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1.
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
2.
Clin Exp Hypertens ; 42(1): 16-23, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-30554536

RESUMO

Objective: The aim of this study was to assess indices of a comprehensive panel of central aortic pressure and arterial stiffness for prediction of cardiovascular events in a hypertensive cohort.Methods: Noninvasive measurements of central aortic blood pressure, brachial pressure, wave reflection augmentation index, pressure amplification, pulse wave velocity (PWV) and carotid intima-media thickness (IMT) were obtained in 675 hypertensive patients (age 61 ± 9 years, 425 males) for a mean follow-up period 25 ± 4 months. The primary endpoints were defined as cardiovascular disease (CVD) events or death from CVD.Results: After adjusting for confounding factors, central systolic (cSBP) and pulse pressure (cPP) showed higher hazard ratios (HR/10 mmHg) for cardiovascular events (CV) compared to peripheral pressure indices (pSBP, pPP) at age >60 years (cSBP: HR = 1.18, pSBP: HR = 1.17, p = 0.034; cPP: HR = 1.28, pPP: HR = 1.2, p = 0.019). Each SD increase in IMT and in central augmented pressure (cAP) entailed a 1.4 times higher risk of increased total events in elderly patients (age >60 years). For males, each SD increase in cAP was associated with 1.36 times higher risk of increased total events. For females, each SD increase in cAIx and cAP was associated with 0.4 and 0.5 times lower risk of increased total and major CV, respectively. This sex difference is most likely due to lack of age-related increase of cAIx in females after age >60 years compared to males.Conclusions: Central pressure improved prediction of CVD compared to peripheral pressure during a relatively short-term follow up of approximately 2 years at age >60 years.


Assuntos
Pressão Arterial , Hipertensão/fisiopatologia , Rigidez Vascular , Idoso , Angina Instável/epidemiologia , Aorta , Determinação da Pressão Arterial , Espessura Intima-Media Carotídea , Ponte de Artéria Coronária/estatística & dados numéricos , Morte Súbita Cardíaca/epidemiologia , Feminino , Seguimentos , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Intervenção Coronária Percutânea/estatística & dados numéricos , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Análise de Onda de Pulso , Ressuscitação/estatística & dados numéricos , Acidente Vascular Cerebral/epidemiologia
4.
Emerg Med J ; 36(9): 529-534, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31326954

RESUMO

BACKGROUND: Trauma team activation criteria have a variable performance in the paediatric population. We aimed to identify predictors for high-level resource utilisation during trauma resuscitation in the ED. METHODS: A retrospective study was conducted in the ED of a tertiary paediatric hospital. Patient data were collected from trauma surveillance registry and analysis was performed to identify significant predictors. We then assessed the sensitivity and specificity of proposed models with respect to observed patient outcomes. RESULTS: Among 11 282 cases, the mean age was 6.1±4.9 (SD) years old. Fall was the most common mechanism of injury in 7364 (65.3%) patients. Eighty-eight (0.8%) patients required at least one high-level resource. Significant predictors for high-resource utilisation were overall GCS of <14 (relative risk (RR) 38.841, 95% CI 21.328 to 70.739, p<0.001), high-risk mechanisms of fall from height and motor vehicle collision (RR 7.863, 95% CI 4.687 to 13.192, p<0.001), as well as age-specific tachycardia (RR 1.796, 95% CI 1.145 to 2.817, p=0.0108). A model consisting of GCS and high-risk mechanism would under-triage 21 (0.2%) patients and over-triage 681 (6.0%) patients. When age-specific tachycardia was added, 8 (0.1%) less patients would be under-triaged but an additional 3251 (28.9%) patients would be over-triaged. CONCLUSION: As utilisation of high-level resources in paediatric trauma was rare, it was difficult to find an appropriate balance between under-triage and over-triage. Between the two, minimising the proportion of under-triage is more important as patient safety is paramount in paediatric trauma care.


Assuntos
Utilização de Instalações e Serviços/estatística & dados numéricos , Fidelidade a Diretrizes/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Ressuscitação/estatística & dados numéricos , Ferimentos e Lesões/terapia , Criança , Pré-Escolar , Utilização de Instalações e Serviços/organização & administração , Utilização de Instalações e Serviços/normas , Feminino , Escala de Coma de Glasgow/estatística & dados numéricos , Hospitais Pediátricos/organização & administração , Hospitais Pediátricos/normas , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Masculino , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/organização & administração , Padrões de Prática Médica/normas , Sistema de Registros/estatística & dados numéricos , Ressuscitação/normas , Estudos Retrospectivos , Singapura , Centros de Atenção Terciária/organização & administração , Centros de Atenção Terciária/normas , Centros de Atenção Terciária/estatística & dados numéricos , Centros de Traumatologia/organização & administração , Centros de Traumatologia/normas , Centros de Traumatologia/estatística & dados numéricos , Triagem/organização & administração , Triagem/normas , Triagem/estatística & dados numéricos , Ferimentos e Lesões/diagnóstico
5.
J Nurs Adm ; 49(7-8): 372-376, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31335519

RESUMO

Creating nurse-driven protocols empower nurses to practice at the top of their scope and provide early interventions. This article describes the development and implementation of an evidence-based, nurse-driven resuscitation protocol for cardiac surgical patients who suffer cardiac arrest using a theoretical framework and leadership-driven process. Readers will gain knowledge of the collaborative process required to develop and implement a complex practice change. Process measures, outcomes, and lessons learned are presented.


