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1.
N Engl J Med ; 382(12): 1103-1111, 2020 03 19.
Artigo em Inglês | MEDLINE | ID: mdl-32068366

RESUMO

BACKGROUND: In critically ill, mechanically ventilated patients, daily interruption of sedation has been shown to reduce the time on ventilation and the length of stay in the intensive care unit (ICU). Data on whether a plan of no sedation, as compared with a plan of light sedation, has an effect on mortality are lacking. METHODS: In a multicenter, randomized, controlled trial, we assigned, in a 1:1 ratio, mechanically ventilated ICU patients to a plan of no sedation (nonsedation group) or to a plan of light sedation (i.e., to a level at which the patient was arousable, defined as a score of -2 to -3 on the Richmond Agitation and Sedation Scale [RASS], on which scores range from -5 [unresponsive] to +4 [combative]) (sedation group) with daily interruption. The primary outcome was mortality at 90 days. Secondary outcomes were the number of major thromboembolic events, the number of days free from coma or delirium, acute kidney injury according to severity, the number of ICU-free days, and the number of ventilator-free days. Between-group differences were calculated as the value in the nonsedation group minus the value in the sedation group. RESULTS: A total of 710 patients underwent randomization, and 700 were included in the modified intention-to-treat analysis. The characteristics of the patients at baseline were similar in the two trial groups, except for the score on the Acute Physiology and Chronic Health Evaluation (APACHE) II, which was 1 point higher in the nonsedation group than in the sedation group, indicating a greater chance of in-hospital death. The mean RASS score in the nonsedation group increased from -1.3 on day 1 to -0.8 on day 7 and, in the sedation group, from -2.3 on day 1 to -1.8 on day 7. Mortality at 90 days was 42.4% in the nonsedation group and 37.0% in the sedated group (difference, 5.4 percentage points; 95% confidence interval [CI], -2.2 to 12.2; P = 0.65). The number of ICU-free days and of ventilator-free days did not differ significantly between the trial groups. The patients in the nonsedation group had a median of 27 days free from coma or delirium, and those in the sedation group had a median of 26 days free from coma or delirium. A major thromboembolic event occurred in 1 patient (0.3%) in the nonsedation group and in 10 patients (2.8%) in the sedation group (difference, -2.5 percentage points; 95% CI, -4.8 to -0.7 [unadjusted for multiple comparisons]). CONCLUSIONS: Among mechanically ventilated ICU patients, mortality at 90 days did not differ significantly between those assigned to a plan of no sedation and those assigned to a plan of light sedation with daily interruption. (Funded by the Danish Medical Research Council and others; NONSEDA ClinicalTrials.gov number, NCT01967680.).


Assuntos
Sedação Consciente , Estado Terminal/terapia , Hipnóticos e Sedativos/administração & dosagem , Respiração Artificial , Idoso , Idoso de 80 Anos ou mais , Coma/complicações , Sedação Consciente/métodos , Estado Terminal/mortalidade , Delírio/complicações , Feminino , Humanos , Infusões Intravenosas , Unidades de Terapia Intensiva , Análise de Intenção de Tratamento , Estimativa de Kaplan-Meier , Tempo de Internação , Masculino , Midazolam/administração & dosagem , Pessoa de Meia-Idade , Propofol/administração & dosagem , Respiração Artificial/efeitos adversos , Tromboembolia/etiologia
2.
PLoS One ; 15(1): e0227471, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31978127

