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1.
Medicine (Baltimore) ; 98(27): e16261, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31277148

RESUMO

BACKGROUND: Nowadays most of the intensive care units (ICUs) operate as a closed format in comparison to an open format. The new concept of a closed ICU is where patients are admitted under the full responsibility of a trained intensivist, whereas an open ICU is where patients are admitted under the care of another attending physician and intensivists are just available for consultation. In this analysis, we aimed to systematically compare mortality rate and other clinical features observed in open vs closed ICU formats. METHODS: Biomedical and pharmacological bibliographic database Excerpta Medica database (EMBASE), Medical Literature Analysis and Retrieval System Online (MEDLINE), the Cochrane Central and www.ClinicalTrials.gov were searched for required English publications. Mortality, the frequency of patients requiring mechanical ventilation, central line, arterial line and pulmonary arterial catheter were assessed respectively. Statistical analysis was carried out by the RevMan software. Odds ratios (OR) with 95% confidence intervals (CIs) were used to represent the data following analysis. RESULTS: Five studies with a total number of 6160 participants enrolled between years 1992 to 2007 were included. Results of this analysis showed that mortality rate was significantly higher in the open format ICU (OR: 1.31, 95% CI: 1.17-1.48; P = .00001) (using a fixed effect model) and (OR: 1.31, 95% CI: 1.09-1.59; P = .005) (using a random effect model). Closed format ICUs were associated with significantly higher number of patients that required central line (OR: 0.56, 95% CI: 0.34-0.92; P = .02). Patients requiring mechanical ventilation (OR: 1.08, 95% CI: 0.65-1.78; P = .77), patients requiring arterial line (OR: 1.05, 95% CI: 0.49-2.29; P = .89) and patients requiring pulmonary arterial catheter (OR: 0.86, 95% CI: 0.40-1.87; P = .71) were similar in the open vs the closed setting. CONCLUSION: This analysis showed that mortality rate was significantly higher in an open as compared to a closed format ICU. However, the frequency of patients requiring mechanical ventilation, arterial line and pulmonary arterial catheter was similarly observed. Larger trials are expected to further confirm those hypotheses.


Assuntos
Estado Terminal/mortalidade , Unidades de Terapia Intensiva/estatística & dados numéricos , Inovação Organizacional , Saúde Global , Mortalidade Hospitalar/tendências , Humanos , Tempo de Internação/tendências , Taxa de Sobrevida/tendências
2.
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
3.
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
4.
Medicine (Baltimore) ; 98(20): e15473, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31096444

RESUMO

PURPOSE: Selenium supplementation is a potentially promising adjunctive therapy for critically ill patients, but the results are controversy among studies. Accordingly, we performed this meta-analysis to more clearly detect the efficacy and safety of selenium supplementation on critically ill patients. METHODS: Systematic literature retrieval was carried out to obtain RCTs on selenium supplementation for critically ill patients up to August 2017. Data extraction and quality evaluation of these studies were performed by 2 investigators. Statistical analyses was performed by RevMan 5.3. Trial sequential analysis (TSA) was conducted to control the risks of type I and type II errors and calculate required information size (RIS). RESULTS: Totally 19 RCTs involving 3341 critically ill patients were carried out in which 1694 participates were in the selenium supplementation group, and 1647 in the control. The aggregated results suggested that compared with the control, intravenous selenium supplement as a single therapy could decrease the total mortality (RR = 0.86, 95% CI: 0.78-0.95, P = .002, TSA-adjusted 95% CI = 0.77-0.96, RIS = 4108, n = 3297) and may shorten the length of stay in hospital (MD -2.30, 95% CI -4.03 to -0.57, P = .009), but had no significant treatment effect on 28-days mortality (RR = 0.96, 95% CI: 0.85-1.09, P = .54) and could not shorten the length of ICU stay (MD -0.15, 95% CI -1.68 to 1.38, P = .84) in critically ill patients. Our results also showed that selenium supplementation did not increase incidence of drug-induced side effect compared with the control (RR 1.04, 95% CI 0.83 to 1.30, P = .73). CONCLUSIONS: The current evidence suggests that the use of selenium could reduce the total mortality, and TSA results showed that our outcome is reliable and no more randomized controlled trials are needed. But selenium supplementation might have no effect on reducing 28-days mortality as well as the incidence of new infections, or on length of stay in ICU or mechanical ventilation. However, the results should be used carefully because of potential limitations.


