Effect of an Albumin Infusion Treatment Protocol on Delayed Cerebral Ischemia and Relevant Outcomes in Patients with Subarachnoid Hemorrhage

Un protocolo de manejo institucional para pacientes con hemorragia subaracnoidea (HSA) basado en la evaluación cardíaca inicial, la permisividad de los balances negativos de líquidos y el uso de una infusión continua de albúmina como fluidoterapia principal durante los primeros 5 días de estancia en la unidad de cuidados intensivos (UCI). se implementó en nuestro hospital en 2014. Tenía como objetivo lograr y mantener la euvolemia y la estabilidad hemodinámica para prevenir eventos isquémicos y complicaciones en la UCI reduciendo los períodos de hipovolemia o inestabilidad hemodinámica. Este estudio tuvo como objetivo evaluar el efecto del protocolo de manejo implementado sobre la incidencia de isquemia cerebral retardada (ICD), la mortalidad y otros resultados relevantes en pacientes con HSA durante la estancia en la UCI.Q1Background An institutional management protocol for patients with subarachnoid hemorrhage (SAH) based on initial cardiac assessment, permissiveness of negative fluid balances, and use of a continuous albumin infusion as the main fluid therapy for the first 5 days of the intensive care unit (ICU) stay was implemented at our hospital in 2014. It aimed at achieving and maintaining euvolemia and hemodynamic stability to prevent ischemic events and complications in the ICU by reducing periods of hypovolemia or hemodynamic instability. This study aimed at assessing the effect of the implemented management protocol on the incidence of delayed cerebral ischemia (DCI), mortality, and other relevant outcomes in patients with SAH during ICU stay. Methods We conducted a quasi-experimental study with historical controls based on electronic medical records of adults with SAH admitted to the ICU at a tertiary care university hospital in Cali, Colombia. The patients treated between 2011 and 2014 were the control group, and those treated between 2014 and 2018 were the intervention group. We collected baseline clinical characteristics, cointerventions, occurrence of DCI, vital status after 6 months, neurological status after 6 months, hydroelectrolytic imbalances, and other SAH complication. Multivariable and sensitivity analyses that controlled for confounding and considered the presence of competing risks were used to adequately estimate the effects of the management protocol. The study was approved by our institutional ethics review board before study start. Results One hundred eighty-nine patients were included for analysis. The management protocol was associated with a reduced incidence of DCI (hazard ratio 0.52 [95% confidence interval 0.33–0.83] from multivariable subdistribution hazards model) and hyponatremia (relative risk 0.55 [95% confidence interval 0.37–0.80]). The management protocol was not associated with higher hospital or long-term mortality, nor with a higher occurrence of other unfavorable outcomes (pulmonary edema, rebleeding, hydrocephalus, hypernatremia, pneumonia). The intervention group also had lower daily and cumulative administered fluids compared with historic controls (p < 0.0001). Conclusions A management protocol based on hemodynamically oriented fluid therapy in combination with a continuous albumin infusion as the main fluid during the first 5 days of the ICU stay appears beneficial for patients with SAH because it was associated with reduced incidence of DCI and hyponatremia. Proposed mechanisms include improved hemodynamic stability that allows euvolemia and reduces the risk of ischemia, among others.Revista Internacional - IndexadaS

An Umbrella Review With Meta-Analysis of Chest Computed Tomography for Diagnosis of COVID-19: Considerations for Trauma Patient Management

BackgroundRT-PCR testing is the standard for diagnosis of COVID-19, although it has its suboptimal sensitivity. Chest computed tomography (CT) has been proposed as an additional tool with diagnostic value, and several reports from primary and secondary studies that assessed its diagnostic accuracy are already available. To inform recommendations and practice regarding the use of chest CT in the in the trauma setting, we sought to identify, appraise, and summarize the available evidence on the diagnostic accuracy of chest CT for diagnosis of COVID-19, and its application in emergency trauma surgery patients; overcoming limitations of previous reports regarding chest CT accuracy and discussing important considerations regarding its role in this setting.MethodsWe conducted an umbrella review using Living Overview of Evidence platform for COVID-19, which performs regular automated searches in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and more than 30 other sources. The review was conducted following the JBI methodology for systematic reviews. The Grading of Recommendations, Assessment, Development, and Evaluation approach for grading the certainty of the evidence is reported (registered in International Prospective Register of Systematic Reviews, CRD42020198267).ResultsThirty studies that fulfilled selection criteria were included; 19 primary studies provided estimates of sensitivity (0.91, 95%CI = [0.88–0.93]) and specificity (0.73, 95%CI = [0.61; 0.82]) of chest CT for COVID-19. No correlation was found between sensitivities and specificities (ρ = 0.22, IC95% [–0.33; 0.66]). Diagnostic odds ratio was estimated at: DOR = 27.5, 95%CI (14.7; 48.5). Evidence for sensitivity estimates was graded as MODERATE, and for specificity estimates it was graded as LOW.ConclusionThe value of chest CT appears to be that of an additional screening tool that can easily detect PCR false negatives, which are reportedly highly frequent. Upon the absence of PCR testing and impossibility to perform RT-PCR in trauma patients, chest CT can serve as a substitute with increased value and easy implementation.Systematic Review Registration[www.crd.york.ac.uk/prospero], identifier [CRD42020198267]

