RESUMEN
PURPOSE: To understand the epidemiology and healthcare use of critically ill patients experiencing homelessness compared to critically ill patients with stable housing. METHODS: This retrospective population-based cohort study included adults admitted to any ICU in Alberta, Canada, for a 3-year period. Administrative and clinical data from the hospital, ICU and emergency department were used to examine healthcare resource use (processes of care, ICU and hospital length of stay, hospital readmission and emergency room visits). Regression was used to quantify differences in healthcare use by housing status. RESULTS: 2.3% (n = 1086) of patients admitted to the ICU were experiencing homelessness; these patients were younger, more commonly admitted for medical reasons and had fewer comorbidities compared to those with stable housing. Processes of care in the ICU were mostly similar, but healthcare use after ICU was different; patients experiencing homelessness who survived their index hospitalization were more than twice as likely to have a visit to the emergency department (OR = 2.3 times, 95% CI 2.0-2.6, < 0.001) or be readmitted to hospital (OR = 2.1, 95% CI 1.8-2.4, p < 0.001) within 30 days, and stayed 10.1 days longer in hospital (95% CI 8.6-11.6, p < 0.001), compared with those who have stable housing. CONCLUSIONS: Patients experiencing homelessness have different characteristics at ICU admission and have similar processes of care in ICU, but their subsequent use of healthcare resources was higher than patients with stable housing. These findings can inform strategies to prepare patients experiencing homelessness for discharge from the ICU to reduce healthcare resource use after critical illness.
Asunto(s)
Enfermedad Crítica , Personas con Mala Vivienda , Adulto , Humanos , Estudios Retrospectivos , Enfermedad Crítica/epidemiología , Enfermedad Crítica/terapia , Estudios de Cohortes , Alberta/epidemiologíaRESUMEN
BACKGROUND/OBJECTIVES: Venous thromboembolism (VTE) is a leading cause of preventable, in-hospital deaths; critically ill patients have a higher risk. Effective and efficient strategies to prevent VTE exist; however, neurocritical care patients present unique challenges due to competing risk of bleeding. The objective of this study was to examine current VTE prophylaxis practices among neurocritical care patients, concordance with guideline-recommended care, and the association with clinical outcomes. METHODS: This retrospective cohort study of patients admitted to ten adult, medical-surgical and neurological intensive care units (ICUs) in nine hospitals between 2014 and 2017 using administrative and clinical data. Neurocritical care patients were classified based on the primary admission diagnosis. Concordance with guideline-recommended care was evaluated using recommendations from recent guidelines. RESULTS: 20.0% of 23,191 patients were classified as neurocritical care. Among neurocritical care patients, pharmacological VTE prophylaxis was administered on 60.9% of all ICU days, mechanical VTE prophylaxis on 46.9%, and no VTE prophylaxis on 12.2% of all ICU days. Type of VTE prophylaxis was associated with sex, neurological diagnosis, and invasive neurological monitoring. Fifty-six percentage of ICU days were guideline concordant but concordance varied by recommendation (range 6-100%) and by type of VTE prophylaxis recommended (p = 0.05); among patients where guidelines recommended use of pharmacologic prophylaxis, care was concordant 26.6% of ICU days, whereas for mechanical prophylaxis it was concordant 80.5% of ICU days. There was an overall improvement in guideline concordance on 2.3% of ICU days after the publication of the Society of Neurocritical Care guideline (p = 0.005). CONCLUSIONS: Neurocritical care patients commonly receive mechanical VTE prophylaxis despite guidelines recommending the use of pharmacological VTE prophylaxis. Our findings suggest uncertainty around best VTE prophylaxis practices for neurocritical care patients remains.
Asunto(s)
Cuidados Críticos , Adhesión a Directriz , Guías de Práctica Clínica como Asunto , Tromboembolia Venosa/terapia , Adulto , Anciano , Alberta , Auditoría Clínica , Cuidados Críticos/métodos , Cuidados Críticos/normas , Cuidados Críticos/estadística & datos numéricos , Medicina Basada en la Evidencia , Femenino , Adhesión a Directriz/normas , Adhesión a Directriz/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto/normas , Estudios RetrospectivosRESUMEN
BACKGROUND: Standard treatment practice for the hypotensive patient with poor tissue perfusion is rapid volume resuscitation; in some scenarios, such as septic shock, this is performed with targeted goal-directed endpoints within 6 h of presentation. As a result, patients often develop significant positive fluid accumulation, which has been associated with poor outcomes above certain thresholds. METHODS: The aim of the current paper is to provide guidance for active pharmacological fluid management in the patient with, or at risk for, clinically significant positive fluid balance from either resuscitation for hypovolaemic shock or acute decompensated heart failure. RESULTS: We develop rationale for pharmacological fluid management targets (prevention of worsening fluid accumulation, achievement of slow vs rapid net negative fluid balance) in the context of phases of critical illness provided in the earlier Acute Dialysis Quality Initiative 12 papers.
