RESUMEN
Dada la importancia del manejo de la sedación, analgesia y delirium en las unidades de cuidados intensivos, y con el fin de actualizar las guías publicadas anteriormente, se decidió elaborar una nueva guía de práctica clínica con los soportes, manejos e intervenciones más relevantes acordes con las publicaciones recientes. Para elaborar esta guía, se reunió un grupo de 24 intensivistas procedentes de 9 países de la Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva. Se acogió la propuesta del Grading of Recommendations Assessment, Development and Evaluation Working Group para emitir el grado de recomendación y evaluar la calidad de la evidencia. Se realizó una búsqueda sistemática de la literatura utilizándose: MEDLINE, las siguientes bases de datos de la biblioteca Cochrane: Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects, National Health Service Economic Evaluation Database, y la base de datos de Literatura Latinoamericana y del Caribe en Ciencias de la Salud (LILACS). Finalmente, se seleccionaron 438 referencias, permitiendo realizar 47 recomendaciones fuertes con evidencia alta y moderada, 14 recomendaciones condicionales con evidencia moderada y 65 recomendaciones condicionales con evidencia baja. Se confirma la importancia del manejo inicial y multimodal del dolor, se hace énfasis en la disminución de los niveles de sedación y la utilización de sedación profunda solo en casos específicos. Aumenta la evidencia y recomendaciones para el uso de medicamentos como dexmedetomidina, remifentanil, ketamina, entre otros
Given the importance of the management of sedation, analgesia and delirium in Intensive Care Units, and in order to update the previously published guidelines, a new clinical practice guide is presented, addressing the most relevant management and intervention aspects based on the recent literature. A group of 24 intensivists from 9 countries of the Pan-American and Iberian Federation of Societies of Critical Medicine and Intensive Therapy met to develop the guidelines. Assessment of evidence quality and recommendations was made according to the Grading of Recommendations Assessment, Development and Evaluation Working Group. A systematic search of the literature was carried out using MEDLINE, Cochrane Library databases such as the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Effects, the National Health Service Economic Evaluation Database and the database of Latin American and Caribbean Literature in Health Sciences (LILACS). A total of 438 references were selected. After consensus, 47 strong recommendations with high and moderate quality evidence, 14 conditional recommendations with moderate quality evidence, and 65 conditional recommendations with low quality evidence were established. Finally, the importance of initial and multimodal pain management was underscored. Emphasis was placed on decreasing sedation levels and the use of deep sedation only in specific cases. The evidence and recommendations for the use of drugs such as dexmedetomidine, remifentanil, ketamine and others were incremented
Asunto(s)
Humanos , Delirio/terapia , Analgesia/métodos , Enfermedad Crítica , Sedación Profunda , Unidades de Cuidados Intensivos , Manejo del Dolor , Dexmedetomidina , Remifentanilo , Ketamina , Enfoque GRADE/normasRESUMEN
Given the importance of the management of sedation, analgesia and delirium in Intensive Care Units, and in order to update the previously published guidelines, a new clinical practice guide is presented, addressing the most relevant management and intervention aspects based on the recent literature. A group of 24 intensivists from 9 countries of the Pan-American and Iberian Federation of Societies of Critical Medicine and Intensive Therapy met to develop the guidelines. Assessment of evidence quality and recommendations was made according to the Grading of Recommendations Assessment, Development and Evaluation Working Group. A systematic search of the literature was carried out using MEDLINE, Cochrane Library databases such as the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Effects, the National Health Service Economic Evaluation Database and the database of Latin American and Caribbean Literature in Health Sciences (LILACS). A total of 438 references were selected. After consensus, 47 strong recommendations with high and moderate quality evidence, 14 conditional recommendations with moderate quality evidence, and 65 conditional recommendations with low quality evidence were established. Finally, the importance of initial and multimodal pain management was underscored. Emphasis was placed on decreasing sedation levels and the use of deep sedation only in specific cases. The evidence and recommendations for the use of drugs such as dexmedetomidine, remifentanil, ketamine and others were incremented.
