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1.
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
2.
S Afr Med J ; 110(6): 484-490, 2020 May 29.
Artigo em Inglês | MEDLINE | ID: mdl-32880559

RESUMO

BACKGROUND: Airway management is an essential skill for doctors working in the emergency department (ED). Safety and efficacy are crucial to its success. Analysis of an airway registry can provide feedback that can be used for quality improvement purposes. OBJECTIVES: To examine the first airway registry from an ED in South Africa (SA), a low- to middle-income country (LMIC), and compare the findings with international data. METHODS: A retrospective analysis of 13 months' data from the airway registry of an academic ED with an annual census of 60 000 patients. Data analysed included demographics, indications for intubation, intubator training level, type of intubation device, number of attempts, adverse events, pre-oxygenation methods, and drug and intravenous fluid use. RESULTS: A total of 321 intubations were included. The majority of the patients (71.6%) had non-traumatic indications for intubation. The overall first-pass intubation success (FPS) rate for doctors was 81.8%. Although this rate is lower than the mean rate suggested in an international meta-analysis (84.1%), it is within the 95% confidence interval (80.1 - 87.4%). Overall FPS rates showed no difference between video laryngoscopy (81.7%) compared with direct laryngoscopy (73.3%) (p-value 0.079), although better glottic views were obtained with video laryngoscopy (80.5% were Cormack-Lehane grade 1). Analysis of pre-oxygenation methods found that although sicker patients had received more aggressive pre-oxygenation, e.g. with non-invasive or bag-mask ventilation techniques, they still desaturated more often (35.8% and 62.5%, respectively) than less sick patients who received simple non-rebreather facemask pre-oxygenation (4.5%). CONCLUSIONS: This analysis of the first airway registry from an SA ED highlights that airway management in an LMIC can be performed on par with accepted international standards. It serves as a good baseline for further research into airway management in other LMICs and provides useful feedback for quality improvement purposes.


Assuntos
Manuseio das Vias Aéreas/métodos , Serviço Hospitalar de Emergência , Adulto , Idoso , Feminino , Hidratação/estatística & dados numéricos , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Laringoscopia , Masculino , Pessoa de Meia-Idade , Oxigenoterapia/estatística & dados numéricos , Sistema de Registros , Estudos Retrospectivos , África do Sul
3.
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
5.
BMJ Open Respir Res ; 7(1)2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32847947

RESUMO

Invasive mechanical has been associated with high mortality in COVID-19. Alternative therapy of high flow nasal therapy (HFNT) has been greatly debated around the world for use in COVID-19 pandemic due to concern for increased healthcare worker transmission.This was a retrospective analysis of consecutive patients admitted to Temple University Hospital in Philadelphia, Pennsylvania, from 10 March 2020 to 24 April 2020 with moderate-to-severe respiratory failure treated with HFNT. Primary outcome was prevention of intubation. Of the 445 patients with COVID-19, 104 met our inclusion criteria. The average age was 60.66 (+13.50) years, 49 (47.12 %) were female, 53 (50.96%) were African-American, 23 (22.12%) Hispanic. Forty-three patients (43.43%) were smokers. Saturation to fraction ratio and chest X-ray scores had a statistically significant improvement from day 1 to day 7. 67 of 104 (64.42%) were able to avoid invasive mechanical ventilation in our cohort. Incidence of hospital-associated/ventilator-associated pneumonia was 2.9%. Overall, mortality was 14.44% (n=15) in our cohort with 13 (34.4%) in the progressed to intubation group and 2 (2.9%) in the non-intubation group. Mortality and incidence of pneumonia was statistically higher in the progressed to intubation group. CONCLUSION: HFNT use is associated with a reduction in the rate of invasive mechanical ventilation and overall mortality in patients with COVID-19 infection.


Assuntos
Infecções por Coronavirus/terapia , Pneumonia Associada a Assistência à Saúde/epidemiologia , Hipóxia/terapia , Intubação Intratraqueal/estatística & dados numéricos , Oxigenoterapia/métodos , Pneumonia Viral/terapia , Insuficiência Respiratória/terapia , Corticosteroides/uso terapêutico , Afro-Americanos , Idoso , Antibacterianos/uso terapêutico , Anticorpos Monoclonais Humanizados/uso terapêutico , Antirreumáticos/uso terapêutico , Azitromicina/uso terapêutico , Betacoronavirus , Cânula , Comorbidade , Infecções por Coronavirus/epidemiologia , Diabetes Mellitus/epidemiologia , Grupo com Ancestrais do Continente Europeu , Feminino , Cardiopatias/epidemiologia , Hispano-Americanos , Humanos , Hidroxicloroquina/uso terapêutico , Hipertensão/epidemiologia , Imunoglobulinas Intravenosas/uso terapêutico , Fatores Imunológicos/uso terapêutico , Pneumopatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Pandemias , Philadelphia/epidemiologia , Pneumonia Associada à Ventilação Mecânica/epidemiologia , Pneumonia Viral/epidemiologia , Pulsoterapia , Insuficiência Renal Crônica/epidemiologia , Estudos Retrospectivos , Índice de Gravidade de Doença , Fumar/epidemiologia
6.
Am J Gastroenterol ; 115(10): 1617-1623, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32852338

