RESUMO
Using a cohort study design, we analysed 17 diagnoses and 9 interventions (including critical care admission) as a composite measure of severe maternal morbidity for pregnancies recorded over 14 years in Scotland. There were 762,918 pregnancies, of which 7947 (10 in 1000 pregnancies) recorded 9345 severe maternal morbidity events, 2802 episodes of puerperal sepsis being the most common (30%). Severe maternal morbidity incidence increased from 9 in 1000 pregnancies in 2012 to 17 in 1000 pregnancies in 2018, due in part to puerperal sepsis recording. The odds ratio (95%CI) for severe maternal morbidity was higher for: older women, for instance 1.22 (1.13-1.33) for women aged 35-39 years and 1.44 (1.27-1.63) for women aged > 40 years compared with those aged 25-29 years; obese women, for instance 1.13 (1.06-1.21) for BMI 30-40 kg.m-2 and 1.32 (1.15-1.51) for BMI > 40 kg.m-2 compared with BMI 18.5-24.9 kg.m-2 ; multiple pregnancy, 2.39 (2.09-2.74); and previous caesarean delivery, 1.52 (1.40-1.65). The median (IQR [range]) hospital stay was 3 (2-5 [1-8]) days with severe maternal morbidity and 2 (1-3 [1-5]) days without. Forty-one women died during pregnancy or up to 42 days after delivery, representing mortality rates per 100,000 pregnancies of about 365 with severe maternal morbidity and 1.6 without. There were 1449 women admitted to critical care, 807 (58%) for mechanical ventilation or support of at least two organs. We recorded an incidence of severe maternal morbidity higher than previously published, possibly because sepsis was coded inaccurately in our databases. Further research may determine the value of this composite measure of severe maternal morbidity.
Assuntos
Hospitalização , Sepse , Idoso , Estudos de Coortes , Feminino , Humanos , Incidência , Tempo de Internação , Mortalidade Materna , Morbidade , Gravidez , Sepse/epidemiologiaRESUMO
Anaemia is common in critical illness, and standard treatment is red blood cell (RBC) transfusion, typically using a restrictive transfusion threshold of 70 g L-1 . However, there are subgroups of patients in whom it is biologically plausible that a higher transfusion threshold may be beneficial, namely, acute sepsis, traumatic brain injury and coexisting cardiovascular disease. In this review article, we will discuss the pathophysiology of anaemia, as well as its prevalence and time course. We will explore the limitations of using haemoglobin concentration as a surrogate for oxygen delivery and the concept of the critical haemoglobin concentration. We will then discuss transfusion thresholds for the general intensive care unit (ICU) population and specific subgroups.
Assuntos
Anemia/terapia , Atenção à Saúde , Transfusão de Eritrócitos , Doença Aguda , Anemia/sangue , Anemia/epidemiologia , Lesões Encefálicas Traumáticas/sangue , Lesões Encefálicas Traumáticas/terapia , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/terapia , Atenção à Saúde/métodos , Atenção à Saúde/normas , Transfusão de Eritrócitos/métodos , Transfusão de Eritrócitos/normas , Humanos , Sepse/sangue , Sepse/terapiaRESUMO
BACKGROUND: The effect of day of the week on outcome after surgery is the subject of debate. The aim was to determine whether day of the week of emergency general surgery alters short- and long-term mortality. METHODS: This was an observational study of all patients undergoing emergency general surgery in Scotland between 1 January 2005 and 31 December 2007, followed to 2012. Multilevel logistic and Cox proportional hazards regression were used to assess the effect of day of the week of surgery on outcome after adjustment for case mix and risk factors. The primary outcome was perioperative mortality; the secondary outcome was overall survival. RESULTS: A total of 50 844 patients were identified, of whom 31 499 had an emergency procedure on Monday to Thursday and 19 345 on Friday to Sunday. Patients undergoing surgery at the weekend were younger (mean 45·9 versus 47·5 years; P < 0·001) and had fewer co-morbidities, but underwent riskier and/or more complex procedures (P < 0·001). Patients who had surgery at the weekend were more likely to have been operated on sooner than those who had weekday surgery (mean time from admission to operation 1·2 versus 1·6 days; P < 0·001). No difference in perioperative mortality (odds ratio 1·00, 95 per cent c.i. 0·89 to 1·13; P = 0·989) or overall survival (hazard ratio 1·01, 0·97 to 1·06; P = 0·583) was observed when surgery was performed at the weekend. There was no difference in overall survival after surgery undertaken on any particular day compared with Wednesday; a borderline reduction in perioperative mortality was seen on Tuesday. CONCLUSION: There was no difference in short- or long-term mortality following emergency general surgery at the weekend, compared with mid-week.
