Impacto de un nuevo modelo de Medicina Intensiva sobre la asistencia en un servicio de Medicina Intensiva / Impact of a new model of intensive care medicine upon healthcare in a department of intensive care medicine

Objetivos Evaluar un nuevo modelo organizativo en un servicio de Medicina Intensiva, con la puesta en marcha de servicio extendido y unidad de apoyo. Diseño Estudio de cohortes retrospectivo, comparativo. Ámbito El estudio se realiza en un SMI de un hospital de tercer nivel (2009-2011). Comparando 3 periodos de tiempo (P1, P2 y P3) deferentes en cuanto a organización y logística dentro nuestro SMI. Pacientes Se analizan todos los enfermos que ingresan en el SMI, durante el periodo de estudio. Se excluyen los pacientes del área de cuidados intensivos materno infantil. Variables de interés Porcentaje de enfermos con estancias menores de 2 días, invasividad empleada en los enfermos; reingreso en el SMI, el tipo de ingreso y el porcentaje de estancias superiores a un mes; APACHE II, las estancias medias en la UCI y la turnicidad de los ingresos. Resultados Analizamos una muestra de 3.209 enfermos; La edad media fue de 58,23 (18,23), con un APACHE II medio de 16,67 (8,23), siendo el 65% varones y presentando una estancia media de 7,3 (10,3) días en el periodo analizado. El ratio APACHEII/número de camas fue de 0,69 (0,34) en P1, frente a 0,68 (0,33) de P2 y 0,76 (0,37) en P3 (< 0,001). El grado de intervención de vigilancia (Grado 1) fue del 42% (39-46%) en P1, 40% (37-43%) en P2 y 31% (28-35%) en P3 (< 0,001). La estancia media en UCI varió de 7,10 días (8,82) en P1, 6,60 días (9,49) en P2 y 8,42 días (12,73) en P3 (< 0,001).Conclusiones Se ha producido un aumento del número de pacientes atendidos por nuestro SMI, con un descenso de pacientes que ingresan en las UCI convencionales. Los enfermos que ingresan ahora en la UCI son enfermos más graves, requieren un nivel de intervención mayor y ocasionan un aumento de la estancia media en la UCI (AU)

Objectives To evaluate a new organizational model in an intensive care unit, with the implementation of early warning systems and a support unit. Design A retrospective, comparative cohort study was carried out. Setting The study was carried out in the Department of Intensive Care Medicine (DICM) of a tertiary hospital (2009-2011), with the comparison of three time periods (P1, P2 and P3) that differed in terms of organization and logistics. Patients We analyzed all patients admitted to the ICU during the study period. Patients from maternal and infant intensive care were excluded. Variables of interest Percentage of patients with stays of under two days, with invasiveness used; readmission to the DICM, type of admission and percentage of stays of longer than one month; APACHE II score, mean stay in the ICU and shift distribution of the admissions. Results We analyzed a sample of 3209 patients (65% males), with a mean age of 58.23 (18.23) years, a mean APACHE II score of 16.67 (8.23), and presenting an occupancy rate of 7.3 (10.3) days in the analyzed period. The ratio APACHE II score/number of beds was 0.69 (0.34) in P1, compared to 0.68 (0.33) in P2 and 0.76 (0.37) in P3 (p<0.001). The intervention surveillance grade (grade 1) was 42% (39-46%) in P1, 40% (37-43%) in P2 and 31% (28-35%) in P3 (p<0.001). The average stay in the ICU ranged from 7.10 days (8.82) in P1to 6.60 days (9.49) in P2 and 8.42 days (12.73) in P3 (p<0.001).Conclusions There has been an increase in the number of patients seen in our DICM, with a decrease in the patients admitted to the conventional ICU. Patients now admitted to the ICU are more seriously ill, require a greater level of intervention, and give rise to an increase in the mean duration of stay in the ICU (AU)

Impact of a new model of intensive care medicine upon healthcare in a department of intensive care medicine.

