RESUMO
Objective: To evaluate the prognostic value of high-sensitivity troponin (hsT) in severe aneurysmal subarachnoid hemorrhage (aSAH). Methods: This prospective non-interventional study was performed at a surgical intensive care unit (ICU) from 2012 to 2015. Consecutive patients who had severe aSAH were included. A modified Rankin Scale score ≥ 4 or death within 3 months defined a poor outcome. hsT levels were measured at ICU admission and 72 hours following symptom onset. Results: A total of 137 patients were analyzed. The median hsT level was 29 ng/L (range: 7-4485). The best threshold level of hsT for predicting a poor outcome was 22 ng/L. At this threshold, the sensitivity was 71% (95% confidence interval [CI]: 58%-81%) and the specificity was 58% (95%CI: 46%-70%). The area under the ROC curve was 0.61 (95%CI: 0.52-0.71). Based on a multivariate analysis, the independent factors for a poor neurological prognosis were a World Federation of Neurologic Surgeons (WFNS) score ≥ 4 (odds ratio [OR]: 2.61; 95%CI: 1.04-6.56) and an hsT level > 22 ng/L (OR: 2.80; 95%CI: 1.18-6.64). Conclusion: In patients with severe aSAH, with regard for the severity of disease (assessed by the WFNS score), an hsT level > 22 ng/L at ICU admission was associated with poor outcomes.
Assuntos
Hemorragia Subaracnóidea/sangue , Troponina T/sangue , Idoso , Cuidados Críticos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Sensibilidade e Especificidade , Hemorragia Subaracnóidea/mortalidade , Resultado do TratamentoRESUMO
IMPORTANCE: It has not been established whether noninvasive ventilation (NIV) reduces the need for invasive mechanical ventilation in patients who develop hypoxemic acute respiratory failure after abdominal surgery. OBJECTIVE: To evaluate whether noninvasive ventilation improves outcomes among patients developing hypoxemic acute respiratory failure after abdominal surgery. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized, parallel-group clinical trial conducted between May 2013 and September 2014 in 20 French intensive care units among 293 patients who had undergone abdominal surgery and developed hypoxemic respiratory failure (partial oxygen pressure <60 mm Hg or oxygen saturation [SpO2] ≤90% when breathing room air or <80 mm Hg when breathing 15 L/min of oxygen, plus either [1] a respiratory rate above 30/min or [2] clinical signs suggestive of intense respiratory muscle work and/or labored breathing) if it occurred within 7 days after surgical procedure. INTERVENTIONS: Patients were randomly assigned to receive standard oxygen therapy (up to 15 L/min to maintain SpO2 of 94% or higher) (n = 145) or NIV delivered via facial mask (inspiratory pressure support level, 5-15 cm H2O; positive end-expiratory pressure, 5-10 cm H2O; fraction of inspired oxygen titrated to maintain SpO2 ≥94%) (n = 148). MAIN OUTCOMES AND MEASURES: The primary outcome was tracheal reintubation for any cause within 7 days of randomization. Secondary outcomes were gas exchange, invasive ventilation-free days at day 30, health care-associated infections, and 90-day mortality. RESULTS: Among the 293 patients (mean age, 63.4 [SD, 13.8] years; n=224 men) included in the intention-to-treat analysis, reintubation occurred in 49 of 148 (33.1%) in the NIV group and in 66 of 145 (45.5%) in the standard oxygen therapy group within+ 7 days after randomization (absolute difference, -12.4%; 95% CI, -23.5% to -1.3%; P = .03). Noninvasive ventilation was associated with significantly more invasive ventilation-free days compared with standard oxygen therapy (25.4 vs 23.2 days; absolute difference, -2.2 days; 95% CI, -0.1 to 4.6 days; P = .04), while fewer patients developed health care-associated infections (43/137 [31.4%] vs 63/128 [49.2%]; absolute difference, -17.8%; 95% CI, -30.2% to -5.4%; P = .003). At 90 days, 22 of 148 patients (14.9%) in the NIV group and 31 of 144 (21.5%) in the standard oxygen therapy group had died (absolute difference, -6.5%; 95% CI, -16.0% to 3.0%; P = .15). There were no significant differences in gas exchange. CONCLUSIONS AND RELEVANCE: Among patients with hypoxemic respiratory failure following abdominal surgery, use of NIV compared with standard oxygen therapy reduced the risk of tracheal reintubation within 7 days. These findings support use of NIV in this setting. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01971892.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Hipóxia/terapia , Intubação Intratraqueal/estatística & dados numéricos , Ventilação não Invasiva/estatística & dados numéricos , Oxigenoterapia/estatística & dados numéricos , Complicações Pós-Operatórias/terapia , Insuficiência Respiratória/terapia , Infecção Hospitalar/epidemiologia , Feminino , Humanos , Hipóxia/etiologia , Unidades de Terapia Intensiva , Análise de Intenção de Tratamento , Intubação Intratraqueal/mortalidade , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/efeitos adversos , Ventilação não Invasiva/mortalidade , Oxigenoterapia/efeitos adversos , Oxigenoterapia/métodos , Oxigenoterapia/mortalidade , Respiração com Pressão Positiva , Troca Gasosa Pulmonar , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/mortalidade , Retratamento/estatística & dados numéricos , Fatores de TempoRESUMO
A new Tetratrichomonas species was identified by molecular and phylogenetic approaches in the pleural fluid from a patient with encysted empyema leading to dyspnea. This observation raised the questions of the real prevalence of pulmonary trichomonosis in humans, the zoonotic potential of trichomonads, and the existence of human-host-adapted strains.
