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2.
Surg Clin North Am ; 99(5): 955-965, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31446920

RESUMO

Surgeons are often asked to perform tracheostomies and percutaneous endoscopic gastrostomies for a wide variety of patients. As consultants, surgeons are tasked with honoring the relationship between the referring provider and the patient while also assessing whether the consult is appropriate given the patient's prognosis and goals of care. This article discusses the most common conditions for which these procedures are requested and reviews the evidence supporting either the placement or avoidance of these tubes in each condition. It provides a framework for surgeons to use when discussing these procedures in the context of goals of care.


Assuntos
Endoscopia Gastrointestinal , Nutrição Enteral , Neoplasias de Cabeça e Pescoço/cirurgia , Doenças do Sistema Nervoso/cirurgia , Traqueostomia , Ferimentos e Lesões/cirurgia , Estado Terminal/terapia , Endoscopia Gastrointestinal/efeitos adversos , Endoscopia Gastrointestinal/mortalidade , Humanos , Cuidados Paliativos/ética , Traqueostomia/efeitos adversos , Traqueostomia/mortalidade
3.
Medicine (Baltimore) ; 98(31): e16678, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31374047

RESUMO

RATIONALE: The benefits of prolonged endotracheal intubation (ETI) in comparison to early tracheotomy is still over the controversy. Little information is available in concern to prolonged ETI more than years. We report the consequence of oral ETI in a 95-year old man for 839 days. PATIENT CONCERNS: This patient was transferred to the intensive care unit due to sputum asphyxia and respiratory arrest. Timely ETI was performed. However, as a neurological insult, extubation had a high risk of failure due to the insufficient ability of sputum clearance. In addition, his family members refused further surgical interventions including tracheotomy. DIAGNOSES: Prolonged ETI occurred in this patient. On day 240 and 329 after ETI, 3D airway image did not reveal laryngeal stenosis or laryngeal lesions. On day 459 and 662, ET tube (ETT) exchanged was performed and the balloon became stiff and inelasticity. INTERVENTIONS: Although a possible tracheoesophageal fistula was suspected by imaging findings on day 547, the gastroscopy did not reveal the fistula on the esophagus. Enteral nutrition was delivered through the gastric tube, while the mediastinal infection was not observed during subsequent follow-up of computed tomography. OUTCOMES: He received tracheostomy due to acute sputum obstruction within ETT and abrupt oxygen desaturation on day 839. LESSONS: During prolonged ETI, more attention should focus on airway humidification, proper cuff pressure and optimal time for tube exchange in order to avoid severe complications.


Assuntos
Manuseio das Vias Aéreas/instrumentação , Intubação Intratraqueal/métodos , Insuficiência Respiratória/terapia , Idoso de 80 Anos ou mais , Estado Terminal/terapia , Esôfago/diagnóstico por imagem , Humanos , Intubação Intratraqueal/efeitos adversos , Masculino , Qualidade de Vida , Tomografia Computadorizada por Raios X
4.
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
5.
Emerg Med Clin North Am ; 37(3): 569-581, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31262422

RESUMO

The emergency department resuscitation of the critically ill geriatric patient is challenging and can be fraught with peril. The anatomic and physiologic changes that occur with aging can significantly influence the recognition of critical illness and the logistics of resuscitation itself. This article discusses the relevant physiologic changes with aging, the effect of these changes on clinical manifestations of critical illness in older adults, and the core principles of resuscitation in this population, with specific attention to sepsis and trauma care. In addition, end-of-life care is also discussed.


Assuntos
Estado Terminal/terapia , Serviço Hospitalar de Emergência , Ressuscitação , Idoso , Fenômenos Fisiológicos Cardiovasculares , Disfunção Cognitiva/complicações , Medicina de Emergência , Fragilidade/complicações , Avaliação Geriátrica , Taxa de Filtração Glomerular , Humanos , Hipnóticos e Sedativos/uso terapêutico , Imunossenescência , Limitação da Mobilidade , Manejo da Dor , Farmacocinética , Exame Físico , Fenômenos Fisiológicos Respiratórios , Sepse/diagnóstico , Sepse/terapia , Assistência Terminal , Equilíbrio Hidroeletrolítico , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia
6.
Rev Med Chil ; 147(4): 409-415, 2019 Apr.
Artigo em Espanhol | MEDLINE | ID: mdl-31344201

