Utilidad de la diferencia venoarterial de PCO2 como predictor de complicaciones en el postoperatorio inmediato del trasplante hepático / Utility of the central venous-to-arterial CO2 difference to predict adverse outcomes after liver transplantation

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)

Utility of the central venous-to-arterial CO2 difference to predict adverse outcomes after liver transplantation.

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.

Encefalopatía hiperamonémica en un paciente tratado con 5-fluorouracilo / Hyperammonemic encephalopathy in a patient treated with 5-fluorouracil

No disponible

Eficacia de la información al alta en la adherencia del paciente polimedicado / Efficiency of the Information Given at Discharge and Adherence of Polymedicated Patients

Objetivo Conocer la utilidad de un programa de información farmacoterapéutica al alta hospitalaria. Método Estudio prospectivo de 3 meses de duración en el que se aleatorizó a los pacientes en 2 grupos según recibieran o no información verbal y escrita sobre su tratamiento al alta hospitalaria. La adherencia se evaluó mediante el test de Morinsky-Green, tanto en el momento del alta, como transcurridos 30-50 días mediante entrevista telefónica. Además se recogió la información sobre la medicación del paciente en ese momento y los cambios respecto a la medicación al alta. Resultados Se incluyeron un total de 59 pacientes, 30 en el grupo control y 29 en el experimental. Entre el alta y la entrevista trascurrieron 42,1±9,6 días. Mientras que en el momento del alta el porcentaje de pacientes adherentes era mayor en el grupo control (83,3 frente a 62,1%, OR=0,33, IC 95%: 0,1 a 1,1, p=0,07), en la entrevista telefónica fue mayor en el grupo experimental (62,5 frente a 88,5%, OR=4,6, IC 95%: 1,1 a 19,8, p=0,03). Las diferencias entre ambos grupos en el resto de las variables (fallecimientos, visitas a urgencias y reingresos hospitalarios) no fueron estadísticamente significativas. En la entrevista telefónica un 70% de los pacientes sufrió algún tipo de cambio respecto al tratamiento al alta hospitalaria. Conclusiones La información al alta por parte del farmacéutico es una herramienta para mejorar la adherencia al tratamiento de los pacientes que debe tener una continuidad debido al elevado número de cambios de tratamiento que sufren estos pacientes (AU)

Objective To evaluate the utility of a post-discharge pharmaceutical care programme. Method Three-month prospective study where patients were randomised into two groups according to whether or not they received verbal and written information about their treatment at hospital discharge. Treatment compliance was assessed by the Morisky–Green test at discharge and at 30–50days via a telephone interview, also collecting information on patient medication. Results A total of 59 patients were included, 30 in the control group and 29 in the experimental group. 42.1±9.6days had elapsed between discharge and the telephone interview. While a higher percentage of patients were adherent to treatment at discharge in the control group (83.3 versus 62.1%, OR=0.33, 95% CI: 0.1–1.1, P=.07), in the telephone interview the percentage in the experimental group was greater (62.5 versus 88.5%, OR=4.6, 95% CI: 1.1–19.8, P=.03). The differences between the two groups for the rest of the variables (deaths, visits to emergency department and hospital readmissions) were not statistically significant. In the telephone interview, 70% of patients’ treatment was changed in some way since hospital discharge. Conclusion A post-discharge pharmaceutical care programme is a tool to improve treatment compliance, which needs continuity due to the large number of treatment changes suffered by these patients (AU)

Desarrollo, implantación y evaluación de un programa de prescripción electrónica asistida de medicamentos en un hospital / Development, implementation and evaluation of an electronic drug prescribing program in a hospital

Objetivo: Desarrollar e implantar herramientas seguras y eficaces para la prescripción electrónica de los tratamientos farmacológicos. Material y método: Se realizó una revisión bibliográfica para cada medicamento o principio activo incluido en la Guía Farmacoterapéutica del Hospital para recoger información acerca de sus interacciones y ajustes posológicos en insuficiencia renal. Se elaboró una base de datos con 62 interacciones clínicamente relevantes y otra de 531 fármacos con recomendaciones posológicas o de monitorización en función del grado de insuficiencia renal (IR). Resultados: La integración de la base de datos de IR permite que desde el Servicio de Farmacia se pueda seleccionar a los pacientes con alteración en la función renal que tienen prescritos medicamentos que requieren ajuste posológico y asesorar sobre las recomendaciones individualizadamente, incorporando esta información a la historia clínica electrónica. Conclusión: esta herramienta, ha mejorado el programa de prescripción electrónica, convirtiéndolo en una prescripción electrónica asistida (AU)

