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1.
Med Care ; 58(1): 38-44, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31688552

RESUMO

OBJECTIVE: The objective of this study was to estimate the frequency and type of adverse events (AEs) among critically ill patients and identify patient and hospital factors associated with AEs and clinical and health care utilization consequences of AEs. MATERIALS AND METHODS: This retrospective cohort study includes patients admitted to 30 intensive care units (ICUs) in Alberta, Canada from May 2014 to April 2017. The main outcome was AEs derived from validated ICD-10, Canadian code algorithms for 18 AEs. Estimates of the proportion and rate of AEs are presented. The association between documented AEs and patient (eg, age, sex, comorbidities) and hospital (eg, ICU site and type, length of stay, readmission) variables are described using regression methods. RESULTS: Of 49,447 hospital admissions with admission to ICU, ≥1 AEs were documented in 12,549 (25%) admissions. The most common AEs were respiratory complications (10%) and hospital-acquired infections (9%). AEs were associated with having ≥2 comorbidities [odds ratio (OR)=1.4, 95% confidence interval (CI)=1.3-1.4], being admitted to the ICU from the operating room or another hospital ward (OR=1.8, 95% CI=1.7-2.0 and OR=2.7, 95% CI=2.5-3.0, respectively) and being readmitted to ICU during their hospital stay (OR=4.8, 95% CI=4.7-5.6). Patients with an AE stayed 5.4 days longer in ICU (95% CI=5.2-5.6 d, P<0.001), 18.2 days longer in hospital (95% CI=17.7-18.8 d, P<0.001) and had increased odds of hospital mortality (OR=1.5, 95% CI=1.4-1.6) than those without an AE. CONCLUSIONS: AEs are common among critically ill patients and certain factors are associated with AEs. Documented AEs are associated with longer stays and increased mortality.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Estado Terminal/mortalidade , Hospitalização/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Alberta/epidemiologia , Resultados de Cuidados Críticos , Infecção Hospitalar/mortalidade , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Hospitais/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Análise de Regressão , Estudos Retrospectivos
2.
Fisioter. Pesqui. (Online) ; 26(1): 3-8, Jan.-Mar. 2019. tab, graf
Artigo em Português | LILACS | ID: biblio-1002020

RESUMO

RESUMO O objetivo deste estudo foi descrever características de sucesso e insucesso do uso da ventilação não invasiva (VNI) na unidade de terapia intensiva (UTI) de um hospital universitário. Trata-se de um estudo observacional prospectivo no qual foram incluídos 75 pacientes, com idade média de 58,3±18,8 anos. Desses, doze necessitaram do uso da VNI por mais de uma vez, totalizando 92 utilizações. Evidenciou-se que, delas, a taxa de sucesso foi de 60,9% (56). O grupo insucesso apresentou mais indivíduos do sexo masculino (p=0,006) e número maior de pacientes com diagnóstico de infecção extrapulmonar (p=0,012). Não foram encontradas diferenças entre os grupos de sucesso e insucesso nos quesitos de modo, modelo, máscara, tempo total de permanência e razões para a instalação da VNI. No grupo insucesso, a pressão positiva inspiratória nas vias aéreas (Ipap) e o volume corrente (VC) foram superiores (p=0,029 e p=0,011, respectivamente). A saturação periférica de oxigênio (p=0,047), o pH (p=0,004), base excess (p=0,006) e o bicarbonato (p=0,013) apresentaram valores inferiores. Concluiu-se que os indivíduos do sexo masculino com diagnóstico de infecção extrapulmonar e que evoluíram com acidose metabólica evoluíram com mais insucesso na utilização da VNI. Esses, necessitaram de parâmetros elevados de Ipap e VC.


RESUMEN El objetivo de este estudio fue desarrollar las características del éxito y del fracaso con el uso de la ventilación no invasiva (VNI) en la unidad de terapia intensiva (UTI) de un hospital universitario. Se trata de un estudio observacional prospectivo en el cual fueron incluidos 75 pacientes, con edad media de 58,3±18,8 años. De estos, 12 necesitaron utilizar la VNI por más de una vez, que totalizó 92 utilizaciones. Se evidenció que, de estas, el índice de éxito fue del 60,9% (56). El grupo que no obtuvo el éxito esperado presentó más individuos del sexo masculino (p=0,006) y número mayor de pacientes con diagnóstico de infecciones extrapulmonares (p=0,012). No fueron encontradas diferencias entre los grupos con éxito y sin éxito en las cuestiones de modo, modelo, máscara, tiempo total de permanencia y razones para la instalación de la VNI. En el grupo sin éxito, la presión positiva inspiratoria en las vías aéreas (Ipap) y el volumen corriente (VC) fueron superiores (p=0,029 y p=0,011, respectivamente). La saturación periférica de oxígeno (p=0,047), el pH(p=0,004), base excess (p=0,0006) y el bicarbonato (p=0,013) presentaron valores inferiores. De este modo, se concluye que los individuos del sexo masculino con diagnóstico de infecciones extrapulmonares y que progresaron con acidose metabólica avanzaron más sin tener éxito en la utilización de la VNI. Además, necesitaron de parámetros elevados de Ipap y VC.


