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1.
BMJ Case Rep ; 14(3)2021 Mar 16.
Artigo em Inglês | MEDLINE | ID: mdl-33727296

RESUMO

A 31-year-old pregnant woman presented with symptomatic COVID-19, which was complicated by progressive hypoxaemia requiring intensive care and emergent delivery by caesarean section. Afterward, she was successfully supported with mechanical ventilation and prone positioning and ultimately recovered. We review literature regarding complications of COVID-19 affecting pregnancy and evidence-based treatment strategies.


Assuntos
/terapia , Cesárea , Posicionamento do Paciente/métodos , Complicações Infecciosas na Gravidez/terapia , Respiração Artificial/métodos , Adulto , Feminino , Humanos , Gravidez , Decúbito Ventral
2.
J Laryngol Otol ; 135(3): 234-240, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33682652

RESUMO

OBJECTIVE: The extent of surgery, the type of device used and head position may influence nasal irrigation. The aim of this study was to determine the effectiveness of topical irrigant delivery to the paranasal sinuses according to these factors. METHOD: Four cadaveric heads underwent four stepwise endoscopic dissections. Irrigations were evaluated after every stage using different delivery devices (squeeze-bottle, gravity-dependent device and syringe) in two head positions (nose-to-sink and vertex down). Irrigant penetration into each sinus was estimated using a four-point scale. RESULTS: A significant positive effect of surgery was demonstrated for each sinus as well as for the delivery device. High-volume irrigant devices are more effective, and the head position plays a significant role in irrigant distribution to the frontal sinus. CONCLUSION: This study further confirms the efficacy of high-volume irrigant devices. A vertex down position during the irrigation could improve delivery to the frontal sinus, and the widening of the ostia increases irrigant access to the sinuses.


Assuntos
Lavagem Nasal/instrumentação , Posicionamento do Paciente/métodos , Cadáver , Endoscopia , Cabeça , Humanos , Seios Paranasais
3.
J Nurs Adm ; 51(4): E13-E17, 2021 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-33734184

RESUMO

AIM: To identify strategies to improve time to prone in ICUs during the coronavirus disease 2019 (COVID-19) pandemic for patients meeting the criteria for prone position ventilation. BACKGROUND: Healthcare systems worldwide experienced an influx of COVID-19 patients, especially in critical care. COVID-19 patients are at risk of acute respiratory distress syndrome (ARDS). Prone position ventilation is the standard of care for mechanically ventilated patients with moderate to severe ARDS. Prone maneuvers in and of itself are time-consuming and labor-intensive, posing additional risks to patients. APPROACH: Our academic medical center developed a travel proning team to address the rapid increase in COVID-19 patients with ARDS necessitating prone positioning. EVALUATION: Over a period of 30 days, 420 ICU patients were intubated, 131 had moderate to severe ARDS and underwent prone positioning. Patients were placed in prone position or returned to supine position more than 834 times over 38 days. At the highest point, 37 procedures were done in 24 hours. CONCLUSION: This quality initiative demonstrated that utilization of a traveling proning team provides efficiency in time to prone. Developing a travel prone team allowed for efficiency in time to prone, supported the ICU clinical teams, and enhanced interdisciplinary collaboration, which is essential during times of crisis.


Assuntos
/enfermagem , Equipe de Assistência ao Paciente , Posicionamento do Paciente/métodos , Decúbito Ventral , Respiração Artificial/enfermagem , /enfermagem , /complicações , Humanos , Unidades de Terapia Intensiva , /etiologia
4.
Ned Tijdschr Geneeskd ; 1652021 02 16.
Artigo em Holandês | MEDLINE | ID: mdl-33651518

RESUMO

Awake prone positioning in COVID-19 patients with respiratory failure has been applied worldwide. We hypothesize that early intervention of awake prone positioning in this patient category might avoid invasive mechanical ventilation and referral to ICU. We observed approximately 30 patients in Suriname in whom awake prone positioning was applied. Also, we reviewed the existing literature on awake prone positioning and discussion of the advantages and disadvantages of this relatively simple intervention. Prospective studies show an improvement in oxygenation, albeit sometimes temporary, but not a reduction in mortality rate or intubation. Mean duration of symptoms in these studies is 10-11 days. Awake prone positioning in COVID-19 patients with a longer duration of symptoms does not improve survival or need for intubation. No prospective studies on early prone position in COVID-19 patients have been conducted yet.


