Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 556
Filtrar
1.
Med Clin North Am ; 104(3): 539-560, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32312414

RESUMO

Some patients with terminal and degenerative illnesses request assistance to hasten death when suffering is refractory to palliative care, or they strongly desire to maximize their autonomy and dignity and minimize suffering. Palliative sedation (PS), voluntarily stopping eating and drinking (VSED), and physician-assisted death (PAD) are possible options of last resort. A decision to choose PS can be made by an informed surrogate decision maker, whereas intact decision-making capacity is required to choose VSED or PAD. For all palliative treatments of last resort, the risk of harm is minimized by the use of checklists, and establishment of policies and procedures.


Assuntos
Sedação Profunda/métodos , Eutanásia Ativa Voluntária/ética , Cuidados Paliativos/ética , Suicídio Assistido/ética , Idoso , Idoso de 80 Anos ou mais , Comunicação , Tomada de Decisões , Comportamento de Ingestão de Líquido/fisiologia , Eutanásia Ativa Voluntária/psicologia , Comportamento Alimentar/psicologia , Humanos , Enfermeiras e Enfermeiros/psicologia , Enfermeiras e Enfermeiros/estatística & dados numéricos , Cuidados Paliativos/tendências , Médicos/tendências , Estados Unidos/epidemiologia
2.
Medicine (Baltimore) ; 99(9): e19001, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32118711

RESUMO

BACKGROUND: Intranasal dexmedetomidine is a relatively new way to sedate young children undergoing nonpainful diagnostic procedures. We performed a meta-analysis to compare the efficacy and safety of intranasal dexmedetomidine in young children with those of oral chloral hydrate, which has been a commonly used method for decades. METHODS: We searched PubMed, Embase, and the Cochrane Library for all randomized controlled trials that compared intranasal dexmedetomidine with oral chloral hydrate in children undergoing diagnostic procedures. Data on success rate of sedation, onset time, recovery time, and adverse effects were extracted and respectively analyzed. RESULTS: Five studies with a total of 720 patients met the inclusion criteria. Intranasal dexmedetomidine provided significant higher success rate of sedation (relative risk [RR], 1.12; 95% confidence interval [CI], 1.02 to 1.24; P = .02; I = 74%) than oral chloral hydrate. Furthermore, it experienced significantly shorter onset time (weight mean difference [WMD], -1.79; 95% CI, -3.23 to -0.34; P = .02; I = 69%). Nevertheless, there were no statistically differences in recovery time (WMD, -10.53; 95% CI, -24.17 to 3.11; P = .13; I = 92%) and the proportion of patients back to normal activities (RR, 1.11; 95% CI, 0.77-1.60; P = .57; I = 0%). Intranasal dexmedetomidine was associated with a significantly lower incidence of nausea and vomiting (RR, 0.05; 95% CI, 0.01-0.22; P < .0001; I = 0%) than oral chloral hydrate. Although adverse events such as bradycardia, hypotension and hypoxia were not synthetized due to lack of data, no clinical interventions except oxygen supplementation were required in any patients. CONCLUSION: Our meta-analysis revealed that intranasal dexmedetomidine is possibly a more effective and acceptable sedation method for infants and toddlers undergoing diagnostic procedures than oral chloral hydrate. Additionally, it shows similar safety profile and could be a potential alternative to oral chloral hydrate.


Assuntos
Hidrato de Cloral/administração & dosagem , Sedação Profunda/métodos , Dexmedetomidina/administração & dosagem , Hipnóticos e Sedativos/administração & dosagem , Administração Intranasal , Administração Oral , Pré-Escolar , Hidrato de Cloral/efeitos adversos , Dexmedetomidina/efeitos adversos , Humanos , Hipnóticos e Sedativos/efeitos adversos , Lactente
3.
Einstein (Sao Paulo) ; 18: eAO5168, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31994609

RESUMO

OBJECTIVE: To understand the use of tools, protocols and comfort measures related to sedation/analgesia, and to screen the occurrence of delirium in pediatric intensive care units. METHODS: A survey with 14 questions was distributed by e-mail to Brazilian critical care pediatricians. Eight questions addressed physician and hospital demographics, and six inquired practices to assess sedation, analgesia, and delirium in pediatric intensive care units. RESULTS: Of 373 questionnaires sent, 61 were answered (16.3%). The majority of physicians were practicing in the Southeast region (57.2%). Of these, 46.5% worked at public hospitals, 28.6% of which under direct state administration. Of respondents, 57.1% used formal protocols for sedation and analgesia, and the Ramsay scale was the most frequently employed (52.5%). Delirium screening scores were not used by 48.2% of physicians. The Cornell Assessment of Pediatric Delirium was the score most often used (23.2%). The majority (85.7%) of physicians did not practice daily sedation interruption, and only 23.2% used non-pharmacological measures for patient comfort frequently, with varied participation of parents in the process. CONCLUSION: This study highlights the heterogeneity of practices for assessment of sedation/analgesia and lack of detection of delirium among critical care pediatricians in Brazil.


