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1.
Disaster Med Public Health Prep ; : 1-7, 2021 Aug 31.
Artigo em Inglês | MEDLINE | ID: mdl-34462041

RESUMO

OBJECTIVE: The aim of this study was to report the results of a nationwide critical-care course for non-intensivists to increase staff capacity of intensive care units (ICUs) during the coronavirus disease 2019 (COVID-19) pandemic in Argentina. METHODS: Three academic organizations, with special funding from 55 private companies, developed a short virtual course comprised of Web-based videos, virtual tutorials, and a forum chat. Each state assigned scholarships to non-ICU staff from public hospitals. Students received active follow-up for the completion of the course and took a survey upon course completion. RESULTS: After 4 m, there were 10,123 students registered from 661 hospitals in 328 cities. Of these, 67.8% passed the course, 29.1% were still ongoing, and 3.1% were inactive. Most students were female (74.2%) with a median of 37 y old (IQR 31-44). The group was composed of 56.5% nurses, 36.2% physicians, and 7.4% physiotherapists, of whom 48.3% did not have any experience in critical care. Mean overall satisfaction was 4.4/5 (standard deviation, 0.9), and 90.7% considered they were able to apply the contents to their practice. CONCLUSIONS: This course was effective for rapid training of non-ICU personnel. The assignment strategy, the educational techniques, and the close follow-up led to low dropout and high success rates and satisfaction.

2.
Lancet Respir Med ; 9(9): 989-998, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34224674

RESUMO

BACKGROUND: Although COVID-19 has greatly affected many low-income and middle-income countries, detailed information about patients admitted to the intensive care unit (ICU) is still scarce. Our aim was to examine ventilation characteristics and outcomes in invasively ventilated patients with COVID-19 in Argentina, an upper middle-income country. METHODS: In this prospective, multicentre cohort study (SATICOVID), we enrolled patients aged 18 years or older with RT-PCR-confirmed COVID-19 who were on invasive mechanical ventilation and admitted to one of 63 ICUs in Argentina. Patient demographics and clinical, laboratory, and general management variables were collected on day 1 (ICU admission); physiological respiratory and ventilation variables were collected on days 1, 3, and 7. The primary outcome was all-cause in-hospital mortality. All patients were followed until death in hospital or hospital discharge, whichever occurred first. Secondary outcomes were ICU mortality, identification of independent predictors of mortality, duration of invasive mechanical ventilation, and patterns of change in physiological respiratory and mechanical ventilation variables. The study is registered with ClinicalTrials.gov, NCT04611269, and is complete. FINDINGS: Between March 20, 2020, and Oct 31, 2020, we enrolled 1909 invasively ventilated patients with COVID-19, with a median age of 62 years [IQR 52-70]. 1294 (67·8%) were men, hypertension and obesity were the main comorbidities, and 939 (49·2%) patients required vasopressors. Lung-protective ventilation was widely used and median duration of ventilation was 13 days (IQR 7-22). Median tidal volume was 6·1 mL/kg predicted bodyweight (IQR 6·0-7·0) on day 1, and the value increased significantly up to day 7; positive end-expiratory pressure was 10 cm H2O (8-12) on day 1, with a slight but significant decrease to day 7. Ratio of partial pressure of arterial oxygen (PaO2) to fractional inspired oxygen (FiO2) was 160 (IQR 111-218), respiratory system compliance 36 mL/cm H2O (29-44), driving pressure 12 cm H2O (10-14), and FiO2 0·60 (0·45-0·80) on day 1. Acute respiratory distress syndrome developed in 1672 (87·6%) of patients; 1176 (61·6%) received prone positioning. In-hospital mortality was 57·7% (1101/1909 patients) and ICU mortality was 57·0% (1088/1909 patients); 462 (43·8%) patients died of refractory hypoxaemia, frequently overlapping with septic shock (n=174). Cox regression identified age (hazard ratio 1·02 [95% CI 1·01-1·03]), Charlson score (1·16 [1·11-1·23]), endotracheal intubation outside of the ICU (ie, before ICU admission; 1·37 [1·10-1·71]), vasopressor use on day 1 (1·29 [1·07-1·55]), D-dimer concentration (1·02 [1·01-1·03]), PaO2/FiO2 on day 1 (0·998 [0·997-0·999]), arterial pH on day 1 (1·01 [1·00-1·01]), driving pressure on day 1 (1·05 [1·03-1·08]), acute kidney injury (1·66 [1·36-2·03]), and month of admission (1·10 [1·03-1·18]) as independent predictors of mortality. INTERPRETATION: In patients with COVID-19 who required invasive mechanical ventilation, lung-protective ventilation was widely used but mortality was high. Predictors of mortality in our study broadly agreed with those identified in studies of invasively ventilated patients in high-income countries. The sustained burden of COVID-19 on scarce health-care personnel might have contributed to high mortality over the course of our study in Argentina. These data might help to identify points for improvement in the management of patients in middle-income countries and elsewhere. FUNDING: None. TRANSLATION: For the Spanish translation of the Summary see Supplementary Materials section.


Assuntos
COVID-19/terapia , Respiração Artificial/estatística & dados numéricos , Insuficiência Respiratória/terapia , Adulto , Idoso , Argentina/epidemiologia , COVID-19/complicações , COVID-19/diagnóstico , COVID-19/mortalidade , Teste de Ácido Nucleico para COVID-19 , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial/métodos , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/virologia , Fatores de Risco , SARS-CoV-2/isolamento & purificação , Volume de Ventilação Pulmonar , Resultado do Tratamento , Adulto Jovem
3.
Rev Bras Ter Intensiva ; 33(1): 48-67, 2021.
Artigo em Espanhol, Inglês | MEDLINE | ID: mdl-33886853

RESUMO

OBJECTIVE: To propose agile strategies for a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for patients with COVID-19-associated acute respiratory distress syndrome, considering the high risk of infection among health workers, the humanitarian treatment that we must provide to patients and the inclusion of patients' families, in a context lacking specific therapeutic strategies against the virus globally available to date and a potential lack of health resources. METHODS: A nonsystematic review of the scientific evidence in the main bibliographic databases was carried out, together with national and international clinical experience and judgment. Finally, a consensus of recommendations was made among the members of the Committee for Analgesia, Sedation and Delirium of the Sociedad Argentina de Terapia Intensiva. RESULTS: Recommendations were agreed upon, and tools were developed to ensure a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for adult patients with acute respiratory distress syndrome due to COVID-19. DISCUSSION: Given the new order generated in intensive therapies due to the advancing COVID-19 pandemic, we propose to not leave aside the usual good practices but to adapt them to the particular context generated. Our consensus is supported by scientific evidence and national and international experience and will be an attractive consultation tool in intensive therapies.


