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3.
BMJ Open ; 11(9): e053610, 2021 09 08.
Artigo em Inglês | MEDLINE | ID: mdl-34497087

RESUMO

INTRODUCTION: The ongoing pandemic could affect the duration, variety and severity of the mental, physical, and cognitive impairments intensive care unit (ICU) survivors and their families frequently present. We aim to determine the impact of the COVID-19 pandemic on the mental, physical, and cognitive health of survivors, the experience of their families and their treating healthcare professionals. METHODS AND ANALYSIS: Prospective, multicentre, mixed-methods cohort study in seven Chilean ICUs. SAMPLE: 450 adults, able to walk independently prior to admission, in ICU and mechanical ventilation >48 hours with and without COVID-19. Clinical Frailty Scale, Charlson comorbidity index, mobility (Functional Status Score for the Status Score for the Intensive Care Unit) and muscle strength (Medical Research Council Sum Score) will be assessed at ICU discharge. Cognitive functioning (Montreal Cognitive Assessment-blind), anxiety and depression (Hospital Anxiety and Depression Scale), post-traumatic stress (Impact of Event Scale-Revised) symptoms, disability (WHO Disability Assessment Schedule 2.0), quality of life (European Quality of Life Health Questionnaire), employment and survival will be assessed at ICU discharge, 3 months and 6 months. A sample will be assessed using actigraphy and the Global Physical Activity Questionnaire at 6 months after ICU discharge. Trajectories of mental, physical, and cognitive impairments will be estimated using multilevel longitudinal modelling. A sensitivity analysis using multiple imputations will be performed to account for missing data and loss-to-follow-up. Survival will be analysed using Kaplan-Meier curves. The perceptions of family members regarding the ICU stay and the later recovery will be explored 3 months after discharge. Healthcare professionals will be invited to discuss the challenges faced during the pandemic using semistructured interviews. Interviews will be thematically analysed by two independent coders to identify the main themes of the experience of family members and healthcare professionals. ETHICS AND DISSEMINATION: The study was approved by the Clinica Alemana Universidad del Desarrollo Ethics Committee (2020-78) and each participating site. Study findings will be published in peer-reviewed journals and disseminated through social media and conference meetings. TRIAL REGISTRATION NUMBER: NCT04979897.


Assuntos
COVID-19 , Pandemias , Adulto , Cognição , Estudos de Coortes , Cuidados Críticos , Humanos , Unidades de Terapia Intensiva , Estudos Multicêntricos como Assunto , Estudos Prospectivos , Qualidade de Vida , SARS-CoV-2
4.
Rev Med Chil ; 149(3): 422-432, 2021 Mar.
Artigo em Espanhol | MEDLINE | ID: mdl-34479321

RESUMO

Since the declaration of SARS CoV-2 pandemic, we have witnessed an accelerated increase in new cases, frequently associated with the need for intensive care and mechanical ventilation. In parallel, we have been invaded by many experts in the press and who expose their knowledge on the behavior of epidemics who use concepts that are not always well understood by the medical community. Some concepts should be knowledgeable to understand the epidemic spread. First, the epidemic spread description is not modeled with an exponential curve, but rather with a Gompertz curve. Second, a gamma curve describes the period of contagiousness. Third, the contagion magnitude or rate can be calculated and modeled. Explaining these mathematical concepts in a simple and graphic way will allow readers to understand better what is happening with the current pandemic.


