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3.
Emerg Med Clin North Am ; 37(4): 811-819, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31563209

RESUMO

Emergency medicine providers may encounter serious GU conditions that need rapid diagnosis and early intervention to avoid severe life- and limb-threatening complications. A fundamental knowledge of several key procedural interventions is incredibly important to optimal patient outcomes.


Assuntos
Serviço Hospitalar de Emergência , Doenças dos Genitais Femininos/diagnóstico , Doenças dos Genitais Masculinos/diagnóstico , Doenças Urológicas/diagnóstico , Cuidados Críticos/métodos , Feminino , Doenças dos Genitais Femininos/patologia , Doenças dos Genitais Femininos/terapia , Doenças dos Genitais Masculinos/patologia , Doenças dos Genitais Masculinos/terapia , Humanos , Masculino , Doenças Urológicas/patologia , Doenças Urológicas/terapia
4.
Medicine (Baltimore) ; 98(35): e16944, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31464933

RESUMO

INTRODUCTION: Head and neck cancer patients are at a high risk to suffer from malnourishment, a risk that increases in postoperative condition and with the use of enteral nutrition (EN). Until now patients who are suffering from indigestion in the intensive care unit (ICU) received treatment in the form of prokinetic drugs, drugs that can lead to serious side effects and only can partially improve digestion functions. Acupuncture was used successfully in several clinical trials to improve postoperative indigestion in cancer patients without any reported adverse events. The study aims are to investigate acupuncture effect in combination with prokinetic drugs in the treatment of indigestion in postoperative oral and hypopharyngeal cancer patients in the ICU. METHODS: Single-center, double-blind randomized control trial will compare between 2 equal groups. A total of 28 patients that will meet the inclusion criteria: age 30 to 80, postplastic surgery for oral cancer or hypopharyngeal cancer, developed feeding intolerance 2 times in the first postoperative day, Apache score <20, and needed EN. Patients will be randomly divided (1:1) into treatment group or control group for 3 treatments in 3 days along with routine ICU treatment. The main outcome measurement will be the number of days a patient needs to reach his total energy expenditure. EXPECTED OUTCOME: The results will shed light on the effectiveness and safety of acupuncture in a double-blind design treating postoperative ICU cancer patients. In addition, the study presents a revolutionary double-blind design that if, will prove as successful might influence the way double-blind acupuncture studies are performed today. OTHER INFORMATION: The study will be conducted in the surgical ICU department, of China medical university hospital, Taichung 404, Taiwan. The study is conducted on stable ICU patients and is anticipated to have minimum risk for adverse events. Patients enrollment and data collection will start from May 15, 2019. The study expected completion time: June 2021.


Assuntos
Terapia por Acupuntura/métodos , Cuidados Críticos/métodos , Dispepsia/terapia , Neoplasias Hipofaríngeas/cirurgia , Neoplasias Bucais/cirurgia , APACHE , Adulto , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Dispepsia/etiologia , Nutrição Enteral/métodos , Feminino , Humanos , Neoplasias Hipofaríngeas/complicações , Masculino , Pessoa de Meia-Idade , Neoplasias Bucais/complicações , Cuidados Pós-Operatórios , Projetos de Pesquisa , Taiwan
5.
Ann R Coll Surg Engl ; 101(7): 487-494, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31362520

RESUMO

INTRODUCTION: Acute pancreatitis is a common surgical emergency. Identifying variations in presentation, incidence and management may assist standardisation and optimisation of care. The objective of the study was to document the current incidence management and outcomes of acute pancreatitis against international guidelines, and to assess temporal trends over the past 20 years. METHODS: A prospective four-month audit of patients with acute pancreatitis was performed across the Wessex region. The Atlanta 2012 classifications were used to define cases, severity and complications. Outcomes were recorded using validated systems and correlated against guideline standards. Case ascertainment was validated with clinical coding and hospital episode statistics data. RESULTS: A total of 283 patient admissions with acute pancreatitis were identified. Aetiology included 153 gallstones (54%), 65 idiopathic (23%), 29 alcohol (10%), 9 endoscopic retrograde cholangiopancreatography (3%), 6 drug related (2%), 5 tumour (2%) and 16 other (6%). Compliance with guidelines had improved compared with our previous regional audit. Results were 6.5% mortality, 74% severity stratification, 23% idiopathic cases, 65% definitive treatment of gallstones within 2 weeks, 39% computed tomography within 6-10 days of severe pancreatitis presentation and 82% severe pancreatitis critical care admission. The Atlanta 2012 severity criteria significantly correlated with critical care stay, length of stay, development of complications and mortality (2% vs 6% vs 36%, P < 0.0001). CONCLUSIONS: The incidence of acute pancreatitis in southern England has risen substantially. The Atlanta 2012 classification identifies patients with severe pancreatitis who have a high risk of fatal outcome. Acute pancreatitis management is seen to have evolved in keeping with new evidence and updated clinical guidelines.