Effect of an albumin infusion protocol on delayed cerebral ischemia in patients with subarachnoid hemorrhage: a quasi-experimental study with historical controls

Objetivo: Evaluar el efecto de un protocolo de manejo con infusión temprana y continua de albúmina sobre la incidencia de isquemia cerebral tardía (ICT), la mortalidad y el estado neurológico, comparado con el manejo estándar, en pacientes adultos con hemorragia subaracnoidea (HSA). - Diseño: estudio cuasi-experimental con controles históricos, basado en historias clínicas electrónicas. - Lugar: Unidad de cuidado intensivo del Hospital Universitario Fundación Valle del Lili, Cali, Colombia. - Población: Adultos de ambos sexos con HSA confirmada por tomografía computarizada del cerebro o punción lumbar, con hospitalización en la unidad de cuidados intensivos. - Intervención: en 2014 ocurrió la implementación de un protocolo institucional de manejo de HSA con infusión continua de albúmina durante los primeros 5 días para optimizar el manejo hemodinámico de todos los pacientes y prevenir complicaciones como la isquemia cerebral tardía. Se contó con dos periodos de atención a pacientes con HSA, - Medición: se recogió información sobre características clínicas de base y cointervenciones. Se comparó la frecuencia isquemia cerebral tardía, mortalidad en UCI y luego de 6 meses, el uso de líquidos y los desbalances hidroelectrolíticos. Se usaron análisis multivariados primarios y de sensibilidad que controlaron confusión y consideraron la presencia de riesgos en competencia para estimar el efecto del protocolo de manejo. - Resultados: 189 pacientes fueron analizados. La intervención se asoció con una reducción en la ocurrencia de ICT (HR= 0.52, IC95%=[0.33; 0.83], p=0.0056) y de hiponatremia (RR = 0. 55, IC 95% [0.37; 0.80]). No se asoció con mayor mortalidad hospitalaria o a largo plazo, ni tampoco con mayor ocurrencia de otros desenlaces desfavorables (edema pulmonar, resangrado, hidrocefalia, hipernatremia, neumonía). - Conclusiones: el beneficio observado de la intervención en este estudio sustenta la conducción de un experimento clínico aleatorizado para evaluar el efecto de la albúmina en infusión continua en el manejo en UCI de los pacientes con HSA.Objective: To evaluate the effect of a management protocol with early and continuous infusion of albumin on the incidence of late cerebral ischemia (CTI), mortality and neurological status, compared with standard management, in adult patients with subarachnoid hemorrhage (SAH) . - Design: quasi-experimental study with historical controls, based on electronic medical records. - Setting: Intensive care unit of Fundación Valle del Lili University Hospital, Cali, Colombia. - Population: Adults of both sexes with SAH confirmed by computed tomography of the brain or lumbar puncture, with hospitalization in the intensive care unit. - Intervention: in 2014, an institutional protocol for the management of SAH with continuous infusion of albumin during the first 5 days was implemented to optimize the hemodynamic management of all patients and prevent complications such as late cerebral ischemia. There were two periods of care for patients with SAH, - Measurement: information was collected on baseline clinical characteristics and co-interventions. The frequency of late cerebral ischemia, mortality in the ICU and after 6 months, the use of fluids and hydroelectrolytic imbalances were compared. Primary multivariate and sensitivity analyzes controlling for confounding and considering the presence of competing risks were used to estimate the effect of the management protocol. - Results: 189 patients were analyzed. The intervention was associated with a reduction in the occurrence of CTI (HR= 0.52, 95% CI=[0.33; 0.83], p=0.0056) and hyponatremia (RR= 0.55, 95% CI [0.37; 0.80]). It was not associated with higher hospital or long-term mortality, nor with a higher occurrence of other unfavorable outcomes (pulmonary edema, rebleeding, hydrocephalus, hypernatremia, pneumonia). - Conclusions: the observed benefit of the intervention in this study supports the conduct of a randomized clinical trial to evaluate the effect of albumin in continuous infusion in the ICU management of patients with SAHMagíster en Epidemiología ClínicaMaestríahttps://orcid.org/0000-0001-9217-9500https://scholar.google.com/citations?user=DInMQ4oAAAAJ&hl=es&oi=aohttps://scienti.minciencias.gov.co/cvlac/visualizador/generarCurriculoCv.do?cod_rh=000172659

