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2.
Crit Care Med ; 48(11): 1553-1555, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33045150

RESUMO

OBJECTIVES: To describe the unique perspective of pediatric intensivists caring for critically ill adults during the coronavirus disease 2019 pandemic. DESIGN: Observational study. SETTING: Academic medical center in New York City. PATIENTS: Coronavirus disease 2019 positive adults requiring admission to an ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In late March 2020, New York Presbyterian Hospital centralized all of its inpatient pediatric units (n = 4) from across the network to a single center, in order to create space to accommodate the increasing number of critically ill adults with coronavirus disease 2019. Within 1 week, the PICU at New York Presbyterian Hospital-Weill Cornell Medicine transferred or discharged all inpatients, underwent a transformation of the physical space, and began admitting adults of all ages with coronavirus disease 2019 related acute respiratory failure. The New York Presbyterian Hospital-Weill Cornell Medicine PICU physician group continued to lead this unit. PICU nurses, respiratory therapists, social workers, and child life specialists joined their PICU physician colleagues to care for these critically ill adults. CONCLUSIONS: In the coronavirus disease 2019 pandemic, PICU physicians are well poised to care for adult patients in a surge capacity, and bring a unique perspective to the experience.


Assuntos
Betacoronavirus , Infecções por Coronavirus/terapia , Cuidados Críticos/organização & administração , Estado Terminal/terapia , Unidades de Terapia Intensiva Pediátrica/organização & administração , Pneumonia Viral/terapia , Centros de Atenção Terciária/organização & administração , Adulto , Infecções por Coronavirus/epidemiologia , Estado Terminal/epidemiologia , Feminino , Humanos , Masculino , Cidade de Nova Iorque , Pandemias , Pneumonia Viral/epidemiologia , Índice de Gravidade de Doença
3.
Med Klin Intensivmed Notfmed ; 115(7): 566-570, 2020 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-33025048

RESUMO

Renal replacement therapy is after mechanical ventilation one of the most important and frequently used organ replacement therapies in daily routine intensive care practice. In contrast to mechanical ventilation, quality standards for renal replacement therapy are less well known and defined. In this position paper of the German Interdisciplinary Association for Intensive Care and Emergency Medicine, we describe quality standards of renal replacement procedures in order to improve therapy of patients with severe acute kidney injury.


Assuntos
Lesão Renal Aguda , Estado Terminal , Lesão Renal Aguda/terapia , Cuidados Críticos , Estado Terminal/terapia , Humanos , Melhoria de Qualidade , Terapia de Substituição Renal
4.
Medicine (Baltimore) ; 99(36): e21596, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32898996

RESUMO

INTRODUCTION: Globally, the coronavirus disease 2019 (COVID-19) is still spreading rapidly. At present, there are no specifically approved therapeutic agents or vaccines for its treatment. Previous studies have shown that the convalescent plasma therapy (CPT) is effective in patients with COVID-19. However, its efficacy in patients with persistently positive nucleic acid test is unknown. PATIENT CONCERNS: In this report, we present the clinical data of 5 critically ill COVID-19 patients admitted, between January 16 and February 26, 2020, in intensive care unit of Xiaogan Central Hospital. DIAGNOSIS AND INTERVENTIONS: All these patients had a persistently positive nucleic acid test and received CPT. All 5 patients had severe respiratory failure, and thus, required invasive mechanical ventilation. The median time from the onset of symptoms to initiating the CPT was 37 (Interquartile range, 34-44) days. OUTCOMES: Only 2 patients were cured and subsequently discharged, while 3 patients succumbed due to multiple organ failure. CONCLUSION: The time of initiating the CPT may be an important factor affecting its efficacy, and its therapeutic effect in the treatment of COVID-19, in the late stage, is limited.


