Factores de riesgo y protección del estrés traumático secundario en los cuidados intensivos: un estudio exploratorio en un hospital terciario de Madrid / Risk and protective factors of secondary traumatic stress in Intensive Care Units: An exploratory study in a hospital in Madrid (Spain)

OBJETIVO: Proponer un modelo de predictores del estrés traumático secundario. DISEÑO: Se trata de un diseño transversal descriptivo. Ámbito: El estudio se llevó a cabo en las unidades de cuidados intensivos de un hospital terciario de Madrid. PARTICIPANTES: La muestra estuvo formada por 103 profesionales sanitarios. INTERVENCIONES: Se creó una batería de cuestionarios que fue rellenada por los profesionales. Respecto al análisis de datos, se utilizó una metodología de redes y análisis de regresión jerárquica. Variables de interés: Se evaluaron variables sociodemográficas tales como género, años de experiencia y puesto, el estrés traumático secundario, la pasión por el trabajo, los estresores laborales, el esfuerzo emocional, la empatía, la autocompasión. RESULTADOS: Se establece: a) para la fatiga por compasión, los años de experiencia como factor de riesgo (β = 0,224 y p = 0,029) y la pasión armoniosa como protector (β = −0,363 y p = 0,001); b) para la sacudida de creencias, el esfuerzo emocional y la empatía como factores de riesgo (β = 0,304 y p = 0,004; β = 0,394 y p = 0,000, respectivamente) y c) para la sintomatología, los estresores laborales y la empatía como factores de riesgo (β = 0,189 y p = 0,039; β = 0,395 y p = 0,000, respectivamente) y los años de experiencia como protector (β = −0,266 y p = 0,002). CONCLUSIONES: Este modelo predictivo del estrés traumático secundario asienta factores protectores que podrían aumentarse, como la pasión armoniosa, y factores de riesgo que sería conveniente reducir, como la empatía y el esfuerzo emocional, con el fin de mejorar la calidad asistencial y de vida de los profesionales

AIM: To propose a predictive model of secondary traumatic stress. DESIGN: A descriptive cross-sectional study was carried out. Context: The study was conducted in the Intensive Care Units of a hospital in Madrid (Spain). PARTICIPANTS: The sample comprised 103 health professionals. INTERVENTIONS: A series of questionnaires were created and completed by the participants. Network analysis and multiple regression were used for data analysis. Variables of interest: Sociodemographic variables such as gender, years of experience and position, secondary traumatic stress, passion for work, work stressors, emotional effort, empathy and self-compassion were evaluated. RESULTS: The result identified the following: a) years of experience as a risk factor for compassion fatigue (β=0.224 and P=0.029), and harmonious passion as a protector (β=−0.363 and P=0.001); b) emotional effort and empathy as risk factors for shattered assumptions (β=0.304 and P=0.004; β=0.394 and P=0.000, respectively); and c), work stressors and empathy as risk factors for symptomatology (β=0.189 and P=0.039; β=0.395 and P=0.000, respectively), and years of experience as a protector (β=−0.266 and P=0.002). CONCLUSIONS: This predictive model of secondary traumatic stress identifies protective factors which could be reinforced, such as harmonious passion, and risk factors which should be reduced, such as empathy and emotional effort, with a view to promoting quality of care and quality of life among these professionals

Pronóstico de los ancianos ventilados mecánicamente en la UCI / Prognosis of elderly patients subjected to mechanical ventilation in the ICU

Objetivo Analizar el pronóstico de los pacientes ancianos ventilados mecánicamente en la Unidad de Cuidados Intensivos (UCI).Diseño y ámbito Análisis secundario de un estudio observacional prospectivo y multicéntrico llevado a cabo durante un periodo de 2 años en 13 UCI españolas. Pacientes Pacientes adultos que precisaron ventilación mecánica (VM) invasiva durante más de 24 horas. Intervencione Ninguna. Variables de interés Datos demográficos, APACHE II, SOFA, motivo de VM, comorbilidad, situación funcional, reintubación, duración de la VM, traqueotomía, mortalidad en la UCI, mortalidad hospitalaria. Resultados Se incluyeron 1.661 pacientes. De ellos 1.127 (67,9%) eran hombres. Edad: 62,1±16,2 años. APACHE II: 20,3±7,5. SOFA total: 8,4±3,5. Cuatrocientos veintitrés pacientes (25,4%) tenían 75 años o más. Los índices de comorbilidad y capacidad funcional fueron peor en este grupo de pacientes (p<0,001 para ambas variables). La mortalidad en la UCI fue superior en este grupo (33,6%) que en los más jóvenes (25,9%) (p=0,002), al igual que la mortalidad hospitalaria (41,8 vs 31,8%; p<0,0001). No hubo diferencias en cuanto a tiempo de VM, incidencia de traqueotomías o índice de reintubaciones. Por causas de VM solo los pacientes ≥ 75 años ventilados por neumonía, sepsis o trauma presentaron una mortalidad en UCI más alta que los menores de esa edad (46,3 vs 33,1% p=0,006; 55 vs 25,8% p=0,002; 63,6 vs 4,5% p<0,001 respectivamente).Conclusiones Los ancianos (≥ 75 años) tienen una mayor mortalidad en UCI y hospitalaria que los más jóvenes sin diferencias en la duración de la VM. Las diferencias son a expensas de patologías como neumonía, sepsis y trauma (AU)

