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1.
Acta Med Indones ; 52(3): 274-282, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33020338

RESUMO

The most severe clinical feature of COVID-19 is Acute Respiratory Distress Syndrome (ARDS) which requires intubation and mechanical ventilation and it occurs in approximately 2.3% of cases. About 94% of of these cases end in death. This case series report two confirmed COVID-19 patients who had met criteria of intubation and mechanical ventilation, but not performed to them. Both patients experienced clinical improvement and recovery. Probably this is due to differences of COVID-19 ARDS (CARDS) with typical or classic ARDS.  CARDS is divided into two phenotypes of type L (Low Elastance) and type H (High Elastance). These different phenotypic also distinguish subsequent pathophysiology and clinical management. These phenotype can be differentiate by chest CT scan. This case series emphasizes the importance of understanding this phenotype so that clinicians can provide more appropriate treatment management and also availability of CT scans in health facilities that manage COVID -19.


Assuntos
Betacoronavirus , Infecções por Coronavirus/diagnóstico , Pneumonia Viral/diagnóstico , Infecções por Coronavirus/epidemiologia , Humanos , Intubação Intratraqueal , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/epidemiologia , Prognóstico , Respiração Artificial , Tomografia Computadorizada por Raios X
3.
Z Gastroenterol ; 58(10): 955-959, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33036049

RESUMO

Colonoscopy is effective in the prevention and screening of colorectal cancer. Whether terminal ileal (TI) intubation is required during conventional colonoscopy and whether it offers clinical benefits with respect to polyp detection rate (PDR) remain unclear. This retrospective study included patients who underwent colonoscopy at our hospital between July 1, 2018 and April 20, 2019. The positive findings and time for TI intubation were recorded. Univariate and multivariate analyses were performed to identify factors associated with PDR. There were 1675 patients with cecal intubation colonoscopy, including 994 (59 %) with TI intubation and 8 (1 %) with intestinal disease. The mean time for TI intubation was 40 seconds (3-338), and the mean time from cecal intubation to arrival at the deep part of TI mucosa was 24 seconds (2-118). The overall PDR was 27 %. On multivariable analysis, age > 50 years [95 % confidence interval (CI) 2.837-4.590], male sex (95 %CI, 0.406-0.649), presence of symptoms (abdominal symptoms vs. asymptomatic, 95 % CI, 1.146-2.468; stool changes vs. asymptomatic, 95 % CI, 1.070-1.834), and non-TI intubation (95 % CI, 1.040-1.648) were independent predictors of higher PDR. Trend analysis indicated decreasing trend of PDR among non-TI intubation group, 0-5 cm TI intubation group, and > 5 cm TI intubation group (30 % vs. 27 % vs. 24 %, respectively; p < 0.05). TI intubation is necessary to identify small bowel disease among a designated population, but it was not suggested to be routinely performed as part of colonoscopy, owing to limited positive intestinal findings, extra time requirement, and possible PDR worsening.


Assuntos
Pólipos do Colo/patologia , Colonoscopia/métodos , Intubação Intratraqueal , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Íleo , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
5.
Crit Care ; 24(1): 597, 2020 10 06.
Artigo em Inglês | MEDLINE | ID: mdl-33023669

RESUMO

BACKGROUND: Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone. METHODS: Prospective, multicenter, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory Sequential Organ Failure Assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate, and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP. RESULTS: A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53-1.43), p = 0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0-2.5) vs 2 IQR 1.0-3.0] days (p = 0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40-2.72), p = 0.92]. CONCLUSION: In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.


