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1.
J Extra Corpor Technol ; 53(1): 27-37, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33814603

RESUMO

Zero-balance ultrafiltration (ZBUF) during cardiopulmonary bypass (CPB) has been purported to reduce pro-inflammatory mediators during cardiac surgery. However, its clinical benefit is equivocal and its effect on renal function unknown. The purpose of this study was to examine the effect of ZBUF on urine output in adult patients undergoing CPB. Following institutional review board approval, 98,953 records from a national registry of adult patients at 215 U.S. hospitals between January 2016 and September 2019 were reviewed. Groups were stratified according to ZBUF use. Anuric patients were excluded from the study as they were patients with missing data on urine output, ultrafiltration use, or ZBUF volume. The primary endpoint was intraoperative urine output normalized to body weight and procedure duration (total operative time). Final analysis of this endpoint was carried out using a linear mixed-effects regression model adjusting for patient and procedural characteristics, as well as practice patterns associated with surgeons and perfusionists. There was a significant 16.1% reduction in median urine output for ZBUF patients (.94 [.54, 1.47] mL/kg/h) vs. the non-ZBUF group (1.12 [.70,-1.73] mL/kg/h), p < .001. After statistically adjusting for patient and procedural characteristics, each liter of ZBUF volume was associated with an estimated change in intraoperative urine output of -.03 mL/kg/h (95% CI: [-.04 to -.02], p < .001). The median ZBUF volume was 1,550 [1,000, 2,600] mL, and when ZBUF was used, conventional ultrafiltration (CUF) was more likely to be used as well (88.4% vs. 44.8%, p < .001). ZBUF patients had median asanguineous volume and crystalloid cardioplegia nearly two times more than non-ZBUF patients, and had slightly higher red blood cell transfusions (17.6% vs. 16.3%, p < .05). The application of ZBUF during CPB was associated with patients having lower urine output and significantly higher use of CUF. Further research is required to determine if these results are reproducible in prospective clinical studies.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Adulto , Transfusão de Eritrócitos , Humanos , Estudos Prospectivos , Ultrafiltração
2.
Ann R Coll Surg Engl ; 103(3): e91-e93, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33645276
3.
Anaesthesia ; 76 Suppl 4: 84-95, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33682105

RESUMO

Iron deficiency and anaemia are global health problems and major causes of morbidity in women. Current definitions of anaemia in women are historic and have been challenged by recent data from observational studies. Menstrual loss, abnormal uterine bleeding and pregnancy put women at risk of developing iron deficiency which can result in severe fatigue, reduced exercise capacity and poor work performance. Iron deficiency and anaemia during pregnancy are associated with adverse maternal and fetal outcomes, including neurocognitive deficits in children born to iron-deficient mothers. Both iron deficiency and anaemia are common in women undergoing surgery but their association with poor outcomes remains uncertain. The enduring burden of iron deficiency and anaemia in women suggests that current strategies for recognition, prevention and treatment are limited in their utility. Improvements in our understanding of iron homeostasis and the development of new iron preparations, which are better absorbed with fewer side-effects, may improve therapeutic effectiveness of oral iron. Intravenous iron is efficacious for correcting anaemia rapidly but high-quality data on patient-centred outcomes and cost-effectiveness are currently lacking. Many recommendations for the treatment of iron deficiency and anaemia in national guidelines are not supported by high-quality evidence. There is a need for robust epidemiological data and well-designed clinical trials. The latter will require collaborative working between researchers and patients to design studies in ways that incorporate patients' perspectives on the research process and target outcomes that matter to them.


