M.C. Martín Delgado

Recomendaciones de tratamiento al final de la vida del paciente crítico

Admission of a patient in the Intensive Care Unit (ICU) is justified when the critical situation can be reverted or relieved. In spite of this, there is high mortality in the ICU in regard to other hospital departments. End-of-life treatment of critical patients and attention to the needs of their relatives is far from being adequate for several reasons: society denies or hides the death, it is very difficult to predict it accurately, treatment is frequently fragmented between different specialists and there is insufficient palliative medicine training, including communication skills. There are frequent conflicts related to the decisions made regarding the critical patients who are in the end of their life, above all, with the limitation of life-sustaining treatments. Most are conflicts of values between the different parties involved: the patient, his relatives and/or representatives, health professionals, and the institution. The SEMICYUC Working Group of Bioethics elaborates these Recommendations of treatment at the end of the life of the critical patient in order to contribute to the improvement of our daily practice in such a difficult field. After analyzing the role of the agents involved in decision making (patient, familiar, professional, and health care institutions), of the ethical and legal foundations of withholding and withdrawal of treatments, guidelines regarding sedation in the end of the life and withdrawal of mechanical ventilation are recommended. The role of advance directives in intensive medicine is clarified and a written form that reflects the decisions made is proposed.

La calidad y la seguridad de la medicina intensiva en España. Algo más que palabras

Int ensive care medicine aims t o of f er cr i t ical pat ient s qual it y medical care adj ust ed t o t heir needs, and in t he safest way possible. This specialized f ield of medical care const i t ut es one of t he main el ement s of al l modern heal t hcare syst ems, represent ing a resource t hat i s increasingly in demand, and which impl ies import ant sanitary costs. In the United States, it has been est imated that over one-half of the populat ion will be admit ted to an Intensive Care Unit (ICU) at some point in l ife, and that an import ant percent age wi l l die in such Unit s, consuming bet ween 0.5-1% of t he Gross Domest ic Product of t he count ry. 1 In recent years, hospi t als wi t h a t endency t o signi f icant ly reduce t he number of avai lable beds have increased their act ivit ies in Intensive Care. Such act ivity has become consolidated not only in the classical Units but has moreover also spread to other areas with clearly prevent ive aims – such as medical emergency t eams or post -crit ical pat ient cont rol.2 The qual i t y of care has gradual l y become a cent ral element in heal t hcare. In t his cont ext , in recent years, pat ient safet y has gained import ance as one of t he key dimensions of quality. This importance is even more manifest in the case of intensive care medicine, not only due to the

Código ético de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC)

Los estatutos de la SEMICYUC definen a ésta como una Corporación Científico-Médica, formada esencialmente por médicos dedicados a la Medicina Intensiva y carente de ánimo de lucro. Los objetivos fundamentales de la SEMICYUC son: 1. Colaborar en la mejora de los niveles de salud de la población, cooperando en la prevención de los procesos críticos con mayor incidencia en la salud pública. 2. Contribuir a la educación sanitaria de la población, principalmente en relación con la patología grave más frecuente. 3. El estudio teórico y práctico de las enfermedades que entran dentro del marco de la especialidad de Medicina Intensiva. 4. Colaborar en el desarrollo y estructuración de la Medicina Intensiva Crítica y la asistencia sanitaria general. 5. Ayudar a la formación médica en sus diferentes niveles, y de manera muy especial en los programas de formación de médicos especialistas en Medicina Intensiva. 6. Favorecer el perfeccionamiento profesional de todos sus miembros. 7. Representar a sus miembros ante las personas y entidades públicas o privadas, así como asesorarles sobre los aspectos sociales, profesionales, deontológicos, y todos aquellos que se deriven de la práctica de la Medicina Intensiva. 8. Defender los intereses profesionales de sus miembros. 9. Representar a España en las Sociedades Internacionales pertinentes, y a éstas en nuestro país. Todo ello enmarcado en los objetivos generales de la Medicina: − La prevención de la enfermedad y de las lesiones y la promoción y mantenimiento de la salud. − El alivio del dolor y del sufrimiento causado por la enfermedad y las dolencias. − La asistencia y curación de los enfermos y el cuidado de los que no pueden ser curados. − Procurar evitar la muerte prematura y velar por una muerte digna. En este sentido la SEMICYUC propone un código ético para cumplir con los objetivos, expresados en sus estatutos, de una forma razonable y con una base Recomendaciones del grupo de trabajo de ética de la SEMICYUC

Limitación del tratamiento de soporte vital en pacientes con ingreso prolongado en UCI. Situación actual en España a la vista del Estudio EPIPUSE