Assuntos
Serviço Hospitalar de Emergência/normas , Procedimentos Cirúrgicos Operatórios/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Fatores de Risco , Escócia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The optimal perioperative use of intensive care unit (ICU) resources is not yet defined. We sought to determine the effect of ICU admission on perioperative (30 day) and long-term mortality. METHODS: This was an observational study of all surgical patients in Scotland during 2005-7 followed up until 2012. Patient, operative, and care process factors were extracted. The primary outcome was perioperative mortality; secondary outcomes were 1 and 4 yr mortality. Multivariable regression was used to construct a risk prediction model to allow standard-risk and high-risk groups to be defined based on deciles of predicted perioperative mortality risk, and to determine the effect of ICU admission (direct from theatre; indirect after initial care on ward; no ICU admission) on outcome adjusted for confounders. RESULTS: There were 572 598 patients included. The risk model performed well (c-index 0.92). Perioperative mortality occurred in 1125 (0.2%) in the standard-risk group (n=510 979) and in 3636 (6.4%) in the high-risk group (n=56 785). Patients with no ICU admission within 7 days of surgery had the lowest perioperative mortality (whole cohort 0.7%; high-risk cohort 5.3%). Indirect ICU admission was associated with a higher risk of perioperative mortality when compared with direct admission for the whole cohort (20.9 vs 12.1%; adjusted odds ratio 2.39, 95% confidence interval 2.01-2.84; P<0.01) and for high-risk patients (26.2 vs 17.8%; adjusted odds ratio 1.64, 95% confidence interval 1.37-1.96; P<0.01). Compared with direct ICU admission, indirectly admitted patients had higher severity of illness on admission, required more organ support, and had an increased duration of ICU stay. CONCLUSIONS: Indirect ICU admission was associated with increased mortality and increased requirement for organ support. TRIAL REGISTRATION: UKCRN registry no. 15761.
Assuntos
Mortalidade Hospitalar , Unidades de Terapia Intensiva/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Recursos em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
BACKGROUND: Ventilator-acquired pneumonia (VAP) remains a significant problem within intensive care units (ICUs). There is a growing recognition of the impact of critical-illness-induced immunoparesis on the pathogenesis of VAP, but the mechanisms remain incompletely understood. We hypothesised that, because of limitations in their routine detection, Mycoplasmataceae are more prevalent among patients with VAP than previously recognised, and that these organisms potentially impair immune cell function. METHODS AND SETTING: 159 patients were recruited from 12 UK ICUs. All patients had suspected VAP and underwent bronchoscopy and bronchoalveolar lavage (BAL). VAP was defined as growth of organisms at >10(4) colony forming units per ml of BAL fluid on conventional culture. Samples were tested for Mycoplasmataceae (Mycoplasma and Ureaplasma spp.) by PCR, and positive samples underwent sequencing for speciation. 36 healthy donors underwent BAL for comparison. Additionally, healthy donor monocytes and macrophages were exposed to Mycoplasma salivarium and their ability to respond to lipopolysaccharide and undertake phagocytosis was assessed. RESULTS: Mycoplasmataceae were found in 49% (95% CI 33% to 65%) of patients with VAP, compared with 14% (95% CI 9% to 25%) of patients without VAP. Patients with sterile BAL fluid had a similar prevalence to healthy donor BAL fluid (10% (95% CI 4% to 20%) vs 8% (95% CI 2% to 22%)). The most common organism identified was M. salivarium. Blood monocytes from healthy volunteers incubated with M. salivarium displayed an impaired TNF-α response to lipopolysaccharide (p=0.0003), as did monocyte-derived macrophages (MDMs) (p=0.024). MDM exposed to M. salivarium demonstrated impaired phagocytosis (p=0.005). DISCUSSION AND CONCLUSIONS: This study demonstrates a high prevalence of Mycoplasmataceae among patients with VAP, with a markedly lower prevalence among patients with suspected VAP in whom subsequent cultures refuted the diagnosis. The most common organism found, M. salivarium, is able to alter the functions of key immune cells. Mycoplasmataceae may contribute to VAP pathogenesis.
