Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 238
Filtrar
1.
World J Emerg Surg ; 16(1): 53, 2021 Oct 14.
Artigo em Inglês | MEDLINE | ID: mdl-34649583

RESUMO

BACKGROUND: It is unknown how frequently damage control (DC) laparotomy is used across trauma centers in different countries. We conducted a cross-sectional survey of trauma centers in the United States, Canada, and Australasia to study variations in use of the procedure and predictors of more frequent use of DC laparotomy. METHODS: A self-administered, electronic, cross-sectional survey of trauma centers in the United States, Canada, and Australasia was conducted. The survey collected information about trauma center and program characteristics. It also asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last year. Multivariable logistic regression was used to identify predictors of a higher reported frequency of use of DC laparotomy. RESULTS: Of the 366 potentially eligible trauma centers sent the survey, 199 (51.8%) trauma program directors or leaders responded [United States = 156 (78.4%), Canada = 26 (13.1%), and Australasia = 17 (8.5%)]. The reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more frequently in level-1 than level-2 or -3 trauma centers. Further, high-volume level-1 centers used DC laparotomy significantly more often than lower volume level-1 centers (p = 0.02). Nearly half (48.4%) of high-volume volume level-1 trauma centers reported using the procedure at least once weekly. Significant adjusted predictors of more frequent use of DC laparotomy included country of origin [odds ratio (OR) for the United States vs. Canada = 7.49; 95% confidence interval (CI) 1.39-40.27], level-1 verification status (OR = 6.02; 95% CI 2.01-18.06), and the assessment of a higher number of severely injured (Injury Severity Scale score > 15) patients (OR per-100 patients = 1.62; 95% CI 1.20-2.18) and patients with penetrating injuries (OR per-5% increase = 1.27; 95% CI 1.01-1.58) in the last year. CONCLUSIONS: The reported frequency of use of DC laparotomy was highly variable across trauma centers. Those centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries.

2.
JMIR Res Protoc ; 2021 Sep 08.
Artigo em Inglês | MEDLINE | ID: mdl-34507273

RESUMO

BACKGROUND: Patients undergoing lower limb revascularization surgery for peripheral artery disease (PAD) have a high-risk of perioperative morbidity and mortality and often have long hospital stays. Use of neuraxial or regional anesthesia instead of general anesthesia may represent one approach to improving outcomes and reducing resource use among these patients. OBJECTIVE: To conduct a systematic review and meta-analysis to determine whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD results in improved health outcomes and costs and a shorter length of hospitalization. METHODS: We will search electronic bibliographic databases (MEDLINE, EMBASE, and the seven databases in Evidence-Based Medicine Reviews, medRxiv, bioRxiv, and Google Scholar), review articles identified during the search, and included article bibliographies. We will include randomized and non-randomized studies comparing use of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD. Two investigators will independently evaluate risk of bias. The primary outcome will be short-term mortality (in-hospital or 30-day). Secondary outcomes will include longer-term mortality; major adverse cardiovascular, pulmonary, and renal events; delirium; deep vein thrombosis or pulmonary embolism; major adverse limb events; neuraxial or regional anesthesia-related complications; graft-related outcomes; length of operation and hospital stay; costs; and patient-reported or functional outcomes. We will calculate summary odds ratios and standardized mean differences using random-effects models. Heterogeneity will be explored using stratified meta-analyses and meta-regression. We will assess for publication bias using Begg's and Egger's tests and use the trim-and-fill method to estimate the potential influence of this bias on summary estimates. Finally, we will use Grading of Recommendations, Assessment, Development, and Evaluation methodology to make an overall rating of the quality of evidence in our effect estimates. RESULTS: The protocol was registered in Prospero, the international register of systematic reviews. We executed the peer-reviewed search strategy on March 2, 2021. We completed the review of titles and abstracts on July 30. CONCLUSIONS: This study will synthesize existing evidence regarding whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD results in improved health outcomes, graft patency, and costs, and a shorter length of hospital stay. Study results will be used to inform practice and future research, including creation of a pilot and then multicenter randomized controlled trial. CLINICALTRIAL: Prospero CRD42021237060.