ABSTRACT The objective of this study was to describe the aspects of success and failure of the use of non-invasive ventilation (NIV) in the intensive care unit (ICU) of a university hospital. This is a prospective observational study that included 75 patients, with 58.3±18.8 years as the mean age. Of these, 12 required the use of NIV more than once, for 92 uses in total. Among these, the success rate was 60.9% (56). The failure group had more males (p=0.006) and a higher number of patients diagnosed with extrapulmonary infection (p=0.012). No differences were found between success and failure groups for the variables mode, model, mask, total length of stay and reasons for NIV installation. In the failure group, inspiratory positive airways pressure (Ipap) and flow volume (FV) were higher (p=0.029 and p=0.011, respectively). Peripheral oxygen saturation (p=0.047), pH (p=0.004), base excess (p=0.006) and bicarbonate (p=0.013) presented lower values. This study concluded that male individuals diagnosed with extrapulmonary infection and whose picture evolved with metabolic acidosis evolved with more failure in NIV use. These patients required higher Ipap and FV parameters.


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Ventilação não Invasiva , Unidades de Terapia Intensiva , Edema Pulmonar/terapia , Insuficiência Respiratória/terapia , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/terapia , Resultados de Cuidados Críticos , Hospitais Universitários
3.
Am Surg ; 85(1): 15-22, 2019 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-30760339

RESUMO

Multiprofessional rounds (MPR) represent a mechanism for the coordination of care in critically ill patients. Herein, we examined the impact of MPR on ventilator days (Vent-day), ICU length of stay (LOS), hospital LOS (HLOS), and mortality. A team developed guidelines for MPR, which began in February 2016. Patients admitted between November 2015 and March 2017 with Acute Physiology and Chronic Health Evaluation (APACHE) IV and injury severity scores were included. Outcome data consisted of Vent-day, Vent-day observed/expected ratio (O/E), ICU LOS, ICU LOS O/E, HLOS, HLOS-O/E, and mortality. Linear regression models are constructed to assess statistical significance. A total of 3372 patients were included. Among surgical patients (n = 343 pre-MPR, n = 1675 post-MPR), MPR was associated with decreases in Vent-day O/E (0.74 pre, 0.59 post, P = 0.03), ICU LOS O/E (0.67 pre, 0.61 post, P = 0.01), and HLOS-O/E (1.47 pre, 1.22 post, P = 0.0005). No mortality difference was observed. For trauma patients (n = 221 pre, n = 1133 post), MPR resulted in a reduction in Vent-days (2.2 days pre, 1.6 days post, P = 0.05). However, no differences were observed for Vent-day O/E, ICU LOS O/E, HLOS-O/E, and mortality. Implementation of MPR was associated with improved outcomes for surgical trauma ICU patients. Sustainability of MPR remains a challenge and requires education and engagement.


Assuntos
Cuidados Críticos , Complicações Pós-Operatórias/terapia , Visitas com Preceptor , Ferimentos e Lesões/terapia , APACHE , Adulto , Idoso , Lista de Checagem , Resultados de Cuidados Críticos , Feminino , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Respiração Artificial , Estudos Retrospectivos , Ferimentos e Lesões/mortalidade
4.
JAMA Neurol ; 76(5): 612-618, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-30667464

RESUMO

Importance: Neurocritical care has grown into an organized specialty that may have consequences for patient care, outcomes, research, and neurointensive care (neuroICU) technology. Observations: Neurocritical care improves care and outcomes of the patients who are neurocritically ill, and neuroICUs positively affect the financial state of health care systems. The development of neurocritical care as a recognized subspecialty has fostered multidisciplinary research, neuromonitoring, and neurocritical care information technology, with advances and innovations in practice and progress. Conclusions and Relevance: Neurocritical care has become an important part of health systems and an established subspecialty of neurology. Understanding its structure, scope of practice, consequences for care, and research are important.


Assuntos
Cuidados Críticos/organização & administração , Neurologia/organização & administração , Pesquisa Biomédica , Tecnologia Biomédica , Circulação Cerebrovascular , Cuidados Críticos/economia , Cuidados Críticos/normas , Resultados de Cuidados Críticos , Eletroencefalografia , Humanos , Unidades de Terapia Intensiva/economia , Pressão Intracraniana , Microdiálise , Monitorização Fisiológica , Neurologia/economia , Neurologia/educação , Neurologia/normas , Equipe de Assistência ao Paciente , Qualidade da Assistência à Saúde
5.
JAMA Netw Open ; 2(1): e186937, 2019 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-30646206

RESUMO

Importance: While machine learning approaches may enhance prediction ability, little is known about their utility in emergency department (ED) triage. Objectives: To examine the performance of machine learning approaches to predict clinical outcomes and disposition in children in the ED and to compare their performance with conventional triage approaches. Design, Setting, and Participants: Prognostic study of ED data from the National Hospital Ambulatory Medical Care Survey from January 1, 2007, through December 31, 2015. A nationally representative sample of 52 037 children aged 18 years or younger who presented to the ED were included. Data analysis was performed in August 2018. Main Outcomes and Measures: The outcomes were critical care (admission to an intensive care unit and/or in-hospital death) and hospitalization (direct hospital admission or transfer). In the training set (70% random sample), using routinely available triage data as predictors (eg, demographic characteristics and vital signs), we derived 4 machine learning-based models: lasso regression, random forest, gradient-boosted decision tree, and deep neural network. In the test set (the remaining 30% of the sample), we measured the models' prediction performance by computing C statistics, prospective prediction results, and decision curves. These machine learning models were built for each outcome and compared with the reference model using the conventional triage classification information. Results: Of 52 037 eligible ED visits by children (median [interquartile range] age, 6 [2-14] years; 24 929 [48.0%] female), 163 (0.3%) had the critical care outcome and 2352 (4.5%) had the hospitalization outcome. For the critical care prediction, all machine learning approaches had higher discriminative ability compared with the reference model, although the difference was not statistically significant (eg, C statistics of 0.85 [95% CI, 0.78-0.92] for the deep neural network vs 0.78 [95% CI, 0.71-0.85] for the reference; P = .16), and lower number of undertriaged critically ill children in the conventional triage levels 3 to 5 (urgent to nonurgent). For the hospitalization prediction, all machine learning approaches had significantly higher discrimination ability (eg, C statistic, 0.80 [95% CI, 0.78-0.81] for the deep neural network vs 0.73 [95% CI, 0.71-0.75] for the reference; P < .001) and fewer overtriaged children who did not require inpatient management in the conventional triage levels 1 to 3 (immediate to urgent). The decision curve analysis demonstrated a greater net benefit of machine learning models over ranges of clinical thresholds. Conclusions and Relevance: Machine learning-based triage had better discrimination ability to predict clinical outcomes and disposition, with reduction in undertriaging critically ill children and overtriaging children who are less ill.


