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COVID-19 , Trasplante de Órganos , Obtención de Tejidos y Órganos , Humanos , Donantes de TejidosAsunto(s)
COVID-19 , Humanos , Unidades de Cuidados Intensivos , Quirófanos , Encuestas y CuestionariosAsunto(s)
Consentimiento por Terceros , Privación de Tratamiento , Cuidados Críticos , Femenino , Humanos , MasculinoAsunto(s)
COVID-19/terapia , Unidades de Cuidado Intensivo Pediátrico , Personal de Enfermería en Hospital/psicología , Estrés Laboral/epidemiología , Admisión y Programación de Personal , Adulto , Anestesiólogos , COVID-19/epidemiología , Toma de Decisiones Clínicas , Femenino , Francia/epidemiología , Encuestas de Atención de la Salud/estadística & datos numéricos , Humanos , Unidades de Cuidados Intensivos , Masculino , Enfermeras Anestesistas , Personal de Enfermería en Hospital/organización & administración , Pandemias , Prevalencia , Autonomía Profesional , Estudios Prospectivos , Autoeficacia , Apoyo SocialRESUMEN
During the first Covid-19 wave, our paediatric intensive care unit (PICU), like many others across the globe, was transformed into an adult ICU for patients with severe Covid-19, due to a shortage of adult ICU beds. Here, we provide a comprehensive description of all the conditions that must be fulfilled to successfully accomplish this transformation. Strong support from all hospital departments was crucial, as their activity was modified by the change. Healthcare workers from various units, notably the paediatric anaesthesiology department, worked in the adult ICU to ensure sufficient staffing. The number of physiotherapists and psychologists was increased. A support system for both healthcare workers and patients' relatives was set up with the help of the mobile paediatric palliative care and support team. Supplies suitable for adults were ordered. Protocols for numerous procedures were written within a few days. Video tutorials, checklists, and simulation sessions were circulated to the entire staff. The head nurses guided and supported the new staff and usual PICU staff. The transformation was achieved within a week. The main difficulties were healthcare worker stress, changes in recommendations over time, absence of visits from relatives, and specific adult issues that paediatricians are unfamiliar with.Conclusion: For the staff, caring for adult patients was made easier by working in their familiar unit instead of being moved to an adult hospital with unfamiliar staff members and equipment. Strong support from the hospital and the assistance of consultants from adult hospital departments were crucial. What is Known: ⢠The dramatic spread across the world of coronavirus disease 2019 generated critical care needs that drastically exceeded resources in many countries worldwide. ⢠Paediatric ICU activity during this period decreased due to lockdown measures and the fact that children rarely required ICU for coronavirus disease 2019. What is New: ⢠We describe how an 18-bed adult Covid-19 ICU was successfully set up in a paediatric hospital during the first wave of the Covid-19 pandemic. ⢠Specific requirements regarding supply, human resources, and procedures, as well as difficulties encountered, are described.
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COVID-19 , Pandemias , Adulto , Niño , Control de Enfermedades Transmisibles , Humanos , Unidades de Cuidados Intensivos , Unidades de Cuidado Intensivo Pediátrico , SARS-CoV-2Asunto(s)
Ansiedad/prevención & control , Cuidados Críticos/psicología , Depresión/prevención & control , Diarios como Asunto , Familia/psicología , Política Organizacional , Trastornos por Estrés Postraumático/prevención & control , Visitas a Pacientes/psicología , Ansiedad/etiología , Trastornos de la Conciencia/psicología , Estudios Cruzados , Delirio/epidemiología , Delirio/etiología , Delirio/prevención & control , Delirio/psicología , Depresión/etiología , Políticas Editoriales , Humanos , Incidencia , Modelos Psicológicos , Estudios Multicéntricos como Asunto , Resultados Negativos , Publicaciones Periódicas como Asunto/normas , Ensayos Clínicos Controlados Aleatorios como Asunto , Índice de Severidad de la Enfermedad , Trastornos por Estrés Postraumático/epidemiología , Trastornos por Estrés Postraumático/etiologíaRESUMEN
BACKGROUND: Delayed graft function is a major determinant of long-term renal allograft survival. Despite considerable efforts to improve donor selection and matching, incidence of delayed graft function remains close to 25%. As neutrophil gelatinase-associated lipocalin (NGAL) has been shown to predict acute renal failure, the authors tested the hypothesis that NGAL measurement in brain-dead donors predicts delayed graft function in kidney recipients. METHODS: In a prospective, multicenter, observational study, serum NGAL was measured in donors at the time of transfer to operating room. The primary endpoint was the delayed graft function, defined as the need for renal replacement therapy during the first week posttransplantation. RESULTS: Among 159 included brain-dead donors, 146 were analyzable leading to 243 renal transplantations. Of these, 56 (23%) needed renal replacement therapy. Donors' NGAL values were similar in case of both delayed and normal graft function in recipients. The area under the receiver-operating curve for NGAL to predict the need for renal replacement therapy before day 8 was 0.50 (95% CI, 0.42 to 0.59). The area under curve for NGAL to predict failure to return to a normal graft function at day 8 was 0.51 (95% CI, 0.44 to 0.59). Using multivariate analysis, NGAL was not associated to the need for renal replacement therapy (odds ratio, 0.99; 95% CI, 0.98 to1.00) or failure to return to a normal graft function at day 8 (odds ratio, 1.00; 95% CI, 0.99 to 1.00). CONCLUSION: NGAL measurement in brain-dead donors at the time of recovery failed to predict delayed or normal graft function in kidney recipients.