RESUMO

BACKGROUND: Delirium is a common and serious acute neuropsychiatric syndrome which is often missed in routine clinical care. Inattention is the core cognitive feature. Diagnostic test accuracy (including cut-points) of a smartphone Delirium App (DelApp) for assessing attention deficits was assessed in older hospital inpatients. METHODS: This was a case-control study of hospitalised patients aged ≥65 years with delirium (with or without pre-existing cognitive impairment), who were compared to patients with dementia without delirium, and patients without cognitive impairment. Reference standard delirium assessment, which included a neuropsychological test battery, was based on Diagnostic and Statistical Manual of Mental Disorders-5 criteria. A separate blinded assessor administered the DelApp arousal assessment (score 0-4) and attention task (0-6) yielding an overall score of 0 to 10 (lower scores indicate poorer performance). Analyses included receiver operating characteristic curves and sensitivity and specificity. Optimal cut-points for delirium detection were determined using Youden's index. RESULTS: A total of 187 patients were recruited, mean age 83.8 (range 67-98) years, 152 (81%) women; n = 61 with delirium; n = 61 with dementia without delirium; and n = 65 without cognitive impairment. Patients with delirium performed poorly on the DelApp (median score = 4/10; inter-quartile range 3.0, 5.5) compared to patients with dementia (9.0; 5.5, 10.0) and those without cognitive impairment (10.0; 10.0, 10.0). Area under the curve for detecting delirium was 0.89 (95% Confidence Interval 0.84, 0.94). At an optimal cut-point of ≤8, sensitivity was 91.7% (84.7%, 98.7%) and specificity 74.2% (66.5%, 81.9%) for discriminating delirium from the other groups. Specificity was 68.3% (56.6%, 80.1%) for discriminating delirium from dementia (cut-point ≤6). CONCLUSION: Patients with delirium (with or without pre-existing cognitive impairment) perform poorly on the DelApp compared to patients with dementia and those without cognitive impairment. A cut-point of ≤8/10 is suggested as having optimal sensitivity and specificity. The DelApp is a promising tool for assessment of attention deficits associated with delirium in older hospitalised adults, many of whom have prior cognitive impairment, and should be further validated in representative patient cohorts.


Assuntos
Delírio/diagnóstico , Aplicativos Móveis , Testes Neuropsicológicos , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Estudos de Casos e Controles , Disfunção Cognitiva/complicações , Disfunção Cognitiva/patologia , Delírio/complicações , Demência/complicações , Demência/patologia , Feminino , Hospitalização , Humanos , Masculino , Curva ROC , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Smartphone
3.
Nursing ; 50(1): 32-37, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31855984

RESUMO

Hospital-acquired delirium often goes unnoticed because the signs and symptoms resemble those of dementia and depression, making diagnosis difficult. This article explores the differences between delirium, dementia, and depression and discusses the role of nursing in patient assessment and education.


Assuntos
Delírio/enfermagem , Doença Iatrogênica/prevenção & controle , Delírio/complicações , Delírio/etiologia , Diagnóstico Diferencial , Humanos , Diagnóstico de Enfermagem , Educação de Pacientes como Assunto , Gestão de Riscos/métodos
4.
PLoS One ; 14(12): e0226412, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31856187

RESUMO

BACKGROUND: Delirium's pathophysiology is poorly understood. We sought to determine if plasma biomarkers of inflammation, coagulation, endothelial activation, and blood brain barrier (BBB) injury were associated with emergency department (ED) delirium duration. METHODS: We enrolled hospitalized patients who were 65 years or older from the ED. Plasma biomarkers of inflammation (interleukin-6 [IL-6], IL-8, soluble tumor necrosis factor receptor I [sTNFRI]), coagulation (Protein C), endothelial activation (plasminogen activating inhibitor-1 [PAI-1]), and BBB injury (S100B) at were measured using blood obtained at enrollment. The dependent variable was ED delirium duration which was determined by the Brief Confusion Assessment Method assessed in the ED and hospitalization. Proportional odds logistic regression analyses were performed adjusted for relevant confounders and allowing for interaction by baseline dementia status. RESULTS: A total of 156 patients were enrolled. IL-6 (POR = 1.59, 95%CI: 1.09-2.32) and PAI-1 (POR = 2.96, 95%CI: 1.48 to 6.85) were independently associated with more prominent ED delirium duration in subjects without dementia only. No significant associations between IL-8, Protein C, sTNRFI, and S100B and ED delirium duration were observed. CONCLUSIONS: Plasma Biomarkers of systemic inflammation and endothelial activation are associated with ED delirium duration in older ED patients without dementia.


Assuntos
Coagulação Sanguínea , Lesões Encefálicas/complicações , Delírio/sangue , Delírio/diagnóstico , Hospitalização , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Barreira Hematoencefálica/lesões , Estudos de Coortes , Delírio/complicações , Delírio/fisiopatologia , Feminino , Humanos , Inflamação/complicações , Masculino , Prognóstico , Fatores de Tempo
5.
Medicina (Kaunas) ; 55(10)2019 Sep 20.
Artigo em Inglês | MEDLINE | ID: mdl-31547219

