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2.
Multimed Man Cardiothorac Surg ; 20202020 Dec 23.
Artículo en Inglés | MEDLINE | ID: covidwho-1007098

RESUMEN

We describe the insertion of the Impella 5.0, a peripherally placed mechanical cardiovascular microaxial pump, in a patient with ischemic left ventricular dysfunction. The Impella is a 7 Fr device capable of achieving a flow of 4.0-5.0 L/min; its use necessitates an open arterial cut-down. A subclavicular incision is used to access the right or left axillary artery. A 10-mm tube graft is anastomosed to the artery through which the Impella 5.0 is inserted. The device traverses the tube graft and is advanced via the aorta, across the aortic valve, to its final position (inflow toward the ventricular apex and outflow above the aorta). The device may remain in situ for 10 days until recovery or until further supports are instituted. Our goal is to demonstrate the insertion of the Impella 5.0 device in a patient with cardiogenic shock whose situation was further complicated by coronavirus disease 2019.


Asunto(s)
Circulación Asistida , Corazón Auxiliar , Implantación de Prótesis , Infarto del Miocardio con Elevación del ST , Choque Cardiogénico , Adulto , Circulación Asistida/instrumentación , Circulación Asistida/métodos , /terapia , Cateterismo Cardíaco/métodos , Humanos , Masculino , Posición Prona/fisiología , Implantación de Prótesis/instrumentación , Implantación de Prótesis/métodos , Infarto del Miocardio con Elevación del ST/complicaciones , Infarto del Miocardio con Elevación del ST/fisiopatología , Choque Cardiogénico/etiología , Choque Cardiogénico/fisiopatología , Choque Cardiogénico/cirugía , Resultado del Tratamiento
3.
Med Hypotheses ; 146: 110443, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: covidwho-957309

RESUMEN

Managing respiratory status of patients with COVID-19 is a high resource, high risk healthcare challenge. Interventions that decrease need for invasive respiratory support and utilization of bedside staff would benefit patients and healthcare personnel alike. Proning has been established as optimal positioning that may reduce the need for escalation of respiratory support. We propose a new application of a wearable device to decrease supine positioning and ameliorate these risks.


Asunto(s)
/fisiopatología , Pulmón/fisiopatología , Modelos Biológicos , Posición Prona/fisiología , Dispositivos Electrónicos Vestibles , Acelerometría/instrumentación , Sistemas de Computación , Humanos , Posicionamiento del Paciente/instrumentación , Posicionamiento del Paciente/métodos , Tecnología de Sensores Remotos/instrumentación , Tecnología de Sensores Remotos/métodos , /fisiopatología , /terapia
4.
Trials ; 21(1): 940, 2020 Nov 23.
Artículo en Inglés | MEDLINE | ID: covidwho-940029

RESUMEN

OBJECTIVES: To assess the effect of prone positioning therapy on intubation rate in awake patients with COVID-19 and acute respiratory failure. TRIAL DESIGN: This is a two-center parallel group, superiority, randomized (1:1 allocation ratio) controlled trial. PARTICIPANTS: All patients admitted to the Hospital Civil de Guadalajara and Hospital General de Occidente in Mexico for COVID-19 associated acute respiratory failure and in need of supplementary oxygen through high-flow nasal cannula are screened for eligibility. INCLUSION CRITERIA: all adult patients admitted to the COVID-19 unit who test positive for COVID-19 by PCR-test and in need for oxygen are eligible for inclusion. Randomization starts upon identification of requirement of a fraction of inspired oxygen ≥30% for an oxygen capillary saturation of ≥90% Exclusion criteria: less than 18 years-old, pregnancy, patients with immediate need of invasive mechanical ventilation (altered mental status, fatigue), vasopressor requirement to maintain median arterial pressure >65 mmHg, contraindications for prone positioning therapy (recent abdominal or thoracic surgery or trauma, facial, pelvic or spine fracture, untreated pneumothorax, do-not-resuscitate or do-not-intubate order, refusal or inability of the patient to enroll in the study. INTERVENTION AND COMPARATOR: Patients of the intervention group will be asked to remain in a prone position throughout the day as long as possible, with breaks according to tolerance. Pillows will be offered for maximizing comfort at chest, pelvis and knees. Monitoring of vital signs will not be suspended. Inspired fraction of oxygen will be titrated to maintain a capillary saturation of 92%-95%. For patients in the control group, prone positioning will be allowed as a rescue therapy. Staff intensivists will monitor the patient's status in both groups on a 24/7 basis. All other treatment will be unchanged and left to the attending physicians. MAIN OUTCOMES: Endotracheal intubation rate for mechanical ventilation at 28 days. RANDOMISATION: Patients will be randomly allocated to either prone positioning or control group at 1:1 ratio. Such randomization will be computer generated and stratified by center with permuted blocks and length of 4. BLINDING (MASKING): Due to logistical reasons, only principal investigators and the data analyst will be blinded to group assignment. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): With an intubation rate of 60% according to recent reports from some American centers, and assuming a decrease to 40% to be clinically relevant, we calculated a total of 96 patients per group, for a beta error of 0.2, and alpha of 0.5. Therefore, we plan to recruit 200 patients, accounting for minimal losses to follow up, with 100 non-intubated patients in the prone position group and a 100 in the control group. TRIAL STATUS: The local registration number is 048-20, with the protocol version number 2.0. The date of approval is 3rd May 2020. Recruitment started on 3rd May and is expected to end in December 2020. TRIAL REGISTRATION: The protocol was retrospectively registered under the title: "Prone Positioning in Non-intubated Patients With COVID-19 Associated Acute Respiratory Failure. The PRO-CARF trial" in ClinicalTrials.gov with the registration number: NCT04477655. Registered on 20 July 2020. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).