Assuntos
Infecções por Coronavirus/terapia , Intubação Intratraqueal/efeitos adversos , Oxigenoterapia/métodos , Pneumonia Viral/terapia , Decúbito Ventral , Vigília , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Medição de Risco
6.
Rev. esp. anestesiol. reanim ; 67(7): 367-373, ago.-sept. 2020. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-192471

RESUMO

La pandemia del COVID-19 ha hecho estragos, no solo en el número de víctimas fatales sino también en la infraestructura de los hospitales y unidades de cuidados intensivos. El número limitado de respiradores es una preocupación de toda la comunidad dada la demanda masiva y a muy corto plazo de estos equipos. Esta presentación tiene como fin dar soluciones sencillas para ventilar pacientes intubados de modo mandatorio utilizando equipos de ventilación no invasiva. Las soluciones propuestas permiten 2 estrategias claras frente al COVID-19: Reemplazar las máquinas de anestesia para disponer de ellas en pacientes. Usar la opción de equipos de ventilación no invasiva para pacientes con COVID-19 a modo de «puente» y a la espera de la liberación de un respirador específico en la unidad de cuidados críticos


COVID-19 pandemic caused not only many deaths around the world but also made evident technical limitations of hospital and intensive care units (ICU). The growing demand of ICU ventilators in a short lapse of time constitutes one of the main community concerns. The main goal of this communication is to give simple solutions to transform a noninvasive ventilator in an invasive one for intubated patients. The proposal can be applied in two well defined strategies for the COVID-19 pandemic: To replace anesthesia workstations, leaving those machines to be used in patients. To apply this option in COVID-19 patients by way of a therapeutic "bridge", waiting for the release of a ventilator in the ICU


Assuntos
Humanos , Respiração Artificial/métodos , Ventiladores Mecânicos/classificação , Ventilação não Invasiva/instrumentação , Intubação Intratraqueal/métodos , Infecções por Coronavirus/complicações , Síndrome Respiratória Aguda Grave/terapia , Planejamento de Instituições de Saúde/métodos , Cuidados Críticos/métodos , Vírus da SARS/patogenicidade , Pandemias , Simulação/métodos
7.
Int J Pharm Compd ; 24(5): 358-364, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32886632

RESUMO

When using ventilators in the management of the coronavirus disease 2019 patient, dense and abundant mucous secretions are formed, obstructing the endotracheal tube and making its aspiration difficult. This situation is worsened if in order to minimize the risk of infection of the medical personnel, the humidifier is disconnected. This circumstance forces the tube to be removed, cleaned, or changed, increasing the workload of the intensive care unit staff. Other therapies tested until now, like mesna, acetylcysteine, or hypertonic saline solution, are valid alternatives, although they have not shown great efficacy for this specific procedure in the past. The sanitary emergency forced the collaboration between a pharmacist and an otorhinolaryngologist to develop the cocamidopropyl betaine surfactant formula, after several tests with different concentrations of the surfactant. The objective of this compounding formula was to resolve a mechanical problem and avoid reintubation due to obstruction of the ventilator tube. The cocamidopropyl betaine surfactant solution 0.075% in saline 0.9% (physiological serum) solution demonstrated to be a well-tolerated formula, using inexpensive materials, was simple to prepare, and was easy to use in clinical practice.


Assuntos
Betaína/análogos & derivados , Infecções por Coronavirus/terapia , Contaminação de Equipamentos/prevenção & controle , Intubação Intratraqueal , Pneumonia Viral/terapia , Tensoativos/farmacologia , Betacoronavirus , Betaína/farmacologia , Humanos , Higiene , Pandemias , Ventiladores Mecânicos
8.
Ann Ital Chir ; 91: 273-276, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32877380