RESUMO

BACKGROUND: In critical patients with acute renal failure, intermittent diffusive renal replacement techniques cause hemodynamic problems due to their high depurative efficiency. This situation is avoided using continuous low efficiency therapies, which are expensive, prevent patient mobilization and add hemorrhagic risk due to systemic anticoagulation. Intermittent and prolonged hemodiafiltration (HDF) has the depurative benefits of diffusion, plus the positive attributes of convection in a less expensive therapy. AIM: To report our experience with intermittent and prolonged on-line HDF in critically ill patients. PATIENTS AND METHODS: During 2016, HDF therapies performed on critical patients with indication of renal replacement therapy were characterized. The hemodynamic profile was evaluated (doses of noradrenaline, blood pressure, heart rate and perfusion parameters). RESULTS: Fifty-one therapies were performed in 25 critical patients, aged 58 ± 11 years (28% women), with an APACHE II score of 22.1 ±10. The average time of the therapies was 4.15 hours (range 3-8 hours), the replacement volume was 75 ± 18 mL/kg/h and ultrafiltration rate was 226 ± 207 mL/h. The mean initial, maximum and final noradrenaline doses were 0.07 ± 0.1, 0.13 ±0.18 and 0.09 ±0.16 µg/kg/min respectively. No differences between patients with low, medium and high doses of noradrenaline or dose increases during therapy, were observed. The greatest decrease in mean arterial pressure was 15.3% and the maximum increase in heart rate was 12.8%. Anticoagulation was not required in 88% of therapies. CONCLUSIONS: High-volume intermittent or prolonged HDF is an effective therapy in critical patients, with good hemodynamic tolerability, lower costs and avoidance of systemic anticoagulation risks.


Assuntos
Lesão Renal Aguda/terapia , Estado Terminal/terapia , Hemodiafiltração/métodos , Terapia de Substituição Renal/métodos , APACHE , Idoso , Análise de Variância , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem , Estudos Prospectivos , Resultado do Tratamento
7.
Z Gerontol Geriatr ; 52(5): 440-456, 2019 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-31278486

RESUMO

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


Assuntos
Cuidados Críticos/métodos , Estado Terminal/terapia , Avaliação Geriátrica/métodos , Idoso , Consenso , Idoso Fragilizado , Humanos
9.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 31(5): 539-544, 2019 May.
Artigo em Chinês | MEDLINE | ID: mdl-31198136

RESUMO

OBJECTIVE: To investigate the benefits and risks of stress ulcer prevention (SUP) using proton pump inhibitors (PPI) for critical patients. METHODS: The clinical data of adult critically ill patients admitted to the intensive care unit (ICU) of Northern Jiangsu People's Hospital from January 2016 to December 2018 were retrospectively analyzed. All patients who were treated with PPI for SUP within the first 48 hours after ICU admission were enrolled in the SUP group. Those who not received PPI were enrolled in the control group. A one-to-one propensity score matching (PSM) was performed to control for potential biases. The gender, age, underlying diseases, main diagnosis of ICU, drug use before ICU admission, sequential organ failure score (SOFA) at ICU admission, risk factors of stress ulcer (SU) and PPI usage were recorded. The end point was the incidence of gastrointestinal bleeding, hospital acquired pneumonia, Clostridium difficile infection and 30-day mortality. Kaplan-Meier survival curves were plotted, and survival analysis was performed using the log-rank test. RESULTS: 1 972 critical patients (788 in the SUP group and 1 184 in the control group) were enrolled, and each group enrolled 358 patients after PSM. Prior to PSM, compared with the control group, the SUP group had older patients, more underlying diseases, higher proportion of acute coronary syndrome (ACS), acute cerebrovascular disease, acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and poisoning in main diagnosis of ICU, more serious illness, and more risk factors of SU, indicating that ICU physicians were more likely to prescribe SUP for these patients. The incidence of gastrointestinal bleeding in the SUP group was significantly lower than that in the control group [1.8% (14/788) vs. 3.7% (44/1 184), P < 0.05], while the incidence of hospital acquired pneumonia and 30-day mortality were significantly higher than those in the control group [6.6% (52/788) vs. 3.5% (42/1 184), 17.9% (141/788) vs. 13.1% (155/1 184), both P < 0.01]. There was no significant difference in the incidence of Clostridium difficile infection between the SUP group and the control group [2.9% (23/788) vs. 1.8% (21/1 184), P > 0.05]. After the propensity scores for age, underlying diseases, severity of illness and SU risk factors were matched, there was no significant difference in the incidence of gastrointestinal bleeding or 30-day mortality between the SUP group and the control group [2.2% (8/358) vs. 3.4% (12/358), 15.9% (57/358) vs. 13.7% (49/358), both P > 0.05], but the incidence of hospital acquired pneumonia in the SUP group was still significantly higher than that in the control group [6.7% (24/358) vs. 3.1% (11/358), P < 0.05]. Kaplan-Meier survival curve analysis showed that the 30-day cumulative survival rate of the SUP group was significantly lower than that of the control group before the PSM (log-rank test: χ2 = 9.224, P = 0.002). There was no significant difference in the 30-day cumulative survival rate between the two groups after PSM (log-rank test: χ2 = 0.773, P = 0.379). CONCLUSIONS: For critical patients, the use of PPI for SUP could not significantly reduce the incidence of gastrointestinal bleeding and mortality, but increase the risk of hospital acquired pneumonia.