Assuntos
COVID-19 , Pandemias , Cuidados Críticos , Humanos , Modelos Teóricos , SARS-CoV-2
5.
Andes Pediatr ; 92(3): 395-405, 2021 Jun.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-34479246

RESUMO

INTRODUCTION: In April 2020, the pediatric multisystem inflammatory syndrome temporarily associated with COVID-19 (MIS-C) was described for the first time. MIS-C could have a severe course and may require critical care support. OBJECTIVE: To describe the clinical, laboratory, and management characteristics of hospitalized children who meet MIS-C criteria with severe presentation in a pediatric critical pa tient unit. PATIENTS AND METHOD: Descriptive prospective study of children with severe MIS-C mana ged by treatment phases with immunoglobulin and methylprednisolone, according to their clinical response. Epidemiological, clinical, laboratory and imaging data were obtained. Phenotypes were classified into Kawasaki and not Kawasaki, comparing their findings. RESULTS: 20 patients were analy zed, the median age was 6 years, 60% were female, and 40% presented comorbidity. SARS-CoV-2 was detected in 90% of the patients. They presented fever as the first symptom, followed by brief and early gastrointestinal symptoms (70%). 75% presented the Kawasaki phenotype. They evolved with lymphopenia, hypoalbuminemia, coagulation alterations, and elevated systemic and cardiac in flammatory parameters. 80% of the cases presented echocardiographic alterations and 90% shock that required critical care support. All the patients had a short and favorable evolution. All patients responded to the established therapy, but 40% required a second phase of treatment. There were no differences when comparing phenotypes. No deaths were reported. CONCLUSION: MIS-C is a new childhood disease whose presentation could be life-threatening. It requires early suspicion, immuno modulatory management, critical care support, and a multidisciplinary approach to obtain the best results and optimize its prognosis.


Assuntos
COVID-19 , SARS-CoV-2 , Síndrome de Resposta Inflamatória Sistêmica , Corticosteroides/uso terapêutico , Antibacterianos/uso terapêutico , Anticoagulantes/uso terapêutico , Transtornos da Coagulação Sanguínea/etiologia , COVID-19/complicações , COVID-19/diagnóstico , COVID-19/terapia , Criança , Cuidados Críticos , Feminino , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Hipoalbuminemia/etiologia , Imunoglobulinas Intravenosas/administração & dosagem , Fatores Imunológicos/administração & dosagem , Unidades de Terapia Intensiva Pediátrica , Linfopenia/etiologia , Masculino , Síndrome de Linfonodos Mucocutâneos/diagnóstico , Estudos Prospectivos , SARS-CoV-2/isolamento & purificação , Choque/etiologia , Choque/terapia , Avaliação de Sintomas , Síndrome de Resposta Inflamatória Sistêmica/complicações , Síndrome de Resposta Inflamatória Sistêmica/diagnóstico , Síndrome de Resposta Inflamatória Sistêmica/terapia
6.
J Med Syst ; 45(10): 92, 2021 Sep 08.
Artigo em Inglês | MEDLINE | ID: mdl-34494167

RESUMO

The Acute Care Surgery model has been implemented by many hospitals in the United States. As complex adaptive systems, healthcare systems are composed of many interacting elements that respond to intrinsic and extrinsic inputs. Systems level analysis may reveal the underlying organizational structure of tactical block allocations like the Acute Care Surgery model. The purpose of this study is to demonstrate one method to identify a key characteristic of complex adaptive systems in the perioperative services. Start and end times for all surgeries performed at the University of Vermont Medical Center OR1 were extracted for two years prior to the transition to an Acute Care Surgery service and two years following the transition. Histograms were plotted for the inter-event times calculated from the difference between surgical cases. A power law distribution was fit to the post-transition histogram. The Kolmogorov-Smirnov test for goodness-of-fit at 95% level of significance shows the histogram plotted from post-transition inter-event times follows a power law distribution (K-S = 0.088, p = 0.068), indicating a Complex Adaptive System. Our analysis demonstrates that the strategic decision to create an Acute Care Surgery service has direct implications on tactical and operational processes in the perioperative services. Elements of complex adaptive systems can be represented by a power law distributions and similar methods may be applied to identify other processes that operate as complex adaptive systems in perioperative care. To make sustained improvements in the perioperative services, focus on manufacturing-based interventions such as Lean Six Sigma should instead be shifted towards the complex interventions that modify system-specific behaviors described by complex adaptive system principles when power law relationships are present.