Assuntos
Analgesia/métodos , Sedação Profunda/métodos , Delírio/diagnóstico , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Pediatras/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Analgesia/efeitos adversos , Analgesia/estatística & dados numéricos , Brasil , Sedação Profunda/efeitos adversos , Sedação Profunda/estatística & dados numéricos , Delírio/etiologia , Humanos , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Inquéritos e Questionários
4.
Rev. Rol enferm ; 42(9): 594-598, sept. 2019. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-187140

RESUMO

La enfermedad terminal a lo largo de su curso presenta numerosos síntomas y tratamientos sintomáticos, cuyo objetivo es paliar el dolor y mejorar el bienestar y la calidad de vida del paciente. Entre esos tratamientos se encuentra la sedación paliativa, cuyo objetivo es aliviar el sufrimiento en los últimos días u horas de vida. Aparte de la sedación paliativa encontramos en algunos países, y cuan-do el paciente lo decide, la eutanasia, que pone fin a la vida del paciente ter-minal con su consentimiento para poder darle la muerte digna que desea. El presente trabajo pretende mostrar la diferencia entre ambos conceptos y los criterios médicos y éticos en los que se basan, además de conocer la situación actual de nuestro país y del resto de Europa con respecto la eutanasia


The terminal illness along its course presents numerous symptoms and symptomatic treatments, whose objective is to alleviate pain and improve the well-being and quality of life of the patient. Among those treatments is the palliative sedation, which aims to relieve suffering in the last days or hours of life. Apart from the palliative sedation we find in some countries, and when the patient decides it, euthanasia, which puts an end to the life of the terminal patient with his consent to be able to give him the dignified death he desires. The present work aims to show the difference between both concepts and the medical and ethical criteria on which they are based, as well as to know the current situation of our country and the rest of Europe regarding euthanasia


Assuntos
Humanos , Eutanásia/ética , Eutanásia/legislação & jurisprudência , Cuidados Paliativos na Terminalidade da Vida/ética , Sedação Profunda/métodos , Sedação Profunda/ética , Anestésicos/administração & dosagem , Europa (Continente) , Anestésicos
5.
Br J Anaesth ; 123(3): 298-308, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31277837

RESUMO

BACKGROUND: Emergence from sedation entails rapid increase in the levels of both awareness and wakefulness, the two axes of consciousness. Functional MRI (fMRI) studies of emergence from sedation often focus on the recovery period, with no description of the moment of emergence. We hypothesised that by focusing on the moment of emergence, novel insights, primarily about subcortical activity and increased wakefulness, will be gained. METHODS: We conducted a resting state fMRI analysis of 17 male subjects (20-40 yr old) gradually entering into and emerging from deep sedation (average computed propofol concentrations of 2.41 and 1.11 µg ml-1, respectively), using target-controlled infusion of propofol. RESULTS: Functional connectivity analysis revealed a robust spatiotemporal signature of return of consciousness, in which subcortical seeds showed transient positive correlations that rapidly turned negative shortly after emergence. Elements of this signature included four components of the ascending reticular activating system: the ventral tegmentum area, the locus coeruleus, median raphe, and the mammillary body. The involvement of the rostral dorsolateral pontine tegmentum, which is specifically impaired in comatose patients with pontine lesions, in emergence was previously unknown. CONCLUSIONS: Emergence from propofol sedation is characterised, and possibly driven, by a transient activation of brainstem loci. Some of these loci are known components of the ascending reticular activating system, whereas an additional locus was found that is also impaired in comatose patients.


Assuntos
Córtex Cerebral/efeitos dos fármacos , Sedação Profunda/métodos , Hipnóticos e Sedativos/farmacologia , Propofol/farmacologia , Adulto , Período de Recuperação da Anestesia , Mapeamento Encefálico/métodos , Tronco Encefálico/diagnóstico por imagem , Tronco Encefálico/efeitos dos fármacos , Tronco Encefálico/fisiologia , Córtex Cerebral/diagnóstico por imagem , Córtex Cerebral/fisiologia , Estado de Consciência/efeitos dos fármacos , Esquema de Medicação , Humanos , Hipnóticos e Sedativos/administração & dosagem , Imagem por Ressonância Magnética , Masculino , Rede Nervosa/efeitos dos fármacos , Propofol/administração & dosagem , Adulto Jovem
6.
Curr Opin Anaesthesiol ; 32(4): 457-463, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31219870

RESUMO

PURPOSE OF REVIEW: The purpose of this review is to discuss current drugs used for intravenous moderate and deep sedation by nonanesthesiologists in the United States. We also explore training expectations for moderate and deep sedation as they play key roles in anesthetic selection and preprocedural planning. RECENT FINDINGS: Although opioids and benzodiazepines are considered the standard for moderate sedation, increased interest in propofol, dexmedetomidine, and other sedative-hyptonic drugs require additional attention in terms of training providers and complying with current practice guidelines. SUMMARY: Moderate sedation providers should be familiar with titrating benzodiazepines and opioids to achieve targeted sedation. The use of propofol and ketamine is generally reserved for deep sedation by qualified professionals. However, the role of dexmedetomidine in procedural sedation continues to evolve as its use is explored in moderate sedation. Providers of all sedation types should be aware of hypotension, apnea, hypoventilation, and hypoxia that can develop and they should be able to manage the patient under these circumstances. Preprocedural planning is an integral training expectation to minimize patient risks.


