Atención integral por cuidados paliativos para pacientes con ventilación mecánica asistida SARS-CoV-2 severos y sus beneficios / Comprehensive care for palliative care for patients with severe SARS-CoV-2 assisted mechanical ventilation and its benefits

Resumen Objetivo. Esta investigación tiene como objetivo describir la población atendida y los beneficios del programa "Lineamiento de atención integral por Cuidados Paliativos en el Área de Salud de Palmares, para pacientes con SARS-CoV-2 severo" con ventilación mecánica asistida, hospitalizados en unidades de cuidados intensivos de la Caja Costarricense del Seguro Social durante la pandemia en Costa Rica, del 10 de junio al 31 de octubre del 2021. Métodos. Estudio descriptivo mixto de la población y los beneficios del programa por medio de indicadores cuantitativos obtenidos del informe de aplicación y cualitativos a través de la realización de una encuesta de satisfacción a usuarios en el período de estudio. Resultados. El programa atendió a 13 pacientes, brindó apoyo en manejo del duelo a los familiares de cinco pacientes que ya habían fallecido y a los cuidadores de ocho pacientes hospitalizados, también ofreció 70 consultas médicas en un período promedio de 62 días. La edad promedio de los pacientes fue de 55 años; doce pacientes presentaban algún factor de riesgo, siendo la obesidad y la falta de esquema de vacunación completo (dos dosis) los más frecuentes. Durante la implementación del programa fallecieron cinco pacientes más, obteniendo una tasa de mortalidad del 78%. A los pacientes que sobrevivieron se les atendió en promedio por 135 días. Con el apoyo del equipo, los pacientes lograron la recuperación clínica de las complicaciones respiratorias y funcionales. Lograron independencia total de actividades básicas de la vida diaria y reinserción social en menos de tres meses después del alta hospitalaria. En general, se documentó una percepción positiva del programa en el 100% de los usuarios, con cambios en el nivel de sufrimiento manifestado por las familias y el apoyo en el manejo del duelo. Conclusión. Con la optimización de uso de los recursos ya existentes en la Caja Costarricense del Seguro Social y la participación social, este programa abordó aspectos no atendidos previamente para los pacientes que sufrieron COVID 19 severo, como el manejo del sufrimiento y/o duelo durante la hospitalización y al egreso. Además, el programa colaboró en la recuperación clínica y funcional de los usuarios sobrevivientes y documentó múltiples beneficios percibidos por el paciente, sus familias, la institución y la sociedad, como el abordaje del sufrimiento, la adecuada atención al duelo, la organización de los recursos asistenciales y la pronta recuperación física, emocional y social del paciente sobreviviente.

Abstract Aim. This research aims to describe the population served and the benefits of the program "Guidelines for integral care for patients with severe SARS-CoV-2 by Palliative Care at the Area de Salud de Palmares " to patients with assisted mechanical ventilation, hospitalized in intensive care units of the Caja Costarricense del Seguro Social during the pandemic in Costa Rica, from June 10 to October 31, 2021. Methods. This study is a mixed descriptive investigation that analyzes quantitative indicators from the report on the program's application and qualitative indicators from a satisfaction survey for the users in the study period. Results. The program treated 13 patients, provided grief management support to the relatives of five patients who had already died and to the caregivers of eight hospitalized patients, and offered 70 medical consultations in an average period of 62 days. The average age of the patients was 55 years; twelve patients had some risk factors, and obesity and lack of a complete vaccination schedule (two doses) were the most frequent. During the program implementation, five more patients died, obtaining a mortality rate of 78%. The average treatment day for surviving patients was 135 days. Through the team's support, patients accomplished clinical recovery from respiratory and functional complications. They got independent basics activities of daily living and social reintegration in less tan three months after discharge. A positive perception of the program was documented in 100% of the program's users, with changes in the level of suffering manifested by the families and the support in grief management. Conclusion. With the optimization of the use of existing resources in the the Caja Costarricense del Seguro Social and the social participation, this program addressed aspects not previously attended to patients who suffered severe COVID 19, such as the management of suffering and/or grief during hospitalization and upon discharge. In addition, the program helped in the clinical and functional recovery of the surviving users, and documented multiple benefits perceived by the patient, their families, the institution, and society, such as the approach to suffering, adequate bereavement care, organization of care resources, and early physical, emotional and social recovery of the survivor patient.

Expert consensus on late stage of critical care management / 中华内科杂志

We wished to establish an expert consensus on late stage of critical care (CC) management. The panel comprised 13 experts in CC medicine. Each statement was assessed based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) principle. Then, the Delphi method was adopted by 17 experts to reassess the following 28 statements. (1) ESCAPE has evolved from a strategy of delirium management to a strategy of late stage of CC management. (2) The new version of ESCAPE is a strategy for optimizing treatment and comprehensive care of critically ill patients (CIPs) after the rescue period, including early mobilization, early rehabilitation, nutritional support, sleep management, mental assessment, cognitive-function training, emotional support, and optimizing sedation and analgesia. (3) Disease assessment to determine the starting point of early mobilization, early rehabilitation, and early enteral nutrition. (4) Early mobilization has synergistic effects upon the recovery of organ function. (5) Early functional exercise and rehabilitation are important means to promote CIP recovery, and gives them a sense of future prospects. (6) Timely start of enteral nutrition is conducive to early mobilization and early rehabilitation. (7) The spontaneous breathing test should be started as soon as possible, and a weaning plan should be selected step-by-step. (8) The waking process of CIPs should be realized in a planned and purposeful way. (9) Establishment of a sleep-wake rhythm is the key to sleep management in post-CC management. (10) The spontaneous awakening trial, spontaneous breathing trial, and sleep management should be carried out together. (11) The depth of sedation should be adjusted dynamically in the late stage of CC period. (12) Standardized sedation assessment is the premise of rational sedation. (13) Appropriate sedative drugs should be selected according to the objectives of sedation and drug characteristics. (14) A goal-directed minimization strategy for sedation should be implemented. (15) The principle of analgesia must be mastered first. (16) Subjective assessment is preferred for analgesia assessment. (17) Opioid-based analgesic strategies should be selected step-by-step according to the characteristics of different drugs. (18) There must be rational use of non-opioid analgesics and non-drug-based analgesic measures. (19) Pay attention to evaluation of the psychological status of CIPs. (20) Cognitive function in CIPs cannot be ignored. (21) Delirium management should be based on non-drug-based measures and rational use of drugs. (22) Reset treatment can be considered for severe delirium. (23) Psychological assessment should be conducted as early as possible to screen-out high-risk groups with post-traumatic stress disorder. (24) Emotional support, flexible visiting, and environment management are important components of humanistic management in the intensive care unit (ICU). (25) Emotional support from medical teams and families should be promoted through"ICU diaries"and other forms. (26) Environmental management should be carried out by enriching environmental content, limiting environmental interference, and optimizing the environmental atmosphere. (27) Reasonable promotion of flexible visitation should be done on the basis of prevention of nosocomial infection. (28) ESCAPE is an excellent project for late stage of CC management.

