Showing papers in "Revista Brasileira De Terapia Intensiva in 2015"

The reality of patients requiring prolonged mechanical ventilation: a multicenter study.

Abstract: Objetivo: Na ultima decada ocorreu um aumento no numero de pacientes que necessitam manutencao de ventilacao mecânica prolongada, resultando no surgimento de uma grande populacao de pacientes cronicos criticamente enfermos. Este estudo estabeleceu a incidencia de ventilacao mecânica prolongada em quatro unidades de terapia intensiva e relatou as diferentes caracteristicas, desfechos hospitalares e impacto nos custos e servicos de pacientes com ventilacao mecânica prolongada (dependencia de ventilacao mecânica por 21 dias ou mais) em comparacao a pacientes sem ventilacao mecânica prolongada (dependencia de ventilacao mecânica inferior a 21 dias). Metodos: Este foi um estudo multicentrico de coorte que envolveu todos os pacientes admitidos em quatro unidades de terapia intensiva. As principais avaliacoes de desfechos incluiram o tempo de permanencia na unidade de terapia intensiva e no hospital, a incidencia de complicacoes durante a permanencia na unidade de terapia intensiva, e a mortalidade na unidade de terapia intensiva e no hospital. Resultados: Durante o periodo do estudo, ocorreram 5.287 admissoes as unidades de terapia intensiva. Alguns desses pacientes (41,5%) necessitaram de suporte ventilatorio (n = 2.197), e 218 dos pacientes (9,9%) cumpriram os criterios de ventilacao mecânica prolongada. Algumas complicacoes se desenvolveram durante a permanencia na unidade de terapia intensiva como fraqueza muscular, ulceras de pressao, sepse nosocomial bacteriana, candidemia, embolia pulmonar, e delirium hiperativo; estas se associaram com um risco significantemente maior de ventilacao mecânica prolongada. Os pacientes de ventilacao mecânica prolongada tiveram um aumento significante da mortalidade na unidade de terapia intensiva (diferenca absoluta = 14,2%; p < 0,001) e da mortalidade hospitalar (diferenca absoluta = 19,1%; p < 0,001). O grupo com ventilacao mecânica prolongada permaneceu mais dias no hospital apos receber alta da unidade de terapia intensiva (26,9 ± 29,3 versus 10,3 ± 20,4 dias; p < 0,001) e acarretou custos mais elevados. Conclusao: A classificacao de pacientes cronicos criticamente enfermos segundo a definicao de ventilacao mecânica prolongada adotada em nosso estudo (dependencia de ventilacao mecânica por periodo igual ou superior a 21 dias) identificou pacientes com risco elevado de complicacoes durante a permanencia na unidade de terapia intensiva, permanencia mais longa na unidade de terapia intensiva e no hospital, taxas de mortalidade maiores e custos mais elevados.

Psychosocial factors and prevalence of burnout syndrome among nursing workers in intensive care units.

Abstract: Objective: To evaluate the prevalence of burnout syndrome among nursing workers in intensive care units and establish associations with psychosocial factors. Methods: This descriptive study evaluated 130 professionals, including nurses, nursing technicians, and nursing assistants, who performed their activities in intensive care and coronary care units in 2 large hospitals in the city of Rio de Janeiro, Brazil. Data were collected in 2011 using a self-reported questionnaire. The Maslach Burnout Inventory was used to evaluate the burnout syndrome dimensions, and the Self Reporting Questionnaire was used to evaluate common mental disorders. Results: The prevalence of burnout syndrome was 55.3% (n = 72). In the quadrants of the demand-control model, low-strain workers exhibited a prevalence of 64.5% of suspected cases of burnout, whereas high-strain workers exhibited a prevalence of 72.5% of suspected cases (p = 0.006). The prevalence of suspected cases of common mental disorders was 27.7%; of these, 80.6% were associated with burnout syndrome (< 0.0001). The multivariate analysis adjusted for gender, age, educational level, weekly work duration, income, and thoughts about work during free time indicated that the categories associated with intermediate stress levels - active work (OR = 0.26; 95%CI = 0.09 - 0.69) and passive work (OR = 0.22; 95%CI = 0.07 - 0.63) - were protective factors for burnout syndrome. Conclusion: Psychosocial factors were associated with the development of burnout syndrome in this group. These results underscore the need for the development of further studies aimed at intervention and the prevention of the syndrome.

Prognostic value of ventricular diastolic dysfunction in patients with severe sepsis and septic shock.

Abstract: Objectives: To evaluate the prevalence of myocardial dysfunction and its prognostic value in patients with severe sepsis and septic shock. Methods: Adult septic patients admitted to an intensive care unit were prospectively studied using transthoracic echocardiography within the first 48 hours after admission and thereafter on the 7th-10th days. Echocardiographic variables of biventricular function, including the E/e' ratio, were compared between survivors and non-survivors. Results: A total of 99 echocardiograms (53 at admission and 46 between days 7 - 10) were performed on 53 patients with a mean age of 74 (SD 13) years. Systolic and diastolic dysfunction was present in 14 (26%) and 42 (83%) patients, respectively, and both types of dysfunction were present in 12 (23%) patients. The E/e' ratio, an index of diastolic dysfunction, was the best predictor of hospital mortality according to the area under the ROC curve (0.71) and was an independent predictor of outcome, as determined by multivariate analysis (OR = 1.36 [1.05 - 1.76], p = 0.02). Conclusion: In septic patients admitted to an intensive care unit, echocardiographic systolic dysfunction is not associated with increased mortality. In contrast, diastolic dysfunction is an independent predictor of outcome.

Nutritional risk assessment in critically ill cancer patients: systematic review.

