Showing papers by "Guilherme Schettino published in 2014"

Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study

Abstract: Sedation overuse is frequent and possibly associated with poor outcomes in the intensive care unit (ICU) patients. However, the association of early oversedation with clinical outcomes has not been thoroughly evaluated. The aim of this study was to assess the association of early sedation strategies with outcomes of critically ill adult patients under mechanical ventilation (MV). A secondary analysis of a multicenter prospective cohort conducted in 45 Brazilian ICUs, including adult patients requiring ventilatory support and sedation in the first 48 hours of ICU admissions, was performed. Sedation depth was evaluated after 48 hours of MV. Multivariate analysis was used to identify variables associated with hospital mortality. A total of 322 patients were evaluated. Overall, ICU and hospital mortality rates were 30.4% and 38.8%, respectively. Deep sedation was observed in 113 patients (35.1%). Longer duration of ventilatory support was observed (7 (4 to 10) versus 5 (3 to 9) days, P = 0.041) and more tracheostomies were performed in the deep sedation group (38.9% versus 22%, P = 0.001) despite similar PaO2/FiO2 ratios and acute respiratory distress syndrome (ARDS) severity. In a multivariate analysis, age (Odds Ratio (OR) 1.02; 95% confidence interval (CI) 1.00 to 1.03), Charlson Comorbidity Index >2 (OR 2.06; 95% CI, 1.44 to 2.94), Simplified Acute Physiology Score 3 (SAPS 3) score (OR 1.02; CI 95%, 1.00 to 1.04), severe ARDS (OR 1.44; CI 95%, 1.09 to 1.91) and deep sedation (OR 2.36; CI 95%, 1.31 to 4.25) were independently associated with increased hospital mortality. Early deep sedation is associated with adverse outcomes and constitutes an independent predictor of hospital mortality in mechanically ventilated patients.

Sepsis-related deaths in Brazil: an analysis of the national mortality registry from 2002 to 2010.

Abstract: Limited population-based epidemiologic information about sepsis’ demography, including its mortality and temporal changes is available from developing countries. We investigated the epidemiology of sepsis deaths in Brazil using secondary data from the Brazilian Mortality Information System. Retrospective descriptive analysis of Brazilian multiple-cause-of-death data between 2002 and 2010, with sepsis-associated International Classification of Diseases, 10th Revision (ICD-10) code indicated as the cause of death. Population-based sepsis associated mortality rates and trends were estimated. Annual population-based mortality rates were calculated using age-stratified population estimates from the 2010 census provided by the Brazilian Institute of Geography and Statistics as denominators. The total number of annual deaths recorded in Brazil increased over the decade, from 982,294 deaths reported in 2002 to 1,133,761 deaths reported in 2010. The number of sepsis associated deaths also increased both in absolute numbers and proportions from 95,972 (9.77% of total deaths) in 2002 to 186,712 deaths (16.46%) in 2010. The age-adjusted rate of sepsis-associated mortality increased from 69.5 deaths per 100,000 to 97.8 deaths per 100,000 population from 2002 to 2010 (P <0.001). Sepsis-associated mortality was higher in individuals older than 60 years of age as compared to subjects aged 0 to 20 years (adjusted rate ratio 15.7 (95% confidence interval (CI) 15.6 to 15.8)) and in male subjects (1.15 (95% CI 1.15 to 1.16)). Between 2002 and 2010 the contribution of sepsis to all cause mortality as reported in multiple-cause-of-death forms increased significantly in Brazil. Age-adjusted mortality rates by sepsis also increased in the last decade. Our results confirm the importance of sepsis as a significant healthcare issue in Brazil.

Intensive care unit visitation policies in Brazil: a multicenter survey.

Abstract: Objetivo: Este estudo teve como objetivo determinar a politica de visitacao predominante nas unidades de terapia intensiva e quais comodidades proporcionadas aos visitantes Metodos: Foram enviados 800 convites a enderecos de e-mail de medicos e enfermeiros intensivistas listados nos grupos de pesquisa da Rede da Associacao de Medicina Intensiva Brasileira e da Rede Brasileira de Pesquisa em Terapia Intensiva A mensagem por e-mail continha um link para um questionario de 33 itens a respeito do perfil de suas respectivas unidades de terapia intensiva Resultados: Foram incluidos no estudo os questionarios de 162 unidades de terapia intensiva localizadas em todas as regioes do pais, mas foram predominantes as das Regioes Sudeste (58%) e Sul (16%) Apenas 2,6% das unidades de terapia intensiva relataram ter politicas liberais de visitacao, enquanto 45,1% das unidades de terapia intensiva possibilitavam dois periodos diarios de visitacao e 69,1% permitiam de 31 a 60 minutos de visita por periodo Em situacoes especiais, como casos de fim de vida, 98,7% delas permitiam visitas em horarios flexiveis Cerca de metade das unidades de terapia intensiva (50,8%) nao oferecia qualquer comodidade aos visitantes Apenas 46,9% das unidades de terapia intensiva tinham uma sala de reuniao com familiares, e 37% nao dispunham de uma sala de espera Conclusao: Nas unidades de terapia intensiva do Brasil, houve predominância de politicas restritivas de visitacao, sendo que a maioria delas so permite dois periodos diarios de visitacao Tambem ha uma ausencia de comodidades para os visitantes

[Is the ICU staff satisfied with the computerized physician order entry? A cross-sectional survey study].

