Admission to Intensive Care for a trauma related to alcohol or drugs, a 'teachable moment' for the beginning of a change. / Ingreso en cuidados intensivos por un traumatismo relacionado con el consumo de alcohol o drogas, un «momento propicio de enseñanza¼ para el inicio del cambio.

OBJECTIVES: To estimate how many of the trauma patients admitted to ICU would be candidates for a secondary prevention programme for trauma related to alcohol or drug use by brief motivational intervention and to define what factors prevent that intervention being performed. METHODS: All 16-70year old trauma patients (n=242) admitted to ICU in 32 non-consecutive months (November 2011 to March 2015) were included in the study, coinciding with the implementation of a screening and brief motivational intervention programme for trauma patients related to substance consumption. The programme includes screening for exposure to substances at admission. Sociodemographic and clinical variables were collected prospectively. RESULTS: The screening for substances was not performed in 38 (15.7%) of all admitted patients. Of the patients screened, 101 (49.5%) were negative. The variables that in greater proportion impeded intervention between screening positive patients were neurological damage due to the trauma with 23 patients (37.1%) and prior psychiatric disorder with 18 (29%). Both variables were associated with substance consumption: negatives 9.9% vs positive 22.3% (P=.001) and negatives 3% vs positive 17.5% (P=.016) respectively. The number of candidates for motivational intervention was 41, 16.9% of all admitted patients. CONCLUSIONS: Almost 2 out of 10 patients were potential candidates. The factors that in a greater proportion precluded the intervention were the same as those associated with consumption. Mortality in ICU was associated with non-compliance with the screening protocol.

Efficacy of an extravascular lung water-driven negative fluid balance protocol.

OBJECTIVE: To analyze the efficacy of negative fluid balance in hypoxemic patients with an elevated extravascular lung water index (EVLWI). DESIGN: A retrospective observational study was made. SETTING: Intensive Care Unit of Virgen de las Nieves Hospital (Spain). PARTICIPANTS: Forty-four patients participated in the study. INTERVENTIONS: We analyzed our database of hypoxemic patients covering a period of 11 consecutive months. We included all hemodynamically stable and hypoxemic patients with EVLWI>9ml/kg. The protocol dictates a negative fluid balance between 500 and 1500ml/day. We analyzed the impact of this negative fluid balance strategy upon pulmonary, hemodynamic, and renal function. MAIN VARIABLES OF INTEREST: Demographic data, severity scores, clinical, hemodynamic, pulmonary, metabolic and renal function data. RESULTS: Thirty-three patients achieved negative fluid balance (NFB group) and 11 had a positive fluid balance (PFB group). In the former group, PaO2/FiO2 improved from 145 (IQR 106, 200) to 210mmHg (IQR 164, 248) (p<0.001), and EVLWI decreased from 14 (11, 18) to 10ml/kg (8, 14) (p<0.001). In the PFB group, EVLWI also decreased from 11 (10, 14) to 10ml/kg (8, 14) at the end of the protocol (p=0.004). For these patients there were no changes in oxygenation, with a PaO2/FiO2 of 216mmHg (IQR 137, 260) at the beginning versus 205mmHg (IQR 99,257) at the end of the study (p=0.08). CONCLUSION: Three out of four hypoxic patients with elevated EVLWI tolerated the NFB protocol. In these subjects, the improvement of various analyzed physiological parameters was greater and faster than in those unable to complete the protocol. Patients who did not tolerate the protocol were usually in more severe condition, though a larger sample would be needed to detect specific characteristics of this group.

Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document).

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Crystalloids and colloids in critical patient resuscitation.

Fluid resuscitation is essential for the survival of critically ill patients in shock, regardless of the origin of shock. A number of crystalloids and colloids (synthetic and natural) are currently available, and there is strong controversy regarding which type of fluid should be administered and the potential adverse effects associated with the use of these products, especially the development of renal failure requiring renal replacement therapy. Recently, several clinical trials and metaanalyses have suggested the use of hydroxyethyl starch (130/0.4) to be associated with an increased risk of death and kidney failure, and data have been obtained showing clinical benefit with the use of crystalloids that contain a lesser concentration of sodium and chlorine than normal saline. This new information has increased uncertainty among clinicians regarding which type of fluid should be used. We therefore have conducted a review of the literature with a view to developing practical recommendations on the use of fluids in the resuscitation phase in critically ill adults.

