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1.
Anesth Analg ; 2020 Nov 30.
Artigo em Inglês | MEDLINE | ID: mdl-33264116

RESUMO

BACKGROUND: International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development. METHODS: In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented. RESULTS: Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking. CONCLUSIONS: This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.

2.
Respir Care ; 2020 Oct 13.
Artigo em Inglês | MEDLINE | ID: mdl-33051254

RESUMO

Recruitment maneuvers (RM) in ARDS are used to improve oxygenation and lung mechanics by apply high airway pressures to re-open collapsed or obstructed peripheral airways and alveoli. In the early 1990's RMs became a central feature of a variant form of lung protective ventilation (LPV) known as "open-lung ventilation" (OLV).This strategy is based upon the belief that repetitive opening and closing of distal airspaces induces shear injury, and therefore contributes both to ventilator-induced lung injury and ARDS-associated mortality.However, the largest, multi-center randomized controlled trial of OLV in moderate to severe ARDS, wherein RM plateau pressures of 50-60 cmH2O were used, was associated with significantly higher mortality compared to traditional LPV. Despite being based upon well conducted pre-clinical and clinical RM studies, the higher mortality associated with the OLV strategy requires re-examining the assumptions and conclusions drawn from those previous studies.This narrative review examines the evidence used to design RM strategies. We also review the radiologic, rheologic, and histopathologic evidence regarding the nature of lung injury, the phenomena of recruitment and derecruitment as it informs our perceptions of recruitment potential in ARDS. Major LPV clinical trial data and other clinical data are also examined to assess the practical necessity of RM in ARDS, and whether a subset of cases might benefit from pursuing RM therapy. Finally, a less a radical approach to RM is offered that might achieve the goals of RM with less risk of harm.

4.
Respir Care ; 2020 Jul 07.
Artigo em Inglês | MEDLINE | ID: mdl-32636278

RESUMO

BACKGROUND: The ratio of end-tidal CO2 pressure to arterial partial pressure of CO2 (P ETCO2 /P aCO2 ) was recently suggested for monitoring pulmonary gas exchange in patients with ARDS associated with COVID-19, yet no evidence was offered supporting that claim. Therefore, we evaluated whether P ETCO2 /P aCO2 might be relevant in assessing ARDS not associated with COVID-19. METHODS: We evaluated the correspondence between P ETCO2 /P aCO2 and the ratio of dead space to tidal volume (VD/VT) measured in 561 subjects with ARDS from a previous study in whom P ETCO2 data were also available. Subjects also were analyzed according to 4 ranges of P ETCO2 /P aCO2 representing increasing illness severity (≥ 0.80, 0.6-0.79, 0.50-0.59, and < 0.50). Correlation was assessed by either Pearson or Spearman tests, grouped comparisons were assessed using either ANOVA or Kruskal-Wallis tests and dichotomous variables assessed by Fisher Exact tests. Normally distributed data are presented as mean and standard deviation(SD) and non-normal data are presented as median and inter-quartile range (IQR). Overall mortality risk was assessed with multivariate logistic regression. Alpha was set at 0.05. RESULTS: P ETCO2 /P aCO2 correlated strongly with VD/VT (r = -0.87 [95% CI -0.89 to -0.85], P < .001). Decreasing P ETCO2 /P aCO2 was associated with increased VD/VT and hospital mortality between all groups. In the univariate analysis, for every 0.01 decrease in P ETCO2 /P aCO2 , mortality risk increased by ∼1% (odds ratio 0.009, 95% CI 0.003-0.029, P < .001) and maintained a strong independent association with mortality risk when adjusted for other variables (odds ratio 0.19, 95% CI 0.04-0.91, P = .039). P ETCO2 /P aCO2 < 0.50 was characterized by very high mean ± SD value for VD/VT (0.82 ± 0.05, P < .001) and high hospital mortality (70%). CONCLUSIONS: Using P ETCO2 /P aCO2 as a surrogate for VD/VT may be a useful and practical measurement for both management and ongoing research into the nature of ARDS.