3.
Crit Care Med ; 2021 Sep 08.
Artigo em Inglês | MEDLINE | ID: mdl-34495878

RESUMO

OBJECTIVES: The coronavirus disease 2019 pandemic has disrupted critical care services across the world. In anticipation of surges in the need for critical care services, governments implemented "lockdown" measures to preserve and create added critical care capacity. Herein, we describe the impact of lockdown measures on the utilization of critical care services and patient outcomes compared with nonlockdown epochs in a large integrated health region. DESIGN: This was a population-based retrospective cohort study. SETTING: Seventeen adult ICUs across 14 acute care hospitals in Alberta, Canada. PATIENTS: All adult (age ≥ 15 yr) patients admitted to any study ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main exposure was ICU admission during "lockdown" occurring between March 16, 2020, and June 30, 2020. This period was compared with two nonpandemic control periods: "year prior" (March 16, 2019, to June 30, 2019) and "pre lockdown" immediately prior (November 30, 2019, to March 15, 2020). The primary outcome was the number of ICU admissions. Secondary outcomes included the following: daily measures of ICU utilization, ICU duration of stay, avoidable delay in ICU discharge, and occupancy; and patient outcomes. Mixed multilevel negative binomial regression and interrupted time series regression were used to compare rates of ICU admissions between periods. Multivariable regressions were used to compare patient outcomes between periods. During the lockdown, there were 3,649 ICU admissions (34.1 [8.0] ICU admissions/d), compared with 4,125 (38.6 [9.3]) during the prelockdown period and 3,919 (36.6 [8.7]) during the year prior. Mean bed occupancy declined significantly during the lockdown compared with the nonpandemic periods (78.7%, 95.9%, and 96.4%; p < 0.001). Avoidable ICU discharge delay also decreased significantly (42.0%, 53.2%, and 58.3%; p < 0.001). During the lockdown, patients were younger, had fewer comorbid diseases, had higher acuity, and were more likely to be medical admissions compared with the nonpandemic periods. Adjusted ICU and hospital mortality and ICU and hospital lengths of stay were significantly lower during the lockdown compared with nonpandemic periods. CONCLUSIONS: The coronavirus disease 2019 lockdown resulted in substantial changes to ICU utilization, including a reduction in admissions, occupancy, patient lengths of stay, and mortality.

4.
J Patient Saf ; 2021 Aug 30.
Artigo em Inglês | MEDLINE | ID: mdl-34469915

RESUMO

OBJECTIVE: This study aimed to estimate the frequency of hospital adverse events (AEs) and explore the rate of AEs over time, and across and within hospital populations. METHODS: Validated search terms were run in MEDLINE and EMBASE; gray literature and references of included studies were also searched. Studies of any design or language providing an estimate of AEs within the hospital were eligible. Studies were excluded if they only provided an estimate for a specific AE, a subgroup of hospital patients or children. Data were abstracted in duplicate using a standardized data abstraction form. Study quality was assessed using the Newcastle-Ottawa Scale. A random-effects meta-analysis estimated the occurrence of hospital AEs, and meta-regression explored the association between hospital AEs, and patient and hospital characteristics. RESULTS: A total of 45,426 unique references were identified; 1,265 full-texts were reviewed and 94 studies representing 590 million admissions from 25 countries from 1961 to 2014 were included. The incidence of hospital AEs was 8.6 per 100 patient admissions (95% confidence interval [CI], 8.3 to 8.9; I2 = 100%, P < 0.001). Half of the AEs were preventable (52.6%), and a third resulted in moderate/significant harm (39.7%). The most evaluated AEs were surgical AEs, drug-related AEs, and nosocomial infections. The occurrence of AEs increased by year (95% CI, -0.05 to -0.04; P < 0.001) and patient age (95% CI = -0.15 to -0.14; P < 0.001), and varied by country income level and study characteristics. Patient sex, hospital type, hospital service, and geographical location were not associated with AEs. CONCLUSIONS: Hospital AEs are common, and reported rates are increasing in the literature. Given the increase in AEs over time, hospitals should reinvest in improving hospital safety with a focus on interventions targeted toward the more than half of AEs that are preventable.