Assuntos
Infecções por Coronavirus/terapia , Estado Terminal/terapia , Pneumonia Viral/terapia , APACHE , Idoso , Betacoronavirus , Infecções por Coronavirus/mortalidade , Estado Terminal/mortalidade , Feminino , Humanos , Imunização Passiva , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/mortalidade , Técnicas de Amplificação de Ácido Nucleico , Pandemias , Pneumonia Viral/mortalidade , Respiração Artificial
5.
BMJ Open ; 10(9): e040175, 2020 09 29.
Artigo em Inglês | MEDLINE | ID: mdl-32994259

RESUMO

INTRODUCTION: The course of the disease in SARS-CoV-2 infection in mechanically ventilated patients is unknown. To unravel the clinical heterogeneity of the SARS-CoV-2 infection in these patients, we designed the prospective observational Maastricht Intensive Care COVID cohort (MaastrICCht). We incorporated serial measurements that harbour aetiological, diagnostic and predictive information. The study aims to investigate the heterogeneity of the natural course of critically ill patients with a SARS-CoV-2 infection. METHODS AND ANALYSIS: Mechanically ventilated patients admitted to the intensive care with a SARS-CoV-2 infection will be included. We will collect clinical variables, vital parameters, laboratory variables, mechanical ventilator settings, chest electrical impedance tomography, ECGs, echocardiography as well as other imaging modalities to assess heterogeneity of the course of a SARS-CoV-2 infection in critically ill patients. The MaastrICCht is also designed to foster various other studies and registries and intends to create an open-source database for investigators. Therefore, a major part of the data collection is aligned with an existing national intensive care data registry and two international COVID-19 data collection initiatives. Additionally, we create a flexible design, so that additional measures can be added during the ongoing study based on new knowledge obtained from the rapidly growing body of evidence. The spread of the COVID-19 pandemic requires the swift implementation of observational research to unravel heterogeneity of the natural course of the disease of SARS-CoV-2 infection in mechanically ventilated patients. Our study design is expected to enhance aetiological, diagnostic and prognostic understanding of the disease. This paper describes the design of the MaastrICCht. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the medical ethics committee (Medisch Ethische Toetsingscommissie 2020-1565/3 00 523) of the Maastricht University Medical Centre+ (Maastricht UMC+), which will be performed based on the Declaration of Helsinki. During the pandemic, the board of directors of Maastricht UMC+ adopted a policy to inform patients and ask their consent to use the collected data and to store serum samples for COVID-19 research purposes. All study documentation will be stored securely for fifteen years after recruitment of the last patient. The results will be published in peer-reviewed academic journals, with a preference for open access journals, while particularly considering deposition of the manuscripts on a preprint server early. TRIAL REGISTRATION NUMBER: The Netherlands Trial Register (NL8613).


Assuntos
Infecções por Coronavirus , Cuidados Críticos/métodos , Estado Terminal , Imagem Multimodal/métodos , Pandemias , Pneumonia Viral , Respiração Artificial , Betacoronavirus/isolamento & purificação , Estudos de Coortes , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/fisiopatologia , Infecções por Coronavirus/terapia , Estado Terminal/epidemiologia , Estado Terminal/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Pneumonia Viral/epidemiologia , Pneumonia Viral/fisiopatologia , Pneumonia Viral/terapia , Prognóstico , Sistema de Registros/estatística & dados numéricos , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Índice de Gravidade de Doença
8.
S Afr Med J ; 110(7): 629-634, 2020 05 26.
Artigo em Inglês | MEDLINE | ID: mdl-32880337

