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2.
Sci Rep ; 11(1): 9001, 2021 04 26.
Artigo em Inglês | MEDLINE | ID: mdl-33903716

RESUMO

Recently, maintaining a certain oxygen saturation measured by pulse oximetry (SpO2) range in mechanically ventilated patients was recommended; attaching the INTELLiVENT-ASV to ventilators might be beneficial. We evaluated the SpO2 measurement accuracy of a Nihon Kohden and a Masimo monitor compared to actual arterial oxygen saturation (SaO2). SpO2 was simultaneously measured by a Nihon Kohden and Masimo monitor in patients consecutively admitted to a general intensive care unit and mechanically ventilated. Bland-Altman plots were used to compare measured SpO2 with actual SaO2. One hundred mechanically ventilated patients and 1497 arterial blood gas results were reviewed. Mean SaO2 values, Nihon Kohden SpO2 measurements, and Masimo SpO2 measurements were 95.7%, 96.4%, and 96.9%, respectively. The Nihon Kohden SpO2 measurements were less biased than Masimo measurements; their precision was not significantly different. Nihon Kohden and Masimo SpO2 measurements were not significantly different in the "SaO2 < 94%" group (P = 0.083). In the "94% ≤ SaO2 < 98%" and "SaO2 ≥ 98%" groups, there were significant differences between the Nihon Kohden and Masimo SpO2 measurements (P < 0.0001; P = 0.006; respectively). Therefore, when using automatically controlling oxygenation with INTELLiVENT-ASV in mechanically ventilated patients, the Nihon Kohden SpO2 sensor is preferable.Trial registration UMIN000027671. Registered 7 June 2017.


Assuntos
Gasometria/métodos , Oximetria/métodos , Respiração Artificial , Idoso , Área Sob a Curva , Gasometria/normas , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Oximetria/normas , Oxigênio/sangue , Reprodutibilidade dos Testes
3.
Health Qual Life Outcomes ; 19(1): 120, 2021 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-33849571

RESUMO

OBJECTIVES: Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions because of constraints or barriers. We aimed to assess the validity and reliability of the Japanese translation of the Measure of Moral Distress for Healthcare Professionals (MMD-HP). METHODS: We translated the questionnaire into Japanese according to the instructions of EORTC Quality of Life group translation manual. All physicians and nurses who were directly involved in patient care at nine departments of four tertiary hospitals in Japan were invited to a survey to assess the construct validity, reliability and factor structure. Construct validity was assessed with the relation to the intention to leave the clinical position, and internal consistency was assessed with Cronbach's alpha. Confirmatory factor analysis was conducted. RESULTS: 308 responses were eligible for the analysis. The mean total score of MMD-HP (range, 0-432) was 98.2 (SD, 59.9). The score was higher in those who have or had the intention to leave their clinical role due to moral distress than in those who do not or did not have the intention of leaving (mean 113.7 [SD, 61.3] vs. 86.1 [56.6], t-test p < 0.001). The confirmatory factor analysis and Cronbach's alpha confirmed the validity (chi-square, 661.9; CMIN/df, 2.14; GFI, 0.86; CFI, 0.88; CFI/TLI, 1.02; RMSEA, 0.061 [90%CI, 0.055-0.067]) and reliability (0.91 [95%CI, 0.89-0.92]) of the instrument. CONCLUSIONS: The translated Japanese version of the MMD-HP is a reliable and valid instrument to assess moral distress among physicians and nurses.


Assuntos
Atenção à Saúde/ética , Pessoal de Saúde/ética , Pessoal de Saúde/psicologia , Princípios Morais , Psicometria/normas , Inquéritos e Questionários/normas , Traduções , Adulto , Grupo com Ancestrais do Continente Asiático/psicologia , Grupo com Ancestrais do Continente Asiático/estatística & dados numéricos , Análise Fatorial , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Psicometria/instrumentação , Reprodutibilidade dos Testes , Estresse Psicológico
4.
Crit Care ; 25(1): 45, 2021 02 02.
Artigo em Inglês | MEDLINE | ID: mdl-33531020

RESUMO

BACKGROUND: Metabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood. METHOD: This was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH < 7.3 and a Base Excess < -4 mEq/L, within 24-h of ICU admission) were included. Screening continued until 10 patients who received and 10 patients who did not receive sodium bicarbonate in the first 24 h (early bicarbonate therapy) were included at each site. The primary outcome was ICU mortality, and the association between sodium bicarbonate and the clinical outcomes were assessed using regression analysis with generalized linear mixed model. RESULTS: We screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO2, and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality. CONCLUSIONS: Early metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.


