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1.
Crit Care ; 27(1): 450, 2023 11 20.
Article in English | MEDLINE | ID: mdl-37986015

ABSTRACT

BACKGROUND: CONCISE is an internationally agreed minimum set of outcomes for use in nutritional and metabolic clinical research in critically ill adults. Clinicians and researchers need to be aware of the clinimetric properties of these instruments and understand any limitations to ensure valid and reliable research. This systematic review and meta-analysis were undertaken to evaluate the clinimetric properties of the measurement instruments identified in CONCISE. METHODS: Four electronic databases were searched from inception to December 2022 (MEDLINE via Ovid, EMBASE via Ovid, CINAHL via Healthcare Databases Advanced Search, CENTRAL via Cochrane). Studies were included if they examined at least one clinimetric property of a CONCISE measurement instrument or recognised variation in adults ≥ 18 years with critical illness or recovering from critical illness in any language. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist for systematic reviews of Patient-Reported Outcome Measures was used. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used in line with COSMIN guidance. The COSMIN checklist was used to evaluate the risk of bias and the quality of clinimetric properties. Overall certainty of the evidence was rated using a modified Grading of Recommendations, Assessment, Development and Evaluation approach. Narrative synthesis was performed and where possible, meta-analysis was conducted. RESULTS: A total of 4316 studies were screened. Forty-seven were included in the review, reporting data for 12308 participants. The Short Form-36 Questionnaire (Physical Component Score and Physical Functioning), sit-to-stand test, 6-m walk test and Barthel Index had the strongest clinimetric properties and certainty of evidence. The Short Physical Performance Battery, Katz Index and handgrip strength had less favourable results. There was limited data for Lawson Instrumental Activities of Daily Living and the Global Leadership Initiative on Malnutrition criteria. The risk of bias ranged from inadequate to very good. The certainty of the evidence ranged from very low to high. CONCLUSIONS: Variable evidence exists to support the clinimetric properties of the CONCISE measurement instruments. We suggest using this review alongside CONCISE to guide outcome selection for future trials of nutrition and metabolic interventions in critical illness. TRIAL REGISTRATION: PROSPERO (CRD42023438187). Registered 21/06/2023.


Subject(s)
Critical Illness , Hand Strength , Adult , Humans , Critical Illness/therapy , Activities of Daily Living , Treatment Outcome , Outcome Assessment, Health Care
2.
Rev. esp. anestesiol. reanim ; 69(9): 526-535, Nov. 2022. ilus, tab, graf
Article in Spanish | IBECS | ID: ibc-211675

ABSTRACT

Objetivo: Evaluar la relación de la diferencia venoarterial de PCO2 (ΔPCO2) con la aparición de complicaciones en el manejo postoperatorio precoz del trasplante hepático. Materiales y métodos: Estudio observacional y prospectivo realizado en una unidad de cuidados intensivos médico-quirúrgica de un hospital universitario. Se incluyó a 150 pacientes adultos que recibieron un trasplante de hígado ortotópico entre enero de 2015 y noviembre de 2018. Los pacientes fueron clasificados en 4grupos predefinidos de acuerdo con la evolución de la ΔPCO2 durante las primeras 6 h del postoperatorio en la unidad de cuidados intensivos, al considerar ese periodo como el de mayor riesgo de alteraciones hemodinámicas: 1) ΔPCO2 persistentemente normal (normal en T0 y T6); 2) ΔPCO2 descendente (alta en T0, normal en T6); 3) ΔPCO2 ascendente (normal en T0, alta en T6) y 4) ΔPCO2 persistentemente alta (alta en T0 y T6). Se comparó la relación de dichos grupos con la aparición de disfunción multiorgánica a las 72 h y las probabilidades de supervivencia globales y en el día 30 se describieron mediante curvas de Kaplan-Meier; las diferencias se calcularon mediante un test log-rank. Para el estudio de la correlación entre índice cardiaco y ΔPCO2 se utilizó el coeficiente de correlación de Spearman. Resultados: La disfunción multiorgánica representada mediante el SOFA a las 72 h (p=0,86) y el Δ-SOFA (p=0,088) no presentó diferencias significativas entre los 4grupos a estudio, de la misma forma que ocurrió con la mortalidad hospitalaria (χ2=5,72; p=0,126) y a los 30 días (χ2=2,23; p=0,5252). Con respecto a la relación entre índice cardiaco y ΔPCO2, se demostró una correlación inversa estadísticamente significativa de valor bajo (rho de Spearman: −0,17; p=0,002). Conclusiones: En pacientes críticos admitidos tras un trasplante hepático, la diferencia venoarterial de PCO2 no predice la mortalidad ni la incidencia de complicaciones en el periodo postoperatorio inmediato.(AU)