Assuntos
Estado Terminal/terapia , Selênio/administração & dosagem , Administração Intravenosa , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estado Terminal/epidemiologia , Estado Terminal/mortalidade , Suplementos Nutricionais , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial/mortalidade , Respiração Artificial/estatística & dados numéricos , Selênio/uso terapêutico , Oligoelementos/administração & dosagem , Oligoelementos/uso terapêutico , Resultado do Tratamento , Adulto Jovem
5.
Drug Discov Ther ; 13(2): 101-107, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31080200

RESUMO

Acute febrile illness (AFI) is one of the commonest indications for hospitalization and can present with varying severity including single or multiple organ dysfunction syndrome (MODS). During monsoon season, there is a spurt of AFI often caused by vector borne diseases leading to substantial morbidity and mortality. Our aim was to determine distribution of etiological causes, differential organ involvement and predictors of mortality in critically ill patients with AFI. It was a hospital based observational study which included patients with AFI with dysfunction of at least one organ system. The study was conducted over 4 months during monsoon season. Admitted patients were included who had been subjected to a standard battery of tests and managed with standard hospital based management protocol. 145 patients were included and etiology of fever was ascertained in 81.4% of patients with the most common single infection being chikungunya (20.7%) followed by dengue (20%) fever. Thrombocytopenia and deranged liver biochemistry each were seen in nearly 75% of the patients. Renal (50.3%) and nervous system (46.2%) dysfunction were the predominant organ failures. 49 patients died (33.8%) which correlated with predicted mortality by APACHE (acute physiological assessment and chronic health evaluation) II score. Independent predictors for mortality were older age (> 55 years) (p = 0.01), acidemia (p = 0.01), altered sensorium (p = 0.02) and coagulopathy (p = 0.048). Sub-group analysis revealed that amongst patients with MODS, hypotension could help differentiate between bacterial and non-bacterial causes (p = 0.01). Critically ill patients with AFI suffer from significant morbidity and mortality. Features like the presence of hypotension in MODS may differentiate between a bacterial cause vis-à-vis viral or protozoal etiology.


Assuntos
Febre de Chikungunya/epidemiologia , Estado Terminal/mortalidade , Dengue/epidemiologia , Hipotensão/epidemiologia , Insuficiência de Múltiplos Órgãos/etiologia , APACHE , Adolescente , Adulto , Febre de Chikungunya/complicações , Febre de Chikungunya/transmissão , Criança , Dengue/complicações , Dengue/transmissão , Feminino , Humanos , Índia , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/classificação , Insuficiência de Múltiplos Órgãos/mortalidade , Estudos Prospectivos , Fatores de Risco , Estações do Ano , Centros de Atenção Terciária , Adulto Jovem
6.
N Engl J Med ; 380(26): 2506-2517, 2019 06 27.
Artigo em Inglês | MEDLINE | ID: mdl-31112380

