Eleven years impact of a stepwise educational program on healthcare associated infections and antibiotics consumption in an intensive care unit of a tertiary hospital in Brazil.

BACKGROUND: Hospital acquired infections (HAI) and liberal use of broad-spectrum antibiotics are common in intensive care unit(ICU)s of low-middle income countries. We investigated the long-term association of a stepwise multifaceted educational program with the incidence of HAIs and antibiotics use in a Brazilian ICU. We also evaluated the program's cost impact. METHODS: We retrieved data from a prospective daily collected database of a twelve bedrooms ICU, all admitted patients within a period of eleven years were enrolled. FINDINGS: From 03/15/2007 to 09/11/2019, we admitted 3059 patients where 2406 (79%) survived the ICU stay. Median age was 51 years-old, and median SAPS3 was 53. The initial density of catheter related blood infection (4.3 events / 1000 patients-day), urinary tract infection (9.2 event / 1000 patients-day) and ventilator associated pneumonia (54.9 events / 1000 patients-day) felt during the observed period to (0.35 events / 1000 patients-day), (0 events / 1000 patients-day), and (1.5 events / 1000 patients-day) respectively. The days of antibiotic therapy also decreased from 797.9 days of therapy / 1000 patients day to 292.3 days of therapy / 1000 patients day. The total cost per patient also decreased. The adjusted mortality rate was steady during the studied period from 23.2% to 22.9%. INTERPRETATION: A stepwise multifaceted educational program is an effective way to reduce hospital-associated infections, improve the rational use of antibiotics, and reduce costs. This impact occurred in a long term, and is probably consistent.

The Hierarchy of Communication Needs: A Novel Communication Strategy for High Mistrust Settings Developed in a Brazilian COVID-ICU.

Context: The COVID-19 pandemic presented unique challenges for health care systems. Overcrowded units, extreme illness severity, uncertain prognoses, and mistrust in providers resulted in a "pressure cooker" where traditional communication strategies were often insufficient. Objectives: Building on well-studied traditional communication interventions, neurobiology principles were used to create a novel communication strategy designed in the COVID-ICU to respond to the unique communication needs of patients within the context of a high mistrust setting. Methods: The hierarchy of communication needs recognizes three specific levels of communication that are essential within high-emotion and low-trust settings. The first level is to establish trust. The second level is to resonate with patients' emotions, helping to reduce arousal and improve empathy. The third level includes the more traditional content of disclosing prognostic information and shared decision-making. When facing communication challenges, clinicians are taught to move back a level and reattune to emotions and/or reestablish trust. Discussion: The COVID pandemic revealed the shortcomings of a primarily cognitive communication style. The hierarchy of communication needs emphasizes trust building, and emotional resonance as prerequisites of effective cognitive discussions, resulting in more effective clinician-patient communication that more fully incorporates cultural humility and better meets the needs of diverse patient populations. Additional research is needed to further develop this strategy and evaluate its impact on patient experience and outcomes.

Limiting life-sustaining treatment for very old ICU patients: cultural challenges and diverse practices.

BACKGROUND: Decisions about life-sustaining therapy (LST) in the intensive care unit (ICU) depend on predictions of survival as well as the expected functional capacity and self-perceived quality of life after discharge, especially in very old patients. However, prognostication for individual patients in this cohort is hampered by substantial uncertainty which can lead to a large variability of opinions and, eventually, decisions about LST. Moreover, decision-making processes are often embedded in a framework of ethical and legal recommendations which may vary between countries resulting in divergent management strategies. METHODS: Based on a vignette scenario of a multi-morbid 87-year-old patient, this article illustrates the spectrum of opinions about LST among intensivsts with a special interest in very old patients, from ten countries/regions, representing diverse cultures and healthcare systems. RESULTS: This survey of expert opinions and national recommendations demonstrates shared principles in the management of very old ICU patients. Some guidelines also acknowledge cultural differences between population groups. Although consensus with families should be sought, shared decision-making is not formally required or practised in all countries. CONCLUSIONS: This article shows similarities and differences in the decision-making for LST in very old ICU patients and recommends strategies to deal with prognostic uncertainty. Conflicts should be anticipated in situations where stakeholders have different cultural beliefs. There is a need for more collaborative research and training in this field.

