Recomendaciones SER sobre la gestión de riesgo del tratamiento con FAME biológicos o sintéticos dirigidos en pacientes con artritis reumatoide / Recommendations by the Spanish Society of Rheumatology on risk management of biological treatment and JAK inhibitors in patients with rheumatoid arthritis

Objetivo: Elaborar recomendaciones basadas en la evidencia disponible y el consenso de expertos, para la gestión del riesgo del tratamiento biológico y los inhibidores de las JAK en pacientes con artritis reumatoide. Métodos: Se identificaron preguntas clínicas de investigación relevantes para el objetivo del documento. Estas preguntas fueron reformuladas en formato PICO (paciente, intervención, comparación, outcome o desenlace) por un panel de expertos, seleccionados en base a su experiencia en el área. Se realizó una revisión sistemática de la evidencia, graduándose de acuerdo a los criterios GRADE (Grading of Recommendations Assessment, Development, and Evaluation). A continuación, se formularon las recomendaciones específicas. Resultados: Se propusieron por el panel de expertos 6preguntas PICO en base a su relevancia clínica y a la existencia de información reciente referentes al riesgo de aparición de infecciones graves, el riesgo de reactivación del virus de la hepatitisB, el riesgo de reactivación del virus varicela-zoster, el riesgo de aparición de cáncer de piel (melanoma y no melanoma) o hematológico, el riesgo de aparición de enfermedad tromboembólica y el riesgo de progresión del virus del papiloma humano. Se formularon un total de 29 recomendaciones, estructuradas por pregunta, basadas en la evidencia encontrada y el consenso de los expertos. Conclusiones: Se presentan las recomendaciones SER sobre la gestión del riesgo del tratamiento con terapias biológicas e inhibidores de las JAK en la artritis reumatoide.(AU)

Objective: To present recommendations based on the available evidence and the consensus of experts, for risk management of biological treatment and JAK inhibitors in patients with rheumatoid arthritis. Methods: Clinical research questions relevant to the purpose of the document were identified. These questions were reformulated in PICO format (patient, intervention, comparison, outcome) by a panel of experts, selected based on their experience in the area. A systematic review of the evidence was carried out, grading according to the GRADE criteria (Grading of Recommendations Assessment, Development, and Evaluation). Specific recommendations were then formulated. Results: Six PICO questions were proposed by the panel of experts based on their clinical relevance and the existence of recent information regarding the risk of occurrence of serious infections, the risk of reactivation of the hepatitisB virus, the risk of reactivation of the virus varicella-zoster, the risk of appearance of skin (melanoma and non-melanoma) or hematological cancer, the risk of appearance of thromboembolic disease and the risk of progression of the human papilloma virus. A total of 29 recommendations were formulated, structured by question, based on the evidence found and the consensus of the experts. Conclusions: The SER recommendations on risk management of treatment with biologic therapies and JAK inhibitors in rheumatoid arthritis are presented.(AU)

Efetividade de um plano de metas fisioterapêuticas em pacientes internados em uma unidade de terapia intensiva: uma análise retrospectiva vs. prospectiva / Effectiveness of a plan of physiotherapy goals in patients hospitalized in an intensive care unit: a retrospective analysis vs. prospective

Introdução: A fisioterapia na unidade de terapia intensiva (UTI) apresenta como objetivo utilizar estratégias de mobilização precoce a fim de reduzir o impacto da fraqueza muscular adquirida na UTI. Logo, este estudo apresenta como objetivo avaliar a efetividade de um plano de metas fisioterapêuticas para pacientes internados em uma Unidade de Terapia Intensiva.Métodos: Estudo de coorte retrospectivo e prospectivo comparativo realizado em uma UTI de um hospital público de Porto Alegre. Foram incluídos pacientes internados entre os meses de janeiro e junho de 2019, maiores de 18 anos e que tiveram alta da UTI. A coleta de dados foi realizada através de informações e relatório que constam no prontuário eletrônico utilizado na Instituição. Foi analisado o desfecho das metas estabelecidas na admissão para sentar fora do leito e deambular.Resultados: A maioria dos pacientes foi do sexo masculino (57,5%). A média de idade foi de 60,52 ± 17,64 anos. A maioria das metas estabelecidas, tanto para sentar fora do leito como para deambular, foram atingidas (89% e 86,9%, respectivamente). Houve correlação significativa entre o alcance de meta para deambulação e ganho de força muscular pelo escore MRC (p = 0,041) e ganho de força muscular quando comparada admissão e alta da UTI (p = 0,004).Conclusão: Este estudo observou que estabelecer metas para sentar fora do leito e deambular para pacientes internados em UTI é efetivo.

Introduction: Physiotherapy in the intensive care unit (ICU) aims to use early mobilization strategies in order to reduce the impact of muscle acquired weakness in the ICU. Therefore, this study aims to evaluate the effectiveness of a physiotherapeutic goal plan for patients admitted to an Intensive Care Unit. Methods: Retrospective and comparative prospective cohort study carried out in an ICU of a public hospital in Porto Alegre. Patients hospitalized between January and June 2019, over 18 years old and discharged from the ICU were included. Data collection was carried out through information and report contained in the electronic medical record used in the Institution. The outcome of goals established at admission for sitting out of bed and walking was analyzed. Results: Most patients were male (57.5%). The mean age was 63.2 ± 16.2 years. Most established goals, both for sitting out of bed and walking, were achieved (89% and 86.9%, respectively). There was a significant correlation between reaching the ambulation goal and muscle strength gain by the MRC score (p= 0.041) and muscle strength gain when comparing admission and discharge from the ICU (p = 0.004). Conclusion: This study observed that establishing goals for sitting out of bed and walking for ICU patients is effective.

Angina de Ludwig / Angina de Ludwig / Ludwig Angina

Introducció. L’angina de Ludwig és un procés infecciós ràpidament progressiu a l’espai submandibular relacionatamb infeccions odontogèniques preexistents. La tomografiacomputada (TC) és útil per definir-ne la localització i l’extensió. Un diagnòstic i un maneig precoços són importantsper evitar complicacions potencialment greus com l’obstrucció de la via aèria.Cas clínic. Adolescent de 14 anys que consulta per odontàlgia amb tumefacció submandibular dolorosa, sialorrea,trisme i disfàgia de 48 hores d’evolució, sense febre associada. Presenta càries en peces dentàries 46-48 i tumescència submandibular dreta, dura i dolorosa al tacte, quesobrepassa la línia mitjana, amb eritema, edema i calor. Alcap de 24 hores d’iniciar l’antibioteràpia, davant l’augmentde la tumefacció i l’empitjorament analític, es fa una TCcervical en què s’objectiva una col·lecció compatible ambabscés al terra de la boca. Es modifica el tractament antibiòtic, s’hi afegeix corticoteràpia i es deriva a cirurgia maxil·lofacial per a tractament quirúrgic.Comentaris. L’angina de Ludwig és una infecció greu delterra de la boca que cal considerar en el diagnòstic diferencial d’una infecció periodontal amb tumefacció submandibular. És de vital importància conèixer-ne les manifestacions locals i sistèmiques per actuar precoçment. (AU)

Introducción. La angina de Ludwig es un proceso infeccioso rápidamente progresivo en el espacio submandibular relacionado coninfecciones odontogénicas preexistentes. La tomografía computarizada (TC) es útil para definir su localización y extensión. Undiagnóstico y manejo precoces son importantes para evitar complicaciones potencialmente graves, como la obstrucción de la víaaérea.Caso clínico. Adolescente de 14 años que consulta por odontalgiacon tumefacción submandibular dolorosa, sialorrea, trismo y disfagia de 48 horas de evolución, sin fiebre asociada. Presenta cariesen piezas dentales 46-48 y tumescencia submandibular derecha, dura y dolorosa al tacto, que sobrepasa la línea media, con eritema, edema y calor. A las 24 horas de iniciar antibioterapia, dadoel aumento de la tumefacción y empeoramiento analítico, se realiza una TC cervical donde se objetiva una colección compatiblecon absceso en el suelo de la boca. Se modifica el tratamientoantibiótico, se añade corticoterapia y se deriva a cirugía maxilofacial para tratamiento quirúrgico. (AU)

Introduction. Ludwig angina is a rapidly progressive infectious process of the submandibular space related to pre-existing odontogenic infections. Computed tomography (CT) is useful to define thelocation and extent. Early diagnosis and management are important to avoid potentially serious complications such as airway obstruction.Case report. A 14-year-old girl presented to the emergency roomwith a 48-hour history of toothache and submandibular swelling,sialorrhea, trismus and dysphagia without associated fever. Physical examination showed caries in teeth number 46-48 and rightsubmandibular tumescence, hard and painful to the touch, whichcrossed the midline, with erythema, edema and heat. Twenty-fourhours after starting antibiotic therapy, given the worsening clinicalcondition and laboratory findings, a cervical CT scan was performed, which showed a collection compatible with abscess in thefloor of the mouth. The antibiotic therapy was changed, corticoidswere added, and the patient was referred to maxillofacial surgeryfor surgical treatment.Comments. Ludwig angina is a serious infection of the floor of themouth that should be considered in the differential diagnosis ofperiodontal infection with submandibular swelling. It is very important to know its local and systemic manifestations for an earlyintervention. (AU)

Estado actual y retos futuros en el tratamiento de las enfermedades reumáticas / Current status and future challenges in the treatment of rheumatic diseases

Las nuevas estrategias, que incluyen el diagnóstico y el tratamiento tempranos, el enfoque de tratamiento dirigido a un objetivo, la remisión como ese objetivo principal del tratamiento, la participación de los pacientes en las decisiones terapéuticas, junto con el desarrollo de nuevos tratamientos efectivos, han cambiado las expectativas de los reumatólogos y de los pacientes con enfermedades reumáticas. Todavía existen, sin embargo, importantes desafíos tales como la seguridad a largo plazo de los tratamientos actuales y poder escoger tratamientos más individualizados y eficaces, de forma tal de elegir el mejor tratamiento para cada paciente. El futuro, como en el resto de la medicina, probablemente sea la prevención del desarrollo de enfermedades reumáticas. Discutiremos estos temas en esta revisión. (AU)

New strategies, including early diagnosis and treatment, targeted therapy, remission as the main objective of treatment, patient involvement in therapeutic decision-making, and the development of new effective therapies, have changed the expectations of rheumatologists and patients with rheumatic diseases.There are still serious challenges, such as the long-term safety of current treatments and the ability to make more individualized and effective treatments to choose the best treatment for each patient. The future, as that of the whole of medical science, will probably lie in preventing the development of rheumatic diseases. We will discuss these issues in this review. (AU)

Efficacy of early goal-directed therapy using FloTrac/EV1000 to improve postoperative outcomes in patients undergoing off-pump coronary artery bypass surgery: a randomized controlled trial.

BACKGROUND: Early goal-directed therapy (EGDT) using FloTrac reduced length of stay (LOS) in intensive care (ICU) and hospital among patients undergoing coronary artery bypass graft (CABG) with a cardiopulmonary bypass. However, this platform in off-pump CABG (OPCAB) has received scant attention, so we evaluated the efficacy of EGDT using FloTrac/EV1000 as a modality for improving postoperative outcomes in patients undergoing OPCAB. METHODS: Forty patients undergoing OPCAB were randomized to the EV1000 or Control group. The Control group received fluid, inotropic, or vasoactive drugs (at the discretion of the attending anesthesiologist) to maintain a mean arterial pressure 65-90 mmHg; central venous pressure 8-12 mmHg; urine output ≥ 0.5 mL kg-1 h-1; SpO2 > 95%; and hematocrit ≥ 30%. The EV1000 group achieved identical targets using information from the FloTrac/EV1000. The goals included stroke volume variation < 13%; cardiac index (CI) of 2.2-4.0 L min-1 m-2; and systemic vascular resistance index of 1500-2500 dynes s-1 cm-5 m-2. RESULTS: The EV1000 group had a shorter LOS in ICU (mean difference - 1.3 d, 95% CI - 1.8 to - 0.8; P < 0.001). The ventilator time for both groups was comparable (P = 0.316), but the hospital stay for the EV1000 group was shorter (mean difference - 1.4 d, 95% CI - 2.1 to - 0.6; P < 0.001). CONCLUSIONS: EGDT using FloTrac/EV1000 compared to conventional protocol reduces LOS in ICU and hospital among patients undergoing OPCAB. Trial registration This study was retrospectively registered at www. CLINICALTRIALS: gov (NCT04292951) on 3 March 2020.

