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2.
Crit Care ; 23(1): 68, 2019 Feb 28.
Artigo em Inglês | MEDLINE | ID: mdl-30819227

RESUMO

BACKGROUND: Data on high-flow nasal oxygen after thoracic surgery are limited and confined to the comparison with low-flow oxygen. Different from low-flow oxygen, Venturi masks provide higher gas flow at a predetermined fraction of inspired oxygen (FiO2). We conducted a randomized trial to determine whether preemptive high-flow nasal oxygen reduces the incidence of postoperative hypoxemia after lung resection, as compared to Venturi mask oxygen therapy. METHODS: In this single-center, randomized trial conducted in a teaching hospital in Italy, consecutive adult patients undergoing thoracotomic lung resection, who were not on long-term oxygen therapy, were randomly assigned to receive high-flow nasal or Venturi mask oxygen after extubation continuously for two postoperative days. The primary outcome was the incidence of postoperative hypoxemia (i.e., ratio of the partial pressure of arterial oxygen to FiO2 (PaO2/FiO2) lower than 300 mmHg) within four postoperative days. RESULTS: Between September 2015 and April 2018, 96 patients were enrolled; 95 patients were analyzed (47 in high-flow group and 48 in Venturi mask group). In both groups, 38 patients (81% in the high-flow group and 79% in the Venturi mask group) developed postoperative hypoxemia, with an unadjusted odds ratio (OR) for the high-flow group of 1.11 [95% confidence interval (CI) 0.41-3] (p = 0.84). No inter-group differences were found in the degree of dyspnea nor in the proportion of patients needing oxygen therapy after treatment discontinuation (OR 1.34 [95% CI 0.60-3]), experiencing pulmonary complications (OR 1.29 [95% CI 0.51-3.25]) or requiring ventilatory support (OR 0.67 [95% CI 0.11-4.18]). Post hoc analyses revealed that PaO2/FiO2 during the study was not different between groups (p = 0.92), but patients receiving high-flow nasal oxygen had lower arterial pressure of carbon dioxide, with a mean inter-group difference of 2 mmHg [95% CI 0.5-3.4] (p = 0.009), and were burdened by a lower risk of postoperative hypercapnia (adjusted OR 0.18 [95% CI 0.06-0.54], p = 0.002). CONCLUSIONS: When compared to Venturi mask after thoracotomic lung resection, preemptive high-flow nasal oxygen did not reduce the incidence of postoperative hypoxemia nor improved other analyzed outcomes. Further adequately powered investigations in this setting are warranted to establish whether high-flow nasal oxygen may yield clinical benefit on carbon dioxide clearance. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02544477 . Registered 9 September 2015.


Assuntos
Pulmão/cirurgia , Oxigenoterapia/instrumentação , Oxigenoterapia/métodos , Idoso , Gasometria/estatística & dados numéricos , Feminino , Humanos , Itália , Masculino , Máscaras/normas , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Troca Gasosa Pulmonar/fisiologia , Procedimentos Cirúrgicos Torácicos/métodos , Resultado do Tratamento
3.
PLoS One ; 14(2): e0211104, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30768603

RESUMO

Portable blood gas analyzers are used to facilitate diagnosis and treatment of disorders related to disturbances of acid-base and electrolyte balance in the ambulatory care of equine patients. The aim of this study was to determine whether 2 portable analyzers produce results in agreement with a stationary analyzer. Blood samples from 23 horses hospitalized for various medical reasons were included in this prospective study. Blood gas analysis and electrolyte concentrations measured by the portable analyzers VetStat and epoc were compared to those produced by the cobas b 123 analyzer via concordance analysis, Passing-Bablok regression and Bland-Altman analysis. Limits of agreement indicated relevant bias between the VetStat and cobas b 123 for partial pressure of oxygen (pO2; 27.5-33.8 mmHg), sodium ([Na+]; 4.3-21.6 mmol/L) and chloride concentration ([Cl-]; 0.3-7.9 mmol/L) and between the epoc and cobas b 123 for pH (0.070-0.022), partial pressure of carbon dioxide (pCO2; 3.6-7.3 mmHg), pO2 (36.2-32.7 mmHg) and [Na+] (0.38.1 mmol/L). The VetStat analyzer yielded results that were in agreement with the cobas b 123 analyzer for determination of pH, pCO2, bicarbonate ([HCO3-]) and potassium concentration [K+], while the epoc analyzer achieved acceptable agreement for [HCO3-] and [K+]. The VetStat analyzer may be useful in performing blood gas analysis in equine samples but analysis of [Na+], [Cl-] and pO2 should be interpreted with caution. The epoc delivered reliable results for [HCO3-] and [K+], while results for pH, pCO2, pO2 and [Na+] should be interpreted with caution.


Assuntos
Gasometria/instrumentação , Eletrólitos/sangue , Cavalos/sangue , Animais , Bicarbonatos/sangue , Gasometria/estatística & dados numéricos , Dióxido de Carbono/sangue , Cloretos/sangue , Feminino , Concentração de Íons de Hidrogênio , Masculino , Oxigênio/sangue , Pressão Parcial , Sistemas Automatizados de Assistência Junto ao Leito , Potássio/sangue , Estudos Prospectivos , Reprodutibilidade dos Testes , Sódio/sangue
4.
Wien Klin Wochenschr ; 131(5-6): 97-103, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30689047