RESUMO

CASE REPORT: A 64-year-old woman presented to our emergency department during the outbreak of the covid-19 emergency in Italy with syncope, anosmia, mild dyspnoea and atypical chest and dorsal pain. A chest CT scan showed an acute type B aortic dissection (ATBAD) and bilateral lung involvement with ground-glass opacity, compatible with interstitial pneumonia. Nasopharyngeal swabs resulted positive for SARS-CoV-2. For the persistence of chest pain, despite the analgesic therapy, we decided to treat her with a TEVAR. Patient's chest and back pain resolved during the first few days after the procedure. No surgical or respiratory complications occurred and the patient was discharged 14 days after surgery. DISCUSSION: By performing the operation under local anesthesia, it was possible to limit both the staff inside the operatory room and droplet/aerosol release. Since we had to perform the operation in a hemodynamics room, thanks to the limited extension of the endoprosthesis and the good caliber of the right vertebral artery we were able to reduce the risk of spinal cord ischemia despite the lack of a revascularization of the left subclavian artery. CONCLUSIONS: A minimally invasive total endovascular approach allows, through local anesthesia and percutaneous access, to avoid surgical cut down and orotracheal intubation. This, combined with a defined management protocol for infected patients, seems to be a reasonable way to perform endovascular aortic procedures in urgent setting, even in a SARSCoV- 2 positive patient. KEY WORDS: COVID-19, Dissection, TEVAR.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Betacoronavirus/isolamento & purificação , Implante de Prótese Vascular/métodos , Infecções por Coronavirus/prevenção & controle , Procedimentos Endovasculares/métodos , Controle de Infecções/métodos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Anestesia Local , Aneurisma Dissecante/complicações , Antibioticoprofilaxia , Anticoagulantes/uso terapêutico , Antivirais/uso terapêutico , Aneurisma da Aorta Torácica/complicações , Contraindicações de Procedimentos , Infecções por Coronavirus/complicações , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/transmissão , Darunavir/uso terapêutico , Diabetes Mellitus Tipo 2/complicações , Quimioterapia Combinada , Enoxaparina/uso terapêutico , Feminino , Humanos , Hidroxicloroquina/uso terapêutico , Complicações Intraoperatórias/prevenção & controle , Intubação Intratraqueal/efeitos adversos , Pessoa de Meia-Idade , Nasofaringe/virologia , Salas Cirúrgicas , Isolamento de Pacientes , Pneumonia Viral/complicações , Pneumonia Viral/tratamento farmacológico , Pneumonia Viral/transmissão , Ritonavir/uso terapêutico , Isquemia do Cordão Espinal/prevenção & controle , Artéria Vertebral/cirurgia
9.
Trials ; 21(1): 758, 2020 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-32883328

RESUMO

OBJECTIVES: Tocilizumab is a humanized monoclonal antibody which targets and inhibits interleukin-6 (IL-6) and has demonstrated efficacy in treating diseases associated with hyper-inflammation. Data are suggestive of tocilizumab as a potential treatment for patients with COVID-19 infection. The aim of this study is to determine the safety and efficacy of standard dose versus low dose tocilizumab in adults with severe, non-critical, PCR-confirmed COVID-19 infection with evidence of progressive decline in respiratory function and evolving systemic inflammation on time to intubation, non-invasive ventilation and/or all-cause mortality. TRIAL DESIGN: This trial is a phase 2, open label, two-stage, multicentre, randomised trial. PARTICIPANTS: Adult subjects with severe, non-critical, PCR-confirmed COVID-19 infection with evidence of progressive decline in respiratory function and evolving systemic inflammation requiring admission to hospital at St. Vincent's University Hospital and Mater Misericordiae University Hospital, Dublin, Ireland. Inclusion criteria Aged 18 years or older. Confirmed SARS-CoV2 infection (as defined by positive PCR). Evidence of hyper inflammatory state as evidenced by at least three of the following: Documented temperature >38°C in the past 48 hours, IL6 >40 pg/ml, or in its absence D-dimer >1.5 µgFEU /ml, Elevated CRP (>100mg/L) and/or a three-fold increase since presentation, Elevated ferritin X5 ULN, Elevated LDH (above the ULN), Elevated fibrinogen (above the ULN). Pulmonary infiltrates on chest imaging. Moderate to severe respiratory failure as defined by PaO2/FiO2≤300mmHg. INTERVENTION AND COMPARATOR: Intervention for participants in this trial is SOC plus Tocilizumab compared to SOC alone (comparator). For Stage 1, following randomisation, subjects will receive either (Arm 1) SOC alone or (Arm 2) SOC plus Tocilizumab (standard single dose - 8mg/kg, infused over 60 minutes. Once stage 1 has fully recruited, subsequent participants will be enrolled directly into Stage 2 and receive either (Arm 1) SOC plus Tocilizumab (standard single dose - 8mg/kg, infused over 60 minutes or (Arm 2) SOC plus Tocilizumab (standard single dose - 4mg/kg, infused over 60 minutes). MAIN OUTCOMES: The primary endpoint for this study is the time to a composite primary endpoint of progression to intubation and ventilation, non-invasive ventilation or death within 28 days post randomisation. RANDOMISATION: Eligible patients will be randomised (1:1) using a central register. Randomisation will be performed through an interactive, web-based electronic data capturing database. In stage 1, eligible participants will be randomised (1:1) to (Arm 1) SOC alone or to (Arm 2) SOC with single dose (8mg/kg, maximum 800mg) intravenous tocilizumab infused over 60 minutes. In stage 2, eligible participants will be randomised (1:1) to receive either (Arm 1) single, standard dose (8mg/kg, maximum 800mg) intravenous tocilizumab infused over 60 minutes or (Arm 2) reduced dose (4mg/kg, maximum 800mg) intravenous tocilizumab infused over 60 minutes. BLINDING: This study is open label. The study will not be blinded to investigators, subjects, or medical or nursing staff. The trial statistician will be blinded for data analysis and will be kept unaware of treatment group assignments. To facilitate this, the randomisation schedule will be drawn up by an independent statistician and objective criteria were defined for the primary outcome to minimize potential bias. NUMBERS TO BE RANDOMISED: In stage 1, 90 subjects will be randomised 1:1, 45 to SOC and 45 subjects to SOC plus Tocilizumab (8mg/kg, infused over 60 minutes). In stage 2, sample size calculation for the dose evaluation stage will use data generated from stage 1 using the same primary endpoint as in stage 1. TRIAL STATUS: The COVIRL002 trial (Protocol version 1.4, 13th May 2020) commenced in May 2020 at St. Vincent's University Hospital and Mater Misericordiae University Hospital, Dublin, Ireland. Recruitment is proceeding with the aim to achieve the target sample size on or before April 2021. TRIAL REGISTRATION: COVIRL002 was registered 25 June 2020 under EudraCT number: 2020-001767-86 and Protocol identification: UCDCRC/20/02. FULL PROTOCOL: The full protocol for COVIRL002 is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).


Assuntos
Anti-Inflamatórios/uso terapêutico , Anticorpos Monoclonais Humanizados/uso terapêutico , Betacoronavirus/efeitos dos fármacos , Infecções por Coronavirus/tratamento farmacológico , Pneumonia Viral/tratamento farmacológico , Anti-Inflamatórios/efeitos adversos , Anticorpos Monoclonais Humanizados/efeitos adversos , Betacoronavirus/patogenicidade , Ensaios Clínicos Fase II como Assunto , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/virologia , Progressão da Doença , Interações entre Hospedeiro e Microrganismos , Humanos , Intubação Intratraqueal , Irlanda , Estudos Multicêntricos como Assunto , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/mortalidade , Pneumonia Viral/virologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento
10.
PLoS One ; 15(9): e0238679, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32881950

RESUMO

PURPOSE: To investigate the role of lung ultrasound score (LUS) in assessing intubation timing for patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia. MATERIALS AND METHODS: Seventy-two patients with critical coronavirus disease 2019 (COVID-19) were admitted to a makeshift intensive care unit (ICU). All patients underwent bedside lung ultrasonography one to two times per day. The patients were either intubated, treated with noninvasive ventilation (NIV), or given high-flow nasal cannula (HFNC) after a discussion with the multidisciplinary group after their conditions worsened. Bedside lung ultrasound was performed daily after intubation, and patients received mechanical ventilation. Lung ultrasound was performed on days 1, 2, 3, 5, and 7 after patients were admitted to the ICU; if the patient was intubated, LUS determination was performed before intubation within 24 h (T1) and on days 1, 2, 5, and 7 after intubation (T2, T3, T4, and T5, respectively).The goal of this study was to evaluate the severity of lung aeration loss in intubated and non-intubated patients with SARS-CoV-2 pneumonia by ultrasound at different time points within one week. RESULTS: A total of 16 patients were included in this study, including nine who were intubated and mechanically ventilated and seven patients without intubation. The number of elderly individuals in the intubated group was higher than in the non-intubated group (P < 0.05). In addition, there were more male than female patients in both groups. Patient characteristics (BMI, SOFA, and PaO2/FiO2 value) were similar between the two groups (P > 0.05). The 28-day mortality rate of intubated patients was higher than that of non-intubated patients; six patients in the intubated group and two patients in the non-intubated group died. Nine intubated patients showed changes in LUS within seven days (n = 9). The mean LUS within 24 h before intubation was 12.8 ± 1.3. LUS was significantly higher on T1 than on T5 (P <0.05), and did not significantly differ from T1 to T4. Comparing LUS between intubated and non-intubated patients on T1 showed that the LUS of intubated patients was significantly higher than that of non-intubated patients (P <0.05). Between the two patient groups, oxygenation index was 140.1 ± 7.7 vs. 137.8 ± 5.9 on T1, and the respiratory rate of the two groups was 26 ± 5 vs. 28 ± 4 breaths/min. Neither oxygenation index nor RR significantly differed between the two groups. CONCLUSION: LUS may be an effective tool for assessing intubation timing in critically ill patients with Covid-19 interstitial pneumonia.


Assuntos
Infecções por Coronavirus/terapia , Intubação Intratraqueal/métodos , Pulmão/diagnóstico por imagem , Pneumonia Viral/terapia , Respiração Artificial/métodos , Ultrassonografia/métodos , Idoso , Infecções por Coronavirus/diagnóstico por imagem , Feminino , Humanos , Intubação Intratraqueal/efeitos adversos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/diagnóstico por imagem , Respiração Artificial/efeitos adversos , Fatores de Tempo
11.
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
12.
Emerg Med Clin North Am ; 38(4): 931-944, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32981627

RESUMO

Emergency physicians must be prepared to rapidly diagnose and resuscitate patients with pulmonary embolism (PE). Certain aspects of PE resuscitation run counter to typical approaches. A specific understanding of the pathophysiology of PE is required to avoid cardiovascular collapse potentially associated with excessive intravenous fluids and positive pressure ventilation. Once PE is diagnosed, rapid risk stratification should be performed and treatment guided by patient risk class. Although anticoagulation remains the mainstay of PE treatment, emergency physicians also must understand the indications and contraindications for thrombolysis and should be aware of new therapies and models of care that may improve outcomes.


Assuntos
Embolia Pulmonar/terapia , Anticoagulantes/uso terapêutico , Biomarcadores/sangue , Angiografia por Tomografia Computadorizada , Estado Terminal , Ecocardiografia , Eletrocardiografia , Serviço Hospitalar de Emergência , Oxigenação por Membrana Extracorpórea , Hidratação , Humanos , Intubação Intratraqueal , Ácido Láctico/sangue , Trombólise Mecânica , Peptídeo Natriurético Encefálico/sangue , Óxido Nítrico/uso terapêutico , Oxigenoterapia , Fragmentos de Peptídeos/sangue , Sistemas Automatizados de Assistência Junto ao Leito , Respiração com Pressão Positiva , Embolia Pulmonar/classificação , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/fisiopatologia , Ressuscitação/métodos , Medição de Risco , Índice de Gravidade de Doença , Terapia Trombolítica , Troponina/sangue , Vasoconstritores/uso terapêutico
13.
Medicine (Baltimore) ; 99(38): e21970, 2020 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-32957315

