Practical approach to inhaled sedation in the critically ill patient. Sedation, analgesia and Delirium Working Group (GTSAD) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC).

The use of sedatives in Intensive Care Units (ICU) is essential for relieving anxiety and stress in mechanically ventilated patients, and it is related to clinical outcomes, duration of mechanical ventilation, and length of stay in the ICU. Inhaled sedatives offer benefits such as faster awakening and extubation, decreased total opioid and neuromuscular blocking agents (NMB) doses, as well as bronchodilator, anticonvulsant, and cardiopulmonary and neurological protective effects. Inhaled sedation is administered using a specific vaporizer. Isoflurane is the recommended agent due to its efficacy and safety profile. Inhaled sedation is recommended for moderate and deep sedation, prolonged sedation, difficult sedation, patients with acute respiratory distress syndrome (ARDS), status asthmaticus, and super-refractory status epilepticus. By offering these significant advantages, the use of inhaled sedatives allows for a personalized and controlled approach to optimize sedation in the ICU.

Shock index and its variants as predictors of mortality in severe traumatic brain injury.

BACKGROUND: The increase in severe traumatic brain injury (sTBI) incidence is a worldwide phenomenon, resulting in a heavy disease burden in the public health systems, specifically in emerging countries. The shock index (SI) is a physiological parameter that indicates cardiovascular status and has been used as a tool to assess the presence and severity of shock, which is increased in sTBI. Considering the high mortality of sTBI, scrutinizing the predictive potential of SI and its variants is vital. AIM: To describe the predictive potential of SI and its variants in sTBI. METHODS: This study included 71 patients (61 men and 10 women) divided into two groups: Survival (S; n = 49) and Non-survival (NS; n = 22). The responses of blood pressure and heart rate (HR) were collected at admission and 48 h after admission. The SI, reverse SI (rSI), rSI multiplied by the Glasgow Coma Score (rSIG), and Age multiplied SI (AgeSI) were calculated. Group comparisons included Shapiro-Wilk tests, and independent samples t-tests. For predictive analysis, logistic regression, receiver operator curves (ROC) curves, and area under the curve (AUC) measurements were performed. RESULTS: No significant differences between groups were identified for SI, rSI, or rSIG. The AgeSI was significantly higher in NS patients at 48 h following admission (S: 26.32 ± 14.2, and NS: 37.27 ± 17.8; P = 0.016). Both the logistic regression and the AUC following ROC curve analysis showed that only AgeSI at 48 h was capable of predicting sTBI outcomes. CONCLUSION: Although an altered balance between HR and blood pressure can provide insights into the adequacy of oxygen delivery to tissues and the overall cardiac function, only the AgeSI was a viable outcome-predictive tool in sTBI, warranting future research in different cohorts.

The effect of mesenchymal stem cells administration on DNA repair gene expressions in critically ill COVID-19 patients: prospective controlled study.

When the studies are evaluated, immunomodulatory effect of MSCs, administration in critically ill patients, obstacle situations in use and side effects, pulmonary fibrosis prevention, which stem cells and their products, regeneration effect, administration route, and dosage are listed under the main heading like. The effect of MSC administration on DNA repair genes in COVID-19 infection is unknown. Our aim is to determine the effect of mesenchymal stem cells (MSCs) therapy applied in critically ill patients with coronavirus infection on DNA repair pathways and genes associated with those pathways. Patients (n = 30) divided into two equal groups. Group-1: Patients in a critically ill condition, Group-2: Patients in critically ill condition and transplanted MSCs. The mechanism was investigated in eleven genes of five different pathways; Base excision repair: PARP1, Nucleotide excision repair (NER): RAD23B and ERCC1, Homologous recombinational repair (HR): ATM, RAD51, RAD52 and WRN, Mismatch repair (MMR): MLH1, MSH2, and MSH6, Direct reversal repair pathway: MGMT. It was found that MSCs application had a significant effect on 6 genes located in 3 different DNA damage response pathways. These are NER pathway genes; RAD23 and ERCC1, HR pathway genes; ATM and RAD51, MMR pathway genes; MSH2 and MSH6 (p < 0.05). Two main points were shown. First, as a result of cellular damage in critical patients with COVID-19, DNA damage occurs and then DNA repair pathways and genes are activated in reaction to this situation. Second, administration of MSC to patients with COVID-19 infection plays a positive role by increasing the expression of DNA repair genes located in DNA damage pathways.

Efficiency of Simulation-Based Learning Using an ABC POCUS Protocol on a High-Fidelity Simulator.

Critically ill patients with rapidly deteriorating clinical status secondary to respiratory and cardio-vascular compromise are at risk for immediate collapse if the underlying pathology is not recognized and treated. Rapid diagnosis is of utmost importance regardless of the setting. Although there are data to support the use of point-of-care ultrasound in critical patients, there is no consensus about the best educational strategy to implement. We designed a curriculum based on the ABC (Airway, Breathing, Circulation) protocol that covers essential airway, lung, and cardiac ultrasound skills needed for fast diagnosis in critical patients and applied it in high-fidelity simulation-based medical education sessions for anesthesia and intensive care residents year one and two. After theoretical and practical assessments, our results show statistical differences in the theoretical knowledge and above-average results in practical assessment. Our proposed curriculum based on a simple ABC POCUS protocol, with an Airway, Breathing, and Circulation approach, is useful in teaching ultrasound basics regarding airway, lung, and cardiac examination using high-fidelity simulation training to anesthesia and intensive care residents, but further research is needed to establish the utility of Simulation-Based Medical Education in Point of Care Ultrasound in the critical patient.

