Implementation of the TALK© clinical self-debriefing tool in operating theatres: a single-centre interventional study.

BACKGROUND: Debriefing in operating theatre environments leads to benefits in mortality, efficiency, productivity, and safety culture; however, it is still not regularly performed. TALK© is a simple and widely applicable team self-debriefing method to collaboratively learn and improve. METHODS: An interventional study introducing TALK© for voluntary clinical debriefing was carried out in operating theatre environments in a UK National Health Service hospital over 18 months. It explored compliance with the Five Steps to Safer Surgery and changes in behaviour in surgical teams regarding consideration and completion of debriefing. RESULTS: Team briefing and compliance with the WHO surgical safety checklist were performed consistently (>95% and >98%, respectively) throughout the study, which included 460 surgical lists. Consideration of debriefing increased at all data collection periods after intervention, from 35.6% to 60.3-97.4% (P≤0.003). Performance of debriefing, which was 23.3% at baseline, reached 39% at 6 months (P=0.039). Team planning of actions for improvement during debriefing also increased (P<0.001). A decline in performance of debriefing and subsequent improvement actions was observed after 6 months, albeit rates were above baseline at 18 months. The most reported reason not to carry out a debriefing was 'lack of issues'. After implementation, nurses and allied healthcare professionals increased their contribution to initiating and leading debriefing. Reported barriers were <18% at baseline, and decreased after intervention. CONCLUSIONS: A simple intervention introducing TALK© for voluntary debriefing in theatres prompted significant changes in team behaviour and sustained growth regarding consideration and performance of debriefing, especially in the first 6 months.

Interstitial pneumonitis and myelosuppression associated to mitomycin C urinary tract instillations: A case report.

Mitomycin C as a treatment for superficial bladder carcinomas and upper urinary tract tumours has been linked to local adverse events. Systemic toxicity has been documented for just a very few cases. This report presents a case of interstitial pneumonitis accompanied by myelosuppression in a 74-year-old patient after receiving the fifth administration of mitomycin C through a ureteral catheter as a treatment for left kidney pyelocaliceal urothelial carcinoma. Therefore, suspecting mitomycin C toxicity, urinary tract instillations were discontinued, and intravenous filgrastim and methylprednisolone were initiated. Currently, after five months since the last mitomycin C urinary tract instillation, the patient is still receiving filgrastim and corticosteroids. A moderate effort dyspnoea persists despite interstitial pulmonary infiltrates have presented a very important reduction. Pancytopenia has also persisted. Blood count and lung function monitoring would be appropriate in patients undergoing mitomycin C instillations, especially in those with established prior lung disease.

Sublingual and buccal drug administration in medical emergencies. / Administración sublingual y bucal de fármacos en situaciones de urgencia y emergencia vital.

Drug administration is crucial to achieve effective therapeutic drug outcomes. In medical emergencies, it is particularly convenient to use drugs that could be administered as an alternative to traditional routes (as oral or intravenous routes), that are not always suitable in these situations. Thus, sublingual and buccal routes offer an alternative to traditional routes, when a rapid onset of action is required. The main objective of this narrative review is to summarize the evidence for the use of sublingual and buccal drug administration in medical emergencies. The evidence obtained has been divided into four common scenarios found in the emergency department and intensive care units: cardiovascular emergencies, acute pain, agitation, and epileptic status. Moreover, the main advantages and disadvantages of sublingual and buccal routes are presented, as the future perspectives in the drug delivery field to overcome the limitations of these routes.

Clopidogrel-induced thrombotic microangiopathy: a case report.