Assuntos
Líquido da Lavagem Broncoalveolar/microbiologia , Infecção Hospitalar/microbiologia , Macrófagos/microbiologia , Monócitos/microbiologia , Mycoplasma/patogenicidade , Pneumonia Bacteriana/microbiologia , Pneumonia Associada à Ventilação Mecânica/microbiologia , Idoso , Broncoscopia , Feminino , Humanos , Unidades de Terapia Intensiva , Lipopolissacarídeos , Masculino , Pessoa de Meia-Idade , Fagocitose , Reação em Cadeia da Polimerase , Prevalência , Reino UnidoRESUMO
Blood transfusion can be life-saving. Anaesthetists regularly request and administer blood components to their patients. All anaesthetists must be familiar with indications and appropriate use of blood and blood components and their alternatives, but close liaison with haematology specialists and their local blood sciences laboratory is encouraged. Considerable changes in approaches to optimal use of blood components, together with the use of alternative products, have become apparent over the past decade, leading to a need to update previous guidelines and adapt them for the use of anaesthetists working throughout the hospital system.
Assuntos
Transfusão de Componentes Sanguíneos/métodos , Anestesiologia , Humanos , Irlanda , Sociedades Médicas , Reino UnidoRESUMO
BACKGROUND: The present qualitative study aimed to explore the factors influencing nutritional recovery in patients after critical illness and to develop a model of care to improve current management of nutrition for this patient group. METHODS: Patients were recruited into the study on discharge from a general intensive care unit (ICU) of a large teaching hospital in central Scotland. Semi-structured interviews were carried out after discharge from the ICU, weekly for the duration of their ward stay, and at 3 months post ICU discharge. Observations of ward practice were undertaken thrice weekly for the duration of the ward stay. RESULTS: Seventeen patients were recruited into the study and, using a grounded theory approach, 'inter-related system breakdowns during the nutritional recovery process' emerged as the overarching core category that influenced patients' experiences of eating after critical illness. This encompassed the categories, 'experiencing a dysfunctional body', 'experiencing socio-cultural changes in relation to eating' and 'encountering nutritional care delivery failures'. CONCLUSIONS: The findings from the present study provide a unique contribution to knowledge by offering important insights into patients' experiences of eating after critical illness. The study has identified numerous nutritional problems and raises questions about the efficacy of current nutritional management in this patient group. Adopting a more individualised approach to nutritional care could ameliorate the nutritional issues experienced by post ICU patients. This will be evaluated in future work.
Assuntos
Assistência ao Convalescente , Estado Terminal/terapia , Comportamento Alimentar , Terapia Nutricional , Adulto , Idoso , Idoso de 80 Anos ou mais , Dieta , Feminino , Hospitais de Ensino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Avaliação Nutricional , Alta do Paciente , Pesquisa Qualitativa , Escócia , Adulto JovemRESUMO
BACKGROUND: Nosocomial infection occurs commonly in intensive care units (ICUs). Although critical illness is associated with immune activation, the prevalence of nosocomial infections suggests concomitant immune suppression. This study examined the temporal occurrence of immune dysfunction across three immune cell types, and their relationship with the development of nosocomial infection. METHODS: A prospective observational cohort study was undertaken in a teaching hospital general ICU. Critically ill patients were recruited and underwent serial examination of immune status, namely percentage regulatory T-cells (Tregs), monocyte deactivation (by expression) and neutrophil dysfunction (by CD88 expression). The occurrence of nosocomial infection was determined using pre-defined, objective criteria. RESULTS: Ninety-six patients were recruited, of whom 95 had data available for analysis. Relative to healthy controls, percentage Tregs were elevated 6-10 days after admission, while monocyte HLA-DR and neutrophil CD88 showed broader depression across time points measured. Thirty-three patients (35%) developed nosocomial infection, and patients developing nosocomial infection showed significantly greater immune dysfunction by the measures used. Tregs and neutrophil dysfunction remained significantly predictive of infection in a Cox hazards model correcting for time effects and clinical confounders {hazard ratio (HR) 2.4 [95% confidence interval (CI) 1.1-5.4] and 6.9 (95% CI 1.6-30), respectively, P=0.001}. Cumulative immune dysfunction resulted in a progressive risk of infection, rising from no cases in patients with no dysfunction to 75% of patients with dysfunction of all three cell types (P=0.0004). CONCLUSIONS: Dysfunctions of T-cells, monocytes, and neutrophils predict acquisition of nosocomial infection, and combine additively to stratify risk of nosocomial infection in the critically ill.
