[Mechanical restraint: its use in intensive cares]. / Contención mecánica: su uso en cuidados intensivos.

OBJECTIVE: To analyze the impact of the use of mechanical restraint (MR) or physical restraints in a Critical Care unit and to evaluate the procedure. BASIC PROCEDURES: A descriptive, prospective study. INCLUSION CRITERIA: patients who required MR from March to June 2010. VARIABLES: demographic, clinical presentation, indications, techniques and devices. A statistical analysis with mean, standard deviation and percentages using the program SPSS 14.0. RESULTS: A total of 85 cases were studied: 65.9% male, mean age 64.19 (±17.9), NEMS 29.3 (±8.2). Incidence of MR: 15.6%. Main indication for MR: Risk of serious disruption of treatment processes (80%). Decision nurse (94.1%). Urgent action: (85.9%). Registration procedure: 57.6%. Information to the family: 9.4%. Previous actions: verbal containment (100%), pharmacological (48.2%). CONCLUSIONS: There is a relevant incidence of MR. The principal reason is that of avoiding interruption of the therapeutic process. The nurse makes the initial decision. Necessary information/training of professionals for legal and ethical repercussions is needed.

NEMS: ¿nuevo predictor de mortalidad en el paciente crítico? / Nems: a new predictor of mortality in the critical patient?

En las unidades de cuidados intensivos se utilizan habitualmente escalas que predicen el riesgo de mortalidad hospitalaria y objetivan las necesidades terapéuticas y asistenciales que requieren los pacientes críticos. El objetivo de este trabajo fue estudiar si el NEMS podía ser utilizado como predictor de mortalidad, comparándolo con el APACHE II. Se realizó un estudio prospectivo en una unidad de cuidados intensivos polivalente de 24 camas. El APACHE II y NEMS se estratificaron en 3 niveles. Se recogieron datos demográficos y el valor en las primeras 24 horas del APACHE II y NEMS. Se incluyeron 1.257 pacientes; fallecieron el 16,4%. Fueron quirúrgicos el 69,6%; la mediana para estancia y edad fue de 2 días (1-4) y 66 años (50-77); el 59,3% fueron hombres. La mediana para vivos y muertos de APACHE II fue 10 (6-20) y 22,5 (17,25-29) respectivamente, (p<0,001) y para NEMS, 24 (18-29) y 34 (25-39,7), (p<0,001). La correlación entre ambas escalas fue rho=0,457, (p<0,01). La regresión logística controlada por edad, sexo y APACHE mostró solo para NEMS elevados un OR=3,1 (IC95%: 1,5-6,6), respecto al nivel mas inferior. Según los resultados no se debe utilizar el NEMS como predictor de mortalidad, aunque el riesgo de muerte aumenta tres veces con NEMS altos (AU)

Abstract Numerical scales are commonly used in intensive care units to predict hospital mortality and to assess the therapeutic effort and care that critically ill patients require. The aim of this work was to study whether the NEMS value can be used as a predictor of mortality, comparing it with the APACHE II. A prospective study in a 24 intensive care unit beds was conducted. The APACHE II and NEMS values were stratified into three levels. Demographic data and the first 24 hours values of APACHE II and NEMS scales were collected. A total of 1257 patients were included, 16.4% of whom died. 69.6% were surgical; median stay was 2 days (1-4). Medianage was 66 years (50-77), 59.3% were men. The median APACHE II and NEMS for the living and the dead in the subsequent course was 10 (6-20) versus 22.5 (17.25 to 29) (p <0.001) and 24(18-29) versus 34 (25 to 39.7) (p < 0.001) respectively. The correlation between both scales was rho = 0.457 (p < 0.01). Logistic regression controlled for age, sex and APACHE II showed an OR of3.1 (95% CI: 1.5-6.6) only for high NEMS, compared to the lowest level. According to the results NEMS should not be used as a predictor of mortality, although the risk of death increases by three times with high NEMS (AU)

[NEMS: a new predictor of mortality in the critical patient?]. / NEMS: ¿nuevo predictor de mortalidad en el paciente crítico?

