Best practices for iatrogenic anaemia prevention in the intensive care unit: Blood-sparing techniques.

Anaemia is a common issue in patients who are admitted to intensive care units and worsens their condition throughout the stay due to the extraction of blood for diagnostic purposes. It is also well-known that an important amount of the carbon dioxide produced by health services is likely attributable to blood donation, testing and manufacture, storage or distribution of blood components. This must be taken into account to perform nursing interventions consistent with the idea of sustainable health care. In this regard, within patient blood management bundles, with the objective of minimizing the use of blood products, it is recommended to use blood-sparing techniques: small volume tubes (SVT) or closed-blood sampling devices (CBSD). Published studies before 2014 (excepting two more recent ones) have shown that by themselves, both techniques reduce drawn volume but do not decrease haemoglobin reduction and/or need of transfusion. Given the lack of cost-effectiveness studies, it may be easier to implement the use of CBSD as it does not require prior consensus on the discard volume or adaptations in the processing of laboratory tests, as is the case with SVT.

Cross-cultural adaptation of the FRAIL scale for critically ill patients in Spain.

AIM: To translate and culturally adapt the FRAIL scale into Spanish and perform a preliminary test of diagnostic accuracy in patients admitted to intensive care units. DESIGN: Cross-sectional diagnostic study. METHODS: Five intensive care units (ICU) in Spain were participated. Stage 1: Three native Spanish-speaking bilingual translators familiar with the field of critical care translated the scale from English into Spanish. Stage 2: Three native English-speaking bilingual translators familiar with critical care medicine. Stage 3: Authors of the original scale compared the English original and back-translated versions of the scale. Stage 4: Five nurses with more than 5 years of ICU experience and five critical care physicians assessed the comprehension and relevance of each of the items of the Spanish version in 30 patients of 3 different age ranges (<50, 50-65 and >65 years). RESULTS: The FRAIL scale was translated and adapted cross-culturally for patients admitted to intensive care units in Spain. The process consisted of four stages: translation, back translation, comparison and pilot test. There was good correspondence between the original scale and the Spanish version in 100% of the items. The participating patients assessed the relevance (content validity) and comprehensibility (face validity) of each of the items of the first Spanish version. The relevance of some of the items scored low when the scale was used in patients younger than 65 years. CONCLUSIONS: We have cross-culturally adapted the FRAIL scale, originally in English, to Spanish for its use in the critical care medical setting in Spanish-speaking countries. IMPLICATIONS FOR PROFESSIONALS: Physicians and nurses can apply the new scale to all patients admitted to the intensive care units. Nursing care can be adapted according to frailty, trying to reduce the side effects of admission to these units for the most fragile patients. REPORTING METHOD: The manuscript's authors have adhered to the EQUATOR guidelines, using the COSMIN reporting guideline for studies on the measurement properties of patient-reported outcome measures. PATIENT OR PUBLIC CONTRIBUTION: In a pilot clinical study, we applied the first version of the FRAIL-Spain scale to intensive care unit (ICU) patients. Five nurses with more than 5 years of ICU experience and five critical care physicians assessed the relevance (content validity) and comprehensibility (face validity) of the five items of the first Spanish version. Relevance was assessed using a 4-point Likert scale ranging from 1 (no relevance) to 4 (high relevance), and comprehensibility was assessed as poor, acceptable or good. Each health professional applied the scale to three patients (total number of patients = 30) of three different age ranges (<50, 50-65 and >65 years) and recorded the time of application of the scale to each patient. Although the frailty scales were initially created by geriatricians to be applied to the elders, there is little experience with their application in critically ill patients of any age. Therefore, more information is needed to determine the relevance of using this scale in critical care patients. In this pilot study, we considered that nurses and critical care physicians should evaluate frailty using this adapted scale in adult patients admitted to the Intensive Care Units.

Enteral nutrition management in critically ill adult patients and its relationship with intensive care unit-acquired muscle weakness: A national cohort study.

OBJECTIVE: To assess the incidence and determinants of ICU-acquired muscle weakness (ICUAW) in adult patients with enteral nutrition (EN) during the first 7 days in the ICU and mechanical ventilation for at least 48 hours. METHODS: A prospective, nationwide, multicentre cohort study in a national ICU network of 80 ICUs. ICU patients receiving invasive mechanical ventilation for at least 48 hours and EN the first 7 days of their ICU stay were included. The primary outcome was incidence of ICUAW. The secondary outcome was analysed, during days 3-7 of ICU stay, the relationship between demographic and clinical data to contribute to the onset of ICUAW, identify whether energy and protein intake can contribute independently to the onset of ICUAW and degree of compliance guidelines for EN. RESULTS: 319 patients were studied from 69 ICUs in our country. The incidence of ICUAW was 153/222 (68.9%; 95% CI [62.5%-74.7%]). Patients without ICUAW showed higher levels of active mobility (p = 0.018). The logistic regression analysis showed no effect on energy or protein intake on the onset of ICUAW. Overfeeding was observed on a significant proportion of patient-days, while more overfeeding (as per US guidelines) was found among patients with obesity than those without (42.9% vs 12.5%; p<0.001). Protein intake was deficient (as per US/European guidelines) during ICU days 3-7. CONCLUSIONS: The incidence of ICUAW was high in this patient cohort. Early mobility was associated with a lower incidence of ICUAW. Significant overfeeding and deficient protein intake were observed. However, energy and protein intake alone were insufficient to explain ICUAW onset. RELEVANCE TO CLINICAL PRACTICE: Low mobility, high incidence of ICUAW and low protein intake suggest the need to train, update and involve ICU professionals in nutritional care and the need for early mobilization of ICU patients.

