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1.
Euro Surveill ; 25(18)2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32400358

RESUMO

An exponential growth model was fitted to critical care admissions from two surveillance databases to determine likely coronavirus disease (COVID-19) case numbers, critical care admissions and epidemic growth in the United Kingdom before the national lockdown. We estimate, on 23 March, a median of 114,000 (95% credible interval (CrI): 78,000-173,000) new cases and 258 (95% CrI: 220-319) new critical care reports, with 527,000 (95% CrI: 362,000-797,000) cumulative cases since 16 February.


Assuntos
Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/transmissão , Coronavirus/isolamento & purificação , Cuidados Críticos/estatística & dados numéricos , Notificação de Doenças/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Pneumonia Viral/diagnóstico , Pneumonia Viral/transmissão , Síndrome Respiratória Aguda Grave/transmissão , Betacoronavirus , Técnicas de Laboratório Clínico , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/virologia , Surtos de Doenças , Monitoramento Epidemiológico , Feminino , Humanos , Incidência , Masculino , Modelos Teóricos , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Vigilância da População , Síndrome Respiratória Aguda Grave/diagnóstico , Síndrome Respiratória Aguda Grave/epidemiologia , Síndrome Respiratória Aguda Grave/virologia , Reino Unido/epidemiologia
2.
Emerg Microbes Infect ; 9(1): 940-948, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32357808

RESUMO

The emerging COVID-19 caused by SARS-CoV-2 infection poses severe challenges to global public health. Serum antibody testing is becoming one of the critical methods for the diagnosis of COVID-19 patients. We investigated IgM and IgG responses against SARS-CoV-2 nucleocapsid (N) and spike (S) protein after symptom onset in the intensive care unit (ICU) and non-ICU patients. 130 blood samples from 38 COVID-19 patients were collected. The levels of IgM and IgG specific to N and S protein were detected by ELISA. A series of blood samples were collected along the disease course from the same patient, including 11 ICU patients and 27 non-ICU patients for longitudinal analysis. N and S specific IgM and IgG (N-IgM, N-IgG, S-IgM, S-IgG) in non-ICU patients increased after symptom onset. N-IgM and S-IgM in some non-ICU patients reached a peak in the second week, while N-IgG and S-IgG continued to increase in the third week. The combined detection of N and S specific IgM and IgG could identify up to 75% of SARS-CoV-2 infected patients in the first week. S-IgG was significantly higher in non-ICU patients than in ICU patients in the third week. In contrast, N-IgG was significantly higher in ICU patients than in non-ICU patients. The increase of S-IgG positively correlated with the decrease of C-reactive protein (CRP) in non-ICU patients. N and S specific IgM and IgG increased gradually after symptom onset and can be used for detection of SARS-CoV-2 infection. Analysis of the dynamics of S-IgG may help to predict prognosis.


Assuntos
Anticorpos Antivirais/imunologia , Betacoronavirus/imunologia , Infecções por Coronavirus/imunologia , Imunoglobulina G/imunologia , Imunoglobulina M/imunologia , Proteínas do Nucleocapsídeo/imunologia , Pneumonia Viral/imunologia , Glicoproteína da Espícula de Coronavírus/imunologia , Idoso , Anticorpos Antivirais/sangue , Proteína C-Reativa/análise , Proteína C-Reativa/imunologia , Técnicas de Laboratório Clínico , Infecções por Coronavirus/sangue , Infecções por Coronavirus/diagnóstico , Cuidados Críticos/estatística & dados numéricos , Feminino , Humanos , Imunoglobulina G/sangue , Imunoglobulina M/sangue , Cinética , Masculino , Pessoa de Meia-Idade , Proteínas do Nucleocapsídeo/sangue , Pandemias , Pneumonia Viral/sangue , Pneumonia Viral/diagnóstico , Glicoproteína da Espícula de Coronavírus/sangue
3.
Recenti Prog Med ; 111(4): 207-211, 2020 Apr.
Artigo em Italiano | MEDLINE | ID: mdl-32319442

RESUMO

On February 21st, 2020 the first case of severe acute respiratory syndrome due to the coronavirus 2 (SARS-CoV-2) causing the CoViD-19 disease, was identified in Italy. In the following days, despite the restrictive public health measures aimed to avoid the infection's spread, the number of cases increased. As of March 8th, 2020, Italy is the 2nd most affected country in the world. As of March 6th, 2020, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) published operational recommendations and ethical considerations to support the clinicians involved in the care of critically-ill CoViD-19 patients, in regard a probable scenario where an imbalance between supply and demand of ICU beds, is put in place by a steadily rising number of these patients.


