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1.
Anaesthesia ; 75 Suppl 1: e134-e142, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31903562

RESUMO

The impact of the use of loop diuretics to prevent cumulative fluid balance in non-oliguric patients is uncertain. This is a retrospective study to estimate the association of time-averaging loop diuretic exposure in a large population of non-cardiac, critically ill patients with a positive fluid balance (> 5% of body weight). The exposure was loop diuretic and the main outcomes were 28-day mortality, severe acute kidney injury and successful mechanical ventilation weaning. Time-fixed and daily time-varying variables were evaluated with a marginal structural Cox model, adjusting bias for time-varying exposure and the presence of time-dependent confounders. A total of 14,896 patients were included. Patients receiving loop diuretics had better survival (unadjusted hazard ratio 0.56, 95%CI 0.39-0.81 and baseline variables adjusted hazard ratio 0.53, 95%CI 0.45-0.62); after full adjusting, loop diuretics had no association with 28-day mortality (full adjusted hazard ratio 1.07, 95%CI 0.74-1.54) or with reducing severe acute kidney injury occurrence during intensive care unit stay - hazard ratio 1.05 (95%CI 0.78-1.42). However, we identified an association with prolonged mechanical ventilation (hazard ratio 1.59, 95%CI 1.35-1.89). The main results were consistent in the sub-group analysis for sepsis, oliguria and the study period (2002-2007 vs. 2008-2012). Also, equivalent doses of up to 80 mg per day of furosemide had no significant association with mortality. After adjusting for time-varying variables, the time average of loop diuretic exposure in non-cardiac, critically ill patients has no association with overall mortality or severe acute kidney injury; however, prolonged mechanical ventilation is a concern.


Assuntos
Cuidados Críticos/métodos , Diuréticos/uso terapêutico , Equilíbrio Hidroeletrolítico , Lesão Renal Aguda/prevenção & controle , Estado Terminal , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Análise de Sobrevida
2.
Arch Dis Child Fetal Neonatal Ed ; 105(1): 50-55, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31123055

RESUMO

OBJECTIVE: Higher rates of neonatal morbidity and mortality at term combined with earlier spontaneous delivery have led to the hypothesis that babies born to South Asian born (SA-born) women may mature earlier and/or their placental function decreases earlier than babies born to Australian and New Zealand born (Aus/NZ-born) women. Whether babies born to SA-born women do better in the preterm period, however, has yet to be evaluated. In this study we investigated respiratory outcomes, indicative of functional maturity, of preterm babies born to SA-born women compared with those of Aus/NZ-born women to explore this hypothesis further. STUDY DESIGN AND SETTING: This retrospective cohort study was conducted at Monash Health. PATIENTS: Data were collected from neonatal and birth records of moderate-late preterm (32-36 weeks) infants born between 2012 and 2015 to SA-born and Aus/NZ-born women. OUTCOME MEASURES: Rates of nursery admissions and neonatal respiratory outcomes were compared. RESULTS: Babies born to Aus/NZ-born women were more likely to be admitted to a nursery (80%) compared with SA-born babies (72%, p=0.004). Babies born to SA-born mothers experienced significantly less hyaline membrane disease (7.8%), required less resuscitation at birth (28.6%) and were less likely to require ventilation (20%) than babies born to Aus/NZ-born mothers (18%, 42.2%, 34.6%; p<0.001). There was no difference in the duration of ventilation or length of stay in hospital. CONCLUSIONS: Moderate-late preterm babies born to SA-born women appear to have earlier functional maturity, as indicated by respiratory outcomes, than Aus/NZ-born babies. Our findings support the hypothesis of earlier fetal maturation in SA-born women.


Assuntos
Grupo com Ancestrais do Continente Asiático , Grupo com Ancestrais do Continente Europeu , Doença da Membrana Hialina/epidemiologia , Nascimento Prematuro , Ressuscitação/estatística & dados numéricos , Adulto , Ásia Sudeste/etnologia , Austrália , Peso ao Nascer , Índice de Massa Corporal , Estudos de Coortes , Feminino , Glucocorticoides/uso terapêutico , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Mães , Nova Zelândia , Admissão do Paciente/estatística & dados numéricos , Cuidado Pré-Natal , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos
3.
Anaesthesia ; 75(2): 202-209, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31549404

RESUMO

Pulmonary complications have a significant impact on morbidity and mortality in patients after major surgery. Lung ultrasound can be used at the bed-side, and has gained widespread acceptance in the intensive care unit. We conducted a prospective study to evaluate whether lung ultrasound could be used as a predictive marker for postoperative ventilatory support in high-risk surgical patients. We included 109 patients admitted to the intensive care unit while having mechanical ventilation of the lungs following major surgery. The PaO2 /FI O2 ratio was calculated on admission and an ultrasound examination performed, including: lung ('lung ultrasound score', number of consolidated lung areas); cardiac (mitral flow); and inferior vena cava imaging (diameter and respiratory variation). Respiratory outcomes included: the need for ventilation support (mechanical ventilation, non-invasive ventilation or high-flow nasal cannula oxygen therapy); acute respiratory distress syndrome; cardiogenic pulmonary oedema; and early or late pulmonary infection. Patients with a lung ultrasound score ≥ 10 had a lower PaO2 /FI O2 ratio, and needed more postoperative ventilatory support, than patients with lung ultrasound score < 10. Twenty patients had acute respiratory distress syndrome, and 14 had cardiogenic pulmonary oedema. The presence of ≥ 2 areas of consolidated lung was associated with a lower PaO2 /FI O2 ratio, postoperative ventilatory support, longer intensive care stay and episodes of ventilator-associated pneumonia requiring antibiotics. Our results suggest that at intensive care unit admission, lung ultrasound scoring and detection of atelectasis can predict postoperative pulmonary outcomes after major visceral surgery, and could enhance bed-side decision making.


