RESUMO
INTRODUCCIÓN La pandemia COVID-19 incrementó la carga de trabajo y expuso el impacto del multiempleo en los servicios de salud. El presente estudio busca caracterizar el multiempleo entre profesionales médicos y de enfermería que trabajaron en internación clínica y cuidados críticos durante la pandemia en la provincia de Buenos Aires (PBA). METODOS Se realizó un estudio exploratorio, descriptivo y transversal, mediante técnicas cuantitativas y cualitativas que combinaron fuentes primarias (encuesta estructurada, entrevistas) y secundarias (bases de datos de recursos humanos). RESULTADOS El cruce de datos arrojó un multiempleo explícito del 12,7% en enfermería y 28,3% en medicina. En la encuesta, 96,3% de médicos y 68,1% de enfermeros declara multiempleo. La media de empleos fue 3,1 para médicos y 1,89 para enfermeros. Los motivos más frecuentes de multiempleo son la subsistencia y el incremento de ingresos. En condiciones adecuadas, el 90% optaría por un empleo, principalmente mujeres y jóvenes. El hospital público surge como el ámbito elegido. No hay coincidencias ni confianza en lograr empleo único. DISCUSIÓN El multiempleo en PBA es difícil de medir mediante los registros vigentes y difiere de los datos auto informados. El problema del multiempleo requiere ser abordado desde la desprecarización del empleo, con perspectiva de género y mejoras en las condiciones económicas y de trabajo.
Assuntos
Pesquisa QualitativaRESUMO
OBJECTIVE: To assess renal dysfunction and outcome in patients treated exclusively with colistin vs. other antibiotics. DESIGN AND SETTING: Prospective cohort study in a mixed ICU in a university-affiliated hospital. PATIENTS: 185 patients infected with Acinetobacter baumannii and Pseudomonas aeruginosa after an ICU stay longer than 48 h: 55 in the colistin group and 130 in the noncolistin group, similar in age, APACHE II, medical status, and SOFA score. MEASUREMENTS AND RESULTS: We recorded data on epidemiology and severity of illness, site of infection, renal function before and after treatment, clinical cure, and mortality. Clinical cure was defined as simultaneous normalization of central temperature (< or = 38 degrees), leukocyte count (< or = 10,000/mm3), and PaO2/FIO2 ratio (>187). Before treatment creatinine was 0.9+/-0.2 in the colistin group and 0.9+/-0.1 in the noncolistin group; after treatment the value was 1.0+/-0.3 in both groups. The most frequent infection was ventilator-associated pneumonia: 53% vs. 66% in colistin and noncolistin groups, respectively, Acinetobacter was the cause in 65% and 60% and Pseudomonas in 35% and 53%. In the noncolistin group 81% of patients were treated with carbapenems. Inadequate empirical antimicrobial treatment was more frequent in the colistin group (100% vs. 8%), but there were no differences in the frequency of clinical cure on day 6 of treatment (15% and 17%) or in mortality (29% and 24%). CONCLUSIONS: Colistin appears to be as safe and as effective as other antimicrobials for treatment of sepsis caused by Acinetobacter and Pseudomonas in critically ill patients.
Assuntos
Infecções por Acinetobacter/tratamento farmacológico , Antibacterianos/uso terapêutico , Colistina/uso terapêutico , Infecções por Pseudomonas/tratamento farmacológico , APACHE , Acinetobacter/efeitos dos fármacos , Adulto , Argentina , Gasometria , Estudos de Coortes , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Pseudomonas/efeitos dos fármacos , Resultado do TratamentoRESUMO
STUDY OBJECTIVES: To determine the incidence of prolonged mechanical ventilation (PMV), which is associated with increased health-care costs and risks of adverse events, and to identify its early predictors. DESIGN: Retrospective cohort. SETTING: A medical-surgical ICU in a university-affiliated hospital. PATIENTS OR PARTICIPANTS: All patients admitted to the ICU over 3 years who received mechanical ventilation (MV) for > 12 h. INTERVENTIONS: None. MEASUREMENTS: PMV was defined as MV lasting > 21 days. We recorded epidemiologic data, severity scores, worst Pao(2)/fraction of inspired oxygen (Fio(2)), presence of shock on ICU admission day, cause for MV, length of MV, ICU length of stay (LOS), and hospital LOS. PMV patients were compared to patients weaned before 21 days (non-PMV group) to determine predictors of PMV. RESULTS: Of 551 hospital admissions, 319 patients (58%) required MV > 12 h. One hundred thirty patients died early and were excluded. Seventy-nine patients (14%) required PMV. The non-PMV group consisted of 110 patients. Simplified acute physiology score (SAPS) II, APACHE (acute physiology and chronic health evaluation) II, therapeutic intervention scoring system, Pao(2)/Fio(2), shock, ICU LOS, and hospital LOS differed significantly between groups. However, logistic regression identified shock on ICU admission day as the only independent predictor of PMV (odds ratio, 3.10; p = 0.001). SAPS II and Pao(2)/Fio(2) had the nearest coefficients and were used to build the predictive model. Sensitivity analysis was performed including the 130 patients who died early, and shock remained the most powerful predictor. CONCLUSIONS: PMV was a frequent event in this cohort. The presence of shock on ICU admission day was the only prognostic factor, even adjusting for severity of illness and hypoxemia.
