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1.
J Clin Monit Comput ; 2020 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-33175254

RESUMO

Processed electroencephalography (pEEG) is used to monitor depth of anaesthesia and/or sedation. A novel device (SedLine®) has been recently introduced into clinical practice. However, there are no published data on baseline SedLine values for awake adult subjects. We aimed to determine baseline values for SedLine-derived parameters in eyes-open and eyes-closed states. We performed a prospective observational study in healthy volunteers. SedLine EEG-derived parameters were recorded for 2 min with eyes closed and 8 min with eyes open. We determined the overall reference range for each value, as well as the reference range in each phase. We investigated changes in recorded parameters between the two phases, and the interaction between EMG, baseline characteristics, and Patient State Index (PSI). We collected data from 50 healthy volunteers, aged 23-63 years. Median PSI was 94 (92-95) with eyes open and 88 (87-91) with eyes closed (p < 0.001 for open versus close). EMG activity decreased from 47.2% (46.6-47.9) with eyes open to 28.6% (28.0-29.3) with eyes closing (p < 0.001). There was a significant positive correlation between EMG and PSI with eyes closed (p = 0.01) but not with eyes open, which was confirmed with linear regression analysis (p = 0.01). In awake volunteers, keeping eyes open induces significant changes to SedLine-derived parameters, most likely due to increased EMG activity (e.g. eye blinking). These findings have implications for the clinical interpretation of PSI parameters and for the planning of future research.

2.
Artigo em Inglês | MEDLINE | ID: mdl-33069558

RESUMO

Inotropes and vasopressors frequently are administered in critically ill and perioperative patients. However, clinical practice is highly variable across clinicians and institutions. The inotropic score and its upgrade "vasoactive-inotropic score" (VIS) can be used to objectively quantify the degree of hemodynamic support. Several studies demonstrated a correlation between high VIS and poor outcome. Furthermore, VIS can help compare different clinical and research experiences. Several recently developed scores include VIS in their model, although they still require independent validation. Conversely, VIS has several pitfalls, including the fact that a universally recognized version that includes all commonly used vasoactive drugs does not exist. In this review, the authors summarize all the VIS, VIS-related, and VIS-validating manuscripts, and suggest a new updated version of VIS that also includes terlipressin, methylene blue, and angiotensin II.

3.
Crit Care Resusc ; 22(3): 200-211, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32900326

RESUMO

OBJECTIVE: Describe characteristics, daily care and outcomes of patients with coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS). DESIGN: Case series of 73 patients. SETTING: Large tertiary hospital in Milan. PARTICIPANTS: Mechanically ventilated patients with confirmed COVID-19 admitted to the intensive care unit (ICU) between 20 February and 2 April 2020. MAIN OUTCOME MEASURES: Demographic and daily clinical data were collected to identify predictors of early mortality. RESULTS: Of the 73 patients included in the study, most were male (83.6%), the median age was 61 years (interquartile range [IQR], 54-69 years), and hypertension affected 52.9% of patients. Lymphocytopenia (median, 0.77 x 103 per mm3; IQR, 0.58-1.00 x 103 per mm3), hyperinflammation with C-reactive protein (median, 184.5 mg/dL; IQR, 108.2-269.1 mg/dL) and pro-coagulant status with D-dimer (median, 10.1 µg/m; IQR, 5.0-23.8 µg/m) were present. Median tidal volume was 6.7 mL/kg (IQR, 6.0-7.5 mL/kg), and median positive end-expiratory pressure was 12 cmH2O (IQR, 10-14 cmH2O). In the first 3 days, prone positioning (12-16 h) was used in 63.8% of patients and extracorporeal membrane oxygenation in five patients (6.8%). After a median follow-up of 19.0 days (IQR, 15.0-27.0 days), 17 patients (23.3%) had died, 23 (31.5%) had been discharged from the ICU, and 33 (45.2%) were receiving invasive mechanical ventilation in the ICU. Older age (odds ratio [OR], 1.12; 95% CI, 1.04-1.22; P = 0.004) and hypertension (OR, 6.15; 95% CI, 1.75-29.11; P = 0.009) were associated with mortality, while early improvement in arterial partial pressure of oxygen (PaO2) to fraction of inspired oxygen (FiO2) ratio was associated with being discharged alive from the ICU (P = 0.002 for interaction). CONCLUSIONS: Despite multiple advanced critical care interventions, COVID-19 ARDS was associated with prolonged ventilation and high short term mortality. Older age and pre-admission hypertension were key mortality risk factors. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04318366.