RESUMO

BACKGROUND AND OBJECTIVES: Delirium is an acute state that causes confusion and occurs frequently after surgery in elderly patients. Delirium is also related to various clinical complications. With increasing numbers of surgeries performed on elderly Koreans, the number of cases of delirium and associated complications will likely rise. The purpose of the present study was to determine whether postoperative delirium in elderly Korean patients negatively influenced other clinical outcomes and their long-term mortality. MATERIALS AND METHODS: The medical records of 1016 elderly patients (65 years or older) who underwent major abdominal surgery from January 2014 to December 2016 were retrospectively investigated. To determine long-term mortality, patients were followed for up to 12 months post-operation. RESULTS: Delirium occurred in 194 patients (18.3%). Postoperative delirium was significantly associated with the length of hospital stay (B = 2.72), length of ICU stay (B = 18.78), adverse medical events (OR = 2.26, CI = 1.45-3.52), reoperation (OR = 5.50, CI = 1.66-18.22), ICU readmission (OR = 14.10, CI = 2.97-66.90), medical costs (B = 2473.85), discharge to somewhere other than the patient's home (OR = 6.01, CI = 3.35-10.76), hospital readmission (OR = 2.73, CI = 1.45-5.14), in-hospital mortality (OR = 3.34, CI = 1.21-9.19), three-month mortality (HR = 3.22, CI = 1.27-8.14), six-month mortality (HR = 2.85, CI = 1.28-6.36), and 12-month mortality (HR = 2.19, CI = 1.10-4.32). CONCLUSIONS: Postoperative delirium in elderly Korean patients was associated with negative clinical outcomes and mortality. For rapid recovery and increased survival rates in surgical patients, effective delirium-prevention care and active delirium treatments are necessary.


Assuntos
Delírio/complicações , Delírio/mortalidade , Complicações Pós-Operatórias/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Vacina Pneumocócica Conjugada Heptavalente , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação , Masculino , Análise Multivariada , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , República da Coreia , Estudos Retrospectivos
6.
Emerg Med Clin North Am ; 37(3): 557-568, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31262421

RESUMO

A subset of intubated patients can safely be extubated in the emergency department (ED). The emergency medicine provider should be prepared for both common and life-threatening complications if considering ED extubation. Patients selected for extubation in the ED should have a low or near zero risk of reintubation or extubation failure. Intensive nursing care, close monitoring, and the ability to reintubate are minimum requirements for EDs considering ED extubation. This article provides a framework for determining appropriate patients for extubation and a practical approach on how to safely perform the procedure.


Assuntos
Extubação/métodos , Serviço Hospitalar de Emergência , Pressão Sanguínea , Delírio/complicações , Frequência Cardíaca , Hemodinâmica , Humanos , Hipóxia/etiologia , Hipóxia/prevenção & controle , Exame Neurológico , Oxigênio/sangue , Cuidados Paliativos , Seleção de Pacientes , Agitação Psicomotora/complicações , Taxa Respiratória , Sons Respiratórios , Medição de Risco , Desmame do Respirador
7.
BMC Emerg Med ; 19(1): 34, 2019 06 13.
Artigo em Inglês | MEDLINE | ID: mdl-31195982

RESUMO

BACKGROUND: Rib fractures are common in ageing people after trauma and delirium is a complication often seen in acutely hospitalized elderly patients. For both conditions, elderly have an increased risk for institutionalization, morbidity, and mortality. This study is the first to investigate risk factors of delirium in elderly patients with rib fractures after trauma. METHODS: A retrospective chart review was performed on patients ≥65 years admitted with rib fractures after blunt chest wall trauma to the Amphia hospital Breda, the Netherlands, between July 2013 and June 2018. Baseline patient, trauma- and treatment-related characteristics were identified. The main objectives were identification of risk factors of delirium and investigation of the effect of delirium on outcomes after rib fractures. Outcomes were additional complications, length of hospital stay, need for institutionalization and mortality within six months. RESULTS: Forty-seven (24.6%) of 191 patients developed a delirium. Independent risk factors for delirium were increased age, physical impairment (lower KATZ-ADL score), nutritional impairment (higher SNAQ score) and the need for a urinary catheter, with odds ratios of 1.07, 0.78, 1.53 and 8.53 respectively. Overall, more complications were observed in patients with delirium. Median ICU and hospital length of stay were 4 and 7 days respectively, of which the latter was significantly longer for delirious patients (p < 0.001). Significantly more patients with delirium were discharged to a nursing home or rehabilitation institution (p < 0.001). The 6-month mortality in delirious patients was nearly twice as high as in non-delirious patients; however, differences did not reach statistical significance. CONCLUSION: Delirium in elderly patients with rib fractures is a serious and common complication, with a longer hospital stay and a higher risk of institutionalization as a consequence. Increased awareness for delirium is imperative, most importantly in older patients, in physically or nutritionally impaired patients and in patients in need of a urinary catheter.


