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BACKGROUND: The use of ultrasound has been reported to be beneficial in challenging neuraxial procedures. The angled probe is responsible for the main limitations of previous ultrasound-assisted techniques. We developed a novel technique for challenging lumbar puncture, aiming to locate the needle entry point which allowed for a horizontal and perpendicular needle trajectory and thereby addressed the drawbacks of earlier ultrasound-assisted techniques. CASE PRESENTATION: Patient 1 was an adult patient with severe scoliosis who underwent a series of intrathecal injections of nusinersen. The preprocedural ultrasound scan revealed a cephalad probe's angulation (relative to the edge of the bed) in the paramedian sagittal oblique view, and then the probe was rotated 90° into a transverse plane and we noted that a rocking maneuver was required to obtain normalized views. Then the shoulders were moved forward to eliminate the need for cephalad angulation of the probe. The degree of rocking was translated to a lateral offset from the midline of the spine through an imaginary lumbar puncture's triangle model, and a needle entry point was marked. The spinal needle was advanced through this marking-point without craniocaudal and lateromedial angulation, and first-pass success was achieved in all eight lumbar punctures. Patient 2 was an elderly patient with ankylosing spondylitis who underwent spinal anesthesia for transurethral resection of the prostate. The patient was positioned anteriorly obliquely to create a vertebral rotation that eliminated medial angulation in the paramedian approach. The procedure succeeded on the first pass. CONCLUSIONS: This ultrasound-assisted paramedian approach with a horizontal and perpendicular needle trajectory may be a promising technique that can help circumvent challenging anatomy. Larger case series and prospective studies are warranted to define its superiority to alternative approaches of lumbar puncture for patients with difficulties.
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Raquianestesia , Ressecção Transuretral da Próstata , Masculino , Adulto , Humanos , Idoso , Punção Espinal/métodos , Ultrassonografia de Intervenção/métodos , Coluna Vertebral , Ultrassonografia , Raquianestesia/métodosRESUMO
Poor outcomes in Subarachnoid Hemorrhage (SAH) are in part due to a unique form of secondary neurological injury known as Delayed Cerebral Ischemia (DCI). DCI is characterized by new neurological insults that continue to occur beyond 72 h after the onset of the hemorrhage. Historically, it was thought to be a consequence of hypoperfusion in the setting of vasospasm. However, DCI was found to occur even in the absence of radiographic evidence of vasospasm. More recent evidence indicates that catastrophic ionic disruptions known as Cortical Spreading Depolarizations (CSD) may be the culprits of DCI. CSDs occur in otherwise healthy brain tissue even without demonstrable vasospasm. Furthermore, CSDs often trigger a complex interplay of neuroinflammation, microthrombi formation, and vasoconstriction. CSDs may therefore represent measurable and modifiable prognostic factors in the prevention and treatment of DCI. Although Ketamine and Nimodipine have shown promise in the treatment and prevention of CSDs in SAH, further research is needed to determine the therapeutic potential of these as well as other agents.