Objective: Test whether the development of abnormal venous-to arterial CO2 difference (ΔPCO2) during the early phases of postoperative care after a liver transplantation is related to multi-organ dysfunction and outcomes. Materials and methods: Prospective cohort study accomplished in a mixed intensive care unit at a university hospital. We included 150 eligible patients after a liver transplantation between 2015 and 2018. Patients were classified in 4predefined groups according to the ΔPCO2 evolution during the first 6h of resuscitation: 1) persistently normal ΔPCO2 (normal at T0 and T6); 2) decreasing ΔPCO2 (high at T0, normal at T6); 3) increasing ΔPCO2 (normal at T0, high at T6); and 4) persistently high ΔPCO2 (high at T0 and T6). Multiorgan dysfunction at day-3 was compared for predefined groups and a Kaplan Meier curve was constructed to show the survival probabilities using a log-rank test to evaluate differences between groups. A Spearman-rho was used to test the agreement between cardiac output and ΔPCO2. Results: There were no significant differences between the study groups regarding higher SOFA scores at day-3 (P=0.86), Δ-SOFA (P=0.088), as well as global mortality rates (χ2=5.72; P=0.126) and mortality rates at day-30 (χ2=2.23; P=0.5252). A significantly poor inverse agreement between cardiac output and ΔPCO2 was observed (rho de Spearman −0,17; P=0,002) at different points of resuscitation. Conclusions: After a liver transplantation, central venous-to-arterial CO2 difference was not associated with survival or postoperative adverse outcomes in a critical care patients population.(AU)


Subject(s)
Humans , Liver Transplantation , Postoperative Complications , Hospitals, University , Intensive Care Units , Prospective Studies , Cardiopulmonary Resuscitation , Anesthesiology
3.
Rev Esp Anestesiol Reanim (Engl Ed) ; 69(9): 526-535, 2022 Nov.
Article in English | MEDLINE | ID: mdl-36280569

ABSTRACT

OBJECTIVE: Test whether the development of abnormal venous-to arterial CO2 difference (ΔPCO2) during the early phases of postoperative care after a liver transplantation (LT) is related to multi-organ dysfunction and outcomes. MATERIALS AND METHODS: Prospective cohort study accomplished in a mixed intensive care unit (ICU) at a university hospital. We included 150 eligible patients after a LT between 2015 and 2018. Patients were classified in four predefined groups according to the ΔPCO2 evolution during the first 6 h of resuscitation: (1) persistently normal ΔPCO2 (normal at T0 and T6); (2) decreasing ΔPCO2 (high at T0, normal at T6); (3) increasing ΔPCO2 (normal at T0, high at T6); and (4) persistently high ΔPCO2 (high at T0 and T6). Multiorgan dysfunction at day-3 was compared for predefined groups and a Kaplan Meier curve was constructed to show the survival probabilities using a log-rank test to evaluate differences between groups. A Spearman-Rho was used to test the agreement between cardiac output and ΔPCO2. RESULTS: There were no significant differences between the study groups regarding higher SOFA scores at day-3 (P = .86), Δ-SOFA (P = .088), as well as global mortality rates (χ²â€¯= 5.72; P = .126) and mortality rates at day-30 (χ²â€¯= 2.23; P = .5252). A significantly poor inverse agreement between cardiac output and ΔPCO2 was observed (r2 -0,17; P = ,002) at different points of resuscitation. CONCLUSIONS: After a LT, central venous-to-arterial CO2 difference was not associated with survival or postoperative adverse outcomes in a critical care patients population.


Subject(s)
Carbon Dioxide , Liver Transplantation , Humans , Prospective Studies , Resuscitation , Intensive Care Units
4.
Crit Care ; 26(1): 240, 2022 08 06.
Article in English | MEDLINE | ID: mdl-35933433