Monitorización hemodinámica integrada: clínica, gasométrica y ecocardiográfica / Integrated hemodynamic monitoring: clinical, gasometric and echocardiographic / Monitorização hemodinâmica integrada: clínica, gasométrica e ecocardiográfica

Introducción: la monitorización hemodinámica constituye un conjunto de técnicas y parámetros que permiten valo rar si la función cardiovascular es la adecuada para mantener la perfusión y la oxigenación tisular que permita sa tisfacer las demandas metabólicas del organismo, valorar el estado y el comportamiento del sistema cardiovascular, orientando sobre la mejor estrategia terapéutica. La presente revisión busca proporcionar una descripción general e integrada de las diferentes técnicas de monitorización, así como aspectos fisiológicos relevantes para su entendi miento y empleo terapéutico. La monitorización hemodinámica acompañada de un adecuado conocimiento de la fisiología cardiovascular permite determinar el estado del sistema cardiovascular, la condición hemodinámica del paciente y la estrategia terapéutica requerida. Su interpretación debe partir de la integración y la correlación de diversos parámetros hemodinámicos.

Introduction: hemodynamic monitoring is a set of techniques and parameters that allow evaluating whether cardio vascular function is adequate to maintain tissue perfusion and oxygenation to satisfy metabolic demands of the or ganism, assess the condition and behavior of the cardiovascular system, providing guidance on the best therapeutic strategy. This review seeks to provide a general and integrated description of the different monitoring techniques, as well as physiological aspects relevant to their understanding and therapeutic use. Hemodynamic monitoring accompanied by an adequate knowledge of cardiovascular physiology allows to determine the state of the cardiovascular system, hemodynamic condition of the patient and therapeutic strategy required, its interpretation must start from the integration and correlation of different hemodynamic parameters.

Introdução: a monitorização hemodinâmica constitui um conjunto de técnicas e parâmetros que permitem avaliar se a função cardiovascular é adequada para manter a perfusão e oxigenação tecidual que permite satisfazer as exi gências metabólicas do organismo, avaliar o estado e comportamento do sistema cardiovascular, orientando sobre a melhor estratégia terapêutica. Esta revisão procura fornecer uma descrição geral e integrada das diferentes técnicas de monitorização, bem como aspectos fisiológicos relevantes para a sua compreensão e utilização terapêutica. A monitorização hemodinâmica acompanhada de um conhecimento adequado da fisiologia cardiovascular permite determinar o estado do sistema cardiovascular, a condição hemodinâmica do doente e a estratégia terapêutica neces sária, a sua interpretação deve partir da integração e correlação de vários parâmetros hemodinâmicos.

Encuesta sobre usos y prácticas de Doppler transcraneal en pacientes neurocríticos en unidades de cuidados intensivos pediátricos de Argentina / Survey on the use and practice of transcranial Doppler ultrasound in neurocritical patients in pediatric intensive care Units in Argentina

Introducción. El uso del Doppler transcraneal (DTC) en pacientes neurocríticos se reporta cada vez más en las terapias intensivas pediátricas. El objetivo de esta encuesta es conocer los usos y prácticas del DTC en la atención neurocrítica y el proceso de formación del personal que realiza el estudio. Materiales y métodos. Encuesta a profesionales de 23 unidades de terapia intensiva pediátrica de Argentina. Resultados. Porcentaje de respuesta del 86 %. Se utilizó en sospecha de muerte encefálica (n = 20), trauma de cráneo (n = 16) y accidente cerebrovascular (n = 16). El intensivista pediátrico es quien realiza los estudios (n = 13/20). Los encuestados utilizan el Doppler para decidir conductas y tratamientos, comenzar el proceso de evaluación de muerte encefálica, solicitar tomografía de cerebro y manejar la presión de perfusión cerebral con vasopresores. Conclusión. Todos los encuestados utilizan los hallazgos del DTC para guiar tratamientos o conductas. La mitad de los encuestados está poco conforme con la capacitación recibida.

Introduction. The use of transcranial Doppler (TCD) ultrasoundin neurocritical patients is reported to be increasingly common in pediatric intensive care units. The objective of this survey was to know about the use and practice of TCD ultrasound in neurocritical care and the training process of staff members performing it. Materials and methods. Survey administered to providers from 23 pediatric intensive care units of Argentina. Results. The percentage of response was 86%. TCD ultrasound was used for suspected brain death (n = 20), head injury (n = 16), and stroke (n = 16). Pediatric intensivists perform the test (n = 13/20). Surveyed participants use TCD ultrasound to decide on treatment and management, start brain death assessment, request brain computed tomography, and manage cerebral perfusion pressure with vasopressors. Conclusion. All surveyed participants use TCD ultrasound findings to guide management or treatments. Half of surveyed participants are little satisfied with their training.

