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1.
Crit Care ; 20: 90, 2016 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-27038791

RESUMO

BACKGROUND: Atrial fibrillation is a common rhythm disturbance in the general medical-surgical intensive care unit. Amiodarone is a popular drug in this setting but evidence to inform clinical practice remains scarce. We aimed to identify whether variation in the clinical use of amiodarone was associated with recurrent atrial fibrillation. METHODS: This was a retrospective audit of 177 critically ill patients who developed new-onset atrial fibrillation after admission to a tertiary level medical-surgical trauma intensive care unit. Patterns of amiodarone prescription (including dosage schedule and duration) were assessed in relation to recurrence of atrial fibrillation during the intensive care unit stay. Known recurrence risk factors, such as inotrope administration, cardiac disease indices, Charlson Comorbidity Index, magnesium concentrations, fluid balance, and potassium concentrations, were also included in adjusted analysis using forward stepwise logistic regression modelling. RESULTS: The cohort had a median (interquartile range) age of 69 years (60-75), Acute Physiology and Chronic Health Evalution II score of 22 (17-28) and Charlson Comorbidity Index of 2 (1-4). A bolus dose of amiodarone followed by infusion (P = 0.02), in addition to continuing amiodarone infusion through to discharge from the intensive care unit (P < 0.001), were associated with less recurrent dysrhythmia. Recurrence after successful treatment was associated with ceasing amiodarone while an inotrope infusion continued (P < 0.001), and was more common in patients with a prior history of congestive cardiac failure (P = 0.04), and a diagnosis of systemic inflammatory response syndrome (P = 0.02). CONCLUSIONS: Amiodarone should be administered as a bolus dose followed immediately with an infusion when treating atrial fibrillation in the medical-surgical intensive care unit. Consideration should be given to continuing amiodarone infusions in patients on inotropes until they are ceased.


Assuntos
Amiodarona/efeitos adversos , Amiodarona/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/etiologia , Estado Terminal/terapia , Idoso , Antiarrítmicos/uso terapêutico , Fibrilação Atrial/epidemiologia , Estudos de Coortes , Feminino , Humanos , Infusões Intravenosas , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos
2.
Clin Infect Dis ; 56(4): 471-7, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23118272

RESUMO

BACKGROUND: Hospitals and quality improvement agencies are vigorously focusing on reducing rates of hospital-acquired infection. Ventilator-associated pneumonia (VAP) is notoriously difficult to diagnose and surveillance is thwarted by the subjectivity of many components of the surveillance definition. Alternative surveillance strategies are needed. Ventilator-associated complications (VAC) is a simple, objective measure of respiratory deterioration. METHODS: VAC is defined by increases in fraction of inspired oxygen (FiO(2)) by ≥ 15% or positive end-expiratory pressure (PEEP) by ≥ 2.5 cm H(2)O lasting ≥ 2 days after stable or decreasing FiO(2) or PEEP lasting ≥ 2 days. We retrospectively assessed patients on mechanical ventilation for ≥ 48 hours in our study intensive care unit (ICU) using electronic medical record data. We analyzed the association between VAC and clinical diagnoses, ICU length of stay, duration of mechanical ventilation, antibiotic use, and mortality. RESULTS: We assessed 153 patients with VAC and 390 without VAC. VAC events were associated with significantly increased ICU length of stay, duration of mechanical ventilation, and consumption of broad-spectrum antibiotics but not with longer hospital stays or ICU mortality. CONCLUSIONS: Surveillance for VAP is subjective and labor intensive. VAC is an objective measure which can be readily obtained from electronic records. It is associated with adverse outcomes and increased broad-spectrum antibiotic usage. VAC may be a useful surveillance tool. The utility of VAC prevention bundles merits assessment.


Assuntos
Antibacterianos/uso terapêutico , Tempo de Internação/estatística & dados numéricos , Pneumonia Associada à Ventilação Mecânica/epidemiologia , Ventiladores Mecânicos/efeitos adversos , Monitoramento Epidemiológico , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Pneumonia Associada à Ventilação Mecânica/diagnóstico , Pneumonia Associada à Ventilação Mecânica/etiologia , Modelos de Riscos Proporcionais , Estudos Retrospectivos
3.
Crit Care Resusc ; 21(1): 53-62, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30857513

RESUMO

OBJECTIVE: Lack of management guidelines for lifethreatening asthma (LTA) risks practice variation. This study aims to elucidate management practices of LTA in the intensive care unit (ICU). DESIGN: A retrospective cohort study. SETTING: Thirteen participating ICUs in Australia between July 2010 and June 2013. PARTICIPANTS: Patients with the principal diagnosis of LTA. MAIN OUTCOME MEASURES: Clinical history, ICU management, patient outcomes, ward education and discharge plans. RESULTS: Of the 270 (267 patients) ICU admissions, 69% were female, with a median age of 39 years (interquartile range [IQR], 26-53 years); 119 (44%) were current smokers; 89 patients (33%) previously required ICU admission, of whom 23 (25%) were intubated. The median ICU stay was 2 days (IQR, 2-4 days). Three patients (1%) died. Seventy-nine patients (29%) received non-invasive ventilation, with 11 (14%) needing subsequent invasive ventilation. Sixty-eight patients (25%) were intubated, with the majority of patients receiving volume cycled synchronised intermittent mechanical ventilation (n = 63; 93%). Drugs used included ß2-agonist by intravenous infusion (n = 69; 26%), inhaled adrenaline (n = 15; 6%) or an adrenaline intravenous infusion (n = 23; 9%), inhaled anticholinergics (n = 238; 90%), systemic corticosteroids (n = 232; 88%), antibiotics (n = 126; 48%) and antivirals (n = 22; 8%). When suitable, 105 patients (n = 200; 53%) had an asthma management plan and 122 (n = 202; 60%) had asthma education upon hospital discharge. Myopathy was associated with hyperglycaemia requiring treatment (odds ratio [OR], 31.6; 95% CI, 2.1-474). Asthma education was more common under specialist thoracic medicine care (OR, 3.0; 95% CI, 1.61-5.54). CONCLUSION: In LTA, practice variation is common, with opportunities to improve discharge management plans and asthma education.


Assuntos
Asma/terapia , Unidades de Terapia Intensiva , Adulto , Austrália , Cuidados Críticos , Feminino , Humanos , Tempo de Internação , Auditoria Médica , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Estudos Retrospectivos
4.
J Crit Care ; 34: 95-102, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-27288618

RESUMO

PURPOSE: To determine whether prophylactic inhaled heparin is effective for the prevention and treatment of pneumonia patients receiving mechanical ventilation (MV) in the intensive care unit. METHODS: A phase 2, double blind randomized controlled trial stratified for study center and patient type (non-operative, post-operative) was conducted in three university-affiliated intensive care units. Patients aged ≥18years and requiring invasive MV for more than 48hours were randomized to usual care, nebulization of unfractionated sodium heparin (5000 units in 2mL) or placebo nebulization with 0.9% sodium chloride (2mL) four times daily with the main outcome measures of the development of ventilator associated pneumonia (VAP), ventilator associated complication (VAC) and sequential organ failure assessment scores in patients with pneumonia on admission or who developed VAP. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12612000038897. RESULTS: Two hundred and fourteen patients were enrolled (72 usual care, 71 inhaled sodium heparin, 71 inhaled sodium chloride). There were no differences between treatment groups in terms of the development of VAP, using either Klompas criteria (6-7%, P=1.00) or clinical diagnosis (24-26%, P=0.85). There was no difference in the clinical consistency (P=0.70), number (P=0.28) or the total volume of secretions per day (P=.54). The presence of blood in secretions was significantly less in the usual care group (P=0.005). CONCLUSION: Nebulized heparin cannot be recommended for prophylaxis against VAP or to hasten recovery from pneumonia in patients receiving MV.


Assuntos
Fibrinolíticos/administração & dosagem , Heparina/administração & dosagem , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Administração por Inalação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Austrália , Método Duplo-Cego , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Nebulizadores e Vaporizadores , Nova Zelândia , Pneumonia Associada à Ventilação Mecânica/tratamento farmacológico , Respiração Artificial , Adulto Jovem
5.
Med J Aust ; 188(5): 292-5, 2008 Mar 03.
Artigo em Inglês | MEDLINE | ID: mdl-18312194

RESUMO

OBJECTIVE: To assess the outcomes for chronic dialysis patients requiring admission to an intensive care unit (ICU) or high dependency unit (HDU). DESIGN: Retrospective audit of prospectively collected data from local and national databases. SETTING: The ICU and HDU at a tertiary referral hospital. PARTICIPANTS: 70 chronic dialysis patients admitted between 2001 and 2006. MAIN OUTCOME MEASURES: Unit and hospital mortality, recurrent admission patterns and median survival after discharge from hospital. RESULTS: For patients' last admissions, mortality in the ICU or HDU was 17% and in hospital was 29%. The 12 deaths in the ICU or HDU occurred a median of 18 hours (range, 3-203 hours) after admission, reflecting the severity of their underlying illness. The independent predictors of death in hospital were age and the number of non-renal organ systems failing. Patients with pulmonary oedema had a lower risk of death than patients admitted for other reasons. Although 21 patients accounted for 55 of 104 admissions (53%), recurrent admissions to the ICU or HDU generally occurred during different hospital admissions. They were not associated with a higher risk of death in hospital. Patients discharged home had a median survival of 2.25 years, and a median survival of 3.5 years from starting dialysis. The median survival for patients on dialysis in Australia in general is 4.5 years (Australia and New Zealand Dialysis and Transplant Registry). CONCLUSION: Dialysis patients discharged home after an ICU or HDU admission have survival similar to that of Australian dialysis patients generally.


Assuntos
Unidades de Terapia Intensiva , Falência Renal Crônica/terapia , Diálise Renal , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Austrália , Estudos de Coortes , Feminino , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Falência Renal Crônica/mortalidade , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento
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