[Physician's adherence to medical indications for invasive procedures in the critical care unit of a university hospital]. / Adherencia médica a las indicaciones de procedimientos invasores en la unidad de pacientes críticos de un hospital universitario.

INTRODUCTION: Physicians' adherence to pre-established criteria for the indication and/or maintenance of invasive devices is a weak point in infection control programs. Fulfillment of the recommendations for preventing infections associated with invasive devices is essential to reduce their risk. OBJECTIVE: To assess the adherence of physicians to the standardized criteria for indication of central venous catheter (CVC) and permanent urinary catheter (PUC) and to the application of supervision guidelines. METHODS: During a period of 7 months, residents of the Critical Patient Unit monitored the adherence to criteria for indication of CVC and PUC recorded in patients' medical records. This information was compared with current regulations to assess compliance. RESULTS: Between April and September 2009, 2078 supervision guidelines were applied. Invasive devices were identified in 47.7%. 10.4% of CVCs and 19.2% of PUCs did not meet criteria for installation and / or maintenance at the time of monitoring. CONCLUSIONS: Adherence of our medical staff to criteria for installation and /or maintenance of CVC and CUP should be improved. Monitoring can be efficiently performed by residents and could reduce infections associated with invasive procedures.

Adherencia médica a las indicaciones de procedimientos invasores en la unidad de pacientes críticos de un hospital universitario / Physician's adherence to medical indications for invasive procedures in the critical care unit of a university hospital

Introduction: Physicians' adherence to pre-established criteria for the indication and/or maintenance of invasive devices is a weak point in infection control programs. Fulfillment of the recommendations for preventing infections associated with invasive devices is essential to reduce their risk. Objective: To assess the adherence of physicians to the standardized criteria for indication of central venous catheter (CVC) and permanent urinary catheter (PUC) and to the application of supervision guidelines. Methods: During a period of 7 months, residents of the Critical Patient Unit monitored the adherence to criteria for indication of CVC and PUC recorded in patients' medical records. This information was compared with current regulations to assess compliance. Results: Between April and September 2009, 2078 supervision guidelines were applied. Invasive devices were identified in 47.7%. 10.4% of CVCs and 19.2% of PUCs did not meet criteria for installation and / or maintenance at the time of monitoring. Conclusions: Adherence of our medical staff to criteria for installation and /or maintenance of CVC and CUP should be improved. Monitoring can be efficiently performed by residents and could reduce infections associated with invasive procedures.

Introducción: La adherencia médica a los criterios de indicación y/o mantención de procedimientos invasores es un punto débil en los programas de control de infecciones. Cumplir las recomendaciones relacionadas a prevención de infecciones asociadas a procedimientos invasores es fundamental para reducir el riesgo de infección. Objetivos: Evaluar la adherencia de médicos residentes a criterios estandarizados de indicaciones médicas de catéter venoso central (CVC) y catéter urinario permanente (CUP) y a aplicar pautas de supervisión para evaluar su cumplimiento. Método: Durante un período de siete meses, residentes de la Unidad de Paciente Crítico (UPC), monitorizaron la adherencia a los criterios de indicación de CVC y CUP registrados en las fichas clínicas de los pacientes. La información registrada se cotejó con la normativa vigente. Resultados: Entre abril y octubre de 2009 se aplicaron 2.078 pautas de supervisión, de las cuales 47,7% identificaron invasión al momento de aplicarlas. Un 10,4 y 19,2% de los CVC y CUP, respectivamente, no cumplían con criterios de instalación y/o mantención al momento de la supervisión. Conclusiones: La adherencia de nuestros médicos de UPC a los criterios de instalación y/o mantención de CVC y CUP debe mejorarse. La supervisión puede ser realizada eficientemente por los mismos residentes y podría reducir las infecciones asociadas a procedimientos invasores.

Fiberoptic bronchoscopy-assisted percutaneous tracheostomy is safe in obese critically ill patients: a prospective and comparative study.

BACKGROUND: Obesity has reached epidemic proportions worldwide. In Latin America, 10% to 35% of the population is obese. Obese critically ill patients are at greater risk for requiring intubation and prolonged mechanical ventilation; and in some cases, it is necessary to perform a tracheostomy. OBJECTIVE: The objective of the study was to compare the incidence of perioperative complications associated with percutaneous tracheostomy (PT) using the fiberoptic bronchoscopy-assisted Ciaglia Blue Rhino technique (Cook Critical Care, Bloomington, IN) in obese vs nonobese critically ill patients. PATIENTS AND METHOD: A prospective evaluation was made of 120 patients who underwent PT because of prolonged mechanical ventilation. An analysis of the incidence of operative and early postoperative complications was performed comparing an obese patient group (n = 25) with a nonobese patient group (n = 80). Obesity was defined by a body mass index of at least 30 kg/m(2). RESULTS: The 2 groups had no significant differences in their demographic characteristics. The average body mass index for the obese patient group was 38 +/- 9 kg/m(2) vs 22 +/- 3 kg/m(2) for the nonobese patient group (P < .001). The obese patients required 18 +/- 7 days of mechanical ventilation, on average, before PT vs 16 +/- 7 days for the nonobese patients (P = .15). The incidence of operative complications for the obese patients vs nonobese patients was 8% and 7.5%, respectively (P = 1). The incidence of early postoperative complications was 8% for the obese patients vs 2.5% for the nonobese patients (P = .2). CONCLUSION: Percutaneous tracheostomy using the fiberoptic bronchoscopy-assisted Ciaglia Blue Rhino technique is safe for obese critically ill patients when performed by an experienced intensivist.

Extended prone position ventilation in severe acute respiratory distress syndrome: a pilot feasibility study.

OBJECTIVES: The aim of the study was to evaluate the safety of extended prone position ventilation (PPV) and its impact on respiratory function in patients with severe acute respiratory distress syndrome (ARDS). DESIGN: This was a prospective interventional study. SETTING: Patients were recruited from a mixed medical-surgical intensive care unit in a university hospital. PATIENTS: Fifteen consecutive patients with severe ARDS, previously unresponsive to positive end-expiratory pressure adjustment, were treated with PPV. INTERVENTION: Prone position ventilation for 48 hours or until the oxygenation index was 10 or less (extended PPV). RESULTS: The elapsed time from the initiation of mechanical ventilation to pronation was 35 +/- 11 hours. Prone position ventilation was continuously maintained for 55 +/- 7 hours. Two patients developed grade II pressure ulcers of small extent. None of the patients experienced life-threatening complications or hemodynamic instability during the procedure. The patients showed a statistically significant improvement in Pao(2)/Fio(2) (92 +/- 12 vs 227 +/- 43, P < .0001) and oxygenation index (22 +/- 5 vs 8 +/- 2, P < .0001), reduction of PaCo(2) (54 +/- 9 vs 39 +/- 4, P < .0001) and plateau pressure (32 +/- 2 vs 27 +/- 3, P < .0001), and increment of the static compliance (21 +/- 3 vs 37 +/- 6, P < .0001) with extended PPV. All the parameters continued to improve significantly while they remained in prone position and did not change upon returning the patients to the supine position. CONCLUSIONS: The results obtained suggest that extended PPV is safe and effective in patients with severe ARDS when it is carried out by a trained staff and within an established protocol. Extended PPV is emerging as an effective therapy in the rescue of patients from severe ARDS.