6.
Br J Anaesth ; 125(1): e88-e103, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32416994

RESUMO

BACKGROUND: Capnography is universally accepted as an essential patient safety monitor in high-income countries (HICs) yet is often unavailable in low and middle-income countries (LMICs). Increasing capnography availability has been proposed as one of many potential approaches to improving perioperative outcomes in LMICs. This scoping review summarises the existing literature on the effect of capnography on patient outcomes to help prioritise interventions and guide expansion of capnography in LMICs. METHODS: We searched MEDLINE and EMBASE databases for articles published between 1980 and March 2019. Studies that assessed the impact of capnography on morbidity, mortality, or the use of airway interventions both inside and outside the operating room were included. RESULTS: The search resulted in 7445 unique papers, and 31 were included for analysis. Retrospective and non-randomised data suggest capnography use may improve outcomes in the operating room, ICU, and emergency department, and during resuscitation. Prospective data on capnography use for procedural sedation suggest earlier detection of hypoventilation and a reduction in haemoglobin desaturation events. No randomised studies exist that assess the impact of capnography on patient outcomes. CONCLUSION: Despite widespread endorsement of capnography as a mandatory perioperative monitor, rigorous data demonstrating its impact on patient outcomes are limited, especially in LMICs. The association between capnography use and a reduction in serious airway complications suggests that closing the capnography gap in LMICs may represent a significant opportunity to improve patient safety. Additional data are needed to quantify the global capnography gap and better understand the barriers to capnography scale-up in LMICs.


Assuntos
Capnografia/métodos , Capnografia/estatística & dados numéricos , Países Desenvolvidos , Países em Desenvolvimento , Segurança do Paciente/estatística & dados numéricos , Humanos , Pobreza
8.
Am J Surg ; 219(2): 263-268, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31732117

RESUMO

BACKGROUND: The Kampala Advanced Trauma Course (KATC) was developed in 2007 due to a locally identified need for an advanced trauma training curriculum for the resource-constrained setting. We describe the design, implementation and evaluation of the course. METHODS: The course has been delivered to over 1,000 interns rotating through surgery at Mulago National Referral Hospital. Participants from 2013 to 2016 were surveyed after completion of the course. RESULTS: The KATC was developed with local faculty and includes didactic and simulation modules. Over 50% of survey respondents reported feeling confident performing and teaching 7 of 11 course skills and felt the most relevant skill was airway management(30.2%). Participants felt least confident managing head trauma(26.4%). Lack of equipment(52.8%) was identified as the most common barrier to providing trauma care. CONCLUSIONS: Providers are confident with most skill sets after taking the KATC. Minimal dependence on instructors from high-income countries has kept the course sustainable and maximized local relevance.


Assuntos
Competência Clínica , Currículo , Educação de Pós-Graduação em Medicina/métodos , Traumatologia/educação , Adulto , Atitude do Pessoal de Saúde , Bases de Dados Factuais , Países em Desenvolvimento , Feminino , Humanos , Masculino , Estudos Retrospectivos , Centros de Atenção Terciária , Uganda
9.
Anesth Analg ; 129(3): 839-846, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31425228

RESUMO

BACKGROUND: In Africa, most countries have fewer than 1 physician anesthesiologist (PA) per 100,000 population. Nonphysician anesthesia providers (NPAPs) play a large role in the workforce of many low- and middle-income countries (LMICs), but little information has been systematically collected to describe existing human resources for anesthesia care models. An understanding of existing PA and NPAP training pathways and roles is needed to inform anesthesia workforce planning, especially for critically underresourced countries. METHODS: Between 2016 and 2018, we conducted electronic, phone, and in-person surveys of anesthesia providers in Africa. The surveys focused on the presence of anesthesia training programs, training program characteristics, and clinical scope of practice after graduation. RESULTS: One hundred thirty-one respondents completed surveys representing data for 51 of 55 countries in Africa. Most countries had both PA and NPAP training programs (57%; mean, 1.6 pathways per country). Thirty distinct training pathways to become an anesthesia provider could be discriminated on the basis of entry qualification, duration, and qualification gained. Of these 30 distinct pathways, 22 (73%) were for NPAPs. Physician and NPAP program durations were a median of 48 and 24 months (ranges: 36-72, 9-48), respectively. Sixty percent of NPAP pathways required a nursing background for entry, and 60% conferred a technical (eg, diploma/license) qualification after training. Physicians and NPAPs were trained to perform most anesthesia tasks independently, though few had subspecialty training (such as regional or cardiac anesthesia). CONCLUSIONS: Despite profound anesthesia provider shortages throughout Africa, most countries have both NPAP and PA training programs. NPAP training pathways, in particular, show significant heterogeneity despite relatively similar scopes of clinical practice for NPAPs after graduation. Such heterogeneity may reflect the varied needs and resources for different settings, though may also suggest lack of consensus on how to train the anesthesia workforce. Lack of consistent terminology to describe the anesthesia workforce is a significant challenge that must be addressed to accelerate workforce research and planning efforts.