Assuntos
Acidose/tratamento farmacológico , Bicarbonato de Sódio/administração & dosagem , APACHE , Acidose/epidemiologia , Idoso , Austrália/epidemiologia , Feminino , Humanos , Incidência , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Internacionalidade , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Bicarbonato de Sódio/farmacologia , Bicarbonato de Sódio/uso terapêutico , Taiwan/epidemiologia
5.
BMC Anesthesiol ; 20(1): 94, 2020 04 25.
Artigo em Inglês | MEDLINE | ID: mdl-32334537

RESUMO

BACKGROUND: INTELLiVENT-ASV® (I-ASV) is a closed-loop ventilation mode that automatically controls the ventilation settings. Although a number of studies have reported the usefulness of I-ASV, the clinical situations in which it may be useful have not yet been clarified. We aimed to report our initial 3 years of experience using I-ASV, particularly the clinical conditions and the technical and organizational factors associated with its use. Furthermore, we evaluated the usefulness of I-ASV and determined the predictive factors for successful management with I-ASV. METHODS: This single-center, retrospective observational study included patients who were ventilated using the Hamilton G5® ventilator (Hamilton Medical AG, Rhäzüns, Switzerland) from January 2016 to December 2018. The patients were categorized into the "I-ASV success" group and "I-ASV failure" group (those receiving mechanical ventilation with I-ASV along with any other mode). Multivariate analysis was performed to identify factors associated with successful I-ASV management. RESULTS: Of the 189 patients, 135 (71.4%) were categorized into the I-ASV success group. In the I-ASV success group, the reasons for ICU admission included post-elective surgery (94.1%), post-emergent surgery (81.5%), and other medical reasons (55.6%). I-ASV failure was associated with a low P/F ratio (278 vs. 167, P = 0.0003) and high Acute Physiology and Chronic Health Evaluation (APACHE) II score (21 vs. 26, P < 0.0001). The main reasons for not using I-ASV included strong inspiratory effort and asynchrony. The APACHE II score was an independent predictive factor for successful management with I-ASV, with an odds ratio of 0.92 (95% confidential interval 0.87-0.96, P = 0.0006). The area under the receiver operating curve for the APACHE II score was 0.722 (cut-off: 24). CONCLUSIONS: In this study, we found that 71.4% of the fully mechanically ventilated patients could be managed successfully with I-ASV. The APACHE II score was an independent factor that could help predict the successful management of I-ASV. To improve I-ASV management, it is necessary to focus on patient-ventilator interactions.


Assuntos
Unidades de Terapia Intensiva , Pulmão/metabolismo , Respiração Artificial/métodos , APACHE , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
6.
Crit Care ; 23(1): 283, 2019 Aug 19.
Artigo em Inglês | MEDLINE | ID: mdl-31426849

RESUMO

BACKGROUND: Altered coagulation and alveolar injury are the hallmarks of acute respiratory distress syndrome (ARDS). However, whether the biomarkers that reflect pathophysiology differ depending on the etiology of ARDS has not been examined. This study aimed to investigate the biomarker profiles of coagulopathy and alveolar epithelial injury in two subtypes of ARDS: patients with direct common risk factors (dARDS) and those with idiopathic or immune-related diseases (iARDS), which are classified as "ARDS without common risk factors" based on the Berlin definition. METHODS: This retrospective, observational study included adult patients who were admitted to the intensive care unit (ICU) at a university hospital with a diagnosis of ARDS with no indirect risk factors. Plasma biomarkers (thrombin-antithrombin complex [TAT], plasminogen activator inhibitor [PAI]-1, protein C [PC] activity, procalcitonin [PCT], surfactant protein [SP]-D, and KL-6) were routinely measured during the first 5 days of the patient's ICU stay. RESULTS: Among 138 eligible patients with ARDS, 51 were excluded based on the exclusion criteria (n = 41) or other causes of ARDS (n = 10). Of the remaining 87 patients, 56 were identified as having dARDS and 31 as having iARDS. Among the iARDS patients, TAT (marker of thrombin generation) and PAI-1 (marker of inhibited fibrinolysis) were increased, and PC activity was above normal. In contrast, PC activity was significantly decreased, and TAT or PAI-1 was present at much higher levels in dARDS compared with iARDS patients. Significant differences were also observed in PCT, SP-D, and KL-6 between patients with dARDS and iARDS. The receiver operating characteristic (ROC) analysis showed that areas under the ROC curve for PC activity, PAI-1, PCT, SP-D, and KL-6 were similarly high for distinguishing between dARDS and iARDS (PC 0.86, P = 0.33; PAI-1 0.89, P = 0.95; PCT 0.89, P = 0.66; and SP-D 0.88, P = 0.16 vs. KL-6 0.90, respectively). CONCLUSIONS: Coagulopathy and alveolar epithelial injury were observed in both patients with dARDS and with iARDS. However, their biomarker profiles were significantly different between the two groups. The different patterns of PAI-1, PC activity, SP-D, and KL-6 may help in differentiating between these ARDS subtypes.