Assuntos
Cuidados Críticos , Aprendizado de Máquina , Triagem/métodos , Adolescente , Criança , Criança Hospitalizada/estatística & dados numéricos , Pré-Escolar , Cuidados Críticos/métodos , Cuidados Críticos/normas , Resultados de Cuidados Críticos , Serviço Hospitalar de Emergência/organização & administração , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Modelos Educacionais , Valor Preditivo dos Testes , Prognóstico , Melhoria de Qualidade , Estados Unidos
6.
Crit Care Med ; 47(4): 535-542, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30608280

RESUMO

OBJECTIVES: To identify the prevalence, risk factors, and outcomes of intra-abdominal hypertension in a mixed multicenter ICU population. DESIGN: Prospective observational study. SETTING: Fifteen ICUs worldwide. PATIENTS: Consecutive adult ICU patients with a bladder catheter. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four hundred ninety-one patients were included. Intra-abdominal pressure was measured a minimum of every 8 hours. Subjects with a mean intra-abdominal pressure equal to or greater than 12 mm Hg were defined as having intra-abdominal hypertension. Intra-abdominal hypertension was present in 34.0% of the patients on the day of ICU admission (159/467) and in 48.9% of the patients (240/491) during the observation period. The severity of intra-abdominal hypertension was as follows: grade I, 47.5%; grade II, 36.6%; grade III, 11.7%; and grade IV, 4.2%. The severity of intra-abdominal hypertension during the first 2 weeks of the ICU stay was identified as an independent predictor of 28- and 90-day mortality, whereas the presence of intra-abdominal hypertension on the day of ICU admission did not predict mortality. Body mass index, Acute Physiology and Chronic Health Evaluation II score greater than or equal to 18, presence of abdominal distension, absence of bowel sounds, and positive end-expiratory pressure greater than or equal to 7 cm H2O were independently associated with the development of intra-abdominal hypertension at any time during the observation period. In subjects without intra-abdominal hypertension on day 1, body mass index combined with daily positive fluid balance and positive end-expiratory pressure greater than or equal to 7 cm H2O (as documented on the day before intra-abdominal hypertension occurred) were associated with the development of intra-abdominal hypertension during the first week in the ICU. CONCLUSIONS: In our mixed ICU patient cohort, intra-abdominal hypertension occurred in almost half of all subjects and was twice as prevalent in mechanically ventilated patients as in spontaneously breathing patients. Presence and severity of intra-abdominal hypertension during the observation period significantly and independently increased 28- and 90-day mortality. Five admission day variables were independently associated with the presence or development of intra-abdominal hypertension. Positive fluid balance was associated with the development of intra-abdominal hypertension after day 1.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Estado Terminal/mortalidade , Hipertensão Intra-Abdominal/diagnóstico , Hipertensão Intra-Abdominal/epidemiologia , Cavidade Abdominal/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Resultados de Cuidados Críticos , Feminino , Humanos , Incidência , Unidades de Terapia Intensiva/estatística & dados numéricos , Hipertensão Intra-Abdominal/mortalidade , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/mortalidade , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Adulto Jovem
7.
Rev. enferm. UFPE on line ; 13(1): 9-14, jan. 2019. ilus, tab
Artigo em Português | BDENF - Enfermagem | ID: biblio-1005918

RESUMO

Objetivo: identificar o perfil epidemiológico e os fatores relacionados ao óbito em pacientes críticos que sofreram traumatismo cranioencefálico. Método: trata-se de um estudo quantitativo, descritivo e transversal, com coleta de dados em prontuários. Realizaram-se estatísticas descritivas e o teste exato de Fisher adotando-se p-valor <0,05 como significativo. Apresentam-se os resultados em tabela. Resultados: revelam-se que, dos 61 pacientes, 80,3% eram do sexo masculino; 72,1% tinham <40 anos de idade; em 72,5% o traumatismo ocorreu por acidente motociclístico; 91,8% foram considerados graves; 65,5%, insuficiência circulatória; 48,1% apresentaram sequelas na alta por deficit neurológico e 32,7% por deficit motor e 16,4% foram a óbito. Acrescenta-se que o sexo masculino (p-valor = 0,02) e a insuficiência circulatória (p-valor = 0,05) apresentaram correlação com o óbito. Conclusão: identificou-se que a maioria dos pacientes era homens jovens, com trauma por motocicletas, apresentaram-se graves, com sequelas e o óbito relacionou-se com o sexo masculino e a insuficiência circulatória. Acredita-se que o percentual de óbitos não foi alto, porém, a morbidade foi elevada.(AU)