Assuntos
Enfermagem Baseada em Evidências , Implementação de Plano de Saúde/organização & administração , Enfermeiras Administradoras , Ressuscitação/métodos , Parada Cardíaca , Humanos , Unidades de Terapia Intensiva , Melhoria de Qualidade , Ressuscitação/estatística & dados numéricos , Sobrevida
6.
Crit Care ; 23(1): 259, 2019 07 23.
Artigo em Inglês | MEDLINE | ID: mdl-31337421

RESUMO

BACKGROUND: Intravenous fluids, an essential component of sepsis resuscitation, may paradoxically worsen outcomes by exacerbating endothelial injury. Preclinical models suggest that fluid resuscitation degrades the endothelial glycocalyx, a heparan sulfate-enriched structure necessary for vascular homeostasis. We hypothesized that endothelial glycocalyx degradation is associated with the volume of intravenous fluids administered during early sepsis resuscitation. METHODS: We used mass spectrometry to measure plasma heparan sulfate (a highly sensitive and specific index of systemic endothelial glycocalyx degradation) after 6 h of intravenous fluids in 56 septic shock patients, at presentation and after 24 h of intravenous fluids in 100 sepsis patients, and in two groups of non-infected patients. We compared plasma heparan sulfate concentrations between sepsis and non-sepsis patients, as well as between sepsis survivors and sepsis non-survivors. We used multivariable linear regression to model the association between volume of intravenous fluids and changes in plasma heparan sulfate. RESULTS: Consistent with previous studies, median plasma heparan sulfate was elevated in septic shock patients (118 [IQR, 113-341] ng/ml 6 h after presentation) compared to non-infected controls (61 [45-79] ng/ml), as well as in a second cohort of sepsis patients (283 [155-584] ng/ml) at emergency department presentation) compared to controls (177 [144-262] ng/ml). In the larger sepsis cohort, heparan sulfate predicted in-hospital mortality. In both cohorts, multivariable linear regression adjusting for age and severity of illness demonstrated a significant association between volume of intravenous fluids administered during resuscitation and plasma heparan sulfate. In the second cohort, independent of disease severity and age, each 1 l of intravenous fluids administered was associated with a 200 ng/ml increase in circulating heparan sulfate (p = 0.006) at 24 h after enrollment. CONCLUSIONS: Glycocalyx degradation occurs in sepsis and septic shock and is associated with in-hospital mortality. The volume of intravenous fluids administered during sepsis resuscitation is independently associated with the degree of glycocalyx degradation. These findings suggest a potential mechanism by which intravenous fluid resuscitation strategies may induce iatrogenic endothelial injury.


Assuntos
Endotélio/fisiopatologia , Hidratação/efeitos adversos , Glicocálix/efeitos dos fármacos , Sepse/tratamento farmacológico , Administração Intravenosa , Adulto , Idoso , Angiopoietina-2/análise , Angiopoietina-2/sangue , Fator Natriurético Atrial/análise , Fator Natriurético Atrial/sangue , Biomarcadores/análise , Biomarcadores/sangue , Endotélio/efeitos dos fármacos , Endotélio/metabolismo , Feminino , Hidratação/métodos , Hidratação/estatística & dados numéricos , Glicocálix/metabolismo , Heparitina Sulfato/análise , Heparitina Sulfato/sangue , Humanos , Masculino , Espectrometria de Massas/métodos , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/análise , Peptídeo Natriurético Encefálico/sangue , Ressuscitação/efeitos adversos , Ressuscitação/métodos , Ressuscitação/estatística & dados numéricos , Sepse/sangue , Sepse/fisiopatologia , Sindecana-1/análise , Sindecana-1/sangue , Trombomodulina/análise , Trombomodulina/sangue , Ativador de Plasminogênio Tecidual/análise , Ativador de Plasminogênio Tecidual/sangue , Receptor 1 de Fatores de Crescimento do Endotélio Vascular/análise , Receptor 1 de Fatores de Crescimento do Endotélio Vascular/sangue
7.
Obstet Gynecol ; 133(6): 1199-1207, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31135735