Abstract: Objetivo:Revisar sistematicamente os principais metodos para avaliacao do risco nutricional utilizados em pacientes oncologicos graves e apresentar aqueles que melhor avaliam os riscos e preveem desfechos clinicos relevantes neste grupo de pacientes, alem de discutir as vantagens e as desvantagens destes metodos, segundo a literatura atual.Metodos:O estudo consistiu de uma revisao sistematica com base na analise de artigos obtidos nas bases de dados PubMed, LILACS e SciELO, realizando as buscas com os termos em ingles: “nutritional risk assessment”, “critically ill” e “cancer”.Resultados:Apenas 6 (17,7%) dos 34 artigos inicialmente obtidos cumpriam os criterios para inclusao e foram selecionados para revisao. Os principais desfechos destes estudos foram que o gasto de energia em repouso se associou com subnutricao e superalimentacao. O escore elevado da Avaliacao Subjetiva Global - Produzida pelo Paciente associou- se de forma significante com baixa ingestao de alimentos, perda de peso e desnutricao. Em termos de marcadores bioquimicos, niveis mais elevados de creatinina, albumina e ureia se associaram de forma significante com mortalidade mais baixa. Os piores indices de sobrevivencia foram encontrados para pacientes com condicoes de desempenho piores, conforme avaliacao usando o Eastern Cooperative Oncologic Group performance status, escore prognostico de Glasgow elevado, baixa albumina/hipoalbuminemia, elevado escore da Avaliacao Subjetiva Global - Produzida Pelo Paciente e para niveis elevados de fosfatase alcalina. Valores de avaliacao do Indice de Risco Nutricional Geriatrico inferiores a 87 se associaram de forma significante com mortalidade. O escore pelo indice prognostico inflamatorio nutricional se associou com condicao nutricional anormal em pacientes oncologicos graves. Dentre os estudos revisados que avaliaram apenas peso e indice de massa corporal, nao se encontrou qualquer desfecho clinico significante.Conclusao:Nenhum dos metodos revisados ajudou a definir o risco entre esses pacientes. Portanto, sugere-se a avaliacao por meio da quantificacao da perda de peso e dos niveis sericos, preferivelmente em combinacao com outros metodos utilizando escores como o Eastern Cooperative Oncologic Group performance status, o escore prognostico de Glasgow e a Avaliacao Subjetiva Global - Produzida Pelo Paciente, ja que seu uso e simples, factivel e util em tais casos.

Adverse events caused by potential drug-drug interactions in an intensive care unit of a teaching hospital

Abstract: Objetivo: Avaliar a existencia de interacoes medicamentosas potenciais na unidade de terapia intensiva de um hospital, com foco nos antimicrobianos. Metodos: Estudo transversal, que analisou prescricoes eletronicas de pacientes da unidade de terapia intensiva de um hospital de ensino, avaliando potenciais interacoes medicamentosas relacionadas aos antimicrobianos, entre 1o de janeiro e 31 de marco de 2014. O consumo dos antimicrobianos foi expresso em dose diaria definida por 100 pacientes-dia. A busca e a classificacao das interacoes foram realizadas com base no sistema Micromedex®. Resultados: Foram analisadas prescricoes diarias de 82 pacientes, totalizando 656 prescricoes. Do total de medicamentos prescritos, 25% eram antimicrobianos, sendo meropenem, vancomicina e ceftriaxona os mais prescritos. Os antimicrobianos mais consumidos, segundo a metodologia de dose diaria definida por 100 pacientes-dia, foram cefepime, meropenem, sulfametoxazol + trimetoprima e ciprofloxacino. A media de interacoes por paciente foi de 2,6. Entre as interacoes, 51% foram classificadas como contraindicadas ou de gravidade importante. Destacaram-se as interacoes altamente significativas (valor clinico 1 e 2), com prevalencia de 98%. Conclusao: Com o presente trabalho verifica-se que os antimicrobianos sao uma classe frequentemente prescrita na unidade de terapia intensiva, apresentando elevada quantidade de interacoes medicamentosas potenciais, sendo a maior parte das interacoes considerada altamente significativa.

Therapeutic hypothermia after cardiac arrest: outcome predictors.

Abstract: Objetivo: A determinacao do prognostico de pacientes em coma apos parada cardiaca tem implicacoes clinicas, eticas e sociais. Exame neurologico, marcadores de imagem e bioquimicos sao ferramentas uteis e bem aceitas na previsao da recuperacao. Com o advento da hipotermia terapeutica, tais informacoes devem de ser confirmadas. Neste estudo procurou-se determinar a validade de diferentes marcadores que podem ser utilizados na deteccao de pacientes com mau prognostico durante um protocolo de hipotermia. Metodos: Foram coletados prospectivamente os dados de pacientes adultos, internados apos parada cardiaca em nossa unidade de terapia intensiva para realizacao de protocolo de hipotermia. Nosso intuito foi realizar um estudo descritivo e analitico para analisar a relacao entre os dados clinicos, parâmetros neurofisiologicos, de imagem e bioquimicos, e o desfecho apos 6 meses, conforme definido pela escala Cerebral Performance Categories (bom, se 1-2, e mau, se 3-5). Foi coletada uma amostra para determinacao de neuroenolase apos 72 horas. Os exames de imagem e neurofisiologicos foram realizados 24 horas apos o periodo de reaquecimento. Resultados: Foram incluidos 67 pacientes, dos quais 12 tiveram evolucao neurologica favoravel. Fibrilacao ventricular e atividade teta no eletroencefalograma se associaram a bom prognostico. Pacientes submetidos a resfriamento mais rapido (tempo medio de 163 versus 312 minutos), com lesao cerebral causada por hipoxia/isquemia detectada na ressonância nuclear magnetica ou niveis de neuroenolase superiores a 58ng/mL se associaram a desfecho neurologico desfavoravel (p < 0,05). Conclusao: A presenca de lesao cerebral causada por hipoxia/isquemia e de neuroenolase foram fortes preditores de ma evolucao neurologica. Apesar da crenca de que atingir rapidamente a temperatura alvo da hipotermia melhora o prognostico neurologico, nosso estudo demonstrou que este fator se associou a um aumento da mortalidade e a uma pior evolucao neurologica.

