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1.
Enferm. intensiva (Ed. impr.) ; 30(4): 181-191, oct.-dic. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-184482

RESUMO

Introducción: Las competencias que abordan en su entorno laboral las enfermeras de cuidados intensivos (UCI), han aumentado con la adquisición de nuevas responsabilidades asociadas a cuidados y dispositivos a realizar al paciente crítico. Múltiples estudios avalan la necesidad de la especialización de las enfermeras que trabajan en este tipo de unidades. Apoyado en estas evidencias, la European Federation of Critical Care Nurse, recomienda unificar la formación de las enfermeras de cuidados intensivos. Por tanto, nos planteamos el siguiente objetivo: valorar las necesidades formativas que detectan las enfermeras de UCI a través de sus vivencias y experiencias profesionales. Método: Estudio cualitativo descriptivo, con enfoque fenomenológico, a través de una entrevista semiestructurada donde se estudiaron los 4 ámbitos que la European Federation of Critical Care Nurse recoge (clínico, profesional, gestión y educativo). Se entrevistaron a 15 enfermeras de una UCI polivalente. Resultados: Los entrevistados reconocen que la formación previa era deficiente para los cuidados y medidas de soporte que tuvieron que afrontar. Consideran que la formación posterior y la experiencia fueron determinantes para poder desarrollar efectivamente su labor profesional. Además afirman que las medidas de soporte y los cuidados son temas a desarrollar continuamente mediante una formación dirigida. Conclusión: Las enfermeras reconocen que debe existir una formación destinada a cumplir las competencias que las UCI requieren, y que estas se ven afectadas por el tipo de unidad y el tipo de pacientes atendidos


Introduction: The competences of intensive care (ICU) nurses in their healthcare environment, have increased with the acquisition of new responsibilities associated with new care and devices for critical patients. Many studies suggest the need for specific training of nurses that work in these units. Based on this evidence, the European Federation of Critical Care Nurses Associations, recommends unifying the training of intensive care nurses. Therefore we set ourselves the following objective: to assess the training needs detected by ICU nurses through their experience and practical knowledge. Method: Descriptive qualitative study, with a phenomenological approach, through semi-structured interview where the four areas (clinical practice, professional, management and educational) covered by the European Federation of Critical Care Nurses Associations were studied. Fifteen nurses from an adult polyvalent ICU were interviewed. Results: The interviewees acknowledged that the previous training was deficient for the care and support measures that they had to face. They considered that subsequent training and experience were decisive in order to carry out their work effectively. They also stated that support measures and care are topics to be developed continuously through targeted training. Conclusion: The nurses in this research study acknowledged that training is needed to achieve the competences required in ICU, and these are affected by the type of unit and patients


Assuntos
Humanos , Masculino , Feminino , Enfermeiras e Enfermeiros/estatística & dados numéricos , Cuidados Críticos/tendências , Educação em Enfermagem/tendências , Unidades de Terapia Intensiva/estatística & dados numéricos , Análise Qualitativa , Competência Clínica , Entrevistas como Assunto/estatística & dados numéricos
2.
Pneumologie ; 73(11): 670-676, 2019 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-31715635

RESUMO

BACKGROUND: Home mechanical ventilation is dramatically evolving in Germany. Patients with non-invasive and invasive ventilation are increasingly treated at home. In-hospital treatment of these patients is also necessary either for control visits or the management of acute medical problems. However, the development of in-hospital patient care, morbidity and mortality of these patients is unknown. METHODS: All patients with long-term dependence on mechanical ventilation for more than three months requiring hospitalisation between 2006 and 2016 were analysed (data obtained from the Federal Statistical Office of Germany). RESULTS: There was an exponential increase in the number of in-patients with long-term dependence of mechanical ventilation. While 24 845 patients were treated in-hospital in 2006, 86 117 patients were treated in 2016. Correspondingly, mortality decreased from 13.2 % (2006) to 5.7 % (2016). In addition, in 2016 47 % of all patients were treated on the intensive care or high dependency care unit. Overall, patients had been severely ill, as there were plenty of medical and neurological co-morbidities. The most common diagnosis was COPD with 58 % of all cases, followed by several cardiology diagnosis. A high number of patients had an impairment of renal function (24 %), in part requiring dialysis. CONCLUSIONS: The rapid development of home mechanical ventilation substantially impacts on the development of the hospital landscape in Germany. The exponential increase of these care-intensive patients is challenging for the health care system and requires a discussion about its limits.


