RESUMO
The use of extracorporeal membrane oxygenation (ECMO) for acute cardiac and/or respiratory failure has grown exponentially in the past several decades. Systemic anticoagulation is a fundamental element of caring for ECMO patients. Hemostatic management during ECMO walks a fine line to balance the risk of safe and effective anticoagulant delivery to mitigate thromboembolic complications and minimizing hemorrhagic sequelae. This review discusses the pharmacology, monitoring parameters, and special considerations for anticoagulation in patients requiring ECMO.
Assuntos
Oxigenação por Membrana Extracorpórea , Hemostáticos , Insuficiência Respiratória , Anticoagulantes/uso terapêutico , Hemorragia , Humanos , Insuficiência Respiratória/terapiaRESUMO
OBJECTIVES: Our primary aim was to ascertain the frequency of postintubation hypotension in immunocompromised critically ill adults with secondary aims of arriving at potential risk factors for the development of postintubation hypotension and its impact on patient-related outcomes. METHODS: Critically ill adult patients (≥18 years) were included from January 1, 2010, to December 31, 2014. We defined immunocompromised as patients with any solid organ or nonsolid organ malignancy or transplant, whether solid organ or not, requiring current chemotherapy. Postintubation hypotension was defined as a decrease in systolic blood pressure to less than 90 mm Hg or a decrease in mean arterial pressure to less than 65 mm Hg or the initiation of any vasopressor medication. Patients were then stratified based on development of postintubation hypotension. Potential risk factors and intensive care unit (ICU) outcome metrics were electronically captured by a validated data mart system. RESULTS: The final cohort included 269 patients. Postintubation hypotension occurred in 141 (52%; 95% confidence interval: 46-58) patients. Several risk factors predicted postintubation hypotension on univariate analysis; however, only Acute Physiology and Chronic Health Evaluation III score in the first 24 hours, preintubation shock status, and preintubation hemodynamic instability remained significant on all 4 multivariate analyses. Patients developing postintubation hypotension had higher ICU and hospital mortality (54 [38%] vs 31 [24%], P = .01; 69 [49%] vs 47 [37%], P = .04). CONCLUSION: Based on previous literature, we found a higher frequency of postintubation hypotension in the immunocompromised than in the nonimmunocompromised critically ill adult patients. Acute Physiology and Chronic Health Evaluation III score in the first 24 hours, preintubation shock status, and preintubation hemodynamic instability were significant predictors on multivariate analyses. Postintubation hypotension led to higher ICU and hospital mortality in those experiencing this complication.
Assuntos
Cuidados Críticos/métodos , Estado Terminal , Hipotensão/etiologia , Unidades de Terapia Intensiva , Intubação Intratraqueal/efeitos adversos , Idoso , Feminino , Humanos , Hipotensão/imunologia , Hipotensão/fisiopatologia , Hospedeiro Imunocomprometido , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de RiscoRESUMO
OBJECTIVE: Predictors of long-term functional impairment in acute respiratory failure of all causes are poorly understood. Our objective was to assess the frequency and predictors of long-term functional impairment or death after invasive mechanical ventilation for acute respiratory failure of all causes. DESIGN: Population-based, observational cohort study. SETTING: Eight adult ICUs of a single center. PATIENTS: All adult patients from Olmsted County, Minnesota, without baseline functional impairment who received mechanical ventilation in ICUs for acute respiratory failure of all causes from 2005 through 2009. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In total, 743 patients without baseline functional impairment received mechanical ventilation in the ICU. At 1- and 5-year follow-up, the rates of survival with return to baseline functional ability were 61% (366/597) and 53% (356/669). Among 71 patients with new functional impairment at 1 year, 55% (39/71) had recovered and were alive without functional impairment at 5 years. Factors predictive of new functional impairment or death at 1 year were age, comorbidities, discharge to other than home, mechanical ventilation of 7 days or longer, and stroke. Of factors known at the time of intubation, the following are predictive of new functional impairment or death: age, comorbidities, nonsurgical condition, Acute Physiology and Chronic Health Evaluation III score, stroke, and sepsis. Post hoc sensitivity analyses revealed no significant change in predictor variables in patient populations when stroke was excluded or who received more than 48 hours of mechanical ventilation. CONCLUSIONS: At 1- and 5-year follow-up, many patients who received mechanical ventilation for acute respiratory failure from all causes are no longer alive or have new moderate-to-severe functional impairment. Functional recovery between year 1 and year 5 is possible and common. Sepsis, stroke, illness severity, age, and comorbidities predict long-term functional outcome at intubation.
Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Recuperação de Função Fisiológica , Respiração Artificial/estatística & dados numéricos , Insuficiência Respiratória/terapia , APACHE , Atividades Cotidianas , Doença Aguda , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Limitação da Mobilidade , Respiração Artificial/efeitos adversos , Respiração Artificial/mortalidade , Insuficiência Respiratória/mortalidade , Fatores de TempoRESUMO
OBJECTIVE: To describe the practice of intubation of the critically ill at a single academic institution, Mayo Clinic's campus in Rochester, Minnesota, and to report the incidence of immediate postintubation complications. PATIENTS AND METHODS: Critically ill adult (≥18 years) patients admitted to a medical-surgical intensive care unit from January 1, 2013, to December 31, 2014, who required endotracheal intubation included. RESULTS: The final cohort included 420 patients. The mean age at intubation was 62.9 ± 16.3 years, with 58% (244) of the cohort as male. The most common reason for intubation was respiratory failure (282 [67%]). The most common airway device used was video laryngoscopy (204 [49%]). Paralysis was used in 264 (63%) patients, with ketamine as the most common sedative (194 [46%]). The most common complication was hypotension (170 [41%]; 95% confidence interval [CI]: 35.7-45.3) followed by hypoxemia (74 [17.6%]; 95% CI: 14.1-21.6), with difficult intubation occurring in 20 (5%; 95% CI: 2.9-7.3). CONCLUSION: We found a high success rate of first-pass intubation in critically ill patients (89.8%), despite the procedure being done primarily by trainees 92.6% of the time; video was the preferred method of laryngoscopy (48.6%). Although our difficult intubation (4.8%) and complication rates typically associated with the act of intubation such as aspiration (1.2%; 95% CI: 0.4-2.8) and esophageal intubation (0.2%; 95% CI: 0.01-1.3) are very low compared to other published rates (8.09%), postintubation hypotension (40.5%) and hypoxemia (17.6%) higher.
Assuntos
Analgésicos Opioides/efeitos adversos , Benzodiazepinas/efeitos adversos , Overdose de Drogas/terapia , Oxigenação por Membrana Extracorpórea/métodos , Hipóxia/terapia , Edema Pulmonar/terapia , Adulto , Gerenciamento Clínico , Overdose de Drogas/diagnóstico por imagem , Humanos , Hipóxia/induzido quimicamente , Hipóxia/diagnóstico por imagem , Masculino , Edema Pulmonar/induzido quimicamente , Edema Pulmonar/diagnóstico por imagemRESUMO
Cardiac tamponade occurring in a patient supported on central veno-arterial extracorporeal membrane oxygenation is depicted in a transesophageal echocardiography image and associated rendering. Prompt recognition of tamponade, which can be assisted with echocardiography, and emergent evacuation is critical to restoring cardiovascular stability.