RESUMO

OBJECTIVE: To evaluate the cost effectiveness of three different approaches to the care of neonates born at 22 weeks of gestation: universal resuscitation, selective resuscitation, or no resuscitation. METHODS: We constructed a decision-analytic model using TreeAge to compare the outcomes of death and survival with and without neurodevelopmental impairment in a theoretical cohort of 5,176 neonates (an estimate of the annual number of deliveries that occur in the 22nd week of gestation in the United States). We took a societal perspective using a lifetime horizon, and all costs were expressed in 2017 U.S. dollars. Effectiveness was based on combined maternal and neonatal quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio was determined (cost/QALY) for each additional survivor. The willingness to pay threshold was set at $100,000/QALY. All model inputs were derived from the literature. Deterministic and probabilistic sensitivity analyses were performed to interrogate model assumptions. RESULTS: Universal resuscitation would result in 373 survivors, 123 of whom would have severe disability. Selective resuscitation would produce 78 survivors with 26 affected by severe impairments. No resuscitation would result in only eight survivors and three neonates with severe sequelae. Selective resuscitation was eliminated by extended dominance because this strategy had a higher incremental cost-effectiveness ratio than universal resuscitation, which was a more effective intervention. The incremental cost-effectiveness ratio of universal resuscitation compared with no resuscitation was not cost effective at $106,691/QALY. Monte Carlo simulations demonstrated that universal resuscitation is more effective but also more expensive compared with no resuscitation, with only 35% of simulations below the willingness to pay threshold. CONCLUSION: In our model, neither selective nor universal resuscitation of 22-week neonates is a cost-effective strategy compared with no resuscitation.


Assuntos
Análise Custo-Benefício , Lactente Extremamente Prematuro , Ressuscitação/economia , Ressuscitação/estatística & dados numéricos , Estudos de Coortes , Técnicas de Apoio para a Decisão , Idade Gestacional , Humanos , Recém-Nascido de Peso Extremamente Baixo ao Nascer , Recém-Nascido , Terapia Intensiva Neonatal/economia , Anos de Vida Ajustados por Qualidade de Vida , Resultado do Tratamento , Estados Unidos
8.
Emerg Med J ; 36(6): 333-339, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31003991

RESUMO

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is prevalent in the UK. Reported survival is lower than in countries with comparable healthcare systems; a better understanding of outcome determinants may identify areas for improvement. METHODS: An analysis of 9109 OHCA attended in East of England between 1 January 2015 and 31 July 2017. Univariate descriptives and multivariable analysis were used to understand the determinants of survival for non-traumatic cardiac arrest (NTCA) and traumatic cardiac arrest (TCA). Two Utstein outcome variables were used: survival to hospital admission and hospital discharge. RESULTS: The incidence of OHCA was 55.1 per 100 000 population/year. The overall survival to hospital admission was 27.6% (95% CI 26.7% to 28.6%) and the overall survival to discharge was 7.9% (95% CI 7.3% to 8.5%). Survival to hospital admission and survival to hospital discharge were both greater in the NTCA group compared with the TCA group: 27.9% vs 19.3% p=0.001, and 8.0% vs 3.8% p=0.012 respectively.Determinants of NTCA and TCA survival were different, and varied according to the outcome examined. In NTCA, bystander cardiopulmonary resuscitation (CPR) was associated with survival at discharge but not at admission, and the likelihood of bystander CPR was dependent on geographical socioeconomic status. An air ambulance was associated with increased survival to both hospital admission and discharge in NTCA, but only with survival to admission in TCA. CONCLUSION: NTCA and TCA are clinically distinct entities with different predictors for outcome-future OHCA reports should aim to separate arrest aetiologies. Determinants of survival to hospital admission and discharge differ in a way that likely reflects the determinants of neurological injury. Bystander CPR public engagement may be best focused in more deprived areas.


Assuntos
Serviços Médicos de Emergência/métodos , Parada Cardíaca Extra-Hospitalar/mortalidade , Ressuscitação/métodos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Serviços Médicos de Emergência/normas , Serviços Médicos de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Sistema de Registros/estatística & dados numéricos , Ressuscitação/normas , Ressuscitação/estatística & dados numéricos , Estudos Retrospectivos , Análise de Sobrevida
9.
Crit Care ; 23(1): 118, 2019 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-30987647

RESUMO

BACKGROUND: We hypothesized that the cardiovascular responses to Surviving Sepsis Guidelines (SSG)-defined resuscitation are predictable based on the cardiovascular state. METHODS: Fifty-five septic patients treated by SSG were studied before and after volume expansion (VE), and if needed norepinephrine (NE) and dobutamine. We measured mean arterial pressure (MAP), cardiac index (CI), and right atrial pressure (Pra) and calculated pulse pressure and stroke volume variation (PPV and SVV), dynamic arterial elastance (Eadyn), arterial elastance (Ea) and left ventricular (LV) end-systolic elastance (Ees), Ees/Ea (VAC), LV ejection efficiency (LVeff), mean systemic pressure analogue (Pmsa), venous return pressure gradient (Pvr), and cardiac performance (Eh), using standard formulae. RESULTS: All patients were hypotensive (MAP 56.8 ± 3.1 mmHg) and tachycardic (113.1 ± 7.5 beat min-1), with increased lactate levels (lactate = 5.0 ± 4.2 mmol L-1) with a worsened VAC. CI was variable but > 2 L min-1 M-2 in 74%. Twenty-eight-day mortality was 48% and associated with admission lactate, blood urea nitrogen (BUN), and creatinine levels but not cardiovascular state. In all patients, both MAP and CI improved following VE, as well as cardiac contractility (Ees). Fluid administration improved Pra, Pmsa, and Pvr in all patients, whereas both HR and Ea decreased after VE, thus normalizing VAC. CI increases were proportional to baseline PPV and SVV. CI increases proportionally decreased PPV and SVV. VE increased MAP > 65 mmHg in 35/55 patients. MAP responders had higher PPV, SVV, and Eadyn than non-responders. NE was given to 20/55 patients in septic shock, but increased MAP > 65 mmHg in only 12. NE increased Ea, Eadyn, Pra, Pmsa, and VAC while decreasing HR, PPV, SVV, and LVeff. MAP responders had higher pre-NE Ees and lower VAC. Dobutamine was given to 6/8 patients who remained hypotensive following NE. It increased Ees, MAP, CI, and LVeff, while decreasing HR, Pra, and VAC. At all times and all steps of the protocol, CI changes were proportional to Pvr changes independent of treatment. CONCLUSIONS: The cardiovascular response to SSG-based resuscitation is highly heterogeneous but predictable from pre-treatment measures of cardiovascular state.