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Doenças do Sistema Nervoso Autônomo , Isquemia Encefálica , Hemorragia Subaracnóidea , Vasoespasmo Intracraniano , Humanos , Isquemia Encefálica/complicações , Isquemia Encefálica/tratamento farmacológico , Nimodipina/uso terapêutico , Infarto Cerebral/complicações , Encéfalo , Vasoespasmo Intracraniano/complicaçõesRESUMO
OBJECTIVES: Our primary aim was to determine the factors leading to prophylactic endotracheal intubation in intensive care unit (ICU) patients undergoing gastrointestinal endoscopy. Secondary aims were to determine the rate of unplanned endotracheal intubations during endoscopy and to determine the rate of aspiration following endoscopy for patients admitted to the ICU. METHODS: Critically ill adult (≥18 years) patients who underwent upper and lower endoscopic procedures from January 2012 to July 2016 in a medical/surgical ICU were included. Determinants of prophylactic endotracheal intubation prior to endoscopy as well as other postprocedure outcomes were electronically captured by a validated data mart system. Given our focus on aspiration in those who were not endotracheally intubated prior to endoscopy, we used a validated definition a priori. RESULTS: A total of 320 patients were included in the final analysis: 76(24%) were intubated prior to endoscopy and 244 (76%) were not. The endotracheally intubated group had a significantly higher Acute Physiologic and Chronic Health Evaluation III (44.5 [16.2] vs 39.5 [15.5]; P = .02) and Sequential Organ Failure Assessment (6.9 [4.4] vs 3.8 [3]; P ≤ .01) scores, higher rate of hematemesis within 24 hours of endoscopy (28 [37%] vs 45 [18%]; P ≤ .01), and higher rate of upper endoscopy (72 [96%] vs 181 [74%]; P ≤ .01). We composed a composite outcome for multivariable analyses, which demonstrated the rate of any complication was significantly higher among those who were intubated prior to the procedure versus those who were not intubated previously (odds ratio: 2.80, 95% confidence interval (CI): 1.16-6.72, P = .02). CONCLUSION: Endoscopy performed in the ICU without endotracheal intubation is safe. However, patient selection for prophylactic intubation prior to endoscopy is of critical importance as illustrated in this study with higher illness severity, planned upper endoscopy, and hematemesis 24 hours prior being key factors on deciding to perform endotracheal intubation. Prophylactic intubation for endoscopy and preexisting cardiac disease were associated with a higher rate of adverse outcomes.
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Sedação Consciente , Estado Terminal/terapia , Endoscopia Gastrointestinal , Intubação Intratraqueal , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos , Endoscopia Gastrointestinal/efeitos adversos , Endoscopia Gastrointestinal/métodos , Hemorragia Gastrointestinal/etiologia , Humanos , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/métodos , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Retrospectivos , Fatores de RiscoRESUMO
PURPOSE: Data regarding best practices for ventilator management strategies that improve outcomes in acute respiratory distress syndrome (ARDS) are readily available. However, little is known regarding processes to ensure compliance with these strategies. We developed a goal-directed mechanical ventilation order set that included physician-specified lung-protective ventilation and oxygenation goals to be implemented by respiratory therapists (RTs). We sought as a primary outcome to determine whether an RT-driven order set with predefined oxygenation and ventilation goals could be implemented and associated with improved adherence with best practice. METHODS: We evaluated 1302 patients undergoing invasive mechanical ventilation (1693 separate episodes of invasive mechanical ventilation) prior to and after institution of a standardized, goal-directed mechanical ventilation order set using a controlled before-and-after study design. Patient-specific goals for oxygenation partial pressure of oxygen in arterial blood (Pao 2), ARDS Network [Net] positive end-expiratory pressure [PEEP]/fraction of inspired oxygen [Fio 2] table use) and ventilation (pH, partial pressure of carbon dioxide) were selected by prescribers and implemented by RTs. RESULTS: Compliance with the new mechanical ventilation order set was high: 88.2% compliance versus 3.8% before implementation of the order set ( P < .001). Adherence to the PEEP/Fio 2 table after implementation of the order set was significantly greater (86.0% after vs 82.9% before, P = .02). There was no difference in duration of mechanical ventilation, intensive care unit (ICU) length of stay, and in-hospital or ICU mortality. CONCLUSIONS: A standardized best practice mechanical ventilation order set can be implemented by a multidisciplinary team and is associated with improved compliance to written orders and adherence to the ARDSNet PEEP/Fio 2 table.
