REMI 2153. El exceso de sedoanalgesia nocturna dificulta el destete

ARTÍCULO ORIGINAL: Variation in diurnal sedation in mechanically ventilated patients who are managed with a sedation protocol alone or a sedation protocol and daily interruption. Mehta S, Meade M, Burry L, Mallick R, Katsios C, Fergusson D, Dodek P, Burns K, Herridge M, Devlin JW, Tanios M, Fowler R, Jacka M, Skrobik Y, Olafson K, Cook D; SLEAP Investigators and the Canadian Critical Care Trials Group. Crit Care. 2016 Aug 1;20(1):233. doi: 10.1186/s13054-016-1405-3. [Resumen] [Artículos relacionados] [Texto completo]
 
INTRODUCCIÓN: La sobresedación se asocia a mayor riesgo de complicaciones y peores resultados clínicos. Muchos pacientes en ventilación mecánica reciben más sedación durante la noche que durante el día, y esta práctica puede prolongar la duración de la ventilación mecánica, aunque la evidencia en este sentido es muy escasa [1].
    
RESUMEN: Se realizó un análisis secundario de un ensayo clínico que comparaba un protocolo de sedación solo o asociado a interrupción diaria de la sedación [2]. Se incluyeron 423 pacientes críticos en ventilación mecánica que recibían infusión continua de opiáceos y/o benzodiacepinas, ajustadas mediante la medición horaria de las escalas de sedación SAS o RASS para mantener sedación ligera (SAS 3 a 4, RASS -3 a 0). Todos los pacientes fueron evaluados diariamente para la posibilidad de un ensayo de respiración espontánea de forma protocolizada. Los pacientes recibieron mayores dosis de midazolam y opiáceos durante la noche que durante el día, a pesar de mantener niveles similares de sedación y de que la carga de trabajo de enfermería fue similar durante el día y la noche. El uso de sujeciones físicas fue similar durante el día y la noche (76,3 frente a 73,7%; P < 0,0001), pero durante el día hubo más retirada accidental de dispositivos (15,9 frente a 9,1%; P < 0,0001). Mediante análisis multivariante se comprobó que el exceso de sedación nocturna se asoció de manera independiente 1) con la ausencia de criterios de prueba de destete, 2) con el fracaso en la prueba de destete y 3) con la decisión de no extubar a pesar de superar la prueba de destete.
   
COMENTARIO: La principal limitación del estudio es su carácter observacional, y el hecho de ceñirse al uso de midazolam y opiáceos, por lo que sus resultados no se pueden extrapolar al uso de otros fármacos, como el propofol o la dexmedetomidina. Pese a ello, el estudio muestra una vez más cómo la cantidad y calidad de la sedoanalgesia en los pacientes críticos puede influir en desenlaces clínicos importantes. Es necesario revisar las pautas de manejo de la sedoanalgesia nocturna, que no debe interferir con la capacidad del paciente para retomar la respiración espontánea; el abordaje del sueño en el paciente ingresado en la UCI debe promover las iniciativas que faciliten el descanso natural [3].
 
Eduardo Palencia Herrejón
Hospital Universitario Infanta Leonor, Madrid.
© REMI, http://medicina-intensiva.com. Agosto 2016.
      
ENLACES:
  1. Diurnal sedative changes during intensive care: impact on liberation from mechanical ventilation and delirium. Seymour CW, Pandharipande PP, Koestner T, Hudson LD, Thompson JL, Shintani AK, Ely EW, Girard TD. Crit Care Med. 2012 Oct;40(10):2788-96. [PubMed] [Texto completo]
  2. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. Mehta S, Burry L, Cook D, Fergusson D, Steinberg M, Granton J, Herridge M, Ferguson N, Devlin J, Tanios M, Dodek P, Fowler R, Burns K, Jacka M, Olafson K, Skrobik Y, Hébert P, Sabri E, Meade M; SLEAP Investigators; Canadian Critical Care Trials Group. JAMA. 2012 Nov 21;308(19):1985-92. [PubMed] [REMI] [Texto completo]
  3. Iniciativa SueñOn®: [http://suenon.recursosencuidados.es/]
BÚSQUEDA EN PUBMED:
  • Enunciado: Variación diurna de la sedación en pacientes ventilados
  • Sintaxis: diurnal sedation mechanical ventilation
  • [Resultados]

