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2.
Can J Surg ; 61(3): 185-194, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29806816

RESUMO

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) is a mostly asymptomatic condition that is strongly associated with 30-day mortality; however, it remains mostly undetected without systematic troponin T monitoring. We evaluated the cost and consequences of postoperative troponin T monitoring to detect MINS. METHODS: We conducted a model-based cost-consequence analysis to compare the impact of routine troponin T monitoring versus standard care (troponin T measurement triggered by ischemic symptoms) on the incidence of MINS detection. Model inputs were based on Canadian patients enrolled in the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) study, which enrolled patients aged 45 years or older undergoing inpatient noncardiac surgery. We conducted probability analyses with 10 000 iterations and extensive sensitivity analyses. RESULTS: The data were based on 6021 patients (48% men, mean age 65 [standard deviation 12] yr). The 30-day mortality rate for MINS was 9.6%. We determined the incremental cost to avoid missing a MINS event as $1632 (2015 Canadian dollars). The cost-effectiveness of troponin monitoring was higher in patient subgroups at higher risk for MINS, e.g., those aged 65 years or more, or with a history of atherosclerosis or diabetes ($1309). CONCLUSION: The costs associated with a troponin T monitoring program to detect MINS were moderate. Based on the estimated incremental cost per health gain, implementation of postoperative troponin T monitoring seems appealing, particularly in patients at high risk for MINS.

3.
Anesth Analg ; 126(4): 1150-1157, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29369093

RESUMO

BACKGROUND: Perioperative ß-blockade reduces the incidence of myocardial infarction but increases that of death, stroke, and hypotension. The elderly may experience few benefits but more harms associated with ß-blockade due to a normal effect of aging, that of a reduced resting heart rate. The tested hypothesis was that the effect of perioperative ß-blockade is more significant with increasing age. METHODS: To determine whether the effect of perioperative ß-blockade on the primary composite event, clinically significant hypotension, myocardial infarction, stroke, and death varies with age, we interrogated data from the perioperative ischemia evaluation (POISE) study. The POISE study randomly assigned 8351 patients, aged ≥45 years, in 23 countries, undergoing major noncardiac surgery to either 200 mg metoprolol CR daily or placebo for 30 days. Odds ratios or hazard ratios for time to events, when available, for each of the adverse effects were measured according to decile of age, and interaction term between age and treatment was calculated. No adjustment was made for multiple outcomes. RESULTS: Age was associated with higher incidences of the major outcomes of clinically significant hypotension, myocardial infarction, and death. Age was associated with a minimal reduction in resting heart rate from 84.2 (standard error, 0.63; ages 45-54 years) to 80.9 (standard error, 0.70; ages >85 years; P < .0001). We found no evidence of any interaction between age and study group regarding any of the major outcomes, although the limited sample size does not exclude any but large interactions. CONCLUSIONS: The effect of perioperative ß-blockade on the major outcomes studied did not vary with age. Resting heart rate decreases slightly with age. Our data do not support a recommendation for the use of perioperative ß-blockade in any age subgroup to achieve benefits but avoid harms. Therefore, current recommendations against the use of ß-blockers in high-risk patients undergoing noncardiac surgery apply across all age groups.

4.
Ann Surg ; 268(2): 357-363, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28486392

RESUMO

OBJECTIVE: To determine the prognostic relevance, clinical characteristics, and 30-day outcomes associated with myocardial injury after noncardiac surgery (MINS) in vascular surgical patients. BACKGROUND: MINS has been independently associated with 30-day mortality after noncardiac surgery. The characteristics and prognostic importance of MINS in vascular surgery patients are poorly described. METHODS: This was an international prospective cohort study of 15,102 noncardiac surgery patients 45 years or older, of whom 502 patients underwent vascular surgery. All patients had fourth-generation plasma troponin T (TnT) concentrations measured during the first 3 postoperative days. MINS was defined as a TnT of 0.03 ng/mL of higher secondary to ischemia. The objectives of the present study were to determine (i) if MINS is prognostically important in vascular surgical patients, (ii) the clinical characteristics of vascular surgery patients with and without MINS, (iii) the 30-day outcomes for vascular surgery patients with and without MINS, and (iv) the proportion of MINS that probably would have gone undetected without routine troponin monitoring. RESULTS: The incidence of MINS in the vascular surgery patients was 19.1% (95% confidence interval (CI), 15.7%-22.6%). 30-day all-cause mortality in the vascular cohort was 12.5% (95% CI 7.3%-20.6%) in patients with MINS compared with 1.5% (95% CI 0.7%-3.2%) in patients without MINS (P < 0.001). MINS was independently associated with 30-day mortality in vascular patients (odds ratio, 9.48; 95% CI, 3.46-25.96). The 30-day mortality was similar in MINS patients with (15.0%; 95% CI, 7.1-29.1) and without an ischemic feature (12.2%; 95% CI, 5.3-25.5, P = 0.76). The proportion of vascular surgery patients who suffered MINS without overt evidence of myocardial ischemia was 74.1% (95% CI, 63.6-82.4). CONCLUSIONS: Approximately 1 in 5 patients experienced MINS after vascular surgery. MINS was independently associated with 30-day mortality. The majority of patients with MINS were asymptomatic and would have gone undetected without routine postoperative troponin measurement.

