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con un seguimiento estricto cl&#237;nico y anal&#237;tico durante las primeras 48-96<span class="elsevierStyleHsp" style=""></span>h&#44; e ingreso precoz en MI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">Inicio de nutrici&#243;n artificial precoz &#40;en las primeras 72<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; utilizando&#44; siempre que sea posible&#44; nutrici&#243;n enteral a trav&#233;s de sonda nasog&#225;strica&#44; nasoyeyunal o transpil&#243;rica<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">11</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">No emplear antibioterapia profil&#225;ctica&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">Indicar el tratamiento quir&#250;rgico fundamentalmente en la necrosis pancre&#225;tica infectada o absceso&#44; intentando posponer la cirug&#237;a hasta el d&#237;a 21 de evoluci&#243;n&#44; si es posible<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">12</span></a>&#46;</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">En el presente estudio quisimos verificar si la aplicaci&#243;n de un protocolo basado en esta Conferencia de Consenso influy&#243; en la evoluci&#243;n cl&#237;nica de los pacientes ingresados por PA en un servicio de MI&#46; Para ello planteamos realizar un an&#225;lisis retrospectivo durante 16 a&#241;os&#44; antes y despu&#233;s de la implantaci&#243;n de un protocolo basado en estas recomendaciones&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">El objetivo primario de este estudio es conocer si las recomendaciones propuestas en la 7&#170; Conferencia de Consenso de la SEMICYUC sobre la Pancreatitis aguda en Medicina Intensiva &#40;09&#47;05&#47;2007&#41;&#44; modificaron la mortalidad&#44; estancia intra UCI y estancia hospitalaria de los pacientes ingresados por PA en un Servicio de Medicina Intensiva&#59; mientras que el objetivo secundario es evaluar si dichas recomendaciones modificaron el manejo de estos pacientes en lo que respecta al ingreso precoz en UCI&#44; uso de nutrici&#243;n enteral precoz&#44; no administrar antibioterapia emp&#237;rica&#44; y posponer la cirug&#237;a hasta el d&#237;a 21 de evoluci&#243;n si es posible&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Pacientes y m&#233;todos</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Objetivos primarios&#58;</span> reflejar si las recomendaciones propuestas en la 7&#46;<span class="elsevierStyleSup">a</span> Conferencia de Consenso de la SEMICYUC sobre la PA en MI &#40;9&#47;05&#47;2007&#41; modificaron la mortalidad hospitalaria&#44; la estancia en MI y la estancia hospitalaria&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Objetivos secundarios&#58;</span> evaluar si las recomendaciones propuestas en la 7&#46;<span class="elsevierStyleSup">a</span> Conferencia de Consenso de la SEMICYUC sobre la PA en MI &#40;9&#47;05&#47;2007&#41; modificaron el manejo de estos pacientes&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Dise&#241;o de estudio</span>&#58; se trata de un estudio observacional&#44; retrospectivo&#44; con un dise&#241;o antes y despu&#233;s en lo que respecta a la 7&#170; Conferencia de Consenso de la SEMICYUC sobre la Pancreatitis aguda en Medicina Intensiva &#40;09&#47;05&#47;2007&#41;&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Poblaci&#243;n a estudio y &#225;mbito de referencia&#58;</span> se ha incluido a todos los pacientes ingresados en el Servicio de Medicina Intensiva del Hospital Donostia por PA&#44; de forma consecutiva&#44; sin que existan criterios de exclusi&#243;n&#46; Se trata de un servicio de Medicina Intensiva con 48 camas&#44; que sirve de referencia a una poblaci&#243;n de 700&#46;000 habitantes&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Periodos de estudio</span>&#58; se ha dividido el periodo de estudio&#44; que va desde el 1 de Enero 2001 hasta 31 Diciembre 2016&#44; en dos periodos&#46; El primero de ellos ser&#237;a el previo a la Conferencia de consenso&#44; entre los a&#241;os 2001 y 2007&#44; y el segundo posterior a la Conferencia de Consenso&#44; entre los a&#241;os 2008 y 2016&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Variables</span>&#46; Se han recogido las siguientes variables en este estudio&#58; variables de filiaci&#243;n &#40;n&#250;mero de paciente&#44; edad&#44; sexo&#41;&#59; periodo de tiempo a estudio &#40;preconferencia de consenso o postconferencia de consenso&#41;&#59; tiempos de ingreso &#40;D&#237;as de ingreso hospital-ingreso UCI&#44; D&#237;as de estancia en UCI&#44; D&#237;as de estancia hospitalaria&#41;&#59; etiolog&#237;a que provoc&#243; el cuadro &#40;biliar&#44; alcoh&#243;lica&#44; idiop&#225;tica&#44; post-CPRE&#44; otras&#41;&#59; grado afectaci&#243;n radiol&#243;gica&#44; medida mediante la escala de Balthazar&#59; scores de gravedad&#44; que incluyen SOFA y APACHE II en las primeras 24 horas&#44; y escala de Ranson&#59; necesidad de ventilaci&#243;n mec&#225;nica &#40;VM&#41; y terapias de reemplazo renal continuas &#40;TRRC&#41;&#59; presi&#243;n intra-abdominal &#40;PIA&#41; m&#225;xima alcanzada durante la estancia en UCI&#59; nutrici&#243;n que se emplea en el paciente a las 48 horas del ingreso &#40;ninguna&#44; enteral&#44; parenteral&#44; mixta&#41;&#59; complicaciones locales que desarrolla el paciente en su estancia hospitalaria &#40;necrosis infectada&#44; hemorragia intraabdominal&#44; perforaci&#243;n de v&#237;scera hueca&#41;&#44; necesidad de cirug&#237;a&#59; fallecimiento y si se presenta&#44; su causa &#40;SIRS inicial&#44; infecci&#243;n pancre&#225;tica&#44; infecci&#243;n nosocomial extrapancre&#225;tica&#44; otros&#41;&#59; desarrollo de sepsis pancre&#225;tica&#59; desarrollo de sepsis extrapancre&#225;tica&#59; uso de antibioterapia emp&#237;rica al ingreso&#44; y gravedad medida mediante la Clasificaci&#243;n basada en Determinantes<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">6</span></a>&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Definiciones aplicadas en este estudio</span><p id="par0080" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">-</span></span><p id="par0085" class="elsevierStylePara elsevierViewall">D&#237;as ingreso hospital-ingreso MI&#58; d&#237;as que transcurrieron desde que el paciente ingres&#243; en un centro hospitalario hasta que ingres&#243; en el Servicio de MI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">-</span></span><p id="par0090" class="elsevierStylePara elsevierViewall">Periodo de protocolo de tratamiento&#58; se establecieron 2 periodos&#44; pre &#40;2001-2007&#41; y post &#40;2007-2016&#41; Conferencia de Consenso&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Etiolog&#237;a&#58;</p></li></ul></p><p id="par0100" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Alcoh&#243;lica&#58; consumo excesivo de alcohol &#40;&#62;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>g&#47;d&#237;a&#41; mantenido durante m&#225;s de 5 a&#241;os&#44; sin otra causa definida de pancreatitis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par0110" class="elsevierStylePara elsevierViewall">Biliar&#58; presencia de c&#225;lculos en la v&#237;a biliar&#44; sin otra causa de pancreatitis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Poscolangiopancreatograf&#237;a retr&#243;grada endosc&#243;pica&#58; pancreatitis que se inici&#243; en los 7 d&#237;as siguientes a la realizaci&#243;n de una colangiopancreatograf&#237;a retr&#243;grada endosc&#243;pica&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par0120" class="elsevierStylePara elsevierViewall">Otras&#58; resto de causas de pancreatitis&#46; Aqu&#237; se incluir&#237;an la pancreatitis postraum&#225;tica&#44; la posquir&#250;rgica y la PA por hipertrigliceridemia&#44; adem&#225;s de otras causas menos frecuentes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par0125" class="elsevierStylePara elsevierViewall">Idiop&#225;tica&#58; cuando no se cumplen los criterios del resto de las etiolog&#237;as&#46;</p></li></ul></p><p id="par0130" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">APACHE II y SOFA&#58; puntuaci&#243;n m&#225;xima obtenida mediante las escalas APACHE II y SOFA durante las primeras 24<span class="elsevierStyleHsp" style=""></span>h de ingreso en MI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Complicaciones locales<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a>&#58; desarrollo&#44; en cualquier momento de su ingreso hospitalario&#44; de necrosis infectada &#40;definida por la presencia de gas en tejido &#91;peri&#93;pancre&#225;tico&#44; un resultado positivo en una tinci&#243;n de Gram o en muestras obtenidas con punci&#243;n-aspiraci&#243;n con aguja fina mediante t&#233;cnicas de imagen&#44; o en muestras obtenidas en quir&#243;fano o en muestras de drenajes&#41;&#44; hemorragia intraabdominal &#40;definida por la presencia de una colecci&#243;n l&#237;quida de densidad sangre por t&#233;cnicas de imagen &#91;TC&#44; RMN&#93;&#44; especialmente si se objetiv&#243; extravasaci&#243;n activa tras la administraci&#243;n de contraste o por la visualizaci&#243;n directa de hemorragia en la cirug&#237;a&#41; o perforaci&#243;n de v&#237;scera hueca &#40;definida por visualizaci&#243;n directa en la cirug&#237;a o por la presencia de alguno de estos hallazgos en las t&#233;cnicas de imagen&#58; neumoperitoneo&#44; presencia de burbujas de gas agrupadas adyacentes a la pared intestinal de un asa&#44; engrosamiento mural y p&#233;rdida de continuidad o discontinuidad en la pared del asa intestinal&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Causa de fallecimiento&#58; SRIS inicial &#40;pacientes que fallecieron por fracaso org&#225;nico originado por la PA en los 7 primeros d&#237;as de ingreso hospitalario&#44; sin que hubiera datos que indicasen infecci&#243;n en la regi&#243;n pancre&#225;tica&#41;&#44; infecci&#243;n pancre&#225;tica &#40;seg&#250;n la definici&#243;n de necrosis infectada dada en el apartado de complicaciones locales&#41;&#44; complicaciones locales &#40;hemorragia intraabdominal o perforaci&#243;n de v&#237;scera hueca&#44; seg&#250;n las definiciones previas &#91;n&#243;tese que la causa de fallecimiento definida como &#171;complicaciones locales&#187; no recogi&#243; la infecci&#243;n pancre&#225;tica&#44; que por su trascendencia constituye una causa diferenciada<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">6&#44;7</span></a>&#93;&#44; infecci&#243;n nosocomial extrapancre&#225;tica &#91;aquella que apareci&#243; durante el ingreso hospitalario&#44; que se manifest&#243; transcurridas 72<span class="elsevierStyleHsp" style=""></span>h o m&#225;s del ingreso del paciente en el hospital&#44; y que en el momento