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2.
JAMA ; 323(3): 225-236, 2020 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-31961418

RESUMO

Importance: It is not known if use of colloid solutions containing hydroxyethyl starch (HES) to correct for intravascular deficits in high-risk surgical patients is either effective or safe. Objective: To evaluate the effect of HES 130/0.4 compared with 0.9% saline for intravascular volume expansion on mortality and postoperative complications after major abdominal surgery. Design, Setting, and Participants: Multicenter, double-blind, parallel-group, randomized clinical trial of 775 adult patients at increased risk of postoperative kidney injury undergoing major abdominal surgery at 20 university hospitals in France from February 2016 to July 2018; final follow-up was in October 2018. Interventions: Patients were randomized to receive fluid containing either 6% HES 130/0.4 diluted in 0.9% saline (n = 389) or 0.9% saline alone (n = 386) in 250-mL boluses using an individualized hemodynamic algorithm during surgery and for up to 24 hours on the first postoperative day, defined as ending at 7:59 am the following day. Main Outcomes and Measures: The primary outcome was a composite of death or major postoperative complications at 14 days after surgery. Secondary outcomes included predefined postoperative complications within 14 days after surgery, durations of intensive care unit and hospital stays, and all-cause mortality at postoperative days 28 and 90. Results: Among 826 patients enrolled (mean age, 68 [SD, 7] years; 91 women [12%]), 775 (94%) completed the trial. The primary outcome occurred in 139 of 389 patients (36%) in the HES group and 125 of 386 patients (32%) in the saline group (difference, 3.3% [95% CI, -3.3% to 10.0%]; relative risk, 1.10 [95% CI, 0.91-1.34]; P = .33). Among 12 prespecified secondary outcomes reported, 11 showed no significant difference, but a statistically significant difference was found in median volume of study fluid administered on day 1: 1250 mL (interquartile range, 750-2000 mL) in the HES group and 1500 mL (interquartile range, 750-2150 mL) in the saline group (median difference, 250 mL [95% CI, 83-417 mL]; P = .006). At 28 days after surgery, 4.1% and 2.3% of patients had died in the HES and saline groups, respectively (difference, 1.8% [95% CI, -0.7% to 4.3%]; relative risk, 1.76 [95% CI, 0.79-3.94]; P = .17). Conclusions and Relevance: Among patients at risk of postoperative kidney injury undergoing major abdominal surgery, use of HES for volume replacement therapy compared with 0.9% saline resulted in no significant difference in a composite outcome of death or major postoperative complications within 14 days after surgery. These findings do not support the use of HES for volume replacement therapy in such patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02502773.


Assuntos
Abdome/cirurgia , Hidratação/métodos , Derivados de Hidroxietil Amido/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Solução Salina/uso terapêutico , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Lesão Renal Aguda/prevenção & controle , Idoso , Método Duplo-Cego , Feminino , Humanos , Cuidados Intraoperatórios , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Estatísticas não Paramétricas
3.
Anaesthesia ; 75 Suppl 1: e83-e89, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31903571

RESUMO

Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. In elective surgery, enhanced recovery has resulted in reduced length of stay and morbidity by the application of procedure-specific, evidence-based interventions inside rigorously implemented patient pathways based on multidisciplinary co-operation. The focus has been on attenuation of peri-operative stress and pain management to facilitate early recovery. Patients undergoing emergency laparotomy are a heterogeneous group consisting mostly of patients with intestinal perforations and/or obstruction with varying levels of comorbidity and frailty. However, present knowledge of the different pathophysiology and peri-operative trajectory of complications in these patient groups is limited. In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.


Assuntos
Abdome/cirurgia , Laparoscopia/métodos , Complicações Pós-Operatórias/prevenção & controle , Recuperação de Função Fisiológica , Emergências , Hidratação , Humanos , Modalidades de Fisioterapia
5.
Food Microbiol ; 85: 103301, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31500710

RESUMO

Lactobacillus paracasei is able to persist in a variety of natural and technological environments despite physico-chemical perturbations, in particular alternations between desiccation and rehydration. However, the way in which it adapts to hydric fluctuations and the genetic determinants involved are not clearly understood. To identify the genes involved in adaptation to desiccation, an annotated library of L. paracasei random transposon mutants was screened for viability after desiccation (25% relative humidity, 25 °C). We found 16 genes that have not been described as being involved in this response. Most of them are linked to either the transport of molecules or to cell wall structure and function. Our screening also identified genes encoding DNA related enzymes and an alarmone necessary for L. paracasei survival. Subsequently, the expression of the identified genes was measured at five stages of the dehydration-rehydration process to decipher the chronology of genetic mechanisms. They were classified into four different transcriptional profiles: genes upregulated during both desiccation and rehydration phases, genes upregulated during the desiccation phase only, genes downregulated during both desiccation and rehydration and genes downregulated only during the rehydration stage. Thus, genetic response to hydric fluctuations seems to occur during desiccation and can continue or not during rehydration. The genes identified should contribute to improve the stabilization of Lactobacillus starters in dry state.


