Carga e trabalho de enfermagem em unidade de terapia intensiva especializada em queimados

It is complex to watch people in the Intensive Care Unit Specialized in Burnt, because the lack of the body's largest organ protection, the skin, as well as inhalation injuries may present hemodynamic changes and conditions of vulnerability to infection. The objective of the study is to evaluate the nursing workload, according to the Nursing Activities Score (NAS) in a Intensive Care Unit for the treatment of burned patients; correlate the workload to sociodemographic aspects, clinicals, severity (SAPS 3), burned surface area (BSA%), degree of burn and outcomes and build a Tutorial to instruct and standardize the instrument application. It is an exploratory and descriptive, prospective, quantitative design study, performed in the burn ICU of a large State Hospital, located in e interior city of São Paulo. The unit consists of 4 beds. The population consisted of patients attending the unit from January to June 2014. The sample consisted of 33 patients, with 447 measurements. We obtained the approval of the Ethics Committee under the number CAAE 26679314.2.0000.5411. The workload was assessed by the NAS, prospectively, referring to the last 24 hours. Pearson correlation was used, ANOVA and Tukey tests, all of them with a significance level of 5% (p=0.05). From the total of 33 patients prevailed males with 61%, white 67%, with a stable relationship 54%, 71% with complete primary education, major burn 55%, with accident caused by alcohol and fire 30%, 53% depressed, submitted to intubation and sedated 45% by use of vasoactive medications associated with 45% and 55% with associated inhalation injury. The month of highest incidence of hospitalizations was February with 27%. Regarding the outcome, 61% were discharged to infirmary. The average NAS was 81.94% for the patients who survived and 86.16% for those who died. The hours of nursing in 24 hours was 19.6%. When comparing the nursing hours according to the NAS and COFEN resolution on the ...É complexo assistir as pessoas em Unidade de Terapia Intensiva Especializada em Queimados, pois a falta de proteção do maior órgão do corpo, a pele, assim como as lesões inalatórias podem apresentar alterações hemodinâmicas e condições de vulnerabilidade para infecção. O objetivo do estudo é avaliar a carga de trabalho de enfermagem, segundo o Nursing Activities Score (NAS), em uma Unidade de Terapia Intensiva destinada ao tratamento de pacientes com queimaduras; correlacionar a carga de trabalho aos aspectos sociodemográficos, clínicos, gravidade (SAPS 3), superfície corporal queimada (SCQ%), grau de queimadura e desfecho e construir um tutorial para instruir e uniformizar a aplicação do instrumento. Trata-se de estudo exploratório e descritivo, prospectivo, de delineamento quantitativo, realizado na UTI de queimados de um Hospital Estadual de grande porte, localizado no interior de São Paulo. A Unidade é composta por 4 leitos. A população constou de pacientes atendidos na unidade no período de janeiro a junho de 2014. A amostra foi de 33 pacientes, com 447 medições. Obteve-se a aprovação do Comitê de Ética sob o nº CAAE 26679314.2.0000.5411. A carga de trabalho foi avaliada por meio do NAS, prospectivamente, referindo-se às últimas 24 horas. Utilizou-se a Correlação de Pearson, o teste Anova e de Tukey, todos com nível de significância de 5% (p≤0,05). Do total de 33 pacientes prevaleceu o gênero masculino com 61%, brancos 67%, com união consensual estável 54%, primeiro grau completo 71%, grande queimado 55%, com acidentes por álcool e fogo 30%, depressivos 53%, submetidos à intubação e sedados 45%, em uso de medicação vasoativa 45% e com lesão inalatória associada 55%. O mês de maior ocorrência das internações foi fevereiro, com 27%. Em relação ao desfecho, 61% receberam alta para enfermaria. A média NAS foi de 81,94% para os pacientes sobreviventes e 86,16 % para os que foram a..

