[Analgesia, sedation, neuromuscular blockade and delirium management practices in Chilean intensive care units]. / Prácticas nacionales de analgesia, sedación y delirium en las Unidades de Cuidados Intensivos de adultos en Chile.

BACKGROUND: The appropriate use of analgesia, sedation, neuromuscular blockade and the diagnosis and prevention of delirium (ASBD) are associated with better outcomes in critically ill patients at Intensive Care Unit (ICUs). AIM: To know the practices about analgesia, sedation, delirium, and neuromuscular blockade use among healthcare professionals working in adult ICUs in Chile. MATERIAL AND METHODS: An electronic survey was sent to 812 professionals working in ICUs using a previously published instrument, which was adapted and authorized by the author. RESULTS: We received 278 surveys. Fifty two percent of respondents were physicians, 34% nurses and 11% physical therapists. Their age ranged between 30 and 39 years in 43% and was over 50 years in 9%. Eighty four percent evaluated pain routinely, but only 26% use a validated scale. Sedation was routinely evaluated with a validated scale and 73% referred to have a protocol. Neuromuscular block is seldom used, and little monitoring occurs (43%). Delirium is routinely evaluated by 48% of respondents, usually using the CAM-ICU scale. CONCLUSIONS: There is a heterogeneous adherence to the ASBD recommended practices. The main gaps are in the assessment of pain, monitoring of neuromuscular blockade and diagnosis of delirium through validated instruments.

Prácticas nacionales de analgesia, sedación y delirium en las Unidades de Cuidados Intensivos de adultos en Chile / Analgesia, sedation, neuromuscular blockade and delirium management practices in Chilean intensive care units

Background: The appropriate use of analgesia, sedation, neuromuscular blockade and the diagnosis and prevention of delirium (ASBD) are associated with better outcomes in critically ill patients at Intensive Care Unit (ICUs). Aim: To know the practices about analgesia, sedation, delirium, and neuromuscular blockade use among healthcare professionals working in adult ICUs in Chile. Material and Methods: An electronic survey was sent to 812 professionals working in ICUs using a previously published instrument, which was adapted and authorized by the author. Results: We received 278 surveys. Fifty two percent of respondents were physicians, 34% nurses and 11% physical therapists. Their age ranged between 30 and 39 years in 43% and was over 50 years in 9%. Eighty four percent evaluated pain routinely, but only 26% use a validated scale. Sedation was routinely evaluated with a validated scale and 73% referred to have a protocol. Neuromuscular block is seldom used, and little monitoring occurs (43%). Delirium is routinely evaluated by 48% of respondents, usually using the CAM-ICU scale. Conclusions: There is a heterogeneous adherence to the ASBD recommended practices. The main gaps are in the assessment of pain, monitoring of neuromuscular blockade and diagnosis of delirium through validated instruments.

Effects of intraoperative adrenergic administration on postoperative hyperlactatemia in open colon surgery: an observational study.

BACKGROUND: Postoperative Hyperlactatemia (PO-HL) is a frequent condition associated with poor prognosis. In recent years, there has been growing evidence that adrenergic stimulation may contribute to increased lactate levels. The use of adrenergic agonists for the control of intraoperative hypotension is frequent, and its impact on the development of PO-HL is unknown. OBJECTIVE: To evaluate whether the use of intraoperative adrenergic agents is associated with the occurrence of PO-HL. METHODS: This was a prospective observational study. The inclusion criteria were undergoing elective open colon surgery, being ≥60 years old and signing informed consent. The exclusion criteria were cognitive impairment, unplanned surgery, and anticipated need for postoperative mechanical ventilation. Baseline and intraoperative variables were collected, and arterial lactate data were collected at baseline and every 6 hours postoperatively for 24 hours. Hyperlactatemia was defined as lactate >2.1 mEq.L-1. RESULTS: We studied 28 patients, 61% of whom developed hyperlactatemia. The variables associated with PO-HL in the univariate analysis were anesthetic time, the total dose of intraoperative ephedrine, and lower intraoperative central venous oxygen saturation (ScvO2). Multivariate analysis confirmed the association between the use of ephedrine (p = 0.004), intraoperative hypotension (p = 0.026), and use of phenylephrine (p = 0.001) with PO-HL. CONCLUSIONS: The use of intraoperative ephedrine, phenylephrine and intraoperative hypotension were independently associated with the development of PO-HL. This finding should lead to new studies in this field, as well as a judicious interpretation of the finding of a postoperative increase in lactate levels.

Consolidated framework for advancing implementation science for the implementation process and adherence assessment of a non-pharmacological delirium prevention program.

OBJECTIVE: To evaluate the contribution of applying the theoretical framework of implementation science for adherence to non-pharmacological interventions to prevent delirium. METHODS: A quasi-experimental prospective design was conducted from March 2017 to October 2018 in a teaching hospital. Participants included 149 healthcare staff and 72 elderly inpatients. A non-pharmacological delirium prevention program was designed, applied and evaluated in accordance with the consolidated framework for advancing implementation research (CFIR). The primary outcome was the global adherence rate to 12 predefined indicators, comparing measurements at baseline (O1), after training (O2) and at a 6-month follow-up (O3) assessed by an external reviewer. Staff knowledge and beliefs about delirium were assessed using a validated tool, and delirium incidence was evaluated using the confusion assessment method. RESULTS: Overall adherence increased from 58.2% (O1) to 77.9% (O2) and 75.6% (O3) (O2 vs. O1: p < 0.001 and O3 vs. O1: p < 0.001). Staff perceptions regarding implementation of non-pharmacological interventions increased from 74.8% to 81.9% (p = 0.004). Delirium incidence was non-significantly reduced from 20% (O1) to 16% (O3) (p = 0.99). CONCLUSIONS: Implementation of a delirium prevention program using a CFIR model was useful in improving adherence to activities included in this program, as well as improving the knowledge and beliefs regarding delirium by healthcare workers. The impact of this implementation strategy on the incidence of delirium should be evaluated in a larger scale multicenter trial.

Tricodisplasia espinulosa asociada a leucemia linfoblástica aguda en edad pediátrica: revisión de la literatura a propósito de un caso / Trichodysplasia spinulosa associated with acute lymphoblastic leukemia in pediatric age: review of the literature regarding a case

La tricodisplasia espinulosa es una patología viral infrecuente causada por un tipo de poliomavirus, el cual se da siempre en contexto de inmunosupresión. Existen reportes que estiman una seroprevalencia en adultos de 70%, y hasta 90% en inmu-nocomprometidos. El cuadro clínico se caracteriza por pápulas color piel hiperqueratósicas en zonas centro faciales, orejas y tronco, asintomáticas o con prurito escaso. Existen métodos de confirmación diagnóstica como PCR o test de Elisa, que no se encuentran disponibles en Chile. Por lo tanto, en nuestro contexto el estudio histopatológico es fun-damental, dada su accesibilidad y que los hallazgos de la biopsia son característicos. El manejo debe siempre considerar, de ser posible, disminuir la in-munosupresión del paciente. Otras medidas son: extracción manual de las lesiones y aplicación de cidofovir o valganciclovir tópicos

Trichodysplasia spinulosa is an infrequent viral pathology caused by a type of polyomavirus, which always occurs in context of immunosuppression. There are reports that estimate sero-prevalence in adults of 70%, and 90% in immunocompromised. Patients have numerous, mildly pruritic, folliculocentric, flesh-colored to pink papules with central keratinaceous spines. There are methods of diagnostic confirmation such as PCR or Elisa test, not available in Chile. The-refore, in our context the histopathological study is fundamental because biopsy findings are cha-racteristic. Management should always consider, if possible, decrease the immunosuppression of the patient. Other measures consist of manual extraction and cidofovir or topical valganciclovir.