[Challenges in care of trauma patient in Spain. The need for implementation of scientific evidence including secondary prevention]. / Retos asistenciales en la atención al paciente traumatizado en España. La necesidad de implementación de la evidencia científica incluyendo la prevención secundaria.

The mortality of trauma patients has improved significantly in recent decades due to a combination of factors: medical care, educational campaigns and structural changes. Generalization of out-of hospital emergence medical services and the hospital care in specific centers for traumatized has undoubtedly contributed to this decline, but other factors such as periodic campaigns to prevent workplace and traffic accidents, as well as improvements in the road network have played a key role. The challenge now is to continue to decrease mortality, for which is essential an analysis of the situation to detect potential areas of improvement. The application of diagnostic or therapeutic actions with scientific evidence is associated with lower mortality, but as in other areas of medicine, the application of scientific evidence in trauma patients is barely 50%. Moreover, nearly 90% of trauma deaths occur in the crash site or in the first 72h of hospitalization, the vast majority as a result of injuries incompatible with life. In these circumstances it is clear that prevention is the most cost-effective activity. As medical practitioners, our role in prevention is mainly focused on the secondary prevention to avoid recidivism, for which it is necessary to identify risk factor (frequently alcohol, illegal drugs, psychotropic medication etc.) and implement a brief motivational intervention. This activity can reduce recidivism by nearly 50%. In Spain, the activity in this field is negligible therefore measures should be implemented for dissemination of secondary prevention in trauma.

Alcohol and/or drug abuse favors trauma recurrence and reduces the trauma-free period.

AIM: A study is made of the influence of alcohol and/or drug abuse upon traumatismo recurrence, with an analysis of the influence of such abuse upon the time to appearance of first injury in patients without antecedents of trauma. DESIGN: A prospective observational study was made. SETTING: Trauma patients admitted to the Intensive care Unit (ICU) of a University Hospital. PATIENTS: Trauma patients admitted to the ICU. INTERVENTION: None. MAIN MEASUREMENTS: Trauma recurrence was defined by a history of previous trauma requiring medical care. The presence of alcohol and other drugs of abuse were determined upon admission after severe trauma. RESULTS: Out of the 166 trauma patients admitted to the ICU during the study period, 102 (87 males) were included in the study. Some substance was detected in 51 patients (50%), most frequently in the males (48/87, p<0.02). The most frequently detected substance was alcohol (39%), followed by cannabis (12%) and cocaine (7%), while more than one substance was found in 10 patients (9.8%). Of the 102 patients, 42 were recurrent trauma cases, and 32 (76%) of them were substance-positive, while only 10 were substance-negative (p<0.001). Of the 60 patients without antecedents of trauma, 19 (32%) were substance-positive, and these were significantly younger (34.3±9 years) than the 41 subjects who were substance-negative (48±23 years) (p<0.001). CONCLUSION: Alcohol and/or drug abuse increases the likelihood of recurrent trauma and may shorten the mean trauma-free period among patients without a history of trauma by almost 15 years.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]. / 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla.

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: « Does this particular AABT reduce the transfusion rate or not?¼ All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

[Impact of noninvasive ventilation failure upon patient prognosis. Subanalysis of a multicenter study]. / Impacto del fracaso de la ventilacion no invasiva en el pronóstico de los pacientes. Subanálisis de un estudio multicéntrico.

OBJECTIVE: Noninvasive ventilation (NIV) constitutes first-line treatment for the exacerbation of obstructive pulmonary disease and cardiogenic lung edema. Several studies suggest that NIV failure could increase the risk of mortality, mainly due to the delay in tracheal intubation. We aimed to evaluate the negative impact of NIV failure in routine practice among Spanish ICUs. PATIENTS: A subanalysis was made of the multicenter validation of the Sabadell Score study, extracting patients with acute respiratory failure requiring either invasive or noninvasive mechanical ventilation, with the exclusion of patients presenting "do not resuscitate and/or do not intubate" orders. VARIABLES: We recorded demographic parameters, ICU-specific treatments and the development of acute renal failure or infections during ICU stay. Patients were followed-up on until hospital discharge or death. The statistic analysis included Cox multiple logistic regression. RESULTS: We analyzed 4132 patients, of whom 1602 (39%) received only invasive mechanical ventilation (IMV), while 529 (13%) received NIV. The latter succeeded in 50% of the patients, but the other 50% required intubation. NIV failure was more common in neurological and postsurgical patients. Mortality was lower than predicted in NIV patients (22% vs. 33%) and similar to predicted in IMV patients (27% vs. 29%). Mortality was lower than predicted in patients in whom NIV proved successful (12% vs. 28%), and in those in whom NIV failed (32% vs. 38%). CONCLUSION: NIV failure and the need of intubation as routinely used do not seem to imply a poorer patient prognosis.

