viernes, 31 de marzo de 2017

Ancianos en UCI / Older ICU patients

Marzo 31, 2017. No. 2645


Daño renal agudo en el anciano en terapia intensiva de un país en desarrollo. Hallazgos clínicos y evolución
Acute kidney injury in elderly intensive care patients from a developing country: clinical features and outcome.
Int J Nephrol Renovasc Dis. 2017 Feb 3;10:27-33. doi: 10.2147/IJNRD.S126534. eCollection 2017.
AIM: The elderly are at high risk of acute kidney injury (AKI) because of structural and functional degeneration over time and with the aging of the population, the demand for intensive care unit (ICU) admission for older patients has risen recently. However, data from developing countries are scarce. This study aimed to describe the incidence of AKI in elderly patients admitted to ICU from a developing country, to determine the most frequent etiologies for renal impairment and identify its risk factors and outcome. METHODS: All patients admitted to the ICU at a Brazilian teaching hospital for 12 consecutive months were followed prospectively from the time of admission until ICU discharge. Elderly was defined as aged >60 years and AKI was defined according to the Kidney Disease Improving Global Outcomes 2012 criteria. Multivariable logistic regression was used to adjust confounding and selection bias. RESULTS: Two hundred elderly patients were included in the study. AKI incidence was 27% and the main etiology was sepsis (48.1%). At logistic regression, baseline creatinine (odds ratio [OR]=5.17, p<0.0001), Acute Physiology and Chronic Health Evaluation (APACHE) II (OR=1.20, p<0.0001), sepsis (OR=2.96, p<0.0001), and longer ICU stay (OR=1.68, p<0.0001) were associated with AKI in elderly patients. Baseline creatinine (OR=1.97, p=0.018), APACHE II (OR=1.29, p<0.0001), sepsis (OR=1.87, p<0.0001), and AKI severity (OR=2.57, p=0.027) were identified as predictors of death. CONCLUSION: AKI was frequent in elderly patients admitted to ICU from a developing country, and it was identified as a risk factor for death. Sepsis was an important risk factor for both AKI and mortality, similar to developed countries and in younger populations.
KEYWORDS: acute kidney injury; elderly; intensive care; mortality

Estimulación de los nutrientes del flujo sanguíneo mesentérico. Implicaciones para los pacientes mayores críticamente enfermos.
Nutrient stimulation of mesenteric blood flow - implications for older critically ill patients.
World J Crit Care Med. 2017 Feb 4;6(1):28-36. doi: 10.5492/wjccm.v6.i1.28. eCollection 2017.
Nutrient ingestion induces a substantial increase in mesenteric blood flow. In older persons (aged ≥ 65 years), particularly those with chronic medical conditions, the cardiovascular compensatory response may be inadequate to maintain systemic blood pressure during mesenteric blood pooling, leading to postprandial hypotension. In older ambulatory persons, postprandial hypotension is an important pathophysiological condition associated with an increased propensity for syncope, falls, coronary vascular events, stroke and death. In older critically ill patients, the administration of enteral nutrition acutely increases mesenteric blood flow, but whether this pathophysiological response is protective, or precipitates mesenteric ischaemia, is unknown. There are an increasing number of olderpatients surviving admission to intensive care units, who are likely to be at increased risk of postprandial hypotension, both during, and after, their stay in hospital. In this review, we describe the prevalence, impact and mechanisms of postprandial hypotension in older people and provide an overview of the impact of postprandial hypotension on feeding prescriptions in older critically ill patients. Finally, we provide evidence that postprandial hypotension is likely to be an unrecognised problem in older survivors of critical illness and discuss potential options for management.
KEYWORDS: Aged; Critical care; Enteral nutrition; Mesenteric ischaemia; Postprandial hypotension

Alteraciones del sueño en los ancianos en terapia intensiva
Sleep disturbance in older ICU patients.
Clin Interv Aging. 2014 Jun 23;9:969-77. doi: 10.2147/CIA.S59927. eCollection 2014.
Maintaining a stable and adequate sleeping pattern is associated with good health and disease prevention. As a restorative process, sleep is important for supporting immune function and aiding the body in healing and recovery. Aging is associated with characteristic changes to sleep quantity and quality, which make it more difficult to adjust sleep-wake rhythms to changing environmental conditions. Sleep disturbance and abnormal sleep-wake cycles are commonly reported in seriously ill older patients in the intensive care unit (ICU). A combination of intrinsic and extrinsic factors appears to contribute to these disruptions. Little is known regarding the effect that sleep disturbance has on health status in the oldest of old (80+), a group, who with diminishing physiological reserve and increasing prevalence of frailty, is at a greater risk of adverse health outcomes, such as cognitive decline and mortality. Here we review how sleep is altered in the ICU, with particular attention to older patients, especially those aged ≥80 years. Further work is required to understand what impact sleep disturbance has on frailty levels and poor outcomes in older critically ill patients.
KEYWORDS: aging; frailty; intensive care unit; sleep; wake rhythm

