Criança dependente de tecnologia: a experiência do cuidado materno

Este estudo tem como objetivo compreender a experiência materna no cuidado ao filho dependente de tecnologia. Utilizamos a abordagem do estudo de caso etnográfico tendo como instrumentos de coleta de dados os genograma e ecomapa, entrevista aberta e observação. Os dados foram organizados em três unidades de significados: a busca pelas causas e por culpados; a alta hospitalar e as demandas para o cuidado e as redes de apoio. O estudo permitiu conhecer a experiência materna em busca por explicações, bem como os sentimentos de desconfiança, insegurança e insatisfação relacionados ao serviço de saúde. Ainda a apropriação da mãe em relação aos cuidados à criança e no que se refere à organização do ambiente domiciliar para recebê-la, a utilização das redes de apoio, destacando a carência de vínculos com familiares e vizinhos e a busca formal e informal para garantir a subsistência da criança doente e dos demais filhos.

Time-related effects of general functional training in spinal cord-injured rats

OBJECTIVES: This prospective, randomized, experimental study with rats aimed to investigate the influence of general treatment strategies on the motor recovery of Wistar rats with moderate contusive spinal cord injury. METHODS: A total of 51 Wistar rats were randomized into five groups: control, maze, ramp, runway, and sham (laminectomy only). The rats underwent spinal cord injury at the T9-T10 levels using the NYU-Impactor. Each group was trained for 12 minutes twice a week for two weeks before and five weeks after the spinal cord injury, except for the control group. Functional motor recovery was assessed with the Basso, Beattie, and Bresnahan Scale on the first postoperative day and then once a week for five weeks. The animals were euthanized, and the spinal cords were collected for histological analysis. RESULTS: Ramp and maze groups showed an earlier and greater functional improvement effect than the control and runway groups. However, over time, unexpectedly, all of the groups showed similar effects as the control group, with spontaneous recovery. There were no histological differences in the injured area between the trained and control groups. CONCLUSION: Short-term benefits can be associated with a specific training regime; however, the same training was ineffective at maintaining superior long-term recovery. These results might support new considerations before hospital discharge of patients with spinal cord injuries.

Long-Term Follow-Up of Patients after Acute Kidney Injury: Patterns of Renal Functional Recovery

Background and Objectives: Patients who survive acute kidney injury (AKI), especially those with partial renal recovery, present a higher long-term mortality risk. However, there is no consensus on the best time to assess renal function after an episode of acute kidney injury or agreement on the definition of renal recovery. In addition, only limited data regarding predictors of recovery are available. Design, Setting, Participants, & Measurements: From 1984 to 2009, 84 adult survivors of acute kidney injury were followed by the same nephrologist (RCRMA) for a median time of 4.1 years. Patients were seen at least once each year after discharge until end stage renal disease (ESRD) or death. In each consultation serum creatinine was measured and glomerular filtration rate estimated. Renal recovery was defined as a glomerular filtration rate value >= 60 mL/min/1.73 m2. A multiple logistic regression was performed to evaluate factors independently associated with renal recovery. Results: The median length of follow-up was 50 months (30-90 months). All patients had stabilized their glomerular filtration rates by 18 months and 83% of them stabilized earlier: up to 12 months. Renal recovery occurred in 16 patients (19%) at discharge and in 54 (64%) by 18 months. Six patients died and four patients progressed to ESRD during the follow up period. Age (OR 1.09, p < 0.0001) and serum creatinine at hospital discharge (OR 2.48, p = 0.007) were independent factors associated with non renal recovery. The acute kidney injury severity, evaluated by peak serum creatinine and need for dialysis, was not associated with non renal recovery. Conclusions: Renal recovery must be evaluated no earlier than one year after an acute kidney injury episode. Nephrology referral should be considered mainly for older patients and those with elevated serum creatinine at hospital discharge.

