Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 131
Filtrar
1.
Ann Intensive Care ; 11(1): 161, 2021 Nov 26.
Artigo em Inglês | MEDLINE | ID: mdl-34825972

RESUMO

BACKGROUND: The role of intravenous immunoglobulins (IVIG) during sepsis is controversial, as different trials on IVIG have observed inconsistent survival benefits. We aimed to elucidate the possible association and clinical significance between circulating levels of immunoglobulins. METHODS: In a subset of 956 patients with severe sepsis and septic shock of the multicentre, open-label RCT ALBIOS, venous blood samples were serially collected 1, 2, and 7 days after enrolment (or at ICU discharge, whichever came first). IgA, IgG and IgM concentrations were assayed in all patients on day 1 and in a subgroup of 150 patients on days 2 and 7. Ig concentrations were measured employing a turbidimetric assay, OSR61171 system. RESULTS: IgA on day 1 had a significant predictive value for both 28-day and 90-day mortality (28-day mortality, HR: 1.50 (95% CI 1.18-1.92); 90-day mortality, HR: 1.54 (95% CI 1.25-1.91)). IgG, but not IgM, on day 1 showed similar results for 28-day (HR 1.83 (95% CI 1.33-2.51) and 90-day mortality HR: 1.66 (95% CI 1.23-2.25)). In addition, lower levels of IgG but not of IgA and IgM, at day 1 were associated with significantly higher risk of secondary infections (533 [406-772] vs 600 [452-842] mg/dL, median [Q1-Q3], p = 0.007). CONCLUSIONS: In the largest cohort study of patients with severe sepsis or septic shock, we found that high levels of IgA and IgG on the first day of diagnosis were associated with a decreased 90-day survival. No association was found between IgM levels and survival. As such, the assessment of endogenous immunoglobulins could be a useful tool to identify septic patients at high risk of mortality. Trial registration #NCT00707122, Clinicaltrial.gov, registered 30 June 2008.

2.
Intensive Care Med ; 47(12): 1347-1367, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34787687

RESUMO

PURPOSE: To provide consensus, and a list of experts' recommendations regarding the basic skills for head-to-toe ultrasonography in the intensive care setting. METHODS: The Executive Committee of the European Society of Intensive Care (ESICM) commissioned the project and supervised the methodology and structure of the consensus. We selected an international panel of 19 expert clinicians-researchers in intensive care unit (ICU) with expertise in critical care ultrasonography (US), plus a non-voting methodologist. The panel was divided into five subgroups (brain, lung, heart, abdomen and vascular ultrasound) which identified the domains and generated a list of questions to be addressed by the panel. A Delphi process based on an iterative approach was used to obtain the final consensus statements. Statements were classified as a strong recommendation (84% of agreement), weak recommendation (74% of agreement), and no recommendation (less than 74%), in favor or against. RESULTS: This consensus produced a total of 74 statements (7 for brain, 20 for lung, 20 for heart, 20 for abdomen, 7 for vascular Ultrasound). We obtained strong agreement in favor for 49 statements (66.2%), 8 weak in favor (10.8%), 3 weak against (4.1%), and no consensus in 14 cases (19.9%). In most cases when consensus was not obtained, it was felt that the skills were considered as too advanced. A research agenda and discussion on training programs were implemented from the results of the consensus. CONCLUSIONS: This consensus provides guidance for the basic use of critical care US and paves the way for the development of training and research projects.

3.
Minerva Anestesiol ; 2021 Oct 12.
Artigo em Inglês | MEDLINE | ID: mdl-34636222

RESUMO

Traumatic brain injury (TBI) is a leading cause of mortality and disability worldwide. Head injured patients may frequently require emergency neurosurgery. The perioperative TBI period is very important as many interventions done in this stage can have a profound effect on the long-term neurological outcome. This practical concise narrative review focused mainly on: 1) the management of severe TBI patients with neurosurgical lesions admitted to a spoke center (i.e. hospital without neurosurgery) and therefore needing a transfer to the hub center (i.e. hospital with neurosurgery); 2) the management of severe TBI patients with intracranial hypertension/brain herniation awaiting for neurosurgery and 3) the neuromonitoring-oriented management in the immediate post-operative period. The proposals presented in this review mainly apply to severe TBI patients admitted to high-income countries.