Assuntos
Infecções por Coronavirus/mortalidade , Pneumonia Viral/mortalidade , Respiração Artificial , /mortalidade , Fatores Etários , Idoso , Betacoronavirus , Causas de Morte , Infecções por Coronavirus/terapia , Feminino , Humanos , Hipertensão/complicações , Itália , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/terapia , /virologia , Fatores de Risco
5.
Blood Purif ; : 1-8, 2020 Jul 13.
Artigo em Inglês | MEDLINE | ID: mdl-32659757

RESUMO

BACKGROUND: There is no information on acute kidney injury (AKI) and continuous renal replacement therapy (CRRT) among invasively ventilated coronavirus disease 2019 (COVID-19) patients in Western healthcare systems. OBJECTIVE: To study the prevalence, characteristics, risk factors and outcome of AKI and CRRT among invasively ventilated COVID-19 patients. METHODS: Observational study in a tertiary care hospital in Milan, Italy. RESULTS: Among 99 patients, 72 (75.0%) developed AKI and 17 (17.7%) received CRRT. Most of the patients developed stage 1 AKI (33 [45.8%]), while 15 (20.8%) developed stage 2 AKI and 24 (33.4%) a stage 3 AKI. Patients who developed AKI or needed CRRT at latest follow-up were older, and among CRRT treated patients a greater proportion had preexisting CKD. Hospital mortality was 38.9% for AKI and 52.9% for CRRT patients. CONCLUSIONS: Among invasively ventilated COVID-19 patients, AKI is very common and CRRT use is common. Both carry a high risk of in-hospital mortality.

7.
J Crit Care ; 58: 89-95, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32402931

RESUMO

PURPOSE: Perioperative myocardial dysfunction occurs frequently in cardiac surgery, and is a risk factor for morbidity and mortality. Levosimendan has been suggested to reduce mortality of patients with perioperative myocardial dysfunction. However, long-term outcome data on its efficacy in cardiac surgery are lacking. MATERIALS AND METHODS: Cardiac surgery patients with perioperative myocardial dysfunction were randomized to levosimendan or placebo, in addition to standard inotropic care. One-year mortality data were collected. RESULTS: We randomized 506 patients (248 to levosimendan 258 to placebo). At 1-year follow-up, 41 patients (16.5%) died in the levosimendan group, while 47 (18.3%) died in the placebo group (absolute risk difference -1.8; 95% CI -8.4 to 4.9; P = .60). Female sex, history of chronic obstructive pulmonary disease, previous myocardial infarction, serum creatinine, hematocrit, mean arterial pressure, and duration of cardiopulmonary bypass were independently associated with 1-year mortality. CONCLUSIONS: Levosimendan administration does not improve 1-year survival in cardiac surgery patients with perioperative myocardial dysfunction. One-year mortality in these patients is 17%. Six predictive factors for long-term mortality were identified. STUDY REGISTRATION NUMBER: NCT00994825 (ClinicalTrials.gov).