OBJECTIVE Limitation of life-sustaining treatment (LLST) is a recommended practice in certain circumstances. Limitation practices are varied, and their application differs from one center to another. The present study evaluates the current situation of LLST practices in patients with prolonged admission to the ICU who suffer worsening of their condition. DESIGN A prospective, observational cohort study was carried out. SETTING Seventy-five Spanish ICUs. PATIENTS A total of 589 patients suffering 777 complications or adverse events with organ function impairment after day 7 of admission, during a three-month recruitment period. MAIN VARIABLES OF INTEREST The timing of limitation, the subject proposing LLST, the degree of agreement within the team, the influence of LLST upon the doctor-patient-family relationship, and the way in which LLST is implemented. RESULTS LLST was proposed in 34.3% of the patients presenting prolonged admission to the ICU with severe complications. The incidence was higher in patients with moderate to severe lung disease, cancer, immunosuppressive treatment or dependence for basic activities of daily living. LLST was finally implemented in 97% of the cases in which it was proposed. The decision within the medical team was unanimous in 87.9% of the cases. The doctor-patient-family relationship usually does not change or even improves in this situation. CONCLUSION LLST in ICUs is usually carried out under unanimous decision of the medical team, is performed more frequently in patients with severe comorbidity, and usually does not have a negative impact upon the relationship with the patients and their families.

Condition monitoring system for characterization of electric motor ball bearings with distributed fault using fuzzy inference tools

The present work shows a condition monitoring system applied to electric motors ball bearings. Unlike most of the previous work on this area, which is mainly focused on the location of single-point defects in bearing components - inner and outer races, cage or ball faults -, this research covers wide range irregularities which are very often more difficult to analyse. In addition to traditional techniques like vibration and current signals, high frequency current bearing pulses and acoustic emissions are also analysed. High frequency bearings current pulses are acquired using motors especially modified. This modification isolates ball bearings from the motor stator frame, except for a bearing housing single point connected to ground through a proper cable where the pulses signal is measured. A multivariable fuzzy inference analysis approach is presented to get around the diagnosis difficulty.

Audits in real time for safety in critical care: Definition and pilot study

UNLABELLED Adverse events significantly impact upon mortality rates and healthcare costs. PURPOSE To design a checklist of safety measures based on relevant scientific literature, apply random checklist measures to critically ill patients in real time (safety audits), and determine its utility and feasibility. METHODS A list of safety measures based on scientific literature was drawn up by investigators. Subsequently, a group of selected experts evaluated these measures using the Delphi methodology. Audits were carried out on 14 days over a period of one month. Each day, 50% of the measures were randomly selected and measured in 50% of the randomized patients. Utility was assessed by measuring the changes in clinical performance after audits, using the variable improvement proportion related to audits. Feasibility was determined by the successful completion of auditing on each of the days on which audits were attempted. RESULTS The final verified checklist comprised 37 measures distributed into 10 blocks. The improvement proportion related to audits was reported in 83.78% of the measures. This proportion was over 25% in the following measures: assessment of the alveolar pressure limit, checking of mechanical ventilation alarms, checking of monitor alarms, correct prescription of the daily treatment orders, daily evaluation of the need for catheters, enteral nutrition monitoring, assessment of semi-recumbent position, and checking that patient clinical information is properly organized in the clinical history. Feasibility: rounds were completed on the 14 proposed days. CONCLUSIONS Audits in real time are a useful and feasible tool for modifying clinical actions and minimizing errors.

The quality and safety of intensive care medicine in Spain. More than just words

q a d El objetivo de la medicina intensiva es ofrecer a los enfermos criticos una asistencia sanitaria ajustada a sus necesidades, de calidad y de la manera mas segura posible. La medicina intensiva constituye uno de los principales componentes de los sistemas sanitarios modernos. Es un recurso con una demanda creciente y que conlleva un gasto sanitario elevado. En Estados Unidos se considera que mas de la mitad de la poblacion ingresara en una unidad de cuidados intensivos (UCI) a lo largo de su vida y que un porcentaje importante fallecera en estas unidades, consumiendo entre el 0,5 y el 1% del producto interior bruto del pais1. Los hospitales actuales con tendencia a reducir de forma significativa las camas disponibles han incrementado en los ultimos anos la actividad de la medicina intensiva. Esta actividad no solo se ha consolidado en las unidades clasicas, sino que se ha extendido fuera de sus paredes a otras areas, con objetivos claramente preventivos, como los equipos de emergencias medicas o el control de los pacientes poscriticos2.

