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Objective:To explore the application value of renal artery resistance index in the diagnosist of intra-abdominal hypertension (IAH) in critically ill patients.Methods:89 patients with risk factors of IAH in the intensive care unit of Zhangzhou Hospital Affiliated to Fujian Medical University from February 2022 to June 2022 were retrospective analyzed. The intra-abdominal pressure (IAP) were measured by bladder, and patients divided into IAH group (IAP≥12 mmHg) and non-IAH group (IAP <12 mmHg). The resistance index (RI) of the right renal aorta, segment artery and interlobar artery were measured by color Doppler ultrasound. The difference between the measurement indicators of patients in the IAH and non-IAH groups and the correlation with IAP were analyzed. As for different indicators to predict the diagnostic efficacy of IAH, ROC curve analysis was used to evaluate the effect. And further multivariate logistic regression analysis was to find independent risk predictor.Results:A total of 89 patients were included in the study, including 44 patients with normal IAP and 45 patients diagnosed IAH. There were significant differences in the right renal aorta, segmental artery and interlobar artery RI (all P<0.01). The interlobar artery RI≥0.698 was the highest diagnostic cut-off,area under the curve was 0.914, sensitivity was 82.2%, specificity was 97.7%, and Jordon index was 0.799. The Spearman correlation analysis of IAP and the ultrasonographic measurements revealed a strong correlation between right renal interlobar artery RI and IAP ( r=0.741, P<0.01). The multivariate logistic regression analysis showed that the right renal interlobar artery RI ( OR= 24.472, 95% CI:5.122~116.919, P<0.01) was an independent risk predictor of IAH ( P<0.01). Conclusion:Right renal interlobar artery RI had better diagnostic efficacy of IAH,renal ultrasound could be used as an alternative, non-invasive technique for the diagnosis and follow-up of IAH.
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ICU-acquired weakness (ICU-AW) is a common complication in the intensive care unit (ICU). The occurrence of ICU-AW directly leads to prolonged ICU stays for critically ill patients, and in severe cases, it continues to affect their quality of life even after discharge. This article provides a comprehensive review of the research progress on ICU-AW based on domestic and foreign studies, aiming to provide a scientific overview of ICU-AW, including its definition, pathophysiology, diagnosis, screening tools, influencing factors, and potential intervention strategies, so as to promote timely planning and implementation of relevant screening and intervention measures.
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Introducción: La enfermedad trombótica asociada a las hemopatías malignas es subestimada en el paciente grave; en ocasiones queda a la sombra de las hemorragias que presentan estos enfermos. Su diagnóstico y tratamiento constituyen un desafío para lograr el aumento de la sobrevida en las unidades de cuidados críticos Objetivos: Analizar los aspectos generales de las alteraciones trombóticas en pacientes graves con hemopatías malignas. Métodos: Se realizó una investigación bibliográfico-documental acerca del tema. Se consultaron en las bases de datos de SciELO y Pubmed, los artículos publicados en los últimos diez años. Análisis y síntesis de la información: Se describen los aspectos generales vinculados con el mecanismo de la coagulación, sus criterios diagnósticos; así como la evolución del paciente con trombosis que ingresan en las unidades de cuidados intensivos. Conclusiones: El conocimiento de las alteraciones tromboembólicas en los pacientes con hemopatías malignas permite un monitoreo adecuado y la creación de estrategias individuales para mejorar la sobrevida de estos enfermos en la la unidad de cuidados intensivos.
Introduction: Thrombotic disease associated with malignant hemopathies is underestimated in critically ill patients; sometimes it remains in the shadow of the hemorrhages that these patients present. Its diagnosis and treatment constitute a challenge to achieve increased survival in these patients in critical care units Objectives: To analyze the general aspects of thrombotic alterations in seriously ill patients with malignant hemopathies. Methods: A bibliographical-documentary research on the subject was carried out. The SciELO and Pubmed databases of the last ten years were consulted. Analysis and synthesis of the information: General aspects related to the coagulation mechanism, its diagnostic criteria are described; as well as the evolution of the patient with thrombosis who is admitted to the intensive care unit. Conclusions: Knowledge of thromboembolic alterations in patients with malignant hemopathies allows adequate monitoring and the creation of individual strategies to improve the survival of these patients in the ICU.
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HumanosRESUMO
Objective:To evaluate and summarize the best evidence of energy and protein intake targets and calculation in adult critically ill patients, and to provide evidence-based basis for critical nutrition management.Methods:Evidence related to energy and protein intake targets and calculation of adult critically ill patients, including guideline, expert consensus, systematic review and evidence summary, were systematically searched in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Library, UpToDate, BMJ Best Practice, Joanna Briggs Institute (JBI), Web of Science, SinoMed, Medive, China National Knowledge Infrastructure, Wanfang database, VIP database, Guidelines International Network (GIN), National Institute for Health and Care Excellence (NICE), National Guideline Clearinghouse (NGC), Registered Nurses Association of Ontario (RNAO), and Society of Critical Care Medicine (SCCM) from January 2012 to June 2022. Two researchers independently evaluated the quality of the included literatures using the JBI Evidence-based Health Care Center evaluation tool and the Appraisal of Clinical Practice Guidelines for Research and Evaluation Ⅱ (AGREE Ⅱ), extracted and summarized the best evidence for the nutritional intake goal and calculation of adult critically ill patients, and described the evidence.Results:A total of 18 literatures were included, including 5 clinical guidelines, 8 expert consensus, 3 systematic reviews and 2 evidence summaries. After literature quality evaluation, 18 articles were all enrolled. The evidence was summarized from the four aspects, including energy target calculation method, dose body weight, energy and protein intake target, and calculation method, 24 pieces of the best evidence were finally formed.Conclusions:The best evidence of energy and protein intake targets and calculation for critically ill patients was summarized based on evidence-based. Clinical medical staff can choose indirect calorimetry to calculate energy goals when equipment is available. Patient's height, body weight should be recorded accurately, dose body weight can be determined by body mass index (BMI). Meanwhile, blood urea nitrogen (BUN) loss, fat-free body weight, simple formulas and other methods should be used to continuously evaluate and adjust protein intake targets, to achieve the purpose of optimizing intensive nutrition support.