Asunto(s)
Infecciones por Coronavirus/complicaciones , Intubación Intratraqueal/instrumentación , Oxígeno/uso terapéutico , Neumonía Viral/complicaciones , Posición Prona/fisiología , Insuficiencia Respiratoria/etiología , Enfermedad Aguda , Adulto , Betacoronavirus/genética , Cánula/efectos adversos , Cánula/provisión & distribución , Estudios de Casos y Controles , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/virología , Femenino , Hospitalización , Humanos , Intubación Intratraqueal/estadística & datos numéricos , Masculino , México/epidemiología , Oxígeno/administración & dosificación , Oxígeno/sangre , Oxígeno/provisión & distribución , Pandemias , Posicionamiento del Paciente/métodos , Neumonía Viral/epidemiología , Neumonía Viral/virología , Insuficiencia Respiratoria/fisiopatología , Insuficiencia Respiratoria/terapia
5.
Emerg Med J ; 37(6): 379-381, 2020 Jun.
Artículo en Inglés | MEDLINE | ID: covidwho-804150

RESUMEN

A short-cut review of the literature was carried out to examine the potential utility of prone positioning in awake patients with hypoxaemic respiratory failure. Four papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that there is no evidence that regular prone positioning in the awake patient with hypoxaemic respiratory failure impacts on clinically relevant outcomes. Further research is required to evaluate the safety and effectiveness of this intervention, compared with routine mobilisation strategies.


Asunto(s)
Hipoxia/terapia , Posición Prona/fisiología , Insuficiencia Respiratoria/terapia , Humanos , Hipoxia/fisiopatología , Guías de Práctica Clínica como Asunto , Insuficiencia Respiratoria/fisiopatología
8.
Heart Lung ; 49(6): 686-687, 2020.
Artículo en Inglés | MEDLINE | ID: covidwho-720530

RESUMEN

Despite proven benefits to prone positioning in ARDS, a disconnect exists regarding the impressions of its utility among members of the healthcare team. While the majority of physicians view prone positioning as beneficial in ARDS, recent data suggest that the minority of ICU nurses have the same impression. The COVID pandemic has raised particularly challenges in terms of availability of personnel and supplies at least in some institutions. We discuss various barriers to implementation of prone positioning and suggest a number of strategies to optimize patient care. We use a multidisciplinary team approach to execute prone positioning in COVID ARDS.


