Respuesta al artículo: La concentración de tratamientos puede mejorar los resultados en cirugía compleja del cáncer

Sr. Editor: Hemos leído con gran interés la editorial de Borras y Guarga1 que creemos expresa el pensamiento de muchos cirujanos de nuestro país^, y con la que coincidimos, al mismo tiempo que quisiéramos hacer una serie de reflexiones constructivas sobre algunos aspectos que no vemos reflejados del todo en la misma. El que la concentración en determinados procedimientos disminuya la mortalidad1 3, ya es una buena razón por sí misma para plantearse la centralización, a pesar de que no todos los estudios lo demuestran4, pero no nos parece suficiente el solo hecho de que el volumen por sí mismo sea el principal criterio que defina el centro de referencia, ya que se pueden operar muchos casos, a nivel individual o de servicio, pero si los resultados no se auditan, se comparan o se hacen públicos, podemos caer en el error de que cantidad no sea igual a calidad3. Desde la Sección de Formación de la Asociación Española de Cirujanos http://www.aecirujanos.es pensamos que las unidades de un servicio que pretenda centralizar procedimientos deberían de estar certificadas al igual que sus profesionales, al mismo tiempo que disponer de tecnología puntera e innovadora que ofrezca las mejores oportunidades de tratamiento a nuestros pacientes, y esto sí que sería un requisito básico para que la centralización tuviese un sentido real, además del volumen, porque significa que los resultados de los profesionales y del centro, están auditados y se pueden ..

A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

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Nurses' perceptions of aids and obstacles to the provision of optimal end of life care in ICU

Contains fulltext : 172380.pdf (publisher's version ) (Open Access

Complicaciones relacionadas con catéteres venosos centrales en niños críticamente enfermos

Objective Placing central venous catheters is essential when managing critically ill children. This paper was thus aimed at identifying the major complications involved in this and determining the incidence of mechanical and infection-related complications associated with central venous catheterization in critically ill children. Material and Methods A descriptive study was undertaken between October 2011 and March 2012 of all new central venous catheters inserted in critically ill children. The definition of central venous catheter infection was based on CDC criteria. Results During the study period 200 central venous catheters were placed, 51 % in male patients, mostly infants; 71 % required mechanical ventilation and 56.5 % medication for hemodynamic support. Respiratory tract infections were the leading diagnosis on admission in 33 % of the cases. Complications were reported in 8.5 % of the children (52 % of these being due to mechanical complication and 48 % to infection). Mechanical complication incidence was 4.5% and eight central venous catheters fulfilled CDC criteria for central line associated blood stream infection (4 % incidence, i.e. 5 per 1,000 catheter/day rate). Conclusions Despite some complications arising from its use, central venous catheter placement is a safe procedure. Mechanical and infection incidence associated with central venous catheter placement should be known, not only because it differs from that regarding adult patients but also because this can help to establish preventative measures for reducing such complications and improving the care of critically ill children

Complicaciones relacionadas con catéteres venosos centrales en niños críticamente enfermos

Objective Placing central venous catheters is essential when managing critically ill children. This paper was thus aimed at identifying the major complications involved in this and determining the incidence of mechanical and infection-related complications associated with central venous catheterization in critically ill children. Material and Methods A descriptive study was undertaken between October 2011 and March 2012 of all new central venous catheters inserted in critically ill children. The definition of central venous catheter infection was based on CDC criteria. Results During the study period 200 central venous catheters were placed, 51 % in male patients, mostly infants; 71 % required mechanical ventilation and 56.5 % medication for hemodynamic support. Respiratory tract infections were the leading diagnosis on admission in 33 % of the cases. Complications were reported in 8.5 % of the children (52 % of these being due to mechanical complication and 48 % to infection). Mechanical complication incidence was 4.5% and eight central venous catheters fulfilled CDC criteria for central line associated blood stream infection (4 % incidence, i.e. 5 per 1,000 catheter/day rate). Conclusions Despite some complications arising from its use, central venous catheter placement is a safe procedure. Mechanical and infection incidence associated with central venous catheter placement should be known, not only because it differs from that regarding adult patients but also because this can help to establish preventative measures for reducing such complications and improving the care of critically ill children

Ten-year Retrospective Study of Treatment of Malignant Colonic Obstructions with Self-expandable Stents

Purpose: To describe the use of self-expandable metallic stents to manage malignant colorectal obstructions and to compare the radiation dose between fluoroscopic guidance of stent placement and combined endoscopic and fluoroscopic guidance. Materials and Methods: From January 1998 to December 2007, 467 oncology patients undergoing colorectal stent placement in a single center were included in the study. Informed consent was obtained in all cases. All procedures were performed with fluoroscopic or combined fluoroscopic and endoscopic guidance. Inclusion criteria were total or partial colorectal obstruction of neoplastic origin. Exclusion criteria were life expectancy shorter than I month, suspicion of perforation, and/or severe colonic neoplastic bleeding. Procedure time and radiation dose were recorded, and technical and clinical success were evaluated. Follow-up was performed by clinical examination and simple abdominal radiographs at 1 day and at I, 3, 6, and 12 months. Results: Of 467 procedures, technical success was achieved in 432 (92.5%). Thirty-five treatments (7.5%) were technical failures, and the patients were advised to undergo surgery. Significant differences in radiation dose and clinical success were found between the fluoroscopy and combined-technique groups (P < .001). Total decompression was achieved in 372 cases, 29 patients showed remarkable improvement, 11 showed slight improvement, and 20 showed clinical failure. Complications were recorded in 89 patients (19%), the most significant were perforation (2.3%) and stent migration (6.9%). Mean interventional time and radiation dose were 67 minutes and 3,378 dGy.cm(2), respectively. Conclusions: Treatment of colonic obstruction with stents requires a long time in the interventional room and considerable radiation dose. Nevertheless, the clinical benefits and improvement in quality of life justify the radiation risk

The Clinical Frailty Scale for mortality prediction of old acutely admitted intensive care patients: a meta-analysis of individual patient-level data.

BACKGROUND: This large-scale analysis pools individual data about the Clinical Frailty Scale (CFS) to predict outcome in the intensive care unit (ICU). METHODS: A systematic search identified all clinical trials that used the CFS in the ICU (PubMed searched until 24th June 2020). All patients who were electively admitted were excluded. The primary outcome was ICU mortality. Regression models were estimated on the complete data set, and for missing data, multiple imputations were utilised. Cox models were adjusted for age, sex, and illness acuity score (SOFA, SAPS II or APACHE II). RESULTS: 12 studies from 30 countries with anonymised individualised patient data were included (n = 23,989 patients). In the univariate analysis for all patients, being frail (CFS ≥ 5) was associated with an increased risk of ICU mortality, but not after adjustment. In older patients (≥ 65 years) there was an independent association with ICU mortality both in the complete case analysis (HR 1.34 (95% CI 1.25-1.44), p < 0.0001) and in the multiple imputation analysis (HR 1.35 (95% CI 1.26-1.45), p < 0.0001, adjusted for SOFA). In older patients, being vulnerable (CFS 4) alone did not significantly differ from being frail. After adjustment, a CFS of 4-5, 6, and ≥ 7 was associated with a significantly worse outcome compared to CFS of 1-3. CONCLUSIONS: Being frail is associated with a significantly increased risk for ICU mortality in older patients, while being vulnerable alone did not significantly differ. New Frailty categories might reflect its "continuum" better and predict ICU outcome more accurately. TRIAL REGISTRATION: Open Science Framework (OSF: https://osf.io/8buwk/ )