Assuntos
Hospitais , Salas Cirúrgicas , Cuidados Críticos , Atenção à Saúde , Humanos , Gestão da Qualidade Total , Estados Unidos
7.
Br J Nurs ; 30(16): 950-955, 2021 Sep 09.
Artigo em Inglês | MEDLINE | ID: mdl-34514835

RESUMO

BACKGROUND: Early warning scores (EWS) have been widely used to aid in the detection of deterioration. The use of technology, alongside EWS, may improve patient safety and lead to improvements in the accuracy of documentation. AIM: The aim of this service evaluation was to understand nurses' and healthcare support worker views around the implementation of handheld electronic devices for documenting care related to the deteriorating patient. METHODS: Before the implementation of an electronic handheld device, in-depth semi-structured interviews with nursing staff and healthcare support workers were undertaken to explore the context for improvement. The Consolidated Framework for Implementation Research was used to analyse, organise and present data, to ensure systematic inquiry across the range of potential facilitators and challenges perceived by staff. In all, 11 interviews were undertaken across three speciality areas (four wards). FINDINGS: Challenges to the use of new technology included staff apprehension around training and education needs and the uncertainty of technological reliability in the clinical setting. Potential facilitators to support the implementation of this technology were: the potential for improved communication across the individual ward and hospital setting and the potential for more streamlined processes for escalation of concerns. CONCLUSION: Three main recommendations for practice emerged. First, nurses should be involved in the development of the systems. Appropriate time is required to embed the technology in practice. Finally, thought must be given not just to the absolute number of devices required and their reliability, but also how new technology interacts in each individual context.


Assuntos
Comunicação , Cuidados Críticos , Hospitais , Humanos , Reprodutibilidade dos Testes , Tecnologia
8.
Front Health Serv Manage ; 38(1): 27-31, 2021 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-34431816

RESUMO

SUMMARY: Critical access hospitals (CAHs) serve their rural communities as the main access points and communication centers for healthcare, typically with very limited financial, staffing, and support resources. Local residents rely on their CAHs as the only providers for many miles around. When the COVID-19 pandemic hit in early 2020, CAH leaders had to rethink operations and priorities, both internally with staffs and externally with community leaders and organizations. Few critical care beds were available when the need was greatest. Testing was problematic, and cultural barriers complicated care. Now, as virus variants strike where vaccination numbers are low, CAH leaders remain wary of financial hits to elective procedure income, limited resources, and added stress for their staffs. Working with community service organizations and larger regional healthcare centers is a crucial strategy for CAHs as they address care delivery issues and ensure that their caregivers can do their jobs now and in the future.


Assuntos
COVID-19/terapia , Cuidados Críticos/organização & administração , Atenção à Saúde/organização & administração , Pessoal de Saúde/psicologia , Pessoal de Saúde/estatística & dados numéricos , Administradores Hospitalares/psicologia , Serviços de Saúde Rural/organização & administração , Adulto , Animais , Atitude do Pessoal de Saúde , Feminino , Administração Hospitalar , Humanos , Illinois , Liderança , Masculino , Pessoa de Meia-Idade , Objetivos Organizacionais , Pandemias , SARS-CoV-2
9.
Med Klin Intensivmed Notfmed ; 116(6): 499-507, 2021 Sep.
Artigo em Alemão | MEDLINE | ID: mdl-34432085

RESUMO

Critically ill patients are at high risk of hemostasis disorders, which can be associated with both an increased risk of bleeding and an increased risk of thromboembolic events. In the case of acute vascular events, specific therapy with drug anticoagulation or platelet aggregation inhibition is essential. In patients with pre-existing conditions, the appropriate continuation of anticoagulation during intensive care treatment is important. Furthermore, in everyday clinical practice, prophylaxis of thromboembolism as well as the question of potential therapeutic options in the treatment of sepsis and infection-triggered disorders of blood coagulation are important. Specific questions arise with the use of extracorporeal devices such as renal replacement and circulatory assist systems. A number of new anticoagulation and anti-platelet drugs have become available in recent years. Laboratory monitoring of anticoagulation is central. In this overview, current aspects of these topics are presented.


