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1.
PLoS One ; 15(12): e0243604, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33320874

RESUMO

BACKGROUND: Coagulation abnormalities in COVID-19 patients have not been addressed in depth. OBJECTIVE: To perform a longitudinal evaluation of coagulation profile of patients admitted to the ICU with COVID-19. METHODS: Conventional coagulation tests, rotational thromboelastometry (ROTEM), platelet function, fibrinolysis, antithrombin, protein C and S were measured at days 0, 1, 3, 7 and 14. Based on median total maximum SOFA score, patients were divided in two groups: SOFA ≤ 10 and SOFA > 10. RESULTS: Thirty patients were studied. Some conventional coagulation tests, as aPTT, PT and INR remained unchanged during the study period, while alterations on others coagulation laboratory tests were detected. Fibrinogen levels were increased in both groups. ROTEM maximum clot firmness increased in both groups from Day 0 to Day 14. Moreover, ROTEM-FIBTEM maximum clot firmness was high in both groups, with a slight decrease from day 0 to day 14 in group SOFA ≤ 10 and a slight increase during the same period in group SOFA > 10. Fibrinolysis was low and decreased over time in all groups, with the most pronounced decrease observed in INTEM maximum lysis in group SOFA > 10. Also, D-dimer plasma levels were higher than normal reference range in both groups and free protein S plasma levels were low in both groups at baseline and increased over time, Finally, patients in group SOFA > 10 had lower plasminogen levels and Protein C ​​than patients with SOFA <10, which may represent less fibrinolysis activity during a state of hypercoagulability. CONCLUSION: COVID-19 patients have a pronounced hypercoagulability state, characterized by impaired endogenous anticoagulation and decreased fibrinolysis. The magnitude of coagulation abnormalities seems to correlate with the severity of organ dysfunction. The hypercoagulability state of COVID-19 patients was not only detected by ROTEM but it much more complex, where changes were observed on the fibrinolytic and endogenous anticoagulation system.


Assuntos
/sangue , Unidades de Terapia Intensiva , /patogenicidade , Idoso , Idoso de 80 Anos ou mais , Antitrombinas/sangue , Testes de Coagulação Sanguínea , /virologia , Feminino , Fibrinólise/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Testes de Função Plaquetária/métodos , Proteína C/metabolismo , Proteína S/metabolismo , Tromboelastografia/métodos
2.
Rev Saude Publica ; 54: 101, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-33111924

RESUMO

This case report aims to describe the conception and preliminary data of the implementation of a telescreening and telemonitoring program of covid-19 for users of the Unified Health System with risk conditions. A system of telerscreening was implemented through which undergraduate students in the health area contact patients by telephone, according to periodicity and predefined criteria, to monitor the evolution of the condition. In eight weeks, 2,190 attempts at remote contact were made with individuals from five health units. The effective number of individuals monitored at the time this writing is 802.


Assuntos
Betacoronavirus , Infecções por Coronavirus/diagnóstico , Pandemias , Pneumonia Viral/diagnóstico , Estudantes de Medicina , Telemedicina , Brasil/epidemiologia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Humanos , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle
5.
Braz J Anesthesiol ; 2020 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-32836520

RESUMO

The care for patients suffering from cardiopulmonary arrest in a context of a COVID-19 pandemic has particularities that should be highlighted. The following recommendations from the Brazilian Association of Emergency Medicine (ABRAMEDE), the Brazilian Society of Cardiology (SBC) and the Brazilian Association of Intensive Medicine (AMIB) and the Brazilian Society of Anesthesiology (SBA), associations and societies official representatives of specialties affiliated to the Brazilian Medical Association (AMB), aim to guide the various assistant teams, in a context of little solid evidence, maximizing the protection of teams and patients. It is essential to wear full Personal Protective Equipment (PPE) for aerosols during the care of Cardiopulmonary Resuscitation (CPR) and it is imperative to consider and treat the potential causes in these patients, especially hypoxia and arrhythmias caused by changes in the QT interval or myocarditis. The installation of an advanced invasive airway must be obtained early and the use of High Efficiency Particulate Arrestance (HEPA) filters at the interface with the valve bag is mandatory; situations of occurrence of CPR during mechanical ventilation and in a prone position demand peculiarities that are different from the conventional CPR pattern. Faced with the care of a patient diagnosed or suspected of COVID-19, the care follows the national and international protocols and guidelines 2015 ILCOR (International Alliance of Resuscitation Committees), AHA 2019 Guidelines (American Heart Association) and the Update of the Cardiopulmonary Resuscitation and Emergency Care Directive of the Brazilian Society of Cardiology 2019.

