Elementos de gestión para un Servicio de Urgencia de un hospital universitario / Management elements for Emergency Service of a university hospital

Emergency Departments (ED) are a key element of the health system, and for various reasons must face the phenomenon of overcrowding, which requires that the Director of Hospitals and Emergency teams to implement various improvements in clinical and administrative management of these units, all aimed at improving the quality of care with the patients and their families on the center of actions. All this in a service where the diagnostic accuracy is complex and service times play an important role. In this chapter we review some elements of management both in terms of people, as relevant critical processes in a shared vision for professionals in the field of health and management processes...

Medicina intensiva en Chile: desafíos para su desarrollo. Documento de la Comisión Nacional de Medicina Intensiva del Ministerio de Salud / Ministry of Health Intensive Care Medicine Commission: Proposals for the development of the discipline

Intensive care medicine in Chile is still in its dawn. It has experienced a progressive growth in the last decade, but continues to be weak. Although investments in the discipline have increased fivefold, there is still a severe deficiency of intensive care specialists. This issue will represent a serious problem in the near future. The Ministry of Health gathered an expert committee to study the problem and propose solutions for the future development of the discipline.

Terapia ocupacional precoz e intensiva en la prevención del delirium en adultos mayores ingresados a unidades de paciente crítico: ensayo clínico randomizado: resultados preliminares / Early and intensive occupational therapy in prevention of delirium in older adults admitted to critical patient unit: randomized clinical trial: prelimary results

Objetivo: comparar la eficacia de la prevención no farmacológica estándar (PnFE) versus la prevención no farmacológica reforzada (PnFR), consistente en prevención no farmacológica estándar más terapia ocupacional (TO) precoz e intensiva, en la incidencia del delirium en adultos mayores (AM) ingresados a unidad de pacientes críticos (UPC). Diseño: ensayo clínico randomizado, en UPC del Hospital Clínico de la Universidad de Chile (HCUCH). Sujetos: 70 pacientes de edad igual o superior a 60 años, ingresados al HCUCH entre abril y octubre del 2011, con necesidad de ingreso a UPC para monitorización, hospitalización por enfermedad aguda/crónica descompensada, con consentimiento del paciente o familiar y sin presencia de delirium al ingreso ni deterioro cognitivo previo al estudio. Materiales y métodos: PnFE (grupo control) consiste en: reorientación, movilización precoz, corrección de déficit sensoriales, manejo ambiental, protocolo de sueño y reducción de fármacos anticolinérgicos, versus PnFR (grupo experimental), que considera las siguientes áreas de intervención de TO: estimulación polisensorial, posicionamiento, estimulación cognitiva, entrenamiento en actividades de la vida diaria básica, estimulación motora de extremidades superiores y participación familiar; durante 5 días, dos veces al día. Se evaluó la presencia del delirium, con el CAM dos veces al día durante 5 días, y la severidad de éste con DRS; previo al alta se evaluó, independencia funcional con FIM, estado cognitivo con MMSE y fuerza de garra con dinamómetro de Jamar. Resultados: la PnFR de TO se asocia a menor incidencia de delirium, afectando al 16,1 por ciento del grupo con prevención no farmacológica estándar versus un 3,1 por ciento del con prevención no farmacológica reforzada, así como a menos días de hospitalización (20,6 días versus 10,4 p=.009). La independencia funcional al alta se mantiene en aspectos cognitivos (32,5 versus 32,9) mientras que en aspectos motores aumenta...