RESUMO

INTRODUCTION: To compare outcomes in patients hospitalized with coronavirus (COVID-19) receiving famotidine therapy with those not receiving famotidine. METHODS: Retrospective, propensity-matched observational study of consecutive COVID-19-positive patients between February 24, 2020, and May 13, 2020. RESULTS: Of 878 patients in the analysis, 83 (9.5%) received famotidine. In comparison to patients not treated with famotidine, patients treated with famotidine were younger (63.5 ± 15.0 vs 67.5 ± 15.8 years, P = 0.021), but did not differ with respect to baseline demographics or preexisting comorbidities. Use of famotidine was associated with a decreased risk of in-hospital mortality (odds ratio 0.37, 95% confidence interval 0.16-0.86, P = 0.021) and combined death or intubation (odds ratio 0.47, 95% confidence interval 0.23-0.96, P = 0.040). Propensity score matching to adjust for age difference between groups did not alter the effect on either outcome. In addition, patients receiving famotidine displayed lower levels of serum markers for severe disease including lower median peak C-reactive protein levels (9.4 vs 12.7 mg/dL, P = 0.002), lower median procalcitonin levels (0.16 vs 0.30 ng/mL, P = 0.004), and a nonsignificant trend to lower median mean ferritin levels (797.5 vs 964.0 ng/mL, P = 0.076). Logistic regression analysis demonstrated that famotidine was an independent predictor of both lower mortality and combined death/intubation, whereas older age, body mass index >30 kg/m, chronic kidney disease, National Early Warning Score, and higher neutrophil-lymphocyte ratio were all predictors of both adverse outcomes. DISCUSSION: Famotidine use in hospitalized patients with COVID-19 is associated with a lower risk of mortality, lower risk of combined outcome of mortality and intubation, and lower levels of serum markers for severe disease in hospitalized patients with COVID-19.(Equation is included in full-text article.).


Assuntos
Infecções por Coronavirus/terapia , Famotidina/uso terapêutico , Intubação Intratraqueal/estatística & dados numéricos , Pneumonia Viral/terapia , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus/isolamento & purificação , Betacoronavirus/patogenicidade , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/virologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/mortalidade , Pneumonia Viral/virologia , Pontuação de Propensão , Estudos Retrospectivos , Índice de Gravidade de Doença , Centros de Atenção Terciária/estatística & dados numéricos , Resultado do Tratamento
7.
Emergencias ; 32(4): 233-241, 2020.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-32692000

RESUMO

OBJECTIVES: To describe the clinical characteristics of patients with coronavirus disease 2019 (COVID-19) treated in hospital emergency departments (EDs) in Spain, and to assess associations between characteristics and outcomes. MATERIAL AND METHODS: Prospective, multicenter, nested-cohort study. Sixty-one EDs included a random sample of all patients diagnosed with COVID-19 between March 1 and April 30, 2020. Demographic and baseline health information, including concomitant conditions; clinical characteristics related to the ED visit and complementary test results; and treatments were recorded throughout the episode in the ED. We calculated crude and adjusted odds ratios for risk of in-hospital death and a composite outcome consisting of the following events: intensive care unit admission, orotracheal intubation or mechanical ventilation, or in-hospital death. The logistic regression models were constructed with 3 groups of independent variables: the demographic and baseline health characteristics, clinical characteristics and complementary test results related to the ED episode, and treatments. RESULTS: The mean (SD) age of patients was 62 (18) years. Most had high- or low-grade fever, dry cough, dyspnea, and diarrhea. The most common concomitant conditions were cardiovascular diseases, followed by respiratory diseases and cancer. Baseline patient characteristics that showed a direct and independent association with worse outcome (death and the composite outcome) were age and obesity. Clinical variables directly associated with worse outcomes were impaired consciousness and pulmonary crackles; headache was inversely associated with worse outcomes. Complementary test findings that were directly associated with outcomes were bilateral lung infiltrates, lymphopenia, a high platelet count, a D-dimer concentration over 500 mg/dL, and a lactate-dehydrogenase concentration over 250 IU/L in blood. CONCLUSION: This profile of the clinical characteristics and comorbidity of patients with COVID-19 treated in EDs helps us predict outcomes and identify cases at risk of exacerbation. The information can facilitate preventive measures and improve outcomes.


