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2.
Support Care Cancer ; 29(1): 179-185, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32328774

RESUMO

PURPOSE: To characterize the practice of subcutaneous hydration provision in the Beer-Sheva home care hospice unit. We also explore the potential connection between the provision of subcutaneous hydration and the incidence of death rattle. METHODS: This was a prospective observational study involving 120 hospice patients. During the 6 days before death, hospice staff recorded whether or not fluids were administered orally and/or subcutaneously; the duration, timing, and quantity of fluid administration; the incidence, timing, and duration of death rattle; and whether medications that can affect death rattle were given. RESULT: Fifty-three percent of the patients received subcutaneous hydration. The mean daily volume administered in the hydration group was 434 ml. There was a significant association between the duration of treatment in the hospice unit and provision of subcutaneous hydration (mean of 51 days in hydration group vs. 31 days in non-hydration group, p = 0.03). Although not statistically significant, males were more likely to receive subcutaneous hydration than females (62% of males vs. 46% of females, p = 0.09). There was a higher incidence of death rattle in men compared to women (54.7% in men vs. 32.8% in women, p = 0.025). A statistically significant association between death rattle and the provision of subcutaneous hydration wasn't demonstrated. CONCLUSION: The decision of whether to provide subcutaneous hydration is individualized taking into consideration the values of the patients and their families. The provision of 500 ml per day of subcutaneous saline during the last 6 days of life does not significantly increase the incidence of death rattle.


Assuntos
Hidratação/métodos , Sons Respiratórios/fisiologia , Águas Salinas/uso terapêutico , Assistência Terminal/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Morte , Feminino , Cuidados Paliativos na Terminalidade da Vida/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
5.
J Stroke Cerebrovasc Dis ; 30(1): 105413, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33160127

RESUMO

BACKGROUND: In adult patients with moyamoya disease (MMD) underwent combined revascularization, cerebral infarction during the acute postoperative phase is common and can lead to neurological dysfunction after revascularization in MMD patients. The aim of this study was to share the experience of individualized perioperative blood pressure (BP) management for adult MMD patients in one single center. METHODS: We retrospectively reviewed 144 adult patients with MMD who underwent 186 procedures of combined revascularization at our institution from March 2013 to July 2019. Clinical features and outcomes were analyzed, in particular regarding cerebral infarction and hyperperfusion syndrome (HPS). All of the patients received individualized management perioperatively, especially about the blood pressure management according to the characteristics of moyamoya disease. RESULTS: Postoperative cerebral infarction and HPS within 14 days after revascularization were recorded. Cerebral infarction occurred in four (2.1%) procedures among four patients. No patients suffered from a malignant cerebral infarction and only one patient had permanent neurological deficits. The incidence of HPS was 10.8% and no one presented with intracranial hemorrhage. All of the symptoms were reversible without any brain parenchymal injury. CONCLUSIONS: Our findings suggest that we can decrease the incidence and extent of cerebral infarction in adult MMD patients following combined revascularization by individualized perioperative BP management.


Assuntos
Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Infarto Cerebral/prevenção & controle , Revascularização Cerebral , Hidratação , Doença de Moyamoya/cirurgia , Assistência Perioperatória , Adulto , Anti-Hipertensivos/efeitos adversos , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/etiologia , Infarto Cerebral/fisiopatologia , Revascularização Cerebral/efeitos adversos , Circulação Cerebrovascular , Feminino , Hidratação/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Doença de Moyamoya/diagnóstico por imagem , Doença de Moyamoya/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
6.
J Stroke Cerebrovasc Dis ; 29(12): 105412, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33254367

RESUMO

INTRODUCTION: Early studies suggest that acute cerebrovascular events may be common in patients with coronavirus disease 2019 (COVID-19) and may be associated with a high mortality rate. Most cerebrovascular events described have been ischemic strokes, but both intracerebral hemorrhage and rarely cerebral venous sinus thrombosis (CVST) have also been reported. The diagnosis of CVST can be elusive, with wide-ranging and nonspecific presenting symptoms that can include headache or altered sensorium alone. OBJECTIVE: To describe the presentation, barriers to diagnosis, treatment, and outcome of CVST in patients with COVID-19. METHODS: We abstracted data on all patients diagnosed with CVST and COVID-19 from March 1 to August 9, 2020 at Boston Medical Center. Subsequently, we reviewed the literature and extracted all published cases of CVST in patients with COVID-19 from January 1, 2020 through August 9, 2020 and included all studies with case descriptions. RESULTS: We describe the clinical features and management of CVST in 3 women with COVID-19 who developed CVST days to months after initial COVID-19 symptoms. Two patients presented with encephalopathy and without focal neurologic deficits, while one presented with visual symptoms. All patients were treated with intravenous hydration and anticoagulation. None suffered hemorrhagic complications, and all were discharged home. We identified 12 other patients with CVST in the setting of COVID-19 via literature search. There was a female predominance (54.5%), most patients presented with altered sensorium (54.5%), and there was a high mortality rate (36.4%). CONCLUSIONS: During this pandemic, clinicians should maintain a high index of suspicion for CVST in patients with a recent history of COVID-19 presenting with non-specific neurological symptoms such as headache to provide expedient management and prevent complications. The limited data suggests that CVST in COVID-19 is more prevalent in females and may be associated with high mortality.