Un desafío sanitario en la gestión del servicio de medicina crítica de un hospital del Ecuador: Vivencias en la pandemia COVID-19 / A health challenge in the management of the critical medicine service of a hospital in Ecuador: Experiences in the COVID-19 pandemic

El SARS COV 2, tomó por sorpresa al mundo, con impacto en el sector salud, generándose una gran crisis sanitaria, golpeados por escasez de insumos, de equipos, de personal y capacidad instalada insuficiente para la atención de la contigencia. Ademas, la infodemia, el pánico y el miedo con sus respectivas consecuencias, se empodero de la sociedad civil, situación que no es ajena a sector salud, por ello, este relato de experiencia tuvo objetivo describir la gestión del servicio de medicina crítica de un hospital de Guayaquil- Ecuador durante la pandemia por el Coronavirus. En los centros asitenciales, el personal se enfrenta all desafío sanitario, principalmente en la gestión del servicio de medicina crítica. Al ser nombrado hospital centinela, con una capacidad instadala redujo de 494 a 200 camas, y se creó además el área de hospitalización de infectología; La interrelación de profesionales de la enfermería, médicos infectólogos, médicos neumólogos, servicios de terapia física y rehabilitación, servicios de nutrición, y los terapistas respiratorios, fue fundamental para afrontar la crisis, para vela por el bienestar del paciente, no solo en la parte física, sino psicología y de humanización. No obtante, el miedo a lo desconocido inherente a la especie humana, se transforma en pánico ante esta enfermedad provocando emociones, sentimientos, vivencias exacerbadas, y la inseguridad y desconfianza en que el sistema sanitario(AU)

SARS COV 2 took the world by surprise, with an impact on the health sector, generating a major health crisis, hit by a shortage of supplies, equipment, personnel and insufficient installed capacity for contingency care. In addition, the infodemic, panic and fear with their respective consequences, empowered civil society, a situation that is not unrelated to the health sector, therefore, this experience report aimed to describe the management of the critical medicine service of a Guayaquil-Ecuador hospital during the Coronavirus pandemic. In care centers, the staff faces the health challenge, mainly in the management of the critical medicine service. Being named a sentinel hospital, with an installed capacity it was reduced from 494 to 200 beds, and the infectious disease hospitalization area was also created; The interrelation of nursing professionals, infectious disease doctors, pulmonologists, physical therapy and rehabilitation services, nutrition services, and respiratory therapists, was essential to face the crisis, to ensure the well-being of the patient, not only in the physics, but psychology and humanization. However, the fear of the unknown inherent in the human species is transformed into panic in the face of this disease, causing emotions, feelings, exacerbated experiences, and insecurity and distrust in the health system(Au)

Avaliação do aporte proteico e de indicadores antropométricos no desfecho clínico de pacientes críticos / Evaluation of protein support and anthropometric indicators in the clinical outcome of critical patients

A terapia nutricional é uma das intervenções terapêuticas mais utilizadas em cuidados intensivos, quando aplicada de forma correta auxilia na diminuição de complicações metabólicas, no equilíbrio imunológico, além de amenizar a perda de massa corporal do paciente gravemente enfermo. Objetivo: avaliar a associação dos indicadores antropométricos e o consumo proteico com o desfecho clínico de pacientes críticos em uso de terapia nutricional enteral (TNE) exclusiva. Materiais e Métodos: Trata-se de um estudo prospectivo de caráter observacional analítico, com a utilização de dados de pacientes adultos e idosos em uso exclusivo de TNE desenvolvido em uma Unidade de Terapia Intensiva (UTI). Realizado por meio da coleta de dados secundários registrados nos prontuários de pacientes ≥ 18 anos, que receberam terapia nutricional enteral exclusiva por pelo menos 72 horas. Utilizou-se os indicadores antropométricos índice de massa corporal (IMC) e circunferência do braço. Para a estimativa das necessidades proteicas, considerou-se a recomendação da American Society for Parenteral and Enteral Nutrition. A adequação nutricional foi realizada por meio da coleta diária do volume da formula enteral prescrita e administrada. Nas análises utilizaram-se testes paramétricos e não paramétricos e foi considerado significante p < 0,05. Resultado: Participaram do estudo 52 pacientes que estiveram em uso de nutrição enteral exclusiva internados na UTI no hospital por pelo menos de 72 horas durante a etapa de coleta de dados. Desses pacientes a maioria era do sexo masculino (76,9%), com idade média de 45,7 anos (DP=15,0, mínimo 20 e máximo 71). O tempo de internação médio foi de 12 dias. Os diagnósticos de AIDS (síndrome da imunodeficiência adquirida) (46,1%) e COVID-19 (13,4%) foram os mais prevalentes. Foram identificados que quase 60% da amostra não tinham comorbidades e o desfecho clínico mais frequente foi a alta hospitalar. Conclusão: Neste estudo não foi verificado associações entre os desfechos clínicos avaliados (alta ou óbito) com o aporte proteico ofertado e os indicadores antropométricos, assim também como não tiveram entre as variáveis demográficas e clínicas investigadas

Nutritional therapy is one of the most used therapeutic interventions in intensive care, when correctly applied, it helps to reduce metabolic complications, immune balance, in addition to mitigating the loss of body mass in seriously ill patients. Objective: to evaluate the association of anthropometric indicators and protein consumption with the clinical outcome of critically ill patients using exclusive enteral nutritional therapy (EN). Materials and Methods: This is a prospective, observational, analytical study, using data from adult and elderly patients exclusively using EN developed in an Intensive Care Unit (ICU). Performed by collecting secondary data recorded in the medical records of patients ≥ 18 years old, who received exclusive enteral nutritional therapy for at least 72 hours. Anthropometric indicators body mass index (BMI) and arm circumference were used. For the estimation of protein requirements, the recommendation of the American Society for Parenteral and Enteral Nutrition was considered. Nutritional adequacy was performed through the daily collection of the volume of the prescribed and administered enteral formula. Parametric and non-parametric tests were used in the analyses, and p < 0.05 was considered significant. Result: The study included 52 patients who had been using exclusive enteral nutrition and were hospitalized in the ICU for at least 72 hours during the data collection stage. Of these patients, the majority were male (76.9%), with a mean age of 45.7 years (SD=15.0, minimum 20 and maximum 71). The mean hospital stay was 12 days. The diagnoses of AIDS (acquired immunodeficiency syndrome) (46.1%) and COVID-19 (13.4%) were the most prevalent. It was identified that almost 60% of the sample had no comorbidities and the most frequent clinical outcome was hospital discharge. Conclusion: In this study, there were no associations between the evaluated clinical outcomes (discharge or death) with the protein intake offered and the anthropometric indicators, as well as they did not have between the demographic and clinical variables investigated

Protocolo para realizar la traqueostomía en pacientes con COVID-19 / A Protocol for Performing Tracheostomy in Patients with COVID-19