4.
Intensive Care Med ; 2021 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-34505911

RESUMO

Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy.

5.
Pediatr Nephrol ; 2021 Sep 20.
Artigo em Inglês | MEDLINE | ID: mdl-34545447

RESUMO

BACKGROUND: Creatinine is distributed between the intracellular and extracellular compartments, and as a result, the measurement of its concentration is strongly related to the fluid status of the patient. An interest has been shown in correcting measured serum creatinine levels according to the fluid balance in order to better specify the degree of acute kidney injury (AKI). METHODS: We conducted a retrospective observational study of 33 children, aged 0 to 5 years, admitted to the pediatric intensive care unit for acute respiratory distress syndrome treated by extracorporeal membrane oxygenation. We compared measured and corrected creatinine and assessed the degree of agreement between these values using both Cohen's kappa and Krippendorff's alpha coefficient. RESULTS: In our cohort, 37% of the classifications made according to measured creatinine levels were erroneous and, in the majority of cases, the degree of AKI was underestimated. CONCLUSION: Correction of the measured creatinine value according to the degree of fluid overload may result in more accurate diagnosis of AKI. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information.

6.
BMJ Open ; 11(8): e047100, 2021 08 11.
Artigo em Inglês | MEDLINE | ID: mdl-34380722

RESUMO

INTRODUCTION: Mechanical ventilatory is a crucial element of acute brain injured patients' management. The ventilatory goals to ensure lung protection during acute respiratory failure may not be adequate in case of concomitant brain injury. Therefore, there are limited data from which physicians can draw conclusions regarding optimal ventilator management in this setting. METHODS AND ANALYSIS: This is an international multicentre prospective observational cohort study. The aim of the 'multicentre observational study on practice of ventilation in brain injured patients'-the VENTIBRAIN study-is to describe the current practice of ventilator settings and mechanical ventilation in acute brain injured patients. Secondary objectives include the description of ventilator settings among different countries, and their association with outcomes. Inclusion criteria will be adult patients admitted to the intensive care unit (ICU) with a diagnosis of traumatic brain injury or cerebrovascular diseases (intracranial haemorrhage, subarachnoid haemorrhage, ischaemic stroke), requiring intubation and mechanical ventilation and admission to the ICU. Exclusion criteria will be the following: patients aged <18 years; pregnant patients; patients not intubated or not mechanically ventilated or receiving only non-invasive ventilation. Data related to clinical examination, neuromonitoring if available, ventilator settings and arterial blood gases will be recorded at admission and daily for the first 7 days and then at day 10 and 14. The Glasgow Outcome Scale Extended on mortality and neurological outcome will be collected at discharge from ICU, hospital and at 6 months follow-up. ETHICS AND DISSEMINATION: The study has been approved by the Ethic committee of Brianza at the Azienda Socio Sanitaria Territoriale-Monza. Data will be disseminated to the scientific community by abstracts submitted to the European Society of Intensive Care Medicine annual conference and by original articles submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04459884.


Assuntos
Isquemia Encefálica , Acidente Vascular Cerebral , Adulto , Encéfalo , Humanos , Unidades de Terapia Intensiva , Pulmão , Estudos Multicêntricos como Assunto , Estudos Observacionais como Assunto , Estudos Prospectivos , Respiração Artificial
7.
J Crit Care ; 66: 78-85, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-34461380

RESUMO

PURPOSE: To investigate the possible association between ventilatory settings on the first day of invasive mechanical ventilation (IMV) and mortality in patients admitted to the intensive care unit (ICU) with severe acute respiratory infection (SARI). MATERIALS AND METHODS: In this pre-planned sub-study of a prospective, multicentre observational study, 441 patients with SARI who received controlled IMV during the ICU stay were included in the analysis. RESULTS: ICU and hospital mortality rates were 23.1 and 28.1%, respectively. In multivariable analysis, tidal volume and respiratory rate on the first day of IMV were not associated with an increased risk of death; however, higher driving pressure (DP: odds ratio (OR) 1.05; 95% confidence interval (CI): 1.01-1.1, p = 0.011), plateau pressure (Pplat) (OR 1.08; 95% CI: 1.04-1.13, p < 0.001) and positive end-expiratory pressure (PEEP) (OR 1.13; 95% CI: 1.03-1.24, p = 0.006) were independently associated with in-hospital mortality. In subgroup analysis, in hypoxemic patients and in patients with acute respiratory distress syndrome (ARDS), higher DP, Pplat, and PEEP were associated with increased risk of in-hospital death. CONCLUSIONS: In patients with SARI receiving IMV, higher DP, Pplat and PEEP, and not tidal volume, were associated with a higher risk of in-hospital death, especially in those with hypoxemia or ARDS.