Systematic review and appraisal of clinical practice guidelines on interventional management for low back pain

Objetivo: Realizar una revisión sistemática de la literatura de las guías de práctica clínica basadas en la evidencia para el tratamiento invasivo del dolor lumbar crónico y evaluar la calidad metodológica de las guías y sus recomendaciones. Materiales y métodos: Se realizó una revisión sistemática de la literatura en las bases de datos electrónicas National Guidelines Clearinghouse, National Institute for Clinical Excellence, Cochrane Back Review Group, PubMed, Clinical Evidence y en Google. Se seleccionaron únicamente guías de práctica clínica para el manejo del dolor lumbar crónico que incluyeran tratamiento invasivo, y con la herramienta AGREE-II se realizó una evaluación de la calidad metodológica por los autores de forma independiente. Adicionalmente se compararon las recomendaciones expuestas en las guías para el tratamiento invasivo del dolor lumbar crónico. Resultados: Cinco guías publicadas desde el año 2005 cumplieron los criterios de inclusión y sólo una está dirigida específicamente al manejo intervencionista. De acuerdo al AGREE-II, los dominios 1 (alcance y objetivo) y 6 (independencia editorial) obtuvieron los mayores puntajes, mientras que los dominios dos (participación de los implicados) y cinco (aplicabilidad) fueron los más bajos. Las recomendaciones diagnósticas y de tratamiento no invasivo fueron similares a través de las guías revisadas, sin embargo la evidencia para el manejo intervencionista fue variable e inconsistente. Conclusiones: En general, el desarrollo metodológico de las guías fue satisfactorio y las publicaciones más recientes presentaron una mejor calidad. Sin embargo, falta mayor claridad en los procesos de costo-efectividad, revisión externa e implementación para facilitar su uso y adherencia. Adicionalmente se deben revisar las recomendaciones en el contexto del paciente, pues la mayoría están dirigidas al dolor lumbar inespecífico, lo que altera el grado de evidencia de las intervenciones.Q4Objective: This article presents a systematic review of the literature on evidence based clinical practice guidelines for the interventional management of chronic low back pain and appraisal of the methodological quality of the guidelines and their recommendations. Methods: A systematic literature review was conducted using electronic databases of The National Guidelines Clearinghouse, National Institute for Clinical Excellence, Cochrane Back Review Group, PubMed, Clinical Evidence and Google. Only clinical practice guidelines on chronic low back pain treatment that encompassed interventional management were included. Two individual appraisers used the AGREE-II instrument to assess the methodological quality of the guidelines and also compare the recommendations regarding the invasive management of chronic low back pain. Results: Five guidelines published since 2005 met the inclusion criteria but only one was specific to interventional treatments. According to the AGREE-II, domains 1 (scope and purpose) and 6 (editorial independence) obtained the highest scores, while domains two (Stakeholder involvement) and five (Applicability) ranked lowest. Recommendations regarding diagnosis and non-invasive treatments were similar throughout the guidelines, however the evidence for interventional management was variable and inconsistent. Conclusions: In general guidelines exhibited a satisfactory methodological development and the most recent publications presented a better quality. However there was a consistent lack of clarity regarding cost-effectiveness, external peer review and implementation that we consider limit the adherence and distribution of the guidelines. Additionally, recommendations should be examined in the context of each patient, as per most targeted non-specific low back pain, which alters the level of evidence for the interventions reviewed.https://orcid.org/0000-0002-7439-4116Revista Internacional - IndexadaN

An Umbrella Review With Meta-Analysis of Chest Computed Tomography for Diagnosis of COVID-19: Considerations for Trauma Patient Management.