Complications related to less-invasive haemodynamic monitoring.

BACKGROUND: The aim of this study was to evaluate the type and incidence of complications during insertion, maintenance, and withdrawal of central arterial catheters used for transpulmonary thermodilution haemodynamic monitoring (PiCCO™). METHODS: We conducted a prospective, observational, multicentre study in 14 European intensive care units (six countries). A total of 514 consecutive patients in whom haemodynamic monitoring by PiCCO™ was indicated were studied. RESULTS: Five hundred and fourteen PiCCO catheters (475 in femoral, 26 in radial, nine in axillary, and four in brachial arteries) were inserted. Arterial access was obtained on the first attempt in 86.4% of the patients. Minor problems such as oozing after insertion (3.3%) or removal of the catheter (3.5%) were observed, but no episodes of serious bleeding (more than 50 ml) were recorded. Small local haematomas were observed after insertion (4.5%) and after removal (1.2%) of the catheter. These complications were not more frequent in patients with coagulation abnormalities. The incidence of site inflammation and catheter-related infection was 2% and 0.78%, respectively. Other complications such as ischaemia (0.4%), pulse loss (0.4%), or femoral artery thrombosis (0.2%) were rare, transient, and all resolved with catheter removal or embolectomy, respectively. CONCLUSIONS: In this series of patients, central arterial catheters used for PiCCO™ monitoring were demonstrated to be a safe alternative for advanced haemodynamic monitoring.

The use of ECMO in ICU. Recommendations of the Spanish Society of Critical Care Medicine and Coronary Units. / Empleo de ECMO en UCI. Recomendaciones de la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias.

The use of extracorporeal membrane oxygenation systems has increased significantly in recent years; given this reality, the Spanish Society of Critical Intensive Care Medicine and Coronary Units (SEMICYUC) has decided to draw up a series of recommendations that serve as a framework for the use of this technique in intensive care units. The three most frequent areas of extracorporeal membrane oxygenation systems use in our setting are: as a cardiocirculatory support, as a respiratory support and for the maintenance of the abdominal organs in donors. The SEMICYUC appointed a series of experts belonging to the three working groups involved (Cardiological Intensive Care and CPR, Acute Respiratory Failure and Transplant work group) that, after reviewing the existing literature until March 2018, developed a series of recommendations. These recommendations were posted on the SEMICYUC website to receive suggestions from the intensivists and finally approved by the Scientific Committee of the Society. The recommendations, based on current knowledge, are about which patients may be candidates for the technique, when to start it and the necessary infrastructure conditions of the hospital centers or, the conditions for transfer to centers with experience. Although from a physiopathological point of view, there are clear arguments for the use of extracorporeal membrane oxygenation systems, the current scientific evidence is weak, so studies are needed that define more precisely which patients benefit most from the technique and when they should start.

[Current concepts of pathophysiology, monitoring and resolution of pulmonary edema]. / Conceptos actuales en la fisiopatología, monitorización y resolución del edema pulmonar*

Pulmonary edema, both in its lesional as well as hydrostatic version, is a frequent cause of acute respiratory failure. From the pathophysiological point of view, the most important advance is undoubtedly the knowledge that the reabsorption process of pulmonary edema is an active process with energy consumption. This concept has revolutionized this field due to the possibility of finding substances or factors that stimulate or inhibit this reabsorption. Furthermore, in the monitoring field, significant advances have also been experimented due to the possibility of quantifying the edema in a simple and reliable way with transpulmonary thermodilution.

[Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)]. / Documento multidisciplinar de consenso sobre elmanejo de la hemorragia masiva (document HEMOMAS)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Abdomen release in prone position does not improve oxygenation in an experimental model of acute lung injury.

OBJECTIVE: To analyze the effect of abdomen release in the prone position on oxygenation in an experimental model of acute lung injury. DESIGN: Experimental randomized controlled study. SETTING: Experimental laboratory of a tertiary university hospital. PARTICIPANTS: Mixed-breed adolescent pigs weighing between 25-31 kg. INTERVENTIONS: Thirty minutes after pulmonary edema was produced with oleic acid, the animals were turned prone and randomized into two groups: group I or control (n = 9), lying directly on the operating table; and group II (n = 11) with abdomen release, with positioning rolls under the upper part of the chest wall and the pelvis to allow free movement of the abdomen. MEASUREMENTS AND RESULTS: The gas exchange, respiratory mechanics, hemodynamics, intra-abdominal pressure (IAP) and the extravascular lung water (EVLW), determined by double indicator dilution method (DI), were recorded at baseline (time 0) and at 30, 60, 90, 120 and 150 min. The PaO2/FIO2 increased in both groups at 30 min after the pigs were placed in the prone position (time 60) and then decreased progressively until the end of the experimental period, with no statistical differences between the groups at any time (73.1 +/- 14.5 vs 79.5 +/- 14.9 at 150 min). Abdomen release was not associated with changes in the respiratory mechanics, EVLW or intra-abdominal pressure. CONCLUSIONS: Abdomen release in prone position does not improve oxygenation in an experimental model of acute lung injury.

Thrombolytic treatment for massive thrombosis of prosthetic cardiac valves.

OBJECTIVE: To present the efficacy of thrombolytic treatment in place of emergency surgery in massive thrombosis of prosthetic cardiac valves (TPCV), and to set out the diagnostic criteria and the patients' evolution. DESIGN: Retrospective study. SETTING: Coronary Care Unit of a Spanish reference hospital. PATIENTS: 7 patients admitted into the ICU with 10 episodes of TPCV and with advanced functional class. INTERVENTIONS: The diagnosis of TPCV was arrived at through clinical data and was confirmed by Doppler-echocardiography before treatment. Thrombolytic treatment (streptokinase, urokinase or rt-PA) was used. The analysis of paired samples between the data before and after treatment was used. MEASUREMENTS AND RESULTS: All the patients underwent an improvement in their clinical condition. A reduction of sPAP and in the mean transprosthetic gradient and an increase in the effective valvular area was achieved. Four patients needed surgical intervention during their follow-up. No case required emergency surgery. One patient died after surgery and the other 6 patients are alive after follow-up of 6-33 months. With the fibrinolytic treatment hemorrhagic complications were always controlled. None of the treated patients presented embolic complications. CONCLUSIONS: Fibrinolytic treatment is the recommended initial treatment in cases of massive TPCV. When fibrinolysis is only partially successful, reoperation can be performed at lower risk. Doppler echocardiography is fundamental in the diagnosis of TPCV and in monitoring the response to fibrinolytic treatment.

Increase in lung volume originated by extrinsic PEEP in patients with auto-PEEP. The role of static lung compliance.

The use of extrinsic positive end expiratory pressure (PEEPe) in patients with auto-PEEP (AP) can reduce the respiratory work during weaning from mechanical ventilation. However, the application of PEEPe can produce a certain level of hyperinflation, an undesirable effect which can limit the efficacy of the reduction of respiratory work. The objective of the present study has been to determine if the increase in end expiratory lung volume (EELV) originated by the PEEPe is related to static lung compliance (SLC). We have studied 14 patients on mechanical ventilation in whom an AP of between 4 and 12 cmH2O was detected. On applying PEEPe equal to half the AP, the EELV increased slightly (77 +/- 64 ml) and was not related to pulmonary compliance. When PEEPe equal to the AP was applied, the EELV increased by 178 +/- 110 ml (range 45-375 ml, p less than 0.05), and there was a significant correlation with SLC (r = 0.659, p less than 0.05). In conclusion, the application of PEEPe equal to the AP causes a moderate increase in EELV. However, in patients with high pulmonary compliance this increase can be more important and must be taken into account when considering the use of PEEPe during weaning.