Use of Demonstrably Effective Therapies in the Treatment of Acute Coronary Syndromes: Comparison between Different Brazilian Regions. Analysis of the Brazilian Registry on Acute Coronary Syndromes (BRACE)

Background: Little is known in our country about regional differences in the treatment of acute coronary disease. Objective: To analyze the behavior regarding the use of demonstrably effective regional therapies in acute coronary disease. Methods: A total of 71 hospitals were randomly selected, respecting the proportionality of the country in relation to geographic location, among other criteria. In the overall population was regionally analyzed the use of aspirin, clopidogrel, ACE inhibitors / AT1 blocker, beta-blockers and statins, separately and grouped by individual score ranging from 0 (no drug used) to 100 (all drugs used). In myocardial infarction with ST elevation (STEMI) regional differences were analyzed regarding the use of therapeutic recanalization (fibrinolytics and primary angioplasty). Results: In the overall population, within the first 24 hours of hospitalization, the mean score in the North-Northeast (70.5 +/- 22.1) was lower (p < 0.05) than in the Southeast (77.7 +/- 29.5), Midwest (82 +/- 22.1) and South (82.4 +/- 21) regions. At hospital discharge, the score of the North-Northeast region (61.4 +/- 32.9) was lower (p < 0.05) than in the Southeast (69.2 +/- 31.6), Midwest (65.3 +/- 33.6) and South (73.7 +/- 28.1) regions; additionally, the score of the Midwest was lower (p < 0.05) than the South region. In STEMI, the use of recanalization therapies was highest in the Southeast (75.4%, p = 0.001 compared to the rest of the country), and lowest in the North-Northeast (52.5%, p < 0.001 compared to the rest of the country). Conclusion: The use of demonstrably effective therapies in the treatment of acute coronary disease is much to be desired in the country, with important regional differences.

How large is the lung recruitability in early acute respiratory distress syndrome: a prospective case series of patients monitored by computed tomography

Introduction: The benefits of higher positive end expiratory pressure (PEEP) in patients with acute respiratory distress syndrome (ARDS) have been modest, but few studies have fully tested the "open-lung hypothesis". This hypothesis states that most of the collapsed lung tissue observed in ARDS can be reversed at an acceptable clinical cost, potentially resulting in better lung protection, but requiring more intensive maneuvers. The short-/middle-term efficacy of a maximum recruitment strategy (MRS) was recently described in a small physiological study. The present study extends those results, describing a case-series of non-selected patients with early, severe ARDS submitted to MRS and followed until hospital discharge or death. Methods: MRS guided by thoracic computed tomography (CT) included two parts: a recruitment phase to calculate opening pressures (incremental steps under pressure-controlled ventilation up to maximum inspiratory pressures of 60 cmH(2)O, at constant driving-pressures of 15 cmH(2)O); and a PEEP titration phase (decremental PEEP steps from 25 to 10 cmH2O) used to estimate the minimum PEEP to keep lungs open. During all steps, we calculated the size of the non-aerated (-100 to +100 HU) compartment and the recruitability of the lungs (the percent mass of collapsed tissue re-aerated from baseline to maximum PEEP). Results: A total of 51 severe ARDS patients, with a mean age of 50.7 years (84% primary ARDS) was studied. The opening plateau-pressure was 59.6 (+/- 5.9 cmH(2)O), and the mean PEEP titrated after MRS was 24.6 (+/- 2.9 cmH(2)O). Mean PaO2/FiO(2) ratio increased from 125 (+/- 43) to 300 (+/- 103; P < 0.0001) after MRS and was sustained above 300 throughout seven days. Non-aerated parenchyma decreased significantly from 53.6% (interquartile range (IQR): 42.5 to 62.4) to 12.7% (IQR: 4.9 to 24.2) (P < 0.0001) after MRS. The potentially recruitable lung was estimated at 45% (IQR: 25 to 53). We did not observe major barotrauma or significant clinical complications associated with the maneuver. Conclusions: MRS could efficiently reverse hypoxemia and most of the collapsed lung tissue during the course of ARDS, compatible with a high lung recruitability in non-selected patients with early, severe ARDS. This strategy should be tested in a prospective randomized clinical trial.