Assuntos
Cuidados Críticos/métodos , Cálculos Biliares/terapia , Auditoria Médica/estatística & dados numéricos , Pancreatite/epidemiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Consumo de Bebidas Alcoólicas/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Cuidados Críticos/normas , Inglaterra/epidemiologia , Feminino , Cálculos Biliares/complicações , Humanos , Incidência , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pancreatite/diagnóstico , Pancreatite/etiologia , Pancreatite/terapia , Admissão do Paciente/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Índice de Gravidade de Doença , Taxa de Sobrevida , Resultado do Tratamento , Adulto Jovem
6.
Presse Med ; 48(7-8 Pt 1): 780-787, 2019.
Artigo em Francês | MEDLINE | ID: mdl-31383383

RESUMO

Interprofessional simulation-based education is effective for learning non-technical critical care skills and strengthening interprofessional team collaboration to optimize quality of care and patient outcome. Implementation of interprofessional simulation sessions in initial and continuing education is facilitated by a team of "champions" from each discipline/profession to ensure educational quality and logistics. Interprofessional simulation training must be integrated into a broader interprofessional curriculum supported by managers, administrators and clinical colleagues from different professional programs. When conducting interprofessional simulation training, it is essential to account for sociological factors (hierarchy, power, authority, interprofessional conflicts, gender, access to information, professional identity) both in scenario design and debriefing. Teamwork assessment tools in interprofessional simulation training may be used to guide debriefing. The interprofessional simulation setting (in-situ or simulation centre) will be chosen according to the learning objectives and the logistics.


Assuntos
Cuidados Críticos/métodos , Educação Médica/métodos , Relações Interprofissionais , Equipe de Assistência ao Paciente , Treinamento por Simulação , Competência Clínica , Cuidados Críticos/normas , Currículo/normas , Educação Médica/normas , Avaliação Educacional/métodos , Humanos , Ciência da Implementação , Equipe de Assistência ao Paciente/organização & administração , Equipe de Assistência ao Paciente/normas , Treinamento por Simulação/métodos , Treinamento por Simulação/organização & administração , Treinamento por Simulação/normas
7.
Medicine (Baltimore) ; 98(26): e16204, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31261567

RESUMO

Several prognostic indices have been employed to predict the outcome of surgical critically ill patients. Among them, acute physiology and chronic health evaluation (APACHE) II, sequential organ failure assessment (SOFA) and simplified acute physiology score (SAPS 3) are widely used. It seems that biological markers such as C-reactive protein (CRP), albumin, and blood lactate levels correlate with the degree of inflammation during the immediate postoperative phase and could be used as independent predictors. The objective of this study is to compare the different predictive values of prognostic indices and biological markers in the outcome of 847 surgical patients admitted to the intensive care unit (ICU) in the postoperative phase.The patients were divided into survivors (n = 765, 57.4% males, age 61, interquartile range 51-71) and nonsurvivors (n = 82, 57.3% males, age 70, interquartile range 58-79). APACHE II, APACHE II death probability (DP), SOFA, SAPS 3, SAPS 3 DP, CRP, albumin, and lactate were recorded on ICU admission (first 24 hours). The area under the ROC curve (AUROC) and 95% confidence interval (95% CI) were used to measure the index accuracy to predict mortality.The AUROC and 95% CI for APACHE II, APACHE II DP, SOFA, SAPS 3, SAPS 3 DP, CRP/albumin ratio, CRP, albumin, and lactate were 0.850 (0.824-0.873), 0.855 (0.829-0.878), 0.791 (0.762-0.818), 0.840 (0.813-0.864), 0.840 (0.813-0.864), 0.731 (0.700-0.761), 0.708 (0.676-0.739), 0.697 (0.665-0.728), and 0.601 (0.567-0.634), respectively. The ICU and overall in-hospital mortality were 6.6 and 9.7%, respectively. The APACHE II, APACHE II DP, SAPS 3, SAPS 3 DP, and SOFA scores showed a better performance than CRP/albumin ratio, CRP, albumin, or lactate to predict in-hospital mortality of surgical critically ill patients.Even though all indices were able to discriminate septic from nonseptic patients, only APACHE II, APACHE II DP, SOFA and to a lesser extent SAPS 3, SAPS 3 DP, and blood lactate levels could predict in the first 24-hour ICU admission surgical patients who have survived sepsis.