Assuntos
Estado Terminal/epidemiologia , Infecção Hospitalar/epidemiologia , Imunidade Celular/fisiologia , Adolescente , Adulto , Idoso , Contagem de Linfócito CD4 , Estudos de Coortes , Complemento C5a/fisiologia , Infecção Hospitalar/microbiologia , Feminino , Antígenos HLA-DR/imunologia , Humanos , Masculino , Pessoa de Meia-Idade , Monócitos/imunologia , Neutrófilos/imunologia , Prognóstico , Estudos Prospectivos , Receptor da Anafilatoxina C5a/biossíntese , Linfócitos T Reguladores/imunologia , Adulto JovemRESUMO
BACKGROUND: Fresh-frozen plasma (FFP) is widely used in critically ill patients, despite a weak evidence base. Factors that influence the decision to transfuse FFP before intravascular catheter insertion are poorly described. METHODS: We undertook a case-controlled study based on a prospective cohort study of 1923 admissions to 29 intensive care units in the UK. Non-bleeding patients with an international normalized ratio (INR) ≥1.5 who underwent intravascular catheterization, but no other invasive procedure, were identified. We compared patient characteristics, illness-related factors, and biochemical and haematological variables between patients who did or did not receive pre-procedural FFP. RESULTS: One hundred and eighty-six patients fulfilled the criteria; 26 received FFP during the 24 h before line insertion (cases) and 160 did not (controls). Factors associated with greater use of prophylactic FFP by clinicians were pre-existing chronic liver disease (P=0.01), higher serum bilirubin before procedure (P=0.01), lower platelet count (P=0.01), higher activated partial thromboplastin time (P=0.001), lower fibrinogen (P=0.01), and concurrent red cell transfusion despite the absence of bleeding (P=0.001). There was no difference in pre-procedural INR [median (1st, 3rd quartile) cases: 1.95 (1.85, 2.6); controls 1.8 (1.6, 2.3); P=0.19]. The mean FFP dose was 11.1 ml kg(-1) (sd 5.7 ml kg(-1)); 53.8% of cases were transfused <10 ml kg(-1). CONCLUSIONS: Chronic liver disease and more abnormal coagulation tests were associated with greater probability of pre-procedural FFP administration before vascular catheterization, whereas the severity of prothrombin time prolongation alone was not. FFP was more likely to be administered when red cells were also transfused, even in the absence of bleeding.
Assuntos
Transfusão de Componentes Sanguíneos/métodos , Cateterismo Venoso Central , Cateterismo Periférico , Tempo de Protrombina , Idoso , Bilirrubina/sangue , Estudos de Casos e Controles , Estudos de Coortes , Cuidados Críticos , Estado Terminal , Transfusão de Eritrócitos/métodos , Feminino , Fibrinogênio , Humanos , Hepatopatias/sangue , Hepatopatias/complicações , Masculino , Pessoa de Meia-Idade , Tempo de Tromboplastina Parcial , Plasma , Contagem de Plaquetas , Estudos Prospectivos , Reino UnidoRESUMO
BACKGROUND: Revision hip arthroplasty (RHA) is associated with high rates of allogeneic blood transfusion (ABT). We aimed to determine factors associated with ABT in patients undergoing RHA in Scottish hospitals, with particular focus on perioperative cell salvage (PCS). METHODS: A prospective observational cohort study of RHA procedures performed in 11 hospitals over 7 months was performed. We recorded predefined patient, surgery-related, and blood conservation factors that may influence perioperative ABT, together with postoperative haemoglobin (Hb) data and ABTs to day 7. We explored factors with strongest independent association with ABT during the perioperative period using multiple regression analysis. RESULTS: Two hundred and ten cases were studied, of whom 58% received ABTs (mean 1.8 units), most of which (52%) occurred on the day of surgery. Eighty-eight (42%) patients received PCS, of whom 68 had red cells re-infused [mean re-infusion volume 312 ml (1st, 3rd quartile: 260, 363 ml)]. In unadjusted comparisons, patients receiving PCS had lower intraoperative (9% vs 40%) and total (55% vs 63%) exposure to ABTs. The mean (95% confidence interval) theatre blood loss was 1013 (899-1128) ml and was higher for combined femoral/acetabular revision and femoral revision than other categories. The mean postoperative Hb transfusion trigger was 80 g litre(-1). In multivariable models, preoperative Hb [odds ratio (OR) 0.35; P<0.001], patient weight (OR 0.96; P=0.004), operating theatre blood loss (OR 1.002; P<0.001), and re-infusion of PCS blood (OR 0.31; P=0.02) were independent predictors of ABT exposure. CONCLUSIONS: PCS is an effective blood conservation strategy for RHA, especially for patients with preoperative anaemia, low body weight, or both.