Assuntos
Estado Terminal/terapia , Úlcera Péptica/prevenção & controle , Inibidores da Bomba de Prótons/uso terapêutico , Adulto , Humanos , Unidades de Terapia Intensiva , Inibidores da Bomba de Prótons/efeitos adversos , Estudos Retrospectivos , Medição de Risco , Estresse Fisiológico
10.
BMC Health Serv Res ; 19(1): 384, 2019 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-31196072

RESUMO

BACKGROUND: When doctors have honest conversations with patients about their illness and involve them in decisions about their care, patients express greater satisfaction with care and lowered anxiety and depression. The Serious Illness Care Programme (the Programme), originally developed in the United States (U.S), promotes meaningful, realistic and focused conversations about patient's wishes, fears and worries for the future with their illness. The Serious Illness Conversation Guide (the guide) provides a framework to structure these conversations. The aim of this paper is to present findings from a study to examine the 'face validity', acceptability and relevance of the Guide for use within the United Kingdom (UK) health care setting. METHODS: A multi-stage approach was undertaken, using three separate techniques: 1. Nominal Group Technique with clinician 'expert groups' to review the Serious Illness Conversation Guide: 14 'experts' in Oncology, Palliative Care and Communication Skills; 2. Cognitive Interviews with 6 patient and public representatives, using the 'think aloud technique'; to explore the cognitive processes involved in answering the questions in the guide, including appropriateness of language, question wording and format 3. Final stakeholder review and consensus. RESULTS: Nominal Group Technique Unanimous agreement the conversation guide could provide a useful support to clinicians. Amendments are required but should be informed directly from the cognitive interviews. Training highlighted as key to underpin the use of the guide. Cognitive interviews The 'holistic' attention to the person as a whole was valued rather than a narrow focus on their disease. Some concern was raised regarding the 'formality' of some wording however and suggestions for amendments were made. Final stakeholder review Stakeholders agreed amendments to 5/13 prompts and unanimously agreed the UK guide should be implemented as a part of the pilot implementation of the Serious Illness Care Programme UK. CONCLUSION: Use of the guide has the potential to benefit patients, facilitating a 'person-centred' approach to these important conversations, and providing a framework to promote shared decision making and care planning. Further research is ongoing, to understand the impact of these conversations on patients, families and clinicians and on concordance of care delivery with expressed patient wishes.


Assuntos
Estado Terminal/terapia , Planejamento de Assistência ao Paciente , Atitude do Pessoal de Saúde , Comunicação , Estado Terminal/psicologia , Tomada de Decisões , Pesquisa sobre Serviços de Saúde , Humanos , Cuidados Paliativos , Planejamento de Assistência ao Paciente/normas , Relações Profissional-Família , Reino Unido
11.
BMC Health Serv Res ; 19(1): 379, 2019 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-31196076

RESUMO

BACKGROUND: Initiating parenteral nutrition (PN) within 24 h in critically ill children is inferior to withholding PN during the first week, as was found in the PEPaNIC study. The aims of this study were to investigate de-implementation of early initiation of PN at PICUs worldwide, and to identify factors influencing de-implementation. METHODS: A cross-sectional online survey was conducted (May - October 2017), consisting of 41 questions addressing current PN practices, the degree of de-implementation, and factors affecting de-implementation. RESULTS: We analysed 81 responses from 39 countries. Of these 81 respondents, 53 (65%) were aware of the findings of the PEPaNIC study, and 43 (53%) have read the article. In these 43 PICUs, PN was completely withheld during the first week in 10 PICUs, of which 5 already withheld PN (12%), and 5 de-implemented early initiation of PN (12%). Partial de-implementation was reported by 17 (40%) and no de-implementation by 16 (37%). Higher de-implementation rates were observed when the interpreted level of evidence and grade of recommendation of PEPaNIC was high. Predominant reasons for retaining early initiation of PN were concerns on withholding amino acids, the safety in undernourished children and neonates, and the long-term consequences. Furthermore, the respondents were waiting for updated guidelines. CONCLUSIONS: One year after the publication of the PEPaNIC trial, only two-thirds of the respondents was aware of the study results. Within this group, early initiation of PN was de-implemented completely in 12% of the PICUs, while 40% asserted partial de-implementation. Increasing the awareness, addressing the intervention-specific questions and more frequently revising international guidelines might help to accelerate de-implementation of ineffective, unproven or harmful healthcare.


