Ebaõnnestunud toitmine TÜ Kliinikumi üldintensiivravi osakonna patsientidel

Käesolevas bakalaureusetöös on uuritud Tartu Ülikooli Kliinikumi anestesioloogia ja intensiivravi kliiniku üldintensiivravi osakonna (edasipidi intensiivravi osakond) patsientide andmeid. Intensiivravi osakonna patsiendid on sageli aparaadihingamisel ning pole võimelised suu kaudu sööma. Seetõttu toidetakse neid üldiselt sondi kaudu otse makku. Kuna paljudel patsientidel on seedetrakti funktsioon häiritud, ei pruugi sondiga toitmine õnnestuda. Sellist situatsiooni nimetatakse ebaõnnestunud toitmiseks. Terminit „ebaõnnestunud toitmine“ kasutatakse intensiivravi osakonna igapäevatöös palju, kuid ühene definitsioon puudub. Bakalaureusetöö eesmärgiks on võrrelda erinevate ebaõnnestunud toitmise definitsioonide mõju ravitulemusele. Samuti on eesmärgiks selgitada välja intensiivravi osakonna haigete suremust prognoosivad tunnused, seejuures teha kindlaks, kas ka mõni ebaõnnestunud toitmise definitsioon on suremust prognoosivate tunnuste hulgas. Bakalaureusetöös on esmalt antud ülevaade andmete analüüsimiseks kasutatud meetoditest. Seejärel on lühidalt kirjeldatud uuritud andmeid, esitatud andmete modelleerimiseks vajalike uute tunnuste definitsioonid, sealhulgas ebaõnnestunud toitmise definitsioonid, ning nende tunnuste jaotuste kirjeldused. Suremuse ja ebaõnnestunud toitmise erinevate definitsioonide vaheliste seoste kindlaks tegemiseks on kasutatud 2 -testi, logistilist regressiooni ja elukestusanalüüsi. Olulised seosed ja mudelite kirjeldused on toodud tulemuste osas. Bakalaureusetöö on kirjutatud tekstitöötlusprogrammiga Microsoft Word 2003. Analüüsid on läbi viidud statistikapakettiga R. Olulisuse tõenäosuseks on kõikjal töös valitud = 0,05

Implementation of enteral feeding protocol in an intensive care unit:Before-and-after study

AIM: To determine the effects of implementing an enteral feeding protocol on the nutritional delivery and outcomes of intensive care patients. METHODS: An uncontrolled, observational before-and-after study was performed in a tertiary mixed medical-surgical intensive care unit (ICU). In 2013, a nurse-driven enteral feeding protocol was developed and implemented in the ICU. Nutrition and outcome-related data from patients who were treated in the study unit from 2011-2012 (the Before group) and 2014-2015 (the After group) were obtained from a local electronic database, the national Population Registry and the hospital’s Infection Control Service. Data from adult patients, readmissions excluded, who were treated for at least 7 d in the study unit were analysed. RESULTS: In total, 231 patients were enrolled in the Before and 249 in the After group. The groups were comparable regarding demographics, patient profile, and severity of illness. Fewer patients were mechanically ventilated on admission in the After group (86.7% vs 93.1% in the Before group, P = 0.021). The prevalence of hospital-acquired infections, length of ICU stay and ICU, 30- and 60-d mortality did not differ between the groups. Patients in the After group had a lower 90-d (P = 0.026) and 120-d (P = 0.033) mortality. In the After group, enteral nutrition was prescribed less frequently (P = 0.039) on day 1 but significantly more frequently on all days from day 3. Implementation of the feeding protocol resulted in a higher cumulative amount of enterally (P = 0.049) and a lower cumulative amount of parenterally (P < 0.001) provided calories by day 7, with an overall reduction in caloric provision (P < 0.001). The prevalence of gastrointestinal symptoms was comparable in both groups, as was the frequency of prokinetic use. Underfeeding (total calories < 80% of caloric needs, independent of route) was observed in 59.4% of the study days Before vs 76.9% After (P < 0.001). Inclusion in the Before group, previous abdominal surgery, intra-abdominal hypertension and the sum of gastrointestinal symptoms were found to be independent predictors of insufficient enteral nutrition. CONCLUSION: The use of a nurse-driven feeding protocol improves the delivery of enteral nutrition in ICU patients without concomitant increases in gastrointestinal symptoms or intra-abdominal hypertension