Assuntos
Biomarcadores/análise , Alvéolos Pulmonares/lesões , Síndrome do Desconforto Respiratório/sangue , Idoso , Biomarcadores/sangue , Feminino , Humanos , Japão , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Alvéolos Pulmonares/fisiopatologia , Síndrome do Desconforto Respiratório/fisiopatologia , Estudos Retrospectivos , Fatores de Risco
7.
Crit Care ; 23(1): 249, 2019 07 09.
Artigo em Inglês | MEDLINE | ID: mdl-31288864

RESUMO

BACKGROUND: Recent studies have suggested a low potential risk for contrast medium-induced kidney injury in patients with relatively normal renal function. However, whether contrast media cause additional deterioration of renal function in patients with acute kidney injury (AKI), including those with sepsis-associated AKI, remains unclear. This study aimed to evaluate the effect of contrast media on renal function and mortality in patients with sepsis who already had AKI. METHODS: We performed a propensity score-matched historical cohort study in the medico-surgical intensive care unit of Jichi Medical University Hospital. Adult patients who were diagnosed with sepsis and AKI were enrolled. Records from our sepsis database from 2011 to 2017 were examined. Septic patients with AKI who received contrast media within 24 h of admission (C group) were matched 1:1 with septic patients who did not receive contrast media (NC group). The primary outcome was deterioration of kidney function (DRF), which was defined as an elevation of serum creatinine levels (> 0.3 mg/dL or 1.5-fold from baseline) or induction of renal replacement therapy. RESULTS: A total of 339 septic patients with AKI were included. After propensity score adjustment, the DRF rate was similar between the C and NC groups (34.0% versus 35.0%; P = 1.00). The 7-day mortality (3.0% versus 6.0%; P = 0.50), 28-day mortality (9.2% versus 15.0%; P = 0.25), and 90-day mortality (25.8% versus 32.1%; P = 0.45) rates were comparable between the two groups. In propensity-adjusted subsets of a high-risk subset (AKI stages 2 and 3 on admission), the rate of DRF was also similar between the two groups. CONCLUSIONS: A single administration of contrast media was not associated with exacerbation of AKI or increased short/long-term mortality in patients with sepsis.


Assuntos
Injúria Renal Aguda/etiologia , Meios de Contraste/efeitos adversos , Injúria Renal Aguda/epidemiologia , Idoso , Estudos de Coortes , Meios de Contraste/uso terapêutico , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Rim/lesões , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Estatísticas não Paramétricas
8.
Crit Care Explor ; 1(5): e0013, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-32166258

RESUMO

Since endothelial function is closely related to organ dysfunction in sepsis and the relationship among endothelial injury, organ dysfunction, and other biomarkers remains unclear, we aimed to evaluate the correlation among endothelial injury, organ dysfunction, and several biomarkers in patients with sepsis. Design: This was a retrospective observational study. Setting: The study was conducted in a university hospital with 14 mixed ICU beds. Patients: ICU patients with sepsis from June 2011 to December 2017 were enrolled in this study. Interventions: Endothelial biomarkers (soluble thrombomodulin, plasminogen activator inhibitor-1, and protein C) and markers of inflammation and coagulation were evaluated during the ICU stay. Sequential Organ Failure Assessment scores were assessed for 7 days after ICU admission to determine organ dysfunction. Variables were compared among five stratified groups according to the Sequential Organ Failure Assessment score (0-2, 3-5, 6-8, 9-12, and 13-24). Regression analysis and 95% CIs were used to evaluate trends in biomarkers. Measurements and Main Results: The patients were divided into five stratified groups (Sequential Organ Failure Assessment 0-2, n = 159 [20.5%]; Sequential Organ Failure Assessment 3-5, n = 296 [38.2%]; Sequential Organ Failure Assessment 6-8, n = 182 [23.5%]; Sequential Organ Failure Assessment 9-12, n = 75 [9.7%]; Sequential Organ Failure Assessment 13-24, n = 31 [4.0%]). Protein C activity was significantly correlated with the severity of organ dysfunction. It was lower on day 1, increased upon successful treatment, and was significantly higher in groups with lower Sequential Organ Failure Assessment scores. Conclusions: Trends and activity of protein C were superior in predicting organ dysfunction compared with other endothelial biomarkers. Monitoring the level of protein C activity is an ideal tool to monitor organ dysfunctions in patients with sepsis.