Assuntos
Cuidados Críticos , Estado Terminal/mortalidade , Estado Terminal/terapia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , APACHE , Idoso , Biomarcadores/sangue , Proteína C-Reativa/metabolismo , Cuidados Críticos/métodos , Feminino , Mortalidade Hospitalar , Humanos , Ácido Láctico/sangue , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Complicações Pós-Operatórias/terapia , Período Pós-Operatório , Curva ROC , Estudos Retrospectivos , Sepse/diagnóstico , Sepse/mortalidade , Sepse/terapia , Albumina Sérica/metabolismo , Escala Psicológica Aguda Simplificada
8.
Z Gerontol Geriatr ; 52(5): 440-456, 2019 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-31278486

RESUMO

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.


Assuntos
Cuidados Críticos/métodos , Estado Terminal/terapia , Avaliação Geriátrica/métodos , Idoso , Consenso , Idoso Fragilizado , Humanos
9.
Medicine (Baltimore) ; 98(26): e16197, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31261562

RESUMO

The aim of this study was to evaluate the clinical feasibility and effectiveness of bedside peripherally inserted central catheter (PICC) using portable digital radiography (DR) in intensive care unit (ICU) patients.Sixty-five ICU patients who underwent PICC were enrolled in this study between May 2016 and May 2017. Of these 65 patients, 45 (69.2%) underwent the procedures bedside in ICU using portable DR, and 20 (30.8%) underwent the procedures at the intervention clinic, both performed by a single interventional radiologist. We retrospectively reviewed electronic medical records for clinical presentation, total procedural time, total radiation dose, total patient transfer time, and clinical outcomes. We performed an independent t test to compare the clinical effectiveness between the 2 groups.The technical and clinical success rates were 100% in both groups, and there were no procedure-related complications. The total radiation dose of bedside PICC at ICU was significantly lower than that of conventional PICC at the intervention clinic (557.9 mGy*cm ± 209.2 vs 985.2 mGy*cm ± 547.6, P < .001). The total procedure time was significantly different between the bedside and conventional PICC groups (26.8 minutes ± 3.9 vs 24.1 minutes ± 5.55, P = .028). The average patient transfer time to the intervention clinic was 26.6 minutes ± 9.8.Bedside PICC using portable DR is a safe and effective procedure option to manage ICU patients in daily clinical practice.


Assuntos
Cateterismo Periférico/instrumentação , Cuidados Críticos , Sistemas Automatizados de Assistência Junto ao Leito , Radiografia Intervencionista/instrumentação , Idoso , Cateterismo Periférico/métodos , Cuidados Críticos/métodos , Estudos de Viabilidade , Feminino , Fluoroscopia/instrumentação , Fluoroscopia/métodos , Humanos , Masculino , Transferência de Pacientes , Doses de Radiação , Radiografia Intervencionista/métodos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
10.
Einstein (Sao Paulo) ; 17(3): eAO4399, 2019 May 30.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31166482