Thrombotic microangiopathy is a serious condition that can be precipitated by exposure to certain medications. Although rare, it is life threatening and requires a high index of clinical suspicion, appropriate laboratory testing and immediate cessation of the offending agent. We present a case of a 75-year-old man with a history of ischaemic heart disease treated with clopidogrel and aspirin. One month after initiating the treatment he developed microangiopathic haemolytic anaemia and thrombocytopenia. Extensive clinical and laboratory investigations suggested thrombotic microangiopathy secondary to clopidogrel. The drug was immediately discontinued and treatment with intravenous corticosteroids was started. Within a week the patient's laboratory parameters normalised, indicating successful recovery. This case highlights the role of early detection and immediate discontinuation of suspected medication in the effective management of clopidogrel-induced thrombotic microangiopathy. Healthcare professionals should consider drug-induced thrombotic microangiopathy as a possible diagnosis in patients receiving clopidogrel who present with thrombocytopenia and microangiopathic haemolytic anaemia.

Characterisation and Outcomes of Patients with Solid Organ Malignancies Admitted to the Intensive Care Unit: Mortality and Impact on Functional Status and Oncological Treatment.

BACKGROUND: Despite the increasing number of ICU admissions among patients with solid tumours, there is a lack of tools with which to identify patients who may benefit from critical support. We aim to characterize the clinical profile and outcomes of patients with solid malignancies admitted to the ICU. METHODS: Retrospective observational study of patients with cancer non-electively admitted to the ICU of the Hospital Clinic of Barcelona (Spain) between January 2019 and December 2019. Data regarding patient and neoplasm characteristics, ICU admission features and outcomes were collected from medical records. RESULTS: 97 ICU admissions of 84 patients were analysed. Lung cancer (22.6%) was the most frequent neoplasm. Most of the patients had metastatic disease (79.5%) and were receiving oncological treatment (75%). The main reason for ICU admission was respiratory failure (38%). Intra-ICU and in-hospital mortality rates were 9.4% and 24%, respectively. Mortality rates at 1, 3 and 6 months were 19.6%, 36.1% and 53.6%. Liver metastasis, gastrointestinal cancer, hypoalbuminemia, elevated basal C-reactive protein, ECOG-PS greater than 2 at ICU admission, admission from ward and an APACHE II score over 14 were related to higher mortality. Functional status was severely affected at discharge, and oncological treatment was definitively discontinued in 40% of the patients. CONCLUSION: Medium-term mortality and functional deterioration of patients with solid cancers non-electively admitted to the ICU are high. Surrogate markers of cachexia, liver metastasis and poor ECOG-PS at ICU admission are risk factors for mortality.

Predictive performance of glomerular filtration rate equations based on cystatin C, creatinine and their combination in critically ill patients.

OBJECTIVE: 24-hour urine creatinine clearance (ClCr 24 hours) remains the gold standard for estimating glomerular filtration rate (GFR) in critically ill patients; however, simpler methods are commonly used in clinical practice. Serum creatinine (SCr) is the most frequently used biomarker to estimate GFR; and cystatin C, another biomarker, has been shown to reflect GFR changes earlier than SCr. We assess the performance of equations based on SCr, cystatin C and their combination (SCr-Cyst C) for estimating GFR in critically ill patients. METHODS: Observational unicentric study in a tertiary care hospital. Patients with cystatin C, SCr and ClCr 24 hours measurements in ±2 days admitted to an intensive care unit were included. ClCr 24 hours was considered the reference method. GFR was estimated using SCr-based equations: Chronic Kidney Disease Epidemiology Collaboration based on creatinine (CKD-EPI-Cr) and Cockcroft-Gault (CG); cystatin C-based equations: CKD-EPI-CystC and CAPA; and Cr-CystC-based equations: CKD-EPI-Cr-CystC. Performance of each equation was assessed by calculating bias and precision, and Bland-Altman plots were built. Further analysis was performed with stratified data into CrCl 24 hours <60, 60-130 and ≥130 mL/min/1.73 m2. RESULTS: We included 275 measurements, corresponding to 186 patients. In the overall population, the CKD-EPI-Cr equation showed the lowest bias (2.6) and best precision (33.1). In patients with CrCl 24 hours <60 mL/min/1.73 m2, cystatin-C-based equations showed the lowest bias (<3.0) and CKD-EPI-Cr-CystC was the most accurate (13.6). In the subgroup of 60≤ CrCl 24 hours <130mL/min/1.73 m2, CKD-EPI-Cr-CystC was the most precise (20.9). However, in patients with CrCl 24 hours ≥130mL/min/1.73 m2, cystatin C-based equations underestimated GFR, while CG overestimated it (22.7). CONCLUSIONS: Our study showed no evidence of superiority of any equation over the others for all evaluated parameters: bias, precision and Lin's concordance correlation coefficient. Cystatin C-based equations were less biased in individuals with impaired renal function (GFR <60 mL/min/1.73 m2). CKD-EPI-Cr-CystC performed properly in patients with GFR from 60-130 mL/min/1.73 m2 and none of them were accurate enough in patients ≥130 mL/min/1.73 m2.

