Profundizando en el conocimiento sobre el manejo del dispositivo para control de la eliminación fecal en el paciente crítico / To go in-depth in the knowledge of the device to control fecal elimination in the critical patient

OBJETIVO: Describir las características generales del paciente y del uso del dispositivo. Conocer presión del globo de retención (PGR) y factores relacionados. Identificar incidencia de fuga, recolocación y lesión perineal asociada al dispositivo (LAD) y factores relacionados. MATERIAL Y MÉTODOS: Estudio observacional analítico longitudinal realizado en UCI polivalente, de junio a diciembre de 2010. La muestra incluyó portadores de Flexi-Seal ®. Se valoraron: características de pacientes y de uso del dispositivo, PGR, fuga y cantidad, recolocación y motivo, LAD, sedoanalgesia en perfusión(SAP), relajación en perfusión, posición, tipo sonda, modalidad ventilatoria(MV), presión intraabdominal(PIA), presión media intratorácica(PMI), PEEP, Glasgow, color-aspecto, consistencia y volumen de heces. Significación p < 0,05. RESULTADOS: Se incluyeron 21 pacientes, 52% varones, edad 54 ± 17años con 30 episodios de inserción, Flexi-Seal-Signal ® un 33%, permanencia 10 ± 8días, principal indicacion «diarrea más lesión piel» en un 33%, retirada «intolerancia y/o expulsión espontánea» en un 30%. PGR mediana (Me) = 40; RI (61-19) cmH2O. Factores asociados significativamente a mayor PGR: ausencia de SAP, decúbito prono, fuga, recolocación, Flexi-Seal ® convencional, MV, menor PEEP y PMI, color-aspecto y mayor PIA. Densidad de incidencia de fuga, recolocación y LAD 43, 30 y 2 casos/100días de sonda, respectivamente. Factores de riesgo de fuga y recolocación: mayor PGR, Glasgow y volumen de heces, menor PIA, MV, modalidad asistida-espontánea OR 2,5; IC (1,6-3,8) y OR 1,7 (1,1-2,7), ausencia SAP OR 3,3 (2,2-5,1) y OR 2,4 (1,5-3,8), relajación en perfusión OR 2,4 (1,4-3,9) y OR 1,8 (1,1-3,1), Flexi-Seal ® convencional OR 2,7 (1,7-4,1) y OR 2 (1,2-3,3), respectivamente. Factores de riesgo de fuga: color-aspecto, decúbito supino, menor PMI y PEEP. CONCLUSIONES: Monitorizar la PGR puede alertar sobre la aparición de fuga y necesidad de recolocación. Conocer los factores asociados a la PGR, fuga y recolocación permitirá desarrollar estrategias para descender su elevada incidencia, como puede ser la disminución de la PGR reduciendo el volumen de hinchado

OBJECTIVE: To describe the general characteristics of the patient and device use. To know retention balloon pressure (RBP) and related factors. To identify rate of leakage incidence, relocation and perineal damage due to the device (PSD) and related risk factors. MATERIAL AND METHODS: An analytical observational, cross-sectional study conducted in a polyvalent ICU from June-December 2010 was performed. The sample included Flexi-Seal ® carriers. Variables evaluated were patient and device use characteristics, RBP, leakage and quantity, relocation and reason, PSD, sedoanalgesia infusion, neuromuscular block, patient position, Flexi-Seal type catheter, ventilatory mode (VM), intra-abdominal pressure (IAP), mean intrathoracic pressure (MITP), PEEP, Glasgow, color-aspect, fecal consistency and volume. Significance P < .05. RESULTS: Twenty-one patients were included, 52% male, aged 54 ± 17 with 30 insertion episodes, Flexi-Seal-Signal ® 33%, 10 ± 8 days permanency, main indication 33% «diarrhea and injured skin»," 30% device removal «intolerance and/or spontaneous expulsion». Median (Me) PGR = 40; RI (61-19) cmH2O. Factors associated to higher PGR: SCI absence, prone-decubitus position, leakage, relocation, conventional Flexi-Seal ®, MV, lower PEEP and IMP, Color-aspect, higher MITP. Leakage, relocation and PSD incidence density 43, 30 and 2 cases/100 days of catheter, respectively. Leakage and relocation risk factors: higher PGR, Glasgow and fecal volume, lower MITP, MV, assisted-spontaneous mode OR 2.5 CI (1.6-3.8) and OR 1.7(1.1-2.7), absence SCI OR 3.3 (2.2-5.1) and OR 2.4 (1.5-3.8), absence neuromuscular block OR 2.4 (1.4-3.9) and OR 1.8 (1.1-3.1), Flexi-Seal® conventional OR 2.7(1.7-4.1) and OR 2 (1.2-3.3), respectively. Leakage risk factors: color-aspect, supine position, lower IMP and PEEP. CONCLUSIONS: Monitoring RBP may alert us about leakage presence and relocation need. Knowing associated risk factors to RBP, leakage and relocation would help to develop strategies to reduce their high incidence rate such as decreasing RBP by reducing inflated volume