Assuntos
Fenômenos Fisiológicos Cardiovasculares , Ressuscitação/normas , Sepse/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Débito Cardíaco/fisiologia , Cardiotônicos/uso terapêutico , Dobutamina/uso terapêutico , Feminino , Frequência Cardíaca/efeitos dos fármacos , Hemodinâmica/efeitos dos fármacos , Humanos , Hipotensão/tratamento farmacológico , Hipotensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Norepinefrina/uso terapêutico , Ressuscitação/métodos , Ressuscitação/estatística & dados numéricos , Sepse/tratamento farmacológico , Choque Séptico/tratamento farmacológico , Choque Séptico/fisiopatologia , Estatísticas não Paramétricas , Volume Sistólico/fisiologia , Vasoconstritores/uso terapêutico
10.
Surgery ; 165(6): 1122-1127, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30871812

RESUMO

BACKGROUND: Women are underrepresented in trauma research, and aggregated results of clinical trials may mask effects that differ by sex. It is unclear whether women respond differently to severe hemorrhage compared with men. We sought to evaluate sex-based differences in outcomes after severe trauma with hemorrhage. METHODS: We performed a secondary analysis of the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial. Trauma patients predicted to require massive transfusion were randomized to a 1:1:1 vs 1:1:2 plasma to platelet to red blood cell transfusion ratio. Analysis was performed according to sex, controlling for clinical characteristics and transfusion arm. RESULTS: A total of 134 women and 546 men were analyzed. In multivariable analysis, there was no difference in mortality at 24 hours (hazard ratio for women 0.64, 95% confidence interval 0.34-1.23, P = .18) or in time to hemostasis (hazard ratio 1.10, 95% confidence interval 0.84-1.42, P = .49) by sex. We observed no difference between sexes in volume of blood products transfused during active hemorrhage. However, after anatomic hemostasis, women received lower volumes of all products, with a 38% reduction in fresh frozen plasma (mean ratio 0.62 (95% confidence interval 0.43-0.89, P = .01), 49% reduction in platelets (mean ratio 0.51, 95% confidence interval 0.33-0.79, P < .01) and 49% reduction in volume of red blood cells (mean ratio 0.51, 95% confidence interval 0.33-0.79, P < .01). CONCLUSION: Mortality and time to hemostasis of trauma patients with hemorrhage did not differ by sex. Although there was no difference in transfusion requirement during active hemorrhage, once hemostasis was achieved, women received fewer units of all blood products than men. Further research is required to determine whether women exhibit differences in coagulation during and after severe traumatic hemorrhage.


Assuntos
Transfusão de Eritrócitos/estatística & dados numéricos , Hemorragia/terapia , Transfusão de Plaquetas/estatística & dados numéricos , Ressuscitação/métodos , Ferimentos e Lesões/complicações , Adulto , Feminino , Hemorragia/etiologia , Hemorragia/mortalidade , Técnicas Hemostáticas/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Ressuscitação/estatística & dados numéricos , Estudos Retrospectivos , Fatores Sexuais , Tempo para o Tratamento , Índices de Gravidade do Trauma , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/terapia , Adulto Jovem
11.
World J Surg ; 43(7): 1700-1707, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30824958

RESUMO

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has the potential to be an alternative to open aortic cross-clamping (ACC). However, its practical indication remains unknown. We examined the usage trend of REBOA and ACC in Japan for severe torso trauma and investigated whether these procedures were associated with the time of death distribution based on a large database from the Japan Trauma Data Bank (JTDB). METHODS: The JTDB from 2004 to 2014 was reviewed. Eligible patients were restricted to those with severe torso trauma, which was defined as an abbreviated injury scale score of ≥4. Patients were classified into groups according to the aortic occlusion procedures. The primary outcomes were the rates of REBOA and ACC use according to the clinical situation. We also evaluated whether the time of death distribution for the first 8 h differed based on these procedures. RESULTS: During the study period, a total of 21,533 patients met our inclusion criteria. Overall, REBOA was more commonly used than ACC for patients with severe torso trauma (2.8% vs 1.5%). However, ACC was more frequently used in cases of thoracic injury and cardiac arrest. Regarding the time of death distribution, the cumulative curve for death in REBOA cases was elevated much more slowly and mostly flat for the first 100 min. CONCLUSIONS: REBOA is more commonly used compared to ACC for patients with severe torso trauma in Japan. Moreover, it appears that REBOA influences the time of death distribution in the hyperacute phase.


