Sedación paliativa en un Hospital Universitario: experiencia tras la puesta en marcha de un protocolo específico / Palliative sedation in a University Hospital: experience after introducing a specific protocol

Pacientes y métodos. Estudio descriptivo prospectivo del registro de sedación paliativa (SP) durante un año tras la puesta en marcha del protocolo de SP. Criterios de inclusión. Pacientes incluidos en el protocolo de SP del Hospital Universitario Virgen Macarena y para los que se había completado la «Hoja de registro de datos». Fuentes de información. Hojas de registro incluidas en el protocolo de SP como anexo n.° 5, incluidas como anexo 1 en este trabajo. Variables. Datos de filiación, datos relativos a la enfermedad de base, pronóstico, nivel de información. Síntoma refractario: tipo, tiempo de evolución y tratamientos aplicados. Participación del enfermo y/o sus representantes en la toma de decisiones. Tipo de sedación, continuidad, profundidad, fármacos utilizados, duración y resultados y reajuste del resto de medidas terapéuticas. Análisis estadístico. Se analizaron las variables mediante SPSS 14.0: para variables cualitativas se estudiaron frecuencias absolutas y proporciones. Para cuantitativas con distribución normal, medias y desviaciones típicas, y con distribución no normal, medianas y rangos. Resultados. En el periodo del estudio constatamos 90 casos de SP. Ello representa el 27,6% de los pacientes atendidos por el equipo de soporte de cuidados paliativos (ESCP) hospitalario, y el 7,03% de los enfermos fallecidos en el hospital. La edad media de los pacientes tratados con SP fue de 59,22 años y rango entre 40,86 y 77,58 años. Un 68,1% fueron hombres. Todos se encontraban en fase avanzada o terminal de su enfermedad, y el 49,5% en fase agónica. En el 90,4% de los casos la patología fundamental fue oncológica. Respecto a la indicación de SP, esta fue realizada de manera conjunta por el médico del ESCP y su médico responsable en 60 casos (66,6%); Los síntomas que motivaron la sedación fueron mayoritariamente: disnea, delirium y dolor. En 5 casos se consultó al Comité de Ética Asistencial. La duración media de la sedación fue de 134,02 h (5,5 días). En el 90% de los casos, la duración osciló entre 50 y 218,04 h (2-9 días). La profundidad de la SP, tras inducción, quedó registrada en el 88,8% de los casos. El consentimiento informado (CI) fue explícito en el 11,2%, otorgado antes de presentar síntomas refractarios y/o fase agónica. En el 88,8% de las sedaciones el CI fue por representación. Respecto a los fármacos empleados como opción inicial, fue midazolam en el 87,8%, y levomepromacina en el 10,2%. Hasta un 15% de sedaciones precisaron cambio o asociación de fármacos. Conclusión. 1) La aplicación de un protocolo de SP y la disponibilidad del ESCP hospitalario y el Comité de Ética asistencial favorecieron el uso seguro (correcto) de la SP en un hospital sin unidad de cuidados paliativos (UCP), y el registro homogéneo de datos para su análisis, con criterios de calidad similares a los que ofrece una UCP. 2) Hemos detectado áreas de mejora que se aplicarán en la segunda versión de nuestro protocolo(AU)