Introducción: Los cirujanos pueden desempeñar un papel valioso en la realización de traqueostomía para apoyar a los equipos de cuidados críticos durante la pandemia global de la COVID-19. Objetivo: Diseñar un protocolo para realizar la traqueostomía en pacientes con la COVID-19. Métodos: Se realizó un estudio descriptivo durante el periodo de marzo a diciembre del año 2020 en el Hospital "Comandante Manuel Fajardo Rivero", de Santa Clara, Villa Clara. Se emplearon como métodos teóricos: el análisis-síntesis e inductivo-deductivo; y como empíricos: análisis documental, grupo nominal y el criterio de especialistas para la valoración del producto diseñado. Resultados: El protocolo fue estructurado en: título, propósito, normas organizativas institucionales, indicaciones, procedimiento de actuación y evaluación. Según el criterio de los especialistas consultados el protocolo diseñado, es pertinente, factible y válido. Conclusiones: Para el diseño del protocolo fue fundamental aplicar y adaptar cuidadosamente la mejor evidencia existente sobre la realización de la traqueostomía. Su estructura permite brindar la mejor atención al paciente con la COVID-19 al tiempo que protege al equipo quirúrgico(AU)

Introduction: Surgeons can play a valuable role in performing tracheostomy, as a support for critical care teams during the global COVID-19 pandemic. Objective: To design a protocol for performing the tracheostomy in patients with COVID-19. Methods: A descriptive study was carried out, during the period from March to December 2020, at Comandante Manuel Fajardo Rivero Hospital, in Santa Clara City, Villa Clara Province. The following theoretical methods were used: analysis-synthesis and inductive-deductive; as well as empirical ones: documentary analysis, nominal group and criteria of specialists for the evaluation of the designed product. Results: The protocol was structured into title, purpose, institutional organizational norms, indications, procedure of action and evaluation. According to the criteria of the specialists consulted, the designed protocol is pertinent, feasible and valid. Conclusions: For the design of the protocol, it was essential to apply and adapt, carefully, the best existing evidence on tracheostomy performance. Its structure allows to provide the best care to the patient with COVID-19 while protecting the surgical team(AU)

Infección nosocomial en Cuidados Intensivos del Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández, de Matanzas / Nosocomial infection in the Intensive Care Unit of the Teaching Clinic-Surgical Hospital Faustino Pérez Hernández, of Matanzas

RESUMEN Introducción: la diseminación de microorganismos multirresistentes en el hospital, constituye un importante problema epidemiológico y terapéutico que afecta especialmente a pacientes de la Unidad de Cuidados Intensivos. Objetivo: escribir el comportamiento de las infecciones nosocomiales y la resistencia antimicrobiana en la Unidad de Cuidados Intensivos. Materiales y métodos: se realizó un estudio de tipo descriptivo, observacional y prospectivo en la Unidad de Cuidados Intensivos del Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández, durante el primer semestre de 2020. El universo estuvo constituido por 102 pacientes que ingresaron en la Unidad de Cuidados Intensivos en el período estudiado, a los que se les realizó estudios microbiológicos. Las variables analizas fueron: causas de ingreso, edad, infecciones nosocomiales, neumonía en ventilados, gérmenes, resistencia antimicrobiana y mortalidad. Se expresaron en tablas y gráficos porcentuales. Resultados: el sexo masculino presentó mayor número de infección nosocomial respecto al femenino, en edades diferentes de la vida. La causa más frecuente de ingreso fue el politrauma. El sitio más común de infección nosocomial fue la vía respiratoria. Predominaron gérmenes como los bacilos gramnegativos fermentadores y las enterobacterias. Antibióticos como los inhibidores de las betalactamasas, otras penicilinas, quinolonas, cefalosporinas, aminoglucósidos y meropenen han adquirido un mayor porciento de resistencia. Conclusiones: la infección nosocomial por bacterias multirresistentes a los antibióticos estratégicos, es un problema dentro de la Unidad de Cuidados Intensivos asociado a la ventilación mecánica, que provoca una elevada mortalidad (AU).

ABSTRACT Introduction: the spread of multi-resistant microorganisms in the hospital is a major epidemiological and therapeutic problem that particularly affects critical patients admitted to the Intensive Care Unit. Objective: to describe the behavior of nosocomial infections and antimicrobial resistance in the Intensive Care Unit. Materials and Methods: a descriptive, observational and prospective study was carried out in the Intensive Care Unit of the Teaching Clinic-Surgical Hospital Faustino Pérez Hernández, during the first half of 2020. The universe was formed by 102 patients who entered the Intensive Care Unit during the studied period, to whom microbiological studies were carried out. The analyzed variables were the following: causes of admission, age, nosocomial infections, ventilator-associated pneumonia, germs, antimicrobial resistance and mortality. The results were expressed in tables and percentage charts. Results: Male sex showed the highest number of nosocomial infection compared to the female, at different ages of life. The most common cause of admission was polytrauma. The most common site of nosocomial infection was the airway. Germs like fermentative Gram-negative bacilli and enterobacteria predominated. Antibiotics such as beta-lactamase inhibitors, other kinds of penicillin, quinolones, cephalosporin, aminoglycosides and meropenen have acquired a higher percent of resistance. Conclusions: nosocomial infection caused by bacteria that have developed multi-resistance to strategic antibiotics is a problem within the Intensive Care Unit, associated to mechanical ventilation, and leads to high mortality (AU).

Subfenótipos baseados em dados clínicos de beira-leito de pacientes críticos com COVID-19: um estudo de coorte / Bedside clinical data subphenotypes of critically ill COVID-19 patients: a cohort study

RESUMO Objetivo: Identificar apresentações mais graves de COVID-19. Métodos: Pacientes consecutivamente admitidos à unidade de terapia intensiva foram submetidos à análise de clusters por meio de método de explorações sequenciais Resultados: Analisamos os dados de 147 pacientes, com média de idade de 56 ± 16 anos e Simplified Acute Physiological Score 3 de 72 ± 18, dos quais 103 (70%) demandaram ventilação mecânica e 46 (31%) morreram na unidade de terapia intensiva. A partir do algoritmo de análise de clusters, identificaram-se dois grupos bem definidos, com base na frequência cardíaca máxima [Grupo A: 104 (IC95% 99 - 109) batimentos por minuto versus Grupo B: 159 (IC95% 155 - 163) batimentos por minuto], frequência respiratória máxima [Grupo A: 33 (IC95% 31 - 35) respirações por minuto versus Grupo B: 50 (IC95% 47 - 53) respirações por minuto] e na temperatura corpórea máxima [Grupo A: 37,4 (IC95% 37,1 - 37,7)ºC versus Grupo B: 39,3 (IC95% 39,1 - 39,5)ºC] durante o tempo de permanência na unidade de terapia intensiva, assim como a proporção entre a pressão parcial de oxigênio no sangue e a fração inspirada de oxigênio quando da admissão à unidade de terapia intensiva [Grupo A: 116 (IC95% 99 - 133) mmHg versus Grupo B: 78 (IC95% 63 - 93) mmHg]. Os subfenótipos foram distintos em termos de perfis inflamatórios, disfunções orgânicas, terapias de suporte, tempo de permanência na unidade de terapia intensiva e mortalidade na unidade de terapia intensiva (com proporção de 4,2 entre os grupos). Conclusão: Nossos achados, baseados em dados clínicos universalmente disponíveis, revelaram dois subfenótipos distintos, com diferentes evoluções de doença. Estes resultados podem ajudar os profissionais de saúde na alocação de recursos e seleção de pacientes para teste de novas terapias.

Abstract Objective: To identify more severe COVID-19 presentations. Methods: Consecutive intensive care unit-admitted patients were subjected to a stepwise clustering method. Results: Data from 147 patients who were on average 56 ± 16 years old with a Simplified Acute Physiological Score 3 of 72 ± 18, of which 103 (70%) needed mechanical ventilation and 46 (31%) died in the intensive care unit, were analyzed. From the clustering algorithm, two well-defined groups were found based on maximal heart rate [Cluster A: 104 (95%CI 99 - 109) beats per minute versus Cluster B: 159 (95%CI 155 - 163) beats per minute], maximal respiratory rate [Cluster A: 33 (95%CI 31 - 35) breaths per minute versus Cluster B: 50 (95%CI 47 - 53) breaths per minute], and maximal body temperature [Cluster A: 37.4 (95%CI 37.1 - 37.7)°C versus Cluster B: 39.3 (95%CI 39.1 - 39.5)°C] during the intensive care unit stay, as well as the oxygen partial pressure in the blood over the oxygen inspiratory fraction at intensive care unit admission [Cluster A: 116 (95%CI 99 - 133) mmHg versus Cluster B: 78 (95%CI 63 - 93) mmHg]. Subphenotypes were distinct in inflammation profiles, organ dysfunction, organ support, intensive care unit length of stay, and intensive care unit mortality (with a ratio of 4.2 between the groups). Conclusion: Our findings, based on common clinical data, revealed two distinct subphenotypes with different disease courses. These results could help health professionals allocate resources and select patients for testing novel therapies.

Renal replacement therapy by the popliteal vein in a critical patient with COVID-19 in the prone position / Terapia renal substitutiva pela veia poplítea em paciente crítico com COVID-19 na posição de pronação

Abstract This patient was a 73-year-old man who initially came to our service with acute respiratory failure secondary to COVID-19. Soon after hospitalization, he was submitted to orotracheal intubation and placed in the prone position to improve hypoxia, due to severe acute respiratory syndrome (SARS). On the third day of hospitalization, he developed acute oliguric kidney injury and volume overload. The nephrology service was activated to obtain deep venous access for renal replacement therapy (RRT). The patient could not be placed in the supine position due to significant hypoxemia. A 50-cm Permcath (MAHURKARTM, Covidien, Massachusetts, USA) was inserted through the left popliteal vein. This case report describes a possible challenging scenario that the interventional nephrologist may encounter when dealing with patients with COVID-19 with respiratory impairment in the prone position.

Resumo O paciente era um homem de 73 anos de idade que inicialmente veio ao nosso serviço com insuficiência respiratória aguda secundária à COVID-19. Logo após a internação, ele foi submetido à intubação orotraqueal e pronado para melhorar a hipóxia devido à síndrome respiratória aguda grave (SARS - do inglês "severe acute respiratory syndrome"). No terceiro dia de internação, o mesmo desenvolveu lesão renal aguda oligúrica e sobrecarga de volume. O serviço de nefrologia foi acionado para realizar acesso venoso profundo para terapia renal substitutiva (TRS). O paciente não pôde ser colocado na posição de decúbito dorsal devido a uma hipoxemia significativa. Um Permcath de 50 cm (MAHURKARTM, Covidien, Massachusetts, EUA) foi inserido através da veia poplítea esquerda. Este relato de caso descreve um possível cenário desafiador com o qual o nefrologista intervencionista pode se deparar ao lidar com pacientes com COVID-19 com problemas respiratórios e colocados em pronação.

Perfil epidemiológico de crianças e adolescentes queimados internados em um hospital público de Goiânia / Epidemiological profile of burned children and adolescents hospitalized in a public hospital in Goiânia

OBJETIVO: Identificar o perfil epidemiológico de crianças e adolescentes queimados internados em um hospital público de Goiânia e verificar se há relação entre a superfície corporal queimada (SQC) e a redução de amplitude de movimento (ADM), necessidade de unidade de terapia intensiva (UTI), óbito e causa da queimadura. MÉTODO: Este é um estudo transversal, foram coletados dados retrospectivos de indivíduos entre 0 e 17 anos que tiveram queimaduras e foram internados na enfermaria ou UTI, no período de janeiro de 2015 a dezembro de 2019. RESULTADOS: A amostra foi composta por 55 pacientes, mediana de idade de 12,25 anos, com predomínio de adolescentes (72,7%) do sexo masculino (65,5%). As principais causas de queimaduras foram líquidos inflamáveis (32,7%), chamas diretas (29,1%) e escaldaduras (21,8%). As escaldaduras foram identificadas como o principal agente causal das queimaduras nas crianças, e os líquidos inflamáveis nos adolescentes (p<0,01). Houve prevalência de queimaduras de 2° grau (85,5%), 54,6% dos pacientes tiveram a SQC >20%, sendo os membros superiores (78,2%) e inferiores (61,8%) as regiões corporais mais acometidas, 40% precisaram de UTI e 29,1% necessitaram de ventilação mecânica (VM). A taxa de óbito foi de 5,5%. Desbridamento (89,1%) e enxertia (41,8%) foram os procedimentos cirúrgicos mais realizados. A maior SQC associou-se com a redução da ADM, necessidade de UTI e óbito (p<0,05). CONCLUSÃO: As crianças de menor idade apresentaram queimaduras por escaldadura e os adolescentes foram mais propensos a se queimarem por líquido inflamável. A SQC associou-se com a redução da ADM, necessidade de UTI e óbito.