Assuntos
Anestesia/métodos , Anestesiologistas/educação , Enfermeiras Anestesistas/educação , Inquéritos e Questionários , África/epidemiologia , Humanos
10.
Respir Care ; 64(5): 493-501, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30992403

RESUMO

BACKGROUND: The Berlin definition of ARDS does not account for nonpulmonary organ failure, which is a major determinant of outcome. We examined whether an increasing severity of hypoxemia across the Berlin definition classifications also corresponded with evidence of multiple organ dysfunction on the day of ARDS onset. We also examined the representation of major etiologies for ARDS across the Berlin definition classifications. METHODS: This single-center, retrospective study examined 15 years of data from a quality assurance program that monitored the use of lung-protective ventilation in ARDS. We analyzed 1,747 subjects without chronic kidney disease or severe chronic liver disease at ARDS onset. The most abnormal laboratory values at ARDS onset were analyzed as cutoff values to assess organ dysfunction. Data were analyzed by using non-parametric analysis of variance (Kruskall-Wallis test) and the Dunn post test. Categorical variables were compared by using the Fisher exact test. Alpha was set at 0.05. Factors independently associated with mortality were assessed by multivariate logistic regression modeling. RESULTS: Nonpulmonary organ dysfunction was present in at least 1 system at ARDS onset that increased with severity: 80% (mild), 83% (moderate), and 90% (severe). ARDS etiologies varied as severity increased: trauma-associated lung injury steadily decreased, whereas lung injury associated with aspiration and pneumonia steadily increased. Hospital mortality also increased significantly with the Berlin definition classifications: mild (22%), moderate (30%), and severe (47%). Multivariate logistic regression modeling revealed that the Berlin definition of severe ARDS was independently associated with mortality, as were cutoff values for renal and hepatic function as well as acidemia. Normal hematologic function and the absence of standard exclusion criteria used for therapeutic clinical trials in ARDS were protective. CONCLUSIONS: Nonpulmonary organ dysfunction was present at ARDS onset in most subjects and was more pronounced as ARDS severity increased. The Berlin definition classification of ARDS provided an elegant scheme for studying the syndrome because it coincided with increasing multiple organ dysfunction.


Assuntos
Insuficiência de Múltiplos Órgãos/etiologia , Escores de Disfunção Orgânica , /complicações , APACHE , Acidose/etiologia , Lesão Renal Aguda/etiologia , Adulto , Feminino , Mortalidade Hospitalar , Humanos , Hipotensão/etiologia , Hipóxia/etiologia , Hepatopatias/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
11.
Simul Healthc ; 14(2): 113-120, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30601468

RESUMO

STATEMENT: Simulation is relatively new in many low-income countries. We describe the challenges encountered, solutions deployed, and the costs incurred while establishing two simulation centers in Uganda. The challenges we experienced included equipment costs, difficulty in procurement, lack of context-appropriate curricula, unreliable power, limited local teaching capacity, and lack of coordination among user groups. Solutions we deployed included improvisation of equipment, customization of low-cost simulation software, creation of context-specific curricula, local administrative support, and creation of a simulation fellowship opportunity for local instructors. Total costs for simulation setups ranged from US $165 to $17,000. For centers in low-income countries trying to establish simulation programs, our experience suggests that careful selection of context-appropriate equipment and curricula, engagement with local and international collaborators, and early emphasis to increase local teaching capacity are essential. Further studies are needed to identify the most cost-effective levels of technological complexity for simulation in similar resource-constrained settings.


