Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 525
Filtrar
1.
Rev Assoc Med Bras (1992) ; 65(6): 839-844, 2019 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-31340314

RESUMO

OBJECTIVE: To verify the association between prone position, increased diuresis, and decreased cumulative fluid balance in critically ill pediatric patients who underwent mechanical ventilation (MV) for pulmonary causes and describe adverse events related to the use of the position. METHODS: This is a retrospective observational study. Patients aged between 1 month and 12 years who underwent MV for pulmonary causes, between January 2013 and December 2015, were selected and divided between those who were put on prone position (PG) and those who were not (CG) during the hospitalization at the Pediatric Intensive Care Unit (PICU). Data were analyzed longitudinally from D1 to D4. RESULTS: A total of 77 patients (PG = 37 and CG = 40) were analyzed. The general characteristics of both groups were similar. In the comparison between the groups, there was no increase in diuresis or decrease in cumulative fluid balance in the prone group. In the longitudinal analysis of D1 to D4, we saw that the PG presented higher diuresis (p = 0.034) and a lower cumulative fluid balance (p = 0.001) in D2. Regarding the use of diuretics, there was greater use of furosemide (P <0.001) and spironolactone (P = 0.04) in the PG. There was no increase in adverse events during the use of the prone position. CONCLUSION: The prone position was not associated with increased diuresis or decreased cumulative fluid balance in critically ill pediatric patients who underwent to MV for pulmonary causes.


Assuntos
Diurese/fisiologia , Decúbito Ventral/fisiologia , Respiração Artificial/efeitos adversos , Equilíbrio Hidroeletrolítico/fisiologia , Criança , Pré-Escolar , Estado Terminal , Feminino , Humanos , Lactente , Recém-Nascido , Tempo de Internação/estatística & dados numéricos , Masculino , Respiração Artificial/mortalidade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
2.
Medicine (Baltimore) ; 98(20): e15473, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31096444

RESUMO

PURPOSE: Selenium supplementation is a potentially promising adjunctive therapy for critically ill patients, but the results are controversy among studies. Accordingly, we performed this meta-analysis to more clearly detect the efficacy and safety of selenium supplementation on critically ill patients. METHODS: Systematic literature retrieval was carried out to obtain RCTs on selenium supplementation for critically ill patients up to August 2017. Data extraction and quality evaluation of these studies were performed by 2 investigators. Statistical analyses was performed by RevMan 5.3. Trial sequential analysis (TSA) was conducted to control the risks of type I and type II errors and calculate required information size (RIS). RESULTS: Totally 19 RCTs involving 3341 critically ill patients were carried out in which 1694 participates were in the selenium supplementation group, and 1647 in the control. The aggregated results suggested that compared with the control, intravenous selenium supplement as a single therapy could decrease the total mortality (RR = 0.86, 95% CI: 0.78-0.95, P = .002, TSA-adjusted 95% CI = 0.77-0.96, RIS = 4108, n = 3297) and may shorten the length of stay in hospital (MD -2.30, 95% CI -4.03 to -0.57, P = .009), but had no significant treatment effect on 28-days mortality (RR = 0.96, 95% CI: 0.85-1.09, P = .54) and could not shorten the length of ICU stay (MD -0.15, 95% CI -1.68 to 1.38, P = .84) in critically ill patients. Our results also showed that selenium supplementation did not increase incidence of drug-induced side effect compared with the control (RR 1.04, 95% CI 0.83 to 1.30, P = .73). CONCLUSIONS: The current evidence suggests that the use of selenium could reduce the total mortality, and TSA results showed that our outcome is reliable and no more randomized controlled trials are needed. But selenium supplementation might have no effect on reducing 28-days mortality as well as the incidence of new infections, or on length of stay in ICU or mechanical ventilation. However, the results should be used carefully because of potential limitations.


Assuntos
Estado Terminal/terapia , Selênio/administração & dosagem , Administração Intravenosa , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estado Terminal/epidemiologia , Estado Terminal/mortalidade , Suplementos Nutricionais , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial/mortalidade , Respiração Artificial/estatística & dados numéricos , Selênio/uso terapêutico , Oligoelementos/administração & dosagem , Oligoelementos/uso terapêutico , Resultado do Tratamento , Adulto Jovem
3.
Braz J Cardiovasc Surg ; 34(1): 70-75, 2019 Jan-Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30810677

RESUMO

BACKGROUND: Acute kidney injury (AKI) is a frequent event after cardiac surgery with increased mortality and morbidity. We explored frequency, risk factors, and associated morbidity and mortality of AKI after isolated coronary artery bypass grafting (CABG) surgery at a single institution. METHODS: All consecutive adults undergoing CABG surgery from March 2013 to October 2016 were assessed for development and severity of AKI based on Acute Kidney Injury Network (AKIN) criteria. The patients were also investigated regarding their need for renal replacement therapy (RRT), predictive risk factors, and associated outcomes, including duration of mechanical ventilation, mortality, intensive care unit (ICU) and hospital length of stay. RESULTS: Of 1737 patients in the study, 275 (15.8%) developed AKI. Twenty-five (12.8%) cases required RRT. Patients with AKI had longer ventilation time, ICU and hospital length of stay (P<0.001). Mortality rates were 28 (10.2%) and 22 (1.5%) in patients with and without AKI, respectively (P<0.001). There was a strong association between advanced age (aOR=1.016, 95% CI=1.002-1.030, P=0.028), diabetes (aOR=1.36, 95% CI=1.022-1.809, P=0.035), on-pump surgery (aOR=2.63, 95% CI=1.543-4.483, P<0.001), transfusion of more than 1 unit of red blood cells (aOR=2.154, 95% CI=1.237-3.753, P=0.007), and prolonged mechanical ventilation and development of AKI (aOR=2.697, 95% CI=1.02407.071, P<0.001). AKI was seen less frequently in those with opium abuse (aOR=0.613, 95% CI=0.409-0.921, P=0.018). CONCLUSION: We demonstrated that advanced age, diabetes, on-pump surgery, red blood cell transfusion, and prolonged mechanical ventilation were independent positive risk factors for the development of AKI after isolated CABG while opium abuse was a protective factor.