RESUMO

BACKGROUND: Dexmedetomidine produces sedation while maintaining a degree of arousability and may reduce the duration of mechanical ventilation and delirium among patients in the intensive care unit (ICU). The use of dexmedetomidine as the sole or primary sedative agent in patients undergoing mechanical ventilation has not been extensively studied. METHODS: In an open-label, randomized trial, we enrolled critically ill adults who had been undergoing ventilation for less than 12 hours in the ICU and were expected to continue to receive ventilatory support for longer than the next calendar day to receive dexmedetomidine as the sole or primary sedative or to receive usual care (propofol, midazolam, or other sedatives). The target range of sedation-scores on the Richmond Agitation and Sedation Scale (which is scored from -5 [unresponsive] to +4 [combative]) was -2 to +1 (lightly sedated to restless). The primary outcome was the rate of death from any cause at 90 days. RESULTS: We enrolled 4000 patients at a median interval of 4.6 hours between eligibility and randomization. In a modified intention-to-treat analysis involving 3904 patients, the primary outcome event occurred in 566 of 1948 (29.1%) in the dexmedetomidine group and in 569 of 1956 (29.1%) in the usual-care group (adjusted risk difference, 0.0 percentage points; 95% confidence interval, -2.9 to 2.8). An ancillary finding was that to achieve the prescribed level of sedation, patients in the dexmedetomidine group received supplemental propofol (64% of patients), midazolam (3%), or both (7%) during the first 2 days after randomization; in the usual-care group, these drugs were administered as primary sedatives in 60%, 12%, and 20% of the patients, respectively. Bradycardia and hypotension were more common in the dexmedetomidine group. CONCLUSIONS: Among patients undergoing mechanical ventilation in the ICU, those who received early dexmedetomidine for sedation had a rate of death at 90 days similar to that in the usual-care group and required supplemental sedatives to achieve the prescribed level of sedation. More adverse events were reported in the dexmedetomidine group than in the usual-care group. (Funded by the National Health and Medical Research Council of Australia and others; SPICE III ClinicalTrials.gov number, NCT01728558.).


Assuntos
Sedação Consciente , Estado Terminal/terapia , Dexmedetomidina , Hipnóticos e Sedativos , Respiração Artificial , Adulto , Idoso , Bradicardia/induzido quimicamente , Estado Terminal/mortalidade , Dexmedetomidina/efeitos adversos , Quimioterapia Combinada , Feminino , Humanos , Hipnóticos e Sedativos/efeitos adversos , Hipotensão/induzido quimicamente , Unidades de Terapia Intensiva , Análise de Intenção de Tratamento , Masculino , Midazolam , Pessoa de Meia-Idade , Propofol , Fatores de Tempo , Resultado do Tratamento
7.
Br J Anaesth ; 122(6): e189-e197, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31005245

RESUMO

BACKGROUND: The aim of this study was to investigate the association of chronic opioid usage with 90-day mortality in critically ill patients after admission to the ICU. METHODS: This retrospective cohort study analysed the medical records of adult patients admitted to ICUs in a tertiary academic hospital between January 2012 and December 2017. Patients taking opioids regularly for more than 4 weeks before ICU admission were defined as chronic opioid users, whereas the others were defined as opioid-naïve patients. RESULTS: We selected 18 409 patients for this study, including 757 (4.1%) chronic opioid users. After propensity matching, 2990 patients (chronic opioid users, 757; opioid-naïve, patient: 2233) were included in the analysis. The odds of 90-day mortality were higher in chronic opioid users than in opioid-naïve patients using both the generalised estimating equation model for the propensity-matched cohort (odds ratio=1.90; 95% confidence interval, 1.57-2.31; P<0.001) and the multivariable logistic regression model for the entire cohort (odds ratio=2.20; 95% confidence interval, 1.81-2.66; P<0.001). Additionally, this association was significant in cancer patients and non-chronic kidney disease (CKD) patients and was not significant in non-cancer and CKD patients. CONCLUSIONS: Our results suggest that in a cohort of critically ill adult patients, chronic opioid use is associated with an increase in 90-day mortality. This association was more evident in cancer patients and non-CKD patients.