Numerical scales are commonly used in intensive care units to predict hospital mortality and to assess the therapeutic effort and care that critically ill patients require. The aim of this work was to study whether the NEMS value can be used as a predictor of mortality, comparing it with the APACHE II. A prospective study in a 24 intensive care unit beds was conducted. The APACHE II and NEMS values were stratified into three levels. Demographic data and the first 24 hours values of APACHE II and NEMS scales were collected. A total of 1257 patients were included, 16.4% of whom died. 69.6% were surgical; median stay was 2 days (1-4). Median age was 66 years (50-77), 59.3% were men. The median APACHE II and NEMS for the living and the dead in the subsequent course was 10 (6-20) versus 22.5 (17.25 to 29) (p <0.001) and 24 (18-29) versus 34 (25 to 39.7) (p<0.001) respectively. The correlation between both scales was rho=0.457 (p<0.01). Logistic regression controlled for age, sex and APACHE II showed an OR of 3.1 (95% CI: 1.5-6.6) only for high NEMS, compared to the lowest level. According to the results NEMS should not be used as a predictor of mortality, although the risk of death increases by three times with high NEMS.

[Evaluation of the effect of a cleaning/disinfection intervention on the rate of multiresistant microorganism infections in the Intensive Care Unit]. / Evaluación del efecto de una intervención de limpieza/desinfección sobre la incidencia de infecciones por microorganismos multirresistentes en una Unidad de Cuidados Intensivos.

AIM: Evaluate the effect of an intervention on the rate of nosocomial infections (NI) produced by multiresistant microorganisms in the Intensive Care Units. MATERIAL AND METHODS: A study was conducted before and after an intervention in two ICUs to control an outbreak of multiresistant Acinetobacter baumanii (MRAB). During the outbreak (from 22-12-06 to 12-2-07) the wards were closed and both the wards and the equipment of both ICUs were cleaned and disinfected. A microbiological sampling was also made. The nosocomial infection rate density of the multiresistant microorganisms was compared between hospitalized patients: preintervention (1-3-2006 to 15-12-2006) and postintervention (1-3-2007 to 15-12-2007). To certify if there were any statistically significant differences between them, a rate ratio (RT) was calculated with a 95% confidence interval. The level of statistical significance was established at p < 0.05. We stratified per unit, per type of microorganism and location of the infection. RESULTS: The global NI incidence rate for multiresistant microorganisms significantly declined after the interventions in both units (RT: 1.83, 95% CI: 1.34-2.50), p < 0.005. A significant decrease was also observed on the NI incidence rate for the following microorganisms: P. aeruginosa (RT: 2.36, 95% CI: 1.41-3.96), Enterobacter BLEE (RT: 2.31, 95% CI: 1.11-4.82) and S. maltophilia (RT: 2.77, 95% CI: 1.10-6.99). In regards to the infection location, a significant decrease in respiratory infection rates was observed (RT: 1.96, 95% CI: 1.29-2.99). CONCLUSION: The intervention conducted to control the MRAB outbreak was effective in reducing the NI incidence of multiresistant microorganisms.

Evaluación del efecto de una intervención de limpieza/ desinfección sobre la incidencia de infecciones por microorganismos multirresistentes en una Unidad de Cuidados Intensivos / Evaluation of the effect of a cleaning/disinfection intervention on the rate of multiresistant microorganism infections in the Intensive Care Unit