Assuntos
Anemia Ferropriva/patologia , Anemia/patologia , Administração Oral , Anemia/tratamento farmacológico , Anemia/terapia , Anemia Ferropriva/tratamento farmacológico , Anemia Ferropriva/terapia , Transfusão de Eritrócitos , Feminino , Hepcidinas/metabolismo , Antagonistas dos Receptores Histamínicos H2/uso terapêutico , Humanos , Ferro/administração & dosagem , Ferro/metabolismo , Saúde da Mulher
4.
N Engl J Med ; 384(11): 1028-1037, 2021 03 18.
Artigo em Inglês | MEDLINE | ID: mdl-33730455

RESUMO

BACKGROUND: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired disease characterized by chronic complement-mediated hemolysis. C5 inhibition controls intravascular hemolysis in untreated PNH but cannot address extravascular hemolysis. Pegcetacoplan, a pegylated peptide targeting proximal complement protein C3, potentially inhibits both intravascular and extravascular hemolysis. METHODS: We conducted a phase 3 open-label, controlled trial to assess the efficacy and safety of pegcetacoplan as compared with eculizumab in adults with PNH and hemoglobin levels lower than 10.5 g per deciliter despite eculizumab therapy. After a 4-week run-in phase in which all patients received pegcetacoplan plus eculizumab, we randomly assigned patients to subcutaneous pegcetacoplan monotherapy (41 patients) or intravenous eculizumab (39 patients). The primary end point was the mean change in hemoglobin level from baseline to week 16. Additional clinical and hematologic markers of hemolysis and safety were assessed. RESULTS: Pegcetacoplan was superior to eculizumab with respect to the change in hemoglobin level from baseline to week 16, with an adjusted (least squares) mean difference of 3.84 g per deciliter (P<0.001). A total of 35 patients (85%) receiving pegcetacoplan as compared with 6 patients (15%) receiving eculizumab no longer required transfusions. Noninferiority of pegcetacoplan to eculizumab was shown for the change in absolute reticulocyte count but not for the change in lactate dehydrogenase level. Functional Assessment of Chronic Illness Therapy-Fatigue scores improved from baseline in the pegcetacoplan group. The most common adverse events that occurred during treatment in the pegcetacoplan and eculizumab groups were injection site reactions (37% vs. 3%), diarrhea (22% vs. 3%), breakthrough hemolysis (10% vs. 23%), headache (7% vs. 23%), and fatigue (5% vs. 15%). There were no cases of meningitis in either group. CONCLUSIONS: Pegcetacoplan was superior to eculizumab in improving hemoglobin and clinical and hematologic outcomes in patients with PNH by providing broad hemolysis control, including control of intravascular and extravascular hemolysis. (Funded by Apellis Pharmaceuticals; PEGASUS ClinicalTrials.gov, NCT03500549.).


Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Complemento C3/antagonistas & inibidores , Complemento C5/antagonistas & inibidores , Inativadores do Complemento/uso terapêutico , Hemoglobinúria Paroxística/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticorpos Monoclonais Humanizados/efeitos adversos , Inativadores do Complemento/efeitos adversos , Diarreia/induzido quimicamente , Quimioterapia Combinada , Transfusão de Eritrócitos , Hemoglobinas/análise , Hemoglobinúria Paroxística/sangue , Hemoglobinúria Paroxística/terapia , Humanos , Injeções Subcutâneas/efeitos adversos , Pessoa de Meia-Idade
5.
J Med Case Rep ; 15(1): 104, 2021 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33648584

RESUMO

BACKGROUND: Pregnancy seems to increase the risk of thrombotic thrombocytopenic purpura (TTP) relapses and make the TTP more severe in any of the pregnancy trimesters, or even during the postpartum period. CASE PRESENTATION: This study highlights details of treating a COVID-19 pregnant patient who survived. This 21-year addicted White woman was admitted at her 29th week and delivered a stillbirth. She was transferred to another hospital after showing signs of TTP, which was caused by a viral infection. CONCLUSION: This viral infection caused fever and dyspnea, and the patient was tested positive for COVID-19 infection. A chest computed tomography scan showed diffuse multiple bilateral consolidations and interlobar septal thickening. She stayed at the Intensive Care Unit for 20 days and treated with plasmapheresis. As far as we know, this is the first report of a TTP pregnant patient with COVID-19 infection.


