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1.
Bertrand Sauneuf Claire Bouffard Edouard Cornet Cédric Daubin Isabelle Desmeulles Romain Masson Amélie Seguin Xavier Valette Nicolas Terzi Jean-Jacques Parienti Damien du Cheyron 《Resuscitation》2014
Background
The immature/total granulocyte (I/T-G) ratio increases during severe systemic inflammatory response syndrome. This study evaluated the I/T-G ratio as a predictor of poor outcome after out-of-hospital cardiac arrest (OHCA).Methods
We conducted a pilot prospective cohort study of patients who were admitted in our intensive care unit (ICU) during a one-year period after post-OHCA resuscitation. I/T-G ratio measurements were obtained from blood samples collected on admission using flow cytometry and the outcomes were ICU mortality and post-cardiac arrest syndrome.Results
Among the 130 patients (76% male, median age 54 [46–67] years), the median I/T-G ratio was 0.85 [0.42–1.98]%. The I/T-G ratio was poorly correlated with the SOFA score and lactate level on day 1 (r = 0.25, p = 0.005 and r = 0.5, p < 0.001, respectively). Patients with high I/T-G ratios were more likely to develop post-resuscitation shock (37% vs. 58%, p = 0.02). Patients dying from post-resuscitation shock had a higher I/T-G ratio than patients dying from neurological causes (2 [1–4]% vs. 1.2 [0.6–1.2]%, p = 0.02). The area under the ROC curve based on the I/T-G ratio was 0.82 for predicting ICU mortality.Conclusion
The I/T-G ratio appears to be an accurate predictor of poor outcome. However, the added clinical value of this marker and the possible involvement of immature granulocytes in the pathophysiology of post-cardiac arrest syndrome remain to be investigated. 相似文献2.
Yasser G. Omar Michael Massey Lars W. Andersen Tyler A. Giberson Katherine Berg Michael N. Cocchi Nathan I. Shapiro Michael W. Donnino 《Resuscitation》2013
Aim
We hypothesized that microcirculatory dysfunction, similar to that seen in sepsis, occurs in post-cardiac arrest patients and that better microcirculatory flow will be associated with improved outcome. We also assessed the association between microcirculatory dysfunction and inflammatory markers in the post-cardiac arrest state.Methods
We prospectively evaluated the sublingual microcirculation in post-cardiac arrest patients, severe sepsis/septic shock patients, and healthy control patients using Sidestream Darkfield microscopy. Microcirculatory flow was assessed using the microcirculation flow index (MFI) at 6 and 24 h in the cardiac arrest patients, and within 6 h of emergency department admission in the sepsis and control patients.Results
We evaluated 30 post-cardiac arrest patients, 16 severe sepsis/septic shock patients, and 9 healthy control patients. Sublingual microcirculatory blood flow was significantly impaired in post-cardiac arrest patients at 6 h (MFI 2.6 [IQR: 2–2.9]) and 24 h (2.7 [IQR: 2.3–2.9]) compared to controls (3.0 [IQR: 2.9–3.0]; p < 0.01 and 0.02, respectively). After adjustment for initial APACHE II score, post-cardiac arrest patients had significantly lower MFI at 6-h compared to sepsis patients (p < 0.03). In the post-cardiac arrest group, patients with good neurologic outcome had better microcirculatory blood flow as compared to patients with poor neurologic outcome (2.9 [IQR: 2.4–3.0] vs. 2.6 [IQR: 1.9–2.8]; p < 0.03). There was a trend toward higher median MFI at 24 h in survivors vs. non-survivors (2.8 [IQR: 2.4–3.0] vs. 2.6 [IQR: 2.1–2.8] respectively; p < 0.09). We found a negative correlation between MFI-6 and vascular endothelial growth factor (VEGF) (r = −0.49, p = 0.038). However, after Bonferroni adjustment for multiple comparisons, this correlation was statistically non-significant.Conclusion
Microcirculatory dysfunction occurs early in post-cardiac arrest patients. Better microcirculatory function at 24 h may be associated with good neurologic outcome. 相似文献3.