ABSTRACT

BACKGROUND: Clinical research on nutritional and metabolic interventions in critically ill patients is heterogenous regarding time points, outcomes and measurement instruments used, impeding intervention development and data syntheses, and ultimately worsening clinical outcomes. We aimed to identify and develop a set of core outcome domains and associated measurement instruments to include in all research in critically ill patients. METHODS: An updated systematic review informed a two-stage modified Delphi consensus process (domains followed by instruments). Measurement instruments for domains considered 'essential' were taken through the second stage of the Delphi and a subsequent consensus meeting. RESULTS: In total, 213 participants (41 patients/caregivers, 50 clinical researchers and 122 healthcare professionals) from 24 countries contributed. Consensus was reached on time points (30 and 90 days post-randomisation). Three domains were considered 'essential' at 30 days (survival, physical function and Infection) and five at 90 days (survival, physical function, activities of daily living, nutritional status and muscle/nerve function). Core 'essential' measurement instruments reached consensus for survival and activities of daily living, and 'recommended' measurement instruments for physical function, nutritional status and muscle/nerve function. No consensus was reached for a measurement instrument for Infection. Four further domains met criteria for 'recommended,' but not 'essential,' to measure at 30 days post-randomisation (organ dysfunction, muscle/nerve function, nutritional status and wound healing) and three at 90 days (frailty, body composition and organ dysfunction). CONCLUSION: The CONCISE core outcome set is an internationally agreed minimum set of outcomes for use at 30 and 90 days post-randomisation, in nutritional and metabolic clinical research in critically ill adults.


Subject(s)
Activities of Daily Living , Critical Illness , Adult , Critical Illness/therapy , Delphi Technique , Humans , Multiple Organ Failure , Outcome Assessment, Health Care , Research Design , Treatment Outcome
6.
Med Intensiva (Engl Ed) ; 44(6): 325-332, 2020.
Article in English, Spanish | MEDLINE | ID: mdl-30902398

ABSTRACT

OBJECTIVE: To evaluate the ability of the TRISS and PS14 models to predict mortality rates in our medical system and population. DESIGN: A retrospective observational study was carried out over a 66-month period. BACKGROUND: The study was conducted in the Trauma Intensive Care Unit (ICU) of a third level hospital. PATIENTS: All severe trauma patients (Injury Severity Score≥16 and/or Revised Trauma Score <12) aged> 14 years were included. VARIABLES OF INTEREST: Medical care data were prospectively recorded. The "W" statistic (difference between expected and observed mortality for every 100 patients) and its significance were calculated for each model. Discrimination and calibration were evaluated by means of receiver operating characteristic (ROC) curves, and the Hosmer-Lemeshow test and GiViTI calibration belt, respectively. RESULTS: A total of 1240 patients were included. Survival at hospital discharge was 81.9%. The "W" scores for the TRISS, TRISS 2010 and PS14 models were+6.72 (P<.01), +1.48 (P=.08) and +2.74 (P<.01) respectively. Subgroup analysis revealed significant favorable results for some populations. The areas under the ROC curve for the TRISS, TRISS 2010 and PS14 models were 0.915, 0.919 and 0.914, respectively. There were no significant differences among them (P>.05). Both the Hosmer-Lemeshow test and GiViTI calibration belt demonstrated poor calibration for the three models. CONCLUSIONS: These models are suitable tools for assessing quality of care in a Trauma ICU, affording excellent discrimination but poor calibration. In our institution, survival rates higher than expected were observed.

7.
Med Intensiva (Engl Ed) ; 43(7): 410-415, 2019 Oct.
Article in English, Spanish | MEDLINE | ID: mdl-29887293

ABSTRACT

BACKGROUND: Hypoperfusion plays a central role in shock states, and has been proposed as a coagulopathy trigger. The study of the rotational thromboelastometry (ROTEM) profile during cardiac arrest could offer new insights to the role of hypoperfusion in coagulation during shock states. OUTCOME: To describe the ROTEM profile in a cohort of asystole donors and elucidate the incidence of hyperfibrinolysis. DESIGN: A prospective observational study was carried out in 18 patients consecutively admitted to the ICU after out-of-hospital non-recovered cardiac arrest (CA). Initial rhythm and time between CA and admission were recorded. Conventional coagulation and ROTEM (EXTEM, APTEM, FIBTEM) tests were performed within 30minutes after blood sample collection. SCOPE: An asystole donor reference hospital. PARTICIPANTS: Patients admitted to the ICU after out-of-hospital non-recovered CA. RESULTS: The median age was 50years, and 14 of the patients were men (77.8%). The time from CA to hospital admission expressed as the median (interquartile range) was 91minutes (75-104). The results of the routine tests were: INR 1.25 (1.19-1.34), aPTT 55s (45-73) and fibrinogen 161mg/dl (95-295). For the ROTEM APTEM assay the results were: CT 126s (104-191), CFT 247s (203-694). Hyperfibrinolysis criteria were recorded in 15 patients (83.3%). In addition, MCF improved in APTEM versus EXTEM. Prolonged CA times were associated to lower fibrinogen levels and lower values for MCF FIBTEM (P<.05). CONCLUSIONS: The ROTEM assays revealed severe alterations of the clot formation parameters and a high incidence of hyperfibrinolysis.