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Pressão Positiva Contínua nas Vias Aéreas , Cuidados Críticos , Fidelidade a Diretrizes , Respiração com Pressão Positiva , Síndrome do Desconforto Respiratório/terapia , Volume de Ventilação Pulmonar/fisiologia , Adulto , Idoso , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Melhoria de Qualidade , Síndrome do Desconforto Respiratório/fisiopatologiaRESUMO
OBJECTIVES: Our primary aim was to ascertain the frequency of postintubation hypotension in immunocompromised critically ill adults with secondary aims of arriving at potential risk factors for the development of postintubation hypotension and its impact on patient-related outcomes. METHODS: Critically ill adult patients (≥18 years) were included from January 1, 2010, to December 31, 2014. We defined immunocompromised as patients with any solid organ or nonsolid organ malignancy or transplant, whether solid organ or not, requiring current chemotherapy. Postintubation hypotension was defined as a decrease in systolic blood pressure to less than 90 mm Hg or a decrease in mean arterial pressure to less than 65 mm Hg or the initiation of any vasopressor medication. Patients were then stratified based on development of postintubation hypotension. Potential risk factors and intensive care unit (ICU) outcome metrics were electronically captured by a validated data mart system. RESULTS: The final cohort included 269 patients. Postintubation hypotension occurred in 141 (52%; 95% confidence interval: 46-58) patients. Several risk factors predicted postintubation hypotension on univariate analysis; however, only Acute Physiology and Chronic Health Evaluation III score in the first 24 hours, preintubation shock status, and preintubation hemodynamic instability remained significant on all 4 multivariate analyses. Patients developing postintubation hypotension had higher ICU and hospital mortality (54 [38%] vs 31 [24%], P = .01; 69 [49%] vs 47 [37%], P = .04). CONCLUSION: Based on previous literature, we found a higher frequency of postintubation hypotension in the immunocompromised than in the nonimmunocompromised critically ill adult patients. Acute Physiology and Chronic Health Evaluation III score in the first 24 hours, preintubation shock status, and preintubation hemodynamic instability were significant predictors on multivariate analyses. Postintubation hypotension led to higher ICU and hospital mortality in those experiencing this complication.
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Cuidados Críticos/métodos , Estado Terminal , Hipotensão/etiologia , Unidades de Terapia Intensiva , Intubação Intratraqueal/efeitos adversos , Idoso , Feminino , Humanos , Hipotensão/imunologia , Hipotensão/fisiopatologia , Hospedeiro Imunocomprometido , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de RiscoRESUMO
PURPOSE: To assess whether exposure to modified shock index (MSI) in the first 24 hours of intensive care unit (ICU) admission is associated with increased in-hospital mortality. METHODS: Adult critically ill patients were included in a case-control design with 1:2 matching. Cases (death) and controls (alive) were abstracted by a reviewer blinded to exposure status (MSI). Cases were matched to controls on 3 factors-age, end-stage renal disease, and ICU admission diagnosis. RESULTS: Eighty-three cases and 159 controls were included. On univariate analysis, lorazepam administration (odds ratio [OR]: 5.75, confidence interval [CI] = 2.28-14.47; P ≤ .01), shock requiring vasopressors (OR: 3.62, CI = 1.77-7.40; P ≤ .01), maximum MSI (OR: 2.77 per unit, CI = 1.63-4.71; P ≤ .001), and elevated acute physiologic and chronic health evaluation (APACHE) III score at 1 hour (OR: 1.41 per 10 units, CI = 1.19-1.66; P ≤ .001) were associated with mortality. Maximum MSI (OR: 1.93 per unit, CI = 1.07-3.48, P = .03) and APACHE III score at 1 hour (OR: 1.29 per 10 units, CI = 1.09-1.53; P = .003) remained significant with mortality in the multivariate analysis. The optimal cutoff point for high MSI and mortality was 1.8. CONCLUSION: Critically ill patients who demonstrate an elevated MSI within the first 24 hours of ICU admission have a significant mortality risk. Given that MSI is easily calculated at the bedside, clinicians may institute interventions earlier which could improve survival.
