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)

Trauma-focused cognitive behavioral therapy with Puerto Rican youth in a post-disaster context: Tailoring, implementation, and program evaluation outcomes.

PURPOSE: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) has not yet been systematically evaluated in the Caribbean context, particularly with Hispanic youth exposed to multiple disasters. The objective of this project was twofold: 1) to train mental health providers in Puerto Rico in TF-CBT as part of a clinical implementation project within the largest managed behavioral health organization (MBHO) on the island, and 2) to conduct a program evaluation to determine the feasibility of implementation and the effectiveness of the treatment. METHOD: Fifteen psychologists were trained in TF-CBT. These psychologists then provided TF-CBT to 56 children and adolescents, ages 5-18, in community-based mental health clinics and one primary care clinic with a co-located psychologist in Puerto Rico. The mean number of traumatic events reported by youth referred for TF-CBT was 4.11. RESULTS: Thirty-six out of 56 children enrolled in the project (64.3%) successfully completed all components of TF-CBT. Results demonstrated large effect sizes for reduction in youth-reported posttraumatic stress symptoms (PTSS) (Cohen's d = 1.32), depressive symptoms (Cohen's d = 1.32), and anxiety symptoms (Cohen's d = 1.18). CONCLUSIONS: These results suggest that it was feasible to train providers in TF-CBT, that providers were able to deliver TF-CBT in community-based settings both in person and via telehealth (due to the COVID-19 pandemic), and that TF-CBT was an effective treatment option to address trauma-related concerns for youth in Puerto Rico in a post-disaster context. This project is an important first step in the dissemination and implementation of evidence-based trauma-focused treatment for Hispanic youth and disaster-affected youth in the Caribbean.

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)

A mixed methods investigation of Black college-attending emerging adults' experiences with multilevel racism.

Experiences of racism contribute to the mental health burden of Black individuals in the United States, and during emerging adulthood, these impacts may be especially intensified. The majority of research on racism captures individual-level experiences and utilizes frequency-based measures. This mixed methods investigation examines convergence and divergence between a measure of recent experiences of racism and a measure of worst experiences of racism at multiple levels (individual, cultural, institutional). A sample of 186 Black college-attending emerging adults (Mage = 19.36; 62.7% female) reported their recent experiences using a quantitative measure and their worst experiences via a qualitative open-ended response, which were analyzed via convergent parallel design. The results indicated that a majority of reported worst experiences had an institutional-level component. Although the quantitative measure of recent experiences corresponded with reports of individual-level worst experiences, the institutional- and cultural-level worst experiences were rarely fully captured by the recent experiences measure. Implications for the mental health of Black college-attending emerging adults are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

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

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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.

Elastography in the evaluation of thyroid nodules / Elastografía en la evaluación de nódulos tiroideos

Background: Thyroid nodules are a very common pathology in clinical practice and in imaging studies. Autopsy results indicate a 50% prevalence of thyroid nodules greater than 1 cm in patients with no clinical symptomatology. The goal is to evaluate the accuracy of elastography in the evaluation of thyroid nodules with suspicion of malignancy by comparing the results obtained in qualitative and semi-quantitative elastography with the cytopathological study obtained by BAAF of thyroid nodules and The TI-RADS system. Methods: We included male or female patients over 18 years old, entitled to IMSS, with diagnosis of one or more thyroid nodules, sent to the ultrasound service for FNA and histopathological report at the end of the study. In the statistical analysis, values of sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) were obtained. Results: The results showed that the qualitative elastography by the Asteria Score presents a sensitivity of 86% and a specificity of 53%, PPV of 36% and NPV of 92% , for the semiquantitative elastography a sensitivity of 40%, specificity of 87%, PPV of 50% and NPV of 82%. Conclusions: The elastography in its qualitative and semicuantitative mode are useful to help determine the possibility of malignancy of thyroid nodules as an additional element to ultrasound, but it does not replace the citopathologic result or other diagnostic tests, so it should not be taken as a single test. Additionally the high result of NPV is useful to dismiss the possibility of malignancy.

Introducción: Los nódulos tiroideos son una patología común que se enfrenta en la práctica clínica y en estudios de imagen. El objetivo de este trabajo es valorar la certeza diagnóstica de la elastografía en la evaluación de nódulos tiroideos con sospecha de malignidad comparando el resultado obtenido en la elastografía de forma cualitativa y semicuantitativa con el estudio citopatológico obtenido por BAAF de los nódulos tiroideos y el sistema TI-RADS. Métodos: Se incluyeron pacientes mayores de 18 años de edad, derechohabientes del IMSS, con diagnóstico de uno o varios nódulos tiroideos, enviados al servicio de ultrasonido para la realización de la biopsia con aguja fina (BAAF) y con reporte histopatológico al término del estudio. En el análisis estadístico se obtuvieron valores de sensibilidad, especificidad, valor predictivo positivo (VPP) y valor predictivo negativo (VPN). ResultadoS: Los resultados mostraron que la elastografía cualitativa por el Score de Asteria presenta una sensibilidad del 86%, especificidad del 56%, VPP del 36% y VPN del 92%, y para la elastografía semicuantitativa valores de sensibilidad de 40% , especificidad de 87%, VPP del 50% y VPN del 82%. Conclusiones: La elastografía en su modalidad cualitativa y semicuantitativa, resulta útil para ayudar a determinar la posibilidad de malignidad de los nódulos tiroideos como un elemento adicional al ultrasonido, sin embargo no sustituyen el resultado citopatológico ni otras pruebas diagnósticas, por lo que no debe ser tomado como única prueba.

Helicobacter pylori in esplenectomized patients with immune primary trombocytopenia / Helicobacter pylori en pacientes esplenectomizados con trombocitopenia inmune primaria

Background: Primary Immune Thrombocytopenia (TIP) is an autoimmune disease that accelerates the peripheral destruction of platelets and alters megakaryocytopoiesis. Helicobacter pylori infection and eradication has been associated with an increase in the platelet count in patients with IPT. The aim of this article is to evaluate the platelet response after H. pylori eradication in patients with chronic splenectomized IPT Methods: Between 2008 and 2009, adult patients with a diagnosis of chronic IPT, splenectomized; They were given breath test with carbon 13-labeled urea (PAU13C). Patients who tested positive received eradication treatment with amoxicillin, omeprazole and clarithromycin for 14 days. After 6 weeks of treatment, a second PAU13C was performed. Baseline platelet counts were performed and every six months until the completion of two years. Results: 40 patients, 34 women and 6 men were included, PAU13C was positive in 17 patients (42.5%). H. pylori eradication was obtained in 16 patients (94%) confirmed by post-treatment PAU13C. In the follow-up of the patients it was observed that there was increase of platelets in 7 of the patients with eradication of H. pylori, while of the patients not infected in 9 also an increase of platelets was observed. Conclusions: There were no differences in the increase in platelet count among patients positive or negative to the H. pylori breath test at followup at 24 months.

Introducción: La trombocitopenia inmune primaria (TIP) es una enfermedad autoinmune que acelera la destrucción periférica de las plaquetas y altera la megacariocitopoyesis. La erradicación de la infección por Helicobacter pylori se ha asociado al incremento en la cuenta de plaquetas en los pacientes con TIP. El objetivo de este trabajo fue evaluar la respuesta de plaquetas después de la erradicación del H. pylori en pacientes con TIP crónica esplenectomizados. Métodos: Entre 2008-2009 fueron incluidos pacientes adultos con diagnóstico de TIP crónica, esplenectomizados; se les realizó prueba de aliento con urea marcada con carbono 13 (PAU13C). Los pacientes que resultaron positivos a la prueba recibieron tratamiento de erradicación con amoxicilina, omeprazol y claritromicina por 14 días. Después de 6 semanas de tratamiento, se realizó una segunda PAU13C. Se realizaron cuenta de Plaquetas basal y cada seis meses hasta completar dos años. Resultados: Se incluyeron 40 pacientes, 34 mujeres y 6 hombres, la PAU13C resultó positiva en 17 pacientes (42.5%). La erradicación del H. pylori se obtuvo en 16 pacientes (94%) confirmado por PAU13C postratamiento. En el seguimiento de los pacientes se observó que hubo incremento de las plaquetas en 7 de los pacientes con erradicación del H. pylori, mientras que de los pacientes no infectados en 9 también se observó aumento de plaquetas. Conclusiones: No hubo diferencias en el incremento en la cuenta de plaquetas entre los pacientes positivos o negativos a la prueba de aliento para H. pylori en el seguimiento a 24 meses.