RESUMO

OBJECTIVE: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are the major reason for COPD hospitalization and increased risk for readmissions. The organizational structure of Austrian hospitals provides the opportunity to investigate the impact of specialized respiratory care compared to general care on adherence to guidelines and readmission in AECOPD. METHODS: The data from the European COPD audit, a prospective observational non-interventional cohort trial were analyzed. In total, 823 patients admitted due to AECOPD in 26 hospitals (specialized respiratory care vs. general care) within Austria were included. Patients characteristics and outcomes (length of stay, readmission rate, and mortality) were analyzed in relation to hospital resources (personnel and equipment) and adherence to international guidelines. RESULTS: Patients admitted to general care had more comorbidities (Charlson comorbidity index: 2.6 ± 1.7 vs. 2.0 ± 1.4; p < 0.05) and a shorter length of stay (10.7 ± 7.8 days vs. 12.0 ± 10.2 days; p < 0.05). Patients admitted to specialized respiratory care more often underwent blood gas analysis and non-invasive ventilation (98.4% vs. 81.5% and 68.6% vs. 26.7%, p < 0.01; respectively). In multivariate analysis, the risk for AECOPD readmission was lower (odds ratio, OR 0.72 [0.51;0.91]; p < 0.05) in patients admitted to specialized respiratory care. CONCLUSION: A greater adherence to COPD guidelines with respect to blood gas analysis and non-invasive ventilation and decreased AECOPD readmission risk was observed for patients admitted to specialized respiratory care. Adherence to guidelines may have the potential to decrease COPD readmission rates.


Assuntos
Fidelidade a Diretrizes , Readmissão do Paciente , Doença Pulmonar Obstrutiva Crônica , Idoso , Áustria , Gasometria/estatística & dados numéricos , Estudos de Coortes , Comorbidade , Feminino , Humanos , Tempo de Internação , Masculino , Readmissão do Paciente/estatística & dados numéricos , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/mortalidade , Doença Pulmonar Obstrutiva Crônica/terapia , Estudos Retrospectivos
5.
Am J Emerg Med ; 37(6): 1048-1053, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30131206

RESUMO

INTRODUCTION: Blood gas analyzers can be alternatives to laboratory autoanalyzers for obtaining test results in just a few minutes. We aimed to find out whether the results from blood gas analyzers are reliable when compared to results of core laboratory autoanalyzers. MATERIALS AND METHODS: This retrospective, single-centered study examined the electronic records of patients admitted to the emergency department of a tertiary care teaching hospital between May 2014 and December 2017. Excluded from the study were patients under 18 years old, those lacking data, those who had any treatment before the laboratory tests, those whose venous gas results were reported more than 30 minutes after the blood sample was taken and for whom any of the laboratory tests were performed at a different time, and recurrent laboratory results from a single patient. RESULTS: Laboratory results were analyzed from a total of 31,060 patients. The correlation coefficients for sodium, potassium, hemoglobin, hematocrit, and glucose levels measured by a blood gas analyzer and a laboratory autoanalyzer were 0.725, 0.593, 0.982, 0.958, and 0.984, respectively; however, there were no good, acceptable agreement limits for any of the parameters. In addition, these results did not change according to the different pH stages (acidosis, normal pH and alkalosis). CONCLUSION: The two types of measurements showed a moderate correlation for sodium and potassium levels and a strong correlation for glucose, hemoglobin, and hematocrit levels, but none of the levels had acceptable agreement limits. Clinicians should be aware of the limitations of blood gas analyzer results.


Assuntos
Autoanálise/normas , Gasometria/normas , Adulto , Idoso , Autoanálise/instrumentação , Autoanálise/estatística & dados numéricos , Gasometria/instrumentação , Gasometria/estatística & dados numéricos , Feminino , Glucose/análise , Hematócrito/instrumentação , Hematócrito/normas , Hemoglobinas/análise , Humanos , Masculino , Pessoa de Meia-Idade , Sistemas Automatizados de Assistência Junto ao Leito/normas , Sistemas Automatizados de Assistência Junto ao Leito/estatística & dados numéricos , Potássio/análise , Estudos Retrospectivos , Sódio/análise
6.
Eur J Emerg Med ; 26(1): 53-58, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28777122

RESUMO

OBJECTIVE: The aim of this study was to describe the impact of a clinical network-led quality improvement project on compliance with bundle of care elements (individually and as a 'bundle') for patients treated for chronic obstructive pulmonary disease exacerbations in the emergency department. PARTICIPANTS AND METHODS: A 9-month quality improvement project was performed by a modified knowledge transfer methodology with analysis by before and after data collection. The primary outcomes of interest were compliance with key bundle of care elements (individually and as a 'bundle'). The analysis is descriptive. RESULTS: Seven emergency departments participated in the project. A total of 179 patients were included in the predata and 203 in the postdata. Administration of controlled oxygen therapy (if oxygen given) increased from 74 to 80% (P=nonsignificant). Administration of inhaled bronchodilators increased from 80 to 91% (P=0.004). Administration of systemic corticosteroids increased from 76 to 88% (P=0.003). Administration of antibiotics (if evidence of infection) increased from 85 to 99% (P<0.001). Analysis of a blood gas in nonmild disease increased from 82 to 91% (P=0.04) and administration of noninvasive ventilation if pH less than 7.3 increased from 53 to 81% (P=0.01). Compliance with all appropriate elements of the defined bundle of care increased from 43 to 63% (P<0.001). CONCLUSION: A locally managed, clinical network-supported quality improvement project resulted in significant improvements in compliance with chronic obstructive pulmonary disease bundle of care elements.


Assuntos
Serviço Hospitalar de Emergência/normas , Doença Pulmonar Obstrutiva Crônica/terapia , Corticosteroides/uso terapêutico , Antibacterianos/uso terapêutico , Austrália , Gasometria/estatística & dados numéricos , Broncodilatadores/uso terapêutico , Humanos , Oxigenoterapia/estatística & dados numéricos , Pacotes de Assistência ao Paciente/estatística & dados numéricos , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Melhoria de Qualidade
7.
J Clin Sleep Med ; 14(9): 1539-1550, 2018 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-30176976

RESUMO

STUDY OBJECTIVES: To assess the role of different levels of adherence and long-term effects of positive airway pressure (PAP) therapy on gas exchange, sleepiness, quality of life, depressive symptoms, and all-cause mortality in patients with obesity hypoventilation syndrome (OHS). METHODS: A total of 252 patients with newly diagnosed OHS were followed up for a minimum of 2 years after PAP initiation. PAP adherence (h/night) was monitored. Arterial blood gas samples were taken with patients being alert for more than 4 hours after morning awakening. Subjective daytime sleepiness (Epworth Sleepiness Scale [ESS]), quality of life (Short Form 36 [SF-36]) and patient's depressive symptoms (Beck Depression Inventory [BDI]) were assessed before and at the end of the follow-up period, along with all-cause mortality. RESULTS: At the end of the follow-up period (median duration [25th-75th percentile], 30 [24-52] months), PaO2 increased from baseline (72.7 ± 10.3 versus 63.2 ± 10.6, P < .001) and both PaCO2 and HCO3- decreased (43.0 [39.2-45.0] versus 50.0 [46.7-55.4] and 27.5 ± 3.2 versus 31.4 ± 4.2, respectively, P < .001). In addition, PAP therapy significantly improved ESS (7 [4-9] versus 14 [11-16], P < .001), BDI (8.8 ± 4.9 versus 15.5 ± 7.3, P < .001) and SF-36 (82 [78-87] versus 74 [67-79], P < .001) scores. Over the follow-up period 11 patients died. Patients who used PAP for > 6 h/night had significant improvements (P < .05) in blood gases and SF-36 scores than less adherent patients. CONCLUSIONS: Increased hours of use and long-term therapy with PAP are effective in the treatment of patients with OHS. Clinicians should encourage adherence to PAP therapy in order to provide a significant improvement in clinical status and gas exchange in these patients. COMMENTARY: A commenary on this article appears in this issue on page 1455. CLINICAL TRIAL REGISTRATION: Title: PAP Therapy in Patients With Obesity Hypoventilation Syndrome, Registry: ClinicalTrials.gov, Identifier: NCT03449641, URL: https://clinicaltrials.gov/ct2/show/NCT03449641.


Assuntos
Pressão Positiva Contínua nas Vias Aéreas/métodos , Síndrome de Hipoventilação por Obesidade/terapia , Cooperação do Paciente/estatística & dados numéricos , Idoso , Gasometria/estatística & dados numéricos , Pressão Positiva Contínua nas Vias Aéreas/estatística & dados numéricos , Transtorno Depressivo/complicações , Transtorno Depressivo/psicologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome de Hipoventilação por Obesidade/complicações , Síndrome de Hipoventilação por Obesidade/fisiopatologia , Polissonografia , Estudos Prospectivos , Qualidade de Vida/psicologia , Resultado do Tratamento
8.
PLoS One ; 13(8): e0202194, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30153271

RESUMO

A group of injured yellow-bellied sliders (Trachemys scripta) and river cooters (Pseudemys concinna) were evaluated for a variety of health values at presentation to the NC State Turtle Rescue Team and prior to release. An i-STAT Portable Clinical Analyzer and CG8+ cartridges were used to determine venous blood gas and biochemical values, the packed cell volume (PCV) and total protein were evaluated using hematocrit tubes and high speed centrifugation, and a differential WBC percentage was determined manually with Diff-Quick stained blood smear slides. Forty-six turtles were sampled on presentation and twenty-three of those were sampled again prior to release. Blood values were analyzed for significant differences between samples collected at presentation and prior to release, as well as differences between surviving and non-surviving turtles. Five variables were identified as significantly different between presenting and recuperated samples: pH, pCO2, Glu, % heterophils, and % eosinophils. When comparing samples between turtles that survived versus those that did not, two variables were identified as being significant prognostic indicators; lactate and PCV. Identification of these significant variables can aid in determining patient prognosis and triage therapy for injured aquatic turtles.


Assuntos
Tartarugas/sangue , Tartarugas/lesões , Animais , Análise Química do Sangue/estatística & dados numéricos , Análise Química do Sangue/veterinária , Gasometria/estatística & dados numéricos , Gasometria/veterinária , Proteínas Sanguíneas/análise , Conservação dos Recursos Naturais , Árvores de Decisões , Feminino , Água Doce , Nível de Saúde , Hematócrito/estatística & dados numéricos , Hematócrito/veterinária , Modelos Logísticos , Masculino , North Carolina , Prognóstico
9.
Arch Phys Med Rehabil ; 99(11): 2370-2372, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30130517

