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1.
Br J Anaesth ; 127(4): 569-576, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34256925

RESUMO

BACKGROUND: Fluid overload is associated with poor outcomes. Clinicians might be reluctant to initiate diuretic therapy for patients with recent vasopressor use. We estimated the effect on 30-day mortality of withholding or delaying diuretics after vasopressor use in patients with probable fluid overload. METHODS: This was a retrospective cohort study of adults admitted to ICUs of an academic medical centre between 2008 and 2012. Using a database of time-stamped patient records, we followed individuals from the time they first required vasopressor support and had >5 L cumulative positive fluid balance (plus additional inclusion/exclusion criteria). We compared mortality under usual care (the mix of care actually delivered in the cohort) and treatment strategies restricting diuretic initiation during and for various durations after vasopressor use. We adjusted for baseline and time-varying confounding via inverse probability weighting. RESULTS: The study included 1501 patients, and the observed 30-day mortality rate was 11%. After adjusting for observed confounders, withholding diuretics for at least 24 h after stopping most recent vasopressor use was estimated to increase 30-day mortality rate by 2.2% (95% confidence interval [CI], 0.9-3.6%) compared with usual care. Data were consistent with moderate harm or slight benefit from withholding diuretic initiation only during concomitant vasopressor use; the estimated mortality rate increased by 0.5% (95% CI, -0.2% to 1.1%). CONCLUSIONS: Withholding diuretic initiation after vasopressor use in patients with high cumulative positive balance (>5 L) was estimated to increase 30-day mortality. These findings are hypothesis generating and should be tested in a clinical trial.

4.
Am J Crit Care ; 30(3): 238-241, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33718963

RESUMO

The sudden surge in cases of COVID-19 has presented unprecedented challenges in the care of critically ill patients with the disease. A disease-focused checklist was developed to supplement and streamline the existing structure of rounds during a time of significant resource constraint. A total of 51 critical care consultants across multiple specialties at a tertiary academic medical center were surveyed regarding their preference for a structured checklist. Among the respondents, 82% were in favor of a disease-focused checklist. Mechanical ventilation parameters, rescue ventilation strategies, sedation regimens, inflammatory markers specific to COVID-19, and family communication were the elements most commonly identified as being important for inclusion in such a checklist.


Assuntos
COVID-19/terapia , Lista de Checagem , Cuidados Críticos , Pneumonia Viral/terapia , Visitas com Preceptor , Boston , Feminino , Humanos , Masculino , Determinação de Necessidades de Cuidados de Saúde , Pandemias , Projetos Piloto , Pneumonia Viral/virologia , SARS-CoV-2 , Inquéritos e Questionários , Centros de Atenção Terciária
5.
Anesth Analg ; 133(3): 610-619, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-33497061

RESUMO

BACKGROUND: Residual neuromuscular blockade is associated with an increased incidence of postoperative respiratory complications. The REsidual neuromuscular block Prediction Score (REPS) identifies patients at high risk for residual neuromuscular blockade after surgery. METHODS: A total of 101,510 adults undergoing noncardiac surgery under general anesthesia from October 2005 to December 2018 at a tertiary care center in Massachusetts were analyzed for the primary outcome of postoperative respiratory complications (invasive mechanical ventilation requirement within 7 postoperative days or immediate postextubation desaturation [oxygen saturation {Spo2} <90%] within 10 minutes). The primary objective was to assess the association between the REPS and respiratory complications. The secondary objective was to compare REPS and train-of-four (TOF) ratio <0.90 on the strength of their association with respiratory complications. RESULTS: A high REPS (≥4) was associated with an increase in odds of respiratory complications (adjusted odds ratio [OR], 1.13 [95% confidence interval {CI}, 1.06-1.21]; P < .001). In 6224 cases with available TOF ratio measurements, a low TOF ratio (<0.9) was associated with respiratory complications (adjusted OR, 1.43 [95% CI, 1.11-1.85]; P = .006), whereas a high REPS was not (adjusted OR, 0.96 [95% CI, 0.74-1.23]; P = .73) (P = .018 for comparison between ORs). CONCLUSIONS: The REPS may be implemented as a screening tool to encourage clinicians to use quantitative neuromuscular monitoring in patients at risk of residual neuromuscular blockade. A positive REPS should be followed by a quantitative assessment of the TOF ratio.