Objetivo. Evaluar el efecto de una intervención sobre la incidencia de infecciones nosocomiales(IN) por microorganismos multirresistentes en las Unidades de Cuidados Intensivos (UCI).Material y métodos. Se realizó un estudio antes-después de una intervención para el controlde un brote de Acinetobacter baumannii multirresistente (ABMR) en dos UCI. Durante el brote(del 22-12-06 al 12-2-07) se procedió al cierre y limpieza/desinfección de las salas y equipamientode las dos UCI, con muestreo microbiológico antes y después. Se comparó la densidadde incidencia de IN por microorganismos multirresistentes entre los pacientes ingresados: preintervención(del 1-3-2006 al 15-12-2006) y posintervención (del 1-3-2007 al 15-12-2007). Paracomprobar si existían diferencias estadísticamente signifi cativas se calculó la razón de tasas(RT) y su intervalo de confi anza (IC) al 95%. El nivel de signifi cación estadística se estableció enp < 0,05. Se estratifi có por unidad, tipo de microorganismo y localización de la infección.Resultados. La tasa de incidencia global de IN por microorganismos multirresistentes disminuyósignifi cativamente tras la intervención en ambas unidades (RT: 1,83, IC 95% 1,34-2,50), p < 0,005.También existió disminución signifi cativa en la tasa de incidencia de IN para los microorganismos:P. aeruginosa (RT: 2,36, IC 95% 1,41-3,96), enterobacterias BLEE (RT: 2,31, IC 95% 1,11-4,82) y S.maltophilia (RT: 2,77, IC 95% 1,10-6,99). Con respecto a la localización de la infección resultósignifi cativa la disminución en la tasa de infecciones respiratorias (RT: 1,96, IC 95% 1,29-2,99).Conclusión. La intervención realizada para el control del brote de ABMR fue efectiva paradisminuir la incidencia de IN por otros microorganismos multirresistentes(AU)

Aim. Evaluate the effect of an intervention on the rate of nosocomial infections (NI)produced by multiresistant microorganisms in the Intensive Care Units.Material and methods. A study was conducted before and after an intervention in two ICUsto control an outbreak of multiresistant Acinetobacter baumanii (MRAB). During theoutbreak (from 22-12-06 to 12-2-07) the wards were closed and both the wards and theequipment of both ICUs were cleaned and disinfected. A microbiological sampling was alsomade. The nosocomial infection rate density of the multiresistant microorganisms wascompared between hospitalized patients: preintervention (1-3-2006 to 15-12-2006) andpostintervention (1-3-2007 to 15-12-2007). To certify if there were any statisticallysignifi cant differences between them, a rate ratio (RT) was calculated with a 95% confi denceinterval. The level of statistical signifi cance was established at p < 0.05. We stratifi ed perunit, per type of microorganism and location of the infection.Results. The global NI incidence rate for multiresistant microorganisms signifi cantlydeclined after the interventions in both units (RT: 1.83, 95% CI: 1.34-2.50), p < 0.005. Asignifi cant decrease was also observed on the NI incidence rate for the followingmicroorganisms: P. aeruginosa (RT: 2.36, 95% CI: 1.41-3.96), Enterobacter BLEE (RT: 2.31,95% CI: 1.11-4.82) and S. maltophilia (RT: 2.77, 95% CI: 1.10-6.99). In regards to theinfection location, a signifi cant decrease in respiratory infection rates was observed (RT:1.96, 95% CI: 1.29-2.99).Conclusion. The intervention conducted to control the MRAB outbreak was effective inreducing the NI incidence of multiresistant microorganisms(AU)

[Analysis of the use of nursing personnel in a general intensive care unit. Situation in other european ICUs]. / Análisis del uso de los recursos humanos enfermeros en una unidad de cuidados intensivos polivalente. Situación con el resto de UCIs europeas.

Nursing workloads form the basis for the appropriate provision of nursing personnel. In this study we used the nine equivalents of nursing manpower use score (NEMS) to determine and evaluate the use of nursing staff in our unit. In the first phase we determined the actual workload in the various shifts and diagnostic areas. Statistically significant differences were found among diagnostic areas but not among shifts. Then, to compare our situation with that of other European intensive care units (ICUs), dynamic parameters of the management and efficiency of the use of nursing staff were analyzed following the multicentric EURICUS-I study, which was performed over 4 months in 100 ICUs in 12 European countries. For the comparison, indexes such as the work utilization ratio (WUR), the level of care planned (LOC p) and the level of care operative (LOC op) were used. The results obtained reveal that although our workload is equivalent to the European average, efficiency is greater. Thus, the situation in our unit differs from the downward trend of the data obtained in other European countries.