A guided approach to diagnose severe muscle weakness in the intensive care unit

Abstract: Intensive care unit (ICU) acquired muscle weakness (ICUAW) is a clinically detected condition characterized by diffuse, symmetric weakness involving the limbs and respiratory muscles.(1) Patients have different degrees of limb muscle weakness and are dependent on a ventilator, while the facial muscles are spared. Diagnosis of ICUAW requires that no plausible etiology other than critical illness be identified, and thus, other causes of acute muscle weakness are excluded. One major diagnostic criterion is that ICUAW is detected after the onset of critical illness; therefore, it is important to differentiate ICUAW from Guillain-Barrè syndrome or other acute neuromuscular disorders that may cause respiratory failure and ICU admission (Figure 1).(1) The use of neuromuscular blocking agents for long periods of time, the use of some antibiotics and electrolyte abnormalities, such as hypermagnesemia, hypokalemia, hypercalcemia, and hypophosphatemia, and prolonged immobilization are common in the ICU and should be appropriately treated before a diagnosis of ICUAW is posed.(2) A diagnosis of ICUAW is achieved by manually testing the muscle strength using the Medical Research Council (MRC) scale or by measuring handgrip strength using a dynamometer. MRC muscle strength is assessed in 12 muscle groups (Figure 2): a summed score below 48/60 designates ICUAW or significant weakness, and an MRC score below 36/48 indicates severe weakness.(3) Recently, a simplified version of the scale with only four categories and improved clinimetric properties was proposed (Figure 2).(4) To date, this version has been validated in a small cohort of 60 critically ill patients with excellent inter-rater reliability and high sensitivity and specificity in diagnosing ICUAW compared to complete full MRC.(5) Handgrip dynamometry measures isometric muscle strength and can be used as a quick diagnostic test. Cut-off scores of less than 11kg (IQR 10 40) in males and less than 7kg (IQR 0 7.3) in females are considered to be indicative of ICUAW (Figure 1).(5) Both MRC and handgrip dynamometry are volitional tests and require the patients to be alert, cooperative, and motivated. Sedation, delirium and coma often interfere with the early evaluation of muscle strength in the ICU. However, voluntary muscle strength using the MRC sum score or handgrip dynamometry can be reliably assessed if adequate clinical experience is gained with manual muscle testing in ICU patients and strict guidelines and the use of standardized test procedures and positions are followed to accurately select patients.(6) Common causes of ICUAW include critical illness polyneuropathy (CIP) and myopathy (CIM), which are revealed by appropriate nerve Nicola Latronico1,2, Rik Gosselink3

Maternal near miss in the intensive care unit: clinical and epidemiological aspects

Abstract: Objetivos:Analisar o perfil clinico epidemiologico de mulheres com near miss materno segundo os novos criterios da Organizacao Mundial da Saude.Metodos:Foi realizado um estudo descritivo, tipo corte transversal, analisando- se os prontuarios das pacientes admitidas na unidade de terapia intensiva obstetrica de um hospital terciario do Recife (Brasil), em um periodo de quatro anos. Foram incluidas as mulheres que apresentavam pelo menos um dos criterios de near miss. As variaveis estudadas foram: idade, raca/cor, estado civil, escolaridade, procedencia, numero de gestacoes e consultas de pre-natal, complicacoes e procedimentos realizados, via de parto, idade gestacional no parto e criterios de near miss materno. A analise descritiva foi executada utilizando-se o programa Epi-Info 3.5.1.Resultados:Foram identificados 255 casos de near miss materno, totalizando uma razao de near miss materno de 12,8/1.000 nascidos vivos. Dentre esses casos, 43,2% das mulheres apresentavam ensino fundamental incompleto; 44,7% eram primigestas e 20,5% tinham realizado cesariana previa. Quanto aos diagnosticos especificos, houve predominância dos disturbios hipertensivos (62,7%), sendo que muitos deles foram complicados pela sindrome HELLP (41,2%). Os criterios laboratoriais de near miss foram os mais observados (59,6%), em funcao, principalmente, da elevada frequencia de plaquetopenia aguda (32,5%).Conclusoes:Evidenciou-se uma frequencia elevada de mulheres com baixa escolaridade e primigestas. Com os novos criterios propostos pela Organizacao Mundial da Saude, os disturbios hipertensivos da gestacao continuam sendo os mais comuns entre os casos de near miss materno. Destaca-se ainda a elevada frequencia da sindrome HELLP, o que contribuiu para que a trombocitopenia aguda fosse o criterio mais frequente de near miss.

Patient stress in intensive care: comparison between a coronary care unit and a general postoperative unit.

Abstract: Objetivo: Avaliar e comparar os fatores estressantes identificados pelos pacientes de uma unidade de terapia intensiva coronariana com aqueles percebidos pelos pacientes de uma unidade de terapia intensiva pos-operatoria geral. Metodos: Estudo transversal, descritivo, realizado na unidade de terapia intensiva coronariana e na unidade de terapia intensiva pos-operatoria geral de um hospital privado. Participaram 60 pacientes, sendo 30 de cada unidade de terapia intensiva. Para identificacao dos fatores estressantes, utilizou-se a escala de estressores em unidade de terapia intensiva. Foram calculados o escore medio de cada item da escala e, em seguida, o escore total de estresse). Apos a comparacao entre os grupos, as diferencas foram consideradas significantes quando p < 0,05. Resultados: A idade dos pacientes da unidade de terapia intensiva coronariana foi de 55,63 ± 13,58 e da unidade de terapia intensiva pos-operatoria geral foi de 53,60 ± 17,47 anos. Os principais estressores para a unidade de terapia intensiva coronariana foram “sentir dor”, “estar incapacitado para exercer o papel na familia” e “estar aborrecido”. Para a unidade de terapia intensiva pos-operatoria geral foram “sentir dor”, “estar incapacitado para exercer o papel na familia” e “nao conseguir se comunicar”. A media do escore total de estresse na unidade de terapia intensiva coronariana foi de 104,20 ± 30,95 e, na unidade de terapia intensiva pos-operatoria geral, foi de 116,66 ± 23,72 (p = 0,085). Comparando cada fator estressante separadamente, houve diferenca estatisticamente significante apenas entre tres itens. “Ter a enfermagem constantemente fazendo tarefas ao redor do leito” foi mais estressante para a unidade de terapia intensiva pos-operatoria geral do que para a unidade de terapia intensiva coronariana (p = 0,013). Por outro lado, os itens “escutar sons e ruidos desconhecidos” e “ouvir pessoas falando sobre voce” foram mais estressantes para a unidade de terapia intensiva coronariana (p = 0,046 e 0,005, respectivamente). Conclusao: A percepcao sobre os principais estressores, bem como o escore total de estresse foi semelhante entre a unidade de terapia intensiva coronariana e a unidade de terapia intensiva pos-operatoria geral.

Noninvasive ventilation in status asthmaticus in children: levels of evidence.

