¿Es el paciente crítico competente para tomar decisiones? Razones psicológicas y psicopatológicas de la alteración cognitiva / Is the critical patient competent for decision taking? Psychological and psychopathological reasons of cognitive impairment

Introducción: Factores emocionales pueden condicionar alteraciones cognitivas que bloqueen la habilidad del paciente para razonar, limitando su participación en la toma de decisiones. Objetivos: Evaluar la disposición del paciente crítico para tomar decisiones e identificar qué variables pueden influir en su competencia. Diseño: Estudio observacional descriptivo. Ámbito: Unidad de cuidados. Pacientes: 29 pacientes críticos. Variables: Se analizaron variables sociodemográficas y psicológicas. Se evaluó la capacidad funcional y la reacción psicológica durante la estancia en UCI. Resultados: Muestran que los pacientes están totalmente de acuerdo en que la última palabra a la hora de tomar decisiones corresponde a ellos mismos, prefieren que una mala noticia sea trasmitida por el médico y dicen que la presencia del psicólogo facilitaría el proceso. Que los profesionales no respondan a sus preguntas es el factor de mayor estrés. A mayor nivel de depresión resulta una menor capacidad cognitiva, y para los pacientes con menor capacidad cognitiva, participar en la toma de decisiones supone una sobrecarga. Las variables ansiedad y depresión se relacionan significativamente con la capacidad para tomar decisiones (AU)

Background Emotional factors may lead to cognitive impairment that can adversely affect the capacity of patients to reason, and thereby, limit their participation in decision taking. Purposes: To analyze critical patient aptitude for decision taking, and to identify variables that may influence competence. Design: An observational descriptive study was carried out. Setting: Intensive care unit. Patients: Participants were 29 critically ill patients. Main variables: Social, demographic and psychological variables were analyzed. Functional capacities and psychological reactions during stay in the ICU were assessed. Results: The patients are of the firm opinion that they should have the last word in the taking of decisions; they prefer bad news to be given by the physician; and feel that the presence of a psychologist would make the process easier. Failure on the part of the professional to answer their questions is perceived as the greatest stress factor. Increased depression results in lesser cognitive capacity, and for patients with impaired cognitive capacity, participation in the decision taking process constitutes a burden. The variables anxiety and depression are significantly related to decision taking capacity (AU)

[Is the critical patient competent for decision taking? Psychological and psychopathological reasons of cognitive impairment]. / ¿Es el paciente crítico competente para tomar decisiones? Razones psicológicas y psicopatológicas de la alteración cognitiva.

BACKGROUND: Emotional factors may lead to cognitive impairment that can adversely affect the capacity of patients to reason, and thereby, limit their participation in decision taking. PURPOSES: To analyze critical patient aptitude for decision taking, and to identify variables that may influence competence. DESIGN: An observational descriptive study was carried out. SETTING: Intensive care unit. PATIENTS: Participants were 29 critically ill patients. MAIN VARIABLES: Social, demographic and psychological variables were analyzed. Functional capacities and psychological reactions during stay in the ICU were assessed. RESULTS: The patients are of the firm opinion that they should have the last word in the taking of decisions; they prefer bad news to be given by the physician; and feel that the presence of a psychologist would make the process easier. Failure on the part of the professional to answer their questions is perceived as the greatest stress factor. Increased depression results in lesser cognitive capacity, and for patients with impaired cognitive capacity, participation in the decision taking process constitutes a burden. The variables anxiety and depression are significantly related to decision taking capacity.

Estudio de la mortalidad post-UCI durante 4 años (2006-2009). Análisis de factores en relación con el fallecimiento en planta tras el alta de UCI / Study of post-ICU mortality during 4 years (2006-2009). Analysis of the factors related to death in the ward after discharge from the ICU