Assuntos
Estado Terminal/terapia , Fidelidade a Diretrizes , Unidades de Terapia Intensiva Pediátrica , Nutrição Parenteral/métodos , Criança , Estudos Transversais , Medicina Baseada em Evidências , Feminino , Humanos , Masculino , Nutrição Parenteral/efeitos adversos , Guias de Prática Clínica como Assunto , Fatores de Tempo
12.
Crit Care Resusc ; 21(2): 103-109, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31142240

RESUMO

BACKGROUND: Discomfort experienced by patients admitted to intensive care units (ICUs) is an important indicator of the quality of care provided, but few studies have evaluated the incidence and magnitude of discomfort in critically ill patients. The IPREA (Inconforts des Patients de REAnimation) discomfort questionnaire is a tool developed by French intensivists and validated in the French language with good internal consistency (Cronbach's α, 0.78). OBJECTIVES: To translate and validate in English the IPREA discomfort questionnaire, to evaluate discomfort perceived by patients in intensive care, and to identify predictors of discomfort. DESIGN, SETTING AND PARTICIPANTS: After translating the IPREA questionnaire using published methods that use principles of good practice for translating and culturally adapting patient-reported outcomes measures, all eligible patients (aged > 18 years, Glasgow Coma Scale score of 15, English speaking) admitted to our ICU over the 6-month period from April 2017 to September 2017 were surveyed within 24 hours of ICU discharge. Patient-perceived discomfort was measured using the translated IPREA questionnaire. The patients were asked to score their discomfort for each of 16 items on a scale of 0 (no discomfort) to 100 (maximum discomfort). An overall discomfort score was computed as the mean score of the 16 individual discomfort scores. Multivariate analysis was performed to identify predictors of discomfort. MAIN OUTCOME MEASURES: Translated questionnaire internal consistency. Individual and overall discomfort scores. RESULTS: A total of 168 patients (58% men; mean age, 60.1 ± 14.8 years; mean APACHE [Acute Physiology and Chronic Health Evaluation] II score, 13.8 ± 5.6) completed the questionnaire. The translated questionnaire had good internal consistency (Cronbach's α, 0.82), and good content and construct validity (average inter-item correlation, 0.23). The mean overall discomfort score was 18.4 ± 12.5, and discomfort scores did not differ between men and women or between types of ICUs (general ICU, cardiothoracic ICU or high dependency unit). On multivariate analysis, increasing age was an independent predictor of a low discomfort score (ß, -0.27; 95% CI, -0.42 to -0.12; P = 0.001). CONCLUSION: Patients admitted to our ICU reported low overall discomfort. There was an inverse relationship between age and perceived discomfort. The translated questionnaire for measuring discomfort performed well in our setting and could be applied to the Australian population.


Assuntos
Cuidados Críticos , Estado Terminal/psicologia , Unidades de Terapia Intensiva , Qualidade da Assistência à Saúde , Inquéritos e Questionários/normas , Adolescente , Idoso , Austrália , Estado Terminal/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Psicometria , Reprodutibilidade dos Testes
13.
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
14.
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
15.
Top Companion Anim Med ; 35: 38-41, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31122686

RESUMO

This prospective study assesses the presence of immediate and delayed clinical hypersensitivity reactions in 40 hypoalbuminemic critically ill cats during and after an intravenous administration of 5% human serum albumin (HSA). Twenty hypoalbuminemic critically ill cats with no known exposure to HSA (control group) were also checked in order to highlight any clinical signs related to the underlying disease which could mimic hypersensitivity reactions. The administration of 10-20 mL/kg of 5% HSA at 2 mL/kg/h in critically ill cats did not lead to clinical signs of types I and III hypersensitivity reactions at days 0, 7, 14, 21, and 28, unlike previous findings with 25% HSA in this species.


