The advancement of critical care nursing as a response to the current demands.

The current demand on health services requires that nurses play a key role, by adapting their competencies to different fields and complexity levels. The approach of situations presented by critically ill patients underpins the need for development of specialised competencies in specific areas such as patient safety, prevention and control of healthcare-associated infections, performance of specific techniques and interventions, autonomous medication management or the use of technology, among others. Spain relies on a specialist training programme that is unique worldwide. Training admission is managed through a contract as a "Resident Nurse Intern" (EIR, Enfermera Interna Residente), provided by regional healthcare services. Only 6 specialities have been established and developed, in an uneven manner and with a short provision of places, annually. Given that the specialization in critical care nursing does not exist, nurses usually self-fund their postgraduate training to enhance their opportunities career development. The development of a speciality for critical care nursing is a priority. The models proposed advocate for creating nursing roles that could cover the systemic gaps through the expansion of their competencies and the introduction of procedures that fit nursing into advanced practice, which could be achieved through Advanced Accreditation Diplomas. Simultaneously, it would be convenient to analyse how and why such a dynamic discipline in some countries became stuck in anachronistic models of the Spanish healthcare system. This analysis might contribute to move forward on the development of areas of improvement in terms of service access and quality of care.

Clinical trial: clarithromycin vs. levofloxacin in first-line triple and sequential regimens for Helicobacter pylori eradication.

BACKGROUND: Helicobacter pylori eradication rates with standard triple therapy have declined to unacceptable levels. AIM: To compare clarithromycin and levofloxacin in triple and sequential first-line regimens. METHODS: A total of 460 patients were randomized into four 10-day therapeutic schemes (115 patients per group): (i) standard OCA, omeprazole, clarithromycin and amoxicillin; (ii) triple OLA, omeprazole, levofloxacin and amoxicillin; (iii) sequential OACM, omeprazole plus amoxicillin for 5 days, followed by omeprazole plus clarithromycin plus metronidazole for 5 days; and (iv) modified sequential OALM, using levofloxacin instead of clarithromycin. Eradication was confirmed by 13C-urea breath test. Adverse effects and compliance were assessed by a questionnaire. RESULTS: Per protocol cure rates were: OCA (66%; 95% CI: 57-74%), OLA (82.6%; 75-89%), OACM (80.8%; 73-88%) and OALM (85.2%; 78-91%). Intention-to-treat cure rates were: OCA (64%; 55-73%), OLA (80.8%; 73-88%), OACM (76.5%; 69-85%) and OALM (82.5%; 75-89%). Eradication rates were lower with OCA than with all the other regimens (P < 0.05). No differences in compliance or adverse effects were demonstrated among treatments. CONCLUSIONS: Levofloxacin-based and sequential therapy are superior to standard triple scheme as first-line regimens in a setting with high clarithromycin resistance. However, all of these therapies still have a 20% failure rate.

[Course and cares of intestinal transplant in immediate post-operative period]. / Evolución y cuidados del trasplante intestinal en el postoperatorio inmediato.

OBJECTIVE: Describe the course and immediate post-operative care in patients with intestinal transplant. MATERIAL AND METHODS: Descriptive, prospective study conducted in the Polyvalent Intensive Care Unit of a tertiary hospital for one year. Variables analyzed during the first 48 hours of the post-operative period: vital signs, O2 saturation, weaning time, diuresis, glycemia, catheters, drains, ileostomy, gastrostomy, TISS, NEMS, nursing cares, APACHE II and SAPS II on admission. Statistical analysis with SPSS 11.0. RESULTS: Four patients, 50% women, mean age 42 +/- 8 years. Reason for intestinal transplant: 75% familial adenomatous polyposis with desmoid tumor and 25% mesenteric artery obstruction. They were administered alemtuzumab and tacrolimus. All the patients were carrier of central and arterial venous catheters, and Jackson Pratt abdominal drains (50% two, 50% three). Intubation time (median) 15 hours. APACHE II 10 +/- 6 y SAPS II 16 +/- 4. Means on first and second day of: systolic/diastolic blood pressure 132 +/- 23/73 +/- 11; 130 +/- 25/74 +/- 13 mmHg; glycemia 136 +/- 26/119 +/- 25 mg/dl; diuresis 95 +/- 34/125 +/- 30 cc/hour; TISS28 49 +/- 4/38 +/- 11 and NEMS 27 +/- 0/25 +/- 10, respectively. One re-operation due to hemorrhagic shock. Median study in Intensive Care Unit of 4 days. CONCLUSIONS: 1) They are hemodynamically stable patients with short weaning. They do not have many catheters, functioning ileostomy since the first day and TISS28 and NEMS in the middle of the range. 2) The most specific cares of the intestinal transplant are: surgical wound, drains, ileostomy, gastrostomy. 3) The need for intense immunosuppression implies strict isolation and nursing:patient ratio of 1:1.