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Resumen: La colocación de una sonda enteral es un procedimiento invasivo rutinario que puede presentar complicaciones graves. Presentamos el caso de un hombre de 54 años de edad que presentó paro cardiorrespiratorio secundario a infarto de miocardio y que, después de la colocación de una sonda nasoyeyunal, desarrolló neumotórax, por lo que ameritó su retiro, la colocación de una sonda endopleural y la administración de antibióticos. El paciente mostró adecuada expansión pulmonar, lo cual permitió el retiro de la sonda endopleural a los seis días de su instalación, la extubación del enfermo y finalmente su egreso por mejoría. El neumotórax asociado a la colocación de la sonda enteral se presenta en 1.2% de los pacientes. Los factores de riesgo son: déficit neurológico, alteración de la deglución y del reflejo tusígeno. El tratamiento descrito en la literatura es el retiro de la sonda, el uso de antibióticos y el drenaje torácico.
Abstract: Enteral tube placement is a routine invasive procedure that can present serious complications. We present the case of a 54-year-old man who presented with cardiorespiratory arrest secondary to myocardial infarction and who, after placement of a nasojejunal tube, developed pneumothorax that required removal of the tube, placement of a chest tube and administration of antibiotics. The patient presented adequate lung expansion, which allowed removal of the chest tube six days after its installation, extubation and finally discharge due to improvement. Pneumothorax associated with enteral tube placement occurs in 1.2% of patients. Risk factors are neurological deficit, impaired swallowing and cough reflex. Treatment described in the literature is removal of the tube, use of antibiotics and chest drainage.
Resumo: A colocação de sonda enteral é um procedimento invasivo de rotina que pode apresentar complicações graves. Apresentamos o caso de um homem de 54 anos que apresentou parada cardiorrespiratória secundária a infarto do miocárdio e que, após colocação de sonda nasojejunal, desenvolveu pneumotórax que exigiu sua retirada, colocação de sonda endopleural e administração de antibióticos.O paciente apresentou expansão pulmonar adequada, o que permitiu a retirada do tubo endopleural 6 dias após sua instalação, a extubação do paciente e por fim sua alta por melhora. O pneumotórax associado à colocação de sonda enteral ocorre em 1.2% dos pacientes. Os fatores de risco são: déficit neurológico, deglutição prejudicada e reflexo da tosse. O tratamento descrito na literatura é a retirada da sonda, uso de antibióticos e drenagem torácica.
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Objective:To explore the impact of hypophosphatemia on the occurrence and prognosis of critically ill patient.Methods:The clinical data of critically ill patients admitted to the intensive care unit (ICU) of Tianjin First Central Hospital from October 2021 to April 2022 were retrospectively analyzed. Patients were divided into hypophosphatemia group (serum phosphorus level < 0.80 mmol/L) and non-hypophosphatemia group (serum phosphorus level ≥ 0.80 mmol/L) when they were admitted to the ICU. The following variables were also collected, including gender, age, acute physiology and chronic health evaluationⅡ(APACHE Ⅱ), sequential organ failure assessment (SOFA), serum phosphorus level, serum calcium level, serum magnesium level, white blood cell count (WBC), neutrophil count (NEU), lymphocyte count (LYM), neutrophil/lymphocyte ratio (NLR), C-reactive protein (CRP), presence of infection and infection site, length of hospital stay, ICU stay, 28-day mortality, and mechanical ventilation time. Multivariate Logistic regression analysis was used to evaluate the relationship between each variable and the 28-day mortality. The receiver operator characteristic curve (ROC curve) was drawn, and the area under the ROC curve (AUC) and 95% confidence interval (95% CI) were calculated to evaluate the predictive value of serum phosphorus levels for the prognosis of ICU patients. Results:A total of 263 patients were enrolled, including 54 patients with hypophosphatemia and 209 patients without. The SOFA score, LYM level and the infection rate of patients in the hypophosphatemia group were significantly higher than those in the non-hypophosphatemia group [SOFA score: 6.70±3.17 vs. 5.64±3.59, LYM (×10 9/L): 0.99±0.54 vs. 0.77±0.54, infection rate: 77.78% (42/54) vs. 59.33% (124/209), all P < 0.05], the NLR was significantly lower than that of the non-hypophosphatemia group [10.67 (7.08, 18.02) vs. 12.25 (7.25, 21.68), P < 0.05]. The length of hospital stay, ICU stay, and mechanical ventilation duration in the hypophosphatemia group were significantly longer than those in the non-hypophosphatemia group [length of hospital stay (days): 15 (11, 28) vs. 12 (6, 21), length of ICU stay (days): 10.35±7.80 vs 7.15±6.61, mechanical ventilation duration (days): 3 (0, 12) vs. 2 (0, 5), all P < 0.05]. There was no significant difference in the 28-day mortality between the hypophosphatemia group and the non-hypophosphatemia group [9.26% (5/54) vs. 11.00% (23/209), P > 0.05]. Multivariate Logistic regression analysis showed that APACHE Ⅱ score [odds ratio ( OR) = 1.188, 95% CI was 1.110-1.271], CRP ( OR = 1.016, 95% CI was 1.007-1.026), and NLR ( OR = 1.002, 95% CI was 0.996-1.008) were independent risk factors affecting the 28-day mortality of critically ill patients in ICU (all P < 0.05). ROC curve analysis showed that the AUC of serum phosphorus levels for predicting the length of hospital stay of critically ill patients in ICU > 10 days, ICU stay > 5 days, and mechanical ventilation duration > 5 days were 0.701 (95% CI was 0.632-0.770), 0.771 (95% CI was 0.691-0.852), 0.617 (95% CI was 0.541-0.692), respectively, all P < 0.01. Conclusion:Hypophosphatemia has some predictive value for the length of hospital and ICU stay and mechanical ventilation time in critically ill patients, but it cannot predict the 28-day mortality.