Asunto(s)
Infecciones por Coronavirus , Pandemias , Posicionamiento del Paciente/métodos , Neumonía Viral , Posición Prona/fisiología , Actitud del Personal de Salud , Betacoronavirus , Infecciones por Coronavirus/enfermería , Infecciones por Coronavirus/terapia , Humanos , Neumonía Viral/enfermería , Neumonía Viral/terapia
11.
J Laryngol Otol ; 134(8): 735-738, 2020 Aug.
Artículo en Inglés | MEDLINE | ID: covidwho-678491

RESUMEN

BACKGROUND: Coronavirus disease 2019 is an international pandemic. One of the cardinal features is acute respiratory distress syndrome, and proning has been identified as beneficial for a subset of patients. However, proning is associated with pressure-related side effects, including injury to the nose and face. METHOD: This paper describes a pressure-relieving technique using surgical scrub sponges. This technique was derived based on previous methods used in patients following rhinectomy. CONCLUSION: The increased use of prone ventilation has resulted in a number of referrals to the ENT team with concerns regarding nasal pressure damage. The described technique, which is straightforward and uses readily available materials, has proven effective in relieving pressure in a small number of patients.


Asunto(s)
Infecciones por Coronavirus/prevención & control , Pandemias/prevención & control , Neumonía Viral/prevención & control , Presión/efectos adversos , Posición Prona/fisiología , Respiración Artificial/métodos , Tapones Quirúrgicos de Gaza/normas , Betacoronavirus/aislamiento & purificación , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/transmisión , Infecciones por Coronavirus/virología , Diseño de Equipo/métodos , Traumatismos Faciales/prevención & control , Humanos , Nariz/lesiones , Nariz/cirugía , Posicionamiento del Paciente/métodos , Neumonía Viral/epidemiología , Neumonía Viral/transmisión , Neumonía Viral/virología
12.
BMC Anesthesiol ; 20(1): 177, 2020 07 20.
Artículo en Inglés | MEDLINE | ID: covidwho-656789

RESUMEN

The management of Acute Respiratory Distress Syndrome (ARDS) secondary to the novel Coronavirus Disease 2019 (COVID-19) proves to be challenging and controversial. Multiple studies have suggested the likelihood of an atypical pathophysiology to explain the spectrum of pulmonary and systemic manifestations caused by the virus. The principal paradox of COVID-19 pneumonia is the presence of severe hypoxemia with preserved pulmonary mechanics. Data derived from the experience of multiple centers around the world have demonstrated that initial clinical efforts should be focused into avoid intubation and mechanical ventilation in hypoxemic COVID-19 patients. On the other hand, COVID-19 patients progressing or presenting into frank ARDS with typical decreased pulmonary compliance, represents another clinical enigma to many clinicians, since routine therapeutic interventions for ARDS are still a subject of debate.


Asunto(s)
Betacoronavirus , Infecciones por Coronavirus/terapia , Cuidados Críticos/métodos , Neumonía Viral/terapia , /terapia , Corticoesteroides/uso terapéutico , Biomarcadores/metabolismo , Técnicas de Laboratorio Clínico/métodos , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/tratamiento farmacológico , Infecciones por Coronavirus/transmisión , Infección Hospitalaria/transmisión , Citocinas/metabolismo , Diagnóstico por Imagen , Oxigenación por Membrana Extracorpórea/métodos , Humanos , Hipoxia/virología , Enfermedades del Sistema Inmune/virología , Intubación Intratraqueal , Bloqueo Neuromuscular/métodos , Pandemias , Posicionamiento del Paciente/métodos , Neumonía Viral/diagnóstico , Neumonía Viral/transmisión , Neumonía Viral/virología , Posición Prona/fisiología , Respiración Artificial/métodos , Trombofilia/virología , Vasodilatadores/uso terapéutico
13.
J Intensive Care Med ; 35(8): 818-824, 2020 Aug.
Artículo en Inglés | MEDLINE | ID: covidwho-634271

RESUMEN

It has been well known for decades that prone positioning (PP) improves oxygenation. However, it has gained widespread acceptance only in the last few years since studies have shown significant survival benefit. Many centers have established prone ventilation in their treatment algorithm for mechanically ventilated patients with severe acute respiratory distress syndrome (ARDS). Physiologically, PP should also benefit awake, non-intubated patients with acute hypoxemic respiratory failure. However, proning in non-intubated (PINI) patients did not gain any momentum until a few months ago when the Coronavirus disease 2019 (COVID-19) pandemic surged. A large number of sick patients overwhelmed the health care system, and many centers faced a dearth of ventilators. In addition, outcomes of patients placed on mechanical ventilation because of COVID-19 infection have been highly variable and often dismal. Hence, increased focus has shifted to using various strategies to prevent intubation, such as PINI. There is accumulating evidence that PINI is a low-risk intervention that can be performed even outside intensive care unit with minimal assistance and may prevent intubation in certain patients with ARDS. It can also be performed safely at smaller centers and, therefore, may reduce the patient transfer to larger institutions that are overwhelmed in the current crisis. We present a case series of 2 patients with acute hypoxemic respiratory failure who experienced significant improvements in oxygenation with PP. In addition, the physiology of PP is described, and concerns such as proning in obese and patient's anxiety are addressed; an educational pamphlet that may be useful for both patients and health care providers is provided.