8.
Crit Care Resusc ; 2020 Apr 23.
Artigo em Inglês | MEDLINE | ID: mdl-32353223

RESUMO

Objective: Describe characteristics, daily care and outcomes of patients with coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS). Design: Case series of 73 patients. Setting: Large tertiary hospital in Milan. Participants: Mechanically ventilated patients with confirmed COVID-19 admitted to the intensive care unit (ICU) between 20 February and 2 April 2020. Main outcome measures: Demographic and daily clinical data were collected to identify predictors of early mortality. Results: Of the 73 patients included in the study, most were male (83.6%), the median age was 61 years (interquartile range [IQR], 54-69 years), and hypertension affected 52.9% of patients. Lymphocytopenia (median, 0.77 x 103 per mm3 ; IQR, 0.58-1.00 x 103 per mm3), hyperinflammation with C-reactive protein (median, 184.5 mg/dL; IQR, 108.2-269.1 mg/dL) and pro-coagulant status with D-dimer (median, 10.1 µg/m; IQR, 5.0-23.8 µg/m) were present. Median tidal volume was 6.7 mL/kg (IQR, 6.0-7.5 mL/kg), and median positive end-expiratory pressure was 12 cmH2O (IQR, 10-14 cmH2O). In the first 3 days, prone positioning (12-16 h) was used in 63.8% of patients and extracorporeal membrane oxygenation in five patients (6.8%). After a median follow-up of 19.0 days (IQR, 15.0-27.0 days), 17 patients (23.3%) had died, 23 (31.5%) had been discharged from the ICU, and 33 (45.2%) were receiving invasive mechanical ventilation in the ICU. Older age (odds ratio [OR], 1.12; 95% CI, 1.04-1.22; P = 0.004) and hypertension (OR, 6.15; 95% CI, 1.75-29.11; P = 0.009) were associated with mortality, while early improvement in arterial partial pressure of oxygen (PaO2) to fraction of inspired oxygen (FiO2) ratio was associated with being discharged alive from the ICU (P = 0.002 for interaction). Conclusions: Despite multiple advanced critical care interventions, COVID-19 ARDS was associated with prolonged ventilation and high short term mortality. Older age and pre-admission hypertension were key mortality risk factors. Trial registration: ClinicalTrials.gov identifier: NCT04318366.

9.
Crit Care Med ; 48(7): 1047-1054, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32355134

RESUMO

OBJECTIVES: To investigate the effect of the application of therapeutic hypothermia (32-35°C) on survival and major clinical endpoints in critically ill patients. DATA SOURCES: We searched online database and clinical trial registries dated up to April 30, 2019, and references of relevant studies. STUDY SELECTION: Low risk of bias randomized trials which compared hypothermia applied for at least 24 hours and conventional therapy in critically ill patients were included. We excluded trials investigating therapeutic hypothermia in indications already supported by international guidelines (adult cardiac arrest and hypoxic-ischemic encephalopathy of newborns) or intraoperative hypothermia. DATA EXTRACTION: Titles and abstracts were reviewed independently by two authors. If the articles seemed eligible, full-text articles were reviewed, and data were abstracted using a structured template. DATA SYNTHESIS: Our search retained 14 low risk of bias randomized trials (2,670 patients) performed in three different settings: traumatic brain injury, serious infections, and stroke. Therapeutic hypothermia was associated with an increase in mortality at longest follow-up available (432/1,375 [31%] vs 330/1,295 [25%]; risk ratio, 1.24; 95% CI, 1.10-1.39; p = 0.0004; I = 0%). Pooled results showed no difference of good neurologic outcome among survivors between the two treatment arms (493/1,142 [43%] vs 486/1,067 [46%]; risk ratio, 1.04; 95% CI, 0.97-1.12; p = 0.27; I = 1%). Arrhythmias were significantly increased among patients undergoing therapeutic hypothermia. We found no difference between groups in pneumonia, serious infections, any infection, hemorrhage, renal failure, deep vein thrombosis, and uncontrollable intracranial hypertension. CONCLUSIONS: High-quality randomized evidence indicates that therapeutic hypothermia is associated with higher mortality and no difference in good neurologic outcome compared with normothermia in critically ill patients. Although there still might be a possibility that therapeutic hypothermia is beneficial in a specific setting, routine application of therapeutic hypothermia would better be avoided outside the settings indicated by international guidelines (adult cardiac arrest and hypoxic-ischemic encephalopathy of newborns).