Objetive: Develop and implement safe and effective tools for computer provider order entry to serve as clinical decision support. Material and methods: A literature review was performed for each drug included in the Hospital's pharmaceutical guide for collecting information on clinically relevant drug interactions and dose adjustments in renal failure Results: A database with 62 clinically relevant interactions was developed and integrated into the hospital information program. When an interaction is detected at the time of prescribing an alert is generated to report on its consequences and alternatives. Another database with 531 drugs with dosing or monitoring recommendations specific to the degree of renal failure in each patient was developed and integrated into the hospital information system, so that from the Pharmacy Department we can select patients with impaired renal function who have been prescribed drugs that require dose adjustment and advise on the dosage recommendations for each patient. Conclusion: Due to the development and implementation of these tools, we have improved our computer provider order entry with a clinical decision support system (AU)

[Efficiency of the information given at discharge and adherence of polymedicated patients]. / Eficacia de la información al alta en la adherencia del paciente polimedicado.

OBJECTIVE: To evaluate the utility of a post-discharge pharmaceutical care programme. METHOD: Three-month prospective study where patients were randomised into two groups according to whether or not they received verbal and written information about their treatment at hospital discharge. Treatment compliance was assessed by the Morisky Green test at discharge and at 30-50 days via a telephone interview, also collecting information on patient medication. RESULTS: A total of 59 patients were included, 30 in the control group and 29 in the experimental group. 42.1 ± 9.6days had elapsed between discharge and the telephone interview. While a higher percentage of patients were adherent to treatment at discharge in the control group (83.3 versus 62.1%, OR=0.33, 95% CI: 0.1-1.1, P=.07), in the telephone interview the percentage in the experimental group was greater (62.5 versus 88.5%, OR=4.6, 95% CI: 1.1-19.8, P=.03). The differences between the two groups for the rest of the variables (deaths, visits to emergency department and hospital readmissions) were not statistically significant. In the telephone interview, 70% of patients' treatment was changed in some way since hospital discharge. CONCLUSION: A post-discharge pharmaceutical care programme is a tool to improve treatment compliance, which needs continuity due to the large number of treatment changes suffered by these patients.

Meta-análisis sobre la eficacia de la estrategia de monoterapia con inhibidores de la proteasa potenciados en pacientes VIH+ / Meta-analysis of the effectiveness of the strategy of monotherapy with boosted protease inhibitors in HIV+ patients

Introducción El objetivo del presente trabajo es analizar la evidencia disponible sobre la eficacia de la estrategia de inducción mantenimiento con inhibidores de proteasa potenciados con ritonavir en pacientes adultos VIH respecto al tratamiento convencional. Métodos Se realizó un meta-análisis de ensayos aleatorizados y controlados en pacientes VIH para comparar la eficacia de una estrategia de monoterapia con inhibidores de proteasa potenciados frente al tratamiento antirretroviral convencional. La búsqueda bibliográfica se realizó en PubMed, EMBASE (septiembre 1999–septiembre 2009) y en resúmenes de congresos de los últimos 5 años. Se calcularon los Odds Ratio del fracaso terapéutico y sus intervalos de confianza del 95%. Para combinar los resultados de los estudios individuales seleccionados, se empleó un modelo de efectos fijos basado en el método de Mantel-Haenszel o de efectos aleatorios, en función de que exista o no heterogeneidad en los resultados. Resultados Se localizaron inicialmente un total de 1.510 publicaciones, de las que solo 8 estudios cumplieron los criterios de inclusión en el meta-análisis. El Odds Ratio combinado de los 8 estudios es de 1,39 (IC 95% 1,02–1,90) a favor del grupo de tratamiento con tratamiento antirretroviral convencional, pero con un intervalo de confianza cercano a los límites de la no significación estadística. Conclusión Los resultados del análisis de eficacia combinado en el meta-análisis no encuentran diferencias significativas entre la estrategia convencional y la monoterapia. Esta estrategia se considera recomendable (nivel A de evidencia) en pacientes sin historia de fracaso previo a inhibidores de la proteasa, con carga viral plasmática indetectable y signos o síntomas de toxicidad por análogos de nucleósidos/nucleótidos (AU)