Asunto(s)
Fluidoterapia/efectos adversos , Desequilibrio Hidroelectrolítico/tratamiento farmacológico , Desequilibrio Hidroelectrolítico/etiología , Cuidados Críticos , Técnica Delphi , Diuréticos/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Insuficiencia Cardíaca/etiología , Humanos , Perfusión , Resucitación , Choque/tratamiento farmacológico , Choque/etiología , Choque/terapiaRESUMEN
PURPOSE: We aimed to evaluate the association of early versus late initiation of Continuous renal replacement therapy (CRRT) with mortality in patients with fluid overload. METHODS: This was a retrospective cohort study of patients with fluid overload (FO) treated with CRRT due to severe acute kidney injury (AKI) between January 2015 and December 2017 in a mixed medical intensive care unit of a teaching hospital in Beijing, China. Patients were divided into early (≤15 h) and late (>15 h) groups based on the median time from ICU admission to CRRT initiation. The primary outcome was all-cause mortality at day 60. Multivariable Cox model analysis was used for analysis. RESULTS: The study patients were male predominant (84/150) with a mean age of 64.8 ± 16.7 years. The median FO value before CRRT initiation was 10.1% [6.2-16.1%]. The 60-day mortality rates in the early vs the late CRRT groups were 53.9% and 73%, respectively. On multivariable Cox modelling, the late initiation of CRRT was independently associated with an increased risk of death at 60 days (HR 1.75, 95% CI 1.11-2.74, p = 0.015). CONCLUSIONS: Early initiation of CRRT was independently associated with survival benefits in severe AKI patients with fluid overload.
Asunto(s)
Lesión Renal Aguda , Terapia de Reemplazo Renal Continuo , Desequilibrio Hidroelectrolítico , Lesión Renal Aguda/terapia , Anciano , Anciano de 80 o más Años , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Terapia de Reemplazo Renal , Estudios RetrospectivosRESUMEN
Many patients with heart failure have underlying renal dysfunction, and similarly, patients with kidney failure are prone to cardiac failure. This has led to the concept of cardio-renal syndromes, which can be an acute or chronic cardio-renal syndrome, when cardiac failure causes deterioration in renal function, or acute and/or chronic Reno-Cardiac syndrome, when renal dysfunction leads to cardiac failure. Patients who develop these syndromes have increased risk of hospital admission and mortality. Although there are clinical guidelines for managing both heart failure and chronic kidney disease, there are no agreed guidelines for managing patients with cardio-renal and/or Reno-Cardiac syndromes, as these patients have typically been excluded from clinical trials. We have therefore reviewed the currently available published literature to outline a consensus of current best clinical practice for these patients.
Asunto(s)
Insuficiencia Cardíaca/terapia , Insuficiencia Renal/terapia , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/etiología , Humanos , Guías de Práctica Clínica como Asunto , Diálisis Renal , Insuficiencia Renal/complicaciones , Insuficiencia Renal/etiología , SíndromeRESUMEN
Mesoporous silica molecular sieves have been prepared by the hydrolysis of tetraethylorthosilicate in the presence of low-cost, nontoxic, and biodegradable polyethylene oxide (PEO) surfactants, which act as the structure-directing (templating) agents. This nonionic, surfactant-neutral, inorganic-precursor templating pathway to mesostructures uses hydrogen bonding interactions between the hydrophilic surfaces of flexible rod- or worm-like micelles and Si(OC(2)H(5))(4-x)(OH)(x) hydrolysis products to assemble an inorganic oxide framework. Disordered channel structures with uniform diameters ranging from 2.0 to 5.8 nanometers have been obtained by varying the size and structure of the surfactant molecules. Metal-substituted silica and pure alumina mesostructures have also been prepared by the hydrolysis of the corresponding alkoxides in the presence of PEO surfactants. These results suggest that nonionic templating may provide a general pathway for the preparation of mesoporous oxides.