Assuntos
Educação Médica/métodos , Treinamento por Simulação/estatística & dados numéricos , Custos e Análise de Custo , Países em Desenvolvimento , Equipamentos Médicos Duráveis/economia , Equipamentos Médicos Duráveis/provisão & distribução , Educação Médica/economia , Fontes de Energia Elétrica/normas , Docentes de Medicina/normas , Humanos , Projetos Piloto , Treinamento por Simulação/economia , Uganda
12.
Acad Med ; 94(4): 482-489, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30398990

RESUMO

Large numbers of U.S. physicians and medical trainees engage in hands-on clinical global health experiences abroad, where they gain skills working across cultures with limited resources. Increasingly, these experiences are becoming bidirectional, with providers from low- and middle-income countries traveling to experience health care in the United States, yet the same hands-on experiences afforded stateside physicians are rarely available for foreign medical graduates or postgraduate trainees when they arrive. These physicians are typically limited to observership experiences where they cannot interact with patients in most U.S. institutions. In this article, the authors discuss this inequity in global medical education, highlighting the shortcomings of the observership training model and the legal and regulatory barriers prohibiting foreign physicians from engaging in short-term clinical training experiences. They provide concrete recommendations on regulatory modifications that would allow meaningful short-term clinical training experiences for foreign medical graduates, including the creation of a new visa category, the designation of a specific temporary licensure category by state medical boards, and guidance for U.S. host institutions supporting such experiences. By proposing this framework, the authors hope to improve equity in global health partnerships via improved access to meaningful and productive educational experiences, particularly for foreign medical graduates with commitment to using their new knowledge and training upon return to their home countries.


Assuntos
Médicos Graduados Estrangeiros/legislação & jurisprudência , Saúde Global/educação , Equidade em Saúde/tendências , Educação Médica/métodos , Educação Médica/normas , Emigrantes e Imigrantes/legislação & jurisprudência , Médicos Graduados Estrangeiros/provisão & distribução , Médicos Graduados Estrangeiros/tendências , Saúde Global/tendências , Humanos , Licenciamento/legislação & jurisprudência , Licenciamento/tendências , Estados Unidos
13.
J Thorac Dis ; 10(8): 5030-5038, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30233877

RESUMO

Background: Common causes of acute respiratory distress syndrome (ARDS) include pneumonia, aspiration, non-pulmonary sepsis and trauma. Little is known about pulmonary mechanics and gas exchange in less-common etiologies of ARDS, which comprises 12-23% of cases. Our hospital's ARDS quality assurance database contained a substantial number of these cases. This descriptive study examines the pulmonary mechanics, and gas exchange characteristics of this diverse cohort of ARDS subjects. Methods: Between March 2010 and April 2017 we identified 94 subjects with less common etiologies of ARDS who had dead space fraction (VD/VT) and respiratory system compliance (CRS) measured within 24 hours of ARDS onset; 86 of whom did not have sepsis as a co-diagnosis. There were 18 identifiable sources of ARDS. For descriptive purposes these were subsumed under 10 etiologic categories: pancreatitis (n=16), hemorrhagic shock/reperfusion injury (n=9), transfusion-associated acute lung injury (TRALI) (n=3), drug overdose (n=13), inhalation injury (n=10), idiopathic (n=10), neurogenic (n=8), pulmonary toxicity (n=3), hyper-immune response (n=4), hepatic failure (n=7), and 3 other cases: 2 cutaneous burns and one case of malaria. VD/VT was measured using the Enghoff-Bohr equation. Arterial blood gases were drawn simultaneously with mixed expired CO2 using volumetric capnography and standard pulmonary mechanics measurements. Data are expressed as median (IQR). Comparisons between groups used Kruskal-Wallis and Dunn's post-tests, Mann-Whitney tests or Fisher exact tests. Results: The majority of less common ARDS were from indirect sources (79%) with 9% attributed to direct causes and 11% idiopathic. Because of the small sample sizes, there were no differences in pulmonary mechanics or gas exchange between subgroups classified as indirect, direct and idiopathic, or between subgroups sharing common lung injury mechanisms. Nevertheless, salient trends were apparent particularly in CRS and VD/VT. CRS was most severely reduced in the toxicity subgroup and least impaired in the idiopathic subgroup [18 (11 to 22), and 40 (30 to 43) mL/cmH2O respectively]. VD/VT was extraordinarily high in the hepatic failure subgroup and lowest in pancreatitis [0.78 (0.57 to 0.79) and 0.54 (0.47 to 0.65) respectively]. There was less distinction in oxygenation as median values for all subgroups met moderate ARDS criteria. For the entire cohort, only VD/VT was statistically different between non-survivors and survivors: 0.66 (0.57 to 0.78) vs. 0.59 (0.51 to 0.68), P=0.012. Conclusions: Within a diverse cohort having less common presentations of ARDS, there was apparent variability in the distribution of CRS, VD/VT compared to differences oxygenation dysfunction. Elevated pulmonary dead space still identified patients with higher mortality, as is the case with more common causes of ARDS.