BACKGROUND: RT-PCR testing is the standard for diagnosis of COVID-19, although it has its suboptimal sensitivity. Chest computed tomography (CT) has been proposed as an additional tool with diagnostic value, and several reports from primary and secondary studies that assessed its diagnostic accuracy are already available. To inform recommendations and practice regarding the use of chest CT in the in the trauma setting, we sought to identify, appraise, and summarize the available evidence on the diagnostic accuracy of chest CT for diagnosis of COVID-19, and its application in emergency trauma surgery patients; overcoming limitations of previous reports regarding chest CT accuracy and discussing important considerations regarding its role in this setting. METHODS: We conducted an umbrella review using Living Overview of Evidence platform for COVID-19, which performs regular automated searches in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and more than 30 other sources. The review was conducted following the JBI methodology for systematic reviews. The Grading of Recommendations, Assessment, Development, and Evaluation approach for grading the certainty of the evidence is reported (registered in International Prospective Register of Systematic Reviews, CRD42020198267). RESULTS: Thirty studies that fulfilled selection criteria were included; 19 primary studies provided estimates of sensitivity (0.91, 95%CI = [0.88-0.93]) and specificity (0.73, 95%CI = [0.61; 0.82]) of chest CT for COVID-19. No correlation was found between sensitivities and specificities (ρ = 0.22, IC95% [-0.33; 0.66]). Diagnostic odds ratio was estimated at: DOR = 27.5, 95%CI (14.7; 48.5). Evidence for sensitivity estimates was graded as MODERATE, and for specificity estimates it was graded as LOW. CONCLUSION: The value of chest CT appears to be that of an additional screening tool that can easily detect PCR false negatives, which are reportedly highly frequent. Upon the absence of PCR testing and impossibility to perform RT-PCR in trauma patients, chest CT can serve as a substitute with increased value and easy implementation. SYSTEMATIC REVIEW REGISTRATION: [www.crd.york.ac.uk/prospero], identifier [CRD42020198267]

Cognitive changes after tap test in patients with normal pressure hydrocephalus: a before-and-after study

Abstract Normal pressure hydrocephalus (NPH) leads to cognitive impairment (CI) as part of its triad of symptoms. Assessment of CI before and after a tap test can be used to inform diagnosis, differentiate NPH symptoms from alternative or concomitant causes of CI, and suggest the potential benefits of valve placement. The aims of this study are: to describe cognitive performance in patients with NPH diagnosis before and after a tap test, and to compare CI between patients with NPH meeting criteria for a dementia diagnosis (D +) and those without criteria for dementia (D−) at both baseline and after the tap-test. We performed a Before-and-after study evaluating clinical features and performance on cognitive tests (CERAD, ADAS-COG, SVF, PVF, ROCF and IFS). We included 76 NPH patients, with a median age of 81 years. 65 patients (87.8%) improved cognitive performance after tap test. ROCF (p = 0.018) and IFS (p < 0.001) scores significantly change after the tap test. Dementia was concomitant in 68.4% of patients. D + group showed higher proportion of patients with altered performance in IFS, PVF, SVF, and ROCF than D- group at baseline (p < 0.05). A significant improvement in SVF and IFS was observed exclusively in the D− group after tap test. Our results suggest that executive function and praxis are the cognitive domains more susceptible to improvement after a tap test in a 24-h interval in NPH patients. Moreover, the D− group showed a higher proportion of improvement after the tap test in executive function and verbal fluency test compared with the D + group

Decision making in the end-of-life care of patients who are terminally ill with cancer – a qualitative descriptive study with a phenomenological approach from the experience of healthcare workers

Background: In Colombia, recent legislation regarding end-of-life decisions includes palliative sedation, advance directives and euthanasia. We analysed which aspects influence health professionals´ decisions regarding end-of-life medical decisions and care for cancer patients. Methods: Qualitative descriptive–exploratory study based on phenomenology using semi-structured interviews. We interviewed 28 oncologists, palliative care specialists, general practitioners and nurses from three major Colombian institutions, all involved in end-of-life care of cancer patients: Hospital Universitario San Ignacio and Instituto Nacional de Cancerología in Bogotá and Hospital Universitario San José in Popayan. Results: When making decisions regarding end-of-life care, professionals consider: 1. Patient’s clinical condition, cultural and social context, in particular treating indigenous patients requires special skills. 2. Professional skills and expertise: training in palliative care and experience in discussing end-of-life options and fear of legal consequences. Physicians indicate that many patients deny their imminent death which hampers shared decision-making and conversations. They mention frequent ambiguity regarding who initiates conversations regarding end-of-life decisions with patients and who finally takes decisions. Patients rarely initiate such conversations and the professionals normally do not ask patients directly for their preferences. Fear of confrontation with family members and lawsuits leads healthcare workers to carry out interventions such as initiating artificial feeding techniques and cardiopulmonary resuscitation, even in the absence of expected benefits. The opinions regarding the acceptability of palliative sedation, euthanasia and use of medications to accelerate death without the patients´ explicit request vary greatly. 3. Conditions of the insurance system: limitations exist in the offer of oncology and palliative care services for important proportions of the Colombian population. Colombians have access to opioid medications, barriers to their application are largely in delivery by the health system, the requirement of trained personnel for intravenous administration and ambulatory and home care plans which in Colombia are rare. Conclusions: To improve end-of-life decision making, Colombian healthcare workers and patients need to openly discuss wishes, needs and care options and prepare caregivers. Promotion of palliative care education and development of palliative care centres and home care plans is necessary to facilitate access to end-of-life care. Patients and caregivers’ perspectives are needed to complement physicians’ perceptions and practices.</p