[To go in-depth in the knowledge of the device to control fecal elimination in the critical patient]. / Profundizando en el conocimiento sobre el manejo del dispositivo para control de la eliminación fecal en el paciente crítico.

OBJECTIVE: To describe the general characteristics of the patient and device use. To know retention balloon pressure (RBP) and related factors. To identify rate of leakage incidence, relocation and perineal damage due to the device (PSD) and related risk factors. MATERIAL AND METHODS: An analytical observational, cross-sectional study conducted in a polyvalent ICU from June-December 2010 was performed. The sample included Flexi-Seal(®) carriers. Variables evaluated were patient and device use characteristics, RBP, leakage and quantity, relocation and reason, PSD, sedoanalgesia infusion, neuromuscular block, patient position, Flexi-Seal type catheter, ventilatory mode (VM), intra-abdominal pressure (IAP), mean intrathoracic pressure (MITP), PEEP, Glasgow, color-aspect, fecal consistency and volume. Significance P<.05. RESULTS: Twenty-one patients were included, 52% male, aged 54±17 with 30 insertion episodes, Flexi-Seal-Signal(®) 33%, 10±8 days permanency, main indication 33% «diarrhea and injured skin¼," 30% device removal «intolerance and/or spontaneous expulsion¼. Median (Me) PGR =40; RI (61-19) cmH2O. Factors associated to higher PGR: SCI absence, prone-decubitus position, leakage, relocation, conventional Flexi-Seal(®), MV, lower PEEP and IMP, Color-aspect, higher MITP. Leakage, relocation and PSD incidence density 43, 30 and 2 cases/100 days of catheter, respectively. Leakage and relocation risk factors: higher PGR, Glasgow and fecal volume, lower MITP, MV, assisted-spontaneous mode OR 2.5 CI (1.6-3.8) and OR 1.7(1.1-2.7), absence SCI OR 3.3 (2.2-5.1) and OR 2.4(1.5-3.8), absence neuromuscular block OR 2.4 (1.4-3.9) and OR 1.8 (1.1-3.1), Flexi-Seal(®) conventional OR 2.7(1.7-4.1) and OR 2 (1.2-3.3), respectively. Leakage risk factors: color-aspect, supine position, lower IMP and PEEP. CONCLUSIONS: Monitoring RBP may alert us about leakage presence and relocation need. Knowing associated risk factors to RBP, leakage and relocation would help to develop strategies to reduce their high incidence rate such as decreasing RBP by reducing inflated volume.

Decúbito prono en paciente portador de dispositivo de extracción extracorpórea de CO 2 Novalung / Decubitus prone position in patient with extracorporeal CO2 removal device Novalung