Assuntos
Delírio/complicações , Delírio/epidemiologia , Fraturas das Costelas/complicações , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Delírio/reabilitação , Feminino , Humanos , Tempo de Internação , Masculino , Países Baixos/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Traumatismos Torácicos/complicações , Parede Torácica/lesões , Resultado do Tratamento
8.
J Forensic Leg Med ; 66: 100-106, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31252195

RESUMO

BACKGROUND: Law enforcement personnel often confront violent and dangerous individuals suffering from Excited Delirium Syndrome (ExDS) who need emergent medical evaluation and treatment to optimize the best outcomes for this potentially lethal medical emergency. These subjects typically require physical restraint and use of force measures to control them. We sought to determine if stress-related biomarkers can differentiate ExDS subjects when compared with agitation and stress under other circumstances, including agitation and extreme physical exhaustion and restraint coupled with emotional stressors. METHODS: This was a prospective multi-center study enrolling a convenience sample of patients who presented with agitation or ExDS. Patients were enrolled from three academic emergency departments (ED), two in the United States and one in Canada. Three study groups (SG) included: SG1) patients brought to the ED with ExDS based on the use of standardized clinical criteria; SG2) ED patients with acute agitation who were not in a clinical state of ExDS but required sedation; SG3) a laboratory control group of subjects exercised to physical exhaustion, restrained, and psychologically stressed with threat of Conducted Energy Device (CED) activation. We examined a panel of stress-related biomarkers, including norepinephrine (NE), cortisol, copeptin, orexin A, and dynorphin (Dyn) from the blood of enrolled subjects. RESULTS: A total of 82 subjects were enrolled: 31 in the agitation group, 21 in the ExDS group, and 30 in the laboratory control group. Data were analyzed, comparing the findings between ExDS and the two other groups to determine if specific stress-related biomarkers are associated with ExDS. Biomarker comparisons between subjects identified with ExDS, agitation, and control groups demonstrated that cortisol levels were more elevated in the ExDS group compared with the other groups. Orexin was only significant in ExDs (with Agitated tendency but lot of variability in the group). NE and Dyn increased as response to stress in Agitated and ExDS. CONCLUSIONS: Cortisol levels were more elevated in subjects in the ExDS group compared with the other comparison groups and orexin was elevated in ExDS compared to controls, a trend that did not reach statistical significance in the agitated group. The clinical or diagnostic significance of these difference have yet to be defined and warrants further study.


Assuntos
Morte Súbita , Delírio/complicações , Prisioneiros , Agitação Psicomotora , Estresse Fisiológico , Adulto , Biomarcadores/sangue , Estudos de Casos e Controles , Dinorfinas/sangue , Serviço Hospitalar de Emergência , Glicopeptídeos/sangue , Humanos , Hidrocortisona/sangue , Norepinefrina/sangue , Orexinas/sangue , Polícia , Estudos Prospectivos , Restrição Física/efeitos adversos , Amostragem
10.
Maturitas ; 125: 63-69, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31133220

RESUMO

INTRODUCTION: This review examines whether functional and cognitive decline and mortality after an episode of delirium are comparable between patients with and those without dementia. METHODS: MEDLINE and EMBASE were searched systematically for 'dementia' and 'delirium'. After screening of the results, studies were rated on relevance and validity and data were extracted. Cognitive decline was defined as decline in Mini-Mental State Examination (MMSE) score. Functional decline was defined as decline in Barthel Index (BI), score on the Instrumental Activities of Daily Living (IADL) or institutionalisation. RESULTS: From 5092 potentially relevant articles identified, eight studies were included in the review. The one-year mortality rate ranged from 11% to 45% in patients with dementia versus 22% to 44% in patients without dementia, and the overall absolute rate was 34% (95% CI 0.32-0.36). Pooled data did not show a significant difference between the groups. The MMSE scores and the Barthel Index had improved in both groups after six months, but scores on the Instrumental Activities of Daily Living (IADL) had declined. However, on all measurement points, patients with dementia scored significantly lower than patients without dementia. In addition, patients with dementia had a 33% risk of institutionalisation after an episode of delirium versus 20% in patients without dementia (95% CI 0.06-0.20). CONCLUSION: No significant differences were seen in mortality after delirium between patients with and without dementia. The overall one-year mortality was high (34%). Patients with dementia had significantly lower functional and cognitive scores and their risk of institutionalisation post-delirium was higher. Patients and their caregivers should be given this information, which may also be useful in advance care planning.


