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1.
Undersea Hyperb Med ; 47(3): 405-413, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32931666

RESUMO

Objective: Given the high mortality and prolonged duration of mechanical ventilation of COVID-19 patients, we evaluated the safety and efficacy of hyperbaric oxygen for COVID-19 patients with respiratory distress. Methods: This is a single-center clinical trial of COVID-19 patients at NYU Winthrop Hospital from March 31 to April 28, 2020. Patients in this trial received hyperbaric oxygen therapy at 2.0 atmospheres of pressure in monoplace hyperbaric chambers for 90 minutes daily for a maximum of five total treatments. Controls were identified using propensity score matching among COVID-19 patients admitted during the same time period. Using competing-risks survival regression, we analyzed our primary outcome of inpatient mortality and secondary outcome of mechanical ventilation. Results: We treated 20 COVID-19 patients with hyperbaric oxygen. Ages ranged from 30 to 79 years with an oxygen requirement ranging from 2 to 15 liters on hospital days 0 to 14. Of these 20 patients, two (10%) were intubated and died, and none remain hospitalized. Among 60 propensity-matched controls based on age, sex, body mass index, coronary artery disease, troponin, D-dimer, hospital day, and oxygen requirement, 18 (30%) were intubated, 13 (22%) have died, and three (5%) remain hospitalized (with one still requiring mechanical ventilation). Assuming no further deaths among controls, we estimate that the adjusted subdistribution hazard ratios were 0.37 for inpatient mortality (p=0.14) and 0.26 for mechanical ventilation (p=0.046). Conclusion: Though limited by its study design, our results demonstrate the safety of hyperbaric oxygen among COVID-19 patients and strongly suggests the need for a well-designed, multicenter randomized control trial.


Assuntos
Betacoronavirus , Infecções por Coronavirus/terapia , Oxigenação Hiperbárica/métodos , Pneumonia Viral/terapia , Pontuação de Propensão , Síndrome do Desconforto Respiratório do Adulto/terapia , Adulto , Idoso , Pressão Atmosférica , Estudos de Casos e Controles , Infecções por Coronavirus/complicações , Infecções por Coronavirus/mortalidade , Feminino , Humanos , Oxigenação Hiperbárica/efeitos adversos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/complicações , Pneumonia Viral/mortalidade , Respiração Artificial/mortalidade , Síndrome do Desconforto Respiratório do Adulto/etiologia , Síndrome do Desconforto Respiratório do Adulto/mortalidade , Fatores de Risco , Segurança , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento
2.
J Intensive Care Med ; 35(10): 963-970, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32812834

RESUMO

BACKGROUND: The first confirmed case of novel coronavirus (2019-nCoV) infection in the United States was reported from the state of Washington in January, 2020. By March, 2020, New York City had become the epicenter of the outbreak in the United States. METHODS: We tracked all patients with confirmed coronavirus-19 (COVID-19) infection admitted to intensive care units (ICU) at Montefiore Medical Center (Bronx, NY). Data were obtained through manual review of electronic medical records. Patients had at least 30 days of follow-up. RESULTS: Our first 300 ICU patients were admitted March 10 through April 11, 2020. The majority (60.7%) of patients were men. Acute respiratory distress syndrome (ARDS) was documented in 91.7% of patients; 91.3% required mechanical ventilation. Prone positioning was employed in 58% of patients and neuromuscular blockade in 47.8% of mechanically-ventilated patients. Neither intervention was associated with decreased mortality. Vasopressors were required in 77.7% of patients. Acute kidney injury (AKI) was present on admission in 40.7% of patients, and developed subsequently in 36.0%; 50.9% of patients with AKI received renal replacement therapy (RRT). Overall 30-day mortality rate was 52.3%, and 55.8% among patients receiving mechanical ventilation. In univariate analysis, higher mortality rate was associated with increasing age, male sex, hypertension, obesity, smoking, number of comorbidities, AKI on presentation, and need for vasopressor support. A representative multivariable model for 30-day mortality is also presented, containing patient age, gender, body mass index, and AKI at admission. As of May 11, 2020, 2 patients (0.7%) remained hospitalized. CONCLUSIONS: Mortality in critical illness associated with COVID-19 is high. The majority of patients develop ARDS requiring mechanical ventilation, vasopressor-dependent shock, and AKI. The variation in mortality rates reported to date likely reflects differences in the severity of illness of the evaluated populations.