Investigação da associação de dois oxigenadores em paralelo ou em série durante o suporte respiratório com oxigenação por membrana extracorpórea / Exploring the association of two oxygenators in parallel or in series during respiratory support using extracorporeal membrane oxygenation

RESUMO Objetivo: Caracterizar as pressões, as resistências, a oxigenação e a eficácia da descarboxilação de dois oxigenadores associados em série ou em paralelo durante o suporte com oxigenação veno-venosa por membrana extracorpórea. Métodos: Usando os resultados de insuficiência respiratória grave em suínos associada à disfunção de múltiplos órgãos, ao modelo de suporte com oxigenação por membrana extracorpórea veno-venosa e à modelagem matemática, exploramos os efeitos na oxigenação, descarboxilação e pressões do circuito de associações de oxigenadores em paralelo e em série. Resultados: Testaram-se cinco animais com peso mediano de 80kg. Ambas as configurações aumentaram a pressão parcial de oxigênio após os oxigenadores. O teor de oxigênio da cânula de retorno também foi ligeiramente maior, mas o efeito na oxigenação sistêmica foi mínimo, usando oxigenadores com alto fluxo nominal (~ 7L/minuto). Ambas as configurações reduziram significativamente a pressão parcial de dióxido de carbono sistêmico. Como o fluxo sanguíneo na oxigenação por membrana extracorpórea aumentou, a resistência do oxigenador diminuiu inicialmente, com aumento posterior, com fluxos sanguíneos mais altos, mas pouco efeito clínico. Conclusão: A associação de oxigenadores em paralelo ou em série durante o suporte com oxigenação veno-venosa por membrana extracorpórea proporciona um modesto aumento na depuração da pressão parcial de dióxido de carbono, com leve melhora na oxigenação. O efeito das associações de oxigenadores nas pressões de circuitos extracorpóreos é mínimo.

ABSTRACT Objective: To characterize the pressures, resistances, oxygenation, and decarboxylation efficacy of two oxygenators associated in series or in parallel during venous-venous extracorporeal membrane oxygenation support. Methods: Using the results of a swine severe respiratory failure associated with multiple organ dysfunction venous-venous extracorporeal membrane oxygenation support model and mathematical modeling, we explored the effects on oxygenation, decarboxylation and circuit pressures of in-parallel and in-series associations of oxygenators. Results: Five animals with a median weight of 80kg were tested. Both configurations increased the oxygen partial pressure after the oxygenators. The return cannula oxygen content was also slightly higher, but the impact on systemic oxygenation was minimal using oxygenators with a high rated flow (~ 7L/minute). Both configurations significantly reduced the systemic carbon dioxide partial pressure. As the extracorporeal membrane oxygenation blood flow increased, the oxygenator resistance decreased initially with a further increase with higher blood flows but with a small clinical impact. Conclusion: Association of oxygenators in parallel or in series during venous-venous extracorporeal membrane oxygenation support provides a modest increase in carbon dioxide partial pressure removal with a slight improvement in oxygenation. The effect of oxygenator associations on extracorporeal circuit pressures is minimal.

Palliative care and neurology: a path to neuropalliativism.

This article aims to expand the understanding of how it is possible to alleviate suffering and enable a dignified life trajectory for patients with progressive neurological diseases or with severe and permanent neurological impairment. The four most common disease trajectories described for people with chronic and progressive disease used to advance care planning, Brazilian normative ethical resolutions, evidence-based benefits of palliative care (PC), as well as particularities of PC in neurology, such as neurological symptom control, caring for existential and psychological suffering, care provider's needs and particularities of pediatric neurologic PC are reviewed.

Palliative care and neurology: a path to neuropalliativism / Cuidados Paliativos e Neurologia: um caminho para o neuropaliativismo

ABSTRACT This article aims to expand the understanding of how it is possible to alleviate suffering and enable a dignified life trajectory for patients with progressive neurological diseases or with severe and permanent neurological impairment. The four most common disease trajectories described for people with chronic and progressive disease used to advance care planning, Brazilian normative ethical resolutions, evidence-based benefits of palliative care (PC), as well as particularities of PC in neurology, such as neurological symptom control, caring for existential and psychological suffering, care provider's needs and particularities of pediatric neurologic PC are reviewed.