Assuntos
Atividades Cotidianas , Delírio/complicações , Demência/complicações , Prognóstico , Idoso , Idoso de 80 Anos ou mais , Cognição , Disfunção Cognitiva/complicações , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/mortalidade , Delírio/diagnóstico , Delírio/mortalidade , Demência/diagnóstico , Feminino , Humanos , Institucionalização , Masculino , Morbidade , Mortalidade , Estudos Prospectivos , Estudos Retrospectivos
11.
Intensive Crit Care Nurs ; 53: 84-91, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31079979

RESUMO

OBJECTIVES: In intensive care units, there is a high incidence of delirium, which relates to the risk of complications. Engagement of relatives is an acknowledged part of handling delirium, but knowledge of relatives' perspectives is lacking. AIM: To explore relatives' experiences of delirium in the critically ill patient admitted to an intensive care unit. RESEARCH DESIGN: A qualitative design with a phenomenological approach. Semi-structured interviews with eleven relatives of critically ill patients who had delirium during admission to the intensive care unit. SETTING: An intensive care unit in Denmark. FINDINGS: Three categories emerged: 'Delirium is not the main concern', 'Communication with health-care professionals is crucial', and 'Delirium impacts on relatives'. Relatives had a lack of knowledge of delirium. Symptoms of delirium were thought of as a natural consequence of critical illness and seemed to be a secondary problem. Health-care professionals did not talk about delirium and information was requested. Delirium and the manifestation of it was experienced in different ways and brought different ways of coping. CONCLUSION: Findings give a new insight into relatives' experience of delirium in the intensive care unit. Relatives need more information to better understand delirium. Future research must investigate the potential in helping relatives to cope with delirium, to the benefit of both patient and relatives.


Assuntos
Delírio/enfermagem , Família/psicologia , Pessoal de Saúde/normas , Adaptação Psicológica , Idoso , Delírio/complicações , Dinamarca , Feminino , Pessoal de Saúde/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/organização & administração , Entrevistas como Assunto/métodos , Masculino , Pessoa de Meia-Idade , Relações Profissional-Paciente , Pesquisa Qualitativa , Inquéritos e Questionários
12.
Crit Care Resusc ; 21(2): 110-118, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31142241

RESUMO

OBJECTIVES: Persistent critical illness (PerCI) is associated with high mortality and discharge to institutional care. Little is known about factors involved in its progression, complications and cause of death. We aimed to identify such factors and the time when the original illness was no longer the reason for intensive care unit (ICU) stay. DESIGN: Retrospective matched case-control study using an accepted PerCI definition (> 10 days in ICU). SETTING: Single-centre tertiary metropolitan ICU. PARTICIPANTS: All adult patients admitted during a 2-year period were eligible, matched on diagnostic code, gender, age and risk of death. MAIN RESULTS: Seventy-two patients staying > 10 days (PerCI cases) were matched to 72 control patients. The original illness was no longer a cause for continued ICU stay after a median of 10 days (interquartile range [IQR], 7-16) versus 2 days (IQR, 0-3); P < 0.001. Patients with PerCI were more likely to develop new sepsis (52.8% v 23.6%; P < 0.001), delirium (37.5% v 9.7%; P < 0.001), ICU-acquired weakness (15.3% v 0%, P = 0.001), and to be discharged to chronic care or rehabilitation (37.5% v 16.7%; P < 0.005). Death resulting from sepsis with multi-organ failure occurred in 16.7% v 8.3% of control patients (P = 0.13), and one-third of patients with PerCI were not mechanically ventilated on Day 10. CONCLUSION: PerCI likely results from complications acquired after ICU admission and mostly unrelated to the original illness; by Day 10, the original illness does not appear to be its cause, and new sepsis appears an important association.