Assuntos
Pulmão/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Respiração Artificial/estatística & dados numéricos , Insuficiência Respiratória/diagnóstico por imagem , Ultrassonografia/métodos , Idoso , Diagnóstico Precoce , Feminino , Humanos , Pulmão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos
4.
Arch Dis Child Fetal Neonatal Ed ; 105(1): 64-68, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31092676

RESUMO

OBJECTIVE: Apgar scores of zero at 10 min strongly predict mortality and morbidity in infants. However, recent data reported improved outcomes among infants with Apgar scores of zero at 10 min. We aimed to review the mortality rate and neurodevelopmental outcomes of infants with Apgar scores of zero at 10 min in Japan. DESIGN: Observational study. PATIENTS: Twenty-eight of 768 infants registered in the Baby Cooling Registry of Japan between 2012 and 2016, at >34 weeks' gestation, with Apgar scores of zero at 10 min who were treated with therapeutic hypothermia. INTERVENTIONS: We investigated the time of first heartbeat detection in infants with favourable outcomes and who had neurodevelopmental impairments or died. MAIN OUTCOME MEASURES: Clinical characteristics, mortality rate and neurodevelopmental outcomes at 18-22 months of age were evaluated. RESULTS: Nine (32%) of the 28 infants died before 18 months of age; 16 (57%) survived, but with severe disabilities and 3 (11%) survived without moderate-to-severe disabilities. At 20 min after birth, 14 of 27 infants (52%) did not have a first heartbeat, 13 of them died or had severe disabilities and one infant, who had the first heartbeat at 20 min, survived without disability. CONCLUSION: Our study adds to the recent evidence that neurodevelopmental outcomes among infants with Apgar scores of zero at 10 min may not be uniformly poor. However, in our study, all infants with their first heartbeat after 20 min of age died or had severe disabilities.


Assuntos
Índice de Apgar , Asfixia Neonatal/mortalidade , Hipotermia Induzida , Hipóxia-Isquemia Encefálica/mortalidade , Transtornos do Neurodesenvolvimento/epidemiologia , Asfixia Neonatal/terapia , Reanimação Cardiopulmonar , Seguimentos , Gastrostomia/estatística & dados numéricos , Humanos , Hipóxia-Isquemia Encefálica/terapia , Lactente , Recém-Nascido , Intubação Intratraqueal , Japão/epidemiologia , Testes Neuropsicológicos , Sistema de Registros , Respiração Artificial/estatística & dados numéricos , Traqueostomia/estatística & dados numéricos , Escala de Memória de Wechsler
5.
Pneumologie ; 73(11): 670-676, 2019 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-31715635

RESUMO

BACKGROUND: Home mechanical ventilation is dramatically evolving in Germany. Patients with non-invasive and invasive ventilation are increasingly treated at home. In-hospital treatment of these patients is also necessary either for control visits or the management of acute medical problems. However, the development of in-hospital patient care, morbidity and mortality of these patients is unknown. METHODS: All patients with long-term dependence on mechanical ventilation for more than three months requiring hospitalisation between 2006 and 2016 were analysed (data obtained from the Federal Statistical Office of Germany). RESULTS: There was an exponential increase in the number of in-patients with long-term dependence of mechanical ventilation. While 24 845 patients were treated in-hospital in 2006, 86 117 patients were treated in 2016. Correspondingly, mortality decreased from 13.2 % (2006) to 5.7 % (2016). In addition, in 2016 47 % of all patients were treated on the intensive care or high dependency care unit. Overall, patients had been severely ill, as there were plenty of medical and neurological co-morbidities. The most common diagnosis was COPD with 58 % of all cases, followed by several cardiology diagnosis. A high number of patients had an impairment of renal function (24 %), in part requiring dialysis. CONCLUSIONS: The rapid development of home mechanical ventilation substantially impacts on the development of the hospital landscape in Germany. The exponential increase of these care-intensive patients is challenging for the health care system and requires a discussion about its limits.


Assuntos
Cuidados Críticos , Serviços de Assistência Domiciliar , Assistência ao Paciente/tendências , Respiração Artificial , Cuidados Críticos/métodos , Cuidados Críticos/tendências , Alemanha , Serviços de Assistência Domiciliar/estatística & dados numéricos , Serviços de Assistência Domiciliar/tendências , Hospitalização , Humanos , Unidades de Terapia Intensiva , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos
6.
Isr Med Assoc J ; 21(10): 686-691, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31599512

