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1.
Artigo em Inglês | MEDLINE | ID: mdl-31900470

RESUMO

Frailty is a geriatric syndrome defined by coexistence of unintentional weight loss, low physical reserve or activity and is associated with adverse health events. Neuroimaging studies reported structural white matter changes in frail patients. In the current study, we hypothesized that clinical frailty is associated also with functional changes in motion-related cortical areas, i. e. (pre-)supplementary motor areas (SMA, pre-SMA). We expected that observed functional changes are related to motor-cognitive test performance. We studied a clinical sample of 143 cognitively healthy patients ≥65 years presenting for elective surgery, enrolled in the BioCog prospective multicentric cohort study on postoperative cognitive disorders. Participants underwent preoperative resting-state fMRI, motor-cognitive testing and assessment of Fried's modified frailty criteria. We analyzed functional connectivity associations with frailty and motor-cognitive test performance. Clinically robust patients (N=60) showed higher connectivity in the SMA network compared to frail (N=13) and pre-frail (N=70) patients. No changes were found in the pre-SMA network. SMA connectivity correlated with motor speed (Trail-Making-Test A) and manual dexterity (Grooved Pegboard Test). Our results suggest that diminished functional connectivity of the SMA is an early correlate of functional decline in the elderly. The SMA may serve as a potential treatment target in frailty.

2.
Anesth Analg ; 130(2): 341-351, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30855340

RESUMO

BACKGROUND: Skeletal muscle failure in critical illness (intensive care unit-acquired weakness) is a well-known complication developing early during intensive care unit stay. However, muscle weakness during the perioperative setting has not yet been investigated. METHODS: We performed a subgroup investigation of a prospective observational trial to investigate perioperative muscle weakness. Eighty-nine patients aged 65 years or older were assessed for handgrip strength preoperatively, on the first postoperative day, at intensive care unit discharge, at hospital discharge, and at 3-month follow-up. Functional status was evaluated perioperatively via Barthel index, instrumental activities of daily living, Timed Up and Go test, and functional independence measure. After exclusion of patients with intensive care unit-acquired weakness or intensive care unit stay of ≥72 hours, 59 patients were included into our analyses. Of these, 14 patients had additional pulmonary function tests preoperatively and on postoperative day 1. Blood glucose was measured intraoperatively every 20 minutes. RESULTS: Handgrip strength significantly decreased after surgery on postoperative day 1 by 16.4% (P < .001). Postoperative pulmonary function significantly decreased by 13.1% for vital capacity (P = .022) and 12.6% for forced expiratory volume in 1 second (P = .001) on postoperative day 1. Handgrip strength remained significantly reduced at hospital discharge (P = .016) and at the 3-month follow-up (P = .012). Perioperative glucose levels showed no statistically significant impact on muscle weakness. Instrumental activities of daily living (P < .001) and functional independence measure (P < .001) were decreased at hospital discharge, while instrumental activities of daily living remained decreased at the 3-month follow-up (P = .026) compared to preoperative assessments. CONCLUSIONS: Perioperatively acquired weakness occurred, indicated by a postoperatively decreased handgrip strength, decreased respiratory muscle function, and impaired functional status, which partly remained up to 3 months.

3.
Semin Respir Crit Care Med ; 40(5): 673-686, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31826268

RESUMO

Delirium, the most common form of acute brain dysfunction affecting up to 80% of intensive care unit (ICU) patients, has been shown to predict long-term cognitive impairment, one of the domains in "Post-ICU Syndrome" (PICS). The ICU environment affects several potentially modifiable risk factors for delirium, such as disorientation and disruption, of the sleep-wake cycle. Innovative solutions aim to transform standard concepts of ICU room design to limit potential stressors, and utilizing the patient care space as a treatment tool, exerting positive, therapeutic effects. The main areas affected by most architectural and interior design modifications are sound environment, light control, floor planning, and room arrangement. Implementation of corresponding solutions is challenging considering the significant medical and technical demands of ICUs. This article discusses innovative concepts and promising approaches in ICU design that may be used to prevent stress and to support the healing process of patients, potentially limiting the impact of delirium and PICS.