Assuntos
Betacoronavirus , Infecções por Coronavirus/mortalidade , Cuidados Críticos/estatística & dados numéricos , Estado Terminal/mortalidade , Pneumonia Viral/mortalidade , Lesão Renal Aguda/mortalidade , Lesão Renal Aguda/virologia , Adulto , Idoso , Infecções por Coronavirus/complicações , Cuidados Críticos/métodos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Pandemias , Pneumonia Viral/complicações , Respiração Artificial/mortalidade , Síndrome do Desconforto Respiratório do Adulto/mortalidade , Síndrome do Desconforto Respiratório do Adulto/virologia
3.
Lancet Respir Med ; 8(9): 905-913, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32735841

RESUMO

Background Mortality in acute respiratory failure remains high despite the use of lung-protective ventilation. Recent studies have shown an association between baseline ventilation parameters (driving pressure or mechanical power) and outcomes for patients with acute respiratory distress syndrome. Strategies focused on limiting these parameters have been proposed to further improve outcomes. However, it remains unknown whether driving pressure and mechanical power should be limited over the entire duration of mechanical ventilation and in all patients with acute respiratory failure. We aimed to estimate the association between exposure to different intensities of mechanical ventilation over time and intensive care unit (ICU) mortality in patients with acute respiratory failure. METHODS: In this registry-based, prospective cohort study, we obtained data from the Toronto Intensive Care Observational Registry, which includes all patients receiving mechanical ventilation for 4 h or more in nine ICUs that are affiliated with the University of Toronto (Toronto, ON, Canada). We included all adult (≥18 years) patients who received invasive mechanical ventilation between April 11, 2014, and June 5, 2019. Patients were excluded if they received treatment with extracorporeal life support. The primary outcome was ICU mortality. Bayesian joint models were used to estimate the strength of associations, accounting for informative censoring due to death during follow-up. FINDINGS: Of 13 939 patients recorded in the registry, 13 408 (96·2%) were eligible for descriptive analysis. The primary analysis comprised 7876 (58·7%) patients with complete baseline characteristics, and a secondary analysis included all 13 408 patients after multiple imputation in the joint model analysis. 2409 (18·0%) of 13 408 patients died in the ICU. After adjustment for baseline characteristics, including age and severity of illness, a significant increase in the hazard of death was found to be associated with each daily increment in driving pressure (hazard ratio 1·064, 95% credible interval 1·057-1·071) or mechanical power (hazard ratio 1·060, 95% credible interval 1·053-1·066). These associations persisted over the duration of mechanical ventilation. INTERPRETATION: Cumulative exposure to higher intensities of mechanical ventilation was harmful, even for short durations. Limiting exposure to driving pressure or mechanical power should be evaluated in further studies as promising ventilation strategies to reduce mortality in patients with acute respiratory failure. FUNDING: Canadian Institutes of Health Research.


Assuntos
Respiração Artificial/mortalidade , Insuficiência Respiratória/terapia , Doença Aguda , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Troca Gasosa Pulmonar , Sistema de Registros , Respiração Artificial/métodos , Insuficiência Respiratória/mortalidade , Fatores de Tempo
5.
PLoS One ; 15(6): e0234181, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32479534

RESUMO

INTRODUCTION: In health care systems in need of additional intensive care unit (ICU) beds, the decision to mechanically ventilate critically ill patients in Internal Medicine (IM) Department wards needs to balance patients' health outcomes, possible futility, and logistics. We aimed to examine the survival rates and predictors in these patients. METHODS: We prospectively enrolled consecutive patients receiving mechanical ventilation during their care in the IM wards of a tertiary University hospital between April 2016 and December 2018. Primary outcome was 90-day mortality and secondary outcomes were in-hospital mortality and ICU transfer. RESULTS: Our cohort consisted of 151 unique patient intubations, of whom 74 (49%) patients were transferred to ICU within a median of 0 days (range 0-7). Compared to patients who remained in the wards, patients transferred to ICU had lower in-hospital and 90-day mortality (65% vs. 97%, and 70% vs. 99%, respectively, p<0.001 for both). Amongst several possible predictors of survival in the ICU, sequential organ failure assessment (SOFA) score at the time of intubation had the best prognostic accuracy with an AUROC of 0.818 and 0.855 for in-hospital and 90-day mortality, respectively. A baseline SOFA score ≤8 had a 100% sensitivity for survival prediction in ICU. However, out of 26 patients with SOFA score ≤8 who remained in the wards, only one survived, whereas 19 patients with SOFA score >8 who were transferred to ICUs received futile care. CONCLUSION: Mortality for patients receiving mechanical ventilation in IM wards is almost inevitable when ICU availability is lacking. Therefore, applying additional transfer criteria beyond the SOFA score is imperative.