RESUMO

The main objective of this study was to evaluate the outcomes of extremely elderly patients receiving orotracheal intubation and mechanical ventilation after planned extubation. This retrospective cohort study included extremely elderly patients (>90 years) who received mechanical ventilation and passed planned extubation. We reviewed all intensive care unit patients in a medical center between January 1, 2010, and December 31, 2017. There were 19,518 patients (aged between 20 and 105 years) during the study period. After application of the exclusion criteria, there were 213 patients who underwent planned extubation: 166 patients survived, and 47 patients died. Compared with the mortality group, the survival group had lower Acute Physiology and Chronic Health Evaluation II scores and higher Glasgow Coma Scale (GCS) scores, with scores of 19.7 ±â€Š6.5 (mean ±â€Šstandard deviation) vs 22.2 ±â€Š6.0 (P = .015) and 9.5 ±â€Š3.5 vs 8.0 ±â€Š3.0 (P = .007), respectively. The laboratory data revealed no significant difference between the survival and mortality groups except for blood urea nitrogen (BUN) and hemoglobin. After multivariate logistic regression analysis, a lower GCS, a higher BUN level, weaning beginning 3 days after intubation and reintubation during hospitalization were associated with poor prognosis. In this cohort of extremely elderly patients undergoing planned extubation, a lower GCS, a higher BUN level, weaning beginning 3 days after intubation and reintubation during hospitalization were associated with mortality.


Assuntos
Extubação/mortalidade , Intubação Intratraqueal/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Desmame do Respirador/estatística & dados numéricos , APACHE , Fatores Etários , Idoso de 80 Anos ou mais , Nitrogênio da Ureia Sanguínea , Índice de Massa Corporal , Comorbidade , Escala de Coma de Glasgow , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais
14.
PLoS One ; 15(8): e0233852, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32866219

RESUMO

OBJECTIVE: Hypotension following endotracheal intubation in the ICU is associated with poor outcomes. There is no formal prediction tool to help estimate the onset of this hemodynamic compromise. Our objective was to derive and validate a prediction model for immediate hypotension following endotracheal intubation. METHODS: A multicenter, prospective, cohort study enrolling 934 adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 was conducted to derive and validate a prediction model for immediate hypotension following endotracheal intubation. We defined hypotension as: 1) mean arterial pressure <65 mmHg; 2) systolic blood pressure <80 mmHg and/or decrease in systolic blood pressure of 40% from baseline; 3) or the initiation or increase in any vasopressor in the 30 minutes following endotracheal intubation. RESULTS: Post-intubation hypotension developed in 344 (36.8%) patients. In the full cohort, 11 variables were independently associated with hypotension: increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure <65 mmHg, and acute respiratory failure; diuretic use 24 hours preceding endotracheal intubation; decreasing systolic blood pressure from 130 mmHg; catecholamine and phenylephrine use immediately prior to endotracheal intubation; and use of etomidate during endotracheal intubation. A model excluding unstable patients' pre-intubation (those receiving catecholamine vasopressors and/or who were intubated in the setting of cardiac arrest) was also developed and included the above variables with the exception of sepsis and etomidate. In the full cohort, the 11 variable model had a C-statistic of 0.75 (95% CI 0.72, 0.78). In the stable cohort, the 7 variable model C-statistic was 0.71 (95% CI 0.67, 0.75). In both cohorts, a clinical risk score was developed stratifying patients' risk of hypotension. CONCLUSIONS: A novel multivariable risk score predicted post-intubation hypotension with accuracy in both unstable and stable critically ill patients. STUDY REGISTRATION: Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.