de ingreso del paciente en el hospital no estaba presente ni en periodo de incubaci&#243;n&#93;&#59; en este apartado se incluyeron tanto la infecci&#243;n por cat&#233;ter como la infecci&#243;n respiratoria &#91;principalmente la neumon&#237;a asociada a VM&#93; y la infecci&#243;n urinaria&#46; Para su definici&#243;n se emplearon las definiciones utilizadas por el grupo de trabajo en Enfermedades Infecciosas y Sepsis de la SEMICYUC<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">14&#44;15</span></a>&#46; Uso de VM&#58; definido como la necesidad de VM invasiva en cualquier momento durante la estancia en MI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Uso de TRRC&#58; definido como el uso de TRRC por fracaso renal agudo en cualquier momento de su estancia en MI&#46; En el primer periodo de protocolo &#40;2001-2007&#41; su uso no tuvo criterio definido y se inici&#243; seg&#250;n la decisi&#243;n del m&#233;dico responsable&#46; En el segundo periodo de protocolo &#40;2008-2016&#41; se estableci&#243; como criterio el nivel <span class="elsevierStyleItalic">Failure</span> del RIFLE<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">16</span></a>&#44; por cambios en los protocolos de nuestro servicio de MI para todos los pacientes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Medici&#243;n de PIA&#58; se realiz&#243; utilizando un cat&#233;ter urinario&#44; seg&#250;n las definiciones de la conferencia internacional de expertos en hipertensi&#243;n intraabdominal y s&#237;ndrome compartimental agudo<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">17</span></a>&#46; Se registr&#243; el valor m&#225;s elevado medido durante la estancia en MI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Necesidad de cirug&#237;a&#58; definida por la Conferencia de Consenso de la SEMICYUC sobre PA de 2012<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">10</span></a>&#46; Por protocolo de nuestro hospital&#44; toda cirug&#237;a realizada sobre la celda pancre&#225;tica por complicaciones de la PA exigi&#243; el ingreso previo del paciente en MI&#46; Las principales indicaciones fueron&#58; necrosis infectada o absceso pancre&#225;tico que no pudo ser tratado con t&#233;cnicas de drenaje menos invasivas &#40;step-up&#41;&#44; perforaci&#243;n de v&#237;scera hueca&#44; hemorragia intraabdominal que no pudo ser tratada con t&#233;cnicas endovasculares y s&#237;ndrome compartimental abdominal que no pudo ser tratado con t&#233;cnicas conservadoras&#46;</p></li></ul></p><p id="par0170" class="elsevierStylePara elsevierViewall">El manejo de la necrosis est&#233;ril fue inicialmente conservador&#44; salvo en los casos de m&#225;s de 4 semanas de evoluci&#243;n y persistencia de afectaci&#243;n cl&#237;nica del paciente&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Seg&#250;n el momento en el que se realiz&#243;&#44; la cirug&#237;a se clasific&#243; en precoz&#44; si fue realizada en menos de 21 d&#237;as desde el inicio de la sintomatolog&#237;a&#44; y tard&#237;a&#44; si fue realizada en m&#225;s de 21 d&#237;as desde el inicio de la sintomatolog&#237;a&#46;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">Clasificaci&#243;n Basada en Determinantes<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">4</span></a>&#58;</p></li></ul></p><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pancreatitis aguda leve&#58;</span> se caracteriz&#243; por la ausencia tanto de necrosis &#40;peri&#41;pancre&#225;tica como de fallo org&#225;nico&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pancreatitis aguda moderada&#58;</span> se caracteriz&#243; por la presencia de cualquier tipo de necrosis &#40;peri&#41;pancre&#225;tica est&#233;ril o fallo org&#225;nico transitorio&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pancreatitis aguda grave&#58;</span> se caracteriz&#243; por la presencia de cualquier grado de necrosis &#40;peri&#41;pancre&#225;tica infectada o fallo org&#225;nico persistente&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pancreatitis aguda cr&#237;tica&#58;</span> se caracteriz&#243; por la presencia de necrosis &#40;peri&#41;pancre&#225;tica infectada y fallo org&#225;nico persistente&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">An&#225;lisis estad&#237;stico</span><p id="par0205" class="elsevierStylePara elsevierViewall">Se cre&#243; una base de datos anonimizada que recog&#237;a toda la informaci&#243;n de este estudio&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Se analizaron los datos seg&#250;n la metodolog&#237;a estad&#237;stica correspondiente&#46; Se estimaron las frecuencias absolutas y relativas de las variables cualitativas&#46; Para las variables cuantitativas que siguen una distribuci&#243;n normal&#44; se utiliz&#243; la media y la desviaci&#243;n est&#225;ndar&#46; Para las variables cualitativas con una distribuci&#243;n no param&#233;trica&#44; se emplearon la mediana y los percentiles p25-p75&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">La comparaci&#243;n entre variables cuantitativas se llev&#243; a cabo mediante la prueba T de Student y se emple&#243; ANOVA para el contraste de medias&#46; Cuando las variables no se distribuyeron normalmente se utiliz&#243; el test de Kruskal-Wallis o la U de Mann-Whitney&#46; La comparaci&#243;n de proporciones se realiz&#243; mediante la prueba &#967;<span class="elsevierStyleSup">2</span> o el test exacto de Fisher&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Para determinar la influencia del protocolo aplicado y el periodo de ingreso&#44; y con la idea de evitar factores de confusi&#243;n&#44; se realiz&#243; un an&#225;lisis univariante para conocer cu&#225;les fueron los factores que influyeron en la mortalidad&#46; Posteriormente&#44; aquellas variables con una p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;1 se incluyeron en un an&#225;lisis multivariante de regresi&#243;n log&#237;stica&#46; Los valores perdidos de las variables no recogidas fueron tratados mediante imputaci&#243;n m&#250;ltiple&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Aspectos &#233;ticos y legales</span><p id="par0225" class="elsevierStylePara elsevierViewall">Este estudio fue aprobado por el Comit&#233; de Ensayos Cl&#237;nicos del &#193;rea de Guip&#250;zcoa&#46; Se cumpli&#243; la Ley Org&#225;nica 15&#47;1999 de Protecci&#243;n de Datos de Car&#225;cter Personal y el Real Decreto 994&#47;1999&#44; por el que se aprueba el Reglamento de medidas de seguridad de ficheros automatizados que contengan datos de car&#225;cter personal&#46; Los datos de los pacientes fueron recogidos de forma anonimizada de la base de datos electr&#243;nica&#44; mediante un c&#243;digo num&#233;rico&#46; En ning&#250;n momento se registraron datos identificativos de los pacientes ni hubo forma de entrelazar su filiaci&#243;n y sus datos cl&#237;nicos&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Resultados</span><p id="par0230" class="elsevierStylePara elsevierViewall">Se estudiaron 286 pacientes&#44; 94 en el periodo 2001-2007 y 192 en el periodo 2008-2016&#44; con una edad media de 59 a&#241;os&#44; con predominio de varones&#44; que han presentado un PA de origen principalmente biliar&#44; con una mortalidad hospitalaria global de 23&#44;07&#37;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se muestran las caracter&#237;sticas generales de los pacientes incluidos&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Aplicaci&#243;n del protocolo</span><p id="par0235" class="elsevierStylePara elsevierViewall">La introducci&#243;n del protocolo para el manejo de la PA supuso una disminuci&#243;n de los d&#237;as previos al ingreso en MI&#44; un aumento del uso de nutrici&#243;n enteral y una reducci&#243;n del uso de nutrici&#243;n parenteral&#44; as&#237; como una reducci&#243;n del uso de profilaxis antibi&#243;tica&#46; Sin embargo&#44; no hubo un aumento en la tasa de realizaci&#243;n de cirug&#237;a tard&#237;a &#40;31&#44;4 vs&#46; 26&#44;4&#37;&#44; ns&#41;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se detallan los resultados de la aplicaci&#243;n del protocolo&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Evoluci&#243;n cl&#237;nica seg&#250;n el periodo de estudio</span><p id="par0240" class="elsevierStylePara elsevierViewall">Se observaron cambios entre ambos periodos en lo que respecta a las caracter&#237;sticas de los pacientes&#44; as&#237; como en el n&#250;mero de estos que fueron incluidos&#46; En el segundo periodo&#44; ingres&#243; un mayor n&#250;mero de pacientes y se objetiv&#243; una disminuci&#243;n de la puntuaci&#243;n de Ranson&#44; APACHE II y SOFA en las primeras 24<span class="elsevierStyleHsp" style=""></span>h&#44; con un mayor grado de afectaci&#243;n radiol&#243;gica en la escala de Balthazar&#46; Asimismo&#44; los pacientes incluidos en el segundo periodo tuvieron un mayor porcentaje de PA de origen biliar&#44; con una PIA m&#225;xima menor&#44; un menor uso de VM y una mayor necesidad de TRRC&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">En lo que respecta a los resultados cl&#237;nicos&#44; se evidenci&#243; un descenso de la mortalidad hospitalaria entre ambos periodos &#40;35&#44;1 vs&#46; 17&#44;18&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; con una variaci&#243;n a su vez en las causas de esta&#58; una disminuci&#243;n de infecciones extraabdominales y SRIS inicial en el periodo 2008-2016&#44; con un aumento de las complicaciones locales &#40;perforaci&#243;n intestinal&#44; hemorragia intraabdominal&#41; y otras causas&#46; Al realizar el an&#225;lisis de mortalidad seg&#250;n categor&#237;as de la Clasificaci&#243;n Basada en Determinantes&#44; se observ&#243; un descenso significativo en el subgrupo de las PA graves &#40;37 vs&#46; 19&#44;1&#37;&#41; en este periodo 2008-2016&#46; No se observaron cambios significativos en lo que respecta a la estancia en el Servicio de MI ni en la estancia hospitalaria&#46; La <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> muestra los resultados de forma comparativa entre ambos periodos&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">An&#225;lisis univariante y multivariante de regresi&#243;n log&#237;stica</span><p id="par0250" class="elsevierStylePara elsevierViewall">Como se describe en la metodolog&#237;a&#44; se realiz&#243; primeramente un an&#225;lisis univariante de los diferentes factores relacionados con la mortalidad&#44; tanto cuantitativos como cualitativos &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46; Las variables que se asociaron de forma estad&#237;sticamente significativa con la mortalidad fueron la edad&#44; el APACHE II&#44; la PIA&#44; el SOFA&#44; el Ranson&#44; el periodo de protocolo&#44; la etiolog&#237;a&#44; el