Assuntos
Anticoagulantes , Transtornos da Coagulação Sanguínea , Anticoagulantes/efeitos adversos , Coagulação Sanguínea , Cuidados Críticos , Hemorragia/induzido quimicamente , Humanos
11.
BMJ Open ; 11(8): e048423, 2021 08 30.
Artigo em Inglês | MEDLINE | ID: mdl-34462281

RESUMO

INTRODUCTION: Critical care in low-income and low-middle income countries (LLMICs) is an underdeveloped component of the healthcare system. Given the increasing growth in demand for critical care services in LLMICs, understanding the current capacity to provide critical care is imperative to inform policy on service expansion. Thus, our aim is to describe the provision of critical care in LLMICs with respect to patients, providers, location of care and services and interventions delivered. METHODS AND ANALYSIS: We will search PubMed/MEDLINE, Web of Science and EMBASE for full-text original research articles available in English describing critical care services that specify the location of service delivery and describe patients and interventions. We will restrict our review to populations from LLMICs (using 2016 World Bank classifications) and published from 1 January 2008 to 1 January 2020. Two-reviewer agreement will be required for both title/abstract and full text review stages, and rate of agreement will be calculated for each stage. We will extract data regarding the location of critical care service delivery, the training of the healthcare professionals providing services, and the illnesses treated according to classification by the WHO Universal Health Coverage Compendium. ETHICS AND DISSEMINATION: Reviewed and exempted by the Stanford University Office for Human Subjects Research and IRB on 20 May 2020. The results of this review will be disseminated through scholarly publication and presentation at regional and international conferences. This review is designed to inform broader WHO, International Federation for Emergency Medicine and partner efforts to strengthen critical care globally. PROSPERO REGISTRATION NUMBER: CRD42019146802.


Assuntos
Atenção à Saúde , Países em Desenvolvimento , Cuidados Críticos , Humanos , Pobreza , Literatura de Revisão como Assunto
12.
Crit Care ; 25(1): 316, 2021 08 31.
Artigo em Inglês | MEDLINE | ID: mdl-34461964

RESUMO

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .


Assuntos
COVID-19/terapia , Traqueostomia , Anticorpos Antivirais/sangue , COVID-19/diagnóstico , Teste de Ácido Nucleico para COVID-19 , Cuidados Críticos , Humanos , RNA Viral/sangue , Respiração Artificial , SARS-CoV-2/genética , SARS-CoV-2/imunologia , Tempo para o Tratamento , Traqueostomia/métodos
13.
Crit Care ; 25(1): 304, 2021 08 23.
Artigo em Inglês | MEDLINE | ID: mdl-34425864

RESUMO

BACKGROUND: The Coronavirus disease 2019 (COVID-19) pandemic has underlined the urgent need for reliable, multicenter, and full-admission intensive care data to advance our understanding of the course of the disease and investigate potential treatment strategies. In this study, we present the Dutch Data Warehouse (DDW), the first multicenter electronic health record (EHR) database with full-admission data from critically ill COVID-19 patients. METHODS: A nation-wide data sharing collaboration was launched at the beginning of the pandemic in March 2020. All hospitals in the Netherlands were asked to participate and share pseudonymized EHR data from adult critically ill COVID-19 patients. Data included patient demographics, clinical observations, administered medication, laboratory determinations, and data from vital sign monitors and life support devices. Data sharing agreements were signed with participating hospitals before any data transfers took place. Data were extracted from the local EHRs with prespecified queries and combined into a staging dataset through an extract-transform-load (ETL) pipeline. In the consecutive processing pipeline, data were mapped to a common concept vocabulary and enriched with derived concepts. Data validation was a continuous process throughout the project. All participating hospitals have access to the DDW. Within legal and ethical boundaries, data are available to clinicians and researchers. RESULTS: Out of the 81 intensive care units in the Netherlands, 66 participated in the collaboration, 47 have signed the data sharing agreement, and 35 have shared their data. Data from 25 hospitals have passed through the ETL and processing pipeline. Currently, 3464 patients are included in the DDW, both from wave 1 and wave 2 in the Netherlands. More than 200 million clinical data points are available. Overall ICU mortality was 24.4%. Respiratory and hemodynamic parameters were most frequently measured throughout a patient's stay. For each patient, all administered medication and their daily fluid balance were available. Missing data are reported for each descriptive. CONCLUSIONS: In this study, we show that EHR data from critically ill COVID-19 patients may be lawfully collected and can be combined into a data warehouse. These initiatives are indispensable to advance medical data science in the field of intensive care medicine.