RESUMO

OBJECTIVE: To examine the occurrence of adverse events in patients undergoing assessment for pulmonary rehabilitation when a 6-minute walk test (6MWT) continues despite desaturation below 80%. DESIGN: Retrospective audit following REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) Statement. SETTING: Large teaching hospital. PARTICIPANTS: All patients (N=549) (55% men, mean age 69±11y) assessed for pulmonary rehabilitation (September 2005 to January 2016). INTERVENTIONS: The standardized tests were conducted by experienced cardiorespiratory physiotherapists. Oxyhemoglobin saturation was monitored continuously using a pulse oximeter (lowest value used for analysis). Medical records were reviewed, and adverse events defined as tachycardia, bradycardia, chest pain, or other sign/symptom necessitating cessation. MAIN OUTCOME MEASURE: 6MWT. RESULTS: Data from 672 walk tests were included with mean distance 369 (124) meters. The main diagnoses were chronic obstructive pulmonary disease (70%), interstitial lung disease (14%), and bronchiectasis (8%). Sixty individuals (11%) recorded desaturation below 80% without adverse events. Two adverse events were recorded during tests without desaturation; in 1 instance, chest pain with no evidence of cardiorespiratory compromise and in another, the patient stopped due to concern regarding blood sugar levels (11.5 mmol/L when tested). Independent predictors of desaturation to less than 80% were resting oxyhemoglobin saturation <95% (odds ratio [OR] 3.82, 95% confidence interval [CI] 2.06-7.08) and a diagnosis of interstitial lung disease or pulmonary arterial hypertension (OR 5.24, 95% CI 2.59-10.58). CONCLUSIONS: This study found that desaturation to less than 80% during a 6MWT was not associated with adverse events in a large cohort of patients referred to pulmonary rehabilitation and assessed by experienced physiotherapists, suggesting that test cessation due to desaturation in stable patients may be unwarranted.


Assuntos
Gasometria/estatística & dados numéricos , Pneumopatias/reabilitação , Oxiemoglobinas/metabolismo , Teste de Caminhada/efeitos adversos , Idoso , Tolerância ao Exercício , Feminino , Humanos , Pneumopatias/sangue , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Oxigênio/sangue , Consumo de Oxigênio , Valores de Referência , Estudos Retrospectivos , Teste de Caminhada/métodos
10.
Pediatr Crit Care Med ; 19(8): 699-704, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29927878

RESUMO

OBJECTIVES: To determine whether the association between hyperoxia and increased risk-adjusted mortality in adult intensive care patients is also observed in a pediatric intensive care population. DESIGN: Single-center retrospective analysis of admissions to ICU over a 5-year period commencing January 1, 2012, examining the relationship between PaO2 measured within the first hour of admission and risk-adjusted mortality. Standardized mortality rates were calculated using the Pediatric Index of Mortality-3, and patients were grouped into 50 mm Hg (6.67 kPa) PaO2 bands to assess the relationship between initial PaO2 and risk-adjusted mortality. SETTING: Tertiary PICU with 17 beds and 1,100 annual admissions located in metropolitan Sydney, Australia. PATIENTS: A total of 1,447 patients 0-18 years old with PaO2 recorded at admission to the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 5,176 patients admitted to the ICU during the study period and 1,447 (28%) with PaO2 recorded at admission. A U-shaped relationship between raw mortality and admission PaO2 was observed, with lowest mortality (2.3% and 2.6%, respectively) observed in the 101-150 (13.5-20.0 kPa) and 151-200 mm Hg (20.1-26.7 kPa) bands and the highest mortality observed in patients with PaO2 less than 50 mm Hg (6.67 kPa) with mortality of 5.3%, or greater than 350 mm Hg (46.7 kPa) with mortality of 18.2%. Hyperoxia at admission was associated with an increase in risk-adjusted mortality, with polynomial regression indicating a strong correlation between PaO2 band and risk-adjusted outcome (r = 0.845). When included in a multivariate model that included the Pediatric Index of Mortality-3 variables, the odds ratio for hyperoxia (defined as PaO2 > 250 mm Hg [33.3 kPa]) predicting death was 2.66 (p = 0.047). CONCLUSIONS: In this single-center study, hyperoxia at admission to the PICU was highly correlated with increased risk-adjusted mortality. Further investigation of these observations in a large multicenter cohort is warranted.


Assuntos
Hiperóxia/mortalidade , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Gasometria/estatística & dados numéricos , Criança , Pré-Escolar , Feminino , Humanos , Hiperóxia/sangue , Hiperóxia/diagnóstico , Lactente , Masculino , Estudos Retrospectivos , Risco Ajustado , Fatores de Risco
11.
Respir Care ; 63(7): 907-912, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29739856

RESUMO

BACKGROUND: Transcutaneous monitors are utilized to monitor a patient's respiratory status. Some patients have similar values when comparing transcutaneous carbon dioxide (PtcCO2 ) values with blood gas analysis, whereas others show extreme variability. A retrospective review of data was performed to determine how accurately PtcCO2 correlated with CO2 values obtained by arterial blood gas (ABG) or capillary blood gas. METHODS: To determine whether PtcCO2 values correlated with ABG or capillary blood gas values, subjects' records were retrospectively reviewed. Data collected included the PtcCO2 value at the time of blood gas procurement and the ABG or capillary blood gas PCO2 value. Agreement of pairs of methods (ABG vs PtcCO2 and capillary blood gas vs PtcCO2 ) was assessed with the Bland-Altman approach with limits of agreement estimated with a mixed model to account for serial measurements per subject. RESULTS: A total of 912 pairs of ABG/PtcCO2 values on 54 subjects and 307 pairs of capillary blood gas/PtcCO2 values on 34 subjects were analyzed. The PCO2 range for ABG was 24-106 mm Hg, and PtcCO2 values were 27-133 mm Hg. The PCO2 range for capillary blood gas was 29-108 mm Hg, and PtcCO2 values were 30-103 mm Hg. For ABG/PtcCO2 comparisons, the Pearson correlation coefficient was 0.82, 95% CI was 0.80-0.84, and P was <.001. For capillary blood gas/PtcCO2 comparisons, the Pearson correlation coefficient was 0.77, 95% CI was 0.72-0.81, and P was <.001. For ABG/PtcCO2 , the estimated difference ± SD was -6.79 ± 7.62 mm Hg, and limits of agreement were -22.03 to 8.45. For capillary blood gas/PtcCO2 , the estimated difference ± SD was -1.61 ± 7.64 mm Hg, and limits of agreement were -16.88 to 13.66. The repeatability coefficient was about 30 mm Hg. CONCLUSIONS: Based on these data, capillary blood gas comparisons showed less variation and a slightly lower correlation with PtcCO2 than did ABG comparisons. After accounting for serial measurements per patient, due to the wide limits of agreement and poor repeatability, the utility of relying on PtcCO2 readings for this purpose is questionable.


