Fluid overload occurring as a consequence of overly aggressive fluid resuscitation may adversely affect outcome in hemodynamically unstable critically ill patients. Therefore, following the initial ...fluid resuscitation, it is important to identify which patients will benefit from further fluid administration.
To identify predictors of fluid responsiveness in hemodynamically unstable patients with signs of inadequate organ perfusion.
Search of MEDLINE and EMBASE (1966 to June 2016) and reference lists from retrieved articles, previous reviews, and physical examination textbooks for studies that evaluated the diagnostic accuracy of tests to predict fluid responsiveness in hemodynamically unstable adult patients who were defined as having refractory hypotension, signs of organ hypoperfusion, or both. Fluid responsiveness was defined as an increase in cardiac output following intravenous fluid administration.
Two authors independently abstracted data (sensitivity, specificity, and likelihood ratios LRs) and assessed methodological quality. A bivariate mixed-effects binary regression model was used to pool the sensitivities, specificities, and LRs across studies.
A total of 50 studies (N = 2260 patients) were analyzed. In all studies, indices were measured before assessment of fluid responsiveness. The mean prevalence of fluid responsiveness was 50% (95% CI, 42%-56%). Findings on physical examination were not predictive of fluid responsiveness with LRs and 95% CIs for each finding crossing 1.0. A low central venous pressure (CVP) (mean threshold <8 mm Hg) was associated with fluid responsiveness (positive LR, 2.6 95% CI, 1.4-4.6; pooled specificity, 76%), but a CVP greater than the threshold made fluid responsiveness less likely (negative LR, 0.50 95% CI, 0.39-0.65; pooled sensitivity, 62%). Respiratory variation in vena cava diameter measured by ultrasound (distensibility index >15%) predicted fluid responsiveness in a subgroup of patients without spontaneous respiratory efforts (positive LR, 5.3 95% CI, 1.1-27; pooled specificity, 85%). Patients with less vena cava distensibility were not as likely to be fluid responsive (negative LR, 0.27 95% CI, 0.08-0.87; pooled sensitivity, 77%). Augmentation of cardiac output or related parameters following passive leg raising predicted fluid responsiveness (positive LR, 11 95% CI, 7.6-17; pooled specificity, 92%). Conversely, the lack of an increase in cardiac output with passive leg raising identified patients unlikely to be fluid responsive (negative LR, 0.13 95% CI, 0.07-0.22; pooled sensitivity, 88%).
Passive leg raising followed by measurement of cardiac output or related parameters may be the most useful test for predicting fluid responsiveness in hemodynamically unstable adults. The usefulness of respiratory variation in the vena cava requires confirmatory studies.
Despite substantial public interest, few recommendations on the promotion of good sleep health exist to educate health care providers and the general public on the importance of sleep for overall ...health.
The aim of this American Thoracic Society (ATS) statement is to provide a review of the current scientific literature to assist health care providers, especially pulmonologists and sleep physicians, in making recommendations to patients and the general public about the importance of achieving good quality and adequate quantity of sleep.
ATS members were invited, based on their expertise in sleep medicine, and their conclusions were based on both empirical evidence identified after comprehensive literature review and clinical experience.
We focus on sleep health in both children and adults, including the impact of occupation on sleep, the public health implications of drowsy driving, and the common sleep disorders of obstructive sleep apnea and insomnia. This ATS statement also delineates gaps in research and knowledge that should be addressed and lead to new focused research priorities to advance knowledge in sleep and sleep health.
Good quality and quantity of sleep are essential for good health and overall quality of life; therefore a strong recommendation was made for the implementation of public education programs on the importance of sleep health.
Abstract
Obstructive sleep apnea (OSA) is thought to affect almost 1 billion people worldwide. OSA has well established cardiovascular and neurocognitive sequelae, although the optimal metric to ...assess its severity and/or potential response to therapy remains unclear. The apnea-hypopnea index (AHI) is well established; thus, we review its history and predictive value in various different clinical contexts. Although the AHI is often criticized for its limitations, it remains the best studied metric of OSA severity, albeit imperfect. We further review the potential value of alternative metrics including hypoxic burden, arousal intensity, odds ratio product, and cardiopulmonary coupling. We conclude with possible future directions to capture clinically meaningful OSA endophenotypes including the use of genetics, blood biomarkers, machine/deep learning and wearable technologies. Further research in OSA should be directed towards providing diagnostic and prognostic information to make the OSA diagnosis more accessible and to improving prognostic information regarding OSA consequences, in order to guide patient care and to help in the design of future clinical trials.