RESUMO

BACKGROUND: C-reactive protein (CRP) blood level is associated with clinical outcomes of several diseases. However, the independent predictive role of CRP in the heterogeneous population of patients admitted to internal medicine wards is not known. OBJECTIVES: To determine whether single CRP levels at admission independently predicts clinical outcome and flow of patients in general medicine wards. METHODS: This study comprised 275 patients (50.5% female) with a mean age of 68.25 ± 17.0 years, hospitalized with acute disease in a general internal medicine ward. The association between admission CRP levels and clinical outcomes including mortality, the need for mechanical ventilation, duration of hospitalization, and re-admission within 6 months was determined. RESULTS: A significant association was found between CRP increments of 80 mg/L and risk for the major clinical outcomes measured. The mortality odds ratio (OR) was 1.89 (95% confidence interval (95%CI, 1.37-2.61, P < 0.001), mechanical ventilation OR 1.67 (95%CI, 1.10-2.34, P = 0.006), re-admission within 6 months OR 2.29 (95%CI, 1.66-3.15 P < 0.001), and prolonged hospitalization >7 days OR 2.09 (95%CI, 1.59-2.74, P < 0.001). Lower increments of10 mg/L in CRP levels were associated with these outcomes although with lower ORs. Using a stepwise regression model for admission CRP levels resulted in area under the receiver operating characteristics curves between 0.70 and 0.76 for these outcomes. CONCLUSIONS: A single admission CRP blood level is independently associated with major parameters of clinical outcomes in acute care patients hospitalized in internal medicine wards.


Assuntos
Proteína C-Reativa/análise , Hospitalização/estatística & dados numéricos , Medicina Interna/métodos , Avaliação de Resultados da Assistência ao Paciente , Doença Aguda , Adulto , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Admissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Valor Preditivo dos Testes , Prognóstico , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
7.
Transplant Proc ; 51(7): 2466-2468, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31405745

RESUMO

OBJECTIVE: Despite advances in immunosuppressive drugs, postoperative care, and surgical techniques, bacterial infections remain the most important cause of morbidity and mortality in liver transplant patients. The aim of this study is to evaluate the influence of culture results taken on the first day of admission to intensive care unit on mortality, graft rejection, mechanical ventilation duration, and length of intensive care unit stay. Our study has clinical importance because it is the first study evaluating the cultures obtained on the first day of intensive care unit stays in liver transplant patients. METHODS: Patients' demographic data, transplant type, rates of deceased and living donors, culture results, amount of blood and blood products used intraoperatively, previous hospital admission, mortality, incidence of graft rejection, mechanical ventilation duration, and length of intensive care unit stay were recorded. RESULTS: Mortality and graft rejection were 14.8% and 9%, respectively. The mortality was significantly higher in all 3 cultures and/or in only blood culture-positive patients. Graft rejection, mechanical ventilation duration, and length of intensive care unit stay were significantly higher in patients whose 3 cultures were all positive. Only body mass index had a significant effect on mortality, graft rejection, and positive culture results. CONCLUSIONS: Liver transplant patients' first postoperative day culture results were correlated with mortality, graft rejection, mechanical ventilation duration, and length of intensive care unit stay.


Assuntos
Infecções Bacterianas , Rejeição de Enxerto/epidemiologia , Rejeição de Enxerto/microbiologia , Transplante de Fígado/efeitos adversos , Adolescente , Adulto , Idoso , Infecções Bacterianas/complicações , Infecções Bacterianas/diagnóstico , Criança , Feminino , Humanos , Incidência , Tempo de Internação/estatística & dados numéricos , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Adulto Jovem
8.
Medicine (Baltimore) ; 98(35): e16939, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31464931

RESUMO

The tracheostomy timing for patients with prolonged mechanical ventilation (PMV) was usually delayed in our country. Both physician decision time and tracheostomy delay time (time from physician's suggestion of tracheostomy to procedure day) affect tracheostomy timing. The effect of tracheostomy delay time on outcome has not yet been evaluated before.Patients older than 18 years who underwent tracheostomy for PMV were retrospectively collected. The outcomes between different timing of tracheostomy (early: ≤14 days; late: >14 days of intubation) were compared. We also analyzed the effect of physician decision time, tracheostomy delay time, and procedure type on clinical outcomes.A total of 134 patients were included. There were 57 subjects in the early tracheostomy group and 77 in the late group. The early group had significantly shorter mechanical ventilation duration, shorter intensive care unit stays, and shorter hospital stays than late group. There was no difference in weaning rate, ventilator-associated pneumonia, and in-hospital mortality. The physician decision time (8.1 ±â€Š3.4 vs 18.2 ±â€Š8.1 days, P < .001) and tracheostomy delay time (2.1 ±â€Š1.9 vs 6.1 ±â€Š6.8 days, P < .001) were shorter in the early group than in the late group. The tracheostomy delay time [odds ratio (OR) = 0.908, 95% confidence interval (CI) = 0.832-0.991, P = .031) and procedure type (percutaneous dilatation, OR = 2.489, 95% CI = 1.057-5.864, P = .037) affected successful weaning. Platelet count of >150 × 10/µL (OR = 0.217, 95% CI = 0.051-0.933, P = .043) and procedure type (percutaneous dilatation, OR = 0.252, 95% CI = 0.069-0.912, P = .036) were associated with in-hospital mortality.Shorter tracheostomy delay time is associated with higher weaning success. Percutaneous dilatation tracheostomy is associated with both higher weaning success and lower in-hospital mortality.


