Evaluation of the registry DIALYREG for the assessment of continuous renal replacement techniques in the critically ill patient.

Continuous renal replacement techniques (CRRT) can induce complications and monitoring is crucial to ensure patient safety. We designed a prospective multicenter observational and descriptive study using the DIALYREG registry, an online database located on a REDCap web-based platform that allows real-time data analysis. Our main objective was to identify CRRT-related complications in our intensive care units (ICUs) and implement security measures accordingly. From January 2019 to December 2020, we included 323 patients with admission diagnoses of medical illness (54%), sepsis (24%), postoperative care (20%), and trauma (2%). CRRT indications were homeostasis (42%), oliguria (26%), fluid overload (15%), and hemodynamic optimization (13%). The median initial therapy dose was 30 ml/kg/h (IQR 25-40), and dynamic adjustment was performed in 61% of the treatments. Sets were anticoagulated with heparin (40%), citrate (38%) or no anticoagulation (22%). Citrate anticoagulation had several advantages: more frequent dynamic CRRT dose adjustment (77% vs. 58% with heparin and 56% without anticoagulation, p < 0.05), longer duration of set (median of 55 h, IQR 24-72 vs. 23 h, IQR 12-48 with heparin and 12 h, IQR 12-31 without anticoagulation, p < 0.05), less clotting of the set (26% vs. 46.7% with heparin, p < 0.05), and lower incidence of hypophosphatemia (1% citrate vs. 6% with heparin and 5% without anticoagulation). It was also safe and effective in subgroup analysis of patients with liver disease or sepsis. The main global complications were hypothermia (16%), hypophosphatemia (13%) and metabolic acidosis (10%). Weaning of the therapy was achieved through early discontinuation (56%), nocturnal therapy transition (26%) and progressive SLED (18%). 52% of the patients were discharged from the hospital, while 43% died in the ICU and 5% died during hospitalization. We can conclude that the DIALYREG registry is a feasible tool for real-time control of CRRT in our ICU.

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

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

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

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

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

"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.

Blood purification in the critically ill patient. Prescription tailored to the indication (including the pediatric patient).

We maintain a dynamic position on extracorporeal blood purification therapies (EBPT). Continuous therapies are of choice in the hemodynamically unstable patient. We recommend their early introduction in the course of the disease, and starting with a dose of 30-35mL/kg/h. Above all, however, daily re-evaluation is required of the hemodynamic and metabolic situation and water balance of our patients in order to allow dynamic dose adjustment. Some data suggest that continuous EBPT can favorably influence the clinical course of our patients, even in the absence of acute kidney injury. The potential usefulness of hemofiltration at doses higher than the conventional doses (continuous ultrafiltration >50mL/kg/h or pulses of at least 4h a day to more than 100dosesmL/kg/h) for achieving blood purification has also been commented. We review the possible indications of this technique, together with the peculiarities of implementing these therapies in children.

Improvement of the safety of a clinical process using failure mode and effects analysis: Prevention of venous thromboembolic disease in critical patients. / Mejora en la seguridad de un proceso clínico utilizando el análisis modal de fallos y efectos: profilaxis de la enfermedad tromboembólica venosa en pacientes críticos.