Assuntos
Gasometria/estatística & dados numéricos , Monitorização Transcutânea dos Gases Sanguíneos/estatística & dados numéricos , Artérias , Gasometria/métodos , Capilares , Feminino , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos
12.
Intern Emerg Med ; 13(3): 359-365, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29512020

RESUMO

Auto-titrating noninvasive ventilation (NIV) has been developed as a new mode applying variable expiratory-positive airway pressure (EPAP) in addition to variable inspiratory pressures (IPAP), both to deliver targeted tidal volume (VT) and to eliminate upper airway resistance. The purpose of this study is to evaluate whether NIV with auto-titrating mode will decrease more PaCO2 within a shorter time compared to volume-assured mode in hypercapnic intensive care unit (ICU) patients. The hypercapnic respiratory failure patients treated with average volume assured pressure support- automated EPAP mode (group1) were compared with those treated with average volume-assured pressure support mode (group2). Two groups were matched with each other according to baseline diagnoses, demographic characteristics, arterial blood gas values, target VT settings and daily NIV usage times. Built-in software was used to gather the ventilatory parameters. Twenty-eight patients were included in group 1, and 22 in group 2. The decrease in PaCO2 had been achieved within a shorter time period in group 1 (p < 0.05). This response was more pronounced within the first 6 h (mean reduction in PaCO2 was 7 ± 7 mmHg in group 1 and 2 ± 5 mmHg in group 2, p = 0.025), and significantly greater reductions in PaCO2 (18 ± 11 mmHg in group 1 and 9 ± 8 mmHg in group 2, p = 0.008) and plasma HCO3 levels (from 32 to 30 mEq and from 35 to 35 mEq, p = 0.007) took place within first 4 days. While mean IPAP was similar in both groups, maximum EPAP, mean VT and leak were significantly higher in group 1 than in group 2 (p < 0.05). Results of this preliminary study suggest that, this new auto-titrating NIV mode may provide additional benefit on volume-assured mode in decreasing PaCO2 more efficiently and rapidly in hypercapnic ICU patients.


Assuntos
Manuseio das Vias Aéreas/normas , Ventilação não Invasiva/normas , Respiração com Pressão Positiva/normas , Insuficiência Respiratória/terapia , Idoso , Idoso de 80 Anos ou mais , Manuseio das Vias Aéreas/métodos , Análise de Variância , Gasometria/métodos , Gasometria/estatística & dados numéricos , Distribuição de Qui-Quadrado , Feminino , Humanos , Hipercapnia/terapia , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Ventilação não Invasiva/métodos , Respiração com Pressão Positiva/métodos , Estatísticas não Paramétricas
13.
J Clin Monit Comput ; 32(6): 1065-1072, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29455321

RESUMO

Central venous-to-arterial carbon dioxide difference (PcvaCO2), and its correction by the arterial-to-venous oxygen content difference (PcvaCO2/CavO2) have been proposed as additional tools to evaluate tissue hypoxia. Since the relationship between pressure and content of CO2 (CCO2) might be affected by several factors, some authors advocate for the use of CcvaCO2/CavO2. The aim of the present study was to explore the factors that might intervene in the difference between PcvaCO2/CavO2 and CcvaCO2/CavO2, and to analyze their association with mortality. Observational study in a 30-bed mixed ICU. Fifty-two septic shock patients within the first 24 h of ICU admission were studied. After restoration of mean arterial pressure, hemodynamic and metabolic parameters were evaluated. A total of 110 sets of measurements were performed. Simultaneous PcvaCO2/CavO2 and CcvaCO2/CavO2 values were correlated, but agreement analysis showed a significant proportional bias. The difference between PcvaCO2/CavO2 and CcvaCO2/CavO2 was independently associated with pH, ScvO2, baseline CcvaCO2/CavO2 and hemoglobin. A stepwise regression analysis showed that pH was the single best predictor for the magnitude of such difference, with very limited effect of other variables. At inclusion, variables associated with ICU-mortality were lactate, pH, PcvaCO2/CavO2, and the difference between PcvaCO2/CavO2 and CcvaCO2/CavO2. Initial ScvO2, PcvaCO2, CcvaCO2/CavO2, and cardiac index were not different in survivors and non-survivors. In a population of early septic shock patients, simultaneous values of PcvaCO2/CavO2 and CcvaCO2/CavO2 were not equivalent, and the main determinant of the magnitude of the difference between these two parameters was pH. The PcvaCO2/CavO2 ratio was associated with ICU mortality, whereas CcvaCO2/CavO2 was not.