Early Goal-directed Therapy During Endovascular Coiling Procedures Following Aneurysmal Subarachnoid Hemorrhage: A Pilot Prospective Randomized Controlled Study.

BACKGROUND: Maintenance of euvolemia and cerebral perfusion are recommended for the prevention of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). We conducted a pilot randomized controlled study to assess the feasibility and efficacy of goal-directed therapy (GDT) to correct fluid and hemodynamic derangements during endovascular coiling in patients with aSAH. METHODS: This study was conducted between November 2015 and February 2019 at a single tertiary center in Canada. Adult patients with aSAH within 5 days of aneurysm rupture were randomly assigned to receive either GDT or standard therapy during endovascular coiling. The incidence of dehydration at presentation and the efficacy of GDT were evaluated. RESULTS: Forty patients were allocated to receive GDT (n=21) or standard therapy (n=19). Sixty percent of all patients were found to have dehydration before the coiling procedure commenced. Compared with standard therapy, GDT reduced the duration of intraoperative hypovolemia (mean difference 37.6 [95% confidence interval, 6.2-37.4] min, P=0.006) and low cardiac index (mean difference 30.7 [95% confidence interval, 9.5-56.9] min, P=0.035). There were no differences between the 2 treatment groups with respect to the incidence of vasospasm, stroke, death, and other complications up to postoperative day 90. CONCLUSIONS: A high proportion of aSAH patients presented at the coiling procedure with dehydration and a low cardiac output state; these derangements were more likely to be corrected if the GDT algorithm was used. Compared with standard therapy, use of the GDT algorithm resulted in earlier recognition and more consistent treatment of dehydration and hemodynamic derangement during endovascular coiling.

Retrospective Analysis of the Clinical Efficacy of Early Goal-Directed Therapy Combined with Meticulous Nursing Intervention in Patients with Posttraumatic Sepsis.

Objective: To explore the intervention effect of early goal-directed therapy (EGDT) combined with meticulous nursing on patients with posttraumatic sepsis. Methods: The data of 50 patients with posttraumatic sepsis undergoing EGDT in the emergency department of our hospital from January 2020 to December 2020 were retrospectively analyzed. According to different nursing methods, they were divided into control group (n = 25) with routine nursing measures and observation group (n = 25) with meticulous nursing measures. The application effect of the two nursing modes was scientifically evaluated. Results: No statistical differences in general data were found between the two groups (P > 0.05). After 6 h of intervention, the circulatory function, oxygenation function, and renal function of both groups were better than those before intervention, and central venous pressure (CVP), mean arterial pressure (MAP), blood oxygen (PaO2), oxygenation index (PaO2/FiO2), central venous oxygen saturation (ScvO2), and urine volume in the observation group were notably higher than those in the control group (P < 0.05). The heart rate (HR), serum creatinine (SCr), and blood lactic acid in the observation group were notably lower than those in the control group (P < 0.05). The 28-day survival rate and quality of life after intervention in the observation group were notably higher than those in the control group, with obvious differences between the two groups (P < 0.05). Conclusion: Meticulous nursing intervention for patients with posttraumatic sepsis undergoing EGDT can effectively improve the body's functional indexes, which is superior to the routine nursing in controlling the patients' condition, improving the survival rate and quality of life after intervention, and ensuring the clinical treatment effect. Therefore, it is worthy of promotion.