Assuntos
Respiração Artificial/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Grécia/epidemiologia , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Intubação Intratraqueal/mortalidade , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Curva ROC , Taxa de Sobrevida , Centros de Atenção Terciária/estatística & dados numéricos
9.
Am Heart J ; 226: 24-25, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32425197

RESUMO

Using Mt. Sinai (New York City) EMR health system data, we retrospectively analyzed a cohort of 8438 COVID-19 patients seen between March 1 and April 22, 2020. Risk of intubation and of death rose as a function of increasing age and as a function of greater cardiovascular comorbidity. Combining age and specific comorbidity markers showed patterns suggesting that cardiovascular comorbidities increased relative risks for adverse outcomes most substantially in the younger subjects with progressively diminishing relative effects at older ages.


Assuntos
Betacoronavirus , Doenças Cardiovasculares/epidemiologia , Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Respiração Artificial/estatística & dados numéricos , Fatores Etários , Idoso , Cardiomiopatias/complicações , Cardiomiopatias/epidemiologia , Cardiomiopatias/mortalidade , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/mortalidade , Comorbidade , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/mortalidade , Infecções por Coronavirus/sangue , Infecções por Coronavirus/mortalidade , Registros Eletrônicos de Saúde/estatística & dados numéricos , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Pandemias , Doença Arterial Periférica/epidemiologia , Doença Arterial Periférica/mortalidade , Pneumonia Viral/sangue , Pneumonia Viral/mortalidade , Respiração Artificial/mortalidade , Estudos Retrospectivos , Risco , Troponina I/sangue
10.
Monaldi Arch Chest Dis ; 90(1)2020 Apr 08.
Artigo em Inglês | MEDLINE | ID: covidwho-45830

RESUMO

Severe COVID-19 illness is characterised by the development of Acute Respiratory Distress Syndrome (ARDS), for which the mainstay of treatment is represented by mechanical ventilation. Mortality associated with ARDS due to other causes is in the range of 40-60%, but currently available data are not yet sufficient to draw safe conclusions on the prognosis of COVID-19 patients who require mechanical ventilation. Based on data from cohorts of the related coronavirus-associated illnesses, that is to say Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), prognosis would seem to be worse than ARDS due to other causes such as trauma and other infections. Discussion of prognosis is central to obtaining informed consent for intubation, but in the absence of definitive data it is not clear exactly what this discussion should entail.


Assuntos
Tomada de Decisão Clínica/ética , Infecções por Coronavirus/terapia , Pandemias , Pneumonia Viral/terapia , Respiração Artificial/ética , Síndrome Respiratória Aguda Grave/terapia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/mortalidade , Humanos , Consentimento Livre e Esclarecido/ética , Intubação Intratraqueal , Pandemias/ética , Pneumonia Viral/epidemiologia , Pneumonia Viral/mortalidade , Prognóstico , Respiração Artificial/mortalidade , Síndrome Respiratória Aguda Grave/etiologia , Síndrome Respiratória Aguda Grave/mortalidade
11.
Cardiol J ; 27(2): 175-183, 2020.
Artigo em Inglês | MEDLINE | ID: covidwho-52625

RESUMO

Coronaviruses cause disease in animals and people around the world. Human coronaviruses (HCoV) are mainly known to cause infections of the upper and lower respiratory tract but the symptoms may also involve the nervous and digestive systems. Since the beginning of December 2019, there has been an epidemic of SARS-CoV-2, which was originally referred to as 2019-nCoV. The most common symptoms are fever and cough, fatigue, sputum production, dyspnea, myalgia, arthralgia or sore throat, headache, nausea, vomiting or diarrhea (30%). The best prevention is to avoid exposure. In addition, contact per-sons should be subjected to mandatory quarantine. COVID-19 patients should be treated in specialist centers. A significant number of patients with pneumonia require passive oxygen therapy. Non-invasive ventilation and high-flow nasal oxygen therapy can be applied in mild and moderate non-hypercapnia cases. A lung-saving ventilation strategy must be implemented in acute respiratory distress syndrome and mechanically ventilated patients. Extracorporeal membrane oxygenation is a highly specialized method, available only in selected centers and not applicable to a significant number of cases. Specific pharmacological treatment for COVID-19 is not currently available. Modern medicine is gearing up to fight the new coronavirus pandemic. The key is a holistic approach to the patient including, primar-ily, the use of personal protective equipment to reduce the risk of further virus transmission, as well as patient management, which consists in both quarantine and, in the absence of specific pharmacological therapy, symptomatic treatment.