Assuntos
Artroplastia de Quadril/métodos , Transfusão de Eritrócitos/efeitos adversos , Recuperação de Sangue Operatório/métodos , Reoperação/métodos , Reação Transfusional , Adulto , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica , Transfusão de Sangue/estatística & dados numéricos , Transfusão de Sangue Autóloga , Volume Sanguíneo , Peso Corporal/fisiologia , Estudos de Coortes , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Hemoglobinas/análise , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Recuperação de Sangue Operatório/estatística & dados numéricos , Estudos Prospectivos , Fatores de Risco , Tamanho da AmostraRESUMO
BACKGROUND: Excessive sedation is associated with adverse patient outcomes during critical illness, and a validated monitoring technology could improve care. We developed a novel method, the responsiveness index (RI) of the frontal EMG. We compared RI data with Ramsay clinical sedation assessments in general and cardiac intensive care unit (ICU) patients. METHODS: We developed the algorithm by iterative analysis of detailed observational data in 30 medical-surgical ICU patients and described its performance in this cohort and 15 patients recovering from scheduled cardiac surgery. Continuous EMG data were collected via frontal electrodes and RI data compared with modified Ramsay sedation state assessments recorded regularly by a blinded trained observer. RI performance was compared with Entropy™ across Ramsay categories to assess validity. RESULTS: RI correlated well with the Ramsay category, especially for the cardiac surgery cohort (general ICU patients ρ=0.55; cardiac surgery patients ρ=0.85, both P<0.0001). Discrimination across all Ramsay categories was reasonable in the general ICU patient cohort [P(K)=0.74 (sem 0.02)] and excellent in the cardiac surgery cohort [P(K)=0.92 (0.02)]. Discrimination between 'lighter' vs 'deeper' (Ramsay 1-3 vs 4-6) was good for general ICU patients [P(K)=0.80 (0.02)] and excellent for cardiac surgery patients [P(K)=0.96 (0.02)]. Performance was significantly better than Entropy™. Examination of individual cases suggested good face validity. CONCLUSIONS: RI of the frontal EMG has promise as a continuous sedation state monitor in critically ill patients. Further investigation to determine its utility in ICU decision-making is warranted.
Assuntos
Anestesia , Lobo Frontal/efeitos dos fármacos , Monitorização Fisiológica/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Período de Recuperação da Anestesia , Procedimentos Cirúrgicos Cardíacos , Estudos de Coortes , Cuidados Críticos/métodos , Estado Terminal , Eletromiografia/métodos , Humanos , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Respiração ArtificialRESUMO
BACKGROUND: It is known that 20-30% of fresh frozen plasma (FFP) is used in intensive care units (ICUs), but little is known about variations in decision making between clinicians in relation to coagulopathy management. Our aim was to describe ICU clinicians' beliefs and practice in relation to FFP treatment of non-bleeding coagulopathic critically ill patients. METHODS: Two patient-based scenarios were developed and sent to 2700 members of two UK intensive care professional societies. Scenario 1 was a non-bleeding septic patient with coagulopathy; scenario 2 was a non-bleeding critically ill patient with hepatic cirrhosis and coagulopathy. Responses were sought in relation to FFP prophylaxis, and prior to central venous cannulation. A supplementary question asked clinicians' view of prophylaxis in relation to other ICU procedures. RESULTS: Two-thousand-and-seven-hundred clinicians were surveyed from whom 601 responses were received (22·3% response rate). For scenario 1 52% of respondents stated that they would never routinely administer prophylactic FFP, but this decreased to 9% when central venous cannulation was planned (P < 0·01). There was wide variation in the 'trigger' INR (international normalised ratio) value used prior to central vein cannulation, the most common range being 2·0-2·4. For scenario 2, responses were very similar. More than 80% of clinicians stated that they would routinely treat coagulopathy prior to lumbar puncture, epidural catheterisation, intracranial pressure monitoring and tracheostomy; and 54% prior to chest drain insertion. CONCLUSION: Our survey demonstrated a wide range of responses consistent with important variations in clinical practice and substantial clinical uncertainty in relation to FFP treatment for non-bleeding ICU patients.