Assuntos
Dessecação , Hidratação , Lactobacillus paracasei/genética , Adaptação Fisiológica , Regulação para Baixo , Perfilação da Expressão Gênica , Lactobacillus paracasei/fisiologia , Regulação para Cima , Água
6.
Zhong Nan Da Xue Xue Bao Yi Xue Ban ; 44(10): 1163-1168, 2019 Oct 28.
Artigo em Chinês | MEDLINE | ID: mdl-31857511

RESUMO

OBJECTIVE: To observe the safety and impact on the short-term prognosis for patients of stroke volume variation (SVV) goal-directed fluid therapy (GDFT) in laparoscopic precision hepatectomy.
 Methods: A total of 120 patients (18-65 years old) undergoing laparoscopic precision hepatectomy were randomly divided into the fluid therapy group (group S) guided by SVV and the fluid therapy group (group C) guided by central venous pressure group (CVP), with 60 cases in each group. Mean arterial pressure (MAP) and heart rate (HR) were recorded at the following time: at home calm (T0), the operation started (T1), began to cut the liver (T2), the hepatectomy was acheived (T3), and in the end (T4). The lactic acid was measured at T0 to T4 and 1 day after surgery (T5). The amount of blood loss, urine output and fluid supplement, the incidence of intraoperative hypotension, and the use of neophryn were recorded. The recovery of liver function, Hb, and so on were also recorded.
 Results: Compared with the group C, the number of hypotension cases, the amount of blood loss and the amount of neophryn in the group S were decreased during the operation (P<0.05), while the lactic acid values in the group S were not significantly increased than those in the group C at T3 and T4 (P<0.05) and the elevation of AST, ALT, DBIL and TBIL in the group S was significantly decreased than those in the group C at 1 and 2 d after the operation (P<0.05). Hb and Hct in the group S were higher than those in the group C at 1 d after the surgery (P<0.05). Compared with the group C, the postoperative exhaust time and hospitalization time were shortened in the group S (P<0.05), and the infection rate and ICU admission rate were decreased in the group S (P<0.05).
 Conclusion: SVV-guided GDFT in laparoscopic precise hepatectomy is safe and effective. It reduces intraoperative blood loss and benefits the short-term prognosis of patients after operations. High SVV value (13%-17%) is adopted at the liver resection stage, and SVV value with 8%-12% at the end of trans-section may be used as one of intraoperative liquid therapy in laparoscopic precise hepatectomy.


Assuntos
Hepatectomia , Laparoscopia , Adolescente , Adulto , Idoso , Pressão Venosa Central , Hidratação , Humanos , Pessoa de Meia-Idade , Volume Sistólico , Adulto Jovem
7.
Sichuan Da Xue Xue Bao Yi Xue Ban ; 50(6): 803-807, 2019 Dec.
Artigo em Chinês | MEDLINE | ID: mdl-31880109

RESUMO

OBJECTIVE: To investigate the relationship between fluid management oriented by critical care ultrasound and prognosis in patients with shock. METHODS: We analyzed the data of a randomized controlled trial called Critical Care Ultrasound Oriented Shock Treatment (CCUSOST) in the Department of Critical Care Medicine, West China Hospital retrospectively. 77 patients in the critical care ultrasound oriented treatment group (experimental group) and 70 patients in the conventionally treated group as control were included in the statistics, to evaluate the relationship between fluid intake and prognosis. Univariate and multivariate logistic regression analyses were used to analyze risk factors for ICU mortality. RESULTS: The baseline indexes of the patients in the experimental group and the control group were consistent. The ICU mortality of the experimental group was significantly lower than that of the control group (P < 0.05).The fluid intake in the stabilization and de-escalation phases was less than the the control group (P < 0.05). We divided these shock patients into survival group (92 cases) and non-survival (55 cases) according to whether they died in ICU, and the univariate analysis for ICU mortality showed that acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score, SOFA score, Lac, hourly urine output, total fluid intake, fluid intake in the salvage and optimization stages, fluid intake in the stabilization and de-escalation stages were significantly different (P < 0.05) between survivers and non-survivers. Multivariete analysis showed that the fluid intake during the salvage and optimization phases, fluid intake in the stabilization and de-escalation phases were independent risk factors for ICU mortality. CONCLUSION: Critical care ultrasound oriented shock fluid management could reduce fluid intake of stabilization and de-escalation phases, and improved adverse outcome; whether the fluid intake during stabilization and de-escalation phases, or the fluid intake during the salvage and optimization phases, both were associated with patient prognosis.