Abstract: Objetivo: Avaliar a qualidade das evidencias existentes para embasar diretrizes do emprego da ventilacao mecânica nao invasiva no manejo da crise de asma aguda grave em criancas nao responsivas ao tratamento padrao. Metodos: Busca, selecao e analise de todos os artigos originais sobre asma e ventilacao mecânica nao invasiva em criancas, publicados ate 1o de setembro de 2014, em todos os idiomas, nas bases de dados eletronicas PubMed, Web of Science, Cochrane Library, Scopus e SciELO, encontrados por meio de busca pelos descritores "asthma", "status asthmaticus", "noninvasive ventilation", "bronchospasm", "continuous positive airway pressure", "child", "infant", "pediatrics", "hypercapnia", "respiratory failure", e das palavras-chave "BIPAP", "CPAP", "bilevel", "acute asthma" e "near fatal asthma". Os artigos foram qualificados segundo os graus de evidencias do Sistema GRADE. Resultados: Foram obtidos apenas nove artigos originais. Destes, dois (22%) apresentaram nivel de evidencia A, um (11%) apresentou nivel de evidencia B e seis (67%) apresentaram nivel de evidencia C. Conclusao: Sugere-se que o emprego da ventilacao mecânica nao invasiva na crise de asma aguda grave em criancas nao responsivas ao tratamento padrao e aplicavel a maioria desses pacientes, mas as evidencias nao podem ser consideradas conclusivas, uma vez que pesquisa adicional de alta qualidade provavelmente tenha um impacto modificador na estimativa de efeito.

Progress and perspectives in pediatric acute respiratory distress syndrome

Abstract: Acute respiratory distress syndrome is a disease of acute onset characterized by hypoxemia and infiltrates on chest radiographs that affects both adults and children of all ages. It is an important cause of respiratory failure in pediatric intensive care units and is associated with significant morbidity and mortality. Nevertheless, until recently, the definitions and diagnostic criteria for acute respiratory distress syndrome have focused on the adult population. In this article, we review the evolution of the definition of acute respiratory distress syndrome over nearly five decades, with a special focus on the new pediatric definition. We also discuss recommendations for the implementation of mechanical ventilation strategies in the treatment of acute respiratory distress syndrome in children and the use of adjuvant therapies.

Shortage of intensive care specialists in the United States: recent insights and proposed solutions

Abstract: We believe that before arguing about the “real” or “imagined” intensivist shortage, there are several fundamental issues to address. First, it is important to agree on a definition of an intensivist. High quality practice and credible team leadership of critical care medicine (CCM) should require the intensivist to devote 100% effort to critical care. Unfortunately, this comprises a small fraction of US practitioners and is predominantly limited to academic medical centers with Accredited Council for Graduate Medical Education (ACGME)-accredited fellowship programs. Because the vast majority of adult intensivists are actually part-time practitioners based in pulmonary medicine, operating rooms (surgeons/anesthesiologists), or emergency medicine, the bulk of CCM board certificates are allocated to part-time physicians;

Recomendações farmacêuticas em unidade de terapia intensiva: três anos de atividades clínicas

Abstract: Objective: To analyze the clinical activities performed and the accepted pharmacist recommendations made by a pharmacist as a part of his/her daily routine in an adult clinical intensive care unit over a period of three years. Methods: A cross-sectional, descriptive, and exploratory study was conducted at a tertiary university hospital from June 2010 to May 2013, in which pharmacist recommendations were categorized and analyzed. Results: A total of 834 pharmacist recommendations (278 per year, on average) were analyzed and distributed across 21 categories. The recommendations were mainly made to physicians (n = 699; 83.8%) and concerned management of dilutions (n = 120; 14.4%), dose adjustment (n = 100; 12.0%), and adverse drug reactions (n = 91; 10.9%). A comparison per period demonstrated an increase in pharmacist recommendations with larger clinical content and a reduction of recommendations related to logistic aspects, such as drug supply, over time. The recommendations concerned 948 medications, particularly including systemic anti-infectious agents. Conclusion: The role that the pharmacist played in the intensive care unit of the institution where the study was performed evolved, shifting from reactive actions related to logistic aspects to effective clinical participation with the multi-professional staff (proactive actions).

American Society of Anesthesiologists Score: still useful after 60 years? Results of the EuSOS Study.

Abstract: Objective: The European Surgical Outcomes Study described mortality following in-patient surgery. Several factors were identified that were able to predict poor outcomes in a multivariate analysis. These included age, procedure urgency, severity and type and the American Association of Anaesthesia score. This study describes in greater detail the relationship between the American Association of Anaesthesia score and postoperative mortality. Methods: Patients in this 7-day cohort study were enrolled in April 2011. Consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery with a recorded American Association of Anaesthesia score in 498 hospitals across 28 European nations were included and followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Decision tree analysis with the CHAID (SPSS) system was used to delineate nodes associated with mortality. Results: The study enrolled 46,539 patients. Due to missing values, 873 patients were excluded, resulting in the analysis of 45,666 patients. Increasing American Association of Anaesthesia scores were associated with increased admission rates to intensive care and higher mortality rates. Despite a progressive relationship with mortality, discrimination was poor, with an area under the ROC curve of 0.658 (95% CI 0.642 - 0.6775). Using regression trees (CHAID), we identified four discrete American Association of Anaesthesia nodes associated with mortality, with American Association of Anaesthesia 1 and American Association of Anaesthesia 2 compressed into the same node. Conclusion: The American Association of Anaesthesia score can be used to determine higher risk groups of surgical patients, but clinicians cannot use the score to discriminate between grades 1 and 2. Overall, the discriminatory power of the model was less than acceptable for widespread use.

Right internal jugular vein distensibility appears to be a surrogate marker for inferior vena cava vein distensibility for evaluating fluid responsiveness

Abstract: Objetivo:Investigar se a variacao respiratoria no diâmetro da veia cava inferior (ΔDVCI) e no diâmetro da veia jugular interna direita (ΔDVJID) se correlacionam em pacientes submetidos a ventilacao mecânica.Metodos:Estudo clinico prospectivo realizado em uma unidade de terapia intensiva de um hospital universitario. Foram incluidos 39 pacientes mecanicamente ventilados e com instabilidade hemodinâmica. Os valores da variacao do diâmetro da veia cava inferior e da variacao do diâmetro da veia jugular interna direita foram avaliados por meio de ecografia. A distensibilidade da veia foi calculada como a razao de (A) Dmin - Dmax/Dmin e (B) Dmax - Dmin/media de Dmax - Dmin, e expressa como porcentagem.Resultados:Com ambos os metodos, observou-se correlacao entre a variacao do diâmetro da veia cava inferior e a variacao do diâmetro da veia jugular interna direita: (A) r = 0,34, p = 0,04 e (B) r = 0,51, p = 0,001. Utilizando o ponto de corte de 18% para indicar responsividade a fluidos na variacao do diâmetro da veia cava inferior, pelo o metodo (A), 16 pacientes foram considerados responsivos e 35 medicoes mostraram concordância (Kappa ponderado = 0,80). A area sob a curva ROC foi de 0,951 (IC95% 0,830 - 0,993; valor de corte = 18,92). Usando 12% como ponto de corte para a variacao do diâmetro da veia cava inferior para indicar capacidade de resposta a fluidos, pelo metodo (B), 14 pacientes foram responsivos e 32 medicoes mostraram concordância (Kappa ponderado = 0,65). A area sob a curva ROC foi de 0,903 (IC95% 0,765 - 0,973; valor de corte = 11,86).Conclusao:As variacoes respiratorias nas dimensoes da veia cava inferior e da veia jugular interna direita se correlacionaram e mostraram concordância significativa. Avaliacao da distensibilidade da veia jugular interna direita parece ser uma alternativa a distensibilidade da veia cava inferior para avaliar a responsividade a fluidos.

Decompressive craniectomy in severe traumatic brain injury: prognostic factors and complications

Abstract: Objective: To analyze the clinical characteristics, complications and factors associated with the prognosis of severe traumatic brain injury among patients who undergo a decompressive craniectomy. Methods: Retrospective study of patients seen in an intensive care unit with severe traumatic brain injury in whom a decompressive craniectomy was performed between the years 2003 and 2012. Patients were followed until their discharge from the intensive care unit. Their clinical-tomographic characteristics, complications, and factors associated with prognosis (univariate and multivariate analysis) were analyzed. Results: A total of 64 patients were studied. Primary and lateral decompressive craniectomies were performed for the majority of patients. A high incidence of complications was found (78% neurological and 52% nonneurological). A total of 42 patients (66%) presented poor outcomes, and 22 (34%) had good neurological outcomes. Of the patients who survived, 61% had good neurological outcomes. In the univariate analysis, the factors significantly associated with poor neurological outcome were postdecompressive craniectomy intracranial hypertension, greater severity and worse neurological state at admission. In the multivariate analysis, only postcraniectomy intracranial hypertension was significantly associated with a poor outcome. Conclusion: This study involved a very severe and difficult to manage group of patients with high morbimortality. Intracranial hypertension was a main factor of poor outcome in this population.

Changes in respiratory mechanics during respiratory physiotherapy in mechanically ventilated patients.

Abstract: p < 0.001), tidal volume (T -1 = 550 ± 134mL versus T 0 = 698 ± 155mL; p < 0.001), and peripheral oxygen saturation (T -1 = 96.5 ± 2.29% versus T 0 = 98.2 ± 1.62%; p < 0.001) were observed, in addition to a reduction of respiratory system resistance (T -1 = 14.2 ± 4.63cmH 2 O/L/s versus T 0 = 11.0 ± 3.43cmH2O/L/s; p < 0.001), after applying the respiratory physiotherapy protocol. All changes were present in the assessment performed one hour (T +1 ) after the application of the respiratory physiotherapy protocol. Regarding the hemodynamic variables, an immediate increase in the heart rate after application of the protocol was observed, but that increase was not maintained (T -1 = 88.9 ± 18.7 bpm versus T 0 = 93.7 ± 19.2bpm versus T +1 = 88.5 ± 17.1bpm; p < 0.001). Conclusion: Respiratory therapy leads to immediate changes in the lung mechanics and hemodynamics of mechanical ventilation-dependent patients, and ventilatory changes are likely to remain for at least one hour.

Functional evolution of critically ill patients undergoing an early rehabilitation protocol

Abstract: Objetivo: Avaliar a evolucao funcional dos pacientes submetidos a um protocolo de reabilitacao precoce do paciente grave da admissao ate a alta da unidade de terapia intensiva. Metodos: Foi conduzido um estudo transversal retrospectivo, incluindo 463 pacientes adultos com diagnostico clinico e/ou cirurgico, submetidos a um protocolo de reabilitacao precoce. A forca muscular global foi avaliada na admissao da unidade de terapia intensiva por meio da escala Medical Research Council. De acordo com a pontuacao da Medical Research Council os pacientes foram alocados em um dos quatro planos de intervencao, de acordo com a adequacao ou nao desses parâmetros, com a escala crescente do plano significando melhor status funcional. Os pacientes nao colaborativos foram alocados nos planos de intervencao, conforme seu status funcional. A forca muscular global e/ou o status funcional foram reavaliados na alta da unidade de terapia. Por meio do comparativo entre o plano de Intervencao na admissao (Planoinicial) e na alta (Planofinal). Os pacientes foram categorizados em tres grupos, de acordo com a melhora ou nao do status funcional: respondedores 1 (Planofinal > Planoinicial), respondedores 2 (Planofinal = Planoinicial) e nao respondedores (Planofinal < Planoinicial). Resultados: Dos 463 pacientes submetidos ao protocolo, 432 (93,3%) pacientes responderam positivamente a estrategia de intervencao, apresentando manutencao e/ou melhora do status funcional inicial. Os pacientes clinicos classificados como nao respondedores apresentaram idade superior (74,3 ± 15,1 anos; p = 0,03) e maior tempo de internacao na unidade de terapia intensiva (11,6 ± 14,2 dias; p = 0,047) e no hospital (34,5 ± 34,1 dias; p = 0,002). Conclusao: A manutencao e/ou melhora do status funcional admissional esteve associada com menor tempo de internacao na unidade de terapia intensiva e hospitalar. Os resultados sugerem que o tipo de diagnostico, clinico ou cirurgico, nao e definidor da resposta positiva ao protocolo de reabilitacao precoce.