Assuntos
Cuidados Críticos , Serviços de Assistência Domiciliar , Assistência ao Paciente/tendências , Respiração Artificial , Cuidados Críticos/métodos , Cuidados Críticos/tendências , Alemanha , Serviços de Assistência Domiciliar/estatística & dados numéricos , Serviços de Assistência Domiciliar/tendências , Hospitalização , Humanos , Unidades de Terapia Intensiva , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos
3.
Pediatrics ; 144(4)2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31488695

RESUMO

This is an executive summary of the 2019 update of the 2004 guidelines and levels of care for PICU. Since previous guidelines, there has been a tremendous transformation of Pediatric Critical Care Medicine with advancements in pediatric cardiovascular medicine, transplant, neurology, trauma, and oncology as well as improvements of care in general PICUs. This has led to the evolution of resources and training in the provision of care through the PICU. Outcome and quality research related to admission, transfer, and discharge criteria as well as literature regarding PICU levels of care to include volume, staffing, and structure were reviewed and included in this statement as appropriate. Consequently, the purposes of this significant update are to address the transformation of the field and codify a revised set of guidelines that will enable hospitals, institutions, and individuals in developing the appropriate PICU for their community needs. The target audiences of the practice statement and guidance are broad and include critical care professionals; pediatricians; pediatric subspecialists; pediatric surgeons; pediatric surgical subspecialists; pediatric imaging physicians; and other members of the patient care team such as nurses, therapists, dieticians, pharmacists, social workers, care coordinators, and hospital administrators who make daily administrative and clinical decisions in all PICU levels of care.


Assuntos
Cuidados Críticos/normas , Unidades de Terapia Intensiva Pediátrica , Admissão do Paciente/normas , Alta do Paciente/normas , Pediatria/normas , Triagem/normas , Comitês Consultivos , Criança , Cuidados Críticos/tendências , Técnica Delfos , Humanos , Lactente , Pediatria/tendências
6.
Crit Care ; 23(1): 247, 2019 07 08.
Artigo em Inglês | MEDLINE | ID: mdl-31287020

RESUMO

BACKGROUND: Sepsis remains a complex medical problem and a major challenge in healthcare. Diagnostics and outcome predictions are focused on physiological parameters with less consideration given to patients' medical background. Given the aging population, not only are diseases becoming increasingly prevalent but occur more frequently in combinations ("multimorbidity"). We hypothesized the existence of patient subgroups in critical care with distinct multimorbidity states. We further hypothesize that certain multimorbidity states associate with higher rates of organ failure, sepsis, and mortality co-occurring with these clinical problems. METHODS: We analyzed 36,390 patients from the open source Medical Information Mart for Intensive Care III (MIMIC III) dataset. Morbidities were defined based on Elixhauser categories, a well-established scheme distinguishing 30 classes of chronic diseases. We used latent class analysis to identify distinct patient subgroups based on demographics, admission type, and morbidity compositions and compared the prevalence of organ dysfunction, sepsis, and inpatient mortality for each subgroup. RESULTS: We identified six clinically distinct multimorbidity subgroups labeled based on their dominant Elixhauser disease classes. The "cardiopulmonary" and "cardiac" subgroups consisted of older patients with a high prevalence of cardiopulmonary conditions and constituted 6.1% and 26.4% of study cohort respectively. The "young" subgroup included 23.5% of the cohort composed of young and healthy patients. The "hepatic/addiction" subgroup, constituting 9.8% of the cohort, consisted of middle-aged patients (mean age of 52.25, 95% CI 51.85-52.65) with the high rates of depression (20.1%), alcohol abuse (47.75%), drug abuse (18.2%), and liver failure (67%). The "complicated diabetics" and "uncomplicated diabetics" subgroups constituted 9.4% and 24.8% of the study cohort respectively. The complicated diabetics subgroup demonstrated higher rates of end-organ complications (88.3% prevalence of renal failure). Rates of organ dysfunction and sepsis ranged 19.6-69% and 12.5-46.7% respectively in the six subgroups. Mortality co-occurring with organ dysfunction and sepsis ranges was 8.4-23.8% and 11.7-27.4% respectively. These adverse outcomes were most prevalent in the hepatic/addiction subgroup. CONCLUSION: We identify distinct multimorbidity states that associate with relatively higher prevalence of organ dysfunction, sepsis, and co-occurring mortality. The findings promote the incorporation of multimorbidity in healthcare models and the shift away from the current single-disease paradigm in clinical practice, training, and trial design.


Assuntos
Multimorbidade/tendências , Sepse/complicações , Sepse/mortalidade , Adulto , Idoso , Estudos de Coortes , Cuidados Críticos/métodos , Cuidados Críticos/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos , Escores de Disfunção Orgânica
7.
Crit Care ; 23(Suppl 1): 125, 2019 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-31200737

RESUMO

In the absence of evidence, therapies are often based on intuition, belief, common sense or gut feeling. Over the years, some treatment strategies may become dogmas that are eventually considered as state-of-the-art and not questioned any longer. This might be a reason why there are many examples of "strange" treatments in medical history that have been applied in the absence of evidence and later abandoned for good reasons.In this article, five dogmas relevant to critical care medicine are discussed and reviewed in the light of the available evidence. Dogma #1 relates to the treatment of oliguria with fluids, diuretics, and vasopressors. In this context, it should be considered that oliguria is a symptom rather than a disease. Thus, once hypovolaemia can be excluded as the underlying reason, there is no justification for giving fluids, which may do more harm than good in euvolaemic or hypervolaemic patients. Similarly, there is no solid evidence for forcing diuresis by administering vasopressors and loop diuretics. Dogma #2 addresses the treatment of crush syndrome patients with aggressive fluid therapy using NaCl 0.9%. In fact, this treatment may aggravate renal injury by iatrogenic metabolic acidosis and subsequent renal hypoperfusion. Dogma #3 concerns the administration of NaCl 0.9% to patients undergoing kidney transplantation. Since these patients are usually characterised by hyperkalaemia, the potassium-free solution NaCl 0.9%, containing exclusively 154 mmol/l of sodium and chloride ions each, is often considered as the fluid of choice. However, large volumes of chloride-rich solutions cause hyperchloraemic acidosis in a dose-dependent manner and induce a potassium shift to the extracellular space, thereby increasing serum potassium levels. Thus, balanced electrolyte solutions are to be preferred in this setting. Dogma #4 relates to the fact that enteral nutrition is often withheld for patients with high residual gastric volume due to the theoretical risk of gastro-oesophageal reflux, potentially resulting in aspiration pneumonitis. Despite controversial discussions, there is no clinical data supporting that residual gastric volume should be generally measured, especially not in patients without a gastro-intestinal surgery and/or motility disorders. Clinical evidence rather suggests that abandoning residual gastric volume monitoring does not increase the incidence of pneumonia, but may benefit patients by facilitating adequate enteral feeding. Finally, dogma #5 is about sedating all mechanically ventilated patients because "fighting" against the respirator may cause insufficient ventilation. This concern needs to be balanced against the unwanted consequences of sedation, such as prolonged mechanical ventilation and intensive care unit length of stay as well as increased risk of delirium. Modern concepts based on adequate analgesia and moderate to no sedation appear to be more suitable.In conclusion, dogmas are still common in clinical practice. Since science rather than fiction should govern our actions in intensive care medicine, it is important to remain critical and challenge long established concepts, especially when the underlying evidence is weak or non-existing.