OBJECTIVE: To improve critical patient safety in the prevention of venous thromboembolic disease, using failure mode and effects analysis as safety tool. DESIGN: A contemporaneous cohort study covering the period January 2014-March 2015 was made in 4 phases: phase 1) prior to failure mode and effects analysis; phase 2) conduction of mode analysis and implementation of the detected improvements; phase 3) evaluation of outcomes, and phase 4) (post-checklist introduction impact. SETTING: Patients admitted to the adult polyvalent ICU of a third-level hospital center. PATIENTS: A total of 196 patients, older than 18 years, without thromboembolic disease upon admission to the ICU and with no prior anticoagulant treatment. INTERVENTIONS: A series of interventions were implemented following mode analysis: training, and introduction of a protocol and checklist to increase preventive measures in relation to thromboembolic disease. VARIABLES OF INTEREST: Indication and prescription of venous thrombosis prevention measures before and after introduction of the measures derived from the failure mode and effects analysis. RESULTS: A total of 59, 97 and 40 patients were included in phase 1, 3 and 4, respectively, with an analysis of the percentage of subjects who received thromboprophylaxis. The failure mode and effects analysis was used to detect potential errors associated to a lack of training and protocols referred to thromboembolic disease. An awareness-enhancing campaign was developed, with staff training and the adoption of a protocol for the prevention of venous thromboembolic disease. The prescription of preventive measures increased in the phase 3 group (91.7 vs. 71.2%, P=.001). In the post-checklist group, prophylaxis was prescribed in 97.5% of the patients, with an increase in the indication of dual prophylactic measures (4.7, 6.7 and 41%; P<.05). There were no differences in complications rate associated to the increase in prophylactic measures. CONCLUSIONS: The failure mode and effects analysis allowed us to identify improvements in the prevention of thromboembolic disease in critical patients. We therefore consider that it may be a useful tool for improving patient safety in different processes.

[A first step towards safer sedation and analgesia: A systematic evaluation of outcomes and level of sedation and analgesia in the mechanically ventilated critically ill patient]. / Un primer paso hacia una analgosedación más segura: evaluación sistemática de objetivos y grado de analgesia y sedación en el paciente crítico con ventilación mecánica.

INTRODUCTION: Safe analgesia and sedation strategies are necessary in order to avoid under or over sedation, as well as improving the comfort and safety of critical care patients. OBJECTIVES: To compare and contrast a multidisciplinary protocol of systematic evaluation and management of analgesia and sedation in a group of critical care patients on mechanical ventilation with the usual procedures. MATERIALS AND METHODS: A cohort study with contemporary series was conducted in a tertiary care medical-surgical ICU February to November during 2013 and 2014. The inclusion criteria were mechanical ventilation ≥ 24h and use of sedation by continuous infusion. Sedation was monitored using the Richmond agitation-sedation scale or bispectral index, and analgesia were measured using the numeric rating scale, or behavioural indicators of pain scale. The study variables included; mechanical ventilation time, weaning time, ventilation support time, artificial airway time, continuous sedative infusion time, daily dose and frequency of analgesic and sedative drug use, hospital stay, and ICU and hospital mortality, Richmond agitation-sedation scale, bispectral index, numeric rating scale, and behavioural indicators of pain scale measurements. Kruskal Wallis and Chi2, and a significance of p<.05 were used. RESULTS: The study included 153 admissions, 75 pre-intervention and 78 post-intervention, with a mean age of 55.7±13 years old, and 67% men. Both groups showed similarities in age, reason for admission, and APACHE. There were non-significant decreases in mechanical ventilation time 4 (1.4-9.2) and 3.2 (1.4-8.1) days, respectively; p= 0.7, continuous sedative infusion time 6 (3-11) and 5 (3-11) days; p= 0.9, length of hospital stay 29 (18-52); 25 (14-41) days; p= 0.1, ICU mortality (8 vs. 5%; p= 0.4), and hospital mortality (10.6 vs. 9.4%: p= 0.8). Daily doses of midazolam and remifentanil decreased 347 (227-479) mg/day; 261 (159-358) mg/day; p= 0.02 and 2175 (1427-3285) mcg/day; 1500 (715-2740) mcg/day; p= 0.02, respectively. There were increases in the use of remifentanil (32% vs. 51%; p= 0.01), dexmedetomidine (0 vs.6%; p= 0.02), dexketoprofen (60 vs. 76%; p= 0.03), and haloperidol (15 vs.28%; p= 0.04). The use of morphine decreased (71 vs. 54%; p= 0.03). There was an increase in the number of measurements and Richmond agitation-sedation scale scores 6 (3-17); 21 (9-39); p< 0.0001, behavioural indicators of pain scale 6 (3-18); 19(8-33); p< 0.001 and numeric rating scale 4 (2-6); 8 (6-17); p< 0.0001. CONCLUSIONS: The implementation of a multidisciplinary protocol of systematic evaluation of analgesia and sedation management achieved an improvement in monitoring and adequacy of dose to patient needs, leading to improved outcomes.

