RESUMO
RESUMO Objetivo: Avaliar a capacidade do Teste de Caminhada de 6 Minutos para predizer a melhora do estado funcional físico em longo prazo de pacientes sobreviventes à unidade de terapia intensiva. Métodos: Foram avaliados, de forma prospectiva, entre fevereiro de 2017 e agosto de 2018, em um ambulatório pós-unidade de terapia intensiva, 32 sobreviventes à unidade de terapia intensiva. Foram inscritos consecutivamente os pacientes com permanência na unidade de terapia intensiva acima de 72 horas (para admissões emergenciais) ou acima de 120 horas (para admissões eletivas) que compareceram ao ambulatório pós-unidade de terapia intensiva 4 meses após receberem alta da unidade de terapia intensiva. A associação entre a distância percorrida no Teste de Caminhada de 6 Minutos realizado na avaliação inicial e a evolução do estado funcional físico foi avaliada durante 8 meses, com utilização do Índice de Barthel. Resultados: A distância média percorrida no Teste de Caminhada de 6 Minutos foi significantemente mais baixa nos sobreviventes à unidade de terapia intensiva do que na população geral (405m versus 557m; p < 0,001). A idade (β = -4,0; p < 0,001) e a fraqueza muscular (β = -99,7; p = 0,02) se associaram com a distância percorrida no Teste de Caminhada de 6 Minutos. A distância percorrida no Teste de Caminhada de 6 Minutos se associou com melhora do estado funcional físico no período de 8 meses de acompanhamento desses pacientes (razão de chance para cada 10m: 1,07; IC95% 1,01 - 1,16; p = 0,03). A área sob a curva Característica de Operação do Receptor para predição da melhora funcional física pelo Teste de Caminhada de 6 Minutos foi de 0,72 (IC95% 0,53 - 0,88). Conclusão: O Teste de Caminhada de 6 Minutos, realizado 4 meses após a alta da unidade de terapia intensiva, predisse com precisão moderada a melhora do estado funcional físico de sobreviventes à unidade de terapia intensiva.
ABSTRACT Objective: To evaluate the ability of the 6-Minute Walk Test to predict long-term physical functional status improvement among intensive care unit survivors. Methods: Thirty-two intensive care unit survivors were prospectively evaluated from February 2017 to August 2018 in a post-intensive care unit outpatient clinic in Brazil. Individuals with intensive care unit stays > 72 hours (emergency admissions) or > 120 hours (elective admissions) attending the post-intensive care unit clinic four months after intensive care unit discharge were consecutively enrolled. The association between the 6-Minute Walk Test distance at baseline and physical functional status was assessed over 8 months using the Barthel Index. Results: The mean 6-Minute Walk Test distance was significantly lower in intensive care unit survivors than in the general population (405m versus 557m; p < 0.001). Age (β = -4.0; p < 0.001) and muscle weakness (β = -99.7; p = 0.02) were associated with the 6-Minute Walk Test distance. A 6-Minute Walk Test distance was associated with improvement in physical functional status over the 8-month follow-up (odds ratio for each 10m of 1.07; 95%CI 1.01 - 1.16; p = 0.03). The area under the Receiver Operating Characteristic curve for the 6-Minute Walk Test prediction of physical functional status improvement was 0.72 (95%CI 0.53 - 0.88). Conclusion: The 6-Minute Walk Test performed 4 months after intensive care unit discharge predicted long-term physical functional status among intensive care unit survivors with moderate accuracy.