Assuntos
Infecções por Coronavirus , Cuidados Críticos , Tomada de Decisões/ética , Recursos em Saúde , Número de Leitos em Hospital , Pandemias , Pneumonia Viral , Alocação de Recursos , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Cuidados Críticos/estatística & dados numéricos , Recursos em Saúde/ética , Humanos , Itália , Pneumonia Viral/epidemiologia , Alocação de Recursos/ética
4.
Rev Cardiovasc Med ; 21(1): 1-7, 2020 03 30.
Artigo em Inglês | MEDLINE | ID: mdl-32259899

RESUMO

Approximately 90 days of the SARS-CoV-2 (COVID-19) spreading originally from Wuhan, China, and across the globe has led to a widespread chain of events with imminent threats to the fragile relationship between community health and economic health. Despite near hourly reporting on this crisis, there has been no regular, updated, or accurate reporting of hospitalizations for COVID-19. It is known that many test-positive individuals may not develop symptoms or have a mild self-limited viral syndrome consisting of fever, malaise, dry cough, and constitutional symptoms. However some individuals develop a more fulminant syndrome including viral pneumonia, respiratory failure requiring oxygen, acute respiratory distress syndrome requiring mechanical ventilation, and in substantial fractions leading to death attributable to COVID-19. The pandemic is evolving in a clustered, non-inform fashion resulting in many hospitals with preparedness but few or no cases, and others that are completely overwhelmed. Thus, a considerable risk of spread when personal protection equipment becomes exhausted and a large fraction of mortality in those not offered mechanical ventilation are both attributable to a crisis due to maldistribution of resources. The pandemic is amenable to self-reporting through a mobile phone application that could obtain critical information on suspected cases and report on the results of self testing and actions taken. The only method to understand the clustering and the immediate hospital resource needs is mandatory, uniform, daily reporting of hospital censuses of COVID-19 cases admitted to hospital wards and intensive care units. Current reports of hospitalizations are delayed, uncertain, and wholly inadequate. This paper urges all the relevant stakeholders to take up self-reporting and reporting of hospitalizations of COVID-19 as an urgent task in combating this devastating pandemic.


Assuntos
Infecções por Coronavirus/epidemiologia , Recursos em Saúde/provisão & distribução , Recursos em Saúde/estatística & dados numéricos , Notificação de Abuso , Aplicativos Móveis/estatística & dados numéricos , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Assistência Ambulatorial/estatística & dados numéricos , Infecções por Coronavirus/complicações , Infecções por Coronavirus/terapia , Cuidados Críticos/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Pneumonia Viral/complicações , Pneumonia Viral/terapia , Características de Residência/estatística & dados numéricos , Autorrelato/estatística & dados numéricos
5.
Ann R Coll Surg Engl ; 102(5): 343-347, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32233651

RESUMO

INTRODUCTION: Tracheostomy is a common surgical procedure used to create a secure airway in patients, now performed by a variety of specialties, with a notable rise in critical care environments. It is unclear whether this rise is seen in units with large head and neck surgery departments, and how practice in such units compares with the rest of the UK. METHODS: A three-year retrospective audit was carried out between anaesthetic, surgical and critical care departments. All tracheostomy procedures were recorded anonymously. RESULTS: A total of 523 tracheostomies were performed, 66% of which were in men. The mean patient age was 60 years. The majority (83%) were elective, performed for various indications, while the remaining 17% were emergency tracheostomies performed for pending airway obstruction. A fifth of the tracheostomies were percutaneous procedures. Most emergency tracheostomies (78%) were performed by otolaryngology. Three cricothyroidotomies were performed within critical care and theatres. Complications related to tracheostomy occurred in 47 cases (9%), most commonly lower respiratory tract infection. The mean time to decannulation was 12.8 days. CONCLUSIONS: This paper discusses the findings of a comprehensive, multispecialty audit of tracheostomy experience in a large health board, with over 150 tracheostomies performed annually. Elective cases form the majority although there is a significant case series of emergency tracheostomies performed for a range of pathologies. Around a quarter of those requiring tracheostomy ultimately died, mostly as a result of advanced cancer.


