Resultados de un programa de descolonización de Staphylococcus aureus en cirugía protésica primaria de cadera y rodilla / Results of a preoperative screening and decolonization program for Staphylococcus aureus in primary hip and knee arthroplasty

Introducción: La detección y descolonización del Staphylococcus aureus previo a la cirugía, se postula como la opción para disminuir el riesgo de infección en artroplastias. El objetivo de este estudio fue evaluar la efectividad de un programa de cribado de S. aureus en la artroplastia total de rodilla (ATR) y en la artroplastia total de cadera (ATC), la incidencia de infección respecto a una cohorte histórica y su viabilidad económica. Material y métodos: Estudio pre-postintervención en pacientes intervenidos de ATR y ATC en al año 2021. Se realizó protocolo de detección de colonización nasal por S. aureus y erradicación si procedía, con mupirocina intranasal, cultivo postratamiento con el resultado de 3 semanas entre cultivo postratamiento y cirugía. Se evalúan medidas de eficacia, se analizan costes y se comprara la incidencia de infección respecto a una serie histórica de pacientes intervenidos entre enero y diciembre de 2019, realizando análisis estadístico descriptivo y comparativo. Resultados: Los grupos fueron comparables estadísticamente. Se realizó el cultivo en el 89%, siendo 19 (13%) pacientes positivos. Se confirmó el tratamiento en 18, cultivo control en 14, todos descolonizados; ninguno sufrió infección. Un paciente con cultivo negativo sufrió infección por S. epidermidis. En cohorte histórica: 3 sufrieron infección profunda por S. epidermidis, E. cloacae y S. aureus. El coste del programa fue de 1.661,85€. Conclusión: El programa de cribado detectó el 89% de los pacientes. La prevalencia de infección en el grupo intervención era menor que en la cohorte, siendo S.epidermidis el microorganismo causante, diferente a S. aureus descrito en la literatura y en la cohorte. Consideramos que este programa es económicamente viable, siendo sus costes reducidos y asumibles.(AU)

Introduction: Detection and decolonization of Staphylococcus aureus prior to surgery is postulated as an option to reduce the risk of infection in arthroplasties. The aim of this study was to evaluate the effectiveness of a screening program for S. aureus in total knee arthroplasty (TKA) and total hip arthroplasty (THA), the incidence of infection with respect to a historical cohort, and its economic viability. Material and methods: Pre-post intervention study in patients undergoing primary knee and hip prostheses in 2021, a protocol was carried out to detect nasal colonization by S. aureus and eradication if appropriate, with intranasal mupirocin, post-treatment culture with results three weeks between post-treatment culture and surgery. Efficacy measures are evaluated, costs are analyzed and the incidence of infection is compared with respect to a historical series of patients operated on between January and December 2019, performing a descriptive and comparative statistical analysis. Results: The groups were statistically comparable. Culture was performed in 89%, with 19 (13%) positive patients. Treatment was confirmed in 18, control culture in 14, all decolonized; none suffered infection. One culture-negative patient suffered from Staphylococcus epidermidis infection. In historical cohort: 3 suffered deep infection by S. epidermidis, Enterobacter cloacae, S. aureus. The cost of the program is €1661.85. Conclusion: The screening program detected 89% of the patients. The prevalence of infection in the intervention group was lower than in the cohort, with S. epidermidis being the main microorganism, different from S. aureus described in the literature and in the cohort. We believe that this program is economically viable, as its costs are low and affordable.(AU)

[Translated article] Results of a preoperative screening and decolonization programme for Staphylococcus aureus in primary hip and knee arthroplasty / Resultados de un programa de descolonización de Staphylococcus aureus en cirugía protésica primaria de cadera y rodilla

Introducción: La detección y descolonización del Staphylococcus aureus previo a la cirugía, se postula como la opción para disminuir el riesgo de infección en artroplastias. El objetivo de este estudio fue evaluar la efectividad de un programa de cribado de S. aureus en la artroplastia total de rodilla (ATR) y en la artroplastia total de cadera (ATC), la incidencia de infección respecto a una cohorte histórica y su viabilidad económica. Material y métodos: Estudio pre-postintervención en pacientes intervenidos de ATR y ATC en al año 2021. Se realizó protocolo de detección de colonización nasal por S. aureus y erradicación si procedía, con mupirocina intranasal, cultivo postratamiento con el resultado de 3 semanas entre cultivo postratamiento y cirugía. Se evalúan medidas de eficacia, se analizan costes y se comprara la incidencia de infección respecto a una serie histórica de pacientes intervenidos entre enero y diciembre de 2019, realizando análisis estadístico descriptivo y comparativo. Resultados: Los grupos fueron comparables estadísticamente. Se realizó el cultivo en el 89%, siendo 19 (13%) pacientes positivos. Se confirmó el tratamiento en 18, cultivo control en 14, todos descolonizados; ninguno sufrió infección. Un paciente con cultivo negativo sufrió infección por S. epidermidis. En cohorte histórica: 3 sufrieron infección profunda por S. epidermidis, E. cloacae y S. aureus. El coste del programa fue de 1.661,85€. Conclusión: El programa de cribado detectó el 89% de los pacientes. La prevalencia de infección en el grupo intervención era menor que en la cohorte, siendo S.epidermidis el microorganismo causante, diferente a S. aureus descrito en la literatura y en la cohorte. Consideramos que este programa es económicamente viable, siendo sus costes reducidos y asumibles.(AU)