Assuntos
Lesão Renal Aguda/etiologia , Ponte de Artéria Coronária/efeitos adversos , Lesão Renal Aguda/mortalidade , Idoso , Ponte de Artéria Coronária/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Gravidez , Estudos Prospectivos , Valores de Referência , Respiração Artificial/efeitos adversos , Respiração Artificial/mortalidade , Medição de Risco/métodos , Fatores de Risco , Estatísticas não Paramétricas , Fatores de Tempo , Resultado do Tratamento
4.
Crit Care ; 23(1): 34, 2019 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-30696474

RESUMO

BACKGROUND: Although light sedation levels are associated with several beneficial outcomes for critically ill patients on mechanical ventilation, the majority of patients are still deeply sedated. Organizational factors may play a role on adherence to light sedation levels. We aimed to identify organizational factors associated with a moderate to light sedation target on the first 48 h of mechanical ventilation, as well as the association between early achievement of within-target sedation and mortality. METHODS: This study is a secondary analysis of a multicenter two-phase study (prospective cohort followed by a cluster-randomized controlled trial) performed in 118 Brazilian ICUs. We included all critically ill patients who were on mechanical ventilation 48 h after ICU admission. A moderate to light level of sedation or being alert and calm (i.e., the Richmond Agitation-Sedation Scale of - 3 to 0) was the target for all patients on mechanical ventilation during the study period. We collected data on the type of hospital (public, private, profit and private, nonprofit), hospital teaching status, nursing and physician staffing, and presence of sedation, analgesia, and weaning protocols. We used multivariate random-effects regression with ICU and study phase as random-effects and correction for patients' Simplified Acute Physiology Score 3 and Sequential Organ Failure Assessment. We also performed a mediation analysis to explore whether sedation level was just a mediator of the association between organizational factors and mortality. RESULTS: We included 5719 patients. Only 1710 (29.9%) were on target sedation levels on day 2. Board-certified intensivists on the morning and afternoon shifts were associated with an adequate sedation level on day 2 (OR = 2.43; CI 95%, 1.09-5.38). Target sedation levels were associated with reduced hospital mortality (OR = 0.63; CI 95%, 0.55-0.72). Mediation analysis also suggested such an association, but did not suggest a relationship between the physician staffing model and hospital mortality. CONCLUSIONS: Board-certified intensivists on morning and afternoon shifts were associated with an increased number of patients achieving lighter sedation goals. These findings reinforce the importance of organizational factors, such as intensivists' presence, as a modifiable quality improvement target.


Assuntos
Lista de Checagem/normas , Sedação Profunda/métodos , Respiração Artificial/métodos , Adulto , Idoso , Brasil , Lista de Checagem/estatística & dados numéricos , Estudos de Coortes , Sedação Consciente/métodos , Feminino , Mortalidade Hospitalar , Humanos , Hipnóticos e Sedativos/efeitos adversos , Hipnóticos e Sedativos/uso terapêutico , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Estudos Prospectivos , Respiração Artificial/mortalidade , Escala Psicológica Aguda Simplificada
5.
Respir Res ; 19(1): 245, 2018 Dec 07.
Artigo em Inglês | MEDLINE | ID: mdl-30526610

RESUMO

BACKGROUND: Host-associated microbial communities have important roles in tissue homeostasis and overall health. Severe perturbations can occur within these microbial communities during critical illness due to underlying diseases and clinical interventions, potentially influencing patient outcomes. We sought to profile the microbial composition of critically ill mechanically ventilated patients, and to determine whether microbial diversity is associated with illness severity and mortality. METHODS: We conducted a prospective, observational study of mechanically ventilated critically ill patients with a high incidence of pneumonia in 2 intensive care units (ICUs) in Hamilton, Canada, nested within a randomized trial for the prevention of healthcare-associated infections. The microbial profiles of specimens from 3 anatomical sites (respiratory, and upper and lower gastrointestinal tracts) were characterized using 16S ribosomal RNA gene sequencing. RESULTS: We collected 65 specimens from 34 ICU patients enrolled in the trial (29 endotracheal aspirates, 26 gastric aspirates and 10 stool specimens). Specimens were collected at a median time of 3 days (lower respiratory tract and gastric aspirates; interquartile range [IQR] 2-4) and 6 days (stool; IQR 4.25-6.75) following ICU admission. We observed a loss of biogeographical distinction between the lower respiratory tract and gastrointestinal tract microbiota during critical illness. Moreover, microbial diversity in the respiratory tract was inversely correlated with APACHE II score (r = - 0.46, p = 0.013) and was associated with hospital mortality (Median Shannon index: Discharged alive; 1.964 vs. Deceased; 1.348, p = 0.045). CONCLUSIONS: The composition of the host-associated microbial communities is severely perturbed during critical illness. Reduced microbial diversity reflects high illness severity and is associated with mortality. Microbial diversity may be a biomarker of prognostic value in mechanically ventilated patients. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT01782755 . Registered February 4 2013.


Assuntos
Disbiose/microbiologia , Disbiose/mortalidade , Fenômenos Microbiológicos , Respiração Artificial/efeitos adversos , Respiração Artificial/mortalidade , Idoso , Estado Terminal/epidemiologia , Estado Terminal/terapia , Disbiose/etiologia , Feminino , Humanos , Unidades de Terapia Intensiva/tendências , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos
6.
Med. clín (Ed. impr.) ; 151(11): 435-440, dic. 2018. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-174174