Quantifying the available capacity and resource needs for provision of CAR-T therapies in the National Health Service in Spain: a survey-based study.

OBJECTIVES: To estimate the readiness of Spanish National Health Service (NHS) hospitals to provide chimeric antigen receptor T cell (CAR-T), and to identify and quantify the different resources needed to provide CAR-T considering three scenarios defined by 10, 25 and 50 patients per centre per year. DESIGN: Targeted literature review and quantitative study using a questionnaire and telephone interviews. An algorithm was created to determine hospitals' readiness based on their capacity and capability. All the requirements for quantification were assessed and validated by the steering committee, formed by members of the Spanish Group of Haematopoietic Transplantation and Cell Therapy. A weighting system (from 0 to 1) was established for capability quantification. For resources quantification, a scoring system was established, with 0 points representing the minimum and 3 points the maximum of additional resources that a hospital indicated necessary. SETTING: 40 Spanish hospital centres that perform allogeneic haematopoietic stem cell transplantation were invited to complete the questionnaire for capacity quantification, 28 of which provided valid responses. Nine hospitals participated in the interviews for resource quantification, eight of which had previously been designated by the Ministry of Health (MoH) to provide CAR-T. OUTCOME MEASURE: Current capacity of NHS Spanish sites to administer CAR-T under different theoretical scenarios with varying numbers of procedures, and the potential healthcare resources that would be needed to realise the theoretical capacity requirements. RESULTS: Four hospitals were optimally ready, 17 were somewhat ready and 7 were not ready. The actual extrapolated capacity of the currently designated MoH CAR-T sites would allow treatment of approximately 250 patients per year. Regarding healthcare resource needs, the numbers of haematologists, nurses and beds were the most important limiting factors, and those requiring further growth as patient numbers increased. CONCLUSIONS: Increasing the number of CAR-T-qualified centres and/or increasing resources in the current designated sites are two potential strategies that should be considered to treat CAR-T-eligible patients in Spain.

Mixed-method research protocol: Development and evaluation of a nursing intervention in patients discharged from the intensive care unit.

AIM: (a) To understand patients' lived experience at intensive care unit (ICU) discharge and (b) to evaluate the impact of a nursing empowerment intervention (NEI) on patients' anxiety and depression levels at ICU discharge. DESIGN: A mixed-methods approach will be applied. METHODS: In the qualitative phase, the hermeneutic phenomenological method will be used. Participants will be patients from three university hospitals who will be selected by purposive sampling. Data will be gathered through in-depth interviews and analysed using content analysis. The qualitative data obtained will be employed to develop the nursing intervention. Subsequently, a multicenter, parallel-group, experimental pre-test/post-test design with a control group will be used to measure the effectiveness of the nursing empowerment intervention in the quantitative phase by means of the Hospital Anxiety and Depression Scale (HADS). Simple random probabilistic sampling will include 172 patients in this phase.

[Evaluation of nurse workload in patients undergoing therapeutic hypothermia]. / Valoración de la carga de trabajo de Enfermería en pacientes sometidos a hipotermia terapéutica.