7.
Arq Bras Cardiol ; 114(6): 1078-1087, 2020 06.
Artigo em Inglês, Português | MEDLINE | ID: mdl-32638902

RESUMO

Care for patients with cardiac arrest in the context of the coronavirus disease 2019 (COVID-19) pandemic has several unique aspects that warrant particular attention. This joint position statement by the Brazilian Association of Emergency Medicine (ABRAMEDE), Brazilian Society of Cardiology (SBC), Brazilian Association of Intensive Care Medicine (AMIB), and Brazilian Society of Anesthesiology (SBA), all official societies representing the corresponding medical specialties affiliated with the Brazilian Medical Association (AMB), provides recommendations to guide health care workers in the current context of limited robust evidence, aiming to maximize the protection of staff and patients alike. It is essential that full aerosol precautions, which include wearing appropriate personal protective equipment, be followed during resuscitation. It is also imperative that potential causes of cardiac arrest of particular interest in this patient population, especially hypoxia, cardiac arrhythmias associated with QT prolongation, and myocarditis, be considered and addressed. An advanced invasive airway device should be placed early. Use of HEPA filters at the bag-valve interface is mandatory. Management of cardiac arrest occurring during mechanical ventilation or during prone positioning demands particular ventilator settings and rescuer positioning for chest compressions which deviate from standard cardiopulmonary resuscitation techniques. Apart from these logistical issues, care should otherwise follow national and international protocols and guidelines, namely the 2015 International Liaison Committee on Resuscitation (ILCOR) and 2019 American Heart Association (AHA) guidelines and the 2019 Update to the Brazilian Society of Cardiology Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Guideline.


Assuntos
Reanimação Cardiopulmonar/normas , Infecções por Coronavirus/terapia , Coronavirus , Pandemias , Pneumonia Viral/terapia , Guias de Prática Clínica como Assunto , Comitês Consultivos , Betacoronavirus , Brasil/epidemiologia , Reanimação Cardiopulmonar/métodos , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Humanos , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Sociedades Médicas , Estados Unidos
8.
Einstein (Sao Paulo) ; 18: eAE5793, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-32520071

RESUMO

In December 2019, a series of patients with severe pneumonia were identified in Wuhan, Hubei province, China, who progressed to severe acute respiratory syndrome and acute respiratory distress syndrome. Subsequently, COVID-19 was attributed to a new betacoronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Approximately 20% of patients diagnosed as COVID-19 develop severe forms of the disease, including acute hypoxemic respiratory failure, severe acute respiratory syndrome, acute respiratory distress syndrome and acute renal failure and require intensive care. There is no randomized controlled clinical trial addressing potential therapies for patients with confirmed COVID-19 infection at the time of publishing these treatment recommendations. Therefore, these recommendations are based predominantly on the opinion of experts (level C of recommendation).


Assuntos
Betacoronavirus , Infecções por Coronavirus/diagnóstico , Unidades de Terapia Intensiva/normas , Pneumonia Viral/diagnóstico , Respiração Artificial/normas , Lista de Checagem , Infecções por Coronavirus/terapia , Estado Terminal , Humanos , Pandemias , Pneumonia Viral/terapia , Guias de Prática Clínica como Assunto , Respiração Artificial/métodos , Síndrome Respiratória Aguda Grave/diagnóstico , Síndrome Respiratória Aguda Grave/terapia
9.
Ann Intensive Care ; 10(1): 68, 2020 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-32488524

