802 resultados para Critically-ill Patients


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Objetivo: Analisar os desfechos aumento/diminuição da pressão intracraniana e/ou queda da pressão de perfusão cerebral, proporcionados pela fisioterapia respiratória em pacientes graves assistidos em unidade de terapia intensiva. Métodos: Por meio de uma revisão sistemática da literatura, foram selecionados ensaios clínicos publicados entre 2002 e 2012. A busca envolveu as bases de dados LILACS, SciELO, MedLine e PEDro, usando os descritores physical therapy, physiotherapy, respiratory therapy e randomized controlled trials em cruzamento com o descritor intracranial pressure. Resultados: Foram incluídos 5 estudos, que somaram 164 pacientes, com média de idade entre 25 e 65 anos, e que indicaram que as manobras de fisioterapia respiratória aumentaram significativamente a pressão intracraniana, sem alterar a pressão de perfusão cerebral. Os artigos abordaram as técnicas de vibração, vibrocompressão, tapotagem, drenagem postural, além da manobra de aspiração intratraqueal. Todos os pacientes estavam sob ventilação mecânica invasiva. Conclusão: A fisioterapia respiratória promove aumento da pressão intracraniana. Os estudos sugerem que não há repercussões hemodinâmicas e respiratórias a curto prazo ou alteração da pressão de perfusão cerebral. Entretanto, não há estudos que avaliem desfechos clínicos e que assegurem a segurança das manobras.

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We discuss the reasons why Defensive Medicine is widely used in Brazil and worldwide. The Defensive Medicine is characterized by excessive use of complementary tests, the use of supposedly safer therapeutic procedures, the frequent referral of patients to other specialists and by the refusal to care for critically ill patients and with greater potential for complications. This is a practice that aims to defend the doctor from legal suits. The way the processes are conducted by the judiciary certainly contributes to the consolidation of this foolish practice. The slow pace of justice in our country, associated with the unpreparedness of judges and legal experts in the analysis of cases, leads to an emotional exhaustion of the parties involved. Furthermore, poor training of doctors in our country values the use of sophisticated diagnostic and treatment methods, rather than a thorough clinical examination and appropriate communication with the patient. Besides inefficient in protecting the doctor, Defensive Medicine has severe consequences to the patient and to society, since it generates an additional invaluable cost to medical practice, determines greater suffering to the patient and causes deterioration of the doctor-patient relationship, which has always been marked by trust, respect and personhood.

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Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

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Pós-graduação em Enfermagem - FMB

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Imipenem-resistant Acinetobacter baumannii (IRAB) is a major threat for critically ill patients, including those admitted to burn units. Recent studies have suggested that colonization pressure (the proportion of patients or patient-days harbouring the pathogen of interest) is an important driver of the risk for acquisition of multidrug-resistant organisms. With that in mind, we conducted a cohort study, enrolling 208 patients admitted to a burn unit from November 2008 through December 2009. The outcome of interest was the acquisition of IRAB. In addition to the usual risk factors, we assessed the impact of colonization pressure. The number of wound excisions (odds ratio (OR) 12.06, 95% confidence interval (CI) 2.82-51.64) and the number of antimicrobials used (OR 22.82, 95% CI 5.15-101.19) were significant risk factors for the outcome of interest. On the other hand, colonization pressure (measured for whole time of exposure or up to the last 14, 7, or 3 days) was not associated with the risk for IRAB acquisition.

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Pós-graduação em Fisiopatologia em Clínica Médica - FMB

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The introduction of more efficient diagnostic methods, new techniques in surgery and transplantation, antibiotics and chemotherapeutics more potent and novel materials for prostheses, catheters and probes significantly increased the life expectancy and quality of life of critically ill patients, on the other hand, hospital-acquired infections emerged as important iatrogenic complications. Invasive infections are a growing problem in public health hospitals in Brazil and worldwide. Among the various etiological agents found in the hospital environment, the genus Candida has been the third most frequently isolated pathogen. In general, invasive fungal infections are associated with high morbidity and mortality, difficulties in diagnosis, antimicrobial resistance, length of hospital stay and increased hospital costs. This mini review of the literature describes about epidemiology of hospital infection of Candida species, as well as its virulence factors and drugs resistance

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Pós-graduação em Enfermagem (mestrado profissional) - FMB

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Pós-graduação em Fisiopatologia em Clínica Médica - FMB

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The results of several studies assessing dialysis dose have dampened the enthusiasm of clinicians for considering dialysis dose as a modifiable factor influencing outcomes in patients with acute kidney injury. Powerful evidence from two large, multicenter trials indicates that increasing the dialysis dose, measured as hourly effluent volume, has no benefit in continuous renal replacement therapy (CRRT). However, some important operational characteristics that affect delivered dose were not evaluated. Effluent volume does not correspond to the actual delivered dose, as a decline in filter efficacy reduces solute removal during therapy. We believe that providing accurate parameters of delivered dose could improve the delivery of a prescribed dose and refine the assessment of the effect of dose on outcomes in critically ill patients treated with CRRT.

