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1.
PLoS Med ; 16(9): e1002900, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31498784

RESUMO

BACKGROUND: Improving quality of intrapartum care will reduce intrapartum stillbirth and neonatal mortality, especially in resource-poor settings. Basic neonatal resuscitation can reduce intrapartum stillbirth and early neonatal mortality, if delivered in a high-quality health system, but there is a dearth of evidence on how to scale up such evidence-based interventions. We evaluated the scaling up of a quality improvement (QI) package for neonatal resuscitation on intrapartum-related mortality (intrapartum stillbirth and first day mortality) at hospitals in Nepal. METHODS AND FINDINGS: We conducted a stepped-wedge cluster randomized controlled trial in 12 hospitals over a period of 18 months from April 14, 2017, to October 17, 2018. The hospitals were assigned to one of four wedges through random allocation. The QI package was implemented in a stepped-wedge manner with a delay of three months for each step. The QI package included improving hospital leadership on intrapartum care, building health workers' competency on neonatal resuscitation, and continuous facilitated QI processes in clinical units. An independent data collection system was set up at each hospital to gather data on mortality through patient case note review and demographic characteristics of women using semi-structured exit interviews. The generalized linear mixed model (GLMM) and multivariate logistic regression were used for analyses. During this study period, a total of 89,014 women-infant pairs were enrolled. The mean age of the mother in the study period was 24.0 ± 4.3 years, with 54.9% from disadvantaged ethnic groups and 4.0% of them illiterate. Of the total birth cohort, 54.4% were boys, 16.7% had gestational age less than 37 weeks, and 17.1% had birth weight less than 2,500 grams. The incidence of intrapartum-related mortality was 11.0 per 1,000 births during the control period and 8.0 per 1,000 births during the intervention period (adjusted odds ratio [aOR], 0.79; 95% CI, 0.69-0.92; p = 0.002; intra-cluster correlation coefficient [ICC], 0.0286). The incidence of early neonatal mortality was 12.7 per 1,000 live births during the control period and 10.1 per 1,000 live births during the intervention period (aOR, 0.89; 95% CI, 0.78-1.02; p = 0.09; ICC, 0.1538). The use of bag-and-mask ventilation for babies with low Apgar score (<7 at 1 minute) increased from 3.2% in the control period to 4.0% in the intervention period (aOR, 1.52; 95% CI, 1.32-1.77, p = 0.003). There were two major limitations to the study; although a large sample of women-infant pairs were enrolled in the study, the clustering reduced the power of the study. Secondly, the study was not sufficiently powered to detect reduction in early neonatal mortality with the number of clusters provided. CONCLUSION: These results suggest scaled-up implementation of a QI package for neonatal resuscitation can reduce intrapartum-related mortality and improve clinical care. The QI intervention package is likely to be effective in similar settings. More implementation research is required to assess the sustainability of QI interventions and quality of care. TRIAL REGISTRATION: ISRCTN30829654.


Assuntos
Mortalidade Hospitalar , Mortalidade Infantil , Terapia Intensiva Neonatal , Parto , Morte Perinatal/prevenção & controle , Ressuscitação , Natimorto , Adulto , Feminino , Hospitais Públicos , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Terapia Intensiva Neonatal/normas , Nepal , Morte Perinatal/etiologia , Gravidez , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Ressuscitação/efeitos adversos , Ressuscitação/mortalidade , Ressuscitação/normas , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
2.
Emerg Med J ; 36(9): 520-528, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31320332

RESUMO

BACKGROUND: Intubation is an essential, life-saving skill but associated with a high risk for adverse outcomes. Intubation protocols have been implemented to increase success and reduce complications, but the impact of protocol conformance is not known. Our study aimed to determine association between conformance with an intubation process model and outcomes. METHODS: An interdisciplinary expert panel developed a process model of tasks and sequencing deemed necessary for successful intubation. The model was then retrospectively used to review videos of intubations from 1 February, 2014, to 31 January, 2016, in a paediatric emergency department at a time when no process model or protocol was in existence. RESULTS: We evaluated 113 patients, 77 (68%) were successfully intubated on first attempt. Model conformance was associated with a higher likelihood of first attempt success when using direct laryngoscopy (OR 1.09, 95% CI 1.01 to 1.18). The use of video laryngoscopy was associated with an overall higher likelihood of success on first attempt (OR 2.54, 95% CI 1.10 to 5.88). Thirty-seven patients (33%) experienced adverse events. Model conformance was the only factor associated with a lower odds of adverse events (OR 0.94, 95% CI 0.88 to 0.99). CONCLUSIONS: Conformance with a task-based expert-derived process model for emergency intubation was associated with a higher rate of success on first intubation attempt when using direct laryngoscopy and a lower odds of associated adverse events. Further evaluation of the impact of human factors, such as teamwork and decision-making, on intubation process conformance and success and outcomes is needed.