Assuntos
Hidratação , Unidades de Terapia Intensiva , China , Cuidados Críticos , Humanos , Prognóstico , Estudos Retrospectivos
9.
Zhonghua Shao Shang Za Zhi ; 35(11): 772-775, 2019 Nov 20.
Artigo em Chinês | MEDLINE | ID: mdl-31775464

RESUMO

Because of the complex injury mechanism, hidden tissue injury, and severe systemic injury, the clinical diagnosis and treatment of electric burn still face many challenges, and the mortality and disability rate are still high. In view of the particularity of electric burn and the prognosis of electric burn, especially the quality of wound repair, the author puts forward some personal views on fluid resuscitation, organ protection, and wound repair on the basis of summarizing the new methods of diagnosis and treatment of electric burn at home and abroad at present, and preliminarily explores the standardized diagnosis and treatment of electric burn.


Assuntos
Queimaduras por Corrente Elétrica/diagnóstico , Queimaduras por Corrente Elétrica/terapia , Hidratação , Humanos , Prognóstico , Cicatrização
10.
Crit Care ; 23(1): 377, 2019 11 27.
Artigo em Inglês | MEDLINE | ID: mdl-31775837

RESUMO

BACKGROUND: African children hospitalised with severe febrile illness have a high risk of mortality. The Fluid Expansion As Supportive Therapy (FEAST) trial (ISCRTN 69856593) demonstrated increased mortality risk associated with fluid boluses, but the temporal relationship to bolus therapy and underlying mechanism remains unclear. METHODS: In a post hoc retrospective analysis, flexible parametric models were used to compare change in mortality risk post-randomisation in children allocated to bolus therapy with 20-40 ml/kg 5% albumin or 0.9% saline over 1-2 h or no bolus (control, 4 ml/kg/hour maintenance), overall and for different terminal clinical events (cardiogenic, neurological, respiratory, or unknown/other). RESULTS: Two thousand ninety-seven and 1041 children were randomised to bolus vs no bolus, of whom 254 (12%) and 91 (9%) respectively died within 28 days. Median (IQR) bolus fluid in the bolus groups received by 4 h was 20 (20, 40) ml/kg and was the same at 8 h; total fluids received in bolus groups at 4 h and 8 h were 38 (28, 43) ml/kg and 40 (30, 50) ml/kg, respectively. Total fluid volumes received in the control group by 4 h and 8 h were median (IQR) 10 (6, 15) ml/kg and 10 (10, 26) ml/kg, respectively. Mortality risk was greatest 30 min post-randomisation in both groups, declining sharply to 4 h and then more slowly to 28 days. Maximum mortality risk was similar in bolus and no bolus groups; however, the risk declined more slowly in the bolus group, with significantly higher mortality risk compared to the no bolus group from 1.6 to 101 h (4 days) post-randomisation. The delay in decline in mortality risk in the bolus groups was most pronounced for cardiogenic modes of death. CONCLUSIONS: The increased risk from bolus therapy was not due to a mechanism occurring immediately after bolus administration. Excess mortality risk in the bolus group resulted from slower decrease in mortality risk over the ensuing 4 days. Thus, administration of modest bolus volumes appeared to prevent mortality risk declining at the same rate that it would have done without a bolus, rather than harm associated with bolus resulting from a concurrent increased risk of death peri-bolus administration. TRIAL REGISTRATION: ISRCTN69856593. Date of registration 15 December 2008.


Assuntos
Hidratação , Criança , Humanos , Ressuscitação , Estudos Retrospectivos , Tempo
11.
Methodist Debakey Cardiovasc J ; 15(3): 220-222, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31687102

RESUMO

It is estimated that there are more than 210,000 hospital admissions for acute pancreatitis and more than 56,000 admissions for chronic pancreatitis each year in the United States. Pancreatitis comes with numerous complications that can increase morbidity, mortality, and length of hospital stay. Local and systemic complications include pseudocysts, necrosis, sepsis, multiorgan failure, and vascular complications. Thrombosis of the splanchnic venous system occurs in approximately 2% of patients with pancreatitis, but thrombosis is rarely seen in the arterial system. In this report, we describe a case of thrombosis of the abdominal aorta and superior mesenteric artery in a female patient who presented with acute pancreatitis.