The Baby, the Bathwater, and the Polysomnogram Malhotra, Atul; Ayas, Najib T
American journal of respiratory and critical care medicine,
08/2020, Letnik:
202, Številka:
3
Journal Article
Chronic kidney disease (CKD) is associated with high mortality rates and heavy economic and social burdens. Nearly 10% of the United States population suffer from CKD, with fatal outcomes increased ...by 16-40 times even before reaching end-stage renal disease. The prevalence of obstructive sleep apnea (OSA) is between 3% and 7% in the general population, and has increased dramatically during the last 2 decades along with increased rates of obesity. However, the prevalence of OSA is much greater in patients with CKD. In addition, aggressive dialysis improves OSA. The current literature suggests a bidirectional association between CKD and OSA through a number of potential pathological mechanisms, which increase the possibility of both diseases being possible risk factors for each other. CKD may lead to OSA through a variety of mechanisms, including alterations in chemoreflex responsiveness, pharyngeal narrowing due to fluid overload, and accumulation of uremic toxins. It is also being increasingly recognized that OSA can also accelerate loss of kidney function. Moreover, animals exposed to intermittent hypoxia suffer histopathological renal damage. Potential mechanisms of OSA-associated renal dysfunction include renal hypoxia, hypertension, endothelial dysfunction, activation of the sympathetic nervous system, and increased oxidative stress.
Inadequate sleep and long work hours are long-standing traditions in the medical profession, and work schedules are especially intense in resident physicians. However, it has been increasingly ...recognized that the extreme hours commonly worked by residents may have substantial occupational and patient safety consequences. Largely because of these concerns, new regulations related to resident work hours came into effect July 2011, in the United States. Residents in their first year of training are now restricted to a maximum shift length of 16 hrs, with residents in subsequent years restricted to a maximum of 24 hrs. The purpose of this review is to summarize the literature regarding resident work hours in the intensive care unit, focusing on the potential positive and negative impacts of work hour limits.
The authors electronically searched MEDLINE, manually searched reference lists from retrieved articles, and reviewed their own personal databases for articles relevant to resident work hour limits.
To function well, humans, including physicians, require adequate sleep. Resident work hour limits will likely reduce the incidence of fatigue-related medical errors and improve resident safety and quality of life. However, a reduction in work hours may not represent the panacea for patient safety given the potential for increased errors because of discontinuity. Furthermore, there may be other substantial negative impacts, including reduced clinical exposure, erosion of professionalism, and inadequate preparation for independent practice. Costs of implementation are likely to be substantial.
Currently, there is fairly limited evidence available, and a more in-depth understanding of this complex topic is required to design a residency experience that will provide the next generation of physicians the best compromise between education, experience, and quality patient care. In the end, the primary goal of the postgraduate medical education system must be to ensure the creation of healthy physicians who can provide excellent clinical care in this complex interdisciplinary medical industry and who will have long fulfilling careers providing this outstanding care to their patients.
A recent randomized controlled trial in critical-care units revealed that the elimination of extended-duration work shifts (> or =24 h) reduces the rates of significant medical errors and ...polysomnographically recorded attentional failures. This raised the concern that the extended-duration shifts commonly worked by interns may contribute to the risk of medical errors being made, and perhaps to the risk of adverse events more generally. Our current study assessed whether extended-duration shifts worked by interns are associated with significant medical errors, adverse events, and attentional failures in a diverse population of interns across the United States.
We conducted a Web-based survey, across the United States, in which 2,737 residents in their first postgraduate year (interns) completed 17,003 monthly reports. The association between the number of extended-duration shifts worked in the month and the reporting of significant medical errors, preventable adverse events, and attentional failures was assessed using a case-crossover analysis in which each intern acted as his/her own control. Compared to months in which no extended-duration shifts were worked, during months in which between one and four extended-duration shifts and five or more extended-duration shifts were worked, the odds ratios of reporting at least one fatigue-related significant medical error were 3.5 (95% confidence interval CI, 3.3-3.7) and 7.5 (95% CI, 7.2-7.8), respectively. The respective odds ratios for fatigue-related preventable adverse events, 8.7 (95% CI, 3.4-22) and 7.0 (95% CI, 4.3-11), were also increased. Interns working five or more extended-duration shifts per month reported more attentional failures during lectures, rounds, and clinical activities, including surgery and reported 300% more fatigue-related preventable adverse events resulting in a fatality.
In our survey, extended-duration work shifts were associated with an increased risk of significant medical errors, adverse events, and attentional failures in interns across the United States. These results have important public policy implications for postgraduate medical education.
Obstructive sleep apnea (OSA) patients are at increased risk of cardiovascular disease (CVD). Cell adhesion molecules (CAM) are increased in OSA and CAM are also implicated in the development of CVD. ...Do CAM (ICAM-1, VCAM-1 and E-selectin) have prognostic value in identifying risk of cardiovascular events in OSA? 418 patients were included in the analysis. Mostly male (68.2%), mean age of 50.7 yrs, median AHI 16.5 events/hour, and mean BMI of 31.7 kg/m.sup.2 . 36 cardiovascular events occurred in 8-yrs of follow up. Higher levels of ICAM-1 were associated with developing CVD (HR = 3.65 95% CI 1.40-9.53, 2.sup.nd and 3rd tertiles vs. 1.sup.st tertile), including in patients with OSA (HR = 3.1 95% CI 1.16-8.25). E-selectin was significantly associated with cardiovascular events in patients with moderate to severe OSA (HR = 3.31 95% CI 0.94-11.72, 2.sup.nd and 3.sup.rd tertiles vs. 1.sup.st tertile) but not in patients without moderate to severe OSA (HR = 0.67 95% CI 0.19-2.38), p-value for interaction = 0.07.
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