9.
J Intensive Care ; 6: 55, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30181880

RESUMO

Background: Intravenous glycerol treatment, usually administered in the form of a 5% fructose solution, can be used to reduce intracranial pressure. The administered fructose theoretically influences blood lactate levels, although little is known regarding whether intravenous glycerol treatment causes transient hyperlactatemia. This study aimed to evaluate blood lactate levels in patients who received intravenous glycerol or mannitol. Methods: This single-center prospective observational study was performed at a 14-bed general intensive care unit between August 2016 and January 2018. Patients were excluded if they were < 20 years old or had pre-existing hyperlactatemia (blood lactate > 2.0 mmol/L). The included patients received intravenous glycerol or mannitol to reduce intracranial pressure and provided blood samples for lactate testing before and after the drug infusion (before the infusion and after 15 min, 30 min, 45 min, 60 min, 90 min, 120 min, and 150 min). Results: Among the 33 included patients, 13 patients received 200 mL of glycerol over 30 min, 13 patients received 200 mL of glycerol over 60 min, and 7 patients received 300 mL of mannitol over 60 min. Both groups of patients who received glycerol had significantly higher lactate levels than the mannitol group (2.8 mmol/L vs. 2.2 mmol/L vs. 1.6 mmol/L, P < 0.0001), with the magnitude of the increase in lactate levels corresponding to the glycerol infusion time. There were no significant inter-group differences in cardiac index, stroke volume, or stroke volume variation. In the group that received the 30-min glycerol infusion, blood lactate levels did not return to the normal range until after 120 min. Conclusions: Intravenous administration of glycerol leads to higher blood lactate levels that persist for up to 120 min. Although hyperlactatemia is an essential indicator of sepsis and/or impaired tissue perfusion, physicians should be aware of this phenomenon when assessing the blood lactate levels.

10.
BMC Nephrol ; 19(1): 101, 2018 05 02.
Artigo em Inglês | MEDLINE | ID: mdl-29716530

RESUMO

BACKGROUND: We hypothesized that the use of actual body weight might lead to more frequent misdiagnosis of acute kidney injury (AKI) than when ideal body weight is used in underweight and/or obese patients. We examined which definition of body weight is most effective in establishing a urinary diagnosis of AKI in septic patients. METHODS: Consecutive patients aged ≥ 20 years admitted to the intensive care unit of a university hospital between June 2011 and December 2016 were analyzed. Sepsis was defined in accordance with the Sepsis-3 criteria. AKI was defined as a urinary output of < 0.5 mL/kg/6h during intensive care unit stay. Patients were divided into one of four body mass index-based classes. The severity of illness and 90-day mortality were compared across the body mass index subgroups in patients diagnosed using the actual body weight or ideal body weight. RESULTS: Of 5764 patients, 569 septic patients were analyzed. One hundred and fifty-three (26.9%) and 140 (24.6%) patients were diagnosed as having AKI using actual body weight and ideal body weight, respectively. There were no significant differences in the severity of illness among these groups. Also, 90-day mortality did not differ significantly among these groups. According to body mass index, 90-day mortality significantly differed in patients diagnosed using their actual body weights (underweight vs. normal vs. overweight vs. obese: 76.7% vs. 39.5% vs. 26.0% vs. 35.7%, P = 0.033). CONCLUSION: Generally, using actual body weight to calculate the weight-adjusted hourly urine output for diagnosing AKI increased the sensitivity compared to ideal body weight, irrespective of the severity of illness in septic patients. Delayed diagnosis, however, was more common among underweight patients in this situation, and clinicians should be cautious when diagnosing urinary AKI using actual body weight.


Assuntos
Injúria Renal Aguda/diagnóstico , Peso Corporal , Erros de Diagnóstico , Sepse/complicações , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/urina , Idoso , Índice de Massa Corporal , Creatinina/sangue , Cistatina C/sangue , Diagnóstico Tardio , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Sobrepeso/complicações , Estudos Retrospectivos , Índice de Gravidade de Doença , Magreza/complicações
11.
PLoS One ; 13(1): e0192064, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29381746

RESUMO

INTRODUCTION: The pathogenesis of thrombocytopenia in patients with sepsis is not fully understood. The aims of this study were to investigate changes in thrombopoietic activity over time by using absolute immature platelet counts (AIPC) and to examine the impact of platelet production on thrombocytopenia and mortality in patients with sepsis. METHODS: This retrospective observational study included adult patients with sepsis admitted to the intensive care unit at a university hospital. Two hundred five consecutive sepsis patients were stratified into four groups according to nadir platelet count: severe (nadir ≤40×103/µL), moderate (41-80×103/µL), or mild thrombocytopenia (81-120×103/µL), or normal-increased platelet count (>120×103/µL). The development of thrombocytopenia was assessed during the first week; mortality was assessed at day 28. RESULT: Of the 205 patients included, 61 (29.8%) developed severe thrombocytopenia. On admission, AIPC did not differ among the four groups. In patients with severe thrombocytopenia, AIPC decreased significantly from days 2 to 7, but remained within or above the normal range in the other three groups (overall group comparison, P<0.0001). Multivariate analysis including coagulation biomarkers revealed that AIPC was independently associated with the development of severe thrombocytopenia (day 3 AIPC, odds ratio 0.49 [95% confidence interval (CI) 0.35-0.66], P<0.0001; day 5 AIPC, 0.59 [95% CI 0.45-0.75], P<0.0001). AIPC was a significant predictor of 28-day mortality in Cox hazard models adjusted for Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores (day 3 AIPC, hazard ratio 0.70 [95% CI 0.52-0.89], P = 0.0029; day 5 AIPC, 0.68 [95% CI 0.49-0.87], P = 0.0012). CONCLUSIONS: Thrombopoietic activity was generally maintained in the acute phase of sepsis. However, a decrease in AIPC after admission was independently associated with the development of severe thrombocytopenia and mortality, suggesting the importance of suppressed thrombopoiesis in the pathophysiology of sepsis-induced thrombocytopenia.