RESUMO

BACKGROUND: Survival benefit from low tidal volume (VT) ventilation (LTVV) has been demonstrated for patients with acute respiratory distress syndrome (ARDS), and patients not having ARDS could also benefit from this strategy. Organizational factors may play a role on adherence to LTVV. The present study aimed to identify organizational factors with an independent association with adherence to LTVV. METHODS: Secondary analysis of the database of a multicenter two-phase study (prospective cohort followed by a cluster-randomized trial) performed in 118 Brazilian intensive care units. Patients under mechanical ventilation at day 2 were included. LTVV was defined as a VT ≤ 8 ml/kg PBW on the second day of ventilation. Data on the type and number of beds of the hospital, teaching status, nursing, respiratory therapists and physician staffing, use of structured checklist, and presence of protocols were tested. A multivariable mixed-effect model was used to assess the association between organizational factors and adherence to LTVV. RESULTS: The study included 5719 patients; 3340 (58%) patients received LTVV. A greater number of hospital beds (absolute difference 7.43% [95% confidence interval 0.61-14.24%]; p = 0.038), use of structured checklist during multidisciplinary rounds (5.10% [0.55-9.81%]; p = 0.030), and presence of at least one nurse per 10 patients during all shifts (17.24% [0.85-33.60%]; p = 0.045) were the only three factors that had an independent association with adherence to LTVV. CONCLUSIONS: Number of hospital beds, use of a structured checklist during multidisciplinary rounds, and nurse staffing are organizational factors associated with adherence to LTVV. These findings shed light on organizational factors that may improve ventilation in critically ill patients.

10.
Rev. saúde pública (Online) ; 54: 101, 2020. graf
Artigo em Inglês | LILACS-Express | LILACS, BBO - Odontologia, Sec. Est. Saúde SP | ID: biblio-1139477

RESUMO

ABSTRACT This case report aims to describe the conception and preliminary data of the implementation of a telescreening and telemonitoring program of covid-19 for users of the Unified Health System with risk conditions. A system of telerscreening was implemented through which undergraduate students in the health area contact patients by telephone, according to periodicity and predefined criteria, to monitor the evolution of the condition. In eight weeks, 2,190 attempts at remote contact were made with individuals from five health units. The effective number of individuals monitored at the time this writing is 802.


RESUMO O presente relato de experiência tem como objetivo descrever a concepção e os dados preliminares da implementação de um programa de telerrastreio e telemonitoramento da covid-19 para usuários do Sistema Único de Saúde com condições de risco para agravamento. Foi implantado um sistema de telerrastreio por meio do qual estudantes de graduação na área da saúde contactam os pacientes via telefone, conforme periodicidade e critérios predefinidos, para monitorar a evolução do quadro. Em oito semanas, foram realizadas 2.190 tentativas de contato remoto com indivíduos de cinco unidades de saúde. O número efetivo de indivíduos monitorados no momento da escrita deste artigo é de 802.

11.
Einstein (Säo Paulo) ; 18: eAE5793, 2020. graf
Artigo em Inglês | LILACS-Express | LILACS | ID: biblio-1133727

RESUMO

ABSTRACT In December 2019, a series of patients with severe pneumonia were identified in Wuhan, Hubei province, China, who progressed to severe acute respiratory syndrome and acute respiratory distress syndrome. Subsequently, COVID-19 was attributed to a new betacoronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Approximately 20% of patients diagnosed as COVID-19 develop severe forms of the disease, including acute hypoxemic respiratory failure, severe acute respiratory syndrome, acute respiratory distress syndrome and acute renal failure and require intensive care. There is no randomized controlled clinical trial addressing potential therapies for patients with confirmed COVID-19 infection at the time of publishing these treatment recommendations. Therefore, these recommendations are based predominantly on the opinion of experts (level C of recommendation).


RESUMO Em dezembro de 2019, uma série de pacientes com pneumonia grave foi identificada em Wuhan, província de Hubei, na China. Esses pacientes evoluíram para síndrome respiratória aguda grave e síndrome do desconforto respiratório agudo. Posteriormente, a COVID-19 foi atribuída a um novo betacoronavírus, o coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2). Cerca de 20% dos pacientes com diagnóstico de COVID-19 desenvolvem formas graves da doença, incluindo insuficiência respiratória aguda hipoxêmica, síndrome respiratória aguda grave, síndrome do desconforto respiratório agudo e insuficiência renal aguda e requerem admissão em unidade de terapia intensiva. Não há nenhum ensaio clínico randomizado controlado que avalie potenciais tratamentos para pacientes com infecção confirmada pela COVID-19 no momento da publicação destas recomendações de tratamento. Dessa forma, essas recomendações são baseadas predominantemente na opinião de especialistas (grau de recomendação de nível C).

