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1.
Emerg Med Clin North Am ; 38(4): 857-869, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32981622

RESUMO

The obesity pandemic now affects hundreds of millions of people worldwide. As obesity rates continue to increase, emergency physicians are called on with increasing frequency to resuscitate obese patients. This article discusses important anatomic, physiologic, and practical challenges imposed by obesity on resuscitative care. Impacts on hemodynamic monitoring, airway and ventilator management, and pharmacologic therapy are discussed. Finally, several important clinical scenarios (trauma, cardiac arrest, and sepsis), in which alterations to standard treatments may benefit obese patients, are highlighted.


Assuntos
Obesidade/complicações , Ressuscitação/métodos , Manuseio das Vias Aéreas/métodos , Analgésicos/administração & dosagem , Antibacterianos/administração & dosagem , Composição Corporal , Fármacos Cardiovasculares/administração & dosagem , Doenças Cardiovasculares/complicações , Relação Dose-Resposta a Droga , Serviço Hospitalar de Emergência , Parada Cardíaca/terapia , Humanos , Hipnóticos e Sedativos/administração & dosagem , Medidas de Volume Pulmonar , Consumo de Oxigênio , Farmacocinética , Respiração com Pressão Positiva , Sepse/complicações , Sepse/terapia , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia
2.
Emerg Med Clin North Am ; 38(4): 903-917, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32981625

RESUMO

Care of the critically ill pregnant patient is anxiety-provoking for those unprepared, as the emergency physician must consider not only the welfare of the immediate patient, but of the fetus as well. Familiarity with the physiologic changes of pregnancy and how they affect clinical presentation and management is key. Although some medications may be safer in pregnancy than others, stabilizing the pregnant patient is paramount. Emergency physicians should target pregnancy-specific oxygen and ventilation goals and hemodynamics and should be prepared to perform a perimortem cesarean section, should the mother lose pulses, to increase chances for maternal and fetal survival.


Assuntos
Complicações na Gravidez/terapia , Ressuscitação/métodos , Manuseio das Vias Aéreas , Gasometria , Cesárea , Contraindicações de Medicamentos , Estado Terminal , Serviço Hospitalar de Emergência , Feminino , Monitorização Fetal , Parada Cardíaca/etiologia , Parada Cardíaca/terapia , Humanos , Hipnóticos e Sedativos/administração & dosagem , Intubação Intratraqueal , Troca Materno-Fetal , Ventilação não Invasiva , Circulação Placentária , Gravidez/fisiologia , Complicações na Gravidez/diagnóstico , Insuficiência Respiratória/terapia , Choque/terapia
3.
Medicine (Baltimore) ; 99(36): e21859, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32899015

RESUMO

BACKGROUND: The purpose of this study was to evaluate the effects of adding ketamine to propofol on cognitive functions in patients undergoing sedation for colonoscopy. METHODS: In this randomized, double-blinded, and controlled study, 200 patients were randomly allocated to ketamine/propofol admixture group (Group KP, n = 100), and propofol group (Group P, n = 100). Patients in Group KP received 0.25 mg/kg of ketamine and 0.5 mg/kg of propofol. Patients in Group P received 0.5 mg/kg propofol. Cognitive functions were measured using CogState battery before and after the colonoscopy procedure. Ninety five patients in Group KP and 92 patients in Group P had completed the CogStates tests and were included in the data analysis. RESULTS: Compared with before procedure baseline, the performance on detection and identification tasks were significantly impaired after the procedure in both Group KP (P = .004, P = .001) and Group P patients (P = .005, P < .001). However, one-card learning accuracy and One-back memory was only impaired in Group KP patients (P = .006, P = .040) after the endoscopy but left intact in Group P patients. Group KP patients showed more severe impairment in one-card learning accuracy compared with Group P patients (P = .044). Group KP patients have better 5 minutes MAP (P = .005) and were also less likely to suffer from complications such as respiratory depression (P = .023) and hypotension (P = .015). OAA/S scores, BIS, MAP, complications, recovery times, and endoscopist and patient satisfaction were similar between the 2 groups. CONCLUSION: Although adding ketamine to propofol for sedation in colonoscopy provided fewer complications such as respiratory depression and hypotension, it also causes more impairment in cognitive functions.