Objetivo: Describir la evolución de una paciente portadora del dispositivo. Conocer el efecto del Novalung sobre la ventilación teniendo en cuenta la posición del paciente y la influencia de esta última sobre el flujo de sangre del dispositivo. Elaborar un protocolo de manejo y cuidados del paciente con Novalung. Material y métodos: Caso clínico de un paciente ingresado en UCI polivalente de hospital terciario. Descripción de parámetros: hemodinámicos y respiratorios, farmacológicos, analíticos, nutricionales, de neuromonitorización, de manejo del Novalung y duración ciclos decúbito prono. Test Anova, t de Student, Wilconxon-Mann Witney y correlación de Spearman para conocer comportamiento de variables estudiadas. Significación p<0,05. Resultados: Mujer de 46 años con neumonía nosocomial e insuficiencia respiratoria aguda grave. Indicación del Novalung: disminuir hipercapnia y optimizar manejo ventilatorio ante hipoxemia refractaria. Estancia UCI 26 días, TAM 82 ± 9 mmHg y FC 110 ± 6 lpm durante ingreso, monitorización PICCO 5 días con IC 3,2 ± 0,8 l/min/m2, ELWI 33 ± 4 ml, hemofiltración continua 13,2 días mediana extracción 50 cc/h, noradrenalina 0,68 ± 0,79 /kg/min 15días. Parámetros respiratorios durante ingreso PO2 59 ± 13 mmHg, PCO2 68 ± 35 mmHg, SatO2 85 ± 12%, PO2/FIO2 69 ± 35, volumen corriente 389 ± 141 cc. Novalung 13días, heparina 181,42 ± 145 mUI/kg/min, tiempo de cefalina 57,56 ± 16,41 sg, flujo O2 7 ± 3 l/min, flujo sangre mediana 1.030 cc/h rango intercuartílico 1.447 - 612 cc/h. Ciclos de prono 4, duración 53 ± 27 h. Con Novalung disminuyó PCO2 independientemente de posición 66 ± 21:56 ± 9;p = 0,005. Volumen corriente 512 ± 67:267 ± 72;p = 0,0001. Flujo sangre según posición supino prono 1.053 ± 82:113 ± 112;p = 0,001. No se observó asociación entre flujo sangre y PCO2 (p = 0,2) y entre flujo O2 y PO2 (p = 0,05). Cuidados específicos: monitorizar pulsos pedios y tibiales, mantener integro circuito, prevenir y detectar signos de hemorragia, cuidados del catéter arterial y venoso femoral, vigilar coagulación. Comentarios: Durante el uso del Novalung se consiguió ventilación protectora con volúmenes corrientes bajos, descenso de presión meseta, PEEP e hipercapnia. El flujo de sangre descendió en decúbito prono, pero la PCO2 no se incrementó. El dispositivo no se coaguló (AU)

Objective: To describe the course of a patient with the extracorporeal CO2 removal device and discover the effect of Novalung on ventilation, considering the patient's prone position and its influence on the device's blood flow. To develop a protocol of managing and specific care of a patient with Novalung. Material and methods: A case report of a patient with Novalung in a tertiary hospital ICU unit is reported. Parameters considered are hemodynamic, respiratory, pharmacological, analytical, neuromonitoring, managing of the Novalung and length of decubitus prone cycles. Anova Test, Student's T test, Wilcoxon-Mann Whitney and Spearman correlation. Significance p <0.05.Results: A 46-year old women with nosocomial pneumonia and acute respiratory failure with indication of Novalung to decrease hypercapnia and optimize ventilatory management of refractory hypoxemia. ICU Stay 26 days, MBP 82 ± 9 mmHg, HR 110 ± 6 lpm during the admission, monitoring PICCO 5 days CI 3.2 ± 0.8 l/min/m2, ELWI 33 ± 4 ml, continuous hemofiltration 13.2 days with a median removal 50 cc/h. Norepinephrine dose 0.68 ± 0.79 /kg/min for 15 days. Respiratory parameters during the admission: PO2 59 ± 13 mmHg, PCO2 68 ± 35 mmHg,SatO2 85 ± 12%, PO2/FIO2 69 ± 35, tidal volume 389 ± 141 cc. Novalung 13days, heparin dose 181.42 ± 145 mIU/Kg/min, Cephalin time 57.56 ± 16.41 sec, O2 flow 7 ± 3 l min, median blood flow 1030 cc/h, interquartile range 1447-612 cc/h. Prone cycles 4, duration 53 ± 27 hours. With Novalung PCO2 decreased regardless of position 66 ± 21:56 ± 9,p = 0.005. Tidal volume 512 ± 67:267 ± 72, p = 0.0001. Blood flow on supine-prone position1053 ± 82:113 ± 112, p = 0.001. There was no link between blood flow and PCO2 (p = 0.2) and (p = 0.2) and between O2 and PO2 flow (p = 0.05). Specific care: pedal and tibial pulse monitoring, keep circuit safe to prevent and detect signs of bleeding, femoral arterial and venous catheter care, coagulation monitoring. Comments: During the use of Novalung protective, ventilation, low tidal volumes, decreased pressure plateau, PEEP and hypercapnia were achieved. Blood flow decreased in prone position, but the PCO2 did not increase. The device did not coagulate (AU)

[Decubitus prone position in patient with extracorporeal CO2 removal device Novalung(®)]. / Decúbito prono en paciente portador de dispositivo de extracción extracorpórea de CO(2) Novalung(®).

OBJECTIVE: To describe the course of a patient with the extracorporeal CO2 removal device and discover the effect of Novalung on ventilation, considering the patient's prone position and its influence on the device's blood flow. To develop a protocol of managing and specific care of a patient with Novalung. MATERIAL AND METHODS: A case report of a patient with Novalung in a tertiary hospital ICU unit is reported. Parameters considered are hemodynamic, respiratory, pharmacological, analytical, neuromonitoring, managing of the Novalung and length of decubitus prone cycles. Anova Test, Student's T test, Wilcoxon-Mann Whitney and Spearman correlation. Significance p <0.05. RESULTS: A 46-year old women with nosocomial pneumonia and acute respiratory failure with indication of Novalung to decrease hypercapnia and optimize ventilatory management of refractory hypoxemia. ICU Stay 26 days, MBP 82 ± 9 mmHg, HR 110 ± 6l pm during the admission, monitoring PICCO 5 days CI 3.2 ± 0.8 l/min/m2, ELWI 33 ± 4 ml, continuous hemofiltration 13.2 days with a median removal 50 cc/h. Norepinephrine dose 0.68 ± 0.79 µ/kg/min for 15 days. Respiratory parameters during the admission: PO2 59 ± 13 mmHg, PCO2 68 ± 35 mmHg, SatO2 85 ± 12%, PO2/FIO2 69 ± 35, tidal volume 389 ± 141 cc. Novalung® 13 days, heparin dose 181.42 ± 145 mIU/Kg/min, Cephalin time 57.56 ± 16.41 sec, O2 flow 7 ± 3 l/min, median blood flow 1030 cc/h, interquartile range 1447-612 cc/h. Prone cycles 4, duration 53 ± 27 hours. With Novalung® PCO2 decreased regardless of position 66 ± 21:56 ± 9, p=0.005. Tidal volume 512 ± 67:267 ± 72, p=0.0001. Blood flow on supine-prone position 1053 ± 82:113 ± 112, p=0.001. There was no link between blood flow and PCO2 (p=0.2) and between O2 and PO2 flow (p=0.05). Specific care: pedal and tibial pulse monitoring, keep circuit safe to prevent and detect signs of bleeding, femoral arterial and venous catheter care, coagulation monitoring. COMMENTS: During the use of Novalung protective, ventilation, low tidal volumes, decreased pressure plateau, PEEP and hypercapnia were achieved. Blood flow decreased in prone position, but the PCO2 did not increase. The device did not coagulate.

Monitorización de presiones en técnicas continuas de depuración extrarrenal / Pressure monitoring in continuous renal replacement therapy