Assuntos
Anestesiologia/educação , Sedação Consciente/métodos , Sedação Profunda/métodos , Educação Médica Continuada , Hipnóticos e Sedativos/administração & dosagem , Administração Intravenosa , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Anestesiologia/normas , Apneia/diagnóstico , Apneia/etiologia , Benzodiazepinas/administração & dosagem , Benzodiazepinas/efeitos adversos , Sedação Consciente/efeitos adversos , Sedação Consciente/normas , Estado de Consciência/efeitos dos fármacos , Sedação Profunda/efeitos adversos , Sedação Profunda/normas , Dexmedetomidina/administração & dosagem , Dexmedetomidina/efeitos adversos , Relação Dose-Resposta a Droga , Humanos , Hipnóticos e Sedativos/efeitos adversos , Hipotensão/diagnóstico , Hipotensão/etiologia , Hipoventilação/diagnóstico , Hipoventilação/etiologia , Hipóxia/diagnóstico , Hipóxia/etiologia , Guias de Prática Clínica como Assunto , Propofol/administração & dosagem , Propofol/efeitos adversos
7.
Gastrointest Endosc ; 90(3): 502-505, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31102644

RESUMO

BACKGROUND AND AIMS: The debate between moderate sedation versus deep sedation for index average-risk screening colonoscopies is well known to gastroenterologists. Ensuring the best of all metrics to perform quality colonoscopies for colon cancer prevention is paramount for both patients and physicians alike, because colon cancer remains the leading cause of cancer death and is the most-used screening tool in the United States. The aim of this study was to determine if moderate sedation versus deep sedation affects outcomes of adenoma detection rate (ADR) or polyp detection rate (PDR) in index, average-risk colonoscopies for colon cancer screening. METHODS: A retrospective, single, tertiary care outpatient center study of 585 healthy average-risk patients who underwent index screening colonoscopy between June 1, 2015 to December 31, 2015 (moderate sedation only) and June 1, 2016,to December 31, 2016 (deep sedation only) was performed after Institutional Review Board approval. Demographic data and polyp details were collected to determine ADR and PDR. Patients who were not average risk were excluded from the study. RESULTS: A total of 585 index average-risk screening colonoscopies were included in this study with 57.7% moderate sedation and 42.2% deep sedation. Neither ADR nor PDR was significantly different between the 2 groups (44.1% vs 38.5% [P = .18] and 71.9% vs 67.6% [P = .27], respectively). CONCLUSIONS: In index average-risk screening colonoscopies, deep sedation appears to have no benefit compared with moderate sedation for ADR and PDR.


Assuntos
Adenoma/diagnóstico , Pólipos Adenomatosos/diagnóstico , Pólipos do Colo/diagnóstico , Colonoscopia/métodos , Neoplasias Colorretais/diagnóstico , Sedação Consciente/métodos , Sedação Profunda/métodos , Detecção Precoce de Câncer , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Atenção Terciária
8.
Am J Cardiol ; 124(2): 233-238, 2019 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-31109635

RESUMO

Catheter ablation is nowadays the core treatment of atrial fibrillation (AF). Propofol infusion sedation is an accepted safety strategy; however, respiratory depression with respiratory variations is frequent. Noninvasive mechanical ventilation (NIV) added to deep sedation could improve procedural safety and success. We sought to assess the predictive factors and safety of NIV in combination to propofol deep sedation in left atrial ablation procedures. Procedural data from 252 consecutive patients who underwent left atrial ablation (166 [66%] persistent, 86 [34%] for paroxysmal AF) were analyzed. Sedation with 1% propofol was used in all procedures and controlled by electrophysiologists. Arterial blood gas analysis was performed regularly during the procedure. NIV was indicated for respiratory depression with pH <7.25 and pCO2 >50 mm Hg or agitated patient with the need for more profound sedation. No patient needed endotracheal intubation, and no procedure was abandoned due to adverse effects of sedation. NIV was used in 25 patients (10%). Predictive factors for the use of NIV were high-dose propofol sedation (p = 0.010), persistent AF (p = 0.029), prolonged procedure time (p = 0.006), increased body mass index (p = 0.008) and presence of obstructive sleep apnea (OSA; p <0.001). In a Cox regression analysis, OSA was an independent factor for NIV use (p = 0.016). In conclusion, propofol deep sedation for patients who underwent left atrial ablation is safe. Adding NIV in high-risk patients (i.e., OSA, high body mass index, and lengthy procedure duration) provides better respiratory homeostasis and could impact long-term procedure results.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Sedação Profunda/métodos , Propofol/farmacologia , Respiração Artificial/métodos , Anestésicos Intravenosos/farmacologia , Fibrilação Atrial/fisiopatologia , Feminino , Seguimentos , Frequência Cardíaca/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
9.
Curr Opin Anaesthesiol ; 32(4): 517-522, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31082826