OBJECTIVE: Therapeutic hypothermia (TH) is recommended to minimize neurological damage in patients surviving sudden cardiac arrest (SCA). There is scarcity of data evaluating the nursing workload in these patients. The objective of the study is to assess the workload of nurses whilst treating patients undergoing TH after SCA. METHOD: A 43-month prospective-retrospective comparative cohort study was designed. Patients admitted to intensive care unit, for recovered SCA and persistent coma, were included. A comparison was made using the baseline characteristics, medical management, in-hospital mortality, and nursing workload during the first 96hours using the Therapeutic Intervention Scoring System-28 (TISS-28); Nursing Activities Score (NAS); and Nine Equivalents of Nursing Manpower Use Score (NEMS) scales among patients who received TH and those who did not. RESULTS: A total 46 patients were included: 26 in the TH group and 20 in the Non-TH group. Regarding baseline characteristics and management, the TH group presented higher prevalence of smoking habit (69 vs. 25%, p=0.012), out-of-hospital SCA (96 vs. 55%, p<0.001), and the performance of coronary angiography (96 vs. 65%, p=0.014) compared with the non-TH group. No differences were observed in the nursing workload, assessed by TISS 28, NAS or NEMS scales, or in-hospital mortality. CONCLUSIONS: In this study performance of TH in SCA survivors is not associated with an increase in nursing workload. The installation of a TH program does not require the use of more nursing resources in terms of workload.

Intervenciones enfermeras en las técnicas de depuración extrarrenal continuas con citrato en una unidad de cuidados intensivos / Nursing interventions in continuous extra-renal depuration techniques with citrate in an Intensive Care Unit

Objetivo: describir la utilización de filtros en la terapia de hemodiafiltración venovenosa continua (HDFVCC) durante el primer año de uso de citrato como anticoagulante en la unidad de cuidados intensivos (UCI) del Hospital Clínic de Barcelona, así como las intervenciones enfermeras y la generación de alarmas asociadas a esta terapia.Método: se realizó un estudio descriptivo transversal de serie de casos (dic 2016- dic 2017) con un componente longitudinal -para el análisis de las intervenciones enfermeras y las alarmas-. Se incluyó a mayores de 18 años ingresados en cuidados intensivos que precisaron HDFVVC con citrato. A través de la historia clínica y observación directa se recogieron variables relacionadas con el paciente, la terapia, las alarmas e intervenciones asociadas. Se realizaron índices de estadística descriptiva y análisis bivariantes.Resultados: se incluyeron 17 pacientes que utilizaron 38 filtros en total. El tiempo mediano de duración de la HDFVVC fue de cinco días y el de cada filtro de 52 horas. El motivo más habitual de cambio de filtro fue la coagulación (34%). Se efectuaron un total de 2,9 intervenciones enfermeras por hora (el 70% específicas de la terapia). Se observó una tendencia decreciente, no significativa estadísticamente, de las intervenciones y las alarmas en los tres primeros días.Conclusión: la anticoagulación con citrato en la HDFVVC se asocia con frecuentes intervenciones enfermeras, así como con un aumento de la vida media del filtro. Teniendo en cuenta además la reducción del riesgo hemorrágico, los beneficios del tratamiento globalmente parecen superar sus inconvenientes desde el punto de vista de intervenciones de Enfermería.(AU)

Objective: to describe the use of filters in continuous venovenous hemodiafiltration therapy (CVVHDF) during the first year of use of citrate as anticoagulant in the Intensive Care Unit (ICU) of the Hospital Clínic of Barcelona, as well as nursing interventions and generation of alarms associated to this therapy.Method: a cross-sectional descriptive study was conducted on a series of cases (December, 2016 to December, 2017), with a longitudinal component for the analysis of nursing interventions and alarms. The study included >18-year-old patients hospitalized in Intensive Care who required CVVHDF with citrate. Through clinical records and direct observation, there was a collection of patient and therapy-related variables, as well as of the alarms and the interventions associated. Descriptive statistics indexes were conducted, as well as bivariate analysis.Results: seventeen (17) patients were included, using 38 filters in total. The median time of CVVHDF duration was five days, and 52 hours for each filter. The most common reason for change of filter was coagulation (34%). In total, 2.9 nursing interventions were conducted per hour (70% were specific for the therapy). A decreasing tendency was observed, not statistically significant, for interventions and alarms during the first three days.Conclusion: anticoagulation with citrate in CVVHDF was associated with frequent nursing interventions, as well as with an increase in the half-life of the filter. Taking also into account the reduction in risk of hemorrhage, the benefits of the treatment overall seem to overcome its drawbacks from the point of view of nursing interventions.(AU)