RESUMO

Introducción y objetivo: La eficacia de la ventilación mecánica no invasiva (VMNI) domiciliaria se evalúa mediante la determinación de los valores gasométricos sanguíneos en vigilia, la evolución de la sintomatología, y la monitorización de la ventilación durante la noche. Nuestro objetivo es evaluar si alcanzar unos valores definidos mediante la oximetría nocturna en la monitorización ambulatoria de la ventilación mecánica no invasiva (VMNI) se relaciona con la evolución clínica, gasométrica y la supervivencia de una muestra de pacientes con VMNI domiciliaria. Material y métodos: Estudio observacional de cohortes retrospectivo de una serie de pacientes en tratamiento con VMNI domiciliaria por diferentes causas. Se excluyeron los pacientes con esclerosis lateral amiotrófica y/o menos de 3 meses de seguimiento. Se valora la evolución de la sintomatología, la gasometría arterial basal en vigilia, y los registros oximétricos nocturnos domiciliarios, en cada visita ambulatoria. Se definió buen control oximétrico mantenido (COM) cuando se alcanzan unos valores y se mantienen hasta la última revisión. Se consideraron 2 grupos de pacientes, según alcanzaron o no un buen COM durante el seguimiento. Resultados: se evaluaron 400 pacientes, fueron incluidos finalmente 364 (91%), con una edad mediana de 68 años, el 51% varones. El 37,6% presentaban buen COM a lo largo del seguimiento. Comparando los pacientes con vs. sin buen COM, se obtuvo una menor mortalidad a largo plazo (16,8 vs. 28,2%; p=0,013), mejoría en la sintomatología (33,8 vs. 18,6%; p=0,002), y una menor proporción de pacientes con una PaCO2 persistentemente>50mmHg (14,2 vs. 33,9%; p<0,001). Conclusión: En el seguimiento de pacientes con VMNI domiciliaria en nuestro medio, unos valores definidos en la oximetría nocturna domiciliaria (buen COM) se asocia de forma positiva con una mejoría clínica, gasométrica y una mayor supervivencia a largo plazo


Introduction and objective: The effectiveness of home non-invasive mechanical ventilation (NIMV) is assessed by determining blood gas values in wakefulness, the evolution of their symptoms, and the monitoring of ventilation at night. The aim of our study is to evaluate whether defined values reached with outpatient monitoring by oximetry is related to the clinical, arterial gases and survival of a sample of patients with home NIMV. Material and method: Retrospective observational cohort study of a series of patients receiving home NIMV treatment for different causes. Patients with amyotrophic lateral sclerosis and less than 3 months of follow-up were excluded. The evolution of the patient's symptoms, their baseline arterial blood gases in wakefulness, and home nocturnal oximetry records, are evaluated at each outpatient visit. Good maintained oximetry control (MOC) was defined when mean O2 saturation values were reached and maintained until the last revision. Patient groups were considered, according to whether or not a good MOC was achieved during follow-up. Result: Four hundred patients were evaluated. Three hundred and sixty four (91%) were included in the study; their median age was 68 years, 51% were male. 37.6% had a good MOC during follow-up. Compared to patients with not good MOC, a better long-term mortality was obtained (16.8% vs 28.2%, P=.013), and an improvement in symptoms (33.8% vs 18.6%, P=.002) and a lower proportion of patients with persistently>50mmHg PaCO2 (14.2% vs. 33.9%, P<.001) was observed. Conclusion: In the follow-up of patients with home NIMV in our context, values defined in home nocturnal oximetry (good MOC) are positively associated with clinical, gasometric and longer-term survival


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Respiração Artificial/mortalidade , Ventilação não Invasiva/métodos , Serviços Hospitalares de Assistência Domiciliar , Insuficiência Respiratória/sangue , Oximetria/métodos , Vigília , Hiperventilação , Estudo Observacional , Estudos de Coortes , Respiração Artificial/métodos , Prognóstico , Insuficiência Respiratória/fisiopatologia , Monitorização Transcutânea dos Gases Sanguíneos/métodos
7.
Med Sci Monit ; 24: 4474-4480, 2018 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-29956691

RESUMO

BACKGROUND In our previous study, some changes were presented in obstetric care and we studied the morbidity and mortality trends of infants with <500 grams birth weight. Several neonatal protocol changes occurred during the study period. The aim of this study was to analyze the changes in mortality and morbidity of premature infants in light of changing neonatal protocols. MATERIAL AND METHODS We performed a retrospective study of premature infants with <500 grams birth weight, born at our department between 2006 and 2015. We divided the study period into two 5-year epochs and compared mortality and morbidity rates. We calculated the duration of mechanical ventilation and non-invasive respiratory support, and also investigated the potential impact of the differences in clinical practice. RESULTS The survival rate was 30.8% during first epoch, which was significantly lower than the 70.4% survival rate during second epoch. There was no difference in the rate of complications between the 2 epochs. The total number of ventilator and non-invasive ventilation days was significantly lower in the second epoch. CONCLUSIONS We found significant differences in survival rates but no change in the incidence of morbidities between the 2 epochs. Therefore, although the number of neonates surviving with morbidities has increased, so did the number of those with intact survival. The increased survival of infants born with <500 grams birth weight is not associated with increased rate of morbidities. Protocol changes may have contributed to these findings; however, in a retrospective study it is not possible to separate the impact of individual changes.


Assuntos
Recém-Nascido de muito Baixo Peso/fisiologia , Respiração Artificial/mortalidade , Insuficiência Respiratória/mortalidade , Peso ao Nascer , Feminino , Humanos , Lactente , Recém-Nascido de Baixo Peso , Recém-Nascido , Recém-Nascido Prematuro , Unidades de Terapia Intensiva Neonatal , Masculino , Morbidade , Respiração Artificial/tendências , Estudos Retrospectivos , Taxa de Sobrevida/tendências
8.
Lancet Respir Med ; 6(3): 183-192, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29325753