Assuntos
COVID-19/epidemiologia , Estado Terminal/epidemiologia , Data Warehousing/estatística & dados numéricos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Cuidados Críticos , Humanos , Países Baixos
14.
BMJ Open ; 11(8): e050281, 2021 08 30.
Artigo em Inglês | MEDLINE | ID: mdl-34462282

RESUMO

OBJECTIVES: To assess for increase in pulmonary thromboembolism (PTE) in hospitalised patients with COVID-19, in both critical care and ward environments. SETTING: We reviewed all CT pulmonary angiograms (CTPA) performed in Scotland between 23 March 2020 and 31 May 2020 and identified those with COVID-19 using either classical radiological appearances or positive COVID-19 PCR swab. PARTICIPANTS: All hospitalised patients in Scotland with COVID-19 between 23 March 2020 and 31 May 2020 who underwent a CTPA. PRIMARY OUTCOME MEASURE: To assess if the rate of PTE was increased in those with COVID-19 compared with previously published figures of hospitalised patients. SECONDARY OUTCOME MEASURES: To assess the effect of right heart strain or requirement for critical care on mortality. RESULTS: 3401 CTPAs were reviewed. 192 were positive for PTE in patients with evidence of COVID-19 either real-time PCR swab positive for SARS-CoV-2 (n=104) or having radiological changes consistent with COVID-19 (n=88). The total number of hospital admissions in Scotland between 23rd March 2020 and 31st May 2020 with COVID-19 was 5195. The incidence of PTE during this time was 3.7% in all patients admitted to all hospitals in Scotland with COVID-19 during this period. 475 hospitalised patients were managed in critical care (both level 2 and level 3 care), in whom the incidence of PTE was 6% (n=29). 4720 patients did not require admission to critical care, in whom the incidence of PTE was 3.5% (n=163). There was increased risk of death with right heart strain (25/52 vs 128/140 (p<0.01)) and in critical care (15/29 vs 146/163 (p<0.01)). CONCLUSIONS: We have demonstrated an increased risk of PTE in critical care and ward-based environments. Further studies are required to establish effective prophylactic anticoagulation in this group.


Assuntos
COVID-19 , Embolia Pulmonar , Cuidados Críticos , Hospitais , Humanos , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/epidemiologia , Estudos Retrospectivos , SARS-CoV-2
18.
J Assoc Physicians India ; 69(7): 11-12, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34431267