Assuntos
Respiração com Pressão Positiva , Respiração Artificial , Estudos de Coortes , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Estudos Prospectivos , Volume de Ventilação Pulmonar
8.
Crit Care ; 25(1): 278, 2021 08 05.
Artigo em Inglês | MEDLINE | ID: mdl-34353354

RESUMO

BACKGROUND: Acute brain injuries are associated with high mortality rates and poor long-term functional outcomes. Measurement of cerebrospinal fluid (CSF) biomarkers in patients with acute brain injuries may help elucidate some of the pathophysiological pathways involved in the prognosis of these patients. METHODS: We performed a systematic search and descriptive review using the MEDLINE database and the PubMed interface from inception up to June 29, 2021, to retrieve observational studies in which the relationship between CSF concentrations of protein biomarkers and neurological outcomes was reported in patients with acute brain injury [traumatic brain injury, subarachnoid hemorrhage, acute ischemic stroke, status epilepticus or post-cardiac arrest]. We classified the studies according to whether or not biomarker concentrations were associated with neurological outcomes. The methodological quality of the studies was evaluated using the Newcastle-Ottawa quality assessment scale. RESULTS: Of the 39 studies that met our criteria, 30 reported that the biomarker concentration was associated with neurological outcome and 9 reported no association. In TBI, increased extracellular concentrations of biomarkers related to neuronal cytoskeletal disruption, apoptosis and inflammation were associated with the severity of acute brain injury, early mortality and worse long-term functional outcome. Reduced concentrations of protein biomarkers related to impaired redox function were associated with increased risk of neurological deficit. In non-traumatic acute brain injury, concentrations of CSF protein biomarkers related to dysregulated inflammation and apoptosis were associated with a greater risk of vasospasm and a larger volume of brain ischemia. There was a high risk of bias across the studies. CONCLUSION: In patients with acute brain injury, altered CSF concentrations of protein biomarkers related to cytoskeletal damage, inflammation, apoptosis and oxidative stress may be predictive of worse neurological outcomes.


Assuntos
Biomarcadores/análise , Lesões Encefálicas/complicações , Líquido Cefalorraquidiano , Proteínas/análise , Adulto , Biomarcadores/líquido cefalorraquidiano , Lesões Encefálicas/fisiopatologia , Humanos , Prognóstico
9.
Minerva Anestesiol ; 87(11): 1217-1225, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34337916

RESUMO

BACKGROUND: Fever has been reported as a common symptom in COVID-19 patients. The aim of the study was to describe the characteristics of COVID-19 critically ill patients with fever and to assess if fever management had an impact on some physiologic variables. METHODS: This is a retrospective monocentric cohort analysis of critically ill COVID-19 patients admitted to the Department of Intensive Care Unit (ICU) of Erasme Hospital, Brussels, Belgium, between March 2020 and May 2020. Fever was defined as body temperature ≥38 °C during the ICU stay. We assessed the independent predictors of fever during ICU stay. We reported the clinical and physiological variables before and after the first treated episode of fever during the ICU stay. RESULTS: A total of 72 critically ill COVID-19 patients were admitted to the ICU over the study period and were all eligible for the final analysis; 53 (74%) of them developed fever, after a median of 4 [0-13] hours since ICU admission. In the multivariable analysis, male gender (OR 5.41 [C.I. 95% 1.34-21.92]; P=0.02) and low PaO2/FiO2 ratio (OR 0.99 [C.I. 95% 0.99-1.00]; P=0.04) were independently associated with fever. After the treatment of the first febrile episode, heart rate and respiratory rate significantly decreased together with an increase in PaO2 and SaO2. CONCLUSIONS: In our study, male gender and severe impairment of oxygenation were independently associated with fever in critically ill COVID-19 patients. Fever treatment reduced heart rate and respiratory rate and improved systemic oxygenation.