Detectar posibles razones de la mortalidad de los pacientes críticos trasladados desde la UCI a las plantas del hospital y analizar las potenciales causas atribuibles de esta mortalidad. Diseño Estudio observacional de datos prospectivos analizados retrospectivamente. Muestra Cohorte de 5.328 pacientes ingresados consecutivamente en nuestro SMI cuya evolución se sigue hasta el fallecimiento o el alta hospitalaria. Período Desde enero de 2006 a diciembre de 2009. Método Análisis de significación diferencial de datos epidemiológicos, clínico-asistenciales, de estimación de riesgo de muerte, de coincidencia de diagnóstico de causa de ingreso en UCI y de causa de fallecimiento y de incidencia de limitación de esfuerzo asistencial. Se consideró alta inadecuada de UCI si la muerte acontecía antes de las 48h del traslado, sin limitación de esfuerzo asistencial.ResultadosFallecieron 907 pacientes (tasa estandarizada de 0,9; IC del 95%, 0,87-0,93) de los que 202 fallecieron tras el alta del SMI (el 3,8% de la población total y el 22,3% de los fallecidos); la estancia en planta post-UCI fue de 12,4±17,9 días. No se detectaron diferencias significativas entre los fallecidos en UCI o tras la estancia en UCI respecto a complicaciones infectivas aparecidas tras el ingreso. Tampoco los reingresados en UCI tras el pase a planta presentaron una mayor mortalidad. Se comprueba que la causa de muerte en planta no es significativamente coincidente con la causa de ingreso en UCI. Discusión Cierta mortalidad de pacientes críticos tras el traslado desde UCI es un hecho habitual. Nuestros datos no permiten atribuir esta mortalidad a deficiencias asistenciales (altas inadecuadas o disminución de asistencia en planta). Las razones para esta mortalidad tienen una explicación variada y variable, y en su mayoría corresponden a evolución del paciente diferente de la previsible tras el traslado desde el SMI (AU)

Objective: To detect possible reasons for mortality of critical patients transferred from the ICUto the hospital wards and to analyze the possible attributable causes for such mortality.Design: An observational study of prospectively collected data, analyzed retrospectively.Population: Cohort analysis of 5328 with consecutive admissions to our ICU, whose evolutionwas followed up to hospital discharge or death. Period: From January 2006 to December 2009. Method: An analysis was made of differential significance of epidemiological, clinical-care,death risk estimate, coincidence between ICU admissions reasons and causes of death after ICU discharge, as well as limitation of health care effort incidence. Inappropriate ICU discharge was considered to exist if the death occurred during the first 48 hours after ICU transfer, withoutlimitation of care effort. Results: A total of 907 patients died (SMR = 0.9; 95% CI, 0.87-0.93), 202 of whom died afterICU discharge (3.8% of total sample and 22.3% of all deceased patients), ward length of staybeing 12.4±17.9 days. No significant differences were found between deaths in the ICU or post-ICU deaths regarding infective complications appearing after admission to the ICU. Greatermortality was also not found in those re-admitted to the ICU after having been transferred tothe ward. It was verified that the cause of death in the ward did not significantly coincide withthe cause of admission to the ICU.Discussion: Some mortality after ICU discharge is to be expected. Our data do not allow usto attribute this mortality rate to care deficiencies (inappropriate ICU discharges or deceasedcare in the wards). The reasons for this mortality have a varied and variable explanation. Itmostly corresponds to an evolution of the patients differing from that expected when they were discharged from ICU (AU)

[Study of post-ICU mortality during 4 years (2006-2009). Analysis of the factors related to death in the ward after discharge from the ICU]. / Estudio de la mortalidad post-UCI durante 4 años (2006-2009). Análisis de factores en relación con el fallecimiento en planta tras el alta de UCI.

OBJECTIVE: To detect possible reasons for mortality of critical patients transferred from the ICU to the hospital wards and to analyze the possible attributable causes for such mortality. DESIGN: An observational study of prospectively collected data, analyzed retrospectively. POPULATION: Cohort analysis of 5328 with consecutive admissions to our ICU, whose evolution was followed up to hospital discharge or death. PERIOD: From January 2006 to December 2009. METHOD: An analysis was made of differential significance of epidemiological, clinical-care, death risk estimate, coincidence between ICU admissions reasons and causes of death after ICU discharge, as well as limitation of health care effort incidence. Inappropriate ICU discharge was considered to exist if the death occurred during the first 48 hours after ICU transfer, without limitation of care effort. RESULTS: A total of 907 patients died (SMR=0.9; 95% CI, 0.87-0.93), 202 of whom died after ICU discharge (3.8% of total sample and 22.3% of all deceased patients), ward length of stay being 12.4±17.9 days. No significant differences were found between deaths in the ICU or post-ICU deaths regarding infective complications appearing after admission to the ICU. Greater mortality was also not found in those re-admitted to the ICU after having been transferred to the ward. It was verified that the cause of death in the ward did not significantly coincide with the cause of admission to the ICU. DISCUSSION: Some mortality after ICU discharge is to be expected. Our data do not allow us to attribute this mortality rate to care deficiencies (inappropriate ICU discharges or deceased care in the wards). The reasons for this mortality have a varied and variable explanation. It mostly corresponds to an evolution of the patients differing from that expected when they were discharged from ICU.