Assuntos
Betacoronavirus , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Avaliação de Sintomas , Adolescente , Adulto , Distribuição por Idade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Criança , Pré-Escolar , Comorbidade , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/terapia , Feminino , Mortalidade Hospitalar , Humanos , Lactente , Recém-Nascido , Intubação Intratraqueal/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Neoplasias/epidemiologia , Obesidade/complicações , Razão de Chances , Pandemias , Pneumonia Viral/mortalidade , Pneumonia Viral/terapia , Prognóstico , Estudos Prospectivos , Transtornos Respiratórios/epidemiologia , Respiração Artificial/estatística & dados numéricos , Distribuição por Sexo , Espanha/epidemiologia , Adulto Jovem
8.
S Afr Med J ; 110(5): 400-402, 2020 Apr 29.
Artigo em Inglês | MEDLINE | ID: mdl-32657725

RESUMO

BACKGROUND: Hanging is a common form of self-harm, and emergency care physicians will not infrequently be called upon to manage a survivor.Despite the relative frequency of the injury, there is a paucity of literature on the topic and the spectrum and incidence of associated injuries are poorly described. OBJECTIVES: To review experience with management of victims of hanging at a major trauma centre in South Africa. METHODS: All patients treated by the Pietermaritzburg Metropolitan Trauma Service following a hanging incident between December 2012 and December 2018 were identified from the Hybrid Electronic Medical Registry. Basic demographics were recorded, and the management and outcome of each patient were noted. RESULTS: During the 6-year period under review, a total of 154 patients were seen following a hanging incident. The mean age was 29.4 years. There were 24 females (15.6%) and 130 males (84.4%). The vast majority (n=150; 97.5%) had attempted suicide, and only 4 hangings (2.5%) were accidental. A total of 92 patients (60.9%) had consumed alcohol prior to the incident. There were 23 patients with a Glasgow Coma Score (GCS) <9 (severe traumatic brain injury (TBI)), 14 with a GCS of 9 - 12 (moderate TBI) and 117 with a GCS >12 (mild TBI). A total of 7 patients (4.5%) required intensive care unit admission, and 25 (16.2%) required intubation. The following extracranial injuries were documented on computed tomography scans: hyoid bone fractures (n=2), cervical spine fracture (n=10), mandible fracture (n=4) and oesophageal injury (n=1). Intracranial pathology was evident on 27.0% of scans, with the most common finding being global cerebral ischaemia. The mortality rate was 2.5% (4/154). CONCLUSIONS: Hanging is a common mechanism of self-harm. It is associated with significant injuries and mortality. The acute management of hanging should focus on airway protection followed by detailed imaging of the head and neck. Further work must attempt to include mortuary data on hanging.


Assuntos
Acidentes/estatística & dados numéricos , Asfixia/epidemiologia , Lesões do Pescoço/epidemiologia , Tentativa de Suicídio/estatística & dados numéricos , Adulto , Consumo de Bebidas Alcoólicas/epidemiologia , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/epidemiologia , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/lesões , Esôfago/diagnóstico por imagem , Esôfago/lesões , Feminino , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/epidemiologia , Escala de Coma de Glasgow , Humanos , Osso Hioide/diagnóstico por imagem , Osso Hioide/lesões , Unidades de Terapia Intensiva/estatística & dados numéricos , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Fraturas Mandibulares/diagnóstico por imagem , Fraturas Mandibulares/epidemiologia , Estudos Retrospectivos , Distribuição por Sexo , África do Sul/epidemiologia , Tomografia Computadorizada por Raios X , Centros de Traumatologia
9.
Int J Obes (Lond) ; 44(9): 1832-1837, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32712623

RESUMO

BACKGROUND: Obesity is an epidemic in New York City, the global epicenter of the coronavirus pandemic. Previous studies suggest that obesity is a possible risk factor for adverse outcomes in COVID-19. OBJECTIVE: To elucidate the association between obesity and COVID-19 outcomes. DESIGN: Retrospective cohort study of COVID-19 hospitalized patients tested between March 10 and April 13, 2020. SETTING: SUNY Downstate Health Sciences University, a COVID-only hospital in New York. PARTICIPANTS: In total, 684 patients were tested for COVID-19 and 504 were analyzed. Patients were categorized into three groups by BMI: normal (BMI 18.50-24.99), overweight (BMI 25.00-29.99), and obese (BMI ≥ 30.00). MEASUREMENTS: Primary outcome was 30-day in-hospital mortality, and secondary outcomes were intubation, acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), and acute cardiac injury (ACI). RESULTS: There were 139 patients (27%) with normal BMI, 150 patients who were overweight (30%), and 215 patients with obesity (43%). After controlling for age, gender, diabetes, hypertension, and qSOFA score, there was a significantly increased risk of mortality in the overweight (RR 1.4, 95% CI 1.1-1.9) and obese groups (RR 1.3, 95% CI 1.0-1.7) compared with those with normal BMI. Similarly, there was a significantly increased relative risk for intubation in the overweight (RR 2.0, 95% CI 1.2-3.3) and obese groups (RR 2.4, 95% CI 1.5-4.0) compared with those with normal BMI. Obesity did not affect rates of AKI, ACI, or ARDS. Furthermore, obesity appears to significantly increase the risk of mortality in males (RR 1.4, 95% CI 1.0-2.0, P = 0.03), but not in females (RR 1.2, 95% CI 0.77-1.9, P = 0.40). CONCLUSION: This study reveals that patients with overweight and obesity who have COVID-19 are at increased risk for mortality and intubation compared to those with normal BMI. These findings support the hypothesis that obesity is a risk factor for COVID-19 complications and should be a consideration in management of COVID-19.