Assuntos
/diagnóstico , Plasmaferese , Complicações Hematológicas na Gravidez/diagnóstico , Complicações Infecciosas na Gravidez/diagnóstico , Púrpura Trombocitopênica Trombótica/diagnóstico , Natimorto , Lesão Renal Aguda/terapia , Transtornos Relacionados ao Uso de Anfetaminas , Antivirais/uso terapêutico , Combinação de Medicamentos , Transfusão de Eritrócitos , Feminino , Hemoglobinas/metabolismo , Humanos , Hidroxicloroquina/uso terapêutico , Unidades de Terapia Intensiva , L-Lactato Desidrogenase/metabolismo , Lopinavir/uso terapêutico , Metanfetamina , Gravidez , Complicações Hematológicas na Gravidez/metabolismo , Complicações Hematológicas na Gravidez/terapia , Complicações Infecciosas na Gravidez/metabolismo , Complicações Infecciosas na Gravidez/terapia , Púrpura Trombocitopênica Trombótica/metabolismo , Púrpura Trombocitopênica Trombótica/terapia , Diálise Renal , Ritonavir/uso terapêutico , Tomografia Computadorizada por Raios X , Adulto Jovem
6.
Medicine (Baltimore) ; 100(12): e24804, 2021 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-33761640

RESUMO

RATIONALE: The etiology of non-immune hydrops fetalis is complex, and its prognosis is poor. One of its main causes is anemia. There are few reports on hydrops fetalis due to anemia caused by hereditary spherocytosis (HS), especially regarding its occurrence in the neonatal period. Thus, we report on a case of neonatal HS caused by a new SPTB gene mutation that was characterized by hydrops fetalis. PATIENT CONCERNS: A neonate with intrauterine hydrops fetalis showed severe hyperbilirubinemia and anemia, reticulocytosis, and hepatosplenomegaly. Laboratory examination findings were normal. DIAGNOSES: Gene sequencing of the patient and his parents showed a de novo frameshift mutation in the patient's SPTB gene. Ultimately, the patient was diagnosed with HS. INTERVENTIONS: Exchange and red blood cell transfusions were performed in the neonatal period. OUTCOMES: The child was discharged from the hospital 14 days postnatal because his hemoglobin and bilirubin levels were stable. Red blood cell transfusion was performed once in infancy; however, no further red blood cell transfusions were required within 2 years of age. LESSONS: Hydrops fetalis can be a manifestation of HS. Genetic detection can help confirm the diagnosis of suspected neonatal HS undocumented by other laboratory examinations.


Assuntos
Hidropisia Fetal/genética , Espectrina/genética , Esferocitose Hereditária/diagnóstico , Análise Mutacional de DNA , Transfusão de Eritrócitos , Mutação da Fase de Leitura , Hemoglobinas/análise , Humanos , Hidropisia Fetal/sangue , Hidropisia Fetal/terapia , Recém-Nascido , Masculino , Esferocitose Hereditária/complicações , Esferocitose Hereditária/genética , Esferocitose Hereditária/terapia , Resultado do Tratamento
7.
BMJ Case Rep ; 14(2)2021 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-33547097

RESUMO

Iatrogenic iron overload, which is not uncommon in patients undergoing long-term haemodialysis, arises from a combination of multiple red cell transfusions and parenteral iron infusions that are administered to maintain a haemoglobin concentration of approximately 10 g/dL. Although iron overload due to genetic haemochromatosis is conventionally managed by phlebotomy, patients with haemoglobinopathies and chronic transfusion-induced iron overload are treated with iron-chelation therapy. However, the management of iron overload in our patient who presented with hepatic dysfunction and immunosuppressive drug-induced mild anaemia in the post-renal transplant setting posed unique challenges. We report on the decision-making process used in such a case that led to a successful clinical resolution of hepatic iron overload through the combined use of phlebotomy and erythropoiesis stimulating agents, while avoiding use of iron-chelating agents that could potentially compromise both hepatic and renal function.