Assuntos
Contagem de Plaquetas , Sepse/complicações , Trombocitopenia/patologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sepse/mortalidade , Trombocitopenia/complicações
12.
Crit Care ; 21(1): 229, 2017 Aug 25.
Artigo em Inglês | MEDLINE | ID: mdl-28841902

RESUMO

BACKGROUND: Endothelial activation and damage occur early during sepsis, with activated coagulopathy and playing a major role in the pathophysiology of sepsis-induced acute kidney injury (AKI). The aim of this study was to compare the various biomarkers of endothelial injury with the biomarkers of coagulation and inflammation and to determine a significant predictor of AKI in patients with sepsis. METHODS: We conducted a single-center, retrospective, observational study on patients with sepsis fulfilling the Third International Consensus Definitions for Sepsis and Septic Shock criteria admitted to an adult intensive care unit (ICU) at a university hospital from June 2011 to December 2016. Levels of 13 biomarkers were measured on ICU admission, including markers of endothelial injury (soluble thrombomodulin [sTM], E-selectin, protein C, and plasminogen activator inhibitor-1 [PAI-1]) and markers of coagulation derangement (platelet count, fibrin degradation product [FDP], prothrombin time [PT], fibrinogen, α2-plasminogen inhibitor [α2-PI], antithrombin III [AT III], plasminogen, thrombin-antithrombin complex, and plasmin-α2-plasmin inhibitor complex). All patients with sepsis were reviewed, and the development of AKI was evaluated. Multivariate logistic regression analysis was performed to identify significant independent predictive factors for AKI. RESULTS: Of the 514 patients admitted with sepsis, 351 (68.3%) developed AKI. Compared with the non-AKI group, all the endothelial biomarkers were significantly different in the AKI group (sTM [23.6 vs. 15.6 U/ml, P < 0.0001], E-selectin [65.5 vs. 46.2 ng/ml, P = 0.0497], PAI-1 [180.4 vs. 75.3 ng/ml, P = 0.018], and protein C [45.9 vs. 58.7 ng/ml, P < 0.0001]). Biomarkers of coagulopathy and inflammation, platelet counts, FDP, PT, α2-PI, AT III, plasminogen, and C-reactive protein were significantly different between the two groups. Multivariable logistic regression analysis showed that sTM was an independent predictive factor of AKI, with an AUROC of 0.758 (P < 0.0001). CONCLUSIONS: Endothelial biomarkers were significantly changed in the sepsis patients with AKI. Particularly, sTM was an independent predictive biomarker for the development of AKI that outperformed other coagulation and inflammation biomarkers as well as organ function in patients with sepsis.


Assuntos
Injúria Renal Aguda/diagnóstico , Sepse/complicações , Trombomodulina/análise , APACHE , Injúria Renal Aguda/induzido quimicamente , Idoso , Biomarcadores/análise , Biomarcadores/sangue , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Japão , Masculino , Pessoa de Meia-Idade , Inibidor 1 de Ativador de Plasminogênio/análise , Inibidor 1 de Ativador de Plasminogênio/sangue , Proteína C/análise , Proteína C/metabolismo , Estudos Retrospectivos , Trombomodulina/sangue
13.
Biomed Res Int ; 2017: 7452604, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28567422

RESUMO

BACKGROUND: The risk factors for the mortality rate of Pneumocystis jirovecii pneumonia (PCP) who required mechanical ventilation (MV) remained unknown. METHODS: A retrospective chart review was performed of all PCP patients admitted to our intensive care unit and treated for acute hypoxemic respiratory failure to assess the risk factors for the high mortality. RESULTS: Twenty patients without human immunodeficiency virus infection required mechanical ventilation; 19 received noninvasive ventilation; and 11 were intubated. PEEP was incrementally increased and titrated to maintain FIO2 as low as possible. No mandatory ventilation was used. Sixteen patients (80%) survived. Pneumothorax developed in one patient with rheumatoid arthritis (RA). Median PEEP level in the first 5 days was 10.0 cmH2O and not associated with death. Multivariate analysis showed the association of incidence of interstitial lung disease and increase in serum KL-6 with 90-day mortality. CONCLUSIONS: We found MV strategies to prevent pneumothorax including liberal use of noninvasive ventilation, and PEEP titration and disuse of mandatory ventilation may improve mortality in this setting. Underlying disease of interstitial lung disease was a risk factor and KL-6 may be a useful predictor associated with mortality in patients with RA. These findings will need to be validated in larger studies.