Assuntos
Anestesia Geral , Regras de Decisão Clínica , Recuperação Demorada da Anestesia/etiologia , Pulmão/inervação , Bloqueio Neuromuscular/efeitos adversos , Monitoração Neuromuscular , Transtornos Respiratórios/etiologia , Respiração , Adulto , Idoso , Anestesia Geral/efeitos adversos , Recuperação Demorada da Anestesia/diagnóstico , Recuperação Demorada da Anestesia/fisiopatologia , Recuperação Demorada da Anestesia/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Transtornos Respiratórios/diagnóstico , Transtornos Respiratórios/fisiopatologia , Transtornos Respiratórios/terapia , Respiração Artificial , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
6.
BMJ Open ; 10(10): e040830, 2020 10 23.
Artigo em Inglês | MEDLINE | ID: mdl-33099499

RESUMO

INTRODUCTION: As short-term mortality declines for critically ill patients, a growing number of survivors face long-term physical, cognitive and/or mental health impairments. After hospital discharge, many critical illness survivors require an in-depth plan to address their healthcare needs. Early after hospital discharge, numerous survivors experience inadequate care or a mismatch between their healthcare needs and what is provided. Many patients are readmitted to the hospital, have substantial healthcare resource use and experience long-lasting morbidity. The objective of this study is to investigate the gap in healthcare needs occurring immediately after hospital discharge and its association with hospital readmissions or death for survivors of acute respiratory failure (ARF). METHODS AND ANALYSIS: In this multicentre prospective cohort study, we will enrol 200 survivors of ARF in the intensive care unit (ICU) who are discharged directly home from their acute care hospital stay. Unmet healthcare needs, the primary exposure of interest, will be evaluated as soon as possible within 1 to 4 weeks after hospital discharge, via a standardised telephone assessment. The primary outcome, death or hospital readmission, will be measured at 3 months after discharge. Secondary outcomes (eg, quality of life, cognitive impairment, depression, anxiety and post-traumatic stress disorder) will be measured as part of 3-month and 6-month telephone-based follow-up assessments. Descriptive statistics will be reported for the exposure and outcome variables along with a propensity score analysis, using inverse probability weighting for the primary exposure, to evaluate the relationship between the primary exposure and outcome. ETHICS AND DISSEMINATION: The study received ethics approval from Vanderbilt University Medical Center Institutional Review Board (IRB) and the University of Utah IRB (for the Veterans Affairs site). These results will inform both clinical practice and future interventional trials in the field. We plan to disseminate the results in peer-reviewed journals, and via national and international conferences. TRIAL REGISTRATION DETAILS: ClinicalTrials.gov (NCT03738774). Registered before enrollment of the first patient.


Assuntos
Estado Terminal , Qualidade de Vida , Estudos de Coortes , Atenção à Saúde , Humanos , Unidades de Terapia Intensiva , Estudos Multicêntricos como Assunto , Estudos Prospectivos
7.
Artigo em Inglês | MEDLINE | ID: mdl-32888796

RESUMO

Coronavirus disease 2019, caused by severe acute respiratory syndrome coronavirus 2, is now a global pandemic affecting more than 12 million patients across 188 countries. A significant proportion of these patients require admission to intensive care units for acute hypoxic respiratory failure and are at an increased risk of developing cardiac arrhythmias. The presence of underlying comorbidities, pathophysiologic changes imposed by the disease, and concomitant polypharmacy, increase the likelihood of life-threatening arrhythmias in these patients. Supraventricular, as well as ventricular arrhythmias, are common and are associated with significant morbidity and mortality. It is important to understand the interplay of various causal factors while instituting strategies to mitigate the impact of modifiable risk factors. Furthermore, avoidance and early recognition of drug interactions, along with prompt treatment, might help improve outcomes in this vulnerable patient population.