RESUMO Este artigo visa ampliar a compreensão de como é possível aliviar o sofrimento e possibilitar uma trajetória de vida digna para pacientes com doenças neurológicas progressivas ou com comprometimento neurológico grave e permanente. As quatro trajetórias de doença mais comuns descritas para pessoas com doença crônica e progressiva utilizadas no planejamento antecipado do cuidado, resoluções éticas normativas brasileiras, benefícios baseados em evidências dos cuidados paliativos (CP), além de particularidades dos CP em neurologia, como controle de sintomas neurológicos, cuidados existenciais e sofrimento psicológico, necessidades do cuidador e particularidades do CP neurológico pediátrico são revistos.

Exploring the association of two oxygenators in parallel or in series during respiratory support using extracorporeal membrane oxygenation. / Investigação da associação de dois oxigenadores em paralelo ou em série durante o suporte respiratório com oxigenação por membrana extracorpórea.

OBJECTIVE: To characterize the pressures, resistances, oxygenation, and decarboxylation efficacy of two oxygenators associated in series or in parallel during venous-venous extracorporeal membrane oxygenation support. METHODS: Using the results of a swine severe respiratory failure associated with multiple organ dysfunction venous-venous extracorporeal membrane oxygenation support model and mathematical modeling, we explored the effects on oxygenation, decarboxylation and circuit pressures of in-parallel and in-series associations of oxygenators. RESULTS: Five animals with a median weight of 80kg were tested. Both configurations increased the oxygen partial pressure after the oxygenators. The return cannula oxygen content was also slightly higher, but the impact on systemic oxygenation was minimal using oxygenators with a high rated flow (~ 7L/minute). Both configurations significantly reduced the systemic carbon dioxide partial pressure. As the extracorporeal membrane oxygenation blood flow increased, the oxygenator resistance decreased initially with a further increase with higher blood flows but with a small clinical impact. CONCLUSION: Association of oxygenators in parallel or in series during venous-venous extracorporeal membrane oxygenation support provides a modest increase in carbon dioxide partial pressure removal with a slight improvement in oxygenation. The effect of oxygenator associations on extracorporeal circuit pressures is minimal.

OBJETIVO: Caracterizar as pressões, as resistências, a oxigenação e a eficácia da descarboxilação de dois oxigenadores associados em série ou em paralelo durante o suporte com oxigenação veno-venosa por membrana extracorpórea. MÉTODOS: Usando os resultados de insuficiência respiratória grave em suínos associada à disfunção de múltiplos órgãos, ao modelo de suporte com oxigenação por membrana extracorpórea veno-venosa e à modelagem matemática, exploramos os efeitos na oxigenação, descarboxilação e pressões do circuito de associações de oxigenadores em paralelo e em série. RESULTADOS: Testaram-se cinco animais com peso mediano de 80kg. Ambas as configurações aumentaram a pressão parcial de oxigênio após os oxigenadores. O teor de oxigênio da cânula de retorno também foi ligeiramente maior, mas o efeito na oxigenação sistêmica foi mínimo, usando oxigenadores com alto fluxo nominal (~ 7L/minuto). Ambas as configurações reduziram significativamente a pressão parcial de dióxido de carbono sistêmico. Como o fluxo sanguíneo na oxigenação por membrana extracorpórea aumentou, a resistência do oxigenador diminuiu inicialmente, com aumento posterior, com fluxos sanguíneos mais altos, mas pouco efeito clínico. CONCLUSÃO: A associação de oxigenadores em paralelo ou em série durante o suporte com oxigenação veno-venosa por membrana extracorpórea proporciona um modesto aumento na depuração da pressão parcial de dióxido de carbono, com leve melhora na oxigenação. O efeito das associações de oxigenadores nas pressões de circuitos extracorpóreos é mínimo.

Exploring the Relationship between Shared Decision-Making, Patient-Centered Medicine, and Evidence-Based Medicine.

Shared decision-making is a possible link between the best of patient-centered medicine and evidence-based medicine. This article seeks to describe the link between them. It discusses to what extent the integration of such perspectives is successful in assuring respect for the patient's autonomy. From the evidence herein, we conclude that if the doctor-patient relationship and communication are strengthened to cover all issues relevant to the patient's health and values, is it possible for him or her to achieve more autonomous decisions by this linkage of shared decision-making and patient-centered medicine? SUMMARY: Shared decision-making is a possible link between the best of patient-centered medicine and evidence-based medicine. This article seeks to describe the link between them.