Assuntos
Atitude do Pessoal de Saúde , Transfusão de Componentes Sanguíneos/psicologia , Cuidados Críticos/métodos , Estado Terminal/terapia , Médicos/psicologia , Plasma , Transtornos da Coagulação Sanguínea/terapia , Transfusão de Componentes Sanguíneos/economia , Transfusão de Componentes Sanguíneos/estatística & dados numéricos , Segurança do Sangue , Cateterismo Venoso Central , Tubos Torácicos , Cuidados Críticos/economia , Cuidados Críticos/psicologia , Cuidados Críticos/estatística & dados numéricos , Coleta de Dados , Grupos Diagnósticos Relacionados , Humanos , Unidades de Terapia Intensiva , Coeficiente Internacional Normatizado , Pressão Intracraniana , Prática Profissional , Punções , TraqueostomiaRESUMO
BACKGROUND: The value of respiratory variables as weaning predictors in the intensive care unit (ICU) is controversial. We evaluated the ability of tidal volume (Vt(exp)), respiratory rate (f), minute volume (MV(exp)), rapid shallow breathing index (f/Vt), inspired-expired oxygen concentration difference [(I-E)O(2)], and end-tidal carbon dioxide concentration (Pe'(co(2))) at the end of a weaning trial to predict early weaning outcomes. METHODS: Seventy-three patients who required >24 h of mechanical ventilation were studied. A controlled pressure support weaning trial was undertaken until 5 cm H(2)O continuous positive airway pressure or predefined criteria were reached. The ability of data from the last 5 min of the trial to predict whether a predefined endpoint indicating discontinuation of ventilator support within the next 24 h was evaluated. RESULTS: Pre-test probability for achieving the outcome was 44% in the cohort (n=32). Non-achievers were older, had higher APACHE II and organ failure scores before the trial, and higher baseline arterial H(+) concentrations. The Vt, MV, f, and f/Vt had no predictive power using a range of cut-off values or from receiver operating characteristic (ROC) analysis. The [I-E]O(2) and Pe'(co(2)) had weak discriminatory power [area under the ROC curve: [I-E]O(2) 0.64 (P=0.03); Pe'(co(2)) 0.63 (P=0.05)]. Using best cut-off values for [I-E]O(2) of 5.6% and Pe'(co(2)) of 5.1 kPa, positive and negative likelihood ratios were 2 and 0.5, respectively, which only changed the pre- to post-test probability by about 20%. CONCLUSIONS: In unselected ICU patients, respiratory variables predict early weaning from mechanical ventilation poorly.
Assuntos
Cuidados Críticos , Troca Gasosa Pulmonar/fisiologia , Desmame do Respirador , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva , Valor Preditivo dos Testes , Prognóstico , Testes de Função Respiratória/métodos , Taxa Respiratória/fisiologia , Volume de Ventilação Pulmonar/fisiologia , Fatores de TempoRESUMO
OBJECTIVE: To investigate ward-based rehabilitation after critical illness and undertake a pilot study exploring the feasibility of delivering enhanced physiotherapy and nutritional rehabilitation. DESIGN: Service evaluation (part A) and pilot feasibility randomized controlled trial (part B). SETTING: Hospital inpatient wards following discharge from intensive care. PARTICIPANTS: Part A involved 24 people with an intensive care stay of four days or more. Part B involved 16 participants randomized into a control (n = 8) or intervention (n = 8) group. INTERVENTIONS: Part A defined the current 'standard' physiotherapy and nutritional interventions. In part B the control group received this 'standard' service while the intervention group received this 'standard' service plus enhanced rehabilitation. MAIN MEASURES: Part A collected process outcomes of current interventions and outcomes that included calorie and protein intake and the Rivermead Mobility Index. In part B process outcomes determined differences between groups. Outcomes included those undertaken in part A plus an incremental shuttle test, handgrip dynamometry and visual analogue scales. RESULTS: Part A found low levels of ward-based physiotherapy (walking and transfer practice once per week) and dietetic input (0.8 visits per week). Part B found an increased frequency of both physiotherapy (P = 0.002) and dietetic (P = 0.001) visits in the intervention group. Physical and nutritional outcomes were suitable for use after critical illness, but no statistically significant differences were found between groups. Power calculations indicated 100 participants per group would be required for a definitive study. CONCLUSIONS: This feasibility pilot work has informed the design of a larger study to evaluate enhanced rehabilitation following critical illness.
