Seminario de Trauma: Mejores Prácticas en Trauma Abdominal

Avatar Wilfredo GómezWilfredo Gómez Herrera y el Equipo de ViaMedEm   @ViaMedEm

Es para mi persona un agrado tener nuevamente al Seminario de Trauma con nosotros. Durante estos 4 años de realización el Seminario de Trauma se ha convertido en una de los seminarios más importantes del Colegio de Médicos y Cirujanos de Costa Rica en su apartado de actividades académicas. Es durante este seminario que puedo tener contacto con las personas que hacen posible el crecimiento en salud de este país. Cada uno de los asistentes al seminario se esmera por aprender las últimas tendencias en conocimiento para traducirlas, a la cabecera del paciente, en un mejor desenlace para este y su familia. A través de la utilización de estrategias razonadas y filtradas por los expositores de este seminario, se enriquecen no sólo el médico que asiste sino también los Servicios de Emergencias, servicios donde la presencia de personal capacitado es una exigencia, donde la responsabilidad de toma de decisiones “en tiempo real” convive con cada uno de ellos.

_MG_5668Seguiremos colocando un grano de arena en este gran proyecto que es Medicina de Emergencias para que usted esté seguro que en caso de alguna eventualidad podrá ser evaluado por el mejor personal médico del país.

Muchas gracias a todos los asistentes por hacer real una visión que en un futuro será todavía más grande. Los esperamos en las próximas dos ediciones de este #SemTraum15, en el segundo semestre del 2015.

Material Adicional

Adicional a las presentaciones el Seminario de Trauma le proporciona lecturas de interés para complementar la información recibida. Puede descargar con toda libertad la información a continuación.

Management Guidelines for Penetrating Abdominal Trauma

Current Guidelines for Diagnosis in Blunt Abdominal Trauma

Advances in Abdominal Trauma

Focused Assessment with Sonography for Trauma

Eastern Association for the Surgery of Trauma Practice Management Guidelines for Hemorrhage in Pelvic Fracture

 

Human Tools: from Aragón to Chicago!

Last weekend I had the opportunity to represent to the IC-HU Project in the 13th Cinema and Health 2015 Awards. In Zaragoza, we show our first film "Human Tools", within the category of Assets for health.


It was a very rewarding day.

Human Tools had a great acceptance among the public who attended the event. I received many congratulations for the video and I take this opportunity to congrat everybody who made it possible.

Also it was a wonderful experience because I had the opportunity of seeing the rest of works presented, jobs of high quality both in its implementation as in the message transmitted. 

All the videos highlighted the importance that has the human being within the health care system. What important is for the patient that health professional who "is" human and how easy is to ensure that humanity. Differents proposals: with music in a psychiatric hospital, walking with patients in a health centre or simply saying our name to the patient. Motive for reflection for all of us who work in this.

Human Tools received the second prize in its category!

Many thanks to the IC-HU Project.

Dr. Gabriel Tirado.
Intensivist at Hospital Royo Villanova.




And from Zaragoza, thanks to Gabi Tirado who represented us in the Awards. A new example that reflects this Project belong to everybody....Let´s go to Chicago!!!

As you know, Human Tools is our first film and was made for EVO Competition, SMACC Chicago 2015.



After three months in competition, we have finally obtained what we wanted, and...We will be in Chicago!!!


Human Tools is the winner video of the month of March!. But the real award, are more than 3,500 reproductions of the video and which is serving to generate smiles and consciousness.

Many thanks and just remember: #BeSweetBeHuman.

Happy Friday,
Gabi

REMI 2047. ¿Cómo definir y detectar la sepsis?





Artículo originalSystemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis. Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R. N Engl J Med 2015. [Resumen] [Artículos relacionados]
   
Introducción: Desde hace más de 20 años la sepsis se define como la respuesta inflamatoria a la infección, y se manifiesta por la presencia de dos o más criterios de respuesta inflamatoria sistémica (SRIS), con o sin disfunción de órganos [1, 2]; sin embargo, se reconoce que sus manifestaciones clínicas son variadas y heterogéneas [3], y la validez de la definición de sepsis no se ha evaluado de forma sistemática en una base amplia de pacientes.
      
Resumen: A fin de conocer la sensibilidad y validez de los criterios de definición de sepsis se evaluaron 109.663 pacientes con infección y fallo de órganos atendidos en 172 UCI de Australia y Nueva Zelanda entre 2000 y 2013. De ellos, el 12,1% no cumplían criterios de sepsis (menos de 2 criterios de SRIS). La mortalidad fue menor entre los pacientes sin criterios de SRIS, y a lo largo de los 14 años evaluados, la mortalidad disminuyó sustancialmente tanto en pacientes con como sin SRIS (con SRIS: de 36,1% a 18,3%; P < 0,001; sin SRIS: de 27,7% a 9,3%; P < 0,001). La mortalidad aumentó de forma lineal con cada criterio SRIS adicional (OR ajustada 1,13; IC 95% 1,11-1,15; P < 0,001), sin que se apreciara un punto de corte entre < 2 y 2 o más criterios (punto de corte empleado en la definición de sepsis).
      