Assuntos
Humanos , Sobreviventes , Unidades de Terapia Intensiva , Alta do Paciente , Estudos Prospectivos , Teste de CaminhadaRESUMO
OBJECTIVE: To evaluate the ability of the 6-Minute Walk Test to predict long-term physical functional status improvement among intensive care unit survivors. METHODS: Thirty-two intensive care unit survivors were prospectively evaluated from February 2017 to August 2018 in a post-intensive care unit outpatient clinic in Brazil. Individuals with intensive care unit stays > 72 hours (emergency admissions) or > 120 hours (elective admissions) attending the post-intensive care unit clinic four months after intensive care unit discharge were consecutively enrolled. The association between the 6-Minute Walk Test distance at baseline and physical functional status was assessed over 8 months using the Barthel Index. RESULTS: The mean 6-Minute Walk Test distance was significantly lower in intensive care unit survivors than in the general population (405m versus 557m; p < 0.001). Age (ß = -4.0; p < 0.001) and muscle weakness (ß = -99.7; p = 0.02) were associated with the 6-Minute Walk Test distance. A 6-Minute Walk Test distance was associated with improvement in physical functional status over the 8-month follow-up (odds ratio for each 10m of 1.07; 95%CI 1.01 - 1.16; p = 0.03). The area under the Receiver Operating Characteristic curve for the 6-Minute Walk Test prediction of physical functional status improvement was 0.72 (95%CI 0.53 - 0.88). CONCLUSION: The 6-Minute Walk Test performed 4 months after intensive care unit discharge predicted long-term physical functional status among intensive care unit survivors with moderate accuracy.
OBJETIVO: Avaliar a capacidade do Teste de Caminhada de 6 Minutos para predizer a melhora do estado funcional físico em longo prazo de pacientes sobreviventes à unidade de terapia intensiva. MÉTODOS: Foram avaliados, de forma prospectiva, entre fevereiro de 2017 e agosto de 2018, em um ambulatório pós-unidade de terapia intensiva, 32 sobreviventes à unidade de terapia intensiva. Foram inscritos consecutivamente os pacientes com permanência na unidade de terapia intensiva acima de 72 horas (para admissões emergenciais) ou acima de 120 horas (para admissões eletivas) que compareceram ao ambulatório pós-unidade de terapia intensiva 4 meses após receberem alta da unidade de terapia intensiva. A associação entre a distância percorrida no Teste de Caminhada de 6 Minutos realizado na avaliação inicial e a evolução do estado funcional físico foi avaliada durante 8 meses, com utilização do Índice de Barthel. RESULTADOS: A distância média percorrida no Teste de Caminhada de 6 Minutos foi significantemente mais baixa nos sobreviventes à unidade de terapia intensiva do que na população geral (405m versus 557m; p < 0,001). A idade (ß = -4,0; p < 0,001) e a fraqueza muscular (ß = -99,7; p = 0,02) se associaram com a distância percorrida no Teste de Caminhada de 6 Minutos. A distância percorrida no Teste de Caminhada de 6 Minutos se associou com melhora do estado funcional físico no período de 8 meses de acompanhamento desses pacientes (razão de chance para cada 10m: 1,07; IC95% 1,01 - 1,16; p = 0,03). A área sob a curva Característica de Operação do Receptor para predição da melhora funcional física pelo Teste de Caminhada de 6 Minutos foi de 0,72 (IC95% 0,53 - 0,88). CONCLUSÃO: O Teste de Caminhada de 6 Minutos, realizado 4 meses após a alta da unidade de terapia intensiva, predisse com precisão moderada a melhora do estado funcional físico de sobreviventes à unidade de terapia intensiva.
Assuntos
Unidades de Terapia Intensiva , Sobreviventes , Humanos , Alta do Paciente , Estudos Prospectivos , Teste de CaminhadaRESUMO
INTRODUCTION: Implementation of a weaning protocol is related to better patient prognosis. However, new approaches may take several years to become the standard of care in daily practice. We conducted a prospective cohort study to investigate the effectiveness of a multifaceted strategy to implement a protocol to wean patients from mechanical ventilation (MV) and to evaluate the weaning success rate as well as practitioner adherence to the protocol. METHODS: We investigated all consecutive MV-dependent subjects admitted to a medical-surgical intensive care unit (ICU) for >24h over 7years. The multifaceted strategy consisted of continuing education of attending physicians and ICU staff and regular feedback regarding patient outcomes. The study was conducted in three phases: protocol development, protocol and multifaceted strategy implementation, and protocol monitoring. Data regarding weaning outcomes and physician adherence to the weaning protocol were collected during all phases. RESULTS: We enrolled 2469 subjects over 7years, with 1,943 subjects (78.7%) experiencing weaning success. Physician adherence to the protocol increased during the years of protocol and multifaceted strategy implementation (from 38% to 86%, p<0.01) and decreased in the protocol monitoring phase (from 73.9% to 50.0%, p<0.01). However, during the study years, the weaning success of all subjects increased (from 73.1% to 85.4%, p<0.001). When the weaning protocol was evaluated step-by-step, we found high adherence for noninvasive ventilation use (95%) and weaning predictor measurement (91%) and lower adherence for control of fluid balance (57%) and daily interruption of sedation (24%). Weaning success was higher in patients who had undergone the weaning protocol compared to those who had undergone weaning based in clinical practice (85.6% vs. 67.7%, p<0.001). CONCLUSIONS: A multifaceted strategy consisting of continuing education and regular feedback can increase physician adherence to a weaning protocol for mechanical ventilation.