13.
Arq Bras Cardiol ; 113(3): 449-663, 2019 10 10.
Artigo em Português | MEDLINE | ID: mdl-31621787
14.
Bernoche, Claudia; Timerman, Sergio; Polastri, Thatiane Facholi; Giannetti, Natali Schiavo; Siqueira, Adailson Wagner da Silva; Piscopo, Agnaldo; Soeiro, Alexandre de Matos; Reis, Amélia Gorete Afonso da Costa; Tanaka, Ana Cristina Sayuri; Thomaz, Ana Maria; Quilici, Ana Paula; Catarino, Andrei Hilário; Ribeiro, Anna Christina de Lima; Barreto, Antonio Carlos Pereira; Azevedo, Antonio Fernando Barros de Filho; Pazin, Antonio Filho; Timerman, Ari; Scarpa, Bruna Romanelli; Timerman, Bruno; Tavares, Caio de Assis Moura; Martins, Cantidio Soares Lemos; Serrano, Carlos Vicente Junior; Malaque, Ceila Maria Sant'Ana; Pisani, Cristiano Faria; Batista, Daniel Valente; Leandro, Daniela Luana Fernandes; Szpilman, David; Gonçalves, Diego Manoel; Paiva, Edison Ferreira de; Osawa, Eduardo Atsushi; Lima, Eduardo Gomes; Adam, Eduardo Leal; Peixoto, Elaine; Evaristo, Eli Faria; Azeka, Estela; Silva, Fabio Bruno da; Wen, Fan Hui; Ferreira, Fatima Gil; Lima, Felipe Gallego; Fernandes, Felipe Lourenço; Ganem, Fernando; Galas, Filomena Regina Barbosa Gomes; Tarasoutchi, Flavio; Souza, Germano Emilio Conceição; Feitosa, Gilson Soares Filho; Foronda, Gustavo; Guimarães, Helio Penna; Abud, Isabela Cristina Kirnew; Leite, Ivanhoé Stuart Lima; Linhares, Jaime Paula Pessoa Filho; Moraes, Junior João Batista de Moura Xavier; Falcão, João Luiz Alencar de Araripe; Ramires, Jose Antônio Franchini; Cavalini, José Fernando; Saraiva, José Francisco Kerr; Abrão, Karen Cristine; Pinto, Lecio Figueira; Bianchi, Leonardo Luís Torres; Lopes, Leonardo Nícolau Geisler Daud; Piegas, Leopoldo Soares; Kopel, Liliane; Godoy, Lucas Colombo; Tobase, Lucia; Hajjar, Ludhmila Abrahão; Dallan, Luís Augusto Palma; Caneo, Luiz Fernando; Cardoso, Luiz Francisco; Canesin, Manoel Fernandes; Park, Marcelo; Rabelo, Marcia Maria Noya; Malachias, Marcus Vinícius Bolívar; Gonçalves, Maria Aparecida Batistão; Almeida, Maria Fernanda Branco de; Souza, Maria Francilene Silva; Favarato, Maria Helena Sampaio; Carrion, Maria Julia Machline; Gonzalez, Maria Margarita; Bortolotto, Maria Rita de Figueiredo Lemos; Macatrão-Costa, Milena Frota; Shimoda, Mônica Satsuki; Oliveira-Junior, Mucio Tavares de; Ikari, Nana Miura; Dutra, Oscar Pereira; Berwanger, Otávio; Pinheiro, Patricia Ana Paiva Corrêa; Reis, Patrícia Feitosa Frota dos; Cellia, Pedro Henrique Moraes; Santos Filho, Raul Dias dos; Gianotto-Oliveira, Renan; Kalil Filho, Roberto; Guinsburg, Ruth; Managini, Sandrigo; Lage, Silvia Helena Gelas; Yeu, So Pei; Franchi, Sonia Meiken; Shimoda-Sakano, Tania; Accorsi, Tarso Duenhas; Leal, Tatiana de Carvalho Andreucci; Guimarães, Vanessa; Sallai, Vanessa Santos; Ávila, Walkiria Samuel; Sako, Yara Kimiko.
Arq. bras. cardiol ; 113(3): 449-663, Sept. 2019. tab, graf
Artigo em Português | LILACS-Express | LILACS, Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: biblio-1038561
15.
Intensive Care Med ; 45(7): 928-938, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31089761

