Respuesta del autor: Comentarios al artículo: «Monitorización hemodinámica no invasiva o mínimamente invasiva en el paciente crítico en los servicios de urgencias y emergencias» / Authors’ reply: On «Noninvasive and minimally invasive hemodynamic monitoring in critically ill patients in the emergency department»

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Monitorización hemodinámica no invasiva o mínimamente invasiva en el paciente crítico en los servicios de urgencias y emergencias / None invasive and minimally invasive hemodynamic monitoring in critically ill patients in the emergency department

La monitorización hemodinámica no invasiva o mínimamente invasiva es una herramienta que se utiliza cada vez más en los servicios de urgencias y emergencias, para garantizar el adecuado aporte de oxígeno a los tejidos en el paciente crítico. Ayuda a establecer el diagnóstico diferencial de las posibles causas de shock y a optimizar el tratamiento, cuantificar sus efectos y evitar las posibles complicaciones derivadas del mismo. Los métodos convencionales de monitorización, por sí solos, se han mostrado insuficientes o poco eficientes, como la presión venosa central (SvcO2), para la evaluación hemodinámica de los pacientes críticos. En los últimos años el desarrollo tecnológico ha permitido disponer de monitores que miden de forma continua el gasto cardiaco (GC) del paciente de forma no invasiva (mediante electrodos cutáneos manguito hinchable digital o sensores de fotoespectrometría) o mínimamente invasiva (mediante la canalización de una arteria periférica). Es importante conocer en la práctica clínica, las ventajas y limitaciones que tienen los sistemas de estimación del GC antes de su aplicación. La combinación de las variables clásicas, las variables hemodinámicas y la información anatómica y funcional que nos proporciona la ecografía va a permitir establecer algoritmos de actuación en los servicios de urgencias y emergencias y sistematizar el proceso de reanimación con la intención de obtener una recuperación más rápida (AU)

Noninvasive and minimally invasive hemodynamic monitoring systems are used increasingly in emergency departments to provide adequate tissue oxygenation in critically ill patients. Such monitoring assists in the differential diagnosis of shock, the optimization of treatment and assessment of its effects, and the prevention of complications during care. Recent years have seen the development of noninvasive monitors that measure cardiac output continuously by means of electrodes applied to the skin or spectrophotometric sensors. Minimally invasive systems connected to a peripheral artery catheter have also been developed. Conventional hemodynamic monitoring methods alone have sometimes proven inadequate or inefficient in this setting; an example is the measurement of central venous pressure. The clinician therefore needs to understand the advantages and limitations of the different systems for estimating cardiac output before choosing a monitor. Resuscitation protocols that facilitate the fastest possible recovery in emergency care can be established based on the combination of traditional variables, hemodynamic variables, and anatomical and functional data provided by ultrasonography (AU)

Proyecto PIPA: consenso de recomendaciones y propuestas de mejora para el manejo del paciente anciano con sospecha de infección en los servicios de urgencias de la Comunidad Valenciana / Consensus-based recommendations and proposals for improving the management of elderly emergency patients with suspected infection in the Spanish autonomous community of Valencia: the PIPA project

Objetivo: Desarrollar una serie de recomendaciones y propuestas de mejora basadas en un consenso clínico de expertos sobre aspectos relacionados con la atención del paciente anciano con sospecha de infección en los Servicios de Urgencias y Emergencias (SUH-E) de la Comunidad Valenciana (CV). Metodología: El estudio se divide en tres fases: 1) Diseño de un cuestionario por consenso de un grupo de expertos;2) Realización de una encuesta electrónica para conocer la opinión de los médicos de urgencias y emergencias (MUyE) de la CV; 3) Elaboración de una serie de recomendaciones y propuestas de mejora por consenso de un grupo de expertos a partir de los resultados de dicha encuesta. El consenso se llevó a cabo mediante una metodología Delphi y la encuesta a través de una página web. Resultados: Un grupo de expertos de 21 MUyE consensuaron, tras dos rondas de votación, un cuestionario final de 15 preguntas de las 30 inicialmente planteadas [4 (26,6%) relativas a la clasificación y ubicación del paciente, 5(33,3%) al diagnóstico, y 6 (40,0%) al tratamiento]. El cuestionario final fue sometido a una votación, mediante una encuesta electrónica, de 142 MUyE (77,2%) de los 184 posibles procedentes de 21 SUH-E de la CV. De las 15 recomendación esplanteadas por el grupo coordinador tras la encuesta, se alcanzó un alto grado de consenso (mediana con puntuación > 7) en 11 (73,3%) de ellas por parte del grupo de expertos. Conclusiones: Se establecieron once recomendaciones y propuestas de mejora con un alto grado de consenso para la atención del paciente anciano con sospecha de infección en los SUH-E de la CV (AU)

Objective: To develop expert consensus-based recommendations and proposals on how to improve the care of elderly emergency patients with suspected infection in the autonomous community of Valencia. Methods: This project was carried out in 3 phases: 1) design of a questionnaire by means of consensus among a group of experts; 2) online survey to determine the opinions of emergency physicians in the community of Valencia; and 3) drafting of expert consensus-based recommendations and proposals arising from the results of the survey. The experts used the Delphi method to reach consensus and the survey was posted online. Results: After 2 rounds of voting, 21 emergency medicine experts reached consensus on 15 of the 30 survey items initially proposed: 4 items (26.6%) referred to patient classification and placement, 5 (33.3%) to diagnosis, and 6 (40.0%) to treatment. The resulting online questionnaire was returned by 142 (77.2%) of the 184 emergency physicians belong into 21 hospital emergency departments in the community of Valencia. The experts reached a high level of consensus(mean score, > 7) on 11 (73.3%) of the 15 recommendations posed by the group’s coordinator after the survey. Conclusions: The experts were able to propose 11 consensus-based recommendations and proposals for improving the care of elderly patients with suspected infection in emergency departments in Valencia (AU)

[Consensus-based recommendations and proposals for improving the management of elderly emergency patients with suspected infection in the Spanish autonomous community of Valencia: the PIPA project]. / Proyecto PIPA: consenso de recomendaciones y propuestas de mejora para el manejo del paciente anciano con sospecha de infección en los servicios de urgencias de la Comunidad Valenciana.

OBJECTIVES: To develop expert consensus-based recommendations and proposals on how to improve the care of elderly emergency patients with suspected infection in the autonomous community of Valencia. MATERIAL AND METHODS: This project was carried out in 3 phases: 1) design of a questionnaire by means of consensus among a group of experts; 2) online survey to determine the opinions of emergency physicians in the community of Valencia; and 3) drafting of expert consensus-based recommendations and proposals arising from the results of the survey. The experts used the Delphi method to reach consensus and the survey was posted online. RESULTS: After 2 rounds of voting, 21 emergency medicine experts reached consensus on 15 of the 30 survey items initially proposed: 4 items (26.6%) referred to patient classification and placement, 5 (33.3%) to diagnosis, and 6 (40.0%) to treatment. The resulting online questionnaire was returned by 142 (77.2%) of the 184 emergency physicians belonging to 21 hospital emergency departments in the community of Valencia. The experts reached a high level of consensus (mean score, > 7) on 11 (73.3%) of the 15 recommendations posed by the group's coordinator after the survey. CONCLUSION: The experts were able to propose 11 consensus-based recommendations and proposals for improving the care of elderly patients with suspected infection in emergency departments in Valencia.

OBJETIVO: Desarrollar una serie de recomendaciones y propuestas de mejora basadas en un consenso clínico de expertos sobre aspectos relacionados con la atención del paciente anciano con sospecha de infección en los Servicios de Urgencias y Emergencias (SUH-E) de la Comunidad Valenciana (CV). METODO: El estudio se divide en tres fases: 1) Diseño de un cuestionario por consenso de un grupo de expertos; 2) Realización de una encuesta electrónica para conocer la opinión de los médicos de urgencias y emergencias (MUyE) de la CV; 3) Elaboración de una serie de recomendaciones y propuestas de mejora por consenso de un grupo de expertos a partir de los resultados de dicha encuesta. El consenso se llevó a cabo mediante una metodología Delphi y la encuesta a través de una página web. RESULTADOS: Un grupo de expertos de 21 MUyE consensuaron, tras dos rondas de votación, un cuestionario final de 15 preguntas de las 30 inicialmente planteadas [4 (26,6%) relativas a la clasificación y ubicación del paciente, 5 (33,3%) al diagnóstico, y 6 (40,0%) al tratamiento]. El cuestionario final fue sometido a una votación, mediante una encuesta electrónica, de 142 MUyE (77,2%) de los 184 posibles procedentes de 21 SUH-E de la CV. De las 15 recomendaciones planteadas por el grupo coordinador tras la encuesta, se alcanzó un alto grado de consenso (mediana con puntuación > 7) en 11 (73,3%) de ellas por parte del grupo de expertos. CONCLUSIONES: Se establecieron once recomendaciones y propuestas de mejora con un alto grado de consenso para la atención del paciente anciano con sospecha de infección en los SUH-E de la CV.

[None invasive and minimally invasive hemodynamic monitoring in critically ill patients in the emergency department]. / Monitorización hemodinámica no invasiva o mínimamente invasiva en el paciente crítico en los servicios de urgencias y emergencias.

EN: Noninvasive and minimally invasive hemodynamic monitoring systems are used increasingly in emergency departments to provide adequate tissue oxygenation in critically ill patients. Such monitoring assists in the differential diagnosis of shock, the optimization of treatment and assessment of its effects, and the prevention of complications during care. Recent years have seen the development of noninvasive monitors that measure cardiac output continuously by means of electrodes applied to the skin or spectrophotometric sensors. Minimally invasive systems connected to a peripheral artery catheter have also been developed. Conventional hemodynamic monitoring methods alone have sometimes proven inadequate or inefficient in this setting; an example is the measurement of central venous pressure. The clinician therefore needs to understand the advantages and limitations of the different systems for estimating cardiac output before choosing a monitor. Resuscitation protocols that facilitate the fastest possible recovery in emergency care can be established based on the combination of traditional variables, hemodynamic variables, and anatomical and functional data provided by ultrasonography.

ES: La monitorización hemodinámica no invasiva o mínimamente invasiva es una herramienta que se utiliza cada vez más en los servicios de urgencias y emergencias, para garantizar el adecuado aporte de oxígeno a los tejidos en el paciente crítico. Ayuda a establecer el diagnóstico diferencial de las posibles causas de shock y a optimizar el tratamiento, cuantificar sus efectos y evitar las posibles complicaciones derivadas del mismo. Los métodos convencionales de monitorización, por sí solos, se han mostrado insuficientes o poco eficientes, como la presión venosa central (SvcO2), para la evaluación hemodinámica de los pacientes críticos. En los últimos años el desarrollo tecnológico ha permitido disponer de monitores que miden de forma continua el gasto cardiaco (GC) del paciente de forma no invasiva (mediante electrodos cutáneos manguito hinchable digital o sensores de fotoespectrometría) o mínimamente invasiva (mediante la canalización de una arteria periférica). Es importante conocer en la práctica clínica, las ventajas y limitaciones que tienen los sistemas de estimación del GC antes de su aplicación. La combinación de las variables clásicas, las variables hemodinámicas y la información anatómica y funcional que nos proporciona la ecografía va a permitir establecer algoritmos de actuación en los servicios de urgencias y emergencias y sistematizar el proceso de reanimación con la intención de obtener una recuperación más rápida.

Association of γδ T cells with disease severity and mortality in septic patients.

Gamma-delta T cells are the most abundant of all epithelial-resident lymphocytes and are considered a first line of defense against pathogens in the mucosa. Our objective was to confirm the reduction in γδ T cell subsets and its relationship with mortality in patients with sepsis. We studied 135 patients with sepsis attended in the emergency department and intensive care unit of two hospitals and compared them with a similar control group of healthy subjects. The αß and γδ T cell subsets were determined via flow cytometry according to the stage of the sepsis and its relationship with mortality. All the lymphocyte subsets were reduced with respect to the corresponding subsets in the control group. All the γδ T cell populations decreased significantly as the septic picture worsened. Furthermore, γδ T cells showed decreases at days 2, 3, and 4 from the start of sepsis. Twenty-six patients with sepsis died (19.3%). The γδ T cells, specifically, the CD3(+) CD56(+) γδ T cells, were significantly reduced in those septic patients who died. Our results indicate that, during sepsis, γδ T cells show the largest decrease and this reduction becomes more intense when the septic process becomes more severe. Mortality was associated with a significant decrease in γδ T cells.

Deficit of gammadelta T lymphocytes in the peripheral blood of patients with Crohn's disease.

BACKGROUND: Gammadelta T lymphocytes are an important component of innate immunity. Previous studies have shown their role in the development of Crohn's-like colitis in mice. AIMS: The aim of this study was to measure the γδ T lymphocyte levels in Crohn's disease (CD) patients. METHODS: A prospective study of 40 patients with CD compared with 40 healthy subjects (control group) matched by age and sex was undertaken. Lennard-Jones criteria were used for the diagnosis of CD. Disease activity was measured with the Crohn's disease activity index (CDAI). New patients, patients in remission, and patients with active disease were evaluated. Lymphocytic populations of CD3+, CD4+, CD8+, CD56+, CD19+, and αß and γδ subsets were measured in the peripheral blood of all participants. RESULTS: The levels of CD3+, CD4+, CD8+, and CD19+ lymphocytes were decreased in CD patients compared with the control group (P = 0.002, 0.049, 0.003, and 0.023, respectively). Although both γδ and αß T lymphocytes were lower in patients with CD, γδ T subsets showed the lowest levels in CD patients (mean 0.0259 × 10(9)/l) versus healthy controls (mean 0.0769 × 10(9)/l), P < 0.001. In particular, γδ CD8+ T subsets (mean 0.0068 × 10(9)/l) had the largest difference compared to the control group (mean 0.0199 × 10(9)/l), P = 0.008. CONCLUSIONS: There is a decrease in the global lymphocyte population in the peripheral blood of patients with CD compared to healthy controls. This decrease is more evident in γδ T lymphocytes, especially γδ CD8+ T subsets. Our conclusion is that these results support the theory that a complex alteration of immune responses that affects the total numbers and function of γδ T cells is present in CD.

Epidemiology of sepsis in the Valencian Community (Spain), 1995-2004.

OBJECTIVE: To study the incidence of sepsis in the Valencian Community (Spain) during a period of 10 years (1995-2004). METHODS: We downloaded data on discharge diagnoses of septicemia in all 26 public hospitals in the Valencian Community during the 10-year study period, as well as the additional discharge diagnoses of each patient. RESULTS: We identified 33,767 cases of sepsis during the study period. The age-standardized incidence rates among men increased from 64.11 (95% confidence interval [CI], 60.37-67.85) cases per 100,000 population in 1995 to 114.02 (95% CI, 109.02-118.50) cases per 100,000 population in 2004 (P < .001), and those among women increased from 45.08 (95% CI, 42.01-48.15) cases per 100,000 population in 1995 to 83.62 (95% CI, 79.85-87.39) cases per 100,000 population in 2004 (P < .001). Gram-negative bacteria were the most frequently involved microorganisms (in 21.4% of cases), and there was a significant increase in the number of sepsis cases caused by these organisms from 1999 onward. The mortality rate was approximately 42.5% among patients hospitalized for sepsis, and mortality was associated with organ failure. In addition, mortality was associated with the microorganism responsible not being known, with infection due to fungi, and with polymicrobial sepsis. CONCLUSIONS: The rates of hospitalization both for sepsis overall and for severe sepsis in the Valencian Community (Spain) are lower than those in other countries but are increasing, by 5% each year. The increase in the number of cases in which gram-negative bacteria are the cause of sepsis is notable.

A propósito de las unidades médicas de corta estancia. Réplica / Apropos of short-stay medical units. Response

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Estudio sociosanitario del paciente anciano con perfil de larga estancia y terminal atendido en una unidad médica de corta estancia / Social and health characteristics of elderly patients with chronic and/or terminal diseases (PALET profile) attended in a short stay medical unit

Objetivo: descripción de las características clínicas, funcionales y sociosanitarias de la población anciana con enfermedad crónica y/o terminal (perfil PALET) atendida en la Unidad Médica de Corta Estancia (UMCE) adscrita a un servicio de urgencias, en relación con el resto de pacientes. Material y métodos: estudio descriptivo de todos los pacientes admitidos en la UMCE durante un período de un año. Se recogen edad, sexo, estancia, tipología, situación funcional (índice de Barthel), cognitiva (Pfeiffer), nutricional (Mini Nutritional Assessment), depresión (Yesavage), situación de convivencia y destino de paciente. Se realizó un estudio descriptivo y análisis bivariante (t de Student, χ2), con nivel de significación p < 0,05 (intervalo de confianza [IC] del 95%). Resultados: el número total de pacientes fue de 1.028, (51,0% varones), edad media 71,6 [15-104], mediana 77 años. Perfil PALET 264 (25,7%), pacientes oncológicos 94 (9,1%), otros 770 (65,2%). Estancia media sin diferencias significativas entre grupos. Mortalidad global en UMCE 39 casos (76,9% casos perfil PALET). Los pacientes PALET son mayores, odds ratio [OR] = 8,16 (IC del 95%, 4,18-14,16), p < 0,001; presentan peor situación funcional y mental (p < 0,001) y mayor mortalidad, OR = 10,76 (IC del 95%, 5,03-22,98), p < 0,001, que el resto. Asimismo, necesitan mayor proporción de recursos de tipo domiciliario y de media o larga estancia al alta (p < 0,001). Conclusiones: nuestra UMCE atiende a una proporción importante de ancianos con enfermedad crónica y/o terminal (PALET), cuya situación funcional, mental y nutricional, así como su comorbilidad y elevada tasa de mortalidad, obligan a desarrollar recursos domiciliarios, sociosanitarios y hospitales de apoyo que permitan mejorar la calidad de su atención

Objective: to describe the clinical, functional, health and social characteristics of the elderly population with chronic and/or terminal diseases (PALET profile) in a short-stay medical unit (SSMU) attached to an emergency department in relation to the remaining patients. Material and methods: a descriptive study of all patients admitted to the SSMU during a 1-year period was performed. Data on age, sex, length of hospital stay, patient profile (PALET or oncological), functional status (Barthel index), cognitive status (Pfeiffer), nutritional status (MNA), depression (Yesavage), living arrangements, and destination after discharge were gathered. The statistical analysis consisted of descriptive study and bivariate analysis (Student's t-test, chi-square test) with a significance level of p < 0.05 (95% confidence interval [CI]). Results: there were 1,028 patients (51.0% men), with a mean age of 71.6 years [15-104] (median 77 years). There were 264 PALET patients (25.7%), 94 oncological patients (9.1%), and 770 patients with other diagnoses (65.2%). No significant differences were found between the groups in the mean length of stay. Overall mortality in the SSMU: 39 patients (76.9% PALET patients). PALET patients were older (OR = 8.16 [95% CI: 4.18-14.16], p < 0.001), had poorer functional and mental status (p < 0.001) and showed higher mortality (OR = 10.76 [95% CI: 5.03-22.98], p < 0.001) than the remaining patients. PALET patients required a higher proportion of domiciliary resources and were more likely to be referred to medium- or long-stay facilities at discharge (p < 0.001). Conclusions: our SSMU attends a substantial proportion of elderly patients with chronic and/or terminal diseases (PALET). Because of the functional, mental, and nutritional status of these patients, as well as the presence of comorbidities and the high mortality rate, domiciliary, health and social resources should be developed to improve the quality of care provided to these patients