Assuntos
Estado Terminal/reabilitação , Idoso , Dietoterapia , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Atividade Motora , Modalidades de Fisioterapia , Projetos PilotoRESUMO
BACKGROUND: Ventilator-associated pneumonia surveillance is used as a quality indicator due to concerns that some cases may be preventable and may contribute to mortality. Various surveillance criteria exist for the purposes of national reporting, but a large-scale direct comparison has not been conducted. METHODS: A prospective cohort study applied two routinely used surveillance criteria for ventilator-associated pneumonia from the European Centre for Disease Control and the American Centers for Disease Control to all patients admitted to two large general intensive care units. Diagnostic rates and concordance amongst diagnostic events were compared. FINDINGS: A total of 713 at-risk patients were identified during the study period. The European surveillance algorithm returned a rate of 4.6 cases of ventilator-associated pneumonia per 1000 ventilation days (95% confidence interval 3.1-6.6) and the American surveillance system a rate of 5.4 (3.8-7.5). The concordance between diagnostic events was poor (Cohen's Kappa 0.127 (-0.003 to 0.256)). CONCLUSIONS: The algorithms yield similar rates, but the lack of event concordance reveals the absence of inter-algorithm agreement for diagnosing ventilator-associated pneumonia, potentially undermining surveillance as an indicator of care quality.
Assuntos
Pneumonia Associada à Ventilação Mecânica/epidemiologia , Vigilância em Saúde Pública/métodos , Vigilância de Evento Sentinela , Adulto , Idoso , Algoritmos , Feminino , Hospitais , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Associada à Ventilação Mecânica/microbiologia , Estudos Prospectivos , Escócia/epidemiologiaRESUMO
BACKGROUND: The optimal method for diagnosing ventilator-associated pneumonia (VAP) is controversial and its effect on reported incidence uncertain. This study aimed to model the impact of using either endotracheal aspirate or bronchoalveolar lavage on the reported incidence of pneumonia and then to test effects suggested from theoretical modelling in clinical practice. METHODS: A three-part single-centre study was undertaken. First, diagnostic performance of aspirate and lavage were compared using paired samples from 53 patients with suspected VAP. Secondly, infection surveillance data were used to model the potential effect on pneumonia incidence and antibiotic use of using exclusively aspirate or lavage to investigate suspected pneumonia (643 patients; 110 clinically suspected pneumonia episodes). Thirdly, a practice change initiative was undertaken to increase lavage use; pneumonia incidence and antibiotic use were compared for the 12 months before and after the change. RESULTS: Aspirate overdiagnosed VAP compared with lavage (89% vs 21% of clinically suspected cases, p<0.0001). Modelling suggested that changing from exclusive aspirate to lavage diagnosis would decrease reported pneumonia incidence by 76% (95% CI 67% to 87%) and antibiotic use by 30% (95% CI 20% to 42%). After the practice change initiative, lavage use increased from 37% to 58%. Although clinically suspected pneumonia incidence was unchanged, microbiologically confirmed VAP decreased from 18 to 9 cases per 1000 ventilator days (p = 0.001; relative risk reduction 0.61 (95% CI 0.46 to 0.82)), and mean antibiotic use fell from 9.1 to 7.2 antibiotic days (21% decrease, p = 0.08). CONCLUSIONS: Diagnostic technique impacts significantly on reported VAP incidence and potentially on antibiotic use.
Assuntos
Pneumonia Associada à Ventilação Mecânica/diagnóstico , Antibacterianos/administração & dosagem , Líquido da Lavagem Broncoalveolar/microbiologia , Cuidados Críticos/métodos , Uso de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Incidência , Masculino , Técnicas Microbiológicas/métodos , Pessoa de Meia-Idade , Modelos Biológicos , Pneumonia Associada à Ventilação Mecânica/tratamento farmacológico , Pneumonia Associada à Ventilação Mecânica/epidemiologia , Estudos Prospectivos , Escócia/epidemiologia , Traqueia/microbiologiaRESUMO
The aim of this study was to describe current blood conservation practice during revision hip surgery in Scotland and document practice variation. Revision hip surgery is associated with a high likelihood of blood transfusion. A decrease in the proportion of patients requiring blood transfusion has been documented, but the reasons for this are unclear. Various blood conservation practices are available to clinicians, but the extent to which these are used in Scottish hospitals is not known. A cross-sectional postal survey was sent to all consultant orthopaedic surgeons and consultant anaesthetists participating in revision hip surgery in Scottish hospitals. Responses were received from 92 of 120 (77%) surgeons, and 174 of 216 (81%) anaesthetists (62/92). A total of 62 of 92 (67%) surgeons and 78 of 174 (45%) anaesthetists surveyed participated in revision hip surgery. Blood conservation practice varied widely: 34 of 78 (44%) anaesthetists routinely assessed revision hip patients >or=1 week prior to surgery; 10 of 62 (16%) surgeons and 24 of 78 (31%) anaesthetists routinely used cell salvage; 7 of 78 (9%) anaesthetists and 2 of 62 (3%) surgeons routinely used tranexamic acid; and 45 of 62 (73%) surgeons use a transfusion protocol. A wide variation in the use of blood conservation strategies exists during revision hip surgery in Scotland.
