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1.
Lancet Infect Dis ; 2021 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-34774188

RESUMO

During the current COVID-19 pandemic, health-care workers and uninfected patients in intensive care units (ICUs) are at risk of being infected with SARS-CoV-2 as a result of transmission from infected patients and health-care workers. In the absence of high-quality evidence on the transmission of SARS-CoV-2, clinical practice of infection control and prevention in ICUs varies widely. Using a Delphi process, international experts in intensive care, infectious diseases, and infection control developed consensus statements on infection control for SARS-CoV-2 in an ICU. Consensus was achieved for 31 (94%) of 33 statements, from which 25 clinical practice statements were issued. These statements include guidance on ICU design and engineering, health-care worker safety, visiting policy, personal protective equipment, patients and procedures, disinfection, and sterilisation. Consensus was not reached on optimal return to work criteria for health-care workers who were infected with SARS-CoV-2 or the acceptable disinfection strategy for heat-sensitive instruments used for airway management of patients with SARS-CoV-2 infection. Well designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.

3.
Br J Anaesth ; 2021 Nov 06.
Artigo em Inglês | MEDLINE | ID: mdl-34749991

RESUMO

BACKGROUND: Reports published directly after terrorist mass casualty incidents frequently fail to capture difficulties that may have been encountered. An anonymised consensus-based platform may enable discussion and collaboration on the challenges faced. Our aim was to identify where to focus improvement for future responses. METHODS: We conducted a mixed methods study by email of clinicians' experiences of leading during terrorist mass casualty incidents. An initial survey identified features that worked well, or failed to, during terrorist mass casualty incidents plus ongoing challenges and changes that were implemented as a result. A follow-up, quantitative survey measured agreement between responses within each of the themes using a Likert scale. RESULTS: Thirty-three participants responded from 22 hospitals that had received casualties from a terrorist incident, representing 17 cities in low-middle, middle and high income countries. The first survey identified themes of sufficient (sometimes abundant) human resource, although coordination of staff was a challenge. Difficulties highlighted were communication, security, and management of blast injuries. The most frequently implemented changes were education on specific injuries, revising future plans and preparatory exercises. Persisting challenges were lack of time allocated to training and psychological well-being. The follow-up survey recorded highest agreement amongst correspondents on the need for re-triage at hospital (90% agreement), coordination roles (85% agreement), flexibility (100% agreement), and large-scale exercises (95% agreement). CONCLUSION: This survey collates international experience gained from clinicians managing terrorist mass casualty incidents. The organisation of human response, rather than consumption of physical supplies, emerged as the main finding. NHSH Clinical Effectiveness Unit project registration number: 2020/21-036.

4.
Curr Opin Crit Care ; 27(6): 726-732, 2021 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-34561356

RESUMO

PURPOSE OF REVIEW: The aim of this study was to outline the management of the patient with the open abdomen. RECENT FINDINGS: An open abdomen approach is used after damage control laparotomy, to decrease risk for postsurgery intra-abdominal hypertension, if reoperation is likely and after primary abdominal decompression.Temporary abdominal wall closure without negative pressure is associated with higher rates of intra-abdominal infection and evisceration. Negative pressure systems improve fascial closure rates but increase fistula formation. Definitive abdominal wall closure should be considered once oedema has subsided and the patient has stabilized. Delayed abdominal closure after trauma (>24-48 h) is associated with less achievement of fascial closure and more complications. Protective lung ventilation should be employed early, particularly if respiratory compromise is evident. Conservative fluid management and less sedation may decrease delirium and increase definitive abdominal closure rates. Extubation may be performed before definitive abdominal closure in selected patients. Antibiotic therapy should be brief, targeted and guideline concordant. Survival depends on the underlying disease, the closure method and the course of hospitalization. SUMMARY: Changes in the treatment of patients with the open abdomen include negative temporary closure, conservative fluid management, early protective lung ventilation, decreased sedation and extubation before abdominal closure in selected patients.