IntroducciónLas técnicas de depuración extrarrenal han obtenido grandes avances que han conseguido una ampliación de las indicaciones y una mejora en la tecnología de la monitorización continua de las presiones.ObjetivoEl objetivo del estudio es conocer si existe asociación entre el aumento de las presiones de los circuitos y la duración de éstos.Material y métodosEstudio analítico longitudinal prospectivo, realizado en una unidad de cuidados intensivos polivalente de un hospital terciario, desde octubre de 2008 hasta abril de 2009. Se recogieron datos de filiación de pacientes con técnicas de depuración extrarrenal y valores horarios de: presión de entrada (PE), presión de retorno (PR), presión transmembrana (PTM) y presión prefiltro (PPF). Se utilizó la correlación de Spearman y T de Student.ResultadosSe analizaron 44 sets correspondientes a 11 pacientes (el 45,5% eran hombres y el 54,5% eran mujeres) con un media de edad de 62 años. Se utilizó el mismo catéter de doble luz: GamCath (11 Fr) y la misma terapia: hemodiafiltración venovenosa continua. La media de duración de los circuitos fue de 39h. Los valores de media, mediana, máximo y mínimo de las presiones de la muestra fueron: (-52,17; -52,57; 160 y -256 [milímetros de mercurio] mmHg), PR (98,6; 95,3; 323 y -2mmHg), PTM (58,57; 58,52; 245 y -20mmHg) y PPF (161,76; 159,42; 375 y -13mmHg), respectivamente. Conclusiones: Se demuestra correlación negativa entre la duración de los sets y la media de PR y de PPF. Conclusiones: La muestra obtenida incluía tanto circuitos retirados por tratamiento completo (72h) como por coagulación o cambio en presiones

IntroductionContinuous renal replacement therapy (CRRT) has experienced significant advances that have lead to an increase of its indications and improved the technology used in continued pressures monitoring.AimThis study has aimed to discover if there are any associations between the increase of the circuit pressures and their duration.Materials and methodsA prospective, longitudinal analytic pilot study was conducted in an Intensive Care Unit of a university hospital from October 2008 to April 2009. The study analyzed the patient's information with CRRT and the hourly values of entry pressure (EP), comeback pressure (CP), transmembrane pressure (TMP) and pre-filter pressure (PFP). The Spearman correlation and the Student's T test were used.ResultsThe study analyzed 44 sets corresponding to 11 patients (45.5% men and 54.5% women) with a life expectancy of 62 years. The same light catheter GamCath (11 French) and Continuous Venovenous Hemodiafiltration (CVVHDF) therapy were used in all patients. The mean duration of the circuits was 39h. Mean, median, maximum and minimum values of the sample pressures were: EP:−52.17; −52.57; 160; −256 (millimeters of mercury) mmHg]; CP: (98.6; 95.3; 323; −2mmHg); TMP: (58.57; 58.52; 245; −20mmHg) and PFP: (161.76; 159.42; 375; −13mmHg), respectively.ConclusionsA negative correlation was demonstrated between the duration of the sets and the mean CP and PFP. The sample obtained circuits withdrawn due to finished treatment (72h), and by coagulation or changes in pressures(AU)

[Pressure monitoring in continuous renal replacement therapy]. / Monitorización de presiones en técnicas continuas de depuración extrarrenal.

INTRODUCTION: Continuous renal replacement therapy (CRRT) has experienced significant advances that have lead to an increase of its indications and improved the technology used in continued pressures monitoring. AIM: This study has aimed to discover if there are any associations between the increase of the circuit pressures and their duration. MATERIALS AND METHODS: A prospective, longitudinal analytic pilot study was conducted in an Intensive Care Unit of a university hospital from October 2008 to April 2009. The study analyzed the patient's information with CRRT and the hourly values of entry pressure (EP), comeback pressure (CP), transmembrane pressure (TMP) and pre-filter pressure (PFP). The Spearman correlation and the Student's T test were used. RESULTS: The study analyzed 44 sets corresponding to 11 patients (45.5% men and 54.5% women) with a life expectancy of 62 years. The same light catheter GamCath (11 French) and Continuous Venovenous Hemodiafiltration (CVVHDF) therapy were used in all patients. The mean duration of the circuits was 39 h. Mean, median, maximum and minimum values of the sample pressures were: EP:-52.17; -52.57; 160; -256 (millimeters of mercury) mmHg]; CP: (98.6; 95.3; 323; -2 mmHg); TMP: (58.57; 58.52; 245; -20 mmHg) and PFP: (161.76; 159.42; 375; -13 mmHg), respectively. CONCLUSIONS: A negative correlation was demonstrated between the duration of the sets and the mean CP and PFP. The sample obtained circuits withdrawn due to finished treatment (72 h), and by coagulation or changes in pressures.