Assuntos
Humanos , Masculino , Feminino , Perfil de Saúde , Resultados de Cuidados Críticos , Traumatismos Craniocerebrais , Traumatismos Craniocerebrais/mortalidade , Unidades de Terapia Intensiva , Violência , Acidentes de Trânsito , Registros Médicos , Epidemiologia Descritiva , Estudos Transversais
8.
Epilepsy Res ; 149: 70-75, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30500489

RESUMO

OBJECTIVES: To retrospectively assess the incidence of high beta hydroxybutyrate, low bicarbonate (BIC), high acyl carnitine, low selenium, low magnesium, low zinc, low phosphorus, in a cohort of supplemented patients treated with the ketogenic diet (KD) for medically intractable epilepsy. To analyze effect of age, duration of exposure to KD, type of KD, and route of KD intake on lab abnormalities. To analyze the incidence of clinically actionable results, resulting in medical interventions based on abnormal results and to analyze costs of testing. METHODS: Retrospective chart review and statistical analysis. Association between abnormal values (binary) and categorical variables was tested with Chi-square/Fisher's exact test. Associations between abnormal values (binary) and continuous variables were analyzed with logistic regression. Statistical analyses were performed in SAS 9.4. RESULTS: We included 91 patients with average duration on diet of 46.73 months (IQR 18.8-75.5 months). Most patients were on the classic KD (81 KD- 59% on 4:1 ratio, 10 modified Atkins diet). 74% were orally fed and 70% completed lab visits to the 12-month mark. There was no significant association between abnormal laboratory parameters and duration of exposure, type of diet, route of administration. Younger children were more likely to have low BIC, high acyl carnitine. Older children were more likely to have low phosphorus. Less than 15% of patients reported clinical changes to suggest dietary deficiency in vitamins/ minerals and in < 11% of cases was an actionable laboratory parameter found. SIGNIFICANCE: Our study is the first to document the real-life incidence of selected tests being abnormal when following consensus guidelines on lab testing. Elimination of tests with low yield will result in cost savings of up to $USD 185 per visit. Low phosphorus is frequently found in patients on KD.


Assuntos
Técnicas de Laboratório Clínico/métodos , Resultados de Cuidados Críticos , Dieta Cetogênica/métodos , Epilepsia/complicações , Epilepsia/dietoterapia , Adolescente , Carnitina/análogos & derivados , Carnitina/metabolismo , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Lactente , Masculino , Fósforo/metabolismo
9.
Rev. inf. cient ; 98(5): 673-685, 2019.
Artigo em Espanhol | LILACS | ID: biblio-1024864

RESUMO

Introducción: La rehabilitación temprana del paciente grave es una exigencia de su atención integral. Objetivo: Sistematizar contenidos esenciales relacionados con la rehabilitación temprana del paciente ingresado en la unidad de Terapia Intensiva. Método: En el Hospital General Docente Dr Agostinho Neto, entre enero y julio de 2019 se hizo una revisión narrativa sobre el tema, a través de una búsqueda en bases de datos electrónicas (Biblioteca Virtual en Salud, LILACS, PubMed, SciELO, REDALYC, Scopus). Resultados: Se localizaron 159 documentos y se eligieron 25 relevantes para el objetivo de la revisión. La información se estructuró en los siguientes aspectos: definiciones, uso del método clínico en la rehabilitación temprana del paciente grave, beneficios y protocolos para este fin. Se identificaron controversias sobre los criterios de indicación, el protocolo de actuación, los tiempos de inicio, intensidad y frecuencia de los ejercicios. Conclusiones: Se sistematiza las bases para la rehabilitación temprana en pacientes graves, se revela que es factible para mejorar su recuperación funcional y futura calidad de vida(AU)


Introduction: The early rehabilitation of the serious patient is a requirement of their comprehensive care. Objective: Systematize essential contents related to the early rehabilitation of the patient admitted to the Intensive Care Unit. Method: In the General Teaching Hospital Dr Agostinho Neto, between January and July 2019, a narrative review was made on the subject, through a search in electronic databases (Virtual Health Library, LILACS, PubMed, SciELO, REDALYC, Scopus). Results: 159 documents were located and 25 relevant for the purpose of the review were chosen. The information was structured in the following aspects: definitions, use of the clinical method in the early rehabilitation of the severe patient, benefits and protocols for this purpose. Controversies were identified on the criteria of indication, the protocol of action, the start times, intensity and frequency of the exercises. Conclusions: The bases for early rehabilitation in serious patients are systematized, it is revealed that it is feasible to improve their functional recovery and future quality of life(AU)


Introdução: A reabilitação precoce do paciente grave é uma exigência do seu cuidado integral. Objetivo: Sistematizar conteúdos essenciais relacionados à reabilitação precoce do paciente internado na Unidade de Terapia Intensiva. Método: No Hospital Geral de Ensino Dr Agostinho Neto, entre janeiro e julho de 2019, foi realizada uma revisão narrativa sobre o assunto, por meio de busca em bases de dados eletrônicas (Biblioteca Virtual em Saúde, LILACS, PubMed, SciELO, REDALYC, Scopus). Resultados: Foram localizados 159 documentos e escolhidos 25 relevantes para a finalidade da revisão. As informações foram estruturadas nos seguintes aspectos: definições, uso do método clínico na reabilitação precoce do paciente grave, benefícios e protocolos para esse fim. Controvérsias foram identificadas nos critérios de indicação, protocolo de ação, horário de início, intensidade e frequência dos exercícios. Conclusões: Sistematizadas as bases para a reabilitação precoce em pacientes graves, é possível viabilizar a recuperação funcional e a qualidade de vida futura(AU)