Assuntos
Dióxido de Carbono/sangue , Choque Séptico/sangue , Choque Séptico/fisiopatologia , Idoso , Gasometria/estatística & dados numéricos , Feminino , Monitorização Hemodinâmica/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Prognóstico , Estudos Prospectivos , Choque Séptico/mortalidade
14.
Respir Care ; 63(1): 36-42, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28951466

RESUMO

BACKGROUND: Mechanically ventilated patients increasingly spend hours in emergency department beds before ICU admission. This study evaluated the performance of blood gases in mechanically ventilated subjects in the emergency department and subsequent changes to mechanical ventilation settings. METHODS: This was a multi-center, prospective, observational study of subjects ventilated in the emergency department, conducted at 3 academic emergency departments from July 2011 to March 2013. We measured the rate of arterial blood gas (ABG) and venous blood gas (VBG) analysis, and we assessed the associations between the conditions of hypoxemia, hyperoxia, hypercapnia, or acidemia and changes to mechanical ventilator settings. RESULTS: Of 292 ventilated subjects, 17.1% did not have a blood gas sent in the emergency department. Ventilator changes were made significantly more frequently for subjects who had an ABG as the initial blood gas sent in the emergency department (odds ratio 2.70, 95% CI 1.46-4.99, P = .002). However, findings of hypoxemia, hyperoxia, hypercapnia, or acidemia were not correlated with ventilator adjustments. CONCLUSIONS: In this prospective observational study of subjects mechanically ventilated in the emergency department, the majority had a blood gas checked while in the emergency department. While ABGs were associated with having changes made to ventilator settings in the emergency department, clinical findings of hypoxemia, hyperoxia, hypercapnia, and acidemia were not. Inattention to blood gas results may lead to missed opportunities in guiding ventilator changes in the emergency department.


Assuntos
Gasometria/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Transtornos Respiratórios/diagnóstico , Respiração Artificial/estatística & dados numéricos , Ventiladores Mecânicos/estatística & dados numéricos , Adulto , Idoso , Feminino , Humanos , Hipercapnia/diagnóstico , Hiperóxia/diagnóstico , Hipóxia/diagnóstico , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial/métodos
15.
Comput Math Methods Med ; 2018: 3569346, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30687409

RESUMO

Introduction: The quality of cardiopulmonary resuscitation (CPR) has been shown to impact patient outcomes. However, post-CPR morbidity and mortality remain high, and CPR optimization is an area of active research. One approach to optimizing CPR involves establishing reliable CPR performance measures and then modifying CPR parameters, such as compressions and ventilator breaths, to enhance these measures. We aimed to define a reliable CPR performance measure, optimize the CPR performance based on the defined measure and design a dynamically optimized scheme that varies CPR parameters to optimize CPR performance. Materials and Methods: We selected total blood gas delivery (systemic oxygen delivery and carbon dioxide delivery to the lungs) as an objective function for maximization. CPR parameters were divided into three categories: rescuer dependent, patient dependent, and constant parameters. Two optimization schemes were developed using simulated annealing method: a global optimization scheme and a sequential optimization scheme. Results and Discussion: Variations of CPR parameters over CPR sequences (cycles) were analyzed. Across all patient groups, the sequential optimization scheme resulted in significant enhancement in the effectiveness of the CPR procedure when compared to the global optimization scheme. Conclusions: Our study illustrates the potential benefit of considering dynamic changes in rescuer-dependent parameters during CPR in order to improve performance. The advantage of the sequential optimization technique stemmed from its dynamically adapting effect. Our CPR optimization findings suggest that as CPR progresses, the compression to ventilation ratio should decrease, and the sequential optimization technique can potentially improve CPR performance. Validation in vivo is needed before implementing these changes in actual practice.


Assuntos
Dióxido de Carbono/sangue , Reanimação Cardiopulmonar/métodos , Oxigênio/administração & dosagem , Gasometria/estatística & dados numéricos , Dióxido de Carbono/metabolismo , Reanimação Cardiopulmonar/normas , Reanimação Cardiopulmonar/estatística & dados numéricos , Humanos , Pulmão/metabolismo , Modelos Biológicos , Modelos Estatísticos , Oxigênio/sangue , Respiração , Transporte Respiratório/fisiologia , Resultado do Tratamento
16.
Crit Care ; 21(1): 322, 2017 12 21.
Artigo em Inglês | MEDLINE | ID: mdl-29268775

RESUMO

BACKGROUND: When an out-of-hospital cardiac arrest (OHCA) patient receives cardiopulmonary resuscitation (CPR) in the emergency department (ED), blood laboratory test results can be obtained by using point-of-care testing during CPR. In the present study, the relationship between blood laboratory test results during CPR and outcomes of OHCA patients was investigated. METHODS: This study was a multicenter retrospective analysis of prospective registered data that included 2716 OHCA patients. Data from the EDs of three university hospitals in different areas were collected from January 2009 to December 2014. Univariate and multivariable analyses were conducted to elucidate the factors associated with survival to discharge and neurological outcomes. A final analysis was conducted by including patients who had no prehospital return of spontaneous circulation and those who underwent rapid blood laboratory examination during CPR. RESULTS: Overall, 2229 OHCA patients were included in the final analysis. Among them, the rate of survival to discharge and a good Cerebral Performance Categories Scale score were 14% and 4.4%, respectively. The pH level was independently related to survival to hospital discharge (adjusted OR 6.287, 95% CI 2.601-15.197; p < 0.001) and good neurological recovery (adjusted OR 15.395, 95% CI 3.439-68.911; p < 0.001). None of the neurologically intact patients had low pH levels (< 6.8) or excessive potassium levels (> 8.5 mEq/L) during CPR. CONCLUSIONS: Among the blood laboratory test results during CPR of OHCA patients, pH and potassium levels were observed as independent factors associated with survival to hospital discharge, and pH level was considered as an independent factor related to neurological recovery.