Assuntos
Analgesia/normas , COVID-19/complicações , Consenso , Delírio/terapia , Manejo da Dor/normas , Síndrome do Desconforto Respiratório/terapia , Analgesia/métodos , Analgésicos/administração & dosagem , COVID-19/tratamento farmacológico , Lista de Checagem , Delírio/diagnóstico , Deambulação Precoce , Família , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal/métodos , Bloqueio Neuromuscular/métodos , Bloqueio Neuromuscular/normas , Manejo da Dor/métodos , Medição da Dor/métodos , Medição da Dor/normas , Agitação Psicomotora/terapia
4.
Rev. bras. ter. intensiva ; 33(1): 48-67, jan.-mar. 2021. tab, graf
Artigo em Espanhol | LILACS-Express | LILACS | ID: biblio-1289052

RESUMO

RESUMEN Objetivo: Proponer estrategias agile para este abordaje integral de la analgesia, sedación, delirium, implementación de movilidad temprana e inclusión familiar del paciente con síndrome de dificultad respiratoria aguda por COVID-19, considerando el alto riesgo de infección que existe entre los trabajadores de salud, el tratamiento humanitario que debemos brindar al paciente y su familia, en un contexto de falta estrategias terapéuticas específicas contra el virus globalmente disponibles a la fecha y una potencial falta de recursos sanitarios. Metodos: Se llevó a cabo una revision no sistemática de la evidencia científica en las principales bases de datos bibliográficos, sumada a la experiencia y juicio clínico nacional e internacional. Finalmente, se realizó un consenso de recomendaciones entre los integrantes del Comité de Analgesia, Sedación y Delirium de la Sociedad Argentina de Terapia Intensiva. Resultados: Se acordaron recomendaciones y se desarrollaron herramientas para asegurar un abordaje integral de analgesia, sedación, delirium, implementación de movilidad temprana e inclusión familiar del paciente adulto con síndrome de dificultad respiratoria aguda por COVID-19. Discusión: Ante el nuevo orden generado en las terapias intensivas por la progresión de la pandemia de COVID-19, proponemos no dejar atrás las buenas prácticas habituales, sino adaptarlas al contexto particular generado. Nuestro consenso está respaldado en la evidencia científica, la experiencia nacional e internacional, y será una herramienta de consulta atractiva en las terapias intensivas.


ABSTRACT Objective: To propose agile strategies for a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for patients with COVID-19-associated acute respiratory distress syndrome, considering the high risk of infection among health workers, the humanitarian treatment that we must provide to patients and the inclusion of patients' families, in a context lacking specific therapeutic strategies against the virus globally available to date and a potential lack of health resources. Methods: A nonsystematic review of the scientific evidence in the main bibliographic databases was carried out, together with national and international clinical experience and judgment. Finally, a consensus of recommendations was made among the members of the Committee for Analgesia, Sedation and Delirium of the Sociedad Argentina de Terapia Intensiva. Results: Recommendations were agreed upon, and tools were developed to ensure a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for adult patients with acute respiratory distress syndrome due to COVID-19. Discussion: Given the new order generated in intensive therapies due to the advancing COVID-19 pandemic, we propose to not leave aside the usual good practices but to adapt them to the particular context generated. Our consensus is supported by scientific evidence and national and international experience and will be an attractive consultation tool in intensive therapies.

5.
Rev. argent. salud publica ; 13(Suplemento COVID-19): 1-2, 2021.
Artigo em Espanhol | LILACS, BINACIS, ARGMSAL | ID: biblio-1177597

RESUMO

La dexametasona es, en la actualidad, uno de los pocos tratamientos que ha demostrado ser efectivo en los pacientes con neumonía moderada o grave por el nuevo coronavirus 2019. Una dosis de 6 mg/día de dexametasona base durante 10 días ha demostrado disminuir de manera significativa la mortalidad en estos pacientes. En Argentina, existen diferentes presentaciones comerciales de dexametasona para la administración por vía intravenosa, que contienen distintas sales (dexametasona fosfato sódico y dexametasona fostato ácido). Por este motivo, es importante conocer cuál es la equivalencia de estas presentaciones en relación con la dexametasona base, con el objetivo de asegurar la administración de la dosis de 6 mg/día que demostró disminuir la mortalidad


Assuntos
Argentina , Dexametasona , Mortalidade , Infecções por Coronavirus
6.
J Crit Care ; 58: 41-47, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32335494

RESUMO

PURPOSE: Our main objective was to use the Maximum Acute Gastrointestinal Injury Score (AGImax) to evaluate the prognostic capability of gastrointestinal dysfunction (GID), on hospital mortality in patients on mechanical ventilation (MV) requiring vasopressors. A secondary goal was to analyze the relationship between AGImax and vasopressor dosage with increasing caloric intake. MATERIALS AND METHODS: Prospective multicenter cohort study in ten ICUs across Argentina. Consecutive adult patients on MV, requiring vasopressors and receiving enteral nutrition (EN) were included. AGImax was identified (I-IV) using a modified AGI score. Comparisons of clinical and outcome variables were performed in 3 predetermined EN-groups: <10 kcal/kg/d, ≥10 to <20 kcal/kg/d, or ≥ 20 kcal/kg/d. RESULTS: A total of 494 patients met all inclusion criteria. Forty-four percent of patients had severe AGImax and 17% received <10 kcal/kg/day, indicating more severity and higher mortality. Notable independent predictors of mortality were AGImax, vasopressors, and caloric intake. PN was the only factor which had an inverse relationship to mortality. CONCLUSIONS: In this population, patients with AGImax III-IV were significantly associated with lower caloric intake and greater hospital mortality, highlighting the importance of AGI as a prognostic tool. As PN was linked with lower mortality, it could be an option to explore in further studies.