Assuntos
Protocolos Clínicos/normas , Estado Terminal/terapia , Intubação Intratraqueal/normas , Guias de Prática Clínica como Assunto , Ressuscitação/normas , Adolescente , Bradicardia/epidemiologia , Bradicardia/etiologia , Criança , Pré-Escolar , Serviço Hospitalar de Emergência/normas , Feminino , Humanos , Hipóxia/epidemiologia , Hipóxia/etiologia , Lactente , Recém-Nascido , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/instrumentação , Laringoscópios/efeitos adversos , Masculino , Ressuscitação/efeitos adversos , Ressuscitação/instrumentação , Estudos Retrospectivos , Gravação em Vídeo , Adulto Jovem
3.
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
4.
Implement Sci ; 14(1): 65, 2019 06 19.
Artigo em Inglês | MEDLINE | ID: mdl-31217028

RESUMO

BACKGROUND: Each year, 2.2 million intrapartum-related deaths (intrapartum stillbirths and first day neonatal deaths) occur worldwide with 99% of them taking place in low- and middle-income countries. Despite the accelerated increase in the proportion of deliveries taking place in health facilities in these settings, the stillborn and neonatal mortality rates have not reduced proportionately. Poor quality of care in health facilities is attributed to two-thirds of these deaths. Improving quality of care during the intrapartum period needs investments in evidence-based interventions. We aim to evaluate the quality improvement package-Scaling Up Safer Bundle Through Quality Improvement in Nepal (SUSTAIN)-on intrapartum care and intrapartum-related mortality in public hospitals of Nepal. METHODS: We will conduct a stepped wedge cluster randomized controlled trial in eight public hospitals with each having least 3000 deliveries a year. Each hospital will represent a cluster with an intervention transition period of 2 months in each. With a level of significance of 95%, the statistical power of 90% and an intra-cluster correlation of 0.00015, a study period of 19 months should detect at least a 15% change in intrapartum-related mortality. Quality improvement training, mentoring, systematic feedback, and a continuous improvement cycle will be instituted based on bottleneck analyses in each hospital. All concerned health workers will be trained on standard basic neonatal resuscitation and essential newborn care. Portable fetal heart monitors (Moyo®) and neonatal heart rate monitors (Neobeat®) will be introduced in the hospitals to identify fetal distress during labor and to improve neonatal resuscitation. Independent research teams will collect data in each hospital on intervention inputs, processes, and outcomes by reviewing records and carrying out observations and interviews. The dose-response effect will be evaluated through process evaluations. DISCUSSION: With the global momentum to improve quality of intrapartum care, better understanding of QI package within a health facility context is important. The proposed package is based on experiences from a similar previous scale-up trial carried out in Nepal. The proposed evaluation will provide evidence on QI package and technology for implementation and scale up in similar settings. TRIAL REGISTRATION NUMBER: ISRCTN16741720 . Registered on 2 March 2019.


Assuntos
Hospitais Públicos/organização & administração , Pacotes de Assistência ao Paciente , Assistência Perinatal/normas , Melhoria de Qualidade , Países em Desenvolvimento , Feminino , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Mortalidade Materna , Monitorização Fisiológica/normas , Nepal , Gravidez , Ressuscitação/normas
5.
Am J Nurs ; 119(7): 56-61, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31232778

RESUMO

: This column is designed to help new nurses in their first year at the bedside-a time of insecurity, growth, and constant challenges-and to offer advice as they learn what it means to be a nurse. This article prepares new nurses for their first code, describes what happens during a code, and reviews the responsibilities of the resuscitation team.