RESUMO

PURPOSE OF REVIEW: To review the anesthestic and airway management for gastrointestinal procedures outside of the operating room. RECENT FINDINGS: The number of gastrointestinal endoscopic procedures performed is steadily increasing worldwide. As complexity, duration and invasiveness of procedures increase, there is ever greater requirement for deeper sedation or general anesthesia. A close relationship between anesthetic practitioners and endoscopists is required to ensure safe and successful outcomes. The American Society of Gastrointestinal endoscopy and the British Society of Gastroenterology have recently released guidelines for sedation and general anesthesia in gastrointestinal endoscopy, highlighting the need for careful monitoring for all cases, and anesthetic expertise in complex cases. The recent advances in high-flow nasal oxygenation in sedation may provide alternative options for oxygenation during gastrointestinal sedation, especially in deep sedation and this may reduce the need for general anesthesia. SUMMARY: The advances in gastrointestinal endoscopic intervention have increased the requirement for deep sedation and anesthetic involvement outside of the operating room. Careful titration of anesthetic intervention and close monitoring are required to ensure patient safety.


Assuntos
Anestesiologia/normas , Endoscopia Gastrointestinal/efeitos adversos , Dor Processual/prevenção & controle , Guias de Prática Clínica como Assunto , Manuseio das Vias Aéreas/métodos , Manuseio das Vias Aéreas/normas , Anestesiologia/métodos , Anestésicos/administração & dosagem , Sedação Consciente/métodos , Sedação Consciente/normas , Sedação Profunda/métodos , Sedação Profunda/normas , Endoscopia Gastrointestinal/normas , Gastroenterologia/normas , Humanos , Dor Processual/etiologia , Sociedades Médicas/normas , Reino Unido
10.
Med. intensiva (Madr., Ed. impr.) ; 43(4): 225-233, mayo 2019. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-183127

RESUMO

Objetivo: Conocer la práctica clínica real de las UCI españolas en relación con la analgosedación y delirium, y valorar cómo se ajusta a las recomendaciones actuales. Diseño: Estudio transversal descriptivo elaborado mediante encuesta nacional sobre prácticas de analgosedación y delirium de los pacientes ingresados en UCI los días 16 de noviembre de 2013 y 16 de octubre de 2014. Se envió un cuestionario a través de Internet con el aval de la SEMICYUC. Ámbito: UCI tanto públicas como privadas de todo el territorio nacional. Resultados: Se incluyeron un total de 166 UCI y a 1.567 pacientes. El 61,4% de las UCI contaban con un protocolo de sedación. El 75% de las UCI monitorizaban la sedación y agitación, con RASS como la escala empleada con mayor frecuencia. El dolor se monitorizaba en algo más de la mitad de las UCI, pero las escalas conductuales eran de muy baja implantación. El delirium también presentaba un bajo nivel diagnóstico. Entre los pacientes en ventilación mecánica el midazolam continuaba siendo un sedante de muy amplio uso. Conclusiones: Esta encuesta es la primera realizada en España sobre analgosedación y delirium y nos muestra una fotografía sobre estas prácticas, señala algunos aspectos como los relacionados con la monitorización y usos de escalas, junto con el manejo del delirium, en los que los resultados del estudio animan a desarrollar proyectos docentes que acerquen la práctica clínica real a las recomendaciones nacionales e internacionales


Objective: To know the real clinical practice of Spanish ICUs in relation to analgesia, sedation and delirium, with a view to assessing adherence to current recommendations. Design: A descriptive cross-sectional study was carried out based on a national survey on analgesia, sedation and delirium practices in patients admitted to intensive care on 16 November, 2013 and 16 October, 2014. An on-line questionnaire was sent with the endorsement of the SEMICYUC. Setting: Spanish ICUs in public and private hospitals. Results: A total of 166 ICUs participated, with the inclusion of 1567 patients. The results showed that 61.4% of the ICUs had a sedation protocol, and 75% regularly monitored sedation and agitation - the RASS being the most frequently used scale. Pain was monitored in about half of the ICUs, but the behavioral scales were very little used. Delirium monitoring was implemented in few ICUs. Among the patients on mechanical ventilation, midazolam remained a very commonly used agent. Conclusions: This survey is the first conducted in Spain on the practices of analgesia, sedation and delirium. We identified specific targets for quality improvement, particularly concerning the management of sedation and the assessment of delirium


Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , Idoso , Sedação Profunda/métodos , Delírio/tratamento farmacológico , Unidades de Terapia Intensiva/estatística & dados numéricos , Cuidados Críticos/métodos , Estudos Transversais , Inquéritos e Questionários , Internet/estatística & dados numéricos , Agitação Psicomotora/tratamento farmacológico , Sociedades Médicas/normas , Propofol , Fentanila , Acetaminofen , Dipirona , Espanha
11.
Eur J Anaesthesiol ; 36(6): 390-399, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30950900