Assuntos
Humanos , Reabilitação , Diagnóstico Clínico , Cuidados Críticos , Gravidade do Paciente , Resultados de Cuidados Críticos
11.
Seizure ; 61: 170-176, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30176574

RESUMO

PURPOSE: Few outcome data are available about morbidity associated with endotracheal intubation modalities in critically ill patients with convulsive status epilepticus. We compared etomidate versus sodium thiopental for emergency rapid sequence intubation in patients with out-of-hospital convulsive status epilepticus. METHODS: Patients admitted to our intensive care unit in 2006-2015 were studied retrospectively. The main outcome measure was seizure and/or status epilepticus recurrence within 12 h after rapid sequence intubation. RESULTS: We included 97 patients (60% male; median age, 59 years [IQR, 48-70]). Median time from seizure onset to first antiepileptic drug was 60 min [IQR, 35-90]. Reasons for intubation were coma in 95 (98%), acute respiratory distress in 18 (19%), refractory convulsive status epilepticus in 9 (9%), and shock in 6 (6%) patients; 50 (52%) patients had more than one reason. The hypnotic drugs used were etomidate in 54 (56%) and sodium thiopental in 43 (44%) patients. Seizure and/or status epilepticus recurred in 13 (56%) patients in the etomidate group and 11 patients (44%) in the sodium thiopental group (adjusted common odds ratio [aOR], 0.98; 95%CI, 0.36-2.63; P = 0.97). The two groups were not significantly different for proportions of patients with hemodynamic instability after intubation (aOR, 0.60; 95%CI, 0.23-1.58; P = 0.30) or with difficult endotracheal intubation (OR, 1.28; 95% CI 0.23 to 7.21; P=0.77). CONCLUSIONS: Our findings argue against a difference in seizure and/or status epilepticus recurrences rates between critically ill patients with convulsive status epilepticus given etomidate vs. sodium thiopental as the induction agent for emergency intubation.


Assuntos
Etomidato/uso terapêutico , Hipnóticos e Sedativos/uso terapêutico , Intubação/métodos , Estado Epiléptico/terapia , Tiopental/uso terapêutico , Idoso , Resultados de Cuidados Críticos , Feminino , Escala de Coma de Glasgow , Hemodinâmica/efeitos dos fármacos , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estado Epiléptico/epidemiologia , Resultado do Tratamento
12.
Rev. esp. geriatr. gerontol. (Ed. impr.) ; 53(4): 213-216, jul.-ago. 2018. tab
Artigo em Espanhol | IBECS | ID: ibc-178002

RESUMO

Objetivo: Evaluar la asociación de la situación funcional previa, valorada mediante la escala de Barthel y Short Form-Late Life Function and Disability instrument, en los pacientes mayores de 74 años que precisan de ingreso en la UCI con respecto a su pronóstico y capacidad funcional al alta hospitalaria. Material y métodos: Estudio prospectivo de una cohorte de paciente mayores de 74 años ingresados en UCI polivalente con estancia superior a 48 h. Se analizan variables demográficas, sociales, comorbilidad, cuestionario de discapacidad (Barthel, Short Form-Late Life Function and Disability instrument), motivos de ingreso en UCI, gravedad en UCI (SAPS 3). Se realiza un análisis multivariable para establecer los factores asociados a mortalidad o mala situación funcional al alta (índice de Barthel menor de 35). Resultados: Durante el periodo del estudio ingresaron 219 pacientes mayores de 74 años, de los que 129 (15%) tuvieron estancia mayor de 48 h. La mediana de edad fue de 80 años (77-83) siendo el 52% mujeres. El motivo de ingreso fue cardiopatía isquémica (19%), otra patología médica (38%) y patología quirúrgica (43%). Un 3% de los pacientes presentaba un Barthel inferior a 36 a su ingreso, siendo la mediana de 95 (85-100). La mediana de estancia en UCI fue de 5 días (4-8). La mortalidad en UCI fue del 6%, con una mortalidad hospitalaria del 10%. Al alta hospitalaria el 7% presentaban dependencia grave (Barthel inferior a 36). En esta población los factores asociados de forma independiente con la mortalidad o mala situación funcional al alta del hospital fueron la situación funcional previa al ingreso, en base a Short Form-Late Life Function and Disability instrument (OR 0,95 IC95%; 0,91 a 0,98); y a la gravedad al ingreso evaluada por SAPS 3 (OR 1,10 IC95%; 1,02 a 1,18) p=0,0007. Conclusiones: En pacientes ancianos que precisan ingreso en UCI, presentar una mayor puntuación en la escala SAPS 3 y deterioro funcional en base a una escala son factores asociados a mortalidad o dependencia severa al alta


Objective: To assess the association of previous functional status in elderly patients admitted to the ICU, estimated by the Barthel and Short Form-Late Life Function and Disability instrument scales, and the relationship with prognosis and functional capacity at hospital discharge. Material and methods: Observational prospective study of ICU-admitted patients older than 74 years, with a length of stay greater than 48hours. Demographic data, social background, comorbidities, disability questionnaire (Barthel, Short Form-Late Life Function and Disability instrument), main diagnosis and severity (SAPS 3) on ICU admission were recorded. Factors associated with mortality or poor functional status at hospital discharge (Barthel Index less than 35) were established by multivariate analysis. Results: During the study period, 219 elderly patients were admitted in ICU, of whom 129 (15%) had an ICU length of stay greater than 48hours. The median age was 80 years (77-83), with 52% women. Main diagnoses on admission included ischaemic heart disease (19%), another medical diagnosis (38%), and surgical procedure (43%). A Barthel score <36 (median 95, 85-100) was observed in 3% of the patients on admission. The median ICU length of stay was 5 days (4-8). ICU mortality was 6% (hospital mortality: 10%). On hospital discharge, 7% had severe dependence (Barthel <36). In this population, factors independently associated with mortality or poor functional status at hospital discharge were the pre-admission functional status, based on Short Form-Late Life Function and Disability instrument (OR 0.95, 95% CI, 0.91 to 0.98), and the severity on admission assessed by SAPS 3 (OR 1.10, 95% CI, 1.02 to 1.18), p=.0007. Conclusions: In elderly patients requiring ICU admission, a higher SAPS 3 score and functional impairment on admission were associated with mortality or severe dependence upon discharge


Assuntos
Humanos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/estatística & dados numéricos , Resultados de Cuidados Críticos , Perfil de Impacto da Doença , Prognóstico , Estudos Prospectivos , Tempo de Internação , Indicadores de Morbimortalidade , Idoso Fragilizado/estatística & dados numéricos , Qualidade de Vida
13.
Rev. enferm. UFPE on line ; 12(8): 2163-2169, ago. 2018. ilus, tab
Artigo em Português | BDENF - Enfermagem | ID: biblio-994472

RESUMO

Objetivo: descrever as repercussões das variações glicêmicas e pressóricas de pacientes hipertensos e diabéticos. Método: estudo quantitativo, descritivo e exploratório, com 14 pacientes internados na unidade de terapia intensiva (UTI). Utilizou-se questionário estruturado para coleta de dados. Considerou-se significativo resultado com p < 0,05. Resultados: 78,5% dos pacientes se caracterizavam como hipertensos e 43% diabéticos. O período de internação compreendeu 66±84 dias e o período de ventilação mecânica foi de 70±95 dias. O Acute Physiology and Chronic Health Disease Classification System II (APACHE II) de 26±4 sinalizou a gravidade dos pacientes. Glicemia capilar, tempo de internação e de ventilação mecânica se associaram significativamente ao pior desfecho/óbito (p ≤ 0,05). Conclusão: uma das repercussões das alterações glicêmicas e pressóricas se associou ao risco de lesão renal. Além disso, a inexistência de um controle seguro e eficaz da glicemia conduziu os pacientes ao pior desfecho/óbito. Destaca-se a participação do enfermeiro não apenas para controlar as oscilações glicêmicas, mas também proporcionar um cuidado seguro e auxiliar a tomada de decisão, a fim de aumentar a sobrevida do paciente e garantir uma assistência eficaz e de qualidade.(AU)


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Glicemia , Cuidados Críticos , Diabetes Mellitus , Enfermagem de Cuidados Críticos , Resultados de Cuidados Críticos , Hipertensão , Unidades de Terapia Intensiva , Epidemiologia Descritiva , Inquéritos e Questionários
14.
Rev. habanera cienc. méd ; 17(4): 567-578, jul.-ago. 2018. tab, graf
Artigo em Espanhol | LILACS | ID: biblio-978552

RESUMO

Introducción: Las enfermedades cerebrovasculares ocupan en el mundo occidental la segunda causa de mortalidad, solo superada por las enfermedades cardiovasculares y el cáncer. Objetivo: Identificar factores pronósticos de mortalidad en pacientes ingresados con enfermedad cerebrovascular en la unidad de cuidados intensivos. Material y Métodos: Se realizó un estudio observacional, analítico y retrospectivo en una población de 163 pacientes, 73 fallecidos y 90 vivos. Resultados: La edad media fue de 64±13,9 (p=0,300). En total de 72(44,2 por ciento) pacientes presentaron una complicación y 46(28,2 por ciento) necesitaron ventilación (p=0,000). El mayor número de fallecidos lo aportó la ECV hemorrágica 46(63 por ciento). La mortalidad en los pacientes ventilados fue de 83,3 por ciento. De los 71 pacientes que presentaron complicaciones el mayor número de fallecidos se debió a la sepsis respiratoria con 14(50 por ciento) pacientes. En el análisis univariado los pacientes fallecidos presentaban un APACHE II≥ 15 (OR=10,4; p=0,000; IC 95 por ciento=4,9-21,7); un Glasgow ≤ 9 (OR=11,4; p=0,000; IC 95 por ciento=5,5-23,8); una enfermedad cerebrovascular hemorrágica (OR=3,9; p=0,000; IC 95 por ciento=2,1-7,7) y/o necesitaron de ventilación (OR=11,1; p=0,000; IC 95 por ciento=4,7-26,3). El análisis multivariante determinó que las variables significativamente relacionada con la mortalidad eran el APACHE II ≥15 puntos (OR=4,4; p=0,001; IC 95 por ciento=1,9-10,2); un Glasgow ≤ 9 (OR=4,4; p=0,001; IC 95 por ciento=1,8-10,6). Conclusiones: Los factores pronósticos de mortalidad que se identificaron en los pacientes fueron el APACHE II ≥15 puntos a las 24 horas del ingreso, la escala del coma de Glasgow ≤ 9 puntos al ingreso. La neumonía fue la principal complicación en pacientes fallecidos(AU)


Introduction: Cerebrovascular diseases (CVD) are the second cause of mortality in the Western world, which are only surpassed by cardiovascular diseases and cancer. Objective: To identify prognostic factors for mortality in patients admitted to Intensive Care Units with cerebrovascular diseases. Material and Methods: An observational, analytic, retrospective study was conducted in a population of 163 patients (deceased,73; and alive, 90). Results: The mean age was 64±13,9 (p=0,300). A total of 72(44, 2 percent) patients presented a complication, and 46(28, 2 percent) needed ventilation (p=0,000). The greater number of deceased resulted from hemorrhagic CVD 46(63 percent). Mortality in the ventilated patients was 83, 3 percent. The greater number of the 71 patients that presented complications died of respiratory sepsis, reporting 14(50 percent) patients. From the univariate analysis, the deceased patients presented an APACHE II≥ 15 (OR=10,4; p=0,000; CI 95 percent=4,9-21,7); a Glasgow scale ≤ 9 (OR=11,4; p=0,000; CI 95 percent=5,5-23,8); a hemorrhagic cerebrovascular disease (OR=3,9; p=0,000; CI 95 percent=2,1-7,7); and/or needed ventilation (OR=11,1; p=0,000; CI 95 percent=4,7-26,3). The multivariate analysis determined that the variables that were significantly related to mortality were the APACHE II ≥15 points (OR=4,4; p=0,001; CI 95 percent=1,9-10,2); and Glasgow ≤ 9 (OR=4,4; p=0,001; CI 95 percent=1,8-10,6). Conclusions: The prognostic factors for mortality identified in the patients were the APACHE II ≥15 points at 24 hours after admission, and the Glasgow coma scale ≤ 9 points on admission. Pneumonia was the major complication in the deceased patients(AU)


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/mortalidade , Resultados de Cuidados Críticos , Prognóstico , Estudos Retrospectivos , Acidente Vascular Cerebral/terapia , Estudos Observacionais como Assunto
15.
Curr Opin Crit Care ; 24(5): 421-427, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30045088

RESUMO

PURPOSE OF REVIEW: The burden of critical illness in low-income and middle-income countries (LMICs) is substantial. A better understanding of critical care outcomes is essential for improving critical care delivery in resource-limited settings. In this review, we provide an overview of recent literature reporting on critical care outcomes in LMICs. We discuss several barriers and potential solutions for a better understanding of critical care outcomes in LMICs. RECENT FINDINGS: Epidemiologic studies show higher in-hospital mortality rates for critically ill patients in LMICs as compared with patients in high-income countries (HICs). Recent findings suggest that critical care interventions that are effective in HICs may not be effective and may even be harmful in LMICs. Little data on long-term and morbidity outcomes exist. Better outcomes measurement is beginning to emerge in LMICs through decision support tools that report process outcome measures, studies employing mobile health technologies with community health workers and the development of context-specific severity of illness scores. SUMMARY: Outcomes from HICs cannot be reliably extrapolated to LMICs, so it is important to study outcomes for critically ill patients in LMICs. Specific challenges to achieving meaningful outcomes studies in LMICs include defining the critically ill population when few ICU beds exist, the resource-intensiveness of long-term follow-up, and the need for reliable severity of illness scores to interpret outcomes. Although much work remains to be done, examples of studies overcoming these challenges are beginning to emerge.


Assuntos
Resultados de Cuidados Críticos , Estado Terminal , Assistência à Saúde/normas , Recursos em Saúde/provisão & distribução , Melhoria de Qualidade/normas , Qualidade da Assistência à Saúde/normas , Estado Terminal/mortalidade , Países em Desenvolvimento , Mortalidade Hospitalar , Humanos
16.
Crit Care ; 22(1): 144, 2018 06 04.
Artigo em Inglês | MEDLINE | ID: mdl-29866165

RESUMO

BACKGROUND: Although high-flow nasal cannula therapy (HFNC) has become a popular mode of non-invasive respiratory support (NRS) in critically ill children, there are no randomised controlled trials (RCTs) comparing it with continuous positive airway pressure (CPAP). We performed a pilot RCT to explore the feasibility, and inform the design and conduct, of a future large pragmatic RCT comparing HFNC and CPAP in paediatric critical care. METHODS: In this multi-centre pilot RCT, eligible patients were recruited to either Group A (step-up NRS) or Group B (step-down NRS). Participants were randomised (1:1) using sealed opaque envelopes to either CPAP or HFNC as their first-line mode of NRS. Consent was sought after randomisation in emergency situations. The primary study outcomes were related to feasibility (number of eligible patients in each group, proportion of eligible patients randomised, consent rate, and measures of adherence to study algorithms). Data were collected on safety and a range of patient outcomes in order to inform the choice of a primary outcome measure for the future RCT. RESULTS: Overall, 121/254 eligible patients (47.6%) were randomised (Group A 60%, Group B 44.2%) over a 10-month period (recruitment rate for Group A, 1 patient/site/month; Group B, 2.8 patients/site/month). In Group A, consent was obtained in 29/33 parents/guardians approached (87.9%), while in Group B 84/118 consented (71.2%). Intention-to-treat analysis included 113 patients (HFNC 59, CPAP 54). Most reported adverse events were mild/moderate (HFNC 8/59, CPAP 9/54). More patients switched treatment from HFNC to CPAP (Group A: 7/16, 44%; Group B: 9/43, 21%) than from CPAP to HFNC (Group A: 3/13, 23%; Group B: 5/41, 12%). Intubation occurred within 72 h in 15/59 (25.4%) of HFNC patients and 10/54 (18.5%) of CPAP patients (p = 0.38). HFNC patients experienced fewer ventilator-free days at day 28 (Group A: 19.6 vs. 23.5; Group B: 21.8 vs. 22.2). CONCLUSIONS: Our pilot trial confirms that, following minor changes to consent procedures and treatment algorithms, it is feasible to conduct a large national RCT of non-invasive respiratory support in the paediatric critical care setting in both step-up and step-down NRS patients. TRIAL REGISTRATION: clinicaltrials.gov, NCT02612415 . Registered on 23 November 2015.