Assuntos
Papel do Profissional de Enfermagem , Recursos Humanos de Enfermagem no Hospital , Equipe de Assistência ao Paciente/normas , Ressuscitação/normas , Bacharelado em Enfermagem , Humanos
7.
J Perinat Med ; 47(6): 665-670, 2019 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-31103996

RESUMO

Background Airway obstruction can occur during facemask (FM) resuscitation of preterm infants at birth. Intubation bypasses any upper airway obstruction. Thus, it would be expected that the occurrence of low expiratory tidal volumes (VTes) would be less in infants resuscitated via an endotracheal tube (ETT) rather than via an FM. Our aim was to test this hypothesis. Methods Analysis was undertaken of respiratory function monitoring traces made during initial resuscitation in the delivery suite to determine the peak inflating pressure (PIP), positive end expiratory pressure (PEEP), the VTe and maximum exhaled carbon dioxide (ETCO2) levels and the number of inflations with a low VTe (less than 2.2 mL/kg). Results Eighteen infants were resuscitated via an ETT and 11 via an FM, all born at less than 29 weeks of gestation. Similar inflation pressures were used in both groups (17.2 vs. 18.8 cmH2O, P = 0.67). The proportion of infants with a low median VTe (P = 0.6) and the proportion of inflations with a low VTe were similar in the groups (P = 0.10), as was the lung compliance (P = 0.67). Infants with the lowest VTe had the stiffest lungs (P < 0.001). Conclusion Respiratory function monitoring during initial resuscitation can objectively identify infants who may require escalation of inflation pressures.


Assuntos
Obstrução das Vias Respiratórias/diagnóstico , Lactente Extremamente Prematuro/fisiologia , Monitorização Fisiológica/métodos , Ressuscitação , Volume de Ventilação Pulmonar , Obstrução das Vias Respiratórias/etiologia , Obstrução das Vias Respiratórias/terapia , Testes Respiratórios/métodos , Dióxido de Carbono/análise , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/métodos , Londres , Masculino , Respiração com Pressão Positiva/métodos , Gravidez , Testes de Função Respiratória/métodos , Ressuscitação/efeitos adversos , Ressuscitação/instrumentação , Ressuscitação/métodos , Ressuscitação/normas , Estudos Retrospectivos
8.
Intensive Crit Care Nurs ; 53: 15-22, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31053336

RESUMO

BACKGROUND: The option of family presence during resuscitation was first presented in the late 1980s. Discussion and debate about the pros and cons of this practice has led to an abundant body of international research. AIM: To determine critical care nurses' experiences of, and support for family presence during adult and paediatric resuscitation and their views on the positive and negative effects of this practice. METHODS: A narrative literature review of primary research published 2005 onwards. The search strategy comprised an electronic search of three bibliographic databases, supplemented by exploration of a web-based search engine and hand-searching. RESULTS: Twelve studies formed the review. Research primarily originated from Europe. The findings were obtained from a moderately small number of nurses, and their views were mostly based on conjecture. Among the factors influencing family presence during resuscitation were dominant concerns about harmful effects. There was a noticeable absence of compliance with recommended guidelines for practice, and the provision of a unit protocol or policy to assist decision-making. CONCLUSION: A commitment to family-centred care, educational intervention and the uptake of professional guidance are recommended evidence-informed strategies to enhance nurses' support for this practice in critical care.


Assuntos
Família/psicologia , Enfermeiras e Enfermeiros/psicologia , Ressuscitação/enfermagem , Visitas a Pacientes/psicologia , Enfermagem de Cuidados Críticos/métodos , Humanos , Narração , Relações Profissional-Família , Pesquisa Qualitativa , Ressuscitação/psicologia , Ressuscitação/normas
9.
Crit Care ; 23(1): 158, 2019 05 06.
Artigo em Inglês | MEDLINE | ID: mdl-31060580

RESUMO

IMPORTANCE: The optimal approach to airway management during in-hospital cardiac arrest is unknown. OBJECTIVE: To describe hospital-level variation in endotracheal intubation during cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest and the association between hospital use of endotracheal intubation and arrest survival. DESIGN, SETTING, PARTICIPANTS: Retrospective cohort study of adult patients suffering in-hospital cardiac arrest at Get With The Guidelines-Resuscitation participating hospitals between January, 2000, and December, 2016. Hospitals were categorized into quartiles based on the proportion of in-hospital cardiac arrest patients managed with endotracheal intubation during CPR. Risk-adjusted mixed models with random intercepts were created to assess the association between hospital quartile of in-hospital arrests managed with endotracheal intubation during CPR and survival to hospital discharge. EXPOSURE: Hospital rate of endotracheal intubation during CPR for in-hospital arrest MAIN OUTCOMES AND MEASURES: Survival to hospital discharge RESULTS: Among 155,252 patients suffering in-hospital cardiac arrest at 656 hospitals, 69.7% of patients received endotracheal intubation during CPR and overall survival to discharge was 24.8%. At the hospital level, the median rate of endotracheal intubation use was 71.2% (interquartile range, 63.6 to 78.1%; range, 26.6 to 100%). We found a strong inverse association between hospital rate of endotracheal intubation and survival to discharge (risk-adjusted odds ratio comparing highest intubation quartile vs. lowest intubation quartile, 0.81; 95% confidence interval (CI), 0.74 to 0.90; p value < .001). This association was modified by the presence of respiratory failure prior to arrest (p for interaction < .001), and stratified analyses demonstrated lower patient survival at hospitals with higher rates of endotracheal intubation was limited to patients without respiratory failure prior to cardiac arrest. CONCLUSION: In a national sample of patients suffering IHCA, the use of endotracheal intubation during CPR varied across hospitals. We found a strong inverse association between hospital use of endotracheal intubation during CPR and survival to discharge, but this association was confined to patients without respiratory failure prior to arrest. Identifying the optimal approach to airway management for in-hospital cardiac arrest may have a significant impact on patient survival.


Assuntos
Manuseio das Vias Aéreas/normas , Guias como Assunto , Parada Cardíaca/terapia , Ressuscitação/normas , Idoso , Idoso de 80 Anos ou mais , Manuseio das Vias Aéreas/métodos , Manuseio das Vias Aéreas/estatística & dados numéricos , Estudos de Coortes , Feminino , Parada Cardíaca/mortalidade , Humanos , Intubação Intratraqueal/métodos , Intubação Intratraqueal/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Sistema de Registros/estatística & dados numéricos , Ressuscitação/métodos , Estudos Retrospectivos , Análise de Sobrevida , Fatores de Tempo
11.
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
13.
Transfusion ; 59(S2): 1459-1466, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30980759

RESUMO

BACKGROUND: French military operations in the Sahel conducted since 2013 over more than 5 million square kilometers have challenged the French Military Health Service with specific problems in prolonged field care. STUDY DESIGN AND METHODS: To describe these challenges, we retrospectively analyzed the prehospital data from the first 5 years of these operations within a delimited area. RESULTS: One hundred eighty-three servicemen of different nationalities were evacuated, mainly as a result of explosions (73.2%) or gunshots (21.9%). Their mean number evacuation was 2.2 (minimum, 1; maximum, 8) per medical evacuation with a direct evacuation from the field to a Role 2 medical treatment facility (MTF) for 62% of them. For the highest-priority casualties (N = 46), the median time [interquartile range] from injury to a Role 2 MTF was 130 minutes [70 minutes to 252 minutes], exceeding 120 minutes in 57% of cases and 240 minutes in 26%. The most frequent out-of-hospital medical interventions were external hemostasis, airway and hemopneumothorax management, hypotensive resuscitation, analgesia, immobilization, and antibiotic administration. Prehospital transfusion (RBCs and/or lyophilized plasma) was started three times in the field, two times during helicopter medical evacuation, and five times in tactical fixed wing medical aircraft. Lyophilized plasma was confirmed to be particularly suitable in these settings. One of the specific issues involved in lengthy prehospital time was the importance to reassess and convert tourniquets prior to Role 2 MTF admission. CONCLUSION: Main challenges identified include reducing evacuation times as much as possible, preserving ground deployment of sufficiently trained medics and medical teams, optimization of transfusion strategies, and strengthening specific prolonged field care equipment and training.


Assuntos
Transfusão de Sangue , Serviços Médicos de Emergência , Medicina Militar , Militares , Ressuscitação , Ferimentos e Lesões/terapia , Adulto , Resgate Aéreo , Transfusão de Sangue/métodos , Transfusão de Sangue/normas , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/organização & administração , Serviços Médicos de Emergência/normas , Feminino , França , Humanos , Masculino , Medicina Militar/métodos , Medicina Militar/organização & administração , Medicina Militar/normas , Ressuscitação/métodos , Ressuscitação/normas , Ferimentos e Lesões/mortalidade
14.
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
15.
West J Emerg Med ; 20(2): 228-231, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30881540

RESUMO

Video review for quality and education purposes has been a valued tool for decades. However, the use of this process dropped significantly after the development of the Health Insurance Portability and Accountability Act in the 1990s. Video review was recently reestablished at our institution. By working with our institutional legal counsel and risk management team, we have been able to create a video review process that complies with legal requirements. Literature on this subject has not described the process of obtaining video recordings. We aimed to review the process of obtaining high quality recordings in a secure manner. We hope that in the future, the data collected through our multidisciplinary review process will be helpful in improving quality of care for injured patients and providing coaching and feedback to learners, as well as improving our trauma education curriculum.


Assuntos
Ressuscitação/normas , Gravação em Vídeo , Ferimentos e Lesões/terapia , Humanos , Equipe de Assistência ao Paciente/normas , Melhoria de Qualidade , Ressuscitação/educação , Gestão de Riscos , Traumatologia/educação
16.
Crit Care ; 23(1): 100, 2019 Mar 27.
Artigo em Inglês | MEDLINE | ID: mdl-30917840

RESUMO

OBJECTIVES: To evaluate the resuscitative effects of mechanical and manual chest compression in patients with out-of-hospital cardiac arrest (OHCA). METHODS: All randomized controlled and cohort studies comparing the effects of mechanical compression and manual compression on cardiopulmonary resuscitation in OHCA patients were retrieved from the Cochrane Library, PubMed, EMBASE, and Ovid databases from the date of their establishment to January 14, 2019. The included outcomes were as follows: the return of spontaneous circulation (ROSC) rate, the rate of survival to hospital admission, the rate of survival to hospital discharge, and neurological function. After evaluating the quality of the studies and summarizing the results, RevMan5.3 software was used for the meta-analysis. RESULTS: In total, 15 studies (9 randomized controlled trials and 6 cohort studies) were included. The results of the meta-analysis showed that there were no significant differences in the resuscitative effects of mechanical and manual chest compression in terms of the ROSC rate, the rate of survival to hospital admission and survival to hospital discharge, and neurological function in OHCA patients (ROSC: RCT: OR = 1.12, 95% CI (0.90, 1.39), P = 0.31; cohort study: OR = 1.08, 95% CI (0.85, 1.36), P = 0.54; survival to hospital admission: RCT: OR = 0.95, 95% CI (0.75, 1.20), P = 0.64; cohort study: OR = 0.98 95% CI (0.79, 1.20), P = 0.82; survival to hospital discharge: RCT: OR = 0.87, 95% CI (0.68, 1.10), P = 0.24; cohort study: OR = 0.78, 95% CI (0.53, 1.16), P = 0.22; Cerebral Performance Category (CPC) score: RCT: OR = 0.88, 95% CI (0.64, 1.20), P = 0.41; cohort study: OR = 0.68, 95% CI (0.34, 1.37), P = 0.28). When the mechanical compression group was divided into Lucas and Autopulse subgroups, the Lucas subgroup showed no difference from the manual compression group in ROSC, survival to admission, survival to discharge, and CPC scores; the Autopulse subgroup showed no difference from the manual compression subgroup in ROSC, survival to discharge, and CPC scores. CONCLUSION: There were no significant differences in resuscitative effects between mechanical and manual chest compression in OHCA patients. To ensure the quality of CPR, we suggest that manual chest compression be applied in the early stage of CPR for OHCA patients, while mechanical compression can be used as part of advanced life support in the late stage.


Assuntos
Reanimação Cardiopulmonar/normas , Parada Cardíaca Extra-Hospitalar/terapia , Ressuscitação/normas , Reanimação Cardiopulmonar/métodos , Reanimação Cardiopulmonar/tendências , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Ressuscitação/métodos
17.
Curr Opin Anaesthesiol ; 32(2): 163-168, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30817389

RESUMO

PURPOSE OF REVIEW: Sepsis-3 guidelines have implications in a deeper understanding of the biopathology of the disease. Further, the review focuses on timely topics and new literature on fluid resuscitation, the value of steroids in sepsis, and new therapeutic options such as angiotensin II, vitamin C, and thiamine as well as the emerging role of procalcitonin (PCT) in managing antibiotics. RECENT FINDINGS: Traditional therapies such as type of crystalloid fluid administration and steroid therapy for sepsis are currently under re-evaluation. Angiotensin II is investigated for reversing vasodilatory shock. The role of capillary endothelium leak and cellular metabolism can be affected by vitamin C and thiamine levels. Biomarker level trends, specifically PCT, can aid clinical suspicion of infection. SUMMARY: Sepsis-3 shifts the focus from a noninfectious inflammatory process and an emphasis on a dysregulated host response to infection. Hyperchloremic crystalloid resuscitation is associated with poor clinical outcomes. Steroid administration can reverse shock physiology; however, mortality benefits remain uncertain. Angiotensin II, vitamin C, and thiamine are novel treatment options that need further validation. PCT assays can help discern between infectious and noninfectious inflammation.


Assuntos
Cuidados Críticos/normas , Hidratação/normas , Ressuscitação/normas , Sepse/terapia , Angiotensina II/uso terapêutico , Antibacterianos/uso terapêutico , Ácido Ascórbico/uso terapêutico , Biomarcadores/sangue , Terapia Combinada/métodos , Terapia Combinada/normas , Terapia Combinada/tendências , Cuidados Críticos/métodos , Cuidados Críticos/tendências , Hidratação/métodos , Hidratação/tendências , Glucocorticoides/uso terapêutico , Humanos , Guias de Prática Clínica como Assunto , Pró-Calcitonina/sangue , Ressuscitação/métodos , Ressuscitação/tendências , Sepse/diagnóstico , Sepse/mortalidade , Tiamina/uso terapêutico , Resultado do Tratamento
18.
Curr Opin Anaesthesiol ; 32(2): 227-233, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30817399

RESUMO

PURPOSE OF REVIEW: To examine current literature on thoracic trauma related to military combat and to explore its relevance to the civilian population. RECENT FINDINGS: Damage control resuscitation (DCR) has improved the management of hemorrhaging trauma patients. Permissive hypotension below 110 mmHg and antifibrinolytic use during DCR is widely accepted, whereas the use of freeze-dried plasma and whole blood is gaining popularity. The Modified Physiologic Triaging Tool can be used for primary triage and it may have applications in civilian trauma systems. Although Tactical Combat Casualty Care protocol recommends the Cric-Key device for surgical cricothyroidotomies, other devices may offer comparable performance. Recommendations for regional anesthesia after blunt trauma are not well defined. Increasing amounts of evidence favor the use of extracorporeal membrane oxygenation for refractory hypoxemia and resuscitative endovascular balloon occlusion of the aorta (REBOA) for severe hemorrhage. REBOA outcomes are potentially improved by partial occlusion and small 7 Fr catheters. SUMMARY: The Global War on Terror has provided opportunities to better understand and treat thoracic trauma in military settings. Trauma registries and other data sources have contributed to significant advancements in the management of thoracic trauma in military and civilian populations.


Assuntos
Medicina Militar/métodos , Padrões de Prática Médica/normas , Choque Hemorrágico/terapia , Traumatismos Torácicos/terapia , Lesões Relacionadas à Guerra/terapia , Anestesia por Condução/normas , Oclusão com Balão/normas , Transfusão de Sangue/normas , Oxigenação por Membrana Extracorpórea/normas , Humanos , Medicina Militar/normas , Guias de Prática Clínica como Assunto , Ressuscitação/métodos , Ressuscitação/normas , Choque Hemorrágico/diagnóstico , Choque Hemorrágico/etiologia , Traumatismos Torácicos/complicações , Traumatismos Torácicos/diagnóstico , Resultado do Tratamento , Triagem/métodos , Triagem/normas , Lesões Relacionadas à Guerra/complicações , Lesões Relacionadas à Guerra/diagnóstico
19.
Mil Med ; 184(Suppl 1): 310-317, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30901420