Impact of nonclinical factors on intensive care unit admission decisions: a vignette-based randomized trial (V-TRIAGE). / Impacto de fatores não clínicos nas decisões relacionadas à admissão em unidade de terapia intensiva: um ensaio randomizado com base em vinhetas (V-TRIAGE).

OBJECTIVE: To assess the impact of intensive care unit bed availability, distractors and choice framing on intensive care unit admission decisions. METHODS: This study was a randomized factorial trial using patient-based vignettes. The vignettes were deemed archetypical for intensive care unit admission or refusal, as judged by a group of experts. Intensive care unit physicians were randomized to 1) an increased distraction (intervention) or a control group, 2) an intensive care unit bed scarcity or nonscarcity (availability) setting, and 3) a multiple-choice or omission (status quo) vignette scenario. The primary outcome was the proportion of appropriate intensive care unit allocations, defined as concordance with the allocation decision made by the group of experts. RESULTS: We analyzed 125 physicians. Overall, distractors had no impact on the outcome; however, there was a differential drop-out rate, with fewer physicians in the intervention arm completing the questionnaire. Intensive care unit bed availability was associated with an inappropriate allocation of vignettes deemed inappropriate for intensive care unit admission (OR = 2.47; 95%CI 1.19 - 5.11) but not of vignettes appropriate for intensive care unit admission. There was a significant interaction with the presence of distractors (p = 0.007), with intensive care unit bed availability being associated with increased intensive care unit admission of vignettes inappropriate for intensive care unit admission in the distractor (intervention) arm (OR = 9.82; 95%CI 2.68 - 25.93) but not in the control group (OR = 1.02; 95%CI 0.38 - 2.72). Multiple choices were associated with increased inappropriate allocation in comparison to the omission group (OR = 5.18; 95%CI 1.37 - 19.61). CONCLUSION: Intensive care unit bed availability and cognitive biases were associated with inappropriate intensive care unit allocation decisions. These findings may have implications for intensive care unit admission policies.

OBJETIVO: Avaliar o impacto da disponibilidade de leitos em unidade de terapia intensiva, distratores e formatação da escolha, nas decisões de admissão na unidade de terapia intensiva. MÉTODOS: Este estudo foi um ensaio randomizado fatorial, com utilização de vinhetas baseadas em pacientes. As vinhetas foram consideradas arquetípicas para admissão ou recusa de admissão na unidade de terapia intensiva, conforme julgado por um grupo de especialistas. Médicos de unidade de terapia intensiva foram randomizados para um grupo com distrações (intervenção) ou um grupo controle; a um ambiente de escassez ou de disponibilidade de leitos em unidade de terapia intensiva (disponibilidade) e a uma vinheta com cenário de múltipla escolha ou omissão (status quo). O desfecho primário foi a proporção de alocações adequadas à unidade de terapia intensiva, definida como concordância com as decisões de alocação acordadas pelo grupo de especialistas. RESULTADOS: Analisamos 125 médicos. Em termos gerais, os distratores não tiveram impacto sobre o desfecho; contudo, houve taxa diferenciada de desistências, com menos médicos no grupo intervenção tendo respondido completamente ao questionário. A disponibilidade de leitos em unidade de terapia intensiva se associou com alocações inadequadas de vinhetas consideradas não adequadas para admissão na unidade de terapia intensiva (RC = 2,47; IC95% 1,19 - 5,11), porém não com vinhetas apropriadas para admissão na unidade de terapia intensiva. Ocorreu interação significante com a presença de distratores (p = 0,007), sendo a disponibilidade de leitos na unidade de terapia intensiva associada com maior admissão na unidade de terapia intensiva de vinhetas não apropriadas para admissão na unidade de terapia intensiva no braço com distratores (intervenção) (RC = 9,82; IC95% 2,68 - 25,93), porém não no grupo controle (RC = 5,18; IC95% 1,37 - 19,61). CONCLUSÃO: A disponibilidade de leitos em unidade de terapia intensiva e vieses cognitivos se associaram com decisões inadequadas de alocação à unidade de terapia intensiva. Esses achados podem ter implicações para políticas de admissão na unidade de terapia intensiva.

Accountability for reasonableness and criteria for admission, triage and discharge in intensive care units: an analysis of current ethical recommendations. / Responsabilidade pela razoabilidade e critérios de admissão, triagem e alta em unidades de terapia intensiva: uma análise das recomendações éticas atuais.