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Cuidados Críticos/métodos , Estado Terminal/mortalidade , Mortalidade Hospitalar , Índice de Gravidade de Doença , Choque/diagnóstico , APACHE , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Humanos , Unidades de Terapia Intensiva , Análise Multivariada , Testes Imediatos , Curva ROC , Fatores de RiscoRESUMO
OBJECTIVES: In the last decade, the practice of intubation in the intensive care unit (ICU) has evolved. To further examine the current intubation practice in the ICU, we administered a survey to critical care physicians. DESIGN: Cross-sectional survey study design. SETTING: Thirty-two academic/nonacademic centers nationally and internationally. MEASUREMENTS AND MAIN RESULTS: The survey was developed among a core group of physicians with the assistance of the Survey Research Center at Mayo Clinic, Rochester, Minnesota. The survey was pilot tested for functionality and reliability. The response rate was 82 (51%) of 160 among the 32 centers. Although propofol was the induction drug of choice, there was a significant difference with actual ketamine use and those who indicated a preference for it (ketamine: 52% vs 61%; P < .001). The most common airway device used for intubation was direct laryngoscopy (Miller laryngoscope blade) at 56 (68%) followed by video laryngoscopy at 26 (32%). Most (>90%) indicated that they have a difficult airway cart, but only 55 (67%) indicated they have a documented plan to handle a difficult airway with even lower results for documented review of adverse events (49%). CONCLUSION: Although propofol was the induction drug of choice, ketamine was a medication that many preferred to use, possibly relating to the fact that the most common complication postintubation is hypotension. Direct laryngoscopy remains the primary airway device for endotracheal intubation. Finally, although the majority stated they had a difficult airway cart available, most did not have a documented plan in place when encountering a difficult airway or a documented process to review adverse events surrounding intubation.
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Estado Terminal , Unidades de Terapia Intensiva , Intubação Intratraqueal/normas , Laringoscopia/normas , Anestésicos Intravenosos , Estudos Transversais , Pesquisas sobre Atenção à Saúde , Humanos , Unidades de Terapia Intensiva/normas , Avaliação de Processos e Resultados em Cuidados de Saúde , Padrões de Prática MédicaRESUMO
OBJECTIVE: To describe the practice of intubation of the critically ill at a single academic institution, Mayo Clinic's campus in Rochester, Minnesota, and to report the incidence of immediate postintubation complications. PATIENTS AND METHODS: Critically ill adult (≥18 years) patients admitted to a medical-surgical intensive care unit from January 1, 2013, to December 31, 2014, who required endotracheal intubation included. RESULTS: The final cohort included 420 patients. The mean age at intubation was 62.9 ± 16.3 years, with 58% (244) of the cohort as male. The most common reason for intubation was respiratory failure (282 [67%]). The most common airway device used was video laryngoscopy (204 [49%]). Paralysis was used in 264 (63%) patients, with ketamine as the most common sedative (194 [46%]). The most common complication was hypotension (170 [41%]; 95% confidence interval [CI]: 35.7-45.3) followed by hypoxemia (74 [17.6%]; 95% CI: 14.1-21.6), with difficult intubation occurring in 20 (5%; 95% CI: 2.9-7.3). CONCLUSION: We found a high success rate of first-pass intubation in critically ill patients (89.8%), despite the procedure being done primarily by trainees 92.6% of the time; video was the preferred method of laryngoscopy (48.6%). Although our difficult intubation (4.8%) and complication rates typically associated with the act of intubation such as aspiration (1.2%; 95% CI: 0.4-2.8) and esophageal intubation (0.2%; 95% CI: 0.01-1.3) are very low compared to other published rates (8.09%), postintubation hypotension (40.5%) and hypoxemia (17.6%) higher.
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BACKGROUND: We aim to report the incidence of post-intubation hypotension in the critically ill, to report in-hospital mortality and length of stay in those who developed post-intubation hypotension, and to explore possible risk factors associated with post-intubation hypotension. MATERIAL/METHODS: Adult (≥18 years) ICU patients who received emergent endotracheal intubation were included. We excluded patients if they were hemodynamically unstable 60 minutes pre-intubation. Post-intubation hypotension was defined as the administration of any vasopressor within 60 minutes following intubation. RESULTS: Twenty-nine patients developed post-intubation hypotension (29/147, 20%). Post-intubation hypotension was associated with increased in-hospital mortality (11/29, 38% vs. 19/118, 16%) and length of stay (21 [10-37] vs. 12 [7-21] days) on multivariate analysis. Three risk factors for post-intubation hypotension were identified on multivariate analysis: 1) decreasing mean arterial pressure pre-intubation (per 5 mmHg decrease) (p-value=0.04; 95% CI 1.01-1.55); 2) administration of neuromuscular blockers (p-value=0.03; 95% CI 1.12-6.53); and 3) intubation complication (p-value=0.03; 95% CI 1.16-15.57). CONCLUSIONS: Post-intubation hypotension was common in the ICU and was associated with increased in-hospital mortality and length of stay. These patients were more likely to have had lower mean arterial pressure prior to intubation, received neuromuscular blockers, or suffered a complication during intubation.
