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1.
JAMA ; 322(3): 216-228, 2019 07 16.
Artigo em Inglês | MEDLINE | ID: mdl-31310297

RESUMO

Importance: The effects of intensive care unit (ICU) visiting hours remain uncertain. Objective: To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium. Design, Setting and Participants: Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018. Interventions: Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation. Main Outcomes and Measures: Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory). Results: Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation. Conclusions and Relevance: Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium. Trial Registration: ClinicalTrials.gov Identifier: NCT02932358.


Assuntos
Delírio/prevenção & controle , Família/psicologia , Unidades de Terapia Intensiva/organização & administração , Visitas a Pacientes , Ansiedade , Brasil , Esgotamento Profissional , Cuidados Críticos/psicologia , Estudos Cross-Over , Depressão , Feminino , Educação em Saúde , Hospitalização , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
2.
Trials ; 19(1): 636, 2018 Nov 19.
Artigo em Inglês | MEDLINE | ID: mdl-30454019

RESUMO

BACKGROUND: Most adult intensive care units (ICUs) worldwide adopt restrictive family visitation models (RFVMs). However, evidence, mostly from non-randomized studies, suggests that flexible adult ICU visiting hours are safe policies that can result in benefits such as prevention of delirium and increase in satisfaction with care. Accordingly, the ICU Visits Study was designed to compare the effectiveness and safety of a flexible family visitation model (FFVM) vs. an RFVM on delirium prevention among ICU patients, and also to analyze its potential effects on family members and ICU professionals. METHODS/DESIGN: The ICU Visits Study is a cluster-randomized crossover trial which compares an FFVM (12 consecutive ICU visiting hours per day) with an RFVM (< 4.5 ICU visiting hours per day) in 40 Brazilian adult ICUs. Participant ICUs are randomly assigned to either an FFVM or RFVM in a 1:1 ratio. After enrollment and follow-up of 25 patients, each ICU is crossed over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome is the cumulative incidence of delirium measured by the Confusion Assessment Method for the ICU. Secondary and tertiary outcomes include relevant measures of effectiveness and safety of ICU visiting policies among patients, family members, and ICU professionals. Herein, we describe all primary statistical procedures that will be used to evaluate the results and perform exploratory and sensitivity analyses of this study. This pre-specified statistical analysis plan was written and submitted without knowledge of the study data. DISCUSSION: This a priori statistical analysis plan aims to enhance the transparency of our study, facilitating unbiased analyses of ICU visit study data, and provide guidance for statistical analysis for groups conducting studies in the same field. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02932358 . Registered on 11 October 2016.


Assuntos
Delírio/prevenção & controle , Relações Familiares , Unidades de Terapia Intensiva/estatística & dados numéricos , Visitas a Pacientes/estatística & dados numéricos , Brasil , Pesquisa Comparativa da Efetividade/estatística & dados numéricos , Estudos Cross-Over , Interpretação Estatística de Dados , Delírio/diagnóstico , Delírio/psicologia , Humanos , Modelos Estatísticos , Estudos Multicêntricos como Assunto/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento , Visitas a Pacientes/psicologia
3.
Ann Intensive Care ; 8(1): 50, 2018 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-29808412

RESUMO

BACKGROUND: Point-of-care ultrasonography (POCUS) has recently become a useful tool that intensivists are incorporating into clinical practice. However, the incorporation of ultrasonography in critical care in developing countries is not straightforward. METHODS: Our objective was to investigate current practice and education regarding POCUS among Brazilian intensivists. A national survey was administered to Brazilian intensivists using an electronic questionnaire. Questions were selected by the Delphi method and assessed topics included organizational issues, POCUS technique and training patterns, machine availability, and main applications of POCUS in daily practice. RESULTS: Of 1533 intensivists who received the questionnaire, 322 responded from all of Brazil's regions. Two hundred and five (63.8%) reported having access to an ultrasound machine dedicated to the intensive care unit (ICU); however, this was more likely in university hospitals than in non-university hospitals (80.6 vs. 59.6%; risk ratio [RR] = 1.35 [1.16-1.58], p = 0.002). The main applications of POCUS were ultrasound-guided central vein catheterization (49.4%) and bedside echocardiographic assessment (33.9%). Two hundred and fifty-eight (80.0%) reported having at least one POCUS-trained intensivist in their staff (trained units). Trained units were more likely to perform routine ultrasound-guided jugular vein catheterization than non-trained units (38.6 vs. 16.4%; RR = 2.35 [1.31-4.23], p = 0.001). The proportion of POCUS-trained intensivists and availability of a dedicated ultrasound machine were both independently associated with performing ultrasound-guided jugular vein catheterization (RR = 1.91 [1.32-2.77], p = 0.001) and (RR = 2.20 [1.26-3.29], p = 0.005), respectively. CONCLUSIONS: A significant proportion of Brazilian ICUs had at least one intensivist with POCUS capability in their staff. Although ultrasound-guided central vein catheterization constitutes the main application of POCUS, adherence to guideline recommendations is still suboptimal.