5.
JAMA ; 317(16): 1642-1651, 2017 Apr 25.
Artigo em Inglês | MEDLINE | ID: mdl-28444280

RESUMO

Importance: Little is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality and myocardial injury after noncardiac surgery (MINS). Objective: To determine the association between perioperative hsTnT measurements and 30-day mortality and potential diagnostic criteria for MINS (ie, myocardial injury due to ischemia associated with 30-day mortality). Design, Setting, and Participants: Prospective cohort study of patients aged 45 years or older who underwent inpatient noncardiac surgery and had a postoperative hsTnT measurement. Starting in October 2008, participants were recruited at 23 centers in 13 countries; follow-up finished in December 2013. Exposures: Patients had hsTnT measurements 6 to 12 hours after surgery and daily for 3 days; 40.4% had a preoperative hsTnT measurement. Main Outcomes and Measures: A modified Mazumdar approach (an iterative process) was used to determine if there were hsTnT thresholds associated with risk of death and had an adjusted hazard ratio (HR) of 3.0 or higher and a risk of 30-day mortality of 3% or higher. To determine potential diagnostic criteria for MINS, regression analyses ascertained if postoperative hsTnT elevations required an ischemic feature (eg, ischemic symptom or electrocardiography finding) to be associated with 30-day mortality. Results: Among 21 842 participants, the mean age was 63.1 (SD, 10.7) years and 49.1% were female. Death within 30 days after surgery occurred in 266 patients (1.2%; 95% CI, 1.1%-1.4%). Multivariable analysis demonstrated that compared with the reference group (peak hsTnT <5 ng/L), peak postoperative hsTnT levels of 20 to less than 65 ng/L, 65 to less than 1000 ng/L, and 1000 ng/L or higher had 30-day mortality rates of 3.0% (123/4049; 95% CI, 2.6%-3.6%), 9.1% (102/1118; 95% CI, 7.6%-11.0%), and 29.6% (16/54; 95% CI, 19.1%-42.8%), with corresponding adjusted HRs of 23.63 (95% CI, 10.32-54.09), 70.34 (95% CI, 30.60-161.71), and 227.01 (95% CI, 87.35-589.92), respectively. An absolute hsTnT change of 5 ng/L or higher was associated with an increased risk of 30-day mortality (adjusted HR, 4.69; 95% CI, 3.52-6.25). An elevated postoperative hsTnT (ie, 20 to <65 ng/L with an absolute change ≥5 ng/L or hsTnT ≥65 ng/L) without an ischemic feature was associated with 30-day mortality (adjusted HR, 3.20; 95% CI, 2.37-4.32). Among the 3904 patients (17.9%; 95% CI, 17.4%-18.4%) with MINS, 3633 (93.1%; 95% CI, 92.2%-93.8%) did not experience an ischemic symptom. Conclusions and Relevance: Among patients undergoing noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery was significantly associated with 30-day mortality. Elevated postoperative hsTnT without an ischemic feature was also associated with 30-day mortality.