Vancomycin-resistant enterococcus outbreak in a pediatric intensive care unit: report of successful interventions for control and prevention

The objective of this study is to retrospectively report the results of interventions for controlling a vancomycin-resistant enterococcus (VRE) outbreak in a tertiary-care pediatric intensive care unit (PICU) of a University Hospital. After identification of the outbreak, interventions were made at the following levels: patient care, microbiological surveillance, and medical and nursing staff training. Data were collected from computer-based databases and from the electronic prescription system. Vancomycin use progressively increased after March 2008, peaking in August 2009. Five cases of VRE infection were identified, with 3 deaths. After the interventions, we noted a significant reduction in vancomycin prescription and use (75% reduction), and the last case of VRE infection was identified 4 months later. The survivors remained colonized until hospital discharge. After interventions there was a transient increase in PICU length-of-stay and mortality. Since then, the use of vancomycin has remained relatively constant and strict, no other cases of VRE infection or colonization have been identified and length-of-stay and mortality returned to baseline. In conclusion, we showed that a bundle intervention aiming at a strict control of vancomycin use and full compliance with the Hospital Infection Control Practices Advisory Committee guidelines, along with contact precautions and hand-hygiene promotion, can be effective in reducing vancomycin use and the emergence and spread of vancomycin-resistant bacteria in a tertiary-care PICU.

The Real Importance of Pre-Existing Comorbidities on Long-Term Mortality after Acute Kidney Injury

Background: The causes of death on long-term mortality after acute kidney injury (AKI) have not been well studied. The purpose of the study was to evaluate the role of comorbidities and the causes of death on the long-term mortality after AKI. Methodology/Principal Findings: We retrospectively studied 507 patients who experienced AKI in 2005-2006 and were discharged free from dialysis. In June 2008 (median: 21 months after AKI), we found that 193 (38%) patients had died. This mortality is much higher than the mortality of the population of Sao Paulo City, even after adjustment for age. A multiple survival analysis was performed using Cox proportional hazards regression model and showed that death was associated with Khan's index indicating high risk [adjusted hazard ratio 2.54 (1.38-4.66)], chronic liver disease [1.93 (1.15-3.22)], admission to non-surgical ward [1.85 (1.30-2.61)] and a second AKI episode during the same hospitalization [1.74 (1.12-2.71)]. The AKI severity evaluated either by the worst stage reached during AKI (P=0.20) or by the need for dialysis (P=0.12) was not associated with death. The causes of death were identified by a death certificate in 85% of the non-survivors. Among those who died from circulatory system diseases (the main cause of death), 59% had already suffered from hypertension, 34% from diabetes, 47% from heart failure, 38% from coronary disease, and 66% had a glomerular filtration rate <60 previous to the AKI episode. Among those who died from neoplasms, 79% already had the disease previously. Conclusions: Among AKI survivors who were discharged free from dialysis the increased long-term mortality was associated with their pre-existing chronic conditions and not with the severity of the AKI episode. These findings suggest that these survivors should have a medical follow-up after hospital discharge and that all efforts should be made to control their comorbidities.

Burden of care and its impact on health-related quality of life of caregivers of individuals with spinal cord injury

Objective: to analyze the impact and burden of care on the Health-Related Quality of Life (HRQOL) of caregivers of individuals with a spinal cord injury (SCI). Method: cross-sectional observational study carried out by reviewing medical records and applying questionnaires. The scale Short Form 36 (SF-36) was used to assess HRQOL and the Caregiver Burden Scale (CBScale) for care burden. Results were analyzed quantitatively. Most patients with SCIs were male, aged 35.4 years old on average, with a predominance of thoracic injuries followed by cervical injuries. Most caregivers were female aged 44.8 years old on average. Results: tetraplegia and secondary complications stand out among the clinical characteristics that contributed to greater care burden and worse HRQOL. Association between care burden with HRQOL revealed that the greater the burden the worse the HRQOL. Conclusion: Preventing care burden through strategies that prepare patients for hospital discharge, integrating the support network, and enabling access to health care services are interventions that could minimize the effects arising from care burden and contribute to improving HRQOL.

Effects of neuromuscular electrostimulation in patients with heart failure admitted to ward

Background: Neuromuscular electrostimulation has become a promising issue in cardiovascular rehabilitation. However there are few articles published in the literature regarding neuromuscular electrostimulation in patients with heart failure during hospital stay. Methods: This is a randomized controlled pilot trial that aimed to investigate the effect of neuromuscular electrostimulation in the walked distance by the six-minute walking test in 30 patients admitted to ward for heart failure treatment in a tertiary cardiology hospital. Patients in the intervention group performed a conventional rehabilitation and neuromuscular electrostimulation. Patients underwent 60 minutes of electrostimulation (wave frequency was 20 Hz, pulse duration of 20 us) two times a day for consecutive days until hospital discharge. Results: The walked distance in the six-minute walking test improved 75% in the electrostimulation group (from 379.7 +/- 43.5 to 372.9 +/- 46.9 meters to controls and from 372.9 +/- 62.4 to 500 +/- 68 meters to electrostimulation, p<0.001). On the other hand, the walked distance in the control group did not change. Conclusion: The neuromuscular electrostimulation group showed greater improvement in the walked distance in the six-minute walking test in patients admitted to ward for compensation of heart failure.