Systematic screening is essential for early diagnosis of severe sepsis and septic shock

Abstract: This evidence led to the analysis of the SSC impact in 2010, which involved 15,022 patients from 165 hospitals. This analysis revealed continuous and sustained improvements in compliance with early interventions, especially with antibiotic therapy (odds ratio - OR 0.70; p < 0.001), and blood culture requests (0.78; p < 0.001), along with a reduction in the mortality rate associated with severe sepsis or septic shock (from 30.8% to 27%; p < 0.01).

Etiology and prognostic factors of sepsis among children and adolescents admitted to the intensive care unit.

Abstract: Objective:To determine the etiology and clinical disease progression variables of sepsis associated with the prognosis of patients admitted to a pediatric intensive care unit.Methods:Prospective and retrospective case series. Data were collected from the medical records of patients diagnosed with sepsis who were admitted to the pediatric intensive care unit of a general hospital from January 2011 to December 2013. Bacteria were identified in blood and fluid cultures. Age, sex, vaccination schedule, comorbidities, prior antibiotic use, clinical data on admission, and complications during disease progression were compared in the survival and death groups at a 5% significance level.Results:A total of 115 patients, with a mean age of 30.5 months, were included in the study. Bacterial etiology was identified in 40 patients. Altered peripheral perfusion on admission and diagnosis of severe sepsis were associated with complications. A greater number of complications occurred in the group of patients older than 36 months (p = 0.003; odds ratio = 4.94). The presence of complications during hospitalization was associated with death (odds ratio = 27.7). The main etiological agents were Gram-negative bacteria (15/40), Staphylococcus aureus (11/40) and Neisseria meningitidis (5/40).Conclusion:Gram-negative bacteria and Staphylococcus aureus predominated in the etiology of sepsis among children and adolescents admitted to an intensive care unit. The severity of sepsis and the presence of altered peripheral perfusion on admission were associated with complications. Moreover, the presence of complications was a factor associated with death.

Comparison between a clinical diagnosis method and the surveillance technique of the Center for Disease Control and Prevention for identification of mechanical ventilator-associated pneumonia.

Abstract: Objetivo:Avaliar a concordância entre um novo metodo de vigilância epidemiologica do Center for Disease Control and Prevention e o Clinical Pulmonary Infection Score para deteccao de pneumonia associada a ventilacao mecânica.Metodos:Coorte prospectiva que avaliou pacientes internados nas unidades de terapia intensiva de dois hospitais que permaneceram intubados por mais de 48 horas no periodo de agosto de 2013 a junho de 2014. Os pacientes foram avaliados diariamente pelos fisioterapeutas com o Clinical Pulmonary Infection Score. De forma independente, um enfermeiro aplicou o novo metodo de vigilância proposto pelo Center for Disease Control and Prevention. Avaliou-se a concordância diagnostica entre os metodos. Clinical Pulmonary Infection Score ≥ 7 foi considerado diagnostico clinico de pneumonia associada a ventilacao mecânica, considerando-se diagnostico definitivo a associacao de Clinical Pulmonary Infection Score ≥ 7 com germe isolado em cultura semiquantitativa ≥ 104 unidades formadoras de colonias.Resultados:De 801 pacientes admitidos nas unidades de terapia intensiva, 198 estiveram sob ventilacao mecânica. Destes, 168 permaneceram intubados por mais de 48 horas. Identificaram-se 18 (10,7%) condicoes infecciosas associadas a ventilacao mecânica e 14 (8,3%) pneumonias associadas a ventilacao mecânica possiveis ou provaveis, representando 35% (14/38) diagnosticos clinicos de pneumonia associada a ventilacao mecânica. O metodo do Center for Disease Control and Prevention identificou casos de pneumonia associada a ventilacao mecânica com sensibilidade de 0,37 e especificidade de 1,0, com valor preditivo positivo de 1,0 e negativo de 0,84. As diferencas implicaram em discrepâncias na densidade de incidencia de pneumonia associada a ventilacao mecânica (CDC: 5,2/1000 dias de ventilacao mecânica; Clinical Pulmonary Infection Score ≥ 7: 13,1/1000 dias de ventilacao mecânica).Conclusao:O metodo do Center for Disease Control and Prevention falhou na deteccao de casos de pneumonia associada a ventilacao mecânica e pode nao ser satisfatorio como metodo de vigilância.Objective: To evaluate the agreement between a new epidemiological surveillance method of the Center for Disease Control and Prevention and the clinical pulmonary infection score for mechanical ventilator-associated pneumonia detection.

Relationship between adductor pollicis muscle thickness and subjective global assessment in a cardiac intensive care unit

Abstract: Objective: To verify the relationship between the adductor pollicis muscle thickness test and the subjective global assessment and to correlate it with other anthropometric methods. Methods: This observational cross-sectional study was conducted in the intensive care unit of a cardiology hospital in the state of Rio Grande do Sul, Brazil. The hospitalized patients underwent subjective global assessment and adductor pollicis muscle thickness tests on both hands, along with measurement of the right calf circumference. Laboratory parameters, length of stay, vital signs and electronic medical record data and tests were all collected. Results: The study population included 83 patients, of whom 62% were men. The average age was 68.6 ± 12.5 years. The most common reason for hospitalization was acute myocardial infarction (34.9%), and the most common pathology was systolic blood pressure (63.9%), followed by diabetes mellitus (28.9%). According to subjective global assessment classifications, 62.7% of patients presented no nutritional risk, 20.5% were moderately malnourished and 16.9% were severely malnourished. Women had a higher nutritional risk, according to both the subjective global assessment and the adductor pollicis muscle thickness test, the cutoff for which was < 6.5mm (54.8%; p = 0.001). The pathology presenting the greatest nutritional risk was congestive heart failure (p = 0.001). Evaluation of the receiver operating characteristic (ROC) curve between adductor pollicis muscle thickness and subjective global assessment showed the accuracy of the former, with an area of 0.822. Conclusion: Adductor pollicis muscle thickness proved to be a good method for evaluating nutritional risk.