Assuntos
Protocolos Clínicos , Estado Terminal , Fidelidade a Diretrizes , Unidades de Terapia Intensiva/normas , Guias de Prática Clínica como Assunto , Desmame do Respirador/métodos , Adolescente , Adulto , Idoso , Brasil , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Melhoria de Qualidade , Adulto JovemRESUMO
OBJECTIVE: The number of patients who require prolonged mechanical ventilation increased during the last decade, which generated a large population of chronically ill patients. This study established the incidence of prolonged mechanical ventilation in four intensive care units and reported different characteristics, hospital outcomes, and the impact of costs and services of prolonged mechanical ventilation patients (mechanical ventilation dependency ≥ 21 days) compared with non-prolonged mechanical ventilation patients (mechanical ventilation dependency < 21 days). METHODS: This study was a multicenter cohort study of all patients who were admitted to four intensive care units. The main outcome measures were length of stay in the intensive care unit, hospital, complications during intensive care unit stay, and intensive care unit and hospital mortality. RESULTS: There were 5,287 admissions to the intensive care units during study period. Some of these patients (41.5%) needed ventilatory support (n = 2,197), and 218 of the patients met criteria for prolonged mechanical ventilation (9.9%). Some complications developed during intensive care unit stay, such as muscle weakness, pressure ulcers, bacterial nosocomial sepsis, candidemia, pulmonary embolism, and hyperactive delirium, were associated with a significantly higher risk of prolonged mechanical ventilation. Prolonged mechanical ventilation patients had a significant increase in intensive care unit mortality (absolute difference = 14.2%, p < 0.001) and hospital mortality (absolute difference = 19.1%, p < 0.001). The prolonged mechanical ventilation group spent more days in the hospital after intensive care unit discharge (26.9 ± 29.3 versus 10.3 ± 20.4 days, p < 0.001) with higher costs. CONCLUSION: The classification of chronically critically ill patients according to the definition of prolonged mechanical ventilation adopted by our study (mechanical ventilation dependency ≥ 21 days) identified patients with a high risk for complications during intensive care unit stay, longer intensive care unit and hospital stays, high death rates, and higher costs.
Assuntos
Estado Terminal/terapia , Unidades de Terapia Intensiva/estatística & dados numéricos , Respiração Artificial/métodos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Respiração Artificial/economia , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Fatores de TempoRESUMO
Objetivo: Na última década ocorreu um aumento no número de pacientes que necessitam manutenção de ventilação mecânica prolongada, resultando no surgimento de uma grande população de pacientes crônicos criticamente enfermos. Este estudo estabeleceu a incidência de ventilação mecânica prolongada em quatro unidades de terapia intensiva e relatou as diferentes características, desfechos hospitalares e impacto nos custos e serviços de pacientes com ventilação mecânica prolongada (dependência de ventilação mecânica por 21 dias ou mais) em comparação a pacientes sem ventilação mecânica prolongada (dependência de ventilação mecânica inferior a 21 dias). Métodos: Este foi um estudo multicêntrico de coorte que envolveu todos os pacientes admitidos em quatro unidades de terapia intensiva. As principais avaliações de desfechos incluíram o tempo de permanência na unidade de terapia intensiva e no hospital, a incidência de complicações durante a permanência na unidade de terapia intensiva, e a mortalidade na unidade de terapia intensiva e no hospital. Resultados: Durante o período do estudo, ocorreram 5.287 admissões às unidades de terapia intensiva. Alguns desses pacientes (41,5%) necessitaram de suporte ventilatório (n = 2.197), e 218 dos pacientes (9,9%) cumpriram os critérios de ventilação mecânica prolongada. Algumas complicações se desenvolveram durante a permanência na unidade de terapia intensiva como fraqueza muscular, úlceras de pressão, sepse nosocomial bacteriana, candidemia, embolia pulmonar, e delirium hiperativo; estas se associaram com um risco significantemente maior de ventilação mecânica prolongada. Os pacientes de ventilação mecânica prolongada tiveram um aumento significante da mortalidade na unidade de terapia intensiva (diferença absoluta = 14,2%; p < 0,001) e da mortalidade hospitalar (diferença absoluta = 19,1%; p < 0,001). O grupo com ventilação mecânica prolongada permaneceu mais dias no hospital após receber alta ...
Objective: The number of patients who require prolonged mechanical ventilation increased during the last decade, which generated a large population of chronically ill patients. This study established the incidence of prolonged mechanical ventilation in four intensive care units and reported different characteristics, hospital outcomes, and the impact of costs and services of prolonged mechanical ventilation patients (mechanical ventilation dependency ≥ 21 days) compared with non-prolonged mechanical ventilation patients (mechanical ventilation dependency < 21 days). Methods: This study was a multicenter cohort study of all patients who were admitted to four intensive care units. The main outcome measures were length of stay in the intensive care unit, hospital, complications during intensive care unit stay, and intensive care unit and hospital mortality. Results: There were 5,287 admissions to the intensive care units during study period. Some of these patients (41.5%) needed ventilatory support (n = 2,197), and 218 of the patients met criteria for prolonged mechanical ventilation (9.9%). Some complications developed during intensive care unit stay, such as muscle weakness, pressure ulcers, bacterial nosocomial sepsis, candidemia, pulmonary embolism, and hyperactive delirium, were associated with a significantly higher risk of prolonged mechanical ventilation. Prolonged mechanical ventilation patients had a significant increase in intensive care unit mortality (absolute difference = 14.2%, p < 0.001) and hospital mortality (absolute difference = 19.1%, p < 0.001). The prolonged mechanical ventilation group spent more days in the hospital after intensive care unit discharge (26.9 ± 29.3 versus 10.3 ± 20.4 days, p < 0.001) with higher costs. Conclusion: The classification of chronically critically ill patients according to the definition of prolonged mechanical ventilation adopted by our study (mechanical ventilation ...
Assuntos
Humanos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Respiração Artificial/métodos , Estado Terminal/terapia , Unidades de Terapia Intensiva/estatística & dados numéricos , Respiração Artificial/economia , Respiração Artificial/estatística & dados numéricos , Fatores de Tempo , Incidência , Estudos Retrospectivos , Estudos de Coortes , Mortalidade Hospitalar , Tempo de Internação , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: To determine whether the predictive accuracy of clinical judgment alone can be improved by supplementing it with an objective weaning protocol as a decision support tool. METHODS: This was a multicenter prospective cohort study carried out at three medical/surgical ICUs. The study involved all consecutive difficult-to-wean ICU patients (failure in the first spontaneous breathing trial [SBT]), on mechanical ventilation (MV) for more than 48 h, admitted between January of 2002 and December of 2005. The patients in the protocol group (PG) were extubated after a T-piece weaning trial and were compared with patients who were otherwise extubated (non-protocol group, NPG). The primary outcome measure was reintubation within 48 h after extubation. RESULTS: We included 731 patients-533 (72.9%) and 198 (27.1%) in the PG and NPG, respectively. The overall reintubation rate was 17.9%. The extubation success rates in the PG and NPG were 86.7% and 69.6%, respectively (p < 0.001). There were no significant differences between the groups in terms of age, gender, severity score, or pre-inclusion time on MV. However, COPD was more common in the NPG than in the PG (44.4% vs. 17.6%; p < 0.001), whereas sepsis and being a post-operative patient were more common in the PG (23.8% vs. 11.6% and 42.4% vs. 26.4%, respectively; p < 0.001 for both). The time on MV after the failure in the first SBT was higher in the PG than in the NPG (9 ± 5 days vs. 7 ± 2 days; p < 0.001). CONCLUSIONS: In this sample of difficult-to-wean patients, the use of a weaning protocol improved the decision-making process, decreasing the possibility of extubation failure.
Assuntos
Extubação/efeitos adversos , Extubação/estatística & dados numéricos , Protocolos Clínicos/normas , Tomada de Decisões , Doença Pulmonar Obstrutiva Crônica/terapia , Desmame do Respirador/métodos , Extubação/métodos , Métodos Epidemiológicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Falha de Tratamento , Resultado do TratamentoRESUMO
OBJETIVO: Determinar se a acurácia preditiva do julgamento clínico isolado pode ser melhorada com o uso suplementar de um protocolo de desmame objetivo como ferramenta de suporte para a tomada de decisão. MÉTODOS: Estudo prospectivo multicêntrico de coorte realizado em três UTIs clínicas/cirúrgicas. Foram incluídos no estudo todos os pacientes de difícil desmame (falha no primeiro teste de ventilação espontânea [TVE]), sob ventilação mecânica (VM) por mais de 48 h, admitidos em uma das UTIs entre janeiro de 2002 e dezembro de 2005. Os pacientes do grupo protocolo (GP) foram extubados após teste de tubo T de acordo com um protocolo de desmame e comparados com o grupo de pacientes extubados sem o uso do protocolo (GNP). O desfecho primário foi a taxa de reintubação em até 48 h após a extubação. RESULTADOS: Foram incluídos 731 pacientes - 533 (72,9%) no GP e 198 (27,1%) no GNP. A taxa global de reintubação foi de 17,9%. As taxas de sucesso da extubação no GP e no GNP foram 86,7% e 69,6%, respectivamente (p < 0,001). Não houve diferenças significativas entre os grupos quanto a idade, gênero, escore de gravidade e tempo de VM antes da inclusão. Entretanto, DPOC foi mais frequente no GNP que no GP (44,4% vs. 17,6%; p < 0,001), ao passo que pacientes sépticos e em pós-operatório foram mais comuns no GP (23,8% vs. 11,6% e 42,4% vs. 26,4%, respectivamente; p < 0,001 para ambos). O tempo de VM após a falha no primeiro TVE foi maior no GP que no GNP (9 ± 5 dias vs. 7 ± 2 dias; p < 0,001). CONCLUSÕES: Nesta amostra de pacientes de difícil desmame, o uso de um protocolo de desmame melhorou o processo decisório, reduzindo a possibilidade de falha na extubação.
OBJECTIVE: To determine whether the predictive accuracy of clinical judgment alone can be improved by supplementing it with an objective weaning protocol as a decision support tool. METHODS: This was a multicenter prospective cohort study carried out at three medical/surgical ICUs. The study involved all consecutive difficult-to-wean ICU patients (failure in the first spontaneous breathing trial [SBT]), on mechanical ventilation (MV) for more than 48 h, admitted between January of 2002 and December of 2005. The patients in the protocol group (PG) were extubated after a T-piece weaning trial and were compared with patients who were otherwise extubated (non-protocol group, NPG). The primary outcome measure was reintubation within 48 h after extubation. RESULTS: We included 731 patients-533 (72.9%) and 198 (27.1%) in the PG and NPG, respectively. The overall reintubation rate was 17.9%. The extubation success rates in the PG and NPG were 86.7% and 69.6%, respectively (p < 0.001). There were no significant differences between the groups in terms of age, gender, severity score, or pre-inclusion time on MV. However, COPD was more common in the NPG than in the PG (44.4% vs. 17.6%; p < 0.001), whereas sepsis and being a post-operative patient were more common in the PG (23.8% vs. 11.6% and 42.4% vs. 26.4%, respectively; p < 0.001 for both). The time on MV after the failure in the first SBT was higher in the PG than in the NPG (9 ± 5 days vs. 7 ± 2 days; p < 0.001). CONCLUSIONS: In this sample of difficult-to-wean patients, the use of a weaning protocol improved the decision-making process, decreasing the possibility of extubation failure.
Assuntos
Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Extubação/efeitos adversos , Extubação/estatística & dados numéricos , Protocolos Clínicos/normas , Tomada de Decisões , Doença Pulmonar Obstrutiva Crônica/terapia , Desmame do Respirador/métodos , Extubação/métodos , Métodos Epidemiológicos , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Falha de Tratamento , Resultado do TratamentoRESUMO
OBJECTIVES: Evaluate the safety and effectiveness of a training program for performing ultrasound-guided internal jugular vein cannulation in critically ill patients. METHODS: Cohort prospective study, evaluating adult patients admitted in a teaching intensive care unit (ICU). Catheter placement was performed by an ICU medical resident. The patient's baseline characteristics, vessel's position and operator experience were the evaluated variables. The main outcomes were cannulation success rate and incidence of major complications. RESULTS: A total of 118 consecutive patients were enrolled between May 2008 and November 2009. The success rate of ultrasound guided catheter placement was 90% (106/118), 77% in the first attempt. Major complications occurred in 4% of the cases (n = 5) and were not associated with the analyzed variables. Inability to place the guide wire was the reason for 58% (7/12) of the failures. Operators with more than 15 previous ultrasound guided cannulations had an increased success rate (95% vs. 79%, p = 0.01) and increased failure was related to previous catheterization (26% vs. 7%, p = 0.02). CONCLUSION: Learning ultrasound guidance for IJV vein cannulation was safe and feasible in ICU patients. This process was not associated to complications and better results were achieved across the spectrum of operator experience.
Assuntos
Cateterismo Venoso Central/métodos , Veias Jugulares/cirurgia , Ultrassonografia de Intervenção/métodos , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Cuidados Críticos/métodos , Estado Terminal/terapia , Educação Médica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Punções/métodos , Reprodutibilidade dos Testes , Fatores de Risco , Falha de TratamentoRESUMO
OBJECTIVES: Evaluate the safety and effectiveness of a training program for performing ultrasound-guided internal jugular vein cannulation in critically ill patients. METHODS: Cohort prospective study, evaluating adult patients admitted in a teaching intensive care unit (ICU). Catheter placement was performed by an ICU medical resident. The patient's baseline characteristics, vessel's position and operator experience were the evaluated variables. The main outcomes were cannulation success rate and incidence of major complications. RESULTS: A total of 118 consecutive patients were enrolled between May 2008 and November 2009. The success rate of ultrasound guided catheter placement was 90 percent (106/118), 77 percent in the first attempt. Major complications occurred in 4 percent of the cases (n = 5) and were not associated with the analyzed variables. Inability to place the guide wire was the reason for 58 percent (7/12) of the failures. Operators with more than 15 previous ultrasound guided cannulations had an increased success rate (95 percent vs. 79 percent, p = 0.01) and increased failure was related to previous catheterization (26 percent vs. 7 percent, p = 0.02). CONCLUSION: Learning ultrasound guidance for IJV vein cannulation was safe and feasible in ICU patients. This process was not associated to complications and better results were achieved across the spectrum of operator experience.
OBJETIVO: Avaliar a segurança e efetividade de um programa de treinamento para cateterização da veia jugular interna guiada por ultrassom em pacientes críticos. MÉTODOS: Estudo de coorte prospectivo, avaliando pacientes adultos internados em uma unidade de terapia intensiva com programa de ensino. Os médicos residentes do serviço realizaram as punções de veia jugular interna guiadas por ultrassom. Foram avaliadas as características de base dos pacientes, sintopia dos vasos e experiência dos operadores. Os desfechos primários foram a taxa de sucesso da cateterização e a incidência de complicações graves. RESULTADOS: No período entre maio de 2008 e novembro de 2009 foram avaliados 118 pacientes. A taxa de sucesso da punção guiada por ultrassom foi 90 por cento (106/118), 77 por cento dessas na primeira tentativa. Complicações graves ocorreram em 4 por cento dos casos (n = 5) e não foram associadas às variáveis analisadas. Incapacidade de progredir o fio-guia foi a razão de 58 por cento (7/12) das falhas. Operadores com mais de 15 punções guiadas por ultrassom obtiveram uma maior taxa de sucesso (95 por cento vs. 79 por cento, p = 0,01) e pacientes com cateterização prévia apresentaram um maior número de falhas (26 por cento vs. 7 por cento, p = 0,02). CONCLUSÃO: O aprendizado da técnica de punção de veia jugular interna guiada por ultrasssom é seguro e efetivo em pacientes críticos. Este processo não esteve associado a um aumento da taxa de complicações e melhores resultados são obtidos à medida que aumenta a experiência do operador.
Assuntos
Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cateterismo Venoso Central/métodos , Veias Jugulares/cirurgia , Ultrassonografia de Intervenção/métodos , Distribuição de Qui-Quadrado , Cuidados Críticos/métodos , Estado Terminal/terapia , Educação Médica , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Punções/métodos , Reprodutibilidade dos Testes , Fatores de Risco , Falha de TratamentoRESUMO
OBJETIVOS: A falha de comunicação entre os profissionais de saúde em centros de tratamento intensivo pode estar relacionada ao aumento de mortalidade dos pacientes criticamente doentes. Este estudo teve como objetivo avaliar se falhas de comunicação entre os médicos assistentes e os médicos rotineiros do centro de tratamento intensivo teriam impacto na morbidade e mortalidade dos pacientes críticos. MÉTODOS: Estudo de coorte incluindo pacientes não consecutivos admitidos no centro de tratamento intensivo durante 18 meses. Os pacientes foram divididos em 3 grupos conforme o hábito de comunicação de seus médicos assistentes com os médicos rotineiros: CD - comunicação diária da conduta (>75 por cento dos dias); CE - comunicação eventual (25 a 75 por cento dos dias); RC - rara comunicação (<25 por cento dos dias). Foram coletados dados demográficos, escores de gravidade, motivo de internação no centro de tratamento intensivo, tempo de internação no centro de tratamento intensivo e intervenções realizadas nos pacientes. Foram analisadas as conseqüências da falha na comunicação entre os profissionais médicos (atraso na realização de procedimentos, na realização de exames diagnósticos, no início de antibioticoterapia, no desmame do suporte ventilatório e no uso de vasopressores) e inadequações de prescrição médica (ausência de cabeceira elevada, ausência de profilaxia medicamentosa para úlcera de estresse e para trombose venosa profunda) relacionando-as com o desfecho dos pacientes. RESULTADOS: Foram incluídos 792 pacientes no estudo, sendo agrupados da seguinte maneira: CD (n =529), CE (n =187) e RC (n =76). A mortalidade foi maior nos pacientes pertencentes ao grupo RC (26,3 por cento) comparada aos demais (CD =13,6 por cento e CE =17,1 por cento; p <0,05). A análise multivariada demonstrou que o atraso no início de antibióticos [RR 1,83 (IC95 por cento: 1,36 - 2,25)], o atraso no início do desmame ventilatório [RR 1,63 (IC95 por cento:...
OBJECTIVES: Communication issues between healthcare professionals in intensive care units may be related to critically ill patients increased mortality. This study aimed to evaluate if communication issues involving assistant physicians and routine intensive care unit physicians would impact critically ill patients morbidity and mortality. METHODS: This was a cohort study that included non-consecutive patients admitted to the intensive care unit for 18 months. The patients were categorized in 3 groups according to their assistant doctors versus routine doctors communication uses: DC - daily communication during the stay (>75 percent of the days); EC - eventual communication (25 to 75 percent of the days); RC - rare communication (< 25 percent of the days). Demographic data, severity scores, reason for admission to the intensive care unit and interventions were recorded. The consequences of the medical professionals communication failures (delayed procedures, diagnostic tests, antibiotics, ventilatory weaning, vasopressors) and medical prescriptions inadequacies (no bed head elevation, no stress ulceration and deep venous thrombosis drug prophylaxis), and their relationship with the patients outcomes were analyzed. RESULTS: 792 patients were included, and categorized as follows: DC (n=529); EC (n=187) and RC (n=76). The mortality was increased in the RC patients group (26.3 percent) versus the remainder groups (DC = 13.6 percent and EC = 17.1 percent; p<0.05). A multivariate analysis showed that delayed antibiotics [RR 1.83 (CI95 percent: 1.36 -2.25)], delayed ventilatory weaning [RR 1.63 (CI95 percent: 1.25-2.04)] and no deep venous thrombosis prophylaxis [RR 1.98 (CI95 percent: 1.43 - 3.12)] contributed independently for the increased mortality. CONCLUSION: The failure in the assistant and routine intensive care doctors communication may increase the patients mortality, particularly due to delayed antibiotics and ventilation weaning,...
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OBJECTIVES: Communication issues between healthcare professionals in intensive care units may be related to critically ill patients increased mortality. This study aimed to evaluate if communication issues involving assistant physicians and routine intensive care unit physicians would impact critically ill patients morbidity and mortality. METHODS: This was a cohort study that included non-consecutive patients admitted to the intensive care unit for 18 months. The patients were categorized in 3 groups according to their assistant doctors versus routine doctors communication uses: DC - daily communication during the stay (>75% of the days); EC - eventual communication (25 to 75% of the days); RC - rare communication (< 25% of the days). Demographic data, severity scores, reason for admission to the intensive care unit and interventions were recorded. The consequences of the medical professionals communication failures (delayed procedures, diagnostic tests, antibiotics, ventilatory weaning, vasopressors) and medical prescriptions inadequacies (no bed head elevation, no stress ulceration and deep venous thrombosis drug prophylaxis), and their relationship with the patients outcomes were analyzed. RESULTS: 792 patients were included, and categorized as follows: DC (n=529); EC (n=187) and RC (n=76). The mortality was increased in the RC patients group (26.3%) versus the remainder groups (DC = 13.6% and EC = 17.1%; p<0.05). A multivariate analysis showed that delayed antibiotics [RR 1.83 (CI95%: 1.36 -2.25)], delayed ventilatory weaning [RR 1.63 (CI95%: 1.25-2.04)] and no deep venous thrombosis prophylaxis [RR 1.98 (CI95%: 1.43 - 3.12)] contributed independently for the increased mortality. CONCLUSION: The failure in the assistant and routine intensive care doctors communication may increase the patients mortality, particularly due to delayed antibiotics and ventilation weaning, and lack of deep venous thrombosis prophylaxis prescription.
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OBJECTIVE: The aim of this study was to evaluate the work of breathing (WOB) behavior during a 120-minute successful spontaneous breathing trial (SBT) with T-tube trial, and its predictive value for extubation outcome. DESIGN: A prospective cohort study. SETTING: 2 medical-surgical intensive care units. PATIENTS: Fifty-one consecutive patients mechanically ventilated for more than 48 hours after a successful SBT were extubated based on the institutional protocol and followed for the occurrence of postextubation respiratory distress during 48 hours. MEASUREMENTS AND MAIN RESULTS: All cases were serially monitored during 120 minutes of SBT using the respiratory monitoring system Ventrak 1500 (Medical Novametrix Systems, Wallingford, CT). Successful extubation occurred in 38 (74.5%) of 51 of the sample. Respiratory and hemodynamic parameters, APACHE II score, sex, days on mechanical ventilation, and cause of respiratory failure were unable to predict extubation outcome. The WOB significantly increased during SBT in extubation failure patients (WOB at 1st minute 0.24 +/- 0.06 J/L vs WOB at 120th minute = 0.39 +/- 0.07 J/L; P < .01) when compared to successfully extubated patients (WOB at 1st minute 0.21 +/- 0.08 J/L vs WOB at 120th minute = 0.24 +/- 0.11 J/L; P = .12). The WOB variation was able to predict extubation outcome only after the 90th minute of SBT (extubation failure = 0.35 +/- 0.08 J/L vs extubation success = 0.22 +/- 0.11 J/L; P = .01). CONCLUSION: An increase in the WOB could predict extubation failure during a T-tube trial of 120 minutes.