Assuntos
Artroplastia de Quadril/estatística & dados numéricos , Transfusão de Sangue/estatística & dados numéricos , Anestesia/métodos , Anestesiologia/estatística & dados numéricos , Antifibrinolíticos/administração & dosagem , Perda Sanguínea Cirúrgica/prevenção & controle , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Separação Celular/estatística & dados numéricos , Estudos Transversais , Uso de Medicamentos/estatística & dados numéricos , Inquéritos Epidemiológicos , Hemoglobinometria/estatística & dados numéricos , Humanos , Ferro/administração & dosagem , Ortopedia/estatística & dados numéricos , Cuidados Pós-Operatórios , Padrões de Prática Médica/estatística & dados numéricos , Cuidados Pré-Operatórios , Reoperação/métodos , Reoperação/estatística & dados numéricos , Escócia , Inquéritos e Questionários , Ácido Tranexâmico/administração & dosagemRESUMO
Our intensive care unit has been treating comatose patients, following an out-of-hospital cardiac arrest, with therapeutic hypothermia since 2002. In all, 139 out-of-hospital cardiac arrest patients were admitted in the 4-year period 2002-5. Of these, 27% had a favourable outcome (discharged home or to rehabilitation). Forty-one per cent of patients presenting with ventricular fibrillation (VF) and 7% of non-VF patients had a favourable outcome. No patient with an estimated time from collapse to first attempt at cardiopulmonary resuscitation over 12 min survived to hospital discharge. Twenty-two per cent of patients over 70 years were discharged home, suggesting age was not a barrier to surviving out-of-hospital cardiac arrest. The introduction of a therapeutic hypothermia clinical pathway, at the end of 2003 improved the efficiency of cooling. The percentage of patients cooled to below 34 degrees C within 4 h increased from 15 to 51% and those cooled for more than 12 h increased from 30 to 83%.
Assuntos
Coma/terapia , Cuidados Críticos/métodos , Parada Cardíaca/terapia , Hipotermia Induzida/métodos , APACHE , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Ensaios Clínicos como Assunto , Coma/etiologia , Procedimentos Clínicos , Grupos Diagnósticos Relacionados , Feminino , Parada Cardíaca/complicações , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Prognóstico , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: Despite WHO recommendations, there is currently no national screening and eradication policy for the detection of methicillin-sensitive Staphylococcus aureus (MSSA) in the UK prior to elective orthopaedic surgery. This study aimed to evaluate the effectiveness of current standard methicillin-resistant S. aureus (MRSA) eradication therapies in the context of S. aureus (both MRSA and MSSA) decolonization in an elective orthopaedic population. METHODOLOGY: A total of 100 patients awaiting joint replacement surgery who were positive for S. aureus on PCR nasal screening underwent the current standard MRSA pre-operative decolonization regimen for 5 days. Prior to commencement of the eradication therapy, swabs of the anterior nares, throat and perineum were taken for culture. Further culture swabs were taken at 48-96 h following treatment, at hospital admission for surgery and at hospital discharge. Following the completion of treatment, patients were asked to provide feedback on their experience using Likert rating scales. The primary outcome of this study was S. aureus clearance 48-96 h following eradication treatment.Results/Key Findings. Clearance of S. aureus 48-96 h following treatment was 94â% anterior nares, 66â% throat and 88â% groin. Mean completion with nasal mupirocin was 98â%. There was no statistically significant recolonization effect between the end of the eradication treatment period and the day of surgery (P>0.05) at a median time of 10 days. CONCLUSION: Current MRSA decolonisation regimens are well tolerated and effective for MSSA decolonization for the anterior nares and groin. The decolonization effect is preserved for at least 10 days following treatment.