Ambulance nurses' experiences as the sole caregiver with critical patients during long ambulance transports: an interview study.

BACKGROUND: Working in rural areas involves tackling long distances and occasional lack of supportive resources. Ambulance nurses are faced with the responsibility of making immediate autonomous decisions and providing extended care to critically ill patients during prolonged ambulance transport to reach emergency medical facilities. This study aims to expose the experiences of ambulance nurses acting as primary caregivers for critically ill patients during lengthy ambulance transfers in rural regions. METHOD: Fifteen nurses employed in an ambulance service within sparsely populated rural areas were subjected to semi-structured interviews. The collected data underwent qualitative content analysis. RESULT: The analysis resulted in one overarching theme with two categories. The theme is 'Safety in the Professional Role,' and the two categories are 'Working in sparsely populated areas presents challenges' and 'Rare events: when routine cannot be established.' The findings suggest that working as an ambulance nurse in a rural setting poses various challenges that can be highly stressful. Delivering care to critically ill patients during extended ambulance transports requires the knowledge, experience, and careful planning of the healthcare provider in charge. CONCLUSIONS: The findings underscore the necessity for thorough planning and adaptable thinking when attending to critically ill patients during extended transport scenarios. The absence of supporting resources can render the task demanding. Nevertheless, participants reported an inherent tranquility that aids them in maintaining focus amid their responsibilities.

Comparison between ultrasonography and computed tomography for measuring skeletal muscle mass in critically ill patients with different body mass index.

BACKGROUND & AIM: Among critical patients, there is an early onset of changes in both the quantity and quality of muscle mass. It is essential to find tools that promptly identify this muscle mass loss. The aim of this study was to compare the ultrasonography of the quadriceps femoris to the gold standard, thigh computed tomography (CT) for assessing the musculature of critically ill patients with different body mass index who have suffered traumatic brain injury. METHODS: This is a prospective validation study in an Intensive Care Unit (ICU) specialized in trauma care, located at a tertiary teaching hospital. Our study involved a convenience sample of patients. Sequential ultrasound and CT scans were performed at three distinct time intervals: upon admission, between 24 and 96 h' post-admission, and finally, between 96 and 168 h' post-admission. For all ultrasound measurements, we conducted simultaneous quadriceps CT measurements. The correlation between measurements obtained by ultrasound and computed tomography at three different times and in three BMI ranges was analyzed, in individuals with normal weight, overweight and obese. RESULTS: Results: We analyzed 252 images in 49 patients in time 1, 40 patients in time 2, and 37 in time 3 to compare the thickness quadriceps muscle using US and CT. Of these, 18 patients had a BMI ≤ 24.9 kg/m2 (normal weight), 18 patients from 25 to 29.9 kg/m2 (overweight), and 8 patients had a BMI ≥ 30 kg/m2 (obese). The mean age was 37 years, the majority (94%) were male and the main comorbidities were: hypertension 12%, diabetes 4% and 14% smoking. The results revealed minor discrepancies between measurements obtained through the two methods, these changes were not influenced by the body mass index, with these variations being practically insignificant in the context of clinical application. Thus, the correlation and concordance between the values obtained found a strong positive correlation with good limits of agreement. The Spearman's correlation coefficients obtained were r = 0.89, 0.91 and 0.88, p < 0.01 at T1, T2 and T3 respectively for normal weight, r = 0.91, 0.80 and 0.81, p < 0.01 at T1, T2 and T3 respectively for overweight and r = 0.89, 0.94 and 0.84, p < 0.01 at T1, T2 and T3 respectively for obesity. In addition to a positive correlation, we observed a high agreement between the methods. The Bland & Altman analysis at time 1 showed, respectively, the bias of 1.46, 2.03 and 0.76. At time 2, the bias was 0.42, 3.11 and 2.12. At time 3, the bias was 2.26, 3.38 and 2.11 mm. CONCLUSION: Our findings suggest that measure femoral quadriceps muscle thickness ultrasound-based exhibits a comparable performance to thigh CT. This conclusion stems from the excellent correlation and good agreement observed between ultrasound and CT, which is considered the gold standard for muscle assessment in critically ill patients. TRIAL REGISTRATION: This clinical trial is registered at REBEC https://ensaiosclinicos.gov.br/ identifier: RBR-2bzspnz. The protocol was approved, on July 30, 2019, by the Research Ethics Committee of the Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto - Trial Registration Number: 3,475,851.

Caracterización clínica epidemiológica de pacientes graves con infecciones adquiridas en la comunidad durante la COVID-19

Introducción: los pacientes graves requieren ingreso en las unidades de cuidados intensivos por infecciones adquiridas en la comunidad. Objetivo: caracterizar, desde el punto de vista clínico y epidemiológico, a los pacientes graves con infecciones adquiridas en la comunidad durante la COVID-19. Métodos: estudio observacional, descriptivo, de serie de casos, en el periodo comprendido desde el 1ero de septiembre de 2020 hasta el 31 de enero de 2022. Se incluyeron a 277 pacientes. Se obtuvieron variables epidemiológicas y clínicas. El análisis estadístico se basó en medidas de resumen de la estadística descriptiva y de asociación. Resultados: el 52,7 % de los pacientes correspondieron al sexo femenino. La media de la edad fue 40,2 años (IC 95 %: 37,8-42,4). El Acute Physiology and Chronic Health Evaluation II (APACHE II) medio se estimó en 11, 8 (IC 95 %: 9,7-12,2). La escala Secuencial Organ Failure Assessment (SOFA) promedio fue de 1,8 (IC 95 %:1,4-2,2). El 31,7 % de los pacientes fueron hipertensos y 19,4 % diabéticos. La infección intraabdominal fue la localización principal (52,7 %), seguida de la neumonía (34,7 %). El 98,7 % tenía antimicrobianos al ingreso y el 26,3 % ventilación mecánica artificial. Conclusiones: los pacientes se caracterizan en su mayoría por pertenecer al sexo femenino, estar en la cuarta década de la vida, desarrollar alteraciones de sus sistemas fisiológicos y disfunción de órganos y tener hipertensión arterial y diabetes mellitus; infección intraabdominal o neumonía, así como requerir tratamiento con antimicrobianos, ventilación mecánica invasiva y drogas vasoactivas.