4.
BMJ Open ; 8(4): e021193, 2018 04 13.
Artigo em Inglês | MEDLINE | ID: mdl-29654049

RESUMO

INTRODUCTION: Flexible intensive care unit (ICU) visiting hours have been proposed as a means to improve patient-centred and family-centred care. However, randomised trials evaluating the effects of flexible family visitation models (FFVMs) are scarce. This study aims to compare the effectiveness and safety of an FFVM versus a restrictive family visitation model (RFVM) on delirium prevention among ICU patients, as well as to analyse its potential effects on family members and ICU professionals. METHODS AND ANALYSIS: A cluster-randomised crossover trial involving adult ICU patients, family members and ICU professionals will be conducted. Forty medical-surgical Brazilian ICUs with RFVMs (<4.5 hours/day) will be randomly assigned to either an RFVM (visits according to local policies) or an FFVM (visitation during 12 consecutive hours per day) group at a 1:1 ratio. After enrolment and follow-up of 25 patients, each ICU will be switched over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome will be the cumulative incidence of delirium among ICU patients, measured twice a day using the Confusion Assessment Method for the ICU. Secondary outcome measures will include daily hazard of delirium, ventilator-free days, any ICU-acquired infections, ICU length of stay and hospital mortality among the patients; symptoms of anxiety and depression and satisfaction among the family members; and prevalence of burnout symptoms among the ICU professionals. Tertiary outcomes will include need for antipsychotic agents and/or mechanical restraints, coma-free days, unplanned loss of invasive devices and ICU-acquired pneumonia, urinary tract infection or bloodstream infection among the patients; self-perception of involvement in patient care among the family members; and satisfaction among the ICU professionals. ETHICS AND DISSEMINATION: The study protocol has been approved by the research ethics committee of all participant institutions. We aim to disseminate the findings through conferences and peer-reviewed journals. TRIAL REGISTRATION: NCT02932358.


Assuntos
Delírio , Relações Familiares , Unidades de Terapia Intensiva , Visitas a Pacientes , Adulto , Brasil , Estudos Cross-Over , Delírio/prevenção & controle , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Reprodutibilidade dos Testes
5.
Clin Biochem ; 55: 15-20, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29550510

RESUMO

BACKGROUND: Red blood cell distribution width (RDW) is a predictor of mortality in critically ill patients. Our objective was to investigate the association between the RDW at ICU discharge and the risk of ICU readmission or unexpected death in the ward. METHODS: A secondary analysis of prospectively collected data study was conducted including patients discharged alive from the ICU to the ward. The target variable was the RDW collected at ICU discharge. Elevated RDW was defined as an RDW > 16%. Outcomes of interest included readmission to the ICU, unexpected death in the ward and in-hospital death. Variables with a p-value <0.1 in the univariate analysis or with biological plausibility for the occurrence of the outcome were included in the Cox proportional hazards model for adjustment. RESULTS: We included 813 patients. A total of 138 readmissions to the ICU and 44 unexpected deaths in the ward occurred. Elevated RDW at ICU discharge was independently associated with readmission to the ICU or unexpected death in the ward after multivariable adjustment (HR: 1.901; 95% CI 1.357-2.662). Other variables associated with this outcome included age, tracheostomy and mean corpuscular volume (MCV) at ICU discharge. Similar results were obtained after the exclusion of unexpected deaths in the ward (HR 1.940; CI 1.312-2.871) and for in-hospital deaths (HR 1.716; 95% CI 1.141-2.580). CONCLUSIONS: Elevated RDW at ICU discharge is independently associated with ICU readmission and in-hospital death.


Assuntos
Índices de Eritrócitos , Mortalidade Hospitalar , Unidades de Terapia Intensiva , Readmissão do Paciente , Idoso , Estado Terminal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
6.
J Crit Care ; 30(5): 1039-42, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26169543

RESUMO

PURPOSE: The purpose of the study is to look at the performance of the Prognosis for Prolonged Ventilation (ProVent) score with a short-term outcome as well as when used earlier during the course of prolonged mechanical ventilation (MV). MATERIALS AND METHODS: This retrospective study was performed in a tertiary public hospital from August 2011 to August 2012. All patients admitted to the intensive care unit (ICU) during this period were included in the study. Chronically critically ill (CCI) patients were defined as those with 21 days of MV. In a subsequent analysis, we considered CCI patients to be those with 14 days of MV. The data were collected in 2 ways: review of a prospectively elaborated database and review of electronic records. RESULTS: During the study period, 1360 patients were admitted to the ICU. Of these, 152 patients (11.2%) were considered CCI. Patients with high ProVent score presented higher ICU mortality. Mortality ranged from 25.0% for patients with a score of 0 to 84.0% for patients with a score of greater than or equal to 4. The analysis of the ProVent score performed earlier during the evolution (14 days of MV) was similar. CONCLUSIONS: The ProVent score can be used for short-term prognosis (mortality in the ICU) and earlier in the evaluation of CCI patients.