RESUMO

PURPOSE: New-onset atrial fibrillation (NOAF) is common and associated with increased morbidity and mortality. However, its clinical importance and management in critically ill patients are not well described. The aim of this scoping review is to assess the epidemiology and management strategies of NOAF during critical illness. METHOD: The review was conducted in accordance with the PRISMA extension for scoping reviews. We searched PubMed, EMBASE and the Cochrane Library for studies assessing the incidence, outcome and management strategies of NOAF in adult critically ill patients. The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS: A total of 99 studies were included, of which 79 were observational and 20 were interventional. The incidence of NOAF varied from 1.7% to 43.9% with considerable inter-population variation (very low quality of evidence). Commonly identified risk factors for NOAF included higher age, cardiovascular comorbidities and sepsis. The occurrence of NOAF was associated with adverse outcomes, including stroke, prolonged length of stay and mortality (very low quality of evidence). We found limited data on the optimal management strategy with no evidence for firm benefit or harm for any intervention (very low/low quality of evidence). CONCLUSIONS: The definition and incidence of NOAF in critically ill patients varied considerably and many risk factors were identified. NOAF seemed to be associated with adverse outcomes, but data were very limited and current management strategies are not evidence-based.


Assuntos
Fibrilação Atrial/epidemiologia , Fibrilação Atrial/etiologia , Hospitalização/estatística & dados numéricos , Fatores Etários , Fibrilação Atrial/complicações , Fibrilação Atrial/terapia , Fármacos Cardiovasculares/uso terapêutico , Doenças Cardiovasculares/epidemiologia , Comorbidade , Estado Terminal , Eletrocardiografia , Testes Hematológicos , Humanos , Incidência , Tempo de Internação , Fatores de Risco , Sepse/epidemiologia , Índice de Gravidade de Doença , Fatores Sexuais , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia
16.
JAMA Neurol ; 2019 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-31058947

RESUMO

Importance: Translating evidence into clinical practice in the management of acute ischemic stroke (AIS) and transient ischemic attack (TIA) is challenging, especially in low- and middle-income countries. Objective: To assess the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for care of patients with AIS and TIA. Design, Setting and Participants: This 2-arm cluster-randomized clinical trial assessed 45 hospitals and 2336 patients with AIS and TIA for eligibility before randomization. Eligible hospitals were able to provide care for patients with AIS and TIA in Brazil, Argentina, and Peru. Recruitment started September 12, 2016, and ended February 26, 2018; follow-up ended June 29, 2018. Data were analyzed using the intention-to-treat principle. Interventions: The multifaceted quality improvement intervention included case management, reminders, a roadmap and checklist for the therapeutic plan, educational materials, and periodic audit and feedback reports to each intervention cluster. Main Outcomes and Measures: The primary outcome was a composite adherence score for AIS and TIA performance measures. Secondary outcomes included an all-or-none composite end point of performance measures, the individual process measure components of the composite end points, and clinical outcomes at 90 days after admission (stroke recurrence, death, and disability measured by the modified Rankin scale). Results: A total of 36 hospitals and 1624 patients underwent randomization. Nineteen hospitals were randomized to the quality improvement intervention and 17 to routine care. The overall mean (SD) age of patients enrolled in the study was 69.4 (13.5) years, and 913 (56.2%) were men. Overall mean (SD) composite adherence score for the 10 performance measures in the intervention group hospitals compared with control group hospitals was 85.3% (20.1%) vs 77.8% (18.4%) (mean difference, 4.2%; 95% CI, -3.8% to 12.2%). As a secondary end point, 402 of 817 patients (49.2%) at intervention hospitals received all the therapies that they were eligible for vs 203 of 807 (25.2%) in the control hospitals (odds ratio, 2.59; 95% CI, 1.22-5.53; P = .01). Conclusions and Relevance: A multifaceted quality improvement intervention did not result in a significant increase in composite adherence score for evidence-based therapies in patients with AIS or TIA. However, when using an all-or-none approach, the intervention resulted in improved adherence to evidence-based therapies. Trial Registration: ClinicalTrials.gov Identifier: NCT02223273.