Assuntos
Analgésicos Opioides/administração & dosagem , Estado Terminal/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/efeitos adversos , Cuidados Críticos/estatística & dados numéricos , Esquema de Medicação , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Sistema de Registros , República da Coreia/epidemiologia , Estudos Retrospectivos
8.
Medicine (Baltimore) ; 98(16): e15165, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31008937

RESUMO

Association between heart rate (HR) and in-hospital mortality in general patients irrespective of underlying diseases were not well scrutinized. We assessed the relationship between HR on admission and in-hospital mortality among general inpatients.We used data from Japan Adverse Drug Events (JADE) study, a prospective cohort study. One tertiary care hospital in Japan with 13 medical and 12 surgical wards, and an intensive care unit (ICU). Patients (n = 2360) were ≥12 years old and admitted to this hospital within 3 months; and pregnant women were excluded. We assessed the relationship between HR and mortality in five (<60, 60-79, 80-99, 100-119, ≥120 beats per minutes [bpm]) groups. We also compared the five HR groups according to the age (<70 years; ≥70 years) and wards (medical; surgical; ICU).We enrolled 2360 patients (median age, 71 [interquartile range (IQR) 58-81] years) including 1147, 1068, and 145 patients in the medical and surgical wards, and the ICU, respectively. The median (IQR) HR on admission was 78 (68-91) bpm. Ninety-five patients died during hospitalization. Mortalities in the <60, 60-79, 80-99, 100-119, and ≥120 bpm groups were 2.9% (5/175), 2.7% (28/1047), 3.4% (26/762), 8.2% (24/291), and 14.3% (12/84), respectively (P < .001). The adjusted odds ratios of in-hospital mortality was 3.64 (95% CI 1.88-7.05, P < .001) when HR was ≥100 bpm in the medical ward; and 5.69 (95% CI 1.72-18.82, P = .004) when HR ≥120 bpm in the surgical ward. There was no statistically significant relationship with the ICU.In conclusion, higher HR should be associated with in-hospital mortality among patients with general diseases. Even with less severe condition or outside ICU, HR should be directed attention to and patients with high HR on admission should be taken additional therapy to reduce the further risk of deterioration.


Assuntos
Estado Terminal/mortalidade , Frequência Cardíaca , Admissão do Paciente , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Feminino , Serviços de Saúde para Idosos , Mortalidade Hospitalar , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros
9.
Clin Chim Acta ; 494: 94-99, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30890398

RESUMO

BACKGROUND: There have been no epidemiological studies exploring the prognostic ability of serum total and ionized calcium (tCa and iCa) in critically ill patients with acute kidney injury (AKI). We assessed the association of admission tCa and iCa concentrations with all-cause mortality in these patients. METHODS: We extracted clinical data from the MIMIC-III V1.4 database. Only the data for the first intensive care unit (ICU) admission of each patient were used and baseline data were extracted within 24 h after ICU admission. Cox proportional hazards models and subgroup analyses were used to determine the relationship between tCa and iCa concentrations and 30, 90 and 365-day all-cause mortality in critically ill patients with AKI. A total of 10,207 eligible patients were studied. In multivariate analysis, adjusted for age, ethnicity and gender, both low-tCa (< 7.9 mg/dl) and low-iCa (<1.06 mmol/l) concentrations were significant predictors of risk of all-cause mortality. Furthermore, after adjusting for more confounding factors, low-iCa concentrations remained a significant predictor of all-cause mortality at 30 days, 90 days, 365 days (HR, 95% CI: 1.19, 1.06-1.33; 1.15, 1.05-1.27; 1.10, 1.01-1.20). CONCLUSIONS: Low-iCa concentrations were independent predictors of all-cause mortality in critically ill patients with AKI.


Assuntos
Lesão Renal Aguda/sangue , Lesão Renal Aguda/mortalidade , Cálcio/sangue , Cálcio/química , Causas de Morte , Estado Terminal/mortalidade , Adolescente , Adulto , Idoso , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Adulto Jovem
10.
Ital J Pediatr ; 45(1): 33, 2019 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-30841913

RESUMO

To date, a large number of children are hospitalized inappropriately in adult intensive care units, where the minimum standards of care are not applied to young patients. It is well-known that the child is not a small adult. Recently it has been demonstrated that critically ill children hospitalized in pediatric intensive care receive higher quality of care, and have better outcomes, besides a lower mortality rate, compared to those admitted to adult intensive care units.We believe that the management of the critically ill child is an area of expertise of the neonatologist, who however must acquire specific skills and abilities of pediatric intensive medicine. The new idea of care is to offer in general hospitals 'broader' Neonatal Intensive Care Units, extended to infants and children in early childhood, based on territorial macro-areas and/or population of competence.