Assuntos
Infarto do Miocárdio/mortalidade , Isquemia Miocárdica/mortalidade , Troponina T/sangue , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Período Pós-Operatório , Estudos Prospectivos , Medição de Risco
7.
Trials ; 15: 502, 2014 Dec 20.
Artigo em Inglês | MEDLINE | ID: mdl-25528663

RESUMO

BACKGROUND: Venous thromboembolism (VTE) is a common complication of critical illness with important clinical consequences. The Prophylaxis for ThromboEmbolism in Critical Care Trial (PROTECT) is a multicenter, blinded, randomized controlled trial comparing the effectiveness of the two most common pharmocoprevention strategies, unfractionated heparin (UFH) and low molecular weight heparin (LMWH) dalteparin, in medical-surgical patients in the intensive care unit (ICU). E-PROTECT is a prospective and concurrent economic evaluation of the PROTECT trial. METHODS/DESIGN: The primary objective of E-PROTECT is to identify and quantify the total (direct and indirect, variable and fixed) costs associated with the management of critically ill patients participating in the PROTECT trial, and, to combine costs and outcome results to determine the incremental cost-effectiveness of LMWH versus UFH, from the acute healthcare system perspective, over a data-rich time horizon of ICU admission and hospital admission. We derive baseline characteristics and probabilities of in-ICU and in-hospital events from all enrolled patients. Total costs are derived from centers, proportional to the numbers of patients enrolled in each country. Direct costs include medication, physician and other personnel costs, diagnostic radiology and laboratory testing, operative and non-operative procedures, costs associated with bleeding, transfusions and treatment-related complications. Indirect costs include ICU and hospital ward overhead costs. Outcomes are the ratio of incremental costs per incremental effects of LMWH versus UFH during hospitalization; incremental cost to prevent a thrombosis at any site (primary outcome); incremental cost to prevent a pulmonary embolism, deep vein thrombosis, major bleeding event or episode of heparin-induced thrombocytopenia (secondary outcomes) and incremental cost per life-year gained (tertiary outcome). Pre-specified subgroups and sensitivity analyses will be performed and confidence intervals for the estimates of incremental cost-effectiveness will be obtained using bootstrapping. DISCUSSION: This economic evaluation employs a prospective costing methodology concurrent with a randomized controlled blinded clinical trial, with a pre-specified analytic plan, outcome measures, subgroup and sensitivity analyses. This economic evaluation has received only peer-reviewed funding and funders will not play a role in the generation, analysis or decision to submit the manuscripts for publication. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT00182143 . Date of registration: 10 September 2005.


Assuntos
Anticoagulantes/administração & dosagem , Anticoagulantes/economia , Dalteparina/administração & dosagem , Dalteparina/economia , Custos de Medicamentos , Fibrinolíticos/administração & dosagem , Fibrinolíticos/economia , Heparina/administração & dosagem , Heparina/economia , Custos Hospitalares , Tromboembolia Venosa/economia , Tromboembolia Venosa/prevenção & controle , Anticoagulantes/efeitos adversos , Austrália , Brasil , Protocolos Clínicos , Redução de Custos , Análise Custo-Benefício , Cuidados Críticos , Dalteparina/efeitos adversos , Fibrinolíticos/efeitos adversos , Heparina/efeitos adversos , Humanos , Modelos Econômicos , América do Norte , Estudos Prospectivos , Anos de Vida Ajustados por Qualidade de Vida , Projetos de Pesquisa , Arábia Saudita , Fatores de Tempo , Resultado do Tratamento , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/etiologia
8.
JAMA ; 312(20): 2135-45, 2014 Nov 26.
Artigo em Inglês | MEDLINE | ID: mdl-25362228

RESUMO

IMPORTANCE: Venous thromboembolism (VTE) is a common complication of acute illness, and its prevention is a ubiquitous aspect of inpatient care. A multicenter blinded, randomized trial compared the effectiveness of the most common pharmocoprevention strategies, unfractionated heparin (UFH) and the low-molecular-weight heparin (LMWH) dalteparin, finding no difference in the primary end point of leg deep-vein thrombosis but a reduced rate of pulmonary embolus and heparin-induced thrombocytopenia among critically ill medical-surgical patients who received dalteparin. OBJECTIVE: To evaluate the comparative cost-effectiveness of LMWH vs UFH for prophylaxis against VTE in critically ill patients. DESIGN, SETTING, AND PARTICIPANTS: Prospective economic evaluation concurrent with the Prophylaxis for Thromboembolism in Critical Care Randomized Trial (May 2006 to June 2010). The economic evaluation adopted a health care payer perspective and in-hospital time horizon; derived baseline characteristics and probabilities of intensive care unit and in-hospital events; and measured costs among 2344 patients in 23 centers in 5 countries and applied these costs to measured resource use and effects of all enrolled patients. MAIN OUTCOMES AND MEASURES: Costs, effects, incremental cost-effectiveness of LMWH vs UFH during the period of hospitalization, and sensitivity analyses across cost ranges. RESULTS: Hospital costs per patient were $39,508 (interquartile range [IQR], $24,676 to $71,431) for 1862 patients who received LMWH compared with $40,805 (IQR, $24,393 to $76,139) for 1862 patients who received UFH (incremental cost, -$1297 [IQR, -$4398 to $1404]; P = .41). In 78% of simulations, a strategy using LMWH was most effective and least costly. In sensitivity analyses, a strategy using LMWH remained least costly unless the drug acquisition cost of dalteparin increased from $8 to $179 per dose and was consistent among higher- and lower-spending health care systems. There was no threshold at which lowering the acquisition cost of UFH favored prophylaxis with UFH. CONCLUSIONS AND RELEVANCE: From a health care payer perspective, the use of the LMWH dalteparin for VTE prophylaxis among critically ill medical-surgical patients was more effective and had similar or lower costs than the use of UFH. These findings were driven by lower rates of pulmonary embolus and heparin-induced thrombocytopenia and corresponding lower overall use of resources with LMWH.