10.
Resuscitation ; 152: 16-25, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32437783

RESUMO

INTRODUCTION: Involving laypersons in response to out-of-hospital cardiac arrest through mobile-phone technology is becoming widespread in numerous countries, and different solutions were developed. We performed a systematic review on the impact of alerting citizens as first responders and to provide an overview of different strategies and technologies used. METHODS: We searched electronic databases up to October 2019. Eligible studies described systems to alert citizens first responders to out-of-hospital cardiac arrest through text messages or apps. We analyzed the implementation and performance of these systems and their impact on patients' outcomes. RESULTS: We included 28 manuscripts describing 12 different systems. The first text message system was implemented in 2006 and the first app in 2010. First responders accepted to intervene in median (interquartile) 28.7% (27-29%) of alerts and reached the scene after 4.6 (4.4-5.5) minutes for performing CPR. First responders arrived before ambulance, started CPR and attached a defibrillator in 47% (34-58%), 24% (23-27%) and 9% (6-14%) of cases, respectively. Pooled analysis showed that first responders activation increased layperson-CPR rates (1463/2292 [63.8%] in the intervention group vs. 1094/1989 [55.0%] in the control group; OR = 1.70; 95% CI, 1.11-2.60; p = 0.01) and survival to hospital discharge or at 30 days (327/2273 [14.4%] vs. 184/1955 [9.4%]; OR = 1.51; 95% CI, 1.24-1.84; p < 0.001). CONCLUSIONS: Alerting citizens as first responders in case of out-of-hospital cardiac arrest may reduce the intervention-free time and improve patients' outcomes.

11.
Crit Care Med ; 48(7): e620-e628, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32404636

RESUMO

OBJECTIVES: The potential harm associated with the use of IV vitamin C has not been systematically assessed. We aimed to review the available evidence on harm related to such treatment. DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane Library, National Institute of Health Clinical Trials Register, and World Health Organization International Clinical Trials Registry Platform. STUDY SELECTION: We included studies in adult population that reported harm related to IV high-dose vitamin C which we defined as greater than or equal to 6 g/d, greater than or equal to 75 mg/kg/d, or greater than or equal to 3 g/m/d. DATA EXTRACTION: Two independent investigators screened records and extracted data. DATA SYNTHESIS: We identified 8,149 reports, of which 650 full text were assessed for eligibility, leaving 74 eligible studies. In these studies, 2,801 participants received high-dose vitamin C at a median (interquartile range) dose of 22.5 g/d (8.25-63.75 g/d), 455 mg/kg/d (260-925 mg/kg/d), or 70 g/m/d (50-90 g/m/d); and 932 or more adverse events were reported. Among nine double-blind randomized controlled trials (2,310 patients), adverse events were reported in three studies with an event rate per patient for high-dose vitamin C identical to placebo group in one study (0.1 [1/10] vs 0.1 [1/10]), numerically lower in one study (0.80 [672/839] vs 0.82 [709/869]), and numerically higher in one study (0.33 [24/73] vs 0.23 [17/74]). Six double-blind randomized controlled trials reported no adverse event in either group. Five cases of oxalate nephropathy, five cases of hypernatremia, three cases of hemolysis in glucose-6-phosphate dehydrogenase deficiency patients, two cases of glucometer error, and one case of kidney stones were also reported overall. CONCLUSIONS: There is no consistent evidence that IV high-dose vitamin C therapy is more harmful than placebo in double-blind randomized controlled trials. However, reports of oxalate nephropathy, hypernatremia, glucometer error, and hemolysis in glucose-6-phosphate dehydrogenase deficiency patients warrant specific monitoring.

