RESUMO
OBJECTIVE: The favorable evolution of critically ill patients is often dependent on time-sensitive care intervention. The timing of transfer to the intensive care unit (ICU) therefore may be an important determinant of outcomes in critically ill patients. The aim of this study was to analyze the impact upon patient outcome of the length of stay in the Emergency Care Department. DESIGN: A single-center ambispective cohort study was carried out. SETTING: A general ICU and Emergency Care Department (ED) of a single University Hospital. PATIENTS: We included 269 patients consecutively transferred to the ICU from the ED over an 18-month period. INTERVENTIONS: Patients were first grouped into different cohorts based on ED length of stay (LOS), and were then divided into two groups: (a) ED LOS ≤5h and (b) ED LOS >5h. VARIABLES: Demographic, diagnostic, length of stay and mortality data were compared among the groups. RESULTS: Median ED LOS was 277min (IQR 129-622). Patients who developed ICU complications had a longer ED LOS compared to those who did not (349min vs. 209min, p<0.01). A total of 129 patients (48%) had ED LOS >5h. The odds ratio of dying for patients with ED LOS >5h was 2.5 (95% CI 1.3-4.7). Age and sepsis diagnosis were the risk factors associated to prolongation of ED length of stay. CONCLUSIONS: A prolonged ED stay prior to ICU admission is related to the development of time-dependent complications and increased mortality. These findings suggest possible benefit from earlier ICU transfer and the prompt initiation of organ support.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Idoso , Grupos Diagnósticos Relacionados , Feminino , Mortalidade Hospitalar , Hospitais Universitários/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Espanha , Resultado do TratamentoAssuntos
Coma/induzido quimicamente , Parada Cardíaca/induzido quimicamente , Hidroxicloroquina/intoxicação , Hipopotassemia/induzido quimicamente , Complicações na Gravidez/induzido quimicamente , Adulto , Anisocoria/induzido quimicamente , Doenças do Tecido Conjuntivo/tratamento farmacológico , Emergências , Feminino , Humanos , Gravidez , Complicações na Gravidez/tratamento farmacológico , Tentativa de SuicídioRESUMO
A case of severe graft versus host disease in a liver transplant recipient is presented. Due to HLA similarity between donor and recipient, the demonstration of cellular chimerism had to be made by PCR-HLA-B sequencing. In addition, we review the literature on this entity emphasizing its poor outcome, the difficulty of the differential diagnosis, and the need for the development of new prophylactic and therapeutic strategies in its management.
Assuntos
Doença Enxerto-Hospedeiro/diagnóstico , Antígenos HLA-B , Transplante de Fígado , Adulto , Doença Enxerto-Hospedeiro/epidemiologia , Doença Enxerto-Hospedeiro/genética , Humanos , Masculino , Reação em Cadeia da Polimerase , Quimeras de TransplanteRESUMO
The objective of the study was to investigate whether continuous venovenous hemofiltration (CVVH) would facilitate removal of substantial amounts of tumor necrosis factor (TNF) and interleukin-6 (IL-6) from the circulation in traumatized critically ill patients with multiple organ dysfunction syndrome. The study design was a prospective, nonblind, randomized controlled trial that was set in the trauma intensive care unit of a tertiary university referral hospital. Thirty consecutive critically ill, mechanically ventilated trauma patients with multiple organ dysfunction syndrome (without renal failure) were included in the study. Patients were randomized to either CVVH or conventional treatment. Blood and ultrafiltrate samples were collected from each patient before the initiation of CVVH and after 24, 72, and 168 hours of therapy. In the control group, blood samples were collected during the same periods. In the 30 patients studied, 15 had hemofiltration and 15 did not. Both groups were similar with regard to age (36+/-18 years v 36+/-14 years) and severity scores (injury severity score, 32+/-16 