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Estado Terminal/epidemiologia , Hipotensão/epidemiologia , Hipotensão/etiologia , Intubação Intratraqueal/efeitos adversos , Feminino , Hemodinâmica , Mortalidade Hospitalar , Humanos , Hipotensão/fisiopatologia , Incidência , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Fatores de Risco , Índice de Gravidade de DoençaRESUMO
PURPOSE: The King LT(S)-D laryngeal tube (King LT) has gained popularity as a bridge airway for pre-hospital airway management. In this study, we retrospectively reviewed the use of the King LT and its associated airway outcomes at a single Level 1 trauma centre. METHODS: The data on all adult patients presenting to the Mayo Clinic in Rochester, Minnesota with a King LT in situ from July 1, 2007 to October 10, 2012 were retrospectively evaluated. Data collected and descriptively analyzed included patient demographics, comorbidities, etiology of respiratory failure, airway complications, subsequent definitive airway management technique, duration of mechanical ventilation, and status at discharge. RESULTS: Forty-eight adult patients met inclusion criteria. The most common etiology for respiratory failure requiring an artificial airway was cardiac arrest [28 (58%) patients] or trauma [9 (19%) patients]. Four of the nine trauma patients had facial trauma. Surgical tracheostomy was the definitive airway management technique in 14 (29%) patients. An airway exchange catheter, direct laryngoscopy, and video laryngoscopy were used in 11 (23%), ten (21%), and ten (21%) cases, respectively. Seven (78%) of the trauma patients underwent surgical tracheostomy compared with seven (18%) of the medical patients. Adverse events associated with King LT use occurred in 13 (27%) patients, with upper airway edema (i.e., tongue engorgement and glottic edema) being most common (19%). CONCLUSION: In this study of patients presenting to a hospital with a King LT, the majority of airway exchanges required an advanced airway management technique beyond direct laryngoscopy. Upper airway edema was the most common adverse observation associated with King LT use.
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Manuseio das Vias Aéreas/métodos , Laringoscopia , Traqueostomia , Adulto , Idoso , Manuseio das Vias Aéreas/efeitos adversos , Manuseio das Vias Aéreas/instrumentação , Estudos de Coortes , Feminino , Humanos , Intubação Intratraqueal/instrumentação , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
A series of toxicity tests were conducted to investigate the role of chronological age on zinc tolerance in juvenile brown trout (Salmo trutta). Four different incubation temperatures were used to control the maturation of the juveniles before zinc exposures. These 96-h exposures used flow-through conditions and four chronological ages of fish with weights ranging from 0.148 to 1.432 g. Time-to-death (TTD) data were collected throughout the exposure along with the final mortality. The results indicate that chronological age does not play a predictable role in zinc tolerance for juvenile brown trout. However, a relationship between zinc tolerance and fish size was observed in all chronological age populations, which prompted us to conduct additional exploratory data analysis to quantify how much of an effect size had during this stage of development. The smallest fish (0.148-0.423 g) were shown to be less sensitive than the largest fish (0.639-1.432 g) with LC50 values of 868 and 354 µg Zn/L, respectively. The Kaplan-Meier product estimation method was used to determine survival functions from the TTD data and supports the LC50 results with a greater median TTD for smaller fish than larger juvenile fish. These results indicate that fish size or a related characteristic may be a significant determinant of susceptibility and should be considered in acute zinc toxicity tests with specific attention paid to the expected exposure scenario in the field.