Assuntos
Antivirais/uso terapêutico , Betacoronavirus/efeitos dos fármacos , Infecções por Coronavirus/terapia , Procedimentos Clínicos , Oxigenação por Membrana Extracorpórea , Oxigenoterapia , Pneumonia Viral/terapia , Respiração Artificial , Vacinas Virais/uso terapêutico , Antivirais/efeitos adversos , Betacoronavirus/patogenicidade , Tomada de Decisão Clínica , Técnicas de Laboratório Clínico , Terapia Combinada , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/virologia , Difusão de Inovações , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Humanos , Oxigenoterapia/efeitos adversos , Oxigenoterapia/mortalidade , Pandemias , Seleção de Pacientes , Pneumonia Viral/mortalidade , Pneumonia Viral/transmissão , Pneumonia Viral/virologia , Prognóstico , Respiração Artificial/efeitos adversos , Respiração Artificial/mortalidade , Fatores de Risco , Vacinas Virais/efeitos adversos
12.
Monaldi Arch Chest Dis ; 90(1)2020 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-32268719

RESUMO

Severe COVID-19 illness is characterised by the development of Acute Respiratory Distress Syndrome (ARDS), for which the mainstay of treatment is represented by mechanical ventilation. Mortality associated with ARDS due to other causes is in the range of 40-60%, but currently available data are not yet sufficient to draw safe conclusions on the prognosis of COVID-19 patients who require mechanical ventilation. Based on data from cohorts of the related coronavirus-associated illnesses, that is to say Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), prognosis would seem to be worse than ARDS due to other causes such as trauma and other infections. Discussion of prognosis is central to obtaining informed consent for intubation, but in the absence of definitive data it is not clear exactly what this discussion should entail.


Assuntos
Tomada de Decisão Clínica/ética , Infecções por Coronavirus/terapia , Pandemias , Pneumonia Viral/terapia , Respiração Artificial/ética , Síndrome Respiratória Aguda Grave/terapia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/mortalidade , Humanos , Consentimento Livre e Esclarecido/ética , Intubação Intratraqueal , Pandemias/ética , Pneumonia Viral/epidemiologia , Pneumonia Viral/mortalidade , Prognóstico , Respiração Artificial/mortalidade , Síndrome Respiratória Aguda Grave/etiologia , Síndrome Respiratória Aguda Grave/mortalidade
13.
Methodist Debakey Cardiovasc J ; 16(1): 36-42, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32280416

RESUMO

Cardiogenic shock (CS) is a complex condition characterized by end-organ hypoperfusion and requiring pharmacologic and/or mechanical circulatory support. It is caused by a decline in cardiac output due to a primary cardiac disorder. CS is frequently complicated by multiorgan system dysfunction that requires a multidisciplinary approach in a critical care setting. Appropriate use of diagnostic data using tools available in a modern cardiac intensive care unit should guide optimal management incorporating both pharmacologic and nonpharmacologic therapies to minimize morbidity and mortality.


Assuntos
Fármacos Cardiovasculares/uso terapêutico , Cuidados Críticos , Hemodinâmica , Unidades de Terapia Intensiva , Respiração Artificial , Choque Cardiogênico/terapia , Ultrafiltração , Função Ventricular , Fármacos Cardiovasculares/efeitos adversos , Cateterismo de Swan-Ganz , Terapia Combinada , Mortalidade Hospitalar , Humanos , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Respiração Artificial/efeitos adversos , Respiração Artificial/mortalidade , Fatores de Risco , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Resultado do Tratamento , Ultrafiltração/efeitos adversos
14.
Cardiol J ; 27(2): 175-183, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32286679