Assuntos
Auditoria Médica/estatística & dados numéricos , Traqueostomia/estatística & dados numéricos , Idoso , Anestesiologia/métodos , Anestesiologia/estatística & dados numéricos , Cuidados Críticos/métodos , Cuidados Críticos/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Otolaringologia/métodos , Otolaringologia/estatística & dados numéricos , Estudos Retrospectivos , Escócia , Traqueostomia/efeitos adversos
7.
Br J Anaesth ; 124(5): 535-543, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32147104

RESUMO

BACKGROUND: Elevated high-sensitivity troponin (hsTnT) after noncardiac surgery is associated with higher mortality, but the temporal relationship between early elevated troponin and the later development of noncardiac morbidity remains unclear. METHODS: Prospective observational study of patients aged ≥45 yr undergoing major noncardiac surgery at four UK hospitals (two masked to hsTnT). The exposure of interest was early elevated troponin, as defined by hsTnT >99th centile (≥15 ng L-1) within 24 h after surgery. The primary outcome was morbidity 72 h after surgery, defined by the Postoperative Morbidity Survey (POMS). Secondary outcomes were time to become morbidity-free and Clavien-Dindo ≥grade 3 complications. RESULTS: Early elevated troponin (median 21 ng L-1 [16-32]) occurred in 992 of 4335 (22.9%) patients undergoing elective noncardiac surgery (mean [standard deviation, sd] age, 65 [11] yr; 2385 [54.9%] male). Noncardiac morbidity was more frequent in 494/992 (49.8%) patients with early elevated troponin compared with 1127/3343 (33.7%) patients with hsTnT <99th centile (odds ratio [OR]=1.95; 95% confidence interval [CI], 1.69-2.25). Patients with early elevated troponin had a higher risk of proven/suspected infectious morbidity (OR=1.54; 95% CI, 1.24-1.91) and critical care utilisation (OR=2.05; 95% CI, 1.73-2.43). Clavien-Dindo ≥grade 3 complications occurred in 167/992 (16.8%) patients with early elevated troponin, compared with 319/3343 (9.5%) patients with hsTnT <99th centile (OR=1.78; 95% CI, 1.48-2.14). Absence of early elevated troponin was associated with morbidity-free recovery (OR=0.44; 95% CI, 0.39-0.51). CONCLUSIONS: Early elevated troponin within 24 h of elective noncardiac surgery precedes the subsequent development of noncardiac organ dysfunction and may help stratify levels of postoperative care in real time.


Assuntos
Complicações Pós-Operatórias/diagnóstico , Troponina T/sangue , Idoso , Biomarcadores/sangue , Análise por Conglomerados , Estudos de Coortes , Cuidados Críticos/estatística & dados numéricos , Feminino , Hospitalização , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Morbidade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/etiologia , Cuidados Pós-Operatórios/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Período Pós-Operatório , Estudos Prospectivos , Sensibilidade e Especificidade , Reino Unido/epidemiologia
8.
Isr Med Assoc J ; 22(3): 142-147, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32147977

RESUMO

BACKGROUND: Admission to an intensive care unit (ICU) is an objective marker of severe maternal morbidity (SMM). OBJECTIVES: To determine the prevalence of obstetric ICU admissions in one medical center in Israel and to characterize this population. METHODS: In this retrospective study the files of women coded for pregnancy, birth, or the perinatal period and admission to the ICU were pulled for data extraction (2005-2013). RESULTS: During the study period, 111 women were admitted to the ICU among 120,279 women who delivered babies (0.09%). Their average age was 30 ± 6 years, most were multigravida, a few had undergone fertility treatments, and only 27% had complicated previous pregnancies. Most pregnancies (71.2%) were uneventful prior to admission. ICU admissions were divided equally between direct (usually hemorrhage) and indirect (usually cardiac disease) obstetric causes. CONCLUSIONS: The indications for obstetrics ICU admission correlated with the proximate causes of maternal arrest observed worldwide. While obstetric hemorrhage is often unpredictable, deterioration of heart disease is foreseeable. Attention should be directed specifically toward improving the diagnosis and treatment of maternal heart disease during pregnancy in Israel.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Serviços de Saúde Materna/estatística & dados numéricos , Complicações na Gravidez/epidemiologia , Transtornos Puerperais/epidemiologia , Encaminhamento e Consulta/estatística & dados numéricos , Adulto , Cuidados Críticos/métodos , Feminino , Humanos , Unidades de Terapia Intensiva , Israel/epidemiologia , Cuidado Pós-Natal/métodos , Gravidez , Complicações na Gravidez/terapia , Prevalência , Transtornos Puerperais/terapia , Estudos Retrospectivos , Fatores de Risco
9.
N Z Med J ; 133(1510): 56-61, 2020 02 21.
Artigo em Inglês | MEDLINE | ID: mdl-32078601