Assuntos
Hipotensão/etiologia , Intubação Intratraqueal/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Estado Terminal , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Modelos Biológicos , Estudos Prospectivos
15.
BMC Neurol ; 20(1): 358, 2020 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-32972381

RESUMO

BACKGROUND: The novel coronavirus (COVID-19) global pandemic is associated with an increased incidence of acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO). The treatment of these patients poses unique and significant challenges to health care providers requiring changes in existing protocols. CASE PRESENTATION: A 54-year-old COVID-19 positive patient developed sudden onset left hemiparesis secondary to an acute right middle cerebral artery occlusion (National Institutes of Health Stroke Scale (NIHSS) score = 11). Mechanical thrombectomy (MT) was performed under a new protocol specifically designed to maximize protective measures for the team involved in the care of the patient. Mechanical Thrombectomy was performed successfully under general anesthesia resulting in TICI 3 recanalization. With regards to time metrics, time from door to reperfusion was 60 mins. The 24-h NIHSS score decreased to 2. Patient was discharged after 19 days after improvement of her pulmonary status with modified Rankin Scale = 1. CONCLUSION: Patients infected by COVID-19 can develop LVO that is multifactorial in etiology. Mechanical thrombectomy in a COVID-19 confirmed patient presenting with AIS due to LVO is feasible with current mechanical thrombectomy devices. A change in stroke workflow and protocols is now necessary in order to deliver the appropriate life-saving therapy for COVID-19 positive patients while protecting medical providers.


Assuntos
Infecções por Coronavirus/complicações , Procedimentos Endovasculares/métodos , Infarto da Artéria Cerebral Média/cirurgia , Equipamento de Proteção Individual , Pneumonia Viral/complicações , Trombectomia/métodos , Betacoronavirus , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/cirurgia , Angiografia Cerebral , Angiografia por Tomografia Computadorizada , Serviços Médicos de Emergência , Feminino , Humanos , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Intubação Intratraqueal , Pessoa de Meia-Idade , Pandemias , Reperfusão , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Tempo para o Tratamento , Resultado do Tratamento
16.
Rev Lat Am Enfermagem ; 28: e3347, 2020.
Artigo em Português, Espanhol, Inglês | MEDLINE | ID: mdl-32876287

RESUMO

OBJECTIVE: to compare the mean development time of the techniques of direct laryngoscopy and insertion of supraglottic devices; and to evaluate the success rate in the first attempt of these techniques, considering health professionals wearing specific personal protective equipment (waterproof overalls; gloves; boots; eye protection; mask). METHOD: meta-analysis with studies from LILACS, MEDLINE, CINAHL, Cochrane, Scopus and Web of Science. The keywords were the following: personal protective equipment; airway management; intubation; laryngeal masks. RESULTS: in the "reduction of the time of the procedures" outcome, the general analysis of the supraglottic devices in comparison with the orotracheal tube initially presented high heterogeneity of the data (I2= 97%). Subgroup analysis had an impact on reducing heterogeneity among the data. The "laryngeal mask as a guide for orotracheal intubation" subgroup showed moderate heterogeneity (I2= 74%). The "2ndgeneration supraglottic devices" subgroup showed homogeneity (I2= 0%). All the meta-analyses favored supraglottic devices. In the "success in the first attempt" outcome, moderate homogeneity was found (I2= 52%), showing a higher proportion of correct answers for supraglottic devices. CONCLUSION: in the context of chemical, biological or radiological disaster, the insertion of the supraglottic device proved to be faster and more likely to be successful by health professionals. PROSPERO record (CRD42019136139).