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Truta/fisiologia , Poluentes Químicos da Água/toxicidade , Zinco/toxicidade , Fatores Etários , AnimaisRESUMO
This study examines the effect on aquatic copper toxicity of the chemical fractionation of fulvic acid (FA) that results from its association with iron and aluminum oxyhydroxide precipitates. Fractionated and unfractionated FAs obtained from streamwater and suspended sediment were utilized in acute Cu toxicity tests on Ceriodaphnia dubia. Toxicity test results with equal FA concentrations (6 mg FA/L) show that the fractionated dissolved FA was 3 times less effective at reducing Cu toxicity (EC50 13 ± 0.6 µg Cu/L) than were the unfractionated dissolved FAs (EC50 39 ± 0.4 and 41 ± 1.2 µg Cu/L). The fractionation is a consequence of preferential sorption of molecules having strong metal-binding (more aromatic) moieties to precipitating Fe- and Al-rich oxyhydroxides, causing the remaining dissolved FA to be depleted in these functional groups. As a result, there is more bioavailable dissolved Cu in the water and hence greater potential for Cu toxicity to aquatic organisms. In predicting Cu toxicity, biotic ligand models (BLMs) take into account dissolved organic carbon (DOC) concentration; however, unless DOC characteristics are accounted for, model predictions can underestimate acute Cu toxicity for water containing fractionated dissolved FA. This may have implications for water-quality criteria in systems containing Fe- and Al-rich sediment, and in mined and mineralized areas in particular. Optical measurements, such as specific ultraviolet absorbance at 254 nm (SUVA254), show promise for use as spectral indicators of DOC chemical fractionation and inferred increased Cu toxicity.
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Óxido de Alumínio/química , Benzopiranos/química , Cladocera/efeitos dos fármacos , Cobre/toxicidade , Ferro/química , Poluentes Químicos da Água/toxicidade , Animais , Organismos Aquáticos , Fracionamento Químico , Colorado , Cobre/química , Água Doce , Ligantes , Testes de Toxicidade Aguda/métodos , Poluentes Químicos da Água/químicaRESUMO
OBJECTIVE: To summarize published data regarding the steps of rapid-sequence intubation (RSI); review premedications, induction agents, neuromuscular blockers (NMB), and studies supporting use or avoidance; and discuss the benefits and deficits of combinations of induction agents and NMBs used when drug shortages occur. DATA SOURCE: A search of Medline databases (1966-October 2013) was conducted. STUDY SELECTION AND DATA EXTRACTION: Databases were searched using the terms rapid-sequence intubation, fentanyl, midazolam, atropine, lidocaine, phenylephrine, ketamine, propofol, etomidate thiopental, succinylcholine, vecuronium, atracurium, and rocuronium. Citations from publications were reviewed for additional references. DATA SYNTHESIS: Data were reviewed to support the use or avoidance of premedications, induction agents, and paralytics and combinations to consider when drug shortages occur. CONCLUSIONS: RSI is used to secure a definitive airway in often uncooperative, nonfasted, unstable, and/or critically ill patients. Choosing the appropriate premedication, induction drug, and paralytic will maximize the success of tracheal intubation and minimize complications.
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Intubação Intratraqueal/métodos , Ansiolíticos/provisão & distribuição , Ansiolíticos/uso terapêutico , Humanos , Hipnóticos e Sedativos/provisão & distribuição , Hipnóticos e Sedativos/uso terapêutico , Bloqueadores Neuromusculares/provisão & distribuição , Bloqueadores Neuromusculares/uso terapêuticoRESUMO
OBJECTIVES: Inpatients with language barriers and complex medical needs suffer disparities in quality of care, safety, and health outcomes. Although in-person interpreters are particularly beneficial for these patients, they are underused. We plan to use machine learning predictive analytics to reliably identify patients with language barriers and complex medical needs to prioritize them for in-person interpreters. MATERIALS AND METHODS: This qualitative study used stakeholder engagement through semi-structured interviews to understand the perceived risks and benefits of artificial intelligence (AI) in this domain. Stakeholders included clinicians, interpreters, and personnel involved in caring for these patients or for organizing interpreters. Data were coded and analyzed using NVIVO software. RESULTS: We completed 49 interviews. Key perceived risks included concerns about transparency, accuracy, redundancy, privacy, perceived stigmatization among patients, alert fatigue, and supply-demand issues. Key perceived benefits included increased awareness of in-person interpreters, improved standard of care and prioritization for interpreter utilization; a streamlined process for accessing interpreters, empowered clinicians, and potential to overcome clinician bias. DISCUSSION: This is the first study that elicits stakeholder perspectives on the use of AI with the goal of improved clinical care for patients with language barriers. Perceived benefits and risks related to the use of AI in this domain, overlapped with known hazards and values of AI but some benefits were unique for addressing challenges with providing interpreter services to patients with language barriers. CONCLUSION: Artificial intelligence to identify and prioritize patients for interpreter services has the potential to improve standard of care and address healthcare disparities among patients with language barriers.
