Detección de errores y eventos adversos en UCIPS públicas argentinas / Detection of errors and adverse events in Argentine public ICUs

Los errores y/o eventos adversos relacionados con la atención de la salud deben traducirse en información útil para prevenirlos y garantizar los procesos asistenciales seguros. OBJETIVOS Determinar la frecuencia de errores y eventos adversos relacionados al cuidado de la salud en las Unidades de Cuidados Intensivos Pediátricos (UCIPs) del ámbito público de Argentina y la calidad de la atención. Diseño; Estudio multicéntrico descriptivo observacional con cuatro cohortes transversales. Población; Pacientes entre 1 y 217 meses internados entre el 1 de junio de 2016 y el 31 de marzo 2017 en 6 UCIP. MÉTODOS Se completaron cuestionarios con escala estructurada diseñada por los investigadores para registrar los errores o eventos encontrados durante 24 horas por corte, a pie de cama, por médico, kinesiólogo, enfermero y farmacéutico de cada centro. Para cinco categorías elegidas (ventilación mecánica (VM), accesos permanentes, falla de equipos, alarmas y medicación. Además, se consideró factores de cada UCIPs, de gravedad de los pacientes, factores humanos como sobrecarga de trabajo del equipo, escala NEMS y del sistema. RESULTADOS Se detectaron 1753 errores en los 262 pacientes en los 4 cortes/seis UCIPs en la población de 291 pacientes. Prevalencia de errores 0,90. Los errores más frecuentes fueron las alarmas 71,36%, de accesos 2,45%, de VM 10,38% y de medicación 15,80%. Todos los errores se presentaron en mayor proporción en horario matutino. En la regresión logística múltiple se tomó una de las 3 variables significativas del univariado, el NEMS que mostró asociación estadísticamente significativa con presentar un evento. OR=1,07 (IC95%: 1,03 a 1,11). P valor= 0,01. DISCUSIÓN La sobrecarga de trabajo de enfermería fue lo más significativo y el registro de ello permite evaluar, medir la situación. La falta de atención de alarmas, prescripciones y ruidos de comunicación lo más vulnerables. Se debe gestionar estrategias y prioridades en la atención

Mechanical ventilation in pediatric intensive care units during the season for acute lower respiratory infection: a multicenter study.

OBJECTIVE: To describe the characteristics and outcomes of mechanical ventilation in pediatric intensive care units during the season of acute lower respiratory infections. DESIGN: Prospective cohort of infants and children receiving mechanical ventilation for at least 12 hrs. SETTING: Sixty medical-surgical pediatric intensive care units. PATIENTS: All consecutive patients admitted to participating pediatric intensive care units during a 28-day period. MEASUREMENTS AND MAIN RESULTS: Of 2,156 patients admitted to pediatric intensive care units, 1185 (55%) received mechanical ventilation for a median of 5 days (interquartile range 2-8). Median age was 7 months (interquartile range 2-25). Main indications for mechanical ventilation were acute respiratory failure in 78% of the patients, altered mental status in 15%, and acute on chronic pulmonary disease in 6%. Median length of stay in the pediatric intensive care units was 10 days (interquartile range 6-18). Overall mortality rate in pediatric intensive care units was 13% (95% confidence interval: 11-15) for the entire population, and 39% (95% confidence interval: 23 - 58) in patients with acute respiratory distress syndrome. Of 1150 attempts at liberation from mechanical ventilation, 62% (95% confidence interval: 60-65) used the spontaneous breathing trial, and 37% (95% confidence interval: 35-40) used gradual reduction of ventilatory support. Noninvasive mechanical ventilation was used initially in 173 patients (15%, 95% confidence interval: 13-17). CONCLUSION: In the season of acute lower respiratory infections, one of every two children admitted to pediatric intensive care units requires mechanical ventilation. Acute respiratory failure was the most common reason for mechanical ventilation. The spontaneous breathing trial was the most commonly used method for liberation from mechanical ventilation.

Characterization of pediatric patients receiving prolonged mechanical ventilation.

OBJECTIVE: To describe the characteristics and risk factors of pediatric patients who receive prolonged mechanical ventilation, defined as ventilatory support for >21 days. DESIGN: Prospective cohort. SETTING: Four medical-surgical pediatric intensive care units in four university-affiliated hospitals in Argentina. PATIENTS: All consecutive patients from 1 month to 15 yrs old admitted to participating pediatric intensive care units from June 1, 2007, to August 31, 2007, who received mechanical ventilation (invasive or noninvasive) for >12 hrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic and physiologic data on admission to the pediatric intensive care units, drugs and events during the study period, and outcomes were prospectively recorded. A total of 256 patients were included. Of these, 23 (9%) required mechanical ventilation for >21 days and were assigned to the prolonged mechanical ventilation group. Patients requiring prolonged mechanical ventilation had higher mortality (43% vs. 21%, p < .05) and longer pediatric intensive care unit stay: 35 days [28-64 days] vs. 10 days [6-14]). There was no difference between the groups in age and gender distribution, reasons for admission, incidence of immunodeficiencies, or Paediatric Index of Mortality 2 score. The only difference at admission was a higher rate of genetic diseases in prolonged mechanical ventilation patients (26% vs. 9%, p < .05). There was a higher incidence of septic shock (87% vs. 34%, p < .01), acute respiratory distress syndrome (43% vs. 20%, p < .01), and ventilator-associated pneumonia (35% vs. 8%, p < .01) and higher utilization of dopamine (78% vs. 42%, p < .01), norepinephrine (61% vs. 15%, p < .01), multiple antibiotics (83% vs. 20%, p < .01), and blood transfusions (52% vs. 14%, p < .01). The proportion of extubation failure was higher in the prolonged mechanical ventilation group with similar rates of unplanned extubations in both groups. Variables remaining significantly associated with prolonged mechanical ventilation after multivariate analysis were treatment with multiple antibiotics, septic shock, ventilator-associated pneumonia, and use of norepinephrine. CONCLUSIONS: Patients with prolonged mechanical ventilation have more complications and require more pediatric intensive care unit resources. Mortality in these patients duplicates that from those requiring shorter support.

Critically ill infants and children with influenza A (H1N1) in pediatric intensive care units in Argentina.

OBJECTIVE: To determine the epidemiological features, course, and outcomes of critically ill pediatric patients with Influenza A (H1N1) virus. DESIGN: Prospective cohort of children in pediatric intensive care units (PICUs) due to Influenza A (H1N1) virus infection. SETTING: Seventeen medical-surgical PICUs in tertiary care hospital in Argentina. PATIENTS: All consecutive patients admitted to the PICUs with influenza A (H1N1) viral infection from 15 June to 31 July 2009. MEASUREMENTS AND MAIN RESULTS: Of 437 patients with acute lower respiratory infection in PICUs, 147 (34%) were diagnosed with influenza A (H1N1) related to critical illness. The median age of these patients was 10 months (IQR 3-59). Invasive mechanical ventilation was used in 117 (84%) on admission. The rate of acute respiratory distress syndrome (ARDS) was 80% (118 of 147 patients). Initial non-invasive ventilation failed in 19 of 22 attempts (86%). Mortality at 28 days was 39% (n = 57). Chronic complex conditions (CCCs), acute renal dysfunction (ARD) and ratio PaO(2)/FiO(2) at day 3 on MV were independently associated with a higher risk of mortality. The odds ratio (OR) for CCCs was 3.06, (CI 95% 1.36-6.84); OR for ARD, 3.38, (CI 95% 1.45-10.33); OR for PaO(2)/FiO(2), 4 (CI 95% 1.57-9.59). The administration of oseltamivir within 24 h after admission had a protective effect: OR 0.2 (CI 95% 0.07-0.54). CONCLUSIONS: In children with ARDS, H1N1 as an etiologic agent confers high mortality, and the presence of CCCs in such patients increases the risk of death.