Assuntos
Anticoagulantes/economia , Estado Terminal/economia , Dalteparina/economia , Gastos em Saúde/estatística & dados numéricos , Heparina/economia , Tromboembolia Venosa/prevenção & controle , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Análise Custo-Benefício , Dalteparina/efeitos adversos , Dalteparina/uso terapêutico , Feminino , Serviços de Saúde/estatística & dados numéricos , Heparina/efeitos adversos , Heparina/uso terapêutico , Hospitalização/economia , Humanos , Seguro Saúde/economia , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Embolia Pulmonar/economia , Embolia Pulmonar/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto , Trombocitopenia/induzido quimicamente , Trombocitopenia/economia , Tromboembolia Venosa/economia
9.
JAMA ; 307(21): 2295-304, 2012 Jun 06.
Artigo em Inglês | MEDLINE | ID: mdl-22706835

RESUMO

CONTEXT: Of the 200 million adults worldwide who undergo noncardiac surgery each year, more than 1 million will die within 30 days. OBJECTIVE: To determine the relationship between the peak fourth-generation troponin T (TnT) measurement in the first 3 days after noncardiac surgery and 30-day mortality. DESIGN, SETTING, AND PARTICIPANTS: A prospective, international cohort study that enrolled patients from August 6, 2007, to January 11, 2011. Eligible patients were aged 45 years and older and required at least an overnight hospital admission after having noncardiac surgery. MAIN OUTCOME MEASURES: Patients' TnT levels were measured 6 to 12 hours after surgery and on days 1, 2, and 3 after surgery. We undertook Cox regression analysis in which the dependent variable was mortality until 30 days after surgery, and the independent variables included 24 preoperative variables. We repeated this analysis, adding the peak TnT measurement during the first 3 postoperative days as an independent variable and used a minimum P value approach to determine if there were TnT thresholds that independently altered patients' risk of death. RESULTS: A total of 15,133 patients were included in this study. The 30-day mortality rate was 1.9% (95% CI, 1.7%-2.1%). Multivariable analysis demonstrated that peak TnT values of at least 0.02 ng/mL, occurring in 11.6% of patients, were associated with higher 30-day mortality compared with the reference group (peak TnT ≤ 0.01 ng/mL): peak TnT of 0.02 ng/mL (adjusted hazard ratio [aHR], 2.41; 95% CI, 1.33-3.77); 0.03 to 0.29 ng/mL (aHR, 5.00; 95% CI, 3.72-6.76); and 0.30 ng/mL or greater (aHR, 10.48; 95% CI, 6.25-16.62). Patients with a peak TnT value of 0.01 ng/mL or less, 0.02, 0.03-0.29, and 0.30 or greater had 30-day mortality rates of 1.0%, 4.0%, 9.3%, and 16.9%, respectively. Peak TnT measurement added incremental prognostic value to discriminate those likely to die within 30 days for the model with peak TnT measurement vs without (C index = 0.85 vs 0.81; difference, 0.4; 95% CI, 0.2-0.5; P < .001 for difference between C index values). The net reclassification improvement with TnT was 25.0% (P < .001). CONCLUSION: Among patients undergoing noncardiac surgery, the peak postoperative TnT measurement during the first 3 days after surgery was significantly associated with 30-day mortality.