Assuntos
Tamponamento Cardíaco , Oxigenação por Membrana Extracorpórea , Tamponamento Cardíaco/diagnóstico por imagem , Tamponamento Cardíaco/etiologia , Tamponamento Cardíaco/terapia , Ecocardiografia , Ecocardiografia Transesofagiana , Oxigenação por Membrana Extracorpórea/métodos , HumanosRESUMO
PURPOSE: Our primary aim was to identify predictors of immediate hemodynamic decompensation during the peri-intubation period. METHODS: We conducted a nested case-control study of a previously identified cohort of adult patients needing intubation admitted to a medical-surgical ICU during 2013-2014. Hemodynamic derangement was defined as cardiac arrest and/or the development of systolic blood pressure <90mmHg and/or mean arterial pressure <65mmHg 30min following intubation. Data during the peri-intubation period was analyzed. RESULTS: The final cohort included 420 patients. Immediate hemodynamic derangement occurred in 170 (40%) patients. On multivariate modeling, age/10year increase (OR 1.20, 95% CI 1.03-1.39, p=0.02), pre-intubation non-invasive ventilation (OR 1.71, 95% CI 1.04-2.80, p=0.03), pre-intubation shock index/1 unit (OR 5.37 95% CI 2.31-12.46, p≤0.01), and pre-intubation modified shock index/1 unit (OR 2.73 95% CI 1.48-5.06, p≤0.01) were significantly associated with hemodynamic derangement. Those experiencing hemodynamic derangement had higher ICU [47 (28%) vs. 33 (13%); p≤0.001] and hospital [69 (41%) vs. 51 (20%); p≤0.001] mortality. CONCLUSIONS: Hemodynamic derangement occurred at a rate of 40% and was associated with increased mortality. Increasing age, use of non-invasive ventilation before intubation, and increased pre-intubation shock and modified shock index values were significantly associated with hemodynamic derangement post-intubation.
Assuntos
Estado Terminal , Parada Cardíaca/etiologia , Hemodinâmica/fisiologia , Hipotensão/etiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Intubação Intratraqueal/efeitos adversos , Idoso , Pressão Sanguínea/fisiologia , Estudos de Casos e Controles , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Arterial desaturations experienced during endotracheal intubation (ETI) may lead to poor outcomes. Thus, our primary aim was to identify predictors of arterial desaturation (pulse oximetry <90%) during the peri-intubation period and to assess outcomes of those who developed arterial hypoxemia. METHODS: Adult patients admitted to a medical and/or surgical intensive care unit (ICU) over the time period of January 1st 2013 through December 31st 2014 who required ETI were included. Only the first intubation was captured. Arterial desaturation was defined as pulse oximetry readings of <90% (hypoxemia) in the immediate peri-intubation period. Patients were then grouped in cases (those who developed desaturation) and controls (those who did not develop this complication). RESULTS: The final cohort included 420 patients. Arterial desaturations occurred in 74 (18%) patients. When adjusting for significant predictors on univariate analysis and known predictors of a difficult airway, only acute respiratory failure (OR 2.38; 95% CI: 1.15-4.93; P=0.02) and provider training level (OR 7.12; 95% CI: 1.65-30.67; P=0.016) remained significant. Higher pulse oximetry readings prior to intubation was found to be protective on multivariate analysis (OR 0.92; 95% CI: 0.89-0.96; P<0.01; per one percent increase). CONCLUSIONS: Patients who were intubated for acute respiratory failure and those who were intubated by junior level trainees had increased odds of experiencing arterial desaturation in the peri-intubation period. Patients experiencing arterial desaturation had lower pulse oximetry readings prior to intubation suggesting a possible delay at intubation.
RESUMO
With the ever-increasing adoption of shift models for intensive care unit (ICU) staffing, improving shift-to-shift handoffs represents an important step in reducing medical errors. The authors developed an electronic handoff tool integrated within the existing electronic medical record to improve handoffs in an adult ICU. First, stakeholder (staff intensivists, fellows, and nurse practitioners/physician assistants) input was sought to define what elements they perceived as being essential to a quality handoff. The principal outcome measure of handoff accuracy was the concordance between data transmitted by the outgoing team and data received by the incoming team (termed as agreement). Based on stakeholder input, the authors developed the handoff tool and provided regular education on its use. Handoffs were observed before and after implementation of the tool. There was an increase in the level of agreement for tasks and other important data points handed off without an increase in the time required to complete the handoff.