RESUMO

Coronaviruses cause disease in animals and people around the world. Human coronaviruses (HCoV) are mainly known to cause infections of the upper and lower respiratory tract but the symptoms may also involve the nervous and digestive systems. Since the beginning of December 2019, there has been an epidemic of SARS-CoV-2, which was originally referred to as 2019-nCoV. The most common symptoms are fever and cough, fatigue, sputum production, dyspnea, myalgia, arthralgia or sore throat, headache, nausea, vomiting or diarrhea (30%). The best prevention is to avoid exposure. In addition, contact per-sons should be subjected to mandatory quarantine. COVID-19 patients should be treated in specialist centers. A significant number of patients with pneumonia require passive oxygen therapy. Non-invasive ventilation and high-flow nasal oxygen therapy can be applied in mild and moderate non-hypercapnia cases. A lung-saving ventilation strategy must be implemented in acute respiratory distress syndrome and mechanically ventilated patients. Extracorporeal membrane oxygenation is a highly specialized method, available only in selected centers and not applicable to a significant number of cases. Specific pharmacological treatment for COVID-19 is not currently available. Modern medicine is gearing up to fight the new coronavirus pandemic. The key is a holistic approach to the patient including, primar-ily, the use of personal protective equipment to reduce the risk of further virus transmission, as well as patient management, which consists in both quarantine and, in the absence of specific pharmacological therapy, symptomatic treatment.


Assuntos
Antivirais/uso terapêutico , Betacoronavirus/efeitos dos fármacos , Infecções por Coronavirus/terapia , Procedimentos Clínicos , Oxigenação por Membrana Extracorpórea , Oxigenoterapia , Pneumonia Viral/terapia , Respiração Artificial , Vacinas Virais/uso terapêutico , Antivirais/efeitos adversos , Betacoronavirus/patogenicidade , Tomada de Decisão Clínica , Técnicas de Laboratório Clínico , Terapia Combinada , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/virologia , Difusão de Inovações , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Humanos , Oxigenoterapia/efeitos adversos , Oxigenoterapia/mortalidade , Pandemias , Seleção de Pacientes , Pneumonia Viral/mortalidade , Pneumonia Viral/transmissão , Pneumonia Viral/virologia , Prognóstico , Respiração Artificial/efeitos adversos , Respiração Artificial/mortalidade , Fatores de Risco , Vacinas Virais/efeitos adversos
15.
Neurology ; 94(15): e1634-e1644, 2020 04 14.
Artigo em Inglês | MEDLINE | ID: mdl-32217777

RESUMO

OBJECTIVE: To investigate probabilities of survival and its surrogate, that is, mechanical ventilation, in patients with spinal muscular atrophy (SMA). METHODS: We studied survival in a population-based cohort on clinical prevalence of genetically confirmed, treatment-naive patients with SMA, stratified for best acquired motor milestone (i.e., none: type 1a/b; head control in supine position or rolling: type 1c; sitting independently: type 2a; standing: type 2b; walking: type 3a/b; adult onset: type 4). We also assessed the need for mechanical ventilation as a surrogate endpoint for survival. RESULTS: We included 307 patients with a total follow-up of 7,141 person-years. Median survival was 9 days in SMA type 1a, 7.7 months in type 1b, and 17.0 years in type 1c. Patients with type 2a had endpoint-free survival probabilities of 74.2% and 61.5% at ages 40 and 60 years, respectively. Endpoint-free survival of SMA types 2b, 3, and 4 was relatively normal, at least within the first 60 years of life. Patients with SMA types 1c and 2a required mechanical ventilation more frequently and from younger ages compared to patients with milder SMA types. In our cohort, patients ventilated up to 12 h/d progressed not gradually, but abruptly, to ≥16 h/d. CONCLUSIONS: Shortened endpoint-free survival is an important characteristic of SMA types 1 and 2a, but not types 2b, 3, and 4. For SMA types 1c and 2a, the age at which initiation of mechanical ventilation is necessary may be a more suitable endpoint than the arbitrarily set 16 h/d.