Asunto(s)
Analgesia/métodos , Anestesia/métodos , Enfermedad Crítica/terapia , Delirio/terapia , Analgesia/normas , Anestesia/normas , Benzodiazepinas/administración & dosificación , Sedación Consciente/métodos , Sedación Consciente/normas , Cuidados Críticos/métodos , Cuidados Críticos/normas , Medicina Basada en la Evidencia/normas , Humanos , Hipnóticos y Sedantes/administración & dosificación , Unidades de Cuidados Intensivos , Midazolam/administración & dosificación , Manejo del Dolor/normasRESUMEN
Objetivo: Conocer la práctica clínica real de las UCI españolas en relación con la analgosedación y delirium, y valorar cómo se ajusta a las recomendaciones actuales. Diseño: Estudio transversal descriptivo elaborado mediante encuesta nacional sobre prácticas de analgosedación y delirium de los pacientes ingresados en UCI los días 16 de noviembre de 2013 y 16 de octubre de 2014. Se envió un cuestionario a través de Internet con el aval de la SEMICYUC. Ámbito: UCI tanto públicas como privadas de todo el territorio nacional. Resultados: Se incluyeron un total de 166 UCI y a 1.567 pacientes. El 61,4% de las UCI contaban con un protocolo de sedación. El 75% de las UCI monitorizaban la sedación y agitación, con RASS como la escala empleada con mayor frecuencia. El dolor se monitorizaba en algo más de la mitad de las UCI, pero las escalas conductuales eran de muy baja implantación. El delirium también presentaba un bajo nivel diagnóstico. Entre los pacientes en ventilación mecánica el midazolam continuaba siendo un sedante de muy amplio uso. Conclusiones: Esta encuesta es la primera realizada en España sobre analgosedación y delirium y nos muestra una fotografía sobre estas prácticas, señala algunos aspectos como los relacionados con la monitorización y usos de escalas, junto con el manejo del delirium, en los que los resultados del estudio animan a desarrollar proyectos docentes que acerquen la práctica clínica real a las recomendaciones nacionales e internacionales
Objective: To know the real clinical practice of Spanish ICUs in relation to analgesia, sedation and delirium, with a view to assessing adherence to current recommendations. Design: A descriptive cross-sectional study was carried out based on a national survey on analgesia, sedation and delirium practices in patients admitted to intensive care on 16 November, 2013 and 16 October, 2014. An on-line questionnaire was sent with the endorsement of the SEMICYUC. Setting: Spanish ICUs in public and private hospitals. Results: A total of 166 ICUs participated, with the inclusion of 1567 patients. The results showed that 61.4% of the ICUs had a sedation protocol, and 75% regularly monitored sedation and agitation - the RASS being the most frequently used scale. Pain was monitored in about half of the ICUs, but the behavioral scales were very little used. Delirium monitoring was implemented in few ICUs. Among the patients on mechanical ventilation, midazolam remained a very commonly used agent. Conclusions: This survey is the first conducted in Spain on the practices of analgesia, sedation and delirium. We identified specific targets for quality improvement, particularly concerning the management of sedation and the assessment of delirium
Asunto(s)
Humanos , Femenino , Persona de Mediana Edad , Anciano , Sedación Profunda/métodos , Delirio/tratamiento farmacológico , Unidades de Cuidados Intensivos/estadística & datos numéricos , Cuidados Críticos/métodos , Estudios Transversales , Encuestas y Cuestionarios , Internet/estadística & datos numéricos , Agitación Psicomotora/tratamiento farmacológico , Sociedades Médicas/normas , Propofol , Fentanilo , Acetaminofén , Dipirona , EspañaRESUMEN
OBJECTIVE: To know the real clinical practice of Spanish ICUs in relation to analgesia, sedation and delirium, with a view to assessing adherence to current recommendations. DESIGN: A descriptive cross-sectional study was carried out based on a national survey on analgesia, sedation and delirium practices in patients admitted to intensive care on 16 November, 2013 and 16 October, 2014. An on-line questionnaire was sent with the endorsement of the SEMICYUC. SETTING: Spanish ICUs in public and private hospitals. RESULTS: A total of 166 ICUs participated, with the inclusion of 1567 patients. The results showed that 61.4% of the ICUs had a sedation protocol, and 75% regularly monitored sedation and agitation - the RASS being the most frequently used scale. Pain was monitored in about half of the ICUs, but the behavioral scales were very little used. Delirium monitoring was implemented in few ICUs. Among the patients on mechanical ventilation, midazolam remained a very commonly used agent. CONCLUSIONS: This survey is the first conducted in Spain on the practices of analgesia, sedation and delirium. We identified specific targets for quality improvement, particularly concerning the management of sedation and the assessment of delirium.
Asunto(s)
Analgesia , Sedación Profunda , Delirio/terapia , Anciano , Estudios Transversales , Femenino , Encuestas de Atención de la Salud , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , EspañaRESUMEN
El proyecto denominado «Compromiso por la calidad de las sociedades científicas» impulsado desde el año 2013 por el Ministerio de Sanidad, Servicios Sociales e Igualdad tiene como objetivo disminuir las intervenciones sanitarias innecesarias que no han demostrado eficacia, tienen escasa o dudosa efectividad o no son eficientes. El objetivo de este trabajo es elaborar las recomendaciones de «qué no hacer» seleccionadas para el tratamiento de los pacientes críticos. Se designó un panel de expertos de los 13grupos de trabajo (GT) de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC), elegido por su experiencia clínica o científica para la realización de las recomendaciones. Se analizó la literatura publicada entre los años 2000 y 2017 sobre diferentes cuestiones asociadas a los pacientes críticos. En reuniones de cada GT, los expertos debatieron las propuestas y sintetizaron las conclusiones, que fueron finalmente aprobadas por los GT después de un amplio proceso de revisión interna, realizado durante el primer semestre de 2017. Finalmente, se elaboraron un total de 65 recomendaciones, 5 por cada uno de los 13 GT. Estas recomendaciones se basan en la opinión de expertos y en el conocimiento científico, y pretenden reducir aquellos tratamientos o procedimientos que no aporten valor al proceso asistencial, evitar la exposición de los pacientes críticos a potenciales riesgos y mejorar la adecuación de los recursos sanitarios
The project "Commitment to Quality of Scientific Societies", promoted since 2013 by the Spanish Ministry of Health, seeks to reduce unnecessary health interventions that have not proven effective, have little or doubtful effectiveness, or are not cost-effective. The objective is to establish the "do not do" recommendations for the management of critically ill patients. A panel of experts from the 13 working groups (WGs) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2000 to 2017 was extracted. The clinical evidence was discussed and summarized by the experts in the course of consensus finding of each WG, and was finally approved by the WGs after an extensive internal review process carried out during the first semester of 2017. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and aim to reduce those treatments or procedures that do not add value to the care process; avoid the exposure of critical patients to potential risks; and improve the adequacy of health resources
Asunto(s)
Humanos , Cuidados Críticos/normas , Enfermedad Crítica , Análisis Costo-Beneficio , Cuidados Críticos/métodos , Manejo de la Enfermedad , Apoyo Nutricional , Cuidados Paliativos/normas , Derechos del Paciente , Tecnología de Alto Costo , Cuidado Terminal/normas , Procedimientos InnecesariosRESUMEN
The project "Commitment to Quality of Scientific Societies", promoted since 2013 by the Spanish Ministry of Health, seeks to reduce unnecessary health interventions that have not proven effective, have little or doubtful effectiveness, or are not cost-effective. The objective is to establish the "do not do" recommendations for the management of critically ill patients. A panel of experts from the 13 working groups (WGs) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2000 to 2017 was extracted. The clinical evidence was discussed and summarized by the experts in the course of consensus finding of each WG, and was finally approved by the WGs after an extensive internal review process carried out during the first semester of 2017. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and aim to reduce those treatments or procedures that do not add value to the care process; avoid the exposure of critical patients to potential risks; and improve the adequacy of health resources.
Asunto(s)
Cuidados Críticos/normas , Enfermedad Crítica , Contraindicaciones de los Medicamentos , Contraindicaciones de los Procedimientos , Análisis Costo-Beneficio , Cuidados Críticos/métodos , Manejo de la Enfermedad , Humanos , Apoyo Nutricional , Cuidados Paliativos/normas , Derechos del Paciente , Tecnología de Alto Costo , Cuidado Terminal/normas , Procedimientos InnecesariosRESUMEN
La estandarización de la medicina intensiva puede mejorar el tratamiento del paciente crítico. No obstante, estos programas de estandarización no se han aplicado de forma generalizada en las unidades de cuidados intensivos (UCI). El objetivo de este trabajo es elaborar las recomendaciones para la estandarización del tratamiento de los pacientes críticos. Se seleccionó un panel de expertos de los trece grupos de trabajo (GT) de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC), elegido por su experiencia clínica y/o científica para la realización de las recomendaciones. Se analizó la literatura publicada entre 2002 y 2016 sobre diferentes tópicos de los pacientes críticos. En reuniones de cada GT los expertos discutieron las propuestas y sintetizaron las conclusiones, que fueron finalmente aprobadas por los GT después de un amplio proceso de revisión interna realizado entre diciembre de 2015 y diciembre de 2016. Finalmente, se elaboraron un total de 65 recomendaciones, 5 por cada uno de los 13 GT. Estas recomendaciones se basan en la opinión de expertos y en el conocimiento científico y pretenden servir de guía para los intensivistas como una ayuda en el manejo de los pacientes críticos (AU)
The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients (AU)
Asunto(s)
Humanos , Cuidados Críticos/normas , Enfermedad Crítica/terapia , Pautas de la Práctica en Medicina , Unidades de Cuidados Intensivos/normas , Unidades de Cuidados Coronarios/normas , Privación de Tratamiento/normas , Reanimación Cardiopulmonar/normasRESUMEN
The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.