Infusiones controladas por objetivo y sistemas de circuito cerrado. Límites en expansión / Target-controlled infusions and closed-loop systems: expansion limits

Introducción: La administración manual en bolo ha evolucionado desde la infusión volumétrica basada en regímenes farmacológicos estandarizados, hasta los sistemas de infusión controlada por objetivo y los más sofisticados sistemas de circuito cerrado. Objetivo: Describir los principios tecnológicos y aplicaciones clínicas extendidas de la infusión controlada por objetivo y los sistemas de circuito cerrado. Métodos: Se realizó una revisión no sistemática de la literatura, en bases de datos científicas como Cochrane Database of Systematic Reviews, Pubmed/Medline, EMBASE, Scopus, Web of Science, EBSCOhost, Science Direct, OVID y el buscador académico Google Scholar, en el mes de septiembre del año 2020. Desarrollo: La disponibilidad y portabilidad de dispositivos electrónicos con capacidad de procesamiento avanzado a precios relativamente accesibles, el perfeccionamiento del aprendizaje automático e inteligencia artificial aplicado a las decisiones médicas, y las iteraciones tecnológicas complejas incorporadas en los sistemas de circuito abierto y cerrado, desarrollados originalmente en el campo de la Anestesiología, han posibilitado su expansión a otras especialidades y entornos clínicos tan disímiles como el tratamiento de la diabetes mellitus, administración de fármacos antineoplásicos, ventilación mecánica, control de las variables hemodinámicas y la terapia antimicrobiana en pacientes críticos. Conclusiones: La infusión controlada por objetivo y los sistemas de circuito cerrado se han convertido en tecnologías maduras, seguras y viables, aplicadas clínicamente en múltiples naciones y escenarios, con un desempeño superior a los sistemas manuales tradicionales(AU)

Introduction: Manual bolus administration has evolved from volumetric infusion based on standardized pharmacological regimens to target-controlled infusion systems and the most sophisticated closed-loop systems. Objective: To describe the technological principles and extended clinical applications of target-controlled infusion and closed-loop systems. Methods: A nonsystematic review of the literature was carried out, during September 2020, in scientific databases such as Cochrane Database of Systematic Reviews, Pubmed/Medline, EMBASE, Scopus, Web of Science, EBSCOhost, Science Direct, OVID and the academic search engine Google Scholar. Development: The availability and portability of electronic devices with advanced processing capacity at relatively affordable prices, the refinement of machine learning and artificial intelligence applied to medical decisions, as well as the complex technological iterations incorporated into open and closed-loop systems, originally developed in the field of anesthesiology, have enabled their expansion to other specialties and clinical settings so diverse as treatment of diabetes mellitus, administration of antineoplastic drugs, mechanical ventilation, control of hemodynamic variables and antimicrobial therapy in critical patients. Conclusions: Target-controlled infusion and closed-loop systems have become mature, safe and viable technologies, applied clinically in multiple nations and settings, with superior performance compared to traditional manual systems(AU)

Effect of a factor-based coagulation management on blood product use after major burn injury: A retrospective cohort study.

BACKGROUND: Transfusion of allogenic blood products was shown to be associated with more adverse events and a higher mortality in severely burned patients. This study investigated the impact of a goal-directed and factor-based coagulation algorithm on blood product use and clinical outcomes in severely burned patients. METHODS: This retrospective cohort study included adult patients admitted to the burn center of the University Hospital Zurich with major burn injuries compromising 20-80% of total body surface area. We compared two 3-year periods, one before the introduction of a goal-directed coagulation and transfusion algorithm (period 1: 2009-2011) and one after (period 2: 2016-2018). We applied linear and logistic regression models adjusted for confounders. RESULTS: We analyzed 36 patients (27.8% female) versus 42 patients (14.3% female) in period 1 and 2, respectively. Comorbidities and burn types were comparable between both collectives. Treatment according to the coagulation algorithm resulted in an overall reduction of 33 units of red blood cells (95% CI -52.8 to -12.9, p = 0.002), 9 units fresh frozen plasma (95% CI -14.7 to -2.6, p = 0.006) and 1.4g fibrinogen (95% CI -2.2 to -0.5, p = 0.001) per patient. We observed less infections (61.8% vs. 41.5%, p = 0.11) and a reduced mortality (38.9% vs. 26.8%, p = 0.33) during the algorithm treated period, although not significant. CONCLUSION: Treatment of severely burned patients with a goal-directed coagulation algorithm reduced blood product use and resulted in target-oriented administration of coagulation factors to improve outcomes.