RESUMO

BACKGROUND: Better understanding of risk factors for adverse events during monitored anaesthesia care (MAC) for paediatric gastrointestinal endoscopy may improve outcome in children. OBJECTIVES: To identify the prevalence and predictors of adverse events during MAC for paediatric endoscopy. DESIGN: An observational study. SETTING: Tertiary university hospital, single-centre cohort, from January 2010 to August 2016. PATIENTS: The prospectively collected electronic anaesthetic records of 3435 children aged up to 16 years who underwent diagnostic gastrointestinal endoscopy under MAC were analysed retrospectively. Children with an American Society of Anesthesiologists' physical status at least 4, and those requiring mechanical ventilation and therapeutic or urgent endoscopy were excluded. MAIN OUTCOME MEASURES: The prevalence and predictors of adverse events during MAC for paediatric gastrointestinal endoscopy, with particular reference to the use of different anaesthetic or sedative agents. RESULTS: Mean ±â€ŠSD age of the children was 8.5 ±â€Š4.4 years. The incidences of adverse events and adverse respiratory events were 3.4 and 3.3%, respectively. Multivariate analysis identified 12 independent predictors: age [odds ratio (OR) 0.92, P = 0.002], children's size for example underweight (OR 1.78, P = 0.039), overweight (OR 2.20, P = 0.039), (morbid) obesity (OR 4.25, P = 0.006), presence of respiratory comorbidities (OR 8.18, P < 0.001), recent respiratory infection (OR 23.55, P < 0.001) or both (OR 17.46, P < 0.001), neurological comorbidities (OR 2.18, P = 0.007), upper gastrointestinal endoscopy (OR 5.66, P < 0.001), propofol co-administration with ketamine (OR 10.34, P < 0. 001) or after sevoflurane induction (OR 44.95, P < 0.001), and propofol induction dose (OR 18.97, P < 0.001). Posthoc secondary analyses revealed a significantly higher risk of adverse events (OR 3.9, P < 0.0001) and also significantly more respiratory comorbidities and respiratory infections (P < 0.0001) in children aged less than 2 years when compared with children aged at least 2 years. No cardiovascular events were observed and outcome was uneventful. CONCLUSION: The present cohort demonstrated the feasibility and safety of MAC for paediatric gastrointestinal endoscopy by an experienced team. Although adverse events occurred rarely, their predictive factors were clinically identifiable. Applying this information in risk assessment and modifying anaesthetic management accordingly could improve outcome. TRIAL REGISTRATION: ISRCTN70362666.


Assuntos
Anestesia Geral/efeitos adversos , Sedação Profunda/efeitos adversos , Endoscopia Gastrointestinal/efeitos adversos , Complicações Intraoperatórias/epidemiologia , Monitorização Neurofisiológica Intraoperatória , Adolescente , Anestesia Geral/métodos , Criança , Pré-Escolar , Sedação Profunda/métodos , Estudos de Viabilidade , Feminino , Humanos , Incidência , Lactente , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/etiologia , Masculino , Prevalência , Estudos Prospectivos , Medição de Risco , Fatores de Risco
13.
Crit Care ; 23(1): 130, 2019 04 17.
Artigo em Inglês | MEDLINE | ID: mdl-30995940

RESUMO

OBJECTIVES: We sought to study the association between sedation status, medications (benzodiazepines, opioids, and antipsychotics), and clinical outcomes in a resource-limited setting. DESIGN: A longitudinal study of critically ill participants on mechanical ventilation. SETTING: Five intensive care units (ICUs) in four public hospitals in Lima, Peru. PATIENTS: One thousand six hundred fifty-seven critically ill participants were assessed daily for sedation status during 28 days and vital status by day 90. RESULTS: After excluding data of participants without a Richmond Agitation Sedation Scale score and without sedation, we followed 1338 (81%) participants longitudinally for 18,645 ICU days. Deep sedation was present in 98% of participants at some point of the study and in 12,942 ICU days. Deep sedation was associated with higher mortality (interquartile odds ratio (OR) = 5.42, 4.23-6.95; p < 0.001) and a significant decrease in ventilator (- 7.27; p < 0.001), ICU (- 4.38; p < 0.001), and hospital (- 7.00; p < 0.001) free days. Agitation was also associated with higher mortality (OR = 39.9, 6.53-243, p < 0.001). The most commonly used sedatives were opioids and benzodiazepines (9259 and 8453 patient days respectively), and the latter were associated with a 41% higher mortality in participants with a higher cumulative dose (75th vs 25th percentile, interquartile OR = 1.41, 1.12-1.77; p < 0.01). The overall cumulative dose of benzodiazepines and opioids was high, 774.5 mg and 16.8 g, respectively, by day 7 and by day 28; these doses approximately doubled. Haloperidol was only used in 3% of ICU days; however, the use of it was associated with a 70% lower mortality (interquartile OR = 0.3, 0.22-0.44, p < 0.001). CONCLUSIONS: Deep sedation, agitation, and cumulative dose of benzodiazepines were all independently associated with higher 90-day mortality. Additionally, deep sedation was associated with less ventilator-, ICU-, and hospital-free days. In contrast, haloperidol was associated with lower mortality in our study.