Assuntos
Estado Terminal/mortalidade , Índice de Gravidade de Doença , Idoso , Doença Crônica , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Respiração Artificial/mortalidade , Estudos Retrospectivos
7.
Rev Bras Ter Intensiva ; 26(2): 130-6, 2014.
Artigo em Inglês, Português | MEDLINE | ID: mdl-25028946

RESUMO

OBJECTIVE: To assess the performance of central venous oxygen saturation, lactate, base deficit, and C-reactive protein levels and SOFA and SWIFT scores on the day of discharge from the intensive care unit as predictors of patient readmission to the intensive care unit. METHODS: This prospective and observational study collected data from 1,360 patients who were admitted consecutively to a clinical-surgical intensive care unit from August 2011 to August 2012. The clinical characteristics and laboratory data of readmitted and non-readmitted patients after discharge from the intensive care unit were compared. Using a multivariate analysis, the risk factors independently associated with readmission were identified. RESULTS: The C-reactive protein, central venous oxygen saturation, base deficit, and lactate levels and the SWIFT and SOFA scores did not correlate with the readmission of critically ill patients. Increased age and contact isolation because of multidrug-resistant organisms were identified as risk factors that were independently associated with readmission in this study group. CONCLUSION: Inflammatory and perfusion parameters were not associated with patient readmission. Increased age and contact isolation because of multidrug-resistant organisms were identified as predictors of readmission to the intensive care unit.


Assuntos
Proteína C-Reativa/metabolismo , Inflamação/patologia , Oxigênio/sangue , Readmissão do Paciente/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/metabolismo , Estado Terminal , Feminino , Humanos , Unidades de Terapia Intensiva , Ácido Láctico/metabolismo , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Isolamento de Pacientes/estatística & dados numéricos , Estudos Prospectivos , Fatores de Risco , Adulto Jovem
8.
Rev. bras. ter. intensiva ; 26(2): 130-136, Apr-Jun/2014. tab, graf
Artigo em Português | LILACS | ID: lil-714826

RESUMO

Objetivo: Avaliar o desempenho da saturação venosa central, lactato, défice de bases, níveis de proteína C-reativa, escore SOFA e SWIFT do dia da alta da unidade de terapia intensiva como preditores para readmissão de pacientes na unidade de terapia intensiva. Métodos: Estudo prospectivo observacional com dados coletados de 1.360 pacientes internados consecutivamente no período de agosto de 2011 a agosto de 2012 em uma unidade de terapia intensiva clínico-cirúrgica. Foram comparadas as características clínicas e os dados laboratoriais dos pacientes readmitidos e dos pacientes não readmitidos após a alta da unidade de terapia intensiva. Por meio de análise multivariada, foram identificados os fatores de risco independentemente associados à readmissão. Resultados: A proteína C-reativa, a saturação venosa central, o défice de bases, o lactato, os escores SOFA e o SWIFT não foram associados à readmissão de pacientes graves. Pacientes mais idosos e a necessidade de isolamento de contato devido a germes multirresistentes foram identificados como fatores de risco independentemente associados à readmissão na população estudada. Conclusão: Os parâmetros inflamatórios e perfusionais não foram associados à readmissão. Idade e necessidade de isolamento de contato devido a germes multirresistentes foram identificados como preditores para readmissão na unidade de terapia intensiva. .


Objective: To assess the performance of central venous oxygen saturation, lactate, base deficit, and C-reactive protein levels and SOFA and SWIFT scores on the day of discharge from the intensive care unit as predictors of patient readmission to the intensive care unit. Methods: This prospective and observational study collected data from 1,360 patients who were admitted consecutively to a clinical-surgical intensive care unit from August 2011 to August 2012. The clinical characteristics and laboratory data of readmitted and non-readmitted patients after discharge from the intensive care unit were compared. Using a multivariate analysis, the risk factors independently associated with readmission were identified. Results: The C-reactive protein, central venous oxygen saturation, base deficit, and lactate levels and the SWIFT and SOFA scores did not correlate with the readmission of critically ill patients. Increased age and contact isolation because of multidrug-resistant organisms were identified as risk factors that were independently associated with readmission in this study group. Conclusion: Inflammatory and perfusion parameters were not associated with patient readmission. Increased age and contact isolation because of multidrug-resistant organisms were identified as predictors of readmission to the intensive care unit. .


Assuntos
Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Proteína C-Reativa/metabolismo , Inflamação/patologia , Oxigênio/sangue , Readmissão do Paciente/estatística & dados numéricos , Fatores Etários , Biomarcadores/metabolismo , Estado Terminal , Unidades de Terapia Intensiva , Ácido Láctico/metabolismo , Análise Multivariada , Estudos Prospectivos , Isolamento de Pacientes/estatística & dados numéricos , Fatores de Risco
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