Perioperative outcomes of goal-directed versus conventional fluid therapy in radical cystectomy with enhanced recovery protocol.

PURPOSE: The aim of this study is to evaluate the intra/perioperative fluid management and early postoperative outcomes of patients who underwent radical cystectomy with Enhanced Recovery After Surgery protocol, using goal-directed fluid therapy compared to conventional fluid therapy. METHODS: This cohort study included patients who underwent open RC for urothelial bladder carcinoma with intent to cure and Enhanced Recovery After Surgery protocol between May 2012 and August 2019. Patients who had palliative or salvage cystectomy and/or adjunct procedures, as well as those with missing detailed perioperative data were excluded. Data were compared between patients who received goal-directed fluid therapy using stroke volume variation by FloTrac™/Vigileo system (n = 119) and conventional fluid therapy based on the anesthesiologist discretion (n = 192). Primary outcome variable was 90-day complications and secondary outcome measures included in-hospital GFR trend, length of stay, and 90-day readmission. RESULTS: The goal-directed fluid therapy group received less total and net intra/perioperative fluid, yet early postoperative glomerular filtration rate trends were similar between both groups (p = 0.7). Estimated blood loss, blood transfusion, index hospital stay, 90-day complication and readmission rates were also comparable between the two groups. Multivariable logistic regression showed no significant association between perioperative fluid management method and 90-day complication rate (OR 1.4, 95% CI 0.8-2.4, p = 0.2). CONCLUSION: Stroke volume variation guided goal-directed fluid therapy is safe in radical cystectomy without compromising the renal function. It is associated with less intra- and perioperative fluid infusion; however, no association with hospital stay, 90-day complication or readmission rates were noted.

Early Goal-Directed Therapy With and Without Intermittent Superior Vena Cava Oxygen Saturation Monitoring in Pediatric Septic Shock: A Randomized Controlled Trial.

OBJECTIVE: To compare early goal-directed therapy (EGDT) 'with' and 'without' intermittent superior vena cava oxygen saturation (ScvO2) monitoring in pediatric septic shock. DESIGN: Open label randomized controlled trial. SETTING: Pediatric intensive care unit in a tertiary care center. PARTICIPANTS: Children aged 1 month to 12 year with septic shock. INTERVENTION: Patients not responding to fluid resuscitation (up to 40 mL/kg) were randomized to EGDT 'with' (n=59) and 'without' (n=61) ScvO2 groups. Resuscitation was guided by ScvO2 monitoring at 1-hour, 3-hour, and later on six-hourly in the 'with' ScvO2 group, and by clinical variables in the 'without' ScvO2 group. OUTCOME: Primary outcome was all-cause 28-day mortality. Secondary outcomes were time to and proportion of patients achieving therapeutic endpoints (at 6 hours and PICU stay), need for organ supports, new organ dysfunction (at 24 hours and PICU stay), and length of PICU and hospital stay. RESULTS: The study was stopped after interim analysis due to lower mortality in the intervention group. There was significantly lower all-cause 28-day mortality in EDGT with ScvO2 than without ScvO2 group [37.3% vs. 57.5%, adjusted hazard ratio 0.57, 95%CI 0.33 to 0.97, P=0.04]. Therapeutic endpoints were achieved early in 'with' ScvO2 group [mean (SD) 3.6 (1.6) vs. 4.2 (1.6) h, P=0.03]. Organ dysfunction by sequential organ assessment score during PICU stay was lower in 'with' ScvO2 group [median (IQR) 5 (2,11) vs. 8 (3,13); P=0.03]. There was no significant difference in other secondary outcomes. CONCLUSIONS: EGDT with intermittent ScvO2 monitoring was associated with reduced mortality and improved organ dysfunction in pediatric septic shock.