Pain Behaviors Analyzed by Videorecording in Brain-Injured Patients Admitted to the Intensive Care Unit.

AIM: To describe and classify pain behaviors (facial and body) in brain-injured patients with a low level of consciousness before, during, and after the performance of painful and non-painful care procedures. METHODS: Facial behaviors and body movements in brain-injured patients were videotaped at rest, during the application of three care procedures (two painful and one non-painful), and 15 minutes after completion of these procedures. Each video recording was evaluated by expert evaluators blinded to each other. For each of the behaviors observed, all possible combinations between the three procedures and/or time were compared using the McNemar test. Effect size was measured by the difference in proportions using the Wilson score 95% confidence intervals. RESULTS: Twenty-seven patients were included. The mean (standard deviation) Glasgow Coma Score was 5.4 (1.9). A total of 33 behaviors (29 active, four neutral) were registered. Expression of behaviors was more common during the painful procedures compared with the other time points (non-painful procedures, baseline, and final evaluation). Inter-evaluator agreement was substantial (Kappa index >0.7) in more than 50% of the observed behaviors. CONCLUSIONS: In this study involving brain-injured patients with a low level of consciousness, facial, body, and ventilation-related behaviors were more common during painful procedures. Agreement between evaluators to detect the presence or absence of these behaviors was substantial. These findings underscore the need to develop pain assessment measures specific to this patient population.

Distrés psicológico, ansiedad y depresión en pacientes ingresados en aislamiento hospitalario / Psychological distress, anxiety and depression in patients admitted to hospital isolation

Objetivo: determinar el nivel de distrés psicológico, ansiedad y depresión de los pacientes ingresados en régimen de aislamiento. Secundariamente, analizar la evolución a las 48 horas del aislamiento y la asociación con determinadas características sociodemográficas. Método: estudio descriptivo longitudinal con pacientes ingresados en aislamiento en la Unidad de Medicina Interna de un hospital de segundo nivel de Madrid (España) (N= 90). Se recogieron variables sociodemográficas y clínicas, y el nivel de distrés psicológico, ansiedad y depresión fue evaluado mediante la Hospital Anxiety and Depression Scale los días 1 y 3 de aislamiento. Resultados: se incluyeron N= 78 pacientes. Presentaban distrés psicológico el 38,5%, ansiedad el 12,8% y depresión el 10,3%. A las 48 horas solo se dio aumento significativo del distrés psicológico (p< 0,01). La ansiedad fue más prevalente en pacientes con ingresos económicos bajos (p= 0,02) mientras que la depresión se relacionó con mayor edad (p< 0,01), estancia hospitalaria más larga (p= 0,02), estar casado/a (p= 0,04), estar jubilado/a (p< 0,01), no tener cargas familiares (p= 0,02) y estar aislado/a por yodo (por tratamiento oncológico) (p< 0,01). Los niveles de ansiedad fueron menores en pacientes aislados por yodo (p= 0,04) y cuyo primer tratamiento era yodo (p= 0,01) y en los que no habían tenido un aislamiento previo (p= 0,02); mientras que los de depresión fueron mayores enlos/as viudos/as (p= 0,03), menor nivel educativo (p= 0,05), jubilados/as (p= 0,01), menores ingresos económicos (p= 0,03) y en aislamiento por otras causas (p< 0,01). Conclusiones: los niveles de distrés, ansiedad y depresión no son elevados y apenas varían en el corto plazo de un ingreso en aislamiento.(AU)

Objective: to determine the level of psychological distress, anxiety and depression of patients hospitalized in isolation regime. Secondarily, to analyse the evolution at 48 hours of isolation and its association with specific sociodemographic characteristics. Method: a longitudinal descriptive study with patients admitted in hospital isolation regimen at the Internal Medicine Unit of a second level hospital in Madrid (Spain) (N= 90). Sociodemographic and clinical variables were collected, and their level of psychological distress, anxiety and depression was evaluated through the Hospital Anxiety and Depression Scale at days 1 and 3 of isolation. Results: the study included N= 78 patients; 38.5% of them presented psychological distress, 12.8% presented anxiety, and 10.3% presented depression. At 48 hours, there was only significant increase in psychological distress (p< 0.01). Anxiety was more prevalent in patients with low economic income (p= 0.02), while depression was associated with older age (p< 0.01), longer hospital stay (p= 0.02), being married (p= 0.04), being retired (p< 0.01), not having family dependants (p= 0.02) and being isolated due to iodine (oncological treatment) (p< 0.01). Anxiety levels were lower in patients isolated due to iodine (p= 0.04) and with iodine as their first treatment (p= 0.01) and in those with no previous isolation (p= 0.02); while depression levels were higher in widows / widowers (p= 0.03), those with a lower educational level (p= 0.05), those retired (p= 0.01), patients with lower incomes (p= 0.03) and patients in isolation due to other causes (p< 0.01). Conclusions: distress, anxiety and depression levels are not high and hardly present any variations during the short term of hospitalization in isolation.(AU)

The impact of ABCDE bundle implementation on patient outcomes: A nationwide cohort study.