Patients and methods. A descriptive prospective study of palliative sedation (PS) records during a one year period after starting the PS protocol. Inclusion criteria. Patients included in the PS protocol and those who had completed the «data registry form». Data sources. Registry forms included in the PS protocol as Annex 5 (included as Annex 1 in this study). Variables. Personal data, data regarding basal disease, prognosis, level of information. Refractory symptoms: type, time of evolution and treatments employed. Involvement of the patient and/or representatives in decision making. Type of sedation, continuity, depth, employed, duration and results, and readjustment of other therapeutic measures. Statistical analysis. The SPSS 14.0 was used. For qualitative variables we studied absolute frequencies and proportions. For quantitative variables with normal distribution, we used means and standard deviations, and for non-normal distribution, medians and ranges. Results. In the study period 90 cases of PS were counted. This represented 27.6% of the patients treated in the hospital palliative care support team (PCST), and 7.03% of the total deceased patients in our hospital. Mean age of patients undergoing PS was 59.22 years old, range between 40.86 and 77.58 years, and 68.1% were men. All patients were in an advanced or terminal stage of their condition, and 49.5% in an agonal phase. In 90.4% of the cases, the main pathology was oncological. Regarding PS indication, this was jointly made between the PCST physician and the patient's usual doctor in 60 cases (66.6%). Symptoms leading to sedation were mainly dyspnea, delirium and pain. The Ethics committee was consulted in five cases. Mean time under sedation was 134.02 hours (5.5 days). In 90% of the cases, duration ranged from 50 to 218.04 hours (2-9 days). Depth of PS after induction was registered in 88.8% of the cases. Informed consent (IC) was explicit in 11.2% of the cases,and given prior to the appearance of refractory symptoms and/or agonal phase. In 88.8% of sedation cases, the IC was given by a representative. Midazolam was the most used drug of choice in 87.8% of the cases, and levomepromazine in 10.2%. Up to 15% of sedations required drug changes or combinations. Conclusion. 1) The application of a PS Protocol and the availability of a hospital PCST and an Ethical Care Committee favored a safe (correct) use of PS in a hospital lacking a palliative care unit (PCU), and a homogeneous data registry for their analysis, with quality criteria similar to those offered by a PCU. 2) We have detected areas of improvement that will be applied in the second version of our protocol(AU)

[Palliative sedation in a university hospital: experience after introducing a specific protocol]. / Sedación paliativa en un Hospital Universitario: experiencia tras la puesta en marcha de un protocolo específico.

PATIENTS AND METHODS: A descriptive prospective study of palliative sedation (PS) records during a one year period after starting the PS protocol. INCLUSION CRITERIA: Patients included in the PS protocol and those who had completed the "data registry form". DATA SOURCES: Registry forms included in the PS protocol as Annex 5 (included as Annex 1 in this study). VARIABLES: Personal data, data regarding basal disease, prognosis, level of information. Refractory symptoms: type, time of evolution and treatments employed. Involvement of the patient and/or representatives in decision making. Type of sedation, continuity, depth, employed, duration and results, and readjustment of other therapeutic measures. STATISTICAL ANALYSIS: The SPSS 14.0 was used. For qualitative variables we studied absolute frequencies and proportions. For quantitative variables with normal distribution, we used means and standard deviations, and for non-normal distribution, medians and ranges. RESULTS: In the study period 90 cases of PS were counted. This represented 27.6% of the patients treated in the hospital palliative care support team (PCST), and 7.03% of the total deceased patients in our hospital. Mean age of patients undergoing PS was 59.22 years old, range between 40.86 and 77.58 years, and 68.1% were men. All patients were in an advanced or terminal stage of their condition, and 49.5% in an agonal phase. In 90.4% of the cases, the main pathology was oncological. Regarding PS indication, this was jointly made between the PCST physician and the patient's usual doctor in 60 cases (66.6%). Symptoms leading to sedation were mainly dyspnea, delirium and pain. The Ethics committee was consulted in five cases. Mean time under sedation was 134.02 hours (5.5 days). In 90% of the cases, duration ranged from 50 to 218.04 hours (2-9 days). Depth of PS after induction was registered in 88.8% of the cases. Informed consent (IC) was explicit in 11.2% of the cases,and given prior to the appearance of refractory symptoms and/or agonal phase. In 88.8% of sedation cases, the IC was given by a representative. Midazolam was the most used drug of choice in 87.8% of the cases, and levomepromazine in 10.2%. Up to 15% of sedations required drug changes or combinations. CONCLUSION: 1) The application of a PS Protocol and the availability of a hospital PCST and an Ethical Care Committee favored a safe (correct) use of PS in a hospital lacking a palliative care unit (PCU), and a homogeneous data registry for their analysis, with quality criteria similar to those offered by a PCU. 2) We have detected areas of improvement that will be applied in the second version of our protocol.

Adecuación de la utilización de heparinas de bajo peso molecular en la prevención de la enfermedad tromboembólica venosa / Suitability of the use of low-molecular-weight heparins in the prevention of venous thromboembolism

Objetivo: Conocer la prevalencia de prescripción de heparinas de bajo peso molecular (HBPM) en la profilaxis de la enfermedad tromboembólica venosa en un hospital general, así como la adecuación a las recomendaciones de las guías de práctica clínica. Método: Estudio observacional, descriptivo, de corte transversal, tipo indicación-prescripción, con pacientes ingresados en servicios médicos y quirúrgicos. Resultados: Se incluyeron 345 pacientes. La prevalencia de prescripción de HBPM fue del 44,6% (intervalo de confianza [IC] del 95%, 39,3-50,1). Según el nivel de riesgo tromboembólico se encontró adecuación en la decisión de tratar profilácticamente (o no) en 261 casos (75,7%; IC del 95%, 70,7-80,1), en el resto la pauta de actuación no fue la adecuada, destacando 55 pacientes (15,9%; IC del 95%, 12,2-20,2) con riesgo alto a los que no se había prescrito profilaxis (infrautilización), y 29 pacientes (8,4%; IC del 95%, 5,7-11,8) con riesgo bajo que estaban con profilaxis (sobreutilización). En los pacientes médicos la prevalencia de prescripción fue de 22,6% (IC del 95%, 16,9-29,1) y sólo el 33,3% de los de riesgo tomboembólico alto-moderado recibió profilaxis. La prevalencia de prescripción en cirugía general fue del 84,2% y en traumatología del 91,3%. Conclusiones: En pacientes quirúrgicos el nivel de profilaxis al canzado es adecuado, pero hay un porcentaje importante de pacientes médicos con riesgo tromboembólico medio-alto, que sigue sin recibir la adecuada profilaxis (infrautilización), a pesar de las recomendaciones de consenso con amplio respaldo científico y profesional (AU)

Objective: To investigate the prevalence of low-molecular-weight heparin (LMWH) prescription in venous thromboembolism prophylaxis in a general hospital and the suitability of the recommendations from the clinical practice guidelines. Method: A descriptive, observational and cross-sectional study of the indication-prescription type, carried out on patients admitted to medical departments and for surgery. Results: 345 patients were included. The prevalence of HBPM use was 44.6% (95% CI, 39.3-50.1). Depending on the risk of thromboembolism, the decision to treat prophylactically (or not) was appropriate in 261 cases (75.7%; 95% CI, 70.7-80.1), and the action guidelines were not suitable for the remainder of patients. 55 patients(15.9%; 95% CI, 12.2-20.2) presented a high risk and were not prescribed prophylactically (underuse); and 29 patients (8.4%; 95% CI,5.7-11.8) at low risk were treated prophylactically (overuse). There was a relationship between the appropriateness of the prescription and the type of patient (p<0.01). In the group of medical patients the prevalence of prescription was 22.6% (95% CI, 16.9-29.1) and only33.3% of patients with a high to moderate risk of thromboembolism received prophylaxis. The prevalence of prescription in general surgery was 84.2% and 91.3% in traumatology. Conclusions: The degree of prophylaxis is adequate in surgical patients, but there was a significant percentage of medical patients with a high to moderate risk who did not receive suitable prophylaxis (underuse), despite recommendations with scientific and professional backing (AU)

[Suitability of the use of low-molecular-weight heparins in the prevention of venous thromboembolism]. / Adecuación de la utilización de heparinas de bajo peso molecular en la prevención de la enfermedad tromboembólica venosa.

OBJECTIVE: To investigate the prevalence of low-molecular-weight heparin (LMWH) prescription in venous thromboembolism prophylaxis in a general hospital and the suitability of the recommendations from the clinical practice guidelines. METHOD: A descriptive, observational and cross-sectional study of the indication-prescription type, carried out on patients admitted to medical departments and for surgery. RESULTS: 345 patients were included. The prevalence of HBPM use was 44.6% (95% CI, 39.3-50.1). Depending on the risk of thromboembolism, the decision to treat prophylactically (or not) was appropriate in 261 cases (75.7%; 95% CI, 70.7-80.1), and the action guidelines were not suitable for the remainder of patients. 55 patients (15.9%; 95% CI, 12.2-20.2) presented a high risk and were not prescribed prophylactically (underuse); and 29 patients (8.4%; 95% CI, 5.7-11.8) at low risk were treated prophylactically (overuse). There was a relationship between the appropriateness of the prescription and the type of patient (p<0.01). In the group of medical patients the prevalence of prescription was 22.6% (95% CI, 16.9-29.1) and only 33.3% of patients with a high to moderate risk of thromboembolism received prophylaxis. The prevalence of prescription in general surgery was 84.2% and 91.3% in traumatology. CONCLUSIONS: The degree of prophylaxis is adequate in surgical patients, but there was a significant percentage of medical patients with a high to moderate risk who did not receive suitable prophylaxis (underuse), despite recommendations with scientific and professional backing.

[Quality of life, psychological and social aspects in patients with advanced HIV disease]. / Calidad de vida, aspectos psicológicos y sociales en pacientes con infección VIH avanzada.

OBJECTIVE: The advanced HIV infection carries an important physical, psychological and quality of life deterioration for patients. The introduction of new treatment strategies probably implies a global benefit for HIV patients. We carried out this study in order to know in HIV advanced patients; the clinical situation, the prevalence of psychological alterations (anxiety and depression), the quality of life and the impact of the introduction of new antiretroviral drugs about these variables. METHODS: This is a prospective observational study carried out between January of 1996 and June of 1997 with 52 advanced HIV patients (CD4 cells less than 200/microliter). We carried out 2 clinical interviews with an interval of 12 months being introduced after the first one a change of strategy of antiretroviral treatment. For evaluating the quality of life, the MOS SF-36 was used. The valuation of the anxiety and depression were carried out with the instruments STAI and Beck respectively. RESULTS: An important physical deterioration was found at the beginning of the study with 84.6% of polisymptomatic patients. We found a high prevalence of anxiety (76.9%) and depression (86.6%) that reaches criteria of graveness respectively in 75% and 25% of the cases. The quality of life was severely affected involving most of the dimensions of the SF-36 scale preserving the social function. The introduction of the change of therapeutic strategy produces a reduction of polisymptomtics patients to 54.8% (p = 0.05), of the graveness of the anxiety (p = 0.009) and depression (p = 0.05) and improving in the perception of general health (p = 0.03) and alterations of physical role (p = 0.02). CONCLUSIONS: The advanced HIV infection carries a high symptomatic load with a high prevalence of psychological dysfunctions and deterioration of the quality of life. The new strategies of HIV treatment induce a global improvement to the patients, but it makes necessary a better management of the psychological dysfunctions.

Calidad de vida, aspectos psicológicos y sociales en pacientes con infección VIH avanzada / Quality of life, psychological and social aspects in patients with advanced HIV disease

Fundamento: La infección VIH avanzada conlleva un importante deterioro físico, psíquico y de calidad de vida para el paciente. La introducción de nuevas estrategias de tratamiento probablemente impliquen un beneficio global para los pacientes. Se realiza este estudio con el objetivo de estudiar en pacientes VIH avanzados; la situación clínica, la prevalencia de alteraciones psicológicas(ansiedad y depresión), la calidad de vida y el impacto sobre estas variables de la introducción de nuevos fármacos antirretrovirales. Métodos: Estudio observacional prospectivo realizado entre enero de 1996 y junio de 1997 con 52 pacientes VIH avanzados (recuentos CD4 menores de 200 cel/µl). Se realiza 2 entrevistas clínicas con un intervalo de 12 meses introduciéndose tras la primera un cambio de estrategia de tratamiento antirretroviral. Para la valoración la calidad de vida se utiliza el MOS SF-36. Para la valoración de la ansiedad y depresión se utilizaron el STAI y la escala de Beck respectivamente. Resultados: Existe una importante deterioro físico al inicio del estudio con un 84,6 por ciento de pacientes polisintomáticos. Encontramos una elevada prevalencia de ansiedad (76,9 por ciento) y depresión (86,6 por ciento) que alcanza criterios de gravedad en el 75 por ciento y 25 por ciento de los casos respectivamente. La calidad de vida se ve comprometida severamente con afectación de la mayoría de las dimensiones del SF-36 conservándose la función social. La introducción del cambio de estrategia terapéutica produce una reducción de polisintomáticos a 54,8 por ciento (p=0,05), de la gravedad de la ansiedad (p=0,009) y depresión (p=0,05) y mejoría en la percepción de salud general (p=0,03) y alteraciones de rol físico (p=0,02).Conclusiones: La infección VIH avanzada conlleva una alta carga sintomática con una elevada prevalencia de trastornos de la esfera psicológica y deterioro de la calidad de vida. Las nuevas estrategias de tratamiento antirretroviral inducen una mejoría global a los pacientes, pero hace necesario un abordaje de los trastornos psicológicos (AU)

Objective: The advanced HIV infection carries an important physical, psychological and quality of life deterioration for patients. The introduction of new treatment strategies probably implies a global benefit for HIV patients. We carried out this study in order to know in HIV advanced patients; the clinical situation, the prevalence of psychological alterations (anxiety and depression), the quality of life and the impact of the introduction of new antiretroviral drugs about these variables. Methods: This is a prospective observational study carried out between January of 1996 and June of 1997 with 52 advanced HIV patients (CD4 cells less than 200 /µl). We carried out 2 clinical interviews with an interval of 12 months being introduced after the first one a change of strategy of antiretroviral treatment. For evaluating the quality of life, the MOS SF-36 was used. The valuation of the anxiety and depression were carried out with the instruments STAI and Beck respectively. Results: An important physical deterioration was found at the beginning of the study with 84.6% of polisymptomatic patients. We found a high prevalence of anxiety (76.9%) and depression (86.6%) that reaches criteria of graveness respectively in 75% and 25% of the cases. The quality of life was severely affected involving most of the dimensions of the SF-36 scale preserving the social function. The introduction of the change of therapeutic strategy produces a reduction of polisymptomtics patients to 54.8% (p=0.05), of the graveness of the anxiety (p=0.009) and depression (p=0.05) and improving in the perception of general health (p=0.03) and alterations of physical role (p=0.02). Conclusions: The advanced HIV infection carries a high symptomatic load with a high prevalence of psychological dysfunctions (AU)

[Study of tuberculosis in Huelva prison]. / Estudio de tuberculosis en la prisión de Huelva.

OBJECTIVES: Knowing about the rate of tuberculous infection and disease in prison population and workers in Huelva prison, and the association of tuberculosis with the sociosanitary risk factors. EQUIPMENT AND METHODS: Descriptive research for a year in 141 male prisoners at the age of 20 to 52 years old, from the 1sT of February in 1994 to the 1sT in 1995. RESULTS: The prevalence on tuberculous infection is 46.4% (accumulative incidence); and tuberculous disease 3.5% (accumulative incidence 1.4%) on the prisoners and the prevalence on tuberculous infection on the prison officers is 18.8% (there wasn't incidence) and the was no disease. CONCLUSIONS: It's perceived a high rate of tuberculous disease on the prisoners at the expense of people with infection by HIV and drugs addicts by parenteral way. The socio-cultural variables affect the tuberculous infection and disease tuberculous.