Assuntos
Biomarcadores/sangue , Procedimentos Cirúrgicos Operatórios/mortalidade , Troponina T/sangue , Idoso , Feminino , Humanos , Pacientes Internados/estatística & dados numéricos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Período Pós-Operatório , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Medição de Risco
10.
Clin Biochem ; 44(12): 1021-4, 2011 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-21640092

RESUMO

OBJECTIVES: To determine the proportion of noncardiac surgery patients exceeding the published 99th percentile or change criteria with the high sensitivity Troponin T (hs-TnT) assay. DESIGN AND METHODS: We measured hs-TnT preoperatively and postoperatively on days 1, 2 and 3 in 325 adults. RESULTS: Postoperatively 45% (95% CI: 39-50%) of patients had hs-TnT≥14ng/L and 22% (95% CI:17-26%) had an elevation (≥14ng/L) and change (>85%) in hs-TnT. CONCLUSION: Further research is needed to inform the optimal hs-TnT threshold and change in this setting.


Assuntos
Período Pós-Operatório , Período Pré-Operatório , Troponina T/sangue , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Operatórios
12.
J Clin Neurosci ; 17(1): 64-8, 2010 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-19683448

RESUMO

Non-convulsive seizures and non-convulsive status epilepticus (NCSE) are believed common in comatose patients and are suggested to worsen outcome. The purpose of this study was to prospectively evaluate outcome in patients in critical care units in whom NCSE was suspected to determine how often evidence of seizure activity existed based on an isolated standard 20 minute electroencephalogram (EEG) and to determine what clinical factors predicted outcome. We prospectively reviewed EEGs and clinical charts of patients admitted to a critical care unit at a tertiary care center who were suspected to have non-convulsive seizures. Outcomes were correlated with EEG findings, clinical factors, and acute therapies using univariate and multivariate logistic analyses. Of 189 patients, complete information was available in 169. Eighty-one (47.9%) patients died, 67 (39.6%) were discharged home, and 21 (12.4%) were discharged to long-term care. Four patients had electroencephalographic seizures, two of whom had no clinical manifestations (i.e. non-convulsive). On univariate analysis, increased age, an admitting diagnosis of cardiac arrest, a Glasgow Coma Scale (GCS) score8, and burst suppression were correlated significantly with poor outcome. A past history of seizures and unequivocal tonic-clonic convulsions were correlated significantly with a better outcome. On multivariate analysis, increased age, cardiac arrest, and a GCS score8 were associated with increased mortality (p<0.05). Clinical factors, including age, underlying etiology and GCS score are the most important predicators of outcome in coma. A standard 20 minute EEG did not correlate with a high detection rate of seizure activity. Furthermore, EEG patterns and treatment with anticonvulsant medications did not correlate with outcome.


Assuntos
Coma/mortalidade , Eletroencefalografia/métodos , Convulsões/diagnóstico , Convulsões/mortalidade , Estado Epiléptico/diagnóstico , Estado Epiléptico/mortalidade , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Coma/fisiopatologia , Comorbidade , Morte Súbita Cardíaca/epidemiologia , Eletroencefalografia/estatística & dados numéricos , Epilepsia Tônico-Clônica/diagnóstico , Epilepsia Tônico-Clônica/epidemiologia , Feminino , Escala de Coma de Glasgow , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados (Cuidados de Saúde)/métodos , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Convulsões/fisiopatologia , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Estado Epiléptico/fisiopatologia , Fatores de Tempo , Adulto Jovem
13.
Can J Neurol Sci ; 36(4): 436-42, 2009 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-19650353

RESUMO

OBJECTIVE: To evaluate the incidence of hypoglycemia, hyperglycemia and blood glucose (BG) variability in brain-injured patients and their association with clinical outcomes. METHODS: Retrospective cohort study of brain-injured patients admitted to an 11-bed neurosciences intensive care unit (ICU) from January 1 to December 31, 2003. RESULTS: We included 606 patients. Mean age was 52.3 years, 60.6% were male, 11.9% had diabetes mellitus, and 64% were post-operative. Seventy-five (12.4%) received intensive insulin therapy (IIT) for a median (IQR) 72 (24-154) hours. Hypoglycemia and hyperglycemia occurred in 4.6% (96.4% receiving IIT) and 9.6% (77.6% receiving IIT). Median number of episodes per patient was 3 (75% with > or = 2) and 4 (81% with > or = 2) for hypoglycemia and hyperglycemia. Variable glycemic control occurred in 3.8% (100% receiving IIT) with median number of 13 episodes per patient. In-hospital mortality was 16.7%, median (IQR) ICU and hospital lengths of stay were 2 (1-5) and 8 (3-19) days. Hypoglycemia, hyperglycemia and BG variability showed non-significant but consistent associations with hospital mortality and prolonged lengths of ICU and hospital stay. The rate of recurrence of episodes showed stronger and significant associations with outcome, in particular for BG variability and hyperglycemia. CONCLUSIONS: Hypoglycemia, hyperglycemia and BG variability are relatively common in brain-injured patients and are associated with IIT. An increased frequency of episodes, in particular for BG variability and hyperglycemia, was associated with greater risk of both hospital death and prolonged duration of stay.