Subject(s)
Fibrinolysis/physiology , Out-of-Hospital Cardiac Arrest/blood , Thrombelastography/methods , Tissue Donors , Blood Coagulation Tests , Female , Humans , Male , Middle Aged , Out-of-Hospital Cardiac Arrest/physiopathology , Prospective Studies , Time Factors
8.
Med Intensiva (Engl Ed) ; 42(8): 463-472, 2018 Nov.
Article in English, Spanish | MEDLINE | ID: mdl-29502889

ABSTRACT

OBJECTIVE: To assess whether patient age is independently associated to Intensive Care Unit (ICU) admission after non-cardiac surgery. DESIGN: An observational cohort study of the Spanish subset of the European Surgical Outcome Study (EuSOS) was carried out. SETTING: Hospitals of the public National Health Care System and private hospitals in Spain. INTERVENTION: None. PATIENTS AND METHODS: All patients over 16 years of age undergoing inpatient non-cardiac surgery in the participating hospitals during a 7-day period in the month of April 2011 were consecutively included. MAIN VARIABLES OF INTEREST: ICU admission rate, factors associated with ICU admission and hospital mortality were assessed using logistic regression analysis and fractional polynomial regression. RESULTS: Out of 5412 patients, 677 (12.5%) were admitted to the ICU after surgery. The adjusted odds ratio (95% confidence interval [CI]) for ICU admission was 1.1 (0.8-1.4) for patients aged 65-74 years, 0.7 (0.5-1) for patients aged 75-85 years, and 0.4 (0.2-0.8) for patients over 85 years, respectively. Age, ASA score, grade of surgery (minor, intermediate, major), urgent surgery, surgical specialty, laparoscopic surgery and metastatic disease were independent factors for ICU admission. Global risk-adjusted mortality was 1.4 (95% CI 0.9-2.2). The ASA score, urgent surgery, surgical specialty and diabetes were predictors of hospital mortality. CONCLUSIONS: Elderly patients (over 80 years) appear less likely to be admitted to ICU after non-cardiac surgery in Spanish hospitals. There was no significant association between age and postoperative mortality in this cohort.


Subject(s)
Age Factors , Hospital Mortality , Intensive Care Units/statistics & numerical data , Patient Admission/statistics & numerical data , Postoperative Complications/epidemiology , Adolescent , Adult , Aged , Aged, 80 and over , Arrhythmias, Cardiac/epidemiology , Diagnosis-Related Groups , Hospitals, Private/statistics & numerical data , Hospitals, Public/statistics & numerical data , Hospitals, University/statistics & numerical data , Humans , Length of Stay/statistics & numerical data , Middle Aged , Spain , Surveys and Questionnaires , Young Adult
9.
Med Intensiva (Engl Ed) ; 42(1): 37-46, 2018.
Article in English, Spanish | MEDLINE | ID: mdl-29174280

ABSTRACT

Departments of Critical Care Medicine are characterized by high medical assistance costs and great complexity. Published recommendations on determining the needs of medical staff in the DCCM are based on low levels of evidence and attribute excessive significance to the structural/welfare approach (physician-to-beds ratio), thus generating incomplete and minimalistic information. The Spanish Society of Intensive Care Medicine and Coronary Units established a Technical Committee of experts, the purpose of which was to draft recommendations regarding requirements for medical professionals in the ICU. The Technical Committee defined the following categories: 1) Patient care-related aspects; 2) Activities outside the ICU; 3) Patient safety and clinical management aspects; 4) Teaching; and 5) Research. A subcommittee was established with experts pertaining to each activity category, defining criteria for quantifying the percentage time of the intensivists dedicated to each task, and taking into account occupational category. A quantitative method was applied, the parameters of which were the number of procedures or tasks and the respective estimated indicative times for patient care-related activities within or outside the context of the DCCM, as well as for teaching and research activities. Regarding non-instrumental activities, which are more difficult to evaluate in real time, a matrix of range versus productivity was applied, defining approximate percentages according to occupational category. All activities and indicative times were tabulated, and a spreadsheet was created that modified a previously designed model in order to perform calculations according to the total sum of hours worked and the hours stipulated in the respective work contract. The competencies needed and the tasks which a Department of Critical Care Medicine professional must perform far exceed those of a purely patient care-related character, and cannot be quantified using structural criteria. The method for describing the 5 types of activity, the quantification of specific tasks, the respective times needed for each task, and the generation of a spreadsheet led to the creation of a management instrument.