Assuntos
Sedação Consciente/normas , Sedação Profunda/normas , Resultado do Tratamento , APACHE , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos/administração & dosagem , Analgésicos/efeitos adversos , Analgésicos/uso terapêutico , Antipsicóticos/administração & dosagem , Antipsicóticos/efeitos adversos , Antipsicóticos/uso terapêutico , Estudos de Coortes , Sedação Consciente/efeitos adversos , Sedação Consciente/métodos , Sedação Profunda/efeitos adversos , Sedação Profunda/métodos , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Hipnóticos e Sedativos/uso terapêutico , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Bloqueadores Neuromusculares/administração & dosagem , Bloqueadores Neuromusculares/efeitos adversos , Bloqueadores Neuromusculares/uso terapêutico , Razão de Chances , Peru , Estudos Prospectivos , Respiração Artificial/métodos
14.
Rev Bras Enferm ; 72(2): 463-467, 2019.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31017211

RESUMO

OBJECTIVE: identify delirium and subsyndromal delirium in intensive care patients; age, hospitalization time, and mortality. METHOD: a retrospective, quantitative study conducted in the Intensive Care Unit, using the Richmond Agitation-Sedation Scale to evaluate sedation and the Intensive Care Delirium Screening Checklist for the identification of delirium, with the participation of 157 patients. For statistical analysis, the t-test and the Chi-square test was carried out. RESULTS: the majority presented subsyndromal delirium (49.7%). Mortality was 21.7%. The relationship between delirium and its subsyndromal with hospitalization time was statistically significant for both (p=0.035 and p <0.001), while age was significant only in the subsyndromal delirium (p=0.009). CONCLUSION: the majority of the patients presented subsyndromal delirium. The length of hospital stay was statistically significant in delirium and subsyndroma delirium. Age was significant only in subsyndromal delirium. The mortality of patients with delirium was higher than the others.


Assuntos
Delírio/diagnóstico , Adulto , Idoso , Brasil , Distribuição de Qui-Quadrado , Sedação Profunda/classificação , Sedação Profunda/métodos , Delírio/fisiopatologia , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Projetos de Pesquisa , Estudos Retrospectivos
15.
Br J Anaesth ; 122(4): 480-489, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30857604

RESUMO

BACKGROUND: The Strategy to Reduce the Incidence of Postoperative Delirium in the Elderly trial tested the hypothesis that limiting sedation during spinal anaesthesia decreases in-hospital postoperative delirium after hip fracture repair. This manuscript reports the secondary outcomes of this trial, including mortality and function. METHODS: Two hundred patients (≥65 yr) undergoing hip fracture repair with spinal anaesthesia were randomised to heavier [modified Observer's Assessment of Alertness/Sedation score (OAA/S) 0-2] or lighter (OAA/S 3-5) sedation, and were assessed for postoperative delirium. Secondary outcomes included mortality and return to pre-fracture ambulation level at 1 yr. Kaplan-Meier analysis, multivariable Cox proportional hazard model, and logistic regression were used to evaluate intervention effects on mortality and odds of ambulation return. RESULTS: One-year mortality was 14% in both groups (log rank P=0.96). Independent risk factors for 1-yr mortality included: Charlson comorbidity index [hazard ratio (HR)=1.23, 95% confidence interval (CI), 1.02-1.49; P=0.03], instrumental activities of daily living [HR=0.74, 95% CI, 0.60-0.91; P=0.005], BMI [HR=0.91, 95% CI 0.84-0.998; P=0.04], and delirium severity [HR=1.20, 95% CI, 1.03-1.41; P=0.02]. Ambulation returned to pre-fracture levels, worsened, or was not obtained in 64%, 30%, and 6% of 1 yr survivors, respectively. Lighter sedation did not improve odds of ambulation return at 1 yr [odds ratio (OR)=0.76, 95% CI, 0.24-2.4; P=0.63]. Independent risk factors for ambulation return included Charlson comorbidity index [OR=0.71, 95% CI, 0.53-0.97; P=0.03] and delirium [OR=0.32, 95% CI, 0.10-0.97; P=0.04]. CONCLUSIONS: This study found that in elderly patients having hip fracture surgery with spinal anaesthesia supplemented with propofol sedation, heavier intraoperative sedation was not associated with significant differences in mortality or return to pre-fracture ambulation up to 1 yr after surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT00590707.


Assuntos
Sedação Consciente/métodos , Sedação Profunda/métodos , Delírio do Despertar/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Raquianestesia , Sedação Consciente/efeitos adversos , Relação Dose-Resposta a Droga , Delírio do Despertar/etiologia , Delírio do Despertar/mortalidade , Feminino , Força da Mão , Fraturas do Quadril/mortalidade , Fraturas do Quadril/cirurgia , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Estimativa de Kaplan-Meier , Masculino , Maryland/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Propofol/administração & dosagem , Propofol/efeitos adversos , Recuperação de Função Fisiológica
16.
Semin Pediatr Surg ; 28(1): 33-42, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30824132

RESUMO

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.