Assuntos
Fatores Etários , Atrofia Muscular Espinal/mortalidade , Respiração Artificial/mortalidade , Atrofias Musculares Espinais da Infância/mortalidade , Adulto , Estudos de Coortes , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Caminhada/fisiologia
16.
Acad Emerg Med ; 27(5): 366-374, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32220129

RESUMO

BACKGROUND: While emergency medical services (EMS) often use endotracheal intubation (ETI) or supraglottic airways (SGA), some patients receive only bag-valve-mask (BVM) ventilation during out-of-hospital cardiac arrests (OHCA). Our objective was to compare patient characteristics and outcomes for BVM ventilation to advanced airway management (AAM) in adults with OHCA. METHODS: Using data from the Pragmatic Airway Resuscitation Trial, we identified patients receiving AAM (ETI or a SGA), BVM ventilation only (BVM-only), and BVM ventilation as a rescue after at least one failed attempt at advanced airway placement (BVM-rescue). The outcomes were return of spontaneous circulation (ROSC), 72-hour survival, survival to hospital discharge, neurologically intact survival (Modified Rankin Scale ≤ 3), and the presence of aspiration on a chest radiograph. Comparisons were made using generalized mixed-effects models while adjusting for age, sex, initial rhythm, EMS-witnessed status, bystander cardiopulmonary resuscitation, response time, study cluster, and advanced life support first on scene. RESULTS: Of 3,004 patients enrolled, there were 282 BVM-only, 2,129 AAM, and 156 BVM-rescue patients with complete covariates. Shockable initial rhythms (34% vs. 18.6%) and EMS-witnessed arrests (21.6% vs. 11.3%) were more likely in BVM-only than AAM but similar between BVM-rescue and AAM. Compared to AAM, BVM-only patients had similar ROSC (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 0.96 to 1.73), but higher 72-hour survival (OR = 1.96, 95% CI = 1.42 to 2.69), survival to discharge (OR = 4.47, 95% CI = 3.03 to 6.59), and neurologically intact survival (OR = 7.05, 95% CI = 4.40 to 11.3). Compared to AAM, BVM-rescue patients had similar ROSC (OR = 0.73, 95% CI = 0.47 to 1.12) and 72-hour survival (OR = 1.08, 95% CI = 0.66 to 1.77) but higher survival to discharge (OR = 2.15, 95% CI = 1.17 to 3.95) and neurologically intact survival (OR = 2.64, 95% CI = 1.20 to 5.81). Aspiration incidence was similar. CONCLUSIONS: Bag-valve-mask-only ventilation is associated with improved OHCA outcomes. Despite similar rates of ROSC and 72-hour survival, BVM-rescue ventilation was associated with improved survival to discharge and neurologically intact survival compared to successful AAM.


Assuntos
Reanimação Cardiopulmonar/métodos , Parada Cardíaca Extra-Hospitalar/mortalidade , Respiração Artificial/mortalidade , Adulto , Idoso , Reanimação Cardiopulmonar/mortalidade , Serviços Médicos de Emergência/métodos , Feminino , Humanos , Intubação Intratraqueal/métodos , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Parada Cardíaca Extra-Hospitalar/terapia , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos
18.
PLoS One ; 15(2): e0228458, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32023315

RESUMO

OBJECTIVES: This study evaluated the impact of the presence of a certified nurse specialist in critical care (CNS) as ICU head nurse in an open ICU on clinical outcomes. METHODS: The presence of a CNS as ICU head nurse was implemented in practice in April 2017. To evaluate the impact on patient outcomes before and after the implementation, patients were divided into two groups: before (April 2014 to March 2017; 1988 patients) and after (April 2017 to March 2019; 1664 patients). Patients' demographic data were collected from the ICU database. RESULTS: Multivariable logistic regression analysis revealed that the presence of a CNS as ICU head nurse was associated with lower ICU mortality (odds ratio (OR): 0.52, 95% CI: 0.36-0.73, p < .001) and fewer patients receiving mechanical ventilation in the ICU (OR: 0.20, 95% CI: 0.15-0.26, p < .001). CONCLUSION: CNSs are defined as one type of advanced practice nurses. Having a CNS as a head nurse in the ICU may have helped improve patient outcomes by leveraging these practical skills in nursing management.


Assuntos
Enfermagem de Cuidados Críticos/estatística & dados numéricos , Mortalidade Hospitalar/tendências , Unidades de Terapia Intensiva/estatística & dados numéricos , Enfermeiras Especialistas/estatística & dados numéricos , Supervisão de Enfermagem/estatística & dados numéricos , Respiração Artificial/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/terapia , Criança , Feminino , Gastroenteropatias/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome do Desconforto Respiratório do Adulto/terapia , Estudos Retrospectivos , Taxa de Sobrevida , Adulto Jovem
19.
JAMA Netw Open ; 3(2): e1921520, 2020 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-32074293