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Introduction: Patients undergoing mechanical ventilation (MV) are frequently administered prolonged and/or high doses of opioids which when removed can cause a withdrawal syndrome and difficulty in weaning from MV. We tested the hypothesis that the introduction of enteral methadone during weaning from sedation and analgesia in critically ill adult patients on MV would decrease the weaning time from MV. Methods: A double-blind randomized controlled trial was conducted in the adult intensive care units (ICUs) of four general hospitals in Brazil. The 75 patients, who met the criteria for weaning from MV and had been using fentanyl for more than five consecutive days, were randomized to the methadone (MG) or control group (CG). Within the first 24 hours after study enrollment, both groups received 80% of the original dose of fentanyl, the MG received enteral methadone and the CG received an enteral placebo. After the first 24 hours, the MG received an intravenous (IV) saline solution (placebo), while the CG received IV fentanyl. For both groups, the IV solution was reduced by 20% every 24 hours. The groups were compared by evaluating the MV weaning time and the duration of MV, as well as the ICU stay and the hospital stay. Results: Of the 75 patients randomized, seven were excluded and 68 were analyzed: 37 from the MG and 31 from the CG. There was a higher probability of early extubation in the MG, but the difference was not significant (hazard ratio: 1.52 (95% confidence interval (CI) 0.87 to 2.64; P = 0.11). The probability of successful weaning by the fifth day was significantly higher in the MG (hazard ratio: 2.64 (95% CI: 1.22 to 5.69; P < 0.02). Among the 54 patients who were successfully weaned (29 from the MG and 25 from the CG), the MV weaning time was significantly lower in the MG (hazard ratio: 2.06; 95% CI 1.17 to 3.63; P < 0.004). Conclusions: The introduction of enteral methadone during weaning from sedation and analgesia in mechanically ventilated patients resulted in a decrease in the weaning time from MV.

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Clinicians frequently have to decide when dialysis should be initiated and which modality should be used to support kidney function in critically ill patients with acute kidney injury. In most instances, these decisions are made based on the consideration of a variety of factors including patient condition, available resources and prevailing local practice experience. There is a wide variation worldwide in how these factors influence the timing of initiation and the utilization of various modalities. In this article, we review the therapeutic goals of renal support and the relative advantages and shortcomings of different dialysis techniques. We describe strategies for matching the timing of initiation to the choice of modality to individualize renal support in intensive care unit patients. Copyright (C) 2012 S. Karger AG, Basel

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Background: This pilot study aimed to verify if glycemic control can be achieved in type 2 diabetes patients after acute myocardial infarction (AMI), using insulin glargine (iGlar) associated with regular insulin (iReg), compared with the standard intensive care unit protocol, which uses continuous insulin intravenous delivery followed by NPH insulin and iReg (St. Care). Patients and Methods: Patients (n = 20) within 24 h of AMI were randomized to iGlar or St. Care. Therapy was guided exclusively by capillary blood glucose (CBG), but glucometric parameters were also analyzed by blinded continuous glucose monitoring system (CGMS). Results: Mean glycemia was 141 +/- 39 mg/dL for St. Care and 132 +/- 42 mg/dL for iGlar by CBG or 138 +/- 35 mg/dL for St. Care and 129 +/- 34 mg/dL for iGlar by CGMS. Percentage of time in range (80-180 mg/dL) by CGMS was 73 +/- 18% for iGlar and 77 +/- 11% for St. Care. No severe hypoglycemia (<= 40 mg/dL) was detected by CBG, but CGMS indicated 11 (St. Care) and seven (iGlar) excursions in four subjects from each group, mostly in sulfonylurea users (six of eight patients). Conclusions: This pilot study suggests that equivalent glycemic control without increase in severe hyperglycemia may be achieved using iGlar with background iReg. Data outputs were controlled by both CBG and CGMS measurements in a real-life setting to ensure reliability. Based on CGMS measurements, there were significant numbers of glycemic excursions outside of the target range. However, this was not detected by CBG. In addition, the data indicate that previous use of sulfonylurea may be a potential major risk factor for severe hypoglycemia irrespective of the type of insulin treatment.