Prescripción potencialmente inapropiada y el riesgo de reacciones adversas a medicamentos en adultos mayores en estado crítico.
Potentially inappropriate prescribing and the risk of adverse drug reactions in critically ill older adults.
Pharm Pract (Granada). 2016 Oct-Dec;14(4):818. doi: 10.18549/PharmPract.2016.04.818. Epub 2016 Dec 15.
BACKGROUND: Potentially inappropriate medication (PIM) use in the elderly is associated with increased risk of adverse drug reactions (ADRs), but there is limited information regarding PIM use in the intensive care unit (ICU) setting. OBJECTIVE: The aim of the study is to describe the prevalence and factors associated with the use of PIM and the occurrence of PIM-related adverse reactions in the critically ill elderly. METHODS: This study enrolled all critically ill older adults (60 years or more) admitted to medical or cardiovascular ICUs between January and December 2013, in a large tertiary teaching hospital. For all patients, clinical pharmacists listed the medications given during the ICU stay and data on drugs were analyzed using 2012 Beers Criteria, to identify the prevalence of PIM. For each identified PIM the medical records were analyzed to evaluate factors associated with its use. The frequency of ADRs and, the causal relationship between PIM and the ADRs identified were also evaluated through review of medical records. RESULTS: According to 2012 Beers Criteria, 98.2% of elderly patients used at least one PIM (n=599), of which 24.8% were newly started in the ICUs. In 29.6% of PIMs, there was a clinical circumstance that justified their prescription. The number of PIMs was associated with ICU length of stay and total number of medications. There was at least one ADR identified in 17.8% of patients; more than 40% were attributed to PIM, but there was no statistical association. CONCLUSIONS: There is a high prevalence of PIM used in acutely ill older people, but they do not seem to be the major cause of adverse drug reactions in this population. Although many PIMs had a clinical circumstance that led to their prescription during the course of ICU hospitalization, many were still present upon hospital discharge. Therefore, prescription of PIMs should be minimized to improve the safety of elderly patients.
KEYWORDS: Aged; Brazil; Drug-Related Side Effects and Adverse Reactions; Inappropriate Prescribing; Inpatients; Intensive Care Units
Pronóstico y calidad de vida en los ancianos después de terapia intensiva
Prognosis and quality of life of elderly patients after intensive care.
Swiss Med Wkly. 2012 Sep 10;142:w13671. doi: 10.4414/smw.2012.13671.
Ageing of the world's population raises important questions about the utilisation of the health care system. It is not clear how much should be invested in the last years of life whereas the costs are known to increase in parallel. Since intensive care units (ICU) are costly with highly specialised personnel, it seems of paramount importance that they would be used efficiently. Indeed, in the present context of predicted shortage of physicians in Switzerland, society and politics will need evidence that the care provided by ICUs is appropriate. There is no explicit limitation of care in any country according to age and nonagerians are admitted nowadays into ICUs with critical illness. This review article will address the question of elderly patients in ICU and their outcome. Outcome does not imply surviving ICU but only later during the hospital stay and after discharge. Furthermore, we emphasise the need of examining not solely the hospital survival but the quality of life of the patients when they return to their real life. The fundamental questions are actually "Do they go back to life?" "What is life for elderly people?" These questions lead to more basic questions such as "Are they able to go back home or are they institutionalised? How is their quality of life and functional status after ICU?". We tried to address these questions through the existing literature and our experience while caring for these particular patients. Some clues on the prognostic factors related to their outcome are reported.

Curso sobre Anestesia en Trasplantes, Cirugía abdominal, Plástica, Oftalmología y Otorrinolaringología.
Committee for European Education in Anaesthesiology (CEEA) 
y el Colegio de Anestesiólogos de León A.C.
Abril 7-9, 2017, León Guanajuato, México

Informes  (477) 716 06 16,
Congreso Latinoamericano de Anestesia Regional
Asociación Latinoamericana de Anestesia Regional, Capítulo México
Ciudad de México, Mayo 24-27, 2017
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