Assuntos
Estado Terminal/mortalidade , Mortalidade Hospitalar , Unidades de Terapia Intensiva Neonatal/organização & administração , Terapia Intensiva Neonatal/organização & administração , Neonatologia/organização & administração , Estado Terminal/terapia , Feminino , Necessidades e Demandas de Serviços de Saúde , Hospitalização/estatística & dados numéricos , Humanos , Recém-Nascido , Itália , Tempo de Internação , Masculino , Medição de Risco
11.
Mediators Inflamm ; 2019: 6714080, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30918471

RESUMO

Introduction: Alterations in miR-155 serum levels have been described in inflammatory and infectious diseases. Moreover, a role for miR-155 in aging and age-related diseases was recently suggested. We therefore analyzed a potential age-dependent prognostic value of circulating miR-155 as a serum-based marker in critical illness. Methods: Concentrations of circulating miR-155 were determined in 218 critically ill patients and 76 healthy controls. Results: By using qPCR, we demonstrate that miR-155 serum levels are elevated in patients with critical illness when compared to controls. Notably, levels of circulating miR-155 were independent on the severity of disease, the disease etiology, or the presence of sepsis. In the total cohort, miR-155 was not an indicator for patient survival. Intriguingly, when patients were subdivided according to their age upon admission to the ICU into those younger than 65 years, lower levels of miR-155 turned out as a strong marker, indicating patient mortality with a similar accuracy than other markers frequently used to evaluate critically ill patients on a medical ICU. Conclusion: In summary, the data provided within this study suggest an age-specific role of miR-155 as a prognostic biomarker in patients younger than 65 years. Our study is the first to describe an age-dependent miRNA-based prognostic biomarker in human diseases.


Assuntos
Estado Terminal/mortalidade , MicroRNAs/sangue , MicroRNAs/genética , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Prognóstico , Reação em Cadeia da Polimerase em Tempo Real , Adulto Jovem
12.
Nutrients ; 11(3)2019 Mar 16.
Artigo em Inglês | MEDLINE | ID: mdl-30884840

RESUMO

Small bowel enteral nutrition (SBEN) may improve nutrient delivery to critically ill patients intolerant of gastric enteral nutrition. However, the optimal time and target for evaluating SBEN efficacy are unknown. This retrospective cohort study investigates these parameters in 55 critically ill patients at high nutrition risk (modified NUTRIC score ≥ 5). Daily actual energy intake was recorded from 3 days before SBEN initiation until 7 days thereafter. The energy achievement rate (%) was calculated as follows: (actual energy intake/estimated energy requirement) × 100. The optimal time was determined from the day on which energy achievement rate reached >60% post-SBEN. Assessment results were as follows: median APACHE II score, 27; SOFA score, 10.0; modified NUTRIC score, 7; and median time point of SBEN initiation, ICU day 8. The feeding volume, energy and protein intake, and achievement rate (%) of energy and protein intake increased significantly after SBEN (p < 0.001). An energy achievement rate less than 65% 3 days after SBEN was significantly associated with increased mortality after adjusting for confounding factors (odds ratio, 4.97; 95% confidence interval, 1.44⁻17.07). SBEN improves energy delivery in critically ill patients who are still at high nutrition risk after 1 week of stomach enteral nutrition.