OBJECTIVE: To identify the epidemiological profile of children and adolescents burnt in a public hospital of Goiânia, Brazil, and to verify if there is a relationship between the total body surface area (TBSA) and reduced range of motion (ROM), the need for intensive care unit (ICU), death and cause of the burn. METHODS: This is a cross-sectional study, in which retrospective data was collected from burned individuals between 0 and 17 years hospitalized in the nursery or ICU from January 2015 to December 2019. RESULTS: The sample consisted of 55 patients with, a median age of 12.25 years, with a predominance of adolescents (72.7%) and males (65.5%). The main causes of burns were flammable liquids (32.7%), direct flames (29.1%), and scalding (21.8%). Scalding was identified as the main causal agent in children, and flammable liquids in adolescents (p<0.01). There was a prevalence of 2nd-degree burns (85.5%), 54.6% of the patients had TBSA >20%, with the upper limbs (78.2%) and lower limbs (61.8%) the most affected body regions, 40% needed ICU and 29.1% needed mechanical ventilation. The death rate was 5.5%. Debridement (89.1%) and grafting (41.8%) were the most commonly performed surgical procedures. Higher TBSA was associated with reduced ROM, need for ICU, and death (p<0.05). CONCLUSION: Younger children had scald burns and adolescents were more likely to be burnt by a flammable liquid. TBSA was associated with reduced ROM, need for ICU, and death.

Ultrassonografia da veia cava inferior na avaliação do volume intravascular e fluido-responsividade em pacientes críticos: uma revisão sistemática / Inferior vena cava ultrasound for assessing volume status and fluid responsiveness in critically ill patients: a systematic review

Fundamento: A avaliação do volume intravascular e da fluido-responsividade é uma condição desafiadora no manejo de pacientes críticos. Os métodos diagnósticos precisam garantir segurança, reprodutibilidade e praticidade no monitoramento hemodinâmico. Objetivo: Descrever a aplicabilidade dos índices ultrassonográficos da veia cava inferior na avaliação do volume intravascular e na predição da fluido-responsividade em pacientes críticos. Método: Trata-se de revisão sistemática realizada por meio das bases de dados PubMed®, Lilacs e SciELO nos 5 anos anteriores. Os descritores utilizados foram "inferior vena cava", "ultrasonography", "fluid-responsiveness" e "volume status". Resultados: Foram selecionados 13 artigos compatíveis com os objetivos deste estudo. O índice de colapsibilidade da veia cava inferior variou de 25% a 50% como ponto de corte para definição de hipovolemia. Além disso, apresentou aplicabilidade na predição da fluido-responsividade em pacientes sob respiração espontânea, com pontos de corte variando de 25% a 57%. Em cenários de ventilação mecânica, o índice de distensibilidade da veia cava inferior mostrou-se mais eficaz, quando comparado às demais medidas, para predição de fluido-responsividade, mas foi encontrada variação de 10,2% a 20,5%. O índice diâmetro da veia cava inferior/diâmetro da artéria aorta foi especialmente útil na população pediátrica para definição do volume intravascular, mas em adultos existiram muitas divergências quanto à sua aplicabilidade. Conclusão: A avaliação do volume intravascular e da fluido-responsividade por meio dos índices ultrassonográficos da veia cava inferior apresenta aplicabilidade e segurança no diagnóstico e no monitoramento da instabilidade hemodinâmica. Entretanto, são necessários estudos de padronização de valores em razão das divergências quanto aos pontos de corte utilizados em cada índice.(AU)

Telemedicina en las Unidades de Cuidados Intensivos Pediátricos: Desarrollo de una nueva modalidad asistencial / Telemedicinein Pediatric Intensive Care Units: Development of a new care model

Los Programas telemédicos entre unidades de cuidados intensivos han demostrado ser eficaces en el mundo. En Argentina realizamos el primer programa piloto entre una Unidad de Cuidados Intensivos Pediátricos de Buenos Aires (UCIP- BA) y Santiago del Estero (UCIP-S). En el presente trabajo describimos el desarrollo y la evaluación de una nueva modalidad de asistencia para el diagnóstico, tratamiento y seguimiento a distancia de los pacientes en UCIP. Se implementó un programa de atención sincrónica para pacientes internados y seleccionados por la UCIP-S. Se utilizó un sistema de videoconferencia y se realizó un seguimiento en conjunto de los pacientes. La evaluación se realizó con una encuesta de satisfacción de los usuarios. Ingresaron al estudio 29 pacientes, 72 % del sexo masculino. La edad promedio fue de 35 meses (2-168). El diagnóstico más frecuente fue shock séptico y el acompañamiento en el diagnóstico la conducta más frecuente. Solo cinco pacientes obitaron y se registraron 3 derivaciones al Hospital Garrahan. Se realizaron 155 teleconferencias y 396 consultas, con un tiempo promedio diario de 48 minutos, La media de seguimientos por pacientes fue de 20,6 días (2-107). Tele-UCI mejoró la capacidad de comprensión de la situación clínica (96%) y modificó la relación con la familia (65%). El modelo asistencial demostró un 88.5% de satisfacción. A través de estos resultados concluimos que según los profesionales participantes, Tele-UCI respaldó al equipo que se encarga del seguimiento diario de los pacientes, generando una disminución de traslados de pacientes (AU)

Telemedicine programs between intensive care units have proven effective worldwide. In Argentina we conducted the first pilot program between a Pediatric Intensive Care Unit in Buenos Aires (PICU- BA) and another in Santiago del Estero (PICU-S). In this study, we describe the development and evaluation of a new care modality for the diagnosis, treatment, and remote monitoring of patients in the PICU. A synchronous care program for inpatients selected by PICU-S was implemented. A videoconferencing system was used and patients were monitored together. The program was evaluated with a user satisfaction survey. Twenty-nine patients, 72% of the male sex, were included in the study. Mean age was 35 months (2-168). The most common diagnosis was septic shock and in the majority of cases the diagnosis was confirmed. Only five patients died and three were referred to Garrahan Hospital. Overall, 155 teleconferences and 396 consultations were conducted, with a mean daily time of 48 minutes. Mean monitoring time per patient was 20.6 days (2-107). Tele-ICU improved the ability to understand the clinical situation (96%) and changed the relationship with the family (65%). The care model showed an 88.5% satisfaction rate. Based on these results, we conclude that according to the participating professionals, TeleICU supported the team that is in charge of the daily monitoring of patients, leading to a decrease in patient transfers (AU)

Ultrassonografia Intervencionista para implantação e monitoramento de cateter venoso central de inserção periférica: scoping review / Ultrasonido intervencionista para implantación y monitorización de catéter venoso central insertado periféricamente: revisión del alcance / Interventional ultrasound for implantation and monitoring of peripherally inserted central venous catheter: scoping review

RESUMO Objetivo discutir as evidências disponíveis sobre uso de ultrassonografia na implantação/manutenção de cateter venoso central de inserção periférica no neonato crítico. Método scoping review, baseada nas recomendações de especialistas do Joanna Briggs Institute. Para identificar a questão de investigação foi seguida a versão PCC - Population, Concept and Context. As buscas foram realizadas entre janeiro e março de 2020, em três bases dados e no Google Scholar. Resultados das 354 publicações encontradas resultou uma amostra de 15 artigos, publicados em diversos países, entre 2016 e 2020, em inglês e português. A maioria evidenciava uso da ultrasound point of care (POCUS) para escolha do sítio venoso ou localização da ponta do cateter. Conclusão são necessários mais estudos, investigando a efetividade da POCUS na inserção/manutenção de cateter epicutâneo em neonatos críticos, para basear sua adoção como padrão ouro nesta clientela. O manejo por enfermeiros ainda é incipiente.

RESUMEN Objetivo discutir la evidencia disponible sobre el uso de el ultrasonido en la inserción y mantenimiento de catéteres venosos centrales de inserción periférica en neonatos críticos. Método esta revisión de alcance se basó en recomendaciones de expertos del Instituto Joanna Briggs. Se utilizó el enfoque de población, concepto y contexto (PCC) para identificar la pregunta de investigación. El estudio se realizó entre enero y marzo de 2020 en tres bases de datos y Google Scholar. Resultados en las 354 publicaciones encontradas se obtuvo una muestra de 15 artículos publicados en varios países entre 2016 y 2020, en inglés y portugués. La mayoría mostró que se usaba el punto de atención de ultrasonido (POCUS) para elegir el sitio venoso o ubicar la punta del catéter. Conclusión se necesitan más estudios para investigar la efectividad de POCUS en la inserción y mantenimiento de catéteres epicutáneos en neonatos críticos, para respaldar su adopción como el estándar de oro en esta clientela. El manejo por parte de enfermeras es aún incipiente.

ABSTRACT Objective to discuss the available evidence on the use of ultrasound in insertion and maintenance of peripherally inserted central venous catheters in critical neonates. Method this scoping review was based on recommendations by experts from the Joanna Briggs Institute. The population, concept and context (PCC) approach was used to identify the research question. The study was carried out between January and March 2020 in three databases and Google Scholar. Results a sample of 15 articles published in several countries between 2016 and 2020, in English and Portuguese, was obtained in the 354 publications found. Most showed ultrasound point of care (POCUS) being used to choose the venous site or locate the catheter tip. Conclusion further studies are needed to investigate the effectiveness of POCUS in insertion and maintenance of epicutaneous catheters in critical neonates, to support its adoption as the gold standard in this clientele. Handling by nurses is still incipient.

Depresión en ancianos graves con neumonía adquirida en la comunidad / Depression in seriously-ill elder people with community-acquired pneumonia

RESUMEN Introducción: aquellos países con alto grado de envejecimiento poblacional muestran asociaciones importantes con diferentes enfermedades, por ejemplo, la neumonía adquirida en la comunidad y la depresión en los ancianos. Objetivos: relacionar la depresión con la mortalidad y evaluar efectos de los antidepresivos, en los pacientes con neumonía adquirida en la comunidad, ingresados en la Unidad de Cuidados Intensivos del Hospital Militar Central "Dr. Carlos J. Finlay". Materiales y métodos: se realizó un estudio analítico, longitudinal prospectivo, con todos los pacientes con neumonía adquirida en la comunidad, ingresados en la Unidad de Cuidados Intensivos Emergentes, del Hospital Militar "Dr. Carlos J. Finlay". Periodo correspondiente a enero del 2018 hasta abril del 2019 que cumplieron con los criterios de inclusión. El universo lo constituyó 160 pacientes. Resultados: existieron 55 pacientes con síntomas de depresión previos al ingreso, (34 %). El 78 % de fallecidos presentaron depresión al ingreso. La edad media de los no deprimidos fue de 74, la más alta de los deprimidos fue de 80,80. No presentaron signos de depresión 93 pacientes vivos y 43 que la presentaron y fallecieron con una gran significación estadística p 0,000. RR 6,8. Se observó una marcada relación entre la mortalidad y el no recibir tratamiento para la depresión, (37) p 0,000. Conclusiones: la neumonía y la depresión son enfermedades que tienen una relación íntima. Esta asociación cuenta con una elevada mortalidad, así como el impacto del tratamiento antidepresivo en la evolución del paciente es definitorio en el ámbito de los cuidados intensivos (AU).

ABSTRACT Introduction: those countries with a high level of population ageing show important associations to different diseases, for example, community acquired pneumonia and depression in elder people. Objectives: to establish the relationship of depression with mortality and to evaluate the effect of antidepressants in patients with community-acquired pneumonia admitted in the Intensive Care Unit of the Central Military Hospital "Dr. Carlos J. Finlay". Materials and methods: a prospective, longitudinal, analytic study was carried out with all patients with community-acquired pneumonia, admitted in the Intensive Care Unit of the Central Military Hospital "Dr. Carlos J. Finlay" in the period from January 2018 until April 2019, who fulfilled the inclusion criteria. The universe were 160 patients. Results: there were 55 patients with depression symptoms before the admission. 78 % of the deceased showed depression at the admittance. The medium age of the non-depressed ones was 74 years; the highest age of the depressed ones was 80.80 years. 93 living patients did not present depression signs, and 43 presented them and died with a great statistical significance p: 0.000 RR: 6.8. A remarked relation was observed between mortality and not receiving treatment for depression (37) p 0,000. Conclusions: pneumonia and depression are diseases having a tight relationship. This association yields a high mortality, and the impact of the anti-depression treatment on the patient's evolution is defining in the intensive care settings (AU).

Validación externa del modelo predictivo de mortalidad en ancianos con neumonía adquirida en la comunidad / External validation of the predictive model of mortality in elder people with community-acquired pneumonia

RESUMEN Introducción: la neumonía adquirida en la comunidad es la enfermedad infecciosa que conlleva una mayor mortalidad en los países desarrollados. El diagnóstico pasa por varios momentos, el cuadro clínico, la analítica y las imágenes. Objetivos: realizar la validación externa de un modelo matemático predictivo de mortalidad en pacientes ingresados por neumonía grave adquirida en la comunidad. Material y métodos: estudio longitudinal prospectivo (cohorte) con un grupo, con todos los pacientes que ingresaron en la Unidad de Cuidados intensivos emergentes con el diagnóstico de neumonía adquirida en la comunidad en el Hospital Militar Dr. Carlos J. Finlay, de febrero de 2018 hasta marzo del 2019. El universo estuvo constituido por 160 pacientes y no se tomó muestra alguna. Resultados: índice de Kappa K=1. Test Hosmer Lemenshow 0,650 con elevado ajuste. Resultados del modelo con sensibilidad= 79%. Especificidad: 91% con (VPP): 80 y (VPN)= 91. RR: 9,1. Área bajo la Curva = 0997. Porcentaje de aciertos en la regresión logística de 88,4 %. Conclusiones: el modelo propuesto constituyo una herramienta útil en la detección temprana de pacientes con riesgo de muerte a corto plazo. Permitió unificar en una sola variable el resultado de otras que aparentemente no tienen relación entre ellas; con lo que se hace más fácil la interpretación de los resultados, toda vez que este refleja, el conjunto y no la individualidad (AU).

SUMMARY Introduction: community-acquired pneumonia is the infectious disease leading to higher mortality in developed countries. The diagnosis goes through several moments, clinical symptoms, analytics, and images. Objective: to perform the external validation of a predictive mathematical model of mortality in patients admitted by serious community-acquired pneumonia. Methods: longitudinal prospective (cohort) study with a group formed with all patients who were admitted to the Emergent Intensive Care Unit in the Military Hospital ¨Dr. Carlos Juan Finlay¨ with the diagnosis of community-acquired pneumonia, from February 2018 to March 2019. The universe was formed by 160 patients and no sample was chosen. Results: Kappa index K= 1. Hosmer Lemenshow test= 0.650 with a high adjustment. Result of the model with sensibility= 79 %. Specificity= 91 % with (APV) = 80 and (NPV) = 91. RR= 9.1. Area under the curve= 0997. Percentage of correctness in logistic regression of 88.4 %. Conclusions: The proposed model was a useful tool in the early detection of patients at near-term death risk. It allowed to unite in an only variant the result of others that apparently are not related one to another, making it easier the interpretation of the results, since it reflects the whole and not the individuality (AU).

Caracterización del síndrome compartimental abdominal en pacientes críticos / Characterization of abdominal compartment syndrome in critical patients

RESUMEN Introducción: el síndrome compartimental abdominal es una entidad clínica sistémica desencadenada por incremento en la presión intraabdominal, caracterizada clínicamente por distensión abdominal y alteraciones de las funciones respiratoria, cardiovascular, neurológica y renal. Objetivo: caracterizar el comportamiento del síndrome compartimental abdominal en los pacientes críticos que ingresaron en la unidad de cuidados intensivos del Hospital Provincial "José Ramón López Tabrane". Materiales y método: se realizó un estudio prospectivo, descriptivo, y longitudinal que tuvo como universo los pacientes adultos con factores de riesgo conocidos para síndrome compartimental abdominal, tratados entre enero de 2014 a diciembre de 2015. Se le realizó medición sistemática de la presión intraabdominal transvesical y fueron sometidos a descompresión quirúrgica en caso de hipertensión intraabdominal grados III y IV. Resultados: los valores de presión intraabdominal sostenidamente elevados, son directamente proporcionales al desarrollo del síndrome compartimental abdominal y trae aparejado disfunciones en los diferentes sistemas de órganos; en estos casos apareció complicaciones, las cuales se presentaron combinadas para todos los pacientes, y fueron mayoritarias para el grupo con presión intraabdominal grado IV. La mortalidad se comportó en un número bastante elevado lo cual estuvo relacionado con los niveles de presión intraabdominal, así como la posibilidad de que fueran reintervenidos quirúrgicamente estos pacientes. Conclusiones: se debe protocolizar en todo paciente con sospecha de desarrollar un síndrome compartimental abdominal la medición periódica de la presión intraabdominal (AU).

SUMMARY Introduction: the abdominal compartment syndrome is a systemic clinical entity triggered by an increase of the intra abdominal pressure, clinically characterized by abdominal distension and the alteration of the renal, neurological, cardiovascular and respiratory functions. Objective: to characterize the behavior of the abdominal compartment syndrome in critical patients from the intensive care unit of the provincial hospital "Jose Ramon Lopez Tabrane". Materials and methods: a longitudinal, descriptive and prospective study was carried out in a universe of adult patients with risk factors known as abdominal compartment syndrome, treated in the period of time from January 2014 to December 2015. Their transvesical intraabdominal pressure was systematically measured and they underwent surgical decompression in cases of intraabdominal hypertension grades iii and iv. Results: the values of intraabdominal pressure steadily increased are directly proportional to the development of the abdominal compartment syndrome and entails dysfunctions in the different systems of organs; in these cases complications were found, that were combined for all patients and mainly in the group with intraabdominal pressure grade iv. Mortality was present in a certainly increased group, and was related to the levels of intraabdominal pressure, and also to the possibility these patients undergoing surgical treatments again. Conclusions: it should be standardized the periodical measure of the intraabdominal pressure in any patient suspected of developing an abdominal compartment syndrome (AU).