Assuntos
Cuidados Críticos/métodos , Medicina Baseada em Evidências/normas , Cuidados Críticos/tendências , Estado Terminal/terapia , Nutrição Enteral/métodos , Medicina Baseada em Evidências/tendências , Hidratação/métodos , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/tendências , Respiração Artificial/métodos , Respiração Artificial/tendências , Urina/fisiologia
8.
Crit Care ; 23(Suppl 1): 197, 2019 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-31200781

RESUMO

Progress toward determining the true worth of ongoing practices or value of recent innovations can be glacially slow when we insist on following the conventional stepwise scientific pathway. Moreover, a widely accepted but flawed conceptual paradigm often proves difficult to challenge, modify or reject. Yet, most experienced clinicians, educators and clinical scientists privately entertain untested ideas about how care could or should be improved, even if the supporting evidence base is currently thin or non-existent. This symposium encouraged experts to share such intriguing but unproven concepts, each based upon what the speaker considered a logical but unproven rationale. Such free interchange invited dialog that pointed toward new or neglected lines of research needed to improve care of the critically ill. In this summary of those presentations, a brief background outlines the rationale for each novel and deliberately provocative unconfirmed idea endorsed by the presenter.


Assuntos
Cuidados Críticos/tendências , Estado Terminal/terapia , Previsões , Humanos
9.
Cuad. Hosp. Clín ; 60(1): 18-36, jun. 2019. ilus.
Artigo em Espanhol | LILACS, LIBOCS | ID: biblio-1006608

RESUMO

OBJETIVO: el estudio pretende caracterizar la depuración de lactato (DL) en pacientes críticamente enfermos, a gran altitud. DISEÑO: estudio prospectivo de cohorte. ÁMBITO: unidad de Cuidados Intensivos de Adultos del Hospital del Norte de la ciudad de El Alto, La Paz (Bolivia), a 4 150 metros sobre el nivel del mar, periodo 25 de abril 2016-01 de junio 2018. PACIENTES: todos los pacientes ingresados a la Unidad de Cuidados Intensivos de Adultos, nativos de gran altitud, así como residentes de la misma por lo menos los últimos 6 meses. RESULTADOS: se incluyeron 250 pacientes, con sobrevida de 68%, promedio de edad 50 años; en el grupo de 170 supervivientes, poco más de la cuarta parte del lactato de ingreso fue depurado (26%), a comparación del grupo de 80 fallecidos, en el cual incluso el valor de lactato se vio incrementado alrededor de la quinta parte del lactato de ingreso (21%), ambos con p ≤ 0.05 mediante el test de ANOVA. En pacientes críticamente enfermos a gran altitud, el riesgo relativo entre depuración de lactato ≥ 26% y sobrevida es de 2.7 con sensibilidad 0.72 y especificidad de 1. DISCUSIÓN Y CONCLUSIONES: la depuración de lactato en individuos críticamente enfermos nativos de gran altitud, se asocia a mayor sobrevida y debería ser considerado como un objetivo durante la reanimación en pacientes críticos, de forma similar a estudios realizados en otras latitudes


OBJECTIVE: to characterize the lactate clearance on critically ill patients, at high altitude. DESIGN: prospective cohort study. FIELD: critical Care Unit of "Hospital del Norte" in El Alto, La Paz (Bolivia), during the period April 25, 2016 ­ June 01, 2018. PARTICIPANTS: critically ill patients residents of high altitude at least the last 6 months, admitted to the Adult Critical Care Unit. RESULTS: 250 patients were included, with survival of 68%, age average of 50 years; in the 170 survivors, lactate clearance average was 26%, in contrast with 80 deceased patients who presented an increased lactate level of 25%, p ≤ 0.05, both of them through ANOVA test. In high landers critically ill patients, relative risk of lactate clearance ≥ 26% and survival was 2.7 with sensitivity 0.72 and specificity 1. DISCUSSION AND CONCLUSIONS: lactate clearance in critically ill high landers dwellers, is associated with survival and it should be considered also as a reanimation objective, comparable to other studies developed in different latitudes


Assuntos
Humanos , Cuidados Críticos , Estado Terminal , Ácido Láctico/classificação , Cuidados Críticos/tendências
10.
Intensive Crit Care Nurs ; 53: 79-83, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31056235

RESUMO

OBJECTIVES: To assess the potential impact of introducing an already established and effective programme of rehabilitation within a critical care unit in a different organisation. DESIGN: Fifteen-month prospective before/after quality improvement project. SETTING: Seven-bed mixed dependency critical care unit. PARTICIPANTS: 209 patients admitted to critical care for ≥4 days. INTERVENTION: A multi-faceted quality improvement project focussed on changing structure and overcoming local barriers to increase levels of rehabilitation within critical care. MAIN OUTCOME MEASURE: Proportion of patients mobilised within critical care, time to first mobilise and highest level of mobility achieved within critical care. RESULTS: Compared to before the quality improvement project, significantly more patients mobilised within critical care (92% vs 73%, p = 0.003). This resulted in a significant reduction in time to 1st mobilisation (2 vs 3.5 days, P < 0.001), particularly for those patients ventilated ≥4 days (3 vs 14 days) and higher mobility scores at the point of critical care discharge (Manchester mobility score 5 vs 4, p = 0.019). CONCLUSION: The results from this quality improvement project demonstrate the positive impact of introducing a programme of early and structured rehabilitation to a critical care unit within a different organisation. This could provide a framework for introducing similar programmes to other critical care units nationally.


Assuntos
Reabilitação/métodos , APACHE , Idoso , Cuidados Críticos/métodos , Cuidados Críticos/tendências , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Inovação Organizacional , Desenvolvimento de Programas/métodos , Estudos Prospectivos , Melhoria de Qualidade , Reabilitação/tendências , Medicina Estatal/organização & administração , Medicina Estatal/estatística & dados numéricos , Estatísticas não Paramétricas
11.
Crit Care ; 23(1): 112, 2019 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-30961662

RESUMO

BACKGROUND AND OBJECTIVES: Excess fluid balance in acute kidney injury (AKI) may be harmful, and conversely, some patients may respond to fluid challenges. This study aimed to develop a prediction model that can be used to differentiate between volume-responsive (VR) and volume-unresponsive (VU) AKI. METHODS: AKI patients with urine output < 0.5 ml/kg/h for the first 6 h after ICU admission and fluid intake > 5 l in the following 6 h in the US-based critical care database (Medical Information Mart for Intensive Care (MIMIC-III)) were considered. Patients who received diuretics and renal replacement on day 1 were excluded. Two predictive models, using either machine learning extreme gradient boosting (XGBoost) or logistic regression, were developed to predict urine output > 0.65 ml/kg/h during 18 h succeeding the initial 6 h for assessing oliguria. Established models were assessed by using out-of-sample validation. The whole sample was split into training and testing samples by the ratio of 3:1. MAIN RESULTS: Of the 6682 patients included in the analysis, 2456 (36.8%) patients were volume responsive with an increase in urine output after receiving > 5 l fluid. Urinary creatinine, blood urea nitrogen (BUN), age, and albumin were the important predictors of VR. The machine learning XGBoost model outperformed the traditional logistic regression model in differentiating between the VR and VU groups (AU-ROC, 0.860; 95% CI, 0.842 to 0.878 vs. 0.728; 95% CI 0.703 to 0.753, respectively). CONCLUSIONS: The XGBoost model was able to differentiate between patients who would and would not respond to fluid intake in urine output better than a traditional logistic regression model. This result suggests that machine learning techniques have the potential to improve the development and validation of predictive modeling in critical care research.


Assuntos
Lesão Renal Aguda/complicações , Hidratação/instrumentação , Aprendizado de Máquina/normas , Oligúria/etiologia , Lesão Renal Aguda/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/métodos , Cuidados Críticos/tendências , Feminino , Hidratação/métodos , Hidratação/normas , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Modelos Logísticos , Aprendizado de Máquina/tendências , Masculino , Pessoa de Meia-Idade , Oligúria/fisiopatologia , Fatores de Tempo
12.
World J Emerg Surg ; 14: 16, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30976293

RESUMO

The aim of this article is to describe briefly about Chinese ACS surgeons' work status. It is an undeniable fact that the analysis of ED and ACS resources shows negative tendencies and high work overload, resulting in low patient safety and quality of care. And, there was a substantial shortage of surgeons in the subspecialty. So, a set of strategic measures and state policies should be prioritized.


Assuntos
Cuidados Críticos/métodos , Cirurgiões/tendências , China , Cuidados Críticos/tendências , Humanos , Satisfação no Emprego
15.
Crit Care ; 23(1): 80, 2019 Mar 09.
Artigo em Inglês | MEDLINE | ID: mdl-30850013

RESUMO

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2019. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2019 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .


Assuntos
Sepse/classificação , Sepse/fisiopatologia , Cuidados Críticos/tendências , Humanos , Unidades de Terapia Intensiva/organização & administração
16.
Curr Opin Anaesthesiol ; 32(2): 163-168, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30817389

RESUMO

PURPOSE OF REVIEW: Sepsis-3 guidelines have implications in a deeper understanding of the biopathology of the disease. Further, the review focuses on timely topics and new literature on fluid resuscitation, the value of steroids in sepsis, and new therapeutic options such as angiotensin II, vitamin C, and thiamine as well as the emerging role of procalcitonin (PCT) in managing antibiotics. RECENT FINDINGS: Traditional therapies such as type of crystalloid fluid administration and steroid therapy for sepsis are currently under re-evaluation. Angiotensin II is investigated for reversing vasodilatory shock. The role of capillary endothelium leak and cellular metabolism can be affected by vitamin C and thiamine levels. Biomarker level trends, specifically PCT, can aid clinical suspicion of infection. SUMMARY: Sepsis-3 shifts the focus from a noninfectious inflammatory process and an emphasis on a dysregulated host response to infection. Hyperchloremic crystalloid resuscitation is associated with poor clinical outcomes. Steroid administration can reverse shock physiology; however, mortality benefits remain uncertain. Angiotensin II, vitamin C, and thiamine are novel treatment options that need further validation. PCT assays can help discern between infectious and noninfectious inflammation.


Assuntos
Cuidados Críticos/normas , Hidratação/normas , Ressuscitação/normas , Sepse/terapia , Angiotensina II/uso terapêutico , Antibacterianos/uso terapêutico , Ácido Ascórbico/uso terapêutico , Biomarcadores/sangue , Terapia Combinada/métodos , Terapia Combinada/normas , Terapia Combinada/tendências , Cuidados Críticos/métodos , Cuidados Críticos/tendências , Hidratação/métodos , Hidratação/tendências , Glucocorticoides/uso terapêutico , Humanos , Guias de Prática Clínica como Assunto , Pró-Calcitonina/sangue , Ressuscitação/métodos , Ressuscitação/tendências , Sepse/diagnóstico , Sepse/mortalidade , Tiamina/uso terapêutico , Resultado do Tratamento
18.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 31(1): 16-22, 2019 Jan.
Artigo em Chinês | MEDLINE | ID: mdl-30707863

RESUMO

OBJECTIVE: In 2018, a bunch of considerable positive progresses have been presented, including a revised "hour-1 bundle" introduced by international guideline for management of sepsis and septic shock, trans-pulmonary pressure monitoring via esophageal manometry in acute respiratory distress syndrome (ARDS) models, successful trials for new antibiotics, angiotensin II in patients with vasodilatory shock and renal replacement therapy, advanced airway management in out-of-hospital cardiac arrest (OHCA) patients as well cellular immunotherapy for septic shock. But some of investigational trials did not yield expected results. For example, extracorporeal membrane oxygenation (ECMO) therapy for ARDS patients, the strategy of sequencing weaning with early extubation to noninvasive ventilation, prevention of delirium with haloperidol, surrogate decision supported by interprofessional intensive care unit (ICU) team and prophylaxis for gastrointestinal stress ulceration with pantoprazole in ICU. And more importantly, it has been obvious that the voices and evidences gathered by the opponents against guidelines development, compulsory polices of implementing bundled strategy, market position of hydroxyethyl-starch solutions (HES) and the usage of steroid in septic shock have been largely strengthen, highlighting a more divided and controversial situation.


Assuntos
Cuidados Críticos/tendências , Previsões , Humanos
19.
Intensive Care Med ; 45(2): 190-200, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30706120

RESUMO

PURPOSE: Clinical examination is often the first step to diagnose shock and estimate cardiac index. In the Simple Intensive Care Studies-I, we assessed the association and diagnostic performance of clinical signs for estimation of cardiac index in critically ill patients. METHODS: In this prospective, single-centre cohort study, we included all acutely ill patients admitted to the ICU and expected to stay > 24 h. We conducted a protocolised clinical examination of 19 clinical signs followed by critical care ultrasonography for cardiac index measurement. Clinical signs were associated with cardiac index and a low cardiac index (< 2.2 L min-1 m2) in multivariable analyses. Diagnostic test accuracies were also assessed. RESULTS: We included 1075 patients, of whom 783 (73%) had a validated cardiac index measurement. In multivariable regression, respiratory rate, heart rate and rhythm, systolic and diastolic blood pressure, central-to-peripheral temperature difference, and capillary refill time were statistically independently associated with cardiac index, with an overall R2 of 0.30 (98.5% CI 0.25-0.35). A low cardiac index was observed in 280 (36%) patients. Sensitivities and positive and negative predictive values were below 90% for all signs. Specificities above 90% were observed only for 110/280 patients, who had atrial fibrillation, systolic blood pressures < 90 mmHg, altered consciousness, capillary refill times > 4.5 s, or skin mottling over the knee. CONCLUSIONS: Seven out of 19 clinical examination findings were independently associated with cardiac index. For estimation of cardiac index, clinical examination was found to be insufficient in multivariable analyses and in diagnostic accuracy tests. Additional measurements such as critical care ultrasonography remain necessary.


Assuntos
Débito Cardíaco , Estado Terminal/classificação , Idoso , Estudos de Coortes , Cuidados Críticos/métodos , Cuidados Críticos/tendências , Feminino , Hemodinâmica/fisiologia , Humanos , Unidades de Terapia Intensiva/organização & administração , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sensibilidade e Especificidade
20.
Clin Respir J ; 13(4): 232-238, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30724022

RESUMO

BACKGROUND: The shortage in intensivist workforce has been long recognized but no solution has been identified. Meanwhile, fellowships in pulmonary and critical care medicine (PCCM) are expanding, other critical care medicine (CCM) programs are contracting. No explanation exists for this contradictory trend, although understanding contributory factors may lead to a solution for the shortage. The fundamental difference between PCCM and other CCM programs lies in the residency training of trainees. We tested the hypothesis that the nature of CCM practice determines its attractiveness to potential candidates. METHODS: A questionnaire-based survey was administered recording all daily activities in four different kinds of ICUs at two teaching hospitals one was public, and one was private. Activities were categorized into conventional CCM, respiratory, medical, and surgical interventions. RESULTS: The average daily census was 17.6 ± 6.6. Across two MICU, one trauma/surgical and one cardiothoracic ICU the average daily activity ranged from 152 to 203 of these CCM formed 27%-36%, respiratory 10%-13%, medical 43%-59%, and surgical 1%-15%. The combination of medical and respiratory interventions represented >50% of daily activities among all the ICUs. CONCLUSIONS: Quantitative description of ICU activities indicates that the majority of the ICU daily practice relies on medical and respiratory interventions, which may explain why PCCM remains popular.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Mão de Obra em Saúde/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Médicos/provisão & distribução , Adulto , Cuidados Críticos/tendências , Educação de Pós-Graduação em Medicina/normas , Bolsas de Estudo/normas , Feminino , Mão de Obra em Saúde/tendências , Humanos , Internato e Residência/normas , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários
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