Assuntos
Respiração Artificial/estatística & dados numéricos , Traqueostomia/métodos , Desmame do Respirador/estatística & dados numéricos , APACHE , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Mortalidade Hospitalar/tendências , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Pneumonia Associada à Ventilação Mecânica/epidemiologia , Estudos Retrospectivos , Taiwan/epidemiologia , Fatores de Tempo
9.
J Cardiothorac Surg ; 14(1): 136, 2019 Jul 19.
Artigo em Inglês | MEDLINE | ID: mdl-31324190

RESUMO

BACKGROUND: Transcatheter and intraoperative device closure for atrial septal defect (ASD) are widely applied to reduce the incision size and the potential for injury during cardiopulmonary bypass (CPB) in conventional surgical repair. No studies had been conducted to compare the safety and efficiency of these three treatments. METHODS: From January 2018 to April 2018, 87 patients with an isolated ASD who had undergone transcatheter device closure (n = 45), intraoperative device closure (n = 22) and surgical repair (n = 20) were retrospectively reviewed and further analyzed to compare these three treatments. RESULTS: The successful closure rate was similar in the three groups. There was a significant difference in aortic cross-clamping time, CPB duration and operative time between the surgical group and the device groups. The length of intensive care unit stay, postoperative mechanical ventilation time and length of hospital stay were shorter in the two device groups than in the surgical group. The incision was the most extended in the surgical group. Regarding major adverse events, no significant differences were found among the three groups. CONCLUSIONS: Transcatheter and intraoperative device closure and surgical repair for ASD are all safe and effective. Considering their respective disadvantages and advantages, the transcatheter approach may be the first choice for an isolated secundum ASD, the intraoperative approach may be the second choice, and surgical repair may be the last resort.


Assuntos
Cateterismo Cardíaco/métodos , Comunicação Interatrial/cirurgia , Dispositivo para Oclusão Septal , Cateterismo Cardíaco/instrumentação , Ponte Cardiopulmonar , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Tempo de Internação/estatística & dados numéricos , Masculino , Duração da Cirurgia , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento
10.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 31(6): 737-741, 2019 Jun.
Artigo em Chinês | MEDLINE | ID: mdl-31315733

RESUMO

OBJECTIVE: To explore the feasibility of Narcotrend index (NTI) for digital monitoring of light sedation depth in patients undergoing short-term mechanical ventilation after pancreaticoduodenectomy. METHODS: A prospective randomized controlled trial was conducted. Patients with mechanical ventilation for 12-48 hours after pancreaticoduodenectomy admitted to department of critical care medicine of the First Affiliated Hospital of Wannan Medical College from January 2016 to December 2018 were enrolled. They were randomly divided into two groups, and NTI and Richmond agitation-sedation score (RASS) were used to guide light sedation treatment respectively. The implementation effect of light sedation, duration of mechanical ventilation, dosage of sedative drugs, occurrence of adverse events (accidental extubation, delirium, cardiovascular events) and stress response [cortisol, epinephrine, norepinephrine, C-reactive protein (CRP)] were compared between the two groups. RESULTS: A total of 87 patients were enrolled in this study, of whom 45 received NTI-guided sedation assessment and 42 received RASS-guided sedation assessment. There were no significant differences in gender, age, body mass index (BMI), liver function classification, operation time, blood loss, conversion to laparotomy and acute physiology and chronic health evaluation II (APACHE II) score between the two groups. During sedation treatment, the light sedation compliance rate after light sedation, 2, 4, 6 hours and cumulative compliance period number (Dt) in NTI group were higher than those in RASS group [71.1% (32/45) vs. 50.0% (21/42), 80.0% (36/45) vs. 54.8% (23/42), 88.9% (40/45) vs. 59.5% (25/42), 83.9% (642/765) vs. 62.8% (475/756), all P < 0.05]. The dosage of dexmedetomidine in NTI group was higher than that in RASS group (µg×kg-1×h-1: 0.60±0.10 vs. 0.54±0.12, P < 0.01), but more patients in RASS group receiveda larger dose of propofol to maintain sedation [ratio of use of propofol: 64.3% (27/42) vs. 37.8% (17/45), dose of propofol (mg/h): 47.82±7.31 vs. 30.83±10.35, both P < 0.05]. The sedation duration and duration of mechanical ventilation in NTI group were lower than those in RASS group (hours: 15.68±2.43 vs. 17.29±2.43, 16.27±2.42 vs. 18.25±2.04, both P < 0.01). There were no significant differences in hypertension, bradycardia, accidental extubation and delirium between the two groups during sedation treatment, but the incidence of hypotension in RASS group was higher than that in NTI group [35.7% (15/42) vs. 13.3% (6/45), P < 0.05]. Compared with RASS group, epinephrine, norepinephrine and the levels of CRP at treatment of 6 hours with light sedation and 2 hours after tracheal catheter removal in NTI group were decreased [epinephrine (pg/L): 138.35±18.60 vs. 157.50±19.91, 136.24±40.40 vs. 150.46±20.22; norepinephrine (pg/L): 347.34±45.46 vs. 393.75±49.77, 340.59±50.95 vs. 376.37±49.70; CRP (µg/L): 62.26±18.78 vs. 71.31±10.32, 53.30±14.47 vs. 64.26±14.69, all P < 0.05], and cortisol level 6 hours after treatment with light sedation was lower than that of RASS group (nmol/L: 327.03±41.04 vs. 358.12±70.01, P < 0.05). CONCLUSIONS: The application of NTI monitoring to guide light sedation therapy for patients with short-term mechanical ventilation after pancreaticoduodenectomy can better achieve the goal of light sedation.