OBJECTIVES: To evaluate a new organizational model in an intensive care unit, with the implementation of early warning systems and a support unit. DESIGN: A retrospective, comparative cohort study was carried out. SETTING: The study was carried out in the Department of Intensive Care Medicine (DICM) of a tertiary hospital (2009-2011), with the comparison of three time periods (P1, P2 and P3) that differed in terms of organization and logistics. PATIENTS: We analyzed all patients admitted to the ICU during the study period. Patients from maternal and infant intensive care were excluded. VARIABLES OF INTEREST: Percentage of patients with stays of under two days, with invasiveness used; readmission to the DICM, type of admission and percentage of stays of longer than one month; APACHE II score, mean stay in the ICU and shift distribution of the admissions. RESULTS: We analyzed a sample of 3209 patients (65% males), with a mean age of 58.23 (18.23) years, a mean APACHE II score of 16.67 (8.23), and presenting an occupancy rate of 7.3 (10.3) days in the analyzed period. The ratio APACHE II score/number of beds was 0.69 (0.34) in P1, compared to 0.68 (0.33) in P2 and 0.76 (0.37) in P3 (p<0.001). The intervention surveillance grade (grade 1) was 42% (39-46%) in P1, 40% (37-43%) in P2 and 31% (28-35%) in P3 (p<0.001). The average stay in the ICU ranged from 7.10 days (8.82) in P1 to 6.60 days (9.49) in P2 and 8.42 days (12.73) in P3 (p<0.001). CONCLUSIONS: There has been an increase in the number of patients seen in our DICM, with a decrease in the patients admitted to the conventional ICU. Patients now admitted to the ICU are more seriously ill, require a greater level of intervention, and give rise to an increase in the mean duration of stay in the ICU.

SECI (Servicio Extendido de Cuidados Intensivos): Mirando fuera de la UCI / EICS (Extended Intensive Care Service): Looking outside the ICU

El Servicio Extendido de Cuidados Intensivos (SECI) pretende mejorar la morbimortalidad mediante la detección precoz del paciente grave fuera del ámbito de la UCI y poner en práctica acciones precoces, terapéuticas y/o de traslado. En nuestro hospital se ha implantado un SECI con unas características específicas que trabaja en dos vertientes fundamentales: el seguimiento de los pacientes dados de alta de la UCI y la detección de los pacientes graves fuera del ámbito de la UCI en base a la puntuación de un Sistema de aviso temprano (AU)

Early warning systems (EWS) identify patients at risk with a view to improving morbidity and mortality rates using early therapeutic and transfer actions. We have recently implemented an EWS that focuses on two main aspects: the guidance of care after discharge from the ICU, and recognition of the onset of deteriorating health among adult patients in general wards through physiologically based early warning scores (AU)

[EICS (Extended Intensive Care Service): looking outside the ICU]. / SECI (Servicio Extendido de Cuidados Intensivos): mirando fuera de la UCI.

Early warning systems (EWS) identify patients at risk with a view to improving morbidity and mortality rates using early therapeutic and transfer actions. We have recently implemented an EWS that focuses on two main aspects: the guidance of care after discharge from the ICU, and recognition of the onset of deteriorating health among adult patients in general wards through physiologically based early warning scores.

Influence of donor-recipient gender mismatch in early outcome after lung transplantation.

OBJECTIVE: Donor and recipient genders are not considered in lung transplantation (LT) programs. However, recent data have suggested a possible biologic effect of gender combination on the outcome of LT. We ought to evaluate the effect of gender combinations on early survival in a single-institution experience in transplant recipients. METHODS: We analyzed the potential effect of donor-recipient gender combinations (male [M] or female [F]) on early survival of all patients whose LTs were performed between January 1999 and December 2006. Patients were distributed into 4 groups: M donor to M recipient (M-M group); M donor to F recipient (M-F group); F donor to F recipient (F-F group); and F donor to M recipient (F-M group). The comparison between groups was performed using two-tailed Fisher exact test and analysis of variance (ANOVA). RESULTS: During the study period, 152 LTs were performed in 149 patients, including 99 male donors and 53 female donors. The mean age of the recipients was 54 +/- 10 years (range, 14-70). The 30-day survival rate was 86% (95% confidence interval [CI], 77%- 92%) for the M-M group, 67% (95% CI, 41%-87%) for the F-M group, 89% (95% CI, 52%-100%) for the M-F group, and 83% (95% CI, 66%-93%) for the F-F group. No differences were observed between group survivals according to the Fisher test (P = .27). CONCLUSIONS: We found no association between donor-recipient gender mismatch and improved survival in lung transplant recipients. Further investigation is needed to finally understand the possible role of gender combinations in LT.

Prognosis factors in lung transplant recipients readmitted to the intensive care unit.