5.
Syst Rev ; 10(1): 260, 2021 Sep 28.
Artigo em Inglês | MEDLINE | ID: mdl-34583771

RESUMO

BACKGROUND: Citizen engagement in research is an emerging practice that involves members of the general public in research processes such as priority setting, planning, decision-making, research conduct, implementation, evaluation, and dissemination. Engaging citizens in research, particularly health research, increases the relevance of study findings, minimizes waste by facilitating stewardship over resources, and builds public trust in the research. While several existing frameworks guide the application of citizen engagement principles to health research, it is unclear how citizen engagement can be utilized to maximize benefits and minimize risks and challenges in health research. To address the gaps in knowledge around citizen engagement in health research, we propose a scoping review to synthesize the state of knowledge on methods to incorporate and evaluate citizen engagement in research. A protocol is presented in this manuscript. METHODS: The methodology for our scoping review is guided by Arksey and O' Malley's framework for scoping reviews, and additional recommendations by Levac and colleagues. We will include peer-reviewed and gray literature that report on citizen engagement in health research (including biomedical, clinical, health systems and services, and social, cultural, environmental and population health) and report method(s) to conduct, measure, or evaluate citizen engagement. We will systematically search electronic databases (MEDLINE, EMBASE, CINAHL, JSTOR, PsycINFO, Scopus, and Science Direct) from inception onwards and search relevant organizations' websites for additional studies, frameworks, and reports on citizen engagement. Title and abstract and full-text citations will be screened independently and in duplicate. Data will be extracted independently and in duplicate, including document characteristics, citizen engagement definitions and goals, and outcomes of citizen engagement (e.g., barriers, facilitators). DISCUSSION: This review will synthesize the definitions, goals, methods, outcomes, and significance of citizen engagement in health research, as well as any potential barriers, facilitators, and challenges outlined in existing literature. The findings will provide an evidence-based foundation for developing new or improved guidance for citizen engagement in health research. Overall, we anticipate that our scoping review will be a preliminary step to meaningful engagement of citizens in research and strengthen the relationship between the scientific community and the public through transparency and collaboration. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework  https://osf.io/hzcbr .

6.
BMJ Open ; 11(9): e048227, 2021 09 23.
Artigo em Inglês | MEDLINE | ID: mdl-34556510

RESUMO

INTRODUCTION: Flexible visitation policies in hospitals are an important component of care that contributes to reduced stress and increased satisfaction among patients and their family members. Early evidence suggests restricted visitation policies enacted in hospitals during the COVID-19 pandemic are having unintended consequences on patients, family members and healthcare providers. There is a need for a comprehensive summary of the impacts of restricted visitation policies on key stakeholders and approaches to mitigate that impact. METHODS AND ANALYSIS: We will conduct a scoping review as per the Arksey-O'Malley 5-stage scoping review method and the Scoping Review Methods Manual by the Joanna Briggs Institute. We will search relevant electronic databases (eg, CINAHL, MEDLINE, PsycINFO), grey literature and preprint repositories. We will include all study designs including qualitative and quantitative methodologies (excluding protocols) as well as reports, opinions and editorials, to identify the broad impact of restricted hospital visitation policies due to the COVID-19 pandemic on patients, family members or healthcare providers of hospitalised patients, and approaches taken or proposed to mitigate this impact. Two reviewers will calibrate the screening criteria and data abstraction form and will independently screen studies and abstract the data. Narrative synthesis with thematic analysis will be performed. ETHICS AND DISSEMINATION: Ethical approval is not applicable as this review will be conducted on published literature only. This scoping review will identify, describe and categorise impacts of restricted hospital visitation policies due to the COVID-19 pandemic on patients, family members and healthcare providers of hospitalised patients, and approaches that have been taken to mitigate impact. We will provide a comprehensive synthesis by developing a framework of restricted visitation policies and associated impacts. Our results will inform the development of consensus statements on restricted visitation policies to be implemented in future pandemics. PROSPERO REGISTRATION NUMBER: CRD42020221662.


Assuntos
COVID-19 , Pandemias , Família , Pessoal de Saúde , Hospitais , Humanos , Políticas , Projetos de Pesquisa , Literatura de Revisão como Assunto , SARS-CoV-2
7.
Crit Care ; 25(1): 347, 2021 09 25.
Artigo em Inglês | MEDLINE | ID: mdl-34563234

RESUMO

BACKGROUND: Restricted visitation policies in acute care settings because of the COVID-19 pandemic have negative consequences. The objective of this scoping review is to identify impacts of restricted visitation policies in acute care settings, and describe perspectives and mitigation approaches among patients, families, and healthcare professionals. METHODS: We searched Medline, Embase, PsycINFO, Healthstar, CINAHL, Cochrane Central Register of Controlled Trials on January 01/2021, unrestricted, for published primary research records reporting any study design. We included secondary (e.g., reviews) and non-research records (e.g., commentaries), and performed manual searches in web-based resources. We excluded records that did not report primary data. Two reviewers independently abstracted data in duplicate. RESULTS: Of 7810 citations, we included 155 records. Sixty-six records (43%) were primary research; 29 (44%) case reports or case series, and 26 (39%) cohort studies; 21 (14%) were literature reviews and 8 (5%) were expert recommendations; 54 (35%) were commentary, editorial, or opinion pieces. Restricted visitation policies impacted coping and daily function (n = 31, 20%) and mental health outcomes (n = 29, 19%) of patients, families, and healthcare professionals. Participants described a need for coping and support (n = 107, 69%), connection and communication (n = 107, 69%), and awareness of state of well-being (n = 101, 65%). Eighty-seven approaches to mitigate impact of restricted visitation were identified, targeting families (n = 61, 70%), patients (n = 51, 59%), and healthcare professionals (n = 40, 46%). CONCLUSIONS: Patients, families, and healthcare professionals were impacted by restricted visitation polices in acute care settings during COVID-19. The consequences of this approach on patients and families are understudied and warrant evaluation of approaches to mitigate their impact. Future pandemic policy development should include the perspectives of patients, families, and healthcare professionals. TRIAL REGISTRATION: The review was registered on PROSPERO (CRD42020221662) and a protocol peer-reviewed prior to data extraction.


