36 research outputs found
Liberal transfusion strategy improves survival in perioperative but not in critically ill patients. A meta-analysis of randomised trials
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ДЕФИЦИТ ТИАМИНА И ЕГО КОРРЕКЦИЯ ПРИ КРИТИЧЕСКИХ СОСТОЯНИЯХ
The level of thiamine in critically ill patients can be low due to the loss of fluid, nutrition disorders and increased metabolism. The deficiency of thiamine is associated with reduction of respiratory metabolism, increase in lactate level and hypotension. At present, there are no clear evidence that all critically ill patients suffer from thiamine deficiency and face the risk to develop complications associated with thiamine deficiency. However, there is a certain correlation between progressing of thiamine deficiency and deterioration of the patient's state, though it is to be proved. The efficiency of treatment with thiamine is still being discussed since there is no consensus about the group of patients to be treated, thiamine doses and duration of treatment. For successful diagnostics and prediction of clinical outcomes related to thiamine deficiency, it is necessary to adopt standard methods for thiamine tests and the reference analytic method. Уровень тиамина у больных в критическом состоянии может быть снижен из-за потери жидкости, нарушения питания, повышенного метаболизма. Дефицит тиамина сопровождается снижением аэробного метаболизма, увеличением уровня лактата и гипотензией. В настоящее время нет четких доказательств того, что все больные в критическом состоянии имеют недостаточность тиамина и риск развития тиамин-дефицитных осложнений. Тем не менее существует определенная связь между развитием дефицита тиамина и ухудшением состояния больных, хотя это нуждается в дальнейшем подтверждении. Терапевтический эффект лечения тиамином до сих пор обсуждается с отсутствием консенсуса в отношении групп пациентов, доз тиамина и продолжительности лечения. Для успешной диагностики и прогнозирования клинических исходов, связанных с дефицитом тиамина, необходимы стандартизация методов оценки тиамина и принятие референсного аналитического метода.
ЦЕРЕБРАЛЬНАЯ ОКСИМЕТРИЯ В КАРДИОХИРУРГИИ ВЫСОКОГО РИСКА: АКТУАЛЬНОСТЬ И ПРОТОКОЛ КЛИНИЧЕСКОГО ИССЛЕДОВАНИЯ
Cerebral oxymetry is one of the monitoring techniques aimed at the early detection of changes in the brain state. Currently it is being actively introduced into practice, management algorithms for cerebral oxygenation disorders are being developed basing on it, including the ones for cardiac surgeries. Certain data show that this allows decreasing the frequency of post-surgery neurological complications, the duration of patients stay in the intensive care department and general duration of hospital stay. However it is recognized that not all aspects of its using have been provided with the relevant evidence, especially in the respect of cardiac surgical patients with high surgical risk. The main purpose of this research is to draw the attention to the problem and present the protocol of the trial which has been started in our unit. The special emphasis is made on the methodological components of the research, starting with the formulation of research hypothesis, defining finite primary and secondary points, preliminary calculation of sampling and defining statistical analysis methods. We would very much appreciate the feedback from our colleagues and hope that that the other researchers will follow our example when starting big research projects. Церебральная оксиметрия – одна из методик мониторинга, направленного на раннее выявление изменений в состоянии головного мозга. В настоящее время ее активно внедряют в практику, на ее основе разрабатывают алгоритмы коррекции нарушений церебральной оксигенации, в том числе во время кардиохирургических операций. По некоторым данным, это позволяет снизить частоту послеоперационных неврологических осложнений, время пребывания пациентов в палате интенсивной терапии и продолжительность госпитализации. Тем не менее признается, что не все аспекты ее использования получили необходимую доказательную базу, особенно применительно к кардиохирургическим пациентам с высоким операционным риском. Основная цель данной работы – привлечь внимание к проблеме и представить протокол начатого исследования. Особый акцент попытались сделать на методологическую составляющую работы, начиная с формулирования гипотезы исследования, определения конечных первичных и вторичных точек, предварительного расчета объема выборки, определения методов статистического анализа. Будем признательны коллегам за конструктивную критику и рассчитываем, что нашему примеру последуют и другие исследователи, приступающие к большим исследовательским проектам.