SEMICYUC 2012. Recommendations for intensive care management of acute pancreatitis.

OBJECTIVE: Significant changes in the management of acute pancreatitis have taken place since the 2004 Pamplona Consensus Conference. The objective of this conference has been the revision and updating of the Conference recommendations, in order to unify the integral management of potentially severe acute pancreatitis in an ICU. PARTICIPANTS: Spanish and international intensive medicine physicians, radiologists, surgeons, gastroenterologists, emergency care physicians and other physicians involved in the treatment of acute pancreatitis. LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION: The GRADE method has been used for drawing them up. DRAWING UP THE RECOMMENDATIONS: The selection of the committee members was performed by means of a public announcement. The bibliography has been revised from 2004 to the present day and 16 blocks of questions on acute pancreatitis in a ICU have been drawn up. Firstly, all the questions according to groups have been drawn up in order to prepare one document. This document has been debated and agreed upon by computer at the SEMICYUC Congress and lastly at the Consensus Conference which was held with the sole objective of drawing up these recommendations. CONCLUSIONS: Eighty two recommendations for acute pancreatitis management in an ICU have been presented. Of these 84 recommendations, we would emphasize the new determinants-based classification of acute pancreatitis severity, new surgical techniques and nutritional recommendations. Note. This summary only lists the 84 recommendations of the 16 questions blocks except blocks greater relevance and impact of its novelty or because they modify the current management.

Handling continuous renal replacement therapy-related adverse effects in intensive care unit patients: the dialytrauma concept.

Continuous renal replacement therapy (CRRT) is increasingly used for the management of critically ill patients. As a consequence, the incidence of complications that accompany CRRT is also rising. However, a standardized approach for preventing or minimizing these adverse events is lacking. Dialytrauma is a newly proposed concept that encompasses all harmful adverse events related to CRRT while providing a framework for prevention or, at the least, early recognition of these events in order to attenuate the consequences. A mainstay of this approach is the utilization of a dedicated checklist for improving CRRT quality and patient safety. In this context, we discuss the most important adverse effects of CRRT and review current strategies to minimize them.

Desarrollo de una herramienta de comunicación para la seguridad del paciente (Briefing). Experiencia en una unidad de cuidados intensivos de trauma y emergencias / Development of communication tool for patient safety (

Objetivo: Validar una herramienta de seguridad utilizada en sectores de alto riesgo (briefing de seguridad) en la medicina intensiva. Diseño: Estudio prospectivo, observacional y analítico. Ámbito: UCI de Trauma y Emergencias de un hospital terciario. Pacientes: Pacientes con trauma grave (Injury Severity Score-ISS>16). Intervención: Recogida de incidentes, relacionados con la seguridad del paciente (SP). Variables: Características de la población, estado de la unidad, incidentes de SP, aspectos de la herramienta e impacto sobre la cultura de seguridad. Resultados: Se incluyeron 441 pacientes (edad media 39,9±17,5 años), 75,15% hombres, 89% con trauma cerrado y un 10,5% de mortalidad. La herramienta se aplicó en 586 turnos de 798 posibles (73,4%) y se recogieron 942 incidentes (2,20 incidentes por paciente). Los incidentes más frecuentes se relacionaron con la medicación (20,7%), los dispositivos (colocación 4,03% y mantenimiento 17,8%) y la vía aérea y la ventilación mecánica (VM) (17,09%). Se estableció una correlación entre la presencia de incidentes y las características del enfermo (mayor Injury Severity Score, presencia de VM y terapias de reemplazo renal continuo) y con el estado de la unidad (más de 6 pacientes por turno sobre 8 posibles y el periodo vacacional). La herramienta influyó en diferentes aspectos de la cultura de seguridad de la unidad de manera significativa (frecuencia de comunicación, número de eventos, pérdida de carácter punitivo y trabajo de manera activa en SP). Conclusiones: El briefing es una herramienta para la recogida de los incidentes, simple, fácil de usar, útil para implantar mejoras e influir en la cultura de seguridad (AU)