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Objective:To investigate the correlation of monocyte/lymphocyte ratio (MLR) with the prognosis and adverse event in critically ill patients.Methods:Basic information of patients were extracted from Medical Information Mart for Intensive Care-Ⅲ (MIMIC-Ⅲ), including demographics, blood routine, biochemical indexes, systemic inflammatory response syndrome score (SIRS), sequential organ failure assessment (SOFA) score, and outcome, etc. MLR on the first day of intensive care unit (ICU) admission was calculated. The receiver operating characteristic curve (ROC curve) was applied to evaluate the prognostic value of MLR on the 30-day mortality and its cut-off value. According to the cut-off value, the patients were divided into two groups, and the differences between the groups were compared. Logistic regression model was used to analyze the relationship of MLR with 30-day mortality, continuous renal replacement therapy (CRRT), mechanical ventilation, the length of ICU stay, and total hospitalization time.Results:① A total of 43 174 critically ill patients were included. ROC curve showed that area under ROC curve (AUC) of MLR in predicting 30-day mortality was 0.655 [95% confidence interval (95% CI) was 0.632-0.687]. The cut-off value of MLR calculated according to the maximum Yoden index was 0.5. There were 16 948 patients with MLR ≥ 0.5 (high MLR group) and 26 226 patients with MLR < 0.5 (low MLR group). ② Compared with the low MLR group, the high MLR group had higher age, proportion of male, body mass index (BMI) [age (years old): 66.0 (51.7, 78.4) vs. 57.6 (27.1, 74.6), proportion of male: 57.2% vs. 52.5%, BMI (kg/m 2): 26.5 (22.5, 31.1) vs. 24.7 (14.3, 29.7)]. The high MLR group also had higher incidence of complications (hypertension: 49.2% vs. 44.6%, chronic heart failure: 32.6% vs. 21.7%, diabetes mellitus: 27.0% vs. 23.4%, chronic obstructive pulmonary disease: 21.5% vs. 16.1%, renal insufficiency: 19.3% vs. 13.1%), and higher white blood cell count (WBC), blood glucose, lactate (Lac), serum creatinine (SCr), SIRS score and SOFA score [WBC (×10 9/L): 13.8 (9.6, 19.2) vs. 11.5 (8.4, 15.6), blood glucose (mmol/L): 8.66 (6.88, 11.49) vs. 8.27 (6.55, 10.88), Lac (mmol/L): 2.2 (1.5, 3.7) vs. 2.1 (1.4, 3.3), SCr (μmol/L): 106.1 (70.7, 176.8) vs. 88.4 (70.7, 132.6), SIRS score: 3 (2, 4) vs. 2 (2, 3), SOFA score: 4 (2, 7) vs. 3 (1, 5)]. The 30-day mortality, and the proportion of patients with length of ICU stay > 5 days, total hospitalization time > 14 days, CRRT and mechanical ventilation > 5 days were significantly higher in high MLR group (30-day mortality: 20.0% vs. 8.3%, length of ICU stay > 5 days: 33.2% vs. 20.4%, total hospitalization time > 14 days: 33.7% vs. 16.2%, CRRT: 3.6% vs. 0.7%, mechanical ventilation > 5 days: 18.4% vs. 5.7%), with statistically significant differences (all P < 0.05). ③ After adjusted with the related factors, multivariate Logistic regression analysis showed that elevated MLR was an independent risk factor for increased 30-day mortality [odd ratio ( OR) = 1.54, 95% CI was 1.37-1.72, P < 0.001]. Moreover, the increased MLR was independently associated with the increased risk of usage of CRRT ( OR = 2.77, 95% CI was 2.18-3.51), mechanical ventilation > 5 days ( OR = 2.45, 95% CI was 2.21-2.72), the length of ICU stay > 5 days ( OR = 2.29, 95% CI was 2.10-2.49), and total hospitalization time > 14 days ( OR = 2.28, 95% CI was 2.08-2.49), all P < 0.001. Conclusions:Retrospective analysis of large sample shows that MLR elevation is an independent risk factor for 30-day mortality, usage of CRRT, prolonged mechanical ventilation time, prolonged hospitalization, prolonged length of ICU stay. MLR can be used for risk stratification of severe patients.
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Objective:To investigate the risk factors affecting the prognosis of patients with acute kidney injury (AKI) in the intensive care unit (ICU) based on the Medical Information Mart for Intensive Care Ⅲ (MIMIC-Ⅲ) database, and to establish a prognostic model for AKI.Methods:Patients (aged ≥ 18 years) with acute renal failure, admitted to the ICU for the first time, and had complete hospital records (the RIFLE diagnostic criteria were used in the database, and the diagnosis was expressed as AKI in this article) were screened from MIMIC-Ⅲ database according to diagnostic codes. Patients were divided into two groups based on survival state at discharge, and the general information, underlying diseases, injury factors, vital signs and laboratory indicators within 24 hours after AKI, related intervention and prognostic indicators were analyzed. Univariate and multivariate Logistic regression analysis were used to determine the risk factors affecting mortality in patients with AKI and established a prediction model. The receiver operator characteristic curve (ROC curve) was used to analyze the predictive value of the prediction model for the prognosis of AKI patients.Results:There were 4 554 patients with AKI included and 862 died, with mortality of 18.93%. Univariate Logistic regression analysis was performed for factors that might be associated with death in AKI patients, and the results showed that age, hypertension, lymphoma, metastatic carcinoma, vancomycin, aspirin, coagulation abnormalities, cardiac arrest, sepsis or septic shock, invasive mechanical ventilation, white blood cell count (WBC), platelet count (PLT), K +, blood urea nitrogen (BUN), total bilirubin (TBil), renal replacement therapy (RRT) and length of stay (LOS) were independent risk factors [odds ratio ( OR) and 95% confidence interval (95% CI) were 1.002 (1.001-1.003), 0.764 (0.618-0.819), 1.749 (1.112-2.752), 2.606 (1.968-3.451), 1.779 (1.529-2.071), 0.689 (0.563-0.842), 1.871 (1.590-2.201), 2.468 (1.209-5.036), 2.610 (2.226-3.060), 2.154 (1.853-2.505), 1.105 (1.009-1.021), 0.998 (0.997-0.998), 1.132 (1.057-1.212), 1.008 (1.006-1.011), 1.061 (1.049-1.073), 2.142 (1.793-2.997), 0.805 (0.778-1.113), all P < 0.05]. Further binary Logistic regression analysis showed that lymphoma, metastatic cancer, vancomycin, cardiac arrest, sepsis or septic shock, coagulation dysfunction, invasive mechanical ventilation, increased BUN, increased TBil, increased or decreased blood K + and increased WBC were independent risk factors for death [β values were 0.636, 1.005, 0.207, 0.894, 0.787, 0.346, 0.686, 0.006, 0.051, 0.085, and 0.009; OR and 95% CI were 1.889 (1.177-3.031), 2.733 (2.027-3.683), 1.229 (1.040-1.453), 2.445 (1.165-5.133), 2.197 (1.850-2.610), 1.413 (1.183-1.689), 1.987 (1.688-2.338), 1.006 (1.003-1.009), 1.052 (1.039-1.065), 1.089 (1.008-1.176), and 1.009 (1.004-1.015), respectively, all P < 0.05]. The Hosmer-Lemeshow test showed that the AKI prognostic model was able to fit the observed data well ( P = 0.604). ROC curve analysis showed that the area under ROC curve (AUC) of the AKI prognostic model was 0.716 (95% CI was 0.697-0.735), when the cut-off value was 0.320, the sensitivity was 71.9%, the specificity was 60.1%, the positive likelihood ratio was 1.80, and the negative likelihood ratio was 0.47. Conclusion:The prognostic prediction model of AKI in critically ill patients established and based on the MIMIC-Ⅲ database may have practical significance for prognostic risk assessment of AKI and later intervention.