Assuntos
Mucina-1/sangue , Pneumocystis carinii , Pneumonia por Pneumocystis/terapia , Respiração Artificial , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia por Pneumocystis/sangue , Pneumonia por Pneumocystis/etiologia , Estudos Retrospectivos
14.
Springerplus ; 5(1): 716, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27375985

RESUMO

PURPOSE: Low tidal volume ventilation improves the outcomes of acute respiratory distress syndrome (ARDS). However, no studies have investigated the use of a rescue therapy involving mechanical ventilation when low tidal volume ventilation cannot maintain homeostasis. Inverse ratio ventilation (IRV) is one candidate for such rescue therapy, but the roles and effects of IRV as a rescue therapy remain unknown. METHODS: We undertook a retrospective review of the medical records of patients with ARDS who received IRV in our hospital from January 2007 to May 2014. Gas exchange, ventilation, and outcome data were collected and analyzed. RESULTS: Pressure-controlled IRV was used for 13 patients during the study period. Volume-controlled IRV was not used. IRV was initiated on 4.4 ventilation days when gas exchange could not be maintained. IRV significantly improved the PaO2/FiO2 from 76 ± 27 to 208 ± 91 mmHg without circulatory impairment. The mean duration of IRV was 10.5 days, and all survivors were weaned from mechanical ventilation and discharged. The 90-day mortality rate was 38.5 %. Univariate analysis showed that the duration of IRV was associated with the 90-day mortality rate. No patients were diagnosed with pneumothorax. CONCLUSIONS: Pressure-controlled IRV provided acceptable gas exchange without apparent complications and served as a successful bridge to conventional treatment when used as a rescue therapy for moderate to severe ARDS.

15.
J Intensive Care ; 4: 26, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27057312

RESUMO

BACKGROUND: Patient-ventilator asynchrony is a major cause of difficult weaning from mechanical ventilation. Neurally adjusted ventilatory assist (NAVA) is reported useful to improve the synchrony in patients with sustained low lung compliance. However, the role of NAVA has not been fully investigated. CASE PRESENTATION: The patient was a 63-year-old Japanese man with acute respiratory distress syndrome secondary to respiratory infection. He was treated with extracorporeal membrane oxygenation for 7 days and survived. Dynamic compliance at withdrawal of extracorporeal membrane oxygenation decreased to 20 ml/cmH2O or less, but gas exchange was maintained by full support with assist/control mode. However, weaning from mechanical ventilation using a flow trigger failed repeatedly because of patient-ventilator asynchrony with hypercapnic acidosis during partial ventilator support despite using different types of ventilators and different trigger levels. Weaning using NAVA restored the regular respiration and stable and normal acid-base balance. Electromyographic analysis of the diaphragm clearly showed improved triggering of both the start and the end of spontaneous inspiration. Regional ventilation monitoring using electrical impedance tomography showed an increase in tidal volume and a ventilation shift to the dorsal regions during NAVA, indicating that NAVA could deliver gas flow to the dorsal regions to adjust for the magnitude of diaphragmatic excursion. NAVA was applied for 31 days, followed by partial ventilatory support with a conventional flow trigger. The patient was discharged from the intensive care unit on day 110 and has recovered enough to be able to live without a ventilatory support for 5 h per day. CONCLUSION: Our experience showed that NAVA improved not only patient-ventilator synchrony but also regional ventilation distribution in an acute respiratory distress patient with sustained low lung compliance.

16.
Am J Nephrol ; 42(1): 57-64, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26337793

RESUMO

BACKGROUND/AIMS: Acute kidney injury (AKI) is associated with high mortality. Multiple AKI severity scores have been derived to predict patient outcome. We externally validated new AKI severity scores using the Japanese Society for Physicians and Trainees in Intensive Care (JSEPTIC) database. METHODS: New AKI severity scores published in the 21st century (Mehta, Stuivenberg Hospital Acute Renal Failure (SHARF) II, Program to Improve Care in Acute Renal Disease (PICARD), Vellore and Demirjian), Liano, Simplified Acute Physiology Score (SAPS) II and lactate were compared using the JSEPTIC database that collected retrospectively 343 patients with AKI who required continuous renal replacement therapy (CRRT) in 14 intensive care units. Accuracy of the severity scores was assessed by the area under the receiver-operator characteristic curve (AUROC, discrimination) and Hosmer-Lemeshow test (H-L test, calibration). RESULTS: The median age was 69 years and 65.8% were male. The median SAPS II score was 53 and the hospital mortality was 58.6%. The AUROC curves revealed low discrimination ability of the new AKI severity scores (Mehta 0.65, SHARF II 0.64, PICARD 0.64, Vellore 0.64, Demirjian 0.69), similar to Liano 0.67, SAPS II 0.67 and lactate 0.64. The H-L test also demonstrated that all assessed scores except for Liano had significantly low calibration ability. CONCLUSIONS: Using a multicenter database of AKI patients requiring CRRT, this study externally validated new AKI severity scores. While the Demirjian's score and Liano's score showed a better performance, further research will be required to confirm these findings.


