RESUMO
The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.
Assuntos
Cuidados Críticos/normas , Adulto , Terapia Combinada , Cuidados Críticos/métodos , Estado Terminal/terapia , Tomada de Decisões , Gerenciamento Clínico , Humanos , Unidades de Terapia Intensiva/normas , Cuidados para Prolongar a Vida/normas , Monitorização Fisiológica/normas , Cuidados Paliativos , Equipe de Assistência ao Paciente , Sistema de Registros , Sociedades Médicas , Espanha , Assistência Terminal/normas , Revelação da VerdadeRESUMO
OBJECTIVE: To present the preliminary results of a non-heart beating donor (NHBD) program in a city of under 500,000 inhabitants. DESIGN: A prospective observational study was conducted between 2010 and 2011. SETTING: Virgen de las Nieves Hospital and metropolitan area of Granada (Spain). POPULATION: NHBD and brain dead donors (BDD) in the province of Granada during 2010 and 2011. STUDY VARIABLES: Characteristics of NHBD, out- and in-hospital times, family and legal refusals, preservation methods, and family information procedure. Organs: reasons for organ non-validness, and harvested and transplanted organs. Recipients: hemodialysis sessions and creatinine at discharge. BDD: number of real donors (RD) and of kidney transplants. RESULTS: Among the BDD there were 102 RD and 104 kidney transplants were carried out. In asystole, 22 potential donors, 21 eligible donors, 20 RD and 13 used donors were registered. The mean age among the RD was 50 years (range 33-62)(16 males and 4 females). Twenty-one kidney and two liver transplants from NHBD were performed. There were a number of reasons for organ non-validness. The mean number of post-transplantation hemodialysis sessions was 1.4 (range 0-6). The mean hospital stay was 25 days (range 14-41), and the mean creatinine concentration at discharge was 3.4mg/dl (range 1.5-6.4). There was one family rejection and no legal (court-ruled) rejections. The preservation methods and family information procedure are described. CONCLUSIONS: The preliminary results support the development of NHBD programs in cities with under 500,000 inhabitants. In 2011, NHBD accounted for 20.19% of the kidney transplants and 19.60% of the global organ donations in the province of Granada.
Assuntos
Obtenção de Tecidos e Órgãos/normas , Adulto , Morte Encefálica , Protocolos Clínicos , Morte Súbita Cardíaca , Serviço Hospitalar de Emergência/normas , Feminino , Humanos , Transplante de Rim/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Estudos ProspectivosRESUMO
Spain has become one of the most active countries in donation after controlled cardiac death, using normothermic abdominal perfusion with ECMO in more than 50% of all donors - a situation contributed to by the creation of mobile teams to support hospitals lacking this technology. The donation process must be respectful of the wishes and values of the patients and their relatives, especially if there is pre mortem manipulation, and the absence of cerebral perfusion should be guaranteed. The liver is the most benefited organ by reducing biliary complications as well as the loss of grafts. In renal transplantation, the technique could contribute to reduce the incidence of delayed graft function. In addition, the procedure is compatible with surgical rapid recovery in hypothermia when there is also lung donation. The future lies in the consolidation of cardiac donation by extending normothermic perfusion to the thoracic cavity.
Assuntos
Oxigenação por Membrana Extracorpórea , Morte , Humanos , Preservação de Órgãos , Perfusão , EspanhaRESUMO
OBJECTIVE: The COVID-19 pandemic has threatened to collapse hospital and ICU services, and it has affected the care programs for non-COVID patients. The objective was to develop a mathematical model designed to optimize predictions related to the need for hospitalization and ICU admission by COVID-19 patients. DESIGN: Prospective study. SETTING: Province of Granada (Spain). POPULATION: COVID-19 patients hospitalized, admitted to ICU, recovered and died from March 15 to September 22, 2020. STUDY VARIABLES: The number of patients infected with SARS-CoV-2 and hospitalized or admitted to ICU for COVID-19. RESULTS: The data reported by hospitals was used to develop a mathematical model that reflects the flow of the population among the different interest groups in relation to COVID-19. This tool allows to analyse different scenarios based on socio-health restriction measures, and to forecast the number of people infected, hospitalized and admitted to the ICU. CONCLUSIONS: The mathematical model is capable of providing predictions on the evolution of the COVID-19 sufficiently in advance as to anticipate the peaks of prevalence and hospital and ICU care demands, and also the appearance of periods in which the care for non-COVID patients could be intensified.