15.
Anesth Analg ; 126(2): 579-587, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29189269

RESUMO

BACKGROUND: Currently, no reliable method exists for continuous, noninvasive measurements of absolute cerebral blood flow (CBF). We sought to determine how changes measured by ultrasound-tagged near-infrared spectroscopy (UT-NIRS) compare with changes in CBF as measured by transcranial Doppler (TCD) in healthy volunteers during profound hypocapnia and hypercapnia. METHODS: Ten healthy volunteers were monitored with a combination of TCD, UT-NIRS (c-FLOW, Ornim Medical), as well as heart rate, blood pressure, end-tidal PCO2 (PEtCO2), end-tidal O2, and inspired O2. Inspired CO2 and minute ventilation were controlled to achieve 5 stable plateau goals of EtCO2 at 15-20, 25-30, 35-40, 45-50, and 55-60 mm Hg, for a total of 7 measurements per subject. CBF was assessed at a steady state, with the TCD designated as the reference standard. The primary analysis was a linear mixed-effect model of TCD and UT-NIRS flow with PEtCO2, which accounts for repeated measures. Receiver operating characteristic curves were determined for detection of changes in CBF. RESULTS: Hyperventilation (nadir PEtCO2 17.1 ± 2.4) resulted in significantly decreased mean flow velocity of the middle cerebral artery from baseline (to 79% ± 22%), but not a consistent decrease in UT-NIRS cerebral flow velocity index (n = 10; 101% ± 6% of baseline). Hypercapnia (peak PEtCO2 59.3 ± 3.3) resulted in a significant increase from baseline in both mean flow velocity of the middle cerebral artery (153% ± 25%) and UT-NIRS (119% ± 11%). Comparing slopes versus PEtCO2 as a percent of baseline for the TCD (1.7% [1.5%-2%]) and UT-NIRS (0.4% [0.3%-0.5%]) shows that the UT-NIRS slope is significantly flatter, P < .0001. Area under the receiver operating characteristic curve was significantly higher for the TCD than for UT-NIRS, 0.97 (95% confidence interval, 0.92-0.99) versus 0.75 (95% confidence interval, 0.66-0.82). CONCLUSIONS: Our data indicate that UT-NIRS cerebral flow velocity index detects changes in CBF only during hypercarbia but not hypocarbia in healthy subjects and with much less sensitivity than TCD. Additional refinement and validation are needed before widespread clinical utilization of UT-NIRS.


Assuntos
Velocidade do Fluxo Sanguíneo/fisiologia , Circulação Cerebrovascular/fisiologia , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Ultrassonografia Doppler Transcraniana/métodos , Adulto , Feminino , Humanos , Masculino , Monitorização Intraoperatória/métodos , Monitorização Intraoperatória/normas , Espectroscopia de Luz Próxima ao Infravermelho/normas , Ultrassonografia Doppler Transcraniana/normas
16.
Respir Care ; 63(1): 1-10, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29018041