Asunto(s)
Ansiedad , Infecciones por Coronavirus , Obesidad , Pandemias , Posicionamiento del Paciente/métodos , Neumonía Viral , Posición Prona/fisiología , Insuficiencia Respiratoria , Adulto , Ansiedad/fisiopatología , Ansiedad/prevención & control , Betacoronavirus/aislamiento & purificación , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/metabolismo , Infecciones por Coronavirus/fisiopatología , Infecciones por Coronavirus/terapia , Humanos , Hipoxia/etiología , Hipoxia/terapia , Masculino , Obesidad/epidemiología , Obesidad/fisiopatología , Consumo de Oxígeno , Terapia por Inhalación de Oxígeno/métodos , Neumonía Viral/diagnóstico por imagen , Neumonía Viral/epidemiología , Neumonía Viral/etiología , Neumonía Viral/metabolismo , Neumonía Viral/fisiopatología , Neumonía Viral/psicología , Neumonía Viral/terapia , Respiración Artificial/métodos , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/fisiopatología , Insuficiencia Respiratoria/psicología , Insuficiencia Respiratoria/terapia , Resultado del Tratamiento
15.
Clin Med (Lond) ; 20(4): e97-e103, 2020 07.
Artículo en Inglés | MEDLINE | ID: covidwho-530986

RESUMEN

Medical teams continue to treat many patients with COVID-19 infection. This disease can result in profound hypoxaemia that may necessitate intubation and invasive mechanical ventilation in those who are critically ill. This intervention carries risk to both patients and healthcare workers and utilises significant hospital resource for prolonged periods. Simple, safe interventions that can be used before critical deterioration are highly desirable. The prone position in conscious non-ventilated patients with COVID-19 infection may improve oxygenation in the short term and defer or prevent the need for intubation in some. However, clinicians must be aware that there is a small evidence base for this intervention currently. This review sets out evidence regarding the use of this technique to aid the decision making of frontline staff.


Asunto(s)
Infecciones por Coronavirus/terapia , Posicionamiento del Paciente , Neumonía Viral/terapia , Posición Prona , Estado de Conciencia , Humanos , Terapia por Inhalación de Oxígeno/métodos , Pandemias , Posicionamiento del Paciente/efectos adversos , Posición Prona/fisiología , Respiración Artificial
16.
Acta Paediatr ; 109(8): 1539-1544, 2020 08.
Artículo en Inglés | MEDLINE | ID: covidwho-458994

RESUMEN

The world is facing an explosive COVID-19 pandemic. Some cases rapidly develop deteriorating lung function, which causes deep hypoxaemia and requires urgent treatment. Many centres have started treating patients in the prone position, and oxygenation has improved considerably in some cases. Questions have been raised regarding the mechanisms behind this. The mini review provides some insights into the role of supine and prone body positions and summarises the latest understanding of the responsible mechanisms. The scope for discussion is outside the neonatal period and entirely based on experimental and clinical experiences related to adults. The human respiratory system is a complex interplay of many different variables. Therefore, this mini review has prioritised previous and ongoing research to find explanations based on three scientific areas: gravity, lung structure and fractal geometry and vascular regulation. It concludes that gravity is one of the variables responsible for ventilation/perfusion matching but in concert with lung structure and fractal geometry, ventilation and regulation of lung vascular tone. Since ventilation distribution does not change between supine and prone positions, the higher expression of nitric oxide in dorsal lung vessels than in ventral vessels is likely to be the most important mechanism behind enhanced oxygenation in the prone position.


Asunto(s)
Infecciones por Coronavirus/fisiopatología , Infecciones por Coronavirus/terapia , Hipoxia/prevención & control , Neumonía Viral/fisiopatología , Neumonía Viral/terapia , Humanos , Pandemias , Posición Prona/fisiología
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