Assuntos
Injúria Renal Aguda/mortalidade , Índice de Gravidade de Doença , Injúria Renal Aguda/terapia , Idoso , Área Sob a Curva , Calibragem , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Japão , Masculino , Pessoa de Meia-Idade , Curva ROC , Terapia de Substituição Renal , Estudos Retrospectivos
17.
J Crit Care ; 30(5): 998-1002, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26220246

RESUMO

PURPOSE: We aimed to study the clinical characteristics, courses, and outcomes of critically ill patients with septic acute kidney injury (AKI) treated with continuous renal replacement therapy (CRRT) in comparison with nonseptic AKI treated with CRRT. METHODS: This is a multicenter retrospective observational study conducted in 14 Japanese intensive care units in 2010. All adult patients with severe AKI treated with CRRT were eligible (n = 343), and information on patient characteristics, variables at CRRT initiation, CRRT settings, and outcomes was collected. Patients were categorized into the septic AKI group and the nonseptic AKI group according to contributing factors to AKI. RESULTS: Approximately half of study patients (48.7%) had sepsis/septic shock as a contributing factor to AKI, and patients with septic AKI treated with CRRT had more serious clinical conditions than patients with nonseptic AKI. However, no significant difference was observed in intensive care unit mortality (48.5% vs 43.8%; P = .44) and hospital mortality (61.1% vs 56.3%; P = .42) between patients with septic and nonseptic AKIs treated with CRRT. Furthermore, sepsis was associated with lower hospital mortality (odds ratio, 0.378; P = .012) in multivariable regression analysis. CONCLUSION: Sepsis may not be a risk factor for mortality in patients with AKI whose condition has become severe enough to require CRRT.


Assuntos
Injúria Renal Aguda/mortalidade , Estado Terminal/mortalidade , Terapia de Substituição Renal/mortalidade , Sepse/mortalidade , Injúria Renal Aguda/sangue , Injúria Renal Aguda/fisiopatologia , Adulto , Idoso , Biomarcadores/sangue , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Razão de Chances , Prognóstico , Terapia de Substituição Renal/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Sepse/complicações , Sepse/fisiopatologia , Taxa de Sobrevida
18.
Intern Med ; 54(7): 731-5, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25832933

RESUMO

Objective Fibre-optic bronchoscopy with bronchoalveolar lavage (FOB-BAL) is an important tool for diagnosing and selecting treatment for acutely hypoxaemic patients with diffuse lung infiltrates. However, FOB-BAL carries a risk of significant hypoxaemia and subsequent tracheal intubation during and after the procedure. The application of FOB-BAL using a laryngeal mask airway (LMA) in combination with continuous positive airway pressure (CPAP) may minimize the incidence of hypoxaemia; however, the safety and efficacy of this procedure have not been investigated. Methods A retrospective chart review was performed from April to September 2013. Data regarding the recovered volume of BAL fluid, incidence of tracheal intubation within eight hours after the completion of FOB-BAL, respiratory and haemodynamic parameters and treatment modifications were collected for the evaluation. Results Ten trials of FOB-BAL using an LMA and CPAP were performed in nine patients with severe acute hypoxaemia associated with diffuse lung infiltrates. The BAL fluid recovery rate was 56%, and the procedure was completed without subsequent complications. In addition, the percutaneous arterial oxygen saturation decreased to 95.7%±3.8%, although it was never lower than 90.0% during the procedure, and no patients required intubation. Furthermore, the arterial blood pressure significantly but transiently decreased due to sedation, and the procedure yielded diagnostic information in all nine patients. Conclusion FOB-BAL using LMA and CPAP appears to be safe and effective in patients who develop severe acute hypoxaemia.


Assuntos
Lavagem Broncoalveolar/instrumentação , Hipóxia/terapia , Intubação Intratraqueal/instrumentação , Máscaras Laríngeas , Síndrome do Desconforto Respiratório/terapia , Insuficiência Respiratória/terapia , Idoso , Lavagem Broncoalveolar/efeitos adversos , Broncoscopia/métodos , Pressão Positiva Contínua nas Vias Aéreas , Feminino , Tecnologia de Fibra Óptica , Hemodinâmica , Humanos , Hipóxia/etiologia , Intubação Intratraqueal/efeitos adversos , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Troca Gasosa Pulmonar , Síndrome do Desconforto Respiratório/etiologia , Insuficiência Respiratória/etiologia , Estudos Retrospectivos
19.
Crit Care ; 18(5): 539, 2014 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-25672828