8.
J Intensive Care ; 8: 70, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32939266

RESUMO

Corona virus 2 (SARS-CoV2/ Severe Acute Respiratory Syndrome Corona Virus 2) infection has emerged as a global health crisis. Incidence of thromboembolic disease is reported to be high in SARS-CoV2 disease and is seen in a multitude of organ systems ranging from cutaneous thrombosis to pulmonary embolism, stroke or coronary thrombosis sometimes with catastrophic outcomes. Evidence points towards a key role of thromboembolism, hypercoagulability and over production of proinflammatory cytokines mimicking a "cytokine storm" which leads to multiorgan failure. This brief narrative review highlights the pathophysiology and risk factors of thromboembolic disease and provides a framework for management of anticoagulation based on the current evidence.

10.
Anesthesiology ; 133(5): 985-996, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32773686

RESUMO

Preparedness measures for the anticipated surge of coronavirus disease 2019 (COVID-19) cases within eastern Massachusetts included the establishment of alternate care sites (field hospitals). Boston Hope hospital was set up within the Boston Convention and Exhibition Center to provide low-acuity care for COVID-19 patients and to support local healthcare systems. However, early recognition of the need to provide higher levels of care, or critical care for the potential deterioration of patients recovering from COVID-19, prompted the development of a hybrid acute care-intensive care unit. We describe our experience of implementing rapid response capabilities of this innovative ad hoc unit. Combining quality improvement tools for hazards detection and testing through in situ simulation successfully identified several operational hurdles. Through rapid continuous analysis and iterative change, we implemented appropriate mitigation strategies and established rapid response and rescue capabilities. This study provides a framework for future planning of high-acuity services within a unique field hospital setting.


Assuntos
Betacoronavirus , Simulação por Computador/normas , Infecções por Coronavirus/terapia , Análise do Modo e do Efeito de Falhas na Assistência à Saúde/normas , Equipe de Respostas Rápidas de Hospitais/normas , Unidades de Terapia Intensiva/normas , Pneumonia Viral/terapia , Boston/epidemiologia , COVID-19 , Infecções por Coronavirus/epidemiologia , Cuidados Críticos/métodos , Cuidados Críticos/normas , Análise do Modo e do Efeito de Falhas na Assistência à Saúde/métodos , Humanos , Pandemias , Pneumonia Viral/epidemiologia , Desenvolvimento de Programas/métodos , Desenvolvimento de Programas/normas , Melhoria de Qualidade/normas , SARS-CoV-2
12.
Anesth Analg ; 131(2): 378-386, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32459668

RESUMO

The morbidity, mortality, and blistering pace of transmission of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented worldwide health crisis. Coronavirus disease 2019 (COVID-19), the disease produced by SARS-CoV-2 infection, is remarkable for persistent, severe respiratory failure requiring mechanical ventilation that places considerable strain on critical care resources. Because recovery from COVID-19-associated respiratory failure can be prolonged, tracheostomy may facilitate patient management and optimize the use of mechanical ventilators. Several important considerations apply to plan tracheostomies for COVID-19-infected patients. After performing a literature review of tracheostomies during the severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks, we synthesized important learning points from these experiences and suggested an approach for perioperative teams involved in these procedures during the COVID-19 pandemic. Multidisciplinary teams should be involved in decisions regarding timing and appropriateness of the procedure. As the theoretical risk of disease transmission is increased during aerosol-generating procedures (AGPs), stringent infectious precautions are warranted. Personal protective equipment (PPE) should be available and worn by all personnel present during tracheostomy. The number of people in the room should be limited to those absolutely necessary. Using the most experienced available operators will minimize the total time that staff is exposed to an infectious aerosolized environment. An approach that secures the airway in the safest and quickest manner will minimize the time any part of the airway is open to the environment. Deep neuromuscular blockade (train-of-four ratio = 0) will facilitate surgical exposure and prevent aerosolization due to patient movement or coughing. For percutaneous tracheostomies, the bronchoscopist should be able to reintubate if needed. Closed-loop communication must occur at all times among members of the team. If possible, after tracheostomy is performed, waiting until the patient is virus-free before changing the cannula or downsizing may reduce the chances of health care worker infection. Tracheostomies in COVID-19 patients present themselves as extremely high risk for all members of the procedural team. To mitigate risk, systematic meticulous planning of each procedural step is warranted along with strict adherence to local/institutional protocols.