Serum concentrations of vitamin D and organ dysfunction in patients with severe sepsis and septic shock

Abstract: Objectives: To evaluate the serum concentrations of vitamin D and their variations in patients with severe sepsis or septic shock and in control subjects upon admission and after 7 days of hospitalization in the intensive care unit and to correlate these concentrations with the severity of organ dysfunction. Methods: This case-control, prospective, observational study involved patients aged > 18 years with severe sepsis or septic shock paired with a control group. Serum vitamin D concentrations were measured at inclusion (D0) and on the seventh day after inclusion (D7). Severe deficiency was defined as vitamin D levels < 10ng/ml, deficiency as levels between 10 and 20ng/ml, insufficiency as levels between 20 and 30ng/ml, and sufficiency as levels ≥ 30ng/mL. We considered a change to a higher ranking, together with a 50% increase in the absolute concentration, to represent an improvement. Results: We included 51 patients (26 with septic shock and 25 controls). The prevalence of vitamin D concentration ≤ 30ng/ml was 98%. There was no correlation between the serum concentration of vitamin D at D0 and the SOFA score at D0 or D7 either in the general population or in the group with septic shock. Patients with improvement in vitamin D deficiency had an improved SOFA score at D7 (p = 0.013). Conclusion: In the population studied, patients with septic shock showed improvement in the serum concentrations of vitamin D on the seventh day compared with the controls. We also found a correlation between higher vitamin D concentrations and a greater decrease in the severity of organ dysfunction.

Endotracheal suctioning in intubated newborns: an integrative literature review

Abstract: Evidence-based practices search for the best available scientific evidence to support problem solving and decision making. Because of the complexity and amount of information related to health care, the results of methodologically sound scientific papers must be integrated by performing literature reviews. Although endotracheal suctioning is the most frequently performed invasive procedure in intubated newborns in neonatal intensive care units, few Brazilian studies of good methodological quality have examined this practice, and a national consensus or standardization of this technique is lacking. Therefore, the purpose of this study was to review secondary studies on the subject to establish recommendations for endotracheal suctioning in intubated newborns and promote the adoption of best-practice concepts when conducting this procedure. An integrative literature review was performed, and the recommendations of this study are to only perform endotracheal suctioning in newborns when there are signs of tracheal secretions and to avoid routinely performing the procedure. In addition, endotracheal suctioning should be conducted by at least two people, the suctioning time should be less than 15 seconds, the negative suction pressure should be below 100 mmHg, and hyperoxygenation should not be used on a routine basis. If indicated, oxygenation is recommended with an inspired oxygen fraction value that is 10 to 20% greater than the value of the previous fraction, and it should be performed 30 to 60 seconds before, during and 1 minute after the procedure. Saline instillation should not be performed routinely, and the standards for invasive procedures must be respected.

Blood transfusions in septic shock: is 7.0 g/dL really the appropriate threshold?

Abstract: Objetivo: Avaliar os efeitos imediatos da transfusao de hemacias nos niveis de saturacao venosa central de oxigenio e de lactato em pacientes com choque septico usando diferentes niveis gatilho de hemoglobina para indicar transfusao. Metodos: Incluimos pacientes com diagnostico de choque septico nas ultimas 48 horas e niveis de hemoglobina abaixo de 9,0g/dL. Os pacientes foram randomizados para receber imediatamente transfusao se as concentracoes se mantivessem acima de 9,0g/dL (Grupo Hb9) ou adiar a transfusao ate que a hemoglobina caisse abaixo de 7,0g/dL (Grupo Hb7). Os niveis de hemoglobina, lactato e saturacao venosa central de oxigenio foram determinados antes e 1 hora apos cada transfusao. Resultados: Incluimos 46 pacientes, totalizando 74 transfusoes. Os pacientes do Grupo Hb7 tiveram uma reducao significante nos niveis medianos de lactato de 2,44 (2,00 - 3,22) mMol/L para 2,21 (1,80 - 2,79) mMol/L; p = 0,005. Isto nao foi observado no Grupo Hb9 [1,90 (1,80 - 2,65) mMol/L para 2,00 (1,70 - 2,41) mMol/L; p = 0,23]. A saturacao venosa central de oxigenio aumentou no Grupo Hb7 [68,0 (64,0 - 72,0)% para 72,0 (69,0 - 75,0)%; p < 0,0001], mas nao no Grupo Hb9 [72,0 (69,0 - 74,0)% para 72,0 (71,0 - 73,0)%; p = 0,98]. Pacientes com elevados niveis de lactato ou saturacao venosa central de oxigenio menor que 70% na avaliacao basal tiveram um aumento significante nessas variaveis, independentemente dos niveis basais de hemoglobina. Pacientes com valores normais nao demonstraram diminuicao em quaisquer dos grupos. Conclusao: A transfusao de hemacias aumentou a saturacao venosa central de oxigenio e diminuiu os niveis de lactato em pacientes com hipoperfusao, independentemente de seus niveis basais de hemoglobina. A transfusao nao pareceu influenciar essas variaveis em pacientes sem hipoperfusao. ClinicalTrials.gov NCT01611753

Recurrent rhabdomyolysis secondary to hyponatremia in a patient with primary psychogenic polydipsia.

Abstract: Rhabdomyolysis is characterized by the destruction of skeletal muscle tissue, and its main causes are trauma, toxic substances and electrolyte disturbances. Among the latter is hyponatremia-induced rhabdomyolysis, a rare condition that occurs mainly in patients with psychogenic polydipsia. Psycogenic polydipsia mostly affects patients with schizophrenia, coursing with hyponatremia in almost 25% of the cases. It is also in this context that rhabdomyolysis secondary to hyponatremia occurs most often. In this article, the case of a 49-year-old male with a history of schizophrenia, medicated with clozapine, and brought to the emergency room in a state of coma and seizures is described. Severe hypoosmolar hyponatremia with cerebral edema was found on a computed tomography examination, and a subsequent diagnosis of hyponatremia secondary to psychogenic polydipsia was made. Hyponatremia correction therapy was started, and the patient was admitted to the intensive care unit. After the hyponatremia correction, the patient presented with analytical worsening, showing marked rhabdomyolysis with a creatine phosphokinase level of 44.058 UI/L on day 3 of hospitalization. The condition showed a subsequent progressive improvement with therapy, with no occurrence of kidney damage. This case stresses the need for monitoring rhabdomyolysis markers in severe hyponatremia, illustrating the condition of rhabdomyolysis secondary to hyponatremia induced by psychogenic polydipsia, which should be considered in patients undergoing treatment with neuroleptics.