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Introducción: La desnutrición en pacientes ingresados en una sala de terapia intensiva es elevada, pero en el anciano crítico es aún mayor, con repercusión sobre el aparato respiratorio, prolongación de la ventilación y otras complicaciones. Objetivo: Caracterizar el estado nutricional en pacientes geriátricos con ventilación mecánica en una unidad de cuidados intensivos. Métodos: Se realizó un estudio descriptivo, prospectivo y de corte transversal durante el periodo de enero de 2017 a marzo de 2019 en la unidad de cuidados intensivos del Hospital General Docente "Orlando Pantoja Tamayo". Se estudiaron 83 pacientes con edades mayor o igual a 60 años, los cuales requirieron del uso de ventilación mecánica más de 24 h. El estado nutricional fue evaluado con el empleo del índice de control nutricional. Resultados: Predominó el sexo masculino, el grupo de edades de 60 a 74 años, y las enfermedades tipo quirúrgicas. Solo 9,1 % de los que recibieron ventilación mecánica invasiva no estaban desnutrido. Los que fallecieron tenían desnutrición moderada o severa. Conclusiones: En los pacientes geriátricos ventilados, ingresados en la unidad de cuidados intensivos, se encontró un alto grado de malnutrición. La desnutrición moderada o severa predominó en la mayoría de los que recibieron ventilación mecánica invasiva y en el grupo de fallecidos(AU)
Introduction: Malnutrition in patients hospitalized in an intensive care room is high, but it is even higher in the critically-ill elderly patient, with repercussions on the respiratory system, prolonged ventilation, and other complications. Objective: To characterize the nutritional status of geriatric patients under mechanical ventilation in an intensive care unit. Methods: A descriptive, prospective and cross-sectional study was carried out during the period from January 2017 to March 2019, in the intensive care unit of Orlando Pantoja Tamayo General Teaching Hospital. 83 patients aged 60 or older were studied; they required mechanical ventilation for more than 24 hours. The nutritional status was evaluated with the use of the nutritional control score. Results: There was a predominance of the male sex, the age group 60-74 years, and of surgical diseases. Only 9.1% of those who received invasive mechanical ventilation were not undernourished. Those who died had moderate or severe undernutrition. Conclusions: In ventilated geriatric patients hospitalized in the intensive care unit, a high degree of malnutrition was found. Moderate or severe malnutrition predominated in the majority of those who received invasive mechanical ventilation and in the group of the deceased(AU)
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Humanos , Idoso , Idoso de 80 Anos ou mais , Respiração Artificial/efeitos adversos , Desnutrição/complicações , Desnutrição/epidemiologia , Inquéritos Nutricionais/normas , Epidemiologia Descritiva , Estudos Transversais , Estudos Prospectivos , Resultados de Cuidados Críticos , Unidades de Terapia Intensiva/estatística & dados numéricosRESUMO
OBJECTIVE: To explore the application of therapy drug monitoring of imipenem in ICU, and to provide evidence for the use of imipenem in critically ill patients. METHODS: A cross-sectional survey was conducted to collect clinical data of 67 patients receiving therapeutic drug monitoring of imipenem in ICU from January 1, 2016 to December 31, 2018. Using SPSS21.0 statistical software, 71 cases of therapeutic drug monitoring data (blood drug concentration, f%T>MIC) and related clinical data were analyzed. RESULTS: Of all 71 cases of therapeutic drug monitoring, there are 37 cases (52.11%) f%TMIC≥40%,26 cases(36.62%)f%TMIC70%,and 10 cases(14.08%) f%TMIC=100%. f%TMIC of all cases with 0.25 g q6h were 70%. Among other dosage regimens, the highest proportion of f%T>MIC>40% was 1 g q12h (66.67%) and the highest proportion of f%T>MIC>70% was 0.5 g q8h(43.59%). According to different f%T>MIC, those patients were divided into ≤40% group, >40%-70% group and>70%group. Only group>70% showed a downward trend in the infection index of patients before and after medication. The body temperature decreased significantly (P=0.004), while the average PCT level of group MIC>70% group showed a downward trend in serum creatinine after treatment, but there was no significant difference (P=0.285). The serum drug concentration in CRRT group was slightly higher than that in non-CRRT group, and there was no significant difference in f%T>MIC (P=0.376, P=0.209, P=0.988). CONCLUSION: The level of f%T>MIC of imipenem in ICU is unsatisfactory. For critically ill patients, when imipenem f%T>MIC>70%, the antimicrobial effect is better.
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El soporte nutricional que se brinda a los pacientes críticos, constituye para la mayoría la única vía de acceso a través de la cual es posible cubrir sus requerimientos nutricionales diarios. Sin embargo, se ha identificado que la presencia de deuda calórica impide cubrir dichos requerimientos. Este estudio determinó la deuda calórica y su potencial efecto clínico a través de una cohorte prospectiva que incluyó 191 pacientes que recibieron soporte nutricional en unidades de cuidado intensivo (UCI). Se evaluó la magnitud de la deuda calórica, los principales factores que la favorecen y se exploraron diferencias en desenlaces clínicos relacionados con mortalidad, complicaciones infecciosas y tiempo de estancia en UCI. Los resultados evidenciaron que la deuda calórica estuvo presente en el 73,8%(IC 95% = 67%-80%) de los pacientes evaluados; la principal causa estuvo relacionada con la interrupción de la nutrición enteral y no se encontró asociación entre el porcentaje de adecuación calórico y los desenlaces evaluados. Esta evaluación permitió establecer que la mayoría de los pacientes, a pesar de recibir soporte nutricional, se encuentran expuestos a deuda calórica siendo necesario generar estrategias de atención que permitan disminuir la exposición de esta población a dicha condición.