RESUMO

BACKGROUND: Animal models of serious infection suggest that 24 h of induced hypothermia improves circulatory and respiratory function and reduces mortality. We tested the hypothesis that a reduction of core temperature to 32-34°C attenuates organ dysfunction and reduces mortality in ventilator-dependent patients with septic shock. METHODS: In this randomised, controlled, open-label trial, we recruited patients from ten intensive care units (ICUs) in three countries in Europe and North America. Inclusion criteria for patients with severe sepsis or septic shock were a mean arterial pressure of less than 70 mm Hg, mechanical ventilation in an ICU, age at least 50 years, predicted length of stay in the ICU at least 24 h, and recruitment into the study within 6 h of fulfilling inclusion criteria. Exclusion criteria were uncontrolled bleeding, clinically important bleeding disorder, recent open surgery, pregnancy or breastfeeding, or involuntary psychiatric admission. We randomly allocated patients 1:1 (with variable block sizes ranging from four to eight; stratified by predictors of mortality, age, Acute Physiology and Chronic Health Evaluation II score, and study site) to routine thermal management or 24 h of induced hypothermia (target 32-34°C) followed by 48 h of normothermia (36-38°C). The primary endpoint was 30 day all-cause mortality in the modified intention-to-treat population (all randomly allocated patients except those for whom consent was withdrawn or who were discovered to meet an exclusion criterion after randomisation but before receiving the trial intervention). Patients and health-care professionals giving the intervention were not masked to treatment allocation, but assessors of the primary outcome were. This trial is registered with ClinicalTrials.gov, number NCT01455116. FINDINGS: Between Nov 1, 2011, and Nov 4, 2016, we screened 5695 patients. After recruitment of 436 of the planned 560 participants, the trial was terminated for futility (220 [50%] randomly allocated to hypothermia and 216 [50%] to routine thermal management). In the hypothermia group, 96 (44·2%) of 217 died within 30 days versus 77 (35·8%) of 215 in the routine thermal management group (difference 8·4% [95% CI -0·8 to 17·6]; relative risk 1·2 [1·0-1·6]; p=0·07]). INTERPRETATION: Among patients with septic shock and ventilator-dependent respiratory failure, induced hypothermia does not reduce mortality. Induced hypothermia should not be used in patients with septic shock. FUNDING: Trygfonden, Lundbeckfonden, and the Danish National Research Foundation.


Assuntos
Hipotermia Induzida/mortalidade , Insuficiência Respiratória/terapia , Choque Séptico/terapia , APACHE , Idoso , Europa (Continente) , Feminino , Humanos , Hipotermia Induzida/métodos , Unidades de Terapia Intensiva , Masculino , América do Norte , Respiração Artificial/métodos , Respiração Artificial/mortalidade , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/mortalidade , Choque Séptico/complicações , Choque Séptico/mortalidade , Resultado do Tratamento
9.
J Crit Care ; 43: 321-326, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29239831

RESUMO

PURPOSE: Multidrug-resistant (MDR) Gram-negative infection increases risk of mortality, other complications, and costs. The objective of this study was to determine the prevalence of and identify factors associated with in-hospital mortality among critically ill surgical patients. MATERIALS AND METHODS: This case-control study included critically ill surgical patients from 2011 to 2014 who had a carbapenem-resistant Enterobacteriaceae (CRE), MDR P. aeruginosa, or MDR Acinetobacter spp. infection. Characteristics of patients surviving to hospital discharge were compared to those of non-survivors. RESULTS: Sixty-two patients were included. Of these, 21 (33.9%) died prior to discharge. Vasopressors and mechanical ventilation prior to index culture were more common in non-survivors vs. survivors (76.2% vs. 46.3%, p=0.03; and 100% vs. 63.4%, p=0.001). ICU and hospital LOS prior to index culture was longer in non-survivors vs. survivors (median 19 vs. 4days, p=0.001; and median 25 vs. 7days, p=0.009). In multivariate logistic regression, achievement of source control was the only variable associated with decreased in-hospital mortality [0.04 (95% CI 0.003-0.52); p=0.01]. CONCLUSIONS: MDR Gram-negative infection is associated with significant in-hospital mortality among critically ill surgical patients. Source control, along with prior ICU LOS, mechanical ventilation status, vasopressor use, and definitive antibiotic choice, are important predictors of survival in this population.


Assuntos
Estado Terminal/mortalidade , Farmacorresistência Bacteriana Múltipla , Infecções por Bactérias Gram-Negativas/mortalidade , Mortalidade Hospitalar , Adulto , Idoso , Antibacterianos/uso terapêutico , Estudos de Casos e Controles , Feminino , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Humanos , Masculino , Maryland , Pessoa de Meia-Idade , Prevalência , Respiração Artificial/mortalidade , Fatores de Risco
10.
Respir Care ; 63(4): 380-387, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29208755

RESUMO

BACKGROUND: Increasing numbers of individuals are being initiated on home mechanical ventilation, including noninvasive (bi-level) and invasive mechanical ventilation delivered via tracheostomy due to chronic respiratory failure to enable symptom management and promote quality of life. Given the high care needs of these individuals, a better understanding of the indications for home mechanical ventilation, and health-care utilization is needed. METHODS: We performed a retrospective cohort study using provincial health administrative data from Ontario, Canada (population ∼13,000,000). Home mechanical ventilation users were characterized using health administrative data to determine the indications for home mechanical ventilation, the need for acute care at the time of ventilation approval, and their health service use and mortality rates following approval. RESULTS: The annual incidence of home mechanical ventilation approval rose from 1.8/100,000 in 2000 to 5.0/100,000 in 2012, or an annual increase of approximately 0.3/100,000 persons/y. The leading indications were neuromuscular disease, thoracic restriction, and COPD. The indication for the remainder could not be determined due to limitations of the administrative databases. Of the 4,670 individuals, 23.0% commenced home mechanical ventilation following an acute care hospitalization. Among individuals who survived at least 1 y, fewer required hospitalization in the year that followed home mechanical ventilation approval (29.9% vs 39.8%) as compared with the year prior. CONCLUSIONS: Utilization of home mechanical ventilation is increasing in Ontario, Canada, and further study is needed to clarify the factors contributing to this and to further optimize utilization of health-care resources.