Assuntos
Ingestão de Energia , Trato Gastrointestinal/lesões , Escala de Gravidade do Ferimento , Choque/terapia , Vasopressinas/uso terapêutico , Adulto , Argentina , Estudos de Coortes , Feminino , Humanos , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Respiração Artificial , Choque/mortalidade , Vasopressinas/administração & dosagem
7.
J Crit Care ; 53: 8-10, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31174174

RESUMO

PURPOSE: Gender disparities in healthcare are striking, notwithstanding an increase in female students and physicians. Underrepresentation of women in leadership positions is well-documented; however, information from low and middle-income countries (LMICs) is still sparse. The Argentinian Society of Intensive Care Medicine (SATI) aimed to characterize the gender composition in Argentine ICUs. METHODS AND RESULTS: Between 8/1/2018 and 1/1/2019, 131 questionnaires were submitted to ICU Department Chairs of SATI research networks. Gender distribution of the different staffing levels, board certification and hospital characteristics were recorded. One-hundred and four were completed, including 2186 physicians; 44% were female. Female participation decreased with highest responsibility: only 23% of Department Chairs were female (P = .002 vs. the rest of the staffing categories, adjusted for multiple comparisons). Residents exhibited the highest proportion of female physicians (47%). Board certification was similar for both sexes (62.3% vs. 62.2%, P = .97). Female/male distribution in public and private hospitals was 47%/53% and 40/60% (P < .01), respectively. CONCLUSION: Our data provide evidence of an important gender gap in ICU management in a LMIC. Women were poorly represented in the leadership positions, although qualifications were similar to men. Moreover, female physicians worked more frequently in the public health subsector, usually underfinanced in LMICs-a surrogate of a gender pay gap.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Identidade de Gênero , Unidades de Terapia Intensiva/estatística & dados numéricos , Médicos/estatística & dados numéricos , Recursos Humanos/estatística & dados numéricos , Adulto , Argentina/epidemiologia , Feminino , Hospitais Públicos , Humanos , Masculino , Inquéritos e Questionários
8.
Eur J Clin Microbiol Infect Dis ; 37(4): 785-794, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29318460

RESUMO

2017 ESCMID practice guidelines reported safety concerns and weak evidence of benefit supporting use of aerosolized antibiotics in mechanically ventilated patients. Our primary goal was to assess current patterns of aerosolized antibiotic prescription in mechanically ventilated patients. A sequential global survey was performed prior to the release of the ESCMID guidelines, from the 1st of February to the 30th of April 2017, using an electronic platform. Responses were analyzed comparing geographical regions. A total of 410 units responded, with 261 (177 from Europe) being eligible for the full survey. 26.8% of units reported not using aerosolized antibiotics. The two major indications amongst prescribing units were ventilator-associated pneumonia and ventilator-associated tracheobronchitis (74.3% and 49.4%, respectively). 63.6% of units indicated prescription solely in response to multi-drug resistant organisms. In comparison with a survey undertaken in 2014, there was a significant reduction in use of aerosolized antibiotics for prophylaxis (50.6% vs 7.7%, p < 0.05) and colonization (52.9% vs 25.3%, p < 0.05). The large majority of units (91.7%) reported only prescribing in patients with positive pulmonary cultures. Asia appeared to be an outlier, with 53.3% of units reporting empirical use. The most commonly used device was the jet nebulizer. The most commonly prescribed drugs were colistin methanesulfonate (57.6%), colistin base (41.9%) and amikacin (31.4%), although there was considerable heterogeneity across geographical areas. A significant gap exists between ESCMID clinical practice recommendations and the use of aerosolized antibiotics in clinical practice. Our findings indicate an urgent need for high-quality education to bring practice into line with evidence-based guidelines.


Assuntos
Administração por Inalação , Anti-Infecciosos/administração & dosagem , Nebulizadores e Vaporizadores , Respiração Artificial/estatística & dados numéricos , Infecções Respiratórias/tratamento farmacológico , Anti-Infecciosos/uso terapêutico , Estudos Transversais , Humanos , Nebulizadores e Vaporizadores/estatística & dados numéricos , Respiração Artificial/métodos , Infecções Respiratórias/epidemiologia
9.
Rev Bras Ter Intensiva ; 29(1): 39-46, 2017.
Artigo em Português, Inglês | MEDLINE | ID: mdl-28444071

RESUMO

Objective:: To determine the effectiveness of a quality management program in reducing the incidence and severity of pressure ulcers in critical care patients. Methods:: This was a quasi-experimental, before-and-after study that was conducted in a medical-surgical intensive care unit. Consecutive patients who had received mechanical ventilation for ≥ 96 hours were included. A "Process Improvement" team designed a multifaceted interventional process that consisted of an educational session, a pressure ulcer checklist, a smartphone application for lesion monitoring and decision-making, and a "family prevention bundle". Results:: Fifty-five patients were included in Pre-I group, and 69 were included in the Post-I group, and the incidence of pressure ulcers in these groups was 41 (75%) and 37 (54%), respectively. The median time for pressure ulcers to develop was 4.5 [4 - 5] days in the Pre-I group and 9 [6 - 20] days in the Post-I group after admission for each period. The incidence of advanced-grade pressure ulcers was 27 (49%) in the Pre-I group and 7 (10%) in the Post-I group, and finally, the presence of pressure ulcers at discharge was 38 (69%) and 18 (26%), respectively (p < 0.05 for all comparisons). Family participation totaled 9% in the Pre-I group and increased to 57% in the Post-I group (p < 0.05). A logistic regression model was used to analyze the predictors of advanced-grade pressure ulcers. The duration of mechanical ventilation and the presence of organ failure were positively associated with the development of pressure ulcers, while the multifaceted intervention program acted as a protective factor. Conclusion:: A quality program based on both a smartphone application and family participation can reduce the incidence and severity of pressure ulcers in patients on prolonged acute mechanical ventilation.