uso de VM y TRRC&#44; y la gravedad seg&#250;n la Clasificaci&#243;n Basada en Determinantes&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0255" class="elsevierStylePara elsevierViewall">En el siguiente paso&#44; se realiz&#243; un an&#225;lisis multivariante de regresi&#243;n log&#237;stica &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46; Las variables que presentaron p&#233;rdidas fueron las siguientes&#58; SOFA m&#225;xima en las primeras 24<span class="elsevierStyleHsp" style=""></span>h &#40;87 casos&#44; 30&#44;4&#37;&#41;&#44; PIA m&#225;xima durante su estancia en MI &#40;216 casos&#44; 75&#44;5&#37;&#41;&#44; &#237;ndice de masa corporal &#40;19 casos&#44; 6&#44;64&#37;&#41;&#44; puntuaci&#243;n seg&#250;n la escala de Balthazar &#40;6 casos&#44; 2&#44;10&#37;&#41;&#44; Ranson &#40;37 casos&#44; 12&#44;93&#37;&#41;&#46; Los valores perdidos se trataron mediante imputaci&#243;n m&#250;ltiple para evitar la exclusi&#243;n de casos&#44; salvo la PIA&#44; que debido a su alto porcentaje de p&#233;rdidas fue eliminado directamente del an&#225;lisis multivariante&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0260" class="elsevierStylePara elsevierViewall">El periodo de aplicaci&#243;n del protocolo mostr&#243; una relaci&#243;n estad&#237;sticamente significativa con la mortalidad&#44; para el ingreso en el periodo 2008-2016 frente al periodo 2001-2007 &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46; Otros factores que se relacionaron de forma estad&#237;sticamente significativa fueron la edad&#44; el APACHE II&#44; el uso de VM y la no realizaci&#243;n de cirug&#237;a&#46; La Clasificaci&#243;n Basada en Determinantes mostr&#243; una p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;054&#44; por lo que se consider&#243; no significativo&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Discusi&#243;n</span><p id="par0265" class="elsevierStylePara elsevierViewall">En este art&#237;culo se analiz&#243; la influencia cl&#237;nica que pudiera tener la aplicaci&#243;n de un protocolo para el manejo de los pacientes con PA que ingresan en un servicio de MI&#44; basado en la Conferencia de Consenso SEMICYUC de 2007<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">10</span></a>&#46; Para ello se emple&#243; una serie retrospectiva de 286 pacientes&#44; con un alto porcentaje de formas graves y cr&#237;ticas seg&#250;n la Clasificaci&#243;n Basada en Determinantes<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">4</span></a>&#44; lo que supone una de las series m&#225;s grandes publicadas hasta la actualidad&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Las Recomendaciones de la Conferencia de Consenso describieron varios puntos de mejora para el manejo de los pacientes con PA en MI&#44; como el uso de nutrici&#243;n enteral precoz&#44; el ingreso precoz en MI&#44; el retraso en la cirug&#237;a y el cese de la profilaxis antibi&#243;tica&#46; En este estudio el grado de cumplimentaci&#243;n de los objetivos fue importante en lo que respecta al ingreso precoz&#44; el uso de nutrici&#243;n enteral precoz<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">18</span></a> y el cese en el uso de la profilaxis antibi&#243;tica<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">19&#44;20</span></a>&#44; pero no en la realizaci&#243;n de cirug&#237;a tard&#237;a&#44; lo que supone un punto de mejora para nuestra unidad&#46; La monitorizaci&#243;n protocolizada de la PIA fue otra mejora incluida a partir del a&#241;o 2012&#44; a ra&#237;z del cambio en las Recomendaciones SEMICYUC de ese a&#241;o<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">10&#44;21</span></a>&#44; ya que es conocida su influencia sobre el curso cl&#237;nico de la PA<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">22&#44;23</span></a>&#46; Sin embargo&#44; dado que la recogida de datos fue retrospectiva&#44; hubo un alto porcentaje de casos en los que no se pudo registrar&#44; y se decidi&#243; no incluirlo como resultado de cambio en el manejo de los pacientes ni incluirlo en el an&#225;lisis multivariante&#46; El manejo mediante t&#233;cnicas no invasivas o m&#237;nimamente invasivas de la necrosis pancre&#225;tica infectada se inici&#243; el a&#241;o 2013<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">12</span></a> y pudo haber influido en los resultados finales&#44; pero no se estudi&#243; espec&#237;ficamente en este trabajo&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">En lo que respecta a los resultados cl&#237;nicos&#44; se observaron cambios importantes entre los periodos 2001-2007 y 2008-2016&#58; un aumento en el n&#250;mero de casos&#44; con una reducci&#243;n en los marcadores de gravedad&#44; y un descenso llamativo de la mortalidad hospitalaria&#44; con cambios en sus causas&#46; De forma llamativa&#44; no hubo cambios significativos en lo que se refiere a la estancia en MI y la estancia hospitalaria entre ambos periodos&#46; Es por ello que la interpretaci&#243;n de los datos debe hacerse con mucha precauci&#243;n&#46; Se registr&#243; una reducci&#243;n relativa de la mortalidad del 50&#37; entre ambos periodos de protocolo&#44; con una mortalidad hospitalaria absoluta inferior al 20&#37; en el segundo&#46; Esta mortalidad fue muy inferior a la descrita en otras series&#58; por ejemplo&#44; Bumbasirevic et al&#46; describieron una mortalidad del 53&#44;6&#37; para pacientes con PA en MI<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a>&#59; un estudio multic&#233;ntrico reciente en 46 servicios de MI present&#243; una mortalidad del 28&#44;7&#37;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a>&#46; Si se analizan las categor&#237;as de la Clasificaci&#243;n Basada en Determinantes&#44; la reducci&#243;n de la mortalidad fue significativa en el caso de las PA graves&#44; y la mortalidad que presentaron los pacientes con PA grave y cr&#237;tica en este estudio fue inferior a la recogida en otras series<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">24&#8211;28</span></a>&#46; Con ello&#44; parece que el descenso de la mortalidad no se debi&#243; &#250;nicamente a un mayor ingreso de formas m&#225;s leves en el periodo 2008-2016&#44; sino que pudiera estar tambi&#233;n en relaci&#243;n con un mejor manejo de los pacientes&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Asimismo&#44; se registraron cambios en la causa de mortalidad&#44; ya que se redujo mucho tanto la debida a infecci&#243;n extraabdominal como por SRIS inicial&#44; y aument&#243; la mortalidad por complicaciones locales &#40;perforaci&#243;n intestinal&#44; hemorragia intraabdominal&#41;&#46; Creemos que el ingreso precoz&#44; junto con la mejora en las medidas de soporte&#44; pudo justificar la reducci&#243;n de mortalidad por SRIS inicial&#44; tal y como han descrito otros autores<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">9&#44;29&#8211;31</span></a>&#46; En lo que respecta a las complicaciones locales&#44; no hubo cambios significativos en el porcentaje de pacientes que desarrollaron las mismas entre ambos periodos&#44; ni en su mortalidad&#44; siendo similar al descrito en otras series<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">30&#8211;32</span></a>&#46; Sin embargo&#44; hubo un aumento en el peso porcentual sobre la mortalidad global de los pacientes fallecidos por perforaci&#243;n intestinal y hemorragia intraabdominal&#46; En ello pudo haber contribuido el descenso de la mortalidad por SRIS inicial e infecci&#243;n extraabdominal&#44; y la dificultad de tratamiento que presentan estas complicaciones&#44; adem&#225;s de su aparici&#243;n tard&#237;a&#44; en pacientes que ya mostraban una afectaci&#243;n org&#225;nica importante&#44; y necrosis infectada&#44; previamente tratada en muchas ocasiones&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">Dado que pudo haber factores de confusi&#243;n que explicaran la reducci&#243;n de la mortalidad entre ambos periodos&#44; se llev&#243; a cabo un an&#225;lisis multivariante mediante regresi&#243;n log&#237;stica&#44; en el cual el periodo de tratamiento se mantuvo como variable&#44; relacionado de forma significativa con la mortalidad hospitalaria&#46; Este an&#225;lisis multivariante present&#243; varias limitaciones&#44; m&#225;s trat&#225;ndose de una recogida de datos retrospectiva&#46; Los valores perdidos fueron escasos&#44; salvo para la variable SOFA&#44; m&#225;xima en las primeras 24<span class="elsevierStyleHsp" style=""></span>h de estancia en MI&#44; y fueron tratadas mediante imputaci&#243;n m&#250;ltiple&#46; Como se ha descrito previamente&#44; la PIA m&#225;xima recogida fue excluida directamente por su alto porcentaje de casos perdidos&#44; lo que pudo haber influido en el resultado final&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">Adem&#225;s de la naturaleza retrospectiva del estudio y la influencia potencial de los valores perdidos&#44; hubo otras limitaciones que hacen que los buenos resultados en la reducci&#243;n de la mortalidad deban ser interpretados con mucha cautela&#46; Como se ha indicado anteriormente&#44; en el periodo de protocolo 2008-2016 se registr&#243; un cambio en el perfil cl&#237;nico de los pacientes&#44; con un mayor n&#250;mero de estos y una reducci&#243;n de la gravedad medida mediante APACHE II&#44; SOFA y Ranson&#44; probablemente asociado a un ingreso m&#225;s precoz&#46; Adem&#225;s&#44; hubo cambios en la etiolog&#237;a de estos pacientes&#44; un menor uso de VM y un mayor uso de TRRC&#46; El mayor uso de TRRC se debi&#243; a cambios generales de nuestro servicio de MI&#44; al establecer como criterio de inicio de TRRC el criterio <span class="elsevierStyleItalic">Failure</span> del RIFLE&#46; Existen estudios que evidencian que el uso de TRRC puede reducir la mortalidad de los casos de PA m&#225;s graves&#44; lo que pude haber influido en nuestros resultados<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">33&#44;34</span></a>&#46; Por a&#241;adidura&#44; el largo periodo de recogida de datos y su naturaleza unic&#233;ntrica hizo que otros cambios generales pudieran haber condicionado nuestros resultados&#44; y no las hubi&#233;ramos estudiado&#44; como las pol&#237;ticas de seguridad&#44; o las campa&#241;as de reducci&#243;n de infecciones nosocomiales<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">35&#44;36</span></a>&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Resultar&#237;a interesante que la experiencia recogida en nuestro centro fuera corroborada en otros hospitales o fuera estudiada en series multic&#233;ntricas amplias&#44; de forma prospectiva y en un menor periodo de tiempo&#44; para ver si se consigue una mejor&#237;a en la evoluci&#243;n cl&#237;nica de los pacientes con PA en