КОРРЕКЦИЯ ЦЕРЕБРАЛЬНОЙ ОКСИГЕНАЦИИ С ЦЕЛЬЮ СНИЖЕНИЯ РАЗВИТИЯ ПОСЛЕОПЕРАЦИОННЫХ ОСЛОЖНЕНИЙ У КАРДИОХИРУРГИЧЕСКИХ ПАЦИЕНТОВ ВЫСОКОГО РИСКА
The imbalance between oxygen delivery and consumption in the brain can lead to unfavorable post-operative outcomes of cardiac surgery. The authors evaluated the effect of the protocol on management of cerebral oxygenation episodes during the post-operative period in the patients undergoing cardiac surgery and facing a high risk of complications. Subjects: Patients who underwent coronary bypass surgery and/or cardiac valve surgery with cardiopulmonary bypass, were randomly divided into two groups: the interventional group (n = 60), where a special protocol was used to manage desaturation episodes, and the control group (n = 60) where only blinded monitoring of cerebral oximetry was used. Within 30 days after surgery, the development of desaturation episodes during surgery was assessed as well as the occurrence of complications (myocardial infarction, brain damage of the 1st and 2nd types, infectious complications, prolonged artificial ventilation of the lungs, arrhythmia, repeated thoracotomy, acute renal damage) in both groups. Results. The duration and intensity of desaturation did not significantly differ between the groups. The composite outcome was observed in 41 (68.3%) patients in the intervention group and in 38 (63.3%) of them in the control group (p = 0.70), and no significant difference was found in the frequency of individual components of the composite outcome. It was found out that desaturation significantly affected the development of delirium (odds ratio 1.03, 95% confidence interval 1.01–1.05, p = 0.03, to reduce % of the area under saturation curve for the less than 60% of the absolute value per every 5 minutes). Conclusion. The cerebral oximetry correction protocol provided no effect on prevention of complications in high-risk patients undergoing cardiac surgery. However, the reduction of cerebral oximetry turned out to be significant to predict the development of post-operative delirium, and it noted the need to search for ways to manage oxygen imbalance during surgery.Нарушение баланса между доставкой и потреблением кислорода в головном мозге может привести к неблагоприятным послеоперационным исходам в кардиохирургической практике. Авторы оценили влияние протокола по устранению эпизодов снижения церебральной оксигенации на течение послеоперационного периода у кардиохирургических пациентов с высоким риском развития осложнений. Методы. Пациенты, которым выполняли операции коронарного шунтирования и/или коррекции клапанного аппарата сердца в условиях искусственного кровообращения, рандомизированы на две группы: интервенционную (n = 60), где для коррекции эпизодов десатурации использовали специальный протокол, и контрольную группу (n = 60), где осуществляли только ослепленный мониторинг церебральной оксиметрии. Выполнена оценка развития эпизодов десатурации во время операции и возникновения осложнений (инфаркт миокарда, повреждения головного мозга 1-го и 2-го типов, инфекционные осложнения, продленная искусственная вентиляция легких, аритмия, реторакотомия, острое почечное повреждение) в течение 30 дней после операции в обеих группах. Результаты. Продолжительность и выраженность десатурации достоверно не различались между группами. Композитный исход возник у 41 (68,3%) пациента в интервенционной группе и у 38 (63,3%) – в контрольной (p = 0,70), также не обнаружено достоверных различий в частоте развития отдельных компонентов композитного исхода. Выявлено, что десатурация значительно влияет на развитие делирия (отношение шансов 1,03, 95%-ный доверительный интервал 1,01–1,05, p = 0,03 для снижения на каждые 5 мин∙% площади под кривой сатурации менее абсолютного значения 60%). Заключение. Протокол коррекции церебральной оксиметрии не оказывал влияния на предотвращение развития осложнений у кардиохирургических пациентов высокого риска. Однако снижение церебральной оксиметрии оказалось прогностически значимым в развитии послеоперационного делирия, что указывает на необходимость поиска подходов к устранению нарушения кислородного баланса во время операции
Anaemia and blood transfusion in the critically ill patient with cardiovascular disease