RESUMO

OBJECTIVE: To determine whether pre-hospital statin use is associated with lower renal replacement therapy requirement and/or death during intensive care unit stay. METHODS: Prospective cohort analysis. We analyzed 670 patients consecutively admitted to the intensive care unit of an academic tertiary-care hospital. Patients with ages ranging from 18 to 80 years admitted to the intensive care unit within the last 48 hours were included in the study. RESULTS: Mean age was 66±16.1 years old, mean body mass index 26.6±4/9kg/m2 and mean abdominal circumference was of 97±22cm. The statin group comprised 18.2% of patients and had lower renal replacement therapy requirement and/or mortality (OR: 0.41; 95%CI: 0.18-0.93; p=0.03). The statin group also had lower risk of developing sepsis during intensive care unit stay (OR: 0.42; 95%CI: 0.22-0.77; p=0.006) and had a reduction in hospital length-of-stay (14.7±17.5 days versus 22.3±48 days; p=0.006). Statin therapy was associated with a protective role in critical care setting independently of confounding variables, such as gender, age, C-reactive protein, need of mechanical ventilation, use of pressor agents and presence of diabetes and/or coronary disease. CONCLUSION: Statin therapy prior to hospital admission was associated with lower mortality, lower renal replacement therapy requirement and sepsis rates.


Assuntos
Lesão Renal Aguda/terapia , HDL-Colesterol/efeitos dos fármacos , LDL-Colesterol/efeitos dos fármacos , Colesterol , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Terapia de Substituição Renal/estatística & dados numéricos , Triglicerídeos , APACHE , Lesão Renal Aguda/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Proteína C-Reativa/análise , Colesterol/sangue , HDL-Colesterol/sangue , LDL-Colesterol/sangue , Creatinina/sangue , Cuidados Críticos/métodos , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Curva ROC , Valores de Referência , Terapia de Substituição Renal/mortalidade , Reprodutibilidade dos Testes , Fatores de Risco , Resultado do Tratamento , Triglicerídeos/sangue , Adulto Jovem
11.
BMJ ; 365: l1927, 2019 06 04.
Artigo em Inglês | MEDLINE | ID: mdl-31164326

RESUMO

OBJECTIVE: To evaluate the effect of intensive care unit (ICU) admission on mortality among patients with ST elevation myocardial infarction (STEMI). DESIGN: Retrospective cohort study. SETTING: 1727 acute care hospitals in the United States. PARTICIPANTS: Medicare beneficiaries (aged 65 years or older) admitted with STEMI to either an ICU or a non-ICU unit (general/telemetry ward or intermediate care) between January 2014 and October 2015. MAIN OUTCOME MEASURE: 30 day mortality. An instrumental variable analysis was done to account for confounding, using as an instrument the additional distance that a patient with STEMI would need to travel beyond the closest hospital to arrive at a hospital in the top quarter of ICU admission rates for STEMI. RESULTS: The analysis included 109 375 patients admitted to hospital with STEMI. Hospitals in the top quarter of ICU admission rates admitted 85% or more of STEMI patients to an ICU. Among patients who received ICU care dependent on their proximity to a hospital in the top quarter of ICU admission rates, ICU admission was associated with lower 30 day mortality than non-ICU admission (absolute decrease 6.1 (95% confidence interval -11.9 to -0.3) percentage points). In a separate analysis among patients with non-STEMI, a group for whom evidence suggests that routine ICU care does not improve outcomes, ICU admission was not associated with differences in mortality (absolute increase 1.3 (-0.9 to 3.4) percentage points). CONCLUSIONS: ICU care for STEMI is associated with improved mortality among patients who could be treated in an ICU or non-ICU unit. An urgent need exists to identify which patients with STEMI benefit from ICU admission and what about ICU care is beneficial.


Assuntos
Cuidados Críticos , Mortalidade Hospitalar , Unidades de Terapia Intensiva/estatística & dados numéricos , Infarto do Miocárdio com Supradesnível do Segmento ST , Idoso , Cuidados Críticos/métodos , Cuidados Críticos/organização & administração , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicare/estatística & dados numéricos , Mortalidade , Determinação de Necessidades de Cuidados de Saúde , Avaliação de Processos e Resultados (Cuidados de Saúde) , Infarto do Miocárdio com Supradesnível do Segmento ST/economia , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Estados Unidos/epidemiologia
12.
Medicine (Baltimore) ; 98(23): e15833, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31169685