Comentario: El estudio demuestra que la actualidad definición de sepsis no detecta una octava parte de los pacientes con infección y fallo de órganos, y que el punto de corte en 2 criterios de SRIS para etiquetar al paciente como "séptico" es arbitrario. En la actualidad se están validando herramientas informáticas como alertasepsis®, que pueden ser capaces de detectar una mayor proporción de pacientes con infecciones graves y valorar de forma individualizada el riesgo de muerte.
   
Eduardo Palencia Herrejón
Hospital Universitario Infanta Leonor, Madrid.
© REMI, http://medicina-intensiva.com. Abril 2015.
      
Enlaces:
  1. Palencia Herrejón E. La sepsis: definiciones y estadios. [REMI 2004; 4(6): C1]
  2. The natural history of the systemic inflammatory response syndrome (SIRS). A prospective study. Rangel-Frausto MS, Pittet D, Costigan M, Hwang T, Davis CS, Wenzel RP. JAMA 1995; 273: 117-123. [PubMed]
  3. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G; International Sepsis Definitions Conference. 2001 SCCM/ ESICM/ ACCP/ ATS/ SIS International Sepsis Definitions Conference. Intensive Care Med 2003; 29: 530-538. [PubMed
  4. Palencia Herrejón E. Alertasepsis®, herramienta informática para la detección de la sepsis. [REMI 2014; 14(4): A192]
Búsqueda en PubMed:
  • Enunciado: Criterios de definición de sepsis
  • Sintaxis: sepsis[mh] definition criteria 
  • [Resultados]
       

Variability among ICU in managing patients with preexisting limits on Life-Sustaining therapies

Hello everybody, my dear friends.

Today Iñaki Saralegui share with us the following article recently published in JAMA Internal Medicine: Variability Among US Intensive Care Units 
in Managing the Care of Patients Admitted
 With Preexisting Limits on Life-Sustaining Therapies .

It is a retrospective study that analyzes the data from the IMPACT project, which includes 277.693 patients admitted to 141 ICUs from 105 hospitals in the United States, from 2001 to 2008. Of them 4,8% had some order of limitation on Life-Sustaining Therapies (LLST) prior to the admission in the ICU; the average age of these patients with LLST was superior to the rest and had greater comorbidity and score in predicting mortality. The most common limitation was the order of not attempting CPR (DNR order), subscribed in 77' 4% patients with LLST prior to their admission.

Almost 25% of patients with prior DNR orders received CPR during their stay in the unit. Patients with prior admission DNR order who died in ICU, 15% received CPR. On the other hand, 40% of patients with prior admission LLST received some kind of treatment of life support, such as vasoactive drugs, mechanical ventilation, renal replacement therapy.


These results show that preferences of ICU patients about medical orders LLST-related are not always taken into account when it´s time of making decisions. This may reflect a paternalistic model and a lack of communication between health providers involved in the care of the patient.

On the other hand it is known that many people write advance wills or advance directive documents without the advice of health care staff, hence the elections reflected in these documents are not based on adequate information to adopt them. In these cases it is possible that they don´t help to improve decision-making.



In addition, numerous studies on the planning of care and treatment in United States (Advance Care Planning) indicate that for people who write documents the most important decision is to appoint a representative. This person will be the valid interlocutor with the responsible doctor. In case that the patient requires an admission in the hospital and even in the ICU, medical decision can deviate in appearance from what is expressed in the document, perhaps by the acceptance of a conditioned treatment (in time and amount of treatment) after receiving enough information for a shared decision.

The LLST as medical decision accepted by the patient or the family, or the rejection of treatments expressed in an advance directive document, should be known by all health staff involved and taken into account to adjust treatment.

In the case that the patient change his/her opinion after receiving medical information, or his/her representative agreed with medical staff a treatment plan that may contradict previously expressed is recommended to explain the decision in the medical history.


In Spain there is a great variability in the implementation of protocols and recommendations on care at the end of life in ICU patients, despite the efforts of dissemination of the Bioethics working group of SEMICYUC.

The integration of palliative care in the field of intensive care medicine is far from being ideal.

With respect to the planning of care and treatment, the goal seems more focused on the number of redacted documents than in the process of communication required to make an informed decision. It doesn't seem to be interested if its disclosure in chronic patients is actually helping to adapt the care received in the last months of life to the preferences of the ill person.

A long way to walk, as a team, with the patient and their family as a reference. Values, consensus, uncertainty, care.

Words that should encourage us to improve our daily task.

Dr. Iñaki Saralegui (@InakiSaralegui)
Hospital Universitario de Álava.

My ICU days, by Marina García

July 9th 2014: I open my eyes...

I can´t move my hands, body-wide pain is unbearable, something out of my throat and I am not at home. I don't know where I am or what time is, there are photos of my son and my husband, some drawings with my name, an image of the Virgin of St. Nicholas and a rosary. There is an amethyst and a quartz, as on an altar.

I hear noises, many, I look to one side and I see a device that sounds, many cables out of my body that go to different places

Then comes Fabian. Turn off the machine. He calls me by my name and ask me how I am while he brushes my hair telling me that outside it is dawning.

