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2.
Artigo em Inglês | MEDLINE | ID: mdl-31445833

RESUMO

OBJECTIVES: Postoperative hemorrhage in cardiac surgery is a significant cause of morbidity and mortality. Standard laboratory tests fail as predictors for bleeding in the surgical setting. The use of viscoelastic (VE) hemostatic assays thromboelastography (TEG) and rotational thromboelastometry (ROTEM) could be an advantage in patients undergoing cardiac surgery. The objective of this meta-analysis was to analyze the effects (benefits and harms) of VE-guided transfusion practice in cardiac surgery patients. DESIGN: A meta-analysis of randomized trials. SETTING: For this study, PubMed, EMBASE, Scopus, and the Cochrane Collaboration database were searched, and only randomized controlled trials were included. A systematic review and meta-analysis were performed in accordance with the standards set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, using a random-effects model. PARTICIPANTS: The study comprised adult cardiac surgery patients. INTERVENTIONS: VE-hemostatic assays transfusion algorithm compared with transfusion algorithms based on clinicians' discretion. MEASUREMENTS AND MAIN RESULTS: Seven comparative randomized controlled trials were considered, including a total of 1,035 patients (522 patients in whom a TEG- or ROTEM-based transfusion algorithm was used). In patients treated according to VE-guided algorithms, red blood cell (odds ratio 0.61; 95% confidence interval [CI]: 0.37-0.99; p: 0.04; I2: 66%) and fresh frozen plasma transfusions (risk difference 0.22; 95% CI: 0.11-0.33; p < 0.0001; I2: 79%) use was reduced; platelets transfusion was not reduced (odds ratio 0.61; 95% CI: 0.32-1.15; p: 0.12; I2 74%). CONCLUSIONS: This study demonstrated that the use of VE assays in cardiac surgical patients is effective in reducing allogenic blood products exposure, postoperative bleeding at 12 and 24 hours after surgery, and the need for redo surgery unrelated to surgical bleeding.

3.
Curr Opin Crit Care ; 25(3): 259-265, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30946038

RESUMO

PURPOSE OF REVIEW: To provide an integrated clinical approach to the critically ill patients in shock. RECENT FINDINGS: The complexity behind shock mechanism has improved in the last decades; as consequence, conventional generalized practices have been questioned, in favour of different approaches, titrated to patient's individual response. Bedside clinical examination has been demonstrated to be a reliable instrument to recognize the mismatch between cardiac function and peripheral oxygen demand. Mottling skin and capillary refill time have been recently proposed using a semi-quantitative approach as reliable tool to guide shock therapy; lactate, ΔCO2 and ScVO2 are also useful to track the effect of the therapies overtime. Critical care echocardiography is useful to assess the source of the shock, to choice the correct the therapy and to customize the therapy. Finally, a more sophisticated and invasive calibrated monitoring should be promptly adopted in case of refractory or mixed shock state to titrate the therapy on predefined goals, avoiding the inappropriate use of fluids and vasoactive drugs. SUMMARY: Bedside haemodynamic assessment in critically ill patients should be considered an integrated approach supporting the decision-making process and should be based on clinical examination and critical care echocardiography.

4.
Pain Pract ; 19(6): 586-593, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30791208

RESUMO

BACKGROUND: Pain management after surgery is crucial to decrease perioperative morbidity and mortality. Acute pain services (APS) are multidisciplinary teams that represent a modern strategy to address pain inside hospitals. The APS defines and applies pain treatment protocols specific for each surgery. To evaluate the performance of the APS at our institute, we performed a large retrospective cohort study focusing on complications of epidural analgesia and IV opiates. METHODS: Data from the 10 years of activity of the APS were collected. Pain was assessed using the VAS at rest (VASr) and during movement (VASm) at each daily visit; the presence of side effects and complications was also assessed. RESULTS: A total of 17,913 adult patients were followed by APS during the study period. Epidural analgesia was used in 7,776 cases (43%), while 9,239 (52%) patients used IV patient-controlled analgesia (PCA). A combination of the 2 was used in 87 patients (0.5%). A total of 456 perineural catheters (2.6%) were placed, while 442 patients(2.5%) used other analgesic techniques. We recorded 163 dural punctures during catheter placement, with no epidural hematoma, epidural abscess, or meningitis, and no permanent modification in sensitive or motor functions. CONCLUSIONS: In our large case series, APS was confirmed safe and effective in treating postoperative pain, using both epidural analgesia and IV PCA with morphine.