Assuntos
/complicações , Posicionamento do Paciente/métodos , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , Vigília , /fisiopatologia , Humanos , Pulmão/fisiopatologia , Masculino , Decúbito Ventral , Estudos Prospectivos , Insuficiência Respiratória/fisiopatologia , Suriname , Fatores de Tempo
5.
J Emerg Nurs ; 47(2): 279-287.e1, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33558073

RESUMO

INTRODUCTION: In March and April 2020 of the coronavirus disease 2019 pandemic, site clinical practice guidelines were implemented for prone positioning of patients with suspected coronavirus disease 2019 in hypoxic respiratory distress who are awake, alert, and spontaneously breathing. The purpose of this pandemic disaster practice improvement project was to measure changes in pulse oximetry associated with prone positioning of patients with coronavirus disease 2019 infection in adult acute respiratory distress or adult respiratory distress syndrome, who are awake, alert, spontaneously breathing, and nonintubated. METHODS: A retrospective chart review of patients who were coronavirus disease 2019 positive in the emergency department from March 30, 2020 to April 30, 2020 was conducted for patients with a room air pulse oximetry <90% and a preprone position pulse oximetry ≤94% who tolerated prone positioning for at least 30 minutes. The primary outcome was the change in pulse oximetry associated with prone positioning, measured on room air, with supplemental oxygen, and approximately 30 minutes after initiating prone positioning. Median and mean differences were compared with the Wilcoxon signed-rank test and paired t-test. RESULTS: Of the 440 patients with coronavirus disease 2019, 31 met inclusion criteria. Median pulse oximetry increased as 83% (interquartile range, 75%-86%) on room air, 90% (interquartile range, 89%-93%) with supplemental oxygen, and 96% (interquartile range, 94%-98%) with prone positioning (z = -4.48, P < .001). A total of 45% (n = 14) were intubated during their hospital stay, and 26% (n = 8) of the included patients died. DISCUSSION: In patients with coronavirus disease 2019 who are awake, alert, and spontaneously breathing, an initially low pulse oximetry reading improved with prone positioning. Future studies are needed to determine the association of prone positioning with subsequent endotracheal intubation and mortality.


Assuntos
/complicações , Posicionamento do Paciente/métodos , /terapia , Feminino , Humanos , Hipóxia/complicações , Hipóxia/diagnóstico , Hipóxia/terapia , Intubação Intratraqueal , Masculino , Registros Médicos , Pessoa de Meia-Idade , New Jersey , Oximetria , Decúbito Ventral , Estudos Retrospectivos
6.
Ann Am Thorac Soc ; 18(2): 300-307, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33522870

RESUMO

Rationale: Prone positioning reduces mortality in patients with severe acute respiratory distress syndrome (ARDS), a feature of severe coronavirus disease 2019 (COVID-19). Despite this, most patients with ARDS do not receive this lifesaving therapy.Objectives: To identify determinants of prone-positioning use, to develop specific implementation strategies, and to incorporate strategies into an overarching response to the COVID-19 crisis.Methods: We used an implementation-mapping approach guided by implementation-science frameworks. We conducted semistructured interviews with 30 intensive care unit (ICU) clinicians who staffed 12 ICUs within the Penn Medicine Health System and the University of Michigan Medical Center. We performed thematic analysis using the Consolidated Framework for Implementation Research. We then conducted three focus groups with a task force of ICU leaders to develop an implementation menu, using the Expert Recommendations for Implementing Change framework. The implementation strategies were adapted as part of the Penn Medicine COVID-19 pandemic response.Results: We identified five broad themes of determinants of prone positioning, including knowledge, resources, alternative therapies, team culture, and patient factors, which collectively spanned all five Consolidated Framework for Implementation Research domains. The task force developed five specific implementation strategies, including educational outreach, learning collaborative, clinical protocol, prone-positioning team, and automated alerting, elements of which were rapidly implemented at Penn Medicine.Conclusions: We identified five broad themes of determinants of evidence-based use of prone positioning for severe ARDS and several specific strategies to address these themes. These strategies may be feasible for rapid implementation to increase use of prone positioning for severe ARDS with COVID-19.