RESUMO

AIM: Oesophagectomy is a complex operation, with high rates of morbidity and mortality. Traditional post-operative care often involves admission to an intensive care unit, however with advancing surgical and anaesthetic techniques this may not be routinely required. The objective of this study is to investigate the utilisation of intensive care-specific resources following oesophagectomy in a New Zealand tertiary hospital. METHODS: All patients undergoing oesophagectomy over a five-year period at Christchurch Hospital, New Zealand were identified and data collected. Utilisation of ICU-specific resources and the occurrence of complications in relation to ICU discharge were recorded. RESULTS: Fifty-two patients underwent oesophagectomy between 1 January 2015 and 31 May 2019. The majority (75%) were extubated prior to admission to ICU, and only 8% required non-invasive positive pressure ventilation after extubation. Haemodynamic support with inotropic or vasopressor agents was required in 48% of patients. Most complications were managed in a non-ICU setting. The ICU readmission rate was 16%-all but one of these readmissions was following reoperation. CONCLUSION: This study shows a large proportion of post-operative oesophagectomy patients do not require ICU level support, however in the absence of a reliable pre-operative predictive tool, post-operative ICU care is still required in our setting. An individualised post-operative approach could be explored to help divert stable patients, potentially up to half of the group, away from ICU.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Esofagectomia , Utilização de Instalações e Serviços/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/terapia , Idoso , Auditoria Clínica , Cuidados Críticos/métodos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Alta do Paciente/estatística & dados numéricos , Segurança do Paciente , Cuidados Pós-Operatórios/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos
10.
Bull Cancer ; 107(3): 308-321, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32035648

RESUMO

INTRODUCTION: Health care utilization of people with lung cancer (LC) the last year of life, their causes of death and place of death and the associated expenditure have been poorly described together. Then we conducted an observational study. METHODS: People with LC covered by the French health Insurance general scheme (77% of the population) who died in 2015 were identified in the national health data system, together with their health care utilization and, in 95% of cases, their causes of death. RESULTS: A total of 22,899 individuals were included (mean age: 68 years, SD±11.4), 72% of whom died in short-stay hospitals (SSH), 4% in hospital-at-home, 8% in Rehab hospital, 2% in skilled nursing homes and 14% at home. One-half of these people had also a chronic respiratory tract disease and 18% another cancer. Hospital palliative care (HPC) was identified for 65% of people, but for only 9% prior to their end-of-life stay. During the last month of life, 49% of people had two or more SSH stays, 15% were admitted to an intensive care unit, 23% received a chemotherapy session (13% during the last 14 days). The main cause of death was cancer for 92% of individuals (LC for 82%) The mean expenditure during the last year of life was €43,329 per individual. DISCUSSION: This study indicates high rates of intensive care unit admissions and chemotherapy during the last month of life and a SSH hospital-centered management with intensive use of HPC mainly during the end-of-life stay.


Assuntos
Gastos em Saúde , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Neoplasias Pulmonares/economia , Neoplasias Pulmonares/terapia , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Comorbidade , Cuidados Críticos/economia , Cuidados Críticos/estatística & dados numéricos , Tratamento Farmacológico/economia , Tratamento Farmacológico/estatística & dados numéricos , Feminino , França/epidemiologia , Mortalidade Hospitalar , Humanos , Cobertura do Seguro/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/mortalidade , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos/estatística & dados numéricos , Características de Residência , Assistência Terminal/estatística & dados numéricos , Fatores de Tempo
11.
J Korean Med Sci ; 35(7): e54, 2020 Feb 24.
Artigo em Inglês | MEDLINE | ID: mdl-32080988

RESUMO

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.


Assuntos
Cuidados Críticos , Serviço Hospitalar de Emergência , Cobertura do Seguro , Sistemas Automatizados de Assistência Junto ao Leito , Ultrassonografia , Cuidados Críticos/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Padrões de Prática Médica , República da Coreia , Ultrassonografia/estatística & dados numéricos
12.
J Surg Res ; 245: 492-499, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31446191

RESUMO

BACKGROUND: Older adults with isolated rib fractures are often admitted to an intensive care unit (ICU) because of presumedly increased morbidity and mortality. However, evidence-based guidelines are limited. We sought to identify characteristics of these patients that predict the need for ICU care. MATERIALS AND METHODS: We analyzed patients ≥50 y old at our center during 2013-2017 whose only indication for ICU admission, if any, was isolated rib fractures. The primary outcome was any critical care intervention (e.g., intubation) or adverse event (e.g., hypoxemia) (CCIE) based on accepted critical care guidelines. We used stepwise logistic regression to identify characteristics that predict CCIEs. RESULTS: Among 401 patients, 251 (63%) were admitted to an ICU. Eighty-three patients (33%) admitted to an ICU and 7 (5%) admitted to the ward experienced a CCIE. The most common CCIEs were hypotension (10%), frequent respiratory therapy (9%), and oxygen desaturation (8%). Predictors of CCIEs included incentive spirometry <1 L (OR 4.72, 95% CI 2.14-10.45); use of a walker (OR 2.86, 95% CI 1.29-6.34); increased chest Abbreviated Injury Scale score (AIS 3 OR 5.83, 95% CI 2.34-14.50); age ≥72 y (OR 2.68, 95% CI 1.48-4.86); and active smoking (OR 2.11, 95% CI 1.06-4.20). CONCLUSIONS: Routine ICU admission is not necessary for most older adults with isolated rib fractures. The predictors we identified warrant prospective evaluation for development of a clinical decision rule to preclude unnecessary ICU admissions.