RESUMO

BACKGROUND: Spontaneous breathing trials (SBTs) and daily sedation interruptions (DSIs) reduce both the duration of mechanical ventilation and ICU length of stay (LOS). The impact of these practices in patients with ARDS has not previously been reported. We examined whether implementation of SBT/DSI protocols reduce duration of mechanical ventilation and ICU LOS in a retrospective group of subjects with ARDS at a large, urban, level-1 trauma center. METHODS: All ARDS survivors from 2002 to 2016 (N = 1,053) were partitioned into 2 groups: 397 in the pre-SBT/DSI group (June 2002-December 2007) and 656 in the post-SBT/DSI group (January 2009-April 2016). Patients from 2008, during the protocol implementation period, were excluded. An additional SBT protocol database (2008-2010) was used to assess the efficacy of SBT in transitioning subjects with ARDS to unassisted breathing. Comparisons were assessed by either unpaired t tests or Mann-Whitney tests. Multiple comparisons were made using either one-way analysis of variance or Kruskal-Wallis and Dunn's tests. Linear regression modeling was used to determine variables independently associated with mechanical ventilation duration and ICU LOS; differences were considered statistically significant when P < .05. RESULTS: Compared to the pre-protocol group, subjects with ARDS managed with SBT/DSI protocols experienced pronounced reductions both in median (IQR) mechanical ventilation duration (14 [6-29] vs 9 [4-17] d, respectively, P < .001) and median ICU LOS (18 [8-33] vs 13 [7-22] d, respectively P < .001). In the final model, only treatment in the SBT/DSI period and higher baseline respiratory system compliance were independently associated with reduced mechanical ventilation duration and ICU LOS. Among subjects with ARDS in the SBT performance database, most achieved unassisted breathing with a median of 2 SBTs. CONCLUSION: Evidenced-based protocols governing weaning and sedation practices were associated with both reduced mechanical ventilation duration and ICU LOS in subjects with ARDS. However, higher respiratory system compliance in the SBT/DSI cohort also contributed to these improved outcomes.


Assuntos
Sedação Consciente/métodos , Respiração Artificial/estatística & dados numéricos , Desmame do Respirador/métodos , Adulto , Protocolos Clínicos , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Respiração Artificial/métodos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
17.
Respir Care ; 62(8): 1014-1022, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28559468

RESUMO

BACKGROUND: ARDS is characterized by decreased functional residual capacity (FRC), heterogeneous lung injury, and severe hypoxemia. Tidal ventilation is preferentially distributed to ventilated alveoli. Aerosolized prostaglandin I2 exploits this pathophysiology by inducing local vasodilation, thereby increasing ventilation-perfusion matching and reducing hypoxemia. Therefore, aerosolized prostaglandin I2 efficacy may depend upon FRC. Both PaO2 /FIO2 and compliance of the respiratory system (CRS) are indirect signifiers of FRC and thus may partly determine the response to aerosolized prostaglandin I2. METHODS: We reviewed the records of 208 ARDS subjects who received aerosolized prostaglandin I2 and had arterial blood gases done before and after the initiation of therapy, without other ventilator manipulations. Subjects were grouped according to baseline PaO2 /FIO2 (lowest: < 60, intermediate: 60-90, highest: > 90 mm Hg) and CRS (< 20, 20-29, 30-39, and ≥ 40 mL/cm H2O) and by other factors, such as sepsis. Comparisons were analyzed by paired t tests, or Kruskal-Wallis and Dunn post-tests. Multivariate logistic regression modeling was done to determine which of 18 clinically relevant factors were most predictive for responding to aerosolized prostaglandin I2. α was set at .05. RESULTS: Mean PaO2 /FIO2 increased by 33 mm Hg (42%) upon initiation of prostaglandin I2, with a responder rate of 62%. PaO2 /FIO2 increased significantly in all oxygenation groups. The highest baseline PaO2 /FIO2 group had the greatest improvement and responder rate (51 ± 63 mm Hg, and 82%). In addition, those with sepsis had a smaller improvement in PaO2 /FIO2 compared with those without sepsis (18 ± 35 vs 40 ± 55 mm Hg, P = .002). Both PaO2 /FIO2 and responder rate increased as CRS improved, but between-group improvements were not as consistent. In the final model, the only factors that predicted a positive response to aerosolized prostaglandin I2 were baseline PaO2 /FIO2 (odds ratio 1.10 [1.004-1.205], P = .042) and CRS (odds ratio 1.04 [1.01-1.08], P = .02). CONCLUSIONS: Aerosolized prostaglandin I2 improves oxygenation in approximately 60% of ARDS cases. A favorable response was most strongly associated with baseline PaO2 /FIO2 and CRS.