The nutritional support offered to critically ill patients is, for most of them, the only means to fulfill their daily nutritional requirements. However, it has been documented that nutritional support is not enough to cover such needs, due to the presence of caloric debt. We seek to determine the caloric debt and its potential to clinical affect critically ill patients that receive nutritional support in the Intensive Care Unit (ICU). We conducted a prospective cohort study with 191 patients. We assessed the magnitude of caloric debt and its related factors. We also explored variations in clinical outcomes related to mortality, infectious complications and ICU stay length. Caloric debt was found in 73.8% (95% CI = 67-80%) of patients who received less than 80% of their daily caloric requirements. Main causes were related to enteral nutrition interruption. We found no association between caloric debt and the evaluated outcomes. This evaluation made it possible to establish that the majority of patients, despite receiving nutritional support, were exposed to caloric debt, and it is necessary to generate care strategies to reduce the patients' exposure to this condition.
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Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Nutrição Enteral , Nutrição Parenteral , Restrição Calórica/efeitos adversos , Unidades de Terapia Intensiva , Estudos Prospectivos , Fatores de Risco , Seguimentos , Estado Terminal , Apoio Nutricional , Ingestão de Alimentos , HospitalizaçãoRESUMO
Introducción: Las unidades de atención al paciente gravemente enfermo informan numerosos casos con desnutrición. Para poder estimarlo es necesario utilizar indicadores dietéticos, antropométricos, bioquímicos e inmunológicos. Objetivo: Caracterizar el estado nutricional de los pacientes posoperados ingresados en una unidad de cuidados intensivos. Métodos: Se realizó un estudio descriptivo, prospectivo de corte transversal. Los valores se obtuvieron de los indicadores antropométricos (circunferencia media del brazo y circunferencia de la pantorrilla), bioquímicos (albúmina, colesterol, triglicéridos y creatinina) e inmunológicos (conteo total de linfocitos) de 98 pacientes ingresados en dicha unidad. El estado nutricional fue evaluado mediante variables independientes. Resultados: Predominaron los pacientes con estadía entre 1-7 días (71,4 por ciento), la ventilación mecánica se utilizó en 33,6 por ciento, fallecieron 19,3 por ciento de los pacientes, y predominó el grupo de afecciones intraabdominales 38,8 por ciento. La linfopenia (68,3 por ciento) y la hipoalbuminemia (62,2 por ciento) fueron más significativas, seguida de la circunferencia media del brazo (CMB) en rango de desnutrición (47,9 por ciento). No se demostró asociación de las variables nutricionales con la estadía, ni la necesidad de ventilación mecánica. Todas las variables se asociaron con el estado al egreso. Conclusiones: Predominó la estadía alrededor de una semana, la tercera parte de la muestra requirió apoyo ventilatorio, y la mortalidad fue baja. De las variables nutricionales estudiadas no se encontró asociación de estas con la estadía ni el uso de ventilación mecánica pero sí con el estado al egreso(AU)
Introduction: Critically ill care units report numerous cases of malnutrition. In order to estimate such statistics, it is necessary to use dietary, anthropometric, biochemical and immunological indicators. Objective: To characterize the nutritional status of postoperative patients admitted to an intensive care unit. Methods: A descriptive, prospective, cross-sectional study was carried out. The values ;were obtained from the indicators of the type anthropometric (average arm and calf circumference), biochemical (albumin, cholesterol, triglycerides and creatinine) and immunological (total lymphocyte count) of 98 patients admitted to the unit. The nutritional status was evaluated by independent variables. Results: Patients with 1-7 days of stay predominated (71.4 percent), mechanical ventilation was used in 33.6 percent, 19.3 percent of patients died, and the group of intra-abdominal conditions predominated (38.8 percent). Lymphopenia (68.3 percent) and hypoalbuminemia (62.2 percent) were more significant, followed by average arm circumference (AAC) in the malnutrition range (47.9 percent). There was no association of nutritional variables with the stay, nor the need for mechanical ventilation. All the variables were associated with the state at the time of discharge. Conclusions: A stay of about one week predominated, one third of the sample required ventilatory support, and mortality was low. Among all the nutritional variables studied, no association was found with the stay or the use of mechanical ventilation, but instead with the state at discharge(AU)
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Humanos , Masculino , Feminino , Cuidados Pós-Operatórios/métodos , Estado Nutricional , Estado Terminal , Unidades de Terapia Intensiva/normas , Epidemiologia Descritiva , Estudos TransversaisRESUMO
Resumen: La lesión renal aguda es una de las entidades más comunes en el Área de Terapia Intensiva, llega a presentarse hasta en 50% de los enfermos que ingresan a la Unidad de Terapia Intensiva. Se han desarrollado herramientas de detección de riesgo de lesión renal aguda, las cuales utilizan información de rutina altamente accesible (AKI predictor). El objetivo es determinar el desempeño de AKI predictor en la detección de daño renal y requerimiento de terapia sustitutiva renal (TSR) en pacientes adultos admitidos a la Unidad de Terapia Intensiva. Material y métodos: Se recolectaron de manera retrospectiva variables demográficas, bioquímicas, clínicas y el valor de AKI predictor al ingreso y 24 horas de cada paciente admitido en un periodo de ocho meses; asimismo, se determinó el concepto de daño renal definido como requerimiento de TSR y/o progresión de daño renal definida como un incremento de la creatinina ≥ 0.3 mg/dL en 24 horas y/o presencia de diuresis < 0.5 mL/kg/hora a las 48 horas. Se construyeron curvas receiver operating characteristics con el fin de determinar el desempeño del AKI predictor en la detección de daño renal o requerimiento de TSR por separado. Resultados: Se incluyó un total de 95 pacientes, donde aquéllos con daño renal mostraron mayor gravedad de la enfermedad por Sequential Organ Failure Assessment score, mayor proporción de pacientes con sepsis, uso de vasopresores, mortalidad y estancia en la Unidad de Terapia Intensiva. La herramienta AKI predictor calculada al ingreso mostró un área bajo la curva significativa de 0.76 para le detección de daño renal, 0.85 para requerimiento de TSR y calculada a las 24 horas un área bajo la curva significativa de 0.91 para detección de TSR. Conclusiones: La herramienta AKI predictor se muestra como una opción viable en la práctica diaria para la evaluación dinámica de aquellos pacientes que muestren progresión del daño renal, dejando como última consecuencia el uso de TSR.
Abstract: Acute kidney injury (AKI) is one of the most common entities in the intensive care area. It occurs in up to 50% of patients admitted to the intensive care unit (ICU). New tools to detect AKI risk using highly accessible routine information have been developed (AKI predictor). The goal is to determine the performance of the AKI predictor tool to detect renal damage and renal replacement therapy (RRT) requirement in adult patients admitted to the ICU. Material and methods: Demographic, biochemical, clinical variables and AKI predictor percentages at admission and at 24 hours were retrospectively collected of every patient admitted in an 8 months period, likewise the concept of renal damage was determined, defined as requirement of RRT and/or an increment of creatinine ≥ 0.3 mg/dL in 24 hours and/or urine output < 0.5 mL/kg/h at 48 hours. Receiver operating characteristics curves were developed in order to determine the performance of the AKI predictor to detect renal damage or RRT requirement by separate. Results: 95 patients were included in the analysis, those with renal damage showed higher illness severity by Sequential Organ Failure Assessment score, higher proportion of these patients presented sepsis, need for vasopressors, mortality and longer UCI stay. AKI predictor tool showed a significant area under the curve (AUC) of 0.76 for renal damage detection, 0.85 for requirement of RRT and calculated at 24 hours an AUC of 0.91 for RRT requirement. Conclusions: The AKI predictor tool it is shown as a viable option in daily practice for the dynamic evaluation of those patients who will show renal damage progression until its final consequence RRT.
Resumo: Introdução: A lesão renal aguda (LRA) é uma das entidades mais comuns na área de terapia intensiva, podendo ocorrer em até 50% dos pacientes internados em unidade de terapia intensiva (UTI). Foram desenvolvidas ferramentas de detecção de risco para o LRA, que usam informações de rotina altamente acessíveis (preditor de AKI). Objetivo: Determinar o desempenho do preditor de LRA na detecção de dano renal e a necessidade de terapia renal substitutiva (TRS) em pacientes adultos admitidos na UTI. Métodos: Variáveis clínicas, demográficas, bioquímicas e o valor do preditor de IRA foram coletados retrospectivamente na admissão e 24 horas de cada paciente em um período de 8 meses, bem como o conceito de dano renal definido como requisito de TRS e/ou progressão do dano renal definido como aumento da creatinina ≥ 0.3 mg/dL em 24 horas e/ou presença de diurese < 0.5 mL/kg/hora às 48 horas. As curvas Receiver Operating Characteristics foram construídas com o objetivo de determinar o desempenho do preditor de AKI na detecção de dano renal ou exigência de TSR separadamente. Resultados: Foram incluídos 95 pacientes, sendo que aqueles com lesão renal apresentaram maior gravidade da doença devido ao escore Sequential Organ Failure Assessment, maior proporção de pacientes com sepse, uso de vasopressores, mortalidade e permanência na UTI. O instrumento preditor AKI calculado na admissão, mostrou uma área significativa sob a curva (ABC) de 0.76 para a detecção de dano renal, 0.85 para a necessidade de TSR e calculada às 24 horas um ABC significativa de 0.91 para a detecção de TSR. Conclusão: O instrumento preditor de AKI é apresentado como uma opção viável na prática diária para a avaliação dinâmica daqueles pacientes que apresentarão progressão da lesão renal até a última consequência do uso da TRS.
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O comprometimento físico funcional é um aspecto significativo em pacientes críticos e para que seja possível intervir de forma precoce, torna-se importante analisar o estado funcional destes indivíduos. Este é um estudo longitudinal e prospectivo, do qual participaram 40 indivíduos internados na UTI do HU/UFSC em Ventilação Mecânica (VM) por pelo menos 48h. Na inclusão ao estudo (AV1) foram coletados dados referentes ao estado funcional e fragilidade prévios; na segunda etapa (AV2) - avaliação da força muscular e do estado funcional; e na alta clínica (AV3) reavaliação da força muscular, estado funcional e check list dos marcos funcionais. De forma geral, os pacientes apresentaram prejuízo significativo na funcionalidade no despertar, com Índice de Barthel médio de 3,33 ± 6 e Escore Perme de 8,18 ± 3,99 e também na alta da UTI, com Índice de Barthel médio de 12,7 ± 13,99 e Escore Perme de 13,68 ± 6. O estado funcional e a fragilidade prévios se relacionaram com os desfechos clínicos (p = 0,022 e p = 0.019, respectivamente). O estado funcional no despertar teve correlação com o desfecho funcional (p < 0,001). A força muscular periférica se alterou juntamente com o estado funcional tanto no despertar (p = 0,005 e p < 0,001) quanto na alta da UTI (p = 0,002). Sendo assim, pode-se dizer que o estado funcional dos pacientes reduziu significativamente durante a internação na UTI, comparada há um mês antes da admissão, e manteve-se baixa após a alta dessa unidade. Verificou-se ainda que o estado funcional e a fragilidade prévios se relacionam com o desfecho clínico e que o estado funcional no despertar se relaciona com o desfecho funcional. A força muscular periférica também se alterou juntamente com o estado funcional. (AU)
Functional physical impairment is a significant aspect in critically ill patients and in order to be able to intervene at an early stage, it is important to analyze the functional status of these individuals. This is a longitudinal and prospective study, in which participated 40 patients hospitalized at ICU of the HU/UFSC in mechanical ventilation for at least 48 hours. At inclusion in the study (AV1) data was collected regarding the previous functional status and frailty, at second stage (AV2) - evaluation of muscle strength and functional status and clinical discharge (AV3) revaluation of muscle strength, functional status and a check list of functional milestones. In general, the patients presented significant impairment of functionality at awakening, with a Barthel Index mean of 3.33 ± 6 and Perme Score of 8.18 ± 3.99, and at ICU discharge, with a Barthel Index with mean of 12.7 ± 13.99 and a Perme Score of 13.68 ± 6. The previous functional and frailty status was related to the clinical outcome (p = 0.022 and p=0.019, respectively). The functional status at awakening had a correlation with the functional outcome (p<0.001). The peripheral muscle strength modifies with functional status in both the awakening (p=0,005 e p<0,001) and discharge of the ICU (p=0,002). Therefore, the functional status of patients has significantly reduced during ICU stay, compared with the status one month prior, and remains low after discharge. It was also find that the functional status and previous frailty relate with the clinical outcome and that the functional status at awakening correlated to functional outcome. The peripheral muscle strength also modifies with functional status. (AU)
Assuntos
Humanos , Estado Funcional , Pacientes Internados , Estado Terminal , Deambulação Precoce , Força Muscular , Fragilidade , Unidades de Terapia IntensivaRESUMO
The transfer of critically ill patients is related to the treatment and prognosis of patients. It is not only the work of saving lives and injuries in the medical and health system, but also a measure of the ability and level of public health services in a region. "Non-emergency medical transshipment service" is a new form of business which is emerging at present. The phenomenon of "illegal ambulance" derived from it has attracted the attention of relevant government departments and has become the focus of media. The solution of this problem involves many aspects. The perspectives of defining the orientation of transfer work, constructing transfer service system, formulating transfer process norms and improving the quality of transfer efficiency are discussed in this paper, and it clearly puts forward that the development of "non-emergency medical transfer service" should adhere to the development path of marketization, diversification, standardization and specialization.
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OBJECTIVE: To evaluate the association between Cystatin C levels change and the clinical outcomes of critically ill patients.METHODS: There were altogether 4642 patients in intensive care unit(ICU)of West China Hospital of Sichuan university from 28 th August 2009 to 16 th April 2010,and their general conditions were recorded,including sex,age,and being with or without diabetes mellitus;then the database was established accordingly.The patients were divided into four groups according to the change of Cys C values in ICU:high increase(>1 mg/L),slight increase(≤1 mg/L),high decrease(>1 mg/L)and slight decrease(≤1 mg/L).The difference in 30-day mortality in patients were compared.The patients were followed up for 8 years.RESULTS: One thousand and thirty-six patients were included in this study,272 cases died within 30 days,with the highest in patients of the group with high increase of Cystatin C(77.9%),followed the high-decrease group(33.3%);the mortality rate of group with slight decrease was the lowest among the four groups(16.5%).The 8-year survival of 764 patients who did not die within 30 days was 54.58%.CONCLUSION: The change of Cystatin C value is closely related to the 30-day mortality of critically ill patients.The lowest 30-day mortality of critically ill patients is the group with slight decrease of Cystatin C.
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Objective To analyze the effect of probiotics combined with early enteral nutrition on infection and gastrointestinal dysfunction in patients undergoing mechanical ventilation in intensive care unit (ICU).Methods Prospective cohort study was adopted to select patients who admitted to ICU in a hospital from February 2016 to October 2017, they were randomly divided into three groups:A, B, and C.Group A received early enteral nutrition combined with probiotics, group B received early enteral nutrition, and group C received early parenteral nutrition.Infection condition, level of infection indicators (on the 3 rd, 7 th and 14 th day after treatment), occurrence of gastrointestinal dysfunction, acute physiology and chronic health evaluation II (APACHE II) on the 14 th day after treatment were compared among three groups.Results Incidences of infection in group A, B, and C were 6.00%, 20.00%, and 22.00% respectively, difference among three groups was significant (χ2=8.57, P=0.01).C-reactive protein (CRP) and white blood cell count (WBC) in group A on the 7 th and 14 th day were both lower than those in group B and C;procalcitonin (PCT) in group A and B on the 3 rd day were both lower than that in group C;PCT in group A on the 7 th and 14 th day were both lower than those in group B and C;difference were all statistically significant (all P< 0.05).Incidence of abdominal distension (8.00%), diarrhea (4.00%) and gastric retention (4.00%) in group A were the lowest among three groups.APACHE II score in group A on the 14 th day after treatment was lowest.Conclusion Early enteral nutrition combined with probiotics for treatment of ICU patients with mechanical ventilation can effectively reduce the incidence of infection and gastrointestinal dysfunction, promote rehabilitation, which is worth promoting the application.
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Objective To determine the safety criteria for early goal-oriented rehabilition exercise in patients undergoing mechanical ventilation in intensive care unit (ICU) by systematic review.Methods Randomized controlled trails (RCTs) and cohort studies about early goal-oriented rehabilition exercise in patients undergoing mechanical ventilation in ICU were retrieved in CBM,CNKI,Wanfang Data,PubMed,Cochrane Library and Web of Science from their foundation to March 2018,and other sources as supplement was also retrieved.The intervention program of RCT study was ICU routine nursing in control group,early activity in observation group,and early activity in cohort study without control group.Early activities included active and passive activities on the bed,sitting upright,bed-chair transfer,standing and walking.Literature screening and data extraction were performed independently by two researchers.Variables or parameters.related to cardiovascular,respiratory,nervous,orthopedic and other systems were collected for safety criteria.Variables or parameters used in at least three literatures were collected for each system.Cochrane 5.1.0 was used to evaluate the quality of RCT study,and Newcastle-Ottawa scale (NOS) was used to evaluate the quality of cohort study.Results A total of 24 articles about early activity of patients undergoing mechanical ventilation in ICU were enrolled,involving 4647 patients,including 11 RCT studies involving 1 031 patients,509 in control group and 522 in observation group;13 cohort studies including 3616 patients.It was shown by systematic review that safety criteria for early activity in patients undergoing mechanical ventilation in ICU involved five systems,20 variables or parameters.The cardiovascular system included 8 variables or parameters,such as 40 bpm < heart rate (HR) < 130 bpm (n =4),hemodynamic stability (n =5),no myocardial infarction (n =3),no arrhythmia (n =4),no vascular active drugs (n =4),90 mmHg < systolic blood pressure (SBP) < 200 mmHg (1 mmHg =0.133 kPa,n =4),65 mmHg ≤ mean arterial pressure (MAP) ≤ 110 mmHg (n =3),no history of cardiopulmonary resuscitation (CPR,n =5).The respiratory system included 4 variables or parameters,involving 5 times/min < respiratory rate (RR) < 40 times/min (n =5),fraction of inspired oxygen (FiO2) ≤ 0.60 and positive end-expiratory pressure (PEEP) ≤ 10 cmH2O (1 cmH2O =0.098 kPa,n =4),FiO2 < 0.60 or PEEP < 10 cmH2O (n =3),pulse blood oxygenation (SpO2) > 0.88 (n =5).The nervous system included 4 variables,including no neuromuscular disease (n =7),no increase in intracranial pressure (n =7),no coma (n =4),understand and do the right thing (n =4).The orthopedic system included 2 variables,including no fracture (n =3),no unstable fracture (n =8).Other factors included 2 variables,including no open abdomen wound (n =4),and no palliative care (n =3).Conclusions This study identified safety criteria for early goal-directed rehabilition exercise in patients undergoing mechanical ventilation in ICU included five systems of cardiovascular,respiratory,neurological,orthopedic,and other systems,in which cardiovascular and respiratory systems were the most frequently cited variables or parameters.The consistency of each system security criteria or variables reported by different literatures was high,but the parameters need to be further verified by high-quality study.