Assuntos
/terapia , Posicionamento do Paciente/normas , Lacunas da Prática Profissional , Melhoria de Qualidade , /terapia , Adulto , Prática Clínica Baseada em Evidências , Feminino , Humanos , Ciência da Implementação , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Posicionamento do Paciente/métodos , Decúbito Ventral , Pesquisa Qualitativa
8.
BMJ Case Rep ; 14(1)2021 Jan 11.
Artigo em Inglês | MEDLINE | ID: mdl-33431531

RESUMO

Angiofibroma is a benign soft tissue tumour presenting as a gradually progressive swelling in the vulvovaginal area in women and in the inguinoscrotal region in men. Being a rare tumour, there are only a few case reports in the literature, and among them, presentation as perineal herniation is very rare. En bloc resection of angiofibroma either via laparoscopic or open approach is the choice of treatment to avoid recurrence. Detailed pathological examination and immunohistochemistry workup are imperative to distinguish it from various mesenchymal tumours. Perineal hernia is itself rare and may occur spontaneously or following abdominoperineal resection, sacrectomy or pelvic exenteration. Surgical repair via open transabdominal and transperineal approaches has been described. Here, we report a case of a young woman who presented with spontaneous reducible perineal hernia with a soft tissue tumour as its content, which on histopathological investigation was found to be an angiofibroma.


Assuntos
Angiofibroma/diagnóstico , Hérnia/etiologia , Herniorrafia/métodos , Períneo/patologia , Neoplasias de Tecidos Moles/diagnóstico , Adulto , Angiofibroma/complicações , Angiofibroma/patologia , Angiofibroma/cirurgia , Feminino , Humanos , Imagem por Ressonância Magnética , Posicionamento do Paciente/métodos , Períneo/diagnóstico por imagem , Períneo/cirurgia , Neoplasias de Tecidos Moles/complicações , Neoplasias de Tecidos Moles/patologia , Neoplasias de Tecidos Moles/cirurgia
10.
BMC Pulm Med ; 21(1): 38, 2021 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-33482796

RESUMO

BACKGROUND: Clinical management of COVID-19 requires close monitoring of lung function. While computed tomography (CT) offers ideal way to identify the phenotypes, it cannot monitor the patient response to therapeutic interventions. We present a case of ventilation management for a COVID-19 patient where electrical impedance tomography (EIT) was used to personalize care. CASE PRESENTATION: The patient developed acute respiratory distress syndrome, required invasive mechanical ventilation, and was subsequently weaned. EIT was used multiple times: to titrate the positive end-expiratory pressure, understand the influence of body position, and guide the support levels during weaning and after extubation. We show how EIT provides bedside monitoring of the patient´s response to various therapeutic interventions and helps guide treatments. CONCLUSION: EIT provides unique information that may help the ventilation management in the pandemic of COVID-19.


Assuntos
/diagnóstico por imagem , Impedância Elétrica , Pulmão/diagnóstico por imagem , Posicionamento do Paciente/métodos , Respiração Artificial/métodos , Tomografia/métodos , /fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva/métodos , /terapia , Desmame do Respirador/métodos
11.
BMC Anesthesiol ; 21(1): 9, 2021 01 08.
Artigo em Inglês | MEDLINE | ID: mdl-33419396

RESUMO

BACKGROUND: Pneumonia induced by 2019 Coronavirus (COVID-19) is characterized by hypoxemic respiratory failure that may present with a broad spectrum of clinical phenotypes. At the beginning, patients may have normal lung compliance and be responsive to noninvasive ventilatory support, such as CPAP. However, the transition to more severe respiratory failure - Severe Acute Respiratory Syndrome (SARS-CoV-2), necessitating invasive ventilation is often abrupt and characterized by a severe V/Q mismatch that require cycles of prone positioning. The aim of this case is to report the effect on gas exchange, respiratory mechanics and hemodynamics of tripod (or orthopneic sitting position) used as an alternative to prone position in a patient with mild SARS-CoV-2 pneumonia ventilated with helmet CPAP. CASE PRESENTATION: A 77-year-old awake and collaborating male patient with mild SARS-CoV-2 pneumonia and ventilated with Helmet CPAP, showed sudden worsening of gas exchange without dyspnea. After an unsuccessful attempt of prone positioning, we alternated three-hours cycles of semi-recumbent and tripod position, still keeping him in CPAP. Arterial blood gases (PaO2/FiO2, PaO2, SaO2, PaCO2 and A/a gradient), respiratory (VE, VT, RR) and hemodynamic parameters (HR, MAP) were collected in the supine and tripod position. Cycles of tripod position were continued for 3 days. The patient had a clinically important improvement in arterial blood gases and respiratory parameters, with stable hemodynamic and was successfully weaned and discharged to ward 10 days after pneumonia onset. CONCLUSIONS: Tripod position during Helmet CPAP can be applied safely in patients with mild SARS-CoV-2 pneumonia, with improvement of oxygenation and V/Q matching, thus reducing the need for intubation.