Assuntos
Betacoronavirus/patogenicidade , Infecções por Coronavirus/terapia , Controle de Infecções , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Exposição Ocupacional/prevenção & controle , Assistência Perioperatória , Pneumonia Viral/terapia , Traqueostomia , Aerossóis , COVID-19 , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/virologia , Humanos , Exposição Ocupacional/efeitos adversos , Duração da Cirurgia , Pandemias , Equipe de Assistência ao Paciente , Equipamento de Proteção Individual , Pneumonia Viral/diagnóstico , Pneumonia Viral/transmissão , Pneumonia Viral/virologia , Medição de Risco , Fatores de Risco , SARS-CoV-2 , Fatores de Tempo , Traqueostomia/efeitos adversos , Resultado do Tratamento
13.
Anesth Analg ; 130(1): 2-13, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31569164

RESUMO

Atrial fibrillation (AF) is the most common arrhythmia in the perioperative period. Previously considered a benign and self-limited entity, recent data suggest that perioperative AF is associated with considerable morbidity and mortality and may predict long-term AF and stroke risk in some patients. Despite known risk factors, AF remains largely unpredictable, especially after noncardiac surgery. As a consequence, strategies to minimize perioperative risk are mostly supportive and include avoiding potential arrhythmogenic triggers and proactively treating patient- and surgery-related factors that might precipitate AF. In addition to managing AF itself, clinicians must also address the hemodynamic perturbations that result from AF to prevent end-organ dysfunction. This review will discuss current evidence with respect to causes, risk factors, and outcomes of patients with AF, and address current controversies in the perioperative setting.


Assuntos
Fibrilação Atrial/terapia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Fibrilação Atrial/etiologia , Fibrilação Atrial/mortalidade , Fibrilação Atrial/fisiopatologia , Hemodinâmica , Humanos , Período Perioperatório , Prognóstico , Medição de Risco , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/mortalidade
14.
J Intensive Care Med ; 35(11): 1338-1345, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31446829

RESUMO

PURPOSE: International clinical practice guidelines call for initial volume resuscitation of at least 30 mL/kg body weight for patients with sepsis-induced hypotension or shock. Although not considered in the guidelines, preexisting cardiac dysfunction may be an important factor clinicians weigh in deciding the quantity of volume resuscitation for patients with septic shock. METHODS: We conducted a multicenter survey of clinicians who routinely treat patients with sepsis to evaluate their beliefs, behaviors, knowledge, and perceived structural barriers regarding initial volume resuscitation for patients with sepsis and concomitant heart failure with reduced ejection fraction (HFrEF) <40%. Initial volume resuscitation preferences were captured as ordinal values, and additional testing for volume resuscitation preferences was performed using McNemar and Wilcoxon signed rank tests as indicated. Univariable logistic regression models were used to identify significant predictors of ≥30 mL/kg fluid administration. RESULTS: A total of 317 clinicians at 9 US hospitals completed the survey (response rate 47.3%). Most respondents were specialists in either internal medicine or emergency medicine. Substantial heterogeneity was found regarding sepsis resuscitation preferences for patients with concomitant HFrEF. The belief that patients with septic shock and HFrEF should be exempt from current sepsis bundle initiatives was shared by 39.4% of respondents. A minimum fluid challenge of ∼30 mL/kg or more was deemed appropriate in septic shock by only 56.4% of respondents for patients with concomitant HFrEF, compared to 89.1% of respondents for patients without HFrEF (P < .01). Emergency medicine physicians were most likely to feel that <30 mL/kg was most appropriate in patients with septic shock and HFrEF. CONCLUSIONS: Clinical equipoise exists regarding initial volume resuscitation for patients with sepsis-induced hypotension or shock and concomitant HFrEF. Future studies and clinical practice guidelines should explicitly address resuscitation in this subpopulation.