5.
Artigo em Inglês | MEDLINE | ID: mdl-30502311

RESUMO

OBJECTIVE: To assess the beneficial effects of noninvasive ventilation in treating postoperative pulmonary complications in patients undergoing thoracoabdominal aortic aneurysm (TAAA) open repair surgery. DESIGN: Randomized controlled trial. SETTING: University tertiary-care hospital. PARTICIPANTS: Forty patients who underwent elective TAAA open repair. INTERVENTIONS: Patients were randomized to the "noninvasive ventilation" group, receiving 2-hour cycles of noninvasive ventilation every 8 hours for at least 3 days in addition to the best available postoperative treatment currently in use at the authors' institution versus the "standard" group, not receiving noninvasive ventilation treatment MEASUREMENTS AND MAIN RESULTS: The primary outcome of clinical worsening, described as a composite outcome of need for therapeutic noninvasive ventilation, need for mechanical ventilation owing to respiratory causes, need for intensive care unit admission owing to respiratory causes, and in-hospital mortality, occurred in 2 (11%) patients in the noninvasive ventilation group versus 12 (57%) in the standard group (p = 0.002; relative risk 0.18; 95% confidence interval 0.047-0.72). CONCLUSION: Noninvasive ventilation is a promising, affordable, and easy-to-use tool to prevent postoperative respiratory complications after TAAA open surgical repair.

6.
Abdom Radiol (NY) ; 43(12): 3241-3249, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29948053

RESUMO

OBJECTIVES: The objective of our study was to systematically review the evidence about synchronous colorectal cancer diagnosed with or without computed tomography colonography (CTC). MATERIALS AND METHODS: Two systematic searches were performed (PubMed and EMBASE) for studies reporting the prevalence of synchronous colorectal cancer (CRC): one considering patients who underwent CTC and the another one considering patients who did not undergo CTC. A three-level analysis was performed to determine the prevalence of patients with synchronous CRC in both groups of studies. Heterogeneity was explored for multiple variables. Pooled prevalence and 95% confidence interval (CI) were calculated. A quality assessment (STROBE) was done for the studies. RESULTS: For CTC studies, among 2645 articles initially found, 21 including 1673 patients, published from 1997 to 2018, met the inclusion criteria. For non-CTC studies, among 6192 articles initially found, 27 including 111,873 patients published from 1974 to 2015 met the inclusion criteria. The pooled synchronous CRC prevalence was 5.7% (95% CI 4.7%-7.1%) for CTC studies, and 3.9% (95% CI 3.3%-4.4%) for non-CTC studies, with a significant difference (p = 0.004). A low heterogeneity was found for the CTC group (I2 = 10.3%), whereas a high heterogeneity was found in the non-CTC group of studies (I2 = 93.5%), and no significant explanatory variables were found. Of the 22 STROBE items, a mean of 18 (82%) was fulfilled by CTC studies, and a mean of 16 (73%) by non-CTC studies. CONCLUSIONS: The prevalence of synchronous CRC was about 4-6%. The introduction of CTC is associated with a significant increase of the prevalence of synchronous CRCs.