Abstract: Objective: To evaluate the satisfaction of the intensive care unit staff with a computerized physician order entry and to compare the concept of the computerized physician order entry relevance among intensive care unit healthcare workers. Methods: We performed a cross-sectional survey to assess the satisfaction of the intensive care unit staff with the computerized physician order entry in a 30-bed medical/surgical adult intensive care unit using a self-administered questionnaire. The questions used for grading satisfaction levels were answered according to a numerical scale that ranged from 1 point (low satisfaction) to 10 points (high satisfaction). Results: The majority of the respondents (n=250) were female (66%) between the ages of 30 and 35 years of age (69%). The overall satisfaction with the computerized physician order entry scored 5.74±2.14 points. The satisfaction was lower among physicians (n=42) than among nurses, nurse technicians, respiratory therapists, clinical pharmacists and diet specialists (4.62±1.79 versus 5.97±2.14, p<0.001); satisfaction decreased with age (p<0.001). Physicians scored lower concerning the potential of the computerized physician order entry for improving patient safety (5.45±2.20 versus 8.09±2.21, p<0.001) and the ease of using the computerized physician order entry (3.83±1.88 versus 6.44±2.31, p<0.001). The characteristics independently associated with satisfaction were the system's user-friendliness, accuracy, capacity to provide clear information, and fast response time. Conclusion: Six months after its implementation, healthcare workers were satisfied, albeit not entirely, with the computerized physician order entry. The overall users' satisfaction with computerized physician order entry was lower among physicians compared to other healthcare professionals. The factors associated with satisfaction included the belief that digitalization decreased the workload and contributed to the intensive care unit quality with a user-friendly and accurate system and that digitalization provided concise information within a reasonable time frame.

In vitro and in vivo validation of stored swine erythrocyte viability to establish an experimental model of homologous red blood cell transfusion: a pilot study.

Abstract: Results: After 14 days of storage, the red blood cell units had lower volumes and equivalent total concentrations of hemoglobin and hematocrit compared to human standards. The free hemoglobin concentration increased from 31.0±9.3 to 112.4±31.4mg/dL (p<0.001), and the hemolysis index increased from 0.1±0.1 to 0.5±0.1% (p<0.001). However, these tests were within the acceptable range for human standards. The percentage of radioactivity in supernatant samples was similar at baseline and after 24 hours, thus excluding significant hemolysis. No evidence of splenic sequestration of radioactive erythrocytes was found. Conclusion: Swine red blood cells stored for 14 days are viable and can be used in experimental studies of transfusion. These validation experiments are important to aid investigators in establishing experimental models of transfusion.

Symptoms of anxiety, depression and post-traumatic stress in pairs of patients and their family members during and following ICU stay: who suffers most?

Abstract: To compare the incidence of anxiety, depression and post-traumatic stress symptoms in pairs of patients and respective family members during the ICU stay and at 30 and 90 days post ICU discharge. According to the literature, both patients and family members suffer from psychological distress during and following an ICU stay [1]. Although these issues have been discussed, to date few studies have addressed the pairs at three times.

Adding value to mechanical ventilation.

Abstract: http://dx.doi.org/10.1590/S1806-37132014000500002 hospitalization for patients with respiratory failure and requiring mechanical ventilation is estimated to be US$34,000, allow us to extrapolate that Brazil will spend nearly R$54.5 billion/year, considering 12% of healthcare expenditures(8) and 1.1% of the gross domestic product,9) on hospital treatment of patients with acute respiratory failure or acute exacerbation of chronic respiratory failure. The figures presented above, bearing in mind that they are the result of a simple epidemiological, mathematical, and financial exercise, draw attention to the huge impact that respiratory failure and mechanical ventilation have on heath policy in Brazil. However, it is important to remember that ventilatory support is known to be a cost-effective treatment for most patients. Studies published in recent years have shown figures ranging from US$26,000 to US$175,000 per quality-adjusted life year (QALY), depending on the etiology of respiratory failure, comorbidities, and patient age.(10) Although arbitrary, it is current practice to accept treatments resulting in US$50,000150,000/QALY as cost-effective.(11) The published recommendations(1-4) state that the results of treatment of patients with acute respiratory failure have improved greatly in recent decades, and what is most interesting is that this advance is more attributable to a better understanding of the pathophysiology of respiratory failure and to the prevention of ventilator-associated complications than to the development of new drugs or technologies. Mechanical ventilators, in their basic essence, have changed very little over this period, but the way they are used has changed completely, evolving from an aggressive strategy to correct hypoxemia and/or hypercapnia to a strategy focused on delivering a minimum alveolar ventilation to ensure gas exchange, sparing the lungs from further injury and thereby providing the time needed for lung recovery. Brazil has played a decisive role in the development of these modern concepts of mechanical ventilation, particularly in the understanding of the pathophysiology of ARDS and in being a pioneer in demonstrating the benefits of using protective ventilatory strategies. (12,13) Adding value to mechanical ventilation