Subject(s)
Critical Care/organization & administration , Health Workforce , Hospital Departments/organization & administration , Intensive Care Units/organization & administration , Medical Staff, Hospital/supply & distribution , Efficiency, Organizational , Humans , Medicine , Models, Theoretical , Patient Safety , Research , Spain , Time and Motion Studies
11.
Med Intensiva ; 41(9): 513-522, 2017 Dec.
Article in English, Spanish | MEDLINE | ID: mdl-28259366

ABSTRACT

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) affords mechanical circulatory assistance associated to high mortality. However, weaning from such mechanical support may not imply improved short- or long-term survival. This study describes the characteristics and evolution of patients with refractory cardiogenic shock (RCS) subjected to venoarterial ECMO (VA-ECMO) in a hospital with a heart transplant program. DESIGN: A single-center, retrospective cohort study was carried out. SETTING: The cardiovascular ICU of a tertiary hospital. PATIENTS: Forty-six patients consecutively subjected to VA-ECMO over 6 years. INTERVENTIONS: Hospital mortality after weaning from ECMO and overall survival (OS) were analyzed. RESULTS: Fifteen patients (33%) died with VA-ECMO and 31 (67%) were weaned after 8 days of support (IQR: 5-15). Fourteen patients under went transplantation. Hospital mortality in these patients was 32% (10/31), and was associated to age (P=.001), SAPS II score (P=.009), cannulation bleeding (P=.01) and post-acute myocardial infarction RCS (P=.001). After a median follow-up of 27 months (IQR: 11-49), 91% of the patients discharged from hospital were still alive. Overall survival after weaning from assistance was associated to the type of cardiac disease (P=.002). Patients with RCS after acute myocardial infarction had a poorer prognosis. CONCLUSIONS: In our experience, VA-ECMO can be used as mechanical assistance in the management of RCS. The technique is associated to high early mortality, though the long-term survival rate after hospital discharge is good.


Subject(s)
Extracorporeal Membrane Oxygenation/methods , Shock, Cardiogenic/therapy , Ventilator Weaning , Adult , Aged , Brain Damage, Chronic/etiology , Comorbidity , Female , Follow-Up Studies , Heart Transplantation , Hemorrhage/etiology , Hospital Mortality , Humans , Kaplan-Meier Estimate , Length of Stay/statistics & numerical data , Male , Middle Aged , Myocardial Infarction/complications , Myocardial Infarction/mortality , Prognosis , Retrospective Studies , Severity of Illness Index , Shock, Cardiogenic/etiology , Shock, Cardiogenic/mortality , Shock, Cardiogenic/surgery
12.
Intensive care med ; 43(3)Mar. 2017. tab
Article in English | BIGG - GRADE guidelines | ID: biblio-948580

ABSTRACT

PURPOSE: To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness. METHODS: We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined "early" EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds. RESULTS: We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion. CONCLUSIONS: We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.


Subject(s)
Humans , Catastrophic Illness/therapy , Critical Illness/therapy , Enteral Nutrition/standards , Time Factors , GRADE Approach
14.
Med Intensiva ; 41(4): 201-208, 2017 May.
Article in English, Spanish | MEDLINE | ID: mdl-27553889

ABSTRACT

OBJECTIVE: The favorable evolution of critically ill patients is often dependent on time-sensitive care intervention. The timing of transfer to the intensive care unit (ICU) therefore may be an important determinant of outcomes in critically ill patients. The aim of this study was to analyze the impact upon patient outcome of the length of stay in the Emergency Care Department. DESIGN: A single-center ambispective cohort study was carried out. SETTING: A general ICU and Emergency Care Department (ED) of a single University Hospital. PATIENTS: We included 269 patients consecutively transferred to the ICU from the ED over an 18-month period. INTERVENTIONS: Patients were first grouped into different cohorts based on ED length of stay (LOS), and were then divided into two groups: (a) ED LOS ≤5h and (b) ED LOS >5h. VARIABLES: Demographic, diagnostic, length of stay and mortality data were compared among the groups. RESULTS: Median ED LOS was 277min (IQR 129-622). Patients who developed ICU complications had a longer ED LOS compared to those who did not (349min vs. 209min, p<0.01). A total of 129 patients (48%) had ED LOS >5h. The odds ratio of dying for patients with ED LOS >5h was 2.5 (95% CI 1.3-4.7). Age and sepsis diagnosis were the risk factors associated to prolongation of ED length of stay. CONCLUSIONS: A prolonged ED stay prior to ICU admission is related to the development of time-dependent complications and increased mortality. These findings suggest possible benefit from earlier ICU transfer and the prompt initiation of organ support.