Assuntos
Cuidados Críticos , Estado Terminal/mortalidade , Sepse/complicações , Adulto , Estudos de Casos e Controles , Causas de Morte , Estado Terminal/terapia , Infecção Hospitalar/mortalidade , Delírio/complicações , Delírio/mortalidade , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Doenças Neuromusculares/complicações , Doenças Neuromusculares/mortalidade , Estudos Retrospectivos , Sepse/mortalidade
13.
Clin Geriatr Med ; 35(2): 221-236, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30929884

RESUMO

Falls frequently occur in persons with cognitive impairment, including delirium. This article presents a systematic review of the association between falls and delirium in adults aged 65 years or older. For the studies that compared falls and delirium, the risk ratio was consistently elevated (median RR 4.5, range 1.4-12.6) and statistically significant in all but one study. These results suggest that falls and delirium are inextricably linked. There is a need to further refine fall risk assessment tools and protocols to specifically include delirium for consideration as a risk factor that needs additional assessment and management.


Assuntos
Acidentes por Quedas/prevenção & controle , Delírio/complicações , Delírio/prevenção & controle , Hospitalização , Idoso , Idoso de 80 Anos ou mais , Avaliação Geriátrica , Humanos , Medição de Risco , Fatores de Risco
14.
Anesth Analg ; 128(4): 781-788, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30883423

RESUMO

Neuroinflammation has become a key hallmark of neurological complications including perioperative pathologies such as postoperative delirium and longer-lasting postoperative cognitive dysfunction. Dysregulated inflammation and neuronal injury are emerging from clinical studies as key features of perioperative neurocognitive disorders. These findings are paralleled by a growing body of preclinical investigations aimed at better understanding how surgery and anesthesia affect the central nervous system and possibly contribute to cognitive decline. Herein, we review the role of postoperative neuroinflammation and underlying mechanisms in immune-to-brain signaling after peripheral surgery.


Assuntos
Transtornos Cognitivos/complicações , Disfunção Cognitiva/complicações , Delírio/complicações , Inflamação/complicações , Transtornos Neurocognitivos/complicações , Anestesia/efeitos adversos , Anestesiologia , Animais , Biomarcadores , Barreira Hematoencefálica , Encéfalo/fisiopatologia , Humanos , Doenças do Sistema Nervoso , Neuroimagem , Período Perioperatório , Complicações Pós-Operatórias/etiologia , Período Pós-Operatório , Transdução de Sinais
15.
BMJ Case Rep ; 12(3)2019 Mar 07.
Artigo em Inglês | MEDLINE | ID: mdl-30850570

RESUMO

A 26-year-old cachectic man presented with an altered mental status. He was agitated, tremulous, hyperthermic and diaphoretic with largely dilated pupils. Collateral history revealed acute ingestion of 3,4-methylenedioxymethamphetamine on a background of chronic drug abuse. His condition deteriorated requiring sedation and intubation with transfer to the intensive care unit. A diagnosis of serotonin syndrome was made, based on his findings in keeping with the Hunter criteria, and he was treated with supportive management during a resultant and briefly sustained delirium. With gradual resolution of his agitated state, further questioning and blood work a concurrent, and potentially contributory, thyrotoxicosis was revealed. The patient was commenced on treatment for this with urgent outpatient follow-up with both a local otolaryngologist and endocrinologist for consideration of further treatment.


Assuntos
3,4-Metilenodioxianfetamina/análogos & derivados , Síndrome da Serotonina/diagnóstico , Tireotoxicose/diagnóstico , Tremor/diagnóstico , 3,4-Metilenodioxianfetamina/efeitos adversos , 3,4-Metilenodioxianfetamina/toxicidade , Adulto , Assistência ao Convalescente , Antiarrítmicos/uso terapêutico , Antitireóideos/uso terapêutico , Carbimazol/administração & dosagem , Carbimazol/uso terapêutico , Delírio/complicações , Delírio/terapia , Diagnóstico Diferencial , Humanos , Unidades de Terapia Intensiva , Masculino , Propranolol/administração & dosagem , Propranolol/uso terapêutico , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Tireotoxicose/sangue , Tireotoxicose/tratamento farmacológico , Tireotropina/análise , Resultado do Tratamento
16.
J Clin Nurs ; 28(11-12): 2351-2360, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30653772