Assuntos
Cuidados Críticos/métodos , Serviços de Assistência Domiciliar/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Respiração Artificial/métodos , Insuficiência Respiratória/terapia , Adulto , Idoso , Doença Crônica , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Ontário , Qualidade de Vida , Respiração Artificial/mortalidade , Insuficiência Respiratória/mortalidade , Estudos Retrospectivos
11.
Crit Care Med ; 46(1): e81-e86, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29068858

RESUMO

OBJECTIVES: The outcomes of critically ill patients who undergo interhospital transfer are not well understood. Physicians assume that patients who undergo interhospital transfer will receive more advanced care that may translate into decreased morbidity or mortality relative to a similar patient who is not transferred. However, there is little empirical evidence to support this assumption. We examined country-level U.S. data from the Nationwide Readmissions Database to examine whether, in mechanically ventilated patients with sepsis, interhospital transfer is associated with a mortality benefit. DESIGN: Retrospective data analysis using complex survey design regression methods with propensity score matching. SETTING: The Nationwide Readmissions Database contains information about hospital admissions from 22 States, accounting for roughly half of U.S. hospitalizations; the database contains linkage numbers so that admissions and transfers for the same patient can be linked across 1 year of follow-up. PATIENTS: From the 2013 Nationwide Readmission Database Sample, 14,325,172 hospital admissions were analyzed. There were 61,493 patients with sepsis and on mechanical ventilation. Of these, 1,630 patients (2.7%) were transferred during their hospitalization. A propensity-matched cohort of 1,630 patients who did not undergo interhospital transfer was identified. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The exposure of interest was interhospital transfer to an acute care facility. The primary outcome was hospital mortality; the secondary outcome was hospital length of stay. The propensity score included age, gender, insurance coverage, do not resuscitate status, use of renal replacement therapy, presence of shock, and Elixhauser comorbidities index. After propensity matching, interhospital transfer was not associated with a difference in in-hospital mortality (12.3% interhospital transfer vs 12.7% non-interhospital transfer; p = 0.74). However, interhospital transfer was associated with a longer total hospital length of stay (12.8 d interquartile range, 7.7-21.6 for interhospital transfer vs 9.1 d interquartile range, 5.1-17.0 for non-interhospital transfer; p < 0.01). CONCLUSIONS: Patients with sepsis requiring mechanical ventilation who underwent interhospital transfer did not have improved outcomes compared with a cohort with matched characteristics who were not transferred. The study raises questions about the risk-benefit profile of interhospital transfer as an intervention.


Assuntos
Avaliação de Resultados (Cuidados de Saúde)/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Respiração Artificial/mortalidade , Sepse/mortalidade , Sepse/terapia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Análise de Regressão , Estudos Retrospectivos , Web Semântica , Estados Unidos
12.
J Crit Care ; 43: 42-47, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28843663

RESUMO

OBJECTIVE: To determine the incidence, risk factors and outcomes of acute brain failure (ABF) in a mixed medical and surgical cohort of critically ill patients and its effect on ICU & hospital mortality. DESIGN: Observational electronic medical record (EMR) based retrospective cohort study of critically ill patients admitted to the ICU between 2006 and 2013. SETTING: Tertiary academic medical center. PATIENTS: Consecutive adult (>18years) critically ill patients admitted to medical and surgical ICUs. Patients admitted to the Neuroscience, Pediatric and Neonatal ICUs were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: ABF was defined by the presence of delirium (positive CAM-ICU) or depressed level of consciousness (by abnormal GCS and FOUR scores) in the absence of deep sedation (RASS<-3). Severity of ABF was categorized as grade I if there was delirium with GCS consistently >8 and grade II if the GCS was ≤8 with or without delirium during the ICU hospitalization. ABF duration was not used for this study. Univariate and multivariable analyses were used to access the factors associated with the development of ABF and its effect on short and long term mortality. Of 67,333 ICU patients included in the analysis, ABF was present in 30,610 (44.6%). Patients with ABF had an isolated delirium in 1985 (6.5%) patients, isolated depressed consciousness in 18,323 (59.9%), and both delirium and depressed consciousness in 10,302 (33.6%) patients. When adjusted for comorbidities and severity of illness ABF was associated with increased hospital (OR 3.47; 95% CI 3.19-3.79), and at one year (OR 2.36; 95% CI 2.24-2.50) mortality. Both hospital and one year mortality correlated with the increased severity of ABF. The factors most strongly associated with ABF were pre-admission dementia (OR 7.86; 95% CI 6.15-10.19) and invasive ventilation (OR 2.32; 95% CI 2.24-2.40) but older age, female sex, presence of liver disease, renal failure, diabetes mellitus, malignancy and COPD were also associated with increased risk of ABF. CONCLUSIONS: ABF is a common complication of critical illness and is associated with increased short and long term mortality. The risk of ABF was particularly high in older patients with baseline dementia, COPD, diabetes, liver and renal disease and those treated with invasive mechanical ventilation.


Assuntos
Transtornos da Consciência/fisiopatologia , Estado Terminal/mortalidade , Delírio/fisiopatologia , Adulto , Idoso , Comorbidade , Estado de Consciência , Transtornos da Consciência/diagnóstico , Transtornos da Consciência/mortalidade , Delírio/diagnóstico , Delírio/mortalidade , Diabetes Mellitus/fisiopatologia , Determinação de Ponto Final , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Unidades de Terapia Intensiva , Hepatopatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Insuficiência Renal Crônica/fisiopatologia , Respiração Artificial/mortalidade , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida
13.
Am J Emerg Med ; 36(2): 226-233, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28780231

RESUMO

BACKGROUND: The effects of high flow nasal cannula (HFNC) on adult patients when used before mechanical ventilation (MV) are unclear. We aimed to determine the effectiveness of HFNC when used before MV by comparison to conventional oxygen therapy (COT) and noninvasive positive pressure ventilation (NIPPV). METHODS: The Pubmed, Embase, Medline, Cochrane Central Register of Controlled Trials (CENTRAL) as well as the Information Sciences Institute (ISI) Web of Science were searched for all the controlled studies that compared HFNC with NIPPV and COT when used before MV in adult patients. The primary outcome was the rate of endotracheal intubation and the secondary outcomes were intensive care unit (ICU) mortality and length of ICU stay (ICU LOS). RESULTS: Eight trials with a total of 1084 patients were pooled in our final studies. No significant heterogeneity was found in outcome measures. Compared both with COT and NIPPV, HFNC could reduce both of the rate of endotracheal intubation (OR 0.62, 95% CI 0.38-0.99, P=0.05; OR 0.48, 95% CI 0.31-0.73, P=0.0006) and ICU mortality (OR 0.47, 95% CI 0.24-0.93, P=0.03; OR 0.36, 95% CI 0.20-0.63, P=0.0004). As for the ICU LOS, we did not find any advantage of HFNC over COT or NIPPV. CONCLUSIONS: When used before MV, HFNC can improve the prognosis of patients compared both with the COT and NIPPV.