MI&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conclusiones</span><p id="par0300" class="elsevierStylePara elsevierViewall">La aplicaci&#243;n de un protocolo para el manejo de los pacientes con PA ingresados en MI&#44; basado en la 7&#46;<span class="elsevierStyleSup">a</span> Conferencia de Consenso de la SEMICYUC&#44; tuvo como consecuencia un mejor abordaje de estos pacientes en lo que respecta a ingreso precoz en MI&#44; uso de nutrici&#243;n enteral y cese en el uso de antibioterapia profil&#225;ctica&#44; y pudo estar relacionado con un descenso de su mortalidad hospitalaria&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Autor&#237;a</span><p id="par0305" class="elsevierStylePara elsevierViewall">Tanto Leyre Amas como Felix Zubia han contribuido en la recogida&#44; el an&#225;lisis y la interpretaci&#243;n de los datos&#44; el dise&#241;o del estudio y la redacci&#243;n del art&#237;culo&#44; habiendo ambos aprobado la versi&#243;n final de este&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conflicto de intereses</span><p id="par0310" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n tipo de conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Conocer si la implantaci&#243;n de un protocolo para el manejo de la pancreatitis aguda &#40;PA&#41; en Medicina Intensiva &#40;MI&#41; redund&#243; en la mejora de los resultados cl&#237;nicos&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Serie de casos&#44; observacional&#44; retrospectivo&#44; con un dise&#241;o antes-despu&#233;s&#46; Periodo de estudio&#58; 1&#47;01&#47;2001-31&#47;12&#47;2016&#44; dividido en 2 periodos &#40;preprotocolo 2001-2007&#59; posprotocolo 2008-2016&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">&#193;mbito</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Un servicio de MI con 48 camas y poblaci&#243;n de 700&#46;000 habitantes&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Participantes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pacientes ingresados en MI con PA&#46; No hubo criterios de exclusi&#243;n&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Intervenciones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se aplicaron las recomendaciones propuestas en la 7&#46;<span class="elsevierStyleSup">a</span> Conferencia de Consenso &#40;2007&#41; de la SEMICYUC sobre la PA en el segundo periodo&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Variables de inter&#233;s principales</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Edad&#44; sexo&#44; APACHE II&#44; SOFA&#44; periodo a estudio&#44; d&#237;as previos al ingreso en MI&#44; tipo de nutrici&#243;n&#44; cirug&#237;a&#44; profilaxis antibi&#243;tica&#44; mortalidad hospitalaria&#44; estancia en MI&#44; estancia hospitalaria&#44; clasificaci&#243;n basada en determinantes&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Doscientos ochenta y seis pacientes &#40;94 preprotocolo&#44; 192 posprotocolo&#41;&#44; mortalidad hospitalaria de 66&#160;casos &#40;23&#44;1&#37;&#41;&#46; La aplicaci&#243;n del protocolo supuso una disminuci&#243;n de la estancia hospitalaria previa al ingreso en MI&#44; y de la profilaxis antibi&#243;tica&#44; con un aumento del uso de nutrici&#243;n enteral&#46; Se evidenci&#243; un descenso de la mortalidad hospitalaria en el segundo periodo &#40;35&#44;1 vs&#46; 17&#44;18&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; sin cambios significativos en la estancia en MI ni en la hospitalaria&#46; En el an&#225;lisis multivariante&#44; la variable &#171;periodo de tratamiento&#187; mantuvo significaci&#243;n estad&#237;stica respecto a la mortalidad hospitalaria &#40;OR 0&#44;34 en 2008-2016&#44; IC 95&#37; 0&#44;15-0&#44;74&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El establecimiento de un protocolo podr&#237;a estar relacionado con un descenso de la mortalidad de los pacientes ingresados en MI por PA&#46;</p></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objective</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">To determine whether the implementation of a protocol for the management of patients with acute pancreatitis &#40;AP&#41; in an Intensive Care Unit &#40;ICU&#41; improves the clinical outcomes&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Design</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A retrospective&#44; before-after observational case series study was carried out&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Study period</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">1 January 2001 to 31 December 2016&#44; divided in 2 periods &#40;pre-protocol 2001-2007&#44; post-protocol 2008-2016&#41;&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Scope</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">An ICU with 48 beds and a recruitment population of 700&#44;000 inhabitants&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Participants</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">AP patients admitted to the ICU&#44; with no exclusion criteria&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Interventions</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">The recommendations proposed in the 7th Consensus Conference of the SEMICYUC on AP &#40;5 September 2007&#41; were applied in the second period&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Main variables of interest</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Patient age&#44; sex&#44; APACHE II&#44; SOFA&#44; study period&#44; pre-ICU hospital stay&#44; nutrition&#44; surgery&#44; antibiotic prophylaxis&#44; hospital mortality&#44; ICU length of stay&#44; hospital length of stay&#44; determinant-based classification&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">The study comprised 286 patients &#40;94 in the pre-protocol period&#44; 192 in the post-protocol period&#41;&#44; with a global in-hospital mortality rate of 23&#46;1&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>66&#41;&#46; Application of the protocol decreased the pre-ICU hospital stay and the use of antibiotic prophylaxis&#44; and increased the use of enteral nutrition&#46; Hospital mortality decreased in the second period &#40;35&#46;1 vs&#46; 17&#46;18&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; with no significant changes in ICU and hospital stays&#46; In the multivariate logistic regression analysis&#44; the variable period of treatment remained as a variable of statistical significance in terms of hospital mortality &#40;OR 0&#46;34 for the period 2008-2016&#44; 95&#37; CI 0&#46;15-0&#46;74&#41;&#46;</p></span> <span id="abst0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">The implementation of a protocol could result in decreased mortality among AP patients admitted to the ICU&#46;</p></span>"
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            "titulo" => "Scope"
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            "titulo" => "Participants"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">APACHE II&#58; Acute Physiology And Chronic Health Evaluation II&#59; DE&#58; desviaci&#243;n est&#225;ndar&#59; ns&#58; no significativo&#59; PIA m&#225;xima&#58; presi&#243;n intraabdominal m&#225;xima registrada durante su estancia en Medicina Intensiva&#59; SOFA&#58; Sequential Organ Failure Assessment&#59; TRRC&#58; t&#233;cnicas de reemplazo renal continuo&#59; VM&#58; ventilaci&#243;n mec&#225;nica&#46;</p>"
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;27&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2008-2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">159 &#40;72&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">D&#237;as hospital-MI&#44; mediana &#40;p25-p75&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0-4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#44;75-2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Etiolog&#237;a&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alcoh&#243;lica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51 &#40;23&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;13&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;017</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Biliar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94 &#40;42&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;36&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hiperlipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;6&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Idiop&#225;tica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;14&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;34&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Post-CPRE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;10&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;9&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otras&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;2&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">APACHE II m&#225;ximo en primeras 24</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h&#44; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">SOFA m&#225;ximo en primeras 24</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h&#44; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE &#40;valores perdidos</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">87 casos&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Ranson&#44; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Puntos TC &#40;Balthazar&#41;&#44; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PIA m&#225;ximo en primeras 24</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h &#40;mmHg&#41;&#44; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE &#40;valores perdidos</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">216 casos&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Cirug&#237;a&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97 &#40;44&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;56&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">D&#237;a IQ&#44; mediana &#40;p25-p75&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;4&#44;5-27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;2-20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Nutrici&#243;n en primeras 48</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">ns</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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ORIGINAL
Resultados de la modificación de un protocolo de manejo para la pancreatitis aguda en Medicina Intensiva
Results of the modification of an acute pancreatitis management protocol in Intensive Care medicine
L. Amas Gómeza,
Autor para correspondencia
leyre_amas@hotmail.com

Autor para correspondencia.