Assuntos
Hipnóticos e Sedativos/uso terapêutico , Monitorização Fisiológica/métodos , Pancreaticoduodenectomia , Respiração Artificial/estatística & dados numéricos , Dexmedetomidina/uso terapêutico , Estudos de Viabilidade , Feminino , Humanos , Masculino , Estudos Prospectivos , Fatores de Tempo
11.
Medicina (Kaunas) ; 55(7)2019 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-31311172

RESUMO

Background and objectives: Myasthenia gravis (MG) and Guillain-Barré Syndrome (GBS) are autoimmune neuromuscular disorders that may present as neuromuscular emergencies requiring mechanical ventilation and critical care. Comparative outcomes of these disease processes, once severe enough to require mechanical ventilation, are not known. In this study, we compared the patients requiring mechanical ventilation in terms of in-hospital complications, length of stay, disability, and mortality between these two disease entities at a national level. Materials and Methods: Mechanically ventilated patients with primary diagnosis of MG (n = 6684) and GBS (n = 5834) were identified through retrospective analysis of Nationwide Inpatient Sample (NIS) database for the years 2006 to 2014. Results: Even though mechanically ventilated MG patients were older (61.0 ± 19.1 versus 54.9 ± 20.1 years) and presented with more medical comorbidities, they had lower disease severity on admission, as well as lower in-hospital complications sepsis, pneumonia, and urinary tract infections as compared with GBS patients. In the multivariate analysis, after adjusting for confounders including treatment, GBS patients had significantly higher disability (odds ratio (OR) 15.6, 95% confidence interval (CI) 10.9-22.2) and a longer length of stay (OR 3.48, 95% CI 2.22-5.48). There was no significant difference in mortality between the groups (8.45% MG vs. 10.0% GBS, p = 0.16). Conclusion: Mechanically ventilated GBS patients have higher disease severity at admission along with more in-hospital complications, length of stay, and disability compared with MG patients. Potential explanations for these findings include delay in the diagnosis, poor response to immunotherapy particularly in patients with axonal GBS variant, or longer recovery time after nerve damage.


Assuntos
Síndrome de Guillain-Barré/complicações , Miastenia Gravis/complicações , Insuficiência Respiratória/etiologia , Adulto , Idoso , Doenças Autoimunes/complicações , Doenças Autoimunes/fisiopatologia , Feminino , Síndrome de Guillain-Barré/fisiopatologia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Miastenia Gravis/fisiopatologia , Doenças Neuromusculares/complicações , Doenças Neuromusculares/fisiopatologia , Razão de Chances , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos
12.
Transplant Proc ; 51(7): 2430-2433, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31280887

RESUMO

PURPOSE: The aim of this study is to investigate the effects of risk scores (Pediatric End-stage Liver Disease [PELD], Child-Turcotte-Pugh [CTP], and Pediatric Risk of Mortality [PRISM-III]) of pediatric liver transplant patients on the postoperative period. METHOD: Seven cadaveric and 45 living donors, totaling 52 pediatric liver transplantation (LT) patients, were reviewed retrospectively. PELD and CTP scores were calculated based on data at hospital admission. PRISM-III score was calculated from data during the first 24 hours of intensive care unit (ICU) admission. Hospital length of stay (LOS), ICU LOS, patients who developed acute kidney injury (AKI), requirement for inotropic-vasopressor therapy, hospital mortality, long-term mortality, duration of mechanical ventilation, metabolic disease, and demographic features were documented.For CTP score, class C was defined as high, and A and B as low. Cutoff values of PELD and PRISM-III scores were detected by using receiver operating characteristic curves. According to these cutoff values, patients were divided into 2 groups as high and low for each score. Documented data was analyzed and compared in groups for each score. RESULTS: Hospital LOS was significantly longer in the high-PELD (P = .01) and high-CTP (P = .01) groups. ICU LOS was significantly longer in the high-PRISM-III group (P = .01). Requirement for inotropic-vasopressor therapy was significantly higher in the high-PELD (P = .04) and high-CTP (P = .04) groups. CONCLUSION: Hemodynamic instability and long hospital LOS can be expected in pediatric post-LT patients with high PELD or CTP scores; there is also the risk that AKI maybe higher for high-PELD score patients. Unexpectedly, the PRISM-III score did not have any correlation with the severity of physiological condition and mortality.


Assuntos
Doença Hepática Terminal/mortalidade , Transplante de Fígado/mortalidade , Medição de Risco/métodos , Índice de Gravidade de Doença , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/mortalidade , Criança , Doença Hepática Terminal/cirurgia , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Transplante de Fígado/métodos , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Período Pós-Operatório , Curva ROC , Valores de Referência , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento
13.
J Trauma Acute Care Surg ; 87(3): 559-565, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31205210

RESUMO

BACKGROUND: We hypothesize that if both energy expenditure and oxygenation are optimized (EEOO) toward ventilator tolerance, this would provide patients with the best condition to be liberated from the ventilator. We defined ventilator tolerance as having a respiratory quotient value between 0.7 and 1.0 while maintaining saturations above 98% with FIO2 70% or less and a normal respiratory rate without causing disturbances to the patient's pH. METHODS: This is a single-institution prospective cohort study of ventilator dependent patients within a closed trauma intensive care unit (ICU). The study period was over 52 months. A total of 1,090 patients were part of the primary analysis. The test group (EEOO) was compared to a historical cohort, comparing 26 months in each study group. The primary outcome of this study was number of ventilator days. Secondary outcomes included in-hospital mortality, ICU length of stay (LOS), overall hospital length of stay, tracheostomy rates, reintubation rates, and in-hospital complication rates, such as pneumonia and Acute Respiratory Distress Syndrome (ARDS) ARDS. Both descriptive and multivariable regression analyses were performed to compare the effects of the EEOO protocol with our standard protocols alone. RESULTS: The primary outcome of number of ventilator days was significantly shorter the EEOO cohort by nearly 3 days. This was significant even after adjustment for age, sex, race, comorbidities, nutrition type, and injury severity, (4.3 days vs. 7.2 days, p = 0.0001). The EEOO cohort also had significantly lower ICU days, hospital days, and overall complications rates. CONCLUSION: Optimizing the patient's nutritional regimen to ventilator tolerance and optimizing oxygenation by means of targeted pulmonary mechanics and inspired FIO2 may be associated with lower ventilator and ICU days, as well as overall complication rates. LEVEL OF EVIDENCE: Therapeutic, Level IV.