Postoperative complications and mortality after major gastrointestinal surgery

Background and objective: The incidence of postoperative complications and death is low in the general population, but a subgroup of high-risk patients can be identified amongst whom adverse postoperative outcomes occur more frequently. The present study was undertaken to describe the incidence of postoperative complications, length of stay, and mortality after major abdominal surgery for gastrointestinal, hepatobiliary and pancreatic malignancies and to identify the risk factors for impaired outcome. Material and methods: Data of patients, operated on for gastro-intestinal malignancies during 2009–2010 were retrieved from the clinical database of Tartu University Hospital. Major outcome data included incidence of postoperative complications, hospital-, 30-day, 90-day and 1-year mortality, and length of ICU and hospital stay. High-risk patients were defined as patients with American Society of Anesthesiologists (ASA) physical status ≥3 and revised cardiac risk index (RCRI) ≥3. Multivariate analysis was used to determine the risk factors for postoperative mortality and morbidity. Results: A total of 507 (259 men and 248 women, mean age 68.3 ± 11.3 years) were operated on for gastrointestinal, hepatobiliary, or pancreatic malignancies during 2009 and 2010 in Tartu University Hospital, Department of Surgical Oncology. 25% of the patients were classified as high risk patients. The lengths of intensive care and hospital stay were 4.4 ± 7 and 14.5 ± 10 days, respectively. The rate of postoperative complications was 33.5% in the total cohort, and 44% in high-risk patients. The most common complication was delirium, which occurred in 12.8% of patients. For patients without high risk (ASA < III; RCRI < 3) in-hospital, 30-, 90-day and 1-year mortality were 2%, 5%, 12.7% and 26.0%. Patients with ASA ≥ III and RCRI ≥ 3 had 2.3% in-hospital mortality, and at 30-, 90 days and 1 year the mortality was 8.5%, 17.8%, and 42.2%, respectively (P = 0.001, P < 0.0001 and P < 0.0001 compared to the lower risk patients). On multivariate analysis, age above 70 years, ASA ≥ III, RCRI ≥ 3, duration of surgery >130 min, and positive fluid balance >1300 mL after the 1st postoperative day, were identified as independent risk factors for the development of complications. Conclusion: The complication rate after major gastro-intestinal surgery is high. ASA physical status and revised cardiac risk index adequately reflect increased risk for postoperative complications and worse short and long-term outcome

Mootorsõidukite kokkupõrked jalakäijatega Eestis: regionaalhaiglate 116 ravijuhu ning kohtuarstliku lahangu analüüs

Taust ja eesmärgid. Vigastussurmade osakaal Eestis on Euroopa Liidu üks suuremaid. Liiklussurmadel on selles arvestatav osa. Uuringu eesmärk on analüüsida liikluses vigastatud jalakäijate andmeid, vigastuste profiili, käsitlust ja vigastustejärgset suremust.Metoodika. Retrospektiivne analüüs jalakäijana mootorsõidukiõnnetusse sattunud ja regionaalhaiglatesse hospitaliseeritud patsientide ravijuhtudest ning kohtuarstlikes ekspertiisikeskustes lahatud surnukehadest ajavahemikul 01.01.2015–31.12.2015. Uuringu valimisse kuulunud isikute haigestumise ja surma välispõhjused olid dokumenteeritud rahvusvahelise haiguste klassifikatsiooni 10. versiooni (RHK-10) diagnoosikoodidega V02–V09 (sõidukiõnnetuses vigastatud jalakäija). Lisaks valimi üldandmetele dokumenteeriti vigastuste profiil, haigus- ja ravitüsistused ning suremus. Uurimistöö esmane eesmärk oli kirjeldada valimi patsientide vigastustejärgset suremust.Tulemused. Uuringusse kaasati 116 juhtu, kellest 94 olid haiglatesse hospitaliseeritud haiged ja 22 sündmuskohalt kohtuarstlikule lahangule viidud juhud. Valimi keskmine vanus oli 42,8 ± 26,9 aastat ja 56,0% olid mehed. Kõige enam vigastusi toimus novembris ja detsembris ning kellaajaliselt ajavahemikul 16.00–19.00. Domineerivad vigastused olid roidemurrud ja sääreluumurrud vastavalt 31,9%-l ja 28,4%-l juhtudest. Üldsuremus oli 23,3%. 81,5% surmlõpetest toimus haigla eel. Haiglasse jõudnute suremus oli 5,3%. Peamiseks surmapõhjuseks olid rasked ajuvigastused. Tüsistusi esines 8,5%-l juhtudest.Järeldused. Pea iga neljas mootorsõidukiõnnetuses vigastatud uuringuvalimi jalakäija suri. Valdav osa surmadest leiab aset sündmuskohal. Haiglasse jõudnute suremus on sarnane teiste riikidega. Õnnetuste sesoonne iseloom ja ööpäevane jaotumus väärivad tähelepanu liikluskorralduse parandamise aspektist

Workplace bullying and violence as risk factors for type 2 diabetes : a multicohort study and meta-analysis