12.
Crit Care Resusc ; 22(2): 91-94, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-32227819

RESUMO

At the end of 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak spread from China all around the world, causing thousands of deaths. In Italy, the hardest hit region was Lombardy, with the first reported case on 20 February 2020. San Raffaele Scientific Institute ­ a large tertiary hospital and research centre in Milan, Italy ­ was immediately involved in the management of the public health emergency. Since the beginning of the outbreak, the elective surgical activity of the hospital was rapidly reduced and large areas of the hospital were simultaneously reorganised to admit and assist patients with coronavirus disease 2019 (COVID-19). In addition, the hospital became the regional referral hub for cardiovascular emergencies in order to keep ensuring a high level of health care to non-COVID-19 patients in northern Italy. In a few days, a COVID-19 emergency department was created, improving the general ward capacity to a total number of 279 beds dedicated to patients with COVID-19. Moreover, the number of intensive care unit (ICU) beds was increased from 28 to 72 (54 of them dedicated to patients with COVID-19, and 18 to cardiology and cardiac surgery hub emergencies), both converting pre-existing areas and creating new high technology spaces. All the involved health care personnel were rapidly trained to use personal protection equipment and to manage this particular category of patients both in general wards and ICUs. Furthermore, besides clinical activities, continuously important research projects were carried out in order to find new strategies and more effective therapies to better face an unprecedented health emergency in Italy.

13.
J Cardiothorac Vasc Anesth ; 34(8): 2111-2115, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32173209

RESUMO

OBJECTIVES: To describe international practices on the use of calcium salts during cardiopulmonary bypass (CPB) weaning in adult cardiac surgery patients. DESIGN: Multiple-choice survey on current practice of CPB weaning. SETTING: Online survey using the SurveyMonkey platform. PARTICIPANTS: Departments of cardiac anesthesiology worldwide. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Out of 112 surveys sent, 100 centers from 32 countries replied. The majority of centers (88 of 100 = 88%) administer calcium salts intraoperatively: 71 of 100 (71%) are using these drugs for CPB weaning and 78 of 100 (78%) for correction of hypocalcemia. Among the 88 centers that use calcium salts intraoperatively, 66% (58 of 88) of respondents use calcium chloride, 22% (19 of 88) use calcium gluconate, and 12% (11 of 88) use both drugs. Calcium salts are routinely used during normal (47 of 71 centers = 66%) and difficult (59 of 71 centers = 83%) weaning from CPB. Doses of 5 to 15 mg/kg during termination of CPB were used by 55 of 71 centers (77%) either by bolus (39 of 71, 55%) or over a time period longer than 1 minute (32 of 71 = 45%). Norepinephrine is the most commonly used first line vasopressor or inotropic agent used to support hemodynamics during termination of CPB in 32 out of 100 centers (32%), and calcium is the second one, used by 23 out of 100 centers (23%). CONCLUSION: This survey demonstrates that the majority of cardiac centers use calcium in adult patients undergoing cardiac surgery, especially during weaning from CPB. There is variability on the type of drug, dose, and modality of drug administration.

14.
Crit Care Med ; 48(3): 398-405, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31789701

RESUMO

OBJECTIVES: Epinephrine is frequently used as an inotropic and vasopressor agent in critically ill patients requiring hemodynamic support. Data from observational trials suggested that epinephrine use is associated with a worse outcome as compared with other adrenergic and nonadrenergic vasoactive drugs. We performed a systematic review and meta-analysis of randomized controlled trials to investigate the effect of epinephrine administration on outcome of critically ill patients. DATA SOURCES: PubMed, EMBASE, and Cochrane central register were searched by two independent investigators up to March 2019. STUDY SELECTION: Inclusion criteria were: administration of epinephrine as IV continuous infusion, patients admitted to an ICU or undergoing major surgery, and randomized controlled trials. Studies on epinephrine administration as bolus (e.g., during cardiopulmonary resuscitation), were excluded. The primary outcome was mortality at the longest follow-up available. DATA EXTRACTION: Two independent investigators examined and extracted data from eligible trials. DATA SYNTHESIS: A total of 5,249 studies were assessed, with a total of 12 studies (1,227 patients) finally included in the meta-analysis. The majority of the trials were performed in the setting of septic shock, and the most frequent comparator was a combination of norepinephrine plus dobutamine. We found no difference in all-cause mortality at the longest follow-up available (197/579 [34.0%] in the epinephrine group vs 219/648 [33.8%] in the control group; risk ratio = 0.95; 95% CI, 0.82-1.10; p = 0.49; I = 0%). No differences in the need for renal replacement therapy, occurrence rate of myocardial ischemia, occurrence rate of arrhythmias, and length of ICU stay were observed. CONCLUSIONS: Current randomized evidence showed that continuous IV administration of epinephrine as inotropic/vasopressor agent is not associated with a worse outcome in critically ill patients.


