E. Palencia Herrejón

Síndrome de Kounis

Kounis syndrome was described in 1991 by Kounis and Zavras as the coincidental occurrence of acute coronary syndromes with allergic reactions (anaphylactic or anaphylactoid). Today, allergic angina and allergic myocardial infarction are referred to as Kounis syndrome, and the latter has been reported in association with a variety of drugs, insect stings, food, environmental exposures and medical conditions, among other factors. The incidence is not known, as most of the available information comes from case reports or small case series. In this article, the clinical aspects, diagnosis, pathogenesis, related conditions and therapeutic management of the syndrome are discussed.

Recomendaciones para el tratamiento de los pacientes críticos de los Grupos de Trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC)

The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.

El futuro de la Medicina Intensiva

Although Intensive Care Medicine is a young specialty compared with other medical disciplines, it currently plays a key role in the process of care for many patients. Experience has shown that professionals with specific training in Intensive Care Medicine are needed to provide high quality care to critically ill patients. In Europe, important steps have been taken towards the standardization of training programs of the different member states. However, it is now necessary to take one more step forward, that is, the creation of a primary specialty in Intensive Care Medicine. Care of the critically ill needs to be led by specialists who have received specific and complete training and who have the necessary professional competences to provide maximum quality care to their patients. The future of the specialty presents challenges that must be faced with determination, with the main objective of meeting the needs of the population.

The future of intensive medicine

Abstract Although Intensive Care Medicine is a young specialty compared with other medical disciplines, it currently plays a key role in the process of care for many patients. Experience has shown that professionals with specific training in Intensive Care Medicine are needed to provide high quality care to critically ill patients. In Europe, important steps have been taken towards the standardization of training programs of the different member states. However, it is now necessary to take one more step forward, that is, the creation of a primary specialty in Intensive Care Medicine. Care of the critically ill needs to be led by specialists who have received specific and complete training and who have the necessary professional competences to provide maximum quality care to their patients. The future of the specialty presents challenges that must be faced with determination, with the main objective of meeting the needs of the population. Abstract Although Intensive Care Medicine is a young specialty compared with other medical disciplines, it currently plays a key role in the process of care for many patients. Experience has shown that professionals with specific training in Intensive Care Medicine are needed to provide high quality care to critically ill patients. In Europe, important steps have been taken towards the standardization of training programs of the different member states. However, it is now necessary to take one more step forward, that is, the creation of a primary specialty in Intensive Care Medicine. Care of the critically ill needs to be led by specialists who have received specific and complete training and who have the necessary professional competences to provide maximum quality care to their patients. The future of the specialty presents challenges that must be faced with determination, with the main objective of meeting the needs of the population.

Descontaminación: un tratamiento sin indicaciones

The prevention of ventilator-associated pneumonia (VAP) is a priority in the Intensive Care Unit (ICU). To achieve this goal, clinical practice guidelines recommend the simultaneous application of a heterogeneous group of preventive measures of proven effectiveness. That is why we are presently seeing a reduction in VAP incidence to values previously considered unreachable. Better compliance with clinical practice guidelines has resulted in VAP rates approaching zero in multiple studies. Faced with the measures recommended in these guidelines, selective digestive decontamination (SDD), used together with other infection control practices, has shown efficacy in hospitals with high baseline incidence of pneumonia. However, its effectiveness in hospitals with good compliance of clinical practice guidelines and lower rates of VAP is highly unlikely. A serious drawback of DDS is the risk of favoring the selection of resistant microorganisms that can spread easily through the ICU and the hospital. With current standards of infection prevention, DDS is an unnecessary and risky measure, which should not be used on a widespread basis. Those situations in which the DDS may increase the effectiveness of properly implemented standard measures are still unknown.

