Valoración de la analgesia, sedación, contenciones y delirio en los pacientes ingresados en unidades de cuidados intensivos españolas. Proyecto ASCyD / Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD

Objetivos: Objetivo principal: Conocer qué unidades de cuidados intensivos (UCI) españolas valoran y registran, de forma normalizada, niveles de dolor, sedación/agitación, delirio y uso de contenciones mecánicas (CM). Objetivos secundarios: Determinar la utilización de herramientas validadas de valoración y explorar los niveles de dolor y sedación/agitación de los pacientes, la prevalencia de deliro y el uso de CM. Método: Estudio observacional, descriptivo, transversal, prospectivo y multicéntrico mediante una encuesta ad hoc con acceso on line, de 2 bloques: bloque1, enfocado a preguntas sobre características de las unidades y práctica habitual, y bloque 2, sobre aspectos de asistencia directa y evaluaciones directas de pacientes ingresados en unidades participantes. Resultados: Participaron 158 unidades y 1.574 pacientes. La valoración normalizada y el registro del dolor de pacientes comunicativos (PC) se realizaba en 109 unidades (69%), el dolor de pacientes no comunicativos (PNC) en 84 (53%), la sedación/agitación en 111 (70%), el delirio en 39 unidades (25%). Registrado el uso de CM en 39 unidades (25%). Se utilizaban escalas validadas para valorar el dolor en PC en 139 unidades (88%), en PNC en 102 (65%), sedación/agitación en 145 (92%), delirio en 53 unidades (34%). En 33 unidades (21%) se valoraba dolor a PC y PNC, sedación/agitación y delirio, y en 8 de estas unidades existía protocolo específico de CM y registro. Entre los pacientes que pudieron ser evaluados, se reportó ausencia de dolor en el 57%, dolor moderado en el 27%; tranquilos y colaboradores el 48%, y el 10% agitados; tenían CM el 21% y delirio el 12,6% de los pacientes. Conclusiones: La valoración del dolor, sedación y delirio está acreditada, obteniéndose bajos porcentajes de pacientes con agitación y delirio. Observamos un elevado porcentaje de pacientes con dolor y moderado uso de la CM. Hay que generalizar el uso de protocolos para valorar, prevenir y tratar el dolor y el delirio mediante un adecuado manejo de la analgesia, de la sedación y un uso individual y reflexivo de las CM. (ClinicalTrials.gov Identifier: NCT03773874)

Aims: Main aim: To determine the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. Secondary aims: To determine the use of validated assessment tools and to explore patients’ levels of pain and sedation/agitation, the prevalence of delirium, and the use of PR. Method: An observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit's characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units. Results: One hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). There was recorded use of PR in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium. Conclusions: The assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC. (ClinicalTrials.gov Identifier: NCT03773874)

Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD. / Valoración de la analgesia, sedación, contenciones y delirio en los pacientes ingresados en unidades de cuidados intensivos españolas. Proyecto ASCyD.

AIMS: Main aim: To determine the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. Secondary aims: To determine the use of validated assessment tools and to explore patients' levels of pain and sedation/agitation, the prevalence of delirium, and the use of PR. METHOD: An observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit's characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units. RESULTS: One hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). There was recorded use of PR in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium. CONCLUSIONS: The assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC. (ClinicalTrials.gov Identifier: NCT03773874).

Cómo analizar y escribir los resultados de una revisión sistemática / How to analyze and write the results of a systematic review

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Evaluación del dolor durante la movilización y la aspiración endotraqueal en pacientes críticos / Evaluation of pain during mobilization and endotracheal aspiration in critical patients

OBJETIVOS: 1) Evaluar la prevalencia de dolor durante 2 procedimientos de enfermería, y 2) analizar la utilidad de ciertos signos vitales y del índice biespectral (BIS) para detectar dolor. MÉTODOS: Estudio prospectivo, observacional y analítico de medidas repetidas en pacientes con ventilación mecánica y sedación. Los procedimientos evaluados fueron la aspiración endotraqueal y la movilización con giro. El dolor se evaluó mediante la Behavioral Pain Scale. Valores más o igual se consideraron dolorosos. Se registraron distintos signos fisiológicos y los valores del BIS. Una variación porcentual > 10% se consideró clínicamente relevante. RESULTADOS: Se analizaron 146 procedimientos en 70 pacientes. La prevalencia de dolor durante los procedimientos fue del 94%. Los signos vitales y los valores del BIS aumentaron significativamente durante los procedimientos respecto el reposo, pero solo la variación del BIS alcanzó relevancia clínica. En un subgrupo de pacientes que recibieron analgesia preventiva antes de los procedimientos, el dolor disminuyó significativamente respecto a los pacientes que no recibieron analgesia preventiva (−2 [RIQ: {−5}-0] vs. 3 [RIQ: 1-4]; p<0,001, respectivamente). CONCLUSIONES: Los procedimientos evaluados son dolorosos. La variación de los signos vitales no es un buen indicador de dolor. La variación del BIS podría ser útil, pero precisa nuevas investigaciones. La administración de analgesia preventiva disminuye la prevalencia de dolor durante los procedimientos