Assuntos
Hipotensão/epidemiologia , Unidades de Terapia Intensiva/normas , Admissão do Paciente/normas , Fraturas das Costelas/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/normas , Cuidados Críticos/estatística & dados numéricos , Feminino , Humanos , Hipotensão/etiologia , Hipotensão/terapia , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Fraturas das Costelas/complicações , Medição de Risco , Centros de Traumatologia/normas , Centros de Traumatologia/estatística & dados numéricos
13.
Med Care ; 58(1): 38-44, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31688552

RESUMO

OBJECTIVE: The objective of this study was to estimate the frequency and type of adverse events (AEs) among critically ill patients and identify patient and hospital factors associated with AEs and clinical and health care utilization consequences of AEs. MATERIALS AND METHODS: This retrospective cohort study includes patients admitted to 30 intensive care units (ICUs) in Alberta, Canada from May 2014 to April 2017. The main outcome was AEs derived from validated ICD-10, Canadian code algorithms for 18 AEs. Estimates of the proportion and rate of AEs are presented. The association between documented AEs and patient (eg, age, sex, comorbidities) and hospital (eg, ICU site and type, length of stay, readmission) variables are described using regression methods. RESULTS: Of 49,447 hospital admissions with admission to ICU, ≥1 AEs were documented in 12,549 (25%) admissions. The most common AEs were respiratory complications (10%) and hospital-acquired infections (9%). AEs were associated with having ≥2 comorbidities [odds ratio (OR)=1.4, 95% confidence interval (CI)=1.3-1.4], being admitted to the ICU from the operating room or another hospital ward (OR=1.8, 95% CI=1.7-2.0 and OR=2.7, 95% CI=2.5-3.0, respectively) and being readmitted to ICU during their hospital stay (OR=4.8, 95% CI=4.7-5.6). Patients with an AE stayed 5.4 days longer in ICU (95% CI=5.2-5.6 d, P<0.001), 18.2 days longer in hospital (95% CI=17.7-18.8 d, P<0.001) and had increased odds of hospital mortality (OR=1.5, 95% CI=1.4-1.6) than those without an AE. CONCLUSIONS: AEs are common among critically ill patients and certain factors are associated with AEs. Documented AEs are associated with longer stays and increased mortality.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Estado Terminal/mortalidade , Hospitalização/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Alberta/epidemiologia , Resultados de Cuidados Críticos , Infecção Hospitalar/mortalidade , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Hospitais/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Análise de Regressão , Estudos Retrospectivos
14.
S Afr Med J ; 109(9): 645-651, 2019 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-31635588

RESUMO

BACKGROUND: When critically ill patients with life-threatening conditions need urgent, expensive, life-sustaining care, admission and triage decision-making may be extremely challenging as critical care practitioners strive to balance these high-stakes, high-stress, time-sensitive decisions against a limited resource. The factors affecting the decision to admit or refuse a patient entry to an intensive care unit (ICU) have not been described in the South African (SA) context. OBJECTIVES: To identify and describe the factors that influence ICU triage decision-making for patients referred to a regional/tertiary facility for intensive care. METHODS: A retrospective review of recorded data from January 2014 to December 2017 was conducted for all referrals to the 12-bed, intensivist-led, closed general ICU at King Edward VIII Hospital, an 800-bed tertiary public facility in KwaZulu-Natal Province, SA. Data were extracted to identify factors associated with the decision to admit or refuse patients referred to the unit. Significant factors on univariate analysis were then included in a multivariable analysis using binary logistic regression to identify significant independent factors. RESULTS: A total of 4 469 referrals were received over the 48-month period studied. Of these, 507 (11.3%) were withdrawn before a final decision of acceptance or refusal and 94 (2.1%) had an unknown outcome, leaving 3 868 referrals where an acceptance/refusal decision was made as our study cohort. Of these, 38.7% were refused admission. The commonest reason for refusal (57.0%) was assessment of the patient as 'too sick' by the admitting specialist. Multivariable analysis identified age, referring discipline as medicine, poor or unknown premorbid functioning, and comorbidities of HIV, malignancy and cardiac failure as significant factors for refusal of admission to the ICU. Referrals were significantly more likely to be accepted from private institutions, and if the comorbidity was asthma or psychiatric disease. CONCLUSIONS: A better understanding of factors affecting ICU admission/refusal decisions will allow for a more effective and appropriate referral process and more rational utilisation of scarce ICU resources. Further prospective studies are necessary to elucidate fully the impact of various other factors.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Estado Terminal/terapia , Unidades de Terapia Intensiva/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Triagem/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Tomada de Decisões , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Retrospectivos , África do Sul , Centros de Atenção Terciária , Adulto Jovem
15.
Anaesthesia ; 74(12): 1509-1523, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31478198

RESUMO

The tragic death of an anaesthetic trainee driving home after a series of night shifts prompted a national survey of fatigue in trainee anaesthetists. This indicated that fatigue was widespread, with significant impact on trainees' health and well-being. Consultants deliver an increasing proportion of patient care resulting in long periods of continuous daytime duty and overnight on-call work, so we wished to investigate their experience of out-of-hours working and the causes and impact of work-related fatigue. We conducted a national survey of consultant anaesthetists and paediatric intensivists in the UK and Ireland between 25 June and 6 August 2018. The response rate was 46% (94% of hospitals were represented): 84% of respondents (95%CI 83.1-84.9%) contribute to a night on-call rota with 32% (30.9-33.1%) working 1:8 or more frequently. Sleep disturbance on-call is common: 47% (45.6-48.4%) typically receive two to three phone calls overnight, and 48% (46.6-49.4%) take 30 min or more to fall back to sleep. Only 15% (14.0-16.0%) reported always achieving 11 h of rest between their on-call and their next clinical duty, as stipulated by the European Working Time Directive. Moreover, 24% (22.8-25.2%) stated that there is no departmental arrangement for covering scheduled clinical duties following a night on-call if they have been in the hospital overnight. Overall, 91% (90.3-91.7%) reported work-related fatigue with over half reporting a moderate or significantly negative impact on health, well-being and home life. We discuss potential explanations for these results and ways to mitigate the effects of fatigue among consultants.


Assuntos
Anestesiologistas/estatística & dados numéricos , Cuidados Críticos/estatística & dados numéricos , Fadiga/epidemiologia , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Tolerância ao Trabalho Programado , Adulto , Idoso , Esgotamento Profissional/epidemiologia , Consultores/estatística & dados numéricos , Técnica Delfos , Feminino , Nível de Saúde , Humanos , Irlanda/epidemiologia , Masculino , Pessoa de Meia-Idade , Admissão e Escalonamento de Pessoal , Sono , Inquéritos e Questionários , Reino Unido/epidemiologia
16.
Pancreatology ; 19(6): 828-833, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31383574

RESUMO

BACKGROUND: Use of minimally invasive techniques has reduced mortality in walled-off pancreatic necrosis (WON) but may be costly. The aim of this study was to evaluate the actual costs associated with the endoscopic management of patients with WON. METHODS: We included a retrospective cohort of WON patients treated with endoscopic, transgastric drainage and necrosectomy (ETDN) during 2013-2014. Costs were calculated for six sub-areas based on a micro-costing model. Students T-test and non-parametric analysis of variance were performed to evaluate costs in relation to disease etiology and outcome. RESULTS: We included 58 patients (50% men, median age 57 years). The most common etiologies were gallstones (57%) and alcohol (19%). Nine patients (16%) died during admission. The median length of stay was 50 days (IQR 31 days). Eighteen patients (31%) needed treatment in our intensive care unit with a median length of stay of 16 days (IQR 31 days). The mean costs and standard deviation of costs (SD) per patient were: diagnostic imaging $2,431 ($2,301), laboratory tests $3,579 ($2,477), blood products $982 ($1,734), endoscopic treatment $3,794 ($1,777), medicine $5,440 ($6,656), and ward cost $41,260 ($35,854). The mean total cost was $57,486 ($46,739). Post-ERCP pancreatitis and mortality predicted higher costs. CONCLUSIONS: This study sheds light on the different costs associated with endoscopic treatment of WON. As nearly three quarters of the costs are related to ward care, initiatives aimed at reducing the length of hospital stay may have a great impact on making endoscopic treatment more cost effective.


Assuntos
Endoscopia/economia , Pancreatite Necrosante Aguda/economia , Custos e Análise de Custo , Cuidados Críticos/economia , Cuidados Críticos/estatística & dados numéricos , Diagnóstico por Imagem/economia , Drenagem , Endoscopia/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Pancreatite Necrosante Aguda/mortalidade , Pancreatite Necrosante Aguda/cirurgia , Estudos Retrospectivos , Stents , Análise de Sobrevida , Resultado do Tratamento
17.
Acta Clin Croat ; 58(1): 50-56, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31363325

RESUMO

The APACHE II scoring system is approved for its benchmarking and mortality predictions, but there are only a few articles published to demonstrate it in neurosurgical patients. Therefore, this study was performed to acknowledge this score and its predictive performance to hospital mortality in a tertiary referral neurosurgical intensive care unit (ICU). All patients admitted to the Neurosurgical ICU from February 1 to July 31, 2011 were recruited. The parameters indicated in APACHE II score were collected. The adjusted predicted risk of death was calculated and compared with the death rate observed. Descriptive statistics including the receiver operating characteristic curve (ROC) was performed. The results showed that 276 patients were admitted during the mentioned period. The APACHE II score was 16.56 (95% CI, 15.84-17.29) and 19.08 (95% CI, 15.40-22.76) in survivors and non-survivors, while the adjusted predicted death rates were 13.39% (95% CI, 11.83-14.95) and 17.49% (95% CI, 9.81-25.17), respectively. The observed mortality was only 4.35%. The area under the ROC of APACHE II score to the hospital mortality was 0.62 (95% CI, 0.44-0.79). In conclusion, not only the APACHE II score in neurosurgical patients indicated low severity, but its performance to predict hospital mortality was also inferior. Additional studies of predicting mortality among these critical patients should be undertaken.


Assuntos
APACHE , Cuidados Críticos/estatística & dados numéricos , Unidades de Terapia Intensiva , Índice de Gravidade de Doença , Sobreviventes/estatística & dados numéricos , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
18.
Crit Care Resusc ; 21(3): 200-211, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31462207

RESUMO

OBJECTIVE: To provide a contemporary description of the demographics, characteristics and outcomes of critically ill Indigenous patients in Australia. DESIGN, SETTING AND PARTICIPANTS: Retrospective database review using the Australian and New Zealand Intensive Care Society Adult Patient Database for intensive care unit (ICU) admissions in 2017-18. Characteristics of critically ill Indigenous patients were compared with non-Indigenous patients. MAIN OUTCOME MEASURES: Primary outcome was hospital mortality. Secondary outcomes examined demographics and resource use. RESULTS: Per capita, Indigenous Australians were overrepresented in the intensive care. They were younger (51 v 66 years), more likely to be admitted from outer regional, rural and remote settings (59% v 15%), more likely to require emergency admission (81% v 59%), and had higher rates of mechanical ventilation (35% v 32%; P < 0.01 for all). Indigenous patients were over-represented in the diagnostic categories of sepsis (15% v 9%), trauma (7% v 5%), and respiratory illness (17% v 15%), and had higher rates of ICU re-admission (7% v 5%; P < 0.01 for all). There was no difference in either unadjusted (7.9% for each; P = 0.96) or adjusted (odds ratio, 1.1; 95% CI, 1.0-1.2) in-hospital mortality. CONCLUSION: Indigenous patients, especially young Indigenous patients, were disproportionately represented in Australian ICUs, particularly for sepsis. The high level of acute illness and high proportion of emergency admissions could be interpreted as representing delayed presentation, which, with a higher re-admission rate, suggest access barriers to health care may exist. Nevertheless, there was no mortality gap between Indigenous and non-Indigenous Australians during a hospital admission for critical illness.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Serviços de Saúde do Indígena/estatística & dados numéricos , Mortalidade Hospitalar/etnologia , Hospitalização/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Grupo com Ancestrais Oceânicos/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Adulto , Distribuição por Idade , Austrália , Estado Terminal , Diagnóstico Tardio , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Estudos Retrospectivos , Adulto Jovem
19.
Emergencias (Sant Vicenç dels Horts) ; 31(4): 245-251, ago. 2019. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-182765

RESUMO

Objetivo: Diseñar un modelo de riesgo para predecir resultado adverso a los 30 días del alta en pacientes adultos atendidos por crisis epiléptica en servicios de urgencias hospitalarios (SUH). Metodología: ACESUR fue un registro observacional de cohortes multipropósito, prospectivo, multicéntrico, con muestreo sistemático y con seguimiento telefónico a 30 días. La variable principal fue la presencia de algún resultado adverso (recurrencia de crisis, revisita al SUH, hospitalización o fallecimiento) a 30 días del alta del SUH. Resultados: Se incluyeron 489 (74%) pacientes de 48 años de mediana (RIC 34-66), dados de alta de 18 SUH con datos de seguimiento. Ciento cuarenta y cuatro (29,4%) presentaron algún resultado adverso a 30 días del alta del SUH. El Modelo RACESUR incluyó la presencia de crisis epiléptica no convulsiva generalizada tónico-clónica como motivo de consulta (OR 2,42; IC 95% 1,49-3,90; p < 0,001), consumo habitual de $ 3 fármacos (OR 1,98; IC 95% 1,283,07; p = 0,002) y visita al SUH en el semestre anterior por cualquier causa (OR 2,34; IC 95% 1,7-3,70; p < 0,001). Cada ítem vale 1 punto. El riesgo de padecer un resultado adverso a 30 días fue de un 62,2% con 3 puntos, 38,5% con 2, 25,9% con 1 y 10,9% con 0 puntos. El área bajo la curva del modelo fue de 0,72 (IC 95% 0,675-0,772; p = 0,025). Conclusiones: El Modelo RACESUR podría ser una herramienta pronóstico de utilidad para identificar al paciente adulto con crisis epiléptica y alto riesgo de presentar resultado adverso a los 30 días del alta de urgencias


Objective: To develop a risk model to predict adverse outcomes within 30 days of discharge in adults attended by hospital emergency departments for an epileptic seizure. Methods: ACESUR (Acute Epileptic Seizures in the Emergency Department) is a prospective multicenter, multipurpose registry of cases obtained by systematic sampling. We made follow-up telephone calls to registered patients 30 days after discharge. Clinical variables for the index visit were extracted from the register and variables at 30 days were collected by telephone. The main outcome variable was the occurrence of any adverse outcome (seizure recurrence, emergency department revisit, hospitalization, or death) within 30 days of discharge. Results: Of the patients from the ACESUR registry discharged from 18 hospitals, we included 489 (74%) with complete follow-up information. The median (interquartile range) age was de 48 (34-66) years. One hundred forty-four patients (29.4%) experienced an adverse outcome within 30 days of discharge. Factors included in the ACESUR risk model were generalized nonconvulsive tonic-clonic epileptic seizure as the reason for the index visit (odds ratio [OR], 2.42; 95% CI, 1.49-3.90; P<.001), ongoing use of 3 or more medications (OR, 1.98; 95% CI, 1.28-3.07; P=.002), and an emergency visit for any reason in the 6 months prior to the index event (OR, 2.34; 95% CI, 1.47-3.70; P<.001). Each factor contributed 1 point to the risk score. A score of 3 was associated with a 62.2% risk of an adverse outcome within 30 days, a score of 2 was associated with a 38.5% risk, a score of 1 with a 25.9% risk, and a score of 0 with a 10.9% risk. The area under the curve receiver operating characteristic curve was 0.72 (95% CI, 0.675-0.772; P=.025). Conclusion: The ACESUR risk model may provide a useful score for identifying patients at high risk of an adverse outcome within 30 days of emergency department discharge after an epileptic seizure


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Convulsões/epidemiologia , Alta do Paciente , Cuidados Críticos/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Estudos Prospectivos , Amostragem Aleatória e Sistemática
20.
Br J Surg ; 106(10): 1393-1403, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31282571

RESUMO

BACKGROUND: Pelvic exenteration (PE) provides a potentially curative option for advanced or recurrent malignancy confined to the pelvis. A clear (R0) resection margin is the strongest prognostic factor predicting long-term survival, driving most technical advances in PE surgery. The aim of this cohort study was to describe changing trends in extent of resection, postoperative complications, mortality and overall survival after PE surgery. METHODS: Consecutive patients who underwent PE for advanced or recurrent pelvic malignancy at a single institution in Sydney, Australia, were identified. The cohort was divided into three groups based on time periods reflecting annual surgical volume: 1994-2006 (20 or fewer procedures per year), 2007-2013 (21-50 procedures per year) and 2014-2017 (over 50 procedures per year). Primary outcomes were extent of resection, postoperative complications, 60-day mortality and 3-year overall survival. Secondary outcomes were patient characteristics, receipt of neoadjuvant therapy and duration of hospital stay. RESULTS: There were increases over time in rates of lateral and posterior compartment resections (P < 0·001), and bony pelvis (P = 0·002) and neurovascular (P < 0·001) excision. For patients undergoing reconstruction, the proportion receiving vertical rectus abdominus myocutaneous flaps increased significantly (P = 0·005). Rates of wound infection, dehiscence, and abdominal and pelvic collections increased over the study interval. Short-term mortality decreased, and 1- and 3-year survival rates improved. CONCLUSION: Technical and surgical advancements have led to more complex PE resections, with R0 and mortality rates improving with higher annual volume. There were associated increases in intraoperative blood loss and postoperative morbidity.


Assuntos
Exenteração Pélvica/métodos , Neoplasias Pélvicas/cirurgia , Análise de Variância , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Cuidados Críticos/estatística & dados numéricos , Feminino , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/cirurgia , Duração da Cirurgia , Readmissão do Paciente/estatística & dados numéricos , Exenteração Pélvica/mortalidade , Neoplasias Pélvicas/mortalidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Resultado do Tratamento
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