Assuntos
Epoprostenol/administração & dosagem , Hipóxia/tratamento farmacológico , Inibidores da Agregação de Plaquetas/administração & dosagem , /fisiopatologia , Administração por Inalação , Adulto , Gasometria , Feminino , Capacidade Residual Funcional , Humanos , Hipóxia/etiologia , Hipóxia/fisiopatologia , Modelos Logísticos , Complacência Pulmonar , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do Tratamento
18.
Respir Care ; 62(10): 1241-1248, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28611227

RESUMO

BACKGROUND: In ARDS, elevated pulmonary dead-space fraction (VD/VT) is a particularly strong indicator of mortality risk. Whether the magnitude of VD/VT is modified by the underlying etiology of ARDS and whether this influences the strength of its association with mortality remains unknown. We sought to elucidate the impact of ARDS etiology on VD/VT and also to determine whether ARDS severity, as classified by the Berlin definition, has correspondence with changes in VD/VT. METHODS: This single-center, retrospective, observational study (2010-2016) measured VD/VT in 685 subjects with ARDS as part of clinical management with lung-protective ventilation. Volumetric capnography was used to measure VD/VT with 99% of measurements occurring within 48 h of ARDS onset. Demographic information as well as illness severity scores and pulmonary mechanics data also were collected. Multivariate logistic regression modeling was done to assess the strength of association between VD/VT and mortality. RESULTS: VD/VT was elevated across etiologies, with aspiration and pneumonia having significantly higher VD/VT than non-pulmonary sepsis or trauma. Differences in the magnitude of VD/VT across etiologies did not necessarily correspond with mortality between etiologies. However, within each etiology grouping, VD/VT was significantly elevated in non-survivors versus survivors. The same results were found in both moderate and severe (but not mild) ARDS using the Berlin definition. In the final adjusted model, the strongest mortality risk was VD/VT, wherein the risk of death increased by 22% for every 0.05 increase in VD/VT. CONCLUSIONS: VD/VT magnitude varies by ARDS etiology, as does mortality. Only in mild ARDS does VD/VT fail to distinguish non-survivors from survivors. Nonetheless, VD/VT has the strongest association with mortality risk in those with ARDS.


Assuntos
Lesão Pulmonar/etiologia , Lesão Pulmonar/mortalidade , Espaço Morto Respiratório/fisiologia , Volume de Ventilação Pulmonar/fisiologia , APACHE , Adulto , Idoso , Capnografia/métodos , Feminino , Humanos , Modelos Logísticos , Lesão Pulmonar/fisiopatologia , Masculino , Pessoa de Meia-Idade , /fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Escala Psicológica Aguda Simplificada
20.
BMC Anesthesiol ; 17(1): 12, 2017 01 26.
Artigo em Inglês | MEDLINE | ID: mdl-28122489

RESUMO

BACKGROUND: Sub-Saharan Africa has a great burden of critical illness with limited health care resources. We evaluated the feasibility and utility of the modified Sequential Organ Function Assessment (mSOFA) score in assessing morbidity and mortality in the National Referral Hospital's intensive care unit (ICU) for one year. METHODS: We conducted a prospective, observational cohort study on patients above 12 years of age admitted to the ICU at Mulago Hospital (Kampala, Uganda). All SOFA scores were determined at admission and at 48 h. We modified the SOFA score by replacing the PaO2/FiO2 ratio with SPO2/FiO2. The primary outcome was ICU mortality. RESULTS: This ICU cohort of 118 patients had a mean age of 37 years and an ICU mortality rate of 46.6%. Non-survivors had higher initial (7.7 SD 3.8 vs. 5.5 SD 3.3; p = 0.007), mean (8.1 SD 3.9 vs 4.7 SD 2.6; p < 0.001) and highest mSOFA scores (9.4 SD 4.2 vs. 5.8 SD 3.2; p < 0.001), with an increase of 1.0 (SD 3.1) mSOFA on average after 48 h when compared to survivors (p < 0.001). The area under the receiver operating characteristic curves for each mSOFA category was: initial-0.68, mean-0.76, highest-0.76 and delta mSOFA-0.74. Multivariate logistic regression analysis showed no significant association between mSOFA scores and mortality. CONCLUSION: Our results confirm that calculation of the mSOFA score is feasible for an ICU population in a resource-limited country. More data are needed to test for an association between mSOFA and mortality.


Assuntos
Países em Desenvolvimento , Unidades de Terapia Intensiva , Escores de Disfunção Orgânica , Adulto , Estado Terminal , Estudos de Viabilidade , Feminino , Humanos , Masculino , Mortalidade , Estudos Prospectivos , Uganda , Adulto Jovem
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