BACKGROUND: The ABCDE bundle is a set of evidence-based practices to systematically reduce the risks of sedation, delirium, and immobility in intensive care patients. Implementing the bundle improves clinical outcome. AIMS AND OBJECTIVES: To investigate the association between patient outcomes and compliance with bundle components ABC (analgosedation algorithms), D (delirium protocol), and E (early mobilization protocol). DESIGN: A Spanish multicentre cohort study of adult patients receiving invasive mechanical ventilation (IMV) for ≥48 h until extubation. METHODS: The primary outcome was pain level, cooperation to permit Medical Research Council Scale administration, patient days of delirium, and mobility. The secondary outcome was cumulative drug dosing by IMV days. Tertiary outcomes (ICU days, IMV days, bed rest days, ICU mortality, ICUAW) and independent variables (analgosedation, delirium, early mobilization protocols) were also studied. RESULTS: Data were collected from 605 patients in 80 ICUs and 5214 patient days with IMV. Two-thirds of the ICUs studied applied no protocols. Pain was not assessed on 83.6% of patient days. Patient cooperation made scale administration feasible on 20.7% of days. Delirium and immobility were found on 4.2% and 69.9% of days, respectively. Patients had shorter stays in ICUs with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components (P = 0.006 and P = 0.03, respectively). Analgosedation protocols were associated with more opioid dosing (P = 0.02), and delirium and early mobilization protocols with more propofol (P = 0.001), dexmedetomidine (P = 0.001), and lower benzodiazepine dosing (P = 0.008). CONCLUSIONS: The implementation rate of ABCDE bundle components was very low in our Spanish setting, but when implemented, patients had a shorter ICU stay, more analgesia dosing, and lighter sedation. RELEVANCE TO CLINICAL PRACTICE: Applying some but not all the bundle components, there is increased analgesia and light sedation drug use, decreased benzodiazepines, and increased patient cooperation and mobility, resulting in a shorter ICU stay and fewer days of IMV.

Variables associated with mobility levels in critically ill patients: A cohort study.

BACKGROUND: Early mobilization in the intensive care unit (ICU) helps improve patients' functional status at discharge. However, many barriers hinder this practice. AIM AND OBJECTIVES: To identify mobility levels acquired by critically ill patients and their variables. DESIGN: A multi-centre cohort study was conducted in adult patients receiving invasive mechanical ventilation for at least 48 hours. METHODS: The primary outcome was level of mobility according to the ICU mobility scale. The secondary outcome was human resource availability and existence of ABCDEF bundle guidelines. A logistic regression was performed, based on days 3 to 5 of the ICU stay and significant association with active mobility. RESULTS: Six hundred and forty-two patients were included from 80 ICUs. Active moving in and out of bed was found on 9.9% of patient-days from day 8 of the ICU stay. Bed exercises, or passive transfers, and immobility were observed on 45.6% and 42.2% of patient-days, respectively. Patients achieving active mobility (189/642, 29.4%) were in ICUs with more physiotherapist hours. Active mobility was more likely with a 1:4 nurse-patient ratio (odds ratio [OR] 3.7 95% confidence interval [CI] [1.2-11.2]), high MRC sum-score (OR 1.05 95% CI [1.04-1.06]) and presence of delirium (OR 1.01 95% CI [1.00-1.02]). By contrast, active mobility was hindered by higher BMI (OR 0.92 95% CI [0.88-0.97]), a 1:3 nurse-patient ratio (OR 0.54 95% CI [0.32-0.93]), or a shift-dependent nurse-patient ratio (OR 0.27 95% CI [0.12-0.62]). CONCLUSIONS: Immobility and passive mobilization were prevalent. A high MRC sum-score and presence of delirium are protective factors of mobilization. A 1:4 nurse-patient ratio shows a stronger association with active mobility than a 1:3 ratio. RELEVANCE TO CLINICAL PRACTICE: Severity-criteria-based nurse-patient ratios hinder mobilization. Active mobilization may be enhanced by using nursing-intervention-based ratios, increasing physiotherapist hours, and achieving wider application of the ABCDEF bundle, resulting in more awake, cooperative patients.

Intervenciones enfermeras más prevalentes en la atención de adultos ingresados en unidades de hospitalización / The most prevalent Nursing interventions in patient care for adults admitted to hospitalization units

Objetivo: identificar las intervenciones enfermeras más prevalentes en la atención del paciente adulto en el contexto de las unidades de hospitalización.Método: diseño multimétodo y multicéntrico realizado en la Comunidad de Madrid. Para llevar a cabo el estudio se contó con un Equipo de Investigación formado por expertos en metodología de la investigación y metodología enfermera. El estudio se desarrolló en tres fases: primero se elaboró un listado con 80 intervenciones de Enfermería NIC, seleccionadas por consenso; en segundo lugar se diseñó una encuesta ad hoc que contenía las 80 NIC con varias opciones de respuesta en función de la frecuencia de realización en la práctica habitual; la tercera fase fue un estudio transversal dirigido a profesionales de Enfermería que trabajaban en unidades de hospitalización de adultos de los 10 hospitales participantes. La encuesta se distribuyó mediante correo electrónico. Se efectuó análisis descriptivo.Resultados: participaron 427 enfermeras. Años de antigüedad media (desviación estándar) 14 (7,74). Las NIC más prevalentes que se realizaban más de tres veces al día fueron: administración de medicación (n= 294; 68,9%); control de la medicación (n= 285; 66,7%); administración de medicación oral (n= 282; 66%); cuidados del dolor (n= 280; 65,6%); escucha activa (277; 64,9%); administración de analgésicos (272; 63,9%); cambio de posición (n= 262; 61,4%), entre otras.Conclusiones: se identificaron las intervenciones realizadas con mayor frecuencia, como primera línea de trabajo encaminado a obtener más información sobre intervenciones y tiempos de ejecución, que ayuden a mejorar la gestión de recursos humanos en función de las necesidades de los pacientes.(AU)