RESUMO

Importance: Low diaphragm muscle mass at the outset of mechanical ventilation may predispose critically ill patients to poor clinical outcomes. Objective: To determine whether lower baseline diaphragm thickness (Tdi) is associated with delayed liberation from mechanical ventilation and complications of acute respiratory failure (reintubation, tracheostomy, prolonged ventilation >14 days, or death in the hospital). Design, Setting, and Participants: Secondary analysis (July 2018 to June 2019) of a prospective cohort study (data collected May 2013 to January 2016). Participants were 193 critically ill adult patients receiving invasive mechanical ventilation at 3 intensive care units in Toronto, Ontario, Canada. Exposures: Diaphragm thickness was measured by ultrasonography within 36 hours of intubation and then daily. Patients were classified as having low or high diaphragm muscle mass according to the median baseline Tdi. Main Outcomes and Measures: The primary outcome was time to liberation from ventilation accounting for the competing risk of death and adjusting for age, body mass index, severity of illness, sepsis, change in Tdi during ventilation, baseline comorbidity, and study center. Secondary outcomes included in-hospital death and complications of acute respiratory failure. Results: A total of 193 patients were available for analysis; the mean (SD) age was 60 (15) years, 73 (38%) were female, and the median (interquartile range) Sequential Organ Failure Assessment score was 10 (8-13). Median (interquartile range) baseline Tdi was 2.3 (2.0-2.7) mm. In the primary prespecified analysis, baseline Tdi of 2.3 mm or less was associated with delayed liberation from mechanical ventilation (adjusted hazard ratio for liberation, 0.51; 95% CI, 0.36-0.74). Lower baseline Tdi was associated a higher risk of complications of acute respiratory failure (adjusted odds ratio, 1.77; 95% CI, 1.20-2.61 per 0.5-mm decrement) and prolonged weaning (adjusted odds ratio, 2.30; 95% CI, 1.42-3.74). Lower baseline Tdi was also associated with a higher risk of in-hospital death (adjusted odds ratio, 1.47; 95% CI, 1.00-2.16 per 0.5-mm decrement), particularly after discharge from the intensive care unit (adjusted odds ratio, 2.68; 95% CI, 1.35-5.32 per 0.5-mm decrement). Conclusions and Relevance: In this study, low baseline diaphragm muscle mass in critically ill patients was associated with prolonged mechanical ventilation, complications of acute respiratory failure, and an increased risk of death in the hospital.


Assuntos
Estado Terminal/mortalidade , Diafragma/diagnóstico por imagem , Respiração Artificial/mortalidade , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Ultrassonografia
20.
Respir Med ; 162: 105877, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32056675

RESUMO

BACKGROUND AND OBJECTIVE: Home mechanical ventilation (HMV) is used in heterogeneous conditions underlying chronic hypercapnic respiratory failure, but there are sparse data on long-term clinical outcomes. The aim was to systematically analyse the time and the circumstances of death on HMV. METHODS: All-cause mortality data of HMV patients were prospectively collected between 2008 and 2018 in a large tertiary centre. Data were categorised into diagnostic groups including neuromuscular disease (NMD), chest wall disease (CWD), chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome (OHS), overlap syndrome of COPD and OSA (overlap) and other group. The primary outcome was time-to-death from initiation of HMV. RESULTS: 1210 deaths were recorded over a 10-year period. Median time-to-death was 19.5 [6-55] months and differed between groups (Kruskal Wallis p < 0.001). CWD (98.5 [23.5-120] months) and slowly progressive NMD (64.5 [28-120] months) had the longest time-to-death on HMV, while OHS (33 [13-75] months) and overlap syndrome (30.5 [14.5-68.5] months) had a longer median time-to-death than COPD (19.5 [7-42.5] months) and motor neurone disease (7 [3-14] months). Daily adherence to HMV of greater than 4 h/night was associated with better outcomes (10 [3-24] vs. 30 [10-76] months; p < 0.001). 43% with confirmed location of death died outside the hospital. CONCLUSIONS: The time-to-death on home mechanical ventilation varies widely across disease groups with chronic respiratory failure and seems to be associated with daily usage time. TRIAL REGISTRATION: researchregistry.com UIN: researchregistry4122.


Assuntos
Respiração Artificial/mortalidade , Insuficiência Respiratória/mortalidade , Idoso , Doença Crônica , Estudos de Coortes , Feminino , Serviços de Assistência Domiciliar , Humanos , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Fatores de Tempo
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