7.
J Thorac Dis ; 10(4): 2125-2134, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29850116

RESUMO

Background: Intra-aortic balloon pump (IABP) had a pivotal role in the therapy of cardiogenic shock (CS), but recent studies have questioned its effects on patients' outcome. Aim of this study is the description of a "real world" series of patients in which IABP was used as a primary mechanical circulatory support (MCS). Methods: All patients who received IABP in our institution during 1 year were prospectively enrolled in our study. The outcomes were: ICU mortality, length of ICU stay, factors associated with mortality and complications of IABP. A logistic regression model was developed to estimate the effect of several risk factors on mortality. Results: A total of 119 patients were enrolled, 54 patients underwent IABP placement for CS unrelated to cardiac surgery (medical CS) and 65 after open-heart surgery. There was no significant difference for mortality between medical CS [12/54 (22.2%)] and cardiac surgery [7/65 (10.8%)] (P=0.09). The morbidity rate related to IABP was 11.3%. Multivariable analysis identified AKI (OR =9.3; 95% CI, 2.0-40.0; P=0.004), inotropic score at the time of IABP implantation (OR =1.06; 95% CI, 1.01-1.11; P=0.009) and history of myocardial revascularization (OR =4.7; 95% CI, 1.1-20.2; P=0.036) as independent predictors for early death (P<0.05). A ROC curve analysis for inotropic score at time of implantation and mortality was performed in the overall population [AUC=0.78 (95% CI, 0.66-0.90)]. A cutoff of 20 has a specificity =72% and sensitivity=74% in this population. Conclusions: Mortality is similar in medical and postcardiotomy CS. The benefits of IABP are limited if the amount of inotropes and the severity of shock are too high.

8.
Nutrition ; 37: 48-52, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28359362

RESUMO

OBJECTIVE: Pulmonary misplacement during the blind insertion of enteral feeding tubes is frequent, particularly in ventilated and neurologically impaired patients. This is probably the first clinical study using the Kangaroo Feeding Tube with IRIS technology (IRIS) which incorporates a camera designed to provide anatomic landmark visualization during insertion. The study aim was to evaluate IRIS performance during bedside gastric placement. METHODS: This is the first prospective study to collect data on the use of IRIS. Twenty consecutive unconscious patients requiring enteral nutrition were recruited at a single center. IRIS placement was considered complete when a clear image of the gastric mucosa appeared. Correct placement was confirmed using a contrast-enhanced abdominal X-ray. To evaluate the device performance over time, the camera was activated every other day up to 17 d postplacement. RESULTS: In 7 (35%) patients, the trachea was initially visualized, requiring a second placement attempt with the same tube. The IRIS camera allowed recognition of the gastric mucosa in 18 (90%) patients. The esophagogastric junction was identified in one patient, while in a second patient the quality of visualization was poor. Contrast-enhanced X-ray confirmed the gastric placement of IRIS in all patients. IRIS allowed identification of gastric mucosa in 14 (70%) patients 3 d after placement. Performance progressively declined with time (P = 0.006, chi-square for trend). CONCLUSION: IRIS placement could have spared X-ray confirmation in almost all patients and prevented misplacement into the airway in about one third. Visualization quality needs to be improved, particularly after the first week.


Assuntos
Nutrição Enteral , Unidades de Terapia Intensiva , Intubação Gastrointestinal/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Animais , Cuidados Críticos , Estado Terminal/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Raios X , Adulto Jovem
9.
Minerva Anestesiol ; 83(7): 720-727, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28276672

RESUMO

BACKGROUND: Lung ultrasound (LUS) is a useful tool for assessing lung status in critically ill patients, but is not widely applied in intensive care units (ICUs). The aim of this study was to investigate the use of LUS in Italian ICUs. METHODS: A questionnaire was distributed to 116 ICU representatives belonging to the Italian GiViTI network, participating in a national project on continuous quality of care assessment. The answers to the questionnaire were analyzed with the data collected in the course of said project. RESULTS: 87 ICUs took part in the study. LUS was performed in 94.3% of them, generally by an internal intensivist. The mean number of tests per bed per week was 0.97 (SD, 1.0). A standardized reporting format was present in only 11% of ICUs. LUS was generally used to investigate known or suspected diseases and as a screening tool in only 10%. The number of testes per bed per week was inversely correlated to the number of beds per physician (P<0.001) and to the provider performing the LUS (P<0.001), but not to other structural, organizational or performance data. CONCLUSIONS: LUS is performed in the majority of ICUs and is generally used to investigate known or suspected diseases. Frequency of use appears to be low and related to selected organizational factors. There is generally no standardized format for reporting LUS findings.