4.
BMC Anesthesiol ; 19(1): 204, 2019 11 07.
Artigo em Inglês | MEDLINE | ID: mdl-31699033

RESUMO

BACKGROUND: Frailty is a frequent and underdiagnosed functional syndrome involving reduced physiological reserves and an increased vulnerability against stressors, with severe individual and socioeconomic consequences. A routine frailty assessment was implemented at our preoperative anaesthesia clinic to identify patients at risk. OBJECTIVE: This study examines the relationship between frailty status and the incidence of in-hospital postoperative complications in elderly surgical patients across several surgical disciplines. DESIGN: Retrospective observational analysis. SETTING: Single center, major tertiary care university hospital. Data collection took place between June 2016 and March 2017. PATIENTS: Patients 65 years old or older were evaluated for frailty using Fried's 5-point frailty assessment prior to elective non-cardiac surgery. Patients were classified into non-frail (0 criteria, reference group), pre-frail (1-2 positive criteria) and frail (3-5 positive criteria) groups. MAIN OUTCOME MEASURES: The incidence of postoperative complications was assessed until discharge from the hospital, using the roster from the National VA Surgical Quality Improvement Program. Propensity score matching and logistic regression analysis were performed. RESULTS: From 1186 elderly patients, 46.9% were classified as pre-frail (n = 556), and 11.4% as frail (n = 135). The rate of complications were significantly higher in the pre-frail (34.7%) and frail groups (47.4%), as compared to the non-frail group (27.5%). Similarly, length of stay (non-frail: 5.0 [3.0;7.0], pre-frail: 7.0 [3.0;9.0], frail 8.0 [4.5;12.0]; p < 0.001) and discharges to care facilities (non-frail:1.6%, pre-frail: 7.4%, frail: 17.8%); p < 0.001) were significantly associated with frailty status. After propensity score matching and logistic regression analysis, the risk for developing postoperative complications was approximately two-fold for pre-frail (OR 1.78; 95% CI 1.04-3.05) and frail (OR 2.08; 95% CI 1.21-3.60) patients. CONCLUSIONS: The preoperative frailty assessment of elderly patients identified pre-frail and frail subgroups to have the highest rate of postoperative complications, regardless of age, surgical discipline, and surgical risk. Significantly increased length of hospitalisation and discharges to care facilities were also observed. Implementation of routine frailty assessments appear to be an effective tool in identifying patients with increased risk. Now future studies are needed to investigate whether patients benefit from optimization of patient counselling, process planning, and risk reduction protocols based on the application of risk stratification.

5.
Eur J Anaesthesiol ; 36(9): 683-687, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31306183

RESUMO

BACKGROUND: Recent guidelines on postoperative delirium (POD) recommend POD screening in all patients, using a validated tool, starting in the recovery room. An operationalisation of the Confusion Assessment Method (CAM) criteria, the 3-Minute Diagnostic Interview for CAM-defined Delirium (3D-CAM), has been developed for use in general medical units. OBJECTIVES: The aim of this study was to evaluate 3D-CAM performance in an adult patient population to detect POD in the recovery room. DESIGN: A prospective diagnostic study. SETTING: Recovery room of a tertiary care university hospital in Berlin, Germany, in 2017. PATIENTS: Patients at least 18 years of age undergoing elective surgery. MAIN OUTCOME MEASURES: Patients were subjected to evaluation by blinded investigators using the 3D-CAM and the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5, reference standard). Sensitivity, specificity and positive predictive value (PPV) and negative predictive value (NPV) were analysed for 3D-CAM, in addition to test-retest and inter-rater reliability analyses. RESULTS: Sixteen out of 176 patients (9.1%) developed POD. The 3D-CAM demonstrated strong test performance (specificity 0.88, sensitivity 1.0, area under the curve 0.94, PPV 0.44 and NPV 1.0), with a test-retest reliability of 90% (n = 10) and inter-rater reliability of 80% (n = 10). CONCLUSION: In this diagnostic study, 3D-CAM showed strong performance for detection of POD in the recovery room. Due to the low training requirements, fast application and high sensitivity, it might be particularly appropriate for clinical staff with limited experience in the assessment of POD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02992717.