[Patient data management systems or unit data management systems. Two clinical management perspectives in Intensive Medicine]. / PDMS o UDMS. Dos perspectivas de gestión clínica en Medicina Intensiva.

The need of availability of information able to describe the activity performed in ICU has two different sides. The first related with the monitoring of the patient himself, his clinical situation changes and the checking of attitudes and reactions of the clinical team related to these changes. The other one focused on the possibility to describe appropriately the general activity of the unit, the epidemiological characteristics of the attended population and the indicators of efectitivity and efficiency that could be used for a continous quality improving. The first one has been named as patient level control, and the second one as unit level control. Industry tried to develop potent instruments (informatized) able to <> information from patient monitoring systems in order to cope with the first quoted need (the so called patient data management systems [PDMS]), but has not yet be able to cross the line between the individual patient and the global unit activity. Authors emphasize the need of having the unit data management systems (UDMS), a not solved problem, as a complement on real time on line information obtained from patients.

[Bias in time delay in ICU admission as a mortality risk factor or "lead time bias"]. / Sesgo de retraso en el ingreso en la Unidad de Cuidados Intensivos como causa de mal pronóstico o lead time bias.

OBJECTIVE: To assess if delay in admission to the Intensive Care Unit (ICU), measured according to the prognostic estimation of survival in critical patients (EPEC) system, influences the final outcome of patients admitted to our ICU. DESIGN: Retrospective and systematic analysis of data collected during six months in 2003. SETTING: Nineteen-bed ICU (15 from Standard intensive care and 4 from intermediate care) in a referral teaching hospital. PATIENTS: Four hundred and eighty one patients consecutively admitted to our ICU and followedup to hospital discharge. MAIN INTEREST VARIABLES: Risk of death was estimated with the EPEC, SAPS II and MPM II 0. Variables collected were gender, age, origin of admission, risk of death by means of the 3 methods mentioned, admission time delay (lead time bias) as measured by EPEC and life status on ICU and hospital discharge (alive or dead). RESULTS: A total of 44 out of 481 patients died during the hospital stay, overall admission delay being 0.7 +/- 1.98 hours (2.96 +/- 3.28, range 0.25-20 hours, for those with delay > 0). No differences were found when comparing delay in admission among those surviving and the deceased, and there was very bad correlation between the prognosis made considering delay time for admission and that established without considering it (SAPS II or MPM II 0). CONCLUSIONS: Our study does not make it possible to relate lead time bias with patient survival. Due to the EPEC design, it is possible to differentiate "physiopathological delay" (inappropriate detection of the critical situation) and "logistic delay" (conditioned by factors such as lack of available beds). Our study as well as the EPEC only considers the latter. It cannot be ruled out that the increase in mortality regarding prognosis is directly related with first type of delay and not with the overall lead time bias.

Sesgo de retraso en el ingreso en la Unidad de Cuidados Intensivos como causa de mal pronóstico o lead time bias / Bias in time delay in ICU admission as a mortality risk factor or “lead time bias”

