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1.
Int J Risk Saf Med ; 2020 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-32538871

RESUMO

BACKGROUND: Nosocomial infection is a significant burden on healthcare facilities. Its multifactorial nature renders it challenging to control. However, quality healthcare necessitates a safer service that poses no harm to the patient. OBJECTIVE: The aim of this project was to reduce the infection rates in the adult ICU to the benchmark levels. METHOD: An internal audit was conducted as a result of the high infection rates in the adult ICU. The audit started with root cause analysis using the fishbone quality tool. FOCUS-PDCA quality tool was used to design the framework. We opted to introduce a change in the staff uniform laundry in addition to a campaign to improve hand hygiene compliance using a multimodality approach. Moreover, we conducted training on aseptic techniques in ventilation, urinary catheter, and central lines insertion. Finally, we changed the ventilator filter to a higher quality brand that meets the standard specifications. Infection rates were monitored before and after the proposed changes. RESULTS: There was a marked reduction in ventilator-associated pneumonia; however, it did not lower the benchmark rates. Catheter line-associated bloodstream infection declined from above to below the benchmark. Catheter-associated urinary tract infection rates were below the benchmark; however, they showed a noticeable reduction. Hand hygiene adherence showed an improvement from 80% to 84%. However, this was below the predetermined target level of 90%. CONCLUSIONS: A multimodal approach is necessary to improve hand hygiene adherence. In-hospital laundry is safer to control nosocomial infections. Quality improvement is a continuous process that guarantees a proper healthcare service as per the quality chasm.

2.
Drug Saf Case Rep ; 6(1): 10, 2019 Oct 11.
Artigo em Inglês | MEDLINE | ID: mdl-31605241

RESUMO

A 72-year-old housewife presented with ischemic cerebrovascular stroke. Intravenous thrombolysis using recombinant tissue plasminogen activator (rt-PA) followed by mechanical thrombectomy under general anesthesia were attempted. The patient developed stridor and tongue swelling, in addition to hypotension and bradycardia, 60 min after completion of the rt-PA infusion. The airway was intubated, and intramuscular adrenaline, together with intravenous hydrocortisone and diphenhydramine, were administered. On the second day, the tongue edema subsided, and the cuff leak test was negative. However, extubation was not attempted due to the development of brain edema. A tracheostomy was later performed, and the patient was weaned off mechanical ventilation.

3.
Int J Crit Illn Inj Sci ; 9(1): 11-15, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30989062

RESUMO

Acute respiratory distress syndrome (ARDS) is a life-threatening disease. Different imaging techniques have been used to diagnose and guide the ventilatory management of patients with ARDS. Chest ultrasound is a reliable tool to identify interstitial syndrome, lung consolidation, lung collapse, and pleural effusion. In addition, echocardiography is essential in the diagnosis of diastolic left ventricle dysfunction and the estimation of elevated ventricle filling pressures, which is necessary before diagnosing ARDS. Therefore, combining chest and heart ultrasound assessment is useful to diagnose ARDS and guide the ventilatory management of the disease. Available data in the literature suggest that protocol-based approaches should be implemented for the purposes of diagnosis and management.

4.
Eur J Trauma Emerg Surg ; 45(2): 245-253, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29234838

RESUMO

BACKGROUND: The aim of the present study is to analyze the clinical and epidemiological characteristics of Traumatic Brain Injury (TBI) following Road Traffic Accidents (RTAs). Moreover, we aim to evaluate the outcome of the TBI victims referred to our medico-surgical Intensive Care Unit (ICU), and to define predictive factors associated with poor prognosis. METHODS: A retrospective study over a 4-year period (2009 to 2012) of 694 patients with head injuries, incurred during road traffic accidents, admitted to the Intensive Care Unit (ICU) of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological, and radiological data were recorded on admission and during the ICU stay. RESULTS: There were 592 males (85.3%), and 102 female patients. The mean age was at 31.8 ± 17.8 years (range 1-91). The mechanism of the accident was detailed in 666 patients (96%). The majority of the victims were motorcycle riders and/or passengers (40.5%), followed by pedestrians (29.1%). Extra-cranial pathology was present in 452 patients (65%). A total of 677 patients (97.6%) required intubation, mechanical ventilation, and sedation. Mean ICU stay was 16 ± 17.4 days. A total of 187 patients (26.9%) died during their hospital stay. The GOS performed within a mean delay of 6 months after hospital discharge was as follows: 198 deaths (28.5%), 13 vegetative state (1.9%), and 349 (50.3%) good recovery and/or moderate disability. A multivariate analysis showed that the factors which correlated with a poor prognosis (mortality and severe disability) were: age > 38 years, Glasgow coma scale score < 8, subdural hematoma, and development of secondary systemic insults (respiratory, circulatory, and metabolic). CONCLUSION: In Tunisia, traumatic brain injury due to RTAs is a frequent cause of ICU admission, especially among young adults, and is associated with high mortality and morbidity rates. The majority of the victims were motorcycle riders and/or passengers and pedestrians. The factors associated with a poor outcome were: age > 38 years, Glasgow Coma Scale score < 8, subdural hematoma, and development of secondary systemic insults (respiratory, circulatory, and metabolic). As a consequence, prevention is highly warranted.


Assuntos
Acidentes de Trânsito , Lesões Encefálicas Traumáticas/fisiopatologia , Traumatismos Craniocerebrais/fisiopatologia , Unidades de Terapia Intensiva , Acidentes de Trânsito/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/mortalidade , Criança , Pré-Escolar , Traumatismos Craniocerebrais/complicações , Traumatismos Craniocerebrais/mortalidade , Feminino , Escala de Coma de Glasgow , Humanos , Lactente , Recém-Nascido , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados da Assistência ao Paciente , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Tunísia/epidemiologia , Adulto Jovem
5.
Ther Adv Endocrinol Metab ; 9(7): 199-208, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29977498

RESUMO

Hyperglycaemia is often observed in severe scorpion-envenomed patients. It is due to a severe autonomic storm with a massive release of catecholamines, increased glucagon levels, cortisol levels, and either decreased insulin levels or insulin resistance. The presence of hyperglycaemia is an indicator of severity in this specific condition. Indeed, hyperglycaemia was associated with the severity of clinical manifestations of severe scorpion envenomation requiring intensive care unit (ICU) admission. In fact, the presence of hyperglycaemia was associated with the presence of respiratory failure, pulmonary oedema, haemodynamic instability, neurological failure, multisystem organ failure, and an increased mortality and ICU length of stay. As a consequence, we think the presence of hyperglycaemia in scorpion-envenomed patients at the emergency department prompts searching for presence of systemic manifestations or cardiorespiratory manifestations. As a consequence, the presence of hyperglycaemia can help screen severe patients at the emergency department. The current management of severe scorpion envenomation involves the admission and close surveillance in the ICU, where vital signs and continuous monitoring enable early initiation of therapy for life-threatening complications. The use of antivenom for scorpion stings remains controversial. All patients with pulmonary oedema should receive prazosin and possibly dobutamine, according the scorpion's species. Mechanical ventilation is usually used in severe cases. Insulin should be reserved for severe cases with confirmed excessive hyperglycaemia (>10 mmol/l).

6.
Pediatr Emerg Care ; 34(3): 198-201, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27261955

RESUMO

PURPOSE: The aim of the study was to identify factors predicting lung contusion in trauma children. METHODS: Retrospective study conducted for a period of 8 years (January 01, 2005-December 31, 2012) in a medical surgical intensive care unit. All trauma patients younger than 15 years were included. Two groups were compared: those with lung contusions (C+ group) and those without lung contusions (C- group). RESULTS: We included 330 patients. The mean (SD) age was 7.6 (4.3) years. Chest injury was diagnosed in 70 patients (21.2%). All our patients needed mechanical ventilation. Lung contusions were diagnosed in 43 patients (13% of all patients and 61.4% of patients with chest trauma). In multivariate analysis, independent factors predicting lung contusion were road traffic accident (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.2-8.6; P = 0.019), increased Pediatric Risk of Mortality (PRISM) score (OR, 1.1; 95% CI, 1.1-1.2; P = 0.017), hepatic contusion (OR, 4.8; 95% CI, 1.3-17.1; P = 0.017), and pelvic ring fracture (OR, 3.5; 95% CI, 1.1-10.5; P = 0.026). Death occurred in 46 patients (13.9%). Intensive care unit mortality was significantly higher in the C+ group (OR, 2.5; 95% CI, 1.2-5.4; P = 0.021). However, mortality was not different between the 2 groups after adjusting for PRISM score (OR, 1.2; 95% CI, 0.5-2.9; P = 0.752) or after adjusting for Injury Severity Score (OR, 0.7; 95% CI, 0.3-2.1; P = 0.565). CONCLUSIONS: Lung contusion is common in critically ill children with chest trauma. The diagnosis should be considered in patients with road traffic accident, increased PRISM score, hepatic contusion, and pelvic ring fracture.