Assuntos
Analgesia/métodos , Sedação Consciente/métodos , Cuidados Críticos/métodos , Sedação Profunda/métodos , Delírio , Assistência Perioperatória/métodos , Analgesia/efeitos adversos , Anestesia/efeitos adversos , Anestesia/métodos , Anestesia/psicologia , Ansiolíticos/uso terapêutico , Ansiedade/tratamento farmacológico , Ansiedade/etiologia , Criança , Sedação Consciente/efeitos adversos , Sedação Consciente/psicologia , Cuidados Críticos/psicologia , Estado Terminal , Sedação Profunda/efeitos adversos , Sedação Profunda/psicologia , Delírio/diagnóstico , Delírio/etiologia , Delírio/prevenção & controle , Delírio/psicologia , Humanos , Pediatria , Assistência Perioperatória/efeitos adversos , Assistência Perioperatória/psicologia
17.
Pediatr. aten. prim ; 21(81): 77-80, ene.-mar. 2019.
Artigo em Espanhol | IBECS | ID: ibc-184539

RESUMO

Conclusiones de los autores del estudio: no hubo asociación entre la duración del ayuno y ningún tipo de evento adverso, lo que indica que retrasar la sedación para cumplir con las pautas de ayuno establecidas por guías clínicas no mejora los resultados de la sedación en niños en el servicio de urgencia. Comentario de los revisores: es prudente mantener rígidamente los protocolos en casos de riesgo como enfermedad grave, hiperémesis, obstrucción intestinal, endoscopia o broncoscopia, pero en otros casos esta práctica carece de evidencia de beneficio, por lo que sería adecuada una revisión de los protocolos de ayuno de preparación para la sedación


Authors' conclusions: there was no association between fasting duration and any type of adverse event, indicating that delaying sedation to meet established fasting guidelines does not improve sedation outcomes for children in the emergency department. Reviewers' commentary: it seems wise to follow strictly the protocols in risky cases such as serious illness, hyperemesis, bowel obstruction, endoscopy or bronchoscopy, but in other situations this practice does not show evidence of benefit, so an appropriate review of protocols on pre-sedation fasting is advisable


Assuntos
Humanos , Masculino , Feminino , Lactente , Pré-Escolar , Criança , Sedação Profunda/métodos , Jejum , Tratamento de Emergência/métodos , Anestésicos/administração & dosagem , Anestésicos/efeitos adversos , Padrões de Prática Médica , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Fatores de Risco
18.
Int J Pediatr Otorhinolaryngol ; 120: 118-122, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30776569

RESUMO

PURPOSE: Drug-induced sleep endoscopy (DISE) is suitable for evaluating persistent obstructive sleep apnea syndrome (OSAS) after adenotonsillar surgery as a means to guide surgical intervention, yet few studies demonstrate its usefulness in resolving the syndrome. We describe our experience of DISE-directed surgery in children with persistent OSAS by analysing objective and subjective outcomes of this treatment. METHODS: Prospective study of 20 otherwise healthy 2-12 year-old children with OSAS persisting after adenotonsillar surgery. All patients underwent DISE-directed surgery and were followed up clinically and with a polysomnogram at 12 ±â€¯3 months. RESULTS: All 20 children had an apnea-hypopnea index (AHI) score ≥1 (mean: 6.1 ±â€¯4.9) and 75% had AHI>3 before surgery. We performed a total of 14 total tonsillectomies (70%), 7 with associated pharyngoplasties; 5 radiofrequency turbinate reductions (25%); 7 radiofrequency lingual tonsil reductions (35%); and 10 revision adenoidectomies (50%). No surgery-related complications were observed. AHI scores at follow-up were significantly lower than AHI scores before surgery (1.895 ±â€¯1.11 vs 6.143 ±â€¯4.88; p < 0.05) and, in 85% (n = 17) of patients, AHI was below 3. There was a significant reduction in the number of children with AHI>3 in follow-up at 12 ±â€¯3 months (15%; n = 3) compared to before surgery (75%; n = 15) (p < 0.005). CONCLUSION: DISE-directed surgery for otherwise healthy children with persistent OSAS is a useful and safe technique to decide a therapeutic strategy and to obtain good objective and subjective results regarding resolution of the syndrome.


Assuntos
Sedação Profunda/métodos , Endoscopia/métodos , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/cirurgia , Adenoidectomia , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Polissonografia , Estudos Prospectivos , Reoperação/métodos , Índice de Gravidade de Doença , Tonsilectomia
19.
Med. intensiva (Madr., Ed. impr.) ; 43(1): 3-9, ene.-feb. 2019. tab, graf
Artigo em Inglês | IBECS | ID: ibc-181524