La humanización de la salud : conceptos, críticas y perspectivas

"Este libro explora los significados, las posibilidades y los límites de la humanización de la salud principalmente desde la perspectiva de la bioética y de las ciencias humanas y sociales, renunciando a la racionalidad empresarial y a la retórica publicitaria que puede tener el concepto. Además, formula propuestas y sugerencias para una verdadera transformación cultural y estructural de las profesiones y de los servicios de salud, cuyo ejercicio supone no solo cuestiones tecnocientíficas y administrativas, sino éticas y morales. Las denuncias sobre la deshumanización de los servicios y de las profesiones de la salud revelan un creciente malestar social por la manera como son tratados los pacientes y los usuarios. Frente a esto, La humanización de la salud: conceptos, críticas y perspectivas subraya la importancia de las humanidades médicas en la reflexión sobre las prácticas, los discursos y el papel de las emociones y lo subjetivo en el campo de la salud. Este libro surge del tercer foro de bioética clínica, historia y filosofía de la medicina, organizado por el Instituto de Bioética de la Pontificia Universidad Javeriana. Las ponencias ampliadas de este foro, escritas desde diversos enfoques, componen las tres partes de esta publicación."Bogot

Treatments for intracranial hypertension in acute brain-injured patients: grading, timing, and association with outcome. Data from the SYNAPSE-ICU study

Purpose: Uncertainties remain about the safety and efficacy of therapies for managing intracranial hypertension in acute brain injured (ABI) patients. This study aims to describe the therapeutical approaches used in ABI, with/without intracranial pressure (ICP) monitoring, among different pathologies and across different countries, and their association with six&nbsp;months mortality and neurological outcome. Methods: A preplanned subanalysis of the SYNAPSE-ICU study, a multicentre, prospective, international, observational cohort study, describing the ICP treatment, graded according to Therapy Intensity Level (TIL) scale, in patients with ABI during the first week of intensive care unit (ICU) admission. Results: 2320 patients were included in the analysis. The median age was 55 (I-III quartiles = 39-69) years, and 800 (34.5%) were female. During the first week from ICU admission, no-basic TIL was used in 382 (16.5%) patients, mild-moderate in 1643 (70.8%), and extreme in 295 cases (eTIL, 12.7%). Patients who received eTIL were younger (median age 49 (I-III quartiles = 35-62) vs 56 (40-69) years, p &lt; 0.001), with less cardiovascular pre-injury comorbidities (859 (44%) vs 90 (31.4%), p &lt; 0.001), with more episodes of neuroworsening (160 (56.1%) vs 653 (33.3%), p &lt; 0.001), and were more frequently monitored with an ICP device (221 (74.9%) vs 1037 (51.2%), p &lt; 0.001). Considerable variability in the frequency of use and type of eTIL adopted was observed between centres and countries. At six&nbsp;months, patients who received no-basic TIL had an increased risk of mortality (Hazard ratio, HR = 1.612, 95% Confidence Interval, CI = 1.243-2.091, p &lt; 0.001) compared to patients who received eTIL. No difference was observed when comparing mild-moderate TIL with eTIL (HR = 1.017, 95% CI = 0.823-1.257, p = 0.873). No significant association between the use of TIL and neurological outcome was observed. Conclusions: During the first week of ICU admission, therapies to control high ICP are frequently used, especially mild-moderate TIL. In selected patients, the use of aggressive strategies can have a beneficial effect on six&nbsp;months mortality but not on neurological outcome