Assuntos
Oclusão com Balão/estatística & dados numéricos , Morte , Procedimentos Endovasculares/estatística & dados numéricos , Ressuscitação/métodos , Traumatismos Torácicos/terapia , Tronco/lesões , Escala Resumida de Ferimentos , Adulto , Idoso , Idoso de 80 Anos ou mais , Aorta , Bases de Dados Factuais , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Ressuscitação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Tempo , Adulto Jovem
12.
BMC Pregnancy Childbirth ; 19(1): 83, 2019 Feb 28.
Artigo em Inglês | MEDLINE | ID: mdl-30819143

RESUMO

BACKGROUND: The first one month of life; the neonatal period is the most risky time for child survival. In Ethiopia, neonatal mortality is unacceptably high, and the trend in reduction is slower as compared to infant and child mortality. The magnitude and associated factors of neonatal mortality in a tertiary care facility were not well documented. Therefore, the aim of this study was to determine neonatal mortality and predictors among neonates admitted to neonatal intensive care unit of Wolaita Sodo University Teaching and Referral Hospital, South Ethiopia. METHODS: A retrospective cohort study design was done among neonates admitted to neonatal intensive care unit of a University Teaching and Referral Hospital from 2015 to 2017. Data were collected using data extraction checklist from the medical registry. The main outcome was the occurrence of death within the first four weeks. The survival time was calculated in days between the date of admission and the date of death. Kaplan-Meier survival was used to depict the pattern of death in 28 days and Cox-Proportional model was used to identify the predictors of the neonatal mortality. RESULTS: A total of 964 neonates which contributed to 5889 neonates-days were included in the study. There were 159 neonatal deaths during the follow-up time. Overall, the neonatal mortality incidence was 27 per 1000 neonates-days. Predictors of neonatal mortality were: multiple birth, mothers who did not attend antenatal care visits, neonates born by cesarean section, not initiated breast feeding within 1 h of birth, neonates resuscitated, hyaline membrane disease and perinatal asphyxia. CONCLUSION: Neonatal mortality at neonatal intensive care unit was high. Managing neonatal complications, initiating breast feeding within 1 h of birth, promoting antenatal care visits, improving quality of services and ensuring continuum of care are recommended to increase survival of neonates.


Assuntos
Países em Desenvolvimento/estatística & dados numéricos , Mortalidade Infantil , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Centros de Atenção Terciária/estatística & dados numéricos , Asfixia Neonatal/mortalidade , Aleitamento Materno/estatística & dados numéricos , Cesárea/estatística & dados numéricos , Etiópia/epidemiologia , Feminino , Hospitais Universitários/estatística & dados numéricos , Humanos , Doença da Membrana Hialina/mortalidade , Incidência , Lactente , Recém-Nascido , Estimativa de Kaplan-Meier , Masculino , Gravidez , Gravidez Múltipla/estatística & dados numéricos , Cuidado Pré-Natal/estatística & dados numéricos , Modelos de Riscos Proporcionais , Ressuscitação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
13.
Eur J Pediatr ; 178(6): 851-861, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30900074

RESUMO

We aimed to correlate amplitude-integrated EEG (aEEG) in neonatal hypoxic ischemic encephalopathy (HIE) with early magnetic resonance imaging (MRI). In this retrospective study, 32 neonates over 35 weeks' gestation with moderate/severe HIE who were treated with hypothermia were included. Early MRI scans and daily aEEG background were categorized to mild/normal, moderate, and severely abnormal. Time to sleep cycling was noted on aEEG. Mantel-Haenszel test for trends was used to explore associations between aEEG and MRI and outcome. LOESS regression was used for exploring the association of cycling with MRI scores. MRI was normal/mildly abnormal in 20 (63%) infants; in 9 (28%), moderately abnormal; and in 3 (9%), severely abnormal. Twenty-seven (84%) infants s urvived. MRI severity score was significantly associated with aEEG background score on the third and fourth days of life (p < 0.01). An increase in the MRI severity score was noted if sleep cycling appeared after the fifth day of life.Conclusions: Depressed aEEG at the third and fourth days of life and appearance of cycling beyond the fifth day of life are associated with cerebral MRI abnormalities and may be associated with increased risk of abnormal outcome. What is known: • Since therapeutic hypothermia has been shown to change long-term outcome, amplitude-integrated EEG in infants with hypoxic ischemic neonatal encephalopathy soon after birth have a limited predictive power for long-term outcome in treated infants. • Brain MRI after therapeutic hypothermia in the above infants has a significant predictive value for long-term outcome What is new: • Background amplitude-integrated EEG activity depression at the age of 3 and 4 days and delay of appearance of cycling activity are associated with worse MRI scores and may be predictive of worse long-term outcome.


Assuntos
Eletroencefalografia/métodos , Hipóxia-Isquemia Encefálica/diagnóstico por imagem , Imagem por Ressonância Magnética/métodos , Eletroencefalografia/estatística & dados numéricos , Feminino , Humanos , Hipotermia Induzida/métodos , Hipotermia Induzida/mortalidade , Hipóxia-Isquemia Encefálica/mortalidade , Hipóxia-Isquemia Encefálica/terapia , Recém-Nascido , Doenças do Recém-Nascido , Imagem por Ressonância Magnética/estatística & dados numéricos , Masculino , Ressuscitação/estatística & dados numéricos , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do Tratamento
14.
P R Health Sci J ; 38(1): 8-14, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30924909

RESUMO

OBJECTIVE: Severe sepsis and Septic Shock may progress in the first hours after presentation and has been associated with an increased mortality. Prompt recognition and treatment of early septic shock (ESS) may improve survival. The purpose of our study was to describe the monitoring and management strategies of ESS, within Intensive Care Units (ICU) in Puerto Rico (PR). METHODS: In order to achieve our objective, a self-administered survey, previously validated by the Canadian Critical Care Trials Group, was administered to 25 physicians during a Critical Care Medicine (CCM) Meeting. Questions about usual monitoring and resuscitation end-points were administered. RESULTS: Most of the participants were affiliated to community hospitals (84%) and 92% were pulmonary or CCM specialists, with more than 15 years of working experience (80%). Monitoring devices and parameters mostly used by at least 85% of the respondents were: Oxygen Saturation, Foley catheters, Telemetry, Heart Rate, Blood Pressure, and Urinary Output. Intra-arterial lines and Central Venous Pressure were less used. Most use normal saline (96%), as the initial fluid of resuscitation. Only 24% would use inotropes to improve perfusion. CONCLUSION: Significant variability exists in the management of ESS among physicians in the ICU in PR. Compared to other studies, fewer physicians in PR use invasive monitoring techniques. These results highlight the need for quality education and training in CCM as well as continuing education in the field.


Assuntos
Cuidados Críticos/métodos , Médicos/estatística & dados numéricos , Ressuscitação/métodos , Choque Séptico/terapia , Adulto , Cuidados Críticos/estatística & dados numéricos , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Porto Rico , Ressuscitação/estatística & dados numéricos
15.
Am J Emerg Med ; 37(1): 94-99, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-29753547

RESUMO

BACKGROUND: During the past 17 years of conflict the deployed US military health care system has found new and innovative ways to reduce combat mortality down to the lowest case fatality rate in US history. There is currently a data dearth of emergency department (ED) care delivered in this setting. We seek to describe ED interventions in this setting. METHODS: We used a series of ED procedure codes to identify subjects within the Department of Defense Trauma Registry from January 2007 to August 2016. RESULTS: During this time, 28,222 met inclusion criteria. The median age of causalities in this dataset was 25 years and most (96.9%) were male, US military (41.3%), and part of Operation Enduring Freedom (66.9%). The majority survived to hospital discharge (95.5%). Most subjects sustained injuries by explosives (55.3%) and gunshot wound (GSW). The majority of subjects had an injury severity score that was considered minor (74.1%), while the preponderance of critically injured casualties sustained injuries by explosive (0.7%). Based on AIS, the most frequently seriously injured body region was the extremities (23.9%). The bulk of administered blood products were packed red blood cells (PRBC, 26.4%). Endotracheal intubation was the most commonly performed critical procedure (11.9%). X-ray (79.9%) was the most frequently performed imaging study. CONCLUSIONS: US military personnel comprised the largest proportion of combat casualties and most were injured by explosive. Within this dataset, ED providers most frequently performed endotracheal intubation, administered blood products, and obtained diagnostic imaging studies.


Assuntos
Serviço Hospitalar de Emergência , Tratamento de Emergência/estatística & dados numéricos , Medicina Militar/estatística & dados numéricos , Militares , Ressuscitação/estatística & dados numéricos , Lesões Relacionadas à Guerra/epidemiologia , Lesões Relacionadas à Guerra/terapia , Adulto , Campanha Afegã de 2001- , Serviço Hospitalar de Emergência/organização & administração , Feminino , Humanos , Escala de Gravidade do Ferimento , Guerra do Iraque 2003-2011 , Masculino , Estados Unidos , Lesões Relacionadas à Guerra/mortalidade , Adulto Jovem
16.
Transfus Clin Biol ; 26(1): 18-26, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29936040

RESUMO

OBJECTIVES: The European trauma guidelines were developed to assist clinicians in the early phase of trauma management to diagnose and treat coagulopathy and bleeding. This study aimed to determine compliance with these European trauma guidelines in a French referral trauma centre. METHODS: Medical charts of trauma patients with an injury severity score≥16 admitted between January 2013 and December 2014 were reviewed. Compliance with 21 recommendations in the first 24-hours of patient management was assessed. RESULTS: There were 145 patients with median ISS of 34 [IQR 25-41]. A good level of compliance (i.e. applied in≥80% of patients) was identified for nine recommendations, inconsistent compliance (i.e. applied in 50 to 79% of patients) for six recommendations, including fibrinogen levels at hospital admission and achievement of a target mean arterial blood pressure (MAP)>80mmHg in patients with major bleeding and TBI (55.5%), and poor compliance (i.e. applied in<50% of patients) for another six recommendations. Poorly applied recommendations included early measurement of lactate or base deficit (32%), early administration of tranexamic acid (18%), and achievement of normocapnia in patients with TBI undergoing invasive ventilation (3%). CONCLUSIONS: In a referral trauma centre, nine of the 21 evaluable recommendations in the European trauma guidelines were applied in≥80% of patients. Early diagnosis and treatment of trauma-related coagulopathy was identified as an area for significant practice improvement. In patients with TBI, efforts should be made to achieve the targeted MAP and to maintain normocapnia.


Assuntos
Transtornos da Coagulação Sanguínea/diagnóstico , Testes de Coagulação Sanguínea/estatística & dados numéricos , Fidelidade a Diretrizes/estatística & dados numéricos , Ferimentos e Lesões/terapia , Adulto , Transtornos da Coagulação Sanguínea/terapia , Feminino , França , Hemodinâmica , Hemorragia/diagnóstico , Hemorragia/etiologia , Hemorragia/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Ressuscitação/estatística & dados numéricos , Estudos Retrospectivos , Centros de Traumatologia , Ferimentos e Lesões/complicações
17.
Mil Med ; 184(5-6): e154-e157, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-30295843

RESUMO

INTRODUCTION: Hemorrhage is the leading cause of potentially preventable death on the battlefield. Hypotension in the setting of trauma portends a higher rate of mortality. We describe the interventions for trauma-related hypotension performed in the prehospital combat setting in accordance with Tactical Combat Casualty Care (TCCC) guidelines. MATERIALS AND METHODS: We searched the Prehospital Trauma Registry for casualties from January 2013 to September 2014. Within that group, we searched for all casualties with documented hypotension by either measured systolic blood pressure ≤90 mmHg or a weak or absent radial pulse documented by the prehospital provider. We used descriptive statistics to analyze the interventions performed in our study sample. RESULTS: Of the 705 casualties available for query, 134 (19.0%) casualties with documented hypotension met inclusion criteria. Most casualties with hypotension had an alert mental status (70.1%), had a medical officer in their chain of care (59.0%), were Afghan (64.2%), and evacuated on an urgent status (78.4%). Explosives were the most frequent mechanism of injury (50.7%). There were 42 fluid administrations documented on 33 (24.6%) casualties. The most common fluid administered was normal saline (52.4%) followed by hetastarch solution (33.3%). There was one documented use of a fluid warmer in this cohort. One subject received four units of packed red blood cells. No other casualties had documented blood product administration. There were no documented administrations of PlasmaLyte. There were four casualties that received lactated Ringer's. CONCLUSION: Most casualties with documented hypotension after trauma in the Prehospital Trauma Registry did not receive prehospital blood or fluid intervention. Of the interventions performed, most did not match with contemporary TCCC guidelines.


Assuntos
Serviços Médicos de Emergência/métodos , Hipotensão/terapia , Ressuscitação/métodos , Ferimentos e Lesões/terapia , Adulto , Campanha Afegã de 2001- , Afeganistão , Distribuição de Qui-Quadrado , Serviços Médicos de Emergência/normas , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Hidratação/métodos , Hidratação/normas , Hemorragia/terapia , Humanos , Hipotensão/complicações , Masculino , Sistema de Registros/estatística & dados numéricos , Ressuscitação/normas , Ressuscitação/estatística & dados numéricos , Ferimentos e Lesões/complicações
18.
J Matern Fetal Neonatal Med ; 32(8): 1230-1237, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29117772

RESUMO

BACKGROUND: Ensuring long-term retention of the acquired practical skills is one of the major aims of a medical school. This depends on the application of training techniques and their combinations. In order to standardize the teaching process, to acquire and maintain a broad array of technical, professional, and interpersonal skills and competencies, and to improve the retention of practical skills, we developed a new training technique - the HybridLab® learning method. It consists of an e-learning platform, hands-on simulation, carefully elaborated learning algorithms (DRAKON), peer-to-peer teaching, and assessment and feedback by peers, and later - by a remote instructor. Summary of the work: The subjects of the study were fifth-year students of the Lithuanian University of Health Sciences Medical Academy who during 2014-2015 were studying the obstetrics and gynecology module in the neonatology cycle. We analyzed the retention of practical skills in the initial neonatal resuscitation among students who were training with the use of our developed HybridLab® technique at 6 and 12 months after the completion of the cycle. SUMMARY OF RESULTS: After 6 and 12 months, mean changes in the subjects' evaluation scores (percentage drop-off between the first and the second total score) dropped by, respectively, 31.8% (SD: 27.5) and 7.7% (SD: 25.6), and did not differ statistically significantly (p = .2). In the group of subjects who were not given a possibility to remember the skills and the course of initial neonatal resuscitation, the mean change between the first and the second total evaluation scores was 42.5% (SD: 26.7). In students who were given such possibility, the mean change between the first and the second total evaluation scores was significantly smaller -12.7% (SD: 13.8) (p < .001). Changes in the evaluation scores of individual skills (first steps, mouth-to-mouth ventilation, and chest compressions) between the first and the second evaluation also differed statistically significantly and were smaller in the group of students who were given a possibility to remember their skills (p < .001). DISCUSSION: The HybridLab® learning method is a novel technique, and thus more studies are required to evaluate the significance of the HybridLab® technique for long-time retention of practical skills. CONCLUSION: As a result of the application of the HybridLab® training technique, practical skill retention among medical students after 6 and 12 months dropped by only about 13%. A recall system significantly improved practical skill retention.


Assuntos
Competência Clínica/estatística & dados numéricos , Educação Médica/métodos , Neonatologia/educação , Ressuscitação/educação , Ensino/estatística & dados numéricos , Competência Clínica/normas , Educação Médica/normas , Avaliação Educacional , Humanos , Recém-Nascido , Lituânia , Rememoração Mental , Neonatologia/métodos , Neonatologia/normas , Ressuscitação/estatística & dados numéricos , Estudantes de Medicina , Ensino/normas
19.
J Surg Res ; 233: 413-419, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30502280

RESUMO

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a bridge to definitive hemostasis in select patients with noncompressible torso hemorrhage. The number of patients who might benefit from this procedure, however, remains incompletely defined. We hypothesized that we could quantify the number of patients presenting to our center over a 2-year period who may have benefited from REBOA. METHODS: All patients presenting to our trauma center from 2014 to 2015 were included. Potential REBOA patients were identified based on anatomic injuries. We used ICD-9 codes to identify REBOA-amenable injury patterns and physiology. We excluded patients with injuries contraindicating REBOA. We then used chart review by two REBOA-experienced independent reviewers to assess each potential REBOA candidate, evaluate the accuracy of our algorithm, and to identify a cohort of confirmed REBOA candidates. RESULTS: Four thousand eight hundred eighteen patients were included of which 666 had injuries potentially amenable to REBOA. Three hundred thirty-five patients were hemodynamically unstable, and 309 patients had contraindications to REBOA. Sixty-four patients had both injury patterns and physiology amenable to REBOA with no contraindications, and these patients were identified as potential REBOA candidates. Of these, detailed independent two physician chart review identified 29 patients (45%) as confirmed REBOA candidates (interrater reliability kappa = 0.94, P < 0.001). CONCLUSIONS: Our database query identified patients with indications for REBOA but overestimated the number of REBOA candidates. To accurately quantify the REBOA candidate population at a given center, an algorithm to identify potential patients should be combined with chart review. STUDY TYPE: Therapeutic study, level V.


Assuntos
Hemorragia/cirurgia , Hospitais Urbanos/organização & administração , Determinação de Necessidades de Cuidados de Saúde/estatística & dados numéricos , Ressuscitação/métodos , Centros de Traumatologia/organização & administração , Adulto , Aorta/cirurgia , Oclusão com Balão/estatística & dados numéricos , Procedimentos Endovasculares/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde , Hemorragia/epidemiologia , Hemorragia/etiologia , Técnicas Hemostáticas/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Ressuscitação/estatística & dados numéricos , Estudos Retrospectivos , Tronco , Centros de Traumatologia/estatística & dados numéricos , Adulto Jovem
20.
Intensive Care Med ; 45(1): 44-54, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30547322

RESUMO

PURPOSE: Caseloads of extracorporeal cardiopulmonary resuscitation (ECPR) have increased considerably, and hospital mortality rates remain high and unpredictable. The present study evaluated the effects of the interplay between age and prolonged low-flow duration (LFD) on hospital survival rates in elderly patients to identify subgroups that can benefit from ECPR. METHODS: Adult patients who received ECPR in our institution (2006-2016) were classified into groups 1, 2, and 3 (18-65, 65-75, and > 75 years, respectively). Data regarding ECPR and adverse events during hospitalization were collected prospectively. The primary end point was favorable neurologic outcome (cerebral performance category 1 or 2) at hospital discharge. RESULTS: In total, 482 patients were divided into groups 1, 2, and 3 (70.5%, 19.3%, and 10.2%, respectively). LFDs were comparable among the groups (40.3, 41.0, and 44.3 min in groups 1, 2, and 3, P = 0.781, 0.231, and 0.382, respectively). Favorable neurologic outcome rates were nonsignificantly lower in group 3 than in the other groups (27.6%, 24.7%, and 18.4% for group 1, 2, and 3, respectively). Subgroup analysis revealed that the favorable neurologic outcome rates in group 1 were 36.7%, 25.4%, and 13.0% for LFDs of < 30, 30-60, and > 60 min, respectively (P = 0.005); in group 2, they were 32.1%, 21.2%, and 23.1%, respectively (P = 0.548); in group 3 they were 25.0%, 20.8%, and 0.0%, respectively (P = 0.274). CONCLUSION: On emergency consultation for ECPR, age and low-flow duration should be considered together to predict neurologic outcome.


Assuntos
Fatores Etários , Oxigenação por Membrana Extracorpórea/normas , Ressuscitação/normas , Fatores de Tempo , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/epidemiologia , Parada Cardíaca Extra-Hospitalar/terapia , Estudos Prospectivos , Ressuscitação/métodos , Ressuscitação/estatística & dados numéricos , Estatísticas não Paramétricas , Resultado do Tratamento
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