Expression of CD64 on Circulating Neutrophils Favoring Systemic Inflammatory Status in Erythema Nodosum Leprosum

<div><p>Erythema Nodosum Leprosum (ENL) is an immune reaction in leprosy that aggravates the patient´s clinical condition. ENL presents systemic symptoms of an acute infectious syndrome with high leukocytosis and intense malaise clinically similar to sepsis. The treatment of ENL patients requires immunosuppression and thus needs to be early and efficient to prevent both disabilities and permanent nerve damage. Some patients experience multiple episodes of ENL and prolonged use of immunosuppressive drugs may lead to serious adverse effects. Thalidomide treatment is extremely effective at ameliorating ENL symptoms. Several mechanisms have been proposed to explain the efficacy of thalidomide in ENL, including the inhibition of TNF production. Given its teratogenicity, thalidomide is prohibitive for women of childbearing age. A rational search for molecular targets during ENL episodes is essential to better understand the disease mechanisms involved, which may also lead to the discovery of new drugs and diagnostic tests. Previous studies have demonstrated that IFN-γ and GM-CSF, involved in the induction of CD64 expression, increase during ENL. The aim of the present study was to investigate CD64 expression during ENL and whether thalidomide treatment modulated its expression. Leprosy patients were allocated to one of five groups: (1) Lepromatous leprosy, (2) Borderline leprosy, (3) Reversal reaction, (4) ENL, and (5) ENL 7 days after thalidomide treatment. The present study demonstrated that CD64 mRNA and protein were expressed in ENL lesions and that thalidomide treatment reduced CD64 expression and neutrophil infiltrates—a hallmark of ENL. We also showed that ENL blood neutrophils exclusively expressed CD64 on the cell surface and that thalidomide diminished overall expression. Patient classification based on clinical symptoms found that severe ENL presented high levels of neutrophil CD64. Collectively, these data revealed that ENL neutrophils express CD64, presumably contributing to the immunopathogenesis of the disease.</p></div

ENL patients present neutrophils expressing CD64 in skin lesions.

<p>(A) Biopsies of (A) ENL and (B) ENL thalidomide-treated patients (ENL Thal) were stained for CD64 (red), myeloperoxidase (MPO; green), and nuclei (DAPI; blue). Co-localized areas of MPO⁺CD64⁺ cells were identified with arrowheads. Right small panels represent the 3 channels. Photomicrographs are representative sections of ENL and ENL Thal (n = 3). Scale bars: 10 μm.</p

CD64 expression is modulated in ENL skin lesions after thalidomide- treatment.

<p>(A) mRNA expression of CD64 (<i>FCGR1A</i>) was assessed by qRT-PCR in ENL skin lesions at diagnosis (ENL) and 7 days after thalidomide-treatment (ENL Thal). Each line with a symbol represents a patient (n = 10). (B) Protein levels obtained from skin lesion fragments were analyzed by Western blot using antibodies against myeloperoxidase (MPO) and GAPH (loading control). The figure shows a representative Western blot analysis of 5 patients in 2 independent experiments (n = 5). The graph shows the MPO normalized values of 5 patients. Box plots show median, interquartile range, sample minimum, and maximum indications. Biopsies of ENL (Ci and Ciii) and ENL Thal (Cii and Civ) were processed for H&E. PMNs were identified with arrowheads. Scale bars = 25 μm. (Cv) ENL and ENL Thal (Cvi) skin lesions were labelled with monoclonal antibody anti-CD64. Immunoperoxidase was performed on cryosections with haematoxylin contrast. Photomicrographs are representative sections from ENL and ENL Thal (n = 6). Scale bars: 25 μm. Statistic: (A) Wilcoxon (* P < 0.05) and (B) Student's t-test (* P< 0.05).</p

Severe ENL presents high PMN CD64 index.

<p>The PMN CD64 index was obtained by flow cytometry of whole blood. The severity scale of ENL was determined based clinical features (<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0004955#pntd.0004955.s009" target="_blank">S7 Table</a>). Statistic: Kruskal-Wallis (*P < 0.05).</p

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p&lt;0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p&lt;0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status