, F. Zubia Olaskoagab
a Servicio de Medicina Intensiva, Hospital Universitario Donostia, OSI Donostialdea, San Sebastián, Guipúzcoa, España
b Servicio de Medicina Intensiva, Departamento de Medicina, Hospital Universitario Donostia, OSI Donostialdea, Euskal Herriko Unibertsitatea/Universidad del País Vasco (UPV-EHU), San Sebastián, Guipúzcoa, España
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con un seguimiento estricto cl&#237;nico y anal&#237;tico durante las primeras 48-96<span class="elsevierStyleHsp" style=""></span>h&#44; e ingreso precoz en MI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">Inicio de nutrici&#243;n artificial precoz &#40;en las primeras 72<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; utilizando&#44; siempre que sea posible&#44; nutrici&#243;n enteral a trav&#233;s de sonda nasog&#225;strica&#44; nasoyeyunal o transpil&#243;rica<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">11</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">No emplear antibioterapia profil&#225;ctica&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">Indicar el tratamiento quir&#250;rgico fundamentalmente en la necrosis pancre&#225;tica infectada o absceso&#44; intentando posponer la cirug&#237;a hasta el d&#237;a 21 de evoluci&#243;n&#44; si es posible<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">12</span></a>&#46;</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">En el presente estudio quisimos verificar si la aplicaci&#243;n de un protocolo basado en esta Conferencia de Consenso influy&#243; en la evoluci&#243;n cl&#237;nica de los pacientes ingresados por PA en un servicio de MI&#46; Para ello planteamos realizar un an&#225;lisis retrospectivo durante 16 a&#241;os&#44; antes y despu&#233;s de la implantaci&#243;n de un protocolo basado en estas recomendaciones&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">El objetivo primario de este estudio es conocer si las recomendaciones propuestas en la 7&#170; Conferencia de Consenso de la SEMICYUC sobre la Pancreatitis aguda en Medicina Intensiva &#40;09&#47;05&#47;2007&#41;&#44; modificaron la mortalidad&#44; estancia intra UCI y estancia hospitalaria de los pacientes ingresados por PA en un Servicio de Medicina Intensiva&#59; 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modificaron el manejo de estos pacientes&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Dise&#241;o de estudio</span>&#58; se trata de un estudio observacional&#44; retrospectivo&#44; con un dise&#241;o antes y despu&#233;s en lo que respecta a la 7&#170; Conferencia de Consenso de la SEMICYUC sobre la Pancreatitis aguda en Medicina Intensiva &#40;09&#47;05&#47;2007&#41;&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Poblaci&#243;n a estudio y &#225;mbito de referencia&#58;</span> se ha incluido a todos los pacientes ingresados en el Servicio de Medicina Intensiva del Hospital Donostia por PA&#44; de forma consecutiva&#44; sin que existan criterios de exclusi&#243;n&#46; Se trata de un servicio de Medicina Intensiva con 48 camas&#44; que sirve de referencia a una poblaci&#243;n de 700&#46;000 habitantes&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Periodos de estudio</span>&#58; se ha dividido el periodo de estudio&#44; que va desde el 1 de Enero 2001 hasta 31 Diciembre 2016&#44; en dos periodos&#46; El primero de ellos ser&#237;a el previo a la Conferencia de consenso&#44; entre los a&#241;os 2001 y 2007&#44; y el segundo posterior a la Conferencia de Consenso&#44; entre los a&#241;os 2008 y 2016&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Variables</span>&#46; Se han recogido las siguientes variables en este estudio&#58; variables de filiaci&#243;n &#40;n&#250;mero de paciente&#44; edad&#44; sexo&#41;&#59; periodo de tiempo a estudio &#40;preconferencia de consenso o postconferencia de consenso&#41;&#59; tiempos de ingreso &#40;D&#237;as de ingreso hospital-ingreso UCI&#44; D&#237;as de estancia en UCI&#44; D&#237;as de estancia hospitalaria&#41;&#59; etiolog&#237;a que provoc&#243; el cuadro &#40;biliar&#44; alcoh&#243;lica&#44; idiop&#225;tica&#44; post-CPRE&#44; otras&#41;&#59; grado afectaci&#243;n radiol&#243;gica&#44; medida mediante la escala de Balthazar&#59; scores de gravedad&#44; que incluyen SOFA y APACHE II en las primeras 24 horas&#44; y escala de Ranson&#59; necesidad de ventilaci&#243;n mec&#225;nica &#40;VM&#41; y terapias de reemplazo renal continuas &#40;TRRC&#41;&#59; presi&#243;n intra-abdominal &#40;PIA&#41; m&#225;xima alcanzada durante la estancia en UCI&#59; nutrici&#243;n que se emplea en el paciente a las 48 horas del ingreso &#40;ninguna&#44; enteral&#44; parenteral&#44; mixta&#41;&#59; complicaciones locales que desarrolla el paciente en su estancia hospitalaria &#40;necrosis infectada&#44; hemorragia intraabdominal&#44; perforaci&#243;n de v&#237;scera hueca&#41;&#44; necesidad de cirug&#237;a&#59; fallecimiento y si se presenta&#44; su causa &#40;SIRS inicial&#44; infecci&#243;n pancre&#225;tica&#44; infecci&#243;n nosocomial extrapancre&#225;tica&#44; otros&#41;&#59; desarrollo de sepsis pancre&#225;tica&#59; desarrollo de sepsis extrapancre&#225;tica&#59; uso de antibioterapia emp&#237;rica al ingreso&#44; y gravedad medida mediante la Clasificaci&#243;n basada en Determinantes<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">6</span></a>&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Definiciones aplicadas en este estudio</span><p id="par0080" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">-</span></span><p id="par0085" class="elsevierStylePara elsevierViewall">D&#237;as ingreso hospital-ingreso MI&#58; d&#237;as que transcurrieron desde que el paciente ingres&#243; en un centro hospitalario hasta que ingres&#243; en el Servicio de MI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">-</span></span><p id="par0090" class="elsevierStylePara elsevierViewall">Periodo de protocolo de tratamiento&#58; se establecieron 2 periodos&#44; pre &#40;2001-2007&#41; y post &#40;2007-2016&#41; Conferencia de Consenso&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Etiolog&#237;a&#58;</p></li></ul></p><p id="par0100" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Alcoh&#243;lica&#58; consumo excesivo de alcohol &#40;&#62;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>g&#47;d&#237;a&#41; mantenido durante m&#225;s de 5 a&#241;os&#44; sin otra causa definida de pancreatitis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par0110" class="elsevierStylePara elsevierViewall">Biliar&#58; presencia de c&#225;lculos en la v&#237;a biliar&#44; sin otra causa de pancreatitis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Poscolangiopancreatograf&#237;a retr&#243;grada endosc&#243;pica&#58; pancreatitis que se inici&#243; en los 7 d&#237;as siguientes a la realizaci&#243;n de una colangiopancreatograf&#237;a retr&#243;grada endosc&#243;pica&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par0120" class="elsevierStylePara elsevierViewall">Otras&#58; resto de causas de pancreatitis&#46; Aqu&#237; se incluir&#237;an la pancreatitis postraum&#225;tica&#44; la posquir&#250;rgica y la PA por hipertrigliceridemia&#44; adem&#225;s de otras causas menos frecuentes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par0125" class="elsevierStylePara elsevierViewall">Idiop&#225;tica&#58; cuando no se cumplen los criterios del resto de las etiolog&#237;as&#46;</p></li></ul></p><p id="par0130" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">APACHE II y SOFA&#58; puntuaci&#243;n m&#225;xima obtenida mediante las escalas APACHE II y SOFA durante las primeras 24<span class="elsevierStyleHsp" style=""></span>h de ingreso en MI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Complicaciones locales<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a>&#58; desarrollo&#44; en cualquier momento de su ingreso hospitalario&#44; de necrosis infectada &#40;definida por la presencia de gas en tejido &#91;peri&#93;pancre&#225;tico&#44; un resultado positivo en una tinci&#243;n de Gram o en muestras obtenidas con punci&#243;n-aspiraci&#243;n con aguja fina mediante t&#233;cnicas de imagen&#44; o en muestras obtenidas en quir&#243;fano o en muestras de drenajes&#41;&#44; hemorragia intraabdominal &#40;definida por la presencia de una colecci&#243;n l&#237;quida de densidad sangre por t&#233;cnicas de imagen &#91;TC&#44; RMN&#93;&#44; especialmente si se objetiv&#243; extravasaci&#243;n activa tras la administraci&#243;n de contraste o por la visualizaci&#243;n directa de hemorragia en la cirug&#237;a&#41; o perforaci&#243;n de v&#237;scera hueca &#40;definida por visualizaci&#243;n directa en la cirug&#237;a o por la presencia de alguno de estos hallazgos en las t&#233;cnicas de imagen&#58; neumoperitoneo&#44; presencia de burbujas de gas agrupadas adyacentes a la pared intestinal de un asa&#44; engrosamiento mural y p&#233;rdida de continuidad o discontinuidad en la pared del asa intestinal&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Causa de fallecimiento&#58; SRIS inicial &#40;pacientes que fallecieron por fracaso org&#225;nico originado por la PA en los 7 primeros d&#237;as de ingreso hospitalario&#44; sin que hubiera datos que indicasen infecci&#243;n en la regi&#243;n pancre&#225;tica&#41;&#44; infecci&#243;n pancre&#225;tica &#40;seg&#250;n la definici&#243;n de necrosis infectada dada en el apartado de complicaciones locales&#41;&#44; complicaciones locales &#40;hemorragia intraabdominal o perforaci&#243;n de v&#237;scera hueca&#44; seg&#250;n las definiciones previas &#91;n&#243;tese que la causa de fallecimiento definida como &#171;complicaciones locales&#187; no recogi&#243; la infecci&#243;n pancre&#225;tica&#44; que por su trascendencia constituye una causa diferenciada<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">6&#44;7</span></a>&#93;&#44; infecci&#243;n nosocomial extrapancre&#225;tica &#91;aquella que apareci&#243; durante el ingreso hospitalario&#44; que se manifest&#243; transcurridas 72<span class="elsevierStyleHsp" style=""></span>h o m&#225;s del ingreso del paciente en el hospital&#44; y que en el momento de ingreso del paciente en el hospital no estaba presente ni en periodo de incubaci&#243;n&#93;&#59; en este apartado se incluyeron tanto la infecci&#243;n por cat&#233;ter como la infecci&#243;n respiratoria &#91;principalmente la neumon&#237;a asociada a VM&#93; y la infecci&#243;n urinaria&#46; Para su definici&#243;n se emplearon las definiciones utilizadas por el grupo de trabajo en Enfermedades Infecciosas y