Assuntos
Concentração de Íons de Hidrogênio , Parada Cardíaca Extra-Hospitalar/induzido quimicamente , Idoso , Gasometria/métodos , Gasometria/estatística & dados numéricos , Reanimação Cardiopulmonar/métodos , Reanimação Cardiopulmonar/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes Imediatos , Estudos Prospectivos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Estatísticas não Paramétricas , Análise de Sobrevida , Fatores de Tempo
17.
Mil Med ; 182(11): e2056-e2060, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-29087881

RESUMO

BACKGROUND: Hemorrhagic shock with occult hypoperfusion is a key challenge to prehospital staff during triage and transfer of patients, especially during mass casualty incidents. Recent advances in Dynamic Light Scattering (DLS), and miniaturization of this technology, has resulted in noninvasive sensors capable of continuously monitoring tissue perfusion. This study evaluated the ability of miniature DLS (mDLS) sensors to assess hemodynamic status in a porcine model of hemorrhage. METHODS: Following ethics committee approval, anesthetized and ventilated pigs underwent graded hemorrhage and then retransfusion. Standard vital signs were monitored in conjunction with a thermodilution cardiac output (CO), central venous pressure (CVP), and arterial blood gases. The mDLS sensor was attached to each animal's leg and all monitoring measurements were taken 5 minutes after completion of each period of hemorrhage and retransfusion to allow equilibration. RESULTS: All measured parameters changed during bleeding and retransfusion. During bleeding; p value were 0.011 for heart rate, 0.07 for CVP, <0.001 for both mean arterial pressure, and mDLS. During retransfusion; p values were 0.023 for heart rate, 0.008 for CVP, and <0.001 for both mean arterial pressure and mDLS. Pearson correlation between changes in mDLS and CO demonstrated r value of 0.917 during hemorrhage and 0.965 during retransfusion. Changes in hemoglobin were not statistically significant during bleeding (p = 0.331) but were during retransfusion (p = 0.0001). Changes of bicarbonate, base excess, and lactate were found to be statistically significant during both phases of the experiment (p = 0.001). CONCLUSIONS: In an animal model of hemorrhagic shock, the mDLS sensor strongly correlates with traditional measures of CO. This initial assessment supports further investigation of this technology in human studies.


Assuntos
Difusão Dinâmica da Luz/métodos , Difusão Dinâmica da Luz/normas , Hemodinâmica/fisiologia , Monitorização Fisiológica/instrumentação , Animais , Gasometria/métodos , Gasometria/estatística & dados numéricos , Débito Cardíaco/fisiologia , Pressão Venosa Central/fisiologia , Frequência Cardíaca/fisiologia , Hemorragia/diagnóstico , Hemorragia/fisiopatologia , Monitorização Fisiológica/métodos , Monitorização Fisiológica/normas , Exame Físico/instrumentação , Exame Físico/métodos , Suínos/sangue
18.
Crit Care ; 21(1): 234, 2017 09 07.
Artigo em Inglês | MEDLINE | ID: mdl-28877748

RESUMO

BACKGROUND: Renin-angiotensin system (RAS) signaling and angiotensin-converting enzyme 2 (ACE2) have been implicated in the pathogenesis of acute respiratory distress syndrome (ARDS). We postulated that repleting ACE2 using GSK2586881, a recombinant form of human angiotensin-converting enzyme 2 (rhACE2), could attenuate acute lung injury. METHODS: We conducted a two-part phase II trial comprising an open-label intrapatient dose escalation and a randomized, double-blind, placebo-controlled phase in ten intensive care units in North America. Patients were between the ages of 18 and 80 years, had an American-European Consensus Criteria consensus diagnosis of ARDS, and had been mechanically ventilated for less than 72 h. In part A, open-label GSK2586881 was administered at doses from 0.1 mg/kg to 0.8 mg/kg to assess safety, pharmacokinetics, and pharmacodynamics. Following review of data from part A, a randomized, double-blind, placebo-controlled investigation of twice-daily doses of GSK2586881 (0.4 mg/kg) for 3 days was conducted (part B). Biomarkers, physiological assessments, and clinical endpoints were collected over the dosing period and during follow-up. RESULTS: Dose escalation in part A was well-tolerated without clinically significant hemodynamic changes. Part B was terminated after 39 of the planned 60 patients following a planned futility analysis. Angiotensin II levels decreased rapidly following infusion of GSK2586881, whereas angiotensin-(1-7) and angiotensin-(1-5) levels increased and remained elevated for 48 h. Surfactant protein D concentrations were increased, whereas there was a trend for a decrease in interleukin-6 concentrations in rhACE2-treated subjects compared with placebo. No significant differences were noted in ratio of partial pressure of arterial oxygen to fraction of inspired oxygen, oxygenation index, or Sequential Organ Failure Assessment score. CONCLUSIONS: GSK2586881 was well-tolerated in patients with ARDS, and the rapid modulation of RAS peptides suggests target engagement, although the study was not powered to detect changes in acute physiology or clinical outcomes. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01597635 . Registered on 26 January 2012.