Assuntos
COVID-19 , Estado Terminal , Humanos , Unidades de Terapia Intensiva , Masculino , Estudos Retrospectivos , SARS-CoV-2
10.
Minerva Anestesiol ; 2021 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-34337922

RESUMO

Refractory intracranial hypertension after traumatic brain injury (TBI) is defined as recurrent increase of intracranial pressure (ICP) above 20-22 mmHg for sustained period of time (10-15 min), despite conventional therapies, such as osmotic therapy, cerebral spinal fluid drainage and mild hyperventilation. As such, more aggressive treatments should be taken into consideration. In particular, therapeutic hypothermia, barbiturates administration and decompressive craniectomy are considered as tier-three or "salvage" interventions, as they have shown to be able to control refractory hypertension, but are also associated with an increased risk of significant side effects. The aim of this review is therefore to describe the evidence supporting the use of these tier-three therapies in the management of refractory intracranial hypertension in TBI patients.

11.
Lancet Neurol ; 20(7): 548-558, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34146513

RESUMO

BACKGROUND: The indications for intracranial pressure (ICP) monitoring in patients with acute brain injury and the effects of ICP on patients' outcomes are uncertain. The aims of this study were to describe current ICP monitoring practises for patients with acute brain injury at centres around the world and to assess variations in indications for ICP monitoring and interventions, and their association with long-term patient outcomes. METHODS: We did a prospective, observational cohort study at 146 intensive care units (ICUs) in 42 countries. We assessed for eligibility all patients aged 18 years or older who were admitted to the ICU with either acute brain injury due to primary haemorrhagic stroke (including intracranial haemorrhage or subarachnoid haemorrhage) or traumatic brain injury. We included patients with altered levels of consciousness at ICU admission or within the first 48 h after the brain injury, as defined by the Glasgow Coma Scale (GCS) eye response score of 1 (no eye opening) and a GCS motor response score of at least 5 (not obeying commands). Patients not admitted to the ICU or with other forms of acute brain injury were excluded from the study. Between-centre differences in use of ICP monitoring were quantified by using the median odds ratio (MOR). We used the therapy intensity level (TIL) to quantify practice variations in ICP interventions. Primary endpoints were 6 month mortality and 6 month Glasgow Outcome Scale Extended (GOSE) score. A propensity score method with inverse probability of treatment weighting was used to estimate the association between use of ICP monitoring and these 6 month outcomes, independently of measured baseline covariates. This study is registered with ClinicalTrial.gov, NCT03257904. FINDINGS: Between March 15, 2018, and April 30, 2019, 4776 patients were assessed for eligibility and 2395 patients were included in the study, including 1287 (54%) with traumatic brain injury, 587 (25%) with intracranial haemorrhage, and 521 (22%) with subarachnoid haemorrhage. The median age of patients was 55 years (IQR 39-69) and 1567 (65%) patients were male. Considerable variability was recorded in the use of ICP monitoring across centres (MOR 4·5, 95% CI 3·8-4·9 between two randomly selected centres for patients with similar covariates). 6 month mortality was lower in patients who had ICP monitoring (441/1318 [34%]) than in those who were not monitored (517/1049 [49%]; p<0·0001). ICP monitoring was associated with significantly lower 6 month mortality in patients with at least one unreactive pupil (hazard ratio [HR] 0·35, 95% CI 0·26-0·47; p<0·0001), and better neurological outcome at 6 months (odds ratio 0·38, 95% CI 0·26-0·56; p=0·0025). Median TIL was higher in patients with ICP monitoring (9 [IQR 7-12]) than in those who were not monitored (5 [3-8]; p<0·0001) and an increment of one point in TIL was associated with a reduction in mortality (HR 0·94, 95% CI 0·91-0·98; p=0·0011). INTERPRETATION: The use of ICP monitoring and ICP management varies greatly across centres and countries. The use of ICP monitoring might be associated with a more intensive therapeutic approach and with lower 6-month mortality in more severe cases. Intracranial hypertension treatment guided by monitoring might be considered in severe cases due to the potential associated improvement in long-term clinical results. FUNDING: University of Milano-Bicocca and the European Society of Intensive Care Medicine.