RESUMEN
PURPOSE: To validate the furosemide stress test (FST) for predicting the progression of acute kidney injury (AKI). MATERIALS AND METHODS: We performed a multicenter, prospective, observational study in patients with stage I or II AKI. The FST (1â¯mg/kg for loop diuretic naïve patients and 1.5â¯mg/kg in patients previously exposed to loop diuretics) was administered. Subsequent urinary flow rate (UFR) recorded and predictive ability of urinary output was measured by the area under the curve receiver operatic characteristics (AuROC). Primary outcome was progression to Stage III AKI. Secondary outcomes included in-hospital mortality and adverse events. RESULTS: We studied 92 critically ill patients. 23 patients progressed to stage III AKI and had significantly lower UFR (pâ¯<â¯0.0001). The UFR during the first 2â¯h was most predictive of progression to stage III AKI (AuROCâ¯=â¯0.87), with an ideal cut-off of less than 200mls, with a sensitivity of 73.9% and specificity of 90.0%. CONCLUSION: In ICU patients without severe CKD with mild AKI, a UFR of less than 200mls in the first 2â¯h after an FST is predictive of progression to stage III AKI. Future studies should focus on incorporating a FST as part of a clinical decision tool for further management of critically ill patients with AKI.
Asunto(s)
Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/mortalidad , Furosemida/farmacología , Lesión Renal Aguda/orina , Anciano , Área Bajo la Curva , Enfermedad Crítica/mortalidad , Progresión de la Enfermedad , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sensibilidad y Especificidad , Inhibidores del Simportador de Cloruro Sódico y Cloruro Potásico , Urodinámica , Adulto JovenRESUMEN
BACKGROUND: Critically ill patients with acute kidney injury (AKI) are at high risk for death and frequently require initiation of renal replacement therapy (RRT). There is wide variation in clinical practice on the indications for and timing of initiation and discontinuation of RRT. Numerous clinical and biochemical factors (i.e. uremic, metabolic, fluid balance) have been used; however, at present there is no consensus to guide clinicians on the most favorable time to initiate and/or discontinue RRT to optimize patient outcomes. METHODS: In this review, we appraise the available clinical studies that have assessed timing of initiation and/or discontinuation of RRT for critically ill patients with AKI. 'Timing' of initiation has been variably defined including use of conventional biomarkers (i.e. serum urea and creatinine), urine output, fluid balance, and time relative to intensive care unit admission. CONCLUSIONS: Numerous studies consistently point toward a survival benefit to early initiation of RRT; however, there is a paucity of high-quality randomized trials. If early RRT is associated with clinical benefit, it remains uncertain whether this is attributable to more rapid metabolic/uremic control, management of fluid balance or a combination of clinical factors. In addition, timing of RRT initiation is likely context-specific and varies by clinical factors and/or etiology of AKI. There is also little data to accurately distinguish in advance between the injured kidney that will need extracorporeal renal support and one that retains capacity for early recovery. Fewer studies have evaluated the process of weaning of RRT or ideal methods to predict sufficient recovery to avoid re-initiation. Longer duration of RRT support, higher illness severity and lower urine output (independent of diuretic therapy) have all predicted need for re-initiation. Additional investigations on these issues are clearly warranted and urgently needed.
Asunto(s)
Riñón/lesiones , Terapia de Reemplazo Renal/métodos , Enfermedad Crítica , Humanos , Enfermedades Renales/sangre , Enfermedades Renales/fisiopatología , Guías de Práctica Clínica como Asunto , Terapia de Reemplazo Renal/normasRESUMEN
Despite the fact that no new clinical outcome studies comparing intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) have been published in the past year, two meta-analyses addressing the topic (Bagshaw et al, Crit Care Med 2008; 36: 610-7, and Pannu et al, JAMA 2008; 299: 793-805) have been published recently. With respect to randomized controlled trials (RCTs), there was a substantial overlap between the studies considered in the analysis by Bagshaw et al and those considered in the analysis by Pannu et al. Although neither metaanalysis showed a benefit for either modality with respect to mortality or renal recovery, the two publications offered vastly different conclusions. Bagshaw et al concluded it is impossible to make any definitive recommendations about dialysis modality choice in AKI because previous studies were not adequately powered and failed to standardize for treatment dose. On the other hand, because the metaanalysis of Pannu et al demonstrated equivalent patient outcomes, and in light of the lower costs of IHD, they suggested that alternate-day hemodialysis should become the preferred therapy in many critically ill patients. As the clinical practice recommendations made by Pannu and colleagues have very important implications, we believe their analysis should be critically assessed. In this review, the weaknesses of the RCTs considered in the meta-analysis by Pannu et al are presented. Furthermore, the assumption by Pannu et al that IHD is associated with lower costs than CRRT is challenged, as they did not consider adequately both the short-term and long-term costs associated with the dialytic management of AKI patients. Based on our critical analysis, we believe the AKI dialytic treatment approach recommended by the JAMA investigators (Pannu et al) is not supported by the aggregate of the available clinical outcome data and, therefore, remains highly controversial. We would like to join with others in the AKI field by strongly recommending that investigators and other clinicians stop trying to make conclusive determinations about dialysis modalities when robust supportive data simply are not available. Instead of additional intermodality comparisons, the focus of future clinical research should be toward generating high-quality data on intramodality interventions, such as treatment dose and timing of treatment initiation. In this regard, at least for CRRT, we anxiously await the results of the ongoing RCTs evaluating the effect of CRRT dose on patient outcome.