Two girls of my age come into my room, Lali and Julia are residents and tell me that I'm in CEMIC in the Intensive Care Unit. I was 26 days sleeping and they wonder how I feel. They evaluate my vital signs, help me to move the legs, explained that rest generates a loss of mobility. They are very kind, say that my family is coming and that I am beautiful. All the time doctors come in, thousand of specialties, Sofia, Ignacio, Paul, they are thousands!.

They explain me that I was admitted here with a serious pneumonia, in Toxic Shock by a fairly rare Bacteria (Staphilococcus aureus resistant to Methicillin). They say that I had some complications, and need the respirator longer to heal me. They are positive and explain me everything whenever I ask.

I ask them for juice, I just want to drink fluids but still I can't.

Anyone who come into the room are happy to see me, I don't even know them.

My husband and my family arrive, I get excited...Lili and Edgardo have come also, they are medical friends who always has been allowed to accompany us, end up explaining everything to me, they tell me that I missed the World Football Cup among other things.

I'm aware and begins the arduous path of rehabilitation.

It is not easy, it is too much for body and mind. I ask them to bring me a watch and my music. My desire is fulfilled and things get more entertaining, I can already hear another sound that is not of the teams. Every day come the physiotherapists, Cora, Hernan, Pablo, Susana, Marcelo, Mariano, Melisa, I think I remember them all. With Melissa, I went back to walking, with Cora ate, and thus I memory as each one of them helped me to return my body.

Nurses are awesome people. They tell me things of their lifes to make my time pass more quickly. Quique is from Leo as my husband. Cordobés is from San Lorenzo just like my son, Luis and Angel have a band together, Mariana has twins, Ines a child fan of video games as mine, Mauricio is married to Romina, another nurse and they have a beautiful baby, Patricia spokes me of Buddhism to make me relax. They are thousands I don't remember the names of all, but there is one single that treat me in a bad manner, all made me part of their lifes.

I take home memories from my ICU stay (52 days), of every member of the team. From the Dr. Valentini, Head of theICU until Carina, the girl who was cleaning my room. She has the most cute and long hair have ever seen.


There were difficult moments. I only could think of seeing my son, and the timetable of visit was so short that the days were becoming impossible. Then came Shiry, one of the coordinators and I told her of how distressing were the nights. I cried and she touched my shoulder and after talking several times, she gave me special permission to be accompanied by a family member 24 hours, only my relatives had to commit to not interfere with the work of the team.


From that day, my recovery was very fast. Everyone was surprised. Love they gave me was infinite. When I was discharged, I knew I was never going to forget this team.

I arrived at home, and I understood how difficult is to humanize the care in an Intensive Care Unit: every patient, every family, and every institutional context is different.


But I have no doubt that in my case they did it and this is why today, only 7 months later, I don´t remember the pain and the suffering. I remember these people who saved me life; when they saw my suffer, they calmed my pain, and when they saw me crying they sat on my bed, looked at me in the eyes, they called me by my name. They told me how strong I am and got me a smile while they did their work without forgetting that primarily are people who live to care for people.


Neumonía Adquirida en la Comunidad: variabilidad local en las indicaciones de tratamiento


Me ha gustado este resumen que hacen en el blog Docencia de Rafalafena de la guía sobre la neumonía de la NICE, publicada en 2014. Me ha gustado y también me ha reconfortado porque las indicaciones de tratamiento que hacen son parecidas a las que yo tenía en mi cabeza y que se alejan bastante de lo que se hace habitualmente en nuestro medio. Al menos, en las urgencias hospitalarias.

Esta es la indicación para el tratamiento de las neumonías leves, que son muchas de las que nosotros atendemos:


Sin embargo, en nuestro entorno es muy frecuente iniciar tratamiento con levofloxacino y, además, los dos primeros días se pauta 500/12h y posteriormente 500/24h hasta completar 7 días de tratamiento.

Me preguntaba yo de dónde habría salido esta pauta y creo que ya lo he descubierto, de la Guía de tratamiento empírico de la enfermedades infecciosas elaborado por el Comité de política antibiótica del Hospital Universitario Donostia en el año 2012 y cuya implementación en los hospitales de su entorno me parece que está muy extendida. En esta guía, para las neumonías de bajo riesgo, señalan la pauta que os he comentado. Claro mal no estará, pero me llama la atención que en una publicación, Guía para el tratamiento empírico de las infecciones respiratorias en el ámbito extrahospitalario, que fue publicada por el Servicio de Microbiología del Hospital Donostia hace ya unos años, 2007, el tratamiento indicado teniendo en cuenta las resistencias de "nuestro" S. Pneumoniae fuera el siguiente:


¿Es que ha cambiado tanto el patrón de resistencias? Si fuera así, creo que debiera estar señalado en la guía del 2012. De todas maneras, no parece muy probable vista esta tendencia de disminución de la resistencias del neumococo que aparecía publicada en la guía del 2007.



 Me preocupa si, una vez más, no estaremos matando moscas a cañonazos...

Por cierto, que ya llueve sobre mojado porque en el año ¡¡2010!! ya hicimos una entrada sobre este tema.