17.
JAMA Cardiol ; 4(5): 408-417, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-30942842

RESUMO

Importance: Studies have found that patients at high cardiovascular risk often fail to receive evidence-based therapies in community practice. Objective: To evaluate whether a multifaceted quality improvement intervention can improve the prescription of evidence-based therapies. Design, Setting, and Participants: In this 2-arm cluster randomized clinical trial, patients with established atherothrombotic disease from 40 public and private outpatient clinics (clusters) in Brazil were studied. Patients were recruited from August 2016 to August 2017, with follow-up to August 2018. Data were analyzed in September 2018. Interventions: Case management, audit and feedback reports, and distribution of educational materials (to health care professionals and patients) vs routine practice. Main Outcomes and Measures: The primary end point was prescription of evidence-based therapies (ie, statins, antiplatelet therapy, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) using the all-or-none approach at 12 months after the intervention period in patients without contraindications. Results: Of the 1619 included patients, 1029 (63.6%) were male, 1327 (82.0%) had coronary artery disease (843 [52.1%] with prior acute myocardial infarction), 355 (21.9%) had prior ischemic stroke or transient ischemic attack, and 197 (12.2%) had peripheral vascular disease, and the mean (SD) age was 65.6 (10.5) years. Among randomized clusters, 30 (75%) were cardiology sites, 6 (15%) were primary care units, and 26 (65%) were teaching institutions. Among eligible patients, those in intervention clusters were more likely to receive a prescription of evidence-based therapies than those in control clusters (73.5% [515 of 701] vs 58.7% [493 of 840]; odds ratio, 2.30; 95% CI, 1.14-4.65). There were no differences between the intervention and control groups with regards to risk factor control (ie, hyperlipidemia, hypertension, or diabetes). Rates of education for smoking cessation were higher among current smokers in the intervention group than in the control group (51.9% [364 of 701] vs 18.2% [153 of 840]; odds ratio, 11.24; 95% CI, 2.20-57.43). The rate of cardiovascular mortality, acute myocardial infarction, and stroke was 2.6% for patients from intervention clusters and 3.4% for those in the control group (hazard ratio, 0.76; 95% CI, 0.43-1.34). Conclusions and Relevance: Among Brazilian patients at high cardiovascular risk, a quality improvement intervention resulted in improved prescription of evidence-based therapies. Trial Registration: ClinicalTrials.gov identifier: NCT02851732.


Assuntos
Doenças Cardiovasculares/tratamento farmacológico , Doenças Cardiovasculares/prevenção & controle , Melhoria de Qualidade , Idoso , Brasil , Doenças Cardiovasculares/epidemiologia , Medicina Baseada em Evidências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Medição de Risco
18.
Crit Care ; 23(1): 34, 2019 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-30696474

RESUMO

BACKGROUND: Although light sedation levels are associated with several beneficial outcomes for critically ill patients on mechanical ventilation, the majority of patients are still deeply sedated. Organizational factors may play a role on adherence to light sedation levels. We aimed to identify organizational factors associated with a moderate to light sedation target on the first 48 h of mechanical ventilation, as well as the association between early achievement of within-target sedation and mortality. METHODS: This study is a secondary analysis of a multicenter two-phase study (prospective cohort followed by a cluster-randomized controlled trial) performed in 118 Brazilian ICUs. We included all critically ill patients who were on mechanical ventilation 48 h after ICU admission. A moderate to light level of sedation or being alert and calm (i.e., the Richmond Agitation-Sedation Scale of - 3 to 0) was the target for all patients on mechanical ventilation during the study period. We collected data on the type of hospital (public, private, profit and private, nonprofit), hospital teaching status, nursing and physician staffing, and presence of sedation, analgesia, and weaning protocols. We used multivariate random-effects regression with ICU and study phase as random-effects and correction for patients' Simplified Acute Physiology Score 3 and Sequential Organ Failure Assessment. We also performed a mediation analysis to explore whether sedation level was just a mediator of the association between organizational factors and mortality. RESULTS: We included 5719 patients. Only 1710 (29.9%) were on target sedation levels on day 2. Board-certified intensivists on the morning and afternoon shifts were associated with an adequate sedation level on day 2 (OR = 2.43; CI 95%, 1.09-5.38). Target sedation levels were associated with reduced hospital mortality (OR = 0.63; CI 95%, 0.55-0.72). Mediation analysis also suggested such an association, but did not suggest a relationship between the physician staffing model and hospital mortality. CONCLUSIONS: Board-certified intensivists on morning and afternoon shifts were associated with an increased number of patients achieving lighter sedation goals. These findings reinforce the importance of organizational factors, such as intensivists' presence, as a modifiable quality improvement target.