RESUMO

Pandemics challenge clinicians and scientists in many ways, especially when the virus is novel and disease expression becomes variable or unpredictable. Under such circumstances, research becomes critical to inform clinical care and protect future patients. Given that severely ill patients admitted to intensive care units are at high risk of mortality, establishing the cause of death at a histopathological level could prove invaluable in contributing to the understanding of COVID-19. Postmortem examination including autopsies would be optimal. However, in the context of high contagion and limited personal protective equipment, full autopsies are not being conducted in South Africa (SA). A compromise would require tissue biopsies and samples to be taken immediately after death to obtain diagnostic information, which could potentially guide care of future patients, or generate hypotheses for finding needed solutions. In the absence of an advance written directive (including a will or medical record) providing consent for postmortem research, proxy consent is the next best option. However, obtaining consent from distraught family members, under circumstances of legally mandated lockdown when strict infection control measures limit visitors in hospitals, is challenging. Their extreme vulnerability and emotional distress make full understanding of the rationale and consent process difficult either before or upon death of a family member. While it is morally distressing to convey a message of death telephonically, it is inhumane to request consent for urgent research in the same conversation. Careful balancing of the principles of autonomy, non-maleficence and justice becomes an ethical imperative. Under such circumstances, a waiver of consent, preferably followed by deferred proxy consent, granted by a research ethics committee in keeping with national ethics guidance and legislation, would fulfil the basic premise of care and research: first do no harm. This article examines the SA research ethics framework, guidance and legislation to justify support for a waiver of consent followed by deferred proxy consent, when possible, in urgent research after death to inform current and future care to contain the pandemic in the public interest.


Assuntos
Infecções por Coronavirus/epidemiologia , Cuidados Críticos/ética , Estado Terminal/terapia , Mortalidade Hospitalar , Consentimento Livre e Esclarecido/ética , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Causas de Morte , Infecções por Coronavirus/prevenção & controle , Cuidados Críticos/legislação & jurisprudência , Estado Terminal/mortalidade , Países em Desenvolvimento , Feminino , Humanos , Controle de Infecções/organização & administração , Unidades de Terapia Intensiva/ética , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Determinação de Necessidades de Cuidados de Saúde , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Projetos de Pesquisa , Medição de Risco , África do Sul , Populações Vulneráveis/estatística & dados numéricos
10.
Infez Med ; 28(3): 357-366, 2020 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-32920571

RESUMO

The current COVID-19 pandemic needs unconventional therapies to tackle the resulted high morbidity and mortality. Convalescent plasma is one of the therapeutic approaches that might be of benefit. Forty nine early-stage critically-ill COVID-19 patients residing in Respiratory Care Units (RCU) of three hospitals in Baghdad, Iraq, were included: 21 received convalescent plasma while 28, namely control group, did not receive it. Recovery or death, length of stay in hospital, and improvement in the clinical course of the disease were monitored clinically along with laboratory monitoring through SARS-CoV-2 RNA detection via PCR, and SARS-CoV-2 IgG and IgM serological monitoring. Patients who received convalescent plasma showed reduced duration of infection in about 4 days and showed less death rate [1/21 versus 8/28 in control group]. In addition, all the patients who were given convalescent plasma showed high levels of SARS-CoV-2 IgG and IgM three days after plasma transfusion. Plasma from donors with high levels of SARS-CoV-2 IgG and donors with positive SRAS-CoV-2 IgM showed better therapeutic results than other donors. Convalescent plasma therapy is an effective therapy if donors with high level of SARS-Cov2 antibodies are selected and if recipients are at their early stage of critical illness, being no more than three days in RCUs.


Assuntos
Betacoronavirus/imunologia , Infecções por Coronavirus/terapia , Plasma/imunologia , Pneumonia Viral/terapia , Anticorpos Antivirais/sangue , Estudos de Casos e Controles , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/imunologia , Estado Terminal/terapia , Feminino , Humanos , Imunização Passiva/métodos , Imunoglobulina G/sangue , Imunoglobulina M/sangue , Iraque/epidemiologia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/imunologia
11.
Acta Biomed ; 91(3)2020 06 04.
Artigo em Inglês | MEDLINE | ID: mdl-32921738