Assuntos
Intubação Intratraqueal/estatística & dados numéricos , Respiração Artificial/métodos , Cânula , Ensaios Clínicos como Assunto , Cuidados Críticos/estatística & dados numéricos , Humanos , Intubação Intratraqueal/mortalidade , Oxigenoterapia/métodos , Oxigenoterapia/mortalidade , Respiração com Pressão Positiva/métodos , Respiração com Pressão Positiva/mortalidade , Respiração Artificial/mortalidade
14.
Trials ; 18(1): 574, 2017 Nov 29.
Artigo em Inglês | MEDLINE | ID: mdl-29187230

RESUMO

BACKGROUND: Delirium is a highly prevalent and morbid syndrome in intensive care units (ICUs). Changing the stressful environment within the ICU via music may be an effective and a scalable way to reduce the burden of delirium. METHODS/DESIGN: The Decreasing Delirium through Music (DDM) study is a three-arm, single-blind, randomized controlled feasibility trial. Sixty patients admitted to the ICU with respiratory failure requiring mechanical ventilation will be randomized to one of three arms (20 participants per arm): (1) personalized music, (2) non-personalized relaxing music, or (3) attention-control. Music preferences will be obtained from all enrolled participants or their family caregivers. Participants will receive two 1-h audio sessions a day through noise-cancelling headphones and mp3 players. Our primary aim is to determine the feasibility of the trial design (recruitment, adherence, participant retention, design and delivery of the music intervention). Our secondary aim is to estimate the potential effect size of patient-preferred music listening in reducing delirium, as measured by the Confusion Assessment Method for the ICU (CAM-ICU). Participants will receive twice daily assessments for level of sedation and presence of delirium. Enrolled participants will be followed in the hospital until death, discharge, or up to 28 days, and seen in the Critical Care Recovery Clinic at 90 days. DISCUSSION: DDM is a feasibility trial to provide personalized and non-personalized music interventions for critically ill, mechanically ventilated patients. Our trial will also estimate the preliminary efficacy of music interventions on reducing delirium incidence and severity. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier: NCT03095443 . Registered on 23 March 2017.


Assuntos
Estado Terminal/terapia , Delírio/prevenção & controle , Unidades de Terapia Intensiva , Musicoterapia/métodos , Música , Preferência do Paciente , Protocolos Clínicos , Estado Terminal/mortalidade , Estado Terminal/psicologia , Delírio/diagnóstico , Delírio/mortalidade , Delírio/psicologia , Estudos de Viabilidade , Feminino , Mortalidade Hospitalar , Humanos , Indiana , MP3-Player , Masculino , Pessoa de Meia-Idade , Musicoterapia/instrumentação , Alta do Paciente , Projetos Piloto , Projetos de Pesquisa , Respiração Artificial/efeitos adversos , Respiração Artificial/mortalidade , Fatores de Risco , Método Simples-Cego , Fatores de Tempo , Resultado do Tratamento
15.
Trials ; 18(1): 582, 2017 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-29197407

RESUMO

BACKGROUND: Postoperative pulmonary complications are a leading cause of morbidity and mortality after cardiac surgery. There are no recommendations on mechanical ventilation associated with cardiopulmonary bypass (CPB) during surgery and anesthesiologists perform either no ventilation (noV) at all during CPB or maintain low tidal volume (LTV) ventilation. Indirect evidence points towards better pulmonary outcomes when LTV is performed but no large-scale prospective trial has yet been published in cardiac surgery. DESIGN: The MECANO trial is a single-center, double-blind, randomized, controlled trial comparing two mechanical ventilation strategies, noV and LTV, during cardiac surgery with CPB. In total, 1500 patients are expected to be included, without any restrictions. They will be randomized between noV and LTV on a 1:1 ratio. The noV group will receive no ventilation during CPB. The LTV group will receive 5 breaths/minute with a tidal volume of 3 mL/kg and positive end-expiratory pressure of 5 cmH2O. The primary endpoint will be a composite of all-cause mortality, early respiratory failure defined as a ratio of partial pressure of oxygen/fraction of inspired oxygen <200 mmHg at 1 hour after arrival in the ICU, heavy oxygenation support (defined as a patient requiring either non-invasive ventilation, mechanical ventilation or high-flow oxygen) at 2 days after arrival in the ICU or ventilator-acquired pneumonia defined by the Center of Disease Control. Lung recruitment maneuvers will be performed in the noV and LTV groups at the end of surgery and at arrival in ICU with an insufflation at +30 cmH20 for 5 seconds. Secondary endpoints are those composing the primary endpoint with the addition of pneumothorax, CPB duration, quantity of postoperative bleeding, red blood cell transfusions, revision surgery requirements, length of stay in the ICU and in the hospital and total hospitalization costs. Patients will be followed until hospital discharge. DISCUSSION: The MECANO trial is the first of its kind to compare in a double-blind design, a no-ventilation to a low-tidal volume strategy for mechanical ventilation during cardiac surgery with CPB, with a primary composite outcome including death, respiratory failure and postoperative pneumonia. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03098524 . Registered on 27 February 2017.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Pneumopatias/prevenção & controle , Pulmão/fisiopatologia , Respiração Artificial/métodos , Volume de Ventilação Pulmonar , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/economia , Procedimentos Cirúrgicos Cardíacos/mortalidade , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/economia , Ponte Cardiopulmonar/mortalidade , Protocolos Clínicos , Método Duplo-Cego , França , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Tempo de Internação , Pneumopatias/economia , Pneumopatias/etiologia , Pneumopatias/fisiopatologia , Projetos de Pesquisa , Respiração Artificial/efeitos adversos , Respiração Artificial/economia , Respiração Artificial/mortalidade , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
16.
Anaesth Intensive Care ; 45(6): 663-675, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-29137575