Assuntos
Empiema Pleural/parasitologia , Infecções por Protozoários/diagnóstico , Infecções por Protozoários/parasitologia , Trichomonadida/classificação , Trichomonadida/isolamento & purificação , Adulto , Animais , Análise por Conglomerados , DNA de Protozoário/química , DNA de Protozoário/genética , DNA Ribossômico/química , DNA Ribossômico/genética , DNA Espaçador Ribossômico/química , DNA Espaçador Ribossômico/genética , Feminino , Genes de RNAr , Humanos , Dados de Sequência Molecular , Filogenia , RNA de Protozoário/genética , RNA Ribossômico 5,8S/genética , Radiografia Torácica , Análise de Sequência de DNA , Trichomonadida/genéticaRESUMO
BACKGROUND: Sepsis profoundly alters immune homeostasis. Cytokine release after whole blood lipopolysaccharide (LPS)-stimulation reflects cell function across multiple immune cell classes and represents the immune response to LPS. The main goal of this study was to evaluate the prognostic value of ex vivo stimulation of whole blood with LPS in sepsis. METHODS: Blood was drawn on day 1 and day 7 after admission, and stimulated ex vivo with LPS. Tumour necrosis factor (TNF)-α, interleukin (IL)-1ß, IL-6 and IL-10 were measured with and without stimulation. Our primary outcome measure was the persistence of at least one organ dysfunction at day 7. Organ dysfunction was defined according to the SOFA components by a score ≥ 2. RESULTS: Forty-nine patients with sepsis from a 21-bed intensive care unit, and 23 healthy volunteers were enrolled. The blood of septic patients was less responsive to ex vivo stimulation with LPS than that of healthy controls at day 1 and 7, as demonstrated by lower TNF-α, IL-1ß, IL-6 and IL-10 release. Persistent organ dysfunction was more frequent in patients with lower IL-10 release at day 1 but such an association was not found for pro-inflammatory cytokines. A persistent low IL-10 release at day 7 was also associated with persistent organ dysfunction. CONCLUSION: These data suggest that the capacity to produce IL-10 in response to whole blood ex vivo stimulation early in sepsis, as well as persistent low IL-10 response over time, may help in prognostication and patient stratification. These results will need to be confirmed in future studies.
Assuntos
Interleucina-10/sangue , Interleucina-1beta/sangue , Interleucina-6/sangue , Insuficiência de Múltiplos Órgãos/sangue , Sepse/sangue , Fator de Necrose Tumoral alfa/sangue , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Lipopolissacarídeos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/imunologia , Escores de Disfunção Orgânica , Avaliação de Resultados em Cuidados de Saúde , Prognóstico , Estudos Prospectivos , Sepse/imunologia , Fatores de TempoRESUMO
The stay in intensive care unit can be potentially traumatic at the origin of post-traumatic stress symptoms. The severity of post-traumatic stress symptoms is linked to the intensity and the type of traumatic memories of the intensive care stay. Sedatives and analgesics given to ventilated patients in intensive care influence the traumatic memory. The level, the duration and the type of sedation-analgesia protocol are risk factors of post-traumatic stress symptoms. Links between sedation, dissociative symptoms, delirium and post-traumatic stress symptoms are documented. Environmental and pharmacological measures are to be considered to reduce the traumatic potential risk of the intensive care. Intensive care caregivers, liaison-psychiatrist and general practitioner have each a specific role to play in the screening of the post-traumatic stress symptoms.