Objective To analyze the prognosis of mechanically ventilated elderly patients in the Intensive Care Unit (ICU).Design and scope Sub-analysis of a prospective multicenter observational cohort study conducted over a period of two years in 13 medical-surgical ICUs in Spain. Patients Adult patients who required mechanical ventilation (MV) for longer than 24hours.InterventionsNone.Study variables Demographic data, APACHE II, SOFA, reason for MV, comorbidity, functional condition, reintubation, duration of MV, tracheotomy, ICU mortality, in-hospital mortality. Results A total of 1661 patients were recruited. Males accounted for 67.9% (n=1127), with a mean age of 62.1±16.2 years. APACHE II: 20.3±7.5. Total SOFA: 8.4±3.5. Four hundred and twenty-three patients (25.4%) were ≥ 75 years of age. Comorbidity and functional condition rates were poorer in these patients (p<0.001 for both variables). Mortality in the ICU was higher in the elderly patients (33.6%) than in the younger subjects (25.9%) (p=0.002). Also, in-hospital mortality was higher in those ≥ 75 years of age. No differences in duration of MV, prevalence of tracheostomy or reintubation incidence were found. Regarding the indication for MV, only the patient ≥ 75 years of age with pneumonia, sepsis or trauma had a higher in-ICU mortality than the younger patients (46.3% vs 33.1%, p=0.006; 55% vs 25.8%, p=0.002; 63.6% vs 4.5%, p<0,001, respectively). No differences were found referred to other reasons for MV. Conclusion Older patients (≥ 75 years) have significantly higher in-ICU and in-hospital mortality than younger patients without differences in the duration of mechanical ventilation. Differences in mortality were at the expense of pneumonia, sepsis and trauma (AU)

Modelo de probabilidad de ventilación mecánica prolongada / Prolonged mechanical ventilation probability model

Objetivo: Diseñar un modelo de probabilidad de ventilación mecánica prolongada (VMP) con variables clínicas obtenidas durante las primeras 24 horas de su instauración. Diseño: Estudio de cohorte, observacional, prospectivo, multicéntrico. Ámbito: Trece UCI españolas polivalentes. Pacientes: Adultos ventilados durante más de 24 horas. Intervenciones: Ninguna. Variables de interés: APACHE II, SOFA, variables clínicas y demográficas, motivo de VM, comorbilidad y estado funcional. Se construyó un modelo de riesgo multivariante en el que la variable dependiente tenía tres posibles estados: 1.- Muerte precoz. 2.- Retirada precoz de la VM. 3.- VMP. Resultados: Se incluyeron 1.661 pacientes. El 67,9% (n=1.127) fueron hombres. Edad: 62,1±16,2 años. APACHE II: 20,3±7,5. SOFA: 8,4±3,5. Las puntuaciones APACHE II y SOFA fueron mayores en pacientes ventilados > 7 días (p=0,04 y p=0,0001 respectivamente). El fracaso de la ventilación no invasiva (VNI) se asoció a VMP (p=0,005). Se generó un modelo de riesgo multivariante con las siguientes variables: APACHE II, SOFA, fracaso de VNI, ubicación hospitalaria antes del ingreso en UCI y motivo de ventilación mecánica. La exactitud del modelo global (..) (AU)

Objective: To design a probability model for prolonged mechanical ventilation (PMV) using variables obtained during the first 24hours of the start of MV. Design: An observational, prospective, multicenter cohort study. Scope: Thirteen Spanish medical-surgical intensive care units. Patients: Adult patients requiring mechanical ventilation for more than 24hours. Interventions: None. Study variables: APACHE II, SOFA, demographic data, clinical data, reason for mechanical ventilation, comorbidity, and functional condition. A multivariate risk model was constructed. The model contemplated a dependent variable with three possible conditions: 1. Early mortality; 2. Early extubation; and 3. PMV. Results: Of the 1661 included patients, 67.9% (n=1127) were men. Age: 62.1±16.2 years. APACHE II: 20.3±7.5. Total SOFA: 8.4±3.5. The APACHE II and SOFA scores were higher in patients ventilated for 7 or more days (p=0.04 and p=0.0001, respectively). Noninvasive ventilation failure was related to PMV (p=0.005). A multivariate model for the three above exposed outcomes was generated. The overall accuracy of the model in the training and validation sample was 0.763 (95%IC: 0.729-0.804) and 0.751 (95%IC: 0.672-0.816), respectively. The likelihood ratios (LRs) for early extubation, involving a cutoff point of 0.65, in the training sample were LR (+): 2.37 (95%CI: 1.77-3.19) and LR (-): 0.47 (95%CI: 0.41-0.55). The LRs for the early mortality model, for a cutoff point of 0.73, in the training sample, were LR (+): 2.64 (95%CI: 2.01-3.4) and LR (-): 0.39 (95%CI: 0.30-0.51). Conclusions: The proposed model could be a helpful tool in decision making. However, because of its moderate accuracy, it should be considered as a first approach, and the results should be corroborated by further studies involving larger samples and the use of standardized criteria (AU)

Prospective study in critically ill non-neutropenic patients: diagnostic potential of (1,3)-ß-D-glucan assay and circulating galactomannan for the diagnosis of invasive fungal disease.