Assuntos
Lesões Encefálicas/fisiopatologia , Pressão Intracraniana/fisiologia , Monitorização Fisiológica/métodos , Adulto , Idoso , Lesões Encefálicas/metabolismo , Lesões Encefálicas Traumáticas/terapia , Estudos de Coortes , Cuidados Críticos , Feminino , Escala de Coma de Glasgow , Escala de Resultado de Glasgow , Humanos , Unidades de Terapia Intensiva , Hipertensão Intracraniana , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
12.
N Engl J Med ; 384(24): 2283-2294, 2021 06 17.
Artigo em Inglês | MEDLINE | ID: mdl-34133859

RESUMO

BACKGROUND: Targeted temperature management is recommended for patients after cardiac arrest, but the supporting evidence is of low certainty. METHODS: In an open-label trial with blinded assessment of outcomes, we randomly assigned 1900 adults with coma who had had an out-of-hospital cardiac arrest of presumed cardiac or unknown cause to undergo targeted hypothermia at 33°C, followed by controlled rewarming, or targeted normothermia with early treatment of fever (body temperature, ≥37.8°C). The primary outcome was death from any cause at 6 months. Secondary outcomes included functional outcome at 6 months as assessed with the modified Rankin scale. Prespecified subgroups were defined according to sex, age, initial cardiac rhythm, time to return of spontaneous circulation, and presence or absence of shock on admission. Prespecified adverse events were pneumonia, sepsis, bleeding, arrhythmia resulting in hemodynamic compromise, and skin complications related to the temperature management device. RESULTS: A total of 1850 patients were evaluated for the primary outcome. At 6 months, 465 of 925 patients (50%) in the hypothermia group had died, as compared with 446 of 925 (48%) in the normothermia group (relative risk with hypothermia, 1.04; 95% confidence interval [CI], 0.94 to 1.14; P = 0.37). Of the 1747 patients in whom the functional outcome was assessed, 488 of 881 (55%) in the hypothermia group had moderately severe disability or worse (modified Rankin scale score ≥4), as compared with 479 of 866 (55%) in the normothermia group (relative risk with hypothermia, 1.00; 95% CI, 0.92 to 1.09). Outcomes were consistent in the prespecified subgroups. Arrhythmia resulting in hemodynamic compromise was more common in the hypothermia group than in the normothermia group (24% vs. 17%, P<0.001). The incidence of other adverse events did not differ significantly between the two groups. CONCLUSIONS: In patients with coma after out-of-hospital cardiac arrest, targeted hypothermia did not lead to a lower incidence of death by 6 months than targeted normothermia. (Funded by the Swedish Research Council and others; TTM2 ClinicalTrials.gov number, NCT02908308.).


Assuntos
Febre/terapia , Hipotermia Induzida , Parada Cardíaca Extra-Hospitalar/terapia , Idoso , Temperatura Corporal , Reanimação Cardiopulmonar/métodos , Coma/etiologia , Coma/terapia , Feminino , Febre/etiologia , Humanos , Hipotermia Induzida/efeitos adversos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/complicações , Parada Cardíaca Extra-Hospitalar/mortalidade , Método Simples-Cego , Resultado do Tratamento
13.
Minerva Anestesiol ; 87(11): 1226-1238, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-33938677

RESUMO

A primary objective in intensive care and perioperative settings is to promote an adequate supply and delivery of oxygen to tissues and organs, particularly to the brain. Cerebral near infrared spectroscopy (NIRS) is a noninvasive, continuous monitoring technique, that can be used to assess cerebral oxygenation. Using NIRS to monitor cerebral oximetry is not new and has been in widespread use in neonates and cardiac surgery for decades. In addition, it has become common to see NIRS being used in adult and pediatric cardiac surgery, acute neurological diseases, neurosurgical procedures, vascular surgery, severe trauma and other acute medical diseases. Furthermore, recent evidence suggests a role for NIRS in the perioperative settings; detecting and preventing episodes of cerebral desaturation aiming to reduce the development of postoperative delirium. NIRS is not without its limitations; these include the risk of extra-cranial contamination, spatial limitations and skin blood flow/volume changes, as well being a measure of localized blood oxygenation underneath the sensor. However, NIRS is a noninvasive technique and can be used in those patients without indications or justification for invasive brain monitoring; non-neurosurgical procedures such as liver transplantation, major orthopedic surgery and critically illness where the brain is at risk. The aim of this manuscript was to discuss the physical principles of NIRS and to report the current evidence regarding its use in critically ill patients without primary non-anoxic brain injury.