Introduction: Detection and decolonization of Staphylococcus aureus prior to surgery is postulated as an option to reduce the risk of infection in arthroplasties. The aim of this study was to evaluate the effectiveness of a screening program for S. aureus in total knee arthroplasty (TKA) and total hip arthroplasty (THA), the incidence of infection with respect to a historical cohort, and its economic viability. Material and methods: Pre-post intervention study in patients undergoing primary knee and hip prostheses in 2021, a protocol was carried out to detect nasal colonization by S. aureus and eradication if appropriate, with intranasal mupirocin, post-treatment culture with results three weeks between post-treatment culture and surgery. Efficacy measures are evaluated, costs are analyzed and the incidence of infection is compared with respect to a historical series of patients operated on between January and December 2019, performing a descriptive and comparative statistical analysis. Results: The groups were statistically comparable. Culture was performed in 89%, with 19 (13%) positive patients. Treatment was confirmed in 18, control culture in 14, all decolonized; none suffered infection. One culture-negative patient suffered from Staphylococcus epidermidis infection. In historical cohort: 3 suffered deep infection by S. epidermidis, Enterobacter cloacae, S. aureus. The cost of the program is €1661.85. Conclusion: The screening program detected 89% of the patients. The prevalence of infection in the intervention group was lower than in the cohort, with S. epidermidis being the main microorganism, different from S. aureus described in the literature and in the cohort. We believe that this program is economically viable, as its costs are low and affordable.(AU)

[Translated article] Results of a preoperative screening and decolonization programme for Staphylococcus aureus in primary hip and knee arthroplasty.

INTRODUCTION: Detection and decolonization of Staphylococcus aureus prior to surgery is postulated as an option to reduce the risk of infection in arthroplasties. The aim of this study was to evaluate the effectiveness of a screening programme for S. aureus in total knee arthroplasty (TKA) and total hip arthroplasty (THA), the incidence of infection with respect to a historical cohort, and its economic viability. MATERIAL AND METHODS: Pre-post intervention study in patients undergoing primary knee and hip prostheses in 2021, a protocol was carried out to detect nasal colonization by S. aureus and eradication if appropriate, with intranasal mupirocin, post-treatment culture with results three weeks between post-treatment culture and surgery. Efficacy measures are evaluated, costs are analyzed and the incidence of infection is compared with respect to a historical series of patients operated on between January and December 2019, performing a descriptive and comparative statistical analysis. RESULTS: The groups were statistically comparable. Culture was performed in 89%, with 19 (13%) positive patients. Treatment was confirmed in 18, control culture in 14, all decolonized; none suffered infection. One culture-negative patient suffered from Staphylococcus epidermidis infection. In historical cohort: three suffered deep infection by S. epidermidis, Enterobacter cloacae, Staphylococcus aureus. The cost of the programme is €1661.85. CONCLUSION: The screening programme detected 89% of the patients. The prevalence of infection in the intervention group was lower than in the cohort, with S. epidermidis being the main micro-organism, different from S. aureus described in the literature and in the cohort. We believe that this programme is economically viable, as its costs are low and affordable.

Implementation of a major trauma team. Analysis of activation and care times in patients admitted to the ICU.

OBJECTIVE: To analyze the factors associated with the activation of the severe trauma care team (STAT) in patients admitted to the ICU, to measure its impact on care times, and to analyze the groups of patients according to activation and level of anatomical involvement. DESIGN: Prospective cohort study of severe trauma admitted to the ICU. From June 2017 to May 2019. Risk factors for the activation of the STAT analysed with logistic regression and CART type classification tree. SETTING: Second level hospital ICU. PATIENTS: Patients admitted consecutively. INTERVENTIONS: No. MAIN VARIABLES OF INTEREST: STAT activation. Demographic variables. Injury severity (ISS), intentionality, mechanism, assistance times, evolutionary complications, and mortality. RESULTS: A total of 188 patients were admitted (46.8% of STAT activation), median age of 52 (37-64) years (activated 47 (27-62) vs not activated 55 (42-67) P = 0.023), males 84.0%. No difference in mortality according to activation. The logistic model finds as factors: care (16.6 (2.1-13.2)) and prehospital intubation (4.2 (1.8-9.8)) and severe lower extremity injury (4.4 (1.6-12.3)). Accidental fall (0.2 (0.1-0.6)) makes activation less likely. The CART model selects the type of trauma mechanism and can separate high and low energy trauma. CONCLUSIONS: Factors associated with STAT activation were prehospital care, requiring prior intubation, high-energy mechanisms, and severe lower extremity injuries. Shorter care times if activated without influencing mortality. We must improve activation in older patients with low-energy trauma and without prehospital care.

Results of a preoperative screening and decolonization program for Staphylococcus aureus in primary hip and knee arthroplasty. / Resultados de un programa de descolonización de Staphylococcus aureus en cirugía protésica primaria de cadera y rodilla.

INTRODUCTION: Detection and decolonization of Staphylococcus aureus prior to surgery is postulated as an option to reduce the risk of infection in arthroplasties. The aim of this study was to evaluate the effectiveness of a screening program for S. aureus in total knee arthroplasty (TKA) and total hip arthroplasty (THA), the incidence of infection with respect to a historical cohort, and its economic viability. MATERIAL AND METHODS: Pre-post intervention study in patients undergoing primary knee and hip prostheses in 2021, a protocol was carried out to detect nasal colonization by S. aureus and eradication if appropriate, with intranasal mupirocin, post-treatment culture with results three weeks between post-treatment culture and surgery. Efficacy measures are evaluated, costs are analyzed and the incidence of infection is compared with respect to a historical series of patients operated on between January and December 2019, performing a descriptive and comparative statistical analysis. RESULTS: The groups were statistically comparable. Culture was performed in 89%, with 19 (13%) positive patients. Treatment was confirmed in 18, control culture in 14, all decolonized; none suffered infection. One culture-negative patient suffered from Staphylococcus epidermidis infection. In historical cohort: 3 suffered deep infection by S. epidermidis, Enterobacter cloacae, S. aureus. The cost of the program is €1661.85. CONCLUSION: The screening program detected 89% of the patients. The prevalence of infection in the intervention group was lower than in the cohort, with S. epidermidis being the main microorganism, different from S. aureus described in the literature and in the cohort. We believe that this program is economically viable, as its costs are low and affordable.