Objetivo. Comprobar cómo el tiempo de retraso en el ingreso, cuantificado conforme al sistema EPEC, influye en el resultado final de los pacientes ingresados en nuestro Servicio de Medicina Intensiva.Diseño. Análisis retrospectivo de datos recogidosde forma sistemática y prospectiva durante un período de 6 meses del año 2003.Ámbito. Servicio de Medicina Intensiva de 19 camas (15 de la Unidad de Cuidados Intensivos convencional y 4 de Cuidados Intermedios) en un hospital docente de referencia.Pacientes. Cuatrocientos ochenta y un pacientesingresados en nuestro Servicio y seguidos hasta su alta hospitalaria. Principales variables de interés. El riesgo de muerte de los pacientes fue estimado por mediode EPEC, SAPS 2 y MPM II 0. Las variables recogidasfueron sexo, edad, procedencia, tipo de paciente,riesgo de muerte por los tres sistemas mencionados, retraso en el ingreso en horas (conforme EPEC) y estado vital (vivo o muerto) tanto a la salida de la Unidad de Cuidados Intensivos como al abandonar el hospital.Resultados. Fallecieron 44 pacientes de los 481ingresados, siendo el retraso global en el ingresode 0,7 ± 1,98 horas (2,96 ± 3,28, límites 0,25-20 horas,para aquellos con retraso > 0). No se enconencontrarondiferencias en el retraso de ingreso entre vivosy fallecidos, y existió una correlación muy malaentre el pronóstico realizado con consideracióndel tiempo de retraso en el ingreso y el que se estableció sin considerarlo (SAPS 2 y MPM II 0).Conclusiones. Nuestro estudio no permite relacionarel sesgo temporal (retraso en el ingreso)con la supervivencia o no de los pacientes. Por eldiseño de EPEC se distingue entre el «retraso fisiopatológico » (detección inapropiada de la situaciónde gravedad) y el «retraso logístico» (condicionadopor factores tales como falta de camas disponibles). Nuestro estudio y EPEC sólo consideran este último. No puede descartarse que el incremento de mortalidad respecto al pronóstico esté relacionado directamente con el primer tipo de retraso y no con el sesgo temporal globalmente considerado

Objective. To assess if delay in admission to theIntensive Care Unit (ICU), measured according tothe prognostic estimation of survival in critical patients (EPEC) system, influences the final outcomeof patients admitted to our ICU.Design. Retrospective and systematic analysis of data collected during six months in 2003. Setting. Nineteen-bed ICU (15 from Standard intensive care and 4 from intermediate care) in a referral teaching hospital.Patients. Four hundred and eighty one patientsconsecutively admitted to our ICU and followedup to hospital discharge Main interest variables. Risk of death was estimated with the EPEC, SAPS II and MPM II 0.Variables collected were gender, age, origin ofadmission, risk of death by means of the 3 methodsmentioned, admission time delay (lead time bias) as measured by EPEC and life status on ICU and hospital discharge (alive or dead).Results. A total of 44 out of 481 patients diedduring the hospital stay, overall admission delaybeing 0.7 ± 1.98 hours (2.96 ± 3.28, range 0.25-20hours, for those with delay > 0). No differenceswere found when comparing delay in admission among those surviving and the deceased, and there was very bad correlation between the prognosis made considering delay time for admission and that established without considering it (SAPS II or MPM II 0).Conclusions. Our study does not make it possibleto relate lead time bias with patient survival.Due to the EPEC design, it is possible to differentiate“physiopathological delay” (inappropriate detection of the critical situation) and “logistic delay”(conditioned by factors such as lack of availablebeds). Our study as well as the EPEC only considers the latter. It cannot be ruled out that the increase in mortality regarding prognosis is directly related with first type of delay and not with the overall lead time bias

[Information strategies in a polyvalent Intensive Care Unit]. / Estrategias de información en una Unidad de Cuidados Intensivos polivalente.

INTRODUCTION: Understanding the information provided to families and surrogates of the critically ill patients admitted to ICUs and its adequate communication without contradictions, is a fundamental aspect related with the possible participation of these persons in the treatment decision making and with the quality perceived regarding the care process. Our aim in this study is to assess these two aspects (information and communication of information). DESIGN: Opinion study elaborated by the medical team and nursing staff of a multidisciplinary ICU. METHOD: Observational qualitative study performed through an open answers questionnaire. Search for agreement on terminology and concepts that should be included in the information and estimation of the different contents of information provided by the main health care professional groups (physicians and nurses). Using the Delphi technique to elaborate an information communication sheet between different staff members in order to homogenize the information process. RESULTS: The analysis of the questionnaire reveals the great heterogeneity of the contents and modes of information provided. This may cause difficulties in understanding and the integration of families and relatives in the care process. The agreement achieved among the different between physicians to facilitate the information and avoid subjective interpretations by the informed people is presented.