Assuntos
Glicemia/metabolismo , Lesões Encefálicas/sangue , Lesões Encefálicas/complicações , Hiperglicemia/complicações , Hipoglicemia/complicações , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Hiperglicemia/sangue , Hipoglicemia/sangue , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estatísticas não Paramétricas
14.
Crit Care ; 13(3): R91, 2009.
Artigo em Inglês | MEDLINE | ID: mdl-19534781

RESUMO

INTRODUCTION: In critical illness, the association of hypoglycemia, blood glucose (BG) variability and outcome are not well understood. We describe the incidence, clinical factors and outcomes associated with an early hypoglycemia and BG variability in critically ill patients. METHODS: Retrospective interrogation of prospectively collected data from the Australia New Zealand Intensive Care Society Adult Patient Database on 66184 adult admissions to 24 intensive care units (ICUs) from 1 January 2000 to 31 December 2005. Primary exposure was hypoglycemia (BG < 4.5 mmol/L) and BG variability (BG < 4.5 and >or= 12.0 mmol/L) within 24 hours of admission. Primary outcome was all-cause mortality. RESULTS: The cumulative incidence of hypoglycemia and BG variability were 13.8% (95% confidence interval (CI) = 13.5 to 14.0; n = 9122) and 2.9% (95%CI = 2.8 to 3.0, n = 1913), respectively. Several clinical factors were associated with both hypoglycemia and BG variability including: co-morbid disease (P < 0.001), non-elective admissions (P < 0.001), higher illness severity (P < 0.001), and primary septic diagnosis (P < 0.001). Hypoglycemia was associated with greater odds of adjusted ICU (odds ratio (OR) = 1.41, 95% CI = 1.31 to 1.54) and hospital death (OR = 1.36, 95% CI = 1.27 to 1.46). Hypoglycemia severity was associated with 'dose-response' increases in mortality. BG variability was associated with greater odds of adjusted ICU (1.5, 95% CI = 1.4 to 1.6) and hospital (1.4, 95% CI = 1.3 to 1.5) mortality, when compared with either hypoglycemia only or neither. CONCLUSIONS: In critically ill patients, both early hypoglycemia and early variability in BG are relatively common, and independently portend an increased risk for mortality.


Assuntos
Estado Terminal/epidemiologia , Transtornos do Metabolismo de Glucose/epidemiologia , Hipoglicemia/epidemiologia , Estado Terminal/mortalidade , Feminino , Transtornos do Metabolismo de Glucose/mortalidade , Mortalidade Hospitalar , Humanos , Hipoglicemia/mortalidade , Incidência , Unidades de Terapia Intensiva , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Nova Zelândia/epidemiologia , Prognóstico , Estudos Retrospectivos
15.
Liver Transpl ; 15(1): 73-8, 2009 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-19109832