Treat-to-target strategy in patients with rheumatoid arthritis: Audit of adherence from real world clinical data / Estrategia de tratar por objetivos en pacientes con artritis reumatoide: auditoría de la adherencia en práctica clínica habitual

Introduction: The current paradigm of the management of rheumatoid arthritis (RA) recommends achieving a state of remission or low disease activity through the treat-to-target strategy. Our study assesses adherence to this strategy. Method: Patients with RA (ACR-EULAR 2010 criteria) were included. From each centre, 19 patients were randomly selected. Clinical histories (CH) were assessed by independent auditors, checking compliance with predefined quality criteria. The study was approved by ethics committees. Results: We included 856 patients (mean age 54 years; 71% women). The use of a combined index (CI) was recorded in 61% of cases. Visits were recorded every 4 weeks using a CI in 4% of CH while attempts were made to achieve remission. Monitoring of disease activity every 6–8 months after reaching the target was recorded in 73% of cases. Conclusions: The implementation of the treat-to-target strategy is barely recorded in patients with RA in routine clinical practice.(AU)

Introducción: El paradigma actual del manejo de la artritis reumatoide (AR) recomienda alcanzar un estado de remisión o baja actividad mediante la estrategia de «tratar por objetivos». Nuestro estudio evalúa la adhesión a esta estrategia. Método: Se incluyeron pacientes con AR (criterios ACR-EULAR 2010). De cada centro, se eligieron al azar 19 pacientes. Auditores independientes evaluaron las historias clínicas (HC), verificando el cumplimiento de criterios de calidad predefinidos. El estudio fue aprobado por los comités de ética. Resultados: Se incluyeron 856 pacientes (edad media, 54 años; 71% mujeres). El uso de un índice combinado (IC) se recogió en el 61% de los casos. En el 4% de las HC se registraron visitas cada 4 semanas utilizando un IC mientras se intentaba alcanzar la remisión. La monitorización de actividad cada 6-8 meses tras alcanzar el objetivo se registró en el 73% de los casos. Conclusiones: La implementación de la estrategia de «tratar por objetivos» apenas está registrada en pacientes con AR en práctica clínica habitual.(AU)

Feasibility and beneficial effects of an early goal directed therapy after cardiac arrest: evaluation by conductance method.

Although beneficial effects of an early goal directed therapy (EGDT) after cardiac arrest and successful return of spontaneous circulation (ROSC) have been described, clinical implementation in this period seems rather difficult. The aim of the present study was to investigate the feasibility and the impact of EGDT on myocardial damage and function after cardiac resuscitation. A translational pig model which has been carefully adapted to the clinical setting was employed. After 8 min of cardiac arrest and successful ROSC, pigs were randomized to receive either EGDT (EGDT group) or therapy by random computer-controlled hemodynamic thresholds (noEGDT group). Therapeutic algorithms included blood gas analysis, conductance catheter method, thermodilution cardiac output and transesophageal echocardiography. Twenty-one animals achieved successful ROSC of which 13 pigs survived the whole experimental period and could be included into final analysis. cTnT and LDH concentrations were lower in the EGDT group without reaching statistical significance. Comparison of lactate concentrations between 1 and 8 h after ROSC exhibited a decrease to nearly baseline levels within the EGDT group (1 h vs 8 h: 7.9 vs. 1.7 mmol/l, P < 0.01), while in the noEGDT group lactate concentrations did not significantly decrease. The EGDT group revealed a higher initial need for fluids (P < 0.05) and less epinephrine administration (P < 0.05) post ROSC. Conductance method determined significant higher values for preload recruitable stroke work, ejection fraction and maximum rate of pressure change in the ventricle for the EGDT group. EGDT after cardiac arrest is associated with a significant decrease of lactate levels to nearly baseline and is able to improve systolic myocardial function. Although the results of our study suggest that implementation of an EGDT algorithm for post cardiac arrest care seems feasible, the impact and implementation of EGDT algorithms after cardiac arrest need to be further investigated.

Emergency nurses' experiences of the implementation of early goal directed fluid resuscitation therapy in the management of sepsis: a qualitative study.