Assuntos
Unidades de Terapia Intensiva , Equipe de Assistência ao Paciente/organização & administração , Lesão por Pressão/prevenção & controle , Respiração Artificial/métodos , Adulto , Idoso , Cuidados Críticos/métodos , Família , Humanos , Incidência , Modelos Logísticos , Pessoa de Meia-Idade , Aplicativos Móveis , Lesão por Pressão/epidemiologia , Lesão por Pressão/patologia , Índice de Gravidade de Doença , Smartphone , Fatores de Tempo , Adulto Jovem
10.
Rev. bras. ter. intensiva ; 29(1): 39-46, jan.-mar. 2017. tab, graf
Artigo em Português | LILACS | ID: biblio-844283

RESUMO

RESUMO Objetivo: Determinar a eficácia de um programa de gestão da qualidade para reduzir a incidência e a gravidade de úlceras por pressão em pacientes de terapia intensiva. Métodos: Estudo com metodologia quasi-experimental, antes-e-depois, conduzido em uma unidade de terapia intensiva clínica e cirúrgica. Incluíram-se os pacientes consecutivos que receberam ventilação mecânica por um período igual ou superior a 96 horas. Uma equipe de Melhoria de Processos delineou um processo de intervenção multifacetado, que consistiu de uma sessão educacional, uma lista de verificação de úlcera de pressão, um aplicativo para smartphone para monitoramento de lesões e um conjunto de normas de tomada de decisão, além de prevenção familiar. Resultados: O Grupo Pré-I incluiu 25 pacientes, e o Grupo Pós-I foi constituído por 69 pacientes. A incidência de úlcera de pressão nestes grupos foi de 41 (75%) e 37 (54%), respectivamente. O tempo mediano para o desenvolvimento das úlceras por pressão foi de 4,5 (4-5) dias no Grupo Pré-I e 9 (6-20) dias no Grupo Pós-I após a admissão para cada um dos períodos. A incidência de úlceras por pressão de grau avançado foi de 27 (49%) no Grupo Pré-I e 7 (10%) no Grupo Pós-I. A presença de úlceras por pressão na alta foi de 38 (69%) e 18 (26%), respectivamente, para os Grupos Pré-I e Pós-I (p < 0,05 para todas as comparações). A participação da família totalizou 9% no Grupo Pré-I e aumentou para 57% no Grupo Pós-I (p < 0,05). Utilizou-se um modelo de regressão logística para analisar os preditores de úlcera de pressão com grau avançado. A duração da ventilação mecânica e a presença de falência de órgão associaram-se positivamente com o desenvolvimento de úlceras por pressão, enquanto o programa multifacetado de intervenção atuou como fator de proteção. Conclusão: Um programa de qualidade, com base em um aplicativo para smartphone e na participação da família, pode reduzir a incidência e a gravidade de úlceras por pressão em pacientes com ventilação mecânica aguda prolongada.


ABSTRACT Objective: To determine the effectiveness of a quality management program in reducing the incidence and severity of pressure ulcers in critical care patients. Methods: This was a quasi-experimental, before-and-after study that was conducted in a medical-surgical intensive care unit. Consecutive patients who had received mechanical ventilation for ≥ 96 hours were included. A "Process Improvement" team designed a multifaceted interventional process that consisted of an educational session, a pressure ulcer checklist, a smartphone application for lesion monitoring and decision-making, and a "family prevention bundle". Results: Fifty-five patients were included in Pre-I group, and 69 were included in the Post-I group, and the incidence of pressure ulcers in these groups was 41 (75%) and 37 (54%), respectively. The median time for pressure ulcers to develop was 4.5 [4 - 5] days in the Pre-I group and 9 [6 - 20] days in the Post-I group after admission for each period. The incidence of advanced-grade pressure ulcers was 27 (49%) in the Pre-I group and 7 (10%) in the Post-I group, and finally, the presence of pressure ulcers at discharge was 38 (69%) and 18 (26%), respectively (p < 0.05 for all comparisons). Family participation totaled 9% in the Pre-I group and increased to 57% in the Post-I group (p < 0.05). A logistic regression model was used to analyze the predictors of advanced-grade pressure ulcers. The duration of mechanical ventilation and the presence of organ failure were positively associated with the development of pressure ulcers, while the multifaceted intervention program acted as a protective factor. Conclusion: A quality program based on both a smartphone application and family participation can reduce the incidence and severity of pressure ulcers in patients on prolonged acute mechanical ventilation.


Assuntos
Humanos , Adulto , Idoso , Adulto Jovem , Equipe de Assistência ao Paciente/organização & administração , Respiração Artificial/métodos , Lesão por Pressão/prevenção & controle , Unidades de Terapia Intensiva , Fatores de Tempo , Índice de Gravidade de Doença , Família , Modelos Logísticos , Incidência , Cuidados Críticos/métodos , Lesão por Pressão/patologia , Lesão por Pressão/epidemiologia , Aplicativos Móveis , Smartphone , Pessoa de Meia-Idade
11.
J Crit Care ; 30(5): 1049-54, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26105747