Aim of the study
The introduction of a paediatric Medical Emergency Team (pMET) was accompanied by integration of weekly in situ simulation team training into routine clinical practice. On a rotational basis, all key ward staff participated in team training, which focused on recognition of the deteriorating child, teamwork and early consultant review of patients with evolving critical illness. This study aimed to evaluate the impact of regular team training on the hospital response to deteriorating in-patients and subsequent patient outcome.Methods
Prospective cohort study of all deteriorating in-patients of a tertiary paediatric hospital requiring admission to paediatric intensive care (PICU) the year before, and after, the introduction of pMET and concurrent team training.Results
Deteriorating patients were: recognised more promptly (before/after pMET: median time 4/1.5 h, p < 0.001), more often reviewed by consultants (45%/76%, p = 0.004), more often transferred to high dependency care (18%/37%, p = 0.021) and more rapidly escalated to intensive care (median time 10.5/5 h, p = 0.024). These improved responses by ward staff extended beyond direct involvement of pMET.There was a trend towards fewer PICU admissions, reduced level of sickness at the time of PICU admission, reduced length of PICU stay and reduced PICU mortality. Introduction of pMET coincided with significantly reduced hospital mortality (p < 0.001).Conclusions
These results indicate that lessons learnt by ward staff during regular in situ team training led to significantly improved recognition and management of deteriorating in-patients with evolving critical illness. Integration of in situ simulation team training in clinical care has potential applications beyond paediatrics. 相似文献4.
John Bro-Jeppesen Jesper Kjaergaard Helle Søholm Michael Wanscher Freddy K. Lippert Jacob E. Møller Lars Køber Christian Hassager 《Resuscitation》2014
Aim
Inducing therapeutic hypothermia (TH) in Out-of-Hospital Cardiac Arrest (OHCA) can be challenging due to its impact on central hemodynamics and vasopressors are frequently used to maintain adequate organ perfusion. The aim of this study was to assess the association between level of vasopressor support and mortality.Methods
In a 6-year period, 310 comatose OHCA patients treated with TH were included. Temperature, hemodynamic parameters and level of vasopressors were registered from admission to 24 h after rewarming. Level of vasopressor support was assessed by the cardiovascular sub-score of Sequential Organ Failure Assessment (SOFA). The population was stratified by use of dopamine as first line intervention (D-group) or use of dopamine + norepinephrine/epinephrine (DA-group). Primary endpoint was 30-day mortality and secondary endpoint was in-hospital cause of death.Results
Patients in the DA-group carried a 49% all-cause 30-day mortality rate compared to 23% in the D-group, plog-rank < 0.0001, corresponding to an adjusted hazard ratio (HR) of 2.0 (95% CI: 1.3–3.0), p = 0.001). The DA-group had an increased 30-day mortality due to neurological injury (HR = 1.7 (95% CI: 1.1–2.7), p = 0.02). Cause of death was anoxic brain injury in 78%, cardiovascular failure in 18% and multi-organ failure in 4%. The hemodynamic changes of TH reversed at normothermia, although the requirement for vasopressor support (cardiovascular SOFA ≥ 3) persisted in 80% of patients.Conclusions
In survivors after OHCA treated with TH the induced hemodynamic changes reversed after normothermia, while the need for vasopressor support persisted. Patients requiring addition of norepinephrine/epinephrine on top of dopamine had an increased 30-day all-cause mortality, as well as death from neurological injury. 相似文献5.
Christopher L. Hunter MD PhD Salvatore Silvestri Matthew DeanJay L. Falk MD Linda Papa 《The American journal of emergency medicine》2013
Objective
Exhaled end-tidal carbon dioxide (Etco2) concentration is associated with lactate levels in febrile patients. We assessed the association of Etco2 with mortality and lactate levels in patients with suspected sepsis.Methods
This was a prospective observational study. We enrolled 201 adult patients presenting with suspected infection and 2 or more systemic inflammatory response syndrome criteria. Lactate and Etco2 were measured and analyzed with patient outcomes.Results
The area under the receiver operator characteristics curve (AUC) was 0.75 (confidence interval [CI], 0.65-0.86) for lactate and mortality and 0.73 (CI, 0.61-0.84) for Etco2 and mortality. When analyzed across the different categories of sepsis, the AUCs for lactate and mortality were 0.61 (CI, 0.36-0.87) for sepsis, 0.69 (CI, 0.48-0.89) for severe sepsis, and 0.74 (CI, 0.55-0.93) for septic shock. The AUCs for Etco2 and mortality were 0.60 (CI, 0.37-0.83) for sepsis, 0.67 (CI, 0.46-0.88) for severe sepsis, and 0.78 (CI, 0.59-0.96) for septic shock. There was a significant inverse relationship between Etco2 and lactate in all categories, with correlation coefficients of − 0.421 (P < .001) in the sepsis group, − 0.597 (P < .001) in the severe sepsis group, and − 0.482 (P = .011), respectively. Adjusted odds ratios were calculated, demonstrating 3 significant predictors of mortality: use of vasopressors 16.4 (95% CI, 1.80-149.2), mechanical ventilation 16.4 (95% CI, 3.13-85.9), and abnormal Etco2 levels 6.48 (95% CI, 1.06-39.54).Conclusions
We observed a significant association between Etco2 concentration and in-hospital mortality in emergency department patients with suspected sepsis across a range of disease severity. 相似文献6.