Assuntos
Peptidil Dipeptidase A/farmacologia , Síndrome do Desconforto Respiratório do Adulto/tratamento farmacológico , Adulto , Idoso , Gasometria/estatística & dados numéricos , Método Duplo-Cego , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Masculino , Pessoa de Meia-Idade , América do Norte , Peptidil Dipeptidase A/uso terapêutico , Projetos Piloto , Placebos
19.
Crit Care ; 21(1): 170, 2017 07 07.
Artigo em Inglês | MEDLINE | ID: mdl-28683763

RESUMO

BACKGROUND: Noninvasive ventilation (NIV) is generally delivered using pneumatically-triggered and cycled-off pressure support (PSP) through a mask. Neurally adjusted ventilatory assist (NAVA) is the only ventilatory mode that uses a non-pneumatic signal, i.e., diaphragm electrical activity (EAdi), to trigger and drive ventilator assistance. A specific setting to generate neurally controlled pressure support (PSN) was recently proposed for delivering NIV by helmet. We compared PSN with PSP and NAVA during NIV using a facial mask, with respect to patient comfort, gas exchange, and patient-ventilator interaction and synchrony. METHODS: Three 30-minute trials of NIV were randomly delivered to 14 patients immediately after extubation to prevent post-extubation respiratory failure: (1) PSP, with an inspiratory support ≥8 cmH2O; (2) NAVA, adjusting the NAVA level to achieve a comparable peak EAdi (EAdipeak) as during PSP; and (3) PSN, setting the NAVA level at 15 cmH2O/µV with an upper airway pressure (Paw) limit to obtain the same overall Paw applied during PSP. We assessed patient comfort, peak inspiratory flow (PIF), time to reach PIF (PIFtime), EAdipeak, arterial blood gases, pressure-time product of the first 300 ms (PTP300-index) and 500 ms (PTP500-index) after initiation of patient effort, inspiratory trigger delay (DelayTR-insp), and rate of asynchrony, determined as asynchrony index (AI%). The categorical variables were compared using the McNemar test, and continuous variables by the Friedman test followed by the Wilcoxon test with Bonferroni correction for multiple comparisons (p < 0.017). RESULTS: PSN significantly improved patient comfort, compared to both PSP (p = 0.001) and NAVA (p = 0.002), without differences between the two latter (p = 0.08). PIF (p = 0.109), EAdipeak (p = 0.931) and gas exchange were similar between modes. Compared to PSP and NAVA, PSN reduced PIFtime (p < 0.001), and increased PTP300-index (p = 0.004) and PTP500-index (p = 0.001). NAVA and PSN significantly reduced DelayTR-insp, as opposed to PSP (p < 0.001). During both NAVA and PSN, AI% was <10% in all patients, while AI% was ≥10% in 7 patients (50%) with PSP (p = 0.023 compared with both NAVA and PSN). CONCLUSIONS: Compared to both PSP and NAVA, PSN improved comfort and patient-ventilator interaction during NIV by facial mask. PSN also improved synchrony, as opposed to PSP only. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03041402 . Registered (retrospectively) on 2 February 2017.


Assuntos
Suporte Ventilatório Interativo/tendências , Máscaras/tendências , Ventilação não Invasiva/métodos , Fenômenos Fisiológicos Respiratórios , Idoso , Gasometria/estatística & dados numéricos , China , Estudos Cross-Over , Feminino , Humanos , Suporte Ventilatório Interativo/métodos , Itália , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/tendências , Estudos Prospectivos , Respiração Artificial/métodos , Respiração Artificial/tendências
20.
Crit Care ; 21(1): 126, 2017 06 02.
Artigo em Inglês | MEDLINE | ID: mdl-28578708

RESUMO

BACKGROUND: Neurally adjusted ventilatory assist (NAVA) could improve patient-ventilator interaction; its effects on ventilation distribution and dead space are still unknown. The aim of this study was to evaluate the effects of varying levels of assist during NAVA and pressure support ventilation (PSV) on ventilation distribution and dead space in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). METHODS: Fifteen mechanically ventilated patients with AECOPD were included in the study. The initial PSV levels were set to 10 cmH2O for 10 min. Thereafter, the ventilator mode was changed to NAVA for another 10 min with the same electrical activity of the diaphragm as during PSV. Furthermore, the ventilation mode was switched between PSV and NAVA every 10 min in the following order: PSV 5 cmH2O; NAVA 50%; PSV 15 cmH2O; and NAVA 150% (relative to the initial NAVA support level). Ventilation distribution in the lung was evaluated in percentages in regions of interest (ROI) of four anteroposterior segments of equal height (ROI1 to ROI4 represents ventral, mid-ventral, mid-dorsal, and dorsal, respectively). Blood gases, ventilation distribution (electrical impedance tomography), diaphragm activity (B-mode ultrasonography), and dead space fraction (PeCO2 and PaCO2) were measured. RESULTS: The trigger and cycle delays were lower during NAVA than during PSV. The work of trigger was significantly lower during NAVA compared to PSV. The diaphragm activities based on ultrasonography were higher during NAVA compared to the same support level during PSV. The ventilation distribution in ROI4 increased significantly (P < 0.05) during NAVA compared to PSV (except for a support level of 50%). Similar results were found in ROI3 + 4. NAVA reduced dead space fraction compared to the corresponding support level of PSV. CONCLUSIONS: NAVA was superior to PSV in AECOPD for increasing ventilation distribution in ROI4 and reducing dead space. TRIAL REGISTRATION: Clinicaltrials.gov, NCT02289573 . Registered on 12 November 2014.


Assuntos
Suporte Ventilatório Interativo/normas , Doença Pulmonar Obstrutiva Crônica/terapia , Espaço Morto Respiratório/fisiologia , APACHE , Idoso , Idoso de 80 Anos ou mais , Gasometria/métodos , Gasometria/estatística & dados numéricos , Impedância Elétrica , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Suporte Ventilatório Interativo/métodos , Suporte Ventilatório Interativo/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Doença Pulmonar Obstrutiva Crônica/complicações , Respiração Artificial/instrumentação , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Tomografia/métodos
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