Guías éticas para la atención durante la pandemia COVID-19: Recomendaciones multisocietarias para asignación de recursos / Ethical guides, criteria for admission in intensive care, palliative care. Multi-society recommendations for allocation of resources during the COVID-19 pandemic

Se presentan las guías sobre ética de asignación de recursos, procesos de triaje con criterios de ingreso y egreso de unidades de cuidados críticos y atención paliativa durante la pandemia. El panel interdisciplinario y multisocietario que las preparó estuvo representado por bioeticistas y por especialistas vinculados al fin de la vida: clínicos, geriatras, emergentólogos, intensivistas, expertos en cuidados paliativos y en reanimación cardiopulmonar. La información disponible indica que aproximadamente 80% de las personas con COVID-19 desarrollarán síntomas leves y no requerirán asistencia hospitalaria, mientras que 15% precisará cuidados intermedios o en salas generales, y el 5% restante requerirá de asistencia en unidades de cuidados intensivos. La necesidad de pensar en justicia y establecer criterios éticos de asignación surgen en condiciones de superación de los recursos disponibles, como en brotes de enfermedades y pandemias, siendo la transparencia el principal criterio para la asignación. Estas guías recomiendan criterios generales de asignación de recursos en base a consideraciones bioéticas, enraizadas en los Derechos Humanos y sustentadas en el valor de la dignidad de la persona humana y principios sustanciales como la solidaridad, la justicia y la equidad. Las guías son recomendaciones de alcance general y su utilidad consiste en acompañar y sostener las decisiones técnicas y científicas que tomen los distintos especialistas en la atención del paciente crítico, pero dado el carácter dinámico de la pandemia, debe asegurarse un proceso de revisión y readaptación permanente de las recomendaciones.

Guidelines on resource allocation, ethics, triage processes with admission and discharge criteria from critical care and palliative care units during the pandemia are here presented. The interdisciplinary and multi-society panel that prepared these guidelines represented by bioethicists and specialists linked to the end of life: clinicians, geriatricians, emergentologists, intensivists, and experts in palliative care and cardiopulmonary resuscitation. The available information indicates that approximately 80% of people with COVID-19 will develop mild symptoms and will not require hospital care, while 15% will require intermediate or general room care, and the remaining 5% will require assistance in intensive care units. The need to think about justice and establish ethical criteria for allocation patients arise in conditions of exceeding available resources, such as outbreaks of diseases and pandemics, with transparency being the main criterion for allocation. These guides recommend general criteria for the allocation of resources relies on bioethical considerations, rooted in Human Rights and based on the value of the dignity of the human person and substantial principles such as solidarity, justice and equity. The guides are recommendations of general scope and their usefulness is to accompany and sustain the technical and scientific decisions made by the different specialists in the care of critically ill patients, but given the dynamic nature of the pandemic, a process of permanent revision and adaptation of recommendations must be ensured.

Función barorrefleja y variabilidad de la presión arterial evaluadas desde el consultorio clínico / Baroreflex function and blood pressure variability evaluated in the clinical consulting room

La variabilidad de la frecuencia cardíaca (FC) y de la presión arterial (PA) se evalúan por lo general mediante Holter y monitorización ambulatoria de la presión arterial (MAPA). Estos exámenes no se encuentran disponibles generalmente en el medio hospitalario. Objetivo: Evaluar los parámetros de la función barorrefleja determinada por electrocardiograma basal y durante la realización de la maniobra de Valsalva (MV), con los indicadores de variabilidad de FC por Holter y PA por MAPA. Métodos: Estudio transversal, observacional. Se incluyeron prospectivamente pacientes adultos, sin enfermedades ni utilización de fármacos que modifiquen la FC o la PA. Se realizó electrocardiograma (ECG) basal de 10 s. La respuesta cronotrópica se evaluó mediante MV estandarizada registrada en ECG. Se realizaron MAPA y Holter de 12 horas. Resultados: Se estudiaron 50 pacientes, observándose que el SDNN del ECG de 10 sy la variación de la FC intra/previa a la MV podrían resultar de utilidad para estimar el valor del SDNN del Holter, parámetro asociado con hipofunción barorrefleja y aumento de riesgo vascular. En cuanto a la PA, no pudo demostrarse mayor variabilidad de PA sistólica por MAPA en los pacientes con disminuciónde la respuesta cronotrópica. Conclusión: Indicadores simples de determinar en el consultorio clínico realizando ECG y MV podrían complementar la evaluación del riesgo cardiovascular y contribuira seleccionar aquellos pacientes en quienes sería conveniente efectuar un estudio de MAPA, tanto paradiagnóstico como para seguimiento...

In-hospital mortality risk factors in community acquired pneumonia: evaluation of immunocompetent adult patients without comorbidities / Fatores de risco para mortalidade intra-hospitalar em pneumonia adquirida em comunidade: avaliação de pacientes imunocompetentes sem comorbidades

Summary Objective: several scores were developed in order to improve the determination of community acquired pneumonia (CAP) severity and its management, mainly CURB-65 and SACP score. However, none of them were evaluated for risk assessment of in-hospital mortality, particularly in individuals who were non-immunosuppressed and/or without any comorbidity. In this regard, the present study was carried out. Methods: we performed a cross-sectional study in 272 immunocompetent patients without comorbidities and with a diagnosis of CAP. Performance of CURB- 65 and SCAP scores in predicting in-hospital mortality was evaluated. Also, variables related to death were assessed. Furthermore, in order to design a model of in-hospital mortality prediction, sampled individuals were randomly divided in two groups. The association of the variables with mortality was weighed and, by multiple binary regression, a model was constructed in one of the subgroups. Then, it was validated in the other subgroup. Results: both scores yielded a fair strength of agreement, and CURB-65 showed a better performance in predicting in-hospital mortality. In our casuistry, age, white blood cell counts, serum urea and diastolic blood pressure were related to death. The model constructed with these variables showed a good performance in predicting in-hospital mortality; moreover, only one patient with fatal outcome was not correctly classified in the group where the model was constructed and in the group where it was validated. Conclusion: our findings suggest that a simple model that uses only 4 variables, which are easily accessible and interpretable, can identify seriously ill patients with CAP .

Resumo Objetivo: diversos escores de gravidade da pneumonia adquirida em comunidade (PAC) foram desenvolvidos com o intuito de melhorar o manejo clínico, em especial os escores CURB-65 e SCAP. Contudo, nenhum dos dois foi avaliado para determinar o risco de morte intra- hospitalar, principalmente em pacientes imunocompetentes e/ou sem comorbidades. Diante disso, propusemo- nos a analisar a utilidade dos escores para prever a mortalidade intra-hospitalar e estudar as variáveis associadas ao desfecho fatal. Métodos: desenvolvemos um trabalho transversal com 272 pacientes imunocompetentes, sem comorbidades e com diagnóstico de PAC. Foi avaliada a eficácia dos escores CURB-65 e SCAP em prever a mortalidade durante a internação. Foram estudadas as variáveis relacionadas a este desfecho. Por fim, a amostra foi dividida em dois subgrupos com o objetivo de desenvolver um modelo de avaliação do risco de morte em um subgrupo, validando-o no outro. Resultados: ambos os escores apresentaram pobre concordância de classificação da gravidade para PAC. O escore CURB-65 mostrou melhor desempenho na avaliação do risco de morte. Em nossa amostra, idade, contagem de glóbulos brancos, ureia sérica e pressão arterial diastólica foram as variáveis que se associaram à mortalidade. O modelo desenvolvido com essas variáveis mostrou eficácia muito boa para prever o desfecho fatal. Inclusive, somente um paciente no grupo de desenvolvimento do modelo e outro no grupo de validação foram classificados de modo incorreto. Conclusão: nossos resultados sugerem que com um modelo de quatro variáveis, de fácil acesso e interpretação, foi possível identificar pacientes gravemente enfermos com PAC. .