Assuntos
Lista de Checagem/normas , Sedação Profunda/métodos , Respiração Artificial/métodos , Adulto , Idoso , Brasil , Lista de Checagem/estatística & dados numéricos , Estudos de Coortes , Sedação Consciente/métodos , Feminino , Mortalidade Hospitalar , Humanos , Hipnóticos e Sedativos/efeitos adversos , Hipnóticos e Sedativos/uso terapêutico , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Estudos Prospectivos , Respiração Artificial/mortalidade , Escala Psicológica Aguda Simplificada
19.
Am Heart J ; 207: 40-48, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30415082

RESUMO

BACKGROUND: Translating evidence into clinical practice in the management of high cardiovascular risk patients is challenging. Few quality improvement interventions have rigorously evaluated their impact on both patient care and clinical outcomes. OBJECTIVES: The main objectives are to evaluate the impact of a multifaceted educational intervention on adherence to local guidelines for the prescription of statins, antiplatelets and angiotensin converting enzyme inhibitors or angiotensin II receptor blockers for high cardiovascular risk patients, as well as on the incidence of major cardiovascular events. DESIGN: We designed a pragmatic two arm cluster randomized trial involving 40 clusters. Clusters are randomized to receive a multifaceted quality improvement intervention or to routine practice (control). The multifaceted intervention includes: reminders, care algorithms, training of a case manager, audit and feedback reports, and distribution of educational materials to health care providers. The primary endpoint is the adherence to combined evidence-based therapies (statins, antiplatelet therapy and angiotensin converting enzyme inhibitors or angiotensin receptor blockers) at 12 months after the intervention period in patients without contra-indications for these medications. All analyses follow the intention-to-treat principle and take the cluster design into account using linear mixed logistic regression modeling. SUMMARY: If proven effective, this multifaceted intervention would have wide utility as a means of promoting optimal usage of evidence-based interventions for the management of high cardiovascular risk patients.


Assuntos
Doenças Cardiovasculares/prevenção & controle , Medicina Baseada em Evidências/estatística & dados numéricos , Adesão à Medicação , Melhoria de Qualidade , Comitês Consultivos/organização & administração , Algoritmos , Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Brasil , Doenças Cardiovasculares/tratamento farmacológico , Gerentes de Casos/educação , Causas de Morte , Auditoria Clínica , Retroalimentação , Pessoal de Saúde/educação , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Análise de Intenção de Tratamento , Modelos Logísticos , Inibidores da Agregação de Plaquetas/uso terapêutico , Sistemas de Alerta , Projetos de Pesquisa , Fatores de Risco
20.
Am Heart J ; 207: 49-57, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30415083

RESUMO

BACKGROUND: Translating evidence into clinical practice in the management of acute ischemic stroke (AIS) and transient ischemic attack (TIA) is challenging especially in low- and middle-income countries. OBJECTIVES: The aim of this study is to assess the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for AIS and TIA patients care. DESIGN: We designed a pragmatic, 2-arm cluster-randomized trial involving 36 clusters and 1624 patients from Brazil, Argentina, and Peru. Hospitals are randomized to receive a multifaceted quality improvement intervention (intervention group) or to routine care (control group). The BRIDGE Stroke multifaceted quality improvement intervention includes case management, reminders, health care providers' educational materials (including treatment algorithms), interactive workshops, and audit and feedback reports. Primary outcome is a composite adherence score to AIS and TIA performance measures. Secondary outcomes include an "all or none" composite end point to performance measures, the individual components of the composite end points, and clinical outcomes at 90 days following admission (stroke recurrence, death, and disability measured by the modified Rankin scale). SUMMARY: The BRIDGE Stroke Trial is an international pragmatic evaluation of a multifaceted quality improvement intervention. If effective, this intervention could be potentially extended widely to improve the quality of care and outcomes of patients with AIS or TIA.


Assuntos
Ataque Isquêmico Transitório/terapia , Melhoria de Qualidade/organização & administração , Qualidade da Assistência à Saúde , Acidente Vascular Cerebral/terapia , Doença Aguda , Comitês Consultivos/organização & administração , Algoritmos , Argentina , Brasil , Administração de Caso/organização & administração , Auditoria Clínica , Medicina Baseada em Evidências , Retroalimentação , Pessoal de Saúde/educação , Hospitais , Humanos , Ataque Isquêmico Transitório/prevenção & controle , Adesão à Medicação , Peru , Guias de Prática Clínica como Assunto , Sistemas de Alerta , Acidente Vascular Cerebral/prevenção & controle , Fatores de Tempo
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