5.
Adv Ther ; 38(10): 5165-5177, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34424502

RESUMO

INTRODUCTION: Concomitant experimental/compassionate drug administration has been all-pervasive in the treatment of COVID-19 patients. The objective of this study was to study the relationship between patient severity, the number of experimental/compassionate medications received (main outcome measure), and patient outcomes [survival to hospital discharge and length of hospital stay (LOS)]. METHODS: Retrospective analysis of data collected in real time during the first pandemic wave in a tertiary care hospital. Data included patient demographics, comorbidities, admission vital signs, laboratory values, most extreme respiratory intervention during hospitalization, and data regarding treatment with compassionate/experimental drugs during their stay. RESULTS: Overall, 292 PCR-confirmed patients with symptoms of COVID-19 were studied (March/April, 2020). Increasing respiratory support correlated with both LOS and mortality. Patients were more likely to receive more than 1 experimental/compassionate drugs as respiratory support escalated, ranging from 3% (n = 4/136) among patients on room air to 77.3% (n = 17/22) of mechanically ventilated/ECMO patients (P < 0.001, linear by linear association). The mean number of experimental/compassionate drugs received also increased with escalating respiratory support (P < 0.001, one-way ANOVA). After adjustment for severity of patient condition, administration of more experimental/compassionate drugs was unrelated to survival (P = 0.24), but was related to increased LOS (P < 0.001). CONCLUSION: Patients that were hospitalized in worse condition were more likely to receive more experimental/compassionate drugs. Treatment was unrelated to survival but may have been related to LOS. This finding raises questions regarding the results of studies on medication effects that adjusted for multiple drug administration.


Assuntos
COVID-19 , Preparações Farmacêuticas , Humanos , Pandemias , Estudos Retrospectivos , SARS-CoV-2
6.
Lancet ; 398(10307): 1257-1268, 2021 10 02.
Artigo em Inglês | MEDLINE | ID: mdl-34454688

RESUMO

Cardiopulmonary resuscitation prioritises treatment for cardiac arrests from a primary cardiac cause, which make up the majority of treated cardiac arrests. Early chest compressions and, when indicated, a defibrillation shock from a bystander give the best chance of survival with a good neurological status. Cardiac arrest can also be caused by special circumstances, such as asphyxia, trauma, pulmonary embolism, accidental hypothermia, anaphylaxis, or COVID-19, and during pregnancy or perioperatively. Cardiac arrests in these circumstances represent an increasing proportion of all treated cardiac arrests, often have a preventable cause, and require additional interventions to correct a reversible cause during resuscitation. The evidence for treating these conditions is mostly of low or very low certainty and further studies are needed. Irrespective of the cause, treatments for cardiac arrest are time sensitive and most effective when given early-every minute counts.


Assuntos
Anafilaxia/terapia , Asfixia/terapia , Reanimação Cardiopulmonar/métodos , Parada Cardíaca/terapia , Hipotermia/terapia , Complicações Cardiovasculares na Gravidez/terapia , Embolia Pulmonar/terapia , Ferimentos e Lesões/terapia , Anafilaxia/complicações , Asfixia/complicações , COVID-19/complicações , COVID-19/terapia , Cardioversão Elétrica , Feminino , Parada Cardíaca/etiologia , Humanos , Hipotermia/complicações , Complicações Intraoperatórias/terapia , Parada Cardíaca Extra-Hospitalar/etiologia , Parada Cardíaca Extra-Hospitalar/terapia , Equipamento de Proteção Individual , Complicações Pós-Operatórias/terapia , Guias de Prática Clínica como Assunto , Gravidez , Embolia Pulmonar/complicações , Retorno da Circulação Espontânea , SARS-CoV-2 , Ferimentos e Lesões/complicações
7.
Eur J Anaesthesiol ; 2021 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-34352806