Introduction: critically ill patients require admission to intensive care units due to community-acquired infections. Objective: to characterize, from a clinical and epidemiological point of view, critical ill patients with community-acquired infections during COVID-19. Results: 52.7% of the patients were female. The mean age was 40.2 years (95% CI: 37.8-42.4). The mean Acute Physiology and Chronic Health Evaluation II (APACHE II) was estimated at 11.8 (95% CI: 9.7-12.2). The mean Sequential Organ Failure Assessment (SOFA) scale was 1.8 (95% CI: 1.4-2.2). 31.7% of the patients were hypertensive and 19.4% diabetic. Intra-abdominal infection was the main location (52.7%), followed by pneumonia (34.7%). 98.7% had antimicrobials on admission and 26.3% had artificial mechanical ventilation. Conclusions: the patients are mostly characterized by being female, being in the fourth decade of life, developing alterations in their physiological systems and organ dysfunction, and having high blood pressure and diabetes mellitus; intra-abdominal infection or pneumonia as well as requiring treatment with antimicrobials, invasive mechanical ventilation and vasoactive drugs.

Introdução: pacientes críticos necessitam de internação em unidades de terapia intensiva devido a infecções adquiridas na comunidade. Objetivo: caracterizar, do ponto de vista clínico e epidemiológico, pacientes graves com infecções comunitárias durante a COVID-19. Métodos: estudo observacional, descritivo, de série de casos, no período de 1º de setembro de 2020 a 31 de janeiro de 2022. Foram incluídos 277 pacientes. Foram obtidas variáveis epidemiológicas e clínicas. A análise estatística baseou-se em medidas-resumo de estatística descritiva e de associação. Resultados: 52,7% dos pacientes eram do sexo feminino. A média de idade foi de 40,2 anos (IC 95%: 37,8-42,4). A média do Acute Physiology and Chronic Health Evaluation II (APACHE II) foi estimada em 11,8 (IC 95%: 9,7-12,2). A média da escala Sequential Organ Failure Assessment (SOFA) foi de 1,8 (IC 95%: 1,4-2,2). 31,7% dos pacientes eram hipertensos e 19,4% diabéticos. A infecção intra-abdominal foi a principal localização (52,7%), seguida de pneumonia (34,7%). 98,7% tinham antimicrobianos na admissão e 26,3% tinham ventilação mecânica artificial. Conclusões: a maioria dos pacientes é do sexo feminino, na quarta década de vida, desenvolve alterações de seus sistemas fisiológicos e disfunção orgânica, além de hipertensão arterial e diabetes mellitus; infecção intra-abdominal ou pneumonia, além de necessitar de tratamento com antimicrobianos, ventilação mecânica invasiva e drogas vasoativas.

Diferencias según sexo en pacientes ingresados en cuidados intensivos / Differences according to sex in patients admitted to intensive care units i: en

Introducción: Hoy día existen disparidades en cuanto al sexo en pacientes con enfermedades graves, lo cual no ha podido ser explicado en los estudios clínico-epidemiológicos realizados hasta el momento. Objetivo: Identificar las diferencias según sexo en pacientes ingresados en cuidados intensivos. Métodos: Se realizó un estudio observacional y prospectivo de 187 pacientes ingresados en la Unidad de Cuidados Intensivos del Hospital General Provincial Carlos Manuel de Céspedes de la provincia de Granma, que incluyó los meses de noviembre y diciembre de 2018-2020. Entre las variables analizadas figuraron: edad, sexo, origen, diagnóstico al ingreso, estado al egreso, estadía hospitalaria, síndrome de respuesta inflamatoria sistémica, estadio de la sepsis, factores de riesgo, infecciones adquiridas en la comunidad y tratamiento requerido. Resultados: En la investigación la mayoría de los pacientes correspondieron al sexo femenino (60,9 %) y la edad media fue de 31,6 y 49,6 años en mujeres y hombres, respectivamente (p=0,000). Asimismo, existieron diferencias significativas en cuanto al origen (p=0,012) y los diagnósticos iniciales (p=0,018); mientras que el promedio del APACHE II resultó ser de 7,2 en mujeres y de 11,6 en hombres (p=0,000) y la escala para la evaluación de fallo orgánico secuencial tuvo una media de 0,7 y 2,0, en ese mismo orden (p=0,000). Conclusiones: Los pacientes del sexo masculino presentaron edad promedio, diagnóstico, origen, gravedad y disfunción de órganos significativamente diferentes a los del femenino. Si bien no se apreciaron disparidades en cuanto a factores de riesgo e infecciones asociadas a la comunidad, la frecuencia de hombres que requieren tratamiento fue significativamente más alta.

