Development of an acute ischemic stroke management course for hospital physicians in emergency departments and intensive care units.

The objective of this study was to evaluate a training course on acute ischemic stroke (AIS) for hospital physicians, part of a regional strategy on AIS patient care. The course comprised an initial self-study (e-Learning) stage and 1-day theoretical-practical course on initial AIS management for Critical Care and Emergency physicians in the Andalusian Health Service (Spain). Data were collected on regional implementation of the stroke code and intravenous thrombolysis treatment. Between 2006 and 2009, 12 courses were attended by 356 physicians from emergency (n=148) and critical care (n=208) departments in the Andalusian health system. The initial stage was failed by 46.4% of trainees; the 1-day AIS course was successfully completed by all trainees, who reported a high satisfaction level. By the end of 2009, all hospitals had adopted the stroke code and approximately 5-6% of patients with AIS received intravenous thrombolysis. This type of healthcare strategy proved effective to improve AIS care in our setting.

Los residentes en las unidades de cuidados intensivos, ¿cuál es su percepción de la formación que reciben? / Residents in an Intensive Care Unit, what perception they have on their training?

Objetivo. Este trabajo intenta responder a la pregunta de cuál es la visión que tienen los residentes de su formación en las unidades de cuidados intensivos (UCI).Sujetos y métodos. Hemos realizado un estudio cualitativo tipo grounded theory. Los participantes son residentes de cualquier especialidad que estuviesen trabajando en las UCI durante el estudio. El diseño tiene tres partes: percepción subjetiva de los residentes de aquellos aspectos que ellos consideran más útiles para su formación, priorización de las actividades regulares más características de las UCI y entrevistas semiestructuradas con informadores claves. Resultados. Nuestro trabajo identifica que los residentes consideran como eje de su formación la práctica clínica a ‘pie de cama’ desarrollada con autonomía y apoyada en una buena tutorización. Paralelamente, otras competencias nucleares como la investigación, la comunicación en situaciones complejas, el trabajo en equipo o la gestión de recursos están infravaloradas, mientras que otras como la seguridad del paciente o la bioética no se han detectado en las respuestas de los residentes. Conclusión. La percepción de los residentes sobre formación durante su estancia en las UCI adolece de algunas carencias, dado que ciertos aspectos claves de la medicina actual no se perciben como prioridades en dicha formación (AU)

Aim. Our work tries to answer the following question: what is the perception of residents on their training in the Intensive Care Units (ICU)?Subjects and methods. We have conducted a qualitative study based on grounded theory. Participants are residents from different specialties working in the ICU of four hospitals of our National Health Service. The study consist of three parts: resident’s subjective perception of those aspects most appreciate in their clinical practice; resident’s prioritizations of routine ICU’s activities, and semi-structured interviews with key informants. Results. According to the resident’s opinions, the clinical practice at the beside of patients, and carried out with autonomy and with a good tutoring support are central to their training; nevertheless some central competencies such as research, difficult communication, team work or resource management are undervalued, while others such as patient safety or bioethics are absent from their comments. Conclusions. Our work highlight that resident’s perception about their training during they compulsory period in ICU has some shortcoming, because some key aspects of current medicine are not perceived as priorities in their training (AU)

Influence of extravascular lung water determination in fluid and vasoactive therapy.

INTRODUCTION: Preload parameters in postresuscitation phase are not sufficiently sensitive to guide fluid therapy in critically ill patients. We analyzed modifications in the fluid therapy and vasoactive drugs of critically ill patients that were produced by inclusion of extravascular lung water (EVLW) data in the treatment protocol and evaluated the short-term response. METHODS: This observational and prospective study included consecutive patients with hypotension or hypoxemia, comparing the therapeutic plan for fluid and vasoactive drug treatment between before and after knowing the EVLW value. RESULTS: We studied 42 patients. After knowing the EVLW, 52.4% (n = 22) of initial therapeutic plans were changed, modifying fluid therapy in all of these cases and vasoactive therapy in 22% of them. EVLW value was 13.91 +/- 5.62 in patients with change of therapeutic plan versus 10 +/- 4.52 in those with no change (p < 0.05). No differences were found in preload parameters as a function of change/no change. The most frequent decision change (n = 13) was to fluid reduction plus diuretic administration, and patients with this modification had significantly (p < 0.05) higher EVLW values compared with the remaining patients with a change in fluid therapy. Out of the 22 patients with a modified therapeutic decision, the therapy proved effective in 18 patients CONCLUSION: Quantification of EVLW in patients who can be considered euvolemic induces important modifications in fluid and vasoactive therapy. These changes generally resulted in a lower volume loading and a positive outcome for the patient.