6.
Int J Med Sci ; 16(5): 665-674, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31217734

RESUMO

BACKGROUNDː Dysglycemia is associated with adverse outcome including increased morbidity and mortality in surgical patients. Acute insulin resistance due to the surgical stress response is seen as a major cause of so-called stress hyperglycemia. However, understanding of factors determining blood glucose (BG) during surgery is limited. Therefore, we investigated risk factors contributing to intraoperative dysglycemia. METHODSː In this subgroup investigation of the BIOCOG study, we analyzed 87 patients of ≥ 65 years with tight intraoperative BG measurement every 20 min during elective surgery. Dysglycemia was defined as at least one intraoperative BG measurement outside the recommended target range of 80-150 mg/dL. Additionally, all postoperative BG measurements in the ICU were obtained. Multivariable logistic regression analysis adjusted for age, sex, American Society of Anesthesiologists (ASA) status, diabetes, type and duration of surgery, minimum Hemoglobin (Hb) and mean intraoperative norepinephrine use was performed to identify risk factors of intraoperative dysglycemia. RESULTSː 46 (52.9%) out of 87 patients developed intraoperative dysglycemia. 31.8% of all intraoperative BG measurements were detected outside the target range. Diabetes [OR 9.263 (95% CI 2.492, 34.433); p=0.001] and duration of surgery [OR 1.005 (1.000, 1.010); p=0.036] were independently associated with the development of intraoperative dysglycemia. Patients who experienced intraoperative dysglycemia had significantly elevated postoperative mean (p<0.001) and maximum BG levels (p=0.001). Length of ICU (p=0.007) as well as hospital stay (p=0.012) were longer in patients with dysglycemia. CONCLUSIONSː Diabetes and duration of surgery were confirmed as independent risk factors for intraoperative dysglycemia, which was associated with adverse outcome. These patients, therefore, might require intensified glycemic control. Increased awareness and management of intraoperative dysglycemia is warranted.


Assuntos
Complicações do Diabetes/epidemiologia , Diabetes Mellitus/cirurgia , Hiperglicemia/epidemiologia , Complicações Intraoperatórias/epidemiologia , Idoso , Glicemia/metabolismo , Complicações do Diabetes/patologia , Complicações do Diabetes/cirurgia , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/patologia , Feminino , Humanos , Hiperglicemia/etiologia , Hiperglicemia/patologia , Hiperglicemia/cirurgia , Insulina/metabolismo , Resistência à Insulina/genética , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/patologia , Complicações Intraoperatórias/cirurgia , Masculino , Fatores de Risco
7.
BMC Health Serv Res ; 19(1): 105, 2019 Feb 07.
Artigo em Inglês | MEDLINE | ID: mdl-30732604

RESUMO

BACKGROUND: Especially patients older than 65 years undergoing surgery are prone to develop frailty-related complications that may go far beyond the index hospitalization (e.g., cognitive impairment following postoperative delirium). However, aging-relevant information are currently not fully integrated into hospitals' perioperative processes. METHODS: We introduce a temporal perspective, which focuses on the social construction of time, to better understand existing barriers to the exchange of frailty-related data, targeting complexity research. Our chosen context is perioperative care provided by a tertiary hospital in Germany that has implemented a special track for patients over 65 years old undergoing elective surgery. The research followed a participatory modelling approach between domain and modelling experts with the goal of creating a feedback loop model of the relevant system relationships and dynamics. RESULTS: The results of the study show how disparate temporal regimes, understood as frameworks for organizing actions in the light of time constraints, time pressure, and deadlines, across different clinical, ambulant, and geriatric care sectors create disincentives to cooperate in frailty-related data exchanges. Moreover, we find that shifting baselines, meaning continuous increases in cost and time pressure in individual sectors, may unintentionally reinforce - rather than discourage - disparate temporal regimes. CONCLUSIONS: Together, these results may (1) help to increase awareness of the importance of frailty-related data exchanges, and (2) impel efforts aiming to transform treatment processes to go beyond sectoral boundaries, taking into account the potential benefits for frail patients arising from integrated care processes using information technology.