16.
Ann Am Thorac Soc ; 16(8): 947-956, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31162935

RESUMO

Critical illness can be lethal and devastating to survivors. Improvements in acute care have increased the number of intensive care unit (ICU) survivors. These survivors confront a range of new or worsened health states that collectively are commonly denominated post-intensive care syndrome (PICS). These problems include physical, cognitive, psychological, and existential aspects, among others. Burgeoning interest in improving long-term outcomes for ICU survivors has driven an array of potential interventions to improve outcomes associated with PICS. To date, the most promising interventions appear to relate to very early physical rehabilitation. Late interventions within aftercare and recovery clinics have yielded mixed results, although experience in heart failure programs suggests the possibility that very early case management interventions may help improve intermediate-term outcomes, including mortality and hospital readmission. Predictive models have tended to underperform, complicating study design and clinical referral. The complexity of the health states associated with PICS suggests that careful and rigorous evaluation of multidisciplinary, multimodality interventions-tied to the specific conditions of interest-will be required to address these important problems.


Assuntos
Doença Crônica/reabilitação , Estado Terminal/psicologia , Nível de Saúde , Unidades de Terapia Intensiva , Sobreviventes/psicologia , Estado Terminal/reabilitação , Humanos , Saúde Mental , Qualidade de Vida
18.
Intensive Care Med ; 45(2): 201-210, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30666366

RESUMO

PURPOSE: Early mobilization within 72 h of intensive care unit (ICU) admission improves functional status at hospital discharge. We aimed to assess the effectiveness of early, goal-directed mobilization in critically ill patients across a broad spectrum of initial consciousness levels. METHODS: Post hoc analysis of the international, randomized, controlled, outcome-assessor blinded SOMS trial conducted 2011-2015. Randomization was stratified according to the immediate post-injury Glasgow Coma Scale (GCS) (≤ 8 or > 8). Patients received either SOMS-guided mobility treatment with a facilitator or standard care. We used general linear models to test the hypothesis that immediate post-randomization GCS modulates the intervention effects on functional independence at hospital discharge. RESULTS: Two hundred patients were included in the intention-to-treat analysis. The significant effect of early, goal-directed mobilization was consistent across levels of GCS without evidence of effect modification, for the primary outcome functional independence at hospital discharge (p = 0.53 for interaction), as well as average achieved mobility level during ICU stay (mean achieved SOMS level) and functional status at hospital discharge measured with the functional independence measure. In patients with low GCS, delay to first mobilization therapy was longer (0.7 ± 0.2 days vs. 0.2 ± 0.1 days, p = 0.008), but early, goal-directed mobilization compared with standard care significantly increased functional independence at hospital discharge in this subgroup of patients with immediate post-randomization GCS ≤ 8 (OR 3.67; 95% CI 1.02-13.14; p = 0.046). CONCLUSION: This post hoc analysis of a randomized controlled trial suggests that early, goal-directed mobilization in patients with an impaired initial conscious state (GCS ≤ 8) is not harmful but effective.


Assuntos
Transtornos da Consciência/classificação , Deambulação Precoce/métodos , Resultado do Tratamento , Idoso , Áustria/epidemiologia , Lesões Encefálicas/fisiopatologia , Transtornos da Consciência/complicações , Transtornos da Consciência/epidemiologia , Cuidados Críticos/métodos , Feminino , Alemanha/epidemiologia , Escala de Coma de Glasgow/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Planejamento de Assistência ao Paciente
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