10.
Anesth Analg ; 124(2): 456-464, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-28099320

RESUMO

Bispectral Index Scale (BIS)-guided closed-loop delivery of anesthetics has been extensively studied. We performed a meta-analysis of all the randomized clinical trials comparing efficacy and performance between BIS-guided closed-loop delivery and manually controlled administration of total IV anesthesia. Scopus, PubMed, EMBASE, and the Cochrane Central Register of clinical trials were searched for pertinent studies. Inclusion criteria were random allocation to treatment and closed-loop delivery systems versus manually controlled administration of total IV anesthesia in any surgical setting. Exclusion criteria were duplicate publications and nonadult studies. Twelve studies were included, randomly allocating 1284 patients. Use of closed-loop anesthetic delivery systems was associated with a significant reduction in the dose of propofol administered for induction of anesthesia (mean difference [MD] = 0.37 [0.17-0.57], P for effect <0.00001, P for heterogeneity = 0.001, I = 74%) and a significant reduction in recovery time (MD = 1.62 [0.60-2.64], P for effect <0.0001, P for heterogeneity = 0.06, I = 47%). The target depth of anesthesia was preserved more frequently with closed-loop anesthetic delivery than with manual control (MD = -15.17 [-23.11 to -7.24], P for effect <0.00001, P for heterogeneity <0.00001, I = 83%). There were no differences in the time required to induce anesthesia and the total propofol dose. Closed-loop anesthetic delivery performed better than manual-control delivery. Both median absolute performance error and wobble index were significantly lower in closed-loop anesthetic delivery systems group (MD = 5.82 [3.17-8.46], P for effect <0.00001, P for heterogeneity <0.00001, I = 90% and MD = 0.92 [0.13-1.72], P for effect = 0.003, P for heterogeneity = 0.07, I = 45%). When compared with manual control, BIS-guided anesthetic delivery of total IV anesthesia reduces propofol requirements during induction, better maintains a target depth of anesthesia, and reduces recovery time.


Assuntos
Anestesia Intravenosa/instrumentação , Anestesia Intravenosa/métodos , Anestésicos Intravenosos/administração & dosagem , Anestesia com Circuito Fechado , Monitores de Consciência , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
11.
Surg Endosc ; 31(1): 85-99, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27287910

RESUMO

INTRODUCTION: Recent studies show contrasting data on the impact of laparoscopy on long-term complications such as the occurrence of small bowel obstruction (SBO) and incisional hernia (IH). The objective of the study was to assess the impact of the laparoscopic approach on the occurrence of SBO and IH after colorectal resection. METHODS: Two trained investigators independently searched MEDLINE, Embase, PubMed, and the Cochrane Central Register of clinical trials for studies comparing laparoscopy to open surgery for mid- to long-term outcomes after colorectal surgery. No language restriction was set. Sensitivity analyses for study design and quality, conversion rate, type of procedure (colon or rectal surgery), and length of follow-up were performed. RESULTS: Eleven RCTs and 14 non-RCT comparative studies for a total of 6540 patients were included in the analysis. Laparoscopy was associated with a significant reduction in the occurrence of SBO (RR 0.57, [95 %CI 0.42-0.76], 16 trials) and IH (RR 0.60, [95 %CI 0.50-0.72], 19 trials). Sensitivity analysis including only RCTs confirmed the reduction in SBO (RR 0.58, [95 %CI 0.39-0.87], 8 trials), while the difference was close to significance for IH (RR 0.76, [95 %CI 0.56-1.03], 7 trials). Sensitivity analysis including only studies with conversion rate lower than 15 % showed a significant protective effect of laparoscopy for both SBO (RR 0.53, [95 %CI 0.37-0.77], 11 trials) and IH (RR 0.58, [95 %CI 0.47-0.72], 12 trials). No significant difference between laparoscopy and open surgery was found when the analysis was limited to studies with conversion rate >15 % (SBO: RR 0.60 [0.32-1.12], IH: RR 0.70 [0.46-1.06]). Length of follow-up did not substantially impact on results. CONCLUSION: Laparoscopic surgery is associated with a significant reduction in both SBO and IH compared to the open approach. A low conversion rate in the laparoscopic group plays a key role for reduction in both SBO and IH.


