Ventilación protectiva en pacientes sin ARDS/Protective ventilation in patients without ARDS

Diciembre 8, 2015. No. 2169

PReVENT-ventilación protectiva en pacientes sin ARDS al inicio de la ventilación. Protocolo de estudio para un ensayo aleatorizado y controlado PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Simonis FD, Binnekade JM, Braber A, Gelissen HP, Heidt J, Horn J, Innemee G, de Jonge E,Juffermans NP, Spronk PE, Steuten LM, Tuinman PR, Vriends M, de Vreede G, de Wilde RB, Serpa Neto A, Gama de Abreu M, Pelosi P, Schultz MJ. Trials. 2015 May 24;16:226. doi: 10.1186/s13063-015-0759-1. Abstract BACKGROUND: It is uncertain whether lung-protective mechanical ventilation using low tidal volumes should be used in all critically ill patients, irrespective of the presence of the acute respiratory distress syndrome (ARDS). A low tidal volume strategy includes use of higher respiratory rates, which could be associated with increased sedation needs, a higher incidence of delirium, and an increased risk of patient-ventilator asynchrony and ICU-acquired weakness. Another alleged side-effect of low tidal volume ventilation is the risk of atelectasis. All of these could offset the beneficial effects of low tidal volume ventilation as found in patients with ARDS.METHODS/DESIGN: PReVENT is a national multicenter randomized controlled trial in invasively ventilated ICU patients without ARDS with an anticipated duration of ventilation of longer than 24 hours in 5 ICUs in The Netherlands. Consecutive patients are randomly assigned to a low tidal volume strategy using tidal volumes from 4 to 6 ml/kg predicted body weight (PBW) or a high tidal volume ventilation strategy using tidal volumes from 8 to 10 ml/kg PBW. The primary endpoint is the number of ventilator-free days and alive at day 28. Secondary endpoints include ICU and hospital length of stay (LOS), ICU and hospital mortality, the incidence of pulmonary complications, including ARDS, pneumonia, atelectasis, and pneumothorax, the cumulative use and duration of sedatives and neuromuscular blocking agents, incidence of ICU delirium, and the need for decreasing of instrumental dead space.DISCUSSION: PReVENT is the first randomized controlled trial comparing a low tidal volume strategy with a high tidal volume strategy, in patients without ARDS at onset of ventilation, that recruits a sufficient number of patients to test the hypothesis that a low tidal volume strategy benefits patients without ARDS with regard to a clinically relevant endpoint. TRIAL REGISTRATION: The trial is registered at www.clinicaltrials.gov under reference numberNCT02153294 on 23 May 2014. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Casa Perioperatoria de Cirugía/Perioperative Surgical Home

De regreso a lo básico. La ¨Casa Perioperatoria de Cirugía¨ Back to Basics: The Perioperative Surgical Home. AORN J. 2015 Sep;102(3):262-6; quiz 267-9. doi: 10.1016/j.aorn.2015.06.012. Spruce L. Abstract The Patient Centered Medical Home (PCMH) is designed to improve care for patients, decrease health care costs, and transform the way in which clinicians deliver primary care. The PCMH is a model for primary care delivery that encompasses comprehensive patient-centered care that is coordinated across all settings and provides accessible services and community support as needed with shorter wait times, enhanced hours, and around-the-clock telephone or electronic access for patient needs. In addition, providers use evidence-based practice and clinical decision support tools to provide the best possible care to patients. This article discusses how the model originated and provides a how-to guide and strategies for success in implementing this model of care. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Relajantes neuromusculares en UCI/Neuromuscular blocking agents in ICU

Diciembre 7 2015. No. 2168

Relajantes neuromusculares en pacientes con ARDS. Sumario de las evidencias actuales de tres estudios aleatorizados y controlados Neuromuscular blocking agents in patients with acute respiratory distress syndrome: a summary of the current evidence from three randomized controlled trials. Neto AS1, Pereira VG, Espósito DC, Damasceno MC, Schultz MJ. Ann Intensive Care. 2012 Jul 26;2(1):33. doi: 10.1186/2110-5820-2-33. CONCLUSIONS: The use of NMBA in the early phase of ARDS improves outcome. PDF Mejor evidencia en cuidados intensivos. Papel de los relajantes neuromusculares en la etapa temprana del síndrome de dificultad respiratoria aguda Best evidence in critical care medicine: The role of neuromuscular blocking drugs in early severe acute respiratory distress syndrome. Needham CJ, Brindley PG. Can J Anaesth. 2012 Jan;59(1):105-8. doi: 10.1007/s12630-011-9615-2. Epub 2011 Nov 1. CONCLUSIONS: Treatment in early severe ARDS with the NMBA, cisatracurium, for 48 hr was associated with lower adjusted 90-day mortality. It was also associated with decreased morbidity, which included increased ventilator-free days, increased ICU-free days, and increased organ failure-free days. These benefits occurred without increasing the incidence of ICU-acquired weakness. PDF Sedación y parálisis Sedation and paralysis. Piriyapatsom A1, Bittner EA, Hines J, Schmidt UH. Respir Care. 2013 Jun;58(6):1024-37. doi: 10.4187/respcare.02232. Abstract Sedation is used almost universally in the care of critically ill patients, especially in those who require mechanical ventilatory support or other life-saving invasive procedures. This review will focus on the sedation strategies for critically ill patients and the pharmacology of commonly used sedative agents. The role of neuromuscular blocking agents in the ICU will be examined and the pharmacology of commonly used agents is reviewed. Finally a strategy for rational use of these sedative and neuromuscular blocking agents in critically ill patients will be proposed. KEYWORDS: critical illness; mechanical ventilation; neuromuscular blocking agent; sedation; sedatives PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Cisatracurium

Diciembre 6 2015. No. 2167

Edad y los efectos de bloqueo neuromuscular del cisatracurio Age and the neuromuscular blockading effects of cisatracurium. Guo J, Zhou X, Yuan X, Shen H, Zhang Y. Int J Clin Exp Med. 2015 Sep 15;8(9):16664-16669. Abstract PURPOSE: To investigate the influence of age on the neuromuscular blocking effect of cisatracurium. METHODS: 90 patients with ASA I and II were assigned to the following groups according to their age: adults, children, and infants. Each group was subdivided into three subgroups according to the first dose of cisatracurium. Patients were administrated at a first dose of cisatracurium randomly, and their responses to train-of-four (TOF) stimulation were observed. When the same degree of the first response (T1) continuously repeats three times, the percentage of T1 inhibition was recorded, and the curve of dose-effect relationship and ED95 were calculated. A second dose of cisatracurium was then administrated (total volume 100 μg/kg). The recovery phase in each patient was observed upon T1 reaching the maximum blocking effect (100%). RESULTS: Once the maximum blocking effect was reached, patients were intubated. There were 83 cases (92.2%) of patients with grade 1 and 7 (7.8%) patients with grade 2 intubating conditions. ED95 was 59.29, 55.88 and 45.39 μg/kg in adults, children, and infants, respectively. ED95 positively correlated with age. The clinical duration of neuromuscular blockade, effective action duration of neuromuscular blockade, and in vivo action duration of neuromuscular blockade in adults was longer than that in children (P<0.05), but shorter than in infants (P<0.05). However, there were no significant differences in the recovery index among groups (P>0.05). CONCLUSION: Age influences the neuromuscular blocking effects of cisatracurium to a certain extent. KEYWORDS: Cisatracurium; age; dose-effect relationship; recovery phase PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015