D. Grimaldi E. Guivarch N. Neveux J. Fichet F. Pène J.-S. Marx J.-D. Chiche L. Cynober J.-P. Mira A. Cariou 《Resuscitation》2013
Aims
Gut dysfunction is suspected to play a major role in the pathophysiology of post-resuscitation disease through an increase in intestinal permeability and endotoxin release. However this dysfunction often remains occult and is poorly investigated. The aim of this pilot study was to explore intestinal failure biomarkers in post-cardiac arrest patients and to correlate them with endotoxemia.Methods
Following resuscitation after cardiac arrest, 21 patients were prospectively studied. Urinary intestinal fatty acid-binding protein (IFABP), which marks intestinal permeability, plasma citrulline, which reflects the functional enterocyte mass, and whole blood endotoxin were measured at admission, days 1–3 and 6. We explored the kinetics of release and the relationship between IFABP, citrulline and endotoxin values.Results
IFABP was extremely high at admission and normalized at D3 (6668 pg/mL vs 39 pg/mL, p = 0.01). Lowest median of citrulline (N = 20–40 μmol/L) was attained at D2 (11 μmol/L at D2 vs 24 μmol/L at admission, p = 0.01) and tended to normalize at D6 (21 μmol/L). During ICU stay, 86% of patients presented a detectable endotoxemia. Highest endotoxin level was positively correlated with highest IFABP level (R2 = 0.31, p = 0.01) and was inversely correlated with lowest plasma citrulline levels (R2 = 0.55, p < 0.001). Endotoxin levels increased between admission and D2 in patients with post-resuscitation shock, whereas it decreases in patients with no shock (median +0.33 EU vs −0.19 EU, p = 0.03). Highest endotoxin level was positively correlated with D3 SOFA score (R2 = 0.45, p = 0.004).Conclusion
Biomarkers of intestinal injury are altered after cardiac arrest and are associated with endotoxemia. This could worsen post-resuscitation shock and organ failure. 相似文献7.
Helle Søholm Kristian Wachtell Søren Loumann Nielsen John Bro-Jeppesen Frants Pedersen Michael Wanscher Søren Boesgaard Jacob Eifer Møller Christian Hassager Jesper Kjaergaard 《Resuscitation》2013
Aims
Out-of-hospital cardiac arrest (OHCA) has been reported to carry very varying morbidity and mortality. However, it remains unclear whether this is caused by intrinsic factors of the OHCA or due to the level of in-hospital care. The aim of this study is to compare 30-day and long-term mortality after OHCA at tertiary heart centres and non-tertiary university hospitals.Methods and results
Data from the Copenhagen OHCA registry from June 2002 through December 2010 included a total of 1218 consecutive patients treated by the same mobile emergency care unit (MECU) with either return of spontaneous circulation (ROSC) or on-going resuscitation (n = 53) at hospital arrival. The MECU transported patients to the nearest hospital unless an ECG on scene suggested ST-segment elevation myocardial infarction, in which case patients were transported to the nearest tertiary centre for acute coronary angiography. Therefore, patients with ST-elevation myocardial infarction (n = 198) were excluded from the analysis. 30-day mortality was 56% vs. 76% and long term (up to 8 years) mortality was 78% vs. 94% for tertiary and non-tertiary hospitals, respectively, both p < 0.001. Multivariate analysis showed that admission to a non-tertiary hospital was independently associated with increased risk of death (HR = 1.32, 95% CI: 1.09–1.59, p = 0.004). Exclusion of patients with on-going resuscitation at admission resulted in HR = 1.34 (1.11–1.62), p = 0.003. A matched pair propensity score analysis of 255 patients confirmed the results of the proportional hazard analysis (HR = 1.35, 95% CI: 1.11–1.65 p = 0.003).Conclusion
Admission to tertiary centres is associated with lower mortality rates after OHCA compared with non-tertiary hospitals. 相似文献8.