RESUMO

Few prospective studies have reported the cumulative incidence of venous thromboembolism (VTE) in the intensive care unit (ICU), especially for patients receiving guideline-recommended VTE prophylaxis. We aimed to design a prospective observational study to investigate the cumulative incidence and risk factors of ICU-acquired VTE for those populations.We prospectively studied 281 consecutively included patients in the ICU at a single center. All patients provided informed consent. Patients received ultrasound evaluation and were followed for VTE before ICU discharge or within 28 days of ICU stay. The type of VTE thromboprophylaxis was also recorded for all patients. Variables from univariate analyses that were associated with VTE were included in the binary logistic regression analysis to determine VTE predictors. The cumulative VTE incidence with 95% confidence interval (CI) was estimated using Kaplan-Meier methods.Patients had a median age of 60 years (range, 18-89) and an acute physiology and chronic health evaluation II score of 17 (range, 4-36). Despite all patients receiving guideline-recommended thromboprophylaxis, the cumulative incidence of VTE at 7, 14, 21, and 28 days was 4.45% (95% CI 2.55-7.71), 7.14% (95% CI 4.61-10.97), 7.53% (95% CI 4.92-11.43), and 9.55% (95% CI 6.55-13.81), respectively. Central venous catheter use (P = .002, odds ratio [OR] = 4.50), Caprini score (P = .012, OR = 1.20), and ICU length of stay (P = .006, OR = 1.08) were independent risk factors related to the incidence of VTE for patients admitted to the ICU.Our prospective observational study found that the 28-day cumulative incidence of VTE was relatively high for patients admitted to the ICU, despite the use of guideline-recommended thromboprophylaxis. Patients with femoral central venous catheter, prolonged ICU length of stay, or a high Caprini score may have an increased risk of developing VTE.


Assuntos
Anticoagulantes/uso terapêutico , Cuidados Críticos/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tromboembolia Venosa/epidemiologia , APACHE , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/normas , Cuidados Críticos/métodos , Cuidados Críticos/normas , Feminino , Humanos , Incidência , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Prospectivos , Fatores de Risco , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle , Adulto Jovem
14.
Am Surg ; 85(4): 409-413, 2019 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-31043203

RESUMO

Since the Transfusion Requirements in Critical Care trial, studies have shown that acutely ill patients can drift as a low as 5 g/dL. This study reviews a transfusion trigger change to 6.5 g/dL, which we hypothesize will conserve resources and improve quality of care. This is a retrospective chart review at an urban Level I trauma center from January through December 2015 after our trauma service changed the transfusion trigger from 7 to 6.5 g/dL. Outcomes in patients before (TT7) and after (TT6.5) the change in transfusion threshold were then compared. One hundred thirty-one discrete patients were included in this trial, with 285 instances of a hemoglobin of 7 g/dL or less and 178 transfusions. Seventy-two patients were before the change in threshold and 59 after. There was no change in length of hospital stay, ICU stay, ventilator days, mortality, and organ system failure after change in the transfusion threshold. After initiation of a more conservative threshold, 72 units of blood were saved. Decreased transfusion threshold was associated with no worse outcomes associated with decreased resource utilization.


Assuntos
Transfusão de Sangue/normas , Cuidados Críticos/normas , Ferimentos e Lesões/terapia , Adulto , Idoso , Protocolos Clínicos , Cuidados Críticos/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Resultado do Tratamento
15.
Scand J Trauma Resusc Emerg Med ; 27(1): 51, 2019 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-31039813

RESUMO

BACKGROUND: Sepsis is a common critical condition caused by the body's overwhelming response to certain infective agents. Many biomarkers, including the serum lactate level, have been used for sepsis diagnosis and guiding treatment. Recently, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) recommended the Sequential Organ Failure Assessment (SOFA) and the quick SOFA (qSOFA) rather than lactate for screening sepsis and assess prognosis. Here, we aim to explore and compare the prognostic accuracy of the lactate level, the SOFA score and the qSOFA score for mortality in septic patients using the public Medical Information Mart for Intensive Care III database (MIMIC III). METHODS: The baseline characteristics, laboratory test results and outcomes for sepsis patients were retrieved from MIMIC III. Survival was analysed by the Kaplan-Meier method. Univariate and multivariate analysis was performed to identify predictors of prognosis. Receiver operating characteristic curve (ROC) analysis was conducted to compare lactate with SOFA and qSOFA scores. RESULTS: A total of 3713 cases were initially identified. The analysis cohort included 1865 patients. The 24-h average lactate levels and the worst scores during the first 24 h of ICU admission were collected. Patients in the higher lactate group had higher mortality than those in the lower lactate group. Lactate was an independent predictor of sepsis prognosis. The AUROC of lactate (AUROC, 0.664 [95% CI, 0.639-0.689]) was significantly higher than that of qSOFA (AUROC, 0.547 [95% CI, 0.521-0.574]), and it was similar to the AUROC of SOFA (AUROC, 0.686 [95% CI, 0.661-0.710]). But the timing of lactate relative to SOFA and qSOFA scores was inconsistent. CONCLUSION: Lactate is an independent prognostic predictor of mortality for patients with sepsis. It has superior discriminative power to qSOFA, and shows discriminative ability similar to that of SOFA.


Assuntos
Cuidados Críticos/métodos , Ácido Láctico/sangue , Sepse/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar/tendências , Humanos , Unidades de Terapia Intensiva , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Prognóstico , Curva ROC , Estudos Retrospectivos , Sepse/diagnóstico , Sepse/mortalidade , Taxa de Sobrevida/tendências
16.
Br J Anaesth ; 123(2): 170-176, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31054772

RESUMO

Maintenance or prompt restoration of an oxygen supply sufficient to facilitate adequate cellular metabolism is fundamental in maintaining organ function. This is particularly relevant when metabolic needs change markedly, for example in response to major surgery or critical illness. The consequences of inadequate tissue oxygenation include wound and anastomotic breakdown, organ dysfunction, and death. However, our ability to identify those at risk and to promptly recognise and correct tissue hypoperfusion is limited. Reliance is placed upon surrogate markers of tissue oxygenation such as arterial blood pressure and serum lactate that are insensitive to early organ compromise. Advances in oxygen sensing technology will facilitate monitoring in various organ beds and allow more precise titration of therapies to physiologically relevant endpoints. Clinical trials will be needed to evaluate any impact on outcomes, however accurate on-line monitoring of the adequacy of tissue oxygenation offers the promise of a paradigm shift in resuscitation and perioperative practice. This narrative review examines current evidence for goal-directed therapy in the optimisation of organ perfusion in high-risk surgical and critically ill patients, and offers arguments to support the potential utility of tissue oxygen monitoring.


Assuntos
Cuidados Críticos/métodos , Hipóxia/terapia , Insuficiência de Múltiplos Órgãos/prevenção & controle , Oxigênio/metabolismo , Complicações Pós-Operatórias/terapia , Procedimentos Cirúrgicos Operatórios , Estado Terminal , Humanos , Risco
17.
Arch. bronconeumol. (Ed. impr.) ; 55(5): 258-265, mayo 2019. tab, ilus
Artigo em Espanhol | IBECS | ID: ibc-181747

RESUMO

La atrofia y la debilidad de los músculos respiratorios y periféricos son un problema frecuente en las Unidades de Cuidados Intensivos (UCI). Su diagnóstico es dificultoso, especialmente en las primeras etapas de la enfermedad crítica. Esto determina que en muchos casos no sea detectada hasta etapas avanzadas, por ejemplo, frente a dificultad para la desvinculación de la asistencia ventilatoria mecánica. El objetivo de esta revisión es describir las principales herramientas con las que contamos actualmente para la evaluación muscular en la UCI, tanto periférica como respiratoria. Se mencionan técnicas con distinto grado de complejidad y especificidad, haciendo particular hincapié en aquellas con mayor aplicabilidad en la práctica clínica diaria, como la ecografía


Atrophy and weakness of the respiratory and peripheral muscles is a common problem in the intensive care unit (ICU). It is difficult to diagnose, particularly in the early stages of critical disease. Consequently, many cases are detected only in advanced stages, for example, when difficulties in mechanical ventilation weaning are encountered. The aim of this review is to describe the main tools that are currently available for evaluation of peripheral and respiratory muscles in the ICU. Techniques of varying complexity and specificity are discussed, and particular emphasis is placed on those with greater relevance in daily clinical practice, such as ultrasound


Assuntos
Músculos Respiratórios/fisiopatologia , Diafragma/patologia , Músculos/fisiopatologia , Cuidados Críticos/métodos , Diafragma/diagnóstico por imagem , Ultrassonografia/métodos , Debilidade Muscular/diagnóstico , Doenças Musculares/fisiopatologia , Pressões Respiratórias Máximas , Eletrofisiologia/métodos , Tomografia Computadorizada por Raios X/métodos , Biomarcadores
18.
Blood Purif ; 47 Suppl 3: 1-2, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30974439
19.
Blood Purif ; 47 Suppl 3: 1-6, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30982026