Assuntos
/complicações , Trombose dos Seios Intracranianos/etiologia , Trombose Venosa/etiologia , Adulto , Idoso , Anticoagulantes/uso terapêutico , /terapia , Feminino , Hidratação , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Trombose dos Seios Intracranianos/diagnóstico por imagem , Trombose dos Seios Intracranianos/terapia , Resultado do Tratamento , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/terapia
7.
Medicine (Baltimore) ; 99(50): e23617, 2020 Dec 11.
Artigo em Inglês | MEDLINE | ID: mdl-33327334

RESUMO

TRIAL DESIGN: This investigator-initiated, single-center, open-label, parallel-group, randomized-controlled pilot study was designed to compare the intraoperative fluid balance and perioperative complications in patients undergoing hepato-biliary-pancreatic surgery with or without stroke volume variation (SVV)-guided fluid management. METHODS: Patients who were aged >18 years and underwent elective major hepato-biliary-pancreatic surgery between June 30, 2015, and August 31, 2016 at our center were randomly assigned to receive SVV-guided or conventional fluid therapy. The intervention group used SVV to determine the patients' volume status. The primary outcome was the total fluid balance per body weight per operation time, and the secondary outcomes were the total amount of intravenous infusion per body weight per operation time and the Sequential Organ Failure Assessment score on postoperative day 1. Patients were randomized by a two-block computer-generated assignment sequence. Masking of patients and assessors was conducted. The patients and assessors were each blinded to the details of the trial; however, the clinicians were not. RESULTS: Of the 69 patients who were initially eligible, 60 provided informed consent for participation in the study. After randomization, three patients dropped out of the study because of deviations from the protocol or unexpected hypotension, leaving 28 and 29 patients in the intervention and control groups, respectively. Patients in both groups had similar characteristics at baseline. The median (interquartile range [IQR]) intraoperative fluid balance in the control and SVV groups was 6.2 (IQR, 4.9-7.9) and 8.1 (IQR, 5.7-10.5) ml/kg/h, respectively (P = .103). The administered intravenous infusion was significantly higher in the SVV group (median, 10.9; IQR, 8.3-15.3 ml/kg/h) than in the control group (median, 9.5; IQR, 7.7-10.3 ml/kg/h) (P = .011). On postoperative day 1, the PaO2/FiO2 ratio was lower in the SVV group (median, 266; IQR, 261-341) than in the control group (median, 346; IQR, 299-380) (P = .019). CONCLUSIONS: Use of the SVV-guided fluid management protocol did not reduce intraoperative fluid balance but increased the intraoperative fluid administration and might worsen postoperative oxygenation. TRIAL REGISTRATION: UMIN000018111.


Assuntos
Procedimentos Cirúrgicos do Sistema Biliar/efeitos adversos , Hidratação , Hipotensão/prevenção & controle , Complicações Intraoperatórias/prevenção & controle , Idoso , Feminino , Humanos , Cuidados Intraoperatórios , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Projetos Piloto , Volume Sistólico
8.
Anesth Analg ; 131(6): 1679-1692, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33186157

RESUMO

In the perioperative setting, acute kidney injury (AKI) is a frequent complication, and AKI itself is associated with adverse outcomes such as higher risk of chronic kidney disease and mortality. Various risk factors are associated with perioperative AKI, and identifying them is crucial to early interventions addressing modifiable risk and increasing monitoring for nonmodifiable risk. Different mechanisms are involved in the development of postoperative AKI, frequently picturing a multifactorial etiology. For these reasons, no single renoprotective strategy will be effective for all surgical patients, and efforts have been attempted to prevent kidney injury in different ways. Some renoprotective strategies and treatments have proven to be useful, some are no longer recommended because they are ineffective or even harmful, and some strategies are still under investigation to identify the best timing, setting, and patients for whom they could be beneficial. With this review, we aim to provide an overview of recent findings from studies examining epidemiology, risk factors, and mechanisms of perioperative AKI, as well as different renoprotective strategies and treatments presented in the literature.