Assuntos
COVID-19/prevenção & controle , Cuidados Críticos , Família , Política de Saúde , Pacientes Internados , Distanciamento Físico , Visitas a Pacientes , COVID-19/psicologia , COVID-19/transmissão , Comunicação , Família/psicologia , Pessoal de Saúde/psicologia , Humanos , Pacientes Internados/psicologia , Serviços de Saúde Mental , Pandemias , Angústia Psicológica , SARS-CoV-2 , Telefone , Visitas a Pacientes/psicologia
8.
JAMA ; 326(11): 1024-1033, 2021 09 21.
Artigo em Inglês | MEDLINE | ID: mdl-34546300

RESUMO

Importance: Growing interest in microbial dysbiosis during critical illness has raised questions about the therapeutic potential of microbiome modification with probiotics. Prior randomized trials in this population suggest that probiotics reduce infection, particularly ventilator-associated pneumonia (VAP), although probiotic-associated infections have also been reported. Objective: To evaluate the effect of Lactobacillus rhamnosus GG on preventing VAP, additional infections, and other clinically important outcomes in the intensive care unit (ICU). Design, Setting, and Participants: Randomized placebo-controlled trial in 44 ICUs in Canada, the United States, and Saudi Arabia enrolling adults predicted to require mechanical ventilation for at least 72 hours. A total of 2653 patients were enrolled from October 2013 to March 2019 (final follow-up, October 2020). Interventions: Enteral L rhamnosus GG (1 × 1010 colony-forming units) (n = 1321) or placebo (n = 1332) twice daily in the ICU. Main Outcomes and Measures: The primary outcome was VAP determined by duplicate blinded central adjudication. Secondary outcomes were other ICU-acquired infections including Clostridioides difficile infection, diarrhea, antimicrobial use, ICU and hospital length of stay, and mortality. Results: Among 2653 randomized patients (mean age, 59.8 years [SD], 16.5 years), 2650 (99.9%) completed the trial (mean age, 59.8 years [SD], 16.5 years; 1063 women [40.1%.] with a mean Acute Physiology and Chronic Health Evaluation II score of 22.0 (SD, 7.8) and received the study product for a median of 9 days (IQR, 5-15 days). VAP developed among 289 of 1318 patients (21.9%) receiving probiotics vs 284 of 1332 controls (21.3%; hazard ratio [HR], 1.03 (95% CI, 0.87-1.22; P = .73, absolute difference, 0.6%, 95% CI, -2.5% to 3.7%). None of the 20 prespecified secondary outcomes, including other ICU-acquired infections, diarrhea, antimicrobial use, mortality, or length of stay showed a significant difference. Fifteen patients (1.1%) receiving probiotics vs 1 (0.1%) in the control group experienced the adverse event of L rhamnosus in a sterile site or the sole or predominant organism in a nonsterile site (odds ratio, 14.02; 95% CI, 1.79-109.58; P < .001). Conclusions and Relevance: Among critically ill patients requiring mechanical ventilation, administration of the probiotic L rhamnosus GG compared with placebo, resulted in no significant difference in the development of ventilator-associated pneumonia. These findings do not support the use of L rhamnosus GG in critically ill patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02462590.


Assuntos
Antibacterianos/uso terapêutico , Lactobacillus rhamnosus , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Probióticos/uso terapêutico , Respiração Artificial , Idoso , Antibacterianos/efeitos adversos , Infecções Bacterianas/prevenção & controle , Diarreia/prevenção & controle , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Respiração Artificial/efeitos adversos , Falha de Tratamento
10.
J Crit Care ; 66: 67-74, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34455165

RESUMO

PURPOSE: Pre-existing psychiatric disorders may lead to negative outcomes following intensive care unit (ICU) discharge. We evaluated the association of pre-existing psychiatric disorders with subsequent healthcare utilization and mortality in patients discharged from ICU. MATERIALS AND METHODS: We retrospectively studied adult patients admitted to 14 medical-surgical ICUs (January 2014-June 2016) with ICU length stay ≥24 h who survived to hospital discharge. Pre-existing psychiatric disorders were identified using algorithms for diagnostic codes captured ≤5 years before ICU admission. Outcomes were healthcare utilization (emergency department visit, hospital or ICU readmission) and mortality. We used logistic regression models with propensity scores to estimate associations, converted to risk ratios (RR). RESULTS: We included 10,598 patients. 37.6% (n = 3982) had a psychiatric history. Patients with pre-existing psychiatric disorders were at higher risk of subsequent emergency department visits (RR 1.49, 95%CI 1.29-1.71), hospital readmission (RR 1.49, 95%CI 1.34-1.66), ICU readmission (RR 2.64, 95%CI 1.55-4.49) one-year post-ICU discharge, compared to patients without pre-existing psychiatric disorders. Patients with pre-existing psychiatric disorders had a higher risk of mortality (RR 1.31, 95%CI 1.00-1.71) six-months post-ICU discharge. CONCLUSION: Critically ill patients with pre-existing psychiatric disorders have an increased risk of healthcare utilization and mortality outcomes following an ICU stay.

12.
Can J Anaesth ; 68(10): 1474-1484, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34195922

RESUMO

PURPOSE: In response to the rapid spread of SARS-CoV-2, hospitals in Canada enacted temporary visitor restrictions to limit the spread of COVID-19 and preserve personal protective equipment supplies. This study describes the extent, variation, and fluctuation of Canadian adult intensive care unit (ICU) visitation policies before and during the first wave of the COVID-19 pandemic. METHODS: We conducted an environmental scan of Canadian hospital visitation policies throughout the first wave of the pandemic. We conducted a two-phased study analyzing both quantitative and qualitative data. RESULTS: We collected 257 documents with reference to visitation policies (preCOVID, 101 [39%]; midCOVID, 71 [28%]; and lateCOVID, 85 [33%]). Of these 257 documents, 38 (15%) were ICU-specific and 70 (27%) referenced the ICU. Most policies during the midCOVID/lateCOVID pandemic period allowed no visitors with specific exceptions (e.g., end-of-life). Framework analysis revealed five overarching themes: 1) reasons for restricted visitation policies; 2) visitation policies and expectations; 3) exceptions to visitation policy; 4) patient and family-centred care; and 5) communication and transparency. CONCLUSIONS: During the first wave of the COVID-19 pandemic, most Canadian hospitals had public-facing visitor restriction policies with specific exception categories, most commonly for patients at end-of-life, patients requiring assistance, or COVID-19 positive patients (varying from not allowed to case-by-case). Further studies are needed to understand the consistency with which visitation policies were operationalized and how they may have impacted patient- and family-centred care.


Assuntos
COVID-19 , Pandemias , Adulto , Canadá , Humanos , Unidades de Terapia Intensiva , Política Organizacional , Políticas , SARS-CoV-2 , Visitas a Pacientes
13.
JMIR Res Protoc ; 10(9): e28759, 2021 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-34161251

RESUMO

BACKGROUND: Surgical site infections (SSIs) are common, costly, and associated with increased morbidity and potential mortality after lower limb revascularization surgery (ie, arterial bypass, endarterectomy, and patch angioplasty). Identifying evidence-informed risk factors for SSI in patients undergoing these surgeries is therefore important. OBJECTIVE: The aim of this study is to conduct a systematic review and meta-analysis of prognostic studies to identify, synthesize, and determine the certainty in the cumulative evidence associated with reported risk factors for early and delayed SSI after lower limb revascularization surgery in adults with peripheral artery disease. METHODS: We will search MEDLINE, Embase, the seven databases in Evidence-Based Medicine Reviews, review articles identified during the search, and included article bibliographies. We will include studies of adults (aged ≥18 years) with peripheral artery disease that report odds ratios, risk ratios, or hazard ratios adjusted for the presence of other risk factors or confounding variables and relating the potential risk factor of interest to the development of SSI after lower limb revascularization surgery. We will exclude studies that did not adjust for confounding, exclusively examined certain high-risk patient cohorts, or included >20% of patients who underwent surgery for indications other than peripheral artery disease. The primary outcomes will be early (in-hospital or ≤30 days) SSI and Szilagyi grade I (cellulitis involving the wound), grade II (infection involving subcutaneous tissue), and grade III (infection involving the vascular graft) SSI. Two investigators will independently extract data and evaluate the study risk of bias using the Quality in Prognosis Studies tool. Adjusted risk factor estimates with similar definitions will be pooled using DerSimonian and Laird random-effects models. Heterogeneity will be explored using stratified meta-analyses and meta-regression. Finally, we will use the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to determine certainty in the estimates of association between reported risk factors and the development of SSI. RESULTS: The protocol was registered in PROSPERO (International Prospective Register of Systematic Reviews). We will execute the peer-reviewed search strategy on June 30, 2021, and then complete the review of titles and abstracts and full-text articles by July 30, 2021, and September 15, 2021, respectively. We will complete the full-text study data extraction and risk of bias assessment by November 15, 2021. We anticipate that we will be able to submit the manuscript for peer review by January 30, 2022. CONCLUSIONS: This study will identify, synthesize, and determine the certainty in the cumulative evidence associated with risk factors for early and delayed SSI after lower limb revascularization surgery in patients with peripheral artery disease. The results will be used to inform practice, clinical practice statements and guidelines, and subsequent research. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42021242557; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=242557. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/28759.