RESUMO

CoVID-19 is a global health emergency, which has paralyzed most of the worldwide health systems. Italy is struggling hard with CoVID-19 pandemic since the end of February 2020, to avoid the collapse of its health  system. The number of CoVID-19 patients and deaths are increasing day by day. At time of writing, in Italy there are 102253 infected patients and 19899 deaths. Despite being a relatively small city, Piacenza is one of the epicentres of the Italian epidemic, and our own hospital - Guglielmo da Saliceto - has quickly become a "CoVID-19 hospital". Fully 80% of beds in our hospital are reserved for ill CoVID-19 patients and ICU has tripled the number of beds. All these changes have required a great effort for all the medical staff to avoid the collpase of the local health system. We struggled to maintain our normal standard of care for each patient, but the severity of the disease and the high number of critically ill patients frustrated our efforts. Here we report our experience and challenge with managing such a disaster. We hope it could be useful for other Emergency Departments trapped in this global pandemic.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Estado Terminal/terapia , Emergências , Serviço Hospitalar de Emergência/organização & administração , Pandemias , Pneumonia Viral/epidemiologia , Infecções por Coronavirus/terapia , Humanos , Itália/epidemiologia , Pneumonia Viral/terapia
12.
PLoS One ; 15(9): e0238352, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32881921

RESUMO

The dose of progressive active mobilization is still uncertain. The purpose of this study is to identify if the addition of a protocol of progressive active mobilization with dose and training load control to usual care is effective in reducing the length of stay in intensive care unit (ICU) and the improvement of the functioning, incidence of ICU-acquired weakness (ICUAW), mechanical ventilation duration and mortality rate in patients hospitalized in ICU. It is Double-blind randomised clinical trial. The setting for this trial will be medical and surgical ICU of a university hospital. The study participants will be 118 patients aged> 18 years admitted to ICU for less than 72 hours. Participants will be randomized to either an experimental or control group. The experimental group will undertake addition of a protocol of progressive active mobilization with dose and training load control to usual care, while the control group will undertake only usual care. The primary outcome will be length of ICU stay. The secondary outcomes will be Cross-sectional area and muscle thickness of the rectus femoris and biceps brachii, Change in muscle strength from the baseline, Functional Status, incidence of ICUAW, Days with mechanical ventilation and Mortality. All statistical analyses will be conducted following intention-to-treat principles. It has a detailed description of the dose of exercise, was designed with the strictest methodological criteria. These characteristics allow to investigate with greater certainty the results progressive active mobilization in critical patients, allowing replication and future combinations in meta-analyzes.


Assuntos
Estado Terminal/terapia , Adulto , Protocolos Clínicos , Estado Terminal/mortalidade , Método Duplo-Cego , Exercício Físico , Músculos Isquiossurais/fisiologia , Humanos , Unidades de Terapia Intensiva , Estimativa de Kaplan-Meier , Tempo de Internação , Força Muscular , Músculo Quadríceps/fisiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial , Adulto Jovem
13.
Med Klin Intensivmed Notfmed ; 115(7): 530-538, 2020 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-32885280

RESUMO

Medical history taking and the clinical examination are the traditional medical tools in making a diagnosis. Both the medical history taking and clinical examination have wrongly lost their practical value in modern emergency and intensive care medicine. When diagnosing an acutely or critically ill patient, the sequence, technique and focus of history taking and the clinical examination must be adapted to the individual situation and the condition of the patient. In this article the continuing central importance of both techniques in the diagnostics of emergency and intensive care patients is practically evaluated and discussed.


Assuntos
Cuidados Críticos , Medicina de Emergência , Estado Terminal/terapia , Serviço Hospitalar de Emergência , Humanos , Anamnese , Exame Físico
14.
Intern Med J ; 50(8): 918-923, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32881275

RESUMO

The novel Coronavirus disease 2019 (COVID-19) outbreak has led to rapid and profound changes in healthcare system delivery and society more broadly. Older adults, and those living with chronic or life-limiting conditions, are at increased risk of experiencing severe or critical symptoms associated with COVID-19 infection and are more likely to die. They may also experience non-COVID-19 related deterioration in their health status during this period. Advance care planning (ACP) is critical for this cohort, yet there is no coordinated strategy for increasing the low rates of ACP uptake in these groups, or more broadly. This paper outlines a number of key reasons why ACP is an urgent priority, and should form a part of the health system's COVID-19 response strategy. These include reducing the need for rationing, planning for surges in healthcare demand, respecting human rights, enabling proactive care coordination and leveraging societal change. We conclude with key recommendations for policy and practice in the system-wide implementation of ACP, to enable a more ethical, coordinated and person-centred response in the COVID-19 context.