Diferencias morales en la toma de decisiones entre los servicios de Medicina Intensiva de los hospitales públicos y privados

Med Intensiva. 2005;29(2):103-5 103 En los hospitales públicos los pacientes deben tener igualdad de acceso a las prestaciones sanitarias. Así lo asegura la Ley General de Sanidad del 25 de abril de 1986 que introduce el principio de universalidad de la asistencia a todos los españoles. Por tanto, estos hospitales deben regir sus criterios bajo el principio de justicia. Las decisiones deben cumplir pues, el ser públicas, a priori y universales, es decir, aplicables a todos por igual, dichas de antemano y ser de conocimiento público. Los hospitales privados se rigen por el principio de beneficencia. En ellos sus criterios se basan en lo que el paciente considere bueno para él. Ello no significa que no deban seguirse otros principios morales, como el de no maleficencia, pero el que marca la pauta de las decisiones es el de beneficencia. En los servicios de Medicina Intensiva (SMI) la muerte está frecuentemente precedida de decisiones de limitación del esfuerzo terapéutico (LET) siendo la retirada de la ventilación mecánica una de las formas más frecuentes de LET. En nuestro medio, la forma de LET más frecuente es la retirada de los fármacos vasoactivos, a continuación el descenso de la fracción inspirada de oxígeno (FIO2) y, en contadas ocasiones, la desconexión del respirador. Diferentes estudios han analizado los factores asociados a la LET, encontrando que la edad, los deseos de los pacientes, la gravedad, la disfunción orgánica crónica y la calidad de vida pasada y futura son sus principales determinantes. En teoría, en los hospitales públicos estas decisiones de LET deberían cumplir, como hemos comentado previamente, criterios de justicia. Es decir, que de una manera global, a los pacientes se les aplicaría LET cuando las posibilidades de supervivencia fueran, por ejemplo, entre el 1% y el 5%, y se haría a todos por igual. Se consideraría pues, fútil, toda intervención terapéutica con estas escasas probabilidades de beneficio basadas en datos científicamente contrastados. Schneiderman et al han propuesto una aproximación cuantitativa al término, considerando fútil si la intervención no produce resultados favorables en más del 1% de los intentos. En nuestro medio, Cabré estudió a 1.340 pacientes con fracaso multiorgánico y analizó su evolución diaria utilizando el SOFA (Sequential Organ Failure Assessment). El autor encontró que si este índice era superior a 10 puntos, la tendencia diaria era mantenerse igual o incrementarse, y en pacientes mayores de 60 años se asociaba con una mortalidad del 98%. En su opinión, sería futil seguir aplicando tratamiento a pacientes con esta mortalidad. Las decisiones de LET en la práctica clínica se enmarcan dentro de lo que se considera como muy escasas probabilidades de recuperación. Sin embargo, si pudiésemos cuantificarlas matemáticamente no estarían muy alejadas de las cifras que propone Schneiderman et al, es decir, en torno al 1%-2%. Cook et al han publicado recientemente en New England Journal of Medicine un estudio que tiene como objetivo estimar los factores clínicos asociados a la decisión de retirada de la ventilación mecáPunto de vista

Motor fault classification system including a novel hybrid feature reduction methodology

The fault diagnosis field is in a continuous movement towards the generation of more reliable and powerful machine health monitoring schemes. Improved data processing methodologies are required to reach high diagnosis demands. For that reason, a contribution in motor fault classification methodology is presented. Different physical magnitudes such as phase currents, voltages and vibrations, are acquired from an electromechanical system based on Brushless DC motor. Statistical features, from time and frequency domains, are calculated to supply a classification algorithm based on Neural Network and enhanced by Genetic Algorithm. The significance of feature space dimensionality, related with the number of used features, for classification success is analyzed. The combination of a feature selection technique (by Sequential Floating Forward Selection), with a feature extraction technique (by Principal Component Analysis), is proposed as a novel hybrid feature reduction methodology to improve the classification performance in electrical machine fault diagnosis. The proposed methodology is validated experimentally and compared with classical feature reduction strategies.

Multidimensional intelligent diagnosis system based on Support Vector Machine Classifier

Heeding the diagnostic requirements of electromechanical systems applied in automotive and aeronautical sectors, a multidimensional diagnostic system based on Support Vector Machine classifier is presented in this paper. In this context, different stationary and non-stationary speed and torque conditions are taken into account over an experimental actuator, in the same way, different single and combined failures scenarios are analyzed. In order to achieve a proper reliability in the diagnosis process, a multidimensional strategy is proposed: currents and vibrations from an electro-mechanical actuator are acquired. A great deal of features is calculated using statistical parameters from the acquired signals in time and frequency domain. Additionally, advanced time-frequency domain analysis techniques, such as Wavelet Packet Transform and Empirical Mode Decomposition, are used to achieve features which provide information in non-stationary conditions. The feature space dimensionality is analyzed by a feature reduction stage based on Partial Least Squares, which optimizes and reduces the feature set to be used for diagnosis proposes. The classification core is based on Support Vector Machine. Moreover, this work provides a performance comparison between the proposed classification algorithm and others such as Neural Network, k- Nearest Neighbor and Classification Trees. Experimental results are presented to demonstrate the feasibility and diagnostic capability of the proposed system.