RESUMO

BACKGROUND: Whether night-time extubation is associated with clinical outcomes is unclear. OBJECTIVE: The aim of this systematic review and meta-analysis was to evaluate the association between night-time extubation and the reintubation rate, mortality, ICU and in-hospital LOS in adult patients, compared with daytime extubation. DESIGN: A systematic review and meta-analysis. DATA SOURCES: PubMed, EMBASE, CINAHL and Web of Science from inception to 2 January 2021 (PROSPERO registration - CRD42020222812). ELIGIBILITY CRITERIA: Randomised, quasi and cluster randomised, and nonrandomised studies describing associations between adult patients' outcomes and time of extubation (daytime/night-time) in intensive care or postanaesthesia care units. RESULTS: Seven retrospective studies were included in the systematic review and meta-analysis, for a total of 293 663 patients. All the studies were performed in United States (USA). All the studies were judged at moderate risk of bias for reintubation and mortality. The analyses were conducted with random effects models. The analyses from adjusted estimates demonstrated no association between night-time extubation and increased risk of either reintubation (OR 1.00; 95% CI 0.88 to 1.13; P = 1.00; I2 = 66%; low-certainty evidence) or all-cause mortality at the longest available follow-up (OR 1.11; 95% CI 0.87 to 1.42; P = 0.39; I2 = 79%; low-certainty evidence), in comparison with daytime extubation. Analyses from unadjusted data for reintubation, mortality and ICU or in-hospital length of stay showed no significant association with night-time extubation. Analyses based on type of admission, number of centres or duration of mechanical ventilation showed no significant subgroup effects. CONCLUSION: Night-time extubation of adult patients was not associated with higher adjusted risks for reintubation or death, in comparison with daytime extubation, but the certainty of the evidence was low.

9.
Crit Care ; 25(1): 250, 2021 07 16.
Artigo em Inglês | MEDLINE | ID: mdl-34271958

RESUMO

A personalized mechanical ventilation approach for patients with adult respiratory distress syndrome (ARDS) based on lung physiology and morphology, ARDS etiology, lung imaging, and biological phenotypes may improve ventilation practice and outcome. However, additional research is warranted before personalized mechanical ventilation strategies can be applied at the bedside. Ventilatory parameters should be titrated based on close monitoring of targeted physiologic variables and individualized goals. Although low tidal volume (VT) is a standard of care, further individualization of VT may necessitate the evaluation of lung volume reserve (e.g., inspiratory capacity). Low driving pressures provide a target for clinicians to adjust VT and possibly to optimize positive end-expiratory pressure (PEEP), while maintaining plateau pressures below safety thresholds. Esophageal pressure monitoring allows estimation of transpulmonary pressure, but its use requires technical skill and correct physiologic interpretation for clinical application at the bedside. Mechanical power considers ventilatory parameters as a whole in the optimization of ventilation setting, but further studies are necessary to assess its clinical relevance. The identification of recruitability in patients with ARDS is essential to titrate and individualize PEEP. To define gas-exchange targets for individual patients, clinicians should consider issues related to oxygen transport and dead space. In this review, we discuss the rationale for personalized approaches to mechanical ventilation for patients with ARDS, the role of lung imaging, phenotype identification, physiologically based individualized approaches to ventilation, and a future research agenda.


Assuntos
Medicina de Precisão/métodos , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/terapia , Humanos , Medicina de Precisão/tendências , Respiração Artificial/tendências , Síndrome do Desconforto Respiratório/diagnóstico por imagem , Síndrome do Desconforto Respiratório/fisiopatologia , Mecânica Respiratória/fisiologia
10.
J Crit Care ; 65: 65-71, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34090150