[Audit of artificial nutrition in an intensive care unit]. / Auditoría de la nutrición artificial en una Unidad de Medicina Intensiva.

OBJECTIVE: To study compliance with an artificial nutrition protocol at an Intensive Care Unit. During a second stage and after introducing the modifications considered appropriate in the protocol, to verify its implementation and compare both series. REFERENCE POPULATION: All patients with artificial nutrition support were included. Artificial nutrition (AN) was deemed to be the dispensation of commercial preparations for enteral nutrition, formulas with amino acids and glucose and the parenteral provision of fat, including propofol in this case, even where it was the only source of energy. The provision of crystalloid solutions was not considered to be AN. The period of observation was two months in both cases. INTERVENTION: The provision of AN to all such patients was systematically recorded on a daily basis. After analysis of the first series, the members at the unit agreed to increase the nitrogen provision. A second series was recorded, with the data being collected for patients with AN during a similar period. RESULTS: The study of the first series revealed the provisions of energy and nitrogen were below theoretical levels (both in the corrected Harris-Benedict test and at the fixed prescription of 25 kcal/kg). In the second series, there was greater agreement between the theoretical values and the amounts actually received. The deviation in energy and nitrogen was significantly less in the second series. And although the total nitrogen load per patient did not reveal any differences, there were discrepancies in the daily provision per patient. On most days, the diet provided covered over 75% of the energy requirements. With parenteral nutrition on its own or in combination with enteral nutrition, the requirements of energy and nitrogen were exceeded. There were no differences between the two series. The type of provision was enteral on 55% of the days and parenteral on 18%. There was no difference in the type of provision between the two series, although there was a difference in the type of diet administered in that the second series saw a significant increase in the provision of hyperproteic diets, both enterally and through patenteral formulations, rising from 9-13 grammes to 18-20 grammes of nitrogen. Using the enteral route on its own, there was a discreet increase in the energy load in the second series, but this did not occur in the other types of provision. Both series revealed over-nutrition in terms of both calories and nitrogen when enteral and parenteral nutrition were used together, although there was no difference between the series. CONCLUSIONS: Early enteral nutrition is possible in critically-ill patients, while artificial nutrition was used most frequently and for longer in our patients. The existence of nutrition protocols allow acceptable levels of nutritional provision. Their controlled use allows the correction of deviations between real and theoretical provisions, customizing the nutrition for each patient. The use of parenteral formulas with high levels of nitrogen requires more accurate adjustment in order to avoid over-nutrition.

Análisis del uso de los recursos humanos enfermeros en una unidad de cuidados intensivos polivalente. situación con el resto de ucis europeas / Analysis of the use of nursing personnel in a general intensive care unit. Situation in other european ICUs

Las cargas de trabajo enfermeras deberían ser la base para la adecuación correcta de los recursos humanos enfermeros. En el presente estudio utilizamos la escala NEMS (nine equivalents of nursing manpower use score), con el objeto de conocer y valorar el uso de los recursos enfermeros en nuestra unidad. En una primera fase conocimos las cargas reales de trabajo en los distintos turnos y zonas diagnósticas, observando la existencia de diferencias estadísticas entre zonas diagnósticas, pero no entre los distintos turnos de trabajo. Posteriormente se analizaron parámetros dinámicos de gestión y eficiencia de uso de recursos humanos siguiendo el estudio multicéntrico EURICUS-I, estudio realizado durante 4 meses en un total de 100 UCIs de 12 países europeos, con el objeto de comparar nuestra situación con el resto de UCIs europeas. Para ello utilizamos índices como el WUR (work utilization ratio), LOC p (level of care planned) y LOC op (level of care operative). De los resultados obtenidos se desprende que a pesar de tener las mismas cargas de trabajo que la media europea, soportamos niveles de eficiencia superiores, es decir, el escenario en el que nos encontramos en nuestra unidad difiere a la baja de los datos obtenidos en Europa (AU)