Assuntos
Colonoscopia/métodos , Sedação Profunda/métodos , Hipnóticos e Sedativos/farmacologia , Ketamina/farmacologia , Complicações Cognitivas Pós-Operatórias/induzido quimicamente , Propofol/farmacologia , Adulto , Sedação Profunda/efeitos adversos , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Ketamina/administração & dosagem , Masculino , Pessoa de Meia-Idade , Propofol/administração & dosagem , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto
4.
Medicine (Baltimore) ; 99(34): e21915, 2020 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-32846859

RESUMO

This retrospective study aimed at identifying the predictors of oxygen desaturation (OD) (i.e., SpO2 < 95%) in patients with obstructive sleep apnea (OSA) requiring deep sedation and developing an algorithm to predict OD.We studied 66 OSA patients undergoing propofol-induced deep sedation for drug-induced sleep endoscopy (DISE). The patients were divided into prediction (n = 35) and validation (n = 31) groups. Patient characteristics and polysomnographic parameters were analyzed with receiver operating characteristic curve and Chi-squared test to identify significant predictors of OD for developing an algorithm in the prediction group. The predictive accuracy, sensitivity, positive predictive value, and negative predictive value of the algorithm were determined in the validation group.Six polysomnographic predictors of OD were identified, including Apnea-Hypopnea Index of total sleep time (AHI-TST), AHI at the stage of rapid eye movement (AHI-REM), percentage of time with oxygen saturation <90% (mO2 < 90%), average SpO2, lowest SpO2, and desaturation index. Stepwise multiple logistic regression analysis demonstrated that low average SpO2 (<95.05%) and high AHI-REM (>16.5 events/h) were independent predictors of OD. The algorithm thus developed showed that patients with an average SpO2 < 95.05% and those with an average SpO2 ≥ 95.05% together with an AHI-REM > 16.5 events/h would be at risk of OD under sedation. The predictive accuracy, sensitivity, positive predictive value, and negative predictive value were 84%, 100%, 83%, 100%, respectively.For patients with OSA, average SpO2 and AHI-REM may enable clinicians to predict the occurrence of oxygen desaturation under deep sedation. Future large-scale studies are needed to validate the findings.


Assuntos
Algoritmos , Sedação Profunda/efeitos adversos , Oxigênio/sangue , Apneia Obstrutiva do Sono/sangue , Apneia Obstrutiva do Sono/fisiopatologia , Adulto , China/epidemiologia , Sedação Profunda/métodos , Endoscopia/métodos , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Masculino , Pessoa de Meia-Idade , Polissonografia/instrumentação , Valor Preditivo dos Testes , Propofol/administração & dosagem , Estudos Retrospectivos , Apneia Obstrutiva do Sono/diagnóstico , Sono REM
5.
Medicine (Baltimore) ; 99(31): e21397, 2020 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-32756133

RESUMO

OBJECTIVES: To evaluate the efficacy and safety of caudal dexmedetomidine in pediatric caudal anesthesia (CA). METHODS: We searched PubMed, Embased, and Cochrane Library (from inception to June 2019) for eligible studies. The primary outcomes were the time to first analgesia, time of postoperative eye opening, intraoperative endtidal sevoflurane concentration, and postoperative sedation score. We calculated pooled risk ratios (RR) and 95% CIs using random- or fixed-effects models. RESULTS: Thirteen trials involving 793 patients were found. Meta-analysis showed that the time to first rescue pain medication and the time from the end of anesthesia to eye opening in the CA+dexmedetomidine group were significantly longer than in the CA group (P < .00001). The intraoperative end-tidal sevoflurane concentration in the CA+dexmedetomidine group was significantly decreased (P < .00001). Dexmedetomidine appeared to increase the rate of bradycardia in the CA+dexmedetomidine group (P = .04). Additionally, the sedation score in the CA+ dexmedetomidine group was significantly higher at 2 hours after the operation compared with the CA group (P < .00001 at 2 hours). CONCLUSIONS: Caudally administered dexmedetomidine is a good alternative for prolonging postoperative analgesia with less pain, decreased intraoperative end-tidal sevoflurane concentration, and full postoperative sedation.


