[Is the NEMS scale useful to describe homogeneously a population of patients in Intensive Care?]. / Puede ayudar la escala NEMS a clasificar de manera homogénea a los pacientes que ingresan en Cuidados Intensivos?

The use of scales that quantify therapeutic effort and severity level is a common practice in Intensive Care Units (ICU). The NEMS and APACHE II scales allow us to objectively determine the therapeutic effort and severity level of the patients admitted to the unit. With the use of both scales, we aimed to control our work quality, comparing the results obtained with various measurements. In this way, we will discover what type of patients require a greater workload, and we will also be able to distribute them according to care levels. We designed a prospective study of 458 patients hospitalized in a 6-bed ICU of a community hospital. The obtained results demonstrate that there is a correlation in our unit between the NEMS and APACHE II scales. Due to the characteristics of our hospital, most of the patients we admit are classified into care level 2 (NEMS 18-30). Surgical patients have a greater NEMS than medical patients (p = 0.02). If we divide our patients according to diseases, it stands out that the highest score corresponds to cardiovascular surgery postoperative patients in a sub-acute period (NEMS 39.13 +/- 13) and the lowest one to traumatologic surgery postoperative patients (NEMS 20.66 +/- 3.72). It is concluded that the NEMS scale is easily applied and can reflect the effort of nursing care staff. With the data obtained through the application of the NEMS and APACHE II scales, we could objectively define our work and classify the patients we treated according to care levels.

¿Puede ayudar la escala NEMS a clasificar de manera homogénea a los pacientes que ingresan en Cuidados Intensivos? / Is the NEMS scale useful to describe homogeneously a population of patients in Intensive Care?

El empleo de escalas cuantificadoras del esfuerzo terapéutico y nivel de gravedad es una práctica habitual en las Unidades de Cuidados Intensivos (UCI). Las escalas NEMS y APACHE nos permiten determinar de manera objetiva el esfuerzo terapéutico y el nivel de gravedad de los pacientes ingresados en la unidad. Mediante el uso de ambas escalas pretendemos hacer un control de calidad de nuestro trabajo, comparando los resultados obtenidos de las diversas mediciones. De esta manera conoceremos qué tipo de pacientes suponen para nosotros una mayor carga de trabajo y podremos además distribuirlos según niveles asistenciales. Diseñamos un estudio prospectivo en 458 pacientes ingresados en una UCI polivalente, de seis camas, de un hospital comarcal. Los resultados obtenidos demuestran que en nuestra unidad existe correlación entre las escalas NEMS y APACHE II. Debido a las características de nuestro hospital, la mayoría de los pacientes que ingresamos se clasifican en el nivel asistencial 2 (NEMS 18-30). Los enfermos quirúrgicos tienen un NEMS mayor que los enfermos médicos (p = 0,02). Si dividimos la muestra según patologías, destacamos que la puntuación más alta corresponde a los enfermos de postoperatorio de cirugía cardiovascular, en período subagudo (NEMS 39,13 ± 13) y la más baja a los de postoperatorio de cirugía traumatológica (NEMS 20,66 ± 3,72). Se constata que la escala NEMS es de fácil aplicación y refleja el esfuerzo asistencial de enfermería. Con los datos obtenidos de la aplicación de las escalas NEMS y APACHE II pudimos definir objetivamente nuestro trabajo y clasificar a los pacientes que tratamos en niveles asistenciales

The use of scales that quantify therapeutic effort and severity level is a common practice in Intensive Care Units (ICU). The NEMS and APACHE II scales allow us to objectively determine the therapeutic effort and severity level of the patients admitted to the unit. With the use of both scales, we aimed to control our work quality, comparing the results obtained with various measurements. In this way, we will discover what type of patients require a greater workload, and we will also be able to distribute them according to care levels. We designed a prospective study of 458 patients hospitalized in a 6-bed ICU of a community hospital. The obtained results demonstrate that there is a correlation in our unit between the NEMS and APACHE II scales. Due to the characteristics of our hospital, most of the patients we admit are classified into care level 2 (NEMS 18-30). Surgical patients have a greater NEMS than medical patients (p = 0.02). If we divide our patients according to diseases, it stands out that the highest score corresponds to cardiovascular surgery postoperative patients in a sub-acute period (NEMS 39.13 ± 13) and the lowest one to traumatologic surgery postoperative patients (NEMS 20.66 ± 3.72). It is concluded that the NEMS scale is easily applied and can reflect the effort of nursing care staff. With the data obtained through the application of the NEMS and APACHE II scales, we could objectively define our work and classify the patients we treated according to care levels

Contrapulsación aórtica. ¿Es posible en los cuidados intensivos de hospitales sin cirugía cardíaca? / Aortic counterpulsation: can it be performed in intensive care units in hospitals without cardiac surgery?

Introducción. El uso de balón de contrapulsación aórtico está habitualmente presente en el ámbito de los servicios de hospitales con cirugía cardíaca. En los enfermos cardíacos complicados con indicación de procedimiento invasivo percutáneo o quirúrgico, se ha demostrado que el uso temprano y preoperatorio de este tipo de soporte mejora los resultados tras la resolución de la situación creada con la cirugía cardíaca pertinente en cada caso. Pacientes y métodos. Se analiza de forma retrospectiva y global a los 9 pacientes que recibieron este tipo de terapia en los primeros 6 meses del año, y se analizan las causas del proceso, las complicaciones presentadas, las técnicas complementarias que recibieron y el resultado final. Resultados. De los 9 pacientes que recibieron esta técnica, dos fallecieron en shock cardiogénico intratable y los otros siete mejoraron de forma inmediata; de estos, dos no necesitaron cirugía cardíaca y los otros cinco fueron intervenidos, con resultados satisfactorios en cuatro de ellos. El traslado de estos pacientes fue posible sin incidencias y con buen resultado. Conclusiones. Si la selección, los cuidados y el seguimiento de los pacientes son adecuados, la contrapulsación aórtica puede proporcionar la estabilidad hemodinámica y la mejoría transitoria a muchos pacientes que precisan un tratamiento quirúrgico o invasor, que puede estar distante temporal y geográficamente (AU)

Síndrome de Holt-Oram / Holt-Oram syndrome

Presentamos el caso de una mujer de 28 años, diagnosticada de prolapso de la válvula mitral con insuficiencia mitral moderada que ingresó en la unidad para monitorización del ritmo cardíaco al presentar arritmias ventriculares con el hallazgo de QTc prolongado sin causa conocida. Durante su ingreso mostró, sin embargo, predominancia de la bradicardia sinusal, marcapasos errante y en ocasiones taquicardias supraventriculares. La observación de los trastornos del ritmo, las malformaciones esqueléticas, similares a las presentes en un familiar directo y el diagnóstico de cardiopatía estructural nos hizo pensar en la presencia de un síndrome mendeliano que englobara estos hallazgos. Esto facilitó el diagnóstico del síndrome de Holt-Oram (AU)

Prolonged sedation of critically ill patients with midazolam or propofol: impact on weaning and costs.

OBJECTIVE: To compare the effectiveness of sedation, the time required for weaning, and the costs of prolonged sedation of critically ill mechanically ventilated patients with midazolam and propofol. DESIGN: Open-label, randomized, prospective, phase IV clinical trial. SETTING: Medical and surgical intensive care unit (ICU) in a community hospital. PATIENTS: All ICU admissions (medical, surgical and trauma) requiring mechanical ventilation for > 24 hrs. A total of 108 patients were included in the study. INTERVENTIONS: Patients were randomized to receive midazolam or propofol. The dose range allowed for each drug was 0.1 to 0.5 mg/kg/hr for midazolam and 1 to 6 mg/kg/hr for propofol. The lowest dose that achieved an adequate patient-ventilator synchrony was infused. All patients received 0.5 mg/kg/24 hrs of morphine chloride. MEASUREMENTS AND MAIN RESULTS: The level of sedation was quantified by the Ramsay scale every 2 hrs until weaning from mechanical ventilation was started. If sedation could not be achieved by infusing the highest dose of midazolam or propofol, the case was recorded as a therapeutic failure. In the propofol group, serum triglycerides were determined every 72 hrs. Concentrations of > 500 mg/dL were also recorded as a therapeutic failure. When the patient was ready for weaning according to defined criteria, sedation was interrupted abruptly and the time from interruption of sedation to the first T-bridge trial and to extubation was measured. Cost analysis was performed based on the cost of intensive care in our unit ($54/hr). In the midazolam group (n = 54), 15 (27.8%) patients died; 11 (20.4%) patients had therapeutic failure; and 28 (51.8%) patients were subjected to a T-bridge trial. In the propofol group (n = 54), these proportions were 11 (20.4%), 18 (33.4% [including seven due to inadequate sedation, and 11 due to hypertriglyceridemia]), and 25 (46.2%), respectively. None of these values was significantly different between the two groups. Duration of sedation was 141.7 +/- 89.4 (SD) hrs and 139.7 +/- 84.7 hrs (p = NS), and cost (US dollars) attributed to sedation was $378 +/- 342 and $1,047 +/- 794 (p = .0001) for the midazolam and propofol groups, respectively. In the midazolam group, time from discontinuation of the drug infusion to extubation was 97.9 +/- 54.6 hrs (48.9 +/- 47.2 hrs to the first disconnection, and 49.0 +/- 23.7 hrs to extubation). In the propofol group, time from discontinuation of the drug infusion to extubation was 34.8 +/- 29.4 hrs (4.0 +/- 3.9 hrs to the first disconnection, and 30.8 +/- 29.2 hrs to extubation). The difference between the two groups in the weaning time was 63.1 +/- 12.5 (SEM) hrs (p < .0001). Cost per patient in the midazolam group (including ICU therapy and sedation with midazolam) was $10,828 +/- 5,734. Cost per patient in the propofol group was $9,466 +/- 5,820, $1,362 less than in the midazolam group. CONCLUSIONS: In our population of critically ill patients sedated with midazolam or propofol over prolonged periods, midazolam and propofol were equally effective as sedative agents. However, despite remarkable differences in the cost of sedation with these two agents, the economic profile is more favorable for propofol than for midazolam due to a shorter weaning time associated with propofol administration.