Introduction The objective of this study is to analyse the available evidence regarding the effectiveness of the strategy of induction maintenance with boosted protease inhibitors with ritonavir in adult HIV patients as compared to conventional treatment. Methods We performed a meta-analysis of randomised controlled trials in HIV patients to compare the efficacy of a monotherapy strategy of boosted protease inhibitors as compared with conventional antiretroviral therapy. The literature search was conducted in PubMed, EMBASE (September 1999–September 2009) and in conference abstracts of the last 5 years. The Odds Ratio of treatment failure and their 95% confidence intervals were calculated. To combine the results of individual studies selected, a fixed effects model based on the Mantel-Haenszel method or random effects was used, depending on whether or not the results were heterogeneous. Results Initially a total of 1510 publications were found, of which just 8 studies met the criteria for inclusion in the meta-analysis. The combined Odds Ratio of the 8 studies is 1.39 (95% CI 1.02–1.90) for the treatment group with conventional antiretroviral treatment, but with a confidence interval close to the limits of statistical non-significance. Conclusion The results of the combined effectiveness analysis in the meta-analysis found no significant differences between the conventional strategy and monotherapy. This strategy is considered recommended (level A evidence) in patients with no history of previous failure of protease inhibitor, with undetectable plasma viral load and signs or symptoms of nucleoside/nucleotide toxicity (AU)

[Meta-analysis of the effectiveness of the strategy of monotherapy with boosted protease inhibitors in HIV+ patients]. / Meta-análisis sobre la eficacia de la estrategia de monoterapia con inhibidores de la proteasa potenciados en pacientes VIH+

INTRODUCTION: The objective of this study is to analyse the available evidence regarding the effectiveness of the strategy of induction maintenance with boosted protease inhibitors with ritonavir in adult HIV patients as compared to conventional treatment. METHODS: We performed a meta-analysis of randomised controlled trials in HIV patients to compare the efficacy of a monotherapy strategy of boosted protease inhibitors as compared with conventional antiretroviral therapy. The literature search was conducted in PubMed, EMBASE (September 1999-September 2009) and in conference abstracts of the last 5 years. The Odds Ratio of treatment failure and their 95% confidence intervals were calculated. To combine the results of individual studies selected, a fixed effects model based on the Mantel-Haenszel method or random effects was used, depending on whether or not the results were heterogeneous. RESULTS: Initially a total of 1510 publications were found, of which just 8 studies met the criteria for inclusion in the meta-analysis. The combined Odds Ratio of the 8 studies is 1.39 (95% CI 1.02-1.90) for the treatment group with conventional antiretroviral treatment, but with a confidence interval close to the limits of statistical non-significance. CONCLUSION: The results of the combined effectiveness analysis in the meta-analysis found no significant differences between the conventional strategy and monotherapy. This strategy is considered recommended (level A evidence) in patients with no history of previous failure of protease inhibitor, with undetectable plasma viral load and signs or symptoms of nucleoside/nucleotide toxicity.

[Insulin therapy at the hospital setting]. / Insulinoterapia en el medio hospitalario.

Hyperglycemia is defined in different studies as a poor prognostic factor relating with higher risk for post-surgical infections, neurological complications, increased hospital staying, and admission to intensive care units. Appropriate use of insulin therapy is one of the key factors assuring the best management of hospitalized patients. The aim of this review was to discuss the most important aspects of insulin use at the hospital setting. We analyzed the different types of insulin commercially available and the factors determining their efficacy, as well as the different regimens and administration routes available at the hospital according to the type of patient and the type of feeding or exogenous intake of carbohydrates. The fear of inducing hypoglycemic episodes at the hospital contributes to an inappropriate prescription of the programmed insulin doses, the use of flexible rapid insulin doses in monotherapy, and setting excessively high glycemia levels. Currently, individualized management of hospital hyperglycemias should replace obsolete insulin regimens in order to reach more stringent glycemia goals and decreasing the number of complications in the hospitalized patient.