Assuntos
Estado Terminal/terapia , Nutrição Enteral/mortalidade , Avaliação Nutricional , Fatores de Tempo , Idoso , Estado Terminal/mortalidade , Ingestão de Energia , Nutrição Enteral/métodos , Feminino , Humanos , Unidades de Terapia Intensiva , Intestino Delgado , Masculino , Pessoa de Meia-Idade , Necessidades Nutricionais , Razão de Chances , Estudos Retrospectivos , Resultado do Tratamento
13.
BMC Pulm Med ; 19(1): 53, 2019 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-30808337

RESUMO

BACKGROUND: Studies investigating the role of hyperoxia in critically ill patients have reported conflicting results. We did this analysis to reveal the effect of hyperoxia in the patients admitted to the intensive care unit (ICU). METHODS: Electronic databases were searched for all the studies exploring the role of hyperoxia in adult patients admitted to ICU. The primary outcome was mortality. Random-effect model was used for quantitative synthesis of the adjusted odds ratio (aOR). RESULTS: We identified 24 trials in our final analysis. Statistical heterogeneity was found between hyperoxia and normoxia groups in patients with mechanical ventilation (I2 = 92%, P < 0.01), cardiac arrest(I2 = 63%, P = 0.01), traumatic brain injury (I2 = 85%, P < 0.01) and post cardiac surgery (I2 = 80%, P = 0.03). Compared with normoxia, hyperoxia was associated with higher mortality in overall patients (OR 1.22, 95% CI 1.12~1.33), as well as in the subgroups of cardiac arrest (OR 1.30, 95% CI 1.08~1.57) and extracorporeal life support (ELS) (OR 1.44, 95% CI 1.03~2.02). CONCLUSIONS: Hyperoxia would lead to higher mortality in critically ill patients especially in the patients with cardiac arrest and ELS.


Assuntos
Estado Terminal/mortalidade , Mortalidade Hospitalar , Hiperóxia/epidemiologia , Lesões Encefálicas Traumáticas/mortalidade , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Parada Cardíaca/mortalidade , Humanos , Hiperóxia/etiologia , Unidades de Terapia Intensiva , Mortalidade , Razão de Chances , Oxigenoterapia/efeitos adversos , Período Pós-Operatório , Respiração Artificial/estatística & dados numéricos
14.
Br J Nurs ; 28(4): 234-241, 2019 Feb 28.
Artigo em Inglês | MEDLINE | ID: mdl-30811231

RESUMO

This article discusses the evidence in relation to preventable deaths and a reported culture of suboptimal care. It warns of the dangers of over-relying on track and trigger systems (TTS) in place of clinical judgement. The article explores cultural and behavioural factors, the effects of short staffing and inappropriate skill mix, which all increase the risk of human error. It emphasises a key message that registered nurses must reflect on the need to change their individual and team approaches to the recognition and assessment of the deteriorating patient.


Assuntos
Deterioração Clínica , Estado Terminal/enfermagem , Monitorização Fisiológica/métodos , Medicina Estatal/organização & administração , Estado Terminal/mortalidade , Humanos , Recursos Humanos de Enfermagem/psicologia , Cultura Organizacional , Fatores de Risco , Reino Unido/epidemiologia
15.
J Cardiothorac Vasc Anesth ; 33(5): 1430-1439, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30600204

RESUMO

The authors aimed to identify interventions documented by randomized controlled trials (RCTs) that reduce mortality in adult critically ill and perioperative patients, followed by a survey of clinicians' opinions and routine practices to understand the clinicians' response to such evidence. The authors performed a comprehensive literature review to identify all topics reported to reduce mortality in perioperative and critical care settings according to at least 2 RCTs or to a multicenter RCT or to a single-center RCT plus guidelines. The authors generated position statements that were voted on online by physicians worldwide for agreement, use, and willingness to include in international guidelines. From 262 RCT manuscripts reporting mortality differences in the perioperative and critically ill settings, the authors selected 27 drugs, techniques, and strategies (66 RCTs, most frequently published by the New England Journal of Medicine [13 papers], Lancet [7], and Journal of the American Medical Association [5]) with an agreement ≥67% from over 250 physicians (46 countries). Noninvasive ventilation was the intervention supported by the largest number of RCTs (n = 13). The concordance between agreement and use (a positive answer both to "do you agree" and "do you use") showed differences between Western and other countries and between anesthesiologists and intensive care unit physicians. The authors identified 27 clinical interventions with randomized evidence of survival benefit and strong clinician support in support of their potential life-saving properties in perioperative and critically ill patients with noninvasive ventilation having the highest level of support. However, clinician views appear affected by specialty and geographical location.