Sepsis de la SEMICYUC<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">14&#44;15</span></a>&#46; Uso de VM&#58; definido como la necesidad de VM invasiva en cualquier momento durante la estancia en MI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Uso de TRRC&#58; definido como el uso de TRRC por fracaso renal agudo en cualquier momento de su estancia en MI&#46; En el primer periodo de protocolo &#40;2001-2007&#41; su uso no tuvo criterio definido y se inici&#243; seg&#250;n la decisi&#243;n del m&#233;dico responsable&#46; En el segundo periodo de protocolo &#40;2008-2016&#41; se estableci&#243; como criterio el nivel <span class="elsevierStyleItalic">Failure</span> del RIFLE<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">16</span></a>&#44; por cambios en los protocolos de nuestro servicio de MI para todos los pacientes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Medici&#243;n de PIA&#58; se realiz&#243; utilizando un cat&#233;ter urinario&#44; seg&#250;n las definiciones de la conferencia internacional de expertos en hipertensi&#243;n intraabdominal y s&#237;ndrome compartimental agudo<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">17</span></a>&#46; Se registr&#243; el valor m&#225;s elevado medido durante la estancia en MI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Necesidad de cirug&#237;a&#58; definida por la Conferencia de Consenso de la SEMICYUC sobre PA de 2012<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">10</span></a>&#46; Por protocolo de nuestro hospital&#44; toda cirug&#237;a realizada sobre la celda pancre&#225;tica por complicaciones de la PA exigi&#243; el ingreso previo del paciente en MI&#46; Las principales indicaciones fueron&#58; necrosis infectada o absceso pancre&#225;tico que no pudo ser tratado con t&#233;cnicas de drenaje menos invasivas &#40;step-up&#41;&#44; perforaci&#243;n de v&#237;scera hueca&#44; hemorragia intraabdominal que no pudo ser tratada con t&#233;cnicas endovasculares y s&#237;ndrome compartimental abdominal que no pudo ser tratado con t&#233;cnicas conservadoras&#46;</p></li></ul></p><p id="par0170" class="elsevierStylePara elsevierViewall">El manejo de la necrosis est&#233;ril fue inicialmente conservador&#44; salvo en los casos de m&#225;s de 4 semanas de evoluci&#243;n y persistencia de afectaci&#243;n cl&#237;nica del paciente&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Seg&#250;n el momento en el que se realiz&#243;&#44; la cirug&#237;a se clasific&#243; en precoz&#44; si fue realizada en menos de 21 d&#237;as desde el inicio de la sintomatolog&#237;a&#44; y tard&#237;a&#44; si fue realizada en m&#225;s de 21 d&#237;as desde el inicio de la sintomatolog&#237;a&#46;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">Clasificaci&#243;n Basada en Determinantes<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">4</span></a>&#58;</p></li></ul></p><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pancreatitis aguda leve&#58;</span> se caracteriz&#243; por la ausencia tanto de necrosis &#40;peri&#41;pancre&#225;tica como de fallo org&#225;nico&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pancreatitis aguda moderada&#58;</span> se caracteriz&#243; por la presencia de cualquier tipo de necrosis &#40;peri&#41;pancre&#225;tica est&#233;ril o fallo org&#225;nico transitorio&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pancreatitis aguda grave&#58;</span> se caracteriz&#243; por la presencia de cualquier grado de necrosis &#40;peri&#41;pancre&#225;tica infectada o fallo org&#225;nico persistente&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pancreatitis aguda cr&#237;tica&#58;</span> se caracteriz&#243; por la presencia de necrosis &#40;peri&#41;pancre&#225;tica infectada y fallo org&#225;nico persistente&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">An&#225;lisis estad&#237;stico</span><p id="par0205" class="elsevierStylePara elsevierViewall">Se cre&#243; una base de datos anonimizada que recog&#237;a toda la informaci&#243;n de este estudio&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Se analizaron los datos seg&#250;n la metodolog&#237;a estad&#237;stica correspondiente&#46; Se estimaron las frecuencias absolutas y relativas de las variables cualitativas&#46; Para las variables cuantitativas que siguen una distribuci&#243;n normal&#44; se utiliz&#243; la media y la desviaci&#243;n est&#225;ndar&#46; Para las variables cualitativas con una distribuci&#243;n no param&#233;trica&#44; se emplearon la mediana y los percentiles p25-p75&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">La comparaci&#243;n entre variables cuantitativas se llev&#243; a cabo mediante la prueba T de Student y se emple&#243; ANOVA para el contraste de medias&#46; Cuando las variables no se distribuyeron normalmente se utiliz&#243; el test de Kruskal-Wallis o la U de Mann-Whitney&#46; La comparaci&#243;n de proporciones se realiz&#243; mediante la prueba &#967;<span class="elsevierStyleSup">2</span> o el test exacto de Fisher&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Para determinar la influencia del protocolo aplicado y el periodo de ingreso&#44; y con la idea de evitar factores de confusi&#243;n&#44; se realiz&#243; un an&#225;lisis univariante para conocer cu&#225;les fueron los factores que influyeron en la mortalidad&#46; Posteriormente&#44; aquellas variables con una p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;1 se incluyeron en un an&#225;lisis multivariante de regresi&#243;n log&#237;stica&#46; Los valores perdidos de las variables no recogidas fueron tratados mediante imputaci&#243;n m&#250;ltiple&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Aspectos &#233;ticos y legales</span><p id="par0225" class="elsevierStylePara elsevierViewall">Este estudio fue aprobado por el Comit&#233; de Ensayos Cl&#237;nicos del &#193;rea de Guip&#250;zcoa&#46; Se cumpli&#243; la Ley Org&#225;nica 15&#47;1999 de Protecci&#243;n de Datos de Car&#225;cter Personal y el Real Decreto 994&#47;1999&#44; por el que se aprueba el Reglamento de medidas de seguridad de ficheros automatizados que contengan datos de car&#225;cter personal&#46; Los datos de los pacientes fueron recogidos de forma anonimizada de la base de datos electr&#243;nica&#44; mediante un c&#243;digo num&#233;rico&#46; En ning&#250;n momento se registraron datos identificativos de los pacientes ni hubo forma de entrelazar su filiaci&#243;n y sus datos cl&#237;nicos&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Resultados</span><p id="par0230" class="elsevierStylePara elsevierViewall">Se estudiaron 286 pacientes&#44; 94 en el periodo 2001-2007 y 192 en el periodo 2008-2016&#44; con una edad media de 59 a&#241;os&#44; con predominio de varones&#44; que han presentado un PA de origen principalmente biliar&#44; con una mortalidad hospitalaria global de 23&#44;07&#37;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se muestran las caracter&#237;sticas generales de los pacientes incluidos&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Aplicaci&#243;n del protocolo</span><p id="par0235" class="elsevierStylePara elsevierViewall">La introducci&#243;n del protocolo para el manejo de la PA supuso una disminuci&#243;n de los d&#237;as previos al ingreso en MI&#44; un aumento del uso de nutrici&#243;n enteral y una reducci&#243;n del uso de nutrici&#243;n parenteral&#44; as&#237; como una reducci&#243;n del uso de profilaxis antibi&#243;tica&#46; Sin embargo&#44; no hubo un aumento en la tasa de realizaci&#243;n de cirug&#237;a tard&#237;a &#40;31&#44;4 vs&#46; 26&#44;4&#37;&#44; ns&#41;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se detallan los resultados de la aplicaci&#243;n del protocolo&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Evoluci&#243;n cl&#237;nica seg&#250;n el periodo de estudio</span><p id="par0240" class="elsevierStylePara elsevierViewall">Se observaron cambios entre ambos periodos en lo que respecta a las caracter&#237;sticas de los pacientes&#44; as&#237; como en el n&#250;mero de estos que fueron incluidos&#46; En el segundo periodo&#44; ingres&#243; un mayor n&#250;mero de pacientes y se objetiv&#243; una disminuci&#243;n de la puntuaci&#243;n de Ranson&#44; APACHE II y SOFA en las primeras 24<span class="elsevierStyleHsp" style=""></span>h&#44; con un mayor grado de afectaci&#243;n radiol&#243;gica en la escala de Balthazar&#46; Asimismo&#44; los pacientes incluidos en el segundo periodo tuvieron un mayor porcentaje de PA de origen biliar&#44; con una PIA m&#225;xima menor&#44; un menor uso de VM y una mayor necesidad de TRRC&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">En lo que respecta a los resultados cl&#237;nicos&#44; se evidenci&#243; un descenso de la mortalidad hospitalaria entre ambos periodos &#40;35&#44;1 vs&#46; 17&#44;18&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; con una variaci&#243;n a su vez en las causas de esta&#58; una disminuci&#243;n de infecciones extraabdominales y SRIS inicial en el periodo 2008-2016&#44; con un aumento de las complicaciones locales &#40;perforaci&#243;n intestinal&#44; hemorragia intraabdominal&#41; y otras causas&#46; Al realizar el an&#225;lisis de mortalidad seg&#250;n categor&#237;as de la Clasificaci&#243;n Basada en Determinantes&#44; se observ&#243; un descenso significativo en el subgrupo de las PA graves &#40;37 vs&#46; 19&#44;1&#37;&#41; en este periodo 2008-2016&#46; No se observaron cambios significativos en lo que respecta a la estancia en el Servicio de MI ni en la estancia hospitalaria&#46; La <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> muestra los resultados de forma comparativa entre ambos periodos&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">An&#225;lisis univariante y multivariante de regresi&#243;n log&#237;stica</span><p id="par0250" class="elsevierStylePara elsevierViewall">Como se describe en la metodolog&#237;a&#44; se realiz&#243; primeramente un an&#225;lisis univariante de los diferentes factores relacionados con la mortalidad&#44; tanto cuantitativos como cualitativos &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46; Las variables que se asociaron de forma estad&#237;sticamente significativa con la mortalidad fueron la edad&#44; el APACHE II&#44; la PIA&#44; el SOFA&#44; el Ranson&#44; el periodo de protocolo&#44; la etiolog&#237;a&#44; el uso de VM y TRRC&#44; y la gravedad seg&#250;n la Clasificaci&#243;n Basada en Determinantes&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0255" class="elsevierStylePara elsevierViewall">En el