Assuntos
Lesão Renal Aguda/prevenção & controle , Lesão Renal Aguda/fisiopatologia , Rim/fisiologia , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/fisiopatologia , Lesão Renal Aguda/etiologia , Anti-Inflamatórios não Esteroides/efeitos adversos , Diuréticos/administração & dosagem , Hidratação/métodos , Humanos , Precondicionamento Isquêmico/métodos , Rim/irrigação sanguínea , Complicações Pós-Operatórias/etiologia , Diálise Renal/métodos , Fatores de Risco , Resultado do Tratamento , Vasoconstritores/administração & dosagem
9.
Anesth Analg ; 131(6): 1708-1720, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33186159

RESUMO

During hyperinflammatory conditions that can occur in acute critical illness, such as shock or hypoperfusion, inflammatory mediators activate the endothelium, fueling a proinflammatory host-response as well as procoagulant processes. These changes result in shedding of the glycocalyx, endothelial hyperpermeability, edema formation, and lead to disturbed microcirculatory perfusion and organ failure. Different fluid strategies that are used in shock may have differential effects on endothelial integrity. Collectively, low protein content fluids seem to have negative effects on the endothelial glycocalyx, aggravating endothelial hyperpermeability, whereas fluids containing albumin or plasma proteins may be superior to normal saline in protecting the glycocalyx and endothelial barrier function. Targeting the endothelium may be a therapeutic strategy to limit organ failure, which hitherto has not received much attention. Treatment targets aimed at restoring the endothelium should focus on maintaining glycocalyx function and/or targeting coagulation pathways or specific endothelial receptors. Potential treatments could be supplementing glycocalyx constituents or inhibiting glycocalyx breakdown. In this review, we summarize mechanisms of endothelial dysfunction during acute critical illness, such as the systemic inflammatory response, shedding of the glycocalyx, endothelial activation, and activation of coagulation. In addition, this review focuses on the effects of different fluid strategies on endothelial permeability. Also, potential mechanisms for treatment options to reduce endothelial hyperpermeability with ensuing organ failure are evaluated. Future research is needed to elucidate these pathways and to translate these data to the first human safety and feasibility trials.


Assuntos
Estado Terminal/terapia , Endotélio Vascular/metabolismo , Microcirculação/fisiologia , Insuficiência de Múltiplos Órgãos/metabolismo , Insuficiência de Múltiplos Órgãos/prevenção & controle , Doença Aguda , Endotélio Vascular/patologia , Hidratação/métodos , Glicocálix/metabolismo , Glicocálix/patologia , Humanos , Insuficiência de Múltiplos Órgãos/patologia , Escores de Disfunção Orgânica
10.
Intensive Care Med ; 46(12): 2157-2167, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33156382

RESUMO

Care for patients with acute respiratory distress syndrome (ARDS) has changed considerably over the 50 years since its original description. Indeed, standards of care continue to evolve as does how this clinical entity is defined and how patients are grouped and treated in clinical practice. In this narrative review we discuss current standards - treatments that have a solid evidence base and are well established as targets for usual care - and also evolving standards - treatments that have promise and may become widely adopted in the future. We focus on three broad domains of ventilatory management, ventilation adjuncts, and pharmacotherapy. Current standards for ventilatory management include limitation of tidal volume and airway pressure and standard approaches to setting PEEP, while evolving standards might focus on limitation of driving pressure or mechanical power, individual titration of PEEP, and monitoring efforts during spontaneous breathing. Current standards in ventilation adjuncts include prone positioning in moderate-severe ARDS and veno-venous extracorporeal life support after prone positioning in patients with severe hypoxemia or who are difficult to ventilate. Pharmacotherapy current standards include corticosteroids for patients with ARDS due to COVID-19 and employing a conservative fluid strategy for patients not in shock; evolving standards may include steroids for ARDS not related to COVID-19, or specific biological agents being tested in appropriate sub-phenotypes of ARDS. While much progress has been made, certainly significant work remains to be done and we look forward to these future developments.


Assuntos
/terapia , Padrão de Cuidado/tendências , /complicações , Hidratação/métodos , Hidratação/tendências , Humanos , Decúbito Ventral/fisiologia , /fisiopatologia
11.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 32(10): 1183-1188, 2020 Oct.
Artigo em Chinês | MEDLINE | ID: mdl-33198860

