Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients. / Recomendaciones para el tratamiento de los pacientes críticos de los Grupos de Trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC).

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.

Blood purification in the critically ill patient. Prescription tailored to the indication (including the pediatric patient).

We maintain a dynamic position on extracorporeal blood purification therapies (EBPT). Continuous therapies are of choice in the hemodynamically unstable patient. We recommend their early introduction in the course of the disease, and starting with a dose of 30-35mL/kg/h. Above all, however, daily re-evaluation is required of the hemodynamic and metabolic situation and water balance of our patients in order to allow dynamic dose adjustment. Some data suggest that continuous EBPT can favorably influence the clinical course of our patients, even in the absence of acute kidney injury. The potential usefulness of hemofiltration at doses higher than the conventional doses (continuous ultrafiltration >50mL/kg/h or pulses of at least 4h a day to more than 100dosesmL/kg/h) for achieving blood purification has also been commented. We review the possible indications of this technique, together with the peculiarities of implementing these therapies in children.

Adult respiratory distress syndrome (ARDS) due to omeprazole-induced drug reaction with eosinophilia and systemic symptoms (DRESS): Case report and review of the literature.

Eosinophilia in not an uncommon findings in the intensive care unit (ICU); however, DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) syndrome, which is characterized by a hypersensitivity reaction to drugs and manifests as eosinophilia, systemic involvement and maculopapular erythematous rash 2-6 weeks after exposure to the offending drug, is an exceptional occurrence. We present the first case described in the literature of DRESS syndrome with pulmonary involvement in the form of interstitial pneumonitis and persistent adult respiratory distress syndrome (ARDS) secondary to proton pump inhibitors (PPI). The patient made a good recovery after withdrawal of the offending drug and long-term treatment with systemic corticosteroids. We also present a systematic review of all cases of DRESS with pulmonary involvement in the form of interstitial pneumonitis and cases of PPI-induced DRESS published to date; none of these describe pulmonary involvement.

New clinical practice guidelines of the surviving sepsis campaign: a critical appraisal.

In 2004 was published the first edition of the "Surviving sepsis campaign" guidelines for the management of severe sepsis and septic shock, opening a new era in the treatment of this syndrome. The paradox is that guidelines application have produced positive results despite including in some cases treatments proven ineffective. Eight years later has been published the third edition of the guides, which updates the prior in the light of new knowledge, but the quality of evidence remains weak. In this paper the authors express their critical view on the current edition of the guides, pointing out their weaknesses and suggesting how the development of future editions should be.

[Kounis syndrome]. / Síndrome de Kounis.

Kounis syndrome was described in 1991 by Kounis and Zavras as the coincidental occurrence of acute coronary syndromes with allergic reactions (anaphylactic or anaphylactoid). Today, allergic angina and allergic myocardial infarction are referred to as Kounis syndrome, and the latter has been reported in association with a variety of drugs, insect stings, food, environmental exposures and medical conditions, among other factors. The incidence is not known, as most of the available information comes from case reports or small case series. In this article, the clinical aspects, diagnosis, pathogenesis, related conditions and therapeutic management of the syndrome are discussed.

[The future of intensive medicine]. / El futuro de la Medicina Intensiva.

Although Intensive Care Medicine is a young specialty compared with other medical disciplines, it currently plays a key role in the process of care for many patients. Experience has shown that professionals with specific training in Intensive Care Medicine are needed to provide high quality care to critically ill patients. In Europe, important steps have been taken towards the standardization of training programs of the different member states. However, it is now necessary to take one more step forward, that is, the creation of a primary specialty in Intensive Care Medicine. Care of the critically ill needs to be led by specialists who have received specific and complete training and who have the necessary professional competences to provide maximum quality care to their patients. The future of the specialty presents challenges that must be faced with determination, with the main objective of meeting the needs of the population.

Oversedation Zero as a tool for comfort, safety and intensive care unit management. / Sobresedación Zero como herramienta de confort, seguridad y gestión en la unidades de cuidados intensivos.

Sedation is necessary in the management of critically ill patients, both to alleviate suffering and to cure patients with diseases that require admission to the intensive care unit. Such sedation should be appropriate to the patient needs at each timepoint during clinical evolution, and neither too low (undersedation) nor too high (oversedation). Adequate sedation influences patient comfort, safety, survival, subsequent quality of life, bed rotation of critical care units and costs. Undersedation is detected and quickly corrected. In contrast, oversedation is silent and difficult to prevent in the absence of management guidelines, collective awareness and teamwork. The Zero Oversedation Project of the Sedation, Analgesia and Delirium Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units aims to offer a practical teaching and collective awareness tool for ensuring patient comfort, safety and management with a view to optimizing the clinical outcomes and minimizing the deleterious effects of excessive sedation. The tool is based on a package of measures that include monitoring pain, analgesia, agitation, sedation, delirium and neuromuscular block, keeping patients pain-free, performing dynamic sedation according to clinical objectives, agreeing upon the multidisciplinary protocol to be followed, and avoiding deep sedation where not clinically indicated.

Management of analgesia, sedation and delirium in Spanish Intensive Care Units: A national two-part survey. / Prácticas de analgosedación y delirium en Unidades de Cuidados Intensivos españolas: Encuesta 2013-2014.

OBJECTIVE: To know the real clinical practice of Spanish ICUs in relation to analgesia, sedation and delirium, with a view to assessing adherence to current recommendations. DESIGN: A descriptive cross-sectional study was carried out based on a national survey on analgesia, sedation and delirium practices in patients admitted to intensive care on 16 November, 2013 and 16 October, 2014. An on-line questionnaire was sent with the endorsement of the SEMICYUC. SETTING: Spanish ICUs in public and private hospitals. RESULTS: A total of 166 ICUs participated, with the inclusion of 1567 patients. The results showed that 61.4% of the ICUs had a sedation protocol, and 75% regularly monitored sedation and agitation - the RASS being the most frequently used scale. Pain was monitored in about half of the ICUs, but the behavioral scales were very little used. Delirium monitoring was implemented in few ICUs. Among the patients on mechanical ventilation, midazolam remained a very commonly used agent. CONCLUSIONS: This survey is the first conducted in Spain on the practices of analgesia, sedation and delirium. We identified specific targets for quality improvement, particularly concerning the management of sedation and the assessment of delirium.

[Consensus document for sepsis code implementation and development in the Community of Madrid]. / Documento de consenso para la implantación y desarrollo del Código Sepsis en la Comunidad de Madrid.

The consensus paper for the implementation and development of the sepsis code, finished in April 2017 is presented here. It was adopted by the Regional Office of Health as a working document for the implementation of the sepsis code in the Community of Madrid, both in the hospital setting (acute, middle and long-stay hospitals) and in Primary Care and Out-of-Hospital Emergency Services. It is now published without changes with respect to the original version, having only added the most significant bibliographical references. The document is divided into four parts: introduction, initial detection and assessment, early therapy and organizational recommendations. In the second to fourth sections, 25 statements or proposals have been included, agreed upon by the authors after several face-to-face meetings and an extensive "online" discussion. The annex includes nine tables that are intended as a practical guide to the activation of the sepsis code. Both the content of the recommendations and their formal writing have been made taking into account their applicability in all areas to which they are directed, which may have very different structural and functional characteristics and features, so that we have deliberately avoided a greater degree of concretion: the objective is not that the sepsis code is organized and applied identically in all of them, but that the health resources work in a coordinated manner aligned in the same direction.

Oncological patients admitted to an intensive care unit. Analysis of predictors of in-hospital mortality. / Pacientes oncológicos ingresados en Unidad de Cuidados Intensivos. Análisis de factores predictivos de mortalidad.

OBJECTIVE: To analyze the factors influencing in-hospital mortality among cancer patients admitted to an Intensive Care Unit (ICU). DESIGN: A retrospective observational study was carried out. SETTING: The ICU of a community hospital. PATIENTS: Adults diagnosed with solid or hematological malignancies admitted to the ICU, excluding those admitted after scheduled surgery and those with an ICU stay of under 24h. INTERVENTIONS: Review of clinical data. VARIABLES OF INTEREST: Referring ward and length of stay prior to admission to the ICU, type of tumor, extent, Eastern Cooperative Oncology Group (ECOG) score, reason for ICU admission, severity (SOFA, APACHE-II, SAPS-II), type of therapy received in the ICU, and in-hospital mortality. RESULTS: A total of 167 patients (mean age 71.1 years, 62.9% males; 79% solid tumors) were included, of which 61 (36%) died during their hospital stay (35 in the ICU). The factors associated to increased in-hospital mortality were ECOG scores 3-4 (OR 7.23, 95%CI: 1.95-26.87), metastatic disease (OR 3.77, 95%CI: 1.70-8.36), acute kidney injury (OR 3.66, 95%CI: 1.49-8.95) and SOFA score at ICU admission (OR 1.26, 95%CI: 1.10-1.43). A total of 60.3% of the survivors were independent at hospital discharge. CONCLUSIONS: In our series, only one-third of the critically ill cancer patients admitted to the ICU died during hospital admission, and more than 50% showed good performance status at hospital discharge. The clinical prognostic factors associated to in-hospital mortality were poor performance status, metastatic disease, SOFA score at ICU admission and acute kidney injury.

Physician staffing needs in critical care departments. / Estimación de las necesidades de profesionales médicos en los servicios de medicina intensiva.

Departments of Critical Care Medicine are characterized by high medical assistance costs and great complexity. Published recommendations on determining the needs of medical staff in the DCCM are based on low levels of evidence and attribute excessive significance to the structural/welfare approach (physician-to-beds ratio), thus generating incomplete and minimalistic information. The Spanish Society of Intensive Care Medicine and Coronary Units established a Technical Committee of experts, the purpose of which was to draft recommendations regarding requirements for medical professionals in the ICU. The Technical Committee defined the following categories: 1) Patient care-related aspects; 2) Activities outside the ICU; 3) Patient safety and clinical management aspects; 4) Teaching; and 5) Research. A subcommittee was established with experts pertaining to each activity category, defining criteria for quantifying the percentage time of the intensivists dedicated to each task, and taking into account occupational category. A quantitative method was applied, the parameters of which were the number of procedures or tasks and the respective estimated indicative times for patient care-related activities within or outside the context of the DCCM, as well as for teaching and research activities. Regarding non-instrumental activities, which are more difficult to evaluate in real time, a matrix of range versus productivity was applied, defining approximate percentages according to occupational category. All activities and indicative times were tabulated, and a spreadsheet was created that modified a previously designed model in order to perform calculations according to the total sum of hours worked and the hours stipulated in the respective work contract. The competencies needed and the tasks which a Department of Critical Care Medicine professional must perform far exceed those of a purely patient care-related character, and cannot be quantified using structural criteria. The method for describing the 5 types of activity, the quantification of specific tasks, the respective times needed for each task, and the generation of a spreadsheet led to the creation of a management instrument.

[Modified aspiration needle muscular biopsy in neuromuscular diseases. Use and advantages over open surgical biopsy]. / Estudio de las enfermedades neuromusculares por biopsia percutánea mediante aguja con aspiración modificada. Utilidad y ventajas sobre la biopsia quirúrgica.

OBJECTIVE: To evaluate aspiration needle muscular biopsy as an alternative to surgical open biopsy, so we focus on its results and tolerance. PATIENTS AND METHODS: We studied 150 patients with muscular pathology of every kind, and aged between 10 and 86 years, using a modified Allendale/Liverpool needle which by our indication has a built-in lateral funnel that provides faultless aspiration in 100% of cases. Percutaneous biopsy neuromuscular disorders study with modified aspiration Allendale needle: use and advantages over surgical biopsy. RESULTS: The biopsy, which was very well tolerated by the patients, children in particular, left no scar and produced fine samples for standard, immunohistochemical, ultrastructural, biochemical and genetic investigation. In children beyond 10 years of age no general anesthetics was required and in many 4-10 years neither. A number of unsuspected cases of mitochondrial or inflammatory myopathy were detected. Patients with cramps or unclearly defined clinical picture did, however, show frequent morphological pathology. In just three cases samples were defective; all others produced changes of diagnostic or prognostic value with 8% without morphologically abnormal changes. CONCLUSIONS: Modified aspiration needle biopsy is the choice method to study muscle. The samples are of excellent quality allowing for any kind of morphological, biochemical or genetic investigation. The procedure is routinely very well tolerated by patients so is very superior to open surgical biopsy, that we still use for infants in selected cases.

[Proton pump inhibitors and infection risk]. / Inhibidores de la bomba de protones y riesgo de infección.

Gastric antisecretory drugs, especially proton pump inhibitors, are among the most used drugs both in ambulatory and hospital settings, and prescription does not always follows approved indications. Experimental data suggest that gastric acid inhibition and the effects of proton pump inhibitors on the immune system can promote the development of infections. In recent years a number of observational studies have found an independent association between the use of proton pump inhibitors and an increased risk of gastrointestinal infections, including those caused by Clostridium difficile, and community and nosocomial pneumonia. This review discusses the current evidence, raises the potential pathogenic mechanisms involved and makes recommendations for current clinical practice and future research.

Intensity of continuous renal replacement therapies in patients with severe sepsis and septic shock: a systematic review and meta-analysis.

The purpose of this study was to assess the efficacy of continuous renal replacement therapies in patients with severe sepsis or septic shock, with or without acute kidney injury. We performed a systematic search in Medline, Embase, Web of Knowledge, Cochrane Library and Clinicaltrials.gov and a hand search of the retrieved studies. We included both randomised controlled clinical trials and subgroups of randomised trials that assessed the effect of continuous renal replacement therapies (at traditional or high doses) and reported clinical outcomes in adult patients with severe sepsis or septic shock. The study selection and data extraction were performed by duplicate. Analysis of heterogeneity and meta-analysis was performed according to the Cochrane Collaboration guidelines for conducting systematic reviews of interventions. Twelve studies (1895 patients) met the inclusion criteria. Pooling of all studies resulted in a mortality risk ratio of 0.96 (95% confidence interval 0.83 to 1.12). The studies showed moderate statistical heterogeneity (I2 statistic 52%, P = 0.02). The effect on mortality was not modified (interaction P values non significant) by the dose of continuous renal replacement therapies, the severity of illness or the risk of bias. The available evidence suggests that these therapies in patients with severe sepsis or septic shock are not associated with an improvement in other outcomes such as haemodynamics, pulmonary gas exchange, multiple organ dysfunction syndrome or length of stay. The best available evidence does not support the routine use of continuous renal replacement therapies (at traditional or high doses) in patients with severe sepsis or septic shock.

[Decontamination. A treatment without indications]. / Descontaminación: un tratamiento sin indicaciones.

The prevention of ventilator-associated pneumonia (VAP) is a priority in the Intensive Care Unit (ICU). To achieve this goal, clinical practice guidelines recommend the simultaneous application of a heterogeneous group of preventive measures of proven effectiveness. That is why we are presently seeing a reduction in VAP incidence to values previously considered unreachable. Better compliance with clinical practice guidelines has resulted in VAP rates approaching zero in multiple studies. Faced with the measures recommended in these guidelines, selective digestive decontamination (SDD), used together with other infection control practices, has shown efficacy in hospitals with high baseline incidence of pneumonia. However, its effectiveness in hospitals with good compliance of clinical practice guidelines and lower rates of VAP is highly unlikely. A serious drawback of DDS is the risk of favoring the selection of resistant microorganisms that can spread easily through the ICU and the hospital. With current standards of infection prevention, DDS is an unnecessary and risky measure, which should not be used on a widespread basis. Those situations in which the DDS may increase the effectiveness of properly implemented standard measures are still unknown.