Assuntos
Sobrecarga de Ferro/etiologia , Sobrecarga de Ferro/terapia , Transplante de Rim , Biópsia , Transfusão de Eritrócitos , Feminino , Hematínicos/administração & dosagem , Humanos , Ferro/administração & dosagem , Sobrecarga de Ferro/diagnóstico , Testes de Função Hepática , Imagem por Ressonância Magnética , Pessoa de Meia-Idade , Fatores de Risco
9.
BMJ Case Rep ; 14(1)2021 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-33509861

RESUMO

We describe the case of a 21-year-old man with a background of sickle cell disease (SCD) who was on acute presentation in a sickle cell crisis required immediate intensive care admission with red blood cell exchange and ventilatory support. He had right frontal lobe infarcts and extensive bilateral deep white matter lesions most likely secondary to fat embolism. Inpatient investigations demonstrated a patent foramen ovale, explaining the route of spread of the fat embolus. He then had a transcatheter closure of the atrial defect. The patient needed prolonged inpatient rehabilitation. He was discharged from hospital in a wheelchair secondary to severe lower limb neurology and bilateral knee heterotopic ossification. He lives with the possibility of early onset dementia and cognitive decline, requiring constant care. The case highlights the multiple manifestations of SCD and their diverse and debilitating consequences.


Assuntos
Anemia Falciforme/fisiopatologia , Infarto Encefálico/fisiopatologia , Disfunção Cognitiva/fisiopatologia , Embolia Gordurosa/fisiopatologia , Leucoencefalopatias/fisiopatologia , Neuralgia/fisiopatologia , Polineuropatias/fisiopatologia , Quadriplegia/fisiopatologia , Anemia Falciforme/complicações , Anemia Falciforme/terapia , Infarto Encefálico/diagnóstico por imagem , Infarto Encefálico/etiologia , Disfunção Cognitiva/etiologia , Contratura/etiologia , Contratura/fisiopatologia , Ecocardiografia , Embolia Gordurosa/etiologia , Transfusão de Eritrócitos , Forame Oval Patente/complicações , Lobo Frontal/diagnóstico por imagem , Humanos , Unidades de Terapia Intensiva , Articulação do Joelho/diagnóstico por imagem , Leucoencefalopatias/diagnóstico por imagem , Leucoencefalopatias/etiologia , Imagem por Ressonância Magnética , Masculino , Neuralgia/etiologia , Ossificação Heterotópica/diagnóstico por imagem , Ossificação Heterotópica/etiologia , Ossificação Heterotópica/fisiopatologia , Plasma , Transfusão de Plaquetas , Polineuropatias/etiologia , Quadriplegia/etiologia , Adulto Jovem
10.
BMJ Case Rep ; 14(1)2021 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-33509862

RESUMO

Small cell lung cancer (SCLC) is a deadly and rapidly progressive disease that can present with various paraneoplastic syndromes on initial workup. Acquired factor VIII (FVIII) deficiency, also known as acquired haemophilia A (AHA), has been identified as a rare paraneoplastic syndrome in SCLC. Here, we present a 61-year-old woman with a massive gastrointestinal bleed and prolonged activated partial thromboplastin time (PTT) in the emergency department. She was diagnosed with rare paraneoplastic AHA secondary to extensive-stage SCLC (ES-SCLC). She was treated with high-dose steroids and factor bypassing agents, which led to the resolution of bleeding and undetectable FVIII inhibitor levels. She was subsequently treated for ES-SCLC with carboplatin, etoposide and atezolizumab. This case report highlights a rare clinical presentation of paraneoplastic AHA that necessitates prompt recognition in patients with SCLC with ongoing bleeding and elevated PTT.


Assuntos
Neoplasias das Glândulas Suprarrenais/diagnóstico , Hemorragia Gastrointestinal/diagnóstico , Hemofilia A/diagnóstico , Neoplasias Pulmonares/diagnóstico , Síndromes Paraneoplásicas/diagnóstico , Carcinoma de Pequenas Células do Pulmão/diagnóstico , Abdome , Neoplasias das Glândulas Suprarrenais/complicações , Neoplasias das Glândulas Suprarrenais/tratamento farmacológico , Neoplasias das Glândulas Suprarrenais/secundário , Anemia/diagnóstico , Anemia/etiologia , Antineoplásicos/uso terapêutico , Autoanticorpos/imunologia , Coagulantes/uso terapêutico , Transfusão de Eritrócitos , Fator VIII/imunologia , Fator VIII/uso terapêutico , Fator VIIa/uso terapêutico , Feminino , Hemorragia Gastrointestinal/etiologia , Hemofilia A/etiologia , Hemofilia A/imunologia , Hemofilia A/terapia , Humanos , Imunossupressores/uso terapêutico , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/patologia , Linfadenopatia , Mediastino , Pessoa de Meia-Idade , Síndromes Paraneoplásicas/etiologia , Síndromes Paraneoplásicas/imunologia , Síndromes Paraneoplásicas/terapia , Carcinoma de Pequenas Células do Pulmão/complicações , Carcinoma de Pequenas Células do Pulmão/tratamento farmacológico , Carcinoma de Pequenas Células do Pulmão/secundário
11.
BMJ Case Rep ; 14(1)2021 Jan 06.
Artigo em Inglês | MEDLINE | ID: mdl-33408108

RESUMO

Prevalence of haemoglobin sickle-ß+ thalassaemia (Hb S/ß+thal) is variable with geography ranging from 0.2% to 10% among sickle cell patients. Clinical presentation of Hb S/ß+thal patients depends on HbA level, with milder disease often going undiagnosed. However, rarely these patients can present with a fulminant vaso-occlusive crisis (VOC). Given VOC can present with non-specific symptoms, the diagnosis and treatment is often delayed. Here, we present a patient who initially developed altered mental status, pancytopenia and multiorgan failure due a critical VOC resulting in bone marrow necrosis and fat embolism. Subsequent workup confirmed that our patient had Sickle-ß+ thalassaemia, which had gone undiagnosed, despite subclinical evidence of haemolysis on routine lab work for years. Following diagnosis and initiation of RBC exchange, he improved significantly and was discharged home. High index of suspicion and bone marrow biopsy is vital for early diagnosis and management of this rare condition.


Assuntos
Anemia Falciforme/complicações , Medula Óssea/patologia , Embolia Gordurosa/etiologia , Talassemia beta/complicações , Adulto , Anemia Falciforme/diagnóstico , Anemia Falciforme/terapia , Biópsia , Embolia Gordurosa/terapia , Transfusão de Eritrócitos , Humanos , Masculino , Necrose/etiologia , Necrose/patologia , Necrose/terapia , Resultado do Tratamento , Vitamina B 12/administração & dosagem , Talassemia beta/diagnóstico , Talassemia beta/terapia
12.
BMJ Case Rep ; 14(1)2021 Jan 11.
Artigo em Inglês | MEDLINE | ID: mdl-33431449

RESUMO

Congenital parvovirus B19 infection is a rare but serious condition that can result in hydrops fetalis and fetal death. Due to the virus' cytotoxic effect on fetal red blood cell precursors, postnatal infection can cause a neonatal viremia and secondary pure red cell aplasia. Here, we describe a case of congenital parvovirus infection in a preterm infant complicated by hydrops fetalis and chronic anaemia that responded to postnatal treatment with intravenous immunoglobulin administered on day of life 44. After treatment, the anaemia resolved as the neonate exhibited interval increases in haemoglobin, haematocrit and reticulocyte count with no subsequent need for red blood cell transfusions.


Assuntos
Anemia/terapia , Imunoglobulinas Intravenosas/administração & dosagem , Infecções por Parvoviridae/tratamento farmacológico , Parvovirus B19 Humano/isolamento & purificação , Complicações Infecciosas na Gravidez/diagnóstico , Adulto , Anemia/sangue , Anemia/virologia , Anticorpos Antivirais/sangue , Anticorpos Antivirais/imunologia , Cordocentese , Ecocardiografia , Transfusão de Eritrócitos , Feminino , Sangue Fetal/virologia , Ruptura Prematura de Membranas Fetais/virologia , Feto/diagnóstico por imagem , Feto/virologia , Humanos , Hidropisia Fetal/sangue , Hidropisia Fetal/diagnóstico , Hidropisia Fetal/terapia , Hidropisia Fetal/virologia , Imunoglobulina M/sangue , Imunoglobulina M/imunologia , Recém-Nascido , Recém-Nascido Prematuro , Transmissão Vertical de Doença Infecciosa , Masculino , Infecções por Parvoviridae/complicações , Infecções por Parvoviridae/congênito , Infecções por Parvoviridae/transmissão , Parvovirus B19 Humano/imunologia , Poli-Hidrâmnios/diagnóstico , Poli-Hidrâmnios/virologia , Gravidez , Complicações Infecciosas na Gravidez/virologia , Resultado do Tratamento , Ultrassonografia Pré-Natal
13.
BMJ Case Rep ; 14(1)2021 Jan 26.
Artigo em Inglês | MEDLINE | ID: mdl-33500299

RESUMO

The use of artemisinin derivatives has been recommended by the WHO guidelines in malaria treatment largely due to its rapid parasite clearance and safety profile. This case report details the development of delayed haemolysis and subsequent severe acute kidney injury (AKI) 13 days after commencing intravenous artesunate treatment for malaria in an Australian returned traveller. Delayed haemolysis may be an under-recognised complication following artesunate use and if severe, can be complicated by AKI. Therefore, close patient follow-up following treatment is required to ensure prompt recognition of this phenomenon.


Assuntos
Lesão Renal Aguda/etiologia , Anemia Hemolítica/induzido quimicamente , Antimaláricos/efeitos adversos , Artesunato/efeitos adversos , Malária Falciparum/tratamento farmacológico , Lesão Renal Aguda/metabolismo , Lesão Renal Aguda/terapia , Administração Intravenosa , Anemia Hemolítica/complicações , Anemia Hemolítica/terapia , Austrália , Transfusão de Eritrócitos , Hidratação , Hemólise , Humanos , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Doença Relacionada a Viagens
14.
Anesthesiology ; 134(3): 395-404, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33503656

RESUMO

BACKGROUND: Removal of cytokines, chemokines, and microvesicles from the supernatant of allogeneic erythrocytes may help mitigate adverse transfusion reactions. Blood bank-based washing procedures present logistical difficulties; therefore, we tested the hypothesis that on-demand bedside washing of allogeneic erythrocyte units is capable of removing soluble factors and is feasible in a clinical setting. METHODS: There were in vitro and prospective, observation cohort components to this a priori planned substudy evaluating bedside allogeneic erythrocyte washing, with a cell saver, during cardiac surgery. Laboratory data were collected from the first 75 washed units given to a subset of patients nested in the intervention arm of a parent clinical trial. Paired pre- and postwash samples from the blood unit bags were centrifuged. The supernatant was aspirated and frozen at -70°C, then batch-tested for cell-derived microvesicles, soluble CD40 ligand, chemokine ligand 5, and neutral lipids (all previously associated with transfusion reactions) and cell-free hemoglobin (possibly increased by washing). From the entire cohort randomized to the intervention arm of the trial, bedside washing was defined as feasible if at least 75% of prescribed units were washed per protocol. RESULTS: Paired data were available for 74 units. Washing reduced soluble CD40 ligand (median [interquartile range]; from 143 [1 to 338] ng/ml to zero), chemokine ligand 5 (from 1,314 [715 to 2,551] to 305 [179 to 488] ng/ml), and microvesicle numbers (from 6.90 [4.10 to 20.0] to 0.83 [0.33 to 2.80] × 106), while cell-free hemoglobin concentration increased from 72.6 (53.6 to 171.6) mg/dl to 210.5 (126.6 to 479.6) mg/dl (P < 0.0001 for each). There was no effect on neutral lipids. Bedside washing was determined as feasible for 80 of 81 patients (99%); overall, 293 of 314 (93%) units were washed per protocol. CONCLUSIONS: Bedside erythrocyte washing was clinically feasible and greatly reduced concentrations of soluble factors thought to be associated with transfusion-related adverse reactions, increasing concentrations of cell-free hemoglobin while maintaining acceptable (less than 0.8%) hemolysis.