Efecto sobre la contaminación microbiológica y de confort del paciente, ante dos diferentes pautas temporales de cambio de cánulas traqueales / Effect of two different tracheal cannula change schedules on microbiological contamination and patient comfort

La traqueotomía es una técnica habitual en las unidades de cuidados intensivos, sin embargo, no existen criterios uniformes sobre la periodicidad con la que deben realizarse los cambios de cánulas traqueales, por ello, el objetivo de nuestro estudio ha sido valorar si ante dos pautas diferentes de cambios de cánulas, no existía modificación en la contaminación microbiológica y se disminuían los episodios dolorosos y de sangrado relacionados con dichos cambios. Se diseñó un estudio comparativo entre dos grupos, un grupo control al que se le realizaron los cambios de cánula cada 48 horas y un grupo experimental al que se le realizaron cada cinco días. En ambos grupos, además de los datos demográficos, se valoró la técnica de traqueotomía utilizada, se realizó estudio microbiológico de la cánula, aspirado bronquial y estoma, se valoraron signos clínicos de infección del estoma y secreciones, se realizó estudio radiológico torácico. Con cada cambio de cánula se valoró el sangrado, dolor, tipo de ventilación, alteración hemodinámica, obstrucción de la vía aérea, realización de falsa vía, saturación de oxígeno previa y postcambio y el tiempo de recuperación. Se incluyeron 29 pacientes y se estudiaron 97 cánulas. Partiendo de una muestra homogénea, observamos que de forma significativa los pacientes que pertenecieron al grupo experimental, se mantuvieron con una radiología torácica normal más tiempo (p= 0,005). Los estomas del grupo experimental presentaron diferencias significativas en cuanto a menor exudado (p= 0,04) y dolor (p= 0,004). Cuando se relacionó la técnica utilizada en la realización de la traqueotomía con los estomas, se observó que de forma significativa estuvieron más enrojecidos (p< 0,004) y exudaron más (p< 0,001) aquellos cuya técnica de elección fue la quirúrgica realizada en la unidad. Como conclusión, podemos afirmar que el prolongar los cambios de cánulas a cinco días no aumenta la incidencia de contaminación y disminuye el dolor en los pacientes traqueotomizados (AU)

[Effect of two different tracheal cannula change schedules on microbiological contamination and patient comfort]. / Efecto sobre la contaminación microbiológica y de confort del paciente, ante dos diferentes pautas temporales de cambio de cánulas traqueales.

Tracheostomy is a commonly used technique in intensive care units, but there are no uniform criteria governing the periodicity with which tracheal cannulas should be changed. The objective of our study was to evaluate if different cannula-change schedules modified microbiological contamination and reduced the pain and bleeding related with cannula changes. In a comparative study of two groups, a control group in which the cannula was change every 48 hours and an experimental group in which the cannula was changed every 5 days were studied. Demographic differences, tracheostomy technique, microbiological study of the cannula, bronchial aspirate and stoma, clinical signs of stomal infection and secretions, and chest radiography were compared in the two groups. With each cannula change, we evaluated bleeding, pain, type of ventilation, hemodynamic disturbances, airway obstruction, opening of a false airway, oxygen saturation before and after cannula change, and recovery time. The study included 29 patients and 97 cannulas. In a homogeneous sample, the patients in the experimental group had a normal chest radiograph for a significantly longer time (p = 0.005). The stomas of the experimental group produced significantly less seepage (p = 0.04) and pain (p = 0.004). When the tracheostomy technique was correlated with the stoma, surgical tracheostomy performed in the unit showed significantly more reddening (p < 0.004) and seeping (p < 0.001). We conclude that prolonging cannula changes to every 5 days did not increase the incidence of contamination and reduced the pain of tracheostomized patients.