Objective: to compare the efficacy of standard non pharmacological prevention of delirium versus intensified prevention of delirium (standard prevention plus early and intensive occupational therapy) in the incidence of delirium in older adults (OA) admitted to critical patient unit (CPU). Desing: randomized control trial, blinded to outcome evaluator, in the CPU of Hospital Clínico Universidad de Chile. Subjects: 70 patients aged 60 years or older, admitted to CPU between April and October of 2011, with need for admission to CPU for monitoring, acute or decompensated chronic illness, without cognitive impairment and consent by patient or family member. Materials and methods: standard prevention group consisted in: reorienting, early mobilization, correction of sensory deficit, environmental management, protocol of sleep and reduction of drugs, and intensified prevention based on standard measured plus early and intensive Occupational therapy: multisensory stimulation, positioning, cognitive stimulation, training in activities of daily living, motor stimulation of the upper extremities and family participation, twice a day for 5 days. Delirium was evaluated (twice a day for 5 days) with CAM and severity with DRS. Primary outcome was delirium incidence, and secondarily were functional independence (FIM), cognitive status (MMSE) and strength of grip with jamar dynamometer at leaving. Results: early intervention and intensive occupational therapy is associated with lower incidence of delirium, affecting 16.1 percent of non-pharmacological standard prevention group and 3.1 percent of intensified prevention group, as well as fewer days of hospitalization (20, 6 days versus 10,4, p= 0,009). The functional independence at leaving keeps in cognitive (32.5 versus 32.9) and is increases significantly in motor aspects (46.5 versus 58.3 l, P =. 03). Conclusion: standard prevention plus early intensive intervention of occupational therapy is effective in...

Delirium postoperatorio: una ventana hacia una mejoría de la calidad y seguridad en la atención de pacientes quirúrgicos / Postoperative delirium: a window to quality improvement and safety in the care of surgical patients

Postoperative delirium or acute confusional state is a common complication among older subjects. Many factors influence its appearance, such as preexistent problems of the patient, medication use, pain, the perioperative anesthetic management and the intensity of the inflammatory reaction to surgical trauma. Its consequences are a longer hospital stay, higher risk of complications and a long term derangement of functional status and cognitive performance. The management of delirium is multifactorial, including the avoidance of precipitating factors, the maintenance of an adequate environment and the conscious use of neuroleptics. The prevention of delirium should be a priority that will improve health care standards.

El delirium postoperatorio constituye una complicación frecuente y relevante de los pacientes quirúrgicos, en particular en los adultos mayores Su génesis es multifactorial participando características preexistentes del paciente, y gatillantes como medicamentos, dolor, el enfrentamiento anestésico peri operatorio y la intensidad de la respuesta inflamatoria asociada al trauma quirúrgico, entre otros. La aparición de delirium postoperatorio se asocia a desenlaces adversos, como una mayor estadía hospitalaria, mayor riesgo de complicaciones, y a una reducción en la funcionalidad y el estado cognitivo en la evolución alejada. Estrategias de prevención no farmacológicas multimodales, han documentado una reducción significativa en la incidencia de delirium. La terapia del delirium, debe enfocarse en la búsqueda y manejo de factores precipitantes, en favorecer un adecuado entorno no farmacológico, y en el uso apropiado de neurolépticos. El adecuado reconocimiento de esta entidad, y la implementación de estrategias de prevención no farmacológicas constituyen actualmente un estándar que promueve una atención de calidad y segura a los pacientes quirúrgicos.

Trastornos del sueño en los pacientes críticos / Sleep disorders in critically ill patients

Sleep disorders are common in critically ill patients, and its consequences still insufficiently clarified. An environment with multiple noxious stimuli, light and hearing, admission for severe acute illness with multisystem disease, and the need for drugs that can disrupt sleep physiology, lead to this situation. We will review the epidemiology and risk factors for these disorders, and its possible consequences. Finally we discuss potential strategies for prevention of sleep disorders in this patient population.

Candidiasis invasoras en el paciente crítico adulto / Invasive candidiasis in critically ill adult patient

Las infecciones invasoras por Candida spp, representan una patología relevante en los pacientes críticos. Para su oportuno diagnóstico es necesaria una elevada sospecha clinica, tomando en consideración el cuadro clinico y la presencia de factores de riesgo. Pese a la incorporación de nuevos fármacos al arsenal terapéutico durante la última década, mantiene una elevada mortalidad. Las claves para mejorar los desenlaces clínicos en estos pacientes son el empleo de una terapia precoz, eficaz y que permita la cobertura de distintas especies de Candida: C albicans y no albicans. Recientes guías internacionales sugieren la terapia empírica con equinocandinas ante la sospecha de candidiasis invasora en esta población de pacientes. Este grupo de fármacos ha documentado adecuada eficacia clínica y seguridad en estos pacientes. Se espera que la incorporación de nuevas equinocandinas al mercado aminore sus costos y mejore el acceso a este grupo de fármacos.

