGs) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2000 to 2017 was extracted. The clinical evidence was discussed and summarized by the experts in the course of consensus finding of each WG, and was finally approved by the WGs after an extensive internal review process carried out during the first semester of 2017. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and aim to reduce those treatments or procedures that do not add value to the care process; avoid the exposure of critical patients to potential risks; and improve the adequacy of health resources.

[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.

Aneurisma de carótida interna y sección de arteria mandibular tras traumatismo craneofacial / Aneurysm of the internal carotid artery and section of the mandibular artery after craniofacial injury

Presentamos el caso de un varón de 18 años, ingresado en nuestro servicio por traumatismo craneofacial. Llegó al hospital con deterioro neurológico, 7 puntos en la escala de coma de Glasgow (GCS) y una importante hemorragia por cavidad oral, precisando intubación orotraqueal. En la exploración, se apreciaba un hematoma laterocervical derecho de crecimiento progresivo, realizándose una tomografía computarizada (TC) con contraste de la región craneocervical. Se visualizaba una fractura de la porción horizontal de la rama mandibular derecha con gran desplazamiento, un voluminoso hematoma cervical y la pérdida de nitidez de los vasos en la carótida derecha.Con estos hallazgos realizamos una arteriografía que demostró la presencia de un seudoaneurisma en la arteria carótida interna derecha a nivel de la segunda vértebra cervical (C2) y fuga de contraste en las ramas de la arteria mandibular, embolizadas durante el procedimiento. La posterior evolución del paciente fue favorable, lo que permitió el alta de la unidad 9 días después (AU)

Neumonía nosocomial por virus herpes simple tipo I / Nosomial Pneunomia due to herpes simplex virus type I

Presentamos el caso de una mujer de 71 años diabética e hipertensa, ingresada por descompensación metabólica. Durante su estancia hospitalaria presentó insuficiencia respiratoria aguda. Tras descartar un tromboembolismo pulmonar, se diagnosticó un proceso neumónico que precisa intubación y ventilación mecánica, y desarrolla un síndrome de distrés respiratorio del adulto. Los datos microbiológicos iniciales fueron negativos. Se realizó una broncofibroscopia con toma de muestras, que evidenció una citología compatible con infección por virus herpes simple tipo I, confirmada posteriormente por el cultivo del virus y la serología en sangre. Ante estos hallazgos se instauró tratamiento con aciclovir intravenoso, evolucionando la enferma de forma favorable. El papel de los virus del grupo herpes como causa de infecciones pulmonares se circunscribe habitualmente a pacientes inmunodeprimidos; fuera de este grupo la presencia de herpes simple comienza a documentarse en enfermos que requieren ventilación mecánica, originando en algunos casos cuadros neumónicos. Lo infrecuente de esta situación puede hacer que en nuestra estrategia diagnóstica olvidemos las pruebas para detectar dichos agentes.. (AU)

[Comparative study of percutaneous tracheotomy and conventional surgical tracheotomy in patients with prolonged intubation]. / Estudio comparativo entre la traqueotomía percutánea y la traqueotomía convencional quirúrgica en pacientes con intubación prolongada.

BACKGROUND: Percutaneous tracheotomy (PT) has become an alternative to conventional surgical tracheotomy (CST) in recent years. Our aim was to compare the advantages and disadvantages of the two techniques in our intensive care unit (ICU). PATIENTS AND METHODS: Two patient groups were compared. Sixty underwent PT and 47 underwent CST, and all were admitted to the ICU between May 1995 and August 1997. PT was performed in 49 by way of progressive dilations, and 11 were performed by Griggs' method using a dilator. Variables studied were age, sex, reason for admission, APACHE II upon admission to the ICU, duration of technique, and immediate and late complications. Statistical analysis was provided by applying a Student t test to contrast quantitative variables and a chi-squared test to compare proportions. RESULTS: The following variables were significantly different. APACHE II upon admission was 18 +/- 5 in the PT group and 15 +/- 6 in the CST group (p < 0.002). Duration of the procedure was 15 +/- 4 minutes in the PT group and 36 +/- 11 in the CST group (p < 0.005). Complications after tracheotomy in PT group patients consisted of 1 false line during a change of cannula and 1 late tracheoesophageal fistula. Complications in the CST group included 16 episodes of slight bleeding, 9 stoma infections, 3 cases of pneumothorax, 2 of bad scarring of the stoma and 1 late fistula (p < 0.005). Time of follow-up was 41 to 76 days for PT patients and 32 to 51 days for CST patients. CONCLUSIONS: PT is a fast, simple procedure that is easy to manage and requires fewer resources (operating theater, personnel and equipment) and causes fewer medium-term complications than does CST.

[Synchronized independent pulmonary ventilation in the treatment of adult respiratory distress syndrome]. / Ventilación pulmonar independiente sincronizada en el tratamiento del síndrome de distrés respiratorio del adulto.

INTRODUCTION: Synchronized independent lung ventilation (SILV) is an effective mode of mechanical ventilation for treating both unilateral and bilateral pulmonary lesions. Oxygenation improves with an increase in the ventilation/perfusion ratio and also diminishes the risk of barotrauma. We describe our broad experience with this technique. Our main objective was to confirm whether SILV is able to improve the alveolar-arterial oxygen difference [P(A-a)O2] of patients with severe adult respiratory distress syndrome (ARDS) in whom conventional mechanical ventilation has not brought about improvement after being used for over 48 hours. PATIENTS AND METHODS: We carried out a descriptive, open, controlled prospective study of 45 patients with severe ARDS, enrolled from among 68 who underwent treatment with SILV. The most frequent cause of ARDS in our study was multiple trauma. The patients diagnosed of ARDS who did not improve with conventional mechanical ventilation were treated with SILV. Clinical characteristics and mortality are described. APACHE II scores, PAOA-aO2, dynamic distensibility were analyzed before and after SILV. The results of SILV were considered good if PA-aO2 improved at least 30% within 48 hours, with no increase in distensibility. RESULTS: No complications due to the technique were observed. Twenty-two patients (48.8%) died, 18 as a result of multiple organ failure and only one (4.5%) because of hypoxia. The improvements in APACHE II and (PA-aO2 were statistically significant, while distensibility did not change. The result was defined as good in most cases (n = 34, 83.8%). CONCLUSIONS: SILV is useful for providing ventilatory support when ARDS fails to improve with conventional mechanical ventilation. Clear improvement in respiratory function was observed, with significant decrease in PA-aO2 and no change in distensibility. SILV is a safe technique with few complications and can be managed by the intensive care unit nursing staff.