Introduction: Nowadays disparities as for sex in patients with serious diseases can be found, which has not been explained in the clinical-epidemiological studies carried out until the moment. Objective: To identify the differences according to sex in patients admitted to intensive care units. Methods: An observational and prospective study of 187 patients admitted to the Intensive Care Units of Carlos Manuel de Céspedes Provincial General Hospital was carried out in Granma that included the months of November and December, 2018-2020. Among the analyzed variables we can mention: age, sex, origin, diagnosis at admission, state when discharged from the unit, hospital stay, syndrome of systemic inflammatory response, stage of the sepsis, risk factors, community acquired infections and required treatment. Results: In the investigation most of the patients corresponded to female sex (60.9 %) and the mean age was 31.6 and 49.6 years in women and men, respectively (p=0.000). Also, significant differences existed as for the origin (p=0.012) and the initial diagnoses (p=0.018); while the average of the APACHE II was 7.2 in women and 11.6 in men (p=0.000) and the Sequential Organ Failure Assessment Score had a mean of 0.7 and 2.0, in that same order (p=0.000). Conclusions: The patients of male sex presented average age, diagnosis, origin, seriousness and dysfunction of organs significantly different to those of female sex. Although disparities were not appreciated as for risk factors and infections associated with the community, the frequency of men that require treatment was significantly higher.

Vascular Access in Patients With Peripheral Arterial Disease Undergoing TAVR: The Hostile Registry.

BACKGROUND: The optimal access route in patients with severe peripheral artery disease (PAD) undergoing transcatheter aortic valve replacement (TAVR) remains undetermined. OBJECTIVES: This study sought to compare clinical outcomes with transfemoral access (TFA), transthoracic access (TTA), and nonthoracic transalternative access (TAA) in TAVR patients with severe PAD. METHODS: Patients with PAD and hostile femoral access (TFA impossible, or possible only after percutaneous treatment) undergoing TAVR at 28 international centers were included in this registry. The primary endpoint was the propensity-adjusted risk of 30-day major adverse events (MAE) defined as the composite of all-cause mortality, stroke/transient ischemic attack (TIA), or main access site-related Valve Academic Research Consortium 3 major vascular complications. Outcomes were also stratified according to the severity of PAD using a novel risk score (Hostile score). RESULTS: Among the 1,707 patients included in the registry, 518 (30.3%) underwent TAVR with TFA after percutaneous treatment, 642 (37.6%) with TTA, and 547 (32.0%) with TAA (mostly transaxillary). Compared with TTA, both TFA (adjusted HR: 0.58; 95% CI: 0.45-0.75) and TAA (adjusted HR: 0.60; 95% CI: 0.47-0.78) were associated with lower 30-day rates of MAE, driven by fewer access site-related complications. Composite risks at 1 year were also lower with TFA and TAA compared with TTA. TFA compared with TAA was associated with lower 1-year risk of stroke/TIA (adjusted HR: 0.49; 95% CI: 0.24-0.98), a finding confined to patients with low Hostile scores (Pinteraction = 0.049). CONCLUSIONS: Among patients with PAD undergoing TAVR, both TFA and TAA were associated with lower 30-day and 1-year rates of MAE compared with TTA, but 1-year stroke/TIA rates were higher with TAA compared with TFA.

Hipoalbuminemia y riesgo de muerte en pacientes críticos en una unidad polivalente

Introducción: La hipoalbuminemia se puede desarrollar en las primeras horas posteriores a una enfermedad aguda y está muy relacionada con un estado inflamatorio activo, independientemente del estado nutricional del paciente. Se ha asociado con la mortalidad hospitalaria en pacientes con complicaciones postquirúrgicas, pacientes con sepsis y trauma. Objetivo: Evaluar la asociación entre los niveles de hipoalbuminemia y el riesgo de mortalidad del paciente crítico en una unidad polivalente. Métodos: Estudio observacional, descriptivo, prospectivo, de serie de casos, con 216 pacientes que ingresaron en la unidad. Se analizaron variables demográficas, clínicas, de laboratorio y se aplicó el índice pronóstico APACHE II. Se determinó la concentración de albúmina al ingreso y se clasificó la hipoalbuminemia en leve (30-35 g/L) y moderada/grave (≤ 30 g/L). Resultados: En el estudio fallecieron 28 pacientes, lo que representó un 13 % del total de pacientes ingresados. La albúmina presentó niveles bajos en 118 pacientes (54,6 %), y de estos, 66 (56 %) presentaron cifras inferiores a los 30 g/L; o sea, una hipoalbuminemia moderada o grave. Los pacientes con hipoalbuminemia moderada-grave tuvieron un riesgo de muerte superior (23,5 %) a aquellos con niveles clasificados como leve (15,3 %), diferencia estadísticamente significativa (p= 0,034); y en el grupo de pacientes con hipoalbuminemia moderada- grave falleció el 67 %, en relación con el 33 % de los pacientes con niveles clasificados como leve. Conclusiones: La hipoalbuminemia moderada-grave se asocia con el riesgo de mortalidad, independientemente del diagnóstico al ingreso.

Introduction: Hypoalbuminemia can develop in the first hours after an acute illness, and is closely related to an active inflammatory state, regardless of the patient's nutritional status. It has been associated with hospital mortality in patients with post-surgical complications, patients with sepsis and trauma. Objective: To evaluate the association between hypoalbuminemia level and the risk of mortality in critically ill patients in a polyvalent unit. Methods: Observational, descriptive, prospective, case series study, with 216 patients admitted to the unit. Demographic, clinical, and laboratory variables were analyzed and the APACHE II prognostic score was applied. Albumin concentration is calculated on admission and hypoalbuminemia is classified as mild (30-35 g/L) and moderate/severe (≤ 30 g/L). Results: In the study, 28 patients died, which represented 13% of the total number of patients admitted. Albumin levels were low in 118 patients (54.6%), and of these 66 patients (56%) were classified as hypoalbuminemia moderate/severe, with albumin values below 30 g/L. Patients with moderate-severe hypoalbuminemia had a higher risk of death (23.5%) than those patients with levels classified as mild (15.3%), a statistically significant difference (p= 0.034); and in the group of patients with moderate-severe hypoalbuminemia, 67% died, in relation to 33% of patients with levels classified as mild. Conclusions: Moderate-severe hypoalbuminemia is associated with mortality risk, regardless of admission diagnosis.

Impacto de la COVID-19 en la salud del paciente poscrítico / Impact of the COVID-19 on health of critical patient

Introducción: Muchos pacientes perciben síntomas persistentes y deterioro en su calidad de vida tras la COVID-19. El paciente crítico es vulnerable a presentar alteraciones físicas y emocionales. El objetivo de este estudio fue valorar la situación funcional y la calidad de vida del paciente poscrítico por la COVID-19. Métodos: Se ha realizado un estudio multicéntrico longitudinal prospectivo en pacientes hospitalizados críticos por la COVID-19 con un seguimiento a 6 meses. Se han recogido variables sociodemográficas, comorbilidad, síntomas persistentes, escala SPPB; repercusión respiratoria y TAC pulmonar, índice de Barthel; variables neuropsicológicas, actividad física (escala IPAQ); calidad de vida (EuroQoL), y satisfacción. Resultados: Se han incluido 115 pacientes. El 75% son varones y el 86% obesos o con sobrepeso. El tiempo medio de hospitalización fue de 38,1±18,4 días, precisando ventilación mecánica el 80,9%. El 25% necesitaba ayuda de otra persona para su autocuidado al alta. El 29,2% presentaba normalidad en la TAC pulmonar a los 134,1+70,9 días. A los 6 meses la recuperación funcional fue favorable, aunque el 36,5% percibía debilidad muscular y el 22% presentaba fragilidad. Un 36,5% de los pacientes refirieron falta de concentración. La dimensión más afectada en la calidad de vida fue la referida al dolor (53%), seguida de la ansiedad o depresión. La mayoría realizaba actividad física baja. La satisfacción por el seguimiento clínico fue elevada. Conclusiones: En los pacientes poscríticos por la COVID-19, a los 6 meses del alta hospitalaria prevalecen alteraciones físicas, funcionales y en la calidad de vida.(AU)

Introduction: Many patients perceive persistent symptoms and impairment in their quality of life after COVID-19. The critical patient is vulnerable to presenting physical and emotional alterations. The objective of this study is to assess the functional evolution and quality of life of the critical patient due to COVID-19. Methods: A prospective longitudinal multicenter study was carried out in critically ill hospitalized patients due to COVID-19 with a 6 month follow-up. Sociodemographic variables, comorbidity, the persistence of symptoms, SPPB scale, pulmonary and respiratory impact, CT scan, Barthel index, neuropsychological variables, physical activity (IPAQ scale), quality of life (Euroqol), and satisfaction were collected. Results: 115 patients were included. 75% are male and 86% are obese or overweight. The average time of hospitalization was 38.1±18.4 days, with 80.9% requiring mechanical ventilation. 25% need help from another person for self-care at discharge. 29.2% had a normal CT lung screening at 134.1+70.9 days. At 6 months, functional recovery is favorable, although 36.5% perceive muscle weakness and 22% present fragility. 36.5% of patients report a lack of concentration. The most affected dimension in quality of life is that referred to pain (53%), followed by anxiety or depression. Most perform low physical activity. Satisfaction with clinical follow-up is high. Conclusions: In post-critical patients due to COVID-19, physical, functional, and quality of life alterations prevail at 6 months after hospital discharge.(AU)

[Impact of the COVID-19 on health of critical patient]. / Impacto de la COVID-19 en la salud del paciente poscrítico.

INTRODUCTION: Many patients perceive persistent symptoms and impairment in their quality of life after COVID-19. The critical patient is vulnerable to presenting physical and emotional alterations. The objective of this study is to assess the functional evolution and quality of life of the critical patient due to COVID-19. METHODS: A prospective longitudinal multicenter study was carried out in critically ill hospitalized patients due to COVID-19 with a 6 month follow-up. Sociodemographic variables, comorbidity, the persistence of symptoms, SPPB scale, pulmonary and respiratory impact, CT scan, Barthel index, neuropsychological variables, physical activity (IPAQ scale), quality of life (Euroqol), and satisfaction were collected. RESULTS: 115 patients were included. 75% are male and 86% are obese or overweight. The average time of hospitalization was 38.1±18.4 days, with 80.9% requiring mechanical ventilation. 25% need help from another person for self-care at discharge. 29.2% had a normal CT lung screening at 134.1+70.9 days. At 6 months, functional recovery is favorable, although 36.5% perceive muscle weakness and 22% present fragility. 36.5% of patients report a lack of concentration. The most affected dimension in quality of life is that referred to pain (53%), followed by anxiety or depression. Most perform low physical activity. Satisfaction with clinical follow-up is high. CONCLUSIONS: In post-critical patients due to COVID-19, physical, functional, and quality of life alterations prevail at 6 months after hospital discharge.

Sentimientos y emociones de los pacientes en el proceso de alta de UCI / Feelings And Emotions That Emerge From The Experience Of Being Discharged From An ICU

Introducción El alta de la Unidad de Cuidados Intensivos (UCI) a la sala de hospitalización activa el sistema afectivo de los pacientes provocando la aparición de sentimientos asociados al proceso de transición. Los objetivos de este trabajo son conocer los sentimientos y emociones que emergen de la experiencia de ser dado de alta de una UCI e identificar los factores que desencadenan bienestar y malestar emocional en los pacientes. Método Estudio cualitativo y descriptivo con enfoque fenomenológico en un hospital de tercer nivel de Barcelona. Se realizaron 20 entrevistas en profundidad para la recogida de datos. Resultados Se identificaron sentimientos y emociones agradables que provocan bienestar cuando se produce la transferencia: Alegría, satisfacción y seguridad, y sentimientos desagradables que producen malestar: Ansiedad, tristeza, miedo, rabia, desprotección y ambivalencia de sentimientos. Conclusiones Es necesaria una reflexión sobre el gran número de sentimientos que evoca el alta de la UCI a la sala de hospitalización y cuáles son los desencadenantes que los provocan para poder trabajar en ellos y propiciar un alta de UCI emocionalmente saludable. (AU)

Introduction: Discharge from the Intensive Care Unit (ICU) to the hospitalization ward activates the affective system of patients, causing the appearance of feelings associated with the transition process. The objectives of this thesis are to know the feelings and emotions that emerge from the experience of being discharged from an ICU and to identify the factors that trigger well-being and emotional discomfort in patients. Methodology: Qualitative and descriptive study with a phenomenological approach in a third level hospital in Barcelona. Twenty in-depth interviews were conducted for data collection. Results: The pleasant feelings and emotions that cause wellbeing when the transfer occurs identified were: Joy, satisfaction and security. The unpleasant feelings that cause discomfort identified were: Anxiety, sadness, fear, anger, lack of protection and ambivalence of feelings. Conclusions: It is necessary to reflect on the large number of feelings that being discharged from the ICU to the hospital ward evokes and what are the triggers that provoke them in order to work on them and promote an emotionally healthy discharge from the ICU. (AU)

Tratamiento rehabilitador de la infección por COVID: caracterización y seguimiento de pacientes hospitalizados en Granada, España / Rehabilitation and COVID disease: characterization and follow-up of hospitalized patients in Granada, Spain

Objetivo: Caracterización de una muestra de pacientes hospitalizados por complicaciones de la infección COVID-19 con atención a potenciales determinantes pronósticos de su evolución e impacto del tratamiento rehabilitador en el desempeño funcional, motor y respiratorio. Método: Estudio descriptivo, retrospectivo, longitudinal de una cohorte de pacientes ingresados con diagnóstico de COVID-19 que requirieron tratamiento rehabilitador en el Hospital Universitario Virgen de las Nieves de Granada desde marzo a junio de 2020, evaluados al ingreso, alta y a los tres meses mediante escalas de condición física (IFIS), valoración funcional: general (Rankin, Barthel), respiratoria (mMRC, BORG) y marcha (FAC). Resultados: Se incluyeron 30 pacientes, edad media 62,8 (54-70) años, 80% alguna comorbilidad: hipertensión 66,7%, obesidad 36,7%, diabetes 33,3%. Estancia hospitalaria media de 45,4 días, 86,7% requirió Unidad de Cuidados Intensivos (UCI) (29,1 días), de ellos 76,7% ventilación mecánica. El 86,7% de los pacientes presentaron alguna complicación, siendo mayor la polineuropatía/miopatía del paciente crítico (83,3% de los pacientes). Al alta, un 80% requirió ayuda para caminar. El índice de funcionalidad mostró una evolución en «U» al ingreso, alta y a los tres meses (Barthel 93,8; 60,0; 91,6, respectivamente). Se encontró un mayor deterioro funcional (Barthel < 60) en pacientes hombres, enfermedad pulmonar obstructiva crónica (EPOC), hipertensión arterial (HTA), obesidad y proteína C reactiva (PCR) elevada al ingreso y evolución más favorable en aquellos con dímero D y linfocitos más elevados al ingreso.ConclusiónLos ingresos hospitalarios por COVID-19 implican complicaciones a nivel funcional, respiratorio y de la marcha mayoritariamente graves pero reversibles parcialmente a los tres meses con tratamiento rehabilitador. Se describen factores potencialmente pronósticos que merecen estudios prospectivos.(AU)

Objective: The characterization of a sample of patients hospitalized with complications of the COVID-19 infection regarding potential prognostic factors, clinical evolution, and impact of rehabilitation treatment on functional, motor, and respiratory outcomes. Method: Descriptive, retrospective, longitudinal study of a cohort of patients under rehabilitation treatment admitted at Virgen de las Nieves University Hospital in Granada from March to June 2020, assessed upon admission, discharge and at 3 rd month using physical condition scales (IFIS) and functional assessment: general (Rankin, Barthel), respiratory (mMRC, BORG) and gait (FAC). Results: 30 patients with a mean age of 62.8 (54-70) years were included, 80% with comorbidity: hypertension 66.7%, obesity 36.7%, diabetes 33.3%. The mean hospital stay was 45.4 days, with 86.7% requiring ICU (29.1 days) and 76.7% of them required mechanical ventilation. An 86.7% of the patients presented with complications, mostly with polyneuropathy-myopathy of the critical patient (83.3%). At discharge, 80% required walking assistance. The functionality index showed a “U”-evolution at admission, discharge and at 3 rd month (Barthel 93.8; 60.0; 91.6 respectively). A greater functional decline (Barthel < 60) was found in male patients, COPD, HT, obesity, and elevated protein C reactive at admission; and a more favourable evolution in those with elevated D-dimer and lymphocyte values upon admission. Conclusión: Hospital admission for COVID-19 patients involve complications at the functional, respiratory and gait levels that are mostly serious but partially reversible at 3 months with rehabilitation treatment. Potential prognostic factors are described and deserve prospective studies.(AU)