Assuntos
Anestesia Caudal , Dexmedetomidina/administração & dosagem , Hipnóticos e Sedativos/administração & dosagem , Ensaios Clínicos Controlados Aleatórios como Assunto , Criança , Humanos , Dor Pós-Operatória/prevenção & controle
6.
Curr Opin Anaesthesiol ; 33(4): 533-538, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32628400

RESUMO

PURPOSE OF REVIEW: The present review provides an overview of the different fields of procedural sedation and analgesia (PSA), describing the evidence from recently published studies concerning anxiety and moderate pain, cardiac interventions, gastrointestinal interventions, and PSA use in infants. It also provides guidance for practitioners of both unscheduled and scheduled procedural sedation, and a summary of the current guideline for PSA. RECENT FINDINGS: Safety always has to be first priority. Recently published literature is focusing on the combination of different well established drugs such as dexmedetomidine, remifentanil, propofol, and ketamine. These traditional and well known drugs are commonly used for PSA. The combinational use of multiple drugs seems to have benefits for both the provider and patient. Furthermore, there is growing interest into specific protocols and adaption for special circumstances. The preferred medications used for PSA should be both effective and well tolerated. SUMMARY: Procedural sedation deserves to have high degree of attention for potential adverse events. New combinations of well established drugs provide a better pharmacokinetic profile, fit to different indications and offer multiple benefits for both provider and patient.


Assuntos
Analgesia/métodos , Anestesia/métodos , Hipnóticos e Sedativos/administração & dosagem , Sedação Consciente , Dexmedetomidina , Humanos , Ketamina , Salas Cirúrgicas , Propofol , Remifentanil
7.
Lancet ; 396(10245): 177-185, 2020 07 18.
Artigo em Inglês | MEDLINE | ID: mdl-32682483

RESUMO

BACKGROUND: Atrial fibrillation and delirium are common consequences of cardiac surgery. Dexmedetomidine has unique properties as sedative agent and might reduce the risk of each complication. This study coprimarily aimed to establish whether dexmedetomidine reduces the incidence of new-onset atrial fibrillation and the incidence of delirium. METHODS: A randomised, placebo-controlled trial was done at six academic hospitals in the USA. Patients who had had cardiac surgery with cardiopulmonary bypass were enrolled. Patients were randomly assigned 1:1, stratified by site, to dexmedetomidine or normal saline placebo. Randomisation was computer generated with random permuted block size 2 and 4, and allocation was concealed by a web-based system. Patients, caregivers, and evaluators were all masked to treatment. The study drug was prepared by the pharmacy or an otherwise uninvolved research associate so that investigators and clinicians were fully masked to allocation. Participants were given either dexmedetomidine infusion or saline placebo started before the surgical incision at a rate of 0·1 µg/kg per h then increased to 0·2 µg/kg per h at the end of bypass, and postoperatively increased to 0·4 µg/kg per h, which was maintained until 24 h. The coprimary outcomes were atrial fibrillation and delirium occurring between intensive care unit admission and the earlier of postoperative day 5 or hospital discharge. All analyses were intention-to-treat. The trial is registered with ClinicalTrials.gov, NCT02004613 and is closed. FINDINGS: 798 patients of 3357 screened were enrolled from April 17, 2013, to Dec 6, 2018. The trial was stopped per protocol after the last designated interim analysis. Among 798 patients randomly assigned, 794 were analysed, with 400 assigned to dexmedetomidine and 398 assigned to placebo. The incidence of atrial fibrillation was 121 (30%) in 397 patients given dexmedetomidine and 134 (34%) in 395 patients given placebo, a difference that was not significant: relative risk 0·90 (97·8% CI 0·72, 1·15; p=0·34). The incidence of delirium was non-significantly increased from 12% in patients given placebo to 17% in those given dexmedetomidine: 1·48 (97·8% CI 0·99-2·23). Safety outcomes were clinically important bradycardia (requiring treatment) and hypotension, myocardial infarction, stroke, surgical site infection, pulmonary embolism, deep venous thrombosis, and death. 21 (5%) of 394 patients given dexmedetomidine and 8 (2%) of 396 patients given placebo, had a serious adverse event as determined by clinicians. 1 (<1%) of 391 patients given dexmedetomidine and 1 (<1%) of 387 patients given placebo died. INTERPRETATION: Dexmedetomidine infusion, initiated at anaesthetic induction and continued for 24 h, did not decrease postoperative atrial arrhythmias or delirium in patients recovering from cardiac surgery. Dexmedetomidine should not be infused to reduce atrial fibrillation or delirium in patients having cardiac surgery. FUNDING: Hospira Pharmaceuticals.


