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de Oliveira E.L.,Intensive Care Unit | Westphal G.A.,General Intensive Care Unit | Mastroeni M.F.,University of the Region of Joinville
Brazilian Journal of Cardiovascular Surgery | Year: 2012

Objective: To describe the demographic and clinical characteristics of patients undergoing coronary artery bypass graft surgery (CABG) and to test their relation to mortality. Methods: This study was a retrospective medical record review of 655 consecutive patients undergoing CABG from May 2002 to April 2010. Results: Of the 655 patients, 12.1% died during the hospital stay. Mortality was significantly (p<0.05) higher in females (17.3%), aged < 70 years (22.8%), in emergency surgery (36.4%), in cases of readmission to the intensive care unit (ICU) (33.3%), when the stay in the ICU was < three days (16.3%), undergoing longer cardiopulmonary bypass (CPB), and with more comorbidities (15.4%). Predictor variables of death identified with logistical regression analysis were: female (OR=2.04), age > 70 years (OR=2.69), emergency surgery (OR=15.43) and urgency (OR=3.81), performance of CPB (OR=2.19) and readmission to the ICU (OR=4.33). Conclusion: Variables such as female sex, increased age, type of surgery, readmission to the ICU, ICU stay, comorbidities, and duration of CPB influence the outcome death in patients undergoing CABG. Thus, such aspects should be considered to reduce hospital mortality in patients undergoing such surgery.

Grocott M.P.W.,University of Southampton | Dushianthan A.,University of Southampton | Hamilton M.A.,General Intensive Care Unit | Mythen M.G.,University College London | And 2 more authors.
British Journal of Anaesthesia | Year: 2013

This systematic review and meta-analysis summarizes the clinical effects of increasing perioperative blood flow using fluids with or without inotropes/vasoactive drugs to explicit defined goals in adults. We included randomized controlled trials of adult patients (aged 16 years or older) undergoing surgery. We included 31 studies of 5292 participants. There was no difference in mortality at the longest follow-up: 282/2615 (10.8%) died in the control group and 238/2677 (8.9%) in the treatment group, RR of 0.89 (95% CI: 0.76-1.05; P=0.18). However, the results were sensitive to analytical methods and withdrawal of studies with methodological limitations. The intervention reduced the rate of three morbidities (renal failure, respiratory failure, and wound infections) but not the rates of arrhythmia, myocardial infarction, congestive cardiac failure, venous thrombosis, and other types of infections. The number of patients with complications was also reduced by the intervention. Hospital length of stay was reduced in the treatment group by 1.16 days. There was no difference in critical care length of stay. The primary analysis of this reviewshowed no difference between groups but this resultwas sensitive to the method of analysis,withdrawal of studieswith methodological limitations, and was dominated by a single large study. Patients receiving this intervention stayed in hospital 1 day less with fewer complications. It is unlikely that the intervention causes harm. The balance of current evidence does not support widespread implementation of this approach to reducemortality but does suggest that complications and duration of hospital stay are reduced. © The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.

Dawson D.,General Intensive Care Unit
Nursing in Critical Care | Year: 2014

Aim: This article aims to guide the nurse caring for a tracheostomy patient, following the main principles of nursing care. Background: Tracheostomy is a surgical procedure to create an opening in the anterior wall of the trachea. Owing to improvement in technological support, the number of adult patients receiving a tracheostomy has increased. This requires the critical care nurse to have an understanding of the essential principles of care for a patient with a tracheostomy tube in situ. Design and method: Literature search was conducted in Medline and Cinahl using the search terms tracheostomy OR tracheotomy AND procedure/nursing care/experience limited to English language and adult. Owing to the lack of empirical research on the care of patients with tracheostomy, evidence is limited and therefore expert consensus is utilized in much of the article. Results: This article considers the indications for a tracheostomy, identifies the component parts of a tracheostomy tube, discusses 12 essential principles of care for a patient with a tracheostomy tube in situ, and finally briefly describes the nurse's role in an emergency and when discharging a patient with a tracheostomy tube to a ward. Conclusion: Performing a tracheostomy has an enormous impact on patients and their care. Relevance to clinical practice: Nurses caring for patients with tracheostomy require an appreciation of the breadth of knowledge needed to provide individual and safe care. It is also important to appreciate the lack of empirical evidence on which to base that care. © 2014 British Association of Critical Care Nurses.

Patel A.,Imperial College London | Patel A.,General Intensive Care Unit | Waheed U.,Imperial College London | Brett S.J.,Imperial College London
Intensive Care Medicine | Year: 2013

Purpose: To assess the impact of 6 % tetrastarch [hydroxyethyl starch (HES) 130/0.4 and 130/0.42] in severe sepsis patients. The primary outcome measure was 90-day mortality. Methods: A structured literature search was undertaken to identify prospective randomised controlled trials (RCTs) in adult patients with severe sepsis receiving 6 % tetrastarch (of potato or waxy maize origin) as part of fluid resuscitation in comparison with other non-HES fluids after randomisation in the critical care setting. A systematic review and meta-analysis were performed. Results: Six RCTs were included (n = 3,033): three from 2012 (n = 2,913) had low risk of bias. Median tetrastarch exposure was 37.4 ml/kg (range 30-43 ml/kg). Ninety-day mortality was associated with tetrastarch exposure [relative risk (RR) 1.13; 95 % confidence interval (CI) 1.02-1.25; p = 0.02] compared with crystalloid. The number needed to harm (NNH) was 28.8 (95 % CI 14.6-942.5). Publication bias and statistical heterogeneity (I 2 = 0 %) were not present. Tetrastarch exposure was also associated with renal replacement therapy (p = 0.01; NNH 15.7) and allogeneic transfusion support (p = 0.001; NNH 9.9). No difference between groups was observed for 28-day mortality, for comparison with colloid as control, or for waxy maize-derived tetrastarch, but power was lacking. Overall mortality was associated with tetrastarch exposure (RR 1.13; 95 % CI 1.02-1.25; p = 0.02). Conclusions: In our analysis, 6 % tetrastarch as part of initial fluid resuscitation for severe sepsis was associated with harm and, as alternatives exist, in our view should be avoided. © 2013 Springer-Verlag Berlin Heidelberg and ESICM.

Toner A.,St. Georges Hospital | Hamilton M.,General Intensive Care Unit
Current Opinion in Critical Care | Year: 2013

Purpose of Review: This review examines the long-term influence of postoperative complications on survival. Although it is intuitive that complications after surgery worsen short-term outcomes, it is not clear to what extent and why a longer-term relationship may exist. Recent Findings: Most studies have focused on outcomes after cancer surgery. Despite mixed results in smaller cohorts, large multicentre analyses consistently identify an association between postoperative complications and long-term mortality. In part, this phenomenon may be due to unmeasured confounding factors or insufficient separation of short and long-term consequences. Nevertheless, functional and biological imprints established during postoperative complications are likely to be relevant, and are the subject of ongoing research. Summary: Patients that develop postoperative complications and survive the immediate risk period, demonstrate worsened long-term mortality. The field of perioperative medicine is increasingly mandated to identify vulnerable individuals, develop and implement strategies to prevent and treat complications, and provide better care pathways after hospital discharge. Copyright © 2013 Lippincott Williams & Wilkins.

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