Objective
To evaluate pre-arrest morbidity score (PAM), prognosis after resuscitation score (PAR) and to identify additional clinical variables associated with survival after in-hospital cardiac arrest (IHCA) treated with cardiopulmonary resuscitation (CPR).Methods
A retrospective observational study involving all cases of IHCA at Skåne University Hospital Malmö 2007–2010.Results
Two-hundred-eighty-seven cases of IHCA were identified (61.3% male; mean age 70 years) of whom 20.2% survived until discharge. The odds ratio (95% confidence interval) for death prior to discharge was 6.49 (1.50–28.19) (p = 0.013) for PAM > 6 and 3.88 (1.95–7.73) (p < 0.001) for PAR > 4. At PAM- and PAR-scores >5, specificity exceeded 90%, while sensitivity was only 20–30%. The odds ratio for in-hospital mortality was 0.38 (0.20–0.72) (p = 0.003) for patients with cardiac monitoring, 9.86 (5.08–19.12) (p < 0.001) for non-shockable vs shockable rhythm, 0.32 (0.15–0.69) (p = 0.004) for presence of ST-elevation myocardial infarction (STEMI), 0.27 (0.09–0.78) (p = 0.016) for patients with independent Activities of Daily Life (ADL) and 13.86 (1.86–103.46) (p = 0.010) for patients with malignancies. Heart rate (HR) on admission (per bpm) [1.024 (1.009–1.040) (p = 0.002)] and sodium plasma concentration on admission (per mmol l−1) [0.92 (0.85–0.99) (p = 0.023)] were significantly associated with in-hospital mortality.Conclusion
PAM- and PAR-scores do not sufficiently discriminate between in-hospital death and survival after IHCA to be used as clinical tools guiding CPR decisions. We confirm that malignancy is associated with increased in-hospital mortality, and cardiac monitoring, shockable rhythm, STEMI and independent ADL, with decreased in-hospital mortality. Interestingly, our results suggest that HR and plasma sodium concentration upon admission may represent new tools for risk stratification. 相似文献9.
Aim
The aim of this study was to evaluate the effect of multi-professional full-scale simulation-based education of staff on the mortality and staff awareness of patients at risk on general wards.Design, settings and patients
A prospective before-and-after study conducted on four general wards at Herlev Hospital, Denmark. In the pre-intervention period (June–July 2006) and post-intervention period (November–December 2007), all patients on the wards had vital signs measured in the evening by study personnel, who also asked nursing staff questions about patients with abnormal vital signs. The mortality of patients with abnormal vital signs was registered from the hospital database. Simplified medical emergency team calling criteria were used to define abnormal vital signs.Intervention
In the intervention period (February–June 2007), 50% of medical and 70% of nursing staff on the wards (app. 220 members of staff) were trained in a 1-day multi-professional full-scale simulation-based course.Results
In the pre- and post-intervention periods, 690 and 873 patients were included and of these 129 and 155, respectively, had abnormal vital signs. No significant differences were observed between the pre- and post-intervention periods concerning the incidence of patients with abnormal vital signs (p = 0.64), staff awareness of patients at risk (p = 0.80), 30-day mortality (p = 1.00), 180-day mortality (p = 1.00) or length of hospital stay (p = 0.11) among patients at risk.Conclusions
This multi-professional education of staff did not affect the rate of mortality or staff awareness of patients at risk on the wards. 相似文献10.