Assuntos
Metabolismo Energético , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Respiração Artificial/métodos , Desmame do Respirador/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/administração & dosagem , Estudos Prospectivos , Respiração Artificial/estatística & dados numéricos , Traqueostomia/estatística & dados numéricos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia , Adulto Jovem
14.
Physiother Res Int ; 24(4): e1793, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31237395

RESUMO

OBJECTIVE: Most patients requiring intubation and mechanical ventilation are extubated successfully at the first attempt; however, a minority experience extubation failure, which is associated with increased risk of ventilator-associated pneumonia, prolonged intensive care unit (ICU) length of stay and mortality. Physiotherapists have expertise to assess cough strength, work of breathing, respiratory muscle strength, and respiratory secretion load, which are important factors in the outcome of extubation. Accurate prediction of extubation outcome could help to inform management plans pre-extubation and postextubation. The primary objective of this service evaluation was to report the accuracy of physiotherapists' prediction of extubation outcome in the adult ICU. METHODS: A single-centre case note review was undertaken. All subjects who received a physiotherapy assessment of extubation suitability prior to extubation between January and March 2016 in the adult ICU of a large teaching hospital in the United Kingdom were included. Assessment, by both specialist and nonspecialist physiotherapists-which included risk stratification of extubation failure as "high," "moderate," or "low"-was undertaken prior to extubation. Logistic regression analysis was performed to determine which pre-extubation factors were predictive of extubation outcome. RESULTS: During the evaluation period, 68 subjects were extubated following a physiotherapy assessment. Physiotherapy risk stratification as "high risk" (OR 4; 95% confidence interval, CI, [1.312]; p=0.009) and "inappropriate" neurological status (OR 3.3; 95% CI [1.0410]; p=0.037) were the only pre-extubation factors significantly associated with extubation failure. Assessment by specialist physiotherapists demonstrated greater sensitivity (100% vs. 22%) but lower specificity (68% vs. 95%) to detect extubation failure compared with the assessment performed by nonspecialist physiotherapists. CONCLUSION: Patients classified as "high risk" of extubation failure by a physiotherapist are significantly more likely to fail extubation. Specialist physiotherapists should be involved in the decision to extubate patients in the adult ICU.


Assuntos
Extubação/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Índice de Gravidade de Doença , Desmame do Respirador/estatística & dados numéricos , Adulto , Feminino , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Modalidades de Fisioterapia , Respiração Artificial/estatística & dados numéricos , Reino Unido
15.
Pediatr Cardiol ; 40(6): 1171-1174, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31177303

RESUMO

The objective of this study was to describe a cohort of patients with clinical myocarditis and normal left ventricular (LV) systolic function on admission. A retrospective chart review at seven tertiary pediatric hospitals identified patients aged < 19 years admitted with an ICD-9 code of myocarditis between 2008 and 2012. Patients were excluded if admission LV systolic ejection fraction was < 50%, fractional shortening (FS) was < 28% or if the admitting or consulting cardiologist did not suspect myocarditis. A total of 75 patients met inclusion criteria. The median age was 15.5 years with an Interquartile Range (IQR) of 13.6-16.6. 33% were female. Patients presented most commonly with chest pain (75%) and dyspnea (24%). On admission, median B-type natriuretic peptide (BNP) was 132 pg/mL (IQR 57-689) and median troponin I (TnI) was 8.4 ng/mL (IQR 2.0-20.3). Electrocardiogram revealed ST elevation in the majority (55%). Magnetic resonance imaging was obtained on 40%, with 63% of those showing evidence of inflammation. Therapies included inotropic support (15%), mechanical ventilation (12%), antiarrhythmic medications (9%), and Extracorporeal Membrane Oxygenation (5%). Those with poor outcomes were noted to have significantly higher BNP, TnI, and creatine kinase levels on presentation. One patient was transplanted and 35% were discharged on heart failure medications. At one year follow-up one patient had died of unspecified causes, 15% required readmission for cardiac reasons, and 21% continued on heart failure medications. The risk associated with clinical myocarditis in the setting of normal ventricular function at presentation may be higher than previously suspected.