Objective: to identify the most prevalent Nursing interventions in adult patient care in the setting of hospitalization units.Method: a study with multi-method and multicenter design conducted at the Autonomous Community of Madrid. A Research Team participated in the study; the team was formed by experts on research methodology and nursing methodology. The study consisted of three phases: a list was prepared first with 80 NIC Nursing interventions, selected by consensus; secondly, an ad hoc survey was designed, containing the 80 NICs with different answer options based on the frequency they were carried out in daily practice; and the third phase was a cross-sectional study targeted to Nursing professionals working at hospitalization units for adult patients from the 10 hospitals involved. The survey was sent by e-mail. Descriptive analysis was conducted.Results: the study included 427 nurses; their mean years of seniority (standard deviation) was 14 (7.74). The most prevalent NICs that were done more than three times per day were: medication administration (n= 294; 68.9%); medication monitoring (n= 285; 66.7%); oral medication administration (n= 282; 66%); pain management (n= 280; 65.6%); active listening (277; 64.9%); administration of analgesics (272; 63.9%); change of position (n= 262; 61.4%), among others.Conclusions: the interventions most frequently carried out were identified, as a first line of work targeted to obtaining more information on interventions and times of performance, which will help to improve the management of human resources based on patient needs.(AU)

Retirada accidental de sondas enterales en el paciente crítico / Accidental removal of feeding tubes in critical patients

Objetivo: evaluar el impacto de una sesión formativa en las tasas de retirada accidental (RA) [autorretirada y retirada por causa externa al paciente (CEP)] de la sonda enteral (SE) y en los niveles de analgosedación e identificación del delirio, en pacientes de un Servicio de Cuidados Intensivos y Grandes Quemados (UCI-UGQ).Método: estudio observacional prospectivo antes-después, realizado en una UCI-UGQ de 24 camas. Primer periodo: del 15-10-2018 al 15-01-2019, segundo periodo: del 15-07-2019 al 15-01-2020. Entre periodos se comunicaron los resultados y se hizo una sesión formativa (sujeción SE, valoración dolor, sedación y delirio). Incluidos todos los pacientes portadores de SE. Variables: demográficas, gravedad, motivo de retirada, evento adverso como consecuencia de la retirada o reinserción, dolor, sedación/agitación y delirio. Análisis: descriptivo y tasas de incidencia por 1.000 días dispositivo. Aprobado por CEIm.Resultados: ingresos en 2018 vs. 2019: 232 vs. 408 (1.586 vs. 3.149 días estancia); mujeres: 34% vs. 42%. SAPS III, Mediana (RIC): 57 (45-67) vs. 45 (33-54). Insertadas 156 vs. 295 SE. Tasas de RA por 1.000 días de dispositivo: global 56,68 vs. 45,87 (p= 0,42); autorretirada 48,13 vs. 37,72 (p= 0,36), CEP 8,56 vs. 8,15 (p= 0,90). No se registraron eventos adversos. En el momento de la autorretirada presentaban dolor (EVN/ESCID> 0) 26,6% vs. 19% pacientes; agitación (RASS> 0) 66,6% vs. 40,6% pacientes; delirio (CAM-ICU positivo) 33,3% vs. 20,3% pacientes.Conclusiones: tras la sesión formativa se observó una reducción no significativa en las tasas de RA. En las autorretiradas se comprobó un descenso significativo de la agitación y un descenso clínicamente relevante del dolor y presencia de delirio.(AU)

Objective: to assess the impact of a training session on accidental removal (AR) rates of the feeding tube (FT) [self-removal and removal due to a cause external to the patient (CEP] and on the levels of analgesia & sedation and delirium detection, in patients from an Intensive Care and Major Burns Unit (ICU-MBU).Method: an observational, before-and-after, prospective study, conducted in a 24-bed ICU-MBU- First period: October, 15th, 2018 to January, 15th, 2019: second period: July, 15th, 2019 to January, 15th, 2020. Results were reported between periods, and a training session was conducted (FT attachment, pain assessment, sedation, and delirium). All patients with FT were included. Variables: demographics, severity, reason for removal, adverse event as a consequence of removal or reinsertion, pain, sedation/agitation, and delirium. Analysis: descriptive, and incidence rates per 1,000 device days. Approved by the Drug Research Ethics Committee (CEIm).Results: hospitalizations in 2018 vs. 2019: 232 vs. 408 (1,586 vs. 3,149 hospitalization days); women: 34% vs. 42%. SAPS III, Median (IQR): 57 (45-67) vs. 45 (33-54). FTs inserted: 156 vs. 295. AR rates per 1,000 device days: overall 56.68 vs. 45.87 (p= 0.42); self-removal: 48.13 vs. 37.72 (p= 0.36), CEP 8.56 vs. 8.15 (p= 0.90). No adverse events were reported. At the time of self-removal, 26.6% vs. 19% patients presented pain (VAS/ESCID> 0); 66.6% vs. 40.6% patients presented agitation (RASS> 0, and 33.3% vs. 20.3% patients presented delirium (positive CAM-ICU).Conclusions: after the training session, a non-significant reduction in AR rates was observed. In cases of self-removal, a significant reduction in agitation was observed, as well as a clinically relevant reduction in pain and presence of delirium.(AU)

Application of the Behavioural Indicators of Pain Scale in patients with traumatic brain injury.