Objective: To validate a safety tool used in high-risk sectors (safety briefing) in intensive care medicine. Design: A prospective, observational and analytical study was carried out. Setting: Trauma and emergency intensive care unit in a tertiary hospital. Patients: Patients with severe trauma (Injury Severity Score ISS>16). Intervention: Documentation of incidents related to patient safety (PS). Variables: Patients characteristics, state of the Unit, patient safety incidents, aspects of the tool (SP) and safety culture impact. Results: We included 441 patients (75.15% males, mean age 39.9±17.5 years), with blunt trauma in 89% and a 10.5% mortality rate. The tool was applied in 586 out of 798 possible shifts (73.4%), and documented 942 events (2.20 incidents per patient). The incidents were more frequently associated with medication (20.7%), devices (placement 4.03%, and maintenance 17.8%) and airway and mechanical ventilation (MV) (17.09%). A correlation was established between the occurrence of incidents and the characteristics of the patient (higher Injury Severity Score, presence of MV, and continuous renal replacement therapies) and the status of the Unit (more than 6 patients per shift out of 8 possible, and holiday period). The tool significantly influenced different aspects of the safety culture of the unit (communication frequency, number of events, punitive loss and active work in PS). Conclusions: Safety briefing is a tool for the documentation of incidents that is simple and easy to use, and is useful for implementing improvements and in influencing safety culture (AU)

[Clinical pathways in acute pancreatitis: recommendations for early multidisciplinary management. Scientific Committee of the SEMICYUC. Working Group on Infectious Diseases (GTEI-SEMICYUC)]. / Hoja de ruta de los cuidados clínicos para la pancreatitis aguda: recomendaciones para el manejo anticipado multidisciplinar (clinical pathways).

There is a growing body of evidence that early management of patients with acute pancreatitis may alter the natural course of disease and improve outcomes of patients. The aim of this paper is to optimize the management of patients with acute pancreatitis during the first 72 h after hospital admission by proposing several clinical care pathways. The proposed pathways are based on the SEMICYUC 2005 Recommendations with incorporation of the latest developments in the field, particularly the determinants-based classification of acute pancreatitis severity. The pathways also incorporate the "alarm signs", the use of therapeutic modalities known as PANCREAS, and the "call to ICU" criteria. Further studies will need to assess whether the adoption of these pathway reduces mortality and morbidity in patients with acute pancreatitis. The previous SEMICYUC guidelines on management of patients with acute pancreatitis in Intensive Care will need to be revised to reflect the recent developments in the field.

[Development of communication tool for patient safety ("Briefing"). Experience in a trauma and emergency intensive care unit]. / Desarrollo de una herramienta de comunicación para la seguridad del paciente (Briefing). Experiencia en una unidad de cuidados intensivos de trauma y emergencias.

OBJECTIVE: To validate a safety tool used in high-risk sectors (safety briefing) in intensive care medicine. DESIGN: A prospective, observational and analytical study was carried out. SETTING: Trauma and emergency intensive care unit in a tertiary hospital. PATIENTS: Patients with severe trauma (Injury Severity Score ISS≥16). INTERVENTION: Documentation of incidents related to patient safety (PS). VARIABLES: Patients characteristics, state of the Unit, patient safety incidents, aspects of the tool (SP) and safety culture impact. RESULTS: We included 441 patients (75.15% males, mean age 39.9±17.5 years), with blunt trauma in 89% and a 10.5% mortality rate. The tool was applied in 586 out of 798 possible shifts (73.4%), and documented 942 events (2.20 incidents per patient). The incidents were more frequently associated with medication (20.7%), devices (placement 4.03%, and maintenance 17.8%) and airway and mechanical ventilation (MV) (17.09%). A correlation was established between the occurrence of incidents and the characteristics of the patient (higher Injury Severity Score, presence of MV, and continuous renal replacement therapies) and the status of the Unit (more than 6 patients per shift out of 8 possible, and holiday period). The tool significantly influenced different aspects of the safety culture of the unit (communication frequency, number of events, punitive loss and active work in PS). CONCLUSIONS: Safety briefing is a tool for the documentation of incidents that is simple and easy to use, and is useful for implementing improvements and in influencing safety culture.

