ABSTRACT
La medicina en general, y la medicina intensiva (SMI) en particular, han presentado grandes cambios a lo largo de los últimos años, en especial en relación a la toma de decisiones sobre las actuaciones a realizar en pacientes efectos de enfermedades crónicas. De esta manera, tanto la enfermedad oncológica como las enfermedades crónicas no oncológicas, en la mayoría de casos, tienen un curso evolutivo mucho más largo, con episodios de descompensación que pueden requerir la instauración de medicina intensiva. Es por ello que actualmente enfermedades que cursan con insuficiencia de un solo órgano, como pueden ser la cirrosis hepática o la miocardiopatía dilatada, por ejemplo, se pueden considerar terminales según su grado de evolución. Esto obliga a los equipos asistenciales a tener no solo conocimientos científico-técnicos sino también bioéticos, para decidir la correcta adecuación diagnóstico-terapéutica en cada caso concreto. En este trabajo se pretenden dar algunas nociones básicas para tomar decisiones clínicas en este grupo de pacientes
Medicine in general and the intensive medicine (ICM) in particular, have presented major changes in recent years, especially in relation to decision-making on the actions to be taken in patients with chronic diseases. Thus, both oncological and non-oncological chronic diseases, in most cases, have a much longer evolutionary course, with decompensation episodes that may require the establishment of intensive medicine. That is why currently diseases with a single organ failure, such as liver cirrhosis or dilated cardiomyopathy, for example, can be considered terminal according to their degree of evolution. This requires health care teams to have not only scientifictechnical knowledge but also bioethical knowledge in order to decide on the correct diagnostic-therapeutic approach in each specific case. In this work, we intend to give some basic notions to make clinical decisions in this group of patients
La medicina en general, I la medicina intensiva (SMI) en particular, han presentat grans canvis al llarg dels últims anys, especialment en relació a la presa de decisions sobre les actuacions que cal dur a terme en pacients afectats de malalties cròniques. Tant la malaltia oncològica com les malalties cròniques no oncològiques, en la majoria de casos, tenen un curs evolutiu molt més llarg, amb episodis de descompensació que poden requerir la instauració de medicina intensiva. És per això que actualment malalties que cursen amb insuficiència d'un sol òrgan, com pot ser la cirrosi hepàtica o la miocardiopatia dilatada, per exemple, es poden considerar terminals segons el seu grau d'evolució. Això obliga els equips assistencials a tenir no només coneixements cientificotècnics sinó també bioètics per decidir la correcta adequació diagnòstic-terapèutica en cada cas concret. En aquest treball es preté aportar algunes nocions bàsiques per a prende decisions clíniques en aquest grup de pacients
Subject(s)
Humans , Hospice Care/ethics , Coronary Care Units , Life Support Care/ethics , Hospitalization , Decision Making/ethics , Chronic Disease , DementiaABSTRACT
PURPOSE: The prognosis of a patient who deteriorates during a prolonged intensive care unit (ICU) stay is difficult to predict. We analyze the prognostic value of the serialized Sequential Organ Failure Assessment (SOFA) score and other variables in the early days after a complication and to build a new predictive score. MATERIALS AND METHODS: EPIPUSE (Evolución y pronóstico de los pacientes con ingreso prolongado en UCI que sufren un empeoramiento, Evolution and prognosis of long intensive care unit stay patients suffering a deterioration) study is a prospective, observational study during a 3-month recruitment period in 75 Spanish ICUs. We focused on patients admitted in the ICU for 7 days or more with complications of adverse events that involve organ dysfunction impairment. Demographics, clinical variables, and serialized SOFA after a supervening clinical deterioration were recorded. Univariate and multivariate analyses were performed, and a predictive model was created with the most discriminating variables. RESULTS: We included 589 patients who experienced 777 cases of severe complication or adverse event. The entire sample was randomly divided into 2 subsamples, one for development purposes (528 cases) and the other for validation (249 cases). The predictive model maximizing specificity is calculated by minimum SOFA + 2 * cardiovascular risk factors + 2 * history of any oncologic disease or immunosuppressive treatment + 3 * dependence for basic activities of daily living. The area under the receiver operating characteristic curve is 0.82. A 14-point cutoff has a positive predictive value of 100% (92.7%-100%) and negative predictive value of 51% (46.4%-55.5%) for death. CONCLUSIONS: EPIPUSE model can predict mortality with a specificity and positive predictive value of 99% in some groups of patients.
Subject(s)
Critical Illness/mortality , Intensive Care Units , Multiple Organ Failure/mortality , Organ Dysfunction Scores , Activities of Daily Living , Aged , Cardiovascular Diseases/epidemiology , Decision Support Techniques , Disease Progression , Female , Humans , Immunosuppressive Agents/therapeutic use , Length of Stay , Male , Middle Aged , Neoplasms/epidemiology , Prognosis , Prospective Studies , ROC Curve , Reproducibility of Results , Risk Assessment , Risk Factors , Spain , Withholding TreatmentABSTRACT
Un aporte que analiza aspectos inherentes a la calidad de la atención y seguridad del paciente centrandose en los aspectos éticos y ofreciendo una mirada que contribuya a su prevención.