Wayne F. GuerraThomas R. Mayfield MS NREMT-P Mary S. MeyersAnne E. Clouatre MHS EMT-P John C. Riccio MD 《The Journal of emergency medicine》2013
Background
Severe sepsis is a condition with a high mortality rate, and the majority of patients are first seen by Emergency Medical Services (EMS) personnel.Objective
This research sought to determine the feasibility of EMS providers recognizing a severe sepsis patient, thereby resulting in better patient outcomes if standard EMS treatments for medical shock were initiated.Methods
We developed the Sepsis Alert Protocol that incorporates a screening tool using point-of-care venous lactate meters. If severe sepsis was identified by EMS personnel, standard medical shock therapy was initiated. A prospective cohort study was conducted for 1 year to determine if those trained EMS providers were able to identify 112 severe sepsis patients before arrival at the Emergency Department. Outcomes of the sample of severe sepsis patients were examined with a retrospective case control study.Results
Trained EMS providers transported 67 severe sepsis patients. They identified 32 of the 67 severe sepsis patients correctly (47.8%). Overall mortality for the sample of 112 severe sepsis patients transported by EMS was 26.7%. Mortality for the sample of severe sepsis patients for whom the Sepsis Alert Protocol was initiated was 13.6% (5 of 37), crude odds ratio for survival until discharge was 3.19 (95% CI 1.14–8.88; p = 0.040).Conclusions
This pilot study is the first to utilize EMS providers and venous lactate meters to identify patients in severe sepsis. Further research is needed to validate the Sepsis Alert Protocol and the potential associated decrease in mortality. 相似文献11.
Background
Erythropoietin activates potent protective mechanisms in non-hematopoietic tissues including the myocardium. In a rat model of ventricular fibrillation, erythropoietin preserved myocardial compliance enabling hemodynamically more effective CPR.Objective
To investigate whether intravenous erythropoietin given within 2 min of physician-led CPR improves outcome from out-of-hospital cardiac arrest.Methods
Erythropoietin (90,000 IU of beta-epoetin, n = 24) was compared prospectively with 0.9% NaCl (concurrent controls = 30) and retrospectively with a preceding group treated with similar protocol (matched controls = 48).Results
Compared with concurrent controls, the erythropoietin group had higher rates of ICU admission (92% vs 50%, p = 0.004), return of spontaneous circulation (ROSC) (92% vs 53%, p = 0.006), 24-h survival (83% vs 47%, p = 0.008), and hospital survival (54% vs 20%, p = 0.011). However, after adjusting for pretreatment covariates only ICU admission and ROSC remained statistically significant. Compared with matched controls, the erythropoietin group had higher rates of ICU admission (92% vs 65%, p = 0.024) and 24-h survival (83% vs 52%, p = 0.014) with statistically insignificant higher ROSC (92% vs 71%, p = 0.060) and hospital survival (54% vs 31%, p = 0.063). However, after adjusting for pretreatment covariates all four outcomes were statistically significant. End-tidal PCO2 (an estimate of blood flow during chest compression) was higher in the erythropoietin group.Conclusions
Erythropoietin given during CPR facilitates ROSC, ICU admission, 24-h survival, and hospital survival. This effect was consistent with myocardial protection leading to hemodynamically more effective CPR (Trial registration: http://isrctn.org. Identifier: ISRCTN67856342). 相似文献12.
Assad Haneya Alois Philipp Claudius Diez Simon Schopka Thomas Bein Markus Zimmermann Matthias Lubnow Andreas Luchner Ayman Agha Michael Hilker Stephan Hirt Christof Schmid Thomas Müller 《Resuscitation》2012
Background
Cardiopulmonary resuscitation (CPR) using extracorporeal life support (ECLS) system has been successfully used to support patients with in- and out-of-hospital cardiac arrest (IHCA, OHCA) when conventional measures have failed. The purpose of the current study is to report on our experience with extracorporeal CPR in non-postcardiotomy patients.Methods
We retrospectively analysed a total of 85 consecutive adult patients, who have been treated with ECLS between January 2007 and January 2012.Results
The mean CPR duration was 40 min (20–70 min). The mean ECLS support duration was 49 h (12–92 h). Twenty-eight patients (33%) had ECLS related complications. Forty patients (47%) were successfully weaned and 29 patients (34%) survived to hospital discharge. Among survivors, 93% were without severe neurologic deficit. Duration of CPR was shorter for survivors than for non-survivors [(25: 20–50 min) vs. (50: 25–86 min); p = 0.003]. Immediately after ECLS start, the mean blood lactate level was lower (p = 0.003), and the mean pH value was higher in the survivors’ group (p < 0.0001) compared to the non-survivors’ group. The CPR duration for the IHCA group (25: 20–50 min) was shorter compared to the OHCA group (70: 55–110 min; p < 0.0001). The survival rate in this group was higher compared to the OHCA group (42% vs. 15%; p < 0.02).Conclusions
CPR using modern miniaturized ECLS systems should be established in the treatment of prolonged cardiac arrest and unsuccessful conventional CPR in selected patients. CPR with ECLS for OHCA has worse outcomes compared to IHCA. Duration of CPR was independent risk factor for mortality after extracorporeal CPR. 相似文献13.