Encuesta sobre valoración del estado nutricional y síndrome de realimentación en las unidades de cuidados intensivos en España / Survey on the assessment of nutritional status and feedback syndrome in Spanish intensive care units

No disponible

Factores de riesgo de deterioro de calidad de vida en pacientes traumáticos críticos. Valoración a los 6 y 12 meses del alta de la unidad de cuidados intensivos / Risk factors for the deterioration of quality of life in critical trauma patients. Assessment at 6 and 12 months after discharge from the intensive care unit

OBJETIVO: Evaluar los factores que influyen en el deterioro de la calidad de vida relacionada con la salud (CVRS) de pacientes traumatizados ingresados en una UCI. DISEÑO: Estudio prospectivo observacional. ÁMBITO: UCI polivalente de un hospital universitario de segundo nivel con servicio de neurocirugía 24 h. PACIENTES: Pacientes traumatizados ingresados en la UCI durante un periodo de 2 años. Evaluación de CVRS previa, a los 6 y 12 meses del alta. Variables de interés Se recogen variables demográficas, tipo y gravedad de lesiones (AIS), nivel de gravedad (APACHE II, ISS, TRISS), estancia, procedimientos, mortalidad y CVRS según los cuestionarios SF-36 y EQ-5D.ResultadosSe completó el seguimiento en 110 pacientes que mostraron un deterioro significativo de su CVRS en todas las dimensiones evaluadas. Según el SF-36 se deterioró más el rol físico a los 12 meses, aunque el componente mental disminuyó más que el componente físico a los 6 meses. La EVA del EQ-5D bajó a los 6 meses hasta 55 (19) y aumentó a los 12 meses hasta 66 (17). En el análisis de regresión logística múltiple las variables relacionadas con peor CVRS fueron: la edad > 45 años, un TRISS > 10, peor calidad de vida previa y tener una lesión grave de las extremidades. CONCLUSIONES: Los pacientes muestran un deterioro marcado de su CVRS a los 6 meses con mejoría a los 12 meses, aunque sin llegar a igualar su estado previo. Los factores que determinan peor calidad de vida son la edad, la gravedad, la CVRS previa y las lesiones graves de las extremidades

OBJECTIVE: To evaluate factors influencing the deterioration of health-related quality of life (HRQoL) in trauma patients admitted to an ICU. DESIGN: A prospective observational study was carried out. SETTING: The combined medical/surgical ICU in a university secondary hospital with 24-hour neurosurgery service. Patients Trauma patients admitted to the ICU during a two-year period. HRQoL assessment prior to admission to the ICU, and at 6 and 12 months after discharge. MAIN VARIABLES: Demographic variables, type and severity of injury (AIS), severity (APACHE II, ISS, TRISS), length of stay, procedures, mortality and HRQoL according to the SF-36 and EQ-5D. RESULTS: We completed the monitoring of 110 patients that showed significant impairment of their HRQoL in all the dimensions assessed. According to the SF-36, physical role was more deteriorated at 12 months, but the mental component decreased more than the physical component after 6 months. The VAS scale of the EQ-5D decreased to 55 at 6 months (19) and increased to 66 at 12 months (17). In the multiple logistic regression analysis, the variables associated with poorer HRQoL were age > 45 years, TRISS > 10, previous porer quality of life, and serious injuries in the extremities. CONCLUSIONS: Patients showed marked deterioration of their HRQoL at 6 months, followed by overall improvement at 12 months, though without reaching their previous state. The factors that determine poorer quality of life include age, severity, previous HRQoL, and severe injuries in the extremities

[Risk factors for the deterioration of quality of life in critical trauma patients. Assessment at 6 and 12 months after discharge from the intensive care unit]. / Factores de riesgo de deterioro de calidad de vida en pacientes traumáticos críticos. Valoración a los 6 y 12 meses del alta de la unidad de cuidados intensivos.

OBJECTIVE: To evaluate factors influencing the deterioration of health-related quality of life (HRQoL) in trauma patients admitted to an ICU. DESIGN: A prospective observational study was carried out. SETTING: The combined medical/surgical ICU in a university secondary hospital with 24-hour neurosurgery service. PATIENTS: Trauma patients admitted to the ICU during a two-year period. HRQoL assessment prior to admission to the ICU, and at 6 and 12 months after discharge. MAIN VARIABLES: Demographic variables, type and severity of injury (AIS), severity (APACHE II, ISS, TRISS), length of stay, procedures, mortality and HRQoL according to the SF-36 and EQ-5D. RESULTS: We completed the monitoring of 110 patients that showed significant impairment of their HRQoL in all the dimensions assessed. According to the SF-36, physical role was more deteriorated at 12 months, but the mental component decreased more than the physical component after 6 months. The VAS scale of the EQ-5D decreased to 55 at 6 months (19) and increased to 66 at 12 months (17). In the multiple logistic regression analysis, the variables associated with poorer HRQoL were age > 45 years, TRISS > 10, previous porer quality of life, and serious injuries in the extremities. CONCLUSIONS: Patients showed marked deterioration of their HRQoL at 6 months, followed by overall improvement at 12 months, though without reaching their previous state. The factors that determine poorer quality of life include age, severity, previous HRQoL, and severe injuries in the extremities.

Estudio comparativo aleatorizado de la intervención quirúrgica temprana frente a la demorada en los pacientes con fractura de cadera tratados con antiagregantes plaquetarios. Determinación de la agregabilidad plaquetaria y el sangrado perioperatorio, y la revisión de la mortalidad al año / Randomised comparative study of early versus delayed surgery in hip-fracture patients on concomitant treatment with antiplatelet drugs. Determination of platelet aggregation, perioperative bleeding and a review of annual mortality

Revisar el tratamiento perioperatorio de los pacientes con fracturas de cadera y tratamiento concomitante con antiagregantes plaquetarios, así como analizar las diferencias de mortalidad al año, y el sangrado perioperatorio según la pauta de cirugía precoz (< 48 h) vs. demorada (> 5 días). Paralelamente, determinar al ingreso y en el preoperatorio inmediato la agregabilidad plaquetaria en todos los pacientes incluidos en el estudio. Pacientes y método. Sobre 175 pacientes mayores de 65 años con fractura de cadera de baja energía se aleatorizaron 3 grupos: antiagregados con cirugía precoz, antiagregados con cirugía demorada, y no antiagregados con cirugía precoz; se recogieron prospectivamente los mismos datos clínicos y analíticos para todos ellos. La agregabilidad plaquetaria se determinó mediante un sistema informatizado semicuantitativo basado en la agregometría por impedancia en sangre completa. Resultados. El sangrado, los requerimientos transfusionales y los resultados analíticos no mostraron diferencias estadísticamente significativas entre los grupos. Un 59,8% de los pacientes que no referían tomar antiagregantes se encontraban analíticamente antiagregados al ingreso, mientras que un 13,5% de los que tomaban antiagregantes no se encontraban correctamente antiagregados. El análisis multivariante mostró mayor mortalidad a 12 meses para las variables del índice de Barthel bajo previo a la fractura (OR: 0,9-0,9) y número de transfusiones (OR: 1,1-1,5). La estancia media fue de 4,1 días mayor en el grupo demorado. Conclusión. La pauta de cirugía precoz para los pacientes en tratamiento antiagregante tiene resultados clínicos parecidos a la demorada, pero mejora la eficiencia hospitalaria al reducir la estancia media. La antiagregación farmacológica referida por el paciente resultó poco concordante con la determinación de la agregabilidad(AU)

Objective. A review of the perioperative management of patients with hip fractures and concomitant therapy with antiplatelet agents, and to analyse the differences in mortality and perioperative bleeding in early surgery (<48 h) versus delayed surgery (>5 days). Platelet aggregation was measured on admission and immediately before surgery in all patients included in the study. Patients and methods. A total of 175 patients over 65 years old, with low energy hip fracture were randomised into 3 groups: Patients on antiplatelet therapy undergoing early surgery, patients on antiplatelet therapy undergoing delayed surgery, and patients not on antiplatelet therapy undergoing early surgery. The same clinical and laboratory data were collected prospectively up to 12 months for all the patients. The platelet aggregation was determined by a semi-quantitative computerised system based on impedance aggregometry in whole blood. Results. Bleeding, transfusion requirements and analytical results showed no significant differences between groups. More than half (59.8%) of the patients not taking antiplatelet therapy had normal platelet aggregation on admission, while 13.5% of those taking antiplatelet agents did not. Multivariate analysis showed increased mortality at 12 months for the variables, low Barthel index before hip fracture (OR: 0.9-0.9) and number of transfusions (OR: 1.1-1.5). The average lenth of stay was 4.1 days greater in the delayed surgery group. Conclusion. Early surgery for patients receiving antiplatelet therapy has similar clinical outcomes to the delayed, but improves hospital efficiency by reducing the average length of stay. The antiplatelet drug reported by the patient showed low concordance with the determination of the platelet aggregation(AU)

[Randomised comparative study of early versus delayed surgery in hip-fracture patients on concomitant treatment with antiplatelet drugs. Determination of platelet aggregation, perioperative bleeding and a review of annual mortality]. / Estudio comparativo aleatorizado de la intervención quirúrgica temprana frente a la demorada en los pacientes con fractura de cadera tratados con antiagregantes plaquetarios. Determinación de la agregabilidad plaquetaria y el sangrado perioperatorio, y la revisión de la mortalidad al año.

OBJECTIVE: A review of the perioperative management of patients with hip fractures and concomitant therapy with antiplatelet agents, and to analyse the differences in mortality and perioperative bleeding in early surgery (<48 h) versus delayed surgery (>5 days). Platelet aggregation was measured on admission and immediately before surgery in all patients included in the study PATIENTS AND METHODS: A total of 175 patients over 65 years old, with low energy hip fracture were randomised into 3 groups: Patients on antiplatelet therapy undergoing early surgery, patients on antiplatelet therapy undergoing delayed surgery, and patients not on antiplatelet therapy undergoing early surgery. The same clinical and laboratory data were collected prospectively up to 12 months for all the patients. The platelet aggregation was determined by a semi-quantitative computerised system based on impedance aggregometry in whole blood. RESULTS: Bleeding, transfusion requirements and analytical results showed no significant differences between groups. More than half (59.8%) of the patients not taking antiplatelet therapy had normal platelet aggregation on admission, while 13.5% of those taking antiplatelet agents did not. Multivariate analysis showed increased mortality at 12 months for the variables, low Barthel index before hip fracture (OR: 0.9-0.9) and number of transfusions (OR: 1.1-1.5). The average lenth of stay was 4.1 days greater in the delayed surgery group. CONCLUSION: Early surgery for patients receiving antiplatelet therapy has similar clinical outcomes to the delayed, but improves hospital efficiency by reducing the average length of stay. The antiplatelet drug reported by the patient showed low concordance with the determination of the platelet aggregation.

Calidad de vida y cuidados paliativos: ¿qué dimensiones podemos mejorar? / No disponible

Objetivo: conocer si la intervención de un equipo de soporte hospitalario (UFISS), mejora la calidad de vida de los pacientes atendidos según la escala Palliative Outcome Scale (POS). Sujetos y método: estudio prospectivo mediante la aplicación de la escala POS al ingreso y alta de los pacientes atendidos por el equipo de Cuidados Paliativos del Hospital Universitario Arnau de Vilanova entre octubre 2006 y enero 2007. Criterios exclusión: sólo una sola valoración; intervención inferior a cinco días; pacientes en situación agónica; evaluaciones con falta de datos. Otras variables estudiadas: edad, sexo y servicio de procedencia. Análisis estadístico con test no paramétrica de la U de Mann-Whitney y diferencia antes y después con test de signos de Wilcoxon. Significación de p < 0,05. Resultados: de los 115 pacientes valorados, 50 cumplían los criterios de inclusión. El 60% eran hombres. Media de edad de 67,5 años (16). Los pacientes provenían de servicios médicos (86%). El resultado global del POS mejora de forma significativa tras la intervención de la UFISS(p < 0,05). También mejoran: dolor (p < 0,01), otros síntomas (p < 0,05),información (p < 0,05), tiempo perdido con tratamientos (p < 0,05), y la manera en cómo se han abordado los asuntos pendientes (p < 0,05). Corregido cada ítem del POS por sexo, edad (menor y mayor de 70 años) y servicio que los deriva, encontramos que los resultados son similares, exceptuando el caso de paciente > 70 años, en los cuales mejora significativamente su nivel de angustia. Conclusiones: la intervención del equipo de UFISS de Cuidados Paliativos mejora significativamente la calidad de vida de los pacientes atendidos. Las áreas que mejoran son el dolor, otros síntomas, la información, el tiempo perdido y la forma de tratar los asuntos pendientes (AU)

Objective: to describe whether an intervention by a Palliative Care Supportive Team in a University Hospital can improve quality of life (QL)as assessed by the Palliative Outcome Scale (POS). Patients and methods: a longitudinal, prospective survey using POS during the first visit and at discharge in all patients treated by our palliative care team (October 2006 to January 2007). Exclusion criteria:1) patients with only one assessment, (survival less than 1 week or first assessment prior to the study period). 2) Assessments with any missing data. 3) Patients in their last hours of life. 4) Assessments with missing data. Other variables we analyzed were: age, sex, and referring department. For patient analyses by groups we used the Mann-Whitney non parametrical U-test, and to establish differences before and after the intervention we used Wilcoxon's test. The level of significance we used was p < 0.05. Results: during the study, of all 115 newly treated patients, 50 were selected for the analysis; 60% were men, average age was 67.5; 86% were referred by medical specialists. Global POS improvement was significant after the palliative care intervention (p < 0.05). The dimensions that improved most were: pain (p < 0.01); other symptoms (p < 0.05); information(p < 0.05), wasted time (p < 0.05), and the way problems were resolved(p < 0.05). A POS analysis by sex, age (younger or older than 70), and ward of origin showed no differences except for anxiety, which improved especially among patients over 70, even though this item did not affect final results. Conclusions: a) a palliative care intervention by a supportive team improves QL for patients; and b) pain, other symptoms, information, waste of time, and the way outstanding matters were dealt with are the QL dimensions that improved most (AU)

[Changes in health-related quality of life after ICU according to diagnostic category. Comparison of two measurement instruments]. / Cambios en la calidad de vida tras UCI según grupo diagnóstico. Comparación de dos instrumentos de medida.

OBJECTIVE: Assessment of health related quality of life (HRQOL) before and 12 months after discharge from a mixed intensive care unit (ICU) according to diagnostic category and the relationship between both instruments. DESIGN: Prospective observational study. SETTING: The combined medical/surgical ICU in a secondary university hospital with 450 beds. PATIENTS: Patients admitted to the ICU over an 18-month period. MAIN VARIABLES: Variables on demography, diagnosis on admission, severity of acute illness score (APACHE II), length of stay, procedures, mortality and the HRQOL were collected using the Short Form SF-36 and EQ-5D questionnaires. Health status prior to admission was evaluated retrospectively. RESULTS: Both questionnaires were answered by 189 patients. A significant deterioration in the quality of life was observed 12 months after ICU discharge. Head injury and neurological patients had worse HRQOL one year after discharge. Multiple trauma patients presented severe physical limitations and pain, but without significant differences on the emotional level. The EQ Visual Analogue Scale and the EQ Index score showed clinically relevant differences in these three groups. Respiratory patients are the only group in whom the HRQOL improved. Comparison between both measurement instruments showed a strong correlation on the physical functioning level, but a weaker correlation on the emotional functioning one. CONCLUSIONS: HRQOL assessment of ICU patients must be done according to a diagnostic category. Both instruments (the EQ-5D and SF-36) are capable of detecting changes in HRQOL. Despite differences in structure and content, both measure similar aspects of quality of life.

Cambios en la calidad de vida tras UCI según grupo diagnóstico. Comparación de dos instrumentos de medida / Changes in health-related quality of life alter ICU according to diagnostic category. Comparison of two measurement instruments

Objetivo. Análisis de la calidad de vida relacionadacon la salud (CVRS). Se evalúan los cambios en la CVRS previa al ingreso en la Unidad de Cuidados Intensivos (UCI) y a los 12 meses del alta según la categoría diagnóstica, así como la relación entre ambos instrumentos de medida.Diseño. Estudio prospectivo observacional.Ámbito. UCI polivalente de un Hospital Uni ver si tario de segundo nivel con 450 camas.Pacientes. Pacientes ingresados en la UCI más de 24 horas, durante un período de 18 meses.Variables de interés. Se recogen variables demográficas,diagnóstico al ingreso, nivel de gravedad (APACHE II), estancia, procedimientos, mortalidad y CVRS mediante los cuestionarios Short Form SF-36 (SF-36) y EuroQoL 5D (EQ-5D). El estado de salud previo al ingreso se evaluó deforma retrospectiva.Resultados. Un total de 189 pacientes responden ambos cuestionarios. La calidad de vida mostró un deterioro significativo a los 12 meses del alta de la UCI. Los pacientes con traumatismo craneoencefálico (TCE) y neurológicos se asociaron con peor CVRS al año del alta. Los pacientes con politrauma presentaron importantes limitaciones físicas y dolor, pero sin diferencias significativas en el aspecto emocional. La EQ escala visual analógica y el EQ tarifa mostraron en estostres grupos una diferencia clínicamente relevante.Los pacientes con problemas respiratorios representaronel único grupo de pacientes que mejoró su CVRS. La comparación entre ambos instrumentos de medida demostró una fuerte correlación en la función física. En el aspecto emocional la correlación fue más débil.Conclusiones. La valoración de la CVRS en lospacientes ingresados en la UCI debe hacerse teniendoen cuenta la categoría diagnóstica. Ambos instrumentos (EQ-5D y SF-36) son capaces de detectar los cambios en la CVRS, y a pesar de algunas diferencias en estructura y contenido miden aspectos similares de la calidad de vida