RESUMO

BACKGROUND: oXiris is a blood purification product that has been launched recently in China. In addition to renal function support and fluid management capabilities, it can also adsorb cytokines and endotoxins. This may complement standard treatment for septic acute kidney injury (AKI) patients to control the amplitude of systemic inflammatory response responsible for acute tissue and organ damage. Objectives of our study are to elucidate characteristics of septic AKI patients who respond to treatment with oXiris and to describe the performance of oXiris through patient cases in the absence of large randomized trials on clinical use of oXiris for septic AKI patients in China. SUMMARY: Here, we present 4 cases managed in intensive care units of major hospitals in China. Key practical aspects from an expert meeting discussing these cases have been included as guidance for the use of oXiris in septic AKI patients. Key Messages: Based on the experience gathered from 4 cases, oXiris should be used early in the treatment of septic AKI patients as an adjuvant therapy with good infection source control. It should not be used to delay or replace infection source control. These cases also demonstrated that patients with high risk of bleeding can use oXiris without additional anticoagulation for up to 36 h without implications on serum protein levels and platelet count. Short of definitive biomarkers to gauge the ideal blood purification initiation and discontinuation time for septic AKI patients, clinical judgment is key to determining optimal use of oXiris in septic AKI patients.


Assuntos
Lesão Renal Aguda/terapia , Hemofiltração/instrumentação , Sepse/terapia , Lesão Renal Aguda/sangue , Adulto , Idoso , Biomarcadores/sangue , Cuidados Críticos/métodos , Hemofiltração/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Sepse/sangue
20.
Transfusion ; 59(S2): 1529-1538, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30980755

RESUMO

Traumatic brain injury (TBI) is a common disorder with high morbidity and mortality, accounting for one in every three deaths due to injury. Older adults are especially vulnerable. They have the highest rates of TBI-related hospitalization and death. There are about 2.5 to 6.5 million US citizens living with TBI-related disabilities. The cost of care is very high. Aside from prevention, little can be done for the initial primary injury of neurotrauma. The tissue damage incurred directly from the inciting event, for example, a blow to the head or bullet penetration, is largely complete by the time medical care can be instituted. However, this event will give rise to secondary injury, which consists of a cascade of changes on a cellular and molecular level, including cellular swelling, loss of membrane gradients, influx of immune and inflammatory mediators, excitotoxic transmitter release, and changes in calcium dynamics. Clinicians can intercede with interventions to improve outcome in the mitigating secondary injury. The fundamental concepts in critical care management of moderate and severe TBI focus on alleviating intracranial pressure and avoiding hypotension and hypoxia. In addition to these important considerations, mechanical ventilation, appropriate transfusion of blood products, management of paroxysmal sympathetic hyperactivity, using nutrition as a therapy, and, of course, venous thromboembolism and seizure prevention are all essential in the management of moderate to severe TBI patients. These concepts will be reviewed using the recent 2016 Brain Trauma Foundation Guidelines to discuss best practices and identify future research priorities.


Assuntos
Transfusão de Componentes Sanguíneos , Lesões Encefálicas Traumáticas , Cuidados Críticos/métodos , Hospitalização , Adulto , Idoso , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/mortalidade , Lesões Encefálicas Traumáticas/fisiopatologia , Lesões Encefálicas Traumáticas/terapia , Feminino , Humanos , Hipotensão/etiologia , Hipotensão/mortalidade , Hipotensão/fisiopatologia , Hipotensão/prevenção & controle , Hipóxia Encefálica/etiologia , Hipóxia Encefálica/mortalidade , Hipóxia Encefálica/fisiopatologia , Hipóxia Encefálica/prevenção & controle , Hipertensão Intracraniana/etiologia , Hipertensão Intracraniana/mortalidade , Hipertensão Intracraniana/fisiopatologia , Hipertensão Intracraniana/prevenção & controle , Masculino , Pessoa de Meia-Idade , Convulsões/etiologia , Convulsões/mortalidade , Convulsões/fisiopatologia , Convulsões/prevenção & controle , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/mortalidade , Tromboembolia Venosa/fisiopatologia , Tromboembolia Venosa/prevenção & controle
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