v 30+/-11; APACHE II score, 22+/-7 v 21+/-6; Goris score, 5.2+/-1.7 v 5.2+/-1.8). Before CVVH, TNF and IL-6 could be detected in the serum of all patients. The mean concentration of TNF was 17+/-22 pg/mL in patients and 22+/-20 pg/mL in control subjects (P = NS). The mean concentration of IL-6 was 2,153+/-2,824 pg/mL in patients and 1,774+/-1,637 pg/mL in control subjects (P = NS). We found a TNF and IL-6 substantial elimination with CVVH (excretion of TNF [microg/d] at 24, 48, and 168 hours: 112.6+/-161.2, 105.2+/-149.4, and 143.1+/-170.0; excretion of IL-6 [microg/d]: 1,655+/-719, 3,091+/-489, and 2,420+/-366). However, no significant difference was found in serum cytokines concentration between groups during the study: mean serum TNF concentration decreased from the pretreatment level to a mean level of 12+/-9.6 pg/mL in patients and 21+/-27 pg/mL in control subjects. Similar results were found with IL-6 concentration that decreased from the pretreatment level to a mean of 554+/-731 pg/mL in patients and 382 +/-568 pg/mL in control subjects. In conclusion, CVVH is associated with removal of substantial amounts of TNF and IL-6 from the circulation in traumatized critically ill patients, but the profile of these mediators is similar to that of controls, suggesting a nonclinically relevant elimination. Further prospective, randomized, clinical trials are needed to support our results.
Assuntos
Hemofiltração , Interleucina-6/sangue , Insuficiência de Múltiplos Órgãos/terapia , Traumatismo Múltiplo/terapia , Fator de Necrose Tumoral alfa/análise , APACHE , Adulto , Humanos , Insuficiência de Múltiplos Órgãos/sangue , Traumatismo Múltiplo/sangue , Traumatismo Múltiplo/diagnóstico , Estudos Prospectivos , Respiração Artificial , Índices de Gravidade do TraumaRESUMO
OBJECTIVES: To compare the effectiveness, characteristics, duration of action, hemodynamic and biochemical effects, and side effects of propofol and midazolam used for continuous intravenous sedation of ventilated critically ill patients. DESIGN: Multicenter, prospective, randomized, nonblinded study. SETTING: Nine Spanish general intensive care units (ICUs). PATIENTS: Ninety-eight patients admitted to the ICU who were mechanically ventilated and required sedation for a minimum of 48 hrs. INTERVENTIONS: Propofol or midazolam was used for induction and maintenance of continuous intravenous sedation for a maximum of 5 days. The effectiveness of those two regimens was assessed according to their effects on ventilatory management and the presence of agitation. MEASUREMENTS AND MAIN RESULTS: In 93% of the patients studied, there was a medical cause necessitating mechanical ventilation. The mean (+/-SD) duration of sedation was 81 +/- 25 hrs and 88 +/- 27 hrs for the propofol and midazolam groups, respectively. The induction dose was 2.24 +/- 0.43 mg/kg over 318 +/- 363 secs for propofol, and 0.22 +/-0.07 mg/kg over 33 +/-29 secs for midazolam. The maintenance dose was 2.8 +/-1.1 mg/kg/hr for propofol and 0.14 +/- 0.10 mg/kg/hr for midazolam. There was no difference regarding the opiate and muscle relaxant requirements between the two groups. Sedation with propofol was more effective in achieving patient-ventilator synchrony than that with midazolam after the first hour of treatment (p < .01). Patients sedated with propofol awoke more rapidly and with less variability that those patients sedated with midazolam (23 +/- 16 mins vs. 137 +/- 185 mins, respectively, p < .05), particularly in those patients requiring deep sedation (27 +/- 16 mins vs. 237 +/- 222 mins, respectively, p < .01). No hemodynamic or biochemical changes were detected in any of the treatment groups. During induction, five patients in the propofol group and two patients in the midazolam group had hypotension. CONCLUSIONS: In this population of critically ill patients, propofol is an effective and safe alternative for sedation, with some advantages, such as short duration of action and high effectiveness over the conventional regimen with benzodiazepines and opiates.