Assuntos
Infecções por Coronavirus , Obesidade/epidemiologia , Pandemias , Pneumonia Viral , Lesão Renal Aguda/epidemiologia , Adulto , Idoso , Betacoronavirus , Índice de Massa Corporal , Comorbidade , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/mortalidade , Diabetes Mellitus Tipo 2/epidemiologia , Feminino , Humanos , Hipertensão/epidemiologia , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Sobrepeso/epidemiologia , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia , Pneumonia Viral/mortalidade , Estudos Retrospectivos , Fatores de Risco
10.
Indian J Med Res ; 151(5): 459-467, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32611916

RESUMO

Background & objectives: Healthcare workers (HCWs) are at an elevated risk of contracting COVID-19. While intense occupational exposure associated with aerosol-generating procedures underlines the necessity of using personal protective equipment (PPE) by HCWs, high-transmission efficiency of the causative agent [severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)] could also lead to infections beyond such settings. Hydroxychloroquine (HCQ), a repurposed antimalarial drug, was empirically recommended as prophylaxis by the National COVID-19 Task Force in India to cover such added risk. Against this background, the current investigation was carried out to identify the factors associated with SARS-CoV-2 infection among HCWs in the country. Methods: A case-control design was adopted and participants were randomly drawn from the countrywide COVID-19 testing data portal maintained by the ICMR. The test results and contact details of HCWs, diagnosed as positive (cases) or negative (controls) for SARS-CoV-2 using real-time reverse transcription-polymerase chain reaction (qRT-PCR), were available from this database. A 20-item brief-questionnaire elicited information on place of work, procedures conducted and use of PPE. Results: Compared to controls, cases were slightly older (34.7 vs. 33.5 yr) and had more males (58 vs. 50%). In multivariate analyses, HCWs performing endotracheal intubation had higher odds of being SARS-CoV-2 infected [adjusted odds ratio (AOR): 4.33, 95% confidence interval (CI): 1.16-16.07]. Consumption of four or more maintenance doses of HCQ was associated with a significant decline in the odds of getting infected (AOR: 0.44; 95% CI: 0.22-0.88); a dose-response relationship existed between frequency of exposure to HCQ and such reductions (χ[2] for trend=48.88; P <0.001). In addition, the use of PPE was independently associated with the reduction in odds of getting infected with SARS-CoV-2. Interpretations & conclusions: Until results of clinical trials for HCQ prophylaxis become available, this study provides actionable information for policymakers to protect HCWs at the forefront of COVID-19 response. The public health message of sustained intake of HCQ prophylaxis as well as appropriate PPE use need to be considered in conjunction with risk homoeostasis operating at individual levels.


Assuntos
Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/transmissão , Pessoal de Saúde , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Exposição Ocupacional , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/transmissão , Adolescente , Adulto , Antimaláricos/uso terapêutico , Betacoronavirus , Estudos de Casos e Controles , Infecções por Coronavirus/prevenção & controle , Feminino , Humanos , Hidroxicloroquina/uso terapêutico , Índia/epidemiologia , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Exposição Ocupacional/prevenção & controle , Pandemias/prevenção & controle , Equipamento de Proteção Individual/estatística & dados numéricos , Pneumonia Viral/prevenção & controle , Fatores de Proteção , Fatores de Risco , Inquéritos e Questionários , Adulto Jovem
11.
Pediatrics ; 146(2)2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32690804

RESUMO

BACKGROUND: That African American (AA) patients have poorer surgical outcomes compared with their white peers is established. The prevailing presumption is that these disparities operate within the context of a higher preoperative comorbidity burden among AA patients. Whether these racial differences in outcomes exist among apparently healthy children (traditionally expected to have low risk of postsurgical complications) has not been previously investigated. METHODS: We performed a retrospective study by analyzing the National Surgical Quality Improvement Program-Pediatric database from 2012 through 2017 and identifying children who underwent inpatient operations and were assigned American Society of Anesthesiologists physical status 1 or 2. We used univariable and risk-adjusted logistic regression to estimate the odds ratios and their 95% confidence intervals (CIs) of postsurgical outcomes comparing AA to white children. RESULTS: Among 172 549 apparently healthy children, the incidence of 30-day mortality, postoperative complications, and serious adverse events were 0.02%, 13.9%, and 5.7%, respectively. Compared with their white peers, AA children had 3.43 times the odds of dying within 30 days after surgery (odds ratio: 3.43; 95% CI: 1.73-6.79). Compared with being white, AA had 18% relative greater odds of developing postoperative complications (odds ratio: 1.18; 95% CI: 1.13-1.23) and 7% relative higher odds of developing serious adverse events (odds ratio: 1.07; 95% CI: 1.01-1.14). CONCLUSIONS: Even among apparently healthy children, being AA is strongly associated with a higher risk of postoperative complications and mortality. Mechanisms underlying the established racial differences in postoperative outcomes may not be fully explained by the racial variation in preoperative comorbidity.


Assuntos
Afro-Americanos/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Complicações Pós-Operatórias/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Bases de Dados Factuais , Emergências , Feminino , Hospitalização , Humanos , Lactente , Recém-Nascido , Intubação Intratraqueal/estatística & dados numéricos , Modelos Logísticos , Masculino , Duração da Cirurgia , Recidiva , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores Sexuais , Estados Unidos/epidemiologia
12.
Med Clin (Barc) ; 155(4): 159-161, 2020 08 28.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-32532461

RESUMO

INTRODUCTION: Cytokine storm syndrome (CSS) is a serious complication of COVID-19 patients. Treatment is tocilizumab. The use of glucocorticoids (GC) is controversial. In other very similar CSS, such as macrophage activation syndrome (MAS) and hemophagocytic syndrome (HFS), the main treatment are corticosteroids. Our objective is to evaluate the efficacy of GC in the CSS by COVID-19. PATIENTS: We included 92 patients with CSS associated to COVID-19 who received GC, GC, and tocilizumab and only tocilizumab. We determine CSS markers. We evaluated mortality, intubation, and a combined variable. RESULTS: In all cases the percentages of events were lower in the group of patients with GC was administered. The hazard ratio of the final variables with GC versus the group in which only tocilizumab was administered was lower as CGs were considered, with statistical significance for survival. DISCUSSION: The early use of GC pulses could control SLC, with a lower requirement to use tocilizumab and a decrease in events such as intubation and death.


Assuntos
Corticosteroides/administração & dosagem , Anticorpos Monoclonais Humanizados/administração & dosagem , Betacoronavirus , Infecções por Coronavirus/complicações , Síndrome da Liberação de Citocina/tratamento farmacológico , Pneumonia Viral/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções por Coronavirus/imunologia , Infecções por Coronavirus/mortalidade , Síndrome da Liberação de Citocina/etiologia , Síndrome da Liberação de Citocina/mortalidade , Esquema de Medicação , Feminino , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/imunologia , Pneumonia Viral/mortalidade , Estudos Retrospectivos
13.
JAMA ; 324(1): 57-67, 2020 07 07.
Artigo em Inglês | MEDLINE | ID: mdl-32496521

RESUMO

Importance: Treatment with noninvasive oxygenation strategies such as noninvasive ventilation and high-flow nasal oxygen may be more effective than standard oxygen therapy alone in patients with acute hypoxemic respiratory failure. Objective: To compare the association of noninvasive oxygenation strategies with mortality and endotracheal intubation in adults with acute hypoxemic respiratory failure. Data Sources: The following bibliographic databases were searched from inception until April 2020: MEDLINE, Embase, PubMed, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and LILACS. No limits were applied to language, publication year, sex, or race. Study Selection: Randomized clinical trials enrolling adult participants with acute hypoxemic respiratory failure comparing high-flow nasal oxygen, face mask noninvasive ventilation, helmet noninvasive ventilation, or standard oxygen therapy. Data Extraction and Synthesis: Two reviewers independently extracted individual study data and evaluated studies for risk of bias using the Cochrane Risk of Bias tool. Network meta-analyses using a bayesian framework to derive risk ratios (RRs) and risk differences along with 95% credible intervals (CrIs) were conducted. GRADE methodology was used to rate the certainty in findings. Main Outcomes and Measures: The primary outcome was all-cause mortality up to 90 days. A secondary outcome was endotracheal intubation up to 30 days. Results: Twenty-five randomized clinical trials (3804 participants) were included. Compared with standard oxygen, treatment with helmet noninvasive ventilation (RR, 0.40 [95% CrI, 0.24-0.63]; absolute risk difference, -0.19 [95% CrI, -0.37 to -0.09]; low certainty) and face mask noninvasive ventilation (RR, 0.83 [95% CrI, 0.68-0.99]; absolute risk difference, -0.06 [95% CrI, -0.15 to -0.01]; moderate certainty) were associated with a lower risk of mortality (21 studies [3370 patients]). Helmet noninvasive ventilation (RR, 0.26 [95% CrI, 0.14-0.46]; absolute risk difference, -0.32 [95% CrI, -0.60 to -0.16]; low certainty), face mask noninvasive ventilation (RR, 0.76 [95% CrI, 0.62-0.90]; absolute risk difference, -0.12 [95% CrI, -0.25 to -0.05]; moderate certainty) and high-flow nasal oxygen (RR, 0.76 [95% CrI, 0.55-0.99]; absolute risk difference, -0.11 [95% CrI, -0.27 to -0.01]; moderate certainty) were associated with lower risk of endotracheal intubation (25 studies [3804 patients]). The risk of bias due to lack of blinding for intubation was deemed high. Conclusions and Relevance: In this network meta-analysis of trials of adult patients with acute hypoxemic respiratory failure, treatment with noninvasive oxygenation strategies compared with standard oxygen therapy was associated with lower risk of death. Further research is needed to better understand the relative benefits of each strategy.


Assuntos
Hipóxia/mortalidade , Intubação Intratraqueal/estatística & dados numéricos , Metanálise em Rede , Ventilação não Invasiva/mortalidade , Oxigênio/administração & dosagem , Insuficiência Respiratória/mortalidade , Adulto , Idoso , Teorema de Bayes , Viés , Causas de Morte , Dispositivos de Proteção da Cabeça , Humanos , Hipóxia/terapia , Máscaras , Pessoa de Meia-Idade , Ventilação não Invasiva/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Insuficiência Respiratória/terapia
14.
Respir Med ; 169: 106023, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32454268

RESUMO

OBJECTIVE: To analyze the risk factors for pulmonary embolism (PE) in patients infected with COVID-19. METHODS: We conducted an observational, retrospective study. Patients with severe infection with COVID-19 and suspected PE were included. RESULTS: Patients with higher levels of D-dimer and those requiring intubation were at a higher risk of developing PE. Higher D-dimer levels were associated with a greater probability of PE 3, 6, 9 and 12 days after determining D-dimer levels with an OR of 1.7, 2.0, 2.4 and 2.4, respectively. CONCLUSION: In conclusion, patients infected with COVID-19 requiring OTI with higher levels of D-dimer have an increased risk of developing PE.


Assuntos
Infecções por Coronavirus/epidemiologia , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Intubação Intratraqueal/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Embolia Pulmonar/epidemiologia , Idoso , Betacoronavirus , Infecções por Coronavirus/sangue , Infecções por Coronavirus/metabolismo , Infecções por Coronavirus/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/sangue , Pneumonia Viral/metabolismo , Pneumonia Viral/terapia , Embolia Pulmonar/sangue , Embolia Pulmonar/metabolismo , Respiração Artificial , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Espanha/epidemiologia
15.
Anaesth Crit Care Pain Med ; 39(3): 361-362, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32360981

Assuntos
Betacoronavirus , Infecções por Coronavirus , Cuidados Críticos/organização & administração , Hospitais Militares/organização & administração , Unidades de Terapia Intensiva/organização & administração , Unidades Móveis de Saúde/organização & administração , Pandemias , Pneumonia Viral , Síndrome do Desconforto Respiratório do Adulto/terapia , Idoso , Anestesia Geral/estatística & dados numéricos , Conversão de Leitos , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Cuidados Críticos/estatística & dados numéricos , Despacho de Emergência Médica/organização & administração , Feminino , França/epidemiologia , Hospitais com menos de 100 Leitos , Serviços Hospitalares Compartilhados/organização & administração , Hospitais Gerais/organização & administração , Hospitais Militares/estatística & dados numéricos , Humanos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Unidades de Terapia Intensiva/estatística & dados numéricos , Unidades de Terapia Intensiva/provisão & distribução , Intubação Intratraqueal/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Unidades Móveis de Saúde/estatística & dados numéricos , Doenças Profissionais/prevenção & controle , Pandemias/prevenção & controle , Admissão do Paciente/estatística & dados numéricos , Transferência de Pacientes/métodos , Transferência de Pacientes/estatística & dados numéricos , Equipamento de Proteção Individual , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Utilização de Procedimentos e Técnicas , Respiração Artificial/estatística & dados numéricos , Síndrome do Desconforto Respiratório do Adulto/epidemiologia , Síndrome do Desconforto Respiratório do Adulto/etiologia
16.
Radiology ; 297(1): E197-E206, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32407255

RESUMO

Background Chest radiography has not been validated for its prognostic utility in evaluating patients with coronavirus disease 2019 (COVID-19). Purpose To analyze the prognostic value of a chest radiograph severity scoring system for younger (nonelderly) patients with COVID-19 at initial presentation to the emergency department (ED); outcomes of interest included hospitalization, intubation, prolonged stay, sepsis, and death. Materials and Methods In this retrospective study, patients between the ages of 21 and 50 years who presented to the ED of an urban multicenter health system from March 10 to March 26, 2020, with COVID-19 confirmation on real-time reverse transcriptase polymerase chain reaction were identified. Each patient's ED chest radiograph was divided into six zones and examined for opacities by two cardiothoracic radiologists, and scores were collated into a total concordant lung zone severity score. Clinical and laboratory variables were collected. Multivariable logistic regression was used to evaluate the relationship between clinical parameters, chest radiograph scores, and patient outcomes. Results The study included 338 patients: 210 men (62%), with median age of 39 years (interquartile range, 31-45 years). After adjustment for demographics and comorbidities, independent predictors of hospital admission (n = 145, 43%) were chest radiograph severity score of 2 or more (odds ratio, 6.2; 95% confidence interval [CI]: 3.5, 11; P < .001) and obesity (odds ratio, 2.4 [95% CI: 1.1, 5.4] or morbid obesity). Among patients who were admitted, a chest radiograph score of 3 or more was an independent predictor of intubation (n = 28) (odds ratio, 4.7; 95% CI: 1.8, 13; P = .002) as was hospital site. No significant difference was found in primary outcomes across race and ethnicity or those with a history of tobacco use, asthma, or diabetes mellitus type II. Conclusion For patients aged 21-50 years with coronavirus disease 2019 presenting to the emergency department, a chest radiograph severity score was predictive of risk for hospital admission and intubation. © RSNA, 2020 Online supplemental material is available for this article.


Assuntos
Infecções por Coronavirus , Pulmão/diagnóstico por imagem , Pandemias , Pneumonia Viral , Adulto , Betacoronavirus , Infecções por Coronavirus/diagnóstico por imagem , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/patologia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Pulmão/patologia , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/diagnóstico por imagem , Pneumonia Viral/epidemiologia , Pneumonia Viral/patologia , Valor Preditivo dos Testes , Prognóstico , Radiografia Torácica , Estudos Retrospectivos , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Adulto Jovem
17.
Anaesthesia ; 75(6): 756-766, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32232991

RESUMO

Estimates of the rate and risk-factors for difficult airway rarely include a denominator for the number of anaesthetics. Approaches such as self-reporting and crowd-sourcing of airway incidents may help identify specific lessons from clinical episodes, but the lack of denominator data, biased reporting and under-reporting does not allow a comprehensive population-based assessment. We used an established state-wide dataset to determine the incidence of failed and difficult intubations between 2015 and 2017 in the state of Victoria in Australia, along with associated patient and surgical risk-factors. A total of 861,533 general anaesthesia episodes were analysed. Of these, 4092 patients with difficult or failed intubation were identified; incidence rates of 0.52% (2015-2016) and 0.43% (2016-2017), respectively. Difficult/failed intubations were most common in patients aged 45-75 and decreased for older age groups, with risk being lower for patients aged >85 than patients aged 35-44. The risk for failed/difficult intubation increased significantly for: patients undergoing emergency surgery (OR 1.80); obese patients (OR 2.48); increased ASA physical status; and increased Charlson Comorbidity Index. Across all age groups, procedures on the nervous system (OR 1.92) and endocrine system (OR 2.03) had the highest risk of failed/difficult intubation. The relative reduced risk for failed/difficult intubations in the elderly population is a novel finding that contrasts with previous research and may suggest a 'compression of morbidity' effect as a moderator. Administrative databases have the potential to improve understanding of peri-operative risk of rare events at a population level.


Assuntos
Tratamento de Emergência/estatística & dados numéricos , Nível de Saúde , Intubação Intratraqueal/métodos , Intubação Intratraqueal/estatística & dados numéricos , Obesidade/complicações , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/estatística & dados numéricos , Criança , Pré-Escolar , Bases de Dados Factuais , Sistema Endócrino/cirurgia , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Fatores de Risco , Vitória , Adulto Jovem
18.
Am J Otolaryngol ; 41(4): 102482, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32317128

RESUMO

PURPOSE: Acute supraglottitis (SG) can potentially lead to rapid airway obstruction. The last few decades have witnessed a shift towards a more conservative approach in airway management of adult SG. This study aims to evaluate this watchful approach based on a large case series combined with a high-level meta-analysis of all reports in the English literature. METHODS: Retrospective case series and meta-analysis. The medical records of all adult patients diagnosed as having SG who were hospitalized in a large-volume tertiary referral center between January 2007 and December 2018 were reviewed. A meta-analysis was conducted on all English literature published between 1990 and 2018. RESULTS: A total of 233 patients (median age 49.1 years, 132 males), were admitted due to acute SG during the study period. No airway intervention was required in 228 patients (97.9%). Five patients (2.1%) required preventive intubation, and two of them (0.9%) were later surgically converted to a tracheotomy. Patients who required airway intervention had higher rates of diabetes (P = .001), cardiovascular diseases (P = .036) and other comorbidities (P = .022). There was no mortality. The meta-analysis revealed that the overall intubation rates random effects model was 8.8% [95% confidence interval (CI) 4.6%-14.0%] and that the tracheotomy random effects model was 2.2% (95% CI; 0.5%-4.8%). The overall mortality rate was 0.89%. CONCLUSIONS: This study provides evidence of low rates of surgical airway intervention in patients diagnosed with SG worldwide. A conservative approach in adult SG is safe and should be advocated. LEVEL OF EVIDENCE: 2.


Assuntos
Intubação Intratraqueal/estatística & dados numéricos , Supraglotite/terapia , Traqueotomia/estatística & dados numéricos , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Comorbidade , Complicações do Diabetes/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
19.
Crit Care ; 24(1): 86, 2020 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-32164739

RESUMO

BACKGROUND: Whereas ICU-acquired weakness may delay extubation in mechanically ventilated patients, its influence on extubation failure is poorly known. This study aimed at assessing the role of ICU-acquired weakness on extubation failure and the relation between limb weakness and cough strength. METHODS: A secondary analysis of two previous prospective studies including patients at high risk of reintubation after a planned extubation, i.e., age greater than 65 years, with underlying cardiac or respiratory disease, or intubated for more than 7 days prior to extubation. Patients intubated less than 24 h and those with a do-not-reintubate order were not included. Limb and cough strength were assessed by a physiotherapist just before extubation. ICU-acquired weakness was clinically diagnosed as limb weakness defined as Medical Research Council (MRC) score < 48 points and severe weakness as MRC sum-score < 36. Cough strength was assessed using a semi-quantitative 5-Likert scale. Extubation failure was defined as reintubation or death within the first 7 days following extubation. RESULTS: Among 344 patients at high risk of reintubation, 16% experienced extubation failure (56/344). They had greater severity and lower MRC sum-score (41 ± 16 vs. 49 ± 13, p < 0.001) and were more likely to have ineffective cough than the others. The prevalence of ICU-acquired weakness at the time of extubation was 38% (130/244). The extubation failure rate was 12% (25/214) in patients with no limb weakness vs. 18% (12/65) and 29% (19/65) in those with moderate and severe limb weakness, respectively (p < 0.01). MRC sum-score and cough strength were weakly but significantly correlated (rho = 0.28, p < .001). After multivariate logistic regression analyses, the lower the MRC sum-score the greater the risk of reintubation; severe limb weakness was independently associated with extubation failure, even after adjustment on cough strength and severity at admission. CONCLUSION: ICU-acquired weakness was diagnosed in 38% in this population of patients at high risk at the time of extubation and was independently associated with extubation failure in the ICU.


Assuntos
Extubação/efeitos adversos , Unidades de Terapia Intensiva , Debilidade Muscular/epidemiologia , Respiração Artificial , Desmame do Respirador , Idoso , Feminino , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Debilidade Muscular/etiologia , Prevalência , Respiração Artificial/estatística & dados numéricos , Resultado do Tratamento , Desmame do Respirador/estatística & dados numéricos
20.
Medicine (Baltimore) ; 99(13): e19675, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32221097

RESUMO

Chronic obstructive pulmonary disease (COPD) has a major impact on mortality and morbidity in patients undergoing cardiac surgery. Mortality risk increases by 50% in patients who were re-intubated or required prolonged mechanical ventilation after the operation. The aim of this study was to assess the impact of COPD on the prediction of postoperative complications and outcome including intensive care unit (ICU) and hospital stay, postoperative morbidity and mortality in patients undergoing all types of cardiac surgery.We performed a retrospective cohort analysis of prospectively collected data from a tertiary cardiac surgery department of a university hospital between 2014 and 2016. We divided patients undergoing cardiac surgery into 2 sub-groups - the first - with a clinical diagnosis of COPD (n = 198) and the second comprised all other non-COPD patients (n = 2980).Among patients with COPD a longer intubation time (P = .039), longer ICU stay (P < .001) and longer hospitalization time (P = .006) was noted as compared with non-COPD patients. Patients with COPD required reintubation more often than non-COPD patients, reintubation occurring twice, 19 (9.60%) versus 144 (4.83%) P = .002, reintubation occurring 3 or more times, 7 (3.54%) versus 34 (1.14%) P = .006. Mortality within 30 days after surgery was higher in patients with pulmonary problems before surgery (P = .003). Multivariable logistic regression analysis corrected for interfering variables showed an increased risk of postoperative bronchoconstriction (odds ratio [OR] = 4.40, P = .002), respiratory failure (OR = 1.67, P = .018), atrial fibrillation (OR = 1.45, P = .023), and use of hemofiltration (OR = 1.60, P = .029) for patients with COPD.Patients with COPD undergoing all types of cardiac surgery are at increased risk of respiratory complications and mortality. The occurrence of COPD was associated with longer ICU and hospital stay. In COPD patients, undergoing cardiac surgery, treatment strategies aimed at preventing reintubation and early weaning mechanical ventilation must be employed to reduce postoperative complications.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Cardiopatias/epidemiologia , Cardiopatias/cirurgia , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Idoso , Procedimentos Cirúrgicos Cardíacos/métodos , Comorbidade , Feminino , Hospitais Universitários/estatística & dados numéricos , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco
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