siguiente paso&#44; se realiz&#243; un an&#225;lisis multivariante de regresi&#243;n log&#237;stica &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46; Las variables que presentaron p&#233;rdidas fueron las siguientes&#58; SOFA m&#225;xima en las primeras 24<span class="elsevierStyleHsp" style=""></span>h &#40;87 casos&#44; 30&#44;4&#37;&#41;&#44; PIA m&#225;xima durante su estancia en MI &#40;216 casos&#44; 75&#44;5&#37;&#41;&#44; &#237;ndice de masa corporal &#40;19 casos&#44; 6&#44;64&#37;&#41;&#44; puntuaci&#243;n seg&#250;n la escala de Balthazar &#40;6 casos&#44; 2&#44;10&#37;&#41;&#44; Ranson &#40;37 casos&#44; 12&#44;93&#37;&#41;&#46; Los valores perdidos se trataron mediante imputaci&#243;n m&#250;ltiple para evitar la exclusi&#243;n de casos&#44; salvo la PIA&#44; que debido a su alto porcentaje de p&#233;rdidas fue eliminado directamente del an&#225;lisis multivariante&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0260" class="elsevierStylePara elsevierViewall">El periodo de aplicaci&#243;n del protocolo mostr&#243; una relaci&#243;n estad&#237;sticamente significativa con la mortalidad&#44; para el ingreso en el periodo 2008-2016 frente al periodo 2001-2007 &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46; Otros factores que se relacionaron de forma estad&#237;sticamente significativa fueron la edad&#44; el APACHE II&#44; el uso de VM y la no realizaci&#243;n de cirug&#237;a&#46; La Clasificaci&#243;n Basada en Determinantes mostr&#243; una p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;054&#44; por lo que se consider&#243; no significativo&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Discusi&#243;n</span><p id="par0265" class="elsevierStylePara elsevierViewall">En este art&#237;culo se analiz&#243; la influencia cl&#237;nica que pudiera tener la aplicaci&#243;n de un protocolo para el manejo de los pacientes con PA que ingresan en un servicio de MI&#44; basado en la Conferencia de Consenso SEMICYUC de 2007<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">10</span></a>&#46; Para ello se emple&#243; una serie retrospectiva de 286 pacientes&#44; con un alto porcentaje de formas graves y cr&#237;ticas seg&#250;n la Clasificaci&#243;n Basada en Determinantes<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">4</span></a>&#44; lo que supone una de las series m&#225;s grandes publicadas hasta la actualidad&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Las Recomendaciones de la Conferencia de Consenso describieron varios puntos de mejora para el manejo de los pacientes con PA en MI&#44; como el uso de nutrici&#243;n enteral precoz&#44; el ingreso precoz en MI&#44; el retraso en la cirug&#237;a y el cese de la profilaxis antibi&#243;tica&#46; En este estudio el grado de cumplimentaci&#243;n de los objetivos fue importante en lo que respecta al ingreso precoz&#44; el uso de nutrici&#243;n enteral precoz<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">18</span></a> y el cese en el uso de la profilaxis antibi&#243;tica<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">19&#44;20</span></a>&#44; pero no en la realizaci&#243;n de cirug&#237;a tard&#237;a&#44; lo que supone un punto de mejora para nuestra unidad&#46; La monitorizaci&#243;n protocolizada de la PIA fue otra mejora incluida a partir del a&#241;o 2012&#44; a ra&#237;z del cambio en las Recomendaciones SEMICYUC de ese a&#241;o<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">10&#44;21</span></a>&#44; ya que es conocida su influencia sobre el curso cl&#237;nico de la PA<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">22&#44;23</span></a>&#46; Sin embargo&#44; dado que la recogida de datos fue retrospectiva&#44; hubo un alto porcentaje de casos en los que no se pudo registrar&#44; y se decidi&#243; no incluirlo como resultado de cambio en el manejo de los pacientes ni incluirlo en el an&#225;lisis multivariante&#46; El manejo mediante t&#233;cnicas no invasivas o m&#237;nimamente invasivas de la necrosis pancre&#225;tica infectada se inici&#243; el a&#241;o 2013<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">12</span></a> y pudo haber influido en los resultados finales&#44; pero no se estudi&#243; espec&#237;ficamente en este trabajo&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">En lo que respecta a los resultados cl&#237;nicos&#44; se observaron cambios importantes entre los periodos 2001-2007 y 2008-2016&#58; un aumento en el n&#250;mero de casos&#44; con una reducci&#243;n en los marcadores de gravedad&#44; y un descenso llamativo de la mortalidad hospitalaria&#44; con cambios en sus causas&#46; De forma llamativa&#44; no hubo cambios significativos en lo que se refiere a la estancia en MI y la estancia hospitalaria entre ambos periodos&#46; Es por ello que la interpretaci&#243;n de los datos debe hacerse con mucha precauci&#243;n&#46; Se registr&#243; una reducci&#243;n relativa de la mortalidad del 50&#37; entre ambos periodos de protocolo&#44; con una mortalidad hospitalaria absoluta inferior al 20&#37; en el segundo&#46; Esta mortalidad fue muy inferior a la descrita en otras series&#58; por ejemplo&#44; Bumbasirevic et al&#46; describieron una mortalidad del 53&#44;6&#37; para pacientes con PA en MI<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a>&#59; un estudio multic&#233;ntrico reciente en 46 servicios de MI present&#243; una mortalidad del 28&#44;7&#37;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a>&#46; Si se analizan las categor&#237;as de la Clasificaci&#243;n Basada en Determinantes&#44; la reducci&#243;n de la mortalidad fue significativa en el caso de las PA graves&#44; y la mortalidad que presentaron los pacientes con PA grave y cr&#237;tica en este estudio fue inferior a la recogida en otras series<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">24&#8211;28</span></a>&#46; Con ello&#44; parece que el descenso de la mortalidad no se debi&#243; &#250;nicamente a un mayor ingreso de formas m&#225;s leves en el periodo 2008-2016&#44; sino que pudiera estar tambi&#233;n en relaci&#243;n con un mejor manejo de los pacientes&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Asimismo&#44; se registraron cambios en la causa de mortalidad&#44; ya que se redujo mucho tanto la debida a infecci&#243;n extraabdominal como por SRIS inicial&#44; y aument&#243; la mortalidad por complicaciones locales &#40;perforaci&#243;n intestinal&#44; hemorragia intraabdominal&#41;&#46; Creemos que el ingreso precoz&#44; junto con la mejora en las medidas de soporte&#44; pudo justificar la reducci&#243;n de mortalidad por SRIS inicial&#44; tal y como han descrito otros autores<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">9&#44;29&#8211;31</span></a>&#46; En lo que respecta a las complicaciones locales&#44; no hubo cambios significativos en el porcentaje de pacientes que desarrollaron las mismas entre ambos periodos&#44; ni en su mortalidad&#44; siendo similar al descrito en otras series<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">30&#8211;32</span></a>&#46; Sin embargo&#44; hubo un aumento en el peso porcentual sobre la mortalidad global de los pacientes fallecidos por perforaci&#243;n intestinal y hemorragia intraabdominal&#46; En ello pudo haber contribuido el descenso de la mortalidad por SRIS inicial e infecci&#243;n extraabdominal&#44; y la dificultad de tratamiento que presentan estas complicaciones&#44; adem&#225;s de su aparici&#243;n tard&#237;a&#44; en pacientes que ya mostraban una afectaci&#243;n org&#225;nica importante&#44; y necrosis infectada&#44; previamente tratada en muchas ocasiones&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">Dado que pudo haber factores de confusi&#243;n que explicaran la reducci&#243;n de la mortalidad entre ambos periodos&#44; se llev&#243; a cabo un an&#225;lisis multivariante mediante regresi&#243;n log&#237;stica&#44; en el cual el periodo de tratamiento se mantuvo como variable&#44; relacionado de forma significativa con la mortalidad hospitalaria&#46; Este an&#225;lisis multivariante present&#243; varias limitaciones&#44; m&#225;s trat&#225;ndose de una recogida de datos retrospectiva&#46; Los valores perdidos fueron escasos&#44; salvo para la variable SOFA&#44; m&#225;xima en las primeras 24<span class="elsevierStyleHsp" style=""></span>h de estancia en MI&#44; y fueron tratadas mediante imputaci&#243;n m&#250;ltiple&#46; Como se ha descrito previamente&#44; la PIA m&#225;xima recogida fue excluida directamente por su alto porcentaje de casos perdidos&#44; lo que pudo haber influido en el resultado final&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">Adem&#225;s de la naturaleza retrospectiva del estudio y la influencia potencial de los valores perdidos&#44; hubo otras limitaciones que hacen que los buenos resultados en la reducci&#243;n de la mortalidad deban ser interpretados con mucha cautela&#46; Como se ha indicado anteriormente&#44; en el periodo de protocolo 2008-2016 se registr&#243; un cambio en el perfil cl&#237;nico de los pacientes&#44; con un mayor n&#250;mero de estos y una reducci&#243;n de la gravedad medida mediante APACHE II&#44; SOFA y Ranson&#44; probablemente asociado a un ingreso m&#225;s precoz&#46; Adem&#225;s&#44; hubo cambios en la etiolog&#237;a de estos pacientes&#44; un menor uso de VM y un mayor uso de TRRC&#46; El mayor uso de TRRC se debi&#243; a cambios generales de nuestro servicio de MI&#44; al establecer como criterio de inicio de TRRC el criterio <span class="elsevierStyleItalic">Failure</span> del RIFLE&#46; Existen estudios que evidencian que el uso de TRRC puede reducir la mortalidad de los casos de PA m&#225;s graves&#44; lo que pude haber influido en nuestros resultados<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">33&#44;34</span></a>&#46; Por a&#241;adidura&#44; el largo periodo de recogida de datos y su naturaleza unic&#233;ntrica hizo que otros cambios generales pudieran haber condicionado nuestros resultados&#44; y no las hubi&#233;ramos estudiado&#44; como las pol&#237;ticas de seguridad&#44; o las campa&#241;as de reducci&#243;n de infecciones nosocomiales<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">35&#44;36</span></a>&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Resultar&#237;a interesante que la experiencia recogida en nuestro centro fuera corroborada en otros hospitales o fuera estudiada en series multic&#233;ntricas amplias&#44; de forma prospectiva y en un menor periodo de tiempo&#44; para ver si se consigue una mejor&#237;a en la evoluci&#243;n cl&#237;nica de los pacientes con