Subject(s)
Emergency Service, Hospital/statistics & numerical data , Intensive Care Units/statistics & numerical data , Length of Stay/statistics & numerical data , Patient Transfer/statistics & numerical data , Aged , Diagnosis-Related Groups , Female , Hospital Mortality , Hospitals, University/statistics & numerical data , Humans , Male , Middle Aged , Prospective Studies , Spain , Treatment Outcome
15.
Med Intensiva ; 40(8): 483-490, 2016 Nov.
Article in English, Spanish | MEDLINE | ID: mdl-27017441

ABSTRACT

OBJECTIVE: To improve critical patient safety in the prevention of venous thromboembolic disease, using failure mode and effects analysis as safety tool. DESIGN: A contemporaneous cohort study covering the period January 2014-March 2015 was made in 4 phases: phase 1) prior to failure mode and effects analysis; phase 2) conduction of mode analysis and implementation of the detected improvements; phase 3) evaluation of outcomes, and phase 4) (post-checklist introduction impact. SETTING: Patients admitted to the adult polyvalent ICU of a third-level hospital center. PATIENTS: A total of 196 patients, older than 18 years, without thromboembolic disease upon admission to the ICU and with no prior anticoagulant treatment. INTERVENTIONS: A series of interventions were implemented following mode analysis: training, and introduction of a protocol and checklist to increase preventive measures in relation to thromboembolic disease. VARIABLES OF INTEREST: Indication and prescription of venous thrombosis prevention measures before and after introduction of the measures derived from the failure mode and effects analysis. RESULTS: A total of 59, 97 and 40 patients were included in phase 1, 3 and 4, respectively, with an analysis of the percentage of subjects who received thromboprophylaxis. The failure mode and effects analysis was used to detect potential errors associated to a lack of training and protocols referred to thromboembolic disease. An awareness-enhancing campaign was developed, with staff training and the adoption of a protocol for the prevention of venous thromboembolic disease. The prescription of preventive measures increased in the phase 3 group (91.7 vs. 71.2%, P=.001). In the post-checklist group, prophylaxis was prescribed in 97.5% of the patients, with an increase in the indication of dual prophylactic measures (4.7, 6.7 and 41%; P<.05). There were no differences in complications rate associated to the increase in prophylactic measures. CONCLUSIONS: The failure mode and effects analysis allowed us to identify improvements in the prevention of thromboembolic disease in critical patients. We therefore consider that it may be a useful tool for improving patient safety in different processes.


Subject(s)
Healthcare Failure Mode and Effect Analysis , Venous Thrombosis , Anticoagulants , Checklist , Cohort Studies , Critical Care , Hospitalization , Humans
17.
Med Intensiva ; 39(9): 530-6, 2015 Dec.
Article in English, Spanish | MEDLINE | ID: mdl-26048410

ABSTRACT

OBJECTIVES: To analyze the nutritional management practices in Intensive Care (ICU) to detect the need for improvement actions. Re-evaluate the process after implementation of improvement actions. DESIGN: Prospective observational study in 3 phases: 1) observation; 2) analysis, proposal development and dissemination; 3) analysis of the implementation. SETTING: ICU of a hospital of high complexity. PARTICIPANTS: Adult ICU forecast more than 48h of artificial nutrition. PRIMARY ENDPOINTS: Parenteral nutrition (PN), enteral nutrition (EN) (type, average effective volume, complications) and average nutritional ratio. RESULTS: A total of 229 patients (phase 1: 110, phase 3: 119). After analyzing the initial results, were proposed: increased use and precocity of EN, increased protein intake, nutritional monitoring effectiveness and increased supplementary indication NP. The measures were broadcast at specific meetings. During phase 3 more patients received EN (55.5 vs. 78.2%, P=.001), with no significant difference in the start time (1.66 vs. 2.33 days), duration (6.82 vs. 10,12 days) or complications (37,7 vs. 47,3%).Use of hyperproteic diets was higher in phase 3 (0 vs. 13.01%, P<.05). The use of NP was similar (48.2 vs. 48,7%) with a tendency to a later onset in phase 3 (1.25±1.25 vs. 2.45±3.22 days). There were no significant differences in the average nutritional ratio (0.56±0.28 vs. 0.61±0.27, P=.56). CONCLUSIONS: The use of EN and the protein intake increased, without appreciating effects on other improvement measures. Other methods appear to be necessary for the proper implementation of improvement measures.