RESUMO

AIMS AND OBJECTIVES: To create a framework for future research through application and critique of the Life Course Health Development Model to the phenomenon of paediatric delirium. BACKGROUND: Delirium in the paediatric intensive care unit is associated with increased duration of mechanical ventilation, length of stay and mortality. Nurses are uniquely positioned at the bedside to identify, prevent and treat delirium. An understanding of the potential long-term consequences of paediatric delirium is necessary to provide impetus for nursing research and practice change. The Life Course Health Development Model is a valuable tool when considering the multiple mechanisms and processes through which the experience of delirium could affect a child's life trajectory. DESIGN: Critical review of the literature through application and critique of the Life Course Health Development Model in the context of paediatric delirium. Gaps in the current understanding of paediatric delirium, as well as future directions for research and practice, are discussed. METHODS: The seven core principles of the model are considered in the context of paediatric delirium. Each of the principles has the potential to further understanding of paediatric delirium and identify areas for future inquiry. This discussion leads to a critique of the ability of the model to lead future research and practice change. CONCLUSIONS: The Life Course Health Development Model depicts a process in which the acute and severe stress of critical illness leads to maladaptive neurologic changes that contribute to the development of delirium and impair a child's life trajectory. RELEVANCE TO CLINICAL PRACTICE: By emphasising the potential lifelong consequences for critically ill children who experience delirium, this application of the Life Course Health Development Model will stimulate discussion, research and practice change among paediatric clinicians and researchers.


Assuntos
Delírio/enfermagem , Criança , Transtornos Cognitivos/etiologia , Transtornos Cognitivos/prevenção & controle , Enfermagem de Cuidados Críticos/métodos , Estado Terminal/enfermagem , Delírio/complicações , Delírio/diagnóstico , Humanos , Unidades de Terapia Intensiva Pediátrica , Transtornos do Neurodesenvolvimento/etiologia , Transtornos do Neurodesenvolvimento/prevenção & controle , Pesquisa em Enfermagem , Respiração Artificial/efeitos adversos
17.
Crit Care Med ; 47(3): 419-427, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30608279

RESUMO

OBJECTIVES: Implementation of delirium guidelines at ICUs is suboptimal. The aim was to evaluate the impact of a tailored multifaceted implementation program of ICU delirium guidelines on processes of care and clinical outcomes and draw lessons regarding guideline implementation. DESIGN: A prospective multicenter, pre-post, intervention study. SETTING: ICUs in one university hospital and five community hospitals. PATIENTS: Consecutive medical and surgical critically ill patients were enrolled between April 1, 2012, and February 1, 2015. INTERVENTIONS: Multifaceted, three-phase (baseline, delirium screening, and guideline) implementation program of delirium guidelines in adult ICUs. MEASUREMENTS AND MAIN RESULTS: The primary outcome was adherence changes to delirium guidelines recommendations, based on the Pain, Agitation and Delirium guidelines. Secondary outcomes were brain dysfunction (delirium or coma), length of ICU stay, and hospital mortality. A total of 3,930 patients were included. Improvements after the implementation pertained to delirium screening (from 35% to 96%; p < 0.001), use of benzodiazepines for continuous sedation (from 36% to 17%; p < 0.001), light sedation of ventilated patients (from 55% to 61%; p < 0.001), physiotherapy (from 21% to 48%; p < 0.001), and early mobilization (from 10% to 19%; p < 0.001). Brain dysfunction improved: the mean delirium duration decreased from 5.6 to 3.3 days (-2.2 d; 95% CI, -3.2 to -1.3; p < 0.001), and coma days decreased from 14% to 9% (risk ratio, 0.5; 95% CI, 0.4-0.6; p < 0.001). Other clinical outcome measures, such as length of mechanical ventilation, length of ICU stay, and hospital mortality, did not change. CONCLUSIONS: This large pre-post implementation study of delirium-oriented measures based on the 2013 Pain, Agitation, and Delirium guidelines showed improved health professionals' adherence to delirium guidelines and reduced brain dysfunction. Our findings provide empirical support for the differential efficacy of the guideline bundle elements in a real-life setting and provide lessons for optimization of guideline implementation programs.