RESUMO

INTRODUCTION: The recommended lower limit of intensity during continuous renal replacement therapy (CRRT) is 20 or 25 mL/kg/h. However, limited information is available to support this threshold. We aimed to evaluate the impact of different intensities of CRRT on the clearance of creatinine and urea in critically ill patients with severe acute kidney injury (AKI). METHODS: This is a multicenter retrospective study conducted in 14 Japanese ICUs in 12 centers. All patients older than 18 years and treated with CRRT due to AKI were eligible. We evaluated the effect of CRRT intensity by two different definitions: daily intensity (the mean intensity over each 24-h period) and average intensity (the mean of daily intensity during the period while CRRT was performed). To study the effect of different CRRT intensity on clearance of urea and creatinine, all patients/daily observations were arbitrarily allocated to one of 4 groups based on the average intensity and daily intensity: <10, 10-15, 15-20, and >20 mL/kg/h. RESULTS: Total 316 patients were included and divided into the four groups according to average CRRT intensity. The groups comprised 64 (20.3%), 138 (43.7%), 68 (21.5%), and 46 patients (14.6%), respectively. Decreases in creatinine and urea increased as the average intensity increased over the first 7 days of CRRT. The relative changes of serum creatinine and urea levels remained close to 1 over the 7 days in the "<10" group. Total 1,101 daily observations were included and divided into the four groups according to daily CRRT intensity. The groups comprised 254 (23.1%), 470 (42.7%), 239 (21.7%), and 138 observations (12.5%), respectively. Creatinine and urea increased (negative daily change) only in the "<10" group and decreased with the increasing daily intensity in the other groups. CONCLUSIONS: The lower limit of delivered intensity to control uremia during CRRT was approximately between 10 and 15 mL/kg/h in our cohort. A prescribed intensity of approximately 15 mL/kg/h might be adequate to control uremia for patients with severe AKI in the ICU. However, considering the limitations due to the retrospective nature of this study, prospective studies are required to confirm our findings.


Assuntos
Terapia de Substituição Renal/métodos , Terapia de Substituição Renal/normas , Uremia/diagnóstico , Uremia/terapia , Idoso , Biomarcadores/sangue , Estudos de Coortes , Creatinina/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Ureia/sangue , Uremia/sangue
20.
Crit Care Med ; 41(11): 2584-91, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23939357

RESUMO

OBJECTIVE: To study the hospital mortality of patients with severe acute kidney injury treated with low-intensity continuous renal replacement therapy. DESIGN: Multicenter retrospective observational study (Japanese Society for Physicians and Trainees in Intensive Care), combined with previously conducted multinational prospective observational study (Beginning and Ending Supportive Therapy). SETTING: Fourteen Japanese ICUs in 12 tertiary hospitals (Japanese Society for Physicians and Trainees in Intensive Care) and 54 ICUs in 23 countries (Beginning and Ending Supportive Therapy). PATIENTS: Consecutive adult patients with severe acute kidney injury requiring continuous renal replacement therapy admitted to the participating ICUs in 2010 (Japanese Society for Physicians and Trainees in Intensive Care, n = 343) and 2001 (Beginning and Ending Supportive Therapy Beginning and Ending Supportive Therapy, n = 1,006). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, variables at continuous renal replacement therapy initiation, continuous renal replacement therapy settings, and outcomes (ICU and hospital mortality and renal replacement therapy requirement at hospital discharge) were collected. Continuous renal replacement therapy intensity was arbitrarily classified into seven subclasses: less than 10, 10-15, 15-20, 20-25, 25-30, 30-35, and more than 35 mL/kg/hr. Multivariable logistic regression analysis was conducted to investigate risk factors for hospital mortality. The continuous renal replacement therapy dose in the Japanese Society for Physicians and Trainees in Intensive Care database was less than half of the Beginning and Ending Supportive Therapy database (800 mL/hr vs 2,000 mL/hr, p < 0.001). Even after adjusting for the body weight and dilution factor, continuous renal replacement therapy intensity was statistically different (14.3 mL/kg/hr vs 20.4 mL/kg/hr, p < 0.001). Patients in the Japanese Society for Physicians and Trainees in Intensive Care database had a lower ICU mortality (46.1% vs 55.3%, p = 0.003) and hospital mortality (58.6% vs 64.2%, p = 0.070) compared with patients in the Beginning and Ending Supportive Therapy database. In multivariable regression analysis after combining the two databases, no continuous renal replacement therapy intensity subclasses were found to be statistically different from the reference intensity (20-25 mL/kg/hr). Several sensitivity analyses (patients with sepsis, patients from Western countries in the Beginning and Ending Supportive Therapy database) confirmed no intensity-outcome relationship. CONCLUSIONS: Continuous renal replacement therapy at a mean intensity of 14.3 mL/kg/hr did not have worse outcome compared with 20-25 mL/kg/hr of continuous renal replacement therapy, currently considered the standard intensity. However, our study is insufficient to support the use of low-intensity continuous renal replacement therapy, and more studies are needed to confirm our findings.


Assuntos
Injúria Renal Aguda/terapia , Hemofiltração/métodos , APACHE , Injúria Renal Aguda/mortalidade , Idoso , Feminino , Hemofiltração/mortalidade , Mortalidade Hospitalar , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Centros de Atenção Terciária
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