Anticoagulantes orales en pacientes frágiles con fibrilación auricular: moviéndose en la incertidumbre en la práctica clínica diaria / Oral anticoagulants in frail patients with atrial fibrillation: moving in the uncertainty of daily clinical practice

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Valoración de la fragilidad: aspecto fundamental en el paciente crítico / Frailty: Critical term for critical care

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[Oral anticoagulation therapy in the elderly population with atrial fibrillation. A review article]. / Anticoagulación en población anciana con fibrilación auricular no valvular. Artículo de revisión.

Aging is an important risk factor for patients with atrial fibrillation. The estimated prevalence of atrial fibrillation in patients aged ≥80 years is 9-10%, and is associated with a four to five fold increased risk of embolic stroke, and with an estimated increased stroke risk of 1.45-fold per decade in aging. Older age is also associated with an increased risk of major bleeding with oral anticoagulant therapy. This review will focus on the role of oral anticoagulation with new oral anticoagulants, non-vitamin K antagonist in populations with common comorbid conditions, including age, chronic kidney disease, coronary artery disease, on multiple medication, and frailty. In patients 75 years and older, randomised trials have shown new oral anticoagulants to be as effective as warfarin, or in some cases superior, with an overall better safety profile, consistently reducing rates of intracranial haemorrhages. Prior to considering oral anticoagulant therapy in an elderly frail patient, a comprehensive assessment should be performed to include the risks and benefits, stroke risk, baseline kidney function, cognitive status, mobility and fall risk, multiple medication, nutritional status assessment, and life expectancy.

Eficacia de la vía subcutánea frente a la hidratación intravenosa en el paciente anciano hospitalizado: estudio controlado aleatorizado / Efficacy of the subcutaneous route compared to intravenous hydration in the elderly hospitalised patient: A randomised controlled study

Introducción: La subcutánea (SC) ha resurgido recientemente como vía de hidratación con potenciales ventajas en población anciana, sin embargo poco se conoce de su aplicación en ambiente hospitalario. El objetivo de este estudio es evaluar la no inferioridad en eficacia de esta vía frente a la intravenosa (IV) en el paciente anciano con deshidratación. Material y métodos: Estudio prospectivo de intervención, controlado y aleatorizado sobre pacientes de 65 y más años ingresados en una Unidad Geriátrica de Agudos con deshidratación leve-moderada e intolerancia oral. Evaluamos la no inferioridad de la sueroterapia subcutánea frente a la intravenosa. La intervención consistió en la administración de hasta un máximo de 1,5 l/día por vía subcutánea vs. intravenosa durante 72 h evaluando variaciones de parámetros bioquímicos (urea, creatinina, osmolaridad), evolución clínica y complicaciones relacionadas con la vía. Resultados: Sesenta y siete pacientes completaron el estudio (34 SC, edad media: 86,4 ± 8,5 años, 41% mujeres, vs. 33 IV, 84,3 ± 6,6, 54,5% mujeres, sin diferencias significativas). La cantidad de líquido infundido al día por ambas vías fue de 1.320 ml ± 400 SC vs. 1.480 ml ± 340 IV, p = 0,092. Durante el seguimiento se objetivaron reducciones similares entre grupos sin significación estadística, con diferencias de medias pre-postintervención de urea (49,6 ± 52,3 SC vs. 50,3 ± 52,3 IV, p = 0,96); creatinina (0,68 ± 0,66 SC vs. 0,60 ± 0,49 IV, p = 0,58), y osmolaridad plasmática (15,6 ± 24,4 SC vs. 21,1 ± 31 IV, p = 0,43). Se objetivaron menos episodios de extracción de catéter en grupo SC con mayor tendencia de edema peri-clisis. Conclusiones: La eficacia de la rehidratación por vía subcutánea en pacientes ancianos hospitalizados con deshidratación leve-moderada no es inferior a la obtenida por vía intravenosa, pudiendo presentar ventajas adicionales (AU)

Introduction: The subcutaneous (SC) route has recently emerged as a rehydration method with potential advantages in the geriatric population. Nevertheless, little is known about its application during hospitalization. The objective of the present study is to evaluate the subcutaneous non-inferiority efficacy in hydration against the intravenous (IV) route in elderly patients with dehydration. Material and methods: A prospective, randomized and controlled interventional trial of patients 65 years and older admitted to an Acute Geriatric Unit with mild to moderate dehydration and oral intolerance, evaluating the non-inferiority of subcutaneous fluid therapy versus the intravenous route. The intervention consisted of the administration of up to 1.5 l/day/route for 72 hours subcutaneous vs. intravenous, evaluating the variations in biochemical parameters (urea, creatinine, osmolarity), clinical outcome, and route related complications. Results: Sixty seven patients completed the study (34 SC, age 86.4±8.5 years, 41% women, vs. 33 IV, 84.3±6.6, 54.5% women, with no significant differences). The amount of fluid administered per day by route was 1.320 ml±400 SC vs. 1.480 ml±340 IV, P=.092. During follow similar reductions were observed between groups without any statistical significance, with mean differences pre-postintervention of urea (49.6±52.3 SC vs. 50.3±52.3 IV, P=.96); creatinine (0.68±0.66 SC vs. 0.60±0.49 IV, P=.58), and osmolarity (15.6±24.4 SC vs. 21.1±31 IV, P=.43). Fewer catheter extraction episodes were observed in the SC group, which also was the group most prone to peri-clysis edema. Conclusions: The efficacy of subcutaneous rehydration in elderly hospitalized patients with mildmoderate dehydration is not inferior to that obtained intravenously, and may even have additional advantages (AU)

[Efficacy of the subcutaneous route compared to intravenous hydration in the elderly hospitalised patient: a randomised controlled study]. / Eficacia de la vía subcutánea frente a la hidratación intravenosa en el paciente anciano hospitalizado: estudio controlado aleatorizado.

INTRODUCTION: The subcutaneous (SC) route has recently emerged as a rehydration method with potential advantages in the geriatric population. Nevertheless, little is known about its application during hospitalization. The objective of the present study is to evaluate the subcutaneous non-inferiority efficacy in hydration against the intravenous (IV) route in elderly patients with dehydration. MATERIAL AND METHODS: A prospective, randomized and controlled interventional trial of patients 65 years and older admitted to an Acute Geriatric Unit with mild to moderate dehydration and oral intolerance, evaluating the non-inferiority of subcutaneous fluid therapy versus the intravenous route. The intervention consisted of the administration of up to 1.5 l/day/route for 72 hours subcutaneous vs. intravenous, evaluating the variations in biochemical parameters (urea, creatinine, osmolarity), clinical outcome, and route related complications. RESULTS: Sixty seven patients completed the study (34 SC, age 86.4 ± 8.5 years, 41% women, vs. 33 IV, 84.3 ± 6.6, 54.5% women, with no significant differences). The amount of fluid administered per day by route was 1.320 ml ± 400 SC vs. 1.480 ml ± 340 IV, P = .092. During follow similar reductions were observed between groups without any statistical significance, with mean differences pre-postintervention of urea (49.6 ± 52.3 SC vs. 50.3 ± 52.3 IV, P=.96); creatinine (0.68 ± 0.66 SC vs. 0.60 ± 0.49 IV, P=.58), and osmolarity (15.6 ± 24.4 SC vs. 21.1 ± 31 IV, P=.43). Fewer catheter extraction episodes were observed in the SC group, which also was the group most prone to peri-clysis edema. CONCLUSIONS: The efficacy of subcutaneous rehydration in elderly hospitalized patients with mild-moderate dehydration is not inferior to that obtained intravenously, and may even have additional advantages.