Objective. Assessment of health related qualityof life (HRQOL) before and 12 months after dischargefrom a mixed intensive care unit (ICU) accordingto diagnostic category and the relationshipbetween both instruments.Design. Prospective observational study.Setting. The combined medical/surgical ICU ina secondary university hospital with 450 beds.Patients. Patients admitted to the ICU over an18-month period.Main variables. Variables on demography, diagnosison admission, severity of acute illness score(APACHE II), length of stay, procedures, mortalityand the HRQOL were collected using the Short Form SF-36 and EQ-5D questionnaires. Health status prior to admission was evaluated retrospectively.Results. Both questionnaires were answered by189 patients. A significant deterioration in thequality of life was observed 12 months after ICUdischarge. Head injury and neurological patients had worse HRQOL one year after discharge. Multiple trauma patients presented severe physical limitations and pain, but without significant differences on the emotional level. The EQ Visual Analogue Scale and the EQ Index score showed clinically relevant differences in these three groups. Respiratory patients are the only group inwhom the HRQOL improved. Comparison between both measurement instruments showed a strong correlation on the physical functioning level, but a weaker correlation on the emotional functioning one.Conclusions. HRQOL assessment of ICU patientsmust be done according to a diagnostic category. Both instruments (the EQ-5D and SF-36) are capable of detecting changes in HRQOL. Despite differences in structure and content, both measure similar aspects of quality of life

Intubación fibroóptica oral. Localización del lugar de resistencia al avance del tubo traqueal y maniobras para solucionarlo. Estudio de simulación en maniquí / Locating the site of resistance to the endotracheal tube in fiberoptic oral intubation and maneuvers to overcome it: a mannequin simulation study

OBJETIVOS: Determinar el lugar más frecuente deresistencia al avance del tubo traqueal durante la intubación fibroóptica oral en maniquí, aplicando un algoritmo de maniobras para solucionarlo.MÉTODO: Se establecieron 4 grupos de estudio dondese compararon dos tipos de tubo traqueal, uno estándary otro reforzado flexible, de 7,5 mm de diámetro interno,combinándolos o no con una cánula orofaríngea de intubación tipo Williams. Se utilizaron dos fibroscopios, uno para realizar la intubación y el otro para observar la localización de la resistencia y la efectividad de las maniobras para evitarlo. Se clasificó el grado de resistencia según la escala de Jones, modificada, desde el grado 0 (intubación sin resistencia), al grado 4 (no intubación), y se registró la localización de la resistencia y el tiempo necesario para cada intubación.RESULTADOS: Se realizaron 250 intubaciones orales. Seencontró resistencia en el 75,2% de los casos. Las localizaciones principales de la obstrucción fueron el cartílago aritenoides derecho y la comisura posterior. En el 89,6% de los casos se intubó la tráquea sin maniobra alguna o con una rotación antihoraria de 90º. Hubo diferencias estadísticamente significativas en resistencia y tiempo de intubación cuando se utilizó la combinación de tubo reforzado flexible y Williams.CONCLUSIONES: La rotación antihoraria de 90º deltubo fue una maniobra efectiva para superar la resistencia. La combinación de un tubo reforzado flexible y Williams es la que presentó menos resistencia y menores tiempos de intubación

OBJECTIVE: To determine the most common trachealpoints of resistance during orotracheal insertion of afiberoptic tube in a mannequin by applying a maneuveralgorithm to overcome the resistance.METHOD: Four study groups were established to compare 2types of endotracheal tube: a standard tube and a reinforced flexible tube with an internal diameter of 7.5 mm. The tubes were used on their own or in combination with a Williams airway intubator. Two fiberoptic bronchoscopes were used, one to perform the test intubation and the other to observe thelocation of resistance and the effectiveness of the maneuvers for overcoming it. The degree of resistance was scored using a modified Jones scale, from 0 (intubation without resistance) to 4 (intubation impossible); location of resistance and timerequired for each intubation were also recorded.RESULTS: A total of 250 oral intubations were performed.Resistance was encountered in 75.2% of the cases. The main locations of obstruction were the right arytenoid cartilage and the posterior commissure. In 89.6% of the cases, intubation of the trachea was achieved without maneuvering or with a 90° counterclockwise rotation. Statistically significant differences were found in resistance and intubation time when the reinforced flexible tube was used with the Williams intubator.CONCLUSIONS: Rotating the tube 90° counterclockwise was an effective maneuver for overcoming resistance. The combination of a reinforced flexible tube and a Williams intubator was associated with less resistance and shorter intubation times

[Locating the site of resistance to the endotracheal tube in fiberoptic oral intubation and maneuvers to overcome it: a mannequin simulation study]. / Intubación fibroóptica oral. Localización del lugar de resistencia al avance del tubo traqueal y maniobras para solucionarlo. Estudio de simulación en maniquí.