Asunto(s)
Lesión Renal Aguda/terapia , Evaluación de Resultado en la Atención de Salud , Diálisis Renal/métodos , Terapia de Reemplazo Renal/métodos , Lesión Renal Aguda/economía , Lesión Renal Aguda/mortalidad , Costo de Enfermedad , Humanos , Metaanálisis como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , Diálisis Renal/economía , Terapia de Reemplazo Renal/economíaRESUMEN
BACKGROUND: Acetaminophen (paracetamol) overdose is a leading cause of acute liver failure (ALF). When patients fulfill the King's College criteria for acetaminophen-induced ALF (AALF), they have a poor prognosis for survival without liver transplantation. Recent advances in artificial liver support have used albumin as a binding and scavenging molecule in ALF. One method, single-pass albumin dialysis (SPAD), involves dialyzing blood against an albumin-containing solution across a high-flux membrane to remove albumin-bound toxins. Herein, we describe our protocol for SPAD and report its use in a case of AALF as a bridge to native liver recovery. CASE: A 41-year-old female with no documented history of liver disease presented with acute acetaminophen toxicity and developed hepatic encephalopathy, coagulopathy and lactic acidosis. The patient met King's College criteria for liver transplantation, based on pH and INR, but was deemed not suitable as a candidate due to psychosocial comorbidities. On day 3 of her ICU admission, she received the first of five consecutive daily runs (total ~77 hours) of SPAD. The patient's course was complicated by cerebral edema requiring mannitol. She was extubated on day 11 and transferred to the ward by day 13. At ICU discharge, her liver function (INR 1.9, bilirubin 435 mmol/L) and kidney function were recovering. She did not have any long-term neurological sequelae. By hospital discharge (day 46) her native liver function had recovered with a bilirubin <100mmol/L. CONCLUSION: We describe a case of a patient with acetaminophen-induced acute liver failure who was successfully bridged to spontaneous native liver recovery as a result of SPAD treatment. In patients with ALF, SPAD may be an additional intervention for temporary extracorporeal support. Further investigation in larger prospective studies is warranted.
Asunto(s)
Acetaminofén/envenenamiento , Albúminas/administración & dosificación , Analgésicos no Narcóticos/envenenamiento , Diálisis/métodos , Fallo Hepático Agudo/inducido químicamente , Fallo Hepático Agudo/terapia , Adulto , Soluciones para Diálisis/química , Sobredosis de Droga/complicaciones , Femenino , Humanos , Hígado ArtificialRESUMEN
PURPOSE: A novel type of adsorptive plasma filtering device (ETX-A) capable of removing endotoxin from blood in a single step has recently been developed using nanotechnology. METHODS: In a miniaturized, ex vivo model of extracorporeal circuits, we tested the capacity to reduce plasma cytokine concentration of ETX-A filters in comparison to standard high-flux (HF) filters, high cut-off (HCO) filters and a control. Blood from six healthy volunteers was spiked with endotoxin and then circulated through closed (ETX-A, control) or open (HF, HCO) circuits. Blood flow was set at 16 ml/min and filtration flow at 1 ml/min. Samples for measurement of IL-1ra and IL-6 were taken at baseline and at 4 hours. RESULTS: Compared to control (703.3 [850.6] pg/mL), in HCO (383.5 [1144.1] pg/mL) and ETX-A (490.1 [683.2] pg/mL) filters, plasma IL-1ra pooled pre- and postfilter concentrations were lower at the end of the experiment (P=0.002; P=0.050, respectively) whereas, in standard HF filters, IL-1ra concentration was higher than control. HCO showed a trend toward a reduced relative increase in IL-6 concentration from commencement to end of experiment compared to control (P=0.07). After pooling end-of-experiment plasma cytokine values of novel blood purification devices, we found HCO + ETX-A superior to H with regard to reduction of IL-1ra (-27.0 [-20.5]% vs. 8.1 [18.9]%; p<0.001) and IL-6 (-18.0 [38.3]% vs. -1.1 [24.3]%; P=0.050) compared to control. CONCLUSIONS: HCO and ETX-A appeared to significantly reduce plasma IL-1ra and, when combined, plasma IL-6 concentration as well. It appears desirable to manufacture full-size blood purification devices using this technology and to explore their effect on cytokine removal.
Asunto(s)
Endotoxemia/terapia , Hemofiltración/instrumentación , Proteína Antagonista del Receptor de Interleucina 1/sangre , Interleucina-6/sangre , Lipopolisacáridos/sangre , Miniaturización , Adulto , Endotoxemia/inmunología , Diseño de Equipo , Humanos , Masculino , Persona de Mediana Edad , Factores de TiempoRESUMEN
Canadian healthcare is changing to include individuals living with frailty, but frailty must be better operationalized and better framed by sound data standards and policy. Frailty results from deficit accumulation in multiple body systems, with exaggerated vulnerability to external stressors. A growing consensus on defining frailty sets the stage for consensus on operationalization and widespread implementation in care settings. Frailty measurement is not yet integrated into daily clinical practice in Canada. Here, we will present how this integration might occur. We hope to demonstrate that implementation must appeal to inter-professional practice needs in different settings or circumstances. In some settings, methods for frailty case finding are expected to evolve as deemed to be most appropriate to the front-line users. In this "hands-off" approach, care providers, supported by emerging knowledge translation on frailty operationalization, would be informed by their setting and local practices to establish patterns of ad hoc case finding and component definition of frailty. This more nimble case finding strategy would be opportunistic, and would appeal to expert clinicians and self-directed teams who emphasize an individualized health care experience for their patients. In other settings, we can shape frailty case finding by building care algorithms around existing standardized practices and data repositories, leading to a systematic application of frailty measures and a more coordinated process of component definition and care protocols. Here, recommended instruments and data standards must be endorsed by health networks locally, provincially and nationally. The interRAI suite of assessment instruments has pan-Canadian standards in place and its pervasiveness makes it the most obvious starting point, especially in home care and long-term care. We anticipate the evolution of an integrated model informed by stakeholders and settings, where policy makers focus on system supports for frailty case finding, while front-line clinicians use case finding strategies to pinpoint and act on key frailty components.
Asunto(s)
Atención a la Salud/organización & administración , Fragilidad/diagnóstico , Evaluación Geriátrica , Anciano , Canadá , Anciano Frágil , HumanosRESUMEN
PURPOSE: The EUPHRATES trial examined the impact of polymyxin B hemoperfusion (PMX) on mortality in patients with septic shock and endotoxemia, defined as EAA ≥ 0.60. No difference was found in 28-day all-cause mortality. However, the trial showed that in some patients with septic shock the burden of endotoxin activity was extreme (EAA ≥ 0.9). In a post hoc analysis, we evaluated the impact of PMX use in patients with septic shock and endotoxin activity measured between 0.6-0.89. METHODS: Post-hoc analysis of the EUPHRATES trial for the 194 patients with EAA ≥ 0.6-0.89 who completed two treatments (PMX or sham). The primary end point was mortality at 28 days adjusted for APACHE II score and baseline mean arterial pressure (MAP). Additional end points included changes in MAP, cumulative vasopressor index (CVI), median EAA reduction, ventilator-free days (VFD), dialysis-free days (DFD) and hospital length of stay. Subpopulations analyzed were site and type of infection and those with norepinephrine dose > 0.1 mcg/kg/min at baseline. RESULTS: At 28 days, 23 patients of 88 (26.1%) in the PMX group died versus 39 of 106 (36.8%) in the sham group [risk difference 10.7%, OR 0.52, 95% CI (0.27, 0.99), P = 0.047]. When unadjusted for baseline variables, P = 0.11. The 28-day survival time in the PMX group was longer than for the sham group [HR 0.56 (95% CI 0.33, 0.95) P = 0.03]. PMX treatment compared with sham showed greater change in MAP [median (IQR) 8 mmHg (- 0.5, 19.5) vs. 4 mmHg (- 4.0, 11) P = 0.04] and VFD [median (IQR) 20 days (0.5, 23.5) vs. 6 days (0, 20), P = 0.004]. There were no significant differences in other end points. There was a significant difference in mortality in PMX-treated patients with no bacterial growth on culture [PMX, 6/30 (20%) vs. sham, 13/31 (41.9%), P = 0.005]. The median EAA change in the population was - 12.9% (range: increase 49.2%-reduction 86.3%). The mortality in the above median EAA change group was PMX: 6/38 (15.7%) vs. sham 15/49 (30.6%), P = 0.08. CONCLUSIONS: These hypothesis-generating results, based on an exploratory post hoc analysis of the EUPHRATES trial, suggest measurable responses in patients with septic shock and an EAA ≥ 0.6 to 0.89 on changes in mean arterial pressure, ventilator-free days and mortality. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01046669. Funding Spectral Medical Incorporated.
Asunto(s)
Antibacterianos/administración & dosificación , Cuidados Críticos , Endotoxemia/tratamiento farmacológico , Hemoperfusión , Polimixina B/administración & dosificación , Choque Séptico/tratamiento farmacológico , Adulto , Anciano , Presión Arterial , Endotoxemia/complicaciones , Endotoxemia/mortalidad , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Choque Séptico/etiología , Choque Séptico/mortalidad , Tasa de SupervivenciaRESUMEN
Background: The optimal amount of protein intake in critically ill patients is uncertain. Objective: In this post hoc analysis of the PermiT (Permissive Underfeeding vs. Target Enteral Feeding in Adult Critically Ill Patients) trial, we tested the hypothesis that higher total protein intake was associated with lower 90-d mortality and improved protein biomarkers in critically ill patients. Design: In this post hoc analysis of the PermiT trial, we included patients who received enteral feeding for ≥3 consecutive days. Using the median protein intake of the cohort as a cutoff, patients were categorized into 2 groups: a higher-protein group (>0.80 g · kg-1 · d-1) and a lower-protein group (≤0.80 g · kg-1 · d-1). We developed a propensity score for receiving higher protein. Primary outcome was 90-d mortality. We also compared serial values of prealbumin, transferrin, 24-h urinary nitrogen, and 24-h nitrogen balance on days 1, 7, and 14. Results: Among the 729 patients included in this analysis, the average protein intake was 0.8 ± 0.3 g · kg-1 · d-1 [1.0 ± 0.2 g · kg-1 · d-1 in the higher-protein group (n = 365) and 0.6 ± 0.2 g · kg-1 · d-1 in the lower-protein group (n = 364); P < 0.0001]. There was no difference in 90-d mortality between the 2 groups [88/364 (24.2%) compared with 94/363 (25.9%), propensity score-adjusted OR: 0.80; 95% CI: 0.56, 1.16; P = 0.24]. Higher protein intake was associated with an increase in 24-h urea nitrogen excretion compared with lower protein intake, but without a significant change in prealbumin, transferrin, or 24-h nitrogen balance. Conclusions: In the PermiT trial, a moderate difference in protein intake was not associated with lower mortality. Higher protein intake was associated with increased nitrogen excretion in the urine without a corresponding change in prealbumin, transferrin, or nitrogen balance. Protein intake needs to be tested in adequately powered randomized controlled trials targeting larger differences in protein intake in high-risk populations.
Asunto(s)
Cuidados Críticos/métodos , Enfermedad Crítica/terapia , Proteínas en la Dieta/administración & dosificación , Ingestión de Energía , Nutrición Enteral , Necesidades Nutricionales , Adulto , Anciano , Biomarcadores/metabolismo , Enfermedad Crítica/mortalidad , Proteínas en la Dieta/uso terapéutico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Nitrógeno/metabolismo , Prealbúmina/metabolismo , Transferrina/metabolismo , Urea/metabolismoRESUMEN
BACKGROUND: The reliability and safety of continuous renal replacement therapy (CRRT) machines have improved, yet there still remains the potential for fluid balance errors to occur during treatment. METHODS: In vitro testing of two Kimal Hygieia CRRT machines (Plus and Ultima) was performed. Normal saline to simulate the blood circuit and standard bicarbonate-based fluid for replacement were used. All tests were performed in CVVH mode at four ultrafiltration (UF) rates. The testing was based on creation of a voluntary fluid balance error by clamping the line that fills the replacement fluid chamber to stop flow to the (simulated) patient. The time to alarms and fluid balance errors were recorded. The alarms were overridden and the accumulated fluid balance error allowed by the machine was determined. RESULTS: The alarm occurred approximately 1 minute after the replacement fluid line was clamped at all UF rates. There was no limit to the number of times the alarm could be overridden and the accumulated negative fluid balance was proportional to the prescribed UF rate. After the replacement fluid chamber was allowed to re-fill, the machine attempted to correct the fluid deficit and consistently delivered excess fluid to generate a positive fluid balance error. CONCLUSIONS: The Hygieia machines appear designed with appropriate alarm and safety features. However, simulated fluid balance errors raise caution for operators. Clinicians and nurses need to understand the clinical implications of alarm overrides. Fluid balance errors caused by failure to acknowledge and correct replacement fluid failure alarms may cause harm to patients.
Asunto(s)
Hemofiltración , Equilibrio Hidroelectrolítico , Seguridad de Equipos , Hemofiltración/efectos adversos , Hemofiltración/instrumentación , Modelos Biológicos , Ultrafiltración , Desequilibrio Hidroelectrolítico/diagnósticoRESUMEN
Contrast-induced nephropathy (CIN) is a leading cause of iatrogenic acute kidney failure. Periprocedural CIN results in a greater risk of requiring renal replacement therapy, prolonged hospitalization, excessive health care costs, potential long term kidney impairment and mortality. Identified risk factors for CIN include premorbid chronic kidney disease, diabetes mellitus, congestive heart failure, critical illness and volume of administered contrast media. Prophylactic interventions for the prevention of CIN remain controversial and uncertain. In this review we critically appraise the evidence for prevention of CIN. In general, every attempt should be made to correct underlying volume depletion, discontinue potential nephrotoxins, reverse any acute kidney dysfunction or when not possible, consider delay of procedure or an alternative modality for imaging. A minimum volume of contrast media should be employed, including going left ventriculogram and performing staged procedures if applicable. There are few interventions with quality evidence for reducing the incidence of CIN. procedure hydration and the use of nonionic iso-osmolar contrast media have consistently demonstrated efficacy. For patients at high risk, there is evidence to suggest benefit with N-acetylcysteine. Clinical studies with adenosine antagonists are encouraging; however, further confirmatory trials are required. Based on the available studies, there is inadequate evidence for the routine use of hemofiltration, atrial natriuretic peptides, calcium channel blockers, or prostaglandins. There is no evidence to support prophylaxis with diuretic therapy, forced diuresis, low dose dopamine, fenoldopam, captopril, or endothelin receptor antagonists. Despite recent advances in the epidemiology, pathophysiology and natural history of CIN, few effective prophylactic or therapeutic interventions have conclusively demonstrated evidence for a reduction in CIN incidence and no therapy has proven efficacious once CIN is established.
Asunto(s)
Medios de Contraste/efectos adversos , Enfermedades Renales/inducido químicamente , Enfermedades Renales/prevención & control , Alberta/epidemiología , Australia/epidemiología , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Humanos , Enfermedades Renales/epidemiología , Radiografía , Factores de RiesgoRESUMEN
BACKGROUND: The optimal means of pre-operative risk stratification in patients with atrial fibrillation (AF) is uncertain. OBJECTIVE: To examine the accuracy of AF thromboembolic risk models (the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores) for predicting 30-day stroke and/or all-cause mortality after non-cardiac surgery in patients with preoperative AF, and to compare these risk scores with the Revised Cardiac Risk Index (RCRI). PATIENTS/METHODS: A multicentre (8 countries, 2007-2011) prospective cohort study of patients ≥ 45 years of age undergoing inpatient non-cardiac surgery, who were followed until 30 days after surgery. We calculated c-statistics for each risk prediction model and net reclassification improvements (NRIs) compared with the RCRI. RESULTS: The 961 patients with preoperative AF were at higher risk of any cardiovascular event in the 30 days postoperatively compared with the 13 001 patients without AF: 26.6% vs. 9.0%; adjusted odds ratio, 1.58; 95% confidence interval [CI], 1.33-1.88. All thromboembolic risk scores predicted postoperative death just as well as the RCRI (with c-indices between 0.67 and 0.72). Compared with the RCRI (which had a c-index of 0.64 for 30-day stroke/death), the CHADS2 (c-index, 0.67; NRI, 0.31; 95% CI, 0.02-0.61) significantly improved postoperative stroke/mortality risk prediction, largely due to improved discrimination of patients who did not subsequently have an event. CONCLUSIONS: In AF patients, the three thromboembolic risk scores performed similarly to the RCRI in predicting death within 30 days and the CHADS2 score was the best predictor of postoperative stroke/death regardless of type of surgery.
Asunto(s)
Fibrilación Atrial/complicaciones , Técnicas de Apoyo para la Decisión , Accidente Cerebrovascular/etiología , Procedimientos Quirúrgicos Operativos/efectos adversos , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Valor Predictivo de las Pruebas , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/mortalidad , Procedimientos Quirúrgicos Operativos/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
The risks and adverse effects of the low dose, new generation progestogen combined oral contraceptives (COCs) are much lower than original studies involving pills containing 50 micrograms estrogen. The main effects are those on the cardiovascular system, lipid and glucose metabolism and cancer. Any effect of the COC on myocardial infarction is probably minimal if the woman has no other risk factors especially smoking. The third generation progestogen, low dose COCs have very little effect on lipid or glucose metabolism. There may be a slight increase in breast cancer if COCs are used under the age of 25 years and for more than 4 to 8 years, and in the risk of cervical cancer. It is too early to estimate long term cancer effects of the newer COCs. Adverse effects such as nausea and breast tenderness can be managed by changing the estrogen dose or the type of progestogen. Overall, the clinical benefits of the COC probably outweight the risks and adverse effects.
PIP: Recent cohort and case control studies of low-dose combined oral contraceptives (COCs) containing the new generation of progestogens have allowed classification of adverse effects into those which are rare but serious and should be considered risks and those which are more frequent but are less of a threat to health. Low-dose COCs continue to affect coagulation in a complex way, but the risk is less than with the older preparations, and it can be minimized by screening women for a personal or familial history of early or unusual thrombosis and for levels of protein C, S, and antithrombin III. Women with true migraine with focal signs should also avoid using COCs. The relative risk of myocardial infarction (MI) may increase from 4:1 in women with one risk factor (age, smoking, hypertension, hyperlipidemia, and diabetes) to 20:1 with two risk factors and 128:1 with three or more risk factors. In the absence of all risk factors, a recent study indicated that the relative risk of MI with COC use was 1.9 for current and past use. COC use also causes a slight increase in hypertension in most women, especially those who are older or have a family history of hypertension. While the COC can affect carbohydrate and lipid metabolism, the new generation of progestogens has reduced these effects. The COC may accelerate presentation of gallbladder disease in predisposed women. The COC protects against benign breast disease but may increase the risk of breast cancer and cervical cancer slightly. There is a strong link between hepatocellular adenoma and COC use, but the incidence is low. Return to fertility after use has not been a problem. Both estrogenic adverse effects (nausea, dizziness, irritability, weight gain, bloating) and progestogenic adverse effects (vaginal dryness, acne, hirsutism, weight gain, depression, loss of libido) can occur in 50% of women, but these generally disappear after a few months of use. In conclusion, the low-dose, third generation COCs are associated with minimal risks in the absence of other risk factors and have many beneficial effects such as the prevention of ovarian and endometrial cancer; a decrease in pelvic inflammatory disease and ectopic pregnancies; and protection from anemia, primary dysmenorrhea, functional ovarian cysts, and benign breast disease as well as from the morbidity and mortality associated with pregnancy.
Asunto(s)
Anticonceptivos Orales Combinados/efectos adversos , Neoplasias de la Mama/inducido químicamente , Sistema Cardiovascular/efectos de los fármacos , Femenino , Humanos , Metabolismo de los Lípidos , Riesgo , Neoplasias del Cuello Uterino/inducido químicamenteRESUMEN
Two thousand and thirty-four patients attending a family planning clinic were tested for the presence of Chlamydia trachomatis infection of the cervix. The incidence of infection was 17.5%. Pregnant patients had a higher incidence of infection (23%), than nonpregnant patients (16.8%; p less than 0.05), and in the former this was not related to age. In nonpregnant women age was found to be an important determinant of infection rate, 22% in the 20 and under age group, and 9% in those over 25 years (p less than 0.01). There was a higher rate of infection in those with abnormal cervical smears, and in those with a coincident sexually transmitted infection; this was not statistically significant. Risk factors for acquiring this infection were identified as patients with more than five life time partners, those 20 years old or less, and pregnant patients, regardless of age or number of partners.
PIP: Chlamydia trachomatis is an obligatory intracellular parasite. The initial genital tract infection in women is most commonly of the columnar cells of the cervix, from which it may spread to other pelvic organs. The parasite may also be carried asymptomatically. Complications of infection are varied. Among women aged younger than 20 years, Chlamydia trachomatis has been shown to cause 63% of acute pelvic inflammatory disease, with an incidence of 30% in all age groups. Among males, Chlamydia trachomatis infection is the cause of 50% of cases of nonspecific urethritis. Such infection may be associated with epididymitis and/or prostatitis, and may subsequently lead to infertility. Neonates exposed to maternal Chlamydia trachomatis infection may develop conjunctivitis or pneumonia. Chlamydia trachomatis infection is probably the most common venereal disease in the world. 2034 patients attending a family planning clinic in Christchurch between May 1984 and July 1985 were tested for the presence of Chlamydia trachomatis infection of the cervix with the goal of defining the high risk groups in which screening may be indicated. 357 of the women had Chlamydia trachomatis infection of the cervix. They were of mean age 21.6 years, and had had an average of eight sex partners since first intercourse. Women who were not infected with Chlamydia were of mean age 23 years and had had an average of six sex partners since first intercourse. Risk factors for acquiring infection with Chlamydia trachomatis were having more than five lifetime partners, being age 20 years or younger, and being pregnant, regardless of the age or number of partners. These findings confirm the need to screen all sexually active women aged 20 years and younger for infection with Chlamydia trachomatis.