Síndrome serotoninérgico asociado a la administración de duloxetina; a propósito de un caso / Serotonin syndrome associated with the administration of duloxetine; report of a case

No disponible

Angioedema de lengua como efecto adverso a micofenolato / Tongue angioedema as an adverse effect to mycophenolate

No disponible

Valoración de la carga de trabajo de Enfermería en pacientes sometidos a hipotermia terapéutica / Evaluation of nurse workload in patients undergoing therapeutic hypothermia

OBJETIVO: La hipotermia terapéutica (HT) se recomienda para minimizar el daño neurológico de pacientes que sobreviven a una parada cardiorrespiratoria (PCR). Existen pocos datos que evalúen la carga de trabajo de Enfermería en estos pacientes. El objetivo del estudio es evaluar la carga de trabajo del personal de Enfermería en pacientes sometidos a HT tras una PCR. MÉTODO: Se diseñó un estudio prospectivo-retrospectivo comparativo de cohortes durante 43 meses donde se incluyeron todos los pacientes ingresados en unidades de cuidados intensivos con PCR recuperada. Se compararon características basales, manejo médico, mortalidad intrahospitalaria, y carga de trabajo de Enfermería en las primeras 96 horas mediante las escalas validadas Therapeutic Intervention Scoring System-28 (TISS-28); Nursing Activities Score (NAS); y Nine Equivalents of Nursing Manpower Use Score (NEMS) entre aquellos pacientes tratados y no tratados mediante HT. RESULTADOS: Se incluyeron 46 pacientes: 26 en el grupo HT y 20 en el grupo no HT. El grupo HT presentó mayor prevalencia de tabaquismo (69 vs. 25%, p = 0,012), PCR extrahospitalaria (96 vs. 55%, p < 0,001) y realización de coronariografías (96 vs. 65%, p = 0,014). No hubo diferencias en la carga de trabajo evaluada por las escalas TISS 28, NAS o NEMS ni tampoco en el pronóstico intrahospitalario. CONCLUSIONES: En este estudio la realización de HT en pacientes que sobreviven a una PCR no se asocia con un aumento de la carga de trabajo de Enfermería. La instauración de programas de HT no requeriría la implementación de más recursos en Enfermería en términos de carga de trabajo

OBJECTIVE: Therapeutic hypothermia (TH) is recommended to minimize neurological damage in patients surviving sudden cardiac arrest (SCA). There is scarcity of data evaluating the nursing workload in these patients. The objective of the study is to assess the workload of nurses whilst treating patients undergoing TH after SCA. METHOD: A 43-month prospective-retrospective comparative cohort study was designed. Patients admitted to intensive care unit, for recovered SCA and persistent coma, were included. A comparison was made using the baseline characteristics, medical management, in-hospital mortality, and nursing workload during the first 96 hours using the Therapeutic Intervention Scoring System-28 (TISS-28); Nursing Activities Score (NAS); and Nine Equivalents of Nursing Manpower Use Score (NEMS) scales among patients who received TH and those who did not. RESULTS: A total 46 patients were included: 26 in the TH group and 20 in the Non-TH group. Regarding baseline characteristics and management, the TH group presented higher prevalence of smoking habit (69 vs. 25%, p = 0 .012), out-of-hospital SCA (96 vs. 55%, p < 0 .001), and the performance of coronary angiography (96 vs. 65%, p = 0 .014) compared with the non-TH group. No differences were observed in the nursing workload, assessed by TISS 28, NAS or NEMS scales, or in-hospital mortality. CONCLUSIONS: In this study performance of TH in SCA survivors is not associated with an increase in nursing workload. The installation of a TH program does not require the use of more nursing resources in terms of workload