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Pacientes Internados , Idioma , Humanos , Inteligência Artificial , Barreiras de Comunicação , Pessoal Técnico de SaúdeRESUMO
OBJECTIVE: This study aims to design, validate and assess the accuracy a deep learning model capable of differentiation Chest X-Rays between pneumonia, acute respiratory distress syndrome (ARDS) and normal lungs. MATERIALS AND METHODS: A diagnostic performance study was conducted using Chest X-Ray images from adult patients admitted to a medical intensive care unit between January 2003 and November 2014. X-ray images from 15,899 patients were assigned one of three prespecified categories: "ARDS", "Pneumonia", or "Normal". RESULTS: A two-step convolutional neural network (CNN) pipeline was developed and tested to distinguish between the three patterns with sensitivity ranging from 91.8% to 97.8% and specificity ranging from 96.6% to 98.8%. The CNN model was validated with a sensitivity of 96.3% and specificity of 96.6% using a previous dataset of patients with Acute Lung Injury (ALI)/ARDS. DISCUSSION: The results suggest that a deep learning model based on chest x-ray pattern recognition can be a useful tool in distinguishing patients with ARDS from patients with normal lungs, providing faster results than digital surveillance tools based on text reports. CONCLUSION: A CNN-based deep learning model showed clinically significant performance, providing potential for faster ARDS identification. Future research should prospectively evaluate these tools in a clinical setting.
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Redes Neurais de Computação , Radiografia Torácica , Síndrome do Desconforto Respiratório , Humanos , Síndrome do Desconforto Respiratório/diagnóstico por imagem , Aprendizado Profundo , Unidades de Terapia Intensiva , Masculino , Feminino , Pneumonia/diagnóstico por imagem , Sensibilidade e Especificidade , Pessoa de Meia-Idade , AdultoRESUMO
BACKGROUND: Intensive care unit (ICU) clinicians encounter frequent challenges with managing vast amounts of fragmented data while caring for multiple critically ill patients simultaneously. This may lead to increased provider cognitive load that may jeopardize patient safety. OBJECTIVES: This systematic review assesses the impact of centralized multipatient dashboards on ICU clinician performance, perceptions regarding the use of these tools, and patient outcomes. METHODS: A literature search was conducted on February 9, 2023, using the EBSCO CINAHL, Cochrane Central Register of Controlled Trials, Embase, IEEE Xplore, MEDLINE, Scopus, and Web of Science Core Collection databases. Eligible studies that included ICU clinicians as participants and tested the effect of dashboards designed for use by multiple users to manage multiple patients on user performance and/or satisfaction compared with the standard practice. We narratively synthesized eligible studies following the SWiM (Synthesis Without Meta-analysis) guidelines. Studies were grouped based on dashboard type and outcomes assessed. RESULTS: The search yielded a total of 2,407 studies. Five studies met inclusion criteria and were included. Among these, three studies evaluated interactive displays in the ICU, one study assessed two dashboards in the pediatric ICU (PICU), and one study examined centralized monitor in the PICU. Most studies reported several positive outcomes, including reductions in data gathering time before rounds, a decrease in misrepresentations during multidisciplinary rounds, improved daily documentation compliance, faster decision-making, and user satisfaction. One study did not report any significant association. CONCLUSION: The multipatient dashboards were associated with improved ICU clinician performance and were positively perceived in most of the included studies. The risk of bias was high, and the certainty of evidence was very low, due to inconsistencies, imprecision, indirectness in the outcome measure, and methodological limitations. Designing and evaluating multipatient tools using robust research methodologies is an important focus for future research.