RESUMO

PURPOSE: To review the characteristics, findings and quality of systematic reviews (SRs) on the effect of any vasopressor/inotrope on outcomes in adult patients with sepsis compared with either no treatment, another vasopressor or inotrope or fluids. MATERIALS AND METHODS: We systematically searched Cochrane Central Register of Controlled Trials, PubMed and Embase (January 1993-March 2021). Descriptive statistics were used. RESULTS: Among the 28 SRs identified, mortality was the primary outcome in most (26/28) and mortality was usually (23/28) studied using randomised controlled trials (RCTs). Fifteen SRs focused exclusively on patients with sepsis or septic shock. Sepsis and septic shock were always grouped for the analysis. Publication bias was consistently low when studied. The most consistent findings were a survival advantage with norepinephrine versus dopamine, which disappeared in analyses restricted to 28-day mortality, and more arrhythmias with dopamine. However, these analyses were dominated by a single study. Only 2 SRs were judged to be of moderate-high quality. Lack of blinding and attrition bias may have affected the outcomes. CONCLUSIONS: The quality of SRs on the effect of vasopressors/inotropes on the outcomes of adult patients with sepsis can be improved, but high-quality, multicenter, RCTs should be preferred to additional SRs on this topic.


Assuntos
Sepse , Choque Séptico , Adulto , Humanos , Estudos Multicêntricos como Assunto , Norepinefrina , Sepse/tratamento farmacológico , Choque Séptico/tratamento farmacológico , Revisões Sistemáticas como Assunto , Vasoconstritores/uso terapêutico
11.
Resuscitation ; 164: 122-129, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33964332

RESUMO

AIM: To estimate the mortality rate, the rate of return of spontaneous circulation (ROSC) and survival with favorable neurological outcome in patients with COVID-19 after in-hospital cardiac arrest (IHCA) and attempted cardiopulmonary resuscitation (CPR). METHODS: PubMed, EMBASE, Web of Science, bioRxiv and medRxiv were surveyed up to 8th February 2021 for studies reporting data on mortality of patients with COVID-19 after IHCA. The primary outcome sought was mortality (in-hospital or at 30 days) after IHCA with attempted CPR. Additional outcomes were the overall rate of IHCA, the rate of non-shockable presenting rhythms, the rate of ROSC and the rate of survival with favorable neurological status. RESULTS: Ten articles were included in the systematic review and meta-analysis, for a total of 1179 COVID-19 patients after IHCA with attempted CPR. The estimated overall mortality rate (in-hospital or at 30 days) was 89.9% (95% Predicted Interval [P.I.] 83.1%-94.2%; 1060/1179 patients; I2 = 82%). The estimated rate of non-shockable presenting rhythms was 89% (95% P.I. 82.8%-93.1%; 1022/1205 patients; I2 = 85%), and the estimated rate of ROSC was 32.9% (95% P.I. 26%-40.6%; 365/1205 patients; I2 = 82%). The estimated overall rate of survival with favorable neurological status at 30 days was 6.3% (95% P.I. 4%-9.7%; 50/851 patients; I2 = 48%). Sensitivity analysis showed that COVID-19 patients had higher risk of death after IHCA than non COVID-19 patients (OR 2.34; 95% C.I. 1.37-3.99; number of studies = 3; 1215 patients). CONCLUSIONS: Although one of three COVID-19 patients undergoing IHCA may achieve ROSC, almost 90% may not survive at 30 days or to hospital discharge.


Assuntos
COVID-19 , Reanimação Cardiopulmonar , Parada Cardíaca , Parada Cardíaca/terapia , Hospitais , Humanos , SARS-CoV-2
12.
Resuscitation ; 164: 40-45, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34004263