AIM: To develop and psychometrically test the Behavioural Indicators of Pain Scale (ESCID) in patients with traumatic brain injury (TBI). DESIGN: A prospective observational study to test the psychometric properties of the Behavioural Indicators of Pain Scale in patients with TBI. METHOD: A convenience sample of patients with TBI, who were non-communicative and using invasive mechanical ventilation was selected. Pain was evaluated by two observers who were blinded from each other. Assessments were performed at baseline via the performance of a painful procedure (aspiration of secretions) and a non-painful procedure (rubbing with a gauze). Assessments were repeated after application of procedures on days 1 and 6 of hospitalization in an intensive care unit. Data were collected between January-December 2016. RESULTS: About 134 patients were included in the study. Of these, 76.1% were men. The mean age of participants was 45.2 (SD 17.5) years. The pain score significantly increased during the painful procedure when compared with the baseline measure and non-painful procedure (p < .001). Patients displayed a greater number of pain-indicating behaviours during the painful procedure on day 6, compared with day 1 (p < .05). This finding coincided with a reduced level of sedation and a greater level of consciousness. CONCLUSION: The ESCID scale detects pain behaviours and discriminates among the different types of stimulation in patients with brain injury, who are uncommunicative and with mechanical ventilation, with good reliability. The ability for patients with brain injury to express behaviours is limited because of the low level of consciousness and the deep level of sedation. IMPACT: This research will have an impact on the practice of pain assessment in patients with brain injury, representing a first step to adapt the content of the ESCID.

Development and initial validation of a Theory of Planned Behaviour questionnaire to assess critical care nurses' intention to use physical restraints.

AIMS: To develop and psychometrically test a Theory of Planned Behaviour (TPB) questionnaire to assess nurses' intention to use physical restraints (PRs) in intubated patients. DESIGN: A psychometric instrument validation study conducted in three phases. METHODS: A theory-driven questionnaire was developed. Eight experts validated the content of the preliminary 58-item questionnaire. A pilot study was conducted including 101 critical care nurses to test the reliability of the items. Construct validity and reliability were tested in a cross-sectional study of 12 units from eight hospitals in Spain (N = 354) from October - December 2017. Participants completed the questions based on the TPB, and socio-demographic and professional variables. RESULTS: The instrument comprised 48 items. All the direct and indirect constructs exhibited acceptable reliability. Confirmatory factor analysis indicated satisfactory fit indices for factorial structure according to the TPB. Nurses showed favourable attitudes, low perception of social pressure and modest perception of behaviour control. Perceived behavioural control and attitude were moderately positively correlated with the intention to use restraints, whereas subjective norm revealed the lowest correlation. Overall, the model explained 33% of the variance in intention. CONCLUSIONS: The Physical Restraint TPB questionnaire is a 48-item self-reporting theoretically based instrument with acceptable reliability and construct validity to identify nurses' intentions to use PRs in intubated patients. IMPACT: Unravelling the key determinants of nurses' intentions to use PRs should be examined to tailor quality improvement projects aimed at de-implementing restraints use in practice and to promote safer care.

Guía de práctica clínica del American College of Critical Care Medicine sobre prevención y manejo del dolor, agitación/sedación, contenciones mecánicas, delirio, inmovilidad y alteraciones del sueño del paciente adulto / Clinical Practice Guidelines of the American College of Critical Care Medicine for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients

Objetivo: Actualizar y ampliar la Guía de Práctica Clínica de 2013 para el manejo del dolor, agitación y delirio en pacientes adultos de la UCI. Diseño: Treinta y dos expertos internacionales, cuatro expertos en metodología, y cuatro supervivientes de enfermedades críticas se reunieron virtualmente, al menos una vez al mes. Todos los grupos de sección se reunieron personalmente en los congresos anuales de la Sociedad de Medicina de Cuidados Críticos; las conexiones virtuales incluyeron a aquellas personas que no pudieron asistir. A priori, se desarrolló una política formal de conflicto de intereses, que se hizo cumplir a lo largo del proceso. Las teleconferencias y debates electrónicos entre los subgrupos, así como el panel al completo, formaron parte del desarrollo de la guía. Todos los miembros del panel realizaron personalmente una revisión general del contenido en enero de 2017. Métodos: Los expertos contenidos, los expertos en metodología, y los supervivientes de la UCI estuvieron representados en cada una de las cinco secciones de la guía: Dolor, Agitación/sedación, Delirio, Inmovilidad (movilización/rehabilitación), y Sueño (interrupción). Cada sección creó preguntas descriptivas y no procesables sobre Población, Intervención, Comparación, y Resultados, basadas en la relevancia clínica percibida. A continuación, el grupo responsable de la guía votó su clasificación, y los pacientes priorizaron su importancia. Para cada pregunta sobre Población, Intervención, Comparación, y Resultados, las distintas secciones buscaron la evidencia mejor disponible, determinaron su calidad, y formularon recomendaciones del tipo declaraciones sobre prácticas "sólidas," "condicionales," o "buenas" basándose en los principios de calificación de valoración, desarrollo y evaluación de recomendaciones. Además, se identificaron explícitamente las brechas de la evidencia y las salvedades clínicas. Resultados: El panel sobre dolor, agitación/sedación, delirio, inmovilidad (movilización/rehabilitación), y sueño (interrupción) emitió 37 recomendaciones (3 sólidas y 34 condicionales), dos declaraciones de prácticas buenas, y 32 declaraciones no calificables y no procesables. Tres preguntas procedentes de la lista de preguntas priorizadas centradas en el paciente carecieron de recomendación. Conclusiones: Concluimos un acuerdo sustancial entre una gran cohorte interdisciplinaria de expertos internacionales en cuanto a la evidencia que respalda las recomendaciones y las brechas en la literatura pendientes en cuanto a evaluación, prevención y tratamiento del dolor, agitación/sedación, delirio, inmovilidad (movilización/rehabilitación), y sueño (interrupción) en adultos críticos. Subrayar dicha evidencia y las necesidades de investigación mejorarán el manejo del dolor, agitación/sedación, delirio, inmovilidad (movilización/rehabilitación), y sueño (interrupción), y aportarán las bases para mejorar los resultados y la ciencia en esta población vulnerable