Assuntos
Encefalopatias/etiologia , Delírio/terapia , Fidelidade a Diretrizes , Idoso , Encefalopatias/epidemiologia , Encefalopatias/prevenção & controle , Estudos Controlados Antes e Depois , Delírio/complicações , Delírio/diagnóstico , Feminino , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Resultado do Tratamento
18.
Medicine (Baltimore) ; 98(1): e13970, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30608436

RESUMO

Prospective case-control study.This study used a prospective multicenter database to investigate whether dural tear (DT) is associated with an increased rate of other perioperative complications.Few studies have had sufficient data accuracy and statistical power to evaluate the association between DT and other complications owing to a low incidence of occurrence.Between 2012 and 2017, 13,188 patients (7174 men and 6014 women) with degenerative lumbar diseases underwent primary lumbar spine surgery. The average age was 64.8 years for men and 68.7 years for women. DT was defined as a tear that was detected intraoperatively. Other investigated intraoperative surgery-related complications were massive hemorrhage (>2 L of blood loss), nerve injury, screw malposition, cage/graft dislocation, surgery performed at the wrong site, and vascular injury. The examined postoperative surgery-related complications were dural leak, surgical-site infection (SSI), postoperative neurological deficit, postoperative hematoma, wound dehiscence, screw/rod failure, and cage/graft failure. Information related to perioperative systemic complications was also collected for cardiovascular diseases, respiratory diseases, renal and urological diseases, cerebrovascular diseases, postoperative delirium, and sepsis.DTs occurred in 451/13,188 patients (3.4%, the DT group). In the DT group, dural leak was observed in 88 patients. After controlling for the potentially confounding variables of age, sex, primary disease, and type of procedure, the surgery-related complications that were more likely to occur in the DT group than in the non-DT group were SSI (odds ratio [OR] 2.68) and postoperative neurological deficit (OR 3.27). As for perioperative systemic complications, the incidence of postoperative delirium (OR 3.21) was significantly high in the DT group.This study demonstrated that DT was associated with higher incidences of postoperative SSI, postoperative neurological deficit, and postoperative delirium, in addition to directly DT-related dural leak.


Assuntos
Dura-Máter/lesões , Degeneração do Disco Intervertebral/patologia , Complicações Intraoperatórias/epidemiologia , Região Lombossacral/patologia , Coluna Vertebral/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Delírio/complicações , Delírio/epidemiologia , Dura-Máter/patologia , Dura-Máter/cirurgia , Feminino , Humanos , Doença Iatrogênica/epidemiologia , Degeneração do Disco Intervertebral/cirurgia , Região Lombossacral/cirurgia , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/complicações , Doenças do Sistema Nervoso/epidemiologia , Doenças do Sistema Nervoso/patologia , Período Perioperatório , Estudos Prospectivos , Coluna Vertebral/cirurgia , Infecção da Ferida Cirúrgica/complicações , Infecção da Ferida Cirúrgica/epidemiologia
19.
J Am Acad Orthop Surg ; 27(6): e293-e300, 2019 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-30358636

RESUMO

BACKGROUND: Averaging length of stay (LOS) ignores patient complexity and is a poor metric for quality control in geriatric hip fracture programs. We developed a predictive model of LOS that compares patient complexity to the logistic effects of our institution's hip fracture care pathway. METHODS: A retrospective analysis was performed on patients enrolled into a hip fracture co-management pathway at an academic level I trauma center from 2014 to 2015. Patient complexity was approximated using the Charlson Comorbidity Index and ASA score. A predictive model of LOS was developed from patient-specific and system-specific variables using a multivariate linear regression analysis; it was tested against a sample of patients from 2016. RESULTS: LOS averaged 5.95 days. Avoidance of delirium and reduced time to surgery were found to be notable predictors of reduced LOS. The Charlson Comorbidity Index was not a strong predictor of LOS, but the ASA score was. Our predictive LOS model worked well for 63% of patients from the 2016 group; for those it did not work well for, 80% had postoperative complications. DISCUSSION: Predictive LOS modeling accounting for patient complexity was effective for identifying (1) reasons for outliers to the expected LOS and (2) effective measures to target for improving our hip fracture program. LEVEL OF EVIDENCE: III.


Assuntos
Avaliação Geriátrica/estatística & dados numéricos , Fraturas do Quadril/cirurgia , Tempo de Internação/estatística & dados numéricos , Modelos Estatísticos , Procedimentos Ortopédicos/estatística & dados numéricos , Idoso , Delírio/complicações , Delírio/epidemiologia , Feminino , Fraturas do Quadril/psicologia , Humanos , Escala de Gravidade do Ferimento , Modelos Lineares , Masculino , Análise Multivariada , Estudos Retrospectivos , Fatores de Tempo
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