OBJECTIVE: To identify outcome predictors and prognostic factors for survival among lung transplant recipients on readmission to the intensive care unit (ICU). METHODS: This was a retrospective study of all lung transplant recipients during a 10-year period from 1997 to 2006. Data collection included age, gender, reason, and type of lung transplantation. Variables specific to individual ICU admissions included admission diagnosis, length of stay, duration of mechanical ventilation, interval from transplantation, Acute Physiology and Chronic Health Evaluation (APACHE) II score on ICU admission, and the identification of systemic organ dysfunction. We used Student t test (or where appropriate, its nonparametric equivalent) or the chi(2) test for comparisons among the patients who died and those who survived their ICU readmissions. RESULTS: Among 144 lung transplant patients 28 were later readmitted to the ICU after at least 1 week. The admission diagnosis was sepsis in 20 cases (71.4%). Seventeen patients died during their ICU stay (60.7%). A higher APACHE II score (P = .008), the presence of three or more dysfunctional organs upon readmission (P = .016), and the need for mechanical ventilation (P = .022) were risk factors for mortality. The mortality risk was also higher among the group with a longer delay to ICU readmission (P = .003). DISCUSSION: Readmission to the ICU, which is common among lung transplant recipients, was associated with a high mortality. Sepsis was the main cause of ICU readmission and the most frequent cause of death. APACHE II score, need for mechanical ventilation, number of dysfunctional organs, and delay in ICU readmission were important prognostic factors.

[Recombinant factor VIIa (rFVIIa). Description of use in a cohort of critical patients and prognostic markers]. / Factor VIIa recombinante (rFVIIa). Descripción de uso en una cohorte de enfermos críticos y marcadores pronósticos.

OBJECTIVE: Describe and identify the factors associated with the survival of the patients who received treatment with rFVIIa in an Intensive Care Unit (ICU). DESIGN: Longitudinal, ambispective, observational, descriptive study in a series of clinical cases performed from July 20, 2004 to July 20, 2006. SCOPE: The study population included 16 hospitalized patients in the Intensive Medicine Department (ICU) of the Hospital Marqués de Valdecilla (Santander). PATIENTS: Inclusion criteria were: Patients who required rFVIIa at some time of their stay in the ICU. RESULTS: Hemodynamic improvement of the patients treated with rFVIIa in an ICU, within the first 3 hours of the infusion (evaluated by an increase of SBP > 20 mmHg and/or increase of DBP > 8 mmHg) was associated to greater survival. CONCLUSIONS: The present series of cases, with the disadvantage of its heterogeneity and the limited number of patients, stresses the role of hemodynamic improvement as a differentiating factor between those patients who survive and those who do not.

Factor VIIa recombinante (rFVIIa). Descripción de uso en una cohorte de enfermos críticos y marcadores pronósticos / Recombinant factor VIIa (rFVIIa). Description of use in a cohort of critical patients and prognostic markers

Objetivo. Describir e identificar los factores asociados con la supervivencia de los pacientes que recibieron tratamiento con factor VIIa recombinante (rFVIIa) en una Unidad de Cuidados Intensivos (UCI). Diseño. Observacional, descriptivo de una serie de casos clínicos, realizado de forma longitudinal y ambispectiva. Durante el período del 20 de julio del 2004 al 20 de julio del 2006. Ámbito. La población de estudio fueron 16 pacientes hospitalizados en el Servicio de Medicina Intensiva (UCI) del Hospital Marqués de Valdecilla de Santander. Pacientes. Los criterios de inclusión fueron: pacientes con requerimiento de rFVIIa en algún momento de su estancia en UCI. Resultados. La mejoría hemodinámica de los pacientes tratados con rFVIIa en una UCI, durante las tres horas siguientes a la infusión (valorado por el incremento de la presión arterial sistólica [PAS] > 20 mmHg y/o el incremento de la presión arterial diastólica [PAD] > 8 mmHg), se asoció a mejor supervivencia. Conclusiones. La presente serie de casos, con el inconveniente de su heterogeneidad y el escaso número de enfermos, resalta el papel de la mejora hemodinámica como factor diferenciador entre aquellos enfermos que sobreviven y los que no lo hacen

Objective. Describe and identify the factors associated with the survival of the patients who received treatment with rFVIIa in an Intensive Care Unit (ICU) Design. Longitudinal, ambispective, observational, descriptive study in a series of clinical cases performed from July 20, 2004 to July 20, 2006. Scope. The study population included 16 hospitalized patients in the Intensive Medicine Department (ICU) of the Hospital Marqués de Valdecilla (Santander). Patients. Inclusion criteria were: Patients who required rFVIIa at some time of their stay in the ICU. Results. Hemodynamic improvement of the patients treated with rFVIIa in an ICU, within the first 3 hours of the infusion (evaluated by an increase of SBP > 20 mmHg and/or increase of DBP > 8 mmHg) was associated to greater survival. Conclusions. The present series of cases, with the disadvantage of its heterogeneity and the limited number of patients, stresses the role of hemodynamic improvement as a differentiating factor between those patients who survive and those who do not

Digital necrosis in a woman over eighty.