OBJECTIVE: To determine the most common tracheal points of resistance during orotracheal insertion of a fiberoptic tube in a mannequin by applying a maneuver algorithm to overcome the resistance. METHOD: Four study groups were established to compare 2 types of endotracheal tube: a standard tube and a reinforced flexible tube with an internal diameter of 7.5 mm. The tubes were used on their own or in combination with a Williams airway intubator. Two fiberoptic bronchoscopes were used, one to perform the test intubation and the other to observe the location of resistance and the effectiveness of the maneuvers for overcoming it. The degree of resistance was scored using a modified Jones scale, from 0 (intubation without resistance) to 4 (intubation impossible); location of resistance and time required for each intubation were also recorded. RESULTS: A total of 250 oral intubations were performed. Resistance was encountered in 75.2% of the cases. The main locations of obstruction were the right arytenoid cartilage and the posterior commissure. In 89.6% of the cases, intubation of the trachea was achieved without maneuvering or with a 90 degrees counterclockwise rotation. Statistically significant differences were found in resistance and intubation time when the reinforced flexible tube was used with the Williams intubator. CONCLUSIONS: Rotating the tube 90 degrees counterclockwise was an effective maneuver for overcoming resistance. The combination of a reinforced flexible tube and a Williams intubator was associated with less resistance and shorter intubation times.

Cuidados Paliativos en pacientes oncológicos y no oncológicos con enfermedad terminal en un hospital de agudos / Palliative Care for patients with end-stage oncologic and non-oncologic disease in an acute-care hospital

Fundamento y objetivo: describir distintas características de las defunciones por cáncer y procesos crónicos en un hospital de agudos con respecto a los cuidados paliativos. Material y método: estudio descriptivo, retrospectivo de 297 pacientes fallecidos por cáncer, insuficiencia cardiaca crónica y enfermedad pulmonar obstructiva crónica. Se recogieron variables epidemiológicas, maniobras de reanimación cardiopulmonar (RCP), síntomas, tratamientos paliativos y su duración, participación de la familia en las decisiones terapéuticas y retirada de medicación no paliativa descritas en las historias clínicas de estos pacientes. Resultados: a pesar de que sólo en el 32% de los casos se especificaba la orden de no realizar maniobras de RCP, el 8% de los pacientes fue sometido a resucitación cardiopulmonar. En el 31% de los pacientes se retiró la medicación no paliativa, de los cuales el 86% eran oncológicos. Conclusión: las medidas paliativas en cuanto al tratamiento y acceso a cuidados paliativos de los pacientes ICC y EPOC son menores que en los oncológicos (AU)

Background and objective: the aim of the study was to describe the palliative care provided to cancer or non-oncologic terminal patients in an acute care hospital. Material and method: we conducted a retrospective study of 297 patients who died from malignant disease, heart failure, and chronic obstructive pulmonary disease. Demographic data, do not resuscitate (DNR)orders, symptoms, reception and duration of palliative care, family participation in therapeutic decisions, and total withdrawal of other drug therapies described in these patients' medical records were obtained. Results: despite the fact that DNR orders were specified only in 32% of cases, 8% of patients were subjected to cardiopulmonary resuscitation. Drug withdrawal was carried out in 31% of patients but 86% died with malignant illness. Conclusion: palliative care for patients with cardiorespiratory terminal illness is less extensive than for oncological patients (AU)

Evaluación funcional en Cuidados Paliativos: correlación entre diferentes escalas / Functional assessment in Palliative Care: Correlation between different scales

Objetivo: conocer el grado de correlación entre cuatro escalas de evaluación funcional (índice de Karnofsky, índice del Eastern Cooperative Oncology Group -ECOG-, índice de Barthel e índice de Katz) en cuidados paliativos. Material y método: estudio prospectivo realizado a través del registro de la situación funcional medida mediante las escalas de Karnofsky, ECOG, Barthel y Katz en pacientes mayores de 18 años afectos de neoplasias sólidas en fase avanzada o terminal no subsidiarias de tratamiento curativo. Se descartaron aquellos pacientes que no otorgaron su consentimiento y los que se encontraban en situación agónica. El análisis de la correlación se realizó de manera gráfica y mediante el test no paramétrico de Spearman. Resultados: se incluyeron 172 evaluaciones procedentes de 111 pacientes. La media de edad fue de 68,7 y la relación hombre mujer fue de 67/44. Las neoplasias más frecuentes fueron las del tubo digestivo 39% seguidas de las pulmonares 21,5% Los coeficientes de correlación obtenidos fueron significativos en todos los casos: KPS-ECOG: -0,899; KPS-BARTHEL: 0,785; KPS-KATZ: 0,816; ECOG-BARTHEL: -0,811; ECOG-KATZ: -0,849; BARTHEL-KATZ: 0,947. Conclusiones: existe buena correlación entre las cuatro escalas estudiadas. Las escalas Barthel y Katz, pese a su buena correlación con KPS y ECOG, parecen aportar una información diferente sobre todo en los casos de mayor dependencia (AU)

Aim: to establish the correlation between four functional assessment scales: Karnofsky Index, ECOG Index, Barthel Index, and Katz Index. Material and method: a prospective study based on functional records using four assessment tools - KPS, Barthel, ECG, and Katz - in advanced cancer patients over 18 years of age. Patients refusing to participate, on specific treatments, or in their last days of life were excluded. The correlation index was established using Spearman's non-parametric test. Results: in all, 172 evaluations from 111 patients were included. Mean age was 68.7 years. The male-to-female ratio was: 67/44. Most frequent malignancies were from the digestive tract (39%) and lung (21.5%). All correlation coefficients were significant: KPS-ECOG: -0.899; KPS-BARTHEL: 0.785; KPS-KATZ: 0.816; ECOG-BARTHEL: -0.811; ECOG-KATZ: -0.849; BARTHEL-KATZ: 0.947. Conclusions: there is good correlation between the Karnofsky Index, ECOG Index, Barthel Index, and Katz Index as analyzed in advanced cancer patients. Barthel and Katz indices seem to provide information differing from that of KPS and ECOG in very low performance status situations (AU)