Evolución y cuidados del trasplante intestinal en el postoperatorio inmediato / Course and cares of intestinal transplant in immediate post-operative period

Objetivo. Describir la evolución y cuidados del postoperatorio inmediato en pacientes con trasplante intestinal. Material y métodos. Estudio descriptivo prospectivo realizado en la Unidad de Cuidados Intensivos Polivalente de un hospital terciario durante un año. Variables analizadas durante las primeras 48 horas del postoperatorio: constantes vitales, saturación O2, tiempo de destete, diuresis, glucemia, catéteres, drenajes, ileostomía, gastrostomía, TISS, NEMS, cuidados de enfermería, APACHE II y SAPS II al ingreso. Análisis estadístico con SPSS 11.0. Resultados. Cuatro pacientes. Mujeres 50%, edad media 42 ± 8 años. Motivo trasplante intestinal: 75% poliposis adenomatosa familiar con tumor desmoides y 25% obstrucción arteria mesentérica. Recibieron alemtuzumab y tacrólimus. Todos los pacientes eran portadores de catéter venoso central, arterial y drenajes abdominales Jackson Pratt (50% dos, 50% tres). Tiempo intubación (mediana) 15 horas. APACHE II 10 ± 6 y SAPS II 16 ± 4. Medias primer y segundo día de: tensión arterial sistólica/diastólica 132 ± 23/73 ± 11; 130 ± 25/74 ± 13 mmHg; glucemia 136 ± 26/119 ± 25 mg/dl; diuresis 95 ± 34/125 ± 30 cc/hora; TISS28 49 ± 4/38 ± 11 y NEMS 27 ± 0/25 ± 10, respectivamente. Una reintervención por shock hemorrágico. Mediana de estancia en Unidad de Cuidados Intensivos 4 días. Conclusiones. 1) Son pacientes hemodinámicamente estables; con destete corto; no portan muchos catéteres; ileostomía funcionante desde el primer día y con TISS28 y NEMS en la media del rango. 2) Los cuidados más específicos del trasplante intestinal son: herida quirúrgica, drenajes, ileostomía, gastrostomía. 3) La necesidad de intensa inmunosupresión implica aislamiento estricto y una ratio de enfermería:paciente 1:1

Objective. Describe the course and immediate post-operative care in patients with intestinal transplant. Material and methods. Descriptive, prospective study conducted in the Polyvalent Intensive Care Unit of a tertiary hospital for one year. Variables analyzed during the first 48 hours of the post-operative period: vital signs, O2 saturation, weaning time, diuresis, glycemia, catheters, drains, ileostomy, gastrostomy, TISS, NEMS, nursing cares, APACHE II and SAPS II on admission. Statistical analysis with SPSS 11.0. Results. Four patients, 50% women, mean age 42 ± 8 years. Reason for intestinal transplant: 75% familial adenomatous polyposis with desmoid tumor and 25% mesenteric artery obstruction. They were administered alemtuzumab and tacrolimus. All the patients were carrier of central and arterial venous catheters, and Jackson Pratt abdominal drains (50% two, 50% three). Intubation time (median) 15 hours. APACHE II 10 ± 6 y SAPS II 16 ± 4. Means on first and second day of: systolic/diastolic blood pressure 132 ± 23/73 ± 11; 130 ± 25/74 ± 13 mmHg; glycemia 136 ± 26/119 ± 25 mg/dl; diuresis 95 ± 34/125 ± 30 cc/hour; TISS28 49 ± 4/38 ± 11 and NEMS 27 ± 0/25 ± 10, respectively. One re-operation due to hemorrhagic shock. Median study in Intensive Care Unit of 4 days. Conclusions. 1) They are hemodynamically stable patients with short weaning. They do not have many catheters, functioning ileostomy since the first day and TISS28 and NEMS in the middle of the range. 2) The most specific cares of the intestinal transplant are: surgical wound, drains, ileostomy, gastrostomy. 3) The need for intense immunosuppression implies strict isolation and nursing:patient ratio of 1:1