Assuntos
Estado Terminal/mortalidade , Lesão Pulmonar/epidemiologia , Adolescente , Criança , Pré-Escolar , Contusões/epidemiologia , Feminino , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva , Lesão Pulmonar/diagnóstico , Lesão Pulmonar/mortalidade , Masculino , Análise Multivariada , Estudos Retrospectivos , Fatores de Risco , Tunísia
7.
Int J Clin Pharm ; 39(5): 998-1003, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28780739

RESUMO

Background The onset of early and/or late seizures in brain injured patients is associated with worse outcome. So far, phenytoin is the most commonly used antiepileptic drug to prevent seizures in this group of patients. Objective In the current metaanalysis, we aimed to compare the efficacy and safety of phenytoin versus levetiracetam for seizure prophylaxis in brain injured patients. Methods A systematic search was conducted in PubMed and Cochrane Library Database by 2 investigators. Four randomized controlled trials (RCTs) were included (295 patients). Data were extracted and the quality of each RCT was assessed. Results Levetiracetam was found to be more effective than phenytoin in seizure prophylaxis (OR = 0.23; CI 95% [0.09-0.56]; Q test p value = 0.18 and I2 = 38%). A trend toward less serious side effects was also found in patients treated with levetiracetam (OR = 0.27; CI 95% [0.07-1.07]; Q test p value = 0.72 and I2 = 0%). Conclusion Levetiracetam is more effective and safer than phenytoin for seizure prophylaxis in brain injured patients.


Assuntos
Anticonvulsivantes/administração & dosagem , Lesões Encefálicas/tratamento farmacológico , Fenitoína/administração & dosagem , Piracetam/análogos & derivados , Profilaxia Pós-Exposição/métodos , Convulsões/prevenção & controle , Lesões Encefálicas/complicações , Humanos , Levetiracetam , Piracetam/administração & dosagem , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Convulsões/etiologia
8.
J Intensive Care ; 5: 44, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28725436

RESUMO

BACKGROUND: The perfusion of splanchnic organs is deeply altered in patients with septic shock. The aim of the study is to identify the predictive factors of septic shock-induced increase of serum lipase and amylase and to assess and evaluate its prognostic impact. METHODS: We conducted a prospective observational study. All adult patients admitted with septic shock were eligible for our study. Serum lipase and amylase were measured on admission. Patients with and those without increased pancreatic enzymes were compared. Predictive factors of pancreatic insult identified by the univariate analysis were integrated in a stepwise multivariate analysis. Odds ratios (OR) with the 95% confidence interval (CI) were calculated accordingly. Second, the sensitivity and the specificity of amylase and lipase to predict intensive care unit (ICU) mortality were identified through the Receiver Operator Curve. RESULTS: Fifty patients were included. Median [quartiles] age was 68.5 [58-81] years. The APACHE II score was 26 [20-31]. Twenty-three patients (46%) had increased serum amylase and/or serum lipase. Diabetes mellitus (OR = 16; 95% CI [1.7-153.5]; p = 0.016), increased blood urea nitrogen (OR = 1.12; 95% CI [1.02-1.20], p = 0.016), and decreased C-reactive protein (OR = 0.97; 95% CI [0.96-0.99]; p = 0.027) were identified as independent factors predicting increased pancreatic enzymes. Twenty patients (40%) died in the ICU. Neither serum amylase level nor serum lipase level was significantly different between survivors and non-survivors (respectively 49 [27.7-106] versus 85.1 [20.1-165] UI/L; p = 0.7 and 165 [88-316] versus 120 [65.5-592] UI/L; p = 0.952). CONCLUSION: Increase of pancreatic enzymes is common in patients with septic shock. Diabetes and impaired renal function are predictive of increased pancreatic enzymes. Such finding does not carry any negative prognostic value.

11.
Am J Ther ; 24(6): e758-e762, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-26938755

RESUMO

Asymptomatic candiduria is a common finding in hospitalized patients. Its management modalities are still a matter of debate. Urinary catheter should be removed or replaced in all cases. In the current meta-analysis, we aimed to compare 2 different strategies in term of candida clearance from the urinary tract: Systemic fluconazole versus conservative management. A systematic search was performed in Pubmed, Web of science, and Cochrane Library database by 2 investigators. Three studies were included (421 patients). Data were extracted and the quality of each study was assessed. Systemic fluconazole was associated with a significantly higher short-term clearance of the funguria after 14 days of treatment [odds ratio = 0.43; confidence interval (CI) 95% (0.26-0.65)]. No significant heterogeneity was found among the included studies (Q statistic test = 0.38; I = 0). In conclusion, fluconazole significantly hasten short-term candida clearance from the urinary tract.


Assuntos
Antifúngicos/uso terapêutico , Candida/efeitos dos fármacos , Candidíase/terapia , Tratamento Conservador , Fluconazol/uso terapêutico , Infecções Urinárias/terapia , Administração Intravenosa , Administração Oral , Adulto , Antifúngicos/farmacologia , Infecções Assintomáticas , Candida/isolamento & purificação , Candidíase/microbiologia , Fluconazol/farmacologia , Humanos , Resultado do Tratamento , Infecções Urinárias/microbiologia
12.
J Intensive Care Med ; 32(5): 346-352, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26951579

RESUMO

BACKGROUND: We aimed to investigate whether serum cholinesterase (SChE) activity can be helpful for the diagnosis of septic shock and to evaluate its usefulness in comparison with procalcitonin (PCT) and C-reactive protein (CRP). METHODS: A prospective single-blinded study conducted in an intensive care unit of university hospital. Patients were classified as having cardiogenic shock, septic shock, or hemorrhagic shock. We also included a control group without neither hemodynamic instability nor sepsis. For all included patients, SChE, PCT, and CRP were simultaneously sampled. RESULTS: The comparison of sepsis markers between all groups showed that the mean values of PCT and CRP were significantly higher in patients with septic shock. However, SChE activity was significantly lower in this group. The SChE activity was found to be more accurate than PCT and CRP for the diagnosis of septic shock. In fact, an SChE activity ≤ 4000 UI/L predicted the diagnosis of septic shock with a sensitivity of 78%, a specificity of 89%, a predictive negative value of 97%, and a predictive positive value of 65%. However, the prognostic value of SChE activity was poor in multivariate analysis. CONCLUSION: The SChE activity level was significantly decreased in patients with septic shock. However, its prognostic value is poor. Our results suggest that SChE activity is useful for the diagnosis of septic shock. Further studies are warranted to confirm our findings.


Assuntos
Infecções Bacterianas/sangue , Colinesterases/sangue , Choque Cardiogênico/diagnóstico , Choque Hemorrágico/diagnóstico , Choque Séptico/diagnóstico , Adulto , Infecções Bacterianas/complicações , Biomarcadores/sangue , Proteína C-Reativa/análise , Calcitonina/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Sensibilidade e Especificidade , Choque Cardiogênico/microbiologia , Choque Hemorrágico/microbiologia , Choque Séptico/microbiologia , Método Simples-Cego
13.
World J Gastrointest Oncol ; 8(7): 526-31, 2016 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-27559431

RESUMO

Sepsis and septic shock are life threatening condition associated with high mortality rate in critically-ill patients. This high mortality is mainly related to the inadequacy between oxygen delivery and cellular demand leading to the onset of multiorgan dysfunction. Whether this multiorgan failure affect the pancreas is not fully investigated. In fact, pancreatic injury may occur because of ischemia, overwhelming inflammatory response, oxidative stress, cellular apoptosis and/or metabolic derangement. Increased serum amylase and/or lipase levels are common in patients with septic shock. However, imaging test rarely reveal significant pancreatic damage. Whether pancreatic dysfunction does affect the prognosis of patients with septic shock or not is still a matter of debate. In fact, only few studies with limited sample size assessed the clinical relevance of the pancreatic injury in this group of patients. In this review, we aimed to describe the epidemiology and the physiopathology of pancreatic injury in septic shock patients, to clarify whether it requires specific management and to assess its prognostic value. Our main finding is that pancreatic injury does not significantly affect the outcome in septic shock patients. Hence, increased serum pancreatic enzymes without clinical features of acute pancreatitis do not require further imaging investigations and specific therapeutic intervention.

14.
Tunis Med ; 94(2): 140-4, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27532531

RESUMO

UNLABELLED: Background : Stress hyperglycemia among patients having an acute pathology is frequently described in recent studies. AIMS: The objectives of this work were to describe epidemiologic features of elderly patients hospitalized in the emergency department and having a hyperglycemia due to stress. METHODS: A retrospective chart review identified patients older than 65 years with obtained serum glucose levels. Patients with diabetes were excluded. Two levels of serum glucose were considered (>6,9 mmol/l and ≤ 6,9 mmol/l).   RESULTS: We included 165.  There were 94 patients with high level of serum glucose level (56,9%). Multivariate analysis found that only cardio-vascular pathologies were more predictive of having stress hyperglycemia (p=0,014, odds-ratio=2,8, IC=1,2-6,4). There were no correlation between serum glucose levels and mortality. CONCLUSION: Stress hyperglycemia is a fairly common disorder but underestimated in emergency department. Its impact on the prognosis of elderly patients remains to be studied.


Assuntos
Serviço Hospitalar de Emergência , Hiperglicemia/epidemiologia , Hiperglicemia/etiologia , Estresse Fisiológico , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Humanos , Masculino , Estudos Retrospectivos , Tunísia/epidemiologia
15.
Ann Transl Med ; 4(9): 175, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27275488

RESUMO

Acute respiratory distress syndrome (ARDS) is a life threatening complication of H1N1 pneumonia. According to the Berlin conference guidelines, severe ARDS requires management with early invasive mechanical ventilation. Whether noninvasive positive pressure ventilation (NIPPV) should be attempted in patients with H1N1 pneumonia is still a matter of debate. We report the case of one patient with severe ARDS without other organ failure. The patient was managed successfully using NIPPV. Endotracheal intubation was avoided and the patient was discharged from the intensive care unit (ICU) after 10 days with a successful outcome. NIPPV can be useful in patients with isolated severe H1N1 ARDS provided early improvement of the oxygenation parameters is achieved. Patients with multiple organ failure or with persistent severe hypoxemia under noninvasive ventilation should be electively intubated and started on invasive mechanical ventilation.

18.
Can J Anaesth ; 63(7): 871-4, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26883961

RESUMO

BACKGROUND: Amniotic fluid embolism is always a severe complication and generally occurs during labour or immediately after childbirth. CLINICAL FEATURES: We report the case of a patient falling victim to amniotic fluid embolism after the medical termination of her pregnancy at 24 weeks of amenorrhea following the discovery of a teratoma-carrying foetus. The amniotic fluid embolism diagnosis was strongly suspected in the face of the sudden onset of severe arterial hypotension, hypoxic respiratory distress, a coma state and disseminated intravascular coagulopathy immediately after the delivery. Additional tests were conducted to support the diagnosis: cytological testing of a peripheral venous sample and maternal broncho-alveolar lavage fluid, dosing of tryptase and alpha-fetoprotein levels as well as screening for insulin-like growth factor binding protein 1. CONCLUSION: Amniotic fluid embolism is a rare and difficult diagnosis, especially in unconventional settings, yet it can be facilitated by screening for amniotic markers and tryptase.


Assuntos
Aborto Eugênico , Embolia Amniótica/diagnóstico , Embolia Amniótica/terapia , Adulto , Feminino , Humanos , Gravidez
19.
Int J Crit Illn Inj Sci ; 6(4): 172-177, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-28149821

RESUMO

OBJECTIVE: To assess the usefulness of the full outline of unresponsiveness (FOUR) score in predicting extubation failure in critically ill intubated patients admitted with disturbed level of conscious in comparison with the Glasgow coma scale (GCS). PATIENTS AND METHODS: All intubated critically ill patients with a disturbed level of consciousness were assessed using both the FOUR score and the GCS. The FOUR score and the GCS were compared regarding their predictive value for successful extubation at 14 days after intubation as a primary outcome measure. The 28-day mortality and the neurological outcome at 3 months were used as secondary outcome measures. RESULTS: Eighty-six patients were included in the study. Median age was 63 (50-77) years. Sex-ratio (M/F) was 1.46. On admission, median GCS was 7 (3-10) while median FOUR score was 8.5 (2.3-11). A GCS ≤ 7 predicted the extubation failure at 14 days after intubation with a sensitivity of 88.5% and specificity of 68.3%, whereas a FOUR score <10 predicted the same outcome with a sensitivity of 80.8% and a specificity of 81.7%. The areas under the curves was significantly higher with the FOUR score than with GCS (respectively 0.867 confidence interval [CI]: 95% [0790-0.944] and 0.832 CI: 95% [0.741-0.923]; P = 0.014). When calculated before extubation, FOUR score <12 predicted extubation failure with a sensitivity of 92.3% and a specificity of 85%, whereas a GCS <12 predicted the same outcome with a sensitivity of 73% and a specificity of 61.7%. Both scores had similar accuracy for predicting 28-day mortality and neurological outcome at 3 months. CONCLUSION: The FOUR score is superior to the GCS for the prediction of successful extubation of intubated critically ill patients.

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