Assuntos
Planejamento Antecipado de Cuidados , Infecções por Coronavirus , Assistência à Saúde , Pandemias , Pneumonia Viral , Planejamento Antecipado de Cuidados/ética , Planejamento Antecipado de Cuidados/organização & administração , Fatores Etários , Austrália/epidemiologia , Betacoronavirus , Deterioração Clínica , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Estado Terminal/terapia , Assistência à Saúde/organização & administração , Assistência à Saúde/tendências , Necessidades e Demandas de Serviços de Saúde/tendências , Direitos Humanos , Humanos , Inovação Organizacional , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia
15.
R I Med J (2013) ; 103(8): 24-28, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32900008

RESUMO

BACKGROUND: Acute kidney injury (AKI) has been reported as a complication of COVID-19. However, the epidemiology, management, and associated outcomes have varied greatly between studies. The pathophysiology remains unclear.  Summary: The etiology of AKI in the setting of COVID-19 appears multifactorial. Systemic effects of sepsis, inflammation, and vascular injury likely play some role. Furthermore, SARS-CoV-2 binds to the angiotensin-converting enzyme 2 receptor, highly expressed in the kidney, providing a route for direct infection. Older age, baseline comorbidities, and respiratory failure are strong risk factors for the development of AKI. Regardless of etiology, AKI carries a significantly increased risk for in-hospital mortality, especially in those with critical illness. Currently, management of AKI in patients with COVID-19 remains supportive. Key Messages: AKI is common in patients with COVID-19. Future studies are needed to examine the response to anti-viral treatment as well as long-term renal outcomes in patients with AKI.


Assuntos
Lesão Renal Aguda , Betacoronavirus , Infecções por Coronavirus , Estado Terminal , Rim , Pandemias , Administração dos Cuidados ao Paciente/métodos , Pneumonia Viral , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/mortalidade , Lesão Renal Aguda/terapia , Lesão Renal Aguda/virologia , Betacoronavirus/isolamento & purificação , Betacoronavirus/fisiologia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/fisiopatologia , Infecções por Coronavirus/terapia , Infecções por Coronavirus/virologia , Estado Terminal/mortalidade , Estado Terminal/terapia , Mortalidade Hospitalar , Humanos , Rim/metabolismo , Rim/virologia , Peptidil Dipeptidase A/metabolismo , Pneumonia Viral/epidemiologia , Pneumonia Viral/fisiopatologia , Pneumonia Viral/terapia , Pneumonia Viral/virologia , Prognóstico , Medição de Risco , Fatores de Risco , Internalização do Vírus
16.
Tohoku J Exp Med ; 252(2): 103-107, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32938838

RESUMO

Coronavirus disease 2019 (COVID-19) is a global public health concern that can be classified as mild, moderate, severe, or critical, based on disease severity. Since the identification of critical patients is crucial for developing effective management strategies, we evaluated clinical characteristics, laboratory data, treatment provided, and oxygenation to identify potential predictors of mortality among critical COVID-19 pneumonia patients. We retrospectively utilized data from seven critical patients who were admitted to our hospital during April 2020 and required mechanical ventilation. The primary endpoint was to clarify potential predictor of mortality. All patients were older than 70 years, five were men, six had hypertension, and three ultimately died. Compared with survivors, non-survivors tended to be never smokers (0 pack-years vs. 30 pack-years, p = 0.08), to have higher body mass index (31.3 kg/m2 vs. 25.3 kg/m2, p = 0.06), to require earlier tracheal intubation after symptom onset (2.7 days vs. 5.5 days, p = 0.07), and had fewer lymphocytes on admission (339 /µL vs. 518 /µL, p = 0.05). During the first week after tracheal intubation, non-survivors displayed lower values for minimum ratio of the partial pressure of oxygen to fractional inspiratory oxygen concentration (P/F ratio) (44 mmHg vs. 122 mmHg, p < 0.01) and poor response to intensive therapy compared with survivors. In summary, we show that obesity and lymphopenia could predict the severity of COVID-19 pneumonia and that the trend of lower P/F ratio during the first week of mechanical ventilation could provide useful prognostic information.


Assuntos
Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Estado Terminal/terapia , Intubação Intratraqueal , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Fumar , Idoso , Betacoronavirus/fisiologia , Estudos de Coortes , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/mortalidade , Estado Terminal/epidemiologia , Estado Terminal/mortalidade , Feminino , Hospitalização , Humanos , Intubação Intratraqueal/mortalidade , Masculino , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/mortalidade , Prognóstico , Radiografia Torácica , Estudos Retrospectivos , Fatores de Risco , Fumar/efeitos adversos , Fumar/epidemiologia , Fumar/mortalidade , Fumar/terapia , Tomografia Computadorizada por Raios X
17.
Malawi Med J ; 32(1): 19-23, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32733655

RESUMO

Background: Globally, critical illness causes up to 45 million deaths every year. The burden is highest in low-income countries such as Malawi. Critically ill patients require good quality, essential care in emergency departments and in hospital wards to avoid negative outcomes such as death. Little is known about the quality of care or the availability of necessary resources for emergency and critical care in Malawi. The aim of this study was to assess the availability of resources for emergency and critical care in Malawi using data from the Service Provision Assessment (SPA). Methods: We conducted a secondary data analysis of the SPA - a nationwide survey of all health facilities. We assessed the availability of resources for emergency and critical care using previously developed standards for hospitals in low-income countries. Each health facility received an availability score, calculated as the proportion of resources that were present. Resource availability was sub-divided into the seven a-priori defined categories of drugs, equipment, support services, emergency guidelines, infrastructure, training and routines. Results: Of the 254 indicators in the standards necessary for assessing the quality of emergency and critical care, SPA collected data for 102 (40.6%). Hospitals had a median resource availability score of 51.6% IQR (42.2-67.2) and smaller health facilities had a median of 37.5% (IQR 28.1-45.3). For the category of drugs, the hospitals' median score was 62.0% IQR (52.4-81.0), for equipment 51.9% IQR (40.7-66.7), support services 33.3% IQR (22.2-77.8) and emergency guidelines 33.3% IQR (0-66.7). SPA did not collect any data for resources in the categories of infrastructure, training or routines. Conclusion: Hospitals in Malawi lack resources for providing emergency and critical care. Increasing data about the availability of resources for emergency and critical care and improving the hospital systems for the care of critically ill patients in Malawi should be prioritized.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Estado Terminal/terapia , Serviço Hospitalar de Emergência/normas , Recursos em Saúde/provisão & distribução , Qualidade da Assistência à Saúde/normas , Estado Terminal/mortalidade , Serviço Hospitalar de Emergência/estatística & dados numéricos , Pesquisas sobre Serviços de Saúde , Instalações de Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde , Humanos , Malaui/epidemiologia , Inquéritos e Questionários
18.
Crit Care ; 24(1): 485, 2020 08 05.
Artigo em Inglês | MEDLINE | ID: mdl-32758295