Chronic vascular disorders of the upper limbs are not frequently encountered in women; in addition, advanced age of onset tends to suggest the presence of common diseases such as arteriosclerosis or microembolization. Nonetheless, diagnosis is not always straightforward and in some cases both-laboratory and instrumental findings can do no more than arouse a diagnostic suspicion. We present a case of acro-localized disorder, which proved difficult to diagnose and which we believe may be attributed to a slowly progressing form of scleroderma of the extremities which, in our case, determined positivity of anticentromere autoantibodies.

[Vascular manifestations in systemic sclerosis (scleroderma)]. / Le manifestazioni vascolari nella sclerosi sistemica (sclerodermia).

Progressive systemic sclerosis (PSS), a disease still of unknown origin, is a generalized autoimmune disorder characterized by immunological abnormalities, microvascular dysfunction, and tissue fibrosis. The mechanism leading to selective microvascular injury in PSS is not completely known, however it is now clear that neuropeptides, vascular endothelium, and disturbances in the regulation of fibroblast function are the three major contributors to the increased fibrosis of skin and internal organs. Thus, endothelial cell and fibroblast dysfunction may be linked through the paracrine activity of soluble endothelial cell products: the cytokine cascade (IL-1, TGF-beta-1, PDGF, TNF, etc.). In systemic sclerosis, the exaggerated generalized vasospastic tendency is clinically represented by Raynaud's phenomenon as shown by an early digital arterial closure after cold stimulation, and by an inadequate vasodilatory response to heat. In this review we summarize recently established data that center around the role of adhesion molecules, immune reactions, and aberrant fibroblast biology and metabolism in effecting vascular and connective tissue alterations in this disease. Only a better knowledge of the pathophysiological process involved in scleroderma might lead to the development of new therapeutic approaches.

[The success of maternal feeding with very low birth weight premature infants, singletons and twins: a 10-year experience]. / Successo dell'allattamento materno nei pretermine di peso molto basso singoli e gemelli: un'esperienza di 10 anni.

UNLABELLED: There are very few reports about the feasibility of maternal milk feeding in very low birthweight preterm infants (VLBW), especially in twins. Therefore we conducted a cohort retrospective study to evaluate the feeding patterns of the 226 VLBW discharged from our neonatal intensive care unit from 1987 to 1996. Their gestational age was 30 +/- 2.6 weeks, birthweight 1166 +/- 224 g and they were hospitalized for 67 +/- 37 days (means +/- 1 SD). Of the 226 VLBW 49% were males, 39% had birthweight below 10 degrees centile for gestational age and 56% were born to non-residents in our area. There were 181 single births and 45 (20%) multiple births, of which 16 from pregnancies with 3 or more fetuses. Of the total cases 22% were discharged feeding maternal milk (MM) exclusively and 21% on mixed-feeding, maternal + formula milk (FM). Percentages were respectively 23% and 18% for single newborns, 11% and 29% for twins. Singletons and twins were discharged on FM with comparable percentages (59 and 60%). With passing years we have noticed a significant increase (chi square for linear trend < 0.01) for maternal milk feeding. In the last 2 years 49% of singletons and 38% of twins were discharged on MM, 14% and 24% on MM + FM, and only 37% and 38% on FM only. Between singletons and twins there were no statistically significant differences as far as feeding at discharge is concerned. CONCLUSIONS: most mothers, if correctly informed and encouraged, are able to breast-feed, exclusively or partially, their VLBW offspring, including twins, in the first months of life.

[The evaluation of autopsy in the pediatric intensive unit]. / Evaluación de la autopsia en la Unidad de Cuidados Intensivos Pediátricos.