Assuntos
/diagnóstico por imagem , Pressão Positiva Contínua nas Vias Aéreas/métodos , Posicionamento do Paciente/métodos , Mecânica Respiratória/fisiologia , Idoso , Humanos , Masculino , Resultado do Tratamento
12.
BMC Pulm Med ; 21(1): 25, 2021 Jan 12.
Artigo em Inglês | MEDLINE | ID: mdl-33435944

RESUMO

BACKGROUND: Intermittent Prone Positioning (IPP) for Acute Respiratory Distress Syndrome (ARDS) decreases mortality. We present a program for IPP using expedient materials for settings of significant limitations in both overwhelmed established ICUs and particularly in low- and middle-income countries (LMICs) treating ARDS due to COVID-19 caused by SARS CoV-2. METHODS: The proning program evolved based on the principles of High Reliability Organizations (HROs) and Crew Resource Management (CRM). Patients with severe ARDS [PaO2:FiO2 ratio (PFr) ≤ 150 on FiO2 ≥ 0.6 and PEEP ≥ 5 cm H2O] received IPP. Patients were placed prone 16 h each day. When PFr was ≥ 200 for > 8 h supine IPP ceased. IPP used available materials without requiring additional work from the bedside team. Changes in PFr, PaCO2, and the SaO2:FiO2 ratio (SaFr) positionally were evaluated using t-statistics and ANOVA with Bonferroni correction (p < 0.017). RESULTS: Between 14APR2020 and 09MAY2020, at the peak of deaths in New York, there were 202 IPPs in 29 patients. Patients were 58.5 ± 1.7 years of age (37, 73), 76% male and had a body mass index (BMI) of 27.8 ± 0.8 (21, 38). Pressor agents were used in 76% and 17% received dialysis. The PFr prior to IPP was 107.5 ± 5.6 and 1 h after IPP was 155.7 ± 11.2 (p < 0.001 compared to pre-prone). PFr after the patients were placed supine was 131.5 ± 9.1 (p = 0.02). Pre-prone PaCO2 was 60.0 ± 2.5 and the 1-h post-prone PaCO2 was 67.2 ± 3.1 (p = 0.02). Supine PaCO2 after IPP was 60.4 ± 3.4 (p = 0.90). The SaFr prior to IPP was 121.3 ± 4.2 and the SaFr 1 h after positioning was 131.5 ± 5.1 (p = 0.03). The post-IPP supine SaFr was 139.7 ± 5.9 (p < 0.001). With ANOVA and Bonferroni correction there were statistically significant changes in PFr (p < 0.001) and SaFr (p < 0.001) and no significant changes in PaCO2 over the four time points measured. Using regression coefficients, the SaFrs predicted by PFrs of 150 and 200 at baseline are 133.2 and 147.3, respectively. CONCLUSIONS: An IPP program for patients with COVID-19 ARDS can be instituted rapidly, safely, and effectively during an overwhelming mass casualty scenario. This approach may be equally applicable in both traditionally austere environments in LMICs and in otherwise capable centers facing situational resource limitations.