Diagnosis of delirium in the critical ill

El delirio es la manifestación más frecuente de disfunción del sistema nervioso central en los enfermos crı́ticos y, a pesar de esto, se trata de un problema minusvalorado, cuyo diagnóstico a menudo se pasa por alto en las unidades de cuidados intensivos (UCI). La importancia del delirio en el enfermo crı́tico aún no es del todo conocida, pero se sabe que su presencia es un predictor independiente de mortalidad, estancia prolongada, duración de la ventilación mecánica y deterioro cognitivo tras el alta, después de ajustar frente a covariables como la edad, la gravedad, la existencia de coma o las comorbilidades y el uso de sedantes u opiáceos. El delirio diagnosticado en pacientes que reciben ventilación mecánica se asocia a un aumento de los costes de la hospitalización, y éstos son directamente proporcionales a la duración y a la gravedad del delirio. Sin embargo, es necesario aclarar que la mera asociación estadı́stica entre la presencia de delirio y estos resultados no quiere decir que exista una relación causa-efecto entre ambos. Por todo lo anterior, es importante disponer de herramientas diagnósticas válidas para detectar el delirio en los enfermos crı́ticos. El diagnóstico definitivo se basa en los criterios definidos por la Asociación Psiquiátrica Americana en la 4. versión del Manual diagnóstico y estadı́stico de los trastornos mentales (DSM-IV TR, del inglés Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision). El método de referencia para el diagnóstico de este sı́ndrome es la entrevista realizada por el psiquiatra con el paciente, con la participación activa de éste que, conducida de una forma estructurada, puede consumir unos 30min. Este acto clı́nico puede requerir también la entrevista con el entorno del paciente (familiares y cuidadores). Como ocurre con otras pruebas diagnósticas de referencia, su aplicación en la UCI en la práctica diaria es difı́cil e impráctica. Por este motivo, en los últimos años se han desarrollado herramientas para la detección del delirio que puede aplicar el personal médico y de enfermerı́a que trabaja en la UCI de forma rápida y fiable, incluso en pacientes intubados que reciben ventilación mecánica. De ellas, las más utilizadas son el ‘‘método para la valoración del estado confusional en la UCI’’ (CAM-ICU, del inglés Confusion Assessment Method for the Intensive Care Unit) y los ‘‘criterios para la detección del delirio en cuidados intensivos’’ (IC-DSC, del inglés Intensive Care Delirium Screening Checklist), desarrolladas en idioma inglés en Estados Unidos y Canadá, respectivamente. Las guı́as de práctica clı́nica de sedación y analgesia de la SEMICYUC (Sociedad Española de Medicina Intensiva, Crı́tica y de Unidades Coronarias) recomiendan la monitorización sistemática del delirio en todos los pacientes ingresados en la UCI mediante herramientas como el CAM-ICU o el IC-DSC, ası́ como el establecimiento de un programa de prevención del delirio y su tratamiento precoz. Por su parte, la Federación Panamericana e Ibérica de Sociedades de Medicina Crı́tica y Terapia Intensiva (FEPIMCTI) recomienda utilizar la escala CAM-ICU para valorar el delirio en todos los pacientes graves que no mantienen grados profundos de sedación. La aplicación del CAM-ICU, como cualquier otro método empleado para el diagnóstico del delirio, se basa en la interacción entre el examinador y el examinado, y contiene elementos cuya interpretación puede verse influida por valores culturales y lingüı́sticos, por lo que la traducción a otro idioma requiere una validación formal antes de poder considerarse una herramienta válida en un ámbito sociocultural distinto de aquél en el que se creó. Hasta ahora, la escala CAM-ICU no se habı́a validado en su traducción al español. En el presente número de la revista Medicina Intensiva se presentan 2 estudios independientes de validación de la traducción del CAM-ICU a nuestro idioma. Tobar et al realizaron la traducción y la adaptación cultural del CAM-ICU al español siguiendo las normas ISPOR ARTICLE IN PRESS

