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1.
J Am Med Inform Assoc ; 29(9): 1567-1576, 2022 08 16.
Artigo em Inglês | MEDLINE | ID: mdl-35751440

RESUMO

BACKGROUND: Patients in the intensive care unit (ICU) are often in critical condition and have a high mortality rate. Accurately predicting the survival probability of ICU patients is beneficial to timely care and prioritizing medical resources to improve the overall patient population survival. Models developed by deep learning (DL) algorithms show good performance on many models. However, few DL algorithms have been validated in the dimension of survival time or compared with traditional algorithms. METHODS: Variables from the Early Warning Score, Sequential Organ Failure Assessment Score, Simplified Acute Physiology Score II, Acute Physiology and Chronic Health Evaluation (APACHE) II, and APACHE IV models were selected for model development. The Cox regression, random survival forest (RSF), and DL methods were used to develop prediction models for the survival probability of ICU patients. The prediction performance was independently evaluated in the MIMIC-III Clinical Database (MIMIC-III), the eICU Collaborative Research Database (eICU), and Shanghai Pulmonary Hospital Database (SPH). RESULTS: Forty variables were collected in total for model development. 83 943 participants from 3 databases were included in the study. The New-DL model accurately stratified patients into different survival probability groups with a C-index of >0.7 in the MIMIC-III, eICU, and SPH, performing better than the other models. The calibration curves of the models at 3 and 10 days indicated that the prediction performance was good. A user-friendly interface was developed to enable the model's convenience. CONCLUSIONS: Compared with traditional algorithms, DL algorithms are more accurate in predicting the survival probability during ICU hospitalization. This novel model can provide reliable, individualized survival probability prediction.


Assuntos
Aprendizado Profundo , Unidades de Terapia Intensiva , APACHE , China , Cuidados Críticos , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/normas , Estudos Retrospectivos
2.
Artigo em Inglês | BIGG - guias GRADE | ID: biblio-1372808

RESUMO

The aim of this Intensive Care Medicine Rapid Practice Guideline (ICM­RPG) was to formulate evidence­based guidance for the use of dexmedetomidine for sedation in invasively mechanically ventilated adults in the intensive care unit (ICU). We adhered to the methodology for trustworthy clinical practice guidelines, including use of the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence, and the Evidence-to-Decision framework to generate recommendations. The guideline panel comprised 28 international panelists, including content experts, ICU clinicians, methodologists, and patient representatives. Through teleconferences and web­based discussions, the panel provided input on the balance and magnitude of the desirable and undesirable effects, the certainty of evidence, patients' values and preferences, costs and resources, feasibility, acceptability, and research priorities. The ICM­RPG panel issued one weak recommendation (suggestion) based on overall moderate certainty of evidence: "In invasively mechanically ventilated adult ICU patients, we suggest using dexmedetomidine over other sedative agents, if the desirable effects including a reduction in delirium are valued over the undesirable effects including an increase in hypotension and bradycardia". This ICM-RPG provides updated evidence-based guidance on the use of dexmedetomidine for sedation in mechanically ventilated adults, and outlines uncertainties and research priorities.


Assuntos
Humanos , Adulto , Respiração Artificial , Dexmedetomidina/uso terapêutico , Sedação Profunda , Unidades de Terapia Intensiva/normas , Hipnóticos e Sedativos/uso terapêutico , Anestesia
3.
J Intensive Care Med ; 37(8): 1005-1014, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35578542

RESUMO

Background: Acute physical function outcomes in ICU survivors of COVID-19 pneumonia has received little attention. Critically ill patients with COVID-19 infection who require invasive mechanical ventilation may undergo greater exposure to some risk factors for ICU-acquired weakness (ICUAW). Purpose: To determine incidence and factors associated with ICUAW at ICU discharge and gait dependence at hospital discharge in mechanically ventilated patients with COVID-19 pneumonia. Methods: Single-centre, prospective cohort study conducted at a tertiary hospital in Madrid, Spain. We evaluated ICUAW with the Medical Research Council Summary Score (MRC-SS). Gait dependence was assessed with the Functional Status Score for the ICU (FSS-ICU) walking subscale. Results: During the pandemic second wave, between 27 July and 15 December, 2020, 70 patients were enrolled. ICUAW incidence was 65.7% and 31.4% at ICU discharge and hospital discharge, respectively. Gait dependence at hospital discharge was observed in 66 (54.3%) patients, including 9 (37.5%) without weakness at ICU discharge. In univariate analysis, ICUAW was associated with the use of neuromuscular blockers (crude odds ratio [OR] 9.059; p = 0.01) and duration of mechanical ventilation (OR 1.201; p = 0.001), but not with the duration of neuromuscular blockade (OR 1.145, p = 0.052). There was no difference in corticosteroid use between patients with and without weakness. Associations with gait dependence were lower MRC-SS at ICU discharge (OR 0.943; p = 0.015), older age (OR 1.126; p = 0.001), greater Charlson Comorbidity Index (OR 1.606; p = 0.011), longer duration of mechanical ventilation (OR 1.128; p = 0.001) and longer duration of neuromuscular blockade (OR 1.150; p = 0.029). Conclusions: In critically ill COVID-19 patients, the incidence of ICUAW and acute gait dependence were high. Our study identifies factors influencing both outcomes. Future studies should investigate optimal COVID-19 ARDS management and impact of dyspnea on acute functional outcomes of COVID-19 ICU survivors.


Assuntos
COVID-19/complicações , Transtornos Neurológicos da Marcha/etiologia , Unidades de Terapia Intensiva , Debilidade Muscular/etiologia , Respiração Artificial , COVID-19/epidemiologia , COVID-19/terapia , Estudos de Coortes , Estado Terminal/terapia , Transtornos Neurológicos da Marcha/epidemiologia , Hospitais , Humanos , Unidades de Terapia Intensiva/normas , Debilidade Muscular/epidemiologia , Estudos Prospectivos , Respiração Artificial/efeitos adversos , Espanha/epidemiologia , Centros de Atenção Terciária
5.
Behav Brain Res ; 421: 113729, 2022 03 12.
Artigo em Inglês | MEDLINE | ID: mdl-34973968

RESUMO

BACKGROUND: Recovery of consciousness is the most important survival factor in patients with acute brain injury and disorders of consciousness (DoC). Since most deaths in the intensive care unit (ICU) occur after withdrawal of life-support, medical decision-making is crucial for acute DoC patients. Neuroimaging informs decision-making, yet the precise effects of MRI on decision-making in the ICU are poorly understood. We investigated the impact of brain MRI on prognostication, therapeutic decisions and physician confidence in ICU patients with DoC. METHODS: In this simulated decision-making study utilizing a prospective ICU cohort, a panel of neurocritical experts first reviewed clinical information (without MRI) from 75 acute DoC patients and made decisions about diagnosis, prognosis and treatment. Following review of the MRI, the panel then decided if the initial decisions needed revision. In parallel, a blinded neuroradiologist reassessed all neuroimaging. RESULTS: MRI led to changes in clinical management of 57 (76%) of patients (Number-Needed-to-Test for any change: 1.32), including revised diagnoses (20%), levels of care (21%), diagnostic confidence (43%) and prognostications (33%). Decisions were revised more often with stroke than with other brain injuries (p = 0.02). However, although MRI revealed additional pathology in 81%, this did not predict revised clinical decision-making (p-values ≥0.08). CONCLUSION: MRI results changed decision-making in 3 of 4 ICU patients, but radiological findings were not predictive of clinical decision-making. This highlights the need to better understand the effects of neuroimaging on management decisions. How MRI influences decision-making in the ICU is an important avenue for research to improve acute DoC management.


Assuntos
Tomada de Decisão Clínica , Transtornos da Consciência/diagnóstico por imagem , Transtornos da Consciência/terapia , Cuidados Críticos , Unidades de Terapia Intensiva , Imageamento por Ressonância Magnética , Neuroimagem , Doença Aguda , Adulto , Idoso , Lesões Encefálicas/complicações , Lesões Encefálicas/diagnóstico por imagem , Lesões Encefálicas/terapia , Transtornos da Consciência/etiologia , Cuidados Críticos/métodos , Cuidados Críticos/normas , Feminino , Humanos , Unidades de Terapia Intensiva/normas , Imageamento por Ressonância Magnética/normas , Masculino , Pessoa de Meia-Idade , Neuroimagem/métodos , Neuroimagem/normas , Prognóstico , Estudos Prospectivos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/terapia
6.
Am J Emerg Med ; 51: 378-383, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34823194

RESUMO

OBJECTIVE: To improve the timely diagnosis and treatment of sepsis many institutions implemented automated sepsis alerts. Poor specificity, time delays, and a lack of actionable information lead to limited adoption by bedside clinicians and no change in practice or clinical outcomes. We aimed to compare sepsis care compliance before and after a multi-year implementation of a sepsis surveillance coupled with decision support in a tertiary care center. DESIGN: Single center before and after study. SETTING: Large academic Medical Intensive Care Unit (MICU) and Emergency Department (ED). POPULATION: Patients 18 years of age or older admitted to *** Hospital MICU and ED from 09/4/2011 to 05/01/2018 with severe sepsis or septic shock. INTERVENTIONS: Electronic medical record-based sepsis surveillance system augmented by clinical decision support and completion feedback. MEASUREMENTS AND MAIN RESULTS: There were 1950 patients admitted to the MICU with the diagnosis of severe sepsis or septic shock during the study period. The baseline characteristics were similar before (N = 854) and after (N = 1096) implementation of sepsis surveillance. The performance of the alert was modest with a sensitivity of 79.9%, specificity of 76.9%, positive predictive value (PPV) 27.9%, and negative predictive value (NPV) 97.2%. There were 3424 unique alerts and 1131 confirmed sepsis patients after the sniffer implementation. During the study period average care bundle compliance was higher; however after taking into account improvements in compliance leading up to the intervention, there was no association between intervention and improved care bundle compliance (Odds ratio: 1.16; 95% CI: 0.71 to 1.89; p-value 0.554). Similarly, the intervention was not associated with improvement in hospital mortality (Odds ratio: 1.55; 95% CI: 0.95 to 2.52; p-value: 0.078). CONCLUSIONS: A sepsis surveillance system incorporating decision support or completion feedback was not associated with improved sepsis care and patient outcomes.


Assuntos
Sistemas de Apoio a Decisões Clínicas , Serviço Hospitalar de Emergência/estatística & dados numéricos , Unidades de Terapia Intensiva/provisão & distribuição , Sepse/diagnóstico , Centros Médicos Acadêmicos , Idoso , Idoso de 80 Anos ou mais , Estudos Controlados Antes e Depois , Serviço Hospitalar de Emergência/normas , Retroalimentação , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/normas , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Pacotes de Assistência ao Paciente/normas , Estudos Retrospectivos , Vigilância de Evento Sentinela , Sepse/mortalidade , Sepse/terapia , Choque Séptico/diagnóstico , Choque Séptico/mortalidade , Choque Séptico/terapia
7.
Am J Surg ; 223(1): 126-130, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34373083

RESUMO

BACKGROUND: Elderly rib fracture patients are generally admitted to an ICU which may result in overutilization of scarce resources. We hypothesized that this practice results in significant overtriage. METHODS: Retrospective study of patients over age 70 with acute rib fracture(s) as sole indication for ICU admission. Primary outcomes were adverse events (intubation, pneumonia, death), which we classified as meriting ICU admission. We utilized Cribari matrices to calculate triage rates. RESULTS: 101 patients met study criteria. 12% had adverse events occurring on average at day 5. Our undertriage rate was 6% and overtriage rate 87%. The 72 overtriaged patients utilized 295 total ICU days. Evaluating guideline modification, ≥3 fractures appears optimal. Changing to this would have liberated 50 ICU days with 3% undertriage. CONCLUSION: Elderly patients with small numbers of rib fractures are overtriaged to ICUs. Modifying guidelines to ≥3 rib fractures will improve resource utilization and save ICU beds.


Assuntos
Unidades de Terapia Intensiva/normas , Admissão do Paciente/normas , Guias de Prática Clínica como Assunto , Fraturas das Costelas/diagnóstico , Triagem/normas , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Estudos Retrospectivos , Centros de Traumatologia/normas
8.
Exp Physiol ; 107(7): 683-693, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34541721

RESUMO

NEW FINDINGS: What is the topic of this review? This review presents the fundamental concepts of respiratory physiology and pathophysiology, with particular reference to lung mechanics and the pulmonary phenotype associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and subsequent coronavirus disease 2019 (COVID-19) pneumonia. What advances does it highlight? The review provides a critical summary of the main physiological aspects to be considered for safe and effective mechanical ventilation in patients with severe COVID-19 in the intensive care unit. ABSTRACT: Severe respiratory failure from coronavirus disease 2019 (COVID-19) pneumonia not responding to non-invasive respiratory support requires mechanical ventilation. Although ventilation can be a life-saving therapy, it can cause further lung injury if airway pressure and flow and their timing are not tailored to the respiratory system mechanics of the individual patient. The pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can lead to a pattern of lung injury in patients with severe COVID-19 pneumonia typically associated with two distinct phenotypes, along a temporal and pathophysiological continuum, characterized by different levels of elastance, ventilation-to-perfusion ratio, right-to-left shunt, lung weight and recruitability. Understanding the underlying pathophysiology, duration of symptoms, radiological characteristics and lung mechanics at the individual patient level is crucial for the appropriate choice of mechanical ventilation settings to optimize gas exchange and prevent further lung injury. By critical analysis of the literature, we propose fundamental physiological and mechanical criteria for the selection of ventilation settings for COVID-19 patients in intensive care units. In particular, the choice of tidal volume should be based on obtaining a driving pressure < 14 cmH2 O, ensuring the avoidance of hypoventilation in patients with preserved compliance and of excessive strain in patients with smaller lung volumes and lower lung compliance. The level of positive end-expiratory pressure (PEEP) should be informed by the measurement of the potential for lung recruitability, where patients with greater recruitability potential may benefit from higher PEEP levels. Prone positioning is often beneficial and should be considered early. The rationale for the proposed mechanical ventilation settings criteria is presented and discussed.


Assuntos
COVID-19/terapia , Lesão Pulmonar/virologia , Respiração Artificial , Síndrome do Desconforto Respiratório/virologia , SARS-CoV-2 , COVID-19/fisiopatologia , Humanos , Unidades de Terapia Intensiva/normas , Lesão Pulmonar/terapia , Respiração Artificial/efeitos adversos , Respiração Artificial/normas , Síndrome do Desconforto Respiratório/terapia , Mecânica Respiratória/fisiologia , Volume de Ventilação Pulmonar/fisiologia
9.
Lancet Infect Dis ; 22(3): e74-e87, 2022 03.
Artigo em Inglês | MEDLINE | ID: mdl-34774188

RESUMO

During the current COVID-19 pandemic, health-care workers and uninfected patients in intensive care units (ICUs) are at risk of being infected with SARS-CoV-2 as a result of transmission from infected patients and health-care workers. In the absence of high-quality evidence on the transmission of SARS-CoV-2, clinical practice of infection control and prevention in ICUs varies widely. Using a Delphi process, international experts in intensive care, infectious diseases, and infection control developed consensus statements on infection control for SARS-CoV-2 in an ICU. Consensus was achieved for 31 (94%) of 33 statements, from which 25 clinical practice statements were issued. These statements include guidance on ICU design and engineering, health-care worker safety, visiting policy, personal protective equipment, patients and procedures, disinfection, and sterilisation. Consensus was not reached on optimal return to work criteria for health-care workers who were infected with SARS-CoV-2 or the acceptable disinfection strategy for heat-sensitive instruments used for airway management of patients with SARS-CoV-2 infection. Well designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.


Assuntos
COVID-19 , Consenso , Controle de Infecções/normas , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Unidades de Terapia Intensiva/normas , SARS-CoV-2/isolamento & purificação , Vacinas contra COVID-19/administração & dosagem , Técnica Delfos , Pessoal de Saúde/normas , Humanos , Equipamento de Proteção Individual/normas
10.
Texto & contexto enferm ; 31: e20210047, 2022. tab, graf
Artigo em Inglês | LILACS, BDENF - Enfermagem | ID: biblio-1361169

RESUMO

ABSTRACT Objective: to perform the adaptation, content validation and semantic analysis of a Multidisciplinary Checklist used in rounds in Intensive Care Units for adults. Method: a methodological study, consisting of three stages: Adaptation of the checklist, performed by one of the authors; Content validation, performed by seven judges/health professionals from a public teaching hospital in Paraná; and Semantic analysis, performed in a philanthropic hospital in the same state. Agreement of the judges and of the target audience in the content validation and semantic analysis stages was calculated using the Content Validity Index and the Agreement Index, respectively, with a minimum acceptable value of 0.80. Results: in the content validation stage, the checklist obtained a total agreement of 0.84. Of the 16 items included in the instrument, 11 (68.75%) were readjusted and four (25%) were excluded for not reaching the minimum agreement. The readjusted items referred to sedation; analgesia; nutrition; glycemic control; headboard elevation; gastric ulcer prophylaxis; prophylaxis for venous thromboembolism; indwelling urinary catheter, central venous catheter; protective mechanical ventilation and spontaneous breathing test. Regarding the items excluded, they referred to the cuff pressure of the orotracheal tube and to Nursing care measures such as taking the patient out of the bed, pressure injury prophylaxis, and ophthalmoprotection. In the semantic analysis, the final agreement of the instrument's items was 0.96. Conclusion: after two evaluation rounds by the judges, testing in critically-ill patients and high inter-evaluator agreement index, the Multidisciplinary Checklist is found with validated content suitable for use in rounds in intensive care.


RESUMEN Objetivo: realizar los procesos de adaptación, validación de contenido y análisis semántico de una Lista de Verificación Multidisciplinaria utilizada en rondas de visitas médicas en una Unidad de Cuidados Intensivos para adultos. Método: estudio metodológico, compuesto por tres etapas: Adaptación de la lista de verificación, realizada por una de las autoras; validación de contenido, a cargo de siete evaluadores/profesionales de la salud que trabajan en un hospital escuela público de Paraná; y análisis semántico, desarrollado en un hospital filantrópico del mismo estado. El nivel de concordancia entre los evaluadores y la población objetivo en las etapas de validación de contenido y análisis semántico se calculó por medio de Índice de Validez de Contenido y del Índice de Concordancia, respectivamente, con un valor mínimo aceptable de 0,80. Resultados: en la etapa de validación de contenido, la lista de verificación obtuvo un valor de concordancia total de 0,84. De los 16 ítems del instrumento, 11 (68,75%) fueron readaptados y cuatro (25%) fueron excluidos por no alcanzar el nivel mínimo de concordancia. Los ítems readaptados se referían a la sedación; analgesia; nutrición; control glicémico; elevación de la cabecera de la cama; profilaxis para úlcera gástrica; profilaxis para tromboembolia venosa; sonda vesical de demora, catéter venoso central; ventilación mecánica protectora y prueba de respiración espontánea. En relación a los ítems excluidos, se refirieron a la presión del manguito del tubo orotraqueal y a la atención de Enfermería, por ejemplo: retirar al paciente de la cama; profilaxis para úlceras por presión; y oftalmoprotección. En el análisis semántico, el nivel de concordancia final de los ítems del instrumento fue de 0,96. Conclusión: después de dos rondas de evaluación a cargo de especialistas, una prueba en pacientes y elevado índice de concordancia entre los evaluadores, la Lista de Verificación Multidisciplinaria se presenta como contenido validado y adecuado para ser empleado en rondas de visitas médicas en cuidados intensivos.


RESUMO Objetivo: realizar a adaptação, validação de conteúdo e análise semântica de um Checklist Multidisciplinar utilizado em rounds em Unidade de Terapia Intensiva Adulto. Método: estudo metodológico, composto de três etapas: Adaptação do checklist, realizada por uma das autoras; validação de conteúdo, realizado por sete juízes/profissionais de saúde de um hospital de ensino público do Paraná; e análise semântica, realizado em um hospital filantrópico do mesmo estado. A concordância dos juízes e do público-alvo nas etapas validação de conteúdo e análise semântica foi calculada pelo índice de validade de conteúdo e índice de concordância, respectivamente, com valor mínimo aceitável de 0,80. Resultados: na etapa validação de conteúdo, o checklist obteve concordância total de 0,84. Dos 16 itens do instrumento, 11 (68,75%) foram readequados e quatro (25%) foram excluídos por não alcançarem a concordância mínima. Os itens readequados se referiam à sedação; analgesia; nutrição; controle glicêmico; elevação da cabeceira; profilaxia para úlcera gástrica; profilaxia para tromboembolismo venoso; sonda vesical de demora, cateter venoso central; ventilação mecânica protetora e teste de respiração espontânea. Já em relação aos itens excluídos, estes se referiam à pressão do balonete do tubo orotraqueal e cuidados de enfermagem, como: retirada do paciente do leito; profilaxia para lesão por pressão; e oftalmoproteção. Na análise semântica, a concordância final dos itens do instrumento foi 0,96. Conclusão: o Checklist Multidisciplinar após duas rodadas de avaliação por juízes, teste em pacientes críticos e alto índice de concordância interavaliadores se apresenta com conteúdo validado e adequado para uso em rounds na assistência intensiva.


Assuntos
Humanos , Adulto , Equipe de Assistência ao Paciente/normas , Lista de Checagem , Unidades de Terapia Intensiva/normas , Semântica , Pessoal de Saúde , Cuidados de Enfermagem/normas
11.
BMJ ; 375: e065871, 2021 12 06.
Artigo em Inglês | MEDLINE | ID: mdl-34872910

RESUMO

Severe pneumonia is associated with high mortality (short and long term), as well as pulmonary and extrapulmonary complications. Appropriate diagnosis and early initiation of adequate antimicrobial treatment for severe pneumonia are crucial in improving survival among critically ill patients. Identifying the underlying causative pathogen is also critical for antimicrobial stewardship. However, establishing an etiological diagnosis is challenging in most patients, especially in those with chronic underlying disease; those who received previous antibiotic treatment; and those treated with mechanical ventilation. Furthermore, as antimicrobial therapy must be empiric, national and international guidelines recommend initial antimicrobial treatment according to the location's epidemiology; for patients admitted to the intensive care unit, specific recommendations on disease management are available. Adherence to pneumonia guidelines is associated with better outcomes in severe pneumonia. Yet, the continuing and necessary research on severe pneumonia is expansive, inviting different perspectives on host immunological responses, assessment of illness severity, microbial causes, risk factors for multidrug resistant pathogens, diagnostic tests, and therapeutic options.


Assuntos
Anti-Infecciosos/uso terapêutico , Gestão de Antimicrobianos/normas , Cuidados Críticos/métodos , Pneumonia/terapia , Anti-Infecciosos/farmacologia , Cuidados Críticos/normas , Estado Terminal/terapia , Resistência a Múltiplos Medicamentos , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/normas , Pneumonia/diagnóstico , Pneumonia/epidemiologia , Pneumonia/microbiologia , Guias de Prática Clínica como Assunto , Fatores de Risco , Índice de Gravidade de Doença , Resultado do Tratamento
12.
S Afr Med J ; 111(5): 426-431, 2021 03 23.
Artigo em Inglês | MEDLINE | ID: mdl-34852883

RESUMO

BACKGROUND: Since the start of the COVID-19 pandemic, surgical operations have been drastically reduced in South Africa (SA). Guidelines on surgical prioritisation during COVID-19 have been published, but are specific to high-income countries. There is a pressing need for context-specific guidelines and a validated tool for prioritising surgical cases during the COVID-19 pandemic. In March 2020, the South African National Surgical Obstetric Anaesthesia Plan Task Team was asked by the National Department of Health to establish a national framework for COVID-19 surgical prioritisation. OBJECTIVES: To develop a national framework for COVID-19 surgical prioritisation, including a set of recommendations and a risk calculatorfor operative care. METHODS: The surgical prioritisation framework was developed in three stages: (i) a literature review of international, national and local recommendations on COVID-19 and surgical care was conducted; (ii) a set of recommendations was drawn up based on the available literature and through consensus of the COVID-19 Task Team; and (iii) a COVID-19 surgical risk calculator was developed and evaluated. RESULTS: A total of 30 documents were identified from which recommendations around prioritisation of surgical care were used to draw up six recommendations for preoperative COVID-19 screening and testing as well as the use of appropriate personal protective equipment. Ninety-nine perioperative practitioners from eight SA provinces evaluated the COVID-19 surgical risk calculator, which had high acceptability and a high level of concordance (81%) with current clinical practice. CONCLUSIONS: This national framework on COVID-19 surgical prioritisation can help hospital teams make ethical, equitable and personalised decisions whether to proceed with or delay surgical operations during this unprecedented epidemic.


Assuntos
COVID-19/prevenção & controle , Cuidados Críticos/ética , Unidades de Terapia Intensiva/normas , Centro Cirúrgico Hospitalar/organização & administração , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Triagem/normas , COVID-19/epidemiologia , Consenso , Procedimentos Cirúrgicos Eletivos , Humanos , Pandemias , SARS-CoV-2 , África do Sul , Centro Cirúrgico Hospitalar/normas
13.
Medicine (Baltimore) ; 100(45): e27592, 2021 Nov 12.
Artigo em Inglês | MEDLINE | ID: mdl-34766561

RESUMO

ABSTRACT: Our objective was to analyze in vitro the persistence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in the packaging material of the drugs dispensed to hospital wards. Additionally, to evaluate if the protection with a double plastic bag prevents the contamination of the medication dispensed to an intensive care unit (ICU).On the first part, different materials containing different drugs within an ICU were sampled to confirm the lack of contamination by SARS-CoV-2. The confirmation of the virus was performed using real time reverse transcription polymerase chain reaction. As a control group, in the microbiology laboratory we inoculated the virus into the different surfaces containing the same drugs included in the first part. Samples were obtained with a sterile swab at 3, 6, 8, 10, 14, 21, and 30 days after inoculation and analyzed through real time reverse transcription polymerase chain reaction.None of the studied materials containing the drugs within an ICU was contaminated by SARS-CoV-2. In the second part, SARS-CoV-2 was found in all surfaces for up to 30 days.The use of double-bag unit-dose system to deliver medication in a pandemic seems effective to prevent the potential transmission of SARS-CoV-2. A striking SARS-CoV-2 RNA stability of up to 30 days was found in the surfaces containing the drugs.


Assuntos
COVID-19/prevenção & controle , Surtos de Doenças/prevenção & controle , Contaminação de Medicamentos/prevenção & controle , Unidades de Terapia Intensiva/normas , Preparações Farmacêuticas , COVID-19/epidemiologia , Hospitais , Humanos , RNA Viral/genética , RNA Viral/isolamento & purificação , Reação em Cadeia da Polimerase em Tempo Real , SARS-CoV-2
16.
Crit Care Med ; 49(11): 1974-1982, 2021 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-34643578
17.
Crit Care Med ; 49(11): e1063-e1143, 2021 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-34605781
18.
Eur J Med Res ; 26(1): 108, 2021 Sep 17.
Artigo em Inglês | MEDLINE | ID: mdl-34535193

RESUMO

Acute respiratory failure (ARF) is still the major cause of intensive care unit (ICU) admission for hematological malignancy (HM) patients although the advance in hematology and supportive care has greatly improved the prognosis. Clinicians have to make decisions whether the HM patients with ARF should be sent to ICU and which ventilation support should be administered. Based on the reported investigations related to management of HM patients with ARF, we propose a selection procedure to manage this population and recommend hematological ICU as the optimal setting to recuse these patients, where hematologists and intensivists can collaborate closely and improve the outcomes. Moreover, noninvasive ventilation (NIV) still has its own place for selected HM patients with ARF who have mild hypoxemia and reversible causes. It is also crucial to monitor the efficacy of NIV closely and switch to invasive mechanical ventilation at appropriate timing when NIV shows no apparent improvement. Otherwise, early IMV should be initiated to HM with ARF who have moderate and severe hypoxemia, adult respiratory distress syndrome, multiple organ dysfunction, and unstable hemodynamic. More studies are needed to elucidate the predictors of ICU mortality and ventilatory mode for HM patients with ARF.


Assuntos
Neoplasias Hematológicas/complicações , Unidades de Terapia Intensiva/normas , Ventilação não Invasiva/métodos , Síndrome do Desconforto Respiratório/terapia , Gerenciamento Clínico , Humanos , Prognóstico , Síndrome do Desconforto Respiratório/etiologia , Síndrome do Desconforto Respiratório/patologia
19.
Best Pract Res Clin Anaesthesiol ; 35(3): 351-368, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34511224

RESUMO

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) induces coronavirus-19 disease (COVID-19) and is a major health concern. Following two SARS-CoV-2 pandemic "waves," intensive care unit (ICU) specialists are treating a large number of COVID19-associated acute respiratory distress syndrome (ARDS) patients. From a pathophysiological perspective, prominent mechanisms of COVID19-associated ARDS (CARDS) include severe pulmonary infiltration/edema and inflammation leading to impaired alveolar homeostasis, alteration of pulmonary physiology resulting in pulmonary fibrosis, endothelial inflammation (endotheliitis), vascular thrombosis, and immune cell activation. Although the syndrome ARDS serves as an umbrella term, distinct, i.e., CARDS-specific pathomechanisms and comorbidities can be noted (e.g., virus-induced endotheliitis associated with thromboembolism) and some aspects of CARDS can be considered ARDS "atypical." Importantly, specific evidence-based medical interventions for CARDS (with the potential exception of corticosteroid use) are currently unavailable, limiting treatment efforts to mostly supportive ICU care. In this article, we will discuss the underlying pulmonary pathophysiology and the clinical management of CARDS. In addition, we will outline current and potential future treatment approaches.


Assuntos
COVID-19/terapia , Cuidados Críticos/normas , Conhecimentos, Atitudes e Prática em Saúde , Unidades de Terapia Intensiva/normas , Síndrome do Desconforto Respiratório/terapia , Corticosteroides/administração & dosagem , Anticoagulantes/administração & dosagem , COVID-19/diagnóstico , COVID-19/fisiopatologia , Cuidados Críticos/tendências , Humanos , Fatores Imunológicos/administração & dosagem , Unidades de Terapia Intensiva/tendências , Respiração Artificial/normas , Respiração Artificial/tendências , Síndrome do Desconforto Respiratório/diagnóstico , Síndrome do Desconforto Respiratório/fisiopatologia
20.
Medicine (Baltimore) ; 100(34): e27060, 2021 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-34449497

RESUMO

ABSTRACT: Antibiotic stewardship (ABS) programs intend to improve outcomes of nosocomial infections and to counteract the emergence of further antimicrobial resistances. At the anesthesiologic-neurosurgical intensive care unit (ICU) of the University Medical Center Regensburg (Germany) we implemented a standard operating procedure (SOP) with clear instructions for the preanalytical handling and storage of microbiological samples. We intended to find out whether the instructions given in the SOP led to a higher rate of ideal material being sent to the laboratory and to overall better quality of the received results.We retraced retrospectively all samples taken in cases of suspected pneumonia, urinary tract infection, bloodstream infection, catheter infection associated with a central venous or arterial catheter and ventriculitis due to external ventricular drainage as well as all smears taken for the screening for multi-resistant bacteria within a time period of 1 year before to 1 year after the implementation of the SOP.In the case of suspected pneumonia and urinary tract infection, large amounts of ideal material were sent to the microbiological laboratory. A remarkable improvement after the implementation of the SOP, however, could only be observed regarding the number of urine samples taken from older urinary catheters, which was significantly lower in the "SOP group". Samples for microbiological diagnostics were taken much more often in the daytime, although storage of the probes did not lead to worse results.Concrete instructions enable adequate preanalytical handling of microbiological probes. However, we could not recognize substantial improvements probably due to a preexisting high process quality on the ICU. Microbiological diagnostics during the night shift has to be improved.


Assuntos
Protocolos Clínicos/normas , Unidades de Terapia Intensiva/organização & administração , Técnicas Microbiológicas/normas , Gestão de Antimicrobianos , Infecção Hospitalar/microbiologia , Infecção Hospitalar/prevenção & controle , Alemanha , Humanos , Unidades de Terapia Intensiva/normas , Neurocirurgia , Estudos Retrospectivos , Fatores de Tempo
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