Assuntos
Remoção de Componentes Sanguíneos/métodos , Quimiocinas , Citocinas , Transfusão de Eritrócitos/métodos , Eritrócitos/química , Reação Transfusional/prevenção & controle , Preservação de Sangue , Estudos de Coortes , Eritrócitos/citologia , Humanos , Sistemas Automatizados de Assistência Junto ao Leito , Estudos Prospectivos
16.
Am J Emerg Med ; 40: 32-36, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33340875

RESUMO

OBJECTIVE: Advanced Trauma Life Support guidelines recommend only 1 L of intravenous (IV) crystalloid before transitioning to blood products. We sought to determine if receiving >1 L of IV crystalloid during the initial resuscitation is associated with worse outcomes. We also sought to determine if receiving no crystalloids is associated with better outcomes. METHODS: We performed a single center retrospective study using trauma registry data, which was supplemented by manual chart review. We only included patients who had an initial heart rate ≥ 100 beats/min or a systolic blood pressure ≤ 90 mmHg. For each patient, we determined the total amount of IV crystalloid administered in the first 3 h after arrival to the hospital plus prehospital crystalloid. We performed multivariate regression analyses to determine if there is an association between the administration of >1 L of crystalloids or no crystalloids with in-hospital mortality, hospital length of stay (LOS), or packed red blood cells (PRBCs) transfused. RESULTS: Between January 1, 2018 and September 30, 2019, there were 878 who met criteria for enrollment. Among those, 55.0% received ≤1 L of IV crystalloids, and 45.0% received >1 L. Multivariate analyses showed no significant association between receiving >1 L and mortality (p = 0.61) or PRBCs transfused (p = 0.29), but patients who received >1 L had longer hospital LOS (p = 0.04). We found no association between receiving no crystalloids and mortality, PRBCs transfused, or LOS. CONCLUSION: On a multivariate analysis of trauma patients, we did not find an association between the administration of >1 L of IV crystalloid and in-hospital mortality or the volume of PRBCs transfused. However, receiving >1 L of crystalloids was associated with a longer hospital LOS. We found no benefit to completely withholding crystalloids.


Assuntos
Soluções Cristaloides/administração & dosagem , Ressuscitação/métodos , Centros de Traumatologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Transfusão de Eritrócitos , Feminino , Mortalidade Hospitalar , Humanos , Infusões Intravenosas , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Nevada , Sistema de Registros , Estudos Retrospectivos , Resultado do Tratamento
17.
Anaesthesia ; 76(1): 19-26, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32406071

RESUMO

Over 30,000 adult cardiac operations are carried out in the UK annually. A small number of these patients need to return to theatre in the first few days after the initial surgery, but the exact proportion is unknown. The majority of these resternotomies are for bleeding or cardiac tamponade. The Association of Cardiothoracic Anaesthesia and Critical Care carried out a 1-year national audit of resternotomy in 2018. Twenty-three of the 35 centres that were eligible participated. The overall resternotomy rate (95%CI) within the period of admission for the initial operation in these centres was 3.6% (3.37-3.85). The rate varied between centres from 0.69% to 7.6%. Of the 849 patients who required resternotomy, 127 subsequently died, giving a mortality rate (95%CI) of 15.0% (12.7-17.5). In patients who underwent resternotomy, the median (IQR [range]) length of stay on ICU was 5 (2-10 [0-335]) days, and time to tracheal extubation was 20 (12-48 [0-2880]) hours. A total of 89.3% of patients who underwent resternotomy were transfused red cells, with a median (IQR [range]) of 4 (2-7 [1-1144]) units of red blood cells. The rate (95%CI) of needing renal replacement therapy was 23.4% (20.6-26.5). This UK-wide audit has demonstrated that resternotomy after cardiac surgery is associated with prolonged intensive care stay, high rates of blood transfusion, renal replacement therapy and very high mortality. Further research into this area is required to try to improve patient care and outcomes in patients who require resternotomy in the first 24 h after cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Reoperação/mortalidade , Reoperação/estatística & dados numéricos , Esternotomia/mortalidade , Esternotomia/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Extubação , Tamponamento Cardíaco/etiologia , Tamponamento Cardíaco/cirurgia , Cuidados Críticos/estatística & dados numéricos , Transfusão de Eritrócitos/mortalidade , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Humanos , Incidência , Tempo de Internação , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/cirurgia , Terapia de Substituição Renal/mortalidade , Terapia de Substituição Renal/estatística & dados numéricos , Reino Unido/epidemiologia
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