RESUMO

Acute kidney injury (AKI) is common in liver failure prior to orthotopic liver transplantation (OLT) and may complicate the intraoperative course. We describe the logistics of intraoperative continuous renal replacement therapy (CRRT) during OLT and the associated clinical outcomes. We performed a retrospective review of adult patients (age > 18 years) receiving intraoperative CRRT during OLT at the University of Alberta Hospital between January 1, 1996 and December 31, 2005. Demographic, detailed clinical, and perioperative data, physiologic and laboratory measures, details of renal replacement therapy (RRT) provided, and data on renal recovery and survival were ascertained. Of 636 OLTs, 41 (6.4%) received intraoperative CRRT. The most common indications for OLT in these patients were hepatitis C (34.2%) and alcoholic (29.3%) cirrhosis. The median [interquartile range (IQR)] Model for End-Stage Liver Disease score was 38 (31-43), and 90.2% were classified as Child-Pugh class C. Preoperatively, 70% were in the intensive care unit, 58.5% were mechanically ventilated, and 48.7% required vasopressor support. The median (IQR) duration of intraoperative CRRT was 258 (189-390) minutes, representing 57% of the total operative time. Filter circuit clotting occurred in 40% but was not associated with a shorter CRRT duration (P = 0.41). No other complications were described. CRRT allowed an even or negative intraoperative fluid balance in 92.7%. CRRT was continued in 78% after OLT for a median (IQR) of 5 (3-11) days. Of these, 24 (75%) were transitioned to intermittent hemodialysis for a median (IQR) of 15 (4-39) days. Survival was 97.6% at 1 month and 75.6% at 1 year. Renal recovery to RRT independence occurred in 100% of survivors by 1 year; however, the mean (standard deviation) estimated glomerular filtration rate (eGFR) was 54.7 (19.1) mL/minute/m(2), with 62.1% having an eGFR < 60 mL/minute/m(2). In conclusion, our data suggest that intraoperative CRRT during OLT is achievable and safe. Intraoperative CRRT may be a valuable adjuvant therapy for those with preoperative AKI. Additional investigations are warranted.


Assuntos
Rim/patologia , Transplante de Fígado/métodos , Terapia de Substituição Renal/métodos , Adolescente , Adulto , Idoso , Feminino , Taxa de Filtração Glomerular , Humanos , Período Intraoperatório , Falência Hepática/terapia , Masculino , Pessoa de Meia-Idade , Diálise Renal , Estudos Retrospectivos
16.
Can J Neurol Sci ; 35(4): 458-71, 2008 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-18973063

RESUMO

OBJECTIVES: 1. To determine the awareness of the literature concerning therapeutic manoeuvres in severe closed head injury (CHI) among Canadian critical care clinicians and neurosurgeons, 2. To identify factors that affect utilization of these manoeuvres, and 3. To compare reported appropriateness and frequency of use with #1 and #2. METHODS: The study design was a systematic scenario-based survey of all neurosurgeons and critical care physicians treating patients with severe CHI in Canada. RESULTS: Fifty-nine of 99 neurosurgeons and 82 of 148 critical care physicians responded (57%). The majority of respondents were not able to identify the highest level of published evidence for most manoeuvres, except for the avoidance of corticosteroids (51%). The factor identified by most respondents as being most important in motivating use of any given manoeuvres was the level of published evidence (25%). Although reported appropriateness and frequency of use of most manoeuvres correlated well with each other, they did not correlate with awareness of evidence. In the case of corticosteroids, there was a strong correlation between non-use of steroids and awareness of evidence (R = -0.30, p = 0.0003). CONCLUSIONS: Respondents to this survey of Canadian physicians treating patients with severe head injury reported published evidence as being the most significant factor affecting use of a therapy. However, most respondents did not correctly identify the highest published level of evidence for most therapies. This study has identified difficulty with research translation that may have clinical implications.


Assuntos
Traumatismos Cranianos Fechados/terapia , Pesquisas sobre Serviços de Saúde , Médicos , Padrões de Prática Médica , Publicações , Adulto , Conscientização , Cuidados Críticos , Educação Médica , Medicina Baseada em Evidências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neurocirurgia , Recursos Humanos
17.
Can J Anaesth ; 55(7): 441-6, 2008 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-18591702

RESUMO

PURPOSE: Guillain-Barré syndrome (GBS) is an acute immunologic attack of the peripheral nerves causing rapidly ascending weakness and areflexia. Occasionally, weakness is severe enough to leave patients paralyzed and without adequate respiratory function. In such patients, intensive care unit (ICU) admission is required. Infrequently, GBS occurs in patients already admitted to the ICU. When this occurs, it can be difficult to distinguish GBS from critical illness neuropathy (CIN). However, it is important to consider GBS in these cases, since treatment options are available, and early treatment is associated with significantly improved outcome. CLINICAL FEATURES: A 28-yr-old man involved in a motor vehicle collision sustained multiple injuries, including T6-T7 thoracic vertebrae fracture. Magnetic resonance imaging identified spinal cord compression at T6-T7, without brain or cervical cord injury. Shortly after admission, the patient developed marked autonomic instability with fluctuating temperatures and severe hypotension. Lower extremity weakness rapidly worsened to paraplegia and new weakness developed affecting bilateral upper extremities and face. Electrodiagnostic studies showed severe axonal polyneuropathy, with denervation in all extremities. The cerebrospinal fluid protein concentration was 5.03 g.L(-1). The patient was treated empirically for the possibility of GBS. Six months later, the patient recovered significant strength in his face and extremities, including his legs. CONCLUSIONS: Guillain-Barré syndrome in trauma patients is rare and is limited to case reports following head trauma. This case also highlights the similarities and the subtle differences between GBS and CIN. Ultimately, definitive diagnosis of GBS may not be possible; however, an empiric course of intravenous immunoglobulins or plasma-exchange may be warranted, if GBS is a reasonable possibility.


