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ABSTRACT Objective: To describe, with a larger number of patients in a real-world scenario following routine implementation, intensivist-led ultrasound-guided percutaneous dilational tracheostomy and the possible risks and complications of the procedure not identified in clinical trials. Methods: This was a phase IV cohort study of patients admitted to three intensive care units of a quaternary academic hospital who underwent intensivist-led ultrasound-guided percutaneous tracheostomy in Brazil from September 2017 to December 2021. Results: There were 4,810 intensive care unit admissions during the study period; 2,084 patients received mechanical ventilation, and 287 underwent tracheostomy, 227 of which were performed at bedside by the intensive care team. The main reason for intensive care unit admission was trauma, and for perform a tracheostomy it was a neurological impairment or an inability to protect the airways. The median time from intubation to tracheostomy was 14 days. Intensive care residents performed 76% of the procedures. At least one complication occurred in 29.5% of the procedures, the most common being hemodynamic instability and extubation during the procedure, with only 3 serious complications. The intensive care unit mortality was 29.1%, and the hospital mortality was 43.6%. Conclusion: Intensivist-led ultrasound-guided percutaneous tracheostomy is feasible out of a clinical trial context with outcomes and complications comparable to those in the literature. Intensivists can acquire this competence during their training but should be aware of potential complications to enhance procedural safety.
RESUMO Objetivo: Descrever, com um número maior de pacientes em um cenário do mundo real após a implementação rotineira, a traqueostomia percutânea guiada por ultrassom conduzida por intensivistas e os possíveis riscos e complicações do procedimento não identificados em estudos clínicos. Métodos: Trata-se de estudo de coorte de fase IV de pacientes internados em três unidades de terapia intensiva de um hospital acadêmico quaternário que foram submetidos a traqueostomia percutânea guiada por ultrassom conduzida por intensivistas no Brasil de setembro de 2017 a dezembro de 2021. Resultados: Entre as 4.810 admissões na unidade de terapia intensiva durante o período do estudo, 2.084 pacientes receberam ventilação mecânica, e 287 foram submetidos a traqueostomia, 227 das quais foram realizadas à beira do leito pela equipe de terapia intensiva. O principal motivo para a admissão na unidade de terapia intensiva foi trauma, e para a realização de uma traqueostomia foi comprometimento neurológico ou incapacidade de proteger as vias aéreas. O tempo médio entre a intubação e a traqueostomia foi de 14 dias. Residentes de terapia intensiva realizaram 76% dos procedimentos. Ao menos uma complicação ocorreu em 29,5% dos procedimentos, sendo instabilidade hemodinâmica e extubação durante o procedimento as complicações mais comuns, com apenas três complicações graves. A mortalidade na unidade de terapia intensiva foi de 29,1%, e a mortalidade hospitalar foi de 43,6%. Conclusão: A traqueostomia percutânea guiada por ultrassom conduzida por intensivistas é viável fora do contexto de um estudo clínico com resultados e complicações comparáveis aos da literatura. Os intensivistas podem adquirir essa competência durante seu treinamento, mas devem estar cientes das possíveis complicações para aumentar a segurança do procedimento.
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Introducción: Los pacientes neurocríticos son aquellos con afectaciones en el sistema nervioso central y otros sistemas vitales, principalmente como consecuencia de traumatismos severos o complicaciones graves derivadas de enfermedades degenerativas. Su atención es fundamental durante el ingreso a las Unidades de Cuidados Intensivos (UCI), y su correcta realización por parte del personal de enfermería puede ser un factor decisivo para reducir efectos colaterales. Objetivo: Reconocer los niveles de conocimientos sobre el cuidado de pacientes neurocríticos del personal de enfermería de la UCI del Centro Médico Naval. Materiales y métodos: Se adaptó un instrumento para la evaluación de los cuidados en pacientes neurocríticos y se conformaron trece reactivos en forma de indicadores sobre tipo de conocimientos. Además, se aplicó una prueba no paramétrica de chi-cuadrada para variables cualitativas y una prueba exacta de Fisher. Resultados: El estudio arrojó una correlación entre un mayor nivel de conocimientos y los años de experiencia (p<0.005), el nivel de estudios (p<0.001) y la edad (p<0.002). No se encontraron asociaciones con el sexo o el turno de servicio. Conclusiones: En 22.5% de los casos se obtuvo un nivel regular de conocimientos, 2.5% tuvo un nivel deficiente y el 75% restante obtuvo un nivel de conocimientos por encima de lo esperado. La asociación entre el nivel de conocimientos sobre el cuidado de pacientes neurocríticos y el nivel de estudios, así como los años de experiencia en servicio, permiten mejorar las técnicas de atención a través de la capacitación continua del personal de enfermería.