Assuntos
Doenças do Gato/terapia , Hipersensibilidade/veterinária , Albumina Sérica Humana/efeitos adversos , Albumina Sérica Humana/uso terapêutico , Animais , Gatos , Estado Terminal/terapia , Feminino , Hipoalbuminemia/veterinária , Infusões Intravenosas , Masculino , Estudos Prospectivos
16.
Top Companion Anim Med ; 35: 47-52, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31122688

RESUMO

The gut is the site of digestion and absorption as well as serving as an endocrine and immune organ. All of these functions may be affected by critical illness. This review will discuss secondary effects of critical illness on the gut in terms of gastrointestinal function that is clinically observable and discuss consequences of gut dysfunction with critical illness to patient outcome. Because there is little evidence-based medicine in the veterinary field, much of our understanding of gut dysfunction with critical illness comes from animal models or from the human medical field. We can extrapolate some of these conclusions and recommendations to companion animals, particularly in dogs, who have similar gastrointestinal physiology to people. Additionally, the evidence regarding gut dysfunction in veterinary patients will be explored. By recognizing signs of dysfunction early and taking preventative measures, we may be able to increase success with treatment of critical illnesses.


Assuntos
Estado Terminal/terapia , Gastroenteropatias/veterinária , Animais , Doenças do Gato/diagnóstico , Doenças do Gato/terapia , Gatos , Doenças do Cão/diagnóstico , Doenças do Cão/terapia , Cães , Gastroenteropatias/diagnóstico , Gastroenteropatias/terapia , Trato Gastrointestinal/fisiopatologia , Humanos
17.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 31(4): 400-402, 2019 Apr.
Artigo em Chinês | MEDLINE | ID: mdl-31109409

RESUMO

OBJECTIVE: With the rapid development of modern science and technology, the treatment level of all disciplines of modern medicine has been rapidly improved. The number of critically ill patients in large third-level first-class general hospitals is increasing day by day. Intensive care unit (ICU) has become an important embodiment of the comprehensive strength of a hospital, especially the affiliated hospital of medical university or a tertiary hospital. This paper aims to discuss the role, status and contribution of critical care medicine in the development and construction of modern medicine and general hospitals, the relationship between hospital management and critical care medicine management, and the future development and construction direction of critical care medicine from the perspective of the managers of third-level first-class general hospitals.


Assuntos
Cuidados Críticos/organização & administração , Hospitais Universitários , Especialização , Estado Terminal/terapia , Humanos , Unidades de Terapia Intensiva
18.
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
19.
Medicine (Baltimore) ; 98(22): e15835, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31145326

RESUMO

There is ongoing controversy about how to address the growing demand for intensive care for critically ill elderly patients. We investigated resource utilization patterns and mortality rates according to age among critically ill patients.We retrospectively analyzed the medical records of patients admitted to a medical intensive care unit (ICU) in a tertiary referral teaching hospital between July 2006 and June 2015. Patients were categorized into non-elderly (age <65 years, n = 4140), young-elderly (age 65-74 years, n = 2306), and old-elderly (age ≥75 years, n = 1508) groups.Among 7954 admissions, the mean age was 61.5 years, and 5061 (63.6%) were of male patients. The proportion of comorbidities increased with age (64.6% in the non-elderly vs 81.4% in the young-elderly vs 82.8% in the old-elderly, P < .001 and P for trend <.001), whereas the baseline Sequential Organ Failure Assessment (SOFA) score decreased with age (8.1 in the non-elderly vs 7.2 in the young-elderly vs 7.2 in the old-elderly, P < .001, R = -.092 and P for trend <.001). Utilization rates of mechanical ventilation (48.6% in the non-elderly vs 48.3% in the young-elderly vs 45.5% in the old-elderly, P = .11) and renal replacement therapy (27.5% in the non-elderly vs 25.5% in the young-elderly vs 24.8% in the old-elderly, P = .069) were comparable between the age groups. The 28-day ICU mortality rates were lower in the young-elderly and the old-elderly groups than in the non-elderly group (35.6% in the non-elderly vs 34.2% in the young-elderly, P = .011; and vs 32.6% in the old-elderly, P = .002).A substantial number of critically ill elderly patients used medical resources as non-elderly patients and showed favorable clinical outcomes. Our results support that underlying medical conditions rather than age per se need to be considered for determining intensive care.


Assuntos
Estado Terminal/terapia , Recursos em Saúde/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Mortalidade Hospitalar/tendências , Hospitais de Ensino/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Terapia de Substituição Renal/estatística & dados numéricos , República da Coreia , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos
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