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Indicadores Básicos de Saúde , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Índice de Gravidade de Doença , Choque/epidemiologia , APACHE , Adulto , Idoso , Argentina , Estudos de Coortes , Feminino , Hospitais Universitários , Humanos , Hipóxia/epidemiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prognóstico , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Sensibilidade e Especificidade , Desmame do RespiradorRESUMO
OBJECTIVE: We examined whether PEEP during the first hours of ARDS can induce such a change in oxygenation that could mask fulfillment of the AECC criteria of a PaO(2)/FIO(2) = 200 essential for ARDS diagnosis. DESIGN AND SETTING: Observational, prospective cohort in two medical-surgical ICU in teaching hospitals. PATIENTS: 48 consecutive patients who met AECC criteria of ARDS on 0 PEEP (ZEEP) at the moment of diagnosis. MEASUREMENTS AND RESULTS: PaO(2)/FIO(2) and lung mechanics were recorded on admission (0 h) to the ICU on ZEEP, and after 6, 12, and 24 h on PEEP levels selected by attending physicians. Lung Injury Score (LIS) was calculated at 0 and 24 h. PaO(2)/FIO(2) rose significantly from 121+/-45 on ZEEP at 0 h, to 234+/-85 on PEEP of 12.8+/-3.7 cmH(2)O after 24 h. LIS did not change significantly (2.34+/-0.53 vs. 2.42+/-0.62). These variables behaved similarly in pulmonary and extrapulmonary ARDS, and in survivors and nonsurvivors. After 24 h only 18 patients (38%) still had a PaO(2)/FIO(2) of 200 or lower. Their mortality was similar to that in the remaining patients (61% vs. 53%). CONCLUSIONS: The use of PEEP improved oxygenation such that one-half of patients after 6 h, and most after 24 h did not fulfill AECC hypoxemia criteria of ARDS. However, LIS remained stable in the overall series. These results suggest that PEEP level should be taken into consideration for ARDS diagnosis.
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Respiração com Pressão Positiva/métodos , Síndrome do Desconforto Respiratório/diagnóstico , Síndrome do Desconforto Respiratório/terapia , APACHE , Idoso , Resistência das Vias Respiratórias , Análise de Variância , Gasometria , Análise Discriminante , Mortalidade Hospitalar , Humanos , Complacência Pulmonar , Pessoa de Meia-Idade , Oxigênio/sangue , Prognóstico , Estudos Prospectivos , Troca Gasosa Pulmonar , Síndrome do Desconforto Respiratório/etiologia , Síndrome do Desconforto Respiratório/mortalidade , Índice de Gravidade de Doença , Análise de Sobrevida , Volume de Ventilação Pulmonar , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: To assess prospectively acute respiratory distress syndrome incidence, etiologies, physiologic and clinical features, and mortality and its predictors in four intensive care units in Argentina. DESIGN: Prospective inception cohort. SETTING: Four general intensive care units in teaching hospitals. PATIENTS: All consecutive adult patients admitted between January 3, 1999, and January 6, 2000, that met the criteria of the American-European Consensus Conference for acute respiratory distress syndrome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 235 patients developed acute respiratory distress syndrome, and 217 survived for >24 hrs; these were further analyzed. Main risk factors were: sepsis (44%, including 65 pneumonia cases), shock (15%), trauma (11%), gastric aspiration (10%), and other (34%). At admission, nonsurvivors had significantly higher Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment and McCabe scores, and lower oxygenation and pH. During the first week, Pao2/Fio2, Sequential Organ Failure Assessment, pH, base excess, and driving pressure consistently discriminated between survivors and nonsurvivors. Hospital mortality was 58%. One third of patients died early. Main causes of death were multiple organ dysfunction syndrome, sepsis, and septic shock; refractory hypoxemia was uncommon. Factors independently associated with mortality were organ dysfunctions on day 3, Pao2/Fio2 on day 3, and McCabe score. CONCLUSIONS: Acute respiratory distress syndrome was a frequent syndrome in this cohort. Sepsis was its leading cause, and pneumonia was the most common single diagnosis. Mortality was high but similar to most recent series that included serious comorbidities. Independent predictors of death 72 hrs after admission emphasize the importance of both extrapulmonary and pulmonary factors together with preexisting severe illnesses.