No disponible

Adaptación de la escala ESCID para medir el dolor en pacientes críticos con daño cerebral / Adaptation of the ESCID scale to measure pain in critical patients with brain damage

OBJETIVO: evaluar la validez de constructo y la fiabilidadde la adaptación de la escala de conductas indicadoras de dolor (ESCID), para valorar el dolor en pacientes críticos con daño cerebral, no comunicativos y sometidos a ventilación mecánica. MÉTODO: sujetos: estudio multicéntrico, observacional. Se llevará a cabo en pacientes críticos con lesión cerebral adquirida, mayores de edad, sometidos a ventilación mecánica invasiva y sin capacidad de comunicación, ingresados en unidades de cuidados intensivos de cuatro hospitales universitarios de tercer nivel de la Comunidad de Madrid. En todos los sujetos se evaluará el dolor con dos instrumentos simultáneamente (ESCID-DC y videograbación). La evaluación del dolor con ESCID-DC se realizará por dos observadores independientes con resultado ciego entre ellos, ante la aplicación de dos procedimientos dolorosos (aspiración de secreciones traqueales y presión en lecho ungueal), y un procedimiento no doloroso. La medición se efectuará únicamente una vez por cada paciente y procedimiento. La medición del dolor se hará en tres momentos: cinco minutos antes, durante y 15 minutos después de cada procedimiento. Cinco minutos antes de iniciar los procedimientos y hasta diez minutos después, dos videocámaras (una enfoca el cuerpo completo, otra solo la cara) captarán imágenes y audio, para posteriormente analizar los cambios gestuales y corporales del sujeto en cada momento, y poder correlacionarlos con los ocho indicadores conductuales de la escala ESCID-DC. CONCLUSIONES: contar con una escala de este tipo con buenas propiedades psicométricas mejorará el manejo del dolor de los pacientes con daño cerebral y, por tanto, la eficacia del tratamiento

OBJECTIVE: to evaluate the validity of the concept and the reliability of the adaptation of the Scale of Behavior Indicators of Pain (ESCID) in order to assess pain in critical patients with brain damage, who are non-communicative and undergoing mechanical ventilation. METHOD: subjects: a multicenter observational study. It will be conducted on critical patients with acquired brain damage, of age, undergoing invasive mechanical ventilation, and unable to communicate, who have been admitted to intensive care units from four 3rd level University Hospitals from the Community of Madrid. Pain will be evaluated in all subjects with two instruments simultaneously (ESCID-DC and video recording). Pain evaluation through ESCID-DC will be conducted by two independent observers with blind results between them, with the application of two painful procedures (aspiration of tracheal secretions and pressure on the nail bed) and a non-painful procedure. Measurement will only be conducted once per patient and procedure. Pain measurement will be conducted at three time points: fiveminutes before, during, and fifteenminutes after each procedure. Five minutes before initiating the procedure and up to ten minutes afterwards, two video cameras will capture images and audio (one will focus on the entire body, the other one only on the face), in order to capture and subsequently analyze the gestural and body changes of the subject at each moment, and to be able to correlate them with the eight behavior indicators of the ESCID-DC scale. CONCLUSIONS: the availability of this type of scale, with good psychometric properties, will improve pain management for patients with brain damage and, therefore, treatment efficacy

Prevention of Ventilator-Associated Pneumonia: The Multimodal Approach of the Spanish ICU "Pneumonia Zero" Program.

OBJECTIVES: The "Pneumonia Zero" project is a nationwide multimodal intervention based on the simultaneous implementation of a comprehensive evidence-based bundle measures to prevent ventilator-associated pneumonia in critically ill patients admitted to the ICU. DESIGN: Prospective, interventional, and multicenter study. SETTING: A total of 181 ICUs throughout Spain. PATIENTS: All patients admitted for more than 24 hours to the participating ICUs between April 1, 2011, and December 31, 2012. INTERVENTION: Ten ventilator-associated pneumonia prevention measures were implemented (seven were mandatory and three highly recommended). The database of the National ICU-Acquired Infections Surveillance Study (Estudio Nacional de Vigilancia de Infecciones Nosocomiales [ENVIN]) was used for data collection. Ventilator-associated pneumonia rate was expressed as incidence density per 1,000 ventilator days. Ventilator-associated pneumonia rates from the incorporation of the ICUs to the project, every 3 months, were compared with data of the ENVIN registry (April-June 2010) as the baseline period. Ventilator-associated pneumonia rates were adjusted by characteristics of the hospital, including size, type (public or private), and teaching (postgraduate) or university-affiliated (undergraduate) status. MEASUREMENTS AND MAIN RESULTS: The 181 participating ICUs accounted for 75% of all ICUs in Spain. In a total of 171,237 ICU admissions, an artificial airway was present on 505,802 days (50.0% of days of stay in the ICU). A total of 3,474 ventilator-associated pneumonia episodes were diagnosed in 3,186 patients. The adjusted ventilator-associated pneumonia incidence density rate decreased from 9.83 (95% CI, 8.42-11.48) per 1,000 ventilator days in the baseline period to 4.34 (95% CI, 3.22-5.84) after 19-21 months of participation. CONCLUSIONS: Implementation of the bundle measures included in the "Pneumonia Zero" project resulted in a significant reduction of more than 50% of the incidence of ventilator-associated pneumonia in Spanish ICUs. This reduction was sustained 21 months after implementation.

Delirium epidemiology in critical care (DECCA): an international study.

INTRODUCTION: Delirium is a frequent source of morbidity in intensive care units (ICUs). Most data on its epidemiology is from single-center studies. Our aim was to conduct a multicenter study to evaluate the epidemiology of delirium in the ICU. METHODS: A 1-day point-prevalence study was undertaken in 104 ICUs from 11 countries in South and North America and Spain. RESULTS: In total, 975 patients were screened, and 497 fulfilled inclusion criteria and were enrolled (median age, 62 years; 52.5% men; 16.7% and 19.9% for ICU and hospital mortality); 64% were admitted to the ICU because of medical causes, and sepsis was the main diagnosis (n = 76; 15.3%). In total, 265 patients were sedated with the Richmond agitation and sedation scale (RASS) deeper than -3, and only 232 (46.6%) patients could be evaluated with the confusion-assessment method for the ICU. The prevalence of delirium was 32.3%. Compared with patients without delirium, those with the diagnosis of delirium had a greater severity of illness at admission, demonstrated by higher sequential organ-failure assessment (SOFA (P = 0.004)) and simplified acute physiology score 3 (SAPS3) scores (P < 0.0001). Delirium was associated with increased ICU (20% versus 5.7%; P = 0.002) and hospital mortality (24 versus 8.3%; P = 0.0017), and longer ICU (P < 0.0001) and hospital length of stay (LOS) (22 (11 to 40) versus 7 (4 to 18) days; P < 0.0001). Previous use of midazolam (P = 0.009) was more frequent in patients with delirium. On multivariate analysis, delirium was independently associated with increased ICU mortality (OR = 3.14 (1.26 to 7.86); CI, 95%) and hospital mortality (OR = 2.5 (1.1 to 5.7); CI, 95%). CONCLUSIONS: In this 1-day international study, delirium was frequent and associated with increased mortality and ICU LOS. The main modifiable risk factors associated with the diagnosis of delirium were the use of invasive devices and sedatives (midazolam).

Effect of a nursing-implemented sedation protocol on weaning outcome.

OBJECTIVE: To evaluate the effect of the implementation of a nursing-driven protocol of sedation on duration of intubation. DESIGN: Before-and-after prospective study. SETTING: 18-bed medical-surgical intensive care unit. PATIENTS: Patients receiving mechanical ventilation longer than 48 hrs who were ready to wean. INTERVENTIONS: During the observational period, sedatives and analgesics were adjusted according to physicians' orders. During the intervention period, sedatives and analgesics were adjusted by nurses according to an algorithm-based sedation guideline, including a sedation scale. MEASUREMENTS AND MAIN RESULTS: A total of 356 patients were included in the study (176 patients in the observational period and 189 patients in the intervention period). There were no significant differences in the duration of intubation between the two periods (median, 7 [interquartile range, 5-13] days vs. 7 [interquartile range, 5-9] days). In a Kaplan-Meier analysis, the probability of successful extubation was higher during the intervention period than during the observational period (log-rank = 0.02). During the intervention period, patients were more awake without a significant increment in the nurse workload; however, there was no significant decrease in the total doses of sedatives and analgesics administered. CONCLUSIONS: The implementation of a nursing-driven protocol of sedation may improve the probability of successful extubation in a heterogeneous population of mechanically ventilated patients.

Descontaminación digestiva selectiva: protocolo de Getafe / Selective digestive decontamination: the Getafe protocol

Entre el 10 y el 50% de los enfermos ventilados mecánicamente en las unidades de cuidados intensivos (UCI) presentan neumonía asociada a la ventilación mecánica (NAVM). Dentro de las medidas preventivas destaca el papel de la descontaminación digestiva selectiva (DDS). En 1998 se desarrolló el protocolo y se inició la aplicación de la DDS en la UCI del Hospital de Getafe. La DDS se aplica a los pacientes que van a requerir ventilación mecánica más de 72 h o con enfermedad en la que se ha demostrado la eficacia de la DDS. La DDS consiste en: 1) administrar un ciclo corto de antibióticos por vía intravenosa; 2) administración oral de antibióticos no absorbibles en forma de solución digestiva y pasta en orofaringe y nariz; 3) medidas de higiene y aislamiento. Con la implementación de esta técnica se ha reducido la tasa de NAVM en un 71% en pacientes medicoquirúrgicos y un 29% en pacientes quemados, sin aumento significativo de los microorganismos multirresistentes

The incidence of ventilator-associated pneumonia (VAP) among mechanically ventilated patients in intensive care units (ICUs) is 10-50%. Notable among preventive measures is selective digestive decontamination (SDD). In 1998, a protocol for SDD was developed and implemented in the ICU of the Hospital Universitario de Getafe. SDD is administered to patients admitted to the ICU who require mechanical ventilation for more than 72 hours and to those with diseases in which the efficacy of SDD has been demonstrated. SDD administration consists of: 1) a short course of systemic antibiotics; 2) oral administration of a solution of non-absorbable antibiotics and topical application in the oropharynx and nose of a non-absorbable antibiotic paste; 3) hygiene and isolation measures. Use of this protocol reduced the rate of VAP by 71% in medical-surgical patients and by 29% in burn patients, without producing a significant increase in multiresistant microorganisms

Does sedation practice delay time to extubation?

UNLABELLED: Criteria for performing a spontaneous breathing trial (SBT) have not been evaluated in controlled trials. An important component of these criteria is neurological status. The objective of this study was to evaluate whether physicians take mental status into consideration before performing an SBT in mechanically ventilated patients. METHODS: This was a prospective, observational study which included 355 mechanically ventilated patients. Daily assessments were made of whether the patients met criteria for performing a SBT. On the day a patient met the criteria, the level of sedation was evaluated using the Glasgow Coma Scale as modified by Cook and Palma (GCS-Cook) and it was registered whether or not the physician carried out an SBT. RESULTS: Two hundred and four patients (57%) underwent an SBT on the day they met the criteria (cohort 1) and in 151 patients (cohort 2) the SBT was delayed a median time of 1 day (interquartile range 1-2). There were differences in the GCS-Cook score on the day the criteria were met for performing an SBT (mean 13+/-3 points in cohort 1 versus 9+/-3 points in cohort 2; P<0.001). There were differences (P<0.001) between the cohorts in days of intubation and length of stay in the intensive care unit. CONCLUSIONS: Neurological status/level of sedation is a factor in the decision whether or not to perform a spontaneous breathing trial.

[Measurement of minimum disposable volume in the extraction of an analysis through an arterial catheter]. / Determinación del volumen mínimo desechable en laextracción de una analítica a través de un catéter arterial.

OBJECTIVE: Arterial catheters are used to extract blood samples. To maintain its permeability we use heparin solution, which may contaminate and alter the desired results. Our aim was to determine the volume of the minimum discards during blood extractions to avoid results that might be altered in the analysis of biochemistry. MATERIAL AND METHODS: A prospective study was carried out in 18 beds intensive care unit. Patients with arterial catheter (Seldicath) were included, maintaining 500 UI of heparin in saline of 500 ml, at a pressure of 300 mmHg through pressurizer (Tycos). The dead space (DS) in the radial arterial system is 0.8 ml and 1 ml in the femoral. We analyzed the reliability of different discards comparing the following: 3 ml + DS, 7.5 ml + DS, 12 ml + DS and 16.5 ml + DS. The statistical analysis was carried out through ANOVA and t Student. RESULTS: In biochemistry, significant differences were not found except for potasium (p< 0.001) with 3 ml+DS during control, although it is not clinically relevant [difference through = 0.1 mEq/l (DS 0.2)]. Significant differences in prothrombina (p = 0.004) were found in coagulation, comparing 3 ml+DS and 16.5 ml + DS and in cefaline, comparing 7.5 ml + DS (p< 0.0001) and 16.5 ml + DS. There were not significant differences in the studies of gases. CONCLUSIONS: Our study shows that to reach a reliable analytical results, it is not necessary to discard more than 3 ml+DS in biochemistry and in blood gases, and to determine cefalina time would necessary to discard a minimum of 7.5 ml+DS.

[Effect of selective digestive decontamination on the nosocomial infection and multiresistant microorganisms incidence in critically ill patients]. / Descontaminación selectiva del tubo digestivo: efecto sobre la incidencia de la infección nosocomial y de los microorganismos multirresistentes en enfermos ingresados en unidades de cuidados intensivos.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a common complication in mechanically ventilated patients. Other infections related to the use of invasive devices, such urinary tract infections (UTI) and central venous catheter-related bloodstream infections are found in patients admitted in intensive care units (ICU). Selective digestive decontamination (SDD) is a set of manoeuvres (hygiene, topic digestive antimicrobials and short course of systemic antibiotics) aimed at decreasing the incidence of nosocomial infections, mainly VAP, in ICU. The objective of this study was to describe the impact of SDD in the rates of nosocomial infections in an 18-bed medical-surgical ICU. PATIENTS AND METHOD: All patients admitted in the ICU from October 1998 to September 1999 with expected mechanical ventilation for at least 72 h or with an illness where SDD has proven to be efficacious. The infection rates during this period were compared with the infection rates of the period without SDD (October 1997 to September 1998). RESULTS: VAP rates decreased from 12.38 to 3.64 per 1000 days of mechanical ventilation (RR 0.3; CI 95%: 0.16 to 0.53). Urinary tract infection rates decreased form 7.70 to 4.51 per 1000 bladder-catheter days (RR 0.6. CI 95%: 0.37 to 0.93). Central venous catheter related bloodstream infections decreased from 5.92 to 2.73 per 1000 catheter days (RR: 0.5. CI 95%: 0.24 to 0.90). There was no emergence of resistant microorganims when SDD was used. CONCLUSIONS: SDD reduces infection rates in ICU without any significant adverse events.