RESUMO

Uncertainty surrounds the optimal approach to feeding the critically ill, with increasing interest in the concept of intentional underfeeding to reduce metabolic stress while maintaining gut integrity. Conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, this systematic review evaluates clinical outcomes reported in studies comparing hypocaloric normonitrogenous or trophic feeding (collectively 'intentional underfeeding') targeted full energy feeding administered via enteral nutrition to adult critically ill patients. Electronic databases including PubMed, CINAHL, EMBASE and CENTRAL were searched up to September 2017 for trials evaluating intentional underfeeding versus targeted energy feeding interventions on clinical outcomes (mortality, length of stay, duration of ventilation, infective complications, feeding intolerance and glycaemic control) among critically ill adult patients. Bias of included studies was assessed using the Cochrane risk of bias tool. Of the 595 articles identified, seven studies (six randomised controlled trials, one non-randomised trial) met the inclusion criteria, representing 2,684 patients (hypocaloric normonitrogenous n=668; trophic n=681; full energy feeding n=1335). Across the studies, there was considerable heterogeneity in study methodology, population, feeding strategy and outcomes and their timepoints. We observed no evidence that intentional underfeeding, when compared to targeting full energy feeding, reduced mortality or duration of ventilation or length of stay. However, limited trial evidence is available on the impact of intentional underfeeding on post-discharge functional and quality of life outcomes.


Assuntos
Estado Terminal/mortalidade , Ingestão de Energia , Nutrição Enteral , Adulto , Humanos , Infecção/mortalidade , Tempo de Internação , Respiração Artificial/mortalidade
17.
Cochrane Database Syst Rev ; 10: CD004427, 2017 10 06.
Artigo em Inglês | MEDLINE | ID: mdl-28982219

RESUMO

BACKGROUND: Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease, is a fatal neurodegenerative disease. Neuromuscular respiratory failure is the most common cause of death, which usually occurs within two to five years of the disease onset. Supporting respiratory function with mechanical ventilation may improve survival and quality of life. This is the second update of a review first published in 2009. OBJECTIVES: To assess the effects of mechanical ventilation (tracheostomy-assisted ventilation and non-invasive ventilation (NIV)) on survival, functional measures of disease progression, and quality of life in ALS, and to evaluate adverse events related to the intervention. SEARCH METHODS: We searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL Plus, and AMED on 30 January 2017. We also searched two clinical trials registries for ongoing studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs involving non-invasive or tracheostomy-assisted ventilation in participants with a clinical diagnosis of ALS, independent of the reported outcomes. We included comparisons with no intervention or the best standard care. DATA COLLECTION AND ANALYSIS: For the original review, four review authors independently selected studies for assessment. Two review authors reviewed searches for this update. All review authors independently extracted data from the full text of selected studies and assessed the risk of bias in studies that met the inclusion criteria. We attempted to obtain missing data where possible. We planned to collect adverse event data from the included studies. MAIN RESULTS: For the original Cochrane Review, the review authors identified two RCTs involving 54 participants with ALS receiving NIV. There were no new RCTs or quasi-RCTs at the first update. One new RCT was identified in the second update but was excluded for the reasons outlined below.Incomplete data were available for one published study comparing early and late initiation of NIV (13 participants). We contacted the trial authors, who were not able to provide the missing data. The conclusions of the review were therefore based on a single study of 41 participants comparing NIV with standard care. Lack of (or uncertain) blinding represented a risk of bias for participant- and clinician-assessed outcomes such as quality of life, but it was otherwise a well-conducted study with a low risk of bias.The study provided moderate-quality evidence that overall median survival was significantly different between the group treated with NIV and the standard care group. The median survival in the NIV group was 48 days longer (219 days compared to 171 days for the standard care group (estimated 95% confidence interval 12 to 91 days, P = 0.0062)). This survival benefit was accompanied by an enhanced quality of life. On subgroup analysis, in the subgroup with normal to moderately impaired bulbar function (20 participants), median survival was 205 days longer (216 days in the NIV group versus 11 days in the standard care group, P = 0.0059), and quality of life measures were better than with standard care (low-quality evidence). In the participants with poor bulbar function (21 participants), NIV did not prolong survival or improve quality of life, although there was significant improvement in the mean symptoms domain of the Sleep Apnea Quality of Life Index by some measures. Neither trial reported clinical data on intervention-related adverse effects. AUTHORS' CONCLUSIONS: Moderate-quality evidence from a single RCT of NIV in 41 participants suggests that it significantly prolongs survival, and low-quality evidence indicates that it improves or maintains quality of life in people with ALS. Survival and quality of life were significantly improved in the subgroup of people with better bulbar function, but not in those with severe bulbar impairment. Adverse effects related to NIV should be systematically reported, as at present there is little information on this subject. More RCT evidence to support the use of NIV in ALS will be difficult to generate, as not offering NIV to the control group is no longer ethically justifiable. Future studies should examine the benefits of early intervention with NIV and establish the most appropriate timing for initiating NIV in order to obtain its maximum benefit. The effect of adding cough augmentation techniques to NIV also needs to be investigated in an RCT. Future studies should examine the health economics of NIV. Access to NIV remains restricted in many parts of the world, including Europe and North America. We need to understand the factors, personal and socioeconomic, that determine access to NIV.


Assuntos
Esclerose Amiotrófica Lateral/mortalidade , Qualidade de Vida , Respiração Artificial/mortalidade , Insuficiência Respiratória/mortalidade , Esclerose Amiotrófica Lateral/complicações , Progressão da Doença , Humanos , Doença dos Neurônios Motores/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial/métodos , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , Análise de Sobrevida , Fatores de Tempo
18.
Trials ; 18(1): 488, 2017 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-29058596