RESUMO

INTRODUCTION: Maternal mortality has risen in the United States during the 21st century. Factors influencing outcome of maternal cardiac arrest (MCA) remain largely unexplored. OBJECTIVE: We sought to further elucidate the factors affecting maternal death from in-hospital (IH) MCA. METHODS: Our query of the American Heart Association's GWTG®-Resuscitation voluntary registry from 2000-2017 revealed 561 index cases of IH MCA with complete outcome data. Logistic regression was performed using hospital death as the primary outcome and included variables with a p value = 0.1 or less based upon univariate analysis. Age, race, year of arrest, pre-existing conditions, first documented pulseless rhythm and location of arrest were used in the model. Sensitivity analyses and assessment of variable interaction were also performed to test model stability. Institutional review deemed this research exempt from ethical approval. RESULTS: Among 561 cases of MCA, 57.2% (321/561) did not survive to hospital discharge. IH death was not associated with maternal age, race and year of event. In the final model, IH death was significantly associated with pre-arrest hypotension/hypoperfusion (OR = 1.80 (95% CI, 1.16-2.79); p = 0.009). The occurrence of MCA outside of the delivery suite (referent group) or operating room was associated with a significantly higher risk of death: ICU/Post-Anesthesia Care Unit (PACU) (OR = 3.32 (95% CI, 2.00-5.52); p < 0.001) and ER/other (OR = 1.89 (95% CI, 1.15-3.11); p = 0.012). While MCA cases with a shockable vs. non-shockable first documented pulseless rhythm had similar outcomes, those with an indeterminate rhythm were less likely to die, (OR = 0.41(95% CI, 0.20-0.84); p = 0.014). In a sensitivity analysis, removal of the indeterminate group did not alter outcomes regarding first documented pulseless rhythm or arrest location. Area under the curve for the final model was 0.715 (95% CI 0.673-0.757). CONCLUSIONS: Our study identified several novel factors associated with IH death of our MCA cohort. More research is required to further understand the pathophysiologic dynamics affecting outcomes of IH MCA in this unique population.


Assuntos
Reanimação Cardiopulmonar , Parada Cardíaca , Parada Cardíaca Extra-Hospitalar , Cardioversão Elétrica , Parada Cardíaca/terapia , Hospitais , Humanos , Sistema de Registros , Estados Unidos/epidemiologia
14.
J Biophotonics ; 14(7): e202100027, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33890427

RESUMO

The helical nature of human sweat ducts, combined with the morphological and dielectric properties of skin, suggests electromagnetic activity in the sub-THz frequency band. A detailed electromagnetic simulation model of the skin, with embedded sweat ducts, was created. The model includes realistic dielectric properties based on the measured water content of each layer of skin, derived from Raman Spectroscopy. The model was verified by comparing it to measurements of the reflection coefficient of the palms of 13 volunteers in the frequency band 350-410 GHz. They were subjected to a measurement protocol intended to induce mental stress, thereby also activating the sweat glands. The Galvanic Skin Response was concurrently measured. Using the simulation model the optimal ac-conductivity for each measurement was found. The range of variation for all subjects was found to be from 100 S/m to a maximum value of 6000 S/m with averages of 1000 S/m. These are one order of magnitude increase from the accepted values for water at these frequencies (~100 s/m at 100 GHz). Considering the known biochemical mechanism for inducing perspiration, we conclude that these ac-conductivity levels are probably valid, even though the real time measurements of sweat ac-conductivity levels inside the duct are inaccessible.


Assuntos
Pele , Suor , Simulação por Computador , Fenômenos Eletromagnéticos , Humanos , Glândulas Sudoríparas
15.
Adv Ther ; 38(4): 1746-1756, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33675524

RESUMO

BACKGROUND: Non-invasive respiratory support including high-flow nasal oxygen (HFNO), continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) is routinely used in the perioperative period. OBJECTIVES: The aim of this narrative review was to discuss some of the existing literature on perioperative non-invasive respiratory support outlining its potential roles in each of the three perioperative periods (pre-, intra- and postoperatively) and to propose the way forward. RESULTS: During induction of anesthesia, non-invasive ventilation (NIV) was associated with improved ventilatory variables and reduced risk of postoperative respiratory complications. HFNO did not seem to confer an advantage in terms of peri-intubation hypoxemia. Intraoperative data on NIV are scarce. Upper airway obstruction and worsening hypoventilation are two risks associated with its use. Compared with conventional oxygenation, HFNO is associated with a reduced risk of hypoxemia. Postoperative NIV has been associated with improved arterial blood gases and a reduced reintubation rate, but no difference was reported for mortality, hospital length of stay, rate of anastomotic leakage, pneumonia-related complications and sepsis or infections. Head-to-head comparison of HFNO versus BiPAP showed no advantage to either mode of support. CONCLUSION: In the preoperative setting, NIV seems to be associated with improved clinical outcomes in specific patient subgroups (obesity, pregnancy). In the postoperative setting, both NIV and HFNO were associated with lower reintubation rates. The literature has provided little evidence regarding the use of non-invasive ventilatory support in other patient subgroups or intraoperatively. There is also little literature regarding the appropriateness of combining different modes of support. In the next years, the combination of several modes of respiratory support should be assessed in targeted populations.


Assuntos
Ventilação não Invasiva , Pressão Positiva Contínua nas Vias Aéreas , Humanos , Intubação Intratraqueal , Pulmão
16.
Crit Care ; 25(1): 115, 2021 03 20.
Artigo em Inglês | MEDLINE | ID: mdl-33743812

RESUMO

BACKGROUND: The mortality of critically ill patients with COVID-19 is high, particularly among those receiving mechanical ventilation (MV). Despite the high number of patients treated worldwide, data on respiratory mechanics are currently scarce and the optimal setting of MV remains to be defined. This scoping review aims to provide an overview of available data about respiratory mechanics, gas exchange and MV settings in patients admitted to intensive care units (ICUs) for COVID-19-associated acute respiratory failure, and to identify knowledge gaps. MAIN TEXT: PubMed, EMBASE, and MEDLINE databases were searched from inception to October 30, 2020 for studies providing at least one ventilatory parameter collected within 24 h from the ICU admission. The quality of the studies was independently assessed using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies. A total of 26 studies were included for a total of 14,075 patients. At ICU admission, positive end expiratory pressure (PEEP) values ranged from 9 to 16.5 cm of water (cmH2O), suggesting that high levels of PEEP were commonly used for setting MV for these patients. Patients with COVID-19 are severely hypoxemic at ICU admission and show a median ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) ranging from 102 to 198 mmHg. Static respiratory system compliance (Crs) values at ICU admission were highly heterogenous, ranging between 24 and 49 ml/cmH2O. Prone positioning and neuromuscular blocking agents were widely used, ranging from 17 to 81 and 22 to 88%, respectively; both rates were higher than previously reported in patients with "classical" acute respiratory distress syndrome (ARDS). CONCLUSIONS: Available data show that, in mechanically ventilated patients with COVID-19, respiratory mechanics and MV settings within 24 h from ICU admission are heterogeneous but similar to those reported for "classical" ARDS. However, to date, complete data regarding mechanical properties of respiratory system, optimal setting of MV and the role of rescue treatments for refractory hypoxemia are still lacking in the medical literature.


Assuntos
COVID-19/fisiopatologia , COVID-19/terapia , Respiração Artificial , COVID-19/complicações , Estado Terminal , Humanos , Unidades de Terapia Intensiva , Síndrome do Desconforto Respiratório/fisiopatologia , Síndrome do Desconforto Respiratório/terapia , Síndrome do Desconforto Respiratório/virologia , Mecânica Respiratória
17.
Crit Care ; 25(1): 106, 2021 03 16.
Artigo em Inglês | MEDLINE | ID: mdl-33726819

RESUMO

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice. METHODS: Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p < 0·05 was considered as unstable). RESULTS: Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16-24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment. CONCLUSION: Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited. TRIAL REGISTRATION: The study was registered with Clinical trials.gov Identifier: NCT04534569.