Assuntos
COVID-19 , COVID-19/epidemiologia , Atenção à Saúde , Humanos , Unidades de Terapia Intensiva , Modelos Teóricos , Pandemias , Estudos Prospectivos , SARS-CoV-2RESUMO
OBJECTIVE: The COVID-19 pandemic has threatened to collapse hospital and ICU services, and it has affected the care programs for non-COVID patients. The objective was to develop a mathematical model designed to optimize predictions related to the need for hospitalization and ICU admission by COVID-19 patients. DESIGN: Prospective study. SETTING: Province of Granada (Spain). POPULATION: COVID-19 patients hospitalized, admitted to ICU, recovered and died from March 15 to September 22, 2020. STUDY VARIABLES: The number of patients infected with SARS-CoV-2 and hospitalized or admitted to ICU for COVID-19. RESULTS: The data reported by hospitals was used to develop a mathematical model that reflects the flow of the population among the different interest groups in relation to COVID-19. This tool allows to analyse different scenarios based on socio-health restriction measures, and to forecast the number of people infected, hospitalized and admitted to the ICU. CONCLUSIONS: The mathematical model is capable of providing predictions on the evolution of the COVID-19 sufficiently in advance as to anticipate the peaks of prevalence and hospital and ICU care demands, and also the appearance of periods in which the care for non-COVID patients could be intensified.
RESUMO
Intensive care to facilitate organ donation (ICOD) is defined as the initiation or continuation of life-sustaining measures, such as mechanical ventilation, in patients with a devastating brain injury with high probability of evolving to brain death and in whom curative treatment has been completely dismissed and considered futile. ICOD incorporates the option to organ donation allowing a holistic approach to end-of-life care, consistent with the patients wills and values. Should the patient not evolve to brain death, life-supportive treatment must be withdrawal and controlled asystolia donation could be evaluated. ICOD is a legitimate practice, within the ethical and legal regulations that contributes increasing the accessibility of patients to transplantation, promoting health by increasing deceased donation by 24%, and with a mean of 2.3 organs transplanted per donor, and collaborating with the sustainability of health-care system. This ONT-SEMICYUC recommendations provide a guide to facilitate an ICOD harmonized practice in spanish ICUs.
Assuntos
Epilepsia Tônico-Clônica/etiologia , Leucoencefalite Hemorrágica Aguda/complicações , Antivirais/uso terapêutico , Afasia/etiologia , Edema Encefálico/tratamento farmacológico , Edema Encefálico/etiologia , Edema Encefálico/cirurgia , Terapia Combinada , Craniectomia Descompressiva , Humanos , Leucoencefalite Hemorrágica Aguda/diagnóstico por imagem , Leucoencefalite Hemorrágica Aguda/tratamento farmacológico , Leucoencefalite Hemorrágica Aguda/cirurgia , Masculino , Metilprednisolona/uso terapêutico , Paresia/etiologia , Plasmaferese , Infecções Respiratórias/complicações , Adulto JovemRESUMO
Spain has become one of the most active countries in donation after controlled cardiac death, using normothermic abdominal perfusion with ECMO in more than 50% of all donors - a situation contributed to by the creation of mobile teams to support hospitals lacking this technology. The donation process must be respectful of the wishes and values of the patients and their relatives, especially if there is pre mortem manipulation, and the absence of cerebral perfusion should be guaranteed. The liver is the most benefited organ by reducing biliary complications as well as the loss of grafts. In renal transplantation, the technique could contribute to reduce the incidence of delayed graft function. In addition, the procedure is compatible with surgical rapid recovery in hypothermia when there is also lung donation. The future lies in the consolidation of cardiac donation by extending normothermic perfusion to the thoracic cavity.
RESUMO
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.
Assuntos
Cuidados Críticos/métodos , Cuidados Críticos/normas , Oxigenação por Membrana Extracorpórea , Humanos , Unidades de Terapia IntensivaRESUMO
PURPOSE: The two aims of this study were first to analyse the feasibility and utility (to improve the care process) of implementing a new real time random safety tool and second to explore the efficacy of this tool in core hospitals (those participating in tool design) versus non-core hospitals. METHODS: This was a prospective study conducted over a period of 4 months in six adult intensive care units (two of which were core hospitals). Safety audits were conducted 3 days per week during the entire study period to determine the efficacy of the 37 safety measures (grouped into ten blocks). In each audit, 50% of patients and 50% of measures were randomized. Feasibility was calculated as the proportion of audits completed over those scheduled and time spent, and utility was defined as the changes in the care process resulting from tool application. RESULTS: A total of 1323 patient-days were analysed. In terms of feasibility, 87.6% of the scheduled audits were completed. The average time spent per audit was 34.5 ± 29 min. Globally, changes in the care process occurred in 5.4% of the measures analysed. In core hospitals, utility was significantly higher in 16 of the 37 measures, all of which were included in good clinical practice guidelines. Most of the clinical changes brought about by the tool occurred in the mechanical ventilation and haemodynamics blocks. Multivariate analyses demonstrated that changes in the care process in each block were associated with the core hospital variable, staffing ratios and severity of patient disease. CONCLUSIONS: Real time safety audits improved the care process and adherence to the clinical practice guidelines and proved to be most useful in situations of high care load and in patients with more severe disease. The effect was greater in core hospitals.