Early markers of acute respiratory distress syndrome development in severe trauma patients.

PURPOSE: The aim of the study was to identify early risk factors for development of acute respiratory distress syndrome (ARDS) in severe trauma patients. MATERIALS AND METHODS: This was a prospective observational study of 693 severe trauma patients (Injury Severity Score >or=16 and/or Revised Trauma Score or=2) of long bone fractures, and with chest injuries (rib/sternal fracture [ICD-9 code 807] and hemo/pneumothorax [ICD-9 code 860/861]). Patients with ARDS required more colloids (P = .005) and red blood cell units (P = .02) than patients without ARDS during the first 24 hours. Multivariate analysis showed that ARDS was related to chest trauma diagnosis (ICD-9 code 807) (odds ratio [OR], 3.85), femoral fracture (OR, 3.16), APACHE II score (OR, 1.05), and blood transfusion during resuscitation (OR, 1.32). CONCLUSIONS: Risk of ARDS development is related to the first 24-hour admission variables, including severe physiologic derangements and specific ICD-9-classified injuries. Blood transfusion may play an independent role.

Six-year mortality and quality of life in critically ill patients with chronic obstructive pulmonary disease.

OBJECTIVE: To study the mortality and quality of life (QOL) of survivors at 6 yrs after intensive care unit (ICU) admission for chronic obstructive pulmonary disease. DESIGN: Prospective, multiple-center cohort study. SETTING: A total of 86 ICUs throughout Spain. PATIENTS: Patients in the Project for the Epidemiological Analysis of Critical Care Patients (PAEEC) project with chronic obstructive pulmonary disease were included. MEASUREMENTS AND MAIN RESULTS: The sample comprised 742 patients; 508 of them were admitted for acute exacerbation of chronic obstructive pulmonary disease, and 379 of these required intermittent positive-pressure ventilation. The mean age of the patients was 65.2 +/- 9.89 yrs, Acute Physiology and Chronic Health Evaluation (APACHE) III score was 66.6 +/- 21.04; preadmission QOL questionnaire score was 7 +/- 4.82 points, and hospital mortality was 31.8%. At 6 yrs, 32.2% had died after hospital discharge, 21.6% could not be traced, and 107 patients were alive (18.3% of the 582 followed-up patients). QOL of survivors was worse than preadmission (6.55 +/- 5.6 vs. 4.92 +/- 4.5 points, p < .05), but 72% of patients were self-sufficient. Among the 379 patients admitted to the ICU for acute chronic obstructive pulmonary disease exacerbation and requiring intermittent positive-pressure ventilation, 36.7% died in the hospital; at 6 yrs after hospital discharge, 31.4% had died, 18.7% could not be traced, and 50 patients (16.2% of followed-up patients) were alive. Multivariate analysis with logistic regression showed that the mortality at 6 yrs was related to age (odds ratio, 1.046; 95% confidence interval, 1.023-1.071), APACHE III score (odds ratio, 1.013; 95% confidence interval, 1.001-1.024), and preadmission QOL score (odds ratio, 1.139; 95% confidence interval, 1.078-1.204). CONCLUSION: The 6-yr mortality of patients with chronic obstructive pulmonary disease requiring ICU admission is high. Mortality is mainly influenced by pre-ICU admission QOL. At 6 yrs, at least 15% are alive; survivors have a worse QOL compared with pre-ICU admission, although three quarters of them are self-sufficient.

Outcome prediction in terms of functional disability and mortality at 1 year among ICU-admitted severe stroke patients: a prospective epidemiological study in the south of the European Union (Evascan Project, Andalusia, Spain).

OBJECTIVES: To analyse 1-year mortality and functional disability outcomes and resource use in critical stroke patients admitted to ICU. DESIGN AND SETTING: Multi-centre, prospective, observational study in 28 Spanish hospitals. PATIENTS. Patients admitted for acute stroke from March-August 1999. INTERVENTION: Collection of data on: severity by Apache III and Glasgow Coma Score; neurological lesion, hospital and 1-year mortality; functional disability at 1 year by Barthel Index and Glasgow Outcome Scale; ICU length of stay, life support techniques, and neurosurgical interventions. MEASUREMENT AND RESULTS: We studied 132 patients: 21% with subarachnoid haemorrhage (SAH), 58% intracerebral haemorrhage (ICH), 20% ischaemic stroke (ISC); Apache III 63+/-29 ICU stay 13+/-12 days; 74% required mechanical ventilation. Hospital and 1-year mortality was 33% (22%:ISC, 32%:SAH, 37%:ICH) and 53.8% (66%:ISC, 39%:SAH, 54%:ICH), respectively. Age, APACHE III, and diagnosis defined hospital mortality. Age, APACHE III, and Glasgow Coma Score defined 1-year mortality. Barthel Index score improved ( P<0.001) between discharge and 1 year; 73% of patients presented severe disability at discharge vs. 26% at 1 year; 8% minimal/no disability at discharge vs. 43.3% at 1 year. Only 17% of subarachnoid haemorrhage patients presented severe disability at 1 year. Admission Apache III and hospital-discharge Barthel Index scores were related to functional outcome at 1 year. CONCLUSIONS: Critical stroke patients are characterized by high severity of illness, elevated resource consumption, and poor outcomes that are mainly influenced by severity and age. Glasgow Coma Score-measured neurological severity is the main determinant of future functional capacity, which is greater at 1 year.

Análisis de mortalidad en una unidad de cuidados intensivos neurotraumatológica según el sistema APACHE III / Analysis of mortality according to the APACHE III system in a neurotrauma intensive care unit

Fundamento. Analizar la mortalidad de los pacientes en una UCI neurotraumatológica de un hospital de referencia, en función de la mortalidad esperada según el sistema predictivo APACHE III en su versión española. Métodos. Estudio prospectivo realizado, durante un período de 4 meses, sobre 155 pacientes que ingresaron de forma consecutiva en una UCI neurotraumatológica de un hospital de tercer nivel. Hemos recogido las siguientes variables: edad, sexo, procedencia, diagnóstico de ingreso, comorbilidad, puntuación en el sistema APACHE III y mortalidad hospitalaria. Hemos calculado la probabilidad de muerte esperada según la fórmula española del sistema pronóstico APACHE III, y la hemos comparado con la mortalidad hospitalaria observada, aplicando el test de Hosmer-Lemeshow. Resultados. Los 155 pacientes estudiados tenían una edad de 46 (DE 19) años; el 74,2 por ciento eran varones. Alcanzaron una puntuación APACHE III de 53,5 (33,4) puntos. En cuanto a los diagnósticos, el 48,4 por ciento fueron traumatismos y el 41,9 por ciento eran pacientes neurológicos. Casi la mayoría de los enfermos ingresaron en la UCI procedentes del servicio de urgencias (43,9 por ciento); fueron trasladados desde otro hospital el 29,7 por ciento; procedían de otra planta hospitalaria el 17,4 por ciento, y el resto de pacientes procedían de cirugía. La mortalidad hospitalaria observada fue del 30,9 por ciento, y la predicha por el sistema APACHE III fue del 28,3 por ciento. El test de Hosmer-Lemeshow no demuestra diferencias estadísticamente significativas entre ambas (H = 2,94; NS).Conclusión. La mortalidad en nuestra unidad es similar a la esperada, constatándose la utilidad del sistema predictivo APACHE III, versión española, en los pacientes críticos neurotraumatológicos (AU)