14.
BMC Palliat Care ; 20(1): 66, 2021 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-33980242

RESUMO

BACKGROUND: Informal caregivers of critically ill patients in intensive care unit (ICUs) experience negative psychological sequelae that worsen after death. We synthesized outcomes reported from ICU bereavement interventions intended to improve informal caregivers' ability to cope with grief. DATA SOURCES: MEDLINE, EMBASE, CINAHL and PsycINFO from inception to October 2020. STUDY SELECTION: Randomized controlled trials (RCTs) of bereavement interventions to support informal caregivers of adult patients who died in ICU. DATA EXTRACTION: Two reviewers independently extracted data in duplicate. Narrative synthesis was conducted. DATA SYNTHESIS: Bereavement interventions were categorized according to the UK National Institute for Health and Clinical Excellence three-tiered model of bereavement support according to the level of need: (1) Universal information provided to all those bereaved; (2) Selected or targeted non-specialist support provided to those who are at-risk of developing complex needs; and/or (3) Professional specialist interventions provided to those with a high level of complex needs. Outcome measures were synthesized according to core outcomes established for evaluating bereavement support for adults who have lost other adults to illness. RESULTS: Three studies of ICU bereavement interventions from 31 ICUs across 26 hospitals were included. One trial examining the effect of family presence at brain death assessment integrated all three categories of support but did not report significant improvement in emotional or psychological distress. Two other trials assessed a condolence letter intervention, which did not decrease grief symptoms and may have increased symptoms of depression and post-traumatic stress disorder, and a storytelling intervention that found no significant improvements in anxiety, depression, post-traumatic stress, or complicated grief. Four of nine core bereavement outcomes were not assessed anytime in follow-up. CONCLUSIONS: Currently available trial evidence is sparse and does not support the use of bereavement interventions for informal caregivers of critically ill patients who die in the ICU.

15.
Crit Care ; 25(1): 146, 2021 04 16.
Artigo em Inglês | MEDLINE | ID: mdl-33863361

RESUMO

BACKGROUND: It is unclear whether vasopressors can be safely administered through a peripheral intravenous (PIV). Systematic review and meta-analysis methodology was used to examine the incidence of local anatomic adverse events associated with PIV vasopressor administration in patients of any age cared for in any acute care environment. METHODS: MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials, and the Database of Abstracts of Reviews of Effects were searched without restriction from inception to October 2019. References of included studies and related reviews, as well as relevant conference proceedings were also searched. Studies were included if they were: (1) cohort, quasi-experimental, or randomized controlled trial study design; (2) conducted in humans of any age or clinical setting; and (3) reported on local anatomic adverse events associated with PIV vasopressor administration. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials or the Joanna Briggs Institute checklist for prevalence studies where appropriate. Incidence estimates were pooled using random effects meta-analysis. Subgroup analyses were used to explore sources of heterogeneity. RESULTS: Twenty-three studies were included in the systematic review, of which 16 and 7 described adults and children, respectively. Meta-analysis from 11 adult studies including 16,055 patients demonstrated a pooled incidence proportion of adverse events associated with PIV vasopressor administration as 1.8% (95% CI 0.1-4.8%, I2 = 93.7%). In children, meta-analysis from four studies and 388 patients demonstrated a pooled incidence proportion of adverse events as 3.3% (95% CI 0.0-10.1%, I2 = 82.4%). Subgroup analyses did not detect any statistically significant effects associated with stratification based on differences in clinical location, risk of bias or design between studies, PIV location and size, or vasopressor type or duration. Most studies had high or some concern for risk of bias. CONCLUSION: The incidence of adverse events associated with PIV vasopressor administration is low. Additional research is required to examine the effects of PIV location and size, vasopressor type and dose, and patient characteristics on the safety of PIV vasopressor administration.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/etiologia , Vasoconstritores/efeitos adversos , Cateterismo Periférico/métodos , Humanos , Vasoconstritores/uso terapêutico
16.
Crit Care Med ; 49(9): 1414-1426, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-33826586

RESUMO

OBJECTIVES: Determine effect of mental health interventions on psychologic outcomes in informal caregivers of critically ill patients. DATA SOURCES: Searches conducted in MEDLINE, Embase, and other databases from inception to October 31, 2019. STUDY SELECTION: Interventions for informal caregivers of critically ill patients in adult ICU, PICU, or neonatal ICU. DATA EXTRACTION: Two independent, blinded reviewers screened citations and extracted data. Random-effects models with inverse variance weighting pooled outcome data when suitable. Psychologic outcomes categorized: 1) negative (anxiety, depression, post-traumatic stress disorder, distress, and burden) or 2) positive (courage, humanity, justice, transcendence, temperance, and wisdom and knowledge). Stratification according to intervention type and patient population was performed. DATA SYNTHESIS: Of 11,201 studies, 102 interventional trials were included (n = 12,676 informal caregivers). Interventions targeted caregiver experience (n = 58), role (n = 6), or support (n = 38). Meta-analysis (56 randomized controlled trials; n = 22 [39%] in adult ICUs; n = 34 [61%] in neonatal ICU or PICU) demonstrated reduced anxiety (ratio of means = 0.92; 95% CI, 0.87-0.97) and depression (ratio of means = 0.83; 95% CI, 0.69-0.99), but not post-traumatic stress disorder (ratio of means = 0.91; 95% CI, 0.80-1.04) or distress (ratio of means = 1.01; 95% CI, 0.95-1.07) among informal caregivers randomized to mental health interventions compared with controls within 3 months post-ICU discharge. Increased humanity (ratio of means = 1.11; 95% CI, 1.07-1.15), transcendence (ratio of means = 1.11; 95% CI, 1.07-1.15), and caregiver burden (ratio of means = 1.08; 95% CI, 1.05-1.12) were observed. No significant effects of mental health interventions observed after 3 months postdischarge. CONCLUSIONS: Mental health interventions for caregivers of critically ill patients improved short-term anxiety, depression, humanity, and transcendence while increasing burden. Clinicians should consider short-term prescriptions of mental health interventions to informal caregivers of critically ill patients with capacity to manage interventions.


Assuntos
Cuidadores/psicologia , Serviços de Saúde Mental/normas , Assistência ao Paciente/psicologia , Estado Terminal/psicologia , Estado Terminal/terapia , Humanos , Unidades de Terapia Intensiva/organização & administração , Serviços de Saúde Mental/tendências , Avaliação de Resultados em Cuidados de Saúde/métodos , Assistência ao Paciente/normas , Qualidade de Vida/psicologia
17.
Am J Respir Crit Care Med ; 204(4): 412-420, 2021 08 15.
Artigo em Inglês | MEDLINE | ID: mdl-33823122

RESUMO

Rationale: Delirium is common in the ICU and portends worse ICU and hospital outcomes. The effect of delirium in the ICU on post-hospital discharge mortality and health resource use is less well known. Objectives: To estimate mortality and health resource use 2.5 years after hospital discharge in critically ill patients admitted to the ICU. Methods: This was a population-based, propensity score-matched, retrospective cohort study of adult patients admitted to 1 of 14 medical-surgical ICUs from January 1, 2014, to June 30, 2016. Delirium was measured by using the 8-point Intensive Care Delirium Screening Checklist. The primary outcome was mortality. The secondary outcome was a composite measure of subsequent emergency department visits, hospital readmission, or mortality. Measurements and Main Results: There were 5,936 propensity score-matched patients with and without a history of incident delirium who survived to hospital discharge. Delirium was associated with increased mortality 0-30 days after hospital discharge (hazard ratio, 1.44 [95% confidence interval, 1.08-1.92]). There was no significant difference in mortality more than 30 days after hospital discharge (delirium: 3.9%, no delirium: 2.6%). There was a persistent increased risk of emergency department visits, hospital readmissions, or mortality after hospital discharge (hazard ratio, 1.12 [95% confidence interval, 1.07-1.17]) throughout the study period. Conclusions: ICU delirium is associated with increased mortality 0-30 days after hospital discharge.