Invasive infections by Candida strains are a relevant pathology in critically ill patients. Candida should be considered where a high risk of infection is present for a critical early diagnosis. Despite the incorporation of new drugs in the therapeutic armamentarium over the last decade, mortality remains high. The key in improving clinical outcomes of these patients are the use of early effective therapies that offer coverage against different strains of Candida: C. albicans and non-albicans. Recent international guidelines suggest empiric therapy with echinocandins in suspected invasive candidiasis in this patient population. This group of drugs adequately documented clinical efficacy and safe use in these patients. The emergence of new echinocandins could improve access to these drugs by reducing their cost.

Traqueostomía en el paciente crítico / Tracheostomy in the critical patient

Tracheostomy has evolved from a complex surgical intervention traditionally performed in the operating room, to a bedside procedure that can be done in the Intensive Care Unit, through a percutaneous approach. Percutaneous tracheostomy has proven to be as safe as open surgical tracheostomy in critically ill patients undergoing mechanical ventilation; therefore it seems to be a more suitable approach for these patients because it avoids the need of mobilizing patients outside their units and is performed in less time. Ciaglia Blue Rhino technique is the most widespread method of percutaneous dilatational tracheostomy, and exhibits an adequate safety profile. Fiberoptic bronchoscopy assistance and preliminary cervical ultrasound examination in selected patients improve the safeness of the procedure. Currently, the available evidencestrongly suggests that achieving an early tracheostomy may shorten mechanical ventilation days and stay in the Intensive Care Unit, but a decline in ventilator-associated pneumonia incidence and overall mortality reduction remains to be proven. In hands of an experienced intensivist, relative contraindications should not be an impediment to perform a percutaneous tracheostomy, since it can be performed safely even in high risk critically ill patients. Recently completed studies and those close to be finished, will provide interesting data on this significant topic.

Traqueostomía percutánea en la Unidad de Cuidados Intensivos / Percutaneous dilatational tracheostomy in the Intensive Care Unit

El desarrollo de las diversas técnicas de traquesotomía percutánea ha facilitado la ejecución de este procedimiento en pacientes críticos sometidos a ventilación mecánica, y ha demostrado ser tanto o más seguro que la traqueostomía abierta en este grupo de enfermos. La traqueostomía percutánea ofrece beneficios adicionales, evitando la necesidad de movilizar a los pacientes a pabellón, acelerando su ejecución y mejorando la utilización de los recursos. En la actualidad la traqueostomía percutánea realizada en la Unidad de Cuidados Intensivos constituye el abordaje de elección para los pacientes críticos. La técnica de Ciaglia Blue Rhino es la modalidad de traqueostomía percutánea por dilatación más difundida a nivel mundial y la que presenta el mejor perfil de seguridad. La asistencia fibrobroncoscópica mejora la seguridad del procedimiento. Algunos pacientes seleccionados pueden beneficiarse de una evaluación previa con ecodoppler cervical. En la actualidad, la evidencia disponible sugiere fuertemente que la realización de una traqueostomía temprana puede reducir los días de ventilación mecánica y la estadía en la Unidad de Cuidados Intensivos, sin embargo aún quedan dudas sobre su verdadero impacto en la incidencia de neumonía asociada a ventilación mecánica y en la reducción de la mortalidad. En manos de un intensivista experimentado las contraindicaciones relativas clásicas no deberían ser un impedimento para la realización de una traqueostomía percutánea, ya que puede ser practicada con seguridad incluso en pacientes críticos de alto riesgo.

The development of various techniques of percutaneous dilatational tracheostomy has facilitated the implementation of this procedure in critically ill patients undergoing mechanical ventilation. Percutaneous dilatational tracheostomy provides additional benefits by avoiding the need to mobilize patients to the operating room, speeding implementation and improving resource utilization. Percutaneous dilatational tracheostomy has proven to be as safe as open surgical tracheostomy in critically ill patients undergoing mechanical ventilation; therefore it seems to be a more suitable approach for these patients. Ciaglia Blue Rhino technique is the most widespread method of percutaneous dilatational tracheostomy around de world and which has the best safety profile. Fiberoptic bronchoscopy assistance and preliminary cervical ultrasound examination in selected patients improve the safety of the procedure. Currently, the available evidence strongly suggests that performing an early tracheostomy may shorten the duration of mechanical ventilation and length of stay on the Intensive Care Unit. However, there are still doubts about its real impact on the incidence of ventilator-associated pneumonia, and in reducing mortality. In hands of an experienced intensivist relative contraindications should not be an impediment to perform a percutaneous dilatational tracheostomy, since it can be performed safely even in high risk critically ill patients.