PA en MI&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conclusiones</span><p id="par0300" class="elsevierStylePara elsevierViewall">La aplicaci&#243;n de un protocolo para el manejo de los pacientes con PA ingresados en MI&#44; basado en la 7&#46;<span class="elsevierStyleSup">a</span> Conferencia de Consenso de la SEMICYUC&#44; tuvo como consecuencia un mejor abordaje de estos pacientes en lo que respecta a ingreso precoz en MI&#44; uso de nutrici&#243;n enteral y cese en el uso de antibioterapia profil&#225;ctica&#44; y pudo estar relacionado con un descenso de su mortalidad hospitalaria&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Autor&#237;a</span><p id="par0305" class="elsevierStylePara elsevierViewall">Tanto Leyre Amas como Felix Zubia han contribuido en la recogida&#44; el an&#225;lisis y la interpretaci&#243;n de los datos&#44; el dise&#241;o del estudio y la redacci&#243;n del art&#237;culo&#44; habiendo ambos aprobado la versi&#243;n final de este&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conflicto de intereses</span><p id="par0310" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n tipo de conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Conocer si la implantaci&#243;n de un protocolo para el manejo de la pancreatitis aguda &#40;PA&#41; en Medicina Intensiva &#40;MI&#41; redund&#243; en la mejora de los resultados cl&#237;nicos&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Serie de casos&#44; observacional&#44; retrospectivo&#44; con un dise&#241;o antes-despu&#233;s&#46; Periodo de estudio&#58; 1&#47;01&#47;2001-31&#47;12&#47;2016&#44; dividido en 2 periodos &#40;preprotocolo 2001-2007&#59; posprotocolo 2008-2016&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">&#193;mbito</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Un servicio de MI con 48 camas y poblaci&#243;n de 700&#46;000 habitantes&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Participantes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pacientes ingresados en MI con PA&#46; No hubo criterios de exclusi&#243;n&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Intervenciones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se aplicaron las recomendaciones propuestas en la 7&#46;<span class="elsevierStyleSup">a</span> Conferencia de Consenso &#40;2007&#41; de la SEMICYUC sobre la PA en el segundo periodo&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Variables de inter&#233;s principales</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Edad&#44; sexo&#44; APACHE II&#44; SOFA&#44; periodo a estudio&#44; d&#237;as previos al ingreso en MI&#44; tipo de nutrici&#243;n&#44; cirug&#237;a&#44; profilaxis antibi&#243;tica&#44; mortalidad hospitalaria&#44; estancia en MI&#44; estancia hospitalaria&#44; clasificaci&#243;n basada en determinantes&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Doscientos ochenta y seis pacientes &#40;94 preprotocolo&#44; 192 posprotocolo&#41;&#44; mortalidad hospitalaria de 66&#160;casos &#40;23&#44;1&#37;&#41;&#46; La aplicaci&#243;n del protocolo supuso una disminuci&#243;n de la estancia hospitalaria previa al ingreso en MI&#44; y de la profilaxis antibi&#243;tica&#44; con un aumento del uso de nutrici&#243;n enteral&#46; Se evidenci&#243; un descenso de la mortalidad hospitalaria en el segundo periodo &#40;35&#44;1 vs&#46; 17&#44;18&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; sin cambios significativos en la estancia en MI ni en la hospitalaria&#46; En el an&#225;lisis multivariante&#44; la variable &#171;periodo de tratamiento&#187; mantuvo significaci&#243;n estad&#237;stica respecto a la mortalidad hospitalaria &#40;OR 0&#44;34 en 2008-2016&#44; IC 95&#37; 0&#44;15-0&#44;74&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El establecimiento de un protocolo podr&#237;a estar relacionado con un descenso de la mortalidad de los pacientes ingresados en MI por PA&#46;</p></span>"
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        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objective</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">To determine whether the implementation of a protocol for the management of patients with acute pancreatitis &#40;AP&#41; in an Intensive Care Unit &#40;ICU&#41; improves the clinical outcomes&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Design</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A retrospective&#44; before-after observational case series study was carried out&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Study period</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">1 January 2001 to 31 December 2016&#44; divided in 2 periods &#40;pre-protocol 2001-2007&#44; post-protocol 2008-2016&#41;&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Scope</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">An ICU with 48 beds and a recruitment population of 700&#44;000 inhabitants&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Participants</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">AP patients admitted to the ICU&#44; with no exclusion criteria&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Interventions</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">The recommendations proposed in the 7th Consensus Conference of the SEMICYUC on AP &#40;5 September 2007&#41; were applied in the second period&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Main variables of interest</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Patient age&#44; sex&#44; APACHE II&#44; SOFA&#44; study period&#44; pre-ICU hospital stay&#44; nutrition&#44; surgery&#44; antibiotic prophylaxis&#44; hospital mortality&#44; ICU length of stay&#44; hospital length of stay&#44; determinant-based classification&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">The study comprised 286 patients &#40;94 in the pre-protocol period&#44; 192 in the post-protocol period&#41;&#44; with a global in-hospital mortality rate of 23&#46;1&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>66&#41;&#46; Application of the protocol decreased the pre-ICU hospital stay and the use of antibiotic prophylaxis&#44; and increased the use of enteral nutrition&#46; Hospital mortality decreased in the second period &#40;35&#46;1 vs&#46; 17&#46;18&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; with no significant changes in ICU and hospital stays&#46; In the multivariate logistic regression analysis&#44; the variable period of treatment remained as a variable of statistical significance in terms of hospital mortality &#40;OR 0&#46;34 for the period 2008-2016&#44; 95&#37; CI 0&#46;15-0&#46;74&#41;&#46;</p></span> <span id="abst0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">The implementation of a protocol could result in decreased mortality among AP patients admitted to the ICU&#46;</p></span>"
        "secciones" => array:9 [
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            "titulo" => "Design"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">APACHE II&#58; Acute Physiology And Chronic Health Evaluation II&#59; DE&#58; desviaci&#243;n est&#225;ndar&#59; ns&#58; no significativo&#59; PIA m&#225;xima&#58; presi&#243;n intraabdominal m&#225;xima registrada durante su estancia en Medicina Intensiva&#59; SOFA&#58; Sequential Organ Failure Assessment&#59; TRRC&#58; t&#233;cnicas de reemplazo renal continuo&#59; VM&#58; ventilaci&#243;n mec&#225;nica&#46;</p>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2008-2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">159 &#40;72&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">D&#237;as hospital-MI&#44; mediana &#40;p25-p75&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0-4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#44;75-2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Etiolog&#237;a&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alcoh&#243;lica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51 &#40;23&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;13&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;017</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Biliar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94 &#40;42&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;36&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hiperlipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;6&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Idiop&#225;tica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;14&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;34&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Post-CPRE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;10&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;9&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otras&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;2&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">APACHE II m&#225;ximo en primeras 24</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h&#44; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">SOFA m&#225;ximo en primeras 24</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h&#44; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE &#40;valores perdidos</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">87 casos&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Ranson&#44; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Puntos TC &#40;Balthazar&#41;&#44; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PIA m&#225;ximo en primeras 24</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h &#40;mmHg&#41;&#44; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE &#40;valores perdidos</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">216 casos&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Cirug&#237;a&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97 &#40;44&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;56&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">D&#237;a IQ&#44; mediana &#40;p25-p75&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;4&#44;5-27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;2-20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Uso de TRRC&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Nutrici&#243;n en primeras 48</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">ns</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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Medicina Intensiva
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?