RESUMO

OBJECTIVE: To observe the effect of early intervention bundle on clinical prognosis of patients with latent/overt septic shock in emergency department and analyze the risk factors for mortality. METHODS: Patients with latent and overt septic shock admitted to the North Hospital of Huashan Hospital Affiliated to Fudan University from January 2018 to December 2019 were retrospectively analyzed and divided into latent shock group and overt shock group. The gender, age, main infection site, the time of shock diagnosis, the indicators of early (3-hour) intervention bundle, 6-hour compliance rate of intervention bundle, the remission time and 28-day prognosis were observed. Logistic regression analysis was used to identify risk factors for 28-day mortality. Receiver operating characteristic (ROC) curve was used to analyze its prognostic value. RESULTS: Totally 181 patients were included in the analysis. There were 102 cases in the latent shock group, and 28-day mortality was 15.69% (16 cases); 79 cases in the overt shock group, and 28-day mortality was 31.65% (25 cases). Compared with the latent shock group, patients in overt shock group had higher compliance rate of early intervention bundle (93.67% vs. 58.82%), higher blood lactate acid at admission [Lac (mmol/L): 7.09±2.08 vs. 5.69±1.27], higher compliance rate of blood culture before antibiotics (93.67% vs. 63.73%), higher proportion of antibiotics use at the first and second hours (45.57% vs. 31.37%, 54.43% vs. 33.33%), higher proportion of rapid fluid resuscitation at the first hour (crystal liquid: 59.49% vs. 11.76%, crystal fluid combined with human serum albumin: 40.51% vs. 0%), and higher proportion of vasoactive use at the first hour (100% vs. 9.80%). The stable time was significantly prolonged (days: 4.40±1.35 vs. 1.49±0.55), while the onset time (days: 1.47±0.97 vs. 2.95±1.61), the time of diagnosis (minutes: 31.30±12.54 vs. 79.15±13.81), 6-hour lactate clearance [(50.27±21.53)% vs. (61.82±13.12)%], the proportion of antibiotics use at the third hour (0% vs. 35.29%), the proportion of rapid fluid resuscitation at the second and third hour (second hour crystal liquid: 0% vs. 60.78%, second hour crystal fluid combined with human serum albumin: 0% vs. 14.71%, third hour crystal liquid: 0% vs. 12.75%), 6-hour compliance rate of the standard of central venous blood saturation (ScvO2, 60.76% vs. 78.43%) and the success rate of treatment (28-day mortality: 31.65% vs. 15.69%) were lower than those of the latent shock group (all P < 0.05). Ten patients with latent shock developed into overt shock within 24 hours after admission. All patients with overt shock needed vasoactive drugs to maintain mean arterial pressure (MAP) ≥ 65 mmHg (1 mmHg = 0.133 kPa). Compared with the survival patients, the Lac (mmol/L: 7.59±2.27 vs. 5.92±1.24) and the proportion of vasoactive drugs use (65.85% vs. 44.29%) were significantly increased in the death patients, while the 6-hour lactate clearance [(46.58±15.83)% vs. (59.60±17.92)%], the proportion of antibiotics use in the third hour (4.88% vs. 24.29%), and 6-hour compliance rate of urine volume and ScvO2 (56.10% vs. 82.86%, 43.90% vs. 78.57%) were significantly decreased (all P < 0.05). Binary Logistic regression analysis showed that Lac at admission, 6-hour lactate clearance, the use of antibiotics at the third hour, rapid fluid resuscitation at the first hour, and 6-hour compliance rate of ScvO2 were independent risk factors for 28-day mortality [odds ratio (OR) was 1.618, 0.021, 0.100, 0.307 and 3.018, all P < 0.05]. ROC curve analysis showed that the Lac at admission had the highest predictive value for 28-day mortality, the area under the ROC curve (AUC) was 0.706; followed by 6-hour compliance rate of ScvO2 (AUC was 0.673). CONCLUSIONS: Patients with latent/overt septic shock need early diagnosis and intervention bundle to improve the 6-hour blood lactate clearance and 6-hour compliance rate of ScvO2 and reduce the mortality.


Assuntos
Choque Séptico , Serviço Hospitalar de Emergência , Hidratação , Humanos , Prognóstico , Estudos Retrospectivos , Choque Séptico/terapia
12.
Am J Gastroenterol ; 115(11): 1775-1785, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33156095

RESUMO

Hyponatremia is frequently seen in patients with ascites secondary to advanced cirrhosis and portal hypertension. Although not apparent in the early stages of cirrhosis, the progression of cirrhosis and portal hypertension leads to splanchnic vasodilation, and this leads to the activation of compensatory mechanisms such as renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system, and antidiuretic hormone (ADH) to ameliorate low circulatory volume. The net effect is the avid retention of sodium and water to compensate for the low effective circulatory volume, resulting in the development of ascites. These compensatory mechanisms lead to impairment of the kidneys to eliminate solute-free water in decompensated cirrhosis. Nonosmotic secretion of antidiuretic hormone (ADH), also known as arginine vasopressin, further worsens excess water retention and thereby hyponatremia. The management of hyponatremia in this setting is a challenge as conventional therapies for hyponatremia including fluid restriction and correction of hypokalemia are frequently inefficacious. In this review, we discuss the pathophysiology, complications, and various treatment modalities, including albumin infusion, selective vasopressin receptor antagonists, or hypertonic saline for patients with severe hyponatremia and those awaiting liver transplantation.