Assuntos
Delírio/mortalidade , Utilização de Instalações e Serviços/estatística & dados numéricos , Unidades de Terapia Intensiva , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Alberta/epidemiologia , Estado Terminal , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Prognóstico , Pontuação de Propensão , Estudos Retrospectivos , Análise de Sobrevida , Adulto Jovem
18.
BMC Health Serv Res ; 21(1): 374, 2021 Apr 22.
Artigo em Inglês | MEDLINE | ID: mdl-33888096

RESUMO

BACKGROUND: The COVID-19 pandemic has led to global shortages in the resources required to care for critically ill patients and to protect frontline healthcare providers. This study investigated physicians' perceptions and experiences of caring for critically ill patients in the context of actual or anticipated resource strain during the COVID-19 pandemic, and explored implications for the healthcare workforce and the delivery of patient care. METHODS: We recruited a diverse sample of critical care physicians from 13 Canadian Universities with adult critical care training programs. We conducted semi-structured telephone interviews between March 25-June 25, 2020 and used qualitative thematic analysis to derive primary themes and subthemes. RESULTS: Fifteen participants (eight female, seven male; median age = 40) from 14 different intensive care units described three overarching themes related to physicians' perceptions and experiences of caring for critically ill patients during the pandemic: 1) Conditions contributing to resource strain (e.g., continuously evolving pandemic conditions); 2) Implications of resource strain on critical care physicians personally (e.g., safety concerns) and professionally (e.g. practice change); and 3) Enablers of resource sufficiency (e.g., adequate human resources). CONCLUSIONS: The COVID-19 pandemic has required health systems and healthcare providers to continuously adapt to rapidly evolving circumstances. Participants' uncertainty about whether their unit's planning and resources would be sufficient to ensure the delivery of high quality patient care throughout the pandemic, coupled with fear and anxiety over personal and familial transmission, indicate the need for a unified systemic pandemic response plan for future infectious disease outbreaks.


Assuntos
COVID-19 , Médicos , Adulto , Canadá/epidemiologia , Estado Terminal/terapia , Feminino , Humanos , Masculino , Pandemias , Percepção , SARS-CoV-2
19.
BMC Psychiatry ; 21(1): 187, 2021 04 09.
Artigo em Inglês | MEDLINE | ID: mdl-33836699

RESUMO

BACKGROUND: Witnessing delirium can be distressing for family caregivers (i.e., relatives or friends) of critically ill patients. This study aimed to evaluate associations between caregiver-detected delirium in critically ill patients and depression and anxiety symptoms in their family caregivers. METHODS: Consecutive adult patient-caregiver dyads were enrolled from a 28-bed medical-surgical intensive care unit. Patient delirium was screened for daily by family caregivers using the Sour Seven instrument. Family caregivers completed the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) instruments daily to assess their own depression and anxiety symptoms. Response feature analysis was used to handle repeated measures. Descriptive statistics and regression analyses were completed. RESULTS: One hundred forty-seven patient-caregiver dyads were enrolled. Clinically significant symptoms of depression and anxiety occurred in 27% and 35% of family caregivers, respectively. Caregiver-detected delirium occurred in 65% of patients, and was not associated with clinically significant caregiver depression (Odds Ratio [OR] 1.4, 95% Confidence Interval [95%CI] 0.6-3.1) or anxiety (OR 1.2, 95%CI 0.6-2.6) symptoms. When stratified by Sour Seven scores, scores 1-3 and 4-9 were associated with increased symptoms of anxiety (OR 3.1, 95%CI 1.3-7.0) and depression (OR 2.6, 95%CI 1.1-6.1) in family caregivers. Caregiver-detected delirium score was associated with severity of family caregiver anxiety symptoms (coefficient 0.2, 95%CI 0.1-0.4), but not depression symptoms (coefficient 0.2, 95%CI -0.0-0.3). CONCLUSIONS: Caregiver-detected patient delirium was associated with increased depression and anxiety symptoms in family caregivers of critically ill patients. Further randomized research is required to confirm these associations.


Assuntos
Cuidadores , Delírio , Adulto , Ansiedade/diagnóstico , Transtornos de Ansiedade , Estado Terminal , Estudos Transversais , Delírio/diagnóstico , Depressão/diagnóstico , Humanos
20.
World J Emerg Surg ; 16(1): 10, 2021 03 11.
Artigo em Inglês | MEDLINE | ID: mdl-33706763

RESUMO

BACKGROUND: Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes). METHODS: We searched 11 databases (1950-April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions. RESULTS: Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications. CONCLUSIONS: Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.


Assuntos
Ferimentos e Lesões/cirurgia , Medicina Baseada em Evidências , Humanos , Análise de Sobrevida , Ferimentos e Lesões/mortalidade
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...