Evaluation of the role of the cannabidiol system in an animal model of ischemia/reperfusion kidney injury

Abstract: Objective: This work aimed to investigate the effects of the administration of cannabidiol in a kidney ischemia/reperfusion animal model. Methods: Kidney injury was induced by 45 minutes of renal ischemia followed by reperfusion. Cannabidiol (5mg/kg) was administered immediately after reperfusion. Results: Ischemia/reperfusion increased the IL-1 and TNF levels, and these levels were attenuated by cannabidiol treatment. Additionally, cannabidiol was able to decrease lipid and protein oxidative damage, but not the nitrite/nitrate levels. Kidney injury after ischemia/reperfusion seemed to be independent of the cannabidiol receptor 1 and cannabidiol receptor 2 (CB1 and CB2) expression levels, as there was no significant increase in these receptors after reperfusion. Conclusion: The cannabidiol treatment had a protective effect against inflammation and oxidative damage in the kidney ischemia/reperfusion model. These effects seemed to be independent of CB1/CB2 receptor activation.

Swallowing rehabilitation of dysphagic tracheostomized patients under mechanical ventilation in intensive care units: a feasibility study

Abstract: Objetivo: Avaliar a factibilidade da implantacao precoce de um programa de reabilitacao da degluticao em pacientes traqueostomizados com disfagia e sob ventilacao mecânica. Metodos: Estudo prospectivo realizado em unidades de terapia intensiva de um hospital universitario. Incluimos pacientes hemodinamicamente estaveis e submetidos a ventilacao mecânica por pelo menos 48 horas e ha no minimo 48 horas com traqueostomia e nivel adequado de consciencia. Os criterios de exclusao foram cirurgia previa na cavidade oral, faringe, laringe e/ou esofago, presenca de doencas degenerativas ou historia pregressa de disfagia orofaringea. Todos os pacientes foram submetidos a um programa de reabilitacao da degluticao. Antes e apos o tratamento de reabilitacao da degluticao, foram determinados um escore estrutural orofaringeo, um escore funcional de degluticao, e um escore otorrinolaringologico estrutural e funcional. Resultados: Foram incluidos 14 pacientes. A duracao media do programa de reabilitacao foi de 12,4 ± 9,4 dias, com media de 5,0 ± 5,2 dias sob ventilacao mecânica. Onze pacientes puderam receber alimentacao por via oral enquanto ainda permaneciam na unidade de terapia intensiva apos 4 (2 - 13) dias de tratamento. Todos os escores apresentaram melhora significante apos o tratamento. Conclusao: Neste pequeno grupo de pacientes, a implantacao de um programa precoce de reabilitacao da degluticao foi factivel, mesmo em pacientes sob ventilacao mecânica.

Ventilação não invasiva com pressão positiva pós-extubação: características e desfechos na prática clínica

Abstract: Objective:To describe postextubation noninvasive positive pressure ventilation use in intensive care unit clinical practice and to identify factors associated with noninvasive positive pressure ventilation failure.Methods:This prospective cohort study included patients aged ≥ 18 years consecutively admitted to the intensive care unit who required noninvasive positive pressure ventilation within 48 hours of extubation. The primary outcome was noninvasive positive pressure ventilation failure.Results:We included 174 patients in the study. The overall noninvasive positive pressure ventilation use rate was 15%. Among the patients who used noninvasive positive pressure ventilation, 44% used it after extubation. The failure rate of noninvasive positive pressure ventilation was 34%. The overall mean ± SD age was 56 ± 18 years, and 55% of participants were male. Demographics; baseline pH, PaCO2 and HCO3; and type of equipment used were similar between groups. All of the noninvasive positive pressure ventilation final parameters were higher in the noninvasive positive pressure ventilation failure group [inspiratory positive airway pressure: 15.0 versus 13.7cmH2O (p = 0.015), expiratory positive airway pressure: 10.0 versus 8.9cmH2O (p = 0.027), and FiO2: 41 versus 33% (p = 0.014)]. The mean intensive care unit length of stay was longer (24 versus 13 days), p < 0.001, and the intensive care unit mortality rate was higher (55 versus 10%), p < 0.001 in the noninvasive positive pressure ventilation failure group. After fitting, the logistic regression model allowed us to state that patients with inspiratory positive airway pressure ≥ 13.5cmH2O on the last day of noninvasive positive pressure ventilation support are three times more likely to experience noninvasive positive pressure ventilation failure compared with individuals with inspiratory positive airway pressure < 13.5 (OR = 3.02, 95%CI = 1.01 - 10.52, p value = 0.040).Conclusion:The noninvasive positive pressure ventilation failure group had a longer intensive care unit length of stay and a higher mortality rate. Logistic regression analysis identified that patients with inspiratory positive airway pressure ≥ 13.5cmH2O on the last day of noninvasive positive pressure ventilation support are three times more likely to experience noninvasive positive pressure ventilation failure.

Measurement of intracranial pressure and short-term outcomes of patients with traumatic brain injury: a propensity-matched analysis.

Abstract: Objective: To assess the impact of intracranial pressure monitoring on the short-term outcomes of traumatic brain injury patients. Methods: Retrospective observational study including 299 consecutive patients admitted due to traumatic brain injury from January 2011 through July 2012 at a Level 1 trauma center in Sao Paulo, Brazil. Patients were categorized in two groups according to the measurement of intracranial pressure (measured intracranial pressure and non-measured intracranial pressure groups). We applied a propensity-matched analysis to adjust for possible confounders (variables contained in the Crash Score prognostic algorithm). Results: Global mortality at 14 days (16%) was equal to that observed in high-income countries in the CRASH Study and was better than expected based on the CRASH calculator score (20.6%), with a standardized mortality ratio of 0.77. A total of 28 patients received intracranial pressure monitoring (measured intracranial pressure group), of whom 26 were paired in a 1:1 fashion with patients from the non-measured intracranial pressure group. There was no improvement in the measured intracranial pressure group compared to the non-measured intracranial pressure group regarding hospital mortality, 14-day mortality, or combined hospital and chronic care facility mortality. Survival up to 14 days was also similar between groups. Conclusion: Patients receiving intracranial pressure monitoring tend to have more severe traumatic brain injuries. However, after adjusting for multiple confounders using propensity scoring, no benefits in terms of survival were observed among intracranial pressure-monitored patients and those managed with a systematic clinical protocol.