Diagnosis of invasive fungal disease (IFD) in patients under intensive care is challenging. Circulating biomarkers, (1,3)-ß-D-glucan (BG) and galactomannan (GM), were prospectively assessed in 98 critically ill patients at risk of IFD. There were 11 cases of invasive aspergillosis (IA; 4 proven and 7 probable), 9 cases of proven invasive candidiasis (IC), 1 case of mixed proven IC and probable IA, 1 case of proven zygomycosis, and 1 case of mixed mycelial proven IFD. In all IA cases there was no significant difference when the area under the receiver operating characteristic curve (AUC) of GM (0.873 [95%CI, 0.75-0.99]) and BG (0.856 [95% CI, 0.71-0.99]) were compared (p = 0.871). The AUC for BG in IC and for the rest of the IFD cases was 0.605 (95% CI, 0.39-0.82) and 0.768 (95% CI, 0.63-0.90) respectively. Positive BG (40%) predated blood culture (n = 3) and abdominal pus (n = 1) a mean of 3.25 days before Candida was grown. In patients with IFD caused by molds, BG appeared a mean of 5.65 days before culture results. For the diagnosis of patients at risk of IC, BG has shown a high NPV (94.5%), with positive results also predating blood cultures in 30% of patients. In conclusion, early BG results permit a timely initiation of antifungal therapy in patients at risk of IFD.

A prospective comparison of galactomannan in bronchoalveolar lavage fluid for the diagnosis of pulmonary invasive aspergillosis in medical patients under intensive care: comparison with the diagnostic performance of galactomannan and of (1→ 3)-ß-d-glucan chromogenic assay in serum samples.

Diagnosis of fungal pneumonia (FP) in critically ill patients is challenging. Circulating biomarkers for the diagnosis of FP have limitations and the combination of different assays in serum samples and directly from the target organ may further improve the diagnosis of FP. We prospectively assessed the diagnostic utility of paired galactomannan (GM) in bronchoalveolar lavage fluid (BAL) and serum GM and (1→3)-ß-D-glucan (BG) assays in critically ill patients at risk of FP. Patients with FP were classified according to European Organisation for Research and Treatment of Cancer-Mycoses Study Group criteria, with modifications. Out of 847 admissions, 51 patients were eligible. There were nine invasive aspergillosis (IA) cases (four proven, five probable), three proven Pneumocysitis jirovecii pneumonia (PJP) cases and one mixed FP case (probable IA and proven PJP). The diagnostic accuracy as given by the area under the receiver operating characteristic curve in IA cases (proven and probable) for GM in BAL was 0.98 (95% CI, 0.94-1.00), whilst for GM and BG in serum it was 0.85 (95% CI, 0.74-0.96) and 0.815 (95% CI, 0.66-0.96), respectively. For IA cases (proven and probable) AUC for GM in BAL was significantly higher than GM and BG in serum (p 0.025 and p 0.032, respectively). In one of four proven and one of six probable IA cases, GM in serum remained negative, whereas GM in BAL was positive. In patients with IA, GM (90%) and BG (80%) appeared a mean of 4.3 days (range, 1-10 days) before Aspergillus was cultured. GM detection in BAL appears to improve the diagnosis of IA in critical patients.

III Mesa de Trabajo SENPE-Baxter: nutrición parenteral complementaria en el paciente crítico / III working meeting senpe-baxter: complementary parenteral nutrition in the critically ill patient

En un debate multidisciplinario y tras revisar la evidencia disponible así como la experiencia de los expertos se establecen las indicaciones y pautas de manejo de la Nutrición Parenteral Complementaria (NPC) en el paciente críticamente enfermo. Se concluye en la importancia de su indicación en todos los casos en que la nutrición enteral (NE) sea insuficiente para cubrir al menos el 60% del objetivo calórico-proteico. El paciente debe cubrir con la NE y la NPC al menos el 80% de sus objetivos calóricos, recomendándose el objetivo del 100%

In the setting of a multidisciplinary debate, and after reviewing the available evidence as well as the experience from experts, the indications and management guidelines for Complementary Parenteral Nutrition (CPN) in the critically ill patient are established. The conclusion refers to the importance of its indication in all the cases where enteral nutrition (EN) is insufficient to cover at least 60% of the caloric-protein target. At least 80% of the patient’s caloric requirements should be covered with EN and CPN, with the recommendation of targeting 100% of the demands