Assuntos
Avaliação Geriátrica/métodos , Disseminação de Informação , Assistência Perioperatória , Complicações Pós-Operatórias/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Idoso Fragilizado , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Segurança do Paciente , Procedimentos Cirúrgicos Operatórios
8.
Anasthesiol Intensivmed Notfallmed Schmerzther ; 53(11-12): 793-796, 2018 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-30458577

RESUMO

Postoperative delirium (POD) is an acute change in the mental state with consciousness and attention deficits. It is a common complication after surgical procedures and can have serious consequences. Thus, the evidence- and consensus-based guidelines for POD appeals with the highest recommendation level that patients be regularly screened for delirium in the postoperative phase, from the recovery room to the fifth postoperative day and at least once per shift, using a validated test instrument for the detection of POD. In 2014, Marcantonio et al. published the 3D-CAM (3-Minute Diagnostic Interview for CAM-defined Delirium). In the 3D-CAM, the algorithm of the Confusion Assessment Method (CAM) is maintained by using individual elements that operationalize the evaluation of the criteria. Therefore, it requires less training, be faster to use, and, due to a standardized approach, has less interrater variability than the CAM, whereas the high sensitivity and specificity are maintained. Our goal was to translate the 3D-CAM from English to German, so as to make this instrument available to German-speaking countries. The translation of the 3D-CAM was based on the 2005 published guideline on Translation and Cultural Adaptation of Patient Reported Outcome Measures of the International Society for Pharmacoeconomics and Outcome Research. Three independent forward translations were harmonized to a preliminary translation, which then was translated back into the original language. Original authors reviewed the back translation. According to a cognitive debriefing, the translation was revised and in addition was adapted for use in the recovery room. Due to close contact with the original authors during the translation process, it was possible to ensure that the contents of the test instrument were remained intact during the translation process.


Assuntos
Anestesia Geral/efeitos adversos , Delírio do Despertar/diagnóstico , Entrevista Psicológica/métodos , Complicações Pós-Operatórias/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Confusão/diagnóstico , Confusão/psicologia , Delírio do Despertar/etiologia , Humanos , Complicações Pós-Operatórias/psicologia , Complicações Pós-Operatórias/terapia , Reprodutibilidade dos Testes , Traduções
9.
Clin Neurophysiol ; 129(8): 1642-1648, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29913339

RESUMO

OBJECTIVE: In pediatric patients, anaesthesia induction is often performed with intravenous Propofol or Sevoflurane inhalation. Although epileptiform discharges have been observed during inductions with Sevoflurane, their occurrence has not been investigated for i.v. Propofol inductions. The aim of this study is to compare the incidence of epileptiform discharges in children during anaesthesia induction using Propofol versus Sevoflurane. METHODS: Prospective, observational cohort study in children aged 0.5-8 years undergoing elective surgery. Children were anaesthetized with either Propofol or Sevoflurane. Bi-frontal electroencephalograms electrodes were placed before start of anaesthesia. Visual electroencephalogram analysis was performed from start of anesthetic agent administration until Intubation with regard to identify epileptiform patterns, i.e. delta with spikes; rhythmic polyspikes; periodic, epileptiform discharges; or suppression with spikes. RESULTS: 39 children were anaesthetized with Propofol, and 18 children with Sevoflurane. Epileptiform discharges were seen in 36% of the children in the Propofol group, versus 67% in the Sevoflurane group (p = 0.03). Incidence of the distinct types of epileptiform discharge differed for periodic, epileptiform discharges (Sevoflurane group 39% vs. Propofol group 3%; p < 0.001). Higher concentration of Remifentanil (≥0.15 µg/kg/min) was associated with less frequent epileptiform discharges (Exp 5.8; CI 95% 1.6/21.2; p = 0.008). CONCLUSIONS: Propofol i.v. induction of anaesthesia in children triggers epileptiform discharges, whereas to a lesser extent than Sevoflurane does. SIGNIFICANCE: Presuming that epileptiform discharges have an impact on postoperative brain function, it is advisable to use Propofol rather than Sevoflurane and higher level of Remifentanil for anaesthesia induction in children.