Assuntos
Cuidados Críticos/métodos , Unidades de Terapia Intensiva , Auditoria Administrativa/métodos , Gestão da Segurança/métodos , Estudos de Viabilidade , Humanos , Tempo de Internação/estatística & dados numéricos , Erros Médicos/prevenção & controle , Escores de Disfunção Orgânica , Admissão e Escalonamento de Pessoal/normas , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Qualidade da Assistência à Saúde/normasAssuntos
COVID-19/epidemiologia , Hospitalização/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Pandemias , SARS-CoV-2 , Adulto , Idoso , COVID-19/complicações , COVID-19/mortalidade , Teste para COVID-19/métodos , Comorbidade , Estudos Transversais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Respiração Artificial/estatística & dados numéricos , Insuficiência Respiratória/terapia , Estudos Retrospectivos , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Estatísticas não Paramétricas , Traqueostomia/estatística & dados numéricosAssuntos
Oxigenação por Membrana Extracorpórea , Parada Cardíaca , Unidades Móveis de Saúde , Preservação de Órgãos/métodos , Equipe de Assistência ao Paciente , Doadores de Tecidos , Obtenção de Tecidos e Órgãos/métodos , Feminino , Humanos , Hipóxia Encefálica , Unidades de Terapia Intensiva , Cuidados para Prolongar a Vida , Masculino , Pessoa de Meia-Idade , Suspensão de TratamentoRESUMO
Despite the high rate of kidney transplantation in Spain, a disparity still exists between the numbers of donors and waiting-list patients. Donors after circulatory death (DCD) have been propagated as a promising approach to reduce the donor kidney shortage. In Europe most of the countries use controlled DCD, but in Spain, mainly uncontrolled DCD are harvested and until 2010 at only four institutions. In January 2010, we began a program of donation after uncontrolled DCD (Maastricht type II; unsuccessful resuscitation). The aim of this observational study was to describe our preliminary results. The numbers of recovered and transplanted organs per DCD were 27. There were no cases of primary nonfunction, but delayed graft function was present in 85% of recipients. Despite this impairment, about 75% of patients reached a serum creatinine below 2 mg/dL in the second month, with 1-year graft and patient survivals of 85% and 100%. Although, our preliminary results with a not very long follow-up and small number of patients suggested that utilization of DCD should be expanded because this type of donor increases the number of cases and opportunities of end-stage renal disease patients to reduce the waiting times for transplantation.
Assuntos
Seleção do Doador , Cardiopatias/mortalidade , Falência Renal Crônica/cirurgia , Transplante de Rim , Doadores de Tecidos/provisão & distribuição , Obtenção de Tecidos e Órgãos , Biomarcadores/sangue , Creatinina/sangue , Função Retardada do Enxerto/sangue , Função Retardada do Enxerto/etiologia , Função Retardada do Enxerto/fisiopatologia , Feminino , Rejeição de Enxerto/sangue , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/fisiopatologia , Sobrevivência de Enxerto , Humanos , Transplante de Rim/efeitos adversos , Transplante de Rim/mortalidade , Masculino , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Espanha , Fatores de Tempo , Resultado do Tratamento , Listas de EsperaRESUMO
BACKGROUND: Lung edema can be influenced by hemodynamic changes in pulmonary circulation. The aim of this study was to evaluate, in an experimental model of acute lung injury, the effect on extravascular lung water (EVLW) of an increase in pulmonary artery pressure (Ppa) without changes in cardiac output and wedge pressure. METHODS: Lung edema was produced by an intravenous oleic acid infusion in mixed-breed pigs weighing 25-31 kg, which, after 20 min, were randomly assigned to a control group (100% FiO(2)) (n = 6) or a high Ppa group (21% FiO(2)) (n = 7). An increase in pulmonary artery pressure of at least 40% over baseline was produced in the high Ppa group by alveolar hypoxia. Hemodynamic, ventilatory and gas exchange parameters were collected at regular intervals. Pulmonary, wedge and capillary pressures were measured with a pulmonary artery catheter and the occlusion technique. EVLW was calculated gravimetrically. RESULTS: At 240 min, both gravimetric-measured EVLW and mean pulmonary artery pressures were significantly higher (P < 0.05) in high Ppa animals vs. controls (12.06 +/- 4.21 vs. 7.98 +/- 2.46 ml/kg and 39.0 +/- 1.3 vs. 26.6 +/- 4.7 mmHg, respectively). Cardiac output (6.8 +/- 2.5 vs. 7.3 +/- 1.3) and pulmonary wedge pressures (9.2 +/- 1.7 vs. 9.4 +/- 2.8 mmHg) were similar. A difference was detected in pulmonary capillary pressures [17.0 +/- 3.3 (high Ppa) vs. 13.8 +/- 2.7 mmHg (controls)] but did not reach statistical significance. CONCLUSIONS: In this model, an increase in pulmonary artery pressure by alveolar hypoxia produces an increase in extravascular lung water, probably related to changes in pulmonary capillary pressures.