Estrategias de información en una Unidad de Cuidados Intensivos polivalente / Information Strategies in a polyvalent intensive care unit

Introducción. La comprensión de la informaciónproporcionada a los familiares y allegados delos enfermos críticos ingresados en la Unidadde Cuidados Intensivos (UCI), y la transmisión,adecuada y sin contradicciones, de esta información,es un aspecto fundamental relacionado con la posible participación en las decisiones terapéuticasy con la calidad percibida respecto al proceso asistencial. Con el fin de establecer la adecuación de estos dos aspectos (comprensión y transmisión de la información) se ha realizado el presente estudio.Diseño. Estudio de opinión elaborado por elequipo médico, con la supervisión de enfermeríade una UCI polivalente.Método. Estudio cualitativo observacional.Encuesta de preguntas de respuesta abierta.Acuerdo de terminología y conceptos que debecontener la información y estimación de los distintoscontenidos de información proporcionada por los principales estamentos asistenciales (médicosy enfermeras). Elaboración, por técnica Delphi, de una hoja de transmisión de la información entre distintos facultativos, con el fin de homogeneizarel proceso informativo.Resultados. El análisis del cuestionario demuestrala gran heterogeneidad de los contenidosy formas de la información proporcionada, lo querepercute en defectos de comprensión y aparentescontradicciones, y a su vez dificulta la comprensiónde esa información y la integración de familiaresy allegados en el proceso asistencial.Se presenta el acuerdo logrado entre los distintosfacultativos encuestados para facilitar la informacióny evitar interpretaciones subjetivas porparte de los informados

Introduction. Understanding the informationprovided to families and surrogates of the criticallyill patients admitted to ICUs and its adequatecommunication without contradictions, is a fundamentaspect related with the possible participationof these persons in the treatment decisionmaking and with the quality perceived regardingthe care process. Our aim in this study is to assessthese two aspects (information and communicationof information).Design. Opinion study elaborated by the medicalteam and nursing staff of a multidisciplinary ICU.Method. Observational qualitative study performedthrough an open answers questionnaire.Search for agreement on terminology and conceptsthat should be included in the informationand estimation of the different contents of informationprovided by the main health care professionalgroups (physicians and nurses). Using theDelphi technique to elaborate an informationcommunication sheet between different staffmembers in order to homogenize the informationprocess.Results. The analysis of the questionnaire revealsthe great heterogeneity of the contents andmodes of information provided. This may cause difficulties in understanding and the integration offamilies and relatives in the care process.The agreement achieved among the differentbetween physicians to facilitate the informationand avoid subjective interpretations by the informedpeople is presented (AU)

[Percutaneous tracheostomy in ventilated patients]. / Traqueostomía percutánea en pacientes ventilados.

INTRODUCTION: Percutaneous tracheostomy is an alternative to conventional surgical tracheostomy. It is associated to a more feasible procedure, that is less invasive and linked to a lower degree of complications. Herein, we review our experience since the implementation of this technique in our Department. DESIGN: Retrospective observational. SETTING: Nineteen-bed intensive care department, in a general reference teaching hospital. PATIENTS AND METHOD: A total of 115 of 130 tracheostomies performed from 2001 to 2003 were retrospectively analyzed. Collected data include epidemiological information, reason for performing the procedure, maintenance time of artificial airway before the tracheostomy and type of ventilatory support or oxygen supplementation before and after the procedure. The modified PEEP (PEEP-mod = FiO2 x PEEP) was calculated, sedation level received before and 4-6 hours after the technique and also 24 hours later, were reviewed. Subsequent patient evolution was collected. INTERVENTIONS: Observational study on the results of routine procedures. VARIABLES OF INTEREST: Blood gases indicators of effectiveness in oxygen supply and the need of mechanical ventilation support. RESULTS: Median age of the 115 reviewed patients was 65 years. The most common admission reasons were: brain vascular accident in 25 cases, head and neck injury in 21, cancer in 11 and sepsis in 10 patients. Tracheostomy was indicated because prolonged mechanical ventilation in 52 patients, coma in 28 and emergency or scheduled surgery in 10 cases. Median length of stay in the ICU before tracheostomy was 14 days. Ninety-two patients were discharged from the ICU, and 52 from the Hospital. The remaining patients died during their hospital stay. Serious complications appeared in 5 patients (4%); 3 of them were the development of fistulae and all of them occurred in patients in whom the tracheostomy was performed in the ICU at bedside. Before the procedure, 72 patients were under mechanical ventilation, but only 56 received ventilatory support 24 hours after tracheostomy. When PEEP-mod values were analyzed, first monitoring of median value was 1.6 (range 0 to 2), 4-6 hours time median value was 2 (1.4-2.45), and 24 hours later median value was 1.2 (0-2) (global variation, p < 0.001). CONCLUSIONS: In our experience, percutaneous tracheostomy performed at bedside in the ICU is an adequate solution with a low complication rate and its makes it possible to reduce the level of ventilatory support.