[Variability in renal dysfunction defining criteria and detection methods in intensive care units: are the international consensus criteria used for diagnosing renal dysfunction?]. / Variabilidad en los criterios de definición y métodos de detección de la disfunción renal en las unidades de cuidados intensivos ¿se aplican los consensos internacionales para el diagnóstico de la disfunción renal?

OBJECTIVE: To evaluate variability in the detection and prevention of acute kidney injury (AKI) in the intensive care unit (ICU), and application of the international recommendations in this field (Acute Dialysis Quality Initiative [ADQI] and Acute Kidney Injury Network [AKIN]). DESIGN: A prospective, observational, multicenter study. SETTING: A total of 42 ICUs in 32 hospitals (78% in third level hospitals and 70.7% general units) recruited for a study on the prevalence of AKI (COFRADE). INTERVENTIONS: Survey. VARIABLES: Aspects related to AKI detection and prevention and renal replacement therapy protocols. RESULTS: The method used for estimating glomerular filtration rate was serum creatinine in 36.6%, creatinine clearance in 41.5% and equations in 22%; none reported using cystatin-C. Only 39.1% ICUs acknowledged the use of stratification systems (13 RIFLE and 3 AKIN). A total of 48.8% ICUs had no written protocols for AKI prevention, 31.7% reported using them only for contrast nephropathy, 7.3% for nephrotoxic drugs and 12.2% for both. In contrast, 63.4% participants had written protocols for renal replacement therapy, 70.7% had implemented a training program, and 53.7% had some method for adjusting doses of drugs when on renal replacement therapy. CONCLUSIONS: We observed important variability regarding diagnostic criteria and prevention of AKI in Spanish ICUs, the application of ADQI or AKIN recommendations still being low in our units. Renal replacement therapy seems to generate more concern among our intensivists than AKI management.

Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Insuficiencia renal aguda / Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): Acute renal failure

El soporte nutricional en la insuficiencia renal aguda está condicionado por el catabolismo del paciente y por el tratamiento del fallo renal. En el paciente crítico es frecuente el fracaso hipermetabólico que obliga a técnicas continuas de reemplazo renal o a hemodiálisis diarias. En los enfermos con catabolismo normal (aparición de nitrógeno ureico inferior a 10 g/ día) y diuresis conservada se puede intentar un tratamiento conservador. En estos casos es preciso realizar un soporte nutricional relativamente hipoprotéico, con proteínas de alto valor biológico y limitaciones hidroelectrolíticas individualizadas. Es necesario un ajuste del aporte de micronutrientes, siendo el bicarbonato el único buffer utilizado. Cuando se utilizan técnicas de depuración extrarrenal desaparecen las limitaciones a los aportes hidroelectrolíticos y nitrogenados, pero éstos deben ser modificados en función del tipo de depuración. Los sistemas continuos de reemplazo renal, en función de su lujo de hemoiltración, precisan altos aporte nitrogenados diarios que en ocasiones pueden alcanzar los 2,5 g de proteínas/ kg. La cuantía de la reposición de volumen puede inducir sobrecargas energéticas, siendo recomendable utilizar líquidos de reposición y diálisis sin glucosa o con una concentración de glucosa de 1 g/ l, con bicarbonato como buffer. Es preciso monitorizar los valores de electrolitos (sobre todo de fósforo, potasio y magnesio) y de micronutrientes, y realizar aportes individualizados (AU)

Nutritional support in acute renal failure must take into account the patient’s catabolism and the treatment of the renal failure. Hypermetabolic failure is common in these patients, requiring continuous renal replacement therapy or daily hemodialysis. In patients with normal catabolism (urea nitrogen below 10 g/ day) and preserved diuresis, conservative treatment can be attempted. In these patients, relatively hypoproteic nutritional support is essential, using proteins with high biological value and limiting luid and electrolyte intake according to the patient’s individual requirements. Micronutrient intake should be adjusted, the only buffering agent used being bicarbonate. Limitations on luid, electrolyte and nitrogen intake no longer apply when extrarenal clearance techniques are used but intake of these substances should be modified according to the type of clearance. Depending on their hemoiltration low, continuous renal replacement systems require high daily nitrogen intake, which can sometimes reach 2.5 g protein/kg. The amount of volume replacement can induce energy overload and therefore the use of glucose-free replacement luids and glucose-free dialysis or a glucose concentration of 1 g/L, with bicarbonate as a buffer, is recommended. Monitoring of electrolyte levels (especially those of phosphorus, potassium and magnesium)and of micronutrients is essential and administration of these substances should be individually- tailored (AU)

Detección de riesgos para la seguridad del paciente en la implementación de técnicas continuas de depuración extracorpórea / Detection of risks for the safety of the patients in the implementation of continuous techniques of extracorporeal depuration (CTED)

IntroducciónLas técnicas de depuración extracorpórea (TCDE) gestionan elevados volúmenes de intercambio de fluidos y precisa control exhaustivo de su seguridad.ObjetivoDetectar riesgos en TCDE y determinar su frecuencia por paciente.Material y métodoEstudio observacional retrospectivo. Criterios de inclusión: pacientes ingresados desde enero a diciembre de 2009 con TCDE en la Unidad de Cuidados Intensivos (UCI) Polivalente del Hospital 12 de Octubre. Identificamos previamente diez riesgos detectables en historias clínicas. Analizamos variables demográficas y del tratamiento. Las variables cuantitativas se expresan como media±desviación estándar y cualitativas, como frecuencias absolutas y relativas. Análisis: SPSS 15.0®.ResultadosSe incluyó a 54 pacientes (11,7%) con media de edad de 59,78±14,8 años; 42 (77,8%) eran varones. En el 81,4% la indicación fue fracaso renal agudo. Se trató al 80,3% con hemodiafiltración. La media de TCDE fue de 112,9±139,9 h, con una mediana [intervalo intercuartílico] de 2 [0-31] filtros por paciente. La frecuencia de riesgo/paciente fue: el 100% de los pacientes sin monitorización de Mg y P, y el 3,7% (n=2) urea; en 16 (29,6%) se produjo coagulación del circuito antes de 24 h y en 25 (46,3%) no se pudo devolver sangre; en 14 (29,3%) faltaba siempre pauta escrita en la orden de tratamiento; en gráfica del paciente no se reflejó las dosis en 2 (3,7%); en 3 pacientes (5,6%) con coagulopatía se pautó anticoagulante en el circuito; en 1 (1,9%) se evidenció sangrado y en 10 (18,5%), hipotermia leve (35-32°C).ConclusionesSe precisa monitorización protocolizada de Mg y P. Se debe pautar la terapia en el tratamiento médico. Se precisa optimizar la técnica para prolongar su duración y evitar pérdidas hemáticas (AU)

IntroductionContinuous techniques of extracorporeal depuration (CTED) manage high volumes of fluid exchange and extensive control of its safety is required.ObjectiveTo detect the risks of CTED and to determine its frequency per patient.Material and methodsAn observational, retrospective study was performed. Inclusion criteria were patients admitted from January 2009 to December 2009, with CTED in the Polyvalent Intensive Care Unit (ICU) of the Hospital 12 de Octubre. We previously identified 10 risks that were detectable in the clinical records. We analyzed demographic and treatment variables. The quantitative variables were expressed as mean±SD and the qualitative ones as absolute and relative frequencies. Analysis: SPSS 15.0®.ResultsA total of 54 patients (11.7%), with ages 59.78±14.8, 42 men (77.8%) were included. In 81.4%, the indication was acute kidney failure; 80.3% were treated with hemodiafiltration. Mean hours of CTED were 112.9±139.9 and the medium of 2 filters per patient (recommended intakes 0-31). Risk/patient rate was: 100% of patients without monitoring of the Mg and P, and 3.7% (n=2) urea; in 16 (29.6%), there was coagulation of the circuit prior to 24hours and in 25 (46.3%) the blood could not be returned; in 14 (29.3%), written regime was always lacking on the order for treatment. The dose was not reflected on the patient's chart in 2 (3.7%); in 3 patients (5.6%) with coagulation disorder, anticoagulants were prescribed in the circuit. In 1 (1.9%) bleeding was observed and in 10 (18.5%) there was mild hypothermia (35-32°C).ConclusionsA standardized monitoring of the Mg and P is required. The therapy should be prescribed in the medical treatment. The technique needs to be improved in order to prolong its duration and avoid blood losses (AU)

[Detection of risks for the safety of the patients in the implementation of continuous techniques of extracorporeal depuration (CTED)]. / Detección de riesgos para la seguridad del paciente en la implementación de técnicas continuas de depuración extracorpórea.

INTRODUCTION: Continuous techniques of extracorporeal depuration (CTED) manage high volumes of fluid exchange and extensive control of its safety is required. OBJECTIVE: To detect the risks of CTED and to determine its frequency per patient. MATERIAL AND METHODS: An observational, retrospective study was performed. Inclusion criteria were patients admitted from January 2009 to December 2009, with CTED in the Polyvalent Intensive Care Unit (ICU) of the Hospital 12 de Octubre. We previously identified 10 risks that were detectable in the clinical records. We analyzed demographic and treatment variables. The quantitative variables were expressed as mean±SD and the qualitative ones as absolute and relative frequencies. ANALYSIS: SPSS 15.0(®). RESULTS: A total of 54 patients (11.7%), with ages 59.78±14.8, 42 men (77.8%) were included. In 81.4%, the indication was acute kidney failure; 80.3% were treated with hemodiafiltration. Mean hours of CTED were 112.9±139.9 and the medium of 2 filters per patient (recommended intakes 0-31). Risk/patient rate was: 100% of patients without monitoring of the Mg and P, and 3.7% (n=2) urea; in 16 (29.6%), there was coagulation of the circuit prior to 24 hours and in 25 (46.3%) the blood could not be returned; in 14 (29.3%), written regime was always lacking on the order for treatment. The dose was not reflected on the patient's chart in 2 (3.7%); in 3 patients (5.6%) with coagulation disorder, anticoagulants were prescribed in the circuit. In 1 (1.9%) bleeding was observed and in 10 (18.5%) there was mild hypothermia (35-32°C). CONCLUSIONS: A standardized monitoring of the Mg and P is required. The therapy should be prescribed in the medical treatment. The technique needs to be improved in order to prolong its duration and avoid blood losses.

[Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): acute renal failure]. / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: insuficiencia renal aguda.

Nutritional support in acute renal failure must take into account the patient's catabolism and the treatment of the renal failure. Hypermetabolic failure is common in these patients, requiring continuous renal replacement therapy or daily hemodialysis. In patients with normal catabolism (urea nitrogen below 10 g/day) and preserved diuresis, conservative treatment can be attempted. In these patients, relatively hypoproteic nutritional support is essential, using proteins with high biological value and limiting fluid and electrolyte intake according to the patient's individual requirements. Micronutrient intake should be adjusted, the only buffering agent used being bicarbonate. Limitations on fluid, electrolyte and nitrogen intake no longer apply when extrarenal clearance techniques are used but intake of these substances should be modified according to the type of clearance. Depending on their hemofiltration flow, continuous renal replacement systems require high daily nitrogen intake, which can sometimes reach 2.5 g protein/kg. The amount of volume replacement can induce energy overload and therefore the use of glucose-free replacement fluids and glucose-free dialysis or a glucose concentration of 1 g/L, with bicarbonate as a buffer, is recommended. Monitoring of electrolyte levels (especially those of phosphorus, potassium and magnesium) and of micronutrients is essential and administration of these substances should be individually-tailored.