Funtabulously Frivolous Friday Five 156

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 155

Question 1

What is the story behind the Cochrane logo?
cochrane

    • The forest plot within the logo shows one of the first meta analyses done by Cochrane. It was showing the benefit of corticosteroids given to women who are about to give birth prematurely.
    • Despite several trials showing the benefit of corticosteroids, adoption of the treatment among obstetricians was slow. The originally systematic review published by Crowley et al (and subsequently updated) was influential in increasing use of this treatment. This simple intervention has probably saved thousands of premature babies. [Reference]

cochrane logo 2

Question 2

You are doing some home decorating and decide to paint the north wing of your house red. You partner pulls out a colour chart from your bag but what is this chart really used for?
colour chart

  • It is a bed side colour chart to detect the level of methaemoglobin (%)
  • Classically the blood drawn is of a chocolate brown colour.
  • You should match a sample of the blood on tissue or filter paper within 5 minutes of taking the sample. [Reference]

Question 3

What dermatological condition gives you the seven year itch?

  • Okay, arguably a lot of dermatological things might make you itch for 7 years but it has been classically been associated with scabies. [Reference]

Question 4

What is scrivener’s palsy?

  • Otherwise known as writers cramp, a neurological condition caused by frequent handwriting. [Reference]

Question 5

What metabolic disorder couldn’t Hannibal Lecter have had?
Hannibal

  • Glucose-6-phosphate dehydrogenase deficiency; he has a liking for liver with Fava beans!

Last update: Aug 26, 2016 @ 5:39 pm

The post Funtabulously Frivolous Friday Five 156 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Hunting the focus of infection

Finding a focus for infection in a child is one of those things that we all know we ‘must do’.  That can be more difficult than it sounds.  Often, no focus is easily found and then the questions are, “Where do I look?  What if I can't find a focus?  I don’t know when to stop looking!”

How many children are seen with significant temperatures, where the eardrum is not easily seen?   On probability alone, the focus is more likely to be a hidden upper respiratory tract infection rather than something else.  Is probability enough to go on? 

Then there are the things that could be called a focus, but are rather soft signs.  Is a runny nose a focus?  If so, how high is the temperature allowed to be?  What about vomiting and diarrhoea?  Is that a focus in its own right?  You could throw that question out to an audience of primary and secondary care clinicians and I could guarantee that the conversation (if it continued in a way that could be called that) would go on for quite some time.  The outcome would almost certainly be that many would agree to disagree.


If you ask me, the answer depends entirely on the circumstances because the focus of infection is not nearly so important as the global assessment and the specifics of the presentation.  If a child presents early in an illness, is relatively well and has just got a runny nose, then that might be enough to go on.  Good symptom management and careful safety netting are probably the most important things in these cases.

Example 1
A 3 year old has a temperature of 38.2 at home.  They have a runny nose and a cough but no other symptoms.  They have no convincing focus of infection in their throat or ears.  Chest is clear and there is no respiratory distress.  Heart and respiratory rate are normal.  During the consultation, they are running around and playing with the toys.

Example 2
A 3 year old has had a temperature of 38 to 39 on and off for three days.  They have a runny nose and a cough but no other symptoms.  They have no convincing focus of infection in their throat or ears.  Chest is clear and there is no respiratory distress.  Heart and respiratory rate are normal.  They are alert but neither cheerful nor very active.  They have just returned from a three week trip to an area where malaria is endemic.

Who would like to accept the runny nose and cough as a focus in child 2?



So when do I need to find a focus?  Here are a few examples of circumstances in which I would want to have something that is fairly definitive:


My two top tips for finding a focus are:

  1. Repeat the ENT examination unless you have already had really good views of tympanic membranes and pharynx
  2. Check a clean catch urine sample

When deciding about how hard to look and how invasive the search should be, don't start at the beginning, start at the end.  The child in front of you and the clinical scenario determine what the hunt will involve.

Edward Snelson
Variable Venator
@sailordoctor