RESUMO
Background: Prior research has demonstrated that low- and low-middle-income countries (LLMICs) bear a higher burden of critical illness and have a higher rate of mortality from critical illness than high-income countries (HICs). There is a pressing need for improved critical care delivery in LLMICs to reduce this inequity. This systematic review aimed to characterise the range of critical care interventions and services delivered within LLMIC health care systems as reported in the literature. Methods: A search strategy using terms related to critical care in LLMICs was implemented in multiple databases. We included English language articles with human subjects describing at least one critical care intervention or service in an LLMIC setting published between 1 January 2008 and 1 January 2020. Results: A total of 1620 studies met the inclusion criteria. Among the included studies, 45% of studies reported on pediatric patients, 43% on adults, 23% on infants, 8.9% on geriatric patients and 4.2% on maternal patients. Most of the care described (94%) was delivered in-hospital, with the remainder (6.2%) taking place in out-of-hospital care settings. Overall, 49% of critical care described was delivered outside of a designated intensive care unit. Specialist physicians delivered critical care in 60% of the included studies. Additional critical care was delivered by general physicians (40%), as well as specialist physician trainees (22%), pharmacists (16%), advanced nursing or midlevel practitioners (8.9%), ambulance providers (3.3%) and respiratory therapists (3.1%). Conclusions: This review represents a comprehensive synthesis of critical care delivery in LLMIC settings. Approximately 50% of critical care interventions and services were delivered outside of a designated intensive care unit. Specialist physicians were the most common health care professionals involved in care delivery in the included studies, however generalist physicians were commonly reported to provide critical care interventions and services. This study additionally characterised the quality of the published evidence guiding critical care practice in LLMICs, demonstrating a paucity of interventional and cost-effectiveness studies. Future research is needed to understand better how to optimise critical care interventions, services, care delivery and costs in these settings. Registration: PROSPERO CRD42019146802.
Assuntos
Estado Terminal , Atenção à Saúde , Lactente , Adulto , Humanos , Criança , Idoso , Pobreza , Cuidados CríticosRESUMO
Acute intracerebral hemorrhage accounts for only a small portion of all stroke presentations, but often leads to a high rate of morbidity and mortality. The presentation of patients with ICH is often similar to other stroke patients and requires rapid recognition, imaging, and evaluation. Treatment begins in the emergency department and focuses on correction of abnormal coagulopathies, blood pressure reduction, emergent treatment of intracranial hypertension, and recognition of those in need of urgent surgical decompression. Patients should be admitted to capable critical care units, with expertise in neurocritical care if available. This review presents evidence-based recommendations for the emergency department identification and management of patients with ICH.
Assuntos
Hemorragia Cerebral , Acidente Vascular Cerebral , Humanos , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/terapia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Serviço Hospitalar de EmergênciaRESUMO
OBJECTIVE: The surge in critically ill patients has pressured hospitals to expand their intensive care unit capacities and critical care staff. This was difficult given the country's shortage of intensivists. This paper describes the implementation of a multidisciplinary central line placement team and its impact in reducing the vascular access workload of ICU physicians during the height of the COVID-19 pandemic. METHODS: Vascular surgeons, interventionalists, and anesthesiologists, were redeployed to the ICU Access team to place central and arterial lines. Nurses with expertise in vascular access were recruited to the team to streamline consultation and assist with line placement. RESULTS: While 51 central and arterial lines were placed per 100 ICU patients in 2019, there were 87 central and arterial lines placed per 100 COVID-19 ICU patients in the sole month of April, 2020. The ICU Access Team placed 107 of the 226 vascular access devices in April 2020, reducing the procedure-related workload of ICU treating teams by 46%. CONCLUSIONS: The ICU Access Team was able to complete a large proportion of vascular access insertions without reported complications. Given another mass casualty event, this ICU Access Team could be reassembled to rapidly meet the increased vascular access needs of patients.
RESUMO
OBJECTIVE: The impact of interhospital transfer (IHT) on outcomes of patients with intracerebral hemorrhage (ICH) has not been well studied. We seek to describe the protocolized IHT and systems of care approach of a New York City hospital system, where ICH patients undergoing minimally invasive surgery (MIS) are transferred to a dedicated ICH center. METHODS: We retrospectively reviewed 100 consecutively admitted patients with spontaneous ICH. We gathered information on demographics, variables related to IHT, clinical and radiographic characteristics, and details about the clinical course and outpatient follow-up. We grouped patients into 2 cohorts: those admitted through IHT and those directly admitted through the emergency department. Primary outcome was good functional outcome at 6 months, defined as modified Rankin Scale score 0-3. RESULTS: Of 100 patients, 89 underwent IHT and 11 were directly admitted. On multivariable analysis, there were no significant differences in 6-month functional outcome between the 2 cohorts. All transfers were managed by a system-wide transfer center and 24/7 hotline for neuroemergencies. An ICH-specific IHT protocol was followed, in which a neurointensivist provided recommendations for stabilizing patients for transfer. Average transfer time was 199.7 minutes and average distance travelled was 13.6 kilometers. CONCLUSIONS: In our hospital system, a centralized approach to ICH management and a dedicated ICH center increased access to specialist services, including MIS. Most patients undergoing MIS were transferred from outside hospitals, which highlights the need for additional studies and descriptions of experiences to further elucidate the impact of and best protocols for the IHT of ICH patients.