RESUMO

BACKGROUND: Hydrogen gas inhalation (HI) improved survival and neurological outcomes in an animal model of post-cardiac arrest syndrome (PCAS). The feasibility and safety of HI for patients with PCAS was confirmed in a pilot study. The objective of this study is to evaluate the efficacy of HI for patients with PCAS. METHODS/DESIGN: The efficacy of inhaled HYdrogen on neurological outcome following BRain Ischemia During post-cardiac arrest care (HYBRID II) trial is an investigator-initiated, randomized, double-blind, placebo-controlled trial designed to enroll 360 adult comatose (Glasgow Coma Scale score < 8) patients who will be resuscitated following an out-of-hospital cardiac arrest of a presumed cardiac cause. The patients will be randomized (1:1) to either the HI or control group. Patients in the HI group will inhale 2% hydrogen with 24% to 50% oxygen, and those in the control group will inhale 24% to 50% oxygen for 18 h after admission via mechanical ventilation. Multidisciplinary post-arrest care, including targeted temperature management (TTM) between 33 °C and 36 °C, will be provided in accordance with the latest guidelines. The primary outcome of interest is the 90-day neurological outcome, as evaluated using the Cerebral Performance Categories scale (CPC). The secondary outcomes of interest are the 90-day survival rate and other neurological outcomes. This study will provide 80% power to detect a 15% change in the proportion of patients with good neurological outcomes (CPCs of 1 and 2), from 50% to 65%, with an overall significance level of 0.05. DISCUSSION: The first multicenter randomized trial is underway to confirm the efficacy of HI on neurological outcomes in comatose out-of-hospital cardiac arrest survivors. Our study has the potential to address HI as an appealing and innovative therapeutic strategy for PCAS in combination with TTM. TRIALS REGISTRATION: University Hospital Medical Information Network (UMIN), 000019820 . Registered on 17 November 2015.


Assuntos
Isquemia Encefálica/terapia , Hidrogênio/administração & dosagem , Parada Cardíaca Extra-Hospitalar/terapia , Respiração Artificial , Ressuscitação , Administração por Inalação , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Isquemia Encefálica/fisiopatologia , Protocolos Clínicos , Terapia Combinada , Método Duplo-Cego , Feminino , Escala de Coma de Glasgow , Humanos , Hidrogênio/efeitos adversos , Japão , Masculino , Pessoa de Meia-Idade , Exame Neurológico , Parada Cardíaca Extra-Hospitalar/diagnóstico , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Recuperação de Função Fisiológica , Projetos de Pesquisa , Respiração Artificial/efeitos adversos , Respiração Artificial/mortalidade , Ressuscitação/efeitos adversos , Ressuscitação/mortalidade , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
19.
Medicine (Baltimore) ; 96(37): e7776, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28906362

RESUMO

The aging population increases the demand of intensive care unit (ICU) treatments. However, the availability of ICU beds is limited. Thus, ICU admission of octogenarians is considered controversial. The population above 80 years is a very heterogeneous group though, and age alone might not be the best predictor. Aim of this study was to analyze resource consumption and outcome of octogenarians admitted to a medical ICU to identify reliable survival predictors in a senescent society.This retrospective observational study analyzes 930 octogenarians and 5732 younger patients admitted to a medical ICU. Admission diagnosis, APACHE II and SAPS II scores, use of ICU resources, and mortality were recorded. Long-term mortality was analyzed using Kaplan-Meier survival curves and multivariate cox regression analysis.Patients ≥80 years old had higher SAPS II (43 vs 38, P < .001) and APACHE II (23 vs 21, P = .001) scores. Consumption of ICU resources by octogenarians was lower in terms of length of stay, mechanical ventilation, and renal replacement therapy. Among octogenarians, ICU survivors got less mechanical ventilation or renal replacement therapy than nonsurvivors. Intra-ICU mortality in the very old was higher (19% vs 12%, P < .001) and long-term survival was lower (HR 1.76, P < .001). Multivariate cox regression analysis of octogenarians revealed that admission diagnosis of myocardial infarction (HR 1.713, P = .023), age (1.08, P = .002), and SAPS II score (HR 1.02, 95%, P = .01) were independent risk factors, whereas admission diagnoses monitoring post coronary intervention (HR .253, P = .002) and cardiac arrhythmia (HR .534, P = .032) had a substantially reduced mortality risk.Octogenarians show a higher intra-ICU and long-term mortality than younger patients. Still, they show a considerable life expectancy after ICU admission even though they get less invasive care than younger patients. Furthermore, some admission diagnoses like myocardial infarction, cardiac arrhythmia and monitoring post cardiac intervention are much stronger predictors for long-term survival than age or SAPS II score in the very old.


Assuntos
Mortalidade Hospitalar , Unidades de Terapia Intensiva , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Alemanha , Recursos em Saúde , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Modelos de Riscos Proporcionais , Terapia de Substituição Renal/mortalidade , Respiração Artificial/mortalidade , Estudos Retrospectivos , Índice de Gravidade de Doença , Centros de Atenção Terciária
20.
West J Emerg Med ; 18(5): 972-979, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28874952

RESUMO

INTRODUCTION: Due to hospital crowding, mechanically ventilated patients are increasingly spending hours boarding in emergency departments (ED) before intensive care unit (ICU) admission. This study aims to evaluate the association between time ventilated in the ED and in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS). METHODS: This was a multi-center, prospective, observational study of patients ventilated in the ED, conducted at three academic Level I Trauma Centers from July 2011 to March 2013. All consecutive adult patients on invasive mechanical ventilation were eligible for enrollment. We performed a Cox regression to assess for a mortality effect for mechanically ventilated patients with each hour of increasing LOS in the ED and multivariable regression analyses to assess for independently significant contributors to in-hospital mortality. Our primary outcome was in-hospital mortality, with secondary outcomes of ventilator days, ICU LOS and hospital LOS. We further commented on use of lung protective ventilation and frequency of ventilator changes made in this cohort. RESULTS: We enrolled 535 patients, of whom 525 met all inclusion criteria. Altered mental status without respiratory pathology was the most common reason for intubation, followed by trauma and respiratory failure. Using iterated Cox regression, a mortality effect occurred at ED time of mechanical ventilation > 7 hours, and the longer ED stay was also associated with a longer total duration of intubation. However, adjusted multivariable regression analysis demonstrated only older age and admission to the neurosciences ICU as independently associated with increased mortality. Of interest, only 23.8% of patients ventilated in the ED for over seven hours had changes made to their ventilator. CONCLUSION: In a prospective observational study of patients mechanically ventilated in the ED, there was a significant mortality benefit to expedited transfer of patients into an appropriate ICU setting.


Assuntos
Serviço Hospitalar de Emergência , Respiração Artificial/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Transferência de Pacientes , Estudos Prospectivos , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos , Fatores de Tempo , Adulto Jovem
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA