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1.
Ann R Coll Surg Engl ; 104(4): 249-256, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34928718

RESUMO

INTRODUCTION: Multiple traumatic rib fractures are associated with significant morbidity and mortality. The last decade has seen a significant increase in rates of surgical fixation for both flail and non-flail rib fractures; the evidence for this has come from largely retrospective studies. The aim of this meta-analysis was to compare the efficacy of this approach with that of non-operative management. METHODS: A systematic search of the literature was performed to identify randomised controlled trials (RCTs) comparing surgical stabilisation to non-operative management. Both flail and non-flail injuries were included. RESULTS: Five RCTs reported the results of 286 patients. Only one study assessed non-flail fractures. The studies were heterogenic in nature and of mixed quality. Surgical stabilisation was associated with a reduction in pneumonia (RR 0.46, 95% confidence intervals (CI) 0.29 to 0.73, I2=42%, p=0.001). The duration of mechanical ventilation (mean difference (MD) -6.3, 95% CI -12.16 to -0.43, I2=95%, p=0.05) and critical care length of stay was also shorter after surgery (mean difference -6.46 days, 95% CI 9.73 to -3.19, p<0.001); however, the overall length of stay in hospital was not (MD -7.18, 95% CI -15.63 to -1.28, I2=94%, p=0.1). No study demonstrated a significant reduction in mortality (RR 0.54, 95% CI 0.18 to 1.8, I2=0%, p=0.28). CONCLUSIONS: Surgical stabilisation of rib fractures is associated with some improved clinical outcomes. Further large RCTs are still needed to confirm if there is also a survival benefit.


Assuntos
Tórax Fundido , Fraturas das Costelas , Ferimentos não Penetrantes , Tórax Fundido/cirurgia , Humanos , Tempo de Internação , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial , Fraturas das Costelas/cirurgia , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/cirurgia
4.
PLoS One ; 17(8): e0272373, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35913973

RESUMO

BACKGROUND: Severe coronavirus disease 2019 (COVID-19) patients frequently require mechanical ventilation (MV) and undergo prolonged periods of bed rest with restriction of activities during the intensive care unit (ICU) stay. Our aim was to address the degree of mobilization in critically ill patients with COVID-19 undergoing to MV support. METHODS: Retrospective single-center cohort study. We analyzed patients' mobility level, through the Perme ICU Mobility Score (Perme Score) of COVID-19 patients admitted to the ICU. The Perme Mobility Index (PMI) was calculated [PMI = ΔPerme Score (ICU discharge-ICU admission)/ICU length of stay], and patients were categorized as "improved" (PMI > 0) or "not improved" (PMI ≤ 0). Comparisons were performed with stratification according to the use of MV support. RESULTS: From February 2020, to February 2021, 1,297 patients with COVID-19 were admitted to the ICU and assessed for eligibility. Out of those, 949 patients were included in the study [524 (55.2%) were classified as "improved" and 425 (44.8%) as "not improved"], and 396 (41.7%) received MV during ICU stay. The overall rate of patients out of bed and able to walk ≥ 30 meters at ICU discharge were, respectively, 526 (63.3%) and 170 (20.5%). After adjusting for confounders, independent predictors of improvement of mobility level were frailty (OR: 0.52; 95% CI: 0.29-0.94; p = 0.03); SAPS III Score (OR: 0.75; 95% CI: 0.57-0.99; p = 0.04); SOFA Score (OR: 0.58; 95% CI: 0.43-0.78; p < 0.001); use of MV after the first hour of ICU admission (OR: 0.41; 95% CI: 0.17-0.99; p = 0.04); tracheostomy (OR: 0.54; 95% CI: 0.30-0.95; p = 0.03); use of extracorporeal membrane oxygenation (OR: 0.21; 95% CI: 0.05-0.8; p = 0.03); neuromuscular blockade (OR: 0.53; 95% CI: 0.3-0.95; p = 0.03); a higher Perme Score at admission (OR: 0.35; 95% CI: 0.28-0.43; p < 0.001); palliative care (OR: 0.05; 95% CI: 0.01-0.16; p < 0.001); and a longer ICU stay (OR: 0.79; 95% CI: 0.61-0.97; p = 0.04) were associated with a lower chance of mobility improvement, while non-invasive ventilation within the first hour of ICU admission and after the first hour of ICU admission (OR: 2.45; 95% CI: 1.59-3.81; p < 0.001) and (OR: 2.25; 95% CI: 1.56-3.26; p < 0.001), respectively; and vasopressor use (OR: 2.39; 95% CI: 1.07-5.5; p = 0.03) were associated with a higher chance of mobility improvement. CONCLUSION: The use of MV reduced mobility status in less than half of critically ill COVID-19 patients.


Assuntos
COVID-19 , Respiração Artificial , COVID-19/terapia , Estudos de Coortes , Estado Terminal/terapia , Humanos , Unidades de Terapia Intensiva , Estudos Retrospectivos
6.
BMC Pulm Med ; 22(1): 296, 2022 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-35915487

RESUMO

BACKGROUND: Coronavirus disease 2019-associated acute respiratory distress syndrome (COVID-19 ARDS) seems to differ from the "classic ARDS", showing initial significant hypoxemia in the face of relatively preserved compliance and evolving later in a scenario of poorly compliant lungs. We tested the hypothesis that in patients with COVID-19 ARDS, the initial value of static compliance of respiratory system (Crs) (1) depends on the previous duration of the disease (i.e., the fewer days of illness, the higher the Crs and vice versa) and (2) identifies different lung patterns of time evolution and response to prone positioning. METHODS: This was a single-center prospective observational study. We enrolled consecutive mechanically ventilated patients with a diagnosis of COVID-19 who met ARDS criteria, admitted to intensive care unit (ICU). Patients were divided in four groups based on quartiles of initial Crs. Relationship between Crs and the previous duration of the disease was evaluated. Respiratory parameters collected once a day and during prone positioning were compared between groups. RESULTS: We evaluated 110 mechanically ventilated patients with a diagnosis of COVID-19 who met ARDS criteria admitted to our ICUs. Patients were divided in groups based on quartiles of initial Crs. The median initial Crs was 41 (32-47) ml/cmH2O. No association was found between the previous duration of the disease and the initial Crs. The Crs did not change significantly over time within each quartile. Positive end-expiratory pressure (PEEP) and driving pressure were respectively lower and greater in patients with lower Crs. Prone positioning significantly improved PaO2/FiO2 in the 4 groups, however it increased the Crs significantly only in patients in lower quartile of Crs. CONCLUSIONS: In our cohort, the initial Crs is not dependent on the previous duration of COVID-19 disease. Prone positioning improves oxygenation irrespective to initial Crs, but it ameliorates respiratory mechanics only in patients with lower Crs.


Assuntos
COVID-19 , Síndrome do Desconforto Respiratório , Humanos , Complacência Pulmonar/fisiologia , Fenótipo , Respiração com Pressão Positiva , Respiração Artificial , Síndrome do Desconforto Respiratório/terapia
7.
Can Vet J ; 63(7): 722-726, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35784775

RESUMO

The use of transthoracic echocardiography (TTE) and esophageal Doppler (ED) for the measurement of hemodynamic variables in anesthetized dogs was studied. Fourteen mixed-breed dogs, without cardiac disease, undergoing general anesthesia for diagnostic or therapeutic procedures were included in this prospective preliminary study. Dogs were premedicated with dexmedetomidine (3 µg/kg) and methadone (0.3 mg/kg), intramuscularly. General anesthesia was induced with propofol intravenously titrated to effect and maintained with isoflurane in oxygen. Animals were positioned in dorsal recumbency. Transthoracic echocardiography was performed using a 5-2 MHz cardiac ultrasound probe placed in the subcostal window, whereas esophageal Doppler was performed using a CardioQ probe (MP50; Deltex Medical, Chichester, UK). Once an appropriate view of the aortic flow was obtained, the variables peak velocity (PV) and velocity-time integral (VTI) were measured. Agreement between methods was evaluated using the Bland-Altman method with single observation per individual. The bias and the limits of agreement (LOA) between the two methods were determined. Mean (± SD) PV was 99.46 cm/s (± 42.73 cm/s) and 110.29 cm/s (± 35.86 cm/s), and VTI was 13.24 cm (± 4.33 cm) and 13.05 cm (± 4.47 cm), for TTE and ED, respectively. Mean differences and LOA were 10.83 cm/s (range: -20.50 to 42.16 cm/s) and -0.19 cm (range: -3.32 to 2.95 cm) for PV and VTI, respectively. No statistically significant differences were determined in the variables measured between TTE and ED in anesthetized dogs without cardiac disease, positioned in dorsal recumbency. This could be of clinical relevance when an evaluation of the intraoperative hemodynamic status of anesthetized dogs is desired.


Concordance entre l'échocardiographie transthoracique et le Doppler oesophagien sur les variables du débit aortique chez des chiens anesthésiés ventilés mécaniquement. L'utilisation de l'échocardiographie transthoracique (TTE) et du Doppler oesophagien (ED) pour la mesure des variables hémodynamiques chez les chiens anesthésiés a été étudiée. Quatorze chiens de race mixte, sans maladie cardiaque, subissant une anesthésie générale pour des procédures diagnostiques ou thérapeutiques ont été inclus dans cette étude préliminaire prospective. Les chiens ont reçu une prémédication avec de la dexmédétomidine (3 µg/kg) et de la méthadone (0,3 mg/kg), par voie intramusculaire. L'anesthésie générale a été induite avec du propofol intraveineux titré à effet et maintenue avec de l'isoflurane dans de l'oxygène. Les animaux ont été placés en décubitus dorsal. L'échocardiographie transthoracique a été réalisée à l'aide d'une sonde à ultrasons cardiaque 5-2 MHz placée dans la fenêtre sous-costale, tandis que le Doppler oesophagien a été réalisé à l'aide d'une sonde CardioQ (MP50; Deltex Medical, Chichester, Royaume-Uni). Une fois qu'une vue appropriée de l'aorte était obtenue, les variables vitesse maximale (PV) et intégrale vitesse-temps (VTI) étaient mesurées. La concordance entre les méthodes a été évaluée à l'aide de la méthode de Bland-Altman avec une seule observation par individu. Le biais et les limites d'accord (LOA) entre les deux méthodes ont été déterminés. La PV moyenne (± SD) était de 99,46 cm/s (± 42,73 cm/s) et 110,29 cm/s (± 35,86 cm/s), et la VTI était de 13,24 cm (± 4,33 cm) et 13,05 cm (± 4,47 cm), pour TTE et ED, respectivement. Les différences moyennes et la LOA étaient de 10,83 cm/s (intervalle : −20,50 à 42,16 cm/s) et de −0,19 cm (intervalle : −3,32 à 2,95 cm) pour PV et VTI, respectivement. Aucune différence statistiquement significative n'a été déterminée dans les variables mesurées entre TTE et ED chez des chiens anesthésiés sans maladie cardiaque, positionnés en décubitus dorsal. Cela pourrait être cliniquement pertinent lorsqu'une évaluation de l'état hémodynamique peropératoire des chiens anesthésiés est souhaitée.(Traduit par Dr Serge Messier).


Assuntos
Doenças do Cão , Cardiopatias , Isoflurano , Animais , Cães , Ecocardiografia , Cardiopatias/veterinária , Isoflurano/farmacologia , Estudos Prospectivos , Respiração Artificial/veterinária
8.
BMC Pulm Med ; 22(1): 268, 2022 Jul 11.
Artigo em Inglês | MEDLINE | ID: mdl-35820835

RESUMO

BACKGROUND: Large variability in mortality exists in patients of acute respiratory distress syndrome (ARDS), especially those with invasive ventilation. The aim of this study was to develop a model to predict risk of in-hospital death in ventilated ARDS patients. METHODS: Ventilated patients with ARDS from two public databases (MIMIC-III and eICU-CRD) were randomly divided as training cohort and internal validation cohort. Least absolute shrinkage and selection operator (LASSO) and then Logistic regression was used to construct a predictive model with demographic, clinical, laboratory, comorbidities and ventilation variables ascertained at first 24 h of ICU admission and invasive ventilation. Our model was externally validated using data from another database (MIMIC-IV). RESULTS: A total of 1075 adult patients from MIMIC-III and eICU were randomly divided into training cohort (70%, n = 752) and internal validation cohort (30%, n = 323). 521 patients were included from MIMIC-IV. From 176 potential predictors, 9 independent predictive factors were included in the final model. Five variables were ascertained within the first 24 h of ICU admission, including age (OR, 1.02; 95% CI: 1.01-1.03), mean of respiratory rate (OR, 1.04; 95% CI: 1.01-1.08), the maximum of INR (OR, 1.14; 95% CI: 1.03-1.31) and alveolo-arterial oxygen difference (OR, 1.002; 95% CI: 1.001-1.003) and the minimum of RDW (OR, 1.17; 95% CI: 1.09-1.27). And four variables were collected within the first 24 h of invasive ventilation: mean of temperature (OR, 0.70; 95% CI: 0.57-0.86), the maximum of lactate (OR, 1.15; 95% CI: 1.09-1.22), the minimum of blood urea nitrogen (OR, 1.02; 95% CI: 1.01-1.03) and white blood cell counts (OR, 1.03; 95% CI: 1.01-1.06). Our model achieved good discrimination (AUC: 0.77, 95% CI: 0.73-0.80) in training cohort but the performance declined in internal (AUC: 0.75, 95% CI: 0.69-0.80) and external validation cohort (0.70, 95% CI: 0.65-0.74) and showed modest calibration. CONCLUSIONS: A risk score based on routinely collected variables at the start of admission to ICU and invasive ventilation can predict mortality of ventilated ARDS patients, with a moderate performance.


Assuntos
Respiração Artificial , Síndrome do Desconforto Respiratório , Adulto , Estudos de Coortes , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Síndrome do Desconforto Respiratório/terapia
9.
Respir Res ; 23(1): 184, 2022 Jul 13.
Artigo em Inglês | MEDLINE | ID: mdl-35831900

RESUMO

BACKGROUND: Ventilator liberation is one of the most challenging aspects in patients with respiratory failure. Most patients are weaned through a transition from full to partial respiratory support, whereas some advocate using a continuous spontaneous ventilation (CSV). However, there is little scientific evidence supporting the practice of pediatric ventilator liberation, including the timing of onset of and the approach to weaning mode. We sought to explore differences in patient effort between a pressure controlled continuous mode of ventilation (PC-CMV) [in this cohort PC assist/control (PC-A/C)] with a reduced ventilator rate and CSV, and to study changes in patient effort with decreasing PS. METHODS: In this prospective physiology cross-over study, we randomized children < 5 years to first PC-A/C with a 25% reduction in ventilator rate, or CSV (continuous positive airway pressure [CPAP] + PS). Patients were then crossed over to the other arm. Patient effort was measured by calculating inspiratory work of breathing (WOB) using the Campbell diagram (WOBCampbell), and by pressure-rate-product (PRP) and pressure-time-product (PTP). Respiratory inductance plethysmography (RIP) was used to calculate the phase angle. Measurements were obtained at baseline, during PC-A/C and CPAP + PS, and during decreasing set PS (maximum -6 cmH2O). RESULTS: Thirty-six subjects with a median age of 4.4 (IQR 1.5-11.9) months and median ventilation time of 4.9 (IQR 3.4-7.0) days were included. Nearly all patients (94.4%) were admitted with primary respiratory failure. WOBCampbell during baseline [0.67 (IQR 0.38-1.07) Joules/L] did not differ between CSV [0.49 (IQR 0.17-0.83) Joules/L] or PC-A/C [0.47 (IQR 0.17-1.15) Joules/L]. Neither PRP, PTP, ∆Pes nor phase angle was different between the two ventilator modes. Reducing pressure support resulted in a statistically significant increase in patient effort, albeit that these differences were clinically negligible. CONCLUSIONS: Patient effort during pediatric ventilation liberation was not increased when patients were in a CSV mode of ventilation compared to a ventilator mode with a ventilator back-up rate. Reducing the level of PS did not lead to clinically relevant increases in patient effort. These data may aid in a better approach to pediatric ventilation liberation. Trial registration clinicaltrials.gov NCT05254691. Registered 24 February 2022.


Assuntos
Insuficiência Respiratória , Trabalho Respiratório , Criança , Pressão Positiva Contínua nas Vias Aéreas , Estudos Cross-Over , Humanos , Lactente , Estudos Prospectivos , Respiração Artificial/métodos , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/terapia , Desmame do Respirador , Trabalho Respiratório/fisiologia
10.
Crit Care ; 26(1): 208, 2022 07 08.
Artigo em Inglês | MEDLINE | ID: mdl-35804453

RESUMO

BACKGROUND: During the COVID-19 pandemic, many more patients were turned prone than before, resulting in a considerable increase in workload. Whether extending duration of prone position may be beneficial has received little attention. We report here benefits and detriments of a strategy of extended prone positioning duration for COVID-19-related acute respiratory distress syndrome (ARDS). METHODS: A eetrospective, monocentric, study was performed on intensive care unit patients with COVID-19-related ARDS who required tracheal intubation and who have been treated with at least one session of prone position of duration greater or equal to 24 h. When prone positioning sessions were initiated, patients were kept prone for a period that covered two nights. Data regarding the incidence of pressure injury and ventilation parameters were collected retrospectively on medical and nurse files of charts. The primary outcome was the occurrence of pressure injury of stage ≥ II during the ICU stay. RESULTS: For the 81 patients included, the median duration of prone positioning sessions was 39 h [interquartile range (IQR) 34-42]. The cumulated incidence of stage ≥ II pressure injuries was 26% [95% CI 17-37] and 2.5% [95% CI 0.3-8.8] for stages III/IV pressure injuries. Patients were submitted to a median of 2 sessions [IQR 1-4] and for 213 (94%) prone positioning sessions, patients were turned over to supine position during daytime, i.e., between 9 AM and 6 PM. This increased duration was associated with additional increase in oxygenation after 16 h with the PaO2/FiO2 ratio increasing from 150 mmHg [IQR 121-196] at H+ 16 to 162 mmHg [IQR 124-221] before being turned back to supine (p = 0.017). CONCLUSION: In patients with extended duration of prone position up to 39 h, cumulative incidence for stage ≥ II pressure injuries was 26%, with 25%, 2.5%, and 0% for stage II, III, and IV, respectively. Oxygenation continued to increase significantly beyond the standard 16-h duration. Our results may have significant impact on intensive care unit staffing and patients' respiratory conditions. TRIAL REGISTRATION: Institutional review board 00006477 of HUPNVS, Université Paris Cité, APHP, with the reference: CER-2021-102, obtained on October 11th 2021. Registered at Clinicaltrials (NCT05124197).


Assuntos
COVID-19 , Síndrome do Desconforto Respiratório , Humanos , Pandemias , Decúbito Ventral , Troca Gasosa Pulmonar , Respiração Artificial/efeitos adversos , Síndrome do Desconforto Respiratório/terapia , Estudos Retrospectivos , Decúbito Dorsal
11.
Minerva Med ; 113(3): 460-470, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35856181

RESUMO

In the chronic obstructive pulmonary disease (COPD), lung and chest-wall morphological alterations determine important and peculiar approaches to mechanical ventilation. Lung emphysema and reduced elastic recoil increase expiratory time, thus worsening dynamic hyperinflation, while airways chronic inflammation rises resistances and can determine distal air-trapping. Muscle wasting and fast fibers prevalence can result in weakness and in an earlier onset of muscle fatigue, prolonging the weaning process. In this narrative review, we explored the connection between altered pathophysiology and necessity for respiratory assistance in COPD, focusing on non-invasive and invasive respiratory management, lung monitoring and weaning difficulties.


Assuntos
Doença Pulmonar Obstrutiva Crônica , Respiração Artificial , Humanos , Pulmão , Doença Pulmonar Obstrutiva Crônica/terapia , Testes de Função Respiratória
12.
Eur Rev Med Pharmacol Sci ; 26(13): 4770-4773, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35856369

RESUMO

OBJECTIVE: Botulism is a very rare disease in Switzerland, with less than one case per year, an incidence of 0.01 cases for 100,000 inhabitants. Indeed, over the past ten years, 9 cases have been reported to Public Health registry. Foodborne botulism (FB) is caused by ingestion of preformed botulinum neurotoxin. Characteristic features should be rapidly recognized, and prompt treatment should be administered to avoid further progression towards respiratory failure and death. CASE REPORT: We report the case of a patient who developed gastrointestinal symptoms just after a sandwich consumption followed by rapidly progressive cranial nerve impairment, truncal muscle weakness in a descending pattern and respiratory failure requiring mechanical ventilation. The diagnosis of foodborne botulism was delayed due to differential diagnosis considerations. Specific antitoxin therapy was administered immediately after firm clinical conviction of botulism, without waiting for serologic results that later confirmed the diagnosis. As expected, muscle weakness recovery was slow, with persistent chronic deficits nine years later. CONCLUSIONS: This case highlights differential diagnosis issues of botulism. These include acute neuromuscular disorders such as myasthenia gravis, Guillain-Barré syndrome, or tick-borne encephalitis. The importance of careful medical history and repeated clinical evaluation to avoid misdiagnosis can be lifesaving. Our case highlights the typical warning signs.


Assuntos
Toxinas Botulínicas , Botulismo , Insuficiência Respiratória , Doença Aguda , Toxinas Botulínicas/uso terapêutico , Botulismo/diagnóstico , Botulismo/epidemiologia , Botulismo/terapia , Humanos , Debilidade Muscular/etiologia , Respiração Artificial/efeitos adversos
14.
PLoS One ; 17(7): e0269876, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35834478

RESUMO

BACKGROUND: Rapid deterioration of oxygenation occurs in novel coronavirus disease 2019 (COVID-19), and prediction of mechanical ventilation (MV) is needed for allocation of patients to intensive care unit. Since intubation is usually decided based on varying clinical conditions, such as required oxygen changes, we aimed to elucidate thresholds of increase in oxygen demand to predict MV use within 12 h. METHODS: A single-center retrospective cohort study using data between January 2020 and January 2021was conducted. Data were retrieved from the hospital data warehouse. Adult patients diagnosed with COVID-19 with a positive polymerase chain reaction (PCR) who needed oxygen during admission were included. Hourly increments in oxygen demand were calculated using two consecutive oxygen values. Covariates were selected from measurements at the closest time points of oxygen data. Prediction of MV use within 12 h by required oxygen changes was evaluated with the area under the receiver operating curves (AUCs). A threshold for increased MV use risk was obtained from restricted cubic spline curves. RESULTS: Among 66 eligible patients, 1835 oxygen data were analyzed. The AUC was 0.756 for predicting MV by oxygen demand changes, 0.888 by both amounts and changes in oxygen, and 0.933 by the model adjusted with respiratory rate, PCR quantification cycle (Ct), and days from PCR. The threshold of increments of required oxygen was identified as 0.44 L/min/h and the probability of MV use linearly increased afterward. In subgroup analyses, the threshold was lower (0.25 L/min/h) when tachypnea or frequent respiratory distress existed, whereas it was higher (1.00 L/min/h) when viral load is low (Ct ≥20 or days from PCR >7 days). CONCLUSIONS: Hourly changes in oxygen demand predicted MV use within 12 h, with a threshold of 0.44 L/min/h. This threshold was lower with an unstable respiratory condition and higher with a low viral load.


Assuntos
COVID-19 , Respiração Artificial , Adulto , Humanos , Pulmão , Oxigênio , Estudos Retrospectivos
15.
Andes Pediatr ; 93(1): 123-133, 2022 Feb.
Artigo em Espanhol | MEDLINE | ID: mdl-35856956

RESUMO

The birth of intensive care was a process that took place in Copenhagen, Denmark, during and after the polio epidemic of 1952-1953. The fact that marks its beginning was that anesthesiologist Björn Ibsen was asked to help and "came out of the operating room", not without some controversy. Ib sen proposed and advocated the use of tracheostomy, suctioning and ventilation. Given the lack of positive pressure ventilators, this task was carried out by students who contributed 165,000 hours of manual ventilation. Few years later, in Gothenburg, Sweden, the anesthesiologist Göran Haglund, motivated by the case of a four years old boy with complicated appendicitis, created the first multi disciplinary pediatric intensive care unit in the world (1955). In Chile, during the 1950s, the concept of pediatric intensive care began to develop under the direction of physicians with a solid vision of the future. Given that the planet is experiencing a pandemic, it seems an appropriate moment to review the role of the polio epidemic in the development of positive pressure ventilation, the birth of intensive care medicine and intensive care units, in order to assess the role of the various tasks and innovations carried out.


Assuntos
Cuidados Críticos , Poliomielite , Criança , Pré-Escolar , Humanos , Unidades de Terapia Intensiva Pediátrica , Respiração Artificial , Ventiladores Mecânicos
16.
Sci Transl Med ; 14(654): eabo2652, 2022 Jul 20.
Artigo em Inglês | MEDLINE | ID: mdl-35857827

RESUMO

Hyperinflammation triggered by SARS-CoV-2 is a major cause of disease severity, with activated macrophages implicated in this response. OP-101, a hydroxyl-polyamidoamine dendrimer-N-acetylcysteine conjugate that specifically targets activated macrophages, improves outcomes in preclinical models of systemic inflammation and neuroinflammation. In this multicenter, randomized, double-blind, placebo-controlled, adaptive phase 2a trial, we evaluated safety and preliminary efficacy of OP-101 in patients with severe COVID-19. Twenty-four patients classified as having severe COVID-19 with a baseline World Health Organization seven-point ordinal scale of ≥5 were randomized to receive a single intravenous dose of placebo (n = 7 patients) or OP-101 at 2 (n = 6), 4 (n = 6), or 8 mg/kg (n = 5 patients). All study participants received standard of care, including corticosteroids. OP-101 at 4 mg/kg was better than placebo at decreasing inflammatory markers; OP-101 at 4 and 8 mg/kg was better than placebo at reducing neurological injury markers, (neurofilament light chain and glial fibrillary acidic protein). Risk for the composite outcome of mechanical ventilation or death at 30 and 60 days after treatment was 71% (95% CI: 29%, 96%) for placebo and 18% (95% CI: 4%, 43%; P = 0.021) for the pooled OP-101 treatment arms. At 60 days, 3 of 7 patients given placebo and 14 of 17 OP-101-treated patients were surviving. No drug-related adverse events were reported. These data show that OP-101 was well tolerated and may have potential to treat systemic inflammation and neuronal injury, reducing morbidity and mortality in hospitalized patients with severe COVID-19.


Assuntos
COVID-19 , Dendrímeros , COVID-19/tratamento farmacológico , Dendrímeros/uso terapêutico , Método Duplo-Cego , Humanos , Inflamação/tratamento farmacológico , Respiração Artificial , SARS-CoV-2 , Resultado do Tratamento
17.
Trials ; 23(1): 576, 2022 Jul 19.
Artigo em Inglês | MEDLINE | ID: mdl-35854358

RESUMO

BACKGROUND: Delirium is a highly prevalent and morbid syndrome in mechanically ventilated intensive care unit (ICU) patients. Music is a promising non-pharmacological intervention with beneficial effects on anxiety and stress, while its effects on delirium duration and severity are not well understood. METHODS/DESIGN: Our study is a two-arm, randomized parallel-group, clinical trial to evaluate the efficacy of music intervention compared to a silence-track attention control on delirium/coma duration in mechanically ventilated critically ill older adults. One hundred sixty mechanically ventilated adults 50 years of age or older will be randomized to one of two arms within 72 h of ICU admission: (1) 1-h music listening sessions twice daily through noise-canceling headphones, or (2) 1-h sessions of a silence track twice daily through noise-canceling headphones. Our primary aim is to compare delirium/coma-free days after randomization during the 7-day study intervention phase using the Confusion Assessment Method for the ICU (CAM ICU) and the Richmond Agitation Sedation Scale (RASS) for delirium and coma. Secondary outcomes include pain and anxiety evaluated twice daily during the intervention phase and throughout the duration of ICU stay using the Critical Care Pain Observation Tool (CPOT) and visual analog scale-anxiety (VAS-A). Enrolled participants will be followed after hospital discharge to further measure cognition as well as screening for depression and anxiety using the following telephone-based instruments: Indiana University Telephone-Based Assessment of Neuropsychological Status (IU TBANS), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7). DISCUSSION: This randomized clinical trial will measure the efficacy of a music listening intervention for delirium and coma duration early in the intensive care unit among older adults. TRIAL REGISTRATION: ClinicalTrials.gov. NCT04182334 .


Assuntos
Delírio , Música , Idoso , Estado Terminal/psicologia , Delírio/diagnóstico , Delírio/prevenção & controle , Humanos , Unidades de Terapia Intensiva , Dor , Respiração Artificial/efeitos adversos
18.
BMC Infect Dis ; 22(1): 632, 2022 Jul 20.
Artigo em Inglês | MEDLINE | ID: mdl-35858876

RESUMO

BACKGROUND: The outbreak of SARS-CoV-2 at the end of 2019 sounded the alarm for early inspection on acute respiratory infection (ARI). However, diagnosis pathway of ARI has still not reached a consensus and its impact on prognosis needs to be further explored. METHODS: ESAR is a multicenter, open-label, randomized controlled, non-inferiority clinical trial on evaluating the diagnosis performance and its impact on prognosis of ARI between mNGS and multiplex PCR. Enrolled patients will be divided into two groups with a ratio of 1:1. Group I will be directly tested by mNGS. Group II will firstly receive multiplex PCR, then mNGS in patients with severe infection if multiplex PCR is negative or inconsistent with clinical manifestations. All patients will be followed up every 7 days for 28 days. The primary endpoint is time to initiate targeted treatment. Secondary endpoints include incidence of significant events (oxygen inhalation, mechanical ventilation, etc.), clinical remission rate, and hospitalization length. A total of 440 participants will be enrolled in both groups. DISCUSSION: ESAR compares the efficacy of different diagnostic strategies and their impact on treatment outcomes in ARI, which is of great significance to make precise diagnosis, balance clinical resources and demands, and ultimately optimize clinical diagnosis pathways and treatment strategies. Trial registration Clinicaltrial.gov, NCT04955756, Registered on July 9th 2021.


Assuntos
COVID-19 , SARS-CoV-2 , COVID-19/diagnóstico , Hospitalização , Humanos , Estudos Multicêntricos como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial , Resultado do Tratamento
19.
Medicine (Baltimore) ; 101(26): e29719, 2022 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-35776996

RESUMO

RATIONALE: Traumatic cervical spinal cord injury (SCI) is a devastating condition leading to respiratory failure that requires permanent mechanical ventilation, which is the main driver of increased medical costs. There is a great demand for establishing therapeutic interventions to treat respiratory dysfunction following severe cervical SCI. PATIENT CONCERNS AND DIAGNOSIS: We present a 24-year-old man who sustained a cervical displaced C2-C3 fracture with SCI due to a traffic accident. As the patient presented with tetraplegia and difficulty in spontaneous breathing following injury, he was immediately intubated and placed on a ventilator with cervical external fixation by halo orthosis. The patient then underwent open reduction and posterior fusion of the cervical spine 3 weeks after injury. Although the patient showed significant motor recovery of the upper and lower limbs over time, only a slight improvement in lung capacity was observed. INTERVENTIONS AND OUTCOMES: At 1.5 years after injury, a diaphragmatic pacing stimulator was surgically implanted to support the patient's respiratory function. The mechanical ventilator support was successfully withdrawn from the patient 14 weeks after implantation. We observed that both the vital capacity and tidal volume of the patient were significantly promoted following implantation. The patient finally returned to daily life without any mechanical support. LESSONS: The findings of this report suggest that diaphragmatic pacing implantation could be a promising treatment for improving respiratory function after severe cervical SCI. To our knowledge, this is the first SCI patient treated with a diaphragm pacing implantation covered by official medical insurance in Japan.


Assuntos
Medula Cervical , Lesões do Pescoço , Lesões dos Tecidos Moles , Traumatismos da Medula Espinal , Fraturas da Coluna Vertebral , Adulto , Diafragma , Humanos , Japão , Masculino , Respiração Artificial , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/terapia , Adulto Jovem
20.
Medicine (Baltimore) ; 101(30): e29447, 2022 Jul 29.
Artigo em Inglês | MEDLINE | ID: mdl-35905254

RESUMO

RATIONALE: The treatment of severe acute respiratory distress syndrome caused by accidental inhalation of nitric acid fumes is challenging. Few successful cases have been reported in literature. Owing to the development of extracorporeal life support, extracorporeal membrane oxygenation (ECMO) may play an important role in treatment. PATIENT CONCERNS: A 40-year-old man was accidentally exposed to nitric acid fumes for 10 minutes in a factory. Mild throat irritation and dyspnea occurred 3.5 hours after exposure. Severe dyspnea recurred approximately two hours later. Chest computed tomography revealed bilateral interstitial edema. Tracheal intubation and mechanical ventilation were provided when the non-invasive ventilator failed to support the patient. However, his vital signs, respiratory function, and circulation were aggravated. DIAGNOSIS: Aspiration pneumonia (inhalation of nitric acid fumes), acute respiratory distress syndrome, and hypertension. INTERVENTIONS: Veno-venous ECMO (VV-ECMO) was started 6 hours after exposure at the intensive care unit. During VV-ECMO, hypoxia improved. However, chest radiography revealed aggravated pulmonary edema. Prone positioning under ultrasound monitoring and high-dose methylprednisolone were administered on the first day. Nebulization and fiberoptic bronchoscopy for airway management were performed on the second day after the exposure. Pulmonary secretions were significantly reduced 48 hours later. OUTCOMES: The patient was weaned off V-V ECMO after 6 days, achieved the standard of extubation after 9 days, and was discharged without serious pulmonary or infectious complications after 12 days of hospitalization. Three weeks after discharge, the patient's lung function showed a slight decline in the diffusion function. Two months after discharge, the patient's lung function returned to normal. LESSON: Early ECMO combined with prone positioning and visualized management through ultrasonography can better improve the prognoses of patients and promote lung function recovery.


Assuntos
Oxigenação por Membrana Extracorpórea , Síndrome do Desconforto Respiratório , Adulto , Dispneia , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Masculino , Ácido Nítrico , Respiração Artificial , Síndrome do Desconforto Respiratório/diagnóstico por imagem , Síndrome do Desconforto Respiratório/etiologia , Síndrome do Desconforto Respiratório/terapia
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