Actualidad y reto de los sistemas de estimación pronóstica en pacientes críticos / Current state and challenge of prognostic estimation system in critical patients

No disponible

Código ético de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) / Code of ethics of the Spanish Society of Intensive Care, Critical and Coronary Units (SEMICYUC)

No disponible

Relación entre pulsioximetría y determinación de la saturación arterial de oxígeno. influencia de los fármacos vasoactivos presores sobre la correlación sattco2-sato2 / Relationship between pulse oximetry and determination of arterial oxygen saturation. influence of vasoactive drugs on the sattco2-sato2 correlation

Objetivo. Estudiar la relación existente entre la saturación de oxígeno obtenida por pulsioximetría (SattcO2) y la obtenida por cooximetría (SatHbO2), o por cálculo de la saturación de oxígeno por el análisis convencional de la gasometría sanguínea (SatO2) y evaluar la posible influencia que en esta relación puedan tener las infusiones de fármacos vasoactivos presores. Pacientes y método. El estudio se llevó a cabo en una UCI polivalente de 15 camas de un hospital docente de referencia, desde diciembre de 1998 a abril de 1999. Se obtuvieron 104 pares simultáneos de muestras procedentes de pacientes ingresados por causa médica o quirúrgica (urgente o programada). De estos pacientes, 57 estaban sometidos a la administración de infusiones presoras vasoactivas. Los datos recogidos fueron: SattcO2, SatHbO2 (por cooximetría) y SatO2 (por análisis convencional de muestra de sangre arterial). El estado hemodinámico de los pacientes se estimó mediante el registro de la presión arterial, la frecuencia cardíaca y la temperatura axilar. Se recogieron el tipo y la dosis de los fármacos vasopresores administrados (noradrenalina, dopamina o dobutamina, o combinaciones de ellas). Tras la obtención de los datos se estableció la correlación entre SattcO2 y SatHbO2 y entre SattcO2 y SatO2, mediante una ecuación de regresión y la concordancia por método de Bland-Altman, y se estudiaron las diferencias existentes entre las saturaciones obtenidas por uno u otro método (diferencia media de saturación de O2).Resultados. El análisis demostró que la administración o no de infusiones de aminas vasoactivas presoras no interfiere en la concordancia y correlación de las saturaciones de oxígeno obtenidas por uno u otro de los métodos mencionados. Las diferencias medias de saturaciones de oxígeno obtenidas fueron menores del 3 por ciento, con rangos de concordancia de 5,35 y 10,38 entre SattcO2 y SatHbO2, según los pacientes recibieran o no aminas vasopresoras, y con rangos de concordancia de 6,23 y 10,42 entre SattcO2 y SatO2 en los mismos subgrupos de pacientes. Conclusión. En nuestro estudio, los datos obtenidos por pulsioximetría constituyen un buen reflejo de la saturación de oxígeno real de la sangre arterial (medida o calculada), aunque la sobrestiman ligeramente (menos del 3 por ciento); esta concordancia es independiente de la utilización de aminas vasoactivas presoras (AU)

Quality of life before intensive care unit admission and its influence on resource utilization and mortality rate.

OBJECTIVE: To analyze the quality of life of critically ill patients before their intensive care admission and its relation to age, variables measured in the intensive care unit (ICU; severity of illness, therapeutic effort, resource utilization, and length of stay), and in-hospital mortality rate. DESIGN: Observational prospective multicenter study. SETTING: Eighty-six medical-surgical ICUs in Spain, including coronary patients. PATIENTS: We studied 8,685 patients between 1992 and 1993. Patients <16 yrs old and those dying within the first 6 hrs were excluded. MEASUREMENTS AND MAIN RESULTS: Data collection included age, gender, admission diagnosis, severity level by Acute Physiology and Chronic Health Evaluation (APACHE) III, quality of life survey score, therapeutic activity level by Therapeutic Intervention Scoring System (TISS), and ICU and hospital mortality rate. Pre-ICU quality-of-life score was 3.74 +/- 4.42 points; 33.24% of patients had a normal quality of life (0 points), and numbers of patients declined logarithmically in relationship to increasing quality-of-life scores, with only 189 patients having a score >15 points. Pre-ICU quality-of-life score correlated with age (r =.289, p <.001), with severity level by APACHE III score (r =.217, p <.001), and weakly with TISS (r =.067, p <.001). There was no correlation between quality of life and length of ICU stay. Patients dying in hospital after ICU discharge (n = 429) had worse quality of life (5.88 +/- 5.38 points) than those dying in the ICU (n = 1,453, 4.8 +/- 4.94), who themselves had a worse quality of life than hospital survivors (n = 6,803, 5.05 +/- 5.07; p <.0001 by analysis of variance), with significant differences between all three groups. In the multivariate analysis, pre-ICU quality-of-life was related to age, APACHE III score, and hospital mortality rate but not to TISS or ICU length of stay. Pre-ICU quality of life was introduced as a variable in the APACHE III prediction model and entered the model after acute physiology score, diagnosis, and age and before prior patient location and comorbidities. The area under the receiver operating characteristics curve was 0.834 when quality-of-life was included and 0.83 when not. CONCLUSIONS: In Spain, the quality of life of critically ill patients before their ICU admission is good, and only a small proportion of patients have a low quality of life before admission. Previous quality of life is related to hospital mortality rate but contributes very little to the discriminatory ability of the APACHE III prediction model and has little influence on ICU resource utilization as measured by length of stay and therapeutic activity.

Initial international use of APACHE. An acute severity of disease measure.

We need objective and reliable ways of measuring the severity of disease of hospitalized patients. This paper demonstrates the international predictive accuracy of a severity of disease measure on 1504 consecutive, unscheduled intensive care admissions to 14 hospitals in the United States, France, Spain, and Finland. Using laboratory data gathered within 24 hours of ICU admission, the Acute Physiology Score of APACHE (Acute Physiology and Chronic Health Evaluation) was a strong and stable predictor of hospital survival and concurrent therapeutic effort. In ordinary least squares and logistic multiple regression analysis, the impact of the Acute Physiology Score (APS) was highly significant (p less than 0.001) and of virtually identical magnitude in the United States and European hospitals. The use of this severity of disease measure should help researchers gain insights concerning the efficacy of medical services and the characteristics of physician decision making by permitting more precise prognostic stratification of severely ill patients.

[Correlation between the Morris' index and pulmonary capillary pressure in patients with acute myocardial infarction]. / Correlación entre índice de Morris y presión capilar pulmonar en pacientes con infarto agudo de miocardio.

The authors study the usefulness of the measurement of the negative area of P in V1 (Morris' index) in patients with acute myocardial infarction. The study was carried out prospectively in 70 patients, 31 of them having a Swan-Ganz catheter inserted permitting simultaneous hemodynamic and electrocardiographic measurements. No overall correlation was found between pulmonary capillary pressure (PCP) and Morris' index (Mlx), but a correlation existed in the subgroup of patients that showed evident variations of Mlx values during the study. On admission a relationship between PCP and Mlx was evident in 68% of the cases, without statistical significance. No PCP-Mlx correlation was found in the patients in whom the Mlx was always normal or abnormal during the study, nor in those with a prior history of arterial hypertension or left heart failure. An intraatrial conduction defect was found in 13% of the cases, no PCP-Mlx correlation being present in those. The fact that the PCP-Mlx correlation is best in patients with changing Mlx values in successive measurements that in patients with a prior history of hypertension or left ventricular failure suggests that Mlx values may vary with changes of left atrial pressure. The measurement of the Mlx to estimate left atrial pressure has little value in patients with conditions that may cause left atrial enlargement and intraatrial conduction defects.