Assuntos
Emergências , Máscaras Laríngeas , Humanos , Intubação Intratraqueal , Laringoscopia , Equipamento de Proteção Individual
19.
Tohoku J Exp Med ; 252(2): 103-107, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32938838

RESUMO

Coronavirus disease 2019 (COVID-19) is a global public health concern that can be classified as mild, moderate, severe, or critical, based on disease severity. Since the identification of critical patients is crucial for developing effective management strategies, we evaluated clinical characteristics, laboratory data, treatment provided, and oxygenation to identify potential predictors of mortality among critical COVID-19 pneumonia patients. We retrospectively utilized data from seven critical patients who were admitted to our hospital during April 2020 and required mechanical ventilation. The primary endpoint was to clarify potential predictor of mortality. All patients were older than 70 years, five were men, six had hypertension, and three ultimately died. Compared with survivors, non-survivors tended to be never smokers (0 pack-years vs. 30 pack-years, p = 0.08), to have higher body mass index (31.3 kg/m2 vs. 25.3 kg/m2, p = 0.06), to require earlier tracheal intubation after symptom onset (2.7 days vs. 5.5 days, p = 0.07), and had fewer lymphocytes on admission (339 /µL vs. 518 /µL, p = 0.05). During the first week after tracheal intubation, non-survivors displayed lower values for minimum ratio of the partial pressure of oxygen to fractional inspiratory oxygen concentration (P/F ratio) (44 mmHg vs. 122 mmHg, p < 0.01) and poor response to intensive therapy compared with survivors. In summary, we show that obesity and lymphopenia could predict the severity of COVID-19 pneumonia and that the trend of lower P/F ratio during the first week of mechanical ventilation could provide useful prognostic information.


Assuntos
Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Estado Terminal/terapia , Intubação Intratraqueal , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Fumar , Idoso , Betacoronavirus/fisiologia , Estudos de Coortes , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/mortalidade , Estado Terminal/epidemiologia , Estado Terminal/mortalidade , Feminino , Hospitalização , Humanos , Intubação Intratraqueal/mortalidade , Masculino , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/mortalidade , Prognóstico , Radiografia Torácica , Estudos Retrospectivos , Fatores de Risco , Fumar/efeitos adversos , Fumar/epidemiologia , Fumar/mortalidade , Fumar/terapia , Tomografia Computadorizada por Raios X
20.
Medicine (Baltimore) ; 99(38): e22289, 2020 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-32957386

RESUMO

The aim of this study was to compare the success of first-attempt tracheal intubation in pediatric patients >1-year old performed using video versus direct laryngoscopy and compare the frequency of tracheal intubation-associated events and desaturation among these patients.Prospective observational cohort study conducted in an Academic pediatric tertiary emergency department. We compared 50 children intubated with Mcgrath Mac video laryngoscope (VL group) and an historical series of 141 children intubated with direct laryngoscopy (DL group). All patients were aged 1 to 18 years.The first attempt success rates were 68% (34/50) and 37.6% (53/141) in the VL and DL groups (P < .01), respectively. There was a lower proportion of tracheal intubation-associated events in the VL group (VL, 31.3% [15/50] vs DL, 67.8% [97/141]; P < .01) and no significant differences in desaturation (VL, 35% [14/50] vs DL 51.8% [72/141]; P = .06). The median number of attempts was 1 (range, 1-5) for the VL group and 2 (range, 1-8) for the DL group (P < .01). Multivariate logistic regression showed that video laryngoscope use was associated with higher chances of first-attempt intubation with an odds ratio of 4.5 (95% confidence interval, 1.9-10.4, P < 0.01).Compared with direct laryngoscopy, VL was associated with higher success rates of first-attempt tracheal intubations and lower rates of tracheal intubation-associated events.


Assuntos
Intubação Intratraqueal/instrumentação , Laringoscopia/instrumentação , Cirurgia Vídeoassistida/instrumentação , Adolescente , Estudos de Casos e Controles , Criança , Pré-Escolar , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Lactente , Intubação Intratraqueal/estatística & dados numéricos , Laringoscopia/estatística & dados numéricos , Masculino , Estudos Prospectivos , Sistema de Registros , Cirurgia Vídeoassistida/estatística & dados numéricos
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