Assuntos
Estado Terminal/mortalidade , Estado Terminal/terapia , Epinefrina/uso terapêutico , Unidades de Terapia Intensiva/estatística & dados numéricos , Vasoconstritores/uso terapêutico , Doenças Cardiovasculares/epidemiologia , Dobutamina/uso terapêutico , Quimioterapia Combinada , Epinefrina/administração & dosagem , Humanos , Infusões Intravenosas , Tempo de Internação , Norepinefrina/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Terapia de Substituição Renal/estatística & dados numéricos , Choque Séptico/tratamento farmacológico , Choque Séptico/mortalidade , Vasoconstritores/administração & dosagem
15.
J Cardiothorac Vasc Anesth ; 34(4): 1023-1041, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31839459

RESUMO

Catecholamines remain the mainstay of therapy for acute cardiovascular dysfunction. However, adrenergic receptors quickly undergo desensitization and downregulation after prolonged stimulation. Moreover, prolonged exposure to high circulating catecholamines levels is associated with several adverse effects on different organ systems. Unfortunately, in critically ill patients, adrenergic downregulation translates into progressive reduction of cardiovascular response to exogenous catecholamine administration, leading to refractory shock. Accordingly, there has been a growing interest in recent years toward use of noncatecholaminergic inotropes and vasopressors. Several studies investigating a wide variety of catecholamine-sparing strategies (eg, levosimendan, vasopressin, ß-blockers, steroids, and use of mechanical circulatory support) have been published recently. Use of these agents was associated with improvement in hemodynamics and decreased catecholamine use but without a clear beneficial effect on major clinical outcomes. Accordingly, additional research is needed to define the optimal management of catecholamine-resistant shock.

16.
J Cardiothorac Vasc Anesth ; 34(1): 235-244, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31350149

RESUMO

The search for safe and effective patient management strategies during weaning from cardiopulmonary bypass is ongoing; intravenous calcium is occasionally used as a first-line drug. The physiologic role of calcium suggests that it can support the function of the cardiovascular system during this critical period. Patients may be mildly hypocalcemic after cardiopulmonary bypass; however, this degree of hypocalcemia does not significantly impair the cardiovascular system. The transient beneficial effects of calcium administration (increase in arterial blood pressure, systemic vascular resistance, cardiac index, stroke volume, and coronary perfusion pressure) might be helpful in cases of moderate contractility reduction or vasoplegia. Nonetheless, effects on clinically relevant endpoints are unknown, and possible systemic side effects, such as transient reduction in internal mammary artery graft flow, attenuation of the effects of ß-sympathomimetics, "stone heart" phenomenon, and pancreatic cellular injury, may limit the use of calcium salts. Further studies are needed to expand the understanding of the effects of calcium administration on patient outcomes.

17.
BMJ Open ; 9(11): e033458, 2019 11 12.
Artigo em Inglês | MEDLINE | ID: mdl-31722954

RESUMO

INTRODUCTION: Vasoplegia is common and associated with a poor prognosis in patients with sepsis and septic shock. Vitamin C therapy in combination with vitamin B1 and glucocorticoid, as well as monotherapy in various doses, has been investigated as a treatment for the vasoplegic state in sepsis, through targeting the inflammatory cascade. However, the combination effect and the relative contribution of each drug have not been well evaluated. Furthermore, the best combination between the three agents is currently unknown. We are planning a systematic review (SR) with network meta-analysis (NMA) to compare the different treatments and identify the combination with the most favourable effect on survival. METHODS AND ANALYSIS: We will include all randomised controlled trials comparing any intervention using intravenous vitamin C, vitamin B1 and/or glucocorticoid with another or with placebo in the treatment of sepsis. We are interested in comparing the following active interventions. Very high-dose vitamin C (≥12 g/day), high-dose vitamin C (≥6 g/day), vitamin C (<6 g/day); low-dose glucocorticoid (<400 mg/day of hydrocortisone (or equivalent)), vitamin B1 and combinations of the drugs above. The primary outcome will be all-cause mortality at the longest follow-up within 1 year but 90 days or longer postrandomisation. All relevant studies will be sought through database searches and trial registries. All reference selection and data extraction will be conducted by two independent reviewers. We will conduct a random-effects NMA to synthesise all evidence for each outcome and obtain a comprehensive ranking of all treatments. We will use the surface under the cumulative ranking curve and the mean ranks to rank the various interventions. To differentiate between the effect of combination therapies and the effect of a component, we will employ a component NMA. ETHICS AND DISSEMINATION: This SR does not require ethical approval. We will publish findings from this systematic review in a peer-reviewed scientific journal and present these at scientific conferences. PROSPERO REGISTRATION NUMBER: CRD42018103860.


Assuntos
Corticosteroides/uso terapêutico , Ácido Ascórbico/uso terapêutico , Choque Séptico/tratamento farmacológico , Tiamina/uso terapêutico , Vasoplegia/tratamento farmacológico , Corticosteroides/administração & dosagem , Ácido Ascórbico/administração & dosagem , Quimioterapia Combinada , Humanos , Metanálise como Assunto , Metanálise em Rede , Projetos de Pesquisa , Choque Séptico/mortalidade , Revisões Sistemáticas como Assunto , Tiamina/administração & dosagem , Resultado do Tratamento
18.
Minerva Cardioangiol ; 67(6): 477-486, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31625706

RESUMO

INTRODUCTION: Several high quality randomized controlled studies were recently published on non-vitamin K oral anticoagulants (NOACs) in patients with or at risk for coronary artery (CAD) or peripheral artery disease (PAD). While a reduction on cardiovascular event is known and an increase in moderate bleeding is expected, the effect of this strategy on survival is currently unknown. Accordingly, we performed a comprehensive systematic review and meta-analysis of randomized controlled trials to investigate the effect of NOAC on survival. EVIDENCE ACQUISITION: We searched Pubmed, EMBASE, Cochrane Central Register, and Clinicaltrials.gov (last updated March 31st 2019). The primary endpoint was all-cause mortality at the longest reported follow-up. Coprimary endpoint was major bleeding according to the International Society on Thrombosis and Hemostasis (ISTH) criterion. EVIDENCE SYNTHESIS: We included ten randomized controlled trials comparing NOACs versus control treatment (placebo, single platelet or dual antiplatelet therapy) enrolling 66665 patients with or at risk for CAD or PAD. NOACs were associated with a decreased risk of mortality (825/41655 [4.4%] versus 405/25010 [5.6%] RR 0.93 [95% CI: 0.87-1.00], P=0.04), and an increased risk for major bleeding (RR 1.62 [95% CI: 1.23-2.13], P=0.0005) when compared to control. Findings were robust to trial sequential, subgroup, and sensitivity analyses. Low doses NOACs were associated with a reduced mortality when compared to standard dose NOACs. CONCLUSIONS: NOACs reduced all-cause mortality in patients with or at risk for CAD or PAD, even though they increased the risk of major bleeding. Future studies regarding the best doses of NOACs are warranted.