Assuntos
/complicações , Hipóxia/etiologia , Hipóxia/terapia , Posicionamento do Paciente/métodos , Posicionamento do Paciente/normas , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , Adulto , Idoso , Protocolos Clínicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Decúbito Ventral , Estudos Prospectivos , Índice de Gravidade de Doença
14.
Crit Care Nurse ; 41(2): 27-35, 2021 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-33341885

RESUMO

BACKGROUND: At the height of the coronavirus disease 2019 (COVID-19) pandemic, Italy had the highest number of deaths in Europe; most occurred in the Lombardy region. Up to 4% of patients with COVID-19 required admission to an intensive care unit because they developed a critical illness (eg, acute respiratory distress syndrome). Numerous patients with acute respiratory distress syndrome who had been admitted to the intensive care unit required rescue therapy like prone positioning. OBJECTIVE: To describe the respiratory management of and the extensive use of prone positioning in patients with COVID-19 at the intensive care unit hub in Lombardy, Italy. METHODS: A total of 89 patients (67% male; median age, 59 years [range, 23-80 years]) with confirmed COVID-19 who were admitted between February 23 and March 31, 2020, were enrolled in this quality improvement project. RESULTS: Endotracheal intubation was required in 86 patients (97%). Prone positioning was used as rescue therapy in 43 (48%) patients. Significantly more younger patients (age ≤ 59 years) were discharged alive (43 of 48 [90%]) than were older patients (age ≥ 60 years; 26 of 41 [63%]; P < .005). Among the 43 patients treated with prone ventilation, 15 (35% [95% CI, 21%-51%]) died in the intensive care unit, of which 10 (67%; P < .001) were older patients. CONCLUSIONS: Prone positioning is one strategy available for treating acute respiratory distress syndrome in patients with COVID-19. During this pandemic, prone positioning can be used extensively as rescue therapy, per a specific protocol, in intensive care units.


Assuntos
/enfermagem , Enfermagem de Cuidados Críticos , Posicionamento do Paciente/enfermagem , Respiração Artificial/enfermagem , /enfermagem , Adulto , Idoso , Idoso de 80 Anos ou mais , /epidemiologia , Feminino , Humanos , Unidades de Terapia Intensiva , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Posicionamento do Paciente/métodos , Decúbito Ventral , Melhoria de Qualidade , Adulto Jovem
15.
Med Hypotheses ; 146: 110443, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33309339

RESUMO

Managing respiratory status of patients with COVID-19 is a high resource, high risk healthcare challenge. Interventions that decrease need for invasive respiratory support and utilization of bedside staff would benefit patients and healthcare personnel alike. Proning has been established as optimal positioning that may reduce the need for escalation of respiratory support. We propose a new application of a wearable device to decrease supine positioning and ameliorate these risks.


Assuntos
/fisiopatologia , Pulmão/fisiopatologia , Modelos Biológicos , Decúbito Ventral/fisiologia , Dispositivos Eletrônicos Vestíveis , Acelerometria/instrumentação , Sistemas Computacionais , Humanos , Posicionamento do Paciente/instrumentação , Posicionamento do Paciente/métodos , Tecnologia de Sensoriamento Remoto/instrumentação , Tecnologia de Sensoriamento Remoto/métodos , /fisiopatologia , /terapia
16.
Monaldi Arch Chest Dis ; 90(4)2020 Dec 23.
Artigo em Inglês | MEDLINE | ID: mdl-33372742

RESUMO

COVID-19 pneumonia has a significant case fatality rate and no effective antiviral drugs are available even after 9 months of the pandemic. The spectrum of COVID-19 disease ranges from asymptomatic cases to severe ARDS with myriad manifestations. Here we report a case of a male patient with severe COVID-19 ARDS who improved after receiving standard therapy but again 'deteriorated' after being stepped down to ward. He complained of worsening shortness of breath and hypoxemia which was found to be mainly positional. After ruling out other causes, he was labeled as a case of platypnea-orthodeoxia syndrome due to underlying lung involvement.  It is important to be aware of this condition in the context of COVID-19 which can be easily diagnosed bedside with pulse oximetry.