Assuntos
Fibrilação Atrial/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Delírio/prevenção & controle , Dexmedetomidina/administração & dosagem , Hipnóticos e Sedativos/administração & dosagem , Esquema de Medicação , Feminino , Humanos , Infusões Intravenosas , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Resultado do Tratamento
8.
Québec; INESSS; 20 juil. 2020.
Não convencional em Francês | BRISA/RedTESA | ID: biblio-1103662

RESUMO

CONTEXTE: Le présent document ainsi que les constats qu'il énonce ont été rédigés en réponse à une interpellation du ministère de la Santé et des Services sociaux dans le contexte de l'urgence sanitaire liée à la maladie à coronavirus (COVID-19) au Québec. L'objectif est de réaliser une recension sommaire des données publiées et de mobiliser les savoirs clés afin d'informer les décideurs publics et les professionnels de la santé et des services sociaux. Vu la nature rapide de cette réponse, les constats ou les positions qui en découlent ne reposent pas sur un repérage exhaustif des données publiées, une évaluation de la qualité méthodologique des études avec une méthode systématique ou sur un processus de consultation élaboré. Dans les circonstances d'une telle urgence de santé publique, l'INESSS reste à l'affût de toutes nouvelles données susceptibles de lui faire modifier cette réponse rapide. PRÉSENTATION DE LA DEMANDE: La COVID-19 peut entraîner certaines complications graves qui nécessitent l'hospitalisation de la personne affectée, notamment le syndrome de détresse respiratoire aigu (ARDS) qui nécessite la mise en place d'une ventilation mécanique. Parmi les médicaments administrés dans le cadre d'une ventilation mécanique se trouve entre autres le propofol, un agent sédatif-hypnotique utilisé pour diminuer l'inconfort d'une intubation aux soins intensifs, ainsi que le rocuronium et le cistracurium, des bloqueurs neuromusculaires non dépolarisants qui permettent, dans certains cas, d'améliorer la synchronisation de la ventilation mécanique. Plusieurs de ces médicaments sont également employés au bloc opératoire, aux urgences, dans les unités de soins palliatifs ainsi que dans le contexte de l'aide médicale à mourir, ce qui crée une compétition entre les différents secteurs cliniques pour l'accès à ces molécules. La pandémie actuelle liée à la COVID-19 exerce une pression mondiale énorme sur les stocks de médicaments utilisés aux soins intensifs. À titre d'exemple, aux États-Unis, la demande pour les sédatifs les plus couramment utilisés aux soins intensifs et au bloc opératoire (propofol, dexmédétomidine, étomidate, kétamine, lorazépam, midazolam) a augmenté de 51 % durant le mois dernier [Phend, 2020]. Neuf grands centres hospitaliers européens ont annoncé, le 2 avril dernier, ne disposer que de 2 semaines de réserves de médicaments essentiels pour les soins critiques [Cheng, 2020]. Au Québec, le propofol est d'ailleurs en situation de rupture de stock jusqu'à la mi-avril auprès de son fabricant, la compagnie Baxter. Afin d'être en mesure de poursuivre la mise en place de la ventilation mécanique auprès des personnes qui le nécessitent, et ce, même en cas de pénurie de propofol, de cisatracurium ou de rocuronium, le MSSS a demandé à l'INESSS d'identifier les médicaments qui pourraient constituer des options alternatives à ces molécules aux soins intensifs et au bloc opératoire, tout en tenant compte des ruptures de stock actuelles et anticipées. MÉTHODOLOGIE Revue de littérature Questions d'évaluation : 1. Quelles sont les alternatives aux stratégies traditionnelles de sédation? 2. Quels sont les principes généraux de sédation qui favorisent l'usage optimal des médicaments? 3. Quelles stratégies de sédation permettent de limiter les risques de pénurie des médicaments? SOMMAIRE DES RÉSULTATS: Question 1: Quelles sont les alternatives aux stratégies traditionnelles de sédation? État actuel des connaissances scientifiques. Question 2: Quels sont les principes généraux de sédation qui favorisent l'usage optimal des médicaments? Question 3: Quelles stratégies de sédation permettent de limiter les risques de pénurie des médicaments?