OBJECTIVE: Because of concerns about the declining autopsy rate, an attempt was made to evaluate the contributions from the postmortem examination in children. PATIENTS AND METHODS: We carried out a retrospective comparison analysis between clinical and pathological diagnosis of 56 consecutive autopsies performed on children who died in the PICU during the period 1983-1995. RESULTS: The autopsy rate was 60%. Autopsy provided valuable clinical information in 50% of the cases. There were major diagnostic errors in three patients (5%), that if detected before death would probably have improved survival. Another 14 cases (25%) showed missed clinical diagnoses related to the basic illness and the cause of death, whose premortem diagnosis would not have prolonged survival. There were no diagnostic discrepancies in 28 cases (50%). The most unexpected findings revealed by the autopsies were iatrogenics (10 cases), metabolic diseases (4 cases), congenital immunodeficiency syndromes (4 cases) and pulmonary opportunistic infections (3 cases). Eight of these diseases were genetic. An age < 12 months or and ICU stay < 24 hours were not predicting factors of a higher incidence of major diagnostic errors. CONCLUSIONS: The value of the autopsy as quality assurance and to detect iatrogenics and occult genetic diseases is unquestionable. New strategies have to be designed to increase the rate of autopsies.

Asymmetries of facial motility during the dissimulation of emotion.

The asymmetrics of facial expression were estimated in a sample of 14 experimental subjects with the Facial Action Coding System during voluntary control of facial mimicry while viewing videotapes. The subjects were instructed to express facially the emotion experienced or to dissimulate their true emotion with a facial expression opposite (incongruous) to what they actually felt. Only during dissimulation did facial mimicry show an asymmetric distribution toward the lower left side of the face.

[Definitions of sepsis in severe juvenile meningococcal infection. A review of 80 cases]. / Definiciones de sepsis en la infección meningocócica infantil grave. Una revisión de 80 casos.

OBJECTIVE: To describe the definitions for sepsis proposed by ACCP/SCCM Consensus Conference and to evaluate its capacity to classify children with severe meningococcal infection in homogeneous risk groups. METHODS: Eighty children with acute meningococcal infection and severe sepsis or septic shock, admitted to the pediatric ICU during a ten years period were reviewed. Mean age: 38 months (1,3 mo-14 yrs). RESULTS: N. meningitidis was isolated in 84%. Sixty-four percent of the patients were bacteremic and 39% showed a positive culture in CSF. Overall mortality was 19%. Fifty-two patients (65%) were in severe sepsis on admission, fifteen of them (29%) developed shock, mortality for this group was 4%. Twenty-eight patients (35%) were in septic shock on admission, mortality was 44%. Overall mortality of the shock group was 35%, mortality of shock on admission was higher than mortality of shock postadmission (44% vs 13%, p = 0.0001). Major complications were: DIC (28%), ARDS (26%), purpura fulminans (21%). There were not major complications or deaths in patients who did not develop shock. Bacteremia was not significant associated with shock or death. Meningitis was more frequent in severe sepsis group but 62% of deaths got it. Univariant analysis showed significant differences between both groups relative to tissular perfusion variables, coagulation and meningeal involvement. Multivariate analysis allowed us to establish a predictive model of survival feasible on admission to the ICU. For its determination three parameters are used: blood pressure, platelets and base excess. CONCLUSION: Definitions proposed for severe sepsis and septic shock are a valuable tool to classify children with acute meningococcal infection in homogeneous risk groups.

[Small cell (oat cell) carcinoma of the prostate. Presentation of a case and review of the literature]. / Carcinoma de células pequeñas ("oat-cell") de próstata. Presentación de un caso y revisión de la literatura.

Prostate small cell carcinoma (SCC) is a rare and fatal condition over which countless enigmas hover both with regard to its origin and biological behaviour as well as to its management, the topic of this paper. We contribute the case of a 69-year old male diagnosed through transrectal biopsy and presenting lung, nodes and bone metastasis who underwent palliative UTR but died within four days of the intervention as a consequence of the metastatic condition. Microscopic and immunohistochemical findings characteristic of this type of tumour are described, emphasising the relevance of diagnosing this entity based on its poor prognosis and different therapeutic approach from that used for typical prostate adenocarcinoma.

[Benign fibrous histiocytoma of the female urethra]. / Histiocitoma fibroso benigno de uretra femenina.

Presentation of one case of benign fibrous histiocytoma of the female urethra in a 49-year old woman. Investigation of the various clinical and diagnostic aspects. Vaginal tumorectomy was curative, and no recurrence was observed 14 months after the control.