RESUMO

PURPOSE: Our goal was to describe the evolution of selected physical and psychologic symptoms and identify the determinants of health-related quality of life (HRQOL) after intensive care unit (ICU) discharge. METHODS: The study is a prospective cohort of consecutive adult patients admitted to a mixed ICU in a university-affiliated hospital, mechanically ventilated for more than 48 hours. During ICU stay, epidemiological data and events probably associated to worsening outcomes were recorded. After discharge, patients were interviewed at 1, 3, 6, and 12 months. Health-related quality of life was assessed with EuroQoL Questionnaire-5 Dimensions, which includes the EQ-index and EQ-Visual Analogue Scale. RESULTS: One hundred twelve patients were followed up, aged 33 [24-49] years, 68% male, 76% previously healthy, and cranial trauma was the main diagnosis. Physical and psychologic symptoms and moderate/severe problems according to the EQ index progressively decreased after discharge, yet were still highly prevalent after 1 year. EQ index improved from 0.22 [0.01-0.69] to 0.52 [0.08-0.81], 0.66 [0.17-0.79], and 0.68 [0.26-0.86] (P < .001, for all vs month 1). EQ-Visual Analogue Scale remained stable, within acceptable values. Independent determinants of EQ-index were time, duration of mechanical ventilation, shock, weakness, and return to study/work. CONCLUSIONS: Determinants of HRQOL after ICU discharge were both related to late sequelae of critical illness and to some events occurring in the ICU. Notwithstanding the high symptom burden, patients still perceived their HRQOL as good.


Assuntos
Estado Terminal/terapia , Qualidade de Vida , Adulto , Argentina , Lesões Encefálicas/psicologia , Efeitos Psicossociais da Doença , Cuidados Críticos , Feminino , Hospitalização , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Estudos Prospectivos , Respiração Artificial , Inquéritos e Questionários , Sobreviventes , Adulto Jovem
12.
Am J Respir Crit Care Med ; 182(1): 41-8, 2010 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-20203241

RESUMO

RATIONALE: The rapid spread of the 2009 Influenza A (H1N1) around the world underscores the need for a better knowledge of epidemiology, clinical features, outcomes, and mortality predictors, especially in the most severe presentations. OBJECTIVES: To describe these characteristics in patients with confirmed, probable, and suspected viral pneumonia caused by 2009 influenza A (H1N1) admitted to 35 intensive care units with acute respiratory failure requiring mechanical ventilation in Argentina, between June 3 and September 7. METHODS: Inception-cohort study including 337 consecutive adult patients. Data were collected in a form posted on the Argentinian Society of Intensive Care website. MEASUREMENTS AND MAIN RESULTS: Proportions of confirmed, probable, or suspected cases were 39%, 8%, and 53% and had similar outcomes. APACHE II was 18 +/- 7; age 47 +/- 17 years; 56% were male; and 64% had underlying conditions, with obesity (24%), chronic obstructive respiratory disease (18%), and immunosupression (15%) being the most common. Seven percent were pregnant. On admission, patients had severe hypoxemia (Pa(O(2))/Fi(O(2)) 140 [87-200]), extensive lung radiologic infiltrates (2.87 +/- 1.03 quadrants) and bacterial coinfection, (25%; mostly with Streptococcus pneumoniae). Use of adjuvants such as recruitment maneuvers (40%) and prone positioning (13%), and shock (72%) and acute kidney injury requiring hemodialysis (17%), were frequent. Mortality was 46%, and was similar across all ages. APACHE II, lowest Pa(O(2))/Fi(O(2)), shock, hemodialysis, prone positioning, and S. pneumoniae coinfection independently predicted death. CONCLUSIONS: Patients with 2009 influenza A (H1N1) requiring mechanical ventilation were mostly middle-aged adults, often with comorbidities, and frequently developed severe acute respiratory distress syndrome and multiorgan failure requiring advanced organ support. Case fatality rate was accordingly high.


Assuntos
Surtos de Doenças , Vírus da Influenza A Subtipo H1N1 , Influenza Humana/mortalidade , Respiração Artificial , Síndrome do Desconforto Respiratório/terapia , APACHE , Adulto , Argentina/epidemiologia , Estudos de Coortes , Feminino , Humanos , Hipóxia/mortalidade , Influenza Humana/complicações , Influenza Humana/terapia , Masculino , Pessoa de Meia-Idade , Pneumonia Pneumocócica/complicações , Pneumonia Pneumocócica/mortalidade , Gravidez , Síndrome do Desconforto Respiratório/etiologia , Síndrome do Desconforto Respiratório/mortalidade
13.
Crit Care Med ; 36(6): 1823-31, 2008 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-18520642

RESUMO

OBJECTIVE: The objective of this study was to determine the epidemiology and outcomes of intra-abdominal hypertension in a heterogeneous intensive care unit population. DESIGN: This was a prospective cohort study. SETTING: This study was conducted at a medical-surgical intensive care unit in a university hospital. PATIENTS: Study patients included all those consecutively admitted during 9 months, staying > 24 hrs, and requiring bladder catheterization. MEASUREMENTS AND MAIN RESULTS: On admission, epidemiologic data and risk factors for intra-abdominal hypertension were studied; then, daily maximal and mean intra-abdominal pressures (IAP(max) and IAP(mean)), abdominal perfusion pressure, fluid balances, filtration gradient, and sequential organ failure assessment score, were registered. IAPs were recorded through a bladder catheter every 6 hrs until death, discharge, or along 7 days. Intra-abdominal hypertension was defined as IAP > or = 12 mm Hg. Abdominal compartment syndrome was defined as IAP > or = 20 mm Hg plus > or = 1 new organ failure. Main outcome measure was hospital mortality. Of 83 patients, considering IAP(max), 31% had intra-abdominal hypertension on admission and another 33% developed it after (23% and 31% with IAP(mean)). Main risk factors were mechanical ventilation, acute respiratory distress syndrome, and fluid resuscitation (relative risk, 5.26, 3.19, and 2.50, respectively). Patients with intra-abdominal hypertension were sicker, had higher mortality (53% vs. 27%, p = .02), and consistently showed higher total and renal sequential organ failure assessment score, daily and cumulative fluid balances, and lower filtration gradient. Nonsurvivors had higher IAP(max), IAP(mean), and fluid balances and lower abdominal perfusion pressure. Abdominal compartment syndrome developed in 12%; 20% survived. Logistic regression identified IAP(max) as an independent predictor of mortality (odds ratio, 1.17; 95% confidence interval, 1.05-1.30; p = .003) after adjusting with Acute Physiology and Chronic Health Evaluation II and comorbidities (odds ratio, 1.15; 95% confidence interval, 1.06-1.25; p = .001; and odds ratio, 2.68; 95% confidence interval, 1.27-5.67; p = .013, respectively). Models with IAP(mean) and abdominal perfusion pressure also performed well. Areas under receiver operating characteristic curves were .81 and .83. CONCLUSIONS: Intra-abdominal hypertension, diagnosed either with IAP(max) or IAP(mean), was frequent and showed an independent association with mortality. Intra-abdominal hypertension was significantly associated with more severe organ failures, particularly renal and respiratory, and a prolonged intensive care unit stay.


Assuntos
Abdome , Síndromes Compartimentais/epidemiologia , Cuidados Críticos/estatística & dados numéricos , Insuficiência de Múltiplos Órgãos/epidemiologia , APACHE , Adulto , Idoso , Estudos de Coortes , Síndromes Compartimentais/diagnóstico , Síndromes Compartimentais/etiologia , Síndromes Compartimentais/mortalidade , Estudos Transversais , Feminino , Mortalidade Hospitalar , Humanos , Pressão Hidrostática , Incidência , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/diagnóstico , Insuficiência de Múltiplos Órgãos/etiologia , Insuficiência de Múltiplos Órgãos/mortalidade , Razão de Chances , Prognóstico , Estudos Prospectivos , Fatores de Risco , Análise de Sobrevida
14.
Chest ; 131(3): 718-724, 2007 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-17356085

RESUMO

OBJECTIVES: To review a series of critically ill obstetric patients admitted to our ICU to assess the spectrum of disease, required interventions, and fetal/maternal mortality, and to identify conditions associated with maternal death. DESIGN: Retrospective cohort. SETTING: Medical-surgical ICU in a university-affiliated hospital. PATIENTS: Pregnant/postpartum admissions between January 1, 1998, and September 30, 2005. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: We studied 161 patients (age, 28 +/- 9 years; mean gestational age, 29 +/- 9 weeks) [mean +/- SD], constituting 10% of 1,571 hospital admissions. APACHE (acute physiology and chronic health evaluation) II score was 14 +/- 8, with 24% predicted mortality; sequential organ failure assessment score was 5 +/- 3; and therapeutic intervention scoring system at 24 h was 25 +/- 9. Forty-one percent of patients required mechanical ventilation (MV). ARDS, shock, and organ dysfunction were present in 19%, 25%, and 48% of patients, respectively. Most patients (63%) were admitted postpartum, and 74% of admissions were of obstetric cause. Hypertensive disease (40%), major hemorrhage (16%), septic abortion (12%), and nonobstetric sepsis (10%) were the principal diagnoses. Maternal mortality was 11%, with multiple organ dysfunction syndrome (44%) and intracranial hemorrhage (39%) as main causes. There were no differences in death rate in patients admitted for obstetric and nonobstetric causes. Fetal mortality was 32%. Only 30% of patients received antenatal care, which was more frequent in survivors (33% vs 6% nonsurvivors, p = 0.014). CONCLUSIONS: Although ARDS, organ failures, shock, and use of MV were extremely frequent in this population, maternal mortality remains within an acceptable range. APACHE II overpredicted mortality in these patients. Septic abortion is still an important modifiable cause of mortality. Efforts should concentrate in increasing antenatal care, which was clearly underprovided in these patients.


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde , Admissão do Paciente/estatística & dados numéricos , Complicações na Gravidez/terapia , Transtornos Puerperais/terapia , APACHE , Aborto Séptico/diagnóstico , Aborto Séptico/mortalidade , Aborto Séptico/terapia , Argentina , Causas de Morte , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/mortalidade , Hemorragia Cerebral/terapia , Estudos de Coortes , Estado Terminal/terapia , Feminino , Morte Fetal/diagnóstico , Morte Fetal/epidemiologia , Morte Fetal/terapia , Mortalidade Hospitalar , Humanos , Hipertensão/diagnóstico , Hipertensão/mortalidade , Hipertensão/terapia , Recém-Nascido , Mortalidade Materna , Insuficiência de Múltiplos Órgãos/diagnóstico , Insuficiência de Múltiplos Órgãos/mortalidade , Insuficiência de Múltiplos Órgãos/terapia , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/mortalidade , Hemorragia Pós-Parto/terapia , Gravidez , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/mortalidade , Transtornos Puerperais/diagnóstico , Transtornos Puerperais/mortalidade , Respiração Artificial/mortalidade , Síndrome do Desconforto Respiratório/diagnóstico , Síndrome do Desconforto Respiratório/mortalidade , Síndrome do Desconforto Respiratório/terapia , Choque/diagnóstico , Choque/mortalidade , Choque/terapia , Taxa de Sobrevida
15.
Crit Care ; 10(3): R89, 2006.
Artigo em Inglês | MEDLINE | ID: mdl-16784546

RESUMO

INTRODUCTION: Our goal was to describe the epidemiology, clinical profiles, outcomes, and factors that might predict progression of critically ill patients to chronically critically ill (CCI) patients, a still poorly characterized subgroup. METHODS: We prospectively studied all patients admitted to a university-affiliated hospital intensive care unit (ICU) between 1 July 2002 and 30 June 2005. On admission, we recorded epidemiological data, the presence of organ failure (multiorgan dysfunction syndrome (MODS)), underlying diseases (McCabe score), acute respiratory distress syndrome (ARDS) and shock. Daily, we recorded MODS, ARDS, shock, mechanical ventilation use, lengths of ICU and hospital stay (LOS), and outcome. CCI patients were defined as those having a tracheotomy placed for continued ventilation. Clinical complications and time to tracheal decannulation were registered. Predictors of progression to CCI were identified by logistic regression. RESULTS: Ninety-five patients (12%) fulfilled the CCI definition and, compared with the remaining 690 patients, these CCI patients were sicker (APACHE II, 21 +/- 7 versus 18 +/- 9 for non-CCI patients, p = 0.005); had more organ dysfunctions (SOFA 7 +/- 3 versus 6 +/- 4, p < 0.003); received more interventions (TISS 32 +/- 10 versus 26 +/- 8, p < 0.0001); and had less underlying diseases and had undergone emergency surgery more frequently (43 versus 24%, p = 0.001). ARDS and shock were present in 84% and 83% of CCI patients, respectively, versus 44% and 48% in the other patients (p < 0.0001 for both). CCI patients had higher expected mortality (38% versus 32%, p = 0.003), but observed mortality was similar (32% versus 35%, p = 0.59). Independent predictors of progression to CCI were ARDS on admission, APACHE II and McCabe scores (odds ratio (OR) 2.26, p < 0.001; OR 1.03, p < 0.01; and OR 0.34, p < 0.0001, respectively). Lengths of mechanical ventilation, ICU and hospital stay were 33 (24 to 50), 39 (29 to 55) and 55 (37 to 84) days, respectively. Tracheal decannulation was achieved at 40 +/- 19 days. CONCLUSION: CCI patients were a severely ill population, in which ARDS, shock, and MODS were frequent on admission, and who suffered recurrent complications during their stay. However, their prognosis was equivalent to that of the other ICU patients. ARDS, APACHE II and McCabe scores were independent predictors of evolution to chronicity.


Assuntos
APACHE , Estado Terminal/mortalidade , Adulto , Doença Crônica , Estudos de Coortes , Cuidados Críticos/métodos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/etiologia , Insuficiência de Múltiplos Órgãos/mortalidade , Estudos Prospectivos , Síndrome do Desconforto Respiratório/etiologia , Síndrome do Desconforto Respiratório/mortalidade
16.
Intensive Care Med ; 31(8): 1058-65, 2005 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-15983759

RESUMO

OBJECTIVE: To assess renal dysfunction and outcome in patients treated exclusively with colistin vs. other antibiotics. DESIGN AND SETTING: Prospective cohort study in a mixed ICU in a university-affiliated hospital. PATIENTS: 185 patients infected with Acinetobacter baumannii and Pseudomonas aeruginosa after an ICU stay longer than 48 h: 55 in the colistin group and 130 in the noncolistin group, similar in age, APACHE II, medical status, and SOFA score. MEASUREMENTS AND RESULTS: We recorded data on epidemiology and severity of illness, site of infection, renal function before and after treatment, clinical cure, and mortality. Clinical cure was defined as simultaneous normalization of central temperature (< or = 38 degrees), leukocyte count (< or = 10,000/mm3), and PaO2/FIO2 ratio (>187). Before treatment creatinine was 0.9+/-0.2 in the colistin group and 0.9+/-0.1 in the noncolistin group; after treatment the value was 1.0+/-0.3 in both groups. The most frequent infection was ventilator-associated pneumonia: 53% vs. 66% in colistin and noncolistin groups, respectively, Acinetobacter was the cause in 65% and 60% and Pseudomonas in 35% and 53%. In the noncolistin group 81% of patients were treated with carbapenems. Inadequate empirical antimicrobial treatment was more frequent in the colistin group (100% vs. 8%), but there were no differences in the frequency of clinical cure on day 6 of treatment (15% and 17%) or in mortality (29% and 24%). CONCLUSIONS: Colistin appears to be as safe and as effective as other antimicrobials for treatment of sepsis caused by Acinetobacter and Pseudomonas in critically ill patients.


Assuntos
Infecções por Acinetobacter/tratamento farmacológico , Antibacterianos/uso terapêutico , Colistina/uso terapêutico , Infecções por Pseudomonas/tratamento farmacológico , APACHE , Acinetobacter/efeitos dos fármacos , Adulto , Argentina , Gasometria , Estudos de Coortes , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Pseudomonas/efeitos dos fármacos , Resultado do Tratamento
17.
Chest ; 127(2): 598-603, 2005 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-15706002

RESUMO

STUDY OBJECTIVES: To determine the incidence of prolonged mechanical ventilation (PMV), which is associated with increased health-care costs and risks of adverse events, and to identify its early predictors. DESIGN: Retrospective cohort. SETTING: A medical-surgical ICU in a university-affiliated hospital. PATIENTS OR PARTICIPANTS: All patients admitted to the ICU over 3 years who received mechanical ventilation (MV) for > 12 h. INTERVENTIONS: None. MEASUREMENTS: PMV was defined as MV lasting > 21 days. We recorded epidemiologic data, severity scores, worst Pao(2)/fraction of inspired oxygen (Fio(2)), presence of shock on ICU admission day, cause for MV, length of MV, ICU length of stay (LOS), and hospital LOS. PMV patients were compared to patients weaned before 21 days (non-PMV group) to determine predictors of PMV. RESULTS: Of 551 hospital admissions, 319 patients (58%) required MV > 12 h. One hundred thirty patients died early and were excluded. Seventy-nine patients (14%) required PMV. The non-PMV group consisted of 110 patients. Simplified acute physiology score (SAPS) II, APACHE (acute physiology and chronic health evaluation) II, therapeutic intervention scoring system, Pao(2)/Fio(2), shock, ICU LOS, and hospital LOS differed significantly between groups. However, logistic regression identified shock on ICU admission day as the only independent predictor of PMV (odds ratio, 3.10; p = 0.001). SAPS II and Pao(2)/Fio(2) had the nearest coefficients and were used to build the predictive model. Sensitivity analysis was performed including the 130 patients who died early, and shock remained the most powerful predictor. CONCLUSIONS: PMV was a frequent event in this cohort. The presence of shock on ICU admission day was the only prognostic factor, even adjusting for severity of illness and hypoxemia.


Assuntos
Indicadores Básicos de Saúde , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Índice de Gravidade de Doença , Choque/epidemiologia , APACHE , Adulto , Idoso , Argentina , Estudos de Coortes , Feminino , Hospitais Universitários , Humanos , Hipóxia/epidemiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prognóstico , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Sensibilidade e Especificidade , Desmame do Respirador
18.
Med. intensiva ; 20(1): 19-23, 2003. tab
Artigo em Espanhol | LILACS | ID: lil-383755

RESUMO

Objetivo: Determinar la incidencia de las distintas infecciones asociadas a catéteres (IAC): colonización del catéter (CC), bacteriemia asociada a catéter (BAC) e infecciones del sitio de salida (ISS), de acuerdo a las definiciones del CDC. Diseño: Estudio observacional, prospectivo, realizado en una UTI polivalente de 8 camas de un hospital escuela, durante el período de un año. Materiales y métodos: Fueron incluidos todos los pacientes ingresados a UTI desde el 01/01/00 al 01/01/01 que requirieran catéteres venosos centrales (CVC) durante más de 24 hs. Se consideró CC como el crecimiento de ò15 UFC en un recuento semicuantitativo o de ò10 UFC en un recuento cuantitativo de la punta distal del catéter con hemocultivos negativos; BAC al aislamiento del mismo germen (idéntica tipificación y sensibilidad) en la punta del catéter por cultivo semicuantitativo o cuantitativo y en hemocultivos periféricos; e ISS ante la presencia de eritema, induración o purulencia hasta 2 cm del sitio de salida del catéter. Los accesos utilizados fueron yugular, femoral y subclavio...


Assuntos
Humanos , Masculino , Adulto , Feminino , Pessoa de Meia-Idade , Infecções por Acinetobacter , Bacteriemia , Cateterismo Venoso Central , Infecções por Bactérias Gram-Negativas , Infecções por Bactérias Gram-Positivas , Infecção Hospitalar/prevenção & controle , Infecções Estafilocócicas , Infecções por Acinetobacter , Argentina , Bacteriemia , Cateterismo , Resistência Microbiana a Medicamentos , Veia Femoral , Infecção Hospitalar/etiologia , Unidades de Terapia Intensiva , Veias Jugulares , Meticilina , Staphylococcus , Veia Subclávia
19.
Med. intensiva ; 20(1): 19-23, 2003. tab
Artigo em Espanhol | BINACIS | ID: bin-4224

RESUMO

Objetivo: Determinar la incidencia de las distintas infecciones asociadas a catéteres (IAC): colonización del catéter (CC), bacteriemia asociada a catéter (BAC) e infecciones del sitio de salida (ISS), de acuerdo a las definiciones del CDC. Diseño: Estudio observacional, prospectivo, realizado en una UTI polivalente de 8 camas de un hospital escuela, durante el período de un año. Materiales y métodos: Fueron incluidos todos los pacientes ingresados a UTI desde el 01/01/00 al 01/01/01 que requirieran catéteres venosos centrales (CVC) durante más de 24 hs. Se consideró CC como el crecimiento de ò15 UFC en un recuento semicuantitativo o de ò10 UFC en un recuento cuantitativo de la punta distal del catéter con hemocultivos negativos; BAC al aislamiento del mismo germen (idéntica tipificación y sensibilidad) en la punta del catéter por cultivo semicuantitativo o cuantitativo y en hemocultivos periféricos; e ISS ante la presencia de eritema, induración o purulencia hasta 2 cm del sitio de salida del catéter. Los accesos utilizados fueron yugular, femoral y subclavio...(AU)


Assuntos
Humanos , Masculino , Adulto , Feminino , Pessoa de Meia-Idade , Infecção Hospitalar/prevenção & controle , Bacteriemia/epidemiologia , Cateterismo Venoso Central/efeitos adversos , Infecções por Acinetobacter/epidemiologia , Infecções Estafilocócicas , Infecções por Bactérias Gram-Positivas , Infecções por Bactérias Gram-Negativas , Infecção Hospitalar/etiologia , Argentina , Unidades de Terapia Intensiva , Bacteriemia/etiologia , Bacteriemia/prevenção & controle , Cateterismo/efeitos adversos , Infecções por Acinetobacter/transmissão , Resistência Microbiana a Medicamentos , Meticilina , Staphylococcus , Veias Jugulares , Veia Subclávia , Veia Femoral
20.
RNC ; 11(3): 96-105, jul.-sept. 2002. tab
Artigo em Espanhol | LILACS | ID: lil-334723

RESUMO

Objetivos: evaluar la eficacia y complicacciones en pacientes críticos que recibieron nutrición enteral, comparando la nutrición gástrica y la pospilórica. Diseño: ensayo clínico prospectivo randomizado. Lugar: Unidad de Terapia Intensiva polivalente de un Hospital Universitario, de 8 camas. Pacientes: un total de 43 pacientes críticos que requirieron NE durante más de 48 horas. Material y métodos: se evaluaron las siguientes complicaciones relacionadas a la NE: 1) gastrointestinales: alto residuo gástrico, diarrea, vómitos, distensión abdominal, regurgitación, constipación; y 2) no gastrointestinales: hiperglucemia y neumonía. Se evaluó la eficacia de administración como tasa de kcal administradas/prescriptas. Intervenciones: los pacientes fueron randomizados a recibir nutrición gástrica o nutrición post pilórico. Resultados: fueron incluídos 43 pacientes; 24 correspondieron a nutrición gástrica y 19 a nutrición postpilórica. Ambos grupos fueron igual en edad, sexo, APACHE II, Mc Cabe, TISS y mortalidad predicha. No hubo diferencias en el porcentaje de pacientes en asistencia ventilatoria mecánica, ni en mortalidad. El grupo postpilórico presento mayor día de ventilación mecánica y en estadía en UTI. Se presentaron 81 por ciento de complicaciones gastrointestinales (NG: 84 NPP: 79), todos las variables no fueron significativas...


Assuntos
Humanos , Intubação Gastrointestinal , Nutrição Enteral/instrumentação , Nutrição Enteral/métodos , Estudos Prospectivos
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