Assuntos
Síndrome de Guillain-Barré/etiologia , Debilidade Muscular/etiologia , Polineuropatias/diagnóstico , Traumatismos da Medula Espinal/complicações , Adulto , Síndrome de Guillain-Barré/terapia , Humanos , Imunoglobulinas Intravenosas/uso terapêutico , Masculino , Debilidade Muscular/terapia , Troca Plasmática , Polineuropatias/imunologia , Polineuropatias/terapia , Traumatismos da Medula Espinal/terapia , Vértebras Torácicas , Resultado do Tratamento
18.
Can J Neurol Sci ; 34(3): 307-12, 2007 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-17803027

RESUMO

OBJECTIVE: To determine: 1. the degrees of consensus and disagreement among Canadian critical care clinicians regarding the appropriateness (benefit exceeding risk) of common therapeutic manoeuvres in patients with severe closed head injury (CHI), and 2. the frequency with which clinicians employed these manoeuvres. METHODS: The study design was a systematic scenario-based survey of all neurosurgeons and critical care physicians treating patients with severe CHI in Canada. RESULTS: In the scenario of acute epidural hematoma with mass effect, respondents agreed very strongly that surgery was appropriate. Clinicians reported mannitol and hypertonic saline as appropriate. Beyond these two interventions, agreement was less strong, and the use of the extraventricular drain (EVD), phenytoin, cooling, hyperventilation, nimodipine, and jugular venous oximetry (JVO) were of uncertain appropriateness. Steroids were considered inappropriate. In a scenario of diffuse axonal injury (DAI), clinicians agreed strongly that fever reduction, early enteral feeding, intensive glucose control, and cerebral perfusion pressure (CPP)-directed management were appropriate. The use of mannitol, hypertonic saline, EVD, JVO, narcotics and propofol were also appropriate. Neuromuscular blockade, surgery, and hyperventilation were of uncertain appropriateness. The appropriateness ratings of the interventions considered in the scenario of an intracranial contusion mirrored the DAI scenario. In general, correlations between the reported appropriateness and frequency of use of each intervention were very high. An exception noted was the use of the JVO. The correlation between CPP-guided therapy and the use of the EVD was weak. CONCLUSIONS: This survey has described current practice with regard to treatment of patients with severe CHI. Areas of variation in perceived appropriateness were identified that may benefit from further evaluation. Suggested priorities for evaluation include the use of osmotic diuretics, anticonvulsants, and intracranial manometry.


Assuntos
Lesões Encefálicas/terapia , Cuidados Críticos/métodos , Traumatismos Cranianos Fechados/terapia , Pesquisas sobre Serviços de Saúde , Neurologia/métodos , Neurocirurgia/métodos , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Anticonvulsivantes/uso terapêutico , Lesões Encefálicas/epidemiologia , Lesões Encefálicas/fisiopatologia , Canadá/epidemiologia , Cuidados Críticos/normas , Lesão Axonal Difusa/tratamento farmacológico , Lesão Axonal Difusa/fisiopatologia , Diuréticos Osmóticos/uso terapêutico , Feminino , Traumatismos Cranianos Fechados/epidemiologia , Traumatismos Cranianos Fechados/fisiopatologia , Hematoma Epidural Craniano/tratamento farmacológico , Hematoma Epidural Craniano/fisiopatologia , Hematoma Epidural Craniano/cirurgia , Humanos , Hipotermia Induzida/estatística & dados numéricos , Unidades de Terapia Intensiva , Hipertensão Intracraniana/diagnóstico , Hipertensão Intracraniana/prevenção & controle , Hipertensão Intracraniana/terapia , Masculino , Desnutrição/prevenção & controle , Desnutrição/terapia , Pessoa de Meia-Idade , Neurologia/normas , Neurocirurgia/normas , Medição de Risco
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