RESUMO

Objective: Cognitive impairment after intensive care unit (ICU) admission is becoming increasingly recognized. High-dose deep sedation has been suggested to play an important role in the development of cognitive impairment. However, the impact of heavy sedation as a single cause in the development of cognitive impairment in ICU patients remains unclear. In this study we investigated whether a three-day deep sedation protocol could reduce cognitive function in mechanically ventilated non-critical patients. Design: A prospective observational study was carried out. Patients: A total of 17 surgical patients were studied. Intervention: None. Variables of interest: Cognitive function before and after ICU admission. Results: Thirty-one patients requiring three days of sedation after microvascular reconstruction were initially enrolled in the study. Sedation in the ICU was maintained with propofol and dexmedetomidine combined with fentanyl. Cognitive function was assessed using a battery of 6 neuropsychological tests two days before surgery and three weeks after surgery. Finally, a total of 17 patients were included in the analysis. Cognitive impairment (defined as a decline of >20% from the pre-admission cognitive evaluation scores in at least two of 6 tests) was observed in 5 of the 17 patients (29%). However, there were no significant differences between the pre- and post-admission cognitive evaluations in 6 tests. Conclusions: Middle-term cognitive function can be impaired in some patients subjected to deep sedation during several days following maxillary-mandibular oral surgery with microvascular reconstruction


Objetivo: Cada vez existe un mayor consenso sobre la afectación cognitiva tras el ingreso en la unidad de cuidados intensivos (UCI). Se ha sugerido que la sedación profunda con dosis elevada desempeña un papel importante en el desarrollo de la alteración cognitiva. Sin embargo, todavía existen dudas sobre el impacto de este tipo de sedación como causa única del desarrollo de alteraciones cognitivas en pacientes ingresados en la UCI. En este estudio, investigamos si la aplicación de un protocolo de sedación profunda durante 3 días disminuía la función cognitiva en pacientes no críticos bajo ventilación mecánica. Diseño: Se llevó a cabo un estudio observacional prospectivo. Pacientes: Se estudió a un total de 17 pacientes quirúrgicos. Intervenciones: Ninguna. Variables de interés: Función cognitiva antes y después del ingreso en la UCI. Resultados: En este estudio se incluyó inicialmente a 31 pacientes que requerían 3 días de sedación tras una reconstrucción microvascular. Se mantuvo la sedación en la UCI con propofol y dexmedetomidina en combinación con fentanilo. Se evaluó la función cognitiva mediante un grupo de 6 pruebas neurofisiológicas antes de la intervención y 3 días después de esta. Por último, se incluyó a un total de 17 pacientes en el análisis. Se observó alteración cognitiva (definida como una reducción>20% frente a las puntuaciones de la evaluación cognitiva previa al ingreso en al menos 2 de las 6 pruebas) en 5 de los 17 pacientes (29%). Sin embargo, no se observaron diferencias significativas entre las evaluaciones previas y posteriores al ingreso en 6 pruebas. Conclusiones: La función cognitiva a medio plazo puede verse afectada en algunos pacientes sometidos a sedación profunda durante varios días tras una cirugía oral maxilar-mandibular con reconstrucción microvascular


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Sedação Profunda/efeitos adversos , Respiração Artificial , Procedimentos Cirúrgicos Bucais , Cuidados Críticos , Disfunção Cognitiva/induzido quimicamente , Estudos Prospectivos , Unidades de Terapia Intensiva , Neurofisiologia , Período Pós-Operatório , Sedação Profunda/métodos , Cognição/efeitos dos fármacos
20.
Rev. esp. anestesiol. reanim ; 66(2): 93-103, feb. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-177298

RESUMO

Esta revisión pretende ofrecer una visión general del estado de conocimiento actual sobre la monitorización de la profundidad anestésica y la detección del momento de pérdida de consciencia, desde los primeros signos clínicos implicados en la anestesia hasta las últimas tecnologías utilizadas en esta área. Tales técnicas son extremadamente importantes para el desarrollo de sistemas automáticos de control de la anestesia y para prevenir episodios de percepción intraoperatoria y sobredosis. Realizamos investigaciones en bases de datos (Pubmed, IEEE Xplore) utilizando términos como control anestésico, profundidad de la anestesia, pérdida de consciencia, BIS y cada uno de los índices existentes. A pesar de los diversos métodos capaces de controlar el estado hipnótico de la anestesia, aún no existe una metodología que detecte con precisión el momento de la pérdida de consciencia durante la inducción de la anestesia general


This review aims to give an overview of the current state of monitoring depth of anaesthesia and detecting the moment of loss of consciousness, from the first clinical signs involved in anaesthesia to the latest technologies used in this area. Such techniques are extremely important for the development of automatic systems for anaesthesia control, including preventing intraoperative awareness episodes and overdoses. A search in the databases Pubmed and IEEE Xplore was performed using terms such anaesthetic monitoring, depth of anaesthesia, loss of consciousness, as well as anaesthesia indexes, namely BIS. Despite the several methods capable of monitoring the hypnotic state of anaesthesia, there is still no methodology to accurate detect the moment of loss of consciousness during induction of general anaesthesia


Assuntos
Humanos , Anestésicos/farmacocinética , Monitores de Consciência , Consciência no Peroperatório/diagnóstico , Estado de Consciência , Monitorização Intraoperatória/métodos , Sedação Profunda/métodos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA