Rapid response to COVID-19, escalation and de-escalation strategies to match surge capacity of Intensive Care beds to a large scale epidemic. / Respuesta rápida a COVID-19, estrategias de escalada y desescalada para ajustar la capacidad suplementaria de camas de UVI a una epidemia de gran magnitud.

BACKGROUND: A major challenge during the COVID-19 outbreak is the sudden increase in ICU bed occupancy rate. In this article we reviewed the strategies of escalation and de-escalation put in place at a large university hospital in Madrid during the COVID-19 outbreak, in order to meet the growing demand of ICU beds. MATERIALS AND METHODS: The data displayed originated from the hospital information system and the hospital contingency plan. RESULTS: The COVID-19 outbreak produced a surge of ICU patients which saturated the available ICU capacity within a few days. A total of four new ICUs had to be opened in order to accommodate all necessary new ICU admissions. Management challenges included infrastructure, material allocation and ICU staffing. Through the strategies put in place the hospital was able to generate a surge capacity of ICU beds of 340%, meet all requirements and also maintain minimal surgical activity. CONCLUSIONS: Hospital surge capacity is to date hardly quantifiable and often has to face physical limitations (material, personnel, spaces). However an extremely flexible and adaptable management strategy can help to overcome some of these limitations and stretch the system capacities during times of extreme need.

Impact of the implementation of vasoactive drug protocols on safety and efficacy in the treatment of critically ill patients.

WHAT IS KNOWN AND OBJECTIVE: The correct management of high-alert medications is a priority issue in expert recommendations for improving the clinical safety of patients. Objectives were to assess the impact of the implementation of vasoactive drug (VAD) protocols on safety and efficacy in the treatment of critically ill patients. METHODS: A prospective before-and-after study on the implementation of different VAD protocols, comparing medication errors (MEs) rates, mean intensive care unit (ICU) stay, mean blood pressure (MAP), heart rate (HR) and oxygen saturation. RESULTS AND DISCUSSION: The study included 432 patients. There was a statistically significant decrease in prescribing errors (55·9%), validation errors (68·1%) and medication administration records (MAR) errors (78·8%). No differences were found between the two phases in ICU stay, MAP, HR and oxygen saturation. WHAT IS NEW AND CONCLUSION: Implementation of protocols decreases variability in clinical practice, reduces the incidence of MEs and maintains the effectiveness of VAD therapy in critically ill patients.

El cálculo de la creatinina sérica basal sobrestima el diagnóstico de alteración renal aguda en pacientes operados de cirugía cardíaca / The calculation of baseline serum creatinine overestimates the diagnosis of acute kidney injury in patients undergoing cardiac surgery

Introducción y objetivo: La definición y clasificación actual de insuficiencia renal aguda se basa en criterios de consenso (sistemas RIFLE y AKIN). De los parámetros recomendados (creatinina, tasa de filtración glomerular y diuresis), la creatinina es el más empleado. En ausencia de valor basal conocido se recomienda su estimación a partir de la ecuación MDRD simplificada, asumiendo en el cálculo una tasa de filtración de 75 ml/min/1,73 m2. El objetivo del presente trabajo fue evaluar la repercusión diagnóstica del empleo de la creatinina basal estimada frente al valor real medido en pacientes operados de cirugía cardíaca. Métodos: Análisis de pacientes operados de cirugía cardíaca mayor incluidos de forma prospectiva en una base de datos. Para cada paciente se calculó el estadio RIFLE máximo alcanzado usando la creatinina basal medida y la estimada. Se analizó la repercusión sobre el diagnóstico mediante coeficientes de correlación intraclase, análisis de concordancia y gráficas de Bland y Altman. Resultados: La incidencia de insuficiencia renal aguda postoperatoria en 2.103 casos operados entre 2002 y 2007 fue del 29,1% al utilizar la creatinina estimada (14,3% con la medida). Esto supone una sobrestimación del 104%, y la correlación intraclase es de 0,12. Excluyendo a los pacientes con insuficiencia renal crónica conocida (tasa de filtrado glomerular [TFG] <60 ml/min/1,73 m2), tanto la sobrestimación (2,4%) como la correlación (0,57) mejoraron. Conclusiones: El cálculo de la creatinina basal a partir de la ecuación MDRD sobrestima la incidencia de insuficiencia renal aguda tras la cirugía cardíaca, y es un método inadecuado para su detección cuando el valor basal se desconoce (AU)

Introduction and objectives: The current definition and classification of acute kidney injury is based on consensus criteria (RIFLE and AKIN systems). Creatinine is the most commonly used of the recommended parameters (creatinine, glomerular filtration rate and diuresis). If the baseline value is not known, it can be calculated based on the simplified MDRD equation, assuming a filtration rate of 75ml/min/1.73m2 for the calculation. The aim of this study was to evaluate the diagnostic impact of using estimated baseline creatinine compared to the actual value measured in patients undergoing cardiac surgery. Methods: Analysis of patients undergoing major cardiac surgery, who were prospectively included in a database. The maximum RIFLE stage reached was calculated for each patient using the measured and estimated baseline creatinine levels. The impact on the diagnosis was analysed using intraclass correlation coefficients, concordance analysis and Bland-Altman plots. Results: The incidence of postoperative acute kidney injury in 2103 cases between 2002 and 2007 was 29.1%, according to estimated creatinine (14.3% with the measure). This represents an overestimation of 104%, with an intraclass correlation of 0.12. By excluding patients with known chronic kidney disease (glomerular filtration rate [<60ml/min/1.73m2), both the overestimation (2.4%) and the correlation (0.57) improved. Conclusions: The calculation of baseline creatinine using the MDRD equation overestimates the incidence of acute kidney injury after cardiac surgery, and is an inadequate method for detection when the baseline value is unknown (AU)

The calculation of baseline serum creatinine overestimates the diagnosis of acute kidney injury in patients undergoing cardiac surgery.

INTRODUCTION AND OBJECTIVES: The current definition and classification of acute kidney injury is based on consensus criteria (RIFLE and AKIN systems). Creatinine is the most commonly used of the recommended parameters (creatinine, glomerular filtration rate and diuresis). If the baseline value is not known, it can be calculated based on the simplified MDRD equation, assuming a filtration rate of 75 ml/min/1.73 m2 for the calculation. The aim of this study was to evaluate the diagnostic impact of using estimated baseline creatinine compared to the actual value measured in patients undergoing cardiac surgery. METHODS: Analysis of patients undergoing major cardiac surgery, who were prospectively included in a database. The maximum RIFLE stage reached was calculated for each patient using the measured and estimated baseline creatinine levels. The impact on the diagnosis was analysed using intraclass correlation coefficients, concordance analysis and Bland-Altman plots. RESULTS: The incidence of postoperative acute kidney injury in 2103 cases between 2002 and 2007 was 29.1%, according to estimated creatinine (14.3% with the measure). This represents an overestimation of 104%, with an intraclass correlation of 0.12. By excluding patients with known chronic kidney disease (glomerular filtration rate [<60 ml/min/1.73 m2), both the overestimation (2.4%) and the correlation (0.57) improved. CONCLUSIONS: The calculation of baseline creatinine using the MDRD equation overestimates the incidence of acute kidney injury after cardiac surgery, and is an inadequate method for detection when the baseline value is unknown.

Predicción de riesgo del fracaso renal agudo / Prediction of acute renal failure risk

One of the cornerstones in acute kidney injury is to identify the patients that will develop this condition in order to minimise the factors capable of triggering the damage. Contrast induced nephropathy and cardiac surgery are among the potential situations that could be associated with a high rate of acute renal failure. This is somewhat similar to experimental models in which the moment of the insult is known. Two cardiac surgery scores and one of contrast induced nephropathy for predictin the development of acute kidney injury are reviewed

Uno de los aspectos principales en el estudio del paciente con FRA es el de identificar a aquellos que desarrollan esta condición con el fin de minimizar los factores que desarrollan el daño. La neuropatía inducida por el contraste y la cirugía cardiaca son las situaciones potenciales que pueden asociarse con una alta probabilidad de desarrollar FRA. Es algo similar a lo que ocurre en los modelos experimentales en los cuales el momento del insulto es conocido previamente. Se han desarrollado dos escalas de predicción en la cirugía cardiaca y una en la neuropatía inducida por contraste, con el fin de prevenir el daño renal

[Conjunctival phenylephrine and acute edema of the lung]. / Fenilefrina por vía conjuntival y edema agudo de pulmón.

We report two cases of acute pulmonary edema occurring in healthy patients during vitreoretinal surgery. The adverse systemic effects of conjunctival phenylephrine are discussed, along with constraints on its clinical use and the concentration that should be used.

[Induction and maintenance of anesthesia with propofol and with thiopental-isoflurane. Comparative study]. / Inducción y mantenimiento de la anestesia con propofol y con tiopental-isoflurano. Estudio comparativo.

Thirty one patients of both sexes, ASA I-II, aged 18-65 years have undergone a randomized trial in order to compare two anesthetic techniques. Patients in group I (n = 15) received a 2.5 mg/kg induction dose of propofol followed by a continuous infusion of the same drug at 3.6-9 mg/kg/h. Patients in group II (n = 16) were induced with 4 mg/kg thiopentone and maintained with 0.5-1.5% isoflurane. Both groups were evaluated for time and quality of induction, collateral effects, quality and hemodynamic stability during maintenance and time and quality of recovery. Induction time for patients in group I (49.6 +/- 15 seg) was significantly longer than for group II patients (23 +/- 3 seg) (p less than 0.01). Respiratory depression (apnea period longer than 20 seconds) was also commoner and longer in group I (p less than 0.01) although no problems were observed with manual ventilation. One patient in group I required an extra dose for induction. Both groups had similar hemodynamic changes along the procedure. Awakening time for patients in group I (24.2 +/- 7.3 min) was significantly longer than for patients in group II (14.3 +/- 4.4 min) (p less than 0.001). Although surgery times were longer in group I, a possible cumulative effect of propofol for infusions over 90 min cannot be discarded.

[Incidence of dural puncture headache after intradural anesthesia carried out by residents]. / Incidencia de cefalea pospunción dural tras anestesia intradural realizada por médicos residentes.

To evaluate dural puncture headache (DPH) after intradural anesthesia (IA) carried out by residents of anesthesiology and reanimation, and its relation with the degree of difficulty of the puncture, a sample of 81 patients with ages ranging between 48 and 88 years was evaluated. The incidence of DPH was 12.35%, and it was not statistically associated with age, sex, anesthetic approach, local anesthetic, or degree of difficulty of lumbar puncture.

[Anesthesia in a patient with toxic epidermal necrolysis]. / Anestesia en un paciente cón necrólisis epidérmica tóxica.

We report the case of a 16-month-old boy weighing 11 kg who presented toxic epidermal necrolysis secondary to phenobarbital administration and underwent emergency laparotomy under general anesthesia because of gastrointestinal bleeding. The boy presented epidermal detachment on the slightest friction (Nikolsky's sign) so monitoring was difficult; in these cases it is advisable to use padded sphygmomanometers and weighted electrodes. Owing to the great extension of denuded skin, these patients must be considered as hypovolemic and ketamine is the drug of choice for anesthesia induction. The maintenance of airways and the proper replacement of fluids and electrolytes are essential for the correct anesthetic treatment of these patients.