[High-intensity chemotherapy versus palliative chemotherapy in patients over 60 years with acute myeloid leukemia]. / Quimioterapia intensa frente a quimioterapia paliativa en pacientes con leucemia mieloblástica mayores de 60 años.

BACKGROUND: The use of high-intensity chemotherapy (HIC) for acute myeloid leukemia (AML) in the elderly is controversial. In the present study, it was assessed complete remission and overall survival of AML patients over 60 years treated with HIC or palliative chemotherapy. METHODS: Patients with ECOG ≤ 2 and adequate organic function received HIC with a base of cytarabine for five or seven days, and an anthracycline for three days. If patients achieved complete remission of leukemia, they received one or two cycles of consolidation with cytarabine. Palliative treatment consisted of supported measures and/or oral or intravenous low-dose chemotherapy. RESULTS: Seven patients treated with HIC achieved complete remission versus only one in the palliative group. Only one patient died during HIC treatment. Median survival for HIC-treated patients was 13.25 months, and only 3.35 months for patients treated with palliative therapy (p < 0.05). CONCLUSION: AML patients of 60 years or older, with good performance status (ECOG ≤ 2) and adequate organ function, may benefit from HIC treatment, with better survival, compared with palliative therapy.

Introducción: el tratamiento con quimioterapia intensa (QTI) en pacientes con leucemia mieloblástica (LMA) mayores de 60 años es controversial. En el presente estudio se evaluó la remisión completa y la supervivencia global de pacientes con LMA mayores de 60 años, tratados con QTI o quimioterapia paliativa. Métodos: los pacientes con adecuada función orgánica y ECOG ≤ 2 recibieron QTI a base de citarabina por cinco o siete días más un antracíclico por tres días y terapia de soporte. En caso de lograr remisión completa de la leucemia recibieron uno o dos ciclos de consolidación con citarabina. El tratamiento paliativo consistió en medidas de soporte o quimioterapia oral o intravenosa en dosis bajas. Resultados: del grupo de QTI siete pacientes alcanzaron remisión completa, comparados con uno del grupo de quimioterapia paliativa. La supervivencia global fue de 13.25 meses para los pacientes con QTI y de 3.35 meses para los pacientes de quimioterapia paliativa (p < 0.05). Conclusión: es posible que los pacientes con LMA mayores de 60 años de edad se beneficien de recibir QTI, comparada con la quimioterapia paliativa.

[Maternal morbidity and mortality in a unit of tertiary care without obstetrics]. / Morbimortalidad materna en una unidad de tercer nivel sin servicio de obstetricia.

BACKGROUND: Maternal morbidity is a health problem for developing countries, the causes of death among obstetric patients varies according to geographic region and other factors, which include health services. The aim of this study was to identify the causes of maternal mortality and morbidity, as well as factors associated with mortality in patients attending on 2011-2012. METHODS: Clinical data of the patients on admission, severity of illness, presence of comorbidity, complications that occurred during treatment and causes of death in pregnant or postpartum patients were analyzed. RESULTS: 137 patients were analyzed, 87 (63.5 %) patients were hospitalized, 36 (41.3 %) cases with severe maternal complication (SMC); most patients with SMC were in the postpartum postcesarean. Eleven patients died, five maternal deaths and 6 late deaths. CONCLUSIONS: SMC and death were more frequent in the postpartum period. The indirect causes of death were more frequent.

Introducción: la morbimortalidad materna representa un problema de salud en los países en desarrollo, las causas de muerte obstétrica dependen de la región geográfica y de otros factores que incluyen la calidad de los servicios de salud. El objetivo de este estudio fue analizar las causas de morbilidad y mortalidad materna en las pacientes atendidas de 2011 a 2012. Métodos: se analizaron los datos de las pacientes en admisión hospitalaria, el diagnóstico y la severidad de la enfermedad, la presencia de comorbilidad y las complicaciones que ocurrieron durante el tratamiento y las causas de muerte de pacientes embarazadas o puérperas. Resultados: fueron atendidas 137 pacientes de las cuales 87 (63.5 %) requirieron ser hospitalizadas, 36 (41.3 %) presentaron criterios para complicación materna severa (CMS); la mayor parte de pacientes con CMS se encontraban en el puerperio postcesárea, Once pacientes fallecieron, cinco se consideraron muertes maternas indirectas y 6 muertes tardías. Conclusiones: las CMS y las muertes fueron más frecuentes en el puerperio. Las causas indirectas fueron las más frecuentes.