Assuntos
Colectomia/métodos , Hérnia Incisional/etiologia , Obstrução Intestinal/etiologia , Intestino Delgado , Laparoscopia , Complicações Pós-Operatórias/etiologia , Reto/cirurgia , Humanos , Hérnia Incisional/prevenção & controle , Obstrução Intestinal/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle
12.
J Cardiothorac Vasc Anesth ; 31(2): 562-568, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27988091

RESUMO

OBJECTIVES: Postoperative pulmonary complications (PPC) are among the most common complications after noncardiac surgery. Men, smokers, and elderly patients with chronic obstructive pulmonary disease or heart failure are more likely to experience PPC. The majority of patients undergoing vascular surgery belong in these categories and are at higher risk of developing PPC. Moreover, the surgical site is one of the most important risk factors associated with PPC, and aortic surgery carries the highest risk. The aim of this systematic review was to obtain an additional understanding of the real incidence of PPC after open abdominal aortic surgery and the impact of PPC on survival. DESIGN: Systematic review and meta-analysis. SETTING: Hospitals PARTICIPANTS: Patients who underwent open abdominal aortic surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A literature search was performed on BioMedCentral, PubMed, Embase, and the Cochrane Register of clinical trials. All prospective or retrospective studies reporting data on PPC after open abdominal aortic surgery were included. Co-primary endpoints were the PPC rate and the correlation between PPC and perioperative mortality. The secondary endpoint was the difference in the PPC rate and mortality between elective and urgent surgery. Data on 269,637 patients from 213 studies were analyzed. The overall median incidence of PPC was 10.3% (interquartile range 5.55%-19.1%). Pneumonia, respiratory insufficiency, prolonged mechanical ventilation, need for unplanned mechanical ventilation, atelectasis, acute respiratory distress syndrome, pulmonary edema, and pleural effusions were the most common PPC reported in the literature. Occurrence of PPC was associated with postoperative mortality (r = 0.65, p<0.01) and was significantly higher in urgent procedures (p<0.001). CONCLUSIONS: Incidence of PPC after open abdominal aortic surgery is high and is associated with increased postoperative morbidity and mortality.


Assuntos
Aorta Abdominal/cirurgia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Transtornos Respiratórios/diagnóstico , Transtornos Respiratórios/epidemiologia , Humanos , Estudos Prospectivos , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/epidemiologia , Estudos Retrospectivos
13.
Intensive Care Med ; 43(1): 29-38, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27620292

RESUMO

PURPOSE: Diaphragmatic dysfunction (DD) has a high incidence in critically ill patients and is an under-recognized cause of respiratory failure and prolonged weaning from mechanical ventilation. Among different methods to assess diaphragmatic function, diaphragm ultrasonography (DU) is noninvasive, rapid, and easy to perform at the bedside. We systematically reviewed the current literature assessing the usefulness and accuracy of DU in intensive care unit (ICU) patients. METHODS: Pubmed, Cochrane Database of Systematic Reviews, Embase, Scopus, and Google Scholar Databases were searched for pertinent studies. We included all original, peer-reviewed studies about the use of DU in ICU patients. RESULTS: Twenty studies including 875 patients were included in the final analysis. DU was performed with different techniques to measure diaphragmatic inspiratory excursion, thickness of diaphragm (Tdi), and thickening fraction (TF). DU is feasible, highly reproducible, and allows one to detect diaphragmatic dysfunction in critically ill patients. During weaning from mechanical ventilation and spontaneous breathing trials, both diaphragmatic excursion and diaphragmatic thickening measurements have been used to predict extubation success or failure. Optimal cutoffs ranged from 10 to 14 mm for excursion and 30-36 % for thickening fraction. During assisted mechanical ventilation, diaphragmatic thickening has been found to be an accurate index of respiratory muscles workload. Observational studies suggest DU as a reliable method to assess diaphragm atrophy in patients undergoing mechanical ventilation. CONCLUSIONS: Current literature suggests that DU could be a useful and accurate tool to detect diaphragmatic dysfunction in critically ill patients, to predict extubation success or failure, to monitor respiratory workload, and to assess atrophy in patients who are mechanically ventilated.