Assuntos
Infecções por Coronavirus/tratamento farmacológico , Cuidados Críticos/métodos , Analgésicos/administração & dosagem , Hipnóticos e Sedativos/administração & dosagem , Bloqueadores Neuromusculares/administração & dosagem , Avaliação da Tecnologia Biomédica , Avaliação em Saúde
9.
Intensive Care Med ; 46(8): 1563-1566, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32588067

RESUMO

Hospitals worldwide are experiencing a shortage in essential intravenous sedative medications. This is attributable to high number and high sedative needs of COVID-19 critical care patients with disruption of drug supply chains. Inhaled volatile anesthetic agents are an abundant resource and readily implementable solution for providing ICU sedation. Inhaled volatile agents may also provide important pulmonary benefits for COVID-19 patients with ARDS that could improve gas exchange and reduce time spent on a ventilator. We review the use of volatile agents, and provide a technical overview and algorithm for administering inhaled volatile-based sedation in ICUs.


Assuntos
Anestésicos Inalatórios , Betacoronavirus , Infecções por Coronavirus/complicações , Hipnóticos e Sedativos/administração & dosagem , Pneumonia Viral/terapia , Síndrome do Desconforto Respiratório do Adulto/terapia , Algoritmos , Anestésicos Inalatórios/administração & dosagem , Anestésicos Inalatórios/efeitos adversos , Anestésicos Intravenosos/provisão & distribução , Humanos , Isoflurano , Pandemias , Pneumonia Viral/complicações , Pneumonia Viral/etiologia , Síndrome do Desconforto Respiratório do Adulto/etiologia , Sevoflurano/efeitos adversos
10.
BMJ Support Palliat Care ; 10(3): 343-349, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32546559

RESUMO

BACKGROUND: Anticipatory prescribing (AP) of injectable medications in advance of clinical need is established practice in community end-of-life care. Changes to prescribing guidelines and practice have been reported during the COVID-19 pandemic. AIMS AND OBJECTIVES: To investigate UK and Ireland clinicians' experiences concerning changes in AP during the COVID-19 pandemic and their recommendations for change. METHODS: Online survey of participants at previous AP national workshops, members of the Association for Palliative Medicine of Great Britain and Ireland and other professional organisations, with snowball sampling. RESULTS: Two hundred and sixty-one replies were received between 9 and 19 April 2020 from clinicians in community, hospice and hospital settings across all areas of the UK and Ireland. Changes to AP local guidance and practice were reported: route of administration (47%), drugs prescribed (38%), total quantities prescribed (35%), doses and ranges (29%). Concerns over shortages of nurses and doctors to administer subcutaneous injections led 37% to consider drug administration by family or social caregivers, often by buccal, sublingual and transdermal routes. Clinical contact and patient assessment were more often remote via telephone or video (63%). Recommendations for regulatory changes to permit drug repurposing and easier community access were made. CONCLUSIONS: The challenges of the COVID-19 pandemic for UK community palliative care has stimulated rapid innovation in AP. The extent to which these are implemented and their clinical efficacy need further examination.


Assuntos
Cuidadores , Vias de Administração de Medicamentos , Cuidados Paliativos/métodos , Padrões de Prática Médica/estatística & dados numéricos , Assistência Terminal/métodos , Administração Bucal , Administração Sublingual , Analgésicos não Entorpecentes/administração & dosagem , Analgésicos Opioides/administração & dosagem , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Fentanila/administração & dosagem , Clínicos Gerais , Cuidados Paliativos na Terminalidade da Vida/métodos , Hospitais para Doentes Terminais , Humanos , Hipnóticos e Sedativos/administração & dosagem , Irlanda/epidemiologia , Lorazepam/administração & dosagem , Metotrimeprazina/administração & dosagem , Antagonistas Muscarínicos/administração & dosagem , Enfermeiras Especialistas , Medicina Paliativa , Pandemias , Médicos , Pneumonia Viral/epidemiologia , Guias de Prática Clínica como Assunto , Inquéritos e Questionários , Telemedicina/métodos , Adesivo Transdérmico , Reino Unido/epidemiologia
12.
Rev. otorrinolaringol. cir. cabeza cuello ; 80(2): 137-146, jun. 2020. tab, graf
Artigo em Espanhol | LILACS | ID: biblio-1115828

RESUMO

INTRODUCCIÓN: La planificación de cirugías para el manejo del síndrome de apneahipopnea obstructiva del sueño (SAHOS) ha incrementado su precisión desde la introducción de la endoscopía del sueño inducido por fármacos (DISE). OBJETIVO: Evaluar la técnica de faringoplastía de reposición con suturas barbadas (BRP) para el colapso velofaríngeo y/o de paredes laterales orofaríngeas evaluado mediante DISE en pacientes con SAHOS. MATERIAL Y MÉTODO: Ochenta y ocho pacientes fueron evaluados para cirugía mediante antropometría, escala de somnolencia de Epworth (ESS) y poligrafía respiratoria. Veinte y seis de 88 pacientes fueron seleccionados. De los 26, 14 accedieron al tratamiento quirúrgico, el que se seleccionó en base a la DISE. En todos los casos, se realizó BRP. RESULTADOS: A los 3 meses de la cirugía hubo mejoría en 10/14 pacientes (criterios de Sher, disminución del índice de apnea-hipoapnea a <20 o 50% del basal). La ESS bajó en promedio de 12 a 5 puntos (p <0,05). No se reportaron incidentes en el posoperatorio y no han ocurrido eventos adversos. CONCLUSIÓN: La técnica de BRP es una técnica sencilla y útil para la expansión anterior y lateral del paladar blando y orofaringe, con una tasa de éxito similar en esta cohorte a la reportada internacionalmente.


INTRODUCTION: Surgical planning for the management of obstructive sleep apneahypopnea syndrome (OSAHS) has changed since the introduction of drug induced sleep endoscopy (DISE). AIM: To evaluate the technique of barbed sutures reposition pharyngoplasty (BRP) for velopharyngeal collapse and/or oropharyngeal lateral walls after DISE evaluation in OSAHS patients. MATERIAL AND METHOD: 88 patients were evaluated for surgery by anthropometry, Epworth sleepiness scale (ESS) and respiratory polygraphy. 26 of 88 patients were selected. Of the 26, 14 agreed to surgical treatment, which was selected on DISE findings. In all cases, BRP was performed. RESULTS: Three months after surgery there was improvement in 10/14 patients (Sher criteria, apnea-hypopnea index reduction at <20 or 50% of baseline). The ESS improved on average 12 to 5 (p <0.05). No incidents were reported in the post-operative period and no adverse events were reported. CONCLUSION: The BRP technique is a simple and useful technique for the anterior and lateral expansion of the soft palate and oropharynx, with a similar success rate in this cohort to that internationally reported.


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Faringe/cirurgia , Técnicas de Sutura , Apneia Obstrutiva do Sono/cirurgia , Endoscopia/métodos , Insuficiência Velofaríngea/cirurgia , Índice de Massa Corporal , Antropometria , Apneia Obstrutiva do Sono/diagnóstico , Sonolência , Hipnóticos e Sedativos/administração & dosagem
14.
Medicine (Baltimore) ; 99(18): e20041, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32358385

RESUMO

Acute brain dysfunction (ABD) is a frequent and severe syndrome occurring in critically ill patients and early identification of high-risk patients is paramount. In the present analysis, we propose a clinically applicable model for early phenotype identification of ABD at the bedside in mechanically ventilated patients, improving the recognition of patients with prolonged ABD.Prospective cohort with 629 mechanically ventilated patients in two medical-surgical intensive care units at academic centers. We applied cluster analysis to identify phenotypes using clinical and biological data. We then tested the association of phenotypes and its respective clinical outcomes. We performed a validation on a new cohort of patients select on subsequent patients admitted to the participants intensive care units.A model with 3 phenotypes best described the study population. A 4-variable model including medical admission, sepsis diagnosis, simplified acute physiologic score II and basal serum C-reactive protein (CRP) accurately classified each phenotype (area under curve 0.82; 95% CI, 0.79-0.86). Phenotype A had the shorter duration of ABD (median, 1 day), while phenotypes B and C had progressively longer duration of ABD (median, 3 and 6 days, respectively; P < .0001). There was an association between the duration of ABD and the baseline CRP levels and simplified acute physiology score II score (sensitivity and specificity of 80%). To increase the sensitivity of the model, we added CRP kinetics. By day 1, a CRP < 1.0 times the initial level was associated with a shorter duration of ABD (specificity 0.98).A model based on widely available clinical variables could provide phenotypes associated with the duration of ABD. Phenotypes with longer duration of ABD (phenotypes B and C) are characterized by more severe inflammation and by significantly worse clinical outcomes.


Assuntos
Coma/epidemiologia , Delírio/epidemiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , APACHE , Centros Médicos Acadêmicos , Idoso , Biomarcadores , Proteína C-Reativa/análise , Análise por Conglomerados , Comorbidade , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Masculino , Pessoa de Meia-Idade , Fenótipo , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Sepse/epidemiologia , Fatores Socioeconômicos , Fatores de Tempo
15.
West J Emerg Med ; 21(3): 677-683, 2020 Apr 21.
Artigo em Inglês | MEDLINE | ID: mdl-32421519

RESUMO

INTRODUCTION: Agitated patients in the prehospital setting pose challenges for both patient care and emergency medical services (EMS) provider safety. Midazolam is frequently used to control agitation in the emergency department setting; however, limited data exist in the prehospital setting. We describe our experience treating patients with midazolam for behavioral emergencies in a large urban EMS system. We hypothesized that using midazolam for acute agitation leads to improved clinical conditions without causing significant clinical deterioration. METHODS: We performed a retrospective review of EMS patient care reports following implementation of a behavioral emergencies protocol in a large urban EMS system from February 2014-June 2016. For acute agitation, paramedics administered midazolam 1 milligram (mg) intravenous (IV), 5 mg intramuscular (IM), or 5 mg intranasal (IN). Results were analyzed using descriptive statistics, Levene's test for assessing variance among study groups, and t-test to evaluate effectiveness based on route. RESULTS: In total, midazolam was administered 294 times to 257 patients. Median age was 30 (interquartile range 24-42) years, and 66.5% were male. Doses administered were 1 mg (7.1%) and 5 mg (92.9%). Routes were IM (52.0%), IN (40.8%), and IV (7.1%). A second dose was administered to 37 patients. In the majority of administrations, midazolam improved the patient's condition (73.5%) with infrequent adverse events (3.4%). There was no significant difference between the effectiveness of IM and IN midazolam (71.0% vs 75.4%; p = 0.24). CONCLUSION: A midazolam protocol for prehospital agitation was associated with reduced agitation and a low rate of adverse events.


Assuntos
Serviços Médicos de Emergência/métodos , Hipnóticos e Sedativos/administração & dosagem , Transtornos Mentais/tratamento farmacológico , Midazolam/administração & dosagem , Administração Intranasal , Administração Intravenosa , Adulto , Pessoal Técnico de Saúde , Protocolos Clínicos , Relação Dose-Resposta a Droga , Esquema de Medicação , Emergências , Feminino , Humanos , Hipnóticos e Sedativos/uso terapêutico , Injeções Intramusculares , Masculino , Midazolam/uso terapêutico , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
18.
Anaesth Crit Care Pain Med ; 39(3): 341-343, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32360979
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