Assuntos
Dispneia , Hipóxia , Pulmão , Posicionamento do Paciente/métodos , Pneumonia Viral , Idoso , /fisiopatologia , Deterioração Clínica , Diagnóstico Diferencial , Dispneia/diagnóstico , Dispneia/etiologia , Humanos , Hipóxia/diagnóstico , Hipóxia/etiologia , Pulmão/diagnóstico por imagem , Pulmão/fisiopatologia , Masculino , Oximetria/métodos , Oxigenoterapia/métodos , Administração dos Cuidados ao Paciente , Pneumonia Viral/diagnóstico , Pneumonia Viral/etiologia , Pneumonia Viral/fisiopatologia , Pneumonia Viral/terapia , Testes de Função Respiratória/métodos , Síndrome , Tomografia Computadorizada por Raios X/métodos
17.
Cochrane Database Syst Rev ; 12: CD013217, 2020 12 21.
Artigo em Inglês | MEDLINE | ID: mdl-33348423

RESUMO

BACKGROUND: The prevalence of substance use, both prescribed and non-prescribed, is increasing in many areas of the world. Substance use by women of childbearing age contributes to increasing rates of neonatal abstinence syndrome (NAS). Neonatal opioid withdrawal syndrome (NOWS) is a newer term describing the subset of NAS related to opioid exposure. Non-pharmacological care is the first-line treatment for substance withdrawal in newborns. Despite the widespread use of non-pharmacological care to mitigate symptoms of NAS, there is not an established definition of, and standard for, non-pharmacological care practices in this population. Evaluation of safety and efficacy of non-pharmacological practices could provide clear guidance for clinical practice. OBJECTIVES: To evaluate the safety and efficacy of non-pharmacological treatment of infants at risk for, or having symptoms consistent with, opioid withdrawal on the length of hospitalization and use of pharmacological treatment for symptom management. Comparison 1: in infants at risk for, or having early symptoms consistent with, opioid withdrawal, does non-pharmacological treatment reduce the length of hospitalization and use of pharmacological treatment? Comparison 2: in infants receiving pharmacological treatment for symptoms consistent with opioid withdrawal, does concurrent non-pharmacological treatment reduce duration of pharmacological treatment, maximum and cumulative doses of opioid medication, and length of hospitalization? SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 10); Ovid MEDLINE; and CINAHL on 11 October 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs), quasi-RCTs, and cluster trials. SELECTION CRITERIA: We included trials comparing single or bundled non-pharmacological interventions to no non-pharmacological treatment or different single or bundled non-pharmacological interventions. We assessed non-pharmacological interventions independently and in combination based on sufficient similarity in population, intervention, and comparison groups studied. We categorized non-pharmacological interventions as: modifying environmental stimulation, feeding practices, and support of the mother-infant dyad. We presented non-randomized studies identified in the search process narratively. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Primary outcomes in infants at risk for, or having early symptoms consistent with, opioid withdrawal included length of hospitalization and pharmacological treatment with one or more doses of opioid or sedative medication. Primary outcomes in infants receiving opioid treatment for symptoms consistent with opioid withdrawal included length of hospitalization, length of pharmacological treatment with opioid or sedative medication, and maximum and cumulative doses of opioid medication. MAIN RESULTS: We identified six RCTs (353 infants) in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated between 1975 and 2018. We identified no RCTs in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. The certainty of evidence for all outcomes was very low to low. We also identified and excluded 34 non-randomized studies published between 2005 and 2018, including 29 in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated and five in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. We identified seven preregistered interventional clinical trials that may qualify for inclusion at review update when complete. Of the six RCTs, four studies assessed modifying environmental stimulation in the form of a mechanical rocking bed, prone positioning, non-oscillating waterbed, or a low-stimulation nursery; one study assessed feeding practices (comparing 24 kcal/oz to 20 kcal/oz formula); and one study assessed support of the maternal-infant dyad (tailored breastfeeding support). There was no evidence of a difference in length of hospitalization in the one study that assessed modifying environmental stimulation (mean difference [MD) -1 day, 95% confidence interval [CI) -2.82 to 0.82; 30 infants; very low-certainty evidence) and the one study of support of the maternal-infant dyad (MD -8.9 days, 95% CI -19.84 to 2.04; 14 infants; very low-certainty evidence). No studies of feeding practices evaluated the length of hospitalization. There was no evidence of a difference in use of pharmacological treatment in three studies of modifying environmental stimulation (typical risk ratio [RR) 1.00, 95% CI 0.86 to 1.16; 92 infants; low-certainty evidence), one study of feeding practices (RR 0.92, 95% CI 0.63 to 1.33; 49 infants; very low-certainty evidence), and one study of support of the maternal-infant dyad (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). Reported secondary outcomes included neonatal intensive care unit (NICU) admission, days to regain birth weight, and weight nadir. One study of support of the maternal-infant dyad reported NICU admission (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). One study of feeding practices reported days to regain birth weight (MD 1.10 days, 95% CI 2.76 to 0.56; 46 infants; very low-certainty evidence). One study that assessed modifying environmental stimulation reported weight nadir (MD -0.28, 95% CI -1.15 to 0.59; 194 infants; very low-certainty evidence) and one study of feeding practices reported weight nadir (MD -0.8, 95% CI -2.24 to 0.64; 46 infants; very low-certainty evidence). AUTHORS' CONCLUSIONS: We are uncertain whether non-pharmacological care for opioid withdrawal in newborns affects important clinical outcomes including length of hospitalization and use of pharmacological treatment based on the six included studies. The outcomes identified for this review were of very low- to low-certainty evidence. Combined analysis was limited by heterogeneity in study design and intervention definitions as well as the number of studies. Many prespecified outcomes were not reported. Although caregivers are encouraged by experts to optimize non-pharmacological care for opioid withdrawal in newborns prior to initiating pharmacological care, we do not have sufficient evidence to inform specific clinical practices. Larger well-designed studies are needed to determine the effect of non-pharmacological care for opioid withdrawal in newborns.