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Muerte Encefálica/sangre , Funcionamiento Retardado del Injerto/sangre , Funcionamiento Retardado del Injerto/epidemiología , Trasplante de Riñón/estadística & datos numéricos , Lipocalinas/sangre , Proteínas Proto-Oncogénicas/sangre , Donantes de Tejidos/estadística & datos numéricos , Proteínas de Fase Aguda/genética , Adulto , Área Bajo la Curva , Funcionamiento Retardado del Injerto/genética , Femenino , Francia/epidemiología , Humanos , Trasplante de Riñón/métodos , Lipocalina 2 , Lipocalinas/genética , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Proteínas Proto-Oncogénicas/genética , Curva ROCRESUMEN
PURPOSE OF REVIEW: The purpose of the present review is to describe the methods using an extracorporeal membranous oxygenation (ECMO) circuit in donors after cardiac death and to evaluate their impact on the outcome of renal transplantation. RECENT FINDINGS: ECMO can be used either in hypothermic conditions for total body cooling or in normothermic conditions and limited to the abdomen in a first phase, before subsequent in-situ cooling. In both cases, oxygen is added to the perfusion, as compared with the usual and simple cold in-situ perfusion. There is a strong experimental rationale to use ECMO in normothermic conditions. The clinical studies in renal transplantation are still few, retrospective with small cohorts (level 3 or 4, according to the Oxford Centre for Evidence-Based Medicine). However, they all reach consistent conclusions with better kidney transplant outcome, both in uncontrolled (type I and II) and controlled (type III) donors, according to the Maastricht classification. SUMMARY: The use of ECMO in donors after cardio-circulatory death should be encouraged and further developed. Experimental work is in progress to better define the optimal conditions of the technique, which will help to limit or even repair the injuries, induced by warm ischaemia.
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Oxigenación por Membrana Extracorpórea/métodos , Paro Cardíaco , Donantes de Tejidos , Muerte , Humanos , Riñón/fisiología , Trasplante de Riñón/métodos , Preservación de Órganos , Recolección de Tejidos y Órganos , Obtención de Tejidos y ÓrganosRESUMEN
INTRODUCTION: Many potential lung transplants are lost because of hypoxemia during donor management. We hypothesized that the apnea test, necessary to confirm the diagnosis of brain death in potential lung donors, was involved in the decrease in the ratio of partial pressure of arterial O2 to fraction of inspired O2 (PaO2/FiO2) and that a single recruitment maneuver performed just after the apnea test can reverse this alteration. METHODS: In this case-control study, we examined the effectiveness of the recruitment maneuver with a comparison cohort of brain dead patients who did not receive the maneuver. Patients were matched one-to-one on the basis of initial PaO2/FiO2 and on the duration of mechanical ventilation before the apnea test. PaO2/FiO2 was measured before (T1), at the end (T2) and two hours after apnea test (T3). RESULTS: Twenty-seven patients were included in each group. The apnea test was associated with a significant decrease in PaO2/FiO2 from 284 ± 98 to 224 ± 104 mmHg (P < 0.001). The decrease in PaO2/FiO2 between T1 and T3 was significantly lower in the recruitment maneuver group than in the control group (-4 (-68-57) vs -61 (-110--18) mmHg, P = 0.02). The number of potential donors with PaO2/FiO2 > 300 mmHg decreased by 58% (95% CI: 28-85%) in the control group vs 0% (95% CI: 0-34%) in the recruitment maneuver group (P < 0.001). CONCLUSIONS: The apnea test induced a decrease in PaO2/FiO2 in potential lung donors. A single recruitment maneuver performed immediately after the apnea test can reverse this alteration and may prevent the loss of potential lung donors.
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Apnea/diagnóstico , Muerte Encefálica/diagnóstico , Donantes de Tejidos , Apnea/fisiopatología , Estudios de Casos y Controles , Femenino , Humanos , Trasplante de Pulmón , Masculino , Persona de Mediana Edad , Respiración con Presión Positiva , Estudios Prospectivos , Fenómenos Fisiológicos RespiratoriosRESUMEN
PURPOSE: Severe postpartum haemorrhage (SPPH) is the leading cause of peripartum hysterectomy and maternal death. There are no easily measurable parameters that indicate the failure of medical therapy and the need for an advanced interventional procedure (AIP) to stop genital tract bleeding. The aim of the study was to define factors predictive of the need for an AIP in the management of emergent PPH. METHODS: The study included two phases: (1) an initial retrospective study of 257 consecutive patients with SPPH, allowing the determination of independent predictors of AIP, which were subsequently grouped in a predictive score, followed by (2) a multicentre study of 239 patients admitted during 2007, designed to validate the score. The main outcome measure was the need for an AIP, defined as uterine artery embolization, intraabdominal packing, arterial ligation or hysterectomy. RESULTS: Abnormalities of placental implantation, prothrombin time <50% (or an International Normalized Ratio >1.64), fibrinogen <2 g/l, troponin detectable, and heart rate >115 bpm were independently predictive of the need for an AIP. The SPPH score included each of the five predictive factors with a value of 0 or 1. The greater the SPPH score, the greater the percentage of patients needing an AIP (11% for SPPH 0, to 75% for SPPH ≥2). The AUC of the ROC curve of the SPPH score was 0.80. CONCLUSIONS: We identified five independent predictors of the need for an AIP in patients with SPPH and persistent bleeding. Using these predictors in a single score could be a reliable screening tool in patients at risk of persistent genital tract bleeding and needing an AIP.