In-hospital mortality risk factors in patients with ascites due to cirrhosis / Fatores de risco de mortalidade intra-hospitalar em pacientes com ascite por cirrose hepática

Introduction: ascites is one of the most common complications of cirrhosis associated with a high rate of mortality. Although several scores have been developed in order to assess the prognosis of the disease, they were designed for predicting liver transplantation requirements and mortality in the short term, but not while in hospital. The aim of this study was to weigh risk factors for in-hospital mortality in adult patients with ascites due to alcoholic cirrhosis. Material and methods: we performed a cross-sectional study in 180 adult patients with diagnosis of cirrhosis with portal hypertension associated with high alcohol intake. The diagnosis of cirrhosis was made by liver echography and portal hypertension was defined by clinical features plus serum-ascites albumin gradient. Sampled individuals were subjected to complete clinical examination. Child Pugh and the MELD scores were applied in all the patients. Results: nineteen patients died while in-hospital. Mortality was associated with increased levels of serum white blood cell, urea, creatinine, prolonged prothrombin time, aspartate aminotransferase and alanine aminotransferase. We conducted a multiple binary logistic to predict in-hospital mortality which yielded that serum urea, creatinine and prothrombin time made a significant contribution to prediction with an OR 14 (95% CI 12.8 - 16.7 p = 0.03), 2 (95% CI 0.5 - 3.47, p = 0.04), and 2 (95% CI 1.03 - 2.31, p = 0.01) linearly-related. Conclusions: our results suggest that acute renal failure and prolonged prothrombin time are predictors of in-hospital mortality in patients with portal hypertension due to alcoholic cirrhosis. .

Introdução: ascite é uma das complicações mais comuns de cirrose associadas a uma elevada taxa de mortalidade. Embora vários escores tenham sido desenvolvidos a fim de avaliar o prognóstico da doença, eles foram concebidos para prever requisitos de transplante de fígado e mortalidade a curto prazo, mas não durante a internação. O objetivo deste estudo foi o de pesar fatores de risco para a mortalidade intra-hospitalar em pacientes adultos com ascite decorrente de cirrose alcoólica. Material e métodos: foi realizado um estudo transversal em 180 pacientes adultos com diagnóstico de cirrose com hipertensão portal, associada à alta ingestão de álcool. O diagnóstico de cirrose foi feita por ecografia hepática e a hipertensão portal foi determinada por características clínicas e pelo gradiente de albumina soro-ascite. Indivíduos avaliados foram submetidos a exame clínico completo. A classificação de Child-Pugh e a escala MELD foram aplicadas em todos os pacientes. Resultados: dezenove pacientes morreram durante a internação. A mortalidade foi associada ao aumento dos níveis de glóbulos brancos, ureia, creatinina, aspartato aminotransferase, alanina aminotransferase e tempo de protrombina prolongado. Realizamos uma logística binária múltipla para prever a mortalidade intra-hospitalar, que confirmou que ureia, creatinina e tempo de protrombina contribuíram significativamente para a previsão, com uma OR = 14 (IC 95% 12,8-16,7 p = 0,03), 2 (IC 95% 0,5-3,47, p = 0,04), e 2 (IC 95% 1,03-2,31, p = 0,01), relacionada linearmente. Conclusões: nossos resultados sugerem que a insuficiência renal aguda e de tempo de protrombina prolongado são preditores de mortalidade intra-hospitalar em pacientes com hipertensão portal decorrente de cirrose alcoólica. .

Alteraciones metabólicas en hijos de padres con hipertensión arterial / Metabolic abnormalities in young offsprings of parents with essential hypertension

El antecedente familiar de hipertensión arterial en jóvenes sanos se ha asociado a hiperinsulinemia, que a su vez produciría aumento en el cortisol sérico, confluyendo ambos mecanismos en daño endotelial renal con la presencia de microalbuminuria. El objetivo del estudio consistió en evaluar en jóvenes sanos, hijos de hipertensos, la asociación entre los niveles de insulinemia, cortisol sérico y microalbuminuria, debido a su relación con mayor riesgo cardiovascular. Se realizó un trabajo transeccional y correlacional en la ciudad de Santa Fe, incluyendo 145 jóvenes sanos mayores de 18 años de edad, que se asignaron a dos grupos: aquellos con antecedente de primer grado de hipertensión arterial esencial (grupo de estudio) y sin dicho antecedente (grupo control). Se valoraron las concentraciones séricas en ayunas de insulina, cortisol, y los niveles de microalbuminuria en primera orina matutina. La media de edad fue de 20 ± 2.9 años, siendo el 58% mujeres. El grupo de estudio incluyó el 48% (n = 69). El 4.8% presentó insulino-resistencia, 13.8% microalbuminuria y el 52% hipercortisolinemia, no encontrándose diferencias significativas de los niveles séricos de insulina y cortisol, ni de microalbuminuria entre los grupos, así como tampoco correlación entre estas variables. No se encontró asociación entre el antecedente de 1er grado de hipertensión arterial y alteraciones de la homeostasis de insulina o cortisol así como tampoco evidencia de daño endotelial con presencia de microalbuminuria.

The familiar history of hypertension in healthy young offsprings is associated with hyperinsulinemia, which could lead to increased serum cortisol, resulting in renal endothelial damage and the presence of microalbuminuria. The aim of this study was to evaluate, in healthy young offsprings of hypertensive parents, association between insulin levels, serum cortisol and microalbuminuria attending to its relationship with increased cardiovascular risk. We performed a cross-sectional correlational study in Santa Fe, Argentina, including 145 healthy individuals aged over 18 years, allocated to two groups: those with a history of essential hypertensive parents (study group) and those without such history (control group). We evaluated fasting serum insulin, cortisol, and microalbuminuria levels in the first morning urine. The mean age was 20 ± 2.9 years, and 58% were women. The study group included 48% (n = 69) of the sample. 4.8% had insulin resistance, microalbuminuria 13.8% and 52% hipercortisolinemia, with no significant differences in serum insulin, cortisol, or microalbuminuria between groups. No correlation was found between these variables. In this study there was no association between a history of first degree hypertension and impaired insulin or cortisol homoeostasis.

Evaluación de predictores clínicos de bacteriemia en adultos hospitalizados por neumonía adquirida en la comunidad / Evaluation of clinical predictors of bacteremia in adults hospitalized for community-acquired pneumonia

OBJETIVO: Identificar elementos clínicos sencillos que hagan posible determinar adecuadamente los casos con mayor probabilidad de presentar aislamientos bacterianos en los hemocultivos. MÉTODOS: Estudio de casos y controles con pacientes internados por neumonía adquirida en la comunidad entre 1998 y 2009, definiéndose como casos a los pacientes que presentaron hemocultivos positivos y como controles a aquellos con hemocultivos negativos. Se registraron variables demográficas y clínicas y se las sometió a un análisis bivariado. Las que presentaron diferencias estadísticamente significativas entre los grupos fueron introducidas en un modelo de regresión logística para definir predictores independientes y generar un modelo de predicción clínica. RESULTADOS: De los 322 pacientes estudiados, 15,2 por ciento tuvo hemocultivos positivos. Diez variables mostraron diferencias significativas, pero solo tres (temperatura <38°C, sodio <135 mEq/L y puntaje CURB-65) fueron seleccionadas para el análisis multivariado. El modelo desarrollado mostró escasa capacidad para predecir el resultado de los hemocultivos (R² = 0,176; Hosmer-Lemeshow: P = 0,338). CONCLUSIONES: Los datos obtenidos en esta serie no evidenciaron elementos clínicos con capacidad suficiente para predecir el resultado de los hemocultivos.

OBJECTIVE: Identify simple clinical elements that can be used to adequately determine the cases with the highest probability of presenting bacterial isolates in blood cultures. METHODS: Case-control study with patients hospitalized for community-acquired pneumonia from 1998-2009. Patients with positive blood cultures were defined as cases, and patients with negative blood cultures were defined as controls. The demographic and clinical variables were recorded and a bivariate analysis was conducted. The variables with statistically significant differences between the groups were introduced in a logistic regression model in order to define the independent predictors and generate a clinical prediction model. RESULTS: A total of 15.2 percent of the 322 patients studied had positive blood cultures. Ten variables showed significant differences, but only three variables (temperature <38°C, sodium <135 mEq/L and CURB-65 score) were selected for the multivariate analysis. The model developed showed limited capacity to predict the result of the blood cultures (R² = 0.176; Hosmer-Lemeshow: P = 0.338). CONCLUSIONS: The data obtained in this series did not demonstrate clinical elements with sufficient capacity to predict the result of the blood cultures.