Assuntos
Tempo de Internação , Entorpecentes/efeitos adversos , Síndrome de Abstinência Neonatal/terapia , Leitos , Aleitamento Materno , Planejamento Ambiental , Humanos , Hipnóticos e Sedativos/uso terapêutico , Equipamentos para Lactente , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Síndrome de Abstinência Neonatal/tratamento farmacológico , Berçários para Lactentes , Tratamento de Substituição de Opiáceos/métodos , Posicionamento do Paciente/métodos , Decúbito Ventral , Ensaios Clínicos Controlados Aleatórios como Assunto
18.
Trials ; 21(1): 940, 2020 Nov 23.
Artigo em Inglês | MEDLINE | ID: mdl-33225990

RESUMO

OBJECTIVES: To assess the effect of prone positioning therapy on intubation rate in awake patients with COVID-19 and acute respiratory failure. TRIAL DESIGN: This is a two-center parallel group, superiority, randomized (1:1 allocation ratio) controlled trial. PARTICIPANTS: All patients admitted to the Hospital Civil de Guadalajara and Hospital General de Occidente in Mexico for COVID-19 associated acute respiratory failure and in need of supplementary oxygen through high-flow nasal cannula are screened for eligibility. INCLUSION CRITERIA: all adult patients admitted to the COVID-19 unit who test positive for COVID-19 by PCR-test and in need for oxygen are eligible for inclusion. Randomization starts upon identification of requirement of a fraction of inspired oxygen ≥30% for an oxygen capillary saturation of ≥90% Exclusion criteria: less than 18 years-old, pregnancy, patients with immediate need of invasive mechanical ventilation (altered mental status, fatigue), vasopressor requirement to maintain median arterial pressure >65 mmHg, contraindications for prone positioning therapy (recent abdominal or thoracic surgery or trauma, facial, pelvic or spine fracture, untreated pneumothorax, do-not-resuscitate or do-not-intubate order, refusal or inability of the patient to enroll in the study. INTERVENTION AND COMPARATOR: Patients of the intervention group will be asked to remain in a prone position throughout the day as long as possible, with breaks according to tolerance. Pillows will be offered for maximizing comfort at chest, pelvis and knees. Monitoring of vital signs will not be suspended. Inspired fraction of oxygen will be titrated to maintain a capillary saturation of 92%-95%. For patients in the control group, prone positioning will be allowed as a rescue therapy. Staff intensivists will monitor the patient's status in both groups on a 24/7 basis. All other treatment will be unchanged and left to the attending physicians. MAIN OUTCOMES: Endotracheal intubation rate for mechanical ventilation at 28 days. RANDOMISATION: Patients will be randomly allocated to either prone positioning or control group at 1:1 ratio. Such randomization will be computer generated and stratified by center with permuted blocks and length of 4. BLINDING (MASKING): Due to logistical reasons, only principal investigators and the data analyst will be blinded to group assignment. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): With an intubation rate of 60% according to recent reports from some American centers, and assuming a decrease to 40% to be clinically relevant, we calculated a total of 96 patients per group, for a beta error of 0.2, and alpha of 0.5. Therefore, we plan to recruit 200 patients, accounting for minimal losses to follow up, with 100 non-intubated patients in the prone position group and a 100 in the control group. TRIAL STATUS: The local registration number is 048-20, with the protocol version number 2.0. The date of approval is 3rd May 2020. Recruitment started on 3rd May and is expected to end in December 2020. TRIAL REGISTRATION: The protocol was retrospectively registered under the title: "Prone Positioning in Non-intubated Patients With COVID-19 Associated Acute Respiratory Failure. The PRO-CARF trial" in ClinicalTrials.gov with the registration number: NCT04477655. Registered on 20 July 2020. FULL PROTOCOL: The full protocol 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
Infecções por Coronavirus/complicações , Intubação Intratraqueal/instrumentação , Oxigênio/uso terapêutico , Pneumonia Viral/complicações , Decúbito Ventral/fisiologia , Insuficiência Respiratória/etiologia , Doença Aguda , Adulto , Betacoronavirus/genética , Cânula/efeitos adversos , Cânula/provisão & distribução , Estudos de Casos e Controles , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/virologia , Feminino , Hospitalização , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Masculino , México/epidemiologia , Oxigênio/administração & dosagem , Oxigênio/sangue , Oxigênio/provisão & distribução , Pandemias , Posicionamento do Paciente/métodos , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Insuficiência Respiratória/fisiopatologia , Insuficiência Respiratória/terapia
20.
Medicine (Baltimore) ; 99(45): e23146, 2020 Nov 06.
Artigo em Inglês | MEDLINE | ID: mdl-33157997

RESUMO

An interest in the fixation of posterior malleolus via the posterolateral approach has gained popularity recently. Most surgeons choose prone or lateral position during the surgery, and this study proposes an additional radiolucent table for easier access to the posterolateral anatomic structure of ankle joint, and compares it with traditional positioning.From September 2014 to September 2018, 21 patients with trimalleolar fractures and 28 patients with posterior malleolus and fibular fractures receiving open reduction and internal fixation (ORIF) using the posterolateral approach with the utilization of an additional radiolucent table were included in Additional Table group. Patients of matched sex, age, and injury type using the same surgical approach with the traditional positioning were selected from the hospital database and included in the Traditional group. Baseline information and clinical parameters were recorded.No significant differences existed concerning age, sex, or operative side between the 2 groups in patients with trimalleolar fractures. The time for positioning was significantly longer in the Traditional group (20.5 ±â€Š6.45 minutes) than the Additional Table group (12 ±â€Š3.5 minutes) (P < .001). Besides, the operative time in the Traditional group (75.28 ±â€Š5.45 minutes) was significantly longer than the Additional Table group (58 ±â€Š5.95 minutes) (P < .001). There was no case of nonunion and malunion in both groups. At 12-month follow-up, the American Orthopedic Foot and Ankle Society Scale (AOFAS) score showed no significant difference between the 2 groups (P = .46). In patients with fibular fracture and posterior malleolus fracture, no significant differences existed concerning age, sex, operative side between the 2 groups. The time for positioning was significantly longer in the Traditional group (16.5 ±â€Š3.45 minutes) than the Additional Table group (11 ±â€Š3.5 minutes) (P < .001). Besides, the operative time in the Traditional group (55.28 ±â€Š8.45 minutes) was significantly longer than the Additional Table group (44 ±â€Š7.95 minutes) (P < .001). There was no case of nonunion and malunion in both groups. At the 12-month follow-up, the AOFAS score showed no significant difference between the 2 groups (P = .26).The novel positioning with an additional table is an excellent choice for trimalleolar fracture, posterior malleolus fracture, with/without distal fibular fracture.


Assuntos
Fraturas do Tornozelo/cirurgia , Fixação Interna de Fraturas , Redução Aberta , Posicionamento do Paciente/métodos , Adulto , Feminino , Fixação Interna de Fraturas/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Redução Aberta/métodos , Estudos Retrospectivos
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