Redes neuronales artificiales en Medicina Intensiva. Ejemplo de aplicación con las variables del MPM II / Artificial neuronal networks in Intensive Medicine. An example of application with MPM II variables

Objetivo. La aplicación del índice de gravedad Mortality Probability Model (MPM II) en nuestra Unidad de Cuidados Intensivos (UCI) nos muestra una mala calibración que nos obliga a buscar modelos reajustados. Diseño. Para el reajuste de los modelos utilizamos técnicas basadas en regresión logística (RL) y una red neuronal artificial (RN) (perceptrón multicapa con retropropagación del error). Para valorar estos modelos utilizamos un grupo de 964 pacientes que se dividen en un grupo de Desarrollo (736 pacientes) y un grupo de Validación (228). Se calcula el modelo MPM II Admisión y a las 24-horas (MPM II-0 y MPM II-24), los modelos reajustados por RL (RLR-0 y RLR-24) y los obtenidos por las RN (RN-0 y RN-24). Los modelos desarrollados se contrastan en el grupo de Validación evaluando sus propiedades de discriminación con el área bajo la curva ROC (ABC [IC 95 %]) y su calibración con el test de Hosmer-Lemeshow C (HLC [p]). Resultados. Los modelos MPM II-0 y MPM-24 obtienen una buena discriminación (ABC > 0,8) con pobre calibración (HLC > 25). Los modelos reajustados (RLR y RN) mejoran en calibración manteniendo una aceptable discriminación. La RN es mejor en discriminación (ABC = 0,85 [0,79-0,90]) y calibración (HLC = 21 [p = 0,005]) en el modelo 24-horas, pero sin alcanzar significación. Conclusión. Una RN es capaz de estratificar el riesgo de mortalidad hospitalaria utilizando las variables del sistema MPM II. En el mismo grupo de pacientes la RN obtiene diferentes probabilidades de muerte. Esto se asocia con una contribución diferente de las variables en los modelos basados en RL o RN

Objective. The application of Mortality Probability Model (MPM II) index of severity in our ICU shows poor calibration that forces us to seek readjusted models. Design. For the readjustment of the models we have used techniques based on Logistic Regression (LR) and an Artificial Neuronal Network (ANN) (multilayer perceptron with error retropropagation). In order to assess these models we analyzed a group of 964 patients divided into a development subgroup (736 patients) and a validation subgroup (228 patients). We calculated the MPM II model at admission and at 24-hours (MPM II-0 and MPM II-24), the models readjusted by LR (LRR-0 and LRR-24), and the models obtained through the ANN (ANN-0 and ANN-24). Developed models were verified in the validation subgroup for evaluating their discrimination properties through the area under the ROC (receiver operating characteristic) curve (AURC [CI 95%]), and for its calibration with the Hosmer-Lemeshow C (HLC [p]) test. Results. MPM II-0 and MPM-24 models showed high discrimination (AURC 0.8) with poor calibration (HLC 25). The readjusted models (LRR and ANN) improved in calibration maintaining an acceptable discrimination. ANN is better for discrimination (AURC = 0.85 [0.79-0.90]) and calibration (HLC = 21 [p = 0.005]) in the 24-hour model, however, without significance. Conclusion. ANN can stratify the risk of hospital mortality using the variables of the MPM II system. ANN shows different death probabilities in the same group of patients. This is associated with a different contribution from the variables in LR- and ANN-based models

Impacto de la incorporación del servicio de neurocirugíaen la unidad de cuidados intensivos de un hospitalde segundo nivel / Impact of the inclusion of neurosurgery on the intensive care unit of a second level hospital

Fundamento. Evaluar el impacto en la demografía y case-mix de la incorporación de los pacientes neuroquirúrgicos a la unidad de cuidados intensivos de un hospital de segundo nivel. Pacientes y método. Utilización de la base de datos de la unidad de cuidados intensivos polivalente. Los años 1999-2000 (445 ingresos) sirven para establecer las previsiones y determinar las características de nuestra unidad, y el año 2001 (287 ingresos), con el servicio de neurocirugía incorporado, para la evaluación. Se recogen de forma prospectiva las siguientes variables: edad, sexo, diagnóstico en el momento del ingreso, evolución, índice de gravedad (APACHE II, SAPS II y MPM II 0-24) y mortalidad. Resultados. En el año 2001 se incorporó a 80 pacientes con la nueva enfermedad a esta unidad de cuidados intensivos. De ellos, 49 eran pacientes neurotraumáticos, con una edad media de 36 (DE = 19) años, un 88 por ciento de varones y una mortalidad del 24 por ciento. Trece tenían una enfermedad vascular neuroquirúrgica, con una edad media de 64 (17) años y una mortalidad del 77 por ciento. Un total de 16 pacientes fueron incluidos en el grupo de neuroquirúrgicos programados y 2 en el grupo de otros. Frente al período 1999-2000, el año 2001 presentó un aumento de los pacientes quirúrgicos, traumáticos y neurológicos, con una disminución de los respiratorios. La media de pacientes con ventilación mecánica pasó del 59 al 63 por ciento y la mortalidad se redujo del 36 al 30 por ciento. La estancia en la unidad de cuidados intensivos pasó de 9 (12) a 12 (17) días. Las propiedades de discriminación y calibración de los scores han mejorado. Conclusiones. La incorporación de una nueva especialidad debe basarse en un aspecto dinámico, por lo que la evaluación de este primer año es importante. Se plantea la necesidad de una unidad de intermedios (para reducir la estancia).El desplazamiento de otros grupos diagnósticos (unidades de cuidados intensivos con problemas de falta de camas) debe tenerse en cuenta (AU)