Diagnóstico del delirio en el enfermo crítico

El delirio es la manifestación más frecuente de disfunción del sistema nervioso central en los enfermos crı́ticos y, a pesar de esto, se trata de un problema minusvalorado, cuyo diagnóstico a menudo se pasa por alto en las unidades de cuidados intensivos (UCI). La importancia del delirio en el enfermo crı́tico aún no es del todo conocida, pero se sabe que su presencia es un predictor independiente de mortalidad, estancia prolongada, duración de la ventilación mecánica y deterioro cognitivo tras el alta, después de ajustar frente a covariables como la edad, la gravedad, la existencia de coma o las comorbilidades y el uso de sedantes u opiáceos. El delirio diagnosticado en pacientes que reciben ventilación mecánica se asocia a un aumento de los costes de la hospitalización, y éstos son directamente proporcionales a la duración y a la gravedad del delirio. Sin embargo, es necesario aclarar que la mera asociación estadı́stica entre la presencia de delirio y estos resultados no quiere decir que exista una relación causa-efecto entre ambos. Por todo lo anterior, es importante disponer de herramientas diagnósticas válidas para detectar el delirio en los enfermos crı́ticos. El diagnóstico definitivo se basa en los criterios definidos por la Asociación Psiquiátrica Americana en la 4. versión del Manual diagnóstico y estadı́stico de los trastornos mentales (DSM-IV TR, del inglés Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision). El método de referencia para el diagnóstico de este sı́ndrome es la entrevista realizada por el psiquiatra con el paciente, con la participación activa de éste que, conducida de una forma estructurada, puede consumir unos 30min. Este acto clı́nico puede requerir también la entrevista con el entorno del paciente (familiares y cuidadores). Como ocurre con otras pruebas diagnósticas de referencia, su aplicación en la UCI en la práctica diaria es difı́cil e impráctica. Por este motivo, en los últimos años se han desarrollado herramientas para la detección del delirio que puede aplicar el personal médico y de enfermerı́a que trabaja en la UCI de forma rápida y fiable, incluso en pacientes intubados que reciben ventilación mecánica. De ellas, las más utilizadas son el ‘‘método para la valoración del estado confusional en la UCI’’ (CAM-ICU, del inglés Confusion Assessment Method for the Intensive Care Unit) y los ‘‘criterios para la detección del delirio en cuidados intensivos’’ (IC-DSC, del inglés Intensive Care Delirium Screening Checklist), desarrolladas en idioma inglés en Estados Unidos y Canadá, respectivamente. Las guı́as de práctica clı́nica de sedación y analgesia de la SEMICYUC (Sociedad Española de Medicina Intensiva, Crı́tica y de Unidades Coronarias) recomiendan la monitorización sistemática del delirio en todos los pacientes ingresados en la UCI mediante herramientas como el CAM-ICU o el IC-DSC, ası́ como el establecimiento de un programa de prevención del delirio y su tratamiento precoz. Por su parte, la Federación Panamericana e Ibérica de Sociedades de Medicina Crı́tica y Terapia Intensiva (FEPIMCTI) recomienda utilizar la escala CAM-ICU para valorar el delirio en todos los pacientes graves que no mantienen grados profundos de sedación. La aplicación del CAM-ICU, como cualquier otro método empleado para el diagnóstico del delirio, se basa en la interacción entre el examinador y el examinado, y contiene elementos cuya interpretación puede verse influida por valores culturales y lingüı́sticos, por lo que la traducción a otro idioma requiere una validación formal antes de poder considerarse una herramienta válida en un ámbito sociocultural distinto de aquél en el que se creó. Hasta ahora, la escala CAM-ICU no se habı́a validado en su traducción al español. En el presente número de la revista Medicina Intensiva se presentan 2 estudios independientes de validación de la traducción del CAM-ICU a nuestro idioma. Tobar et al realizaron la traducción y la adaptación cultural del CAM-ICU al español siguiendo las normas ISPOR ARTICLE IN PRESS

Pacientes oncológicos ingresados en Unidad de Cuidados Intensivos. Análisis de factores predictivos de mortalidad