BACKGROUND: Severe sepsis can lead to organ failure and death if immediate treatment, such as intravenous fluids and antibiotics, are not commenced within the first hour. Time - critical initiation of intravenous fluids which in other words is early goal directed fluid resuscitation has not always been given its clinical priority. This qualitative study aimed at exploring the experiences of emergency nurses initiating early goal directed fluid resuscitation in patients with sepsis. METHODS: Using an exploratory approach, face - to - face semi - structured interviews were conducted with ten registered nurses working in emergency departments across New South Wales, Australia. Thematic analysis was used for data analysis. FINDINGS: Participants described various factors that inhibited the timely initiation of early goal directed fluid resuscitation, some clinical practice challenges, and strategies to improve nursing practice. Most participants, particularly those practicing as Clinical Initiatives Nurses suggested the incorporation of nurse initiated early goal directed fluid resuscitation for patients with sepsis as part of their scope of practice. CONCLUSION: Our findings identified several barriers that inhibit effective nurse - initiated early goal directed fluid resuscitation. It is anticipated that these findings will provide validation for the re-evaluation of the existing protocols and practice guidelines to increase the scope of practice of emergency nurses initiating early goal directed fluid resuscitation.

Goal-directed cerebral perfusion in aortic arch surgery: scientific leap or hype?

Although significant advancements in cerebral protection strategies in aortic surgery have been achieved in recent years, controversy remains on what constitutes the optimal strategy. Deep hypothermic circulatory arrest alone is a viable approach in many instances, but the need for a prolonged duration of circulatory arrest and increasing case complexity have led to the utilization of adjunctive cerebral perfusion strategies. In this review, we discuss the efficacy of deep hypothermic circulatory arrest and its limitations, the role of retrograde cerebral perfusion and unilateral and bilateral antegrade cerebral perfusion, and the trend towards goal-directed perfusion strategies, all emphasizing the pressing need for randomized clinical trials to better define the optimal strategy.

Application of goal-directed therapy for the use of concentrated antithrombin for heparin resistance during cardiac surgery.

The maintenance of anticoagulation in adult patients undergoing cardiopulmonary bypass is dependent upon a number of factors, including heparin concentration and adequate antithrombin activity. Inadequate anticoagulation increases the risk of thrombosis and jeopardizes both vascular and extracorporeal circuit integrity. The purpose of this study was to evaluate a goal-directed approach for the use of antithrombin in patients who were resistant to heparin. Following institutional review board approval, data were obtained from quality improvement records. A goal-directed protocol for antithrombin was established based upon heparin dosing (400 IU kg-1 body weight) and achieving an activated clotting time of ⩾500 seconds prior to cardiopulmonary bypass. Two groups of patients were identified as those receiving antithrombin and those not receiving antithrombin. Outcome measures included activated clotting time values and transfusion rates. Consecutive patients (n = 140) were included in the study with 10 (7.1%) in the antithrombin group. The average antithrombin dose was 1,029.0 ± 164.5 IU and all patients had restoration to the activated clotting time levels. Patients in the antithrombin group were on preoperative heparin therapy (80.0% vs. 24.6%, p = 0.001). Prior to cardiopulmonary bypass the activated clotting time values were lower in the antithrombin group (417.7 ± 56.1 seconds vs. 581.1 ± 169.8 seconds, p = 0.003). Antithrombin patients had a lower heparin sensitivity index (0.55 ± 0.17 vs. 1.05 ± 0.44 seconds heparin-1 IU kg-1, p = 0.001), received more total heparin (961.3 ± 158.5 IU kg-1 vs. 677.5 ± 199.0 IU kg-1, p = 0.001), more cardiopulmonary bypass heparin (22,500 ± 10,300 IU vs. 12,100 ± 13,200 IU, p = 0.016), and more protamine (5.4 ± 1.2 vs. 4.1 ± 1.1 mg kg-1, p = 0.003). The intraoperative transfusion rate was higher in the antithrombin group (70.0% vs. 35.4%, p = 0.035), but no differences were seen postoperatively. Utilization of a goal-directed algorithm for the administration of antithrombin for the treatment of heparin resistance is effective in patients undergoing cardiac surgery.