Insulinoterapia en el medio hospitalario / Insulin therapy the hospital setting

La hiperglucemia se define en diversos estudios como un factor de mal pronóstico relacionado con un mayor riesgo de infecciones postoperatorias, complicaciones neurológicas, aumento de la estancia hospitalaria e ingreso en unidades de cuidados intensivos. El uso adecuado de la terapia insulínica es una de las claves para asegurar el tratamiento óptimo del paciente ingresado en el hospital. El objetivo de esta revisión es discutir los aspectos más importantes del uso de insulina en el medio hospitalario. Se analizan tanto los tipos de insulina existentes en el mercado y los principales factores que determinan su eficacia, como las diferentes pautas y vías de administración que encontramos en el hospital en función del tipo de paciente y del tipo de alimentación o aporte exógeno de hidratos de carbono. El miedo a provocar episodios hipoglucémicos en el hospital, contribuye a una inadecuada prescripción de dosis programadas de insulina, a la utilización de pautas móviles de insulina rápida en monoterapia y al establecimiento de objetivos de glucemia demasiado elevados. Actualmente el tratamiento individualizado de las hiperglucemias hospitalarias debe sustituir a pautas de insulina obsoletas, con el fin de alcanzar objetivos glucémicos más exigentes que disminuyan las complicaciones del paciente durante su ingreso hospitalario (AU)

Hyperglycemia is defined in different studies as a poor prognostic factor relating with higher risk for post-surgical infections, neurological complications, increased hospital staying, and admission to intensive care units. Appropriate use of insulin therapy is one of the key factors assuring the best management of hospitalized patients. The aim of this review was to discuss the most important aspects of insulin use at the hospital setting. We analyzed the different types of insulin commercially available and the factors determining their efficacy, as well as the different regimens and administration routes available at the hospital according to the type of patient and the type of feeding or exogenous intake of carbohydrates. The fear of inducing hypoglycemic episodes at the hospital contributes to an inappropriate prescription of the programmed insulin doses, the use of flexible rapid insulin doses in monotherapy, and setting excessively high glycemia levels. Currently, individualized management of hospital hyperglycemias should replace obsolete insulin regimens in order to reach more stringent glycemia goals and decreasing the number of complications in the hospitalized patient (AU)

[Types of insulin therapy]. / Tipos de insulinoterapia.

Diabetes mellitus is a chronic disease associated with a series of long-term microvascular and macrovascular complications that requires continuing therapeutic control. In recent years, the pharmaceutical industry has developed new types of insulin and administration systems in order to more closely mimic human insulin secretion. In this way, insulin therapy is divided into conventional and intensive regimens according to their complexity. In type 1 diabetes mellitus (T1DM) patients, the treatment of choice is the one which achieves intensive glycemic control. In type 2 diabetes mellitus, we can start with a simplified conventional regimen which could progress into an intensive one similar to that of T1DM treatment. Both types of diabetes require an individualized treatment prescription based on the needs and characteristics of each patient.

Tipos de insulinoterapia / Types of insulin therapy

La diabetes es una enfermedad crónica asociada a una serie de complicaciones macro y microvasculares a largo plazo, que requiere un control terapéutico continuo. En los últimos años se han desarrollado nuevos tipos de insulina y de sistemas de administración, con el objetivo de aproximar las pautas de administración de la insulina al patrón de secreción endógena. Así, según su complejidad, podemos clasificar las pautas en terapia convencional y terapia intensiva. En pacientes con diabetes mellitus tipo 1 (DMT1) la terapia de elección es aquella que alcance un control intensivo de la glucemia del paciente. En la diabetes mellitus tipo 2 se puede comenzar con una pauta convencional más simplificada, que podría evolucionar hacia una terapia intensiva similar a la de la DMT1. En ambos tipos de diabetes, se debe prescribir la pauta insulínica de la forma más individualizada posible en función de las necesidades y características de cada paciente (AU)

Diabetes mellitus is a chronic disease associated with a series of long-term microvascular and macrovascular complications that requires continuing therapeutic control. In recent years, the pharmaceutical industry has developed new types of insulin and administration systems in order to more closely mimic human insulin secretion. In this way, insulin therapy is divided into conventional and intensive regimens according to their complexity. In type 1 diabetes mellitus (T1DM) patients, the treatment of choice is the one which achieves intensive glycemic control. In type 2 diabetes mellitus, we can start with a simplified conventional regimen which could progress into an intensive one similar to that of T1DM treatment. Both types of diabetes require an individualized treatment prescription based on the needs and characteristics of each patient (AU)