RESUMO

OBJECTIVES: A cuffed bag valve mask (BVM) is the most common device used by emergency medical responders to ventilate patients. The BVM can be difficult for users to seal around the patient's mouth and nose. An intraoral mask (IOM) with snorkel-like design may facilitate quicker and better ventilation particularly under austere conditions. METHODS: Both a BVM and IOM were utilized by 27 trained emergency medical technicians and paramedics to ventilate a lightly embalmed cadaver. Ventilation efficacy, workload, and usability were assessed for both devices across four study conditions. RESULTS: The IOM was superior to the BVM in delivered tidal volume ratio (measure of leak, p < 0.03) and minute ventilation (p < 0.0001). Workload, ergonomic and usability assessments indicated that the IOM facilitated gripping through the reduced hand interface size (p < 0.01), decreased user effort (p < 0.001), and reduced upper limb workload (p = 0.0088). CONCLUSIONS: In the assessed model, the IOM represented a better choice for airway management than the standard cuffed BVM. An emergency medical device that is intuitive, efficacious and less demanding has the potential to reduce responder stress and improve resuscitation efforts, especially during austere rescue and patient transport.


Assuntos
Manuseio das Vias Aéreas/normas , Competência Clínica/normas , Serviços Médicos de Emergência/normas , Manuseio das Vias Aéreas/métodos , Competência Clínica/estatística & dados numéricos , Estudos Transversais , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/estatística & dados numéricos , Socorristas/estatística & dados numéricos , Humanos , Máscaras Laríngeas , Militares/estatística & dados numéricos , Nebraska , Ressuscitação/métodos , Ressuscitação/normas , Inquéritos e Questionários , Volume de Ventilação Pulmonar/fisiologia
20.
JAMA ; 321(12): 1200-1210, 2019 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-30912843

RESUMO

Importance: In-hospital cardiac arrest is common and associated with a high mortality rate. Despite this, in-hospital cardiac arrest has received little attention compared with other high-risk cardiovascular conditions, such as stroke, myocardial infarction, and out-of-hospital cardiac arrest. Observations: In-hospital cardiac arrest occurs in over 290 000 adults each year in the United States. Cohort data from the United States indicate that the mean age of patients with in-hospital cardiac arrest is 66 years, 58% are men, and the presenting rhythm is most often (81%) nonshockable (ie, asystole or pulseless electrical activity). The cause of the cardiac arrest is most often cardiac (50%-60%), followed by respiratory insufficiency (15%-40%). Efforts to prevent in-hospital cardiac arrest require both a system for identifying deteriorating patients and an appropriate interventional response (eg, rapid response teams). The key elements of treatment during cardiac arrest include chest compressions, ventilation, early defibrillation, when applicable, and immediate attention to potentially reversible causes, such as hyperkalemia or hypoxia. There is limited evidence to support more advanced treatments. Post-cardiac arrest care is focused on identification and treatment of the underlying cause, hemodynamic and respiratory support, and potentially employing neuroprotective strategies (eg, targeted temperature management). Although multiple individual factors are associated with outcomes (eg, age, initial rhythm, duration of the cardiac arrest), a multifaceted approach considering both potential for neurological recovery and ongoing multiorgan failure is warranted for prognostication and clinical decision-making in the post-cardiac arrest period. Withdrawal of care in the absence of definite prognostic signs both during and after cardiac arrest should be avoided. Hospitals are encouraged to participate in national quality-improvement initiatives. Conclusions and Relevance: An estimated 290 000 in-hospital cardiac arrests occur each year in the United States. However, there is limited evidence to support clinical decision making. An increased awareness with regard to optimizing clinical care and new research might improve outcomes.


Assuntos
Cardioversão Elétrica , Parada Cardíaca/terapia , Hospitalização , Ressuscitação , Adulto , Idoso , Tomada de Decisão Clínica , Feminino , Parada Cardíaca/epidemiologia , Parada Cardíaca/etiologia , Parada Cardíaca/mortalidade , Humanos , Masculino , Guias de Prática Clínica como Assunto , Prognóstico , Melhoria de Qualidade , Ressuscitação/normas , Taxa de Sobrevida , Estados Unidos/epidemiologia
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