Results of a survey on albumin use in clinical practice in intensive care units.

BACKGROUND: Human albumin solutions are used in a number of disorders, though their indications are not clear in all circumstances. These solutions are costly, and their benefit has not been established in all settings. It is therefore interesting to assess the presence of albumin solutions in the daily clinical practice of critical care professionals. OBJECTIVES: To report the standard clinical practices and to describe the variability of albumin solutions use in critically ill patients. DESIGN: A survey sent by e-mail to Spanish and South American Intensive Care Units (ICUs) PERIOD: Planning and execution during the year 2012. METHODS: A questionnaire comprising 35 questions. RESULTS: Fifty-seven surveys were analyzed. The use of albumin solutions was sporadic or negligible in critically ill patients (96.5%). The exceptions were patients with liver disease (87.7% of the responders administered albumin to these patients). A high percentage of professionals claimed to know the available scientific evidence on the use of albumin in patients with liver disease (82.5%) and in patients without liver disease (77.2%). Only 5.3% of the responders preferred to rely on their own experience to establish the indications of albumin use. CONCLUSIONS: The use of albumin solutions is infrequent in ICUs, except in patients with liver disease. Evidence-based knowledge on albumin use is declared to be extensive in ICUs. As a rule, opinions on the use of albumin solutions are based on the scientific recommendations, especially in patients with liver disease. Professional experience rarely prevails over the published clinical guidelines.

[Prolonged sedation in Intensive Care Units]. / Sedación prolongada en Unidades de Cuidados Intensivos.

Sedation and analgesia constitute one of the cornerstones in the management of the critically ill patients. Most patients admitted to an Intensive Care Unit require prolonged sedation and analgesia. It has been demonstrated that adequate sedo- analgesia lessens stress-related events in the critically ill patients, facilitating their management and improving their outcomes. However, the use of sedatives and analgesics, especially when administered in continuous intravenous infusion, may have its complications derived from its infra or over utilization with proved impact on the outcome of critically ill patients. A proper monitoring and the implementation of sedation and analgesia protocols warrant the adequate management of existing sedatives aiding to avoid tolerance and dependency events. Strategies such as "sequential sedation", "dynamic sedation" or "daily sedation interruption" have been proposed as efficacious tools for the avoidance of complications related to prolonged sedation. In the present chapter, concepts related to prolonged sedation (meaning sedation for more than 72 hours) are reviewed; available agents are evaluated and strategies aimed to assure quality in its application are described.

[Loco-regional analgesia]. / Analgesia locorregional.

The epidural analgesia is one of the most effective techniques for pain relief when it is indicated, but it can present potentially serious complications that must precociously be diagnosed and be treated. In the Critical Care setting, epidural analgesia is used for pain control after surgery or major trauma. The technique is simple, a catheter is placed into a virtual cavity, so the administered drugs are absorbed through the epidural space into nerve roots. The administration of local anesthetics, opioids or the combination of both by epidural route (administered in continuous infusion or bolus), provides better analgesia. Also the clonidine can be used. In order to diagnose and to treat suitably the possible complications (pain, urinary retention, nauseas and vomits, itching, motor block, infection, respiratory depression, hypotension) a series of safety measures must be adopted (respiratory and heart rate, blood pressure, sedation score, sensory and motor level assessment, rate of diuresis, temperature and signs of infection).

Sedación prolongada en Unidades de Cuidados Intensivos / Prolonged sedation in intensive care units

La sedoanalgesia es uno de los pilares básicos del manejo del paciente crítico. La mayoría de los pacientes ingresados en una Unidad de Cuidados Intensivos requiere sedoanalgesia de forma prolongada. Una adecuada sedoanalgesia disminuye el grado de estrés del paciente crítico, facilitando su manejo y tratamiento y mejorando su pronóstico. Sin embargo, la sedoanalgesia, sobre todo en perfusión continua, es una práctica que no está exenta de complicaciones derivadas tanto de su infra-como de su sobre-utilización, que pueden empeorar el pronóstico de los pacientes críticos. Una adecuada monitorización y la aplicación de protocolos consensuados en sedoanalgesia garantizan la utilización adecuada de los sedantes evitando fenómenos de tolerancia y dependencia. Estrategias como la sedación secuencial, la sedación dinámica o la interrupción diaria de la sedación se han propuesto como herramientas útiles para evitar complicaciones asociadas a la sedación prolongada. En el presente capítulo se revisan conceptos relacionados con la sedación prolongada, entendida ésta como aquélla cuya duración es mayor de 72 horas; se evalúan los agentes disponibles y se proponen estrategias para garantizar la calidad de su aplicación (AU)