Subject(s)
Critical Care/methods , Intensive Care Units/organization & administration , Nutrition Policy , Trauma Centers/organization & administration , Adult , Aged , Critical Illness/therapy , Dietary Proteins/administration & dosage , Dietary Supplements , Enteral Nutrition/adverse effects , Enteral Nutrition/methods , Enteral Nutrition/statistics & numerical data , Guideline Adherence , Humans , Middle Aged , Nutritional Support , Parenteral Nutrition/methods , Parenteral Nutrition/statistics & numerical data , Prospective Studies , Quality Improvement , Tertiary Care Centers
18.
Med Intensiva ; 39(1): 40-8, 2015.
Article in English, Spanish | MEDLINE | ID: mdl-24907000

ABSTRACT

The benefit of enteral nutrition in critically ill patients has been demonstrated by several studies, especially when it is started early, in the first 24-48h of stay in the Intensive Care Unit, and this practice is currently advised by the main clinical guidelines. The start of enteral nutrition is controversial in patients with hemodynamic failure, since it may trigger intestinal ischemia. However, there are data from experimental studies in animals, as well as from observational studies in humans that allow for hypotheses regarding its beneficial effect and safety. Interventional clinical trials are needed to confirm these findings.


Subject(s)
Critical Care/methods , Critical Illness/therapy , Enteral Nutrition , Animals , Cytokines/physiology , Energy Metabolism , Hemodynamics , Humans , Intensive Care Units , Models, Animal , Observational Studies as Topic , Practice Guidelines as Topic , Prospective Studies , Shock/physiopathology , Shock/therapy , Splanchnic Circulation
19.
Enferm Intensiva ; 24(1): 23-35, 2013.
Article in Spanish | MEDLINE | ID: mdl-23347729

ABSTRACT

OBJECTIVE: To describe the general characteristics of the patient and device use. To know retention balloon pressure (RBP) and related factors. To identify rate of leakage incidence, relocation and perineal damage due to the device (PSD) and related risk factors. MATERIAL AND METHODS: An analytical observational, cross-sectional study conducted in a polyvalent ICU from June-December 2010 was performed. The sample included Flexi-Seal(®) carriers. Variables evaluated were patient and device use characteristics, RBP, leakage and quantity, relocation and reason, PSD, sedoanalgesia infusion, neuromuscular block, patient position, Flexi-Seal type catheter, ventilatory mode (VM), intra-abdominal pressure (IAP), mean intrathoracic pressure (MITP), PEEP, Glasgow, color-aspect, fecal consistency and volume. Significance P<.05. RESULTS: Twenty-one patients were included, 52% male, aged 54±17 with 30 insertion episodes, Flexi-Seal-Signal(®) 33%, 10±8 days permanency, main indication 33% «diarrhea and injured skin¼," 30% device removal «intolerance and/or spontaneous expulsion¼. Median (Me) PGR =40; RI (61-19) cmH2O. Factors associated to higher PGR: SCI absence, prone-decubitus position, leakage, relocation, conventional Flexi-Seal(®), MV, lower PEEP and IMP, Color-aspect, higher MITP. Leakage, relocation and PSD incidence density 43, 30 and 2 cases/100 days of catheter, respectively. Leakage and relocation risk factors: higher PGR, Glasgow and fecal volume, lower MITP, MV, assisted-spontaneous mode OR 2.5 CI (1.6-3.8) and OR 1.7(1.1-2.7), absence SCI OR 3.3 (2.2-5.1) and OR 2.4(1.5-3.8), absence neuromuscular block OR 2.4 (1.4-3.9) and OR 1.8 (1.1-3.1), Flexi-Seal(®) conventional OR 2.7(1.7-4.1) and OR 2 (1.2-3.3), respectively. Leakage risk factors: color-aspect, supine position, lower IMP and PEEP. CONCLUSIONS: Monitoring RBP may alert us about leakage presence and relocation need. Knowing associated risk factors to RBP, leakage and relocation would help to develop strategies to reduce their high incidence rate such as decreasing RBP by reducing inflated volume.