Assuntos
Miocardite/diagnóstico , Função Ventricular Esquerda/fisiologia , Adolescente , Antiarrítmicos/uso terapêutico , Cardiotônicos/uso terapêutico , Dor no Peito/etiologia , Eletrocardiografia , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Feminino , Humanos , Masculino , Miocardite/mortalidade , Miocardite/terapia , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Troponina I/sangue
16.
Dtsch Med Wochenschr ; 144(13): e80-e86, 2019 07.
Artigo em Alemão | MEDLINE | ID: mdl-31252437

RESUMO

BACKGROUND: The term early rehabilitation is defined as a rehabilitation that begins in the early phase after acute illness and is statutory positioned in §â€Š39SGB V. Aim of this investigation is to describe the quality of outcome of pulmonary early rehabilitation. METHOD: Prospective census of functional parameters, status of ventilation and discharge-disposition in a specialized unit for early pulmonary rehabilitation over a period of one year. RESULTS: Out of 190 patients 179 (94.2 %) were previously invasively ventilated. During the treatment period of 39 ±â€Š17 days, FAM-Index increased from 84.4 ±â€Š19.8 to 118.5 ±â€Š23.3 (Ci 30.9 - 37.3, Cohen'd 1.58; p < 0.001), Barthel-Index from 30.5 ±â€Š13.8 to 58.3 ±â€Š16.2 (Ci 25.4 - 33.8, Cohen's d 1.4; p < 0.001) six minute walking distance from 12.9 ±â€Š40.1 m to 131.4 ±â€Š85.2 m (Ci 105.6 - 131.4 m, Cohn's d 1.78; p < 0.001). Patients were less likely to be receive further post-discharge rehabilitation if they were ventilated. CONCLUSION: Patients admitted to the early pulmonary rehabilitation unit were severely compromised, however quality of outcome was favourable and independent of the breathing status (spontaneously breathing vs. non-invasive ventilation or invasive ventilation). Finding discharge dispositions appeared to be more difficult if patients were ventilated.


Assuntos
Respiração Artificial , Testes de Função Respiratória , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Estudos Prospectivos , Reabilitação , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Desmame do Respirador , Caminhada/fisiologia
17.
Acta méd. costarric ; 61(2): 55-61, abr.-jun. 2019. tab, graf
Artigo em Espanhol | LILACS | ID: biblio-1001116

RESUMO

Resumen Objetivo: La ventilación mecánica no invasiva se considera la primera elección de ventilación en pacientes con insuficiencia respiratoria secundaria a enfermedad pulmonar obstructiva crónica reagudizada, edema agudo de pulmón y en inmunocomprometidos. Un aspecto clave de la ventilación mecánica no invasiva es la posibilidad de evitar la entubación endotraqueal y la ventilación mecánica invasiva con sus potenciales complicaciones, y por ende, lograr menor morbimortalidad y estancia hospitalaria. El objetivo principal fue establecer si los pacientes con patología respiratoria sometidos a ventilación mecánica no invasiva presentaron un beneficio estadísticamente significativo en la mortalidad. Como objetivos específicos se determinaron las patologías respiratorias más frecuentes, el tipo de insuficiencia respiratoria asociado a la terapia, la interface más utilizada, las complicaciones más frecuentes, y las patologías respiratorias sometidas a terapia que obtuvieron mayor beneficio en la morbimortalidad. Métodos: Se realizó un estudio prospectivo, observacional y de reporte de casos, de una población adulta de 18 - 85 años hospitalizada en el período comprendido entre el 1 de agosto y el 31 de noviembre de 2014. Se estudió 40 pacientes con patología respiratoria que cumplieron criterios para recibir tratamiento con ventilación mecánica no invasiva. Resultados: El servicio más frecuente donde se utilizó ventilación mecánica no invasiva fue la Unidad de Cuidados Intensivos. Se brindó terapia a más pacientes masculinos con edad promedio de 55 años. El tiempo promedio de terapia fue de 8,4 horas. Los diagnósticos más frecuentes fueron: neumonía, edema agudo de pulmón y edema pulmonar lesional. Para dichos diagnósticos la insuficiencia respiratoria hipoxémica fue la principal indicación. La "full fase" fue la interface más usada. Las complicaciones de úlceras por presión y neumonía fueron infrecuentes. No se encontró cambios gasométricos, de índice respiratorio, ni de gradiente alveolo - arterial durante la terapia. Los puntajes de APACHE-II y SOFA fueron bajos para la mayoría de los pacientes, y el 57,5 % de los pacientes terminó por deshabituarse, con una mortalidad observada del 12 %. Conclusión: Las indicaciones más frecuentes para ventilación mecánica no invasiva en este estudio fueron edema agudo de pulmón y neumonía en el paciente inmunocomprometido. Algunos pacientes con índices respiratorios menores de 150, no se planteó la entubación, pero esto no se reflejó en una mayor tasa de fracaso en la deshabituación, o mayor mortalidad. Debido a la diversidad en la aplicación de la terapia, se debe tratar de protocolizar su uso en el Hospital México, para buscar obtener mejores resultados.


Abstract Aim: The non invasive mechanical ventilation is considered the first choice of ventilation in patients with respiratory insufficiency secondary to exacerbated chronic pulmonary obstructive disease, acute pulmonary edema and immunocompromised patients. The clue of the non invasive mechanical ventilation is the possibility to avoid intubation and invasive mechanical ventilation with its complications, less morbidity and mortality, and less hospital stay. Besides, it is more comfortable, the patient can communicate, eat and drink, cough, avoid the need of profound sedation, and maintain the defense mechanisms of superior airway. The main objective was to establish if the patients who received non invasive ventilation had a benefit in mortality statistically significant. It was also evaluated which were the most frequent pulmonary diseases, the type of respiratory insufficiency associated with the therapy, the type of interface used, the most frequent complications, and which of the pulmonary diseases benefited most in morbidity and mortality with the use of this type of ventilation. Methods: We did a prospective, observational and case report study. Of a total population of 18 - 85 years hospitalized in a period between 1 of August and 31 of November of 2014, we studied a total of 40 patients who developed a respiratory disease who met the criteria to receive treatment with non invasive ventilation. Results: The department who used more non invasive ventilation was the Intensive Care Unit. There were more male patients, with an average age of 55 years. The average time of therapy was 8,4 hours. The most frequent diagnostics where pneumoniae, acute pulmonary edema, and acute respiratory distress syndrome. For these diseases the hipoxemic respiratory insufficiency was the principal indication. The fullface was the main interface used. The complications of pressure ulcers and pneumoniae where infrequent during therapy. There were none shocked patients under therapy and tachycardia was the main risk factor of dying without being statistically significant. We didn't find gasometric changes neither changes in the respiratory index or alveolar-arterial gradient during therapy. The majority of patients with pneumonia and acute pulmonary edema started the therapy with a respiratory index less than 150, but this didn`t relate with more time in therapy neither more mortality. The scores of APACHE-II and SOFA where low at the beginning of the therapy, the observed mortality was of 12%. Conclusion: The most frequent indications for non invasive ventilation obsesrved were acute pulmonary edema and pneumoniae in inmunocompromised patients. The elaboration of protocols to guide the correct use of this ventilations method is needed.


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Pneumonia/complicações , Edema Pulmonar/complicações , Respiração Artificial/estatística & dados numéricos , Costa Rica
19.
Medicine (Baltimore) ; 98(18): e15469, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31045827

RESUMO

BACKGROUND: This meta-analysis aimed to evaluate the effect of dexmedetomidine on prognosis in patients with sepsis. METHODS: Computer-related electronic databases were searched, including PubMed, Embase, Web of Science, the Cochrane Library, and the China National Knowledge Infrastructure, from the date of database construction to January 2019. Stata 12.0 was used to perform a meta-analysis of short-term mortality [intensive care unit (ICU) mortality or 28-day mortality], ICU length of stay, and mechanical ventilation. Mortality was expressed using risk ratio (RR) and 95% confidence interval (CI). ICU length of stay and mechanical ventilation were expressed as weighted mean difference (WMD) and 95% CIs. RESULTS: We finally included 8 randomized controlled trials in this meta-analysis. Compared with the control group, the dexmedetomidine group had a lower occurrence of 28-day mortality (RR, 0.49; 95% CI, 0.35 to 0.69; P = .000) and ICU mortality (RR, 0.44; 95% CI, 0.23 to 0.84; P = .013). However, there was no statistically significant difference for the length of hospital stay (WMD, -0.05; 95% CI, -0.59 to 0.48; P = .840) and mechanical ventilation time (WMD, 1.05; 95% CI, -0.27 to 2.37; P = .392) between dexmedetomidine group and control group. CONCLUSIONS: In patients with sepsis, dexmedetomidine can reduce the short-term mortality of patients, but could not shorten the ICU length of stay and mechanical ventilation time. More clinical randomized controlled trials are needed to verify the efficacy and safety of dexmedetomidine on the length of hospital stay and mechanical ventilation time.


Assuntos
Dexmedetomidina/uso terapêutico , Mortalidade Hospitalar , Unidades de Terapia Intensiva/estatística & dados numéricos , Sepse/tratamento farmacológico , Sepse/mortalidade , Idoso , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial/estatística & dados numéricos
20.
Top Spinal Cord Inj Rehabil ; 25(2): 105-111, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31068742

RESUMO

Background: Functional electrical stimulation (FES) is the application of electrical pulses to a nerve to achieve a functional muscle contraction. Surface electrical stimulation of the nerves that innervate the abdominal muscles, termed abdominal FES, can cause the abdominal muscles to contract, even when paralysed after spinal cord injury. As the abdominal muscles are the major expiratory muscles, and commonly partially or completely paralysed in tetraplegia, abdominal FES offers a promising method of improving respiratory function for this patient group. Objective: The aim of the article is to provide readers with a better understanding of how abdominal FES can be used to improve the health of the spinal cord-injured population. Methods: A narrative review of the abdominal FES literature was performed. Results: Abdominal FES can achieve an immediate effective cough in patients with tetraplegia, while the repeated application over 6 weeks of abdominal FES can improve unassisted respiratory function. Ventilator duration and tracheostomy cannulation time can also be reduced with repeated abdominal FES. Conclusion: Abdominal FES is a noninvasive method to achieve functional improvements in cough and respiratory function in acute and chronically injured people with tetraplegia. Potential practical outcomes of this include reduced ventilation duration, assisted tracheostomy decannulation, and a reduction in respiratory complications. All of these outcomes can contribute to reduced morbidity and mortality, improved quality of life, and significant potential cost savings for local health care providers.


Assuntos
Terapia por Estimulação Elétrica/métodos , Transtornos Respiratórios/reabilitação , Traumatismos da Medula Espinal/reabilitação , Abdome , Doença Aguda , Doença Crônica , Tosse/fisiopatologia , Volume Expiratório Forçado/fisiologia , Previsões , Humanos , Quadriplegia/fisiopatologia , Quadriplegia/reabilitação , Transtornos Respiratórios/complicações , Transtornos Respiratórios/fisiopatologia , Respiração Artificial/estatística & dados numéricos , Terapia Respiratória/métodos , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/fisiopatologia , Desmame do Respirador/estatística & dados numéricos , Capacidade Vital/fisiologia
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