Assuntos
Doenças da Aorta/etiologia , Artéria Mesentérica Superior , Oclusão Vascular Mesentérica/etiologia , Pancreatite/complicações , Trombose/etiologia , Antibacterianos/uso terapêutico , Anticoagulantes/uso terapêutico , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/tratamento farmacológico , Feminino , Hidratação , Humanos , Artéria Mesentérica Superior/diagnóstico por imagem , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/tratamento farmacológico , Pessoa de Meia-Idade , Pancreatite/diagnóstico por imagem , Pancreatite/terapia , Trombose/diagnóstico por imagem , Trombose/tratamento farmacológico , Resultado do Tratamento
16.
Medicine (Baltimore) ; 98(48): e18145, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31770252

RESUMO

BACKGROUND: Hypotensive resuscitation is an old study. But its benefits and losses are still controversial. In clinic, the method of fluid resuscitation needs more reliable experimental evidence. This study's objective is to systematically evaluate the efficacy of hypotensive resuscitation in patients with traumatic hemorrhagic shock. METHODS AND ANALYSIS: Through October 2019, Web of Science, PubMed, the Cochrane Library, EMBASE, and Clinical Trials will be systematically searched to identify randomized controlled trials exploring the efficacy of hypotensive resuscitation in traumatic hemorrhagic shock. Strict screening and quality evaluation will be independently performed on the obtained literature by 2 researchers; outcome indexes will be extracted, and a meta-analysis will be performed on the data using Revman 5.3 software. ETHICS AND DISSEMINATION: The stronger evidence about the efficacy of hypotensive resuscitation in traumatic hemorrhagic shock will be provided for clinicians. TRIAL REGISTRATION NUMBER: PROSPERO CRD42019133169. STRENGTHS OF THIS STUDY: This study is not only a simple combination of data, but also to verify and discuss the reliability of the results, and provide more convincing evidence for clinicians. LIMITATIONS OF THIS STUDY: Firstly, according to the previous literature researching, it is found that the number of relevant randomized controlled trials is small and the quality level of the literature is uneven. Secondly, the efficacy of hypotensive resuscitation is discussed for a long time, different trials may take place at different times. Comparability between different trials is reduced.


Assuntos
Hidratação/métodos , Ressuscitação , Choque Hemorrágico , Ferimentos e Lesões/complicações , Protocolos Clínicos , Humanos , Hipotensão Controlada/métodos , Metanálise como Assunto , Reprodutibilidade dos Testes , Ressuscitação/efeitos adversos , Ressuscitação/métodos , Choque Hemorrágico/complicações , Choque Hemorrágico/terapia
17.
Presse Med ; 48(11 Pt 2): 347-353, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31694791

RESUMO

Plasma exchange is a well-established therapeutic procedure commonly used in many autoimmune disorders. The beneficial effects of plasma exchange are thought to occur through the elimination of pathogenic mediators found in plasma, including autoantibodies, complement components, and cytokines. The catastrophic antiphsopholipid syndrome (CAPS) is a life-threatening variant of the antiphospholipid syndrome (APS) where several thrombosis take place in a short period of time in patients with circulating antiphospholipid antibodies. The triple therapy with anticoagulation, corticosteroids and plasma exchange or intravenous immunoglobulins has been proposed in CAPS. CAPS is a rare disease precluding the conduction of formal clinical trials. However, the observation of a better clinical course of patients who received this treatment supports their use. Plasma exchange has become an established therapeutic procedure in CAPS but there are no studies regarding the better approach and thus its use relies on the experience of the physicians in charge. The current article aims to review potential mechanisms of action of plasma exchange and the technical aspects of this procedure and will focus on its current role in CAPS, the experience published in treating this condition and the treatment protocol that we use in our institution.


Assuntos
Síndrome Antifosfolipídica/terapia , Troca Plasmática/métodos , Corticosteroides/uso terapêutico , Anticorpos Antifosfolipídeos/sangue , Anticoagulantes/uso terapêutico , Síndrome Antifosfolipídica/sangue , Síndrome Antifosfolipídica/imunologia , Terapia Combinada/métodos , Hidratação/métodos , Humanos
18.
Rev Med Suisse ; 15(667): 1866-1869, 2019 Oct 16.
Artigo em Francês | MEDLINE | ID: mdl-31617974

RESUMO

Crystalloid-type solutions are currently recommended for volume resuscitation. Although historically considered as «â€…physiological saline ¼, NaCl 0.9 % has a high concentration of sodium and chloride that can lead to metabolic acidosis and impaired renal function when large volumes are used. Recent evidence confirms that use of low-chloride crystalloids (so-called balanced solutions) could reduce the occurrence of renal failure and should be preferred during high volume resuscitation.


Assuntos
Cuidados Críticos/métodos , Hidratação , Ressuscitação , Humanos , Insuficiência Renal/prevenção & controle , Solução Salina
19.
Medicine (Baltimore) ; 98(43): e17586, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31651865

RESUMO

RATIONALE: Tolvaptan, an oral vasopressin V2 receptor antagonist, is a new approach for the treatment of adult patients with the syndrome of inappropriate antidiuresis (SIADH). However, dose-dependent side effect including rapid increase in serum sodium levels and liver injury, and the expensive price limit the long-term use of tolvaptan. We report a case of SIADH patient treated with intermittent lower dose of tolvaptan combined with fluid restriction. PATIENT CONCERNS: A 60-year-old woman presented of nausea and vomiting, dizzy and amaurosis, and transient disturbance, after a week of persistent diarrhea. DIAGNOSIS: Diagnosis of SIADH was based on severe persistent hyponatremia, decreased plasma osmolality, raised urinary sodium excretion, and the absence of other causes. INTERVENTIONS: She was given the treatment of tolvaptan 15 mg once daily, and experienced tolvaptan-related side effects including thirst and dry mouth, polyuria, and dizziness. Then, single dose of tolvaptan was reduced from 15 to 7.5 mg, and the interval between medication was gradually prolonged from 24 to 72 hours. Meanwhile, serum sodium was negatively correlated with the amount of daily water intake in interval days, so daily water intake of the patient was restricted to 1500 mL in interval days. OUTCOMES: Serum sodium was maintained within the normal range, 137 to 141 mmol/L without liver damage. LESSONS: For patients with chronic SIADH, the tolvaptan dose should be individualized, and the regimen of intermittent lower dose of tolvaptan combined with fluid restriction maybe an effective choice.


Assuntos
Antagonistas dos Receptores de Hormônios Antidiuréticos/administração & dosagem , Hidratação/métodos , Síndrome de Secreção Inadequada de HAD/terapia , Tolvaptan/administração & dosagem , Terapia Combinada , Feminino , Humanos , Síndrome de Secreção Inadequada de HAD/sangue , Pessoa de Meia-Idade , Sódio/sangue , Resultado do Tratamento
20.
Am Surg ; 85(10): 1171-1174, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657318

RESUMO

Avoiding excess fluid administration is necessary when managing critically ill surgical patients. The aim of this study was to delineate the current practices of IV electrolyte (IVE) replacement in a surgical ICU and quantify their contribution to the fluid balance (FB) status. Patients admitted to the surgical ICU over a six-month period were reviewed. Patients undergoing dialysis and those with ICU stay <72 hours were excluded. A total of 248 patients were included. The median age was 60 years, and 57 per cent were male. Overall, 1131 patient ICU days were analyzed. The median daily FB was 672 mL. IVEs were administered in 62 per cent of ICU days. In days that IVEs were used, negative FB was significantly less likely to be achieved (62% vs 69%, P = 0.02). The most commonly administered IVE was calcium (32% of ICU days); however, the largest volume of IVE was administered in the form of phosphorus (median 225 mL). Diuretics were administered in 17 per cent of ICU days. Patients who received diuretics were significantly more likely to receive IVE (70% vs 61%, P = 0.02). Administration of IVE may contribute to the daily positive FB of surgical ICU patients. Implementation of practices that can ameliorate this effect is encouraged.


Assuntos
Estado Terminal , Eletrólitos/administração & dosagem , Infusões Intravenosas/métodos , Procedimentos Cirúrgicos Operatórios , Equilíbrio Hidroeletrolítico , Cálcio/administração & dosagem , Diuréticos/administração & dosagem , Feminino , Hidratação/efeitos adversos , Hidratação/métodos , Humanos , Infusões Intravenosas/estatística & dados numéricos , Unidades de Terapia Intensiva , Sulfato de Magnésio/administração & dosagem , Masculino , Pessoa de Meia-Idade , Fósforo/administração & dosagem , Potássio/administração & dosagem , Estudos Retrospectivos
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