Christian Torgersen Jurka Meichtry Christian A. SchmittingerStefan Bloechlinger Stephan M. JakobJukka Takala Martin W. Dünser 《Resuscitation》2013
Aim of the study
To evaluate the association between haemodynamic variables during the first 24 h after intensive care unit (ICU) admission and neurological outcome in out-of-hospital cardiac arrest (OHCA) victims undergoing therapeutic hypothermia.Methods
In a multi-disciplinary ICU, records were reviewed for comatose OHCA patients undergoing therapeutic hypothermia. The hourly variable time integral of haemodynamic variables during the first 24 h after admission was calculated. Neurologic outcome was assessed at day 28 and graded as favourable or adverse based on the Cerebral Performance Category of 1–2 and 3–5. Bi- and multivariate regression models adjusted for confounding variables were used to evaluate the association between haemodynamic variables and functional outcome.Results
67/134 patients (50%) were classified as having favourable outcome. Patients with adverse outcome had a higher mean heart rate (73 [62–86] vs. 66 [60–78] bpm; p = 0.04) and received noradrenaline more frequently (n = 17 [25.4%] vs. n = 9 [6%]; p = 0.02) and at a higher dosage (128 [56–1004] vs. 13 [2–162] μg h−1; p = 0.03) than patients with favourable outcome. The mean perfusion pressure (mean arterial blood pressure minus central venous blood pressure) (OR = 1.001, 95% CI = 1–1.003; p = 0.04) and cardiac index time integral (OR = 1.055, 95% CI = 1.003–1.109; p = 0.04) were independently associated with adverse outcome at day 28.Conclusion
Mean perfusion pressure and cardiac index during the first 24 h after ICU admission were weakly associated with neurological outcome in an OHCA population undergoing therapeutic hypothermia. Further studies need to elucidate whether norepinephrine-induced increases in perfusion pressure and cardiac index may contribute to adverse neurologic outcome following OHCA. 相似文献14.
Stéphane Manzo-Silberman Jérôme Fichet Armelle Mathonnet Olivier Varenne Sylvie Ricome Aurès Chaib Benjamin Zuber Christian Spaulding Alain Cariou 《Resuscitation》2013
Aim
To compare the feasibility, safety and outcome of IMPELLA Recover LP2.5 cardiac assistance and intra aortic balloon pump (IABP) in patients with post-cardiac arrest shock.Background
The high early mortality rate of post-cardiac arrest patients is attributed to a “post cardiac arrest syndrome” characterized by an acute and transient left ventricular (LV) systolic dysfunction. LV assistance with IMPELLA Recover LP2.5 is proposed in most severe patients.Methods
Retrospective single center registry from January 2007 to October 2010. All survivors of out-of-hospital cardiac arrest with patent or predictive factors for the occurrence of post-resuscitation shock assisted by either IMPELLA or intra aortic balloon pump (IABP) device immediately after the coronary angiogram were included.Results
78 post-cardiac arrest patients were assisted by one of the devices (35 by IMPELLA and 43 by IABP). Median “no flow” and median “low flow” were similar at admission as were hemodynamic parameters. The feasibility of IMPELLA implantation was good (97%). At 28 days, the survival rate without sequellae was 23.0% in the IMPELLA and 29.5% in the IABP group (p = 0.61). Vascular complications were observed equally in both groups (3 vs 2, p = 0.9). Serious bleeding complications occurred in 26% of IMPELLA patients vs 9% of IABP patients (p = 0.06).Conclusion
Early LV assistance by the IMPELLA LP2.5 is feasible in patients with post-resuscitation shock. The rate of complications did not differ substantially in the two groups, except for a trend toward a higher rate of bleeding events with IMPELLA. These encouraging findings must be confirmed in a larger clinical study. 相似文献15.