OBJECTIVES: 1) To assess the prevalence of pain during nursing care procedures, and 2) to evaluate the usefulness of certain vital signs and the bispectral index (BIS) in detecting pain. METHODS: A prospective, observational analytical study was made of procedures (endotracheal aspiration and mobilization with turning) in critically ill sedated patients on mechanical ventilation. The Behavioral Pain Scale was used to assess pain, with scores of more or equal 3 indicating pain. Various physiological signs and BIS values were recorded, with changes of > 10% being considered clinically relevant. RESULTS: A total of 146 procedures in 70 patients were analyzed. Pain prevalence during the procedures was 94%. Vital signs and BIS values increased significantly during the procedures compared to resting conditions, but only the changes in BIS were considered clinically relevant. In the subgroup of patients receiving preemptive analgesia prior to the procedure, pain decreased significantly compared to the group of patients who received no such analgesia (−2 [IQR: {−5}-0] vs. 3 [IQR: 1-4]; P<.001, respectively). CONCLUSIONS: The procedures evaluated in this study are painful. Changes in vital signs are not good indicators of pain. Changes in BIS may provide useful information about pain, but more research is needed. The administration of preemptive analgesia decreases pain during the procedures

[Evaluation of pain during mobilization and endotracheal aspiration in critical patients]. / Evaluación del dolor durante la movilización y la aspiración endotraqueal en pacientes críticos.

OBJECTIVES: 1) To assess the prevalence of pain during nursing care procedures, and 2) to evaluate the usefulness of certain vital signs and the bispectral index (BIS) in detecting pain. METHODS: A prospective, observational analytical study was made of procedures (endotracheal aspiration and mobilization with turning) in critically ill sedated patients on mechanical ventilation. The Behavioral Pain Scale was used to assess pain, with scores of ≥3 indicating pain. Various physiological signs and BIS values were recorded, with changes of >10% being considered clinically relevant. RESULTS: A total of 146 procedures in 70 patients were analyzed. Pain prevalence during the procedures was 94%. Vital signs and BIS values increased significantly during the procedures compared to resting conditions, but only the changes in BIS were considered clinically relevant. In the subgroup of patients receiving preemptive analgesia prior to the procedure, pain decreased significantly compared to the group of patients who received no such analgesia (-2 [IQR: {-5}-0] vs. 3 [IQR: 1-4]; P<.001, respectively). CONCLUSIONS: The procedures evaluated in this study are painful. Changes in vital signs are not good indicators of pain. Changes in BIS may provide useful information about pain, but more research is needed. The administration of preemptive analgesia decreases pain during the procedures.

[Intraobserver reliability and internal consistency of the Behavioral Pain Scale in mechanically-ventilated patients]. / Fiabilidad interobservador y consistencia interna de la Behavioral Pain Scale en pacientes con ventilación mecánica.

BACKGROUND: The Behavioral Pain Scale (BPS) is a tool of pain assessment that often gives contradictory results when used by different raters. OBJECTIVE: To assess internal consistency and interrater reliability of BPS scale in the pain assessment performed by intensives care nurses. METHODS: A prospective observational study in 34 mechanically-ventilated patients, carried out in an Intensive Care Unit from April to June 2012. Variables analyzed included demographic characteristics, diagnosis of referral, clinical status, pain and sedation level. Pain was assessed by two nurses independently at rest (T1) and during a mobilization procedure (T2) using the BPS scale. Internal consistency was calculated by Cronbach's alpha, and intraobserver reliability was determined with the intraclass correlation coefficient (ICC), with a confidence interval (CI) of 95%. This study was approved by the Ethical Committee for Clinical Research. RESULTS: One-hundred and twenty-eight pain assessments were performed. The Cronbach's alpha of total BPS score at rest was 0.66 (95%CI: 0.33 to 0.83) and during mobilization of 0.73 (95%CI: 0.47 to 0.87). The CCI of total BPS score was 0.50 (95%CI: 0.19 to 0.71) at rest and 0.58 (95%CI: 0.31 to 0.77) during mobilization. CONCLUSIONS: The level of internal consistency of the scale is appropriate and moderate interrater agreement. For the BPS useful in clinical practice, it is imperative that nurses have prior experience with a regulated use of this tool.