Assuntos
COVID-19/complicações , Consenso , Técnica Delfos , Insuficiência Respiratória/terapia , Insuficiência Respiratória/virologia , Humanos
18.
J Crit Care ; 63: 8-14, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33549910

RESUMO

PURPOSE: To describe shock severity, physiological stabilization and organ failure in healthy women admitted to the intensive care unit (ICU) after major peripartum hemorrhage (PPH). MATERIALS AND METHODS: Retrospective, descriptive, single center study. RESULTS: Twenty-nine women median age 33 years (interquartile range [IQR] 30-36) and gravidity 5 pregnancies (IQR 3-9) were studied. One woman died. The median maternal admission hematocrit was 28.8 (IQR 25.7-32.4). Median transfusion rates were nine units of packed red blood cells (IQR 7-12.25), eight fresh frozen plasma (IQR 6-12), 17 platelets (IQR 10-22) and 15 cryoprecipitate (IQR 9.75-20). Blood pressure dropped significantly in the six hours following ICU admission. Nonetheless, lactate decreased from 3.23 mmol/L to 1.54 mmol/L within 24 h of ICU admission, renal and pulmonary function were unaffected and coagulopathy was never observed. Two-thirds of the women underwent hysterectomy. One-third underwent repeated surgery. The median length of ICU stay was <48 h and that of mechanical ventilation was <24 h. Increased transfusion rates correlated with lengthier ICU admission (p ≤ 0.01 regardless of blood product). CONCLUSIONS: Ongoing hemorrhage in women with severe PPH manifests subtly and often requires active intervention. Hemorrhage control is required to achieve physiological stabilization and minimize organ damage.


Assuntos
Unidades de Terapia Intensiva , Período Periparto , Adulto , Feminino , Hemorragia , Hospitalização , Humanos , Gravidez , Estudos Retrospectivos
20.
Crit Care ; 25(1): 34, 2021 01 22.
Artigo em Inglês | MEDLINE | ID: mdl-33482873

RESUMO

BACKGROUND: Rapid response teams are intended to improve early diagnosis and intervention in ward patients who develop acute respiratory or circulatory failure. A management protocol including the use of a handheld ultrasound device for immediate point-of-care ultrasound (POCUS) examination at the bedside may improve team performance. The main objective of the study was to assess the impact of implementing such a POCUS-guided management on the proportion of adequate immediate diagnoses in two groups. Secondary endpoints included time to treatment and patient outcomes. METHODS: A prospective, observational, controlled study was conducted in a single university hospital. Two teams alternated every other day for managing in-hospital ward patients developing acute respiratory and/or circulatory failures. Only one of the team used an ultrasound device (POCUS group). RESULTS: We included 165 patients (POCUS group 83, control group 82). Proportion of adequate immediate diagnoses was 94% in the POCUS group and 80% in the control group (p = 0.009). Time to first treatment/intervention was shorter in the POCUS group (15 [10-25] min vs. 34 [15-40] min, p < 0.001). In-hospital mortality rates were 17% in the POCUS group and 35% in the control group (p = 0.007), but this difference was not confirmed in the propensity score sample (29% vs. 34%, p = 0.53). CONCLUSION: Our study suggests that protocolized use of a handheld POCUS device at the bedside in the ward may improve the proportion of adequate diagnosis, the time to initial treatment and perhaps also survival of ward patients developing acute respiratory or circulatory failure. Clinical Trial Registration NCT02967809. Registered 18 November 2016, https://clinicaltrials.gov/ct2/show/NCT02967809 .


Assuntos
Mortalidade/tendências , Ultrassonografia/normas , Idoso , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Quartos de Pacientes/organização & administração , Quartos de Pacientes/estatística & dados numéricos , Sistemas Automatizados de Assistência Junto ao Leito/normas , Sistemas Automatizados de Assistência Junto ao Leito/estatística & dados numéricos , Estudos Prospectivos , Estatísticas não Paramétricas , Ultrassonografia/métodos , Ultrassonografia/estatística & dados numéricos
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