The aim of this multicohort study was to examine whether employees exposed to social stressors at work, such as workplace bullying and violence, have an increased risk of type 2 diabetes. The study included 45,905 men and women (40-65 years of age and free of diabetes at baseline) from four studies in Sweden, Denmark and Finland. Workplace bullying and violence were self-reported at baseline. Incident diabetes was ascertained through national health and medication records and death registers. Marginal structural Cox models adjusted for age, sex, country of birth, marital status and educational level were used for the analyses. Nine per cent of the population reported being bullied at work and 12% were exposed to workplace violence or threats of violence. Bullied participants had a 1.46 (95% CI 1.23, 1.74) times higher risk of developing diabetes compared with non-bullied participants. Exposure to violence or threats of violence was also associated with a higher risk of diabetes (HR 1.26 [95% CI 1.02, 1.56]). The risk estimates attenuated slightly when taking BMI into account, especially for bullying. The results were similar for men and women, and were consistent across cohorts. We found a higher risk of incident type 2 diabetes among employees exposed to bullying or violence in the workplace. Further research is needed to determine whether policies to reduce bullying and violence at work may reduce the incidence of type 2 diabetes in working populations. Research on the mechanisms is also highly warranted.Peer reviewe

Workplace bullying and workplace violence as risk factors for cardiovascular disease : a multi-cohort study

Aims To assess the associations between bullying and violence at work and cardiovascular disease (CVD). Methods and results Participants were 79201 working men and women, aged 18-65years and free of CVD and were sourced from three cohort studies from Sweden and Denmark. Exposure to workplace bullying and violence was measured at baseline using self-reports. Participants were linked to nationwide health and death registers to ascertain incident CVD, including coronary heart disease and cerebrovascular disease. Study-specific results were estimated by marginal structural Cox regression and were combined using fixed-effect meta-analysis. Nine percent reported being bullied at work and 13% recorded exposure to workplace violence during the past year. We recorded 3229 incident CVD cases with a mean follow-up of 12.4years (765 in the first 4years). After adjustment for age, sex, country of birth, marital status, and educational level, being bullied at work vs. not was associated with a hazard ratio (HR) of 1.59 [95% confidence interval (CI) 1.28-1.98] for CVD. Experiencing workplace violence vs. not was associated with a HR of 1.25 (95% CI 1.12-1.40) for CVD. The population attributable risk was 5.0% for workplace bullying and 3.1% for workplace violence. The excess risk remained similar in analyses with different follow-up lengths, cardiovascular risk stratifications, and after additional adjustments. Dose-response relations were observed for both workplace bullying and violence (P-trend <0.001). There was only negligible heterogeneity in study-specific estimates. Conclusion Bullying and violence are common at workplaces and those exposed to these stressors are at higher risk of CVD.Peer reviewe

Incidence, Risk Factors, and Outcomes of Intra-Abdominal Hypertension in Critically Ill Patients-A Prospective Multicenter Study (IROI Study)

To identify the prevalence, risk factors, and outcomes of intra-abdominal hypertension in a mixed multicenter ICU population. Prospective observational study. Fifteen ICUs worldwide. Consecutive adult ICU patients with a bladder catheter. None. Four hundred ninety-one patients were included. Intra-abdominal pressure was measured a minimum of every 8 hours. Subjects with a mean intra-abdominal pressure equal to or greater than 12 mm Hg were defined as having intra-abdominal hypertension. Intra-abdominal hypertension was present in 34.0% of the patients on the day of ICU admission (159/467) and in 48.9% of the patients (240/491) during the observation period. The severity of intra-abdominal hypertension was as follows: grade I, 47.5%; grade II, 36.6%; grade III, 11.7%; and grade IV, 4.2%. The severity of intra-abdominal hypertension during the first 2 weeks of the ICU stay was identified as an independent predictor of 28-and 90-day mortality, whereas the presence of intra-abdominal hypertension on the day of ICU admission did not predict mortality. Body mass index, Acute Physiology and Chronic Health Evaluation II score greater than or equal to 18, presence of abdominal distension, absence of bowel sounds, and positive end-expiratory pressure greater than or equal to 7 cm H2O were independently associated with the development of intra-abdominal hypertension at any time during the observation period. In subjects without intra-abdominal hypertension on day 1, body mass index combined with daily positive fluid balance and positive end-expiratory pressure greater than or equal to 7 cm H2O (as documented on the day before intra-abdominal hypertension occurred) were-associated with the development of intraabdominal hypertension during the first week in the ICU. In our mixed ICU patient cohort, intra-abdominal hypertension occurred in almost half of all subjects and was twice as prevalent in mechanically ventilated patients as in spontaneously breathing patients. Presence and severity of intra-abdominal hypertension during the observation period significantly and independently increased 28-and 90-day mortality. Five admission day variables were independently associated with the presence or development of intra-abdominal hypertension. Positive fluid balance was associated with the development of intra-abdominal hypertension after day 1474535542NIGMS NIH HHSUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USANIH National Institute of General Medical Sciences (NIGMS) [U54 GM104940

Mediation Analyses in the Real World

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