Assuntos
Ascite/metabolismo , Hipertensão Portal/metabolismo , Hiponatremia/metabolismo , Cirrose Hepática/metabolismo , Sistema Renina-Angiotensina/fisiologia , Vasopressinas/metabolismo , Lesão Renal Aguda/metabolismo , Lesão Renal Aguda/fisiopatologia , Insuficiência Hepática Crônica Agudizada/metabolismo , Insuficiência Hepática Crônica Agudizada/fisiopatologia , Albuminas/uso terapêutico , Antagonistas dos Receptores de Hormônios Antidiuréticos/uso terapêutico , Ascite/fisiopatologia , Hidratação , Encefalopatia Hepática/metabolismo , Encefalopatia Hepática/fisiopatologia , Síndrome Hepatorrenal/metabolismo , Síndrome Hepatorrenal/fisiopatologia , Humanos , Hipertensão Portal/fisiopatologia , Hiponatremia/fisiopatologia , Hiponatremia/terapia , Cirrose Hepática/fisiopatologia , Transplante de Fígado , Solução Salina Hipertônica/uso terapêutico , Circulação Esplâncnica/fisiologia , Tolvaptan/uso terapêutico , Vasodilatação/fisiologia
13.
Medicine (Baltimore) ; 99(47): e22702, 2020 Nov 20.
Artigo em Inglês | MEDLINE | ID: mdl-33217793

RESUMO

This study aimed to assess the predictive value of velocity time integral (VTI) of the left ventricular outflow tract (LVOT) on volume expansion test (VET) as an indicator of volume responsiveness in septic shock patients. Septic shock patients undergoing mechanical ventilation were recruited. The hemodynamic parameters before and after VE were monitored by pulse indicated continuous cardiac output (PiCCO) and echocardiography. Heart rate, cardiac index (CI), mean arterial pressure (MAP), central venous pressure, stroke volume variation (SVV), CI and variation of pulse pressure (PPV), and the changes in cardiac parameters (Dheart rate, Dmean arterial pressure, Dcentral venous pressure, DSVV, DCI, and DPPV) were determined. The relationships of hemodynamic parameters and their changes with DVTI were further evaluated with Pearson relation analysis. The value of these parameters in fluid responsiveness prediction was evaluated by using the receiver operating characteristic (ROC) curve analysis. Results showed that 44 VETs were performed in 44 septic shock patients with responsiveness in 24 patients and non-responsiveness in 20. The CI increased by ≥ 15% in responsive patients, but by<15% in non-responsive patients after VET. There were significant differences in the SVV and PPV after VET between responsive and non-responsive groups. DSVV, DPPV, and DCI were positively related to DVTI. The area under ROC curve (AUC) for SVV in fluid responsiveness prediction was 0.80, and the sensitivity and specificity of SVV were 66.5% and 95%, respectively, when the cut-off value was 24.8%. The AUC for PPV in fluid responsiveness prediction was 0.843, and the sensitivity and specificity of PPV were 83.3% and 75%, respectively, when the cut-off value was 25.8%. The AUC for DVTILVOT in fluid responsiveness prediction was 0.956, and the sensitivity and specificity were 87.5% and 95%, respectively, when the cut-off value was 15.9%. In conclusion, DVTILVOT is effective to predict fluid responsiveness after VET in mechanical ventilation patients with septic shock. It may serve as a new, noninvasive and functional hemodynamic parameter with the same accuracy to SVV.


Assuntos
Hidratação/métodos , Hemodinâmica , Choque Séptico/fisiopatologia , Choque Séptico/terapia , APACHE , Pressão Arterial , Pressão Sanguínea , Débito Cardíaco , Ecocardiografia Doppler em Cores , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Estudos Prospectivos , Respiração Artificial , Sensibilidade e Especificidade , Volume Sistólico
14.
N Z Med J ; 133(1525): 11-17, 2020 11 20.
Artigo em Inglês | MEDLINE | ID: mdl-33223544

RESUMO

AIMS: Damage control resuscitation with limited crystalloids and early use of blood products is now considered standard care in major trauma. The purpose of this study was to audit resuscitation practice in trauma patients where a massive transfusion protocol (MTP) had been activated, to determine whether crystalloid administration and adherence to the MTP had improved since an audit and education sessions in July 2017. METHODS: We conducted a retrospective study looking at trauma patients presenting to Christchurch Hospital who had a MTP activated form the 1 May 2016 to 1 March 2019. Patients were identified by cross-referencing the trauma call database with the electronic transfusion registry. RESULTS: Thirty-four patients were included in the audit. There was no significant difference in mean crystalloid administration before and after July 2017 (5.74 litres and 4.86 litres respectively). Patients presenting before July 2017 received a significantly lower mean fresh frozen plasma to red blood cells (FFP:RBC) compared to patients after July 2017. CONCLUSIONS: Trauma patients with major haemorrhage at Christchurch Hospital are still receiving excess crystalloids; however, our audit suggests that compliance with the MTP has improved. Further education involving the entire trauma team is required to improve fluid resuscitation practice.