Background
It is not known how often, to what extent and over what time frame any early warning scores change in surgical patients, and what the implications of these changes are.Setting
Thunder Bay Regional Health Sciences Centre, Ontario, Canada.Methods
The changes in the first three recordings of the abbreviated version of the VitalPAC™ Early Warning Score (ViEWS) after admission to hospital of 18,827 surgical patients, and their relationship to subsequent in-hospital mortality were examined.Results
In the 2.0 SD 2.4 h between admission and the second recording the score changed in 12.6% of patients. If the initial abbreviated ViEWS was =2 points (78% of all patients) the in-hospital mortality was 0.5%, and not significantly different in the 3.7% of patients that either increased or decreased their score. Patients who had an initial score =3 had a significantly higher overall in-hospital mortality (odds ratio 5.48, Chi-square 120.72, p < 0.0001). Of these patients, those with a lower second score (42.3% of patients) had a significantly lower in-hospital mortality than those with an unchanged second score (i.e. 1.5% versus 3.3%, odds ratio 0.43, Chi-square 11.08, p < 0.001).Conclusion
The abbreviated ViEWS score measured on admission identifies the majority of surgical patients who are at low risk of in-hospital death. Patients with an initial abbreviated ViEWS =3 who do not reduce their score within 2–3 h of admission have a further significantly increased mortality. 相似文献16.
Antoine G. Schneider Glenn M. Eastwood Rinaldo Bellomo Michael Bailey Miklos Lipcsey David Pilcher Paul Young Peter Stow John Santamaria Edward Stachowski Satoshi Suzuki Nicholas C. Woinarski Janine Pilcher 《Resuscitation》2013
Background
Arterial carbon dioxide tension (PaCO2) affects neuronal function and cerebral blood flow. However, its association with outcome in patients admitted to intensive care unit (ICU) after cardiac arrest (CA) has not been evaluated.Methods and results
Observational cohort study using data from the Australian New Zealand (ANZ) Intensive Care Society Adult-Patient-Database (ANZICS-APD). Outcomes analyses were adjusted for illness severity, co-morbidities, hypothermia, treatment limitations, age, year of admission, glucose, source of admission, PaO2 and propensity score.We studied 16,542 consecutive patients admitted to 125 ANZ ICUs after CA between 2000 and 2011. Using the APD-PaCO2 (obtained within 24 h of ICU admission), 3010 (18.2%) were classified into the hypo- (PaCO2 < 35 mmHg), 6705 (40.5%) into the normo- (35–45 mmHg) and 6827 (41.3%) into the hypercapnia (>45 mmHg) group. The hypocapnia group, compared with the normocapnia group, had a trend toward higher in-hospital mortality (OR 1.12 [95% CI 1.00–1.24, p = 0.04]), lower rate of discharge home (OR 0.81 [0.70–0.94, p < 0.01]) and higher likelihood of fulfilling composite adverse outcome of death and no discharge home (OR 1.23 [1.10–1.37, p < 0.001]). In contrast, the hypercapnia group had similar in-hospital mortality (OR 1.06 [0.97–1.15, p = 0.19]) but higher rate of discharge home among survivors (OR 1.16 [1.03–1.32, p = 0.01]) and similar likelihood of fulfilling the composite outcome (OR 0.97 [0.89–1.06, p = 0.52]). Cox-proportional hazards modelling supported these findings.Conclusions
Hypo- and hypercapnia are common after ICU admission post-CA. Compared with normocapnia, hypocapnia was independently associated with worse clinical outcomes and hypercapnia a greater likelihood of discharge home among survivors. 相似文献17.
Anne P.F. Wand William Thoo Hayley Sciuriaga Vicky Ting Janett Baker Glenn E. Hunt 《International journal of nursing studies》2014
Background
Systematically targeting modifiable risk factors for delirium may reduce its incidence. However, research interventions have not become part of routine clinical practice. Particular approaches to the education of clinical staff may improve their practice and patient outcomes.Objectives
To evaluate the effectiveness of a multifaceted educational program in preventing delirium in hospitalised older patients and improving staff practice, knowledge and confidence.Design
A before and after study.Setting
A 22-bed general medical ward of a district hospital in Sydney, Australia.Participants
Patients were aged 65 years and over and not delirious upon admission. Of 568 eligible patients, 129 were recruited pre-intervention (3 withdrew initial consent) and 129 patients post-intervention.Methods
Prior to the intervention, in order to establish a baseline, patients were assessed early after admission and again at discharge. The intervention was a one-hour lecture on delirium focusing on prevention for medical and nursing staff followed by weekly interactive tutorials with delirium resource staff and ward modifications. Following the initial education session, data were gathered in a second group of medical ward patients at the same time-points to ascertain the effectiveness of the intervention. Pre and post-intervention data were analysed to determine change in staff objective knowledge and self-ratings of confidence and clinical practice in relation to delirium. The main outcome measures were incident delirium and change in staff practice, confidence and knowledge.Results
The mean age of patients was 81. The pre and post-intervention groups were comparable, aside from greater co morbidity in the pre-intervention group (F(1, 253) = 9.20, p = 0.003). Post-intervention there was a significant reduction in incident delirium (19% vs. 10.1%, X2 = 4.14, p = 0.042), and improved function on discharge (mean improvement 5.3 points, p < 0.001, SD 13.31, 95% CI −7.61 to −2.97). Staff objective knowledge of delirium improved post-intervention and their confidence assessing and managing delirious patients. Staff addressed more risk factors for delirium post-intervention (8.1 vs. 9.8, F(1, 253) = 73.44, p < 0.001).Conclusions
A low-cost educational intervention reduced the incidence of delirium and improved function in older medical patients and staff knowledge and practice addressing risk factors for delirium. The program is readily transferable to other settings, but requires replication due to limitations of the before and after design. 相似文献18.
Aim
Prognosis after cardiac arrest in the era of modern critical care is still poor with a high mortality of approximately 90%. Around 30% of the survivors have neurological impairments. Targeted temperature management (TTM) is the only treatment option which can improve mortality and neurological outcome. It is so far unclear if bleeding complications occur more often in patients undergoing TTM treatment.Methods
We conducted a systematic literature research in September 2013 including three major databases i.e. MEDLINE, EMBASE and CENTRAL. All studies were rated in respect to the ILCOR Guidelines and concerning their level of evidence and quality. We then performed a meta-analysis on bleeding disposition under TTM.Results
We initially found 941 studies out of which 34 matched our requirements and were thus included in our overview. Five studies including 599 patients were summarized in a meta-analysis concerning bleeding complications of all severities. There was a trend toward higher bleeding in patients treated with TTM (RR: 1.30, 95% CI: 0.97–1.74) which did not reach significance (p = 0.085). Seven studies with an overall 599 patients were included in our meta-analysis on bleeding requiring transfusion. There was no significant difference in the incidence of severe bleeding with a risk ratio of 0.97 (95% CI: 0.61–1.56, p = 0.909).Conclusions
The data included in our meta-analysis indicate that, concerning the risk of bleeding, TTM is a safe method for patients after cardiac arrest. We did not observe a significantly higher risk for bleeding in patients undergoing TTM. 相似文献19.
Purpose
The purpose of this study is to compare the impact of older age and nursing home residence on the incidence and morbidity of severe sepsis.Materials and Methods
This was a retrospective analysis of 19 460 emergency department visits from the 2005 to 2009 National Ambulatory Medical Care Surveys with diagnosis of infection with or without severe sepsis (acute organ dysfunction). Clinical outcomes included intensive care unit (ICU) admission, hospital length of stay (LOS), and in-hospital mortality.Results
Older adults (age ≥ 65 years) were 5-fold more likely to have infections classified as severe sepsis than younger adults (6.5% vs 1.3%), and nursing home residents were 7-fold more likely to have a severe sepsis diagnosis compared with nonnursing home residents (14% vs 1.9%). Among visits for severe sepsis, older adults, compared with younger adults, had modestly higher rates of ICU admission (27% vs 21%), hospital LOS (median, 6 vs 5 days), and in-hospital mortality (24% vs 16%). Nursing home residents with severe sepsis, compared with nonnursing home residents, had significantly higher rates of ICU admission (40% vs 21%), hospital LOS (median, 7 vs 5 days), and in-hospital mortality (37% vs 15%).Conclusions
Older adults and particularly nursing home residents have a disproportionately high incidence of and morbidity from severe sepsis. 相似文献20.
Faheem W. Guirgis Cynthia Gerdik Robert L. Wears Deborah J. Williams Colleen J. Kalynych Joseph Sabato Steven A. Godwin 《Resuscitation》2013