Assuntos
Cânula/classificação , Pressão Positiva Contínua nas Vias Aéreas/classificação , Cânula/estatística & dados numéricos , Criança , Pré-Escolar , Pressão Positiva Contínua nas Vias Aéreas/estatística & dados numéricos , Cuidados Críticos/métodos , Resultados de Cuidados Críticos , Feminino , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica/organização & administração , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Londres , Masculino , Oxigenoterapia/métodos , Oxigenoterapia/normas , Oxigenoterapia/estatística & dados numéricos , Projetos Piloto
19.
PLoS One ; 13(2): e0190569, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29489814

RESUMO

IMPORTANCE: Critically ill patients often receive high-intensity life sustaining treatments (LST) in the intensive care unit (ICU), although they can be ineffective and eventually undesired. Determining the risk factors associated with reversals in LST goals can improve patient and provider appreciation for the natural history and epidemiology of critical care and inform decision making around the (continued) use of LSTs. METHODS: This is a single institution retrospective cohort study of patients receiving life sustaining treatment in an academic tertiary hospital from 2009 to 2013. Deidentified patient electronic medical record data was collected via the clinical data warehouse to study the outcomes of treatment limiting Comfort Care and do-not-resuscitate (DNR) orders. Extended multivariable Cox regression models were used to estimate the association of patient and clinical factors with subsequent treatment limiting orders. RESULTS: 10,157 patients received life-sustaining treatment while initially Full Code (allowing all resuscitative measures). Of these, 770 (8.0%) transitioned to Comfort Care (with discontinuation of any life-sustaining treatments) while 1,669 (16%) patients received new DNR orders that reflect preferences to limit further life-sustaining treatment options. Patients who were older (Hazard Ratio(HR) 1.37 [95% CI 1.28-1.47] per decade), with cerebrovascular disease (HR 2.18 [95% CI 1.69-2.81]), treated by the Medical ICU (HR 1.92 [95% CI 1.49-2.49]) and Hematology-Oncology (HR 1.87 [95% CI 1.27-2.74]) services, receiving vasoactive infusions (HR 1.76 [95% CI 1.28, 2.43]) or continuous renal replacement (HR 1.83 [95% CI 1.34, 2.48]) were more likely to transition to Comfort Care. Any new DNR orders were more likely for patients who were older (HR 1.43 [95% CI 1.38-1.48] per decade), female (HR 1.30 [95% CI 1.17-1.44]), with cerebrovascular disease (HR 1.45 [95% CI 1.25-1.67]) or metastatic solid cancers (HR 1.92 [95% CI 1.48-2.49]), or treated by Medical ICU (HR 1.63 [95% CI 1.42-1.86]), Hematology-Oncology (HR 1.63 [95% CI 1.33-1.98]) and Cardiac Care Unit-Heart Failure (HR 1.41 [95% CI 1.15-1.72]). CONCLUSION: Decisions to reverse or limit treatment goals occurs after more than 1 in 13 trials of LST, and is associated with older female patients, receiving non-ventilator forms of LST, cerebrovascular disease, and treatment by certain medical specialty services.


Assuntos
Cuidados para Prolongar a Vida/métodos , Diretivas Antecipadas , Idoso , Estudos de Coortes , Resultados de Cuidados Críticos , Estado Terminal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Conforto do Paciente , Ordens quanto à Conduta (Ética Médica) , Estudos Retrospectivos , Fatores de Risco
20.
Clin Infect Dis ; 67(4): 513-518, 2018 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-29438467

RESUMO

Background: Prophylactic antimicrobial therapy is frequently prescribed for acute aspiration pneumonitis, with the intent of preventing the development of aspiration pneumonia. However, few clinical studies have examined the benefits and harms of this practice. Methods: A retrospective cohort study design was used to compare outcomes of patients with aspiration pneumonitis who received prophylactic antimicrobial therapy with those managed with supportive care only during the initial 2 days following macroaspiration. The primary outcome was in-hospital mortality within 30 days. Secondary outcomes included transfer to critical care and antimicrobial therapy received between days 3 and 14 following macroaspiration including escalation of therapy and antibiotic-free days. Results: Among 1483 patients reviewed, 200 met the case definition for acute aspiration pneumonitis, including 76 (38%) who received prophylactic antimicrobial therapy and 124 (62%) who received supportive management only. After adjusting for patient-level predictors, antimicrobial prophylaxis was not associated with any improvement in mortality (odds ratio, 0.9; 95% confidence interval [CI], 0.4-1.7; P = .7). Patients receiving prophylactic antimicrobial therapy were no less likely to require transfer to critical care (5% vs 6%; P = .7) and subsequently received more frequent escalation of antibiotic therapy (8% vs 1%; P = .002) and fewer antibiotic-free days (7.5 vs 10.9; P < .0001). Conclusions: Prophylactic antimicrobial therapy for patients with acute aspiration pneumonitis does not offer clinical benefit and may generate antibiotic selective pressures that results in the need for escalation of antibiotic therapy among those who develop aspiration pneumonia.


Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia , Mortalidade Hospitalar , Pneumonia Aspirativa/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Resultados de Cuidados Críticos , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Estudos Retrospectivos
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