Assuntos
Lesões Encefálicas , Circulação Cerebrovascular , Adulto , Encéfalo , Criança , Estado Terminal , Humanos , Recém-Nascido , Oximetria , Oxigênio
15.
J Intensive Care Med ; 36(8): 910-917, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33823709

RESUMO

BACKGROUND: To report and compare the characteristics and outcomes of COVID-19 patients on extracorporeal membrane oxygenation (ECMO) to non-COVID-19 acute respiratory distress syndrome (ARDS) patients on ECMO. METHODS: We performed an international retrospective study of COVID-19 patients on ECMO from 13 intensive care units from March 1 to April 30, 2020. Demographic data, ECMO characteristics and clinical outcomes were collected. The primary outcome was to assess the complication rate and 28-day mortality; the secondary outcome was to compare patient and ECMO characteristics between COVID-19 patients on ECMO and non-COVID-19 related ARDS patients on ECMO (non-COVID-19; January 1, 2018 until July 31, 2019). RESULTS: During the study period 71 COVID-19 patients received ECMO, mostly veno-venous, for a median duration of 13 days (IQR 7-20). ECMO was initiated at 5 days (IQR 3-10) following invasive mechanical ventilation. Median PaO2/FiO2 ratio prior to initiation of ECMO was similar in COVID-19 patients (58 mmHg [IQR 46-76]) and non-COVID-19 patients (53 mmHg [IQR 44-66]), the latter consisting of 48 patients. 28-day mortality was 37% in COVID-19 patients and 27% in non-COVID-19 patients. However, Kaplan-Meier curves showed that after a 100-day follow-up this non-significant difference resolves. Non-surviving COVID-19 patients were more acidotic prior to initiation ECMO, had a shorter ECMO run and fewer received muscle paralysis compared to survivors. CONCLUSIONS: No significant differences in outcomes were found between COVID-19 patients on ECMO and non-COVID-19 ARDS patients on ECMO. This suggests that ECMO could be considered as a supportive therapy in case of refractory respiratory failure in COVID-19.


Assuntos
COVID-19 , Oxigenação por Membrana Extracorpórea , Síndrome do Desconforto Respiratório , COVID-19/mortalidade , COVID-19/terapia , Estudos de Coortes , Feminino , Humanos , Internacionalidade , Masculino , Pessoa de Meia-Idade , Síndrome do Desconforto Respiratório/mortalidade , Síndrome do Desconforto Respiratório/terapia , Estudos Retrospectivos
16.
Am J Transplant ; 21(7): 2489-2497, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33880877

RESUMO

Antibiotic underdosing in prophylactic antibiotic regimes after lung transplantation (LTx) can increase the risk of infection. We aimed to study whether ß-lactam concentrations achieved desirable pharmacodynamic targets in the early phase after LTx and the association between drug concentrations and the development of early infections or the acquisition of multidrug-resistant (MDR) strains. We reviewed patients in whom broad-spectrum ß-lactam levels were measured after LTx during antibiotic prophylaxis. ß-Lactam concentrations were considered "insufficient" if drug levels remained below four times the clinical breakpoint of the minimal inhibitory concentration for Pseudomonas aeruginosa. The primary outcome was the occurrence of an infection and/or acquisition of MDR pathogens in the first 14 days after transplantation. A total of 70 patients were included. "Insufficient" drug concentrations were found in 40% of patients. In 27% of patients, an early MDR pathogen was identified and 49% patients were diagnosed with an early posttransplant infection. Patients with "insufficient" drug concentrations acquired more frequently MDR bacteria and/or developed an infection than others (22/28, 79% vs. 20/42, 48% - p = .01). ß-Lactam levels were often found to be below the desired drug targets in the early phase after transplantation and may be associated with the occurrence of early infectious complications.