Subject(s)
Critical Care Nursing/instrumentation , Diarrhea/nursing , Fecal Incontinence/nursing , Critical Illness , Equipment Design , Female , Humans , Longitudinal Studies , Male , Middle Aged
20.
Med. intensiva (Madr., Ed. impr.) ; 35(supl.1): 1-6, nov. 2011. tab
Article in Spanish | IBECS | ID: ibc-136001

ABSTRACT

El Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) elaboró en 2005 unas recomendaciones para el soporte nutricional especializado del paciente crítico. Dado el tiempo transcurrido se consideró oportuno la revisión y actualización de dichas recomendaciones, planificándolas como un documento de consenso con la Sociedad Española de Nutrición Parenteral y Enteral (SENPE). El objetivo primario planteado para el establecimiento de las recomendaciones fue evaluar la mejor evidencia científica disponible para las indicaciones del soporte nutricional y metabólico especializado en el paciente crítico. Las recomendaciones se han realizado por un panel de expertos con amplia experiencia en el soporte nutricional y metabólico de los pacientes en situación crítica y se han llevado a cabo entre octubre de 2009 y marzo de 2011. Se analizaron metaanálisis, estudios clínicos aleatorizados y observacionales, revisiones sistemáticas y puestas al día referentes a pacientes críticos en edad adulta en MEDLINE de 1966 a 2010, EMBASE reviews de 1991 a 2010 y Cochrane Database of Systematic Reviews hasta 2010. Se seleccionaron los criterios medotodológicos establecidos en la Scottish Intercollegiate Guidelines Network y los de la Agency for Health Care Policy and Research, además de la escala de valoración de la calidad de Jadad, ajustando la gradación de la evidencia y la potencia de las recomendaciones siguiendo la propuesta del Grupo GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group). Se seleccionaron 16 situaciones patológicas que fueron desarrolladas, cada una, por grupos de 3 expertos, estableciéndose un sistema de feedback con los 5 miembros del Comité de Redacción y con la totalidad del Grupo de Trabajo. En diferentes reuniones se discutieron y consensuaron todas las discrepancias, poniéndose especial énfasis en el repaso de los niveles de evidencia y grados de recomendación establecidos. El Comité de Redacción procedió al ajuste final para su presentación y aprobación definitiva por todos los miembros del Grupo de Trabajo. Finalmente, el documento se presentó a los comités científicos de las dos sociedades participantes del consenso para su aprobación definitiva. Las presentes recomendaciones pretenden servir de guía para los clínicos con responsabilidades en el manejo y tratamiento de los pacientes críticos y para todos los especialistas interesados en el tratamiento nutricional del paciente hospitalizado (AU)


The Recommendations for Specialized Nutritional Support in Critically-Ill patients were drafted by the Metabolism and Nutrition Working Group of the Spanish Society of Intensive Care Medicine and Coronary Units (SEMICYUC) in 2005. Given the time elapsed since then, these recommendations have been reviewed and updated as a Consensus Document in collaboration with the Spanish Society of Parenteral and Enteral Nutrition (SENPE). The primary aim of these Recommendations was to evaluate the best available scientific evidence for the indications of specialized nutritional and metabolic support in critically-ill patients. The Recommendations have been formulated by an expert panel with broad experience in nutritional and metabolic support in critically-ill patients and were drafted between October 2009 and March 2011. The studies analyzed encompassed metaanalyses, randomized clinical trials, observational studies, systematic reviews and updates relating to critically-ill adults in MEDLINE from 1966 to 2010, EMBASE reviews from 1991 to 2010 and the Cochrane Database of Systematic Reviews up to 2010. The methodological criteria selected were those established in the Scottish Intercollegiate Guidelines Network and the Agency for Health Care policy and Research, as well as those of the Jadad Quality Scale. Adjustment for the level of evidence and grade of recommendation was performed following the proposal of the GRADE group (Grading of RecommendationsAssessment, Development and Evaluation Working Group). Sixteen pathological scenarios were selected and each of them was developed by groups of three experts. A feedback system was established with the five members of the Editorial Committee and with the entire Working Group. All discrepancies were discussed and consensus was reached over several meetings, with special emphasis placed on reviewing the levels of evidence and grades of recommendation. The Editorial Committee made the final adjustments before the document was approved by all the members of the Working Group. Finally, the document was submitted to the Scientiic Committees of the two Societies participating in the Consensus for final approval. The present Recommedations aim to serve as a guide for clinicians involved in the management and treatment of critically-ill patients and for any specialists interested in the nutritional treatment of hospitalized patients (AU)


Subject(s)
Humans , Consensus Development Conferences as Topic , Enteral Nutrition/standards , Critical Care , Parenteral Nutrition/standards , Practice Guidelines as Topic , Societies, Medical/standards , Societies, Scientific/standards , Critical Illness/therapy , Enteral Nutrition/methods , Evidence-Based Medicine , Meta-Analysis as Topic , Parenteral Nutrition/methods , Randomized Controlled Trials as Topic , Spain
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