Clinical prognostic indicators of dysphagia following prolonged orotracheal intubation in ICU patients

Introduction The development of postextubation wallowing dysfunction is well documented in the literature with high prevalence in most studies. However, there are relatively few studies with specific outcomes that focus on the follow-up of these patients until hospital discharge. The purpose of our study was to determine prognostic indicators of dysphagia in ICU patients submitted to prolonged orotracheal intubation (OTI). Methods We conducted a retrospective, observational cohort study from 2010 to 2012 of all patients over 18 years of age admitted to a university hospital ICU who were submitted to prolonged OTI and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist. The prognostic factors analyzed included dysphagia severity rate at the initial swallowing assessment and at hospital discharge, age, time to initiate oral feeding, amount of individual treatment, number of orotracheal intubations, intubation time and length of hospital stay. Results After we excluded patients with neurologic diseases, tracheostomy, esophageal dysphagia and those who were submitted to surgical procedures involving the head and neck, our study sample size was 148 patients. The logistic regression model was used to examine the relationships between independent variables. In the univariate analyses, we found that statistically significant prognostic indicators of dysphagia included dysphagia severity rate at the initial swallowing assessment, time to initiate oral feeding and amount of individual treatment. In the multivariate analysis, we found that dysphagia severity rate at the initial swallowing assessment remained associated with good treatment outcomes. Conclusions Studies of prognostic indicators in different populations with dysphagia can contribute to the design of more effective procedures when evaluating, treating, and monitoring individuals with this type of disorder. Additionally, this study stresses the importance of the initial assessment ratings.

Failure to reduce C-reactive protein levels more than 25% in the last 24 hours before intensive care unit discharge predicts higher in-hospital mortality: A cohort study

Purpose: To discharge a patient from the intensive care unit (ICU) is a complex decision-making process because in-hospital mortality after critical illness may be as high as up to 27%. Static C-reactive protein (CRP) values have been previously evaluated as a predictor of post-ICU mortality with conflicting results. Therefore, we evaluated the CRP ratio in the last 24 hours before ICU discharge as a predictor of in-hospital outcomes. Methods: A retrospective cohort study was performed in 409 patients from a 6-bed ICU of a university hospital. Data were prospectively collected during a 4-year period. Only patients discharged alive from the ICU with at least 72 hours of ICU length of stay were evaluated. Results: In-hospital mortality was 18.3% (75/409). Patients with reduction less than 25% in CRP concentrations at 24 hours as compared with 48 hours before ICU discharge had a worse prognosis, with increased mortality (23% vs 11%, P = .002) and post-ICU length of stay (26 [7-43] vs 11 [5-27] days, P = .036). Moreover, among hospital survivors (n = 334), patients with CRP reduction less than 25% were discharged later (hazard ratio, 0.750; 95% confidence interval, 0.602-0.935; P = .011). Conclusions: In this large cohort of critically ill patients, failure to reduce CRP values more than 25% in the last 24 hours of ICU stay is a strong predictor of worse in-hospital outcomes. (C) 2012 Elsevier Inc. All rights reserved.

Body temperature, Aldrete-Kroulik index, and patient discharge from the Post-Anesthetic Recovery Unit

Patient discharge from post-anesthetic recovery (PAR) depends, among other factors, on normothermia and the patient's score on the Aldrete-Kroulik index. The objective of this study was to verify the relationship between the Aldrete-Kroulik index and body temperature in patients. This study was performed at the University of Sao Paulo University Hospital. Convenience sampling was used, and the sample consisted of 60 patients of ages between 18 and 60 years who underwent general anesthesia. The patients' body temperature was obtained by tympanic measurement, and the Aldrete-Kroulik index was measured on admission and at discharge from post-anesthetic recovery. The data were processed using SPSS, considering a significance level of 5%, and the Spearman and Wilcoxon tests were applied. In conclusion, no significant correlation was found between the two parameters for discharge.