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Objective? To?compare?the?efficacy?and?safety?of?conservative?and?conventional?oxygen?therapy?in?critically?ill?patients.? Methods? Relevant?literature?and?randomized?controlled?trials?(RCTs)?about?the?effect?of?conservative?oxygen?therapy?and?conventional?oxygen?therapy?on?the?prognosis?of?intensive?care?unit?(ICU)?critically?ill?patients?was?searched?from?CNKI,?VIP,?Wanfang?Data,?Chinese?Clinical?Trial?Registry,?PubMed,?Embase,?the?Cochrane?Library,?and?ClinicalTrials.gov?by?using?the?keywords?"critically?ill?patients,?conservative?oxygen?therapy,?liberal?oxygen?therapy,?conventional?oxygen?therapy,?mortality"?until?October?30th?in?2018.?The?main?outcome?indicators?were?short-term?mortality?(28-day?mortality?or?ICU?mortality);?secondary?indicators?were?90-day?mortality,?duration?of?mechanical?ventilation,?the?length?of?ICU?stay,?total?hospitalization?time,?new?infection?rate?in?ICU?and?incidence?of?new?organ?dysfunction?in?ICU.?In?the?conservative?oxygen?therapy?group,?the?aim?of?pulse?oxygen?saturation?(SpO2)?was?0.90-0.92?or?the?arterial?partial?oxygen?pressure?(PaO2)?was?70-100?mmHg?(1?mmHg?=?0.133?kPa),?while?in?conventional?oxygen?therapy?group?SpO2?>?0.96?or?PaO2?>?150?mmHg.?Literature?search,?quality?evaluation?and?data?extraction?was?conducted?independently?by?the?two?authors.?The?quality?of?these?study?was?evaluated?using?Cochrane?risk?deviation?assessment?tool,?and?the?relevant?data?were?analyzed?using?RevMan?5.3?software.? Results? Four?studies?were?included?in?the?analysis,?these?studies?were?assessed?as?moderate?to?high?quality?studies.?A?total?of?1?076?patients?were?enrolled,?with?539?in??the?conservative?oxygen?therapy?group?and?537?in?the?conventional?oxygen?therapy?group.?Compared?with?conventional? oxygen?therapy?group,?short-term?mortality?[odds?ratio?(OR)?=?0.66,?95%?confidence?interval?(95%CI)?=?0.50-0.87,?P?=?0.003]?and?the?incidence?of?new?organ?dysfunction?in?ICU?(OR?=?0.64,?95%CI?=?0.41-0.99,?P?=?0.04)?were?significantly?decreased?in?conservative?oxygen?therapy?group,?duration?of?mechanical?ventilation?was?significantly?prolonged?[standardized?mean?difference?(SMD)?=?17.17,?95%CI?=?7.14-27.21, P?=?0.000?8].?But?there?was?no?significantly?difference?in?90-day?mortality?(OR?=?0.83,?95%CI?=?0.59-1.17,?P?=?0.28),?new?infection?rate?in?ICU?(OR?=?0.90,??95%CI?=?0.66-1.21,?P?=?0.47),?the?length?of?ICU?stay?(SMD?=?-0.22,?95%CI?=?-1.02-0.59,?P?=?0.60)?and?total?hospitalization?time?(SMD?=?1.44,?95%CI?=?-1.43-4.31,?P?=?0.32)?between?the?two?groups.? Conclusion? Compared?with?conventional?oxygen?therapy,?conservative?oxygen?therapy?can?reduce?short-term?mortality?and?the?incidence?of?organ?dysfunction?in?critically?ill?patients,?but?cannot?decrease?the?length?of?ICU?stay?and?total?hospitalization?time.
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Chronic?obstructive?pulmonary?disease?(COPD)?is?a?severe?respiratory?disease?characterized?by?airway?obstruction?with?high?mortality?and?rate?of?recurrence.?Rehabilitation?exercise?can?lessen?the?possibility?of?the?progressive?exacerbation?of?the?patient's?condition,?exerting?an?active?role?in?improving?their?lung?function?and?the?quality?of?the?patients'?life.?Therefore,?we?have?designed?a?lung?function?exercise?bottle,?which?is?capable?of?adjusting?the?pressure?according?to?the?patient's?needs.?It?is?easy?to?operate?and?apply?in?practice.?The?exercise?bottle?is?composed?of?three?components,?including?bottle?body,?threaded?round?cap?and?air?blow?pipe.?The?bottle?body?is?formed?in?rectangle?shape,?and?utilized?to?contain?liquid.?The?filling?opening?is?designed?on?the?top?of?the?bottle.?Outside?of?the?filling?opening,?there?is?a?screw?thread?round?cap,?which?can?adjust?the?pressure?according?to?the?patient's?tolerance,?gradually?increasing?the?training?intensity,and?improving?the?training?effect?thereby.?The?blowpipe?can?be?inserted?into?the?bottle?body?and?the?patient?can?blow?the?air?through?the?tube.?Compared?with?the?traditional?rehabilitation?training,?when?the?newly?invented?lung?function?exercise?bottle?has?been?used?for?rehabilitation?exercise,?the?air?pressure?in?the?bottle?can?be?adjusted,?with?the?advantage?of?wider?range?of?application,?lower?cost?and?more?convenient.?It?provides?a?good?solution?for?clinical?and?home-based?rehabilitation?and?is?worth?of?popularizing.