Assuntos
Cuidados Críticos/métodos , Diafragma/diagnóstico por imagem , Diafragma/fisiopatologia , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estado Terminal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
14.
J Cardiothorac Vasc Anesth ; 30(5): 1386-95, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27499346

RESUMO

OBJECTIVES: Democracy-based medicine is a combination of evidence-based medicine (systematic review), expert assessment, and worldwide voting by physicians to express their opinions and self-reported practice via the Internet. The authors applied democracy-based medicine to key trials in critical care medicine. DESIGN AND SETTING: A systematic review of literature followed by web-based voting on findings of a consensus conference. PARTICIPANTS: A total of 555 clinicians from 61 countries. INTERVENTIONS: The authors performed a systematic literature review (via searching MEDLINE/PubMed, Scopus, and Embase) and selected all multicenter randomized clinical trials in critical care that reported a significant effect on survival and were endorsed by expert clinicians. Then they solicited voting and self-reported practice on such evidence via an interactive Internet questionnaire. Relationships among trial sample size, design, and respondents' agreement were investigated. The gap between agreement and use/avoidance and the influence of country origin on physicians' approach to interventions also were investigated. MEASUREMENTS AND MAIN RESULTS: According to 24 multicenter randomized controlled trials, 15 interventions affecting mortality were identified. Wide variabilities in both the level of agreement and reported practice among different interventions and countries were found. Moreover, agreement and reported practice often did not coincide. Finally, a positive correlation among agreement, trial sample size, and number of included centers was found. On the contrary, trial design did not influence clinicians' agreement. CONCLUSIONS: Physicians' clinical practice and agreement with the literature vary among different interventions and countries. The role of these interventions in affecting survival should be further investigated to reduce both the gap between evidence and clinical practice and transnational differences.


Assuntos
Cuidados Críticos/métodos , Medicina Baseada em Evidências/métodos , Mortalidade Hospitalar , Internacionalidade , Estudos Multicêntricos como Assunto/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Estado Terminal , Humanos , Médicos
15.
Crit Care Med ; 44(12): 2139-2144, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27513539

RESUMO

OBJECTIVE: Noninvasive ventilation is a life-saving technique increasingly used to treat acute respiratory failure. Noninvasive ventilation has been applied mostly in ICUs, but several reasons brought to an increasing application of noninvasive ventilation in ordinary wards. Few articles evaluated the outcomes of patients receiving noninvasive ventilation including long-term follow-up. The aim of the present study was to assess 1-year survival rate of patients treated with noninvasive ventilation outside the ICU for acute respiratory failure of heterogeneous causes and to identify the predictors of long-term mortality. DESIGN: Prospective, observational, pragmatic study. SETTING: Ordinary wards of a teaching hospital. PATIENTS: Consecutive patients treated with noninvasive ventilation for acute respiratory failure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two-hundred and twenty-patients were enrolled. Mortality rates at 30-day, 90-days, and 1-year follow-up were 20%, 26%, and 34%. When excluding patients with "do-not-resuscitate" status, mortality rates were 13%, 19%, and 28%. The multivariate analyses identified solid cancer, pneumonia in hematologic patients, and do-not-resuscitate status as independent predictors of mortality with postoperative acute respiratory failure associated with improved survival. The same predictors were confirmed when excluding do-not-resuscitate patients from the analyses. CONCLUSIONS: Noninvasive ventilation applied in ordinary wards was effective, with long-term outcomes not different from those reported for ICU settings. Solid cancer, pneumonia in hematologic malignancies, and do-not-resuscitate status predicted mortality, whereas patients with postoperative acute respiratory failure had the best survival rate. Additional studies are required to evaluate noninvasive ventilation efficacy in the wards compared with ICU.


Assuntos
Ventilação não Invasiva/mortalidade , Insuficiência Respiratória/terapia , Doença Aguda , Idoso , Feminino , Humanos , Masculino , Ventilação não Invasiva/métodos , Estudos Prospectivos , Insuficiência Respiratória/mortalidade , Análise de Sobrevida
17.
Anal Bioanal Chem ; 408(9): 2215-26, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26753967

RESUMO

Lipidomic analysis is able to measure simultaneously thousands of compounds belonging to a few lipid classes. In each lipid class, compounds differ only by the acyl radical, ranging between C10:0 (capric acid) and C24:0 (lignoceric acid). Although some metabolites have a peculiar pathological role, more often compounds belonging to a single lipid class exert the same biological effect. Here, we present a lipidomics workflow that extracts the tandem mass spectrometry data from individual files and uses them to group compounds into structurally homogeneous clusters by chemical structure hierarchical clustering analysis (CHCA). The case-to-control peak area ratios of the metabolites are then analyzed within clusters. We created two freely available applications to assist the workflow: FragClust to generate the tables to be subjected to CHCA, and TestClust to perform statistical analysis on clustered data. We used the lipidomics data from the plasma of Alzheimer's disease (AD) patients in comparison with healthy controls to test the workflow. To date, the search for plasma biomarkers in AD has not provided reliable results. This article shows that the workflow is helpful to understand the behavior of whole lipid classes in plasma of AD patients.