Traqueostomía percutánea con asistencia fibrobroncoscópica en pacientes críticos de alto riesgo: seguridad de las indicaciones extendidas / Percutaneous dilatational tracheostomy with fiberoptic bronchoscopy assistance in high-risk critically ill patients

Introducción: La traqueostomía percutánea (TP) por dilatación es el método de elección en pacientes críticos que requieren la instalación de una traqueostomía. Sin embargo, una proporción importante de pacientes presentan habitualmente una o más contraindicaciones relativas para la realización de este procedimiento. Objetivo: Comparar la incidencia de complicaciones perioperatorias asociadas a la TP con la técnica de Ciaglia Blue Rhino y asistencia fibrobroncoscópica en pacientes críticos de alto riesgo versus pacientes críticos de bajo riesgo. Pacientes y Método: Se evaluaron en forma prospectiva 180 pacientes sometidos a una TP electiva debido a ventilación mecánica prolongada. Todas las TP fueron realizadas en la Unidad de Pacientes Críticos por un intensivista experimentado en el procedimiento y mediante un abordaje estandarizado. Se registraron variables demográficas, APACHE II, días de ventilación mecánica antes de la TP y la tasa de complicaciones perioperatorias. Resultados: La incidencia de complicaciones operatorias para los pacientes de alto y bajo riesgo fue 4,5 por ciento (3/67) y 5,2 por ciento (6/114), respectivamente (p = 0,81). No se registraron complicaciones operatorias graves, ni muertes asociadas al procedimiento. La incidencia de complicaciones postoperatorias fue 3 por ciento (2/67) para los pacientes de alto riesgo vs. 2,6 por ciento (3/114) para los pacientes de bajo riesgo (p =0,89). La incidencia global de complicaciones perioperatorias fue 7,5 por ciento (5/67) y 7,9 por ciento (9/114) para los pacientes de alto y bajo riesgo, respectivamente (p = 0,92).Conclusión: La TP por dilatación con la técnica de Ciaglia Blue Rhino modificada y asistencia fibrobroncoscópica es segura en pacientes críticos de alto riesgo, cuando es realizada por un intensivista experimentado mediante un abordaje estandarizado.

Background: Percutaneous dilatational tracheostomy (PDT) is the method of choice in critically ill patients requiring the installation of a tracheostomy. However, a significant proportion of patients usually have one or more relative contraindications for this procedure. Objective: To compare the incidence of perioperative complication of PDT with the modified Ciaglia Blue Rhino technique and fiberoptic bronchoscopy assistance in high-risk critically ill patients versus low-risk critically ill patients. Patients and Methods: We prospectively evaluated 180 patients undergoing an elective PDT due to prolonged mechanical ventilation. All of the PDT were performed in the Critical Care Unit for an intensivist experienced in the procedure, using a standardized approach. We recorded demographic variables, APACHE II, days of mechanical ventilation before the PDT and the rate of perioperative complications. Results: The incidence of operative complications for patients high and low risk was 4.5 percent (3/67) and 5.2 percent (6/114), respectively (p =0.81). There were no serious operative complications or deaths associated with the procedure. The incidence of postoperative complications was 3 percent (2/67) for high risk patients vs 2.6 percent (3/114) for low risk patients (p=0.89). The overall incidence of perioperative complications was 7.5 percent (5/67) and 7.9 percent (9/114) for patients at high and low risk, respectively (p =0.92). Conclusions: PDT with the modified Ciaglia Blue Rhino technique and fiberoptic bronchoscopy assistance is safe in critically ill patients at high risk, when performed by an experienced intensivist using a standardized approach.