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Unidades de Terapia Intensiva , HumanosRESUMO
Computer vision (CV), a type of artificial intelligence (AI) that uses digital videos or a sequence of images to recognize content, has been used extensively across industries in recent years. However, in the healthcare industry, its applications are limited by factors like privacy, safety, and ethical concerns. Despite this, CV has the potential to improve patient monitoring, and system efficiencies, while reducing workload. In contrast to previous reviews, we focus on the end-user applications of CV. First, we briefly review and categorize CV applications in other industries (job enhancement, surveillance and monitoring, automation, and augmented reality). We then review the developments of CV in the hospital setting, outpatient, and community settings. The recent advances in monitoring delirium, pain and sedation, patient deterioration, mechanical ventilation, mobility, patient safety, surgical applications, quantification of workload in the hospital, and monitoring for patient events outside the hospital are highlighted. To identify opportunities for future applications, we also completed journey mapping at different system levels. Lastly, we discuss the privacy, safety, and ethical considerations associated with CV and outline processes in algorithm development and testing that limit CV expansion in healthcare. This comprehensive review highlights CV applications and ideas for its expanded use in healthcare.
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BACKGROUND: Lumbar puncture is challenging for patients with scoliosis. Previous ultrasound-assisted techniques for lumbar puncture used the angle of the probe as the needle trajectory; however, reproducing the angle is difficult and increases the number of needle manipulations. In response, we developed a technique that eliminated both the craniocaudal and lateromedial angulation of the needle trajectory to overall improve this technique. We assessed the feasibility and safety of this method in patients with scoliosis and identify factors related to difficult lumbar puncture. METHODS: Patients with spinal muscular atrophy and scoliosis who were referred to the anesthesia department for intrathecal nusinersen administrations were included. With a novel approach that utilized patient position and geometry, lumbar puncture was performed under ultrasound guidance. Success rates, performance times and adverse events were recorded. Clinical-demographic and spinal radiographic data pertaining to difficult procedures were analyzed. RESULTS: Success was achieved in all 260 (100%) lumbar punctures for 44 patients, with first pass and first attempt success rates of 70% (183/260) and 87% (226/260), respectively. Adverse events were infrequent and benign. Higher BMI, greater skin dural sac depth and smaller interlaminar size might be associated with greater difficulty in lumbar puncture. CONCLUSIONS: The novel ultrasound-assisted horizontal and perpendicular interlaminar needle trajectory approach is an effective and safe method for lumbar puncture in patients with spinal deformities. This method can be reliably performed at the bedside and avoids other more typical and complex imaging such as computed tomography guided procedure.
Assuntos
Injeções Espinhais , Atrofia Muscular Espinal , Oligonucleotídeos , Escoliose , Humanos , Escoliose/tratamento farmacológico , Escoliose/diagnóstico por imagem , Atrofia Muscular Espinal/tratamento farmacológico , Atrofia Muscular Espinal/diagnóstico por imagem , Feminino , Masculino , Injeções Espinhais/métodos , Oligonucleotídeos/administração & dosagem , Oligonucleotídeos/uso terapêutico , Criança , Adolescente , Punção Espinal/métodos , Adulto , Adulto Jovem , Pré-EscolarRESUMO
COVID-19 infection has had a profound impact on society. During the initial phase of the pandemic, there were several suggestions that COVID-19 may lead to acute and protracted neurologic sequelae. For example, peripheral neuropathies exhibited distinctive features as compared to those observed in critical care illness. The peripheral nervous system, lacking the protection afforded by the blood-brain barrier, has been a particular site of sequelae and complications subsequent to COVID-19 infection, including Guillain-Barre syndrome, myasthenia gravis, and small fiber neuropathy. We will discuss these disorders in terms of their clinical manifestations, diagnosis, and treatment as well as the pathophysiology in relation to COVID-19.