Sedation and analgesia constitute one of the cornerstones in the management of the critically ill patients. Most patients admitted to an Intensive Care Unit require prolonged sedation and analgesia. It has been demonstrated that adequate sedo-analgesia lessens stress-related events in the critically ill patients, facilitating their management and improving their outcomes. However, the use of sedatives and analgesics, especially when administered in continuous intravenous infusion, may have its complications derived from its infra or over utilization with proved impact on the outcome of critically ill patients. A proper monitoring and the implementation of sedation and analgesia protocols warrant the adequate management of existing sedatives aiding to avoid tolerance and dependency events. Strategies such as “sequential sedation”, “dynamic sedation” or “daily sedation interruption” have been proposed as efficacious tools for the avoidance of complications related to prolonged sedation. In the present chapter, concepts related to prolonged sedation (meaning sedation for more than 72 hours) are reviewed; available agents are evaluated and strategies aimed to assure quality in its application are described (AU)

Analgesia locorregional / Loco-regional analgesia

La analgesia epidural es una de las técnicas más eficaces para el alivio del dolor cuando está indicada, pero puede presentar complicaciones potencialmente graves que deben ser diagnosticadas y tratadas precozmente. Se emplea en Medicina Intensiva en el control del dolor posoperatorio y tras traumatismo grave. La técnica es sencilla: se coloca un catéter en una cavidad virtual permitiendo que los anestésicos locales difundan hasta las raíces nerviosas raquídeas. La administración de anestésicos locales, opiáceos o la combinación de ambos por vía epidural (ad- ministrados de forma intermitente o en infusión continua) proporciona una mejor analgesia. También puede emplearse la clonidina. Para diagnosticar y tratar adecuadamente las posibles complicaciones (dolor, retención urinaria, náuseas y vómitos, prurito, bloqueo motor, infección, depresión respiratoria e hipotensión) deben adoptarse una serie de medidas de seguridad (monitorización respiratoria y hemodinámica, nivel de consciencia, nivel sensitivo, ritmo de diuresis y signos de infección) (AU)

The epidural analgesia is one of the most effective techniques for pain relief when it is indicated, but it can present potentially serious complications that must precociously be diagnosed and be treated. In the Critical Care setting, epidural analgesia is used for pain control after surgery or major trauma. The technique is simple, a catheter is placed into a virtual cavity, so the administered drugs are absorbed through the epidural space into nerve roots. The administration of local anesthetics, opioids or the combination of both by epidural route (administered in continuous infusion or bolus), provides better analgesia. Also the clonidine can be used. In order to diagnose and to treat suitably the possible complications (pain, urinary retention, nauseas and vomits, itching, motor block, infection, respiratory depression, hypotension) a series of safety measures must be adopted (respiratory and heart rate, blood pressure, sedation score, sensory and motor level assessment, rate of diuresis, temperature and signs of infection) (AU)

Vancomicina en perfusión continua, una nueva pauta posológica en las Unidades de Cuidados Intensivos / Continuous Vancomycin Infusion, a new posological scheme for Intensive Care Units

Objetivo. Valorar la eficacia clínica y la incidencia de efectos adversos con la nueva pauta posológica de vancomicina en perfusión continua. Diseño. Estudio prospectivo, descriptivo durante 17 semanas, desde el 1 de septiembre hasta el 31 de diciembre de 2002. Ámbito. Unidad de Cuidados Intensivos (UCI) Polivalente del Hospital Universitario Doce de Octubre de Madrid. Pacientes. Se incluyeron todos los pacientes ingresados en la UCI mayores de 18 años de edad, con sospecha clínica o diagnóstico de infección por cocos grampositivos que fueron tratados con vancomicina en perfusión continua. Durante el período de estudio fueron ingresados 110 pacientes, de los cuales 18 fueron incluidos. Intervención. Se pautó una dosis inicial de carga de 15 mg/kg de peso administrada en 60 minutos, seguida de dosis de mantenimiento de 30 mg/kg de peso cada 12 horas en perfusión continua. Variables de interés principales. Monitorización de los niveles séricos de vancomicina cada 48 horas y de la función renal mediante la determinación de creatinina sérica diaria y el cálculo de aclaramiento de creatinina basal previa al inicio de la perfusión de vancomicina y semanalmente. Resultados. Fueron incluidos en el estudio 18 pacientes de los cuales 14 fueron mujeres. La edad media fue de 61,9 años. El APACHE II medio al ingreso fue de 16,7. Los motivos de ingreso más frecuentes fueron: shock séptico de distintas etiologías, 7 enfermos; insuficiencia respiratoria en 6. El antibiótico se pautó de forma empírica en 4 pacientes. El microorganismo más frecuentemente aislado en los cultivos microbiológicos fue el Staphylococcus epidermidis, 7. La dosis media de vancomicina administrada fue de 25,8 mg/kg/día. Los niveles plasmáticos medios de vancomicina fueron 18,15 µg/ml. La duración media del tratamiento fue de 13,8 días. Se asociaron antibióticos ß-lactámicos en todos los pacientes y aminoglucósidos en 11. En 2 pacientes se suspendió el tratamiento por deterioro de la función renal. Once pacientes presentaron mejoría, en 4 hubo fracaso terapéutico y 3 fallecieron. Conclusiones. La administración de vancomicina en perfusión continua se asocia a una eficacia clínica ligeramente mayor y menores efectos adversos que los descritos con la administración de dosis múltiples. Asimismo supone mayor comodidad de administración, disminución de las cargas de trabajo de enfermería y menor manipulación de los catéteres intravasculares

Aim. To evaluate the clinical effectiveness and incidence of adverse effects related to the new posological scheme of continous vancomycin infusion. Design. Prospective, descriptive 17-week study realized September 1, 2002 to December 31, 2002. Location. Multipurpose Intensive Care Unit of University Hospital Doce de Octubre in Madrid. Patients. There were included all over-18-year-old patients admitted to the Intensive Care Unit for clinically suspected or diagnosed gram-positive cocci infection, and who were receiving treatment with continuous vancomycin infusion. There were 110 patients admitted during the period of study, of which 18 were included. Intervention. There was ordered an initial dose of 15 mg/kg administered over 60 minutes, followed by a maintenance dose in continuous infusion of 30 mg/kg every 12 hours. Main variables of interest. Monitoring of vancomycin serum levels every 48 hours, and of renal function through the daily determination of serum creatinine levels and calculation of basal creatinine clearance at the beginning of vancomycin infusion and weekly thereafter. Results. There were included in the study 18 patients, of whom 14 were women. Average age was 61.9 years old. Average APACHE II scores at time of admittance was 16.7. Most common reasons for admittance were: septic shock of varying ethiology (7 patients), and respiratory failure (6 patients). Antibiotics were empirically prescribed in 4 patients. The microorganism more commonly isolated in microbiological cultures was Staphylococcus epidermidis (7 patients). The average dose of vancomycin administered was 25.8 mg/kg/day. Average plasma levels of vancomycin were 18.15 µg/ml. Average duration of the treatment was 13.8 days. Also included were the use of ß-lactamic antibiotics in all patients, and aminoglycoside antibiotics in 11. Treatment was suspended in 2 patients due to deterioration in renal function. Eleven patients showed improvement, in 4 there was therapeutic failure and 3 patients expired. Conclusions. The administration of continuous vancomycin infusion is associated with slightly greater clinical effectiveness and fewer adverse effects than those described for multiple-dose administrations. It is also easier to administer, requires less work on the part of nursing staff and reduces manipulation of intravenous catheters