Traqueostomía percutánea con asistencia fibrobroncoscópica: evaluación prospectiva de 100 casos consecutivos y revisión de la literatura / Fiberoptic bronchoscopy assisted percutaneous tracheostomy: report of 100 patients

Background: Development of percutaneous techniques for tracheostomy have facilitated its implementation in the intensive care unit (ICU). Aim: To evaluate the safety of performing percutaneous tracheostomy (PT) using the Ciaglia Blue Rhino thechnique with fiberoptic bronchoscopy assistance in patients with prolonged mechanical ventilation. Patients and methods: Prospective evaluation of 100 consecutive patients aged 62±16 years (38 women) subjected to percutaneous tracheostomy. AU the procedures were performed in the ICU. Demographic variables, APACHE II, days of mechanical ventilation before PT, operative and post operative complications were recorded. Results: Mean APACHE II score was 20±3. Patients required on average 16±7 days of mechanical ventilation before PT. Eight patients (8 percent) had operative complications. One had an episode of transitory desaturation, one had a transitory hypotension related to sedation and six had mild bleeding not requiríng transfusión. No patient required conversión to surgical tracheostomy. Four patients (4 percent) presentedpost operative complications. Two had a mild and transitory bleeding ofthe ostomy and two had a displacement ofthe cannula. No other complications were observed. Conclusions: PT using the Ciaglia Blue Rhino technique with fiberoptic bronchoscopy assistance is a safe procedure that can be performed in the ICU by trained intensivists.

Sobrecrecimiento bacteriano intestinal en pacientes con pancreatitis crónica / Small intestine bacterial overgrowth in patients with chronic pancreatitis

Background: Previous reports describe 30-40 percent of small intestine bacterial overgrowth (SIBO) in patients with chronic pancreatitis (CP), SIBO is a cause of persistent symptoms in this group of patients even when they are treated with pancreatic enzymes. Aim: To asses the frequency of SIBO in patients with CP. Patients and methods: We studied 14 patients with CP using an hydrogen breath test with lactulose to detect SIBO, a nonabsorbable carbohydrate, whose results are not influenced by the presence of exocrine insufficiency. Main symptoms and signs were bloating in 9 (64 percent), recurrent abdominal pain in 8 (57 percent), intermittent diarrhea in 5 (36 percent) and steatorrhea in 5 (36 percent). At the same time we studied a healthy control group paired by age and sex. Results: SIBO was present in 13 of 14 patients with CP (92 percent) and in 1 of 14 controls (p<0.001). The only patient with CP and without SIBO was recently diagnosed and had minimal morphologic alterations in computed tomography and endoscopic pancreatography Conclusions: SIBO is common in CP and may be responsible for persistent symptoms. Proper diagnosis and treatment could alleviate symptoms and improve quality of life.

Sedación guiada por protocolo versus manejo convencional en pacientes críticos en ventilación mecánica / Protocol based sedation versus conventional treatment in critically ill patients on mechanical ventilation

Background: Sedatives and analgesic drugs give comfort and allow adequate respiratory support to critically ill patients in mechanical ventilation (MV). Its improper use may increase the duration of MV. Clinical guidelines suggest implementation of protocols, however this is seldom done in clinical practice. Aun: To compare in MV patients, nurse-applied guided by protocol administration of sedatives and analgesic drugs (protocol: group P) with the habitual practice using physicians criteria (control: group C). Material and methods: Inclusión criteria was the need of MV more than 48 h. The exclusión criteria were acute neurological diseases, hepatic cirrhosis, chronic renal failure and limitation of therapeutic efforts. Midazolam and fentanyl were used in both groups. The level of sedation was monitored with the Sedation Agitation Scale (SAS). In the P group, trained nurses applied algorithms to adjust the sedative doses according to a predefined SAS goal. Results: Forty patients were included, 22 aged 65±19 years in group P and 18 aged 54±21 years in group C. Apache II scores were 16±8 and 19±8 in each group. SAS score was more frequently evaluated within goal boundaries in group P than in group C (44 percent and 32 percent, respectively p =0.001). No differences in the proportion of patients with inadequate sedation were observed between treatment groups. Midazolam doses were lower in P than in C group (0.04 (0.02-0.07) and 0.06 (0.03-0.08) mg/kg/h respectively, p =0.005). Conclusions: The implementation of sedation protocol applied by nurses improved the quality of sedation and reduced the doses of Midazolam in mechanically ventilated patients.

Reanimación protocolizada del shcok séptico / Protocolized reanimation of septic shock

Severe sepsis and septic shock are pathologies with an increasing incidence in the world. Annually, in the USA 200.000 people die because of severe sepsis, the same number that die because of a myocardial infarction, being this last disease much more common. In Chile, a multicentric study found a 40 percent of prevalence of severe sepsis in critically ill patients, with amortality of 27 percent. In this scenario, it becomes of great importance the appropriate and integral management of this condition, by means of an early diagnosis and the implementation of anaggressive protocolized resuscitation, guided by clear goals. During the first stage of the resuscitation cristalloids and/ or colloids can be used, in order to expand the intravascular space, searching for CVP around 8 to 12 mmHg. In case of hypotension refractory to the administration of fluids, it is recommended to start with increasing doses of norepinephrin untila MAP of 65 - 75 mmHg is achieved. The intensity of the septic shock can be stratified according to the requirements of norepinephrine. It is of great importance to obtain blood cultures of the patients and to start with empiric antibiotic therapy as soon as possible. The initial metabolic goal must be the normalization of the central venous oxygen saturation. The implementation of the resuscitation bundle during the first six hours, since the diagnose of severe sepsis is done, increases the chances of surviving. Protocols of sedation and analgesia, and the use of protective mechanical ventilation is highly recommended. The use of hydrocortisone and human recombinant protein C in selected patients, may have a beneficial result in the outcome.Vasopressin, terlipressin and high-volume hemofiltration can be used as rescue measures for the most severe patients.

Función pancreática exocrina en diabetes mellitus: Determinación de elastasa fecal / Pancreatic exocrine function in diabetes mellitus: Determination of fecal elastase

Background: One of the complications of diabetes mellitus is the development of pancreatic exocrine insufficiency. Aim: To study pancreatic exocrine function in diabetics patients. Material and methods: Seventy two diabetic patients were included in the protocol, but two were withdrawn because an abdominal CAT scan showed a chronic calcified pancreatitis, previously undiagnosed. Fecal elastase was measured by ELISA and the presence of fat in feces was assessed using the steatocrit. Results: Mean age was 60±12 years and 67 (96%) patients had a type 2 diabetes. Fecal elastase was normal (elastase >200 µg/g) in 47 (67%) patients, mildly decreased (100-200 µg/g) in 10 (14%) and severely decreased in 13 (19%). There was a significant association between elastase levels and time of evolution of diabetes (p=0.049) and between lower elastase levels and the presence of a positive steatocrit (p=0.042). No significant association was found between elastase levels and other chronic complications of diabetes such as retinopathy, nephropathy, neuropathy, microangiopathy or with insulin requirement. Conclusions: One third of this group of diabetic patients had decreased levels of fecal elastase, that was associated with the time of evolution of diabetes. Patients with lower levels of elastase have significantly more steatorrhea. Among diabetics it is possible to find a group of patients with non diagnosed chronic pancreatitis.

Hepatitis crónica por virus C: factores asociados a la severidad del daño histológico / Factors associated with the severity of liver damage in chronic hepatitis C

Background: Twenty percent of patients with chronic hepatitis C evolve to cirrhosis in 10 to 20 years. The degree of steatosis and hepatic iron stores in liver biopsy increase the risk. Age, high body mass index, diabetes mellitus and alcohol consumption are factors associated to the severity of liver damage. Aim: To study the association of steatosis and increased iron stores in the liver biopsy and age, overweight, alcohol consumption and diabetes with the severity of liver damage in patients with hepatitis C virus infection. Patients and methods: Retrospective study of 84 liver biopsies of patients with chronic infection with hepatitis C virus were studied. The pathological appearance was classified as stage I when chronic hepatitis with mild activity without fibrosis was observed; as stage II when moderate chronic hepatitis with mild fibrosis was observed and as stage III when there was a moderate chronic hepatitis with fibrosis or cirrhosis. The amount of steatosis and iron deposition in the biopsy were also assessed. Results: Forty one percent of patients were in stage I, 32% in stage II and 27% in stage III. Patients in stage I were younger than those in stages II and III (40.7 and 52.2 years respectively, p <0,001). No association between the severity of liver damage and the degree of steatosis, hemosiderosis, body mass index or alcohol intake, was observed. The frecuency of diabetes mellitus increased along with pathological staging (3, 15 and 30% in stages I, II and III, respectively, p <0,05). Conclusions: This study confirms that severity of chronic hepatitis C is associated with age and the presence of diabetes mellitus.