Assuntos
Hemorragia Cerebral/cirurgia , Hospitais Urbanos/organização & administração , Procedimentos Neurocirúrgicos , Transferência de Pacientes , Idoso , Avaliação da Deficiência , Emergências , Serviço Hospitalar de Emergência , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Cidade de Nova Iorque , Admissão do Paciente , Equipe de Assistência ao Paciente , Estudos Retrospectivos , Técnicas Estereotáxicas , TriagemRESUMO
BACKGROUND AND PURPOSE: Young patients with malignant cerebral edema have been shown to benefit from early decompressive hemicraniectomy. The impact of concomitant infection with coronavirus disease 2019 (COVID-19) and how this should weigh in on the decision for surgery is unclear. METHODS: We retrospectively reviewed all COVID-19-positive patients admitted to the neuroscience intensive care unit for malignant edema monitoring. Patients with >50% of middle cerebral artery involvement on computed tomography imaging were considered at risk for malignant edema. RESULTS: Seven patients were admitted for monitoring of whom 4 died. Cause of death was related to COVID-19 complications, and these were either seen both very early and several days into the intensive care unit course after the typical window of malignant cerebral swelling. Three cases underwent surgery, and 1 patient died postoperatively from cardiac failure. A good outcome was attained in the other 2 cases. CONCLUSIONS: COVID-19-positive patients with large hemispheric stroke can have a good outcome with decompressive hemicraniectomy. A positive test for COVID-19 should not be used in isolation to exclude patients from a potentially lifesaving procedure.
Assuntos
Isquemia Encefálica/complicações , Isquemia Encefálica/cirurgia , Infecções por Coronavirus/complicações , Craniectomia Descompressiva/métodos , Procedimentos Neurocirúrgicos/métodos , Pneumonia Viral/complicações , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/cirurgia , Adulto , Edema Encefálico/complicações , Edema Encefálico/cirurgia , Isquemia Encefálica/diagnóstico por imagem , COVID-19 , Causas de Morte , Tomada de Decisão Clínica , Cuidados Críticos , Craniectomia Descompressiva/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Procedimentos Neurocirúrgicos/efeitos adversos , Pandemias , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Resultado do TratamentoAssuntos
Isquemia Encefálica/tratamento farmacológico , Hemorragias Intracranianas/epidemiologia , Inibidores da Agregação Plaquetária/uso terapêutico , Medição de Risco , Ativador de Plasminogênio Tecidual/uso terapêutico , Quimioterapia Combinada , Saúde Global , Humanos , Incidência , Fatores de RiscoRESUMO
Although commonly arising from poorly controlled hypertension, spontaneous intracerebral hemorrhage may occur secondary to several other etiologies. Clinical presentation to the emergency department ranges from headache with vomiting to coma. In addition to managing the ABCs, the crux of emergency management lies in stopping hematoma expansion and other complications to prevent clinical deterioration. This may be achieved primarily through anticoagulation reversal, blood pressure, empiric management of intracranial pressure, and early neurosurgical consultation for posterior fossa hemorrhage. Patients must be admitted to intensive care. The effects of intracerebral hemorrhage are potentially devastating with very poor prognoses for functional outcome and mortality.
Assuntos
Cuidados Críticos/métodos , Gerenciamento Clínico , Hipertensão/complicações , Hemorragias Intracranianas , Tomografia Computadorizada por Raios X/métodos , Saúde Global , Humanos , Incidência , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/etiologia , Taxa de Sobrevida/tendênciasRESUMO
Despite the publication of two randomized controlled trials of therapeutic hypothermia after cardiac arrest showing a clear benefit in neurologic outcome and mortality nearly a decade ago, the use of therapeutic hypothermia after successful cardiopulmonary resuscitation remains low. This lag in converting clinical research into practice is likely due in part to a lack of familiarity with a relatively new technology and the need for many providers in the chain of care to understand and feel comfortable with its application, from doctors and nurses in the emergency room, to those in the catheterization laboratory, and ultimately to the staff of the intensive care unit. This review summarizes the physiologic consequences of hypothermia as well as the current literature demonstrating the benefit of hypothermia on select patient populations and the impact of hypothermia on outcome assessment after cardiac arrest.
Assuntos
Encefalopatias/prevenção & controle , Parada Cardíaca , Hipotermia Induzida/métodos , Encefalopatias/diagnóstico , Encefalopatias/etiologia , Eletroencefalografia , Humanos , Monitorização Fisiológica/métodos , Resultado do TratamentoRESUMO
The field of international emergency medicine (IEM) has grown rapidly over the past several decades, with a rise in the number of IEM fellowship positions, sustained growth in the international sections of major emergency medicine organizations, and an increase in the range of topics included under its rubric. One of the greatest obstacles to the continued growth of IEM remains the lack of a high-quality, consolidated, and easily accessible evidence base of literature. In response to this perceived need, members of the Emergency Medicine Residents' Association IEM Committee, in conjunction with members of the Society for Academic Emergency Medicine International Health Interest Group, embarked on the task of creating a recurring review of IEM literature. This article reviews 25 IEM research articles published in 2006. Research articles were selected for the review according to explicit, predetermined criteria that included both methodological quality and perceived impact of the research. It is the authors' hope that this annual review will act as a forum for disseminating best practices while also stimulating further research in the field of IEM.