Assuntos
Potenciais de Ação/efeitos dos fármacos , Anestésicos Inalatórios/administração & dosagem , Anestésicos Intravenosos/administração & dosagem , Monitorização Intraoperatória/métodos , Propofol/administração & dosagem , Sevoflurano/administração & dosagem , Potenciais de Ação/fisiologia , Anestesia/efeitos adversos , Anestesia/métodos , Anestésicos Inalatórios/efeitos adversos , Anestésicos Intravenosos/efeitos adversos , Criança , Pré-Escolar , Estudos de Coortes , Eletroencefalografia/efeitos dos fármacos , Eletroencefalografia/métodos , Feminino , Humanos , Incidência , Lactente , Masculino , Propofol/efeitos adversos , Estudos Prospectivos , Sevoflurano/efeitos adversos
11.
Anasthesiol Intensivmed Notfallmed Schmerzther ; 52(11-12): 765-776, 2017 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-29156481

RESUMO

Introduction: Frailty is a condition of decreased physiological reserves seen in approx. one third of elderly anesthesiological patients, and affecting many aspects of treatment as well as outcome. Although there are over 60 measurement instruments, frailty assessment is still poorly implemented. Understanding why and how to assess frailty is key to its implementation in preoperative anesthesia clinics. Method: After presenting the impact of perioperative frailty and the benefits of an early diagnosis on health related quality of life, we present an overview of the most important tools that can be used in the preoperative frailty assessment. Results: Early diagnosis offer several optimization opportunities for the perioperative period. The most efficient frailty assessment tools are presented and discussed, including physical, cognitive, and psychosocial aspects. Conclusion: Frailty assessments vary immensely in terms of required time, equipment, and expertise. We recommend at least one test for each domain of frailty, so as to obtain a more holistic view of the patient's physiological reserve. The implementation of an adequate and consistent preoperative frailty assessment has the potential to improve patient safety as well as short and long term outcomes.


Assuntos
Anestesia , Fragilidade/diagnóstico , Cuidados Pré-Operatórios , Idoso , Idoso de 80 Anos ou mais , Fragilidade/psicologia , Avaliação Geriátrica , Geriatria , Humanos , Período Perioperatório , Qualidade de Vida
12.
Anasthesiol Intensivmed Notfallmed Schmerzther ; 52(11-12): 785-797, 2017 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-29156482

RESUMO

Frail patients are more prone to develop complications during and after surgery. As the syndrome becomes more common, recognition and special management of frail patients in the perioperative setting is becoming crucial to improve short- and long-term outcomes. Based on current literature and guidelines, we present a compilation of strategies that could be employed to reduce postoperative complication rates in frail patients. Due to their impaired response to stressors, potential perioperative hazards to frail patients are identified and discussed. This includes the risk of dehydration, hypothermia, cardiovascular decompensation, unusual drug reactions, and delirium. The benefits of early mobilization and nutritional support are also discussed. If frailty is detected preoperatively, thus alerting the team about the increased risk of complications, strategies can be implemented in the perioperative setting to improve the chances of successful recovery.


Assuntos
Idoso Fragilizado , Fragilidade/terapia , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Idoso , Idoso de 80 Anos ou mais , Fragilidade/diagnóstico , Avaliação Geriátrica , Humanos , Monitorização Intraoperatória
13.
Visc Med ; 33(4): 267-274, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29034255