OBJECTIVE To analyze the factors influencing in-hospital mortality among cancer patients admitted to an Intensive Care Unit (ICU). DESIGN A retrospective observational study was carried out. SETTING The ICU of a community hospital. PATIENTS Adults diagnosed with solid or hematological malignancies admitted to the ICU, excluding those admitted after scheduled surgery and those with an ICU stay of under 24h. INTERVENTIONS Review of clinical data. VARIABLES OF INTEREST Referring ward and length of stay prior to admission to the ICU, type of tumor, extent, Eastern Cooperative Oncology Group (ECOG) score, reason for ICU admission, severity (SOFA, APACHE-II, SAPS-II), type of therapy received in the ICU, and in-hospital mortality. RESULTS A total of 167 patients (mean age 71.1 years, 62.9% males; 79% solid tumors) were included, of which 61 (36%) died during their hospital stay (35 in the ICU). The factors associated to increased in-hospital mortality were ECOG scores 3-4 (OR 7.23, 95%CI: 1.95-26.87), metastatic disease (OR 3.77, 95%CI: 1.70-8.36), acute kidney injury (OR 3.66, 95%CI: 1.49-8.95) and SOFA score at ICU admission (OR 1.26, 95%CI: 1.10-1.43). A total of 60.3% of the survivors were independent at hospital discharge. CONCLUSIONS In our series, only one-third of the critically ill cancer patients admitted to the ICU died during hospital admission, and more than 50% showed good performance status at hospital discharge. The clinical prognostic factors associated to in-hospital mortality were poor performance status, metastatic disease, SOFA score at ICU admission and acute kidney injury.

Estimación de las necesidades de profesionales médicos en los servicios de medicina intensiva

Departments of Critical Care Medicine are characterized by high medical assistance costs and great complexity. Published recommendations on determining the needs of medical staff in the DCCM are based on low levels of evidence and attribute excessive significance to the structural/welfare approach (physician-to-beds ratio), thus generating incomplete and minimalistic information. The Spanish Society of Intensive Care Medicine and Coronary Units established a Technical Committee of experts, the purpose of which was to draft recommendations regarding requirements for medical professionals in the ICU. The Technical Committee defined the following categories: 1) Patient care-related aspects; 2) Activities outside the ICU; 3) Patient safety and clinical management aspects; 4) Teaching; and 5) Research. A subcommittee was established with experts pertaining to each activity category, defining criteria for quantifying the percentage time of the intensivists dedicated to each task, and taking into account occupational category. A quantitative method was applied, the parameters of which were the number of procedures or tasks and the respective estimated indicative times for patient care-related activities within or outside the context of the DCCM, as well as for teaching and research activities. Regarding non-instrumental activities, which are more difficult to evaluate in real time, a matrix of range versus productivity was applied, defining approximate percentages according to occupational category. All activities and indicative times were tabulated, and a spreadsheet was created that modified a previously designed model in order to perform calculations according to the total sum of hours worked and the hours stipulated in the respective work contract. The competencies needed and the tasks which a Department of Critical Care Medicine professional must perform far exceed those of a purely patient care-related character, and cannot be quantified using structural criteria. The method for describing the 5 types of activity, the quantification of specific tasks, the respective times needed for each task, and the generation of a spreadsheet led to the creation of a management instrument.

Blood purification in the critically ill patient. Prescription tailored to the indication (including the pediatric patient)

We maintain a dynamic position on extracorporeal blood purification therapies (EBPT). Continuous therapies are of choice in the hemodynamically unstable patient. We recommend their early introduction in the course of the disease, and starting with a dose of 30-35mL/kg/h. Above all, however, daily re-evaluation is required of the hemodynamic and metabolic situation and water balance of our patients in order to allow dynamic dose adjustment. Some data suggest that continuous EBPT can favorably influence the clinical course of our patients, even in the absence of acute kidney injury. The potential usefulness of hemofiltration at doses higher than the conventional doses (continuous ultrafiltration >50mL/kg/h or pulses of at least 4h a day to more than 100dosesmL/kg/h) for achieving blood purification has also been commented. We review the possible indications of this technique, together with the peculiarities of implementing these therapies in children.