Assuntos
Transplante de Pulmão , beta-Lactamas , Antibacterianos/uso terapêutico , Farmacorresistência Bacteriana Múltipla , Humanos , Transplante de Pulmão/efeitos adversos , Testes de Sensibilidade Microbiana , beta-Lactamas/farmacologia
17.
Brain Sci ; 11(5)2021 Apr 23.
Artigo em Inglês | MEDLINE | ID: mdl-33922414

RESUMO

Brain dysfunction is associated with poor outcome in critically ill patients. In a post hoc analysis of the Intensive Care over Nations (ICON) database, we investigated the effect of brain dysfunction on hospital mortality in critically ill patients. Brain failure was defined as a neurological sequential organ failure assessment (nSOFA) score of 3-4, based on the assumed Glasgow Coma Scale (GCS) score. Multivariable analyses were performed to assess the independent roles of nSOFA and change in nSOFA from admission to day 3 (ΔnSOFA) for predicting hospital mortality. Data from 7192 (2096 septic and 5096 non-septic) patients were analyzed. Septic patients were more likely than non-septic patients to have brain failure on admission (434/2095 (21%) vs. 617/4665 (13%), p < 0.001) and during the ICU stay (625/2063 (30%) vs. 736/4665 (16%), p < 0.001). The presence of sepsis (RR 1.66 (1.31-2.09)), brain failure (RR 4.85 (3.33-7.07)), and both together (RR 5.61 (3.93-8.00)) were associated with an increased risk of in-hospital death, but nSOFA was not. In the 3280 (46%) patients in whom ΔnSOFA was available, sepsis (RR 2.42 (1.62-3.60)), brain function deterioration (RR 6.97 (3.71-13.08)), and the two together (RR 10.24 (5.93-17.67)) were associated with an increased risk of in-hospital death, whereas improvement in brain function was not.

18.
Membranes (Basel) ; 11(3)2021 Mar 11.
Artigo em Inglês | MEDLINE | ID: mdl-33799847

RESUMO

The high mortality of pediatric acute respiratory distress syndrome (PARDS) is partly related to fluid overload. Extracorporeal membrane oxygenation (ECMO) is used to treat pediatric patients with severe PARDS, but can result in acute kidney injury (AKI) and worsening fluid overload. The objective of this study was to determine whether the addition of CRRT to ECMO in patients with PARDS is associated with increased mortality. METHODS: We conducted a retrospective 7-year study of patients with PARDS requiring ECMO and divided them into those requiring CRRT and those not requiring CRRT. We calculated severity of illness scores, the amount of blood products administered to both groups, and determined the impact of CRRT on mortality and morbidity. RESULTS: We found no significant difference in severity of illness scores except the vasoactive inotropic score (VIS, 45 ± 71 vs. 139 ± 251, p = 0.042), which was significantly elevated during the initiation and the first three days of ECMO. CRRT was associated with an increase in the use of blood products and noradrenaline (p < 0.01) without changing ECMO duration, length of PICU stay or mortality. CONCLUSION: The addition of CRRT to ECMO is associated with a greater consumption of blood products but no increase in mortality.

20.
ASAIO J ; 67(6): 700-708, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-33074866

RESUMO

Veno-venous extracorporeal membrane oxygenation (V-V ECMO) represents a component of the treatment strategy for severe respiratory failure. Clinical evidence on the management of the lung during V-V ECMO are limited just as the consensus regarding timing of weaning. The monitoring of the carbon dioxide (CO2) removal (V'CO2TOT) is subdivided into two components: the membrane lung (ML) and the native lung (NL) are both taken into consideration to evaluate the improvement of the function of the lung and to predict the time to wean off ECMO. We enrolled patients with acute respiratory distress syndrome (ARDS). The V'CO2NL ratio (V'CO2NL/V'CO2TOT) value was calculated based on the distribution of CO2 between the NL and the ML. Of 18 patients, 15 were successfully weaned off of V-V ECMO. In this subgroup, we observed a significant increase in the V'CO2NL ratio comparing the median values of the first and last quartiles (0.32 vs. 0.53, p = 0.0045), without observing any modifications in the ventilation parameters. An increase in the V'CO2NL ratio, independently from any change in ventilation could, despite the limitations of the study, indicate an improvement in pulmonary function and may be used as a weaning index for ECMO.


Assuntos
Dióxido de Carbono/metabolismo , Oxigenação por Membrana Extracorpórea , Síndrome do Desconforto Respiratório/terapia , Adulto , Idoso , Feminino , Humanos , Pulmão/metabolismo , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...