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2017. Other selected articles can be found online at http://ccforum.com/series/annualupdate2017. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901
CARDIOPROTECTIVE EFFECTS OF PHOSPHOCREATINE
Goal of the review: to review theoretical and practical aspects of using exogenous phosphocreatine in the patients with cardio-vascular disorders in various clinical situations, given that phospho-transporting system disorders are the one of pathogenic elements responsible for reduction of cardiac pumping ability
Antithrombotic therapy in patients with COVID-19? -Rationale and Evidence-
In patients with severe or critical Coronavirus disease 2019 (COVID-19) manifestations, a thromboinflammatory syndrome, with diffuse microvascular thrombosis, is increasingly evident as the final step of pro-inflammatory cytokines storm. Actually, no proven effective therapies for novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection exist. Preliminary observations on anticoagulant therapy appear to be associated with better outcomes in moderate and severe COVID-19 patients with signs of coagulopathy and in those requiring mechanical ventilation. The pathophysiology underlying the prothrombotic state elicited by SARS-CoV-2 outlines possible protective mechanisms of antithrombotic therapy (in primis anticoagulants) for this viral illness. The indications for antiplatelet/anticoagulant use (prevention, prophylaxis, therapy) are guided by the clinical context and the COVID-19 severity. We provide a practical approach on antithrombotic therapy management for COVID-19 patients from a multidisciplinary point of view
THIAMINE DEFICIENCY AND ITS MANAGEMENT IN CRITICAL STATES
The level of thiamine in critically ill patients can be low due to the loss of fluid, nutrition disorders and increased metabolism. The deficiency of thiamine is associated with reduction of respiratory metabolism, increase in lactate level and hypotension. At present, there are no clear evidence that all critically ill patients suffer from thiamine deficiency and face the risk to develop complications associated with thiamine deficiency. However, there is a certain correlation between progressing of thiamine deficiency and deterioration of the patient's state, though it is to be proved. The efficiency of treatment with thiamine is still being discussed since there is no consensus about the group of patients to be treated, thiamine doses and duration of treatment. For successful diagnostics and prediction of clinical outcomes related to thiamine deficiency, it is necessary to adopt standard methods for thiamine tests and the reference analytic method
High Flow Nasal Cannula Oxygen vs. Conventional Oxygen Therapy and Noninvasive Ventilation in Emergency Department Patients: A Systematic Review and Meta-Analysis
Background: Acute respiratory failure (ARF) is a common cause of presentation to the Emergency Department (ED). High flow nasal cannula (HFNC) has been introduced as an alternative way to administer oxygen. Objectives: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing HFNC with conventional oxygen therapy (COT) and noninvasive ventilation (NIV) exclusively in the ED setting. Methods: Inclusion criteria were: RCTs on adults with ARF admitted to the ED, investigating HFNC vs. COT or other modes of ventilation. Trials that compared HFNC support outside the ED, were published as an abstract, or nonrandomized were excluded. Results: Four RCTs comparing HFNC with COT and one HFNC to NIV met the criteria. Overall, 775 patients were included. The meta-analysis of the studies comparing HFNC and COT showed no differences in intubation requirement, treatment failure, hospitalization, or mortality. Intolerance was significantly higher with HFNC (risk ratio 6.81 95% confidence interval 1.18\u201339.19; p = 0.03). In the only available RCT comparing HFNC with NIV, no difference was found for intubation rate, treatment failure, tolerance, and dyspnea. Conclusions: We did not find any benefit of HFNC compared with COT and NIV in terms of intubation requirement, treatment failure, hospitalization, and mortality; COT was better tolerated