Assuntos
Transfusão de Sangue/métodos , Hidratação/métodos , Hemorragia/terapia , Ressuscitação/métodos , Ferimentos e Lesões/terapia , Adulto , Auditoria Clínica , Soluções Cristaloides , Feminino , Hemorragia/sangue , Hospitais , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Plasma , Estudos Retrospectivos , Ferimentos e Lesões/sangue
15.
Am J Emerg Med ; 38(10): 2147-2150, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33046295

RESUMO

OBJECTIVE: To determine if following fluid resuscitation recommendations in the Surviving Sepsis Campaign guidelines affects hospital length of stay (LOS) in chronic kidney disease (CKD) patients who present to the emergency department with sepsis-induced hypotension or septic shock. DESIGN: Retrospective, single center, cohort study. SETTING: 433-bed community hospital with a 35-bed emergency department in central Kentucky. PATIENTS: Adults (≥18 years of age) who presented to the emergency department with severe sepsis or septic shock, as defined by the Centers for Medicare and Medicaid Services (CMS), with documented CKD and at least one episode of hypotension within 6 h of presentation. A total of 106 patients were included in the study. MEASUREMENTS AND MAIN RESULTS: Patients were stratified into two groups based on the total volume of weight-based crystalloid fluid bolus initiated within the first three hours of hypotension onset (<27 mL/kg and ≥ 27 mL/kg). There was a statistically significant reduction in the primary outcome of median LOS among patients who received less than 27 mL/kg of a crystalloid fluid bolus (5.1 vs 7.7 days, p = .003). Likewise, there was a statistically significant reduction in the secondary outcome of total cost per case in the reduced fluid volume cohort (p = .019. No significant differences were found in other secondary outcomes, including vasopressor requirements, ICU admission rate, and normalization of MAP at 6 h. CONCLUSION: The results of this single-center, retrospective study indicate that CKD patients who receive guideline-directed fluid resuscitation (≥27 mL/kg) for sepsis-induced hypotension or septic shock experience a longer hospital LOS compared to those who receive a reduced initial fluid volume.


Assuntos
Hidratação/normas , Insuficiência Renal Crônica/complicações , Choque Séptico/terapia , Adulto , Idoso , Análise de Variância , Estudos de Coortes , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hidratação/métodos , Hidratação/estatística & dados numéricos , Humanos , Kentucky , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Insuficiência Renal Crônica/fisiopatologia , Estudos Retrospectivos , Choque Séptico/tratamento farmacológico , Choque Séptico/fisiopatologia
16.
J Small Anim Pract ; 61(12): 738-743, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33064320

RESUMO

OBJECTIVES: To investigate and discuss current fluid and blood products stocked in small animal practices in the UK. METHODS: An online survey was circulated to small animal veterinary practices across the UK. The survey included questions regarding the level of hospital care provided, the type of fluid and blood component products stocked, the most frequently restocked products, and the available options in the event that blood products were required but not stocked. RESULTS: There were 423 responses including 27 duplicates. The remaining 396 respondents represented a spectrum of practices including 19 referral practices. Crystalloids were stocked in all practices. Lactated Ringer's solution was the most frequently re-stocked product in 355 of 396 (90%) of practices. Where synthetic colloids were stocked, gelatin-based colloids (155/178 [87%]) were stocked in preference to hydroxyethyl starches (23/178 [13%]). Blood products were stocked by 81 of 396 (20%) of practices. If a blood product was required but not stocked, 31% of practices would use a pet blood banking service, 28% would use their own blood donors, and 21% would refer. CLINICAL SIGNIFICANCE: This study provides an insight into the fluid and blood products stocked and used by a selection of veterinary practices within the UK and serves as a baseline for ongoing research and decision-making in both veterinary practice and industry.


Assuntos
Hidratação , Derivados de Hidroxietil Amido , Animais , Hidratação/veterinária , Soluções Isotônicas , Inquéritos e Questionários , Reino Unido
17.
Zhonghua Shao Shang Za Zhi ; 36(10): 939-946, 2020 Oct 20.
Artigo em Chinês | MEDLINE | ID: mdl-33105946