RESUMO

OBJECTIVES: 1. To study associations of severity of COVID-19 disease with clinical features and laboratory markers. 2. To develop a model to predict the need for ICU treatment. METHODS: This is an analysis of clinical course in 800 consecutive patients from a dedicated COVID-19 tertiary care hospital in Pune, India (8th April to 15th June 2020). We obtained clinical and laboratory information, severity grading and progress from hospital records. We studied associations of these characteristics with need for ICU management. We developed a predictive model of need for ICU treatment among first 500 patients and tested its sensitivity and specificity in the following 300 patients. RESULTS: Average age was 41 years, 16% were 20 years of age, 55% were male, 50% were asymptomatic and 16% had at least one comorbidity. Using MoHFW India severity guidelines, 73% patients had mild, 6% moderate and 20% severe disease. Severity was associated with higher age, symptomatic presentation, elevated neutrophil and reduced lymphocyte counts and elevated inflammatory markers. Seventy-seven patients needed ICU treatment: they were older (56 years), more symptomatic and had lower SpO2 and abnormal chest X-ray and deranged hematology and biochemistry at admission. A model trained on the first 500 patients, using above variables predicted need for ICU treatment with sensitivity 80%, specificity 88% in subsequent 300 patients; exclusion of expensive laboratory tests (Ferritin, C- Reactive Protein) did not affect accuracy. CONCLUSION: In the early phase of COVID- 19 pendemic, a significant proportion of hospitalized patients were young and asymptomatic. Need for ICU treatment was predicted by simple measures including higher age, symptomatic onset, low SpO2 and abnormal chest X-ray. We propose a simple model for referring patients for treatment at specialized COVID-19 hospitals.


Assuntos
COVID-19 , Adulto , Cuidados Críticos , Humanos , Índia , Masculino , SARS-CoV-2 , Centros de Atenção Terciária
19.
Ther Umsch ; 78(7): 389-394, 2021 Sep.
Artigo em Alemão | MEDLINE | ID: mdl-34427107

RESUMO

Smarter Intensive Care Medicine: Choosing Wisely®, less is more, appropriate is better … and so what? The current situation in the Swiss intensive care medicine! Abstract. The top 9 list of the Swiss Society for Intensive Care Medicine (SSICM) was published in 2017. What is the status of this initiative in terms of its implementation in Swiss intensive care units, its impact on patient care and on the costs of intensive care medicine? What developments in the published evidence justify updating the list and what measures are needed to continue this initiative in the coming years? This article provides an up-to-date overview of the SSICM's Choosing Wisely® initiative.


Assuntos
Medicina , Sociedades Médicas , Cuidados Críticos , Humanos
20.
Dimens Crit Care Nurs ; 40(5): 280-287, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34398564

RESUMO

BACKGROUND: Pediatric intensive care unit (PICU) nurses may consider additional factors beyond validated tools when managing pain and sedation of children. However, these other factors and related beliefs, practices, and decision-making for analgesia and sedation have not been well described. OBJECTIVES: This study describes nurses' beliefs, practices, and decision-making related to sedation and analgesia for mechanically ventilated children on a PICU and a pediatric cardiovascular ICU at a tertiary academic children's medical center in the United States. METHODS: A 35-item web-based survey tool was developed to more fully identify nurses' pain, sedation, comfort, and analgesia beliefs, decisions, planning, and procedures for children who were mechanically ventilated in the ICU. It was distributed to 102 nurses in the PICU, pediatric cardiovascular ICU, and pediatric critical care float pool. RESULTS: Twenty-six nurses (25%) responded; a majority worked the night shift and had 5 years or less of ICU experience. While participants believed intubated pediatric patients required moderate to deep sedation, approximately only half reported patients were adequately sedated. They reported that they were more likely to manage pain and sedation using specific behaviors and changes in vital signs than scores on a standardized scale. Nurses also reported routinely incorporating nonpharmacologic comfort measures. Premedication was more common for invasive procedures than for routine nursing care. DISCUSSION: Pediatric ICU nurses in this study considered factors beyond standardized scales when evaluating and managing pain and sedation of ventilated children. Nurses prioritized children's specific behaviors, vital signs, and their own nursing judgment above standardized scales. Research is needed to describe nurses' practices beyond this small study and to define and validate additional assessment parameters to incorporate into decision-making to improve management and care outcomes.


Assuntos
Analgesia , Enfermeiras e Enfermeiros , Criança , Sedação Consciente , Cuidados Críticos , Humanos , Dor , Respiração Artificial
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