RESUMO

BACKGROUND: While obesity confers an increased risk of death in the general population, numerous studies have reported an association between obesity and improved survival among critically ill patients. This contrary finding has been referred to as the obesity paradox. In this retrospective study, two causal inference approaches were used to address whether the survival of non-obese critically ill patients would have been improved if they had been obese. METHODS: The study cohort comprised 6557 adult critically ill patients hospitalized at the Intensive Care Unit of the Ghent University Hospital between 2015 and 2017. Obesity was defined as a body mass index of ≥ 30 kg/m2. Two causal inference approaches were used to estimate the average effect of obesity in the non-obese (AON): a traditional approach that used regression adjustment for confounding and that assumed missingness completely at random and a robust approach that used machine learning within the targeted maximum likelihood estimation framework along with multiple imputation of missing values under the assumption of missingness at random. 1754 (26.8%) patients were discarded in the traditional approach because of at least one missing value for obesity status or confounders. RESULTS: Obesity was present in 18.9% of patients. The in-hospital mortality was 14.6% in non-obese patients and 13.5% in obese patients. The raw marginal risk difference for in-hospital mortality between obese and non-obese patients was - 1.06% (95% confidence interval (CI) - 3.23 to 1.11%, P = 0.337). The traditional approach resulted in an AON of - 2.48% (95% CI - 4.80 to - 0.15%, P = 0.037), whereas the robust approach yielded an AON of - 0.59% (95% CI - 2.77 to 1.60%, P = 0.599). CONCLUSIONS: A causal inference approach that is robust to residual confounding bias due to model misspecification and selection bias due to missing (at random) data mitigates the obesity paradox observed in critically ill patients, whereas a traditional approach results in even more paradoxical findings. The robust approach does not provide evidence that the survival of non-obese critically ill patients would have been improved if they had been obese.


Assuntos
Estado Terminal/mortalidade , Estado Terminal/terapia , Obesidade/epidemiologia , Idoso , Causalidade , Feminino , Mortalidade Hospitalar/tendências , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento
20.
Clin Nutr ESPEN ; 39: 74-78, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32859332

RESUMO

BACKGROUND & AIMS: COVID-19 pandemic had resulted in a massive increase in the number of patients admitted to intensive care units (ICUs). This created significant organizational challenges including numerous non-specialist ICU caregivers who came to work in the ICU. In this context, pragmatic protocols were essential to simplify nutritional care. We aimed at providing a simple and easy-to-prescribe nutritional protocol and evaluated its usefulness with questionnaires sent to physicians involved in the care of ICU COVID-19 patients. METHODS: A simplified nutrition protocol was distributed to all physicians (n = 122) of the ICU medical team during COVID-19 pandemic. Clinical dieticians estimated energy targets for acute and post-acute phases at patient's admission and suggested adaptations of nutrition therapy. More complex situations were discussed with clinical nutrition doctors and, if required, a clinical evaluation was performed. To further facilitate the procedure, a chart with prescription aids was also distributed to the whole medical ICU team. At the end of the current pandemic wave, a 13-item questionnaire was emailed to the ICU medical team to obtain their opinion on the suggested nutritional therapy. RESULTS: Answers were received from 81/122 medical doctors (MDs) (66% response rate), from intensive care physicians (41%), anaesthesiologists (53%) and MDs from other specialties (6%). Thirty-two percent of MDs felt that their knowledge of nutrition management was insufficient and 45% of the physicians surveyed did not face nutrition management in their daily practice prior to the pandemic. The initially proposed nutritional protocol, the chart with prescription aids and the suggested nutritional proposals were considered as useful to very useful by the majority of physicians surveyed (89.9, 90.7 and 92.1% respectively). The protocol was followed by 92% of MDs, and almost all participants (95%) were convinced that adaptations of nutritional therapy had beneficial effects on patients' outcomes. CONCLUSIONS: Nutritional therapy in critically ill COVID-19 patients is a challenge and the implementation of this specific pandemic simplified nutritional protocol was assessed as useful by a great majority of physicians. Pragmatic and simplified protocols are useful for ensuring the quality of nutritional therapy and could be used in future studies to assess its actual impact on the clinical outcomes of COVID-19 patients.


Assuntos
Infecções por Coronavirus/terapia , Cuidados Críticos/métodos , Apoio Nutricional/métodos , Pneumonia Viral/terapia , Atitude do Pessoal de Saúde , Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/metabolismo , Infecções por Coronavirus/virologia , Estado Terminal/terapia , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/metabolismo , Pneumonia Viral/virologia , Prescrições , Inquéritos e Questionários , Suíça/epidemiologia
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