Assuntos
Doença de Alzheimer/metabolismo , Lipídeos/química , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Cromatografia Líquida de Alta Pressão , Humanos , Estrutura Molecular , Espectrometria de Massas em Tandem
18.
Adv Ther ; 32(10): 971-82, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26521190

RESUMO

INTRODUCTION: Diuretic responsiveness in patients with chronic heart failure (CHF) is better assessed by urine production per unit diuretic dose than by the absolute urine output or diuretic dose. Diuretic resistance arises over time when the plateau rate of sodium and water excretion is reached prior to optimal fluid elimination and may be overcome when hypertonic saline solution (HSS) is added to high doses of furosemide. METHODS: Forty-two consecutively hospitalized patients with refractory CHF were randomized in a 1:1:1 ratio to furosemide doses (125 mg, 250 mg, 500 mg) so that all patients received intravenous furosemide diluted in 150 ml of normal saline (0.9%) in the first step (0-24 h) and the same furosemide dose diluted in 150 ml of HSS (1.4%) in the next step (24-48 h) as to obtain 3 groups as follows: Fourteen patients receiving 125 mg (group 1), fourteen patients receiving 250 mg (group 2), and fourteen patients receiving 500 mg (group 3) of furosemide. Urine samples of all patients were collected at 30, 60, and 90 min, and 3, 4, 5, 6, 8, and 24 h after infusion. Diuresis, sodium excretion, osmolality, and furosemide concentration were evaluated for each urine sample. RESULTS: After randomization, 40 patients completed the study. Two patients, one in group 2 and one in group 3 dropped out. Patients in group 1 (125 mg furosemide) had a mean age of 77 ± 17 years, 43% were male, 6 (43%) had heart failure with a preserved ejection fraction (HFpEF), and 64% were in New York Heart Association (NYHA) class IV; the mean age of patients in group 2 (250 mg furosemide) was 80 ± 8.1 years, 15% were male, 5 (38%) had HFpEF, and 84% were in NYHA class IV; and the mean age of patients in group 3 (500 mg furosemide) was 73 ± 12 years, 54% were male, 6 (46%) had HFpEF, and 69% were in NYHA class IV. HSS added to furosemide increased total urine output, sodium excretion, urinary osmolality, and furosemide urine delivery in all patients and at all time points. The percentage increase was 18,14, and 14% for urine output; 29, 24, and 16% for total sodium excretion; 45, 34, and 20% for urinary osmolarity; and 27, 36, and 32% for total furosemide excretion in groups 1, 2, and 3, respectively. These findings were translated in an improvement in the furosemide dose-response curves in these patients. CONCLUSION: These results may serve as new pathophysiological basis for HSS use in the treatment of refractory CHF.


Assuntos
Diuréticos/uso terapêutico , Furosemida/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Solução Salina Hipertônica/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Diuréticos/administração & dosagem , Relação Dose-Resposta a Droga , Quimioterapia Combinada , Tolerância a Medicamentos , Feminino , Furosemida/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Concentração Osmolar , Solução Salina Hipertônica/administração & dosagem , Sódio/urina
19.
J Minim Invasive Gynecol ; 22(5): 759-66, 2015 Jul-Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25820113