Assuntos
Cuidados Críticos/métodos , Estado Terminal/mortalidade , Internet , Médicos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Inquéritos e Questionários , Cuidados Críticos/tendências , Estado Terminal/terapia , Humanos , Unidades de Terapia Intensiva/tendências , Internet/tendências , Mortalidade/tendências , Médicos/tendências
16.
Nutrients ; 11(1)2019 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-30621003

RESUMO

It is currently uncertain whether early administration of protein improves patient outcomes. We examined mortality rates of critically ill patients receiving early compared to late protein administration. This was a retrospective cohort study of mixed ICU patients receiving enteral or parenteral nutritional support. Patients receiving >0.7 g/kg/d protein within the first 3 days were considered the early protein group and those receiving less were considered the late protein group. The latter were subdivided into late-low group (LL) who received a low protein intake (<0.7 g/kg/d) throughout their stay and the late-high group (LH) who received higher doses (>0.7 g/kg/d) of protein following their first 3 days of admission. The outcome measure was all-cause mortality 60 days after admission. Of the 2253 patients included in the study, 371 (36%) in the early group, and 517 (43%) in the late-high group had died (p < 0.001 for difference). In multivariable Cox regression analysis, while controlling for confounders, early protein administration was associated with increased survival (HR 0.83, 95% CI 0.71⁻0.97, p = 0.017). Administration of protein early in the course of critical illness appears to be associated with improved survival in a mixed ICU population, even after adjusting for confounding variables.


Assuntos
Estado Terminal/mortalidade , Apoio Nutricional/métodos , Proteínas/administração & dosagem , Adulto , Idoso , Calorimetria Indireta , Estudos de Coortes , Cuidados Críticos/métodos , Ingestão de Energia , Feminino , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Necessidades Nutricionais , Nutrição Parenteral , Proteínas/efeitos adversos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
17.
Crit Care ; 23(1): 9, 2019 Jan 10.
Artigo em Inglês | MEDLINE | ID: mdl-30630521

RESUMO

BACKGROUND: The effect of loop diuretic use in critically ill patients on vasopressor support or in shock is unclear. This study aimed to explore the relationship between loop diuretic use and hospital mortality in critically ill patients with vasopressor support. METHODS: Data were extracted from the Medical Information Mart for Intensive Care III database. Adult patients with records of vasopressor use within 48 h after intensive care unit admission were screened. Multivariable logistic regression and propensity score matching was used to investigate any association. RESULTS: Data on 7828 patients were included. The crude hospital mortality was significantly lower in patients with diuretic use (166/1469 vs. 1171/6359, p <  0.001). In the extended multivariable logistic models, the odds ratio (OR) of diuretic use was consistently significant in all six models (OR range 0.56-0.75, p < 0.05 for all). In the subgroup analysis, an interaction effect was detected between diuretic use and fluid balance (FB). In the positive FB subgroup, diuretic use was significantly associated with decreased mortality (OR 0.64, 95% confidence interval (CI) 0.51-0.78) but was insignificant in the negative FB subgroup. In the other subgroups of mean arterial pressure, maximum sequential organ failure assessment score, and lactate level, the association between diuretic use and mortality remained significant and no interaction was detected. After propensity score matching, 1463 cases from each group were well matched. The mortality remained significantly lower in the diuretic use group (165/1463 vs. 231/1463, p < 0.001). CONCLUSIONS: Although residual confounding cannot be excluded, loop diuretic use is associated with lower mortality.


Assuntos
Estado Terminal/mortalidade , Inibidores de Simportadores de Cloreto de Sódio e Potássio/administração & dosagem , Vasoconstritores/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Pressão Arterial/efeitos dos fármacos , Estado Terminal/terapia , Feminino , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Modelos Logísticos , Masculino , Massachusetts , Pessoa de Meia-Idade , Razão de Chances , Escores de Disfunção Orgânica , Pontuação de Propensão , Estudos Retrospectivos , Inibidores de Simportadores de Cloreto de Sódio e Potássio/uso terapêutico , Estatísticas não Paramétricas , Vasoconstritores/uso terapêutico
19.
J Clin Pathol ; 72(4): 325-328, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30593460

RESUMO

We determined the relative strengths of association between 23 most commonly ordered laboratory tests and the adverse outcome as indicators of relative criticalness. The lowest and highest results for 23 most commonly ordered laboratory tests, 24 hours prior to death during critical care unit (CCU) stay or discharge from CCU were extracted from a publicly available CCU database (Medical Information Mart for Intensive Care-III). Following this, the Random Forest model was applied to assess the association between the laboratory results and the outcomes (death or discharge). The mean decrease in Gini coefficient for each laboratory test was then ranked as an indication of their relative importance to the outcome of a patient. In descending order, the 10 laboratory tests with the strongest association with death were: bicarbonate, phosphate, anion gap, white cell count (total), partial thromboplastin time, platelet, total calcium, chloride, glucose and INR; moreover, the strength of association was different for critically high versus low results.


Assuntos
Cuidados Críticos/métodos , Estado Terminal , Técnicas de Apoio para a Decisão , Testes Diagnósticos de Rotina , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Análise Química do Sangue , Coagulação Sanguínea , Tomada de Decisão Clínica , Estado Terminal/mortalidade , Estado Terminal/terapia , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Coeficiente Internacional Normatizado , Contagem de Leucócitos , Aprendizado de Máquina , Masculino , Pessoa de Meia-Idade , Tempo de Tromboplastina Parcial , Alta do Paciente , Contagem de Plaquetas , Valor Preditivo dos Testes , Prognóstico , Fatores de Tempo , Adulto Jovem
20.
World J Gastroenterol ; 24(46): 5203-5214, 2018 Dec 14.
Artigo em Inglês | MEDLINE | ID: mdl-30581269

RESUMO

Liver transplantation for critically ill cirrhotic patients with acute deterioration of liver function associated with extrahepatic organ failures is controversial. While transplantation has been shown to be beneficial on an individual basis, the potentially poorer post-transplant outcome of these patients taken as a group can be held as an argument against allocating livers to them. Although this issue concerns only a minority of liver transplants, it calls into question the very heart of the allocation paradigms in place. Indeed, most allocation algorithms have been centered on prioritizing the sickest patients by using the model for end-stage liver disease score. This has led to allocating increasing numbers of livers to increasingly critically ill patients without setting objective or consensual limits on how sick patients can be when they receive an organ. Today, finding robust criteria to deem certain cirrhotic patients too sick to be transplanted seems urgent in order to ensure the fairness of our organ allocation protocols. This review starts by fleshing out the argument that finding such criteria is essential. It examines five types of difficulties that have hindered the progress of recent literature on this issue and identifies various strategies that could be followed to move forward on this topic, taking into account the recent discussion on acute on chronic liver failure. We move on to review the literature along four axes that could guide clinicians in their decision-making process regarding transplantation of critically ill cirrhotic patients.


Assuntos
Estado Terminal/terapia , Doença Hepática Terminal/cirurgia , Cirrose Hepática/cirurgia , Transplante de Fígado/normas , Obtenção de Tecidos e Órgãos/normas , Estado Terminal/mortalidade , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/mortalidade , Doença Hepática Terminal/patologia , Humanos , Cirrose Hepática/diagnóstico , Cirrose Hepática/mortalidade , Cirrose Hepática/patologia , Transplante de Fígado/ética , Seleção de Pacientes/ética , Guias de Prática Clínica como Assunto , Prognóstico , Alocação de Recursos/ética , Alocação de Recursos/normas , Medição de Risco/normas , Índice de Gravidade de Doença , Obtenção de Tecidos e Órgãos/ética , Resultado do Tratamento
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