RESUMO

INTRODUCTION: Elderly patients suffering from gastrointestinal malignancies are particularly prone to perioperative complications. Elderly patients often present with reduced physiological reserves, and comorbidities can limit treatment options and promote complications. Surgeons and anesthesiologists must be aware of strategies required to deal with this vulnerable subgroup. METHODS: We provide a brief review of current and emerging perioperative strategies for the treatment of elderly patients with gastrointestinal malignancies and frequent comorbidities. RESULTS: Especially in combination with advanced age, the effects of malignancies can be devastating, bringing new health challenges, exacerbating preexisting conditions, and exerting severe psychological strain. An interdisciplinary assessment and process planning provide an ideal setting to identify and prevent potential complications, especially in regards to frailty and cardiovascular risk. In addition, important perioperative considerations are presented, such as malnutrition, fasting, intraoperative neuromonitoring, and hemodynamic control, as well as postoperative early mobilization, pain, and delirium management. CONCLUSION: The decisions and interventions made in the perioperative stage can positively influence many intra- and postoperative factors, significantly improving the chances of successful treatment of elderly cancer patients. Appropriate management can help prevent or mitigate complications, secure a quick recovery, and improve short- and long-term outcomes.

14.
Curr Opin Crit Care ; 22(4): 406-11, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-27272100

RESUMO

PURPOSE OF REVIEW: From an elderly patient's perspective, acute and chronic cognitive disturbances are among the most harmful complications that can occur following surgery. For elderly patients, these complications often mean the end of an independent life. This article focuses on this serious aspect, which is increasingly prevalent in our aging society. Cognitive disturbances are associated with severe outcome impairments and increased mortality. This article aims to provide a current overview regarding the diagnosis, pathophysiology, prevention, and treatment of this severe social problem. RECENT FINDINGS: The current knowledge of risk factors, diagnosis, prevention, and treatment of postoperative delirium and postoperative cognitive dysfunction should help to raise awareness and improve the outcome of delirious patients, particularly in the elderly population. SUMMARY: Especially in elderly patients, postoperative delirium constitutes a common, severe complication. Early diagnosis and supportive treatment are essential to improve outcome. To date, no pharmacological treatment strategy was effective, so that further research about the underlying pathophysiology and the development of treatment strategies are urgently required.


Assuntos
Idoso/psicologia , Transtornos Cognitivos/psicologia , Delírio/psicologia , Complicações Pós-Operatórias/psicologia , Período Pós-Operatório , Envelhecimento , Cognição , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/etiologia , Delírio/diagnóstico , Delírio/etiologia , Humanos , Complicações Pós-Operatórias/diagnóstico , Fatores de Risco
15.
Muscle Nerve ; 50(3): 431-6, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24415656

RESUMO

INTRODUCTION: Muscle weakness in critically ill patients after discharge varies. It is not known whether the electrophysiological distinction between critical illness myopathy (CIM) and critical illness polyneuropathy (CIP) during the early part of a patient's stay in the intensive care unit (ICU) predicts long-term prognosis. METHODS: This was a prospective cohort study of mechanically ventilated ICU patients undergoing conventional nerve conduction studies and direct muscle stimulation in addition to neurological examination during their ICU stay and 1 year after ICU discharge. RESULTS: Twenty-six patients (7 ICU controls, 8 CIM patients, and 11 CIM/CIP patients) were evaluated 1 year after discharge from the ICU. Eighty-eight percent (n = 7) of CIM patients recovered within 1 year compared with 55% (n = 6) of CIM/CIP patients. Thirty-six percent (n = 4) of CIM/CIP patients still needed assistance during their daily routine (P = 0.005). CONCLUSIONS: Early electrophysiological testing predicts long-term outcome in ICU survivors. CIM has a significantly better prognosis than CIM/CIP.


Assuntos
Estado Terminal/terapia , Doenças Musculares/terapia , Polineuropatias/terapia , Potenciais de Ação/fisiologia , Adolescente , Adulto , Idoso , Eletrodiagnóstico , Eletrofisiologia , Feminino , Seguimentos , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/fisiopatologia , Contração Muscular/fisiologia , Força Muscular/fisiologia , Músculo Esquelético/fisiopatologia , Condução Nervosa , Exame Neurológico , Recuperação de Função Fisiológica , Sepse/complicações , Resultado do Tratamento , Adulto Jovem
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