Introduction: Neurocritical patients are those who suffer injuries in the central nervous system and other vital systems, mainly as a result of severe trauma or serious complications derived from degenerative diseases. The adequate care of these patients is essential during their admission to the Intensive Care Units (ICU); correct nursing staff performance is determinant to reduce collateral effects. Objective: To assess the level of neurocritical care expertise of the nursing staff of the ICU in the Centro Médico Naval. Materials and methods: An instrument for the evaluation of neurocritical care was adapted and 13 test items were used as indicators. In addition, a nonparametric chi-square test for qualitative variables and a Fisher exact test were applied. Results: The study showed a significant correlation between a higher level of knowledge and years of experience (p<0.005), level of education (p<0.001) and age (p<0.002). No associations were found between gender and nursing shift. Conclusions: 22.5% of the nursing staff had an average level of knowledge, 2.5% had a deficient level, and the remaining 75% had an unexpectedly high level of knowledge. The association between neurocritical care expertise and educational background, as well as the years of experience, generate an improvement in care skills through the continuous training of nursing staff.
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Humanos , Masculino , Feminino , Adulto , Cuidados Críticos , Avaliação Educacional , Unidades de Terapia IntensivaRESUMO
Due to primary diseases of neurocritical care unit (NCU) patients, they have particularities with low level of consciousness, poor airway protective ability, damaged respiratory drive and respiratory motor conduction pathway. Such patients have higher rates of weaning difficulty, delayed extubation, extubation failure and tracheostomy. There are several guidelines on weaning and extubation for intensive care unit (ICU) patients, while there are no guidelines for for NCU patients. Therefore, we reviewed current guidelines and recommendations on weaning and extubation in both ICU and NCU patients suggesting considerations of neurological condition, level of consciousness and presence of airway protective reflexes before extubation, moreover, we introduced researches about protocols of weaning for NCU patients and related predictors.
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To explore the effect of post-pyloric feeding by spiral nasoenteric tubes on ventilator-associated pneumonia (VAP) in neurocritical care patients. Methods A retrospective study was performed to analyze the clinical data of 175 neurocritical care adult patients with mechanical ventilation (MV) more than 48 hours, who were enrolled in three randomized controlled trials (RCT) conducted by Guangdong Provincial People's Hospital for post-pyloric tube placement between April 2012 to March 2019. The following patient clinical data were collected when patients were enrolled: gender, age, neurologic diagnosis, comorbidities, medication, endotracheal reintubation, bronchoscope treatment, the distal site of nasoenteric tubes, and acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score, sequential organ failure assessment (SOFA) score, Glasgow coma scale (GCS) score, and acute gastrointestinal injury (AGI) grade assessed. Patients were divided into VAP group and non-VAP group according to the occurrence of VAP, and the differences of each index between the two groups were compared. Then the influencing factors of P < 0.1 were included in multivariate Logistic regression analysis to identify the potential risk factors affecting the incidence of VAP. Furthermore, patients were divided into gastric feeding group and post-pyloric feeding group according to the distal site of nasoenteric tubes, and subgroup analysis was performed to evaluate the variety of VAP in patients with different tube sites and status. Results ① Forty-two patients occurred VAP in 175 MV patients, and the incidence of VAP was 24.0%. ② Univariate analysis showed the P value of post-pyloric feeding, APACHE Ⅱscore, GCS score and bronchoscope treatment were less than 0.1, and post-pyloric feeding and GCS score in VAP group were significantly lower than those in non-VAP group [post-pyloric feeding: 19.0% (8/42) vs. 36.8% (49/133), GCS:5 (3, 7) vs. 6 (4, 9), both P < 0.05]. Multivariate Logistic regression analysis indicated that post-pyloric feeding was independent protective factor [odds ratio (OR) = 0.360, 95% confidence internal (95%CI) = 0.151-0.857, P = 0.021] and bronchoscope treatment was the independent risk factor (OR = 2.210, 95%CI = 1.051-4.647, P = 0.036) for VAP. ③ The incidence of VAP was 28.8% (34/118), 0% (0/4), 8.3% (1/12), 26.7% (4/15), 22.2% (2/9) and 5.9% (1/17) respectively when tube tip in stomach, D1, D2, D3, D4 and jejunum confirmed by abdominal radiography. Post-pyloric feeding in each proportion seemed to present lower VAP rate compared with gastric feeding, however, no significant difference was found (all P > 0.05). ④ The incidence of VAP in post-pyloric feeding group was significantly lower than that in gastric feeding group [14.0% (8/57) vs. 28.8% (34/118), OR = 0.403, 95%CI = 0.173-0.941, P = 0.032]. Lower VAP rate appeared on patients with SOFA < 12 (OR = 0.392, 95%CI = 0.154-0.995, P = 0.044) and AGI grade ≥Ⅱ (OR =0.086, 95%CI = 0.011-0.705, P = 0.006) fed by post-pyloric route according to the result of subgroup analysis stratified by age, gender, APACHEⅡ score, SOFA score and AGI grade. Conclusion Post-pyloric feeding would decrease the incidence of VAP in neurocritical care patients on MV.
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The training of neurocritical care is an important component in standardized training of neurosurgical specialists. As a subspeciality of neurosurgery, as well as with the characteristics of critical care medicine, neurocritical care carries its own discipline features. Based on clinical training and practice experiences, the training mode and practice experience were summarized, including basic requirement, theory training, skill training, research training, humanity accomplishment improvement and evaluation stan-dard, in order to discuss the appropriate training mode of neurocritical care in standardized training of neurosurgical specialists, improve the training methods and advance the training effectiveness, and provide reference for cultivating qualified and comprehensively developed neurosurgical specialists.
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Transcranial Doppler ultrasonography(TCD)can be usd to monitor the cerebral blood flow changes noninvasively in real time. It provides important information for cerebrovascular hemodynamics in children with nervous system diseases,especially for the critically ill children.TCD is widely used in diagnosis and therapy of traumatic brain injury,increased intracranial pressure,cerebral vasospasm,stroke,cerebral vascular dysfunction,central nervous system infection,brain death.TCD can reveal the cerebral perfusion and the response to the treatment and help to guide the treatment.Besides,through the analysis of the change of the cerebrovascular hemodynamics,we can find the underlying pathophysiology mechanism of the diseases. In this paper,the application of TCD was reviewed to spread the use of TCD in monitoring and treantment of children in PICU.
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Objetivos: Revisar sistemáticamente la evidencia relacionada con el monitoreo de la presion intracraneana en unidades de cuidado neurocrítico en el contexto de trauma craneoencefálico severo. Criterios de elección: Ensayos clínicos aleatorizados que comparen el uso del monitoreo de la presión intracraneana (PIC) que muestren un estimado de mortalidad/discapacidad a 6 meses, en pacientes mayores de 12 años de edad con trauma craneoencefálico severo (escala de Glasgow menor a 8). Método de búsqueda: En Medline, el Registro Central de Ensayos Controlados (CENTRAL); PubMed, HINARI, EMBASE; Grupo Cochrane de Lesiones y las listas de referencias de artículos. De acuerdo con el Manual Cochrane para meta-análisis y revisión sistemática. Resultados: No hubo diferencias entre el grupo de PIC y el control en el pronóstico de discapacidad (RR [Riesgo Relativo]1.01, 95 por ciento CI 0.87 to 1.18). Sin embargo, el monitoreo de la PIC reduce la estancia en UCI en comparación con otros métodos. La estancia en UCI con tratamiento cerebral específico también se redujo en comparación con grupo control. Conclusiones: En pacientes con trauma craneoencefálico, no hubo diferencia entre el monitoreo de la PIC y el examen clínico sin embargo, para mantener una PIC baja, hubo una sustancial reducción de requerimiento de solución salina hipertónica y un descenso en la hiperventilación trayendo consigo beneficios para pacientes en UCI.
Objectives: To systematically review the evidence of intracranial pressure monitoring in neuro critical care unit in the context of a severe head injury. Study eligibility criteria: Patients were older than 12 years ,had a severe traumatic brain injury (Glasgow coma scale < 8), that compared the use of ICP monitoring with control, that presented an estimate of mortality/ disability prognosis 6 months after injury.only randomized clinical trials. Methods: Searched MEDLINE, the Central Registerof Controlled Trials (CENTRAL); PubMed, HINARI,EMBASE; Cochrane Injuries group and the reference lists of articles. In accordance with the Cochrane handbook for meta-analysis and systematic review. Results: In the ICP and control groups there was no difference in the prognosis of disability (RR [Relative Risk]1.01, 95 percent CI 0.87 to 1.18). However, ICP monitoring reduced the duration of stay in ICU compared to other surveillance methods. The stay in the ICU with specific medical support for brain injury was also reduced compared to the control group. Conclusions: In patients with severe traumatic brain injury, the ICP monitoring was not difference to imaging and clinical examination. However, by keeping the ICP low there was a substantial reduction in the requirement for hypertonic saline and a decrease in hyperventilation providing benefits to thepatient in the ICU.
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Humanos , Unidades de Terapia Intensiva , Pressão Intracraniana , Monitorização Neurofisiológica/métodos , Traumatismos Craniocerebrais/complicações , Traumatismos Craniocerebrais/mortalidade , Cuidados Críticos , PrognósticoRESUMO
Advances in resuscitation and intensive care have led to high rates of survival among neonates with life -threatening conditions such as asphyxia,prematurity and congenital malformations.The sequelae of neurologic con-ditions arises in the neonatal period include lifelong disabilities such as cerebral palsy,epilepsy,intellectual and beha-vioral disabilities.There is an increasing demand for resource -intense strategies for acute neurological care within neo-natal intensive care unit.Neonatal neurocritical care is a multidisciplinary subspecialty that combines expertise in neo-natology,pediatric neurology,radiology,rehabilitation,surgery,and has led to improved outcomes in newborn that have critical illnesses.Neonatal neurocritical care focus the needs of the developing newborn brain,including attention to physiology to help prevent secondary brain injury,a protocol -driven approach for common conditions such as hypoxic -ischemic encephalopathy and seizures,education of specialized teams that use brain monitoring and imaging to evaluate the effect of critical illness on brain function.