RESUMO

STUDY OBJECTIVE: To compare the effects of local anesthetic intraperitoneal nebulization with intraperitoneal instillation during laparoscopic ovarian cystectomy on postoperative morphine consumption and pain. DESIGN: Multicenter, randomized, case-control trial. DESIGN CLASSIFICATION: Canadian Task Force Classification I. SETTING: University hospitals in Italy. PATIENTS: One hundred forty patients scheduled for laparoscopic ovarian cystectomy. INTERVENTIONS: Patients were randomized to receive either nebulization of ropivacaine 150 mg before surgery or instillation of ropivacaine 150 mg before surgery. Nebulization was performed using the Aeroneb Pro device (Aerogen, Galway, Ireland). MEASUREMENTS AND MAIN RESULTS: One hundred forty patients were enrolled, and 123 completed the study. There was no difference between the 2 groups in average morphine consumption (7.3 ± 7.5 mg in the nebulization group vs 9.2 ± 7.2 mg in the instillation group; p = .17). Eighty-two percent of patients in the nebulization group required morphine compared with 96% in the instillation group (p < .05). Patients receiving nebulization had a lower dynamic Numeric Ranking Scale compared with those in the instillation group in the postanesthesia care unit postanesthesia care unit and 4 hours after surgery (p < .05). Ten patients (15%) in the nebulization group experienced shivering in the postanesthesia care unit compared with 2 patients (4%) in the instillation group (p = .035). CONCLUSION: Nebulization of ropivacaine prevents the use of morphine in a significant proportion of patients, reduced postoperative pain during the first hours after surgery, and was associated with a higher incidence of postoperative shivering when compared with instillation.


Assuntos
Amidas/administração & dosagem , Anestésicos Locais/administração & dosagem , Procedimentos Cirúrgicos em Ginecologia , Laparoscopia , Morfina/administração & dosagem , Cistos Ovarianos/cirurgia , Dor Pós-Operatória/tratamento farmacológico , Adulto , Método Duplo-Cego , Feminino , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Humanos , Injeções Intraperitoneais , Laparoscopia/efeitos adversos , Pessoa de Meia-Idade , Nebulizadores e Vaporizadores , Cistos Ovarianos/complicações , Medição da Dor , Dor Pós-Operatória/etiologia , Ropivacaina , Resultado do Tratamento
20.
Crit Care Med ; 43(8): 1559-68, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25821918

RESUMO

OBJECTIVES: We aimed to identify all treatments that affect mortality in adult critically ill patients in multicenter randomized controlled trials. We also evaluated the methodological aspects of these studies, and we surveyed clinicians' opinion and usual practice for the selected interventions. DATA SOURCES: MEDLINE/PubMed, Scopus, and Embase were searched. Further articles were suggested for inclusion from experts and cross-check of references. STUDY SELECTION: We selected the articles that fulfilled the following criteria: publication in a peer-reviewed journal; multicenter randomized controlled trial design; dealing with nonsurgical interventions in adult critically ill patients; and statistically significant effect in unadjusted landmark mortality. A consensus conference assessed all interventions and excluded those with lack of reproducibility, lack of generalizability, high probability of type I error, major baseline imbalances between intervention and control groups, major design flaws, contradiction by subsequent larger higher quality trials, modified intention to treat analysis, effect found only after adjustments, and lack of biological plausibility. DATA EXTRACTION: For all selected studies, we recorded the intervention and its comparator, the setting, the sample size, whether enrollment was completed or interrupted, the presence of blinding, the effect size, and the duration of follow-up. DATA SYNTHESIS: We found 15 interventions that affected mortality in 24 multicenter randomized controlled trials. Median sample size was small (199 patients) as was median centers number (10). Blinded trials enrolled significantly more patients and involved more centers. Multicenter randomized controlled trials showing harm also involved significantly more centers and more patients (p = 0.016 and p = 0.04, respectively). Five hundred fifty-five clinicians from 61 countries showed variable agreement on perceived validity of such interventions. CONCLUSIONS: We identified 15 treatments that decreased/increased mortality in critically ill patients in 24 multicenter randomized controlled trials. However, design affected trial size and larger trials were more likely to show harm. Finally, clinicians view of such trials and their translation into practice varied.


Assuntos
Cuidados Críticos/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Feminino , Fibrose/terapia , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipotermia Induzida/mortalidade , Masculino , Estudos Multicêntricos como Assunto , Decúbito Ventral , Reprodutibilidade dos Testes , Projetos de Pesquisa , Respiração Artificial/métodos , Respiração Artificial/mortalidade , Ácido Tranexâmico/sangue
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