Assuntos
Anticoagulantes/administração & dosagem , Doença da Artéria Coronariana/tratamento farmacológico , Doença Arterial Periférica/tratamento farmacológico , Administração Oral , Anticoagulantes/efeitos adversos , Doença da Artéria Coronariana/mortalidade , Relação Dose-Resposta a Droga , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Doença Arterial Periférica/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto
19.
Ann Card Anaesth ; 22(4): 400-406, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31621676

RESUMO

Background: Percutaneous left atrial appendage occlusion (LAAO) is indicated in subjects with atrial fibrillation who cannot receive oral anticoagulants. This procedure requires transesophageal echocardiography guidance and is usually performed under general anesthesia. The Janus Mask is a new device designed to allow upper endoscopic procedures during noninvasive ventilation (NIV). Aims: This study aims to assess the possibility of performing LAAO under sedation and NIV. Setting: Cardiac electrophysiology laboratory. Design: Case-control study. Materials and Methods: Data from 11 subjects undergoing LAAO under sedation and NIV with the Janus Mask were retrospectively collected. Procedure duration, outcomes, and physicians' satisfaction were compared with those of 11 subjects who underwent LAAO under general anesthesia in the same period. Statistical Analysis: Univariate analysis and analysis of variance for between-groups comparison. Results: The 11 subjects treated with sedation experienced a good outcome, with a high degree of satisfaction from the medical team. An increase in arterial partial pressure of carbon dioxide in the Janus group (45 [43-62] mmHg vs. 33 [30-35] mmHg in the general anesthesia group, P < 0.001) led to a transient pH decrease 45 min after the beginning of the procedure (7.30 [7.18-7.36] vs. 7.40 [7.39-7.46], P = 0.014). No differences in arterial partial pressure of oxygen, FiO2, and hemodynamic parameters were observed. The subjects' conditions at discharge from the recovery room were comparable. No difference in procedure duration was registered. Conclusions: LAAO procedure under sedation and NIV through the Janus Mask is safe and feasible. This strategy might represent a valuable alternative to manage such a compromised and fragile population.


Assuntos
Apêndice Atrial/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Sedação Consciente , Máscaras , Ventilação não Invasiva/métodos , Idoso , Idoso de 80 Anos ou mais , Dióxido de Carbono/sangue , Estudos de Casos e Controles , Ecocardiografia Transesofagiana , Feminino , Humanos , Concentração de Íons de Hidrogênio , Masculino , Oxigênio/sangue , Estudos Retrospectivos , Dispositivo para Oclusão Septal , Resultado do Tratamento
20.
Crit Care Med ; 47(12): 1743-1750, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31609774

RESUMO

OBJECTIVES: Previous trials suggest that vasopressin may improve outcomes in patients with vasodilatory shock. The aim of this study was to evaluate whether vasopressin could be superior to norepinephrine to improve outcomes in cancer patients with septic shock. DESIGN: Single-center, randomized, double-blind clinical trial, and meta-analysis of randomized trials. SETTING: ICU of a tertiary care hospital. PATIENTS: Two-hundred fifty patients 18 years old or older with cancer and septic shock. INTERVENTIONS: Patients were assigned to either vasopressin or norepinephrine as first-line vasopressor therapy. An updated meta-analysis was also conducted including randomized trials published until October 2018. MEASUREMENTS AND MAIN RESULTS: The primary outcome was all-cause mortality at 28 days after randomization. Prespecified secondary outcomes included 90-days all-cause mortality rate; number of days alive and free of advanced organ support at day 28; and Sequential Organ Failure Assessment score 24 hours and 96 hours after randomization. We also measure the prevalence of adverse effects in 28 days. A total of 250 patients were randomized. The primary outcome was observed in 71 patients (56.8%) in the vasopressin group and 66 patients (52.8%) in the norepinephrine group (p = 0.52). There were no significant differences in 90-day mortality (90 patients [72.0%] and 94 patients [75.2%], respectively; p = 0.56), number of days alive and free of advanced organ support, adverse events, or Sequential Organ Failure Assessment score. CONCLUSIONS: In cancer patients with septic shock, vasopressin as first-line vasopressor therapy was not superior to norepinephrine in reducing 28-day mortality rate.


Assuntos
Neoplasias/complicações , Norepinefrina/uso terapêutico , Choque Séptico/complicações , Choque Séptico/tratamento farmacológico , Vasopressinas/uso terapêutico , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Choque Séptico/mortalidade , Vasoconstritores/uso terapêutico
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