Letter to the Editor
Critical patient’s healing walks and photoprotecion: the dark side of the sun
Paseos curativos en pacientes críticos y fotoprotección: el lado oscuro del sol
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"idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Critical patient’s healing walks and photoprotecion: the dark side of the sun" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "552" "paginaFinal" => "553" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Marta de Antonio-Cuscó, Purificación Pérez-Terán, Javier Mateu-de Antonio, Joan Ramon Masclans-Enviz" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Marta" "apellidos" => "de Antonio-Cuscó" "email" => array:1 [ 0 => "mdeantonio@psmar.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Purificación" "apellidos" => "Pérez-Terán" "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "fn0005" ] ] ] 2 => array:3 [ "nombre" => "Javier" "apellidos" => "Mateu-de Antonio" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "fn0005" ] ] ] 3 => array:3 [ "nombre" => "Joan Ramon" "apellidos" => "Masclans-Enviz" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Pharmacy Department, Hospital del Mar, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Intensive Care Unit, Hospital del Mar, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Critical Illness Research Group (GREPAC), Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Medicine, Universitat Pompeu Fabra (UPF), Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Paseos curativos en pacientes críticos y fotoprotección: el lado oscuro del sol" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A prolonged stay in an intensive care unit (ICU) could have detrimental consequences for patients and their families, causing both long-term physical and psychological sequelae.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In this regard, we read with interest the article by Igeño-Cano concerning about benefits of transfer patients outside the ICU to an open area.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However, the impact of solar radiation (SR) on drugs had not been a consideration in the treatment of critical patients up till now, underestimating the risks of adverse reactions (AR) (Supplementary Fig. S1) and photoinstability of drugs administered at that time (Supplementary Table S1). These risks will be even greater in the coming years due to climate change.</p><p id="par0015" class="elsevierStylePara elsevierViewall">For all these reasons, during critically ill patients’ walks, it is advisable to protect the patient against SR as well as the drugs administered, specially avoiding sun exposure during strongest radiation according to the climatic zone (Supplementary Fig. S2).</p><p id="par0020" class="elsevierStylePara elsevierViewall">For patients, it is essential to consider, the night administration of photosensitizing drugs to reduce drug concentrations during the day for drugs with short-medium half-lives, use of a hat, UV protection sunglasses, opaque clothing, keeping the application site of photosensitizing topical or transdermal drugs covered, and the application of a SPF50 cream without photosensitizers.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Likewise, it is important to apply also the pertinent preventive measures to those discontinued drugs with long half-life or prolonged-release formulations administered on previous days, such as azithromycin or depot intramuscular antipsychotics.</p><p id="par0030" class="elsevierStylePara elsevierViewall">It is essential to correctly protect photosensitive medications with opaque or light-protected bags and photo-protected infusion lines to maintain their physical, chemical and pharmacological properties.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The implementation of measures such avoiding times of maximum SR or prioritizing intermittent intravenous infusions over continuous administration could also be useful. Drugs requiring bolus administration could be better administered before going outside to avoid the increase in the patient's body temperature, a factor of drug stability, due to the SR during the walk.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In front of relatively high environmental temperatures (>25 °C/77 °F), refrigerating infusions by wrapping of infusion pumps in cold pouch between 2 freezer packs<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> throughout their administration outside or storing the drug-filled device in the refrigeration before critical patients’ walks could be a strategies to bear in mind for thermolabile drugs. Nevertheless, it is necessary to evaluate the impact of refrigeration on the stability of each specific drug, diluent, and formulation; to avoid the formation of precipitation or crystallization or any other physicochemical instability.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Transdermal drug delivery should also be considered due to drug diffusion into the skin is a temperature-dependent process. Therefore, an optimal strategy could be to maintain the application area covered during administration and for days after removal.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Both enteral and parenteral nutrition must be discontinued due to lipid peroxidation and vitamins degradation.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Because hypoglycemia may occur, glycaemia monitoring or dextrose 5% in water administration is required.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Intensive care medicine faces the challenge of adapting clinical practices to new scenarios to humanize ICU, but this brings also new challenges. In the organization of patients’ walks, it is essential to include a photoprotection protocol adjusted to routine clinical practice.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors’ contributions</span><p id="par0060" class="elsevierStylePara elsevierViewall">All authors have contributed to the manuscript and have read and approved the final manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contributions" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">P. Pérez-Terán and J. 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