RESUMO

Objective: To investigate the effect of fluid resuscitation guided by pulse contour cardiac output (PiCCO) monitoring technology on the organ function in extremely severe burn patients. Methods: From May 2015 to March 2019, 52 patients with extremely severe burn hospitalized in Tongren Hospital of Wuhan University & Wuhan Third Hospital, meeting the inclusion criteria, were recruited to conduct a prospectively randomized control study. The patients were divided into PiCCO monitoring rehydration group (25 cases, 17 males and 8 females) and traditional rehydration group (27 cases, 20 males and 7 females) according to the random number table, with the ages of (47±9) and (49±8) years respectively. After admission, all the patients were rehydrated according to the rehydration formula of the Third Military Medical University during shock stage. In traditional rehydration group, fluid resuscitation of the patients was performed by monitoring the traditional shock indicators such as urine volume and central venous pressure, while PiCCO monitoring was performed in patients in PiCCO monitoring rehydration group, and the global end-diastolic volume index combined with the other relevant indicators of PiCCO monitoring were used to guide rehydration on the basis of the monitoring indicators of traditional rehydration group. The rehydration coefficients and urine volumes per kilogram of body weight per hour during the first and second 24 h post injury were compared between the two groups, which were compared with the corresponding rehydration scheme value of the Third Military Medical University (hereinafter referred to as the scheme value) at the same time. The total rehydration volumes within post injury hour (PIH) 8 and during the first and second 24 h post injury, the urine volumes per hour during the first and second 24 h post injury, and the levels of creatinine, urea nitrogen, lactate clearance rate, procalcitonin, creatine kinase isoenzyme (CK-MB) in blood and mean arterial pressure (MAP) on post injury day (PID) 1, 2, and 3 were measured. The incidence of complications, the application case number of mechanical ventilation, and the mechanical ventilation time within PID 28 were analyzed. Data were statistically analyzed with analysis of variance for repeated measurement, t test, Bonferroni correction, Mann-Whitney U test, chi-square test, and Fisher's exact probability method test. Results: During the second 24 h post injury, the rehydration coefficient of patients in traditional rehydration group was significantly higher than the scheme value (t=5.120, P<0.01). During the first and second 24 h post injury, the rehydration coefficients of patients in PiCCO monitoring rehydration group were significantly higher than the scheme values (t=3.655, 10.894, P<0.01) and those in traditional rehydration group (t=3.172, 2.363, P<0.05 or P<0.01). Within PIH 8, the total rehydration volumes of patients between the two groups were similar. During the first and second 24 h post injury, the total rehydration volumes of patients in PiCCO monitoring rehydration group were significantly higher than those in traditional rehydration group (t=4.428, 3.665, P<0.01). During the first and second 24 h post injury, the urine volumes per kilogram of body weight per hour of patients in traditional rehydration group were significantly higher than the schema values (t=4.293, 6.362, P<0.01), and the urine volumes per kilogram body weight per hour of patients in PiCCO monitoring rehydration group were significantly higher than the schema values (t=6.461, 8.234, P<0.01). The urine volumes per kilogram of body weight per hour and urine volumes per hour of patients in PiCCO monitoring rehydration group during the second 24 h post injury were significantly higher than those in traditional rehydration group (t=2.849, 3.644, P<0.05 or P<0.01). The creatinine levels of patients between the two groups on PID 1, 2, and 3 were similar. The urea nitrogen levels of patients in PiCCO monitoring rehydration group on PID 1, 2, and 3 were (6.8±1.5), (5.6±1.4), (4.4±1.4) mmol/L respectively, which were significantly lower than (8.6±1.8), (6.6±1.5), (5.5±1.4) mmol/L in traditional rehydration group (t=3.817, 2.511, 2.903, P<0.05 or P<0.01). The lactate clearance rates of patients in PiCCO monitoring rehydration group on PID 1, 2, and 3 were significantly higher than those in traditional rehydration group (t=2.516, 4.540, 3.130, P<0.05 or P<0.01). The procalcitonin levels of patients in PiCCO monitoring rehydration group on PID 2 and 3 were significantly lower than those in traditional rehydration group (Z=-2.491, -2.903, P<0.05). The CK-MB level of patients in PiCCO monitoring rehydration group on PID 3 was (35±10) U/L, which was significantly lower than (51±16) U/L in traditional rehydration group (t=4.556, P<0.01). The MAP levels of patients between the two groups on PID 1, 2, and 3 were similar. Within PID 28, the incidence of complications of patients in traditional rehydration group was significantly higher than that in PiCCO monitoring rehydration group (χ(2)=4.995, P<0.05), and the application case number of mechanical ventilation and the mechanical ventilation time of patients between the two groups were similar. Conclusions: The use of PiCCO monitoring technology to guide the early fluid resuscitation of extremely severe burn patients is beneficial for accurate determination of the fluid volume required by the patients and reduction of organ injury caused by improper rehydration.


Assuntos
Queimaduras , Choque , Adulto , Queimaduras/terapia , Débito Cardíaco , Feminino , Hidratação , Humanos , Masculino , Pessoa de Meia-Idade , Ressuscitação , Choque/terapia , Tecnologia
19.
JAMA Netw Open ; 3(10): e2016869, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33057642

RESUMO

Importance: Prehospital plasma administration improves survival in injured patients at risk for hemorrhagic shock and transported by air ambulance. Traumatic brain injury (TBI) is a leading cause of death following trauma, but few early interventions improve outcomes. Objective: To assess the association between prehospital plasma and survival in patients with TBI. Design, Setting, and Participants: The Prehospital Air Medical Plasma (PAMPer) trial was a pragmatic, multicenter, phase 3, cluster randomized clinical trial involving injured patients who were at risk for hemorrhagic shock during air medical transport to a trauma center. The trial was conducted at 6 US sites with 9 level-I trauma centers (comprising 27 helicopter emergency services bases). The original trial analyzed 501 patients, including 230 patients who were randomized to receive plasma and 271 randomized to standard care resuscitation. This secondary analysis of a predefined subgroup included patients with TBI. Data analysis was performed from October 2019 to February 2020. Interventions: Patients were randomized to receive standard care fluid resuscitation or 2 units of thawed plasma. Main Outcomes and Measures: The primary outcome was mortality at 30 days. Patients with TBI were prespecified as a subgroup for secondary analysis and for measurement of markers of brain injury. The 30-day survival benefit of prehospital plasma in subgroups with and without TBI as diagnosed by computed tomography was characterized using Kaplan-Meier survival analysis and Cox proportional hazard regression. Results: In total, 166 patients had TBI (median [interquartile range] age, 43.00 [25.00-59.75] years; 125 men [75.3%]). When compared with the 92 patients who received standard care, the 74 patients with TBI who received prehospital plasma had improved 30-day survival even after adjustment for multiple confounders and assessment of the degree of brain injury with clinical variables and biomarkers (hazard ratio [HR], 0.55; 95% CI, 0.33-0.94; P = .03). Receipt of prehospital plasma was associated with improved survival among patients with TBI with a prehospital Glasgow Coma Scale score of less than 8 (HR, 0.56; 95% CI, 0.35-0.91) and those with polytrauma (HR, 0.50; 95% CI, 0.28-0.89). Patients with TBI transported from the scene of injury had improved survival following prehospital plasma administration (HR, 0.45; 95% CI, 0.26-0.80; P = .005), whereas patients who were transferred from an outside hospital showed no difference in survival for the plasma intervention (HR, 1.00; 95% CI, 0.33-3.00; P = .99). Conclusions and Relevance: These findings are exploratory, but they suggest that receipt of prehospital plasma is associated with improved survival in patients with computed tomography-positive TBI. The prehospital setting may be a critical period to intervene in the care of patients with TBI. Future studies are needed to confirm the clinical benefits of early plasma resuscitation following TBI and concomitant polytrauma. Trial Registration: ClinicalTrials.gov Identifier: NCT01818427.


Assuntos
Lesões Encefálicas Traumáticas/mortalidade , Lesões Encefálicas Traumáticas/terapia , Reanimação Cardiopulmonar/métodos , Serviços Médicos de Emergência/métodos , Hidratação/métodos , Plasma , Choque Hemorrágico/prevenção & controle , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Estados Unidos
20.
Medicine (Baltimore) ; 99(41): e21842, 2020 Oct 09.
Artigo em Inglês | MEDLINE | ID: mdl-33031256

RESUMO

RATIONALE: Despite toxicity and unpredictable adverse effects, ecstasy use has increased in the United States. Onset of hyperpyrexia, rhabdomyolysis, disseminated intravascular coagulation (DIC), among other symptoms, occurs within hours of ingestion. Moreover, patients who experience hyperpyrexia, altered mental status, DIC, and multiorgan failure, rarely survive. This case presents a chronic ecstasy user whose symptoms would have predicted mortality. The report demonstrates a patient who experiences protracted hyperthermia, with delayed rhabdomyolysis and DIC. In addition, his peak creatine kinase (CK) of 409,440 U/L was far greater than the expected 30,000 to 100,000 U/L, being the second largest CK recorded in a survivor. PATIENT CONCERNS: This case report presents a 20-year-old man who presented to the emergency department after experiencing a severe reaction to ecstasy. He was a chronic user who took his baseline dosage while performing at a music event. He experienced hyperpyrexia immediately (106.5°F) while becoming stiff and unresponsive. Before emergency medical service arrival, his friends placed cold compresses on the patient and rested him in an ice filled bathtub. DIAGNOSES: Per history from patient's friends and toxicology results, the patient was diagnosed with ecstasy overdose, which evolved to include protracted hyperthermia and delayed rhabdomyolysis. INTERVENTIONS: Due to a Glasgow coma scale score of 5, he was intubated and sedated with a propofol maintenance. Hyperpyrexia resolved (temperature dropped to 99.1°F) after start of propofol maintenance. He was extubated after 24 hours, upon which he experienced hyperthermia (101.4°F at 48 hours), delayed rhabdomyolysis, and DIC (onset at 37 hours). He remained in hyperthermia for 120 hours until carvedilol permanently returned his temperature to baseline. His plasma CK reached a peak of 409,440 U/L at 35 hours. OUTCOMES: After primary management with intravenous fluids, the patient returned to baseline health without any consequences and was discharged after 8 days. A follow-up of 3 months postdischarge revealed no complications or disability. LESSONS: Clinically, the case highlights how physicians should be aware of the unusual time course adverse effects of ecstasy can have. Lastly, as intensity and duration of hyperpyrexia are predictors of mortality, our case indicates maintenance of sedation with propofol and use of oral carvedilol; both are efficacious for temperature reduction in ecstasy toxicity.


Assuntos
Febre/induzido quimicamente , N-Metil-3,4-Metilenodioxianfetamina/toxicidade , Rabdomiólise/induzido quimicamente , Overdose de Drogas , Febre/terapia , Hidratação , Humanos , Masculino , Rabdomiólise/terapia , Adulto Jovem
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