Osificación heterotópica en paciente con SARS-CoV-2: imágenes gammagráficas y radiológicas / Heterotopic ossification in SARS-CoV-2: Scintigraphic and radiological images

Los pacientes con COVID-19 grave pueden desarrollar restricciones dolorosas del rango de movimiento de las grandes articulaciones debido a osificaciones heterotópicas. Presentamos el caso de un paciente que desarrolló dolor en las caderas después de un ingreso prolongado por neumonía COVID-19 severa. La radiografía convencional, la tomografía computarizada y la gammagrafía ósea mostraron extensas osificaciones heterotópicas en caderas. Es probable que tanto factores locales como sistémicos contribuyan al desarrollo de osificaciones heterotópicas, y es necesario descartar esta entidad cuando estos pacientes refieran dolor articular. El diagnóstico precoz es importante para proporcionar intervenciones no farmacológicas como la movilización pasiva suave y medicación antiinflamatoria y en casos refractarios considerar la resección quirúrgica del hueso ectópico.(AU)

Patients with severe COVID-19 can develop painful range-of-motion restrictions of large joints due to heterotopic ossification. We present the case of a patient who developed hip pain after prolonged admission for severe COVID-19 pneumonia. Conventional radiography, computed tomography and bone scan showed extensive heterotopic ossification in the hips. It is probable that both local and systemic factors contribute to the development of heterotopic ossifications and it is necessary to rule out this entity when these patients reported joint pain. Early diagnosis is important to provide non-pharmacological interventions such as mild passive mobilization and anti-inflammatory medication and in refractory cases surgical resection of the ectopic bone is consider.(AU)

[Heterotopic ossification in SARS-CoV-2: Scintigraphic and radiological images]. / Osificación heterotópica en paciente con SARS-CoV-2: imágenes gammagráficas y radiológicas.

Patients with severe COVID-19 can develop painful range-of-motion restrictions of large joints due to heterotopic ossification. We present the case of a patient who developed hip pain after prolonged admission for severe COVID-19 pneumonia. Conventional radiography, computed tomography and bone scan showed extensive heterotopic ossification in the hips. It is probable that both local and systemic factors contribute to the development of heterotopic ossifications and it is necessary to rule out this entity when these patients reported joint pain. Early diagnosis is important to provide non-pharmacological interventions such as mild passive mobilization and anti-inflammatory medication and in refractory cases surgical resection of the ectopic bone is consider.

Inflammation/Coagulopathy/Immunology Responsive Index Predicts Poor COVID-19 Prognosis.

In the early stage of coronavirus disease 2019 (COVID-19), most cases are identified as mild or moderate illnesses. Approximately 20% of hospitalised patients become severe or critical at the middle or late stage of the disease. The predictors and risk factors for prognosis in those with mild or moderate disease remain to be determined. Of 694 patients with COVID-19, 231 patients with mild or moderate disease, who were hospitalised at 10 hospitals in Wenzhou and nearby counties in China, were enrolled in this retrospective study from 17 January to 20 March 2020. The outcomes of these patients included progression from mild/moderate illness to severe or critical conditions. Among the 231 patients, 49 (21.2%) had a poor prognosis in the hospital. Multivariate logistic regression analysis showed that higher inflammation/coagulopathy/immunology responsive index (ICIRI=[c-reactive protein × fibrinogen × D-dimer]/CD8 T cell count) on admission (OR=345.151, 95% CI=23.014-5176.318) was associated with increased odds ratios for poor prognosis. The area under the receiver operating characteristic curve for ICIRI predicting severe and critical condition progression was 0.65 (95% CI=0.519-0.782) and 0.80 (95% CI=0.647-0.954), with cut-off values of 870.83 and 535.44, respectively. Conversely, age, sex, comorbidity, neutrophil/lymphocyte ratio, CD8 T cell count, and c-reactive protein, fibrinogen, and D-dimer levels alone at admission were not good predictors of poor prognosis in patients with mild or moderate COVID-19. At admission, a novel index, ICIRI, tends to be the most promising predictor of COVID-19 progression from mild or moderate illness to severe or critical conditions.

Incidentes relacionados con la seguridad del paciente crítico durante los traslados intrahospitalarios / Incidents related to critical patients afety during in hospital transfer

Objective: To analyze the incidents related to patient safety (IRSP) and their risk factors during in-hospital transfer (IHT) of critical patients after the application of a protocol, and to evaluate safety during transfer using quality indicators.DesignA prospective, observational and non-intervention cohort study was carried out.SettingA 10-bed multipurpose Intensive Care Unit (ICU) of a second level university hospital.PatientsAll IHTs of critical patients in the ICU for diagnostic tests and to the operating room between March 2011 and March 2017 were included in the study.Main measurementsDemographic variables, patient severity, transfer priority, moment of the day, reason and type of transfer team. Pre-transport checklist items and IRSP were collected. A biannual analysis was made of quality indicators designed for IHT.ResultsA total of 805 transfers were registered, mostly of an urgent nature (53.7%) and for diagnostic tests (77%). In turn, 112 transfers (13.9%) presented some type of IRSP; 54% related to the equipment and 30% related to team and organization. Adverse events occurred in 19 (2.4%) transfers. Risk factors identified in the multivariate analysis were mechanical ventilation and the transport team. The evolution of the indicators related to transport was significantly favorable.ConclusionsAfter the application of an IHT protocol, IRSP are low. The main risk factor is invasive mechanical ventilation. The experience of the team performing IHT influences the detection of a greater number of incidents (AU)

Objetivo: Analizar los incidentes relacionados con la seguridad del paciente (IRSP) durante los traslados intrahospitalarios (TIH) del paciente crítico tras la aplicación de un protocolo, así como sus factores de riesgo. Evaluar la seguridad durante los traslados mediante indicadores de calidad.DiseñoEstudio de cohorte, prospectivo, observacional y no intervencionista.ÁmbitoUnidad de Cuidados Intensivos (UCI) polivalente de 10 camas de un hospital universitario de segundo nivel.PacientesSe incluyen todos los TIH de pacientes críticos realizados de UCI a pruebas diagnósticas y a quirófano entre marzo de 2011 y marzo de 2017.Principales variables del estudioVariables demográficas, gravedad de los pacientes, prioridad del traslado, momento del día, motivo y tipo de equipo del traslado. Se recogen comprobaciones pre-traslado e IRSP. Análisis semestral de indicadores de calidad diseñados para el TIH.ResultadosDe los 805 traslados registrados, la mayoría urgentes (53,7%) y para pruebas diagnósticas (77%), 112 traslados (13,9%) presentaron algún tipo de IRSP, 54% relacionado con el equipamiento y 30% con el equipo y la organización. En 19 (2,4%) traslados se produjeron eventos adversos. En el análisis multivariante los factores de riesgo fueron la ventilación mecánica y el equipo que realiza el traslado. La evolución de los indicadores relacionados con los traslados es significativamente favorable.ConclusionesTras la aplicación de un protocolo de TIH, los IRSP son bajos y el principal factor de riesgo es la ventilación mecánica invasiva. La experiencia del equipo que realiza el TIH influye en la detección de un mayor número de incidentes (AU)

Concordancia de valoraciones del dolor entre la Escala de Conductas Indicadoras del Dolor y Behavioral Pain Scale / Concordance of pain assessment between the Escala de Conductas Indicadoras de Dolor y Behavioral Pain Scale

Introducción: La valoración del dolor del paciente critico se basa en indicadores conductuales. Actualmente existen diversas escalas con diferencias en la forma de puntuar la presencia de dolor. Objetivo: Determinar la concordancia entre mediciones del dolor según la Escala de conductas indicadoras de dolor (ESCID) y la Behavioral Pain Scale (BPS). Métodos: Estudio observacional en pacientes con ventilación mecánica. Se aplicaron la BPS y la ESCID en reposo y durante aspiración de secreciones, a fin de determinar su concordancia mediante el coeficiente Kappa de Cohen y el nivel de dolor de la ESCID. Resultados: La concordancia estadística entre la BPS y la ESCID fue 0.23 según el coeficiente Kappa de Cohen, considerada "regular" de acuerdo con Landis y Koch. La BPS determinó presencia de dolor en 93.4% de pacientes durante la aspiración de secreciones, y la ESCID lo detectó en el 100%, clasificando 80% en nivel moderado­grave. Limitaciones de estudio: Muestra de 15 pacientes. El estudio se realizó en dos momentos. Originalidad: El resultado obtenido no tiene comparación con otro estudio, pues sólo se ha estudiado la concordancia entre observadores. Conclusiones: La concordancia entre las mediciones del dolor con ambas escalas se considera baja. La ESCID muestra mayor sensibilidad, aunque los niveles de puntuaciones bajas pueden ser causados por factores no relacionados con dolor. BPS muestra menor sensibilidad, pues considera la presencia de dolor con puntajes sin clasificaciones intermedias. Este estudio apoya el uso de ESCID como una escala confiable en las valoraciones del dolor.

Introduction: Pain assessment in critical patients is based on behavioral indicators. Currently, there are various scales that differ in their pain-scoring systems. Objective: To determine the concordance between pain measurements according the Behavioural Indicators of Pain Scale (ESCID, by its acronym in Spanish) and Behavioral Pain Scale (BPS). Methods: Observational study in patients subjected to mechanical ventilation. The BPS and the ESCID were applied at rest and during aspiration of secretions, in order to determine their concordance using Cohen's kappa coefficient and pain level according to ESCID. Results: The statistical concordance between the BPS and ESCID was 0.23 according to Cohen's kappa coefficient, considered "regular" as stated by Landis and Koch. BPS determined the presence of pain in 93.4% of patients during aspiration of secretions, and ESCID detected it in 100% of patients, with 80% in the moderate-severe level. Study limitations: Sample of 15 patients. The study was performed two times. Originality: The obtained results have no comparison with other studies, since they only analyze inter-observer concordance. Conclusions: The concordance between pain measurements with both scales is considered low. ESCID shows higher pain sensitivity, although low score levels may be caused by factors not related to pain. BPS shows lower sensitivity, since it considers the presence of pain with scores without intermediate classifications. This study supports the use of ESCID as a reliable scale for pain assessment