Triage for intensive care unit admission is a frequent event and is associated to worse clinical outcomes. The process of triage is variable and may be influenced by biases and prejudices, which could lead to potentially unfair decisions. The Brazilian Federal Council of Medicine (Conselho Federal de Medicina) has recently released a guideline for intensive care unit admission and discharge. The aim of this paper is to evaluate the ethical dilemmas related to the implementation of this guideline, through the accountability for reasonabless approach, known as A4R, as elaborated by Norman Daniels. We conclude that the guideline contemplates A4R conditions, but we observe that there is a need for indication of A4R-concordant criteria to operationalize the guidelines.

Triagem para admissão em unidades de terapia intensiva é um evento frequente, especialmente em situações de escassez de recursos, e está associada a piores desfechos clínicos. O processo de triagem é variável e pode ser guiado por vieses e preconceitos, levando à tomada de decisão potencialmente injusta. O Conselho Federal de Medicina elaborou recentemente uma resolução com os critérios de admissão e alta em unidades de terapia intensiva. O objetivo deste artigo é avaliar os dilemas éticos associados à implementação dessa resolução, tendo como prisma a abordagem do accountability for reasonableness ("responsabilização pela razoabilidade"), conhecido como A4R, conforme parâmetros elaborados por Norman Daniels. Apesar de a resolução em si contemplar as condições do A4R, ainda há espaço para que a norma indique critérios para que a operacionalização da resolução também contemple esses parâmetros.

Impacto de fatores não clínicos nas decisões relacionadas à admissão em unidade de terapia intensiva: um ensaio randomizado com base em vinhetas (V-TRIAGE) / Impact of nonclinical factors on intensive care unit admission decisions: a vignette-based randomized trial (V-TRIAGE)

RESUMO Objetivo: Avaliar o impacto da disponibilidade de leitos em unidade de terapia intensiva, distratores e formatação da escolha, nas decisões de admissão na unidade de terapia intensiva. Métodos: Este estudo foi um ensaio randomizado fatorial, com utilização de vinhetas baseadas em pacientes. As vinhetas foram consideradas arquetípicas para admissão ou recusa de admissão na unidade de terapia intensiva, conforme julgado por um grupo de especialistas. Médicos de unidade de terapia intensiva foram randomizados para um grupo com distrações (intervenção) ou um grupo controle; a um ambiente de escassez ou de disponibilidade de leitos em unidade de terapia intensiva (disponibilidade) e a uma vinheta com cenário de múltipla escolha ou omissão (status quo). O desfecho primário foi a proporção de alocações adequadas à unidade de terapia intensiva, definida como concordância com as decisões de alocação acordadas pelo grupo de especialistas. Resultados: Analisamos 125 médicos. Em termos gerais, os distratores não tiveram impacto sobre o desfecho; contudo, houve taxa diferenciada de desistências, com menos médicos no grupo intervenção tendo respondido completamente ao questionário. A disponibilidade de leitos em unidade de terapia intensiva se associou com alocações inadequadas de vinhetas consideradas não adequadas para admissão na unidade de terapia intensiva (RC = 2,47; IC95% 1,19 - 5,11), porém não com vinhetas apropriadas para admissão na unidade de terapia intensiva. Ocorreu interação significante com a presença de distratores (p = 0,007), sendo a disponibilidade de leitos na unidade de terapia intensiva associada com maior admissão na unidade de terapia intensiva de vinhetas não apropriadas para admissão na unidade de terapia intensiva no braço com distratores (intervenção) (RC = 9,82; IC95% 2,68 - 25,93), porém não no grupo controle (RC = 5,18; IC95% 1,37 - 19,61). Conclusão: A disponibilidade de leitos em unidade de terapia intensiva e vieses cognitivos se associaram com decisões inadequadas de alocação à unidade de terapia intensiva. Esses achados podem ter implicações para políticas de admissão na unidade de terapia intensiva.

Abstract Objective: To assess the impact of intensive care unit bed availability, distractors and choice framing on intensive care unit admission decisions. Methods: This study was a randomized factorial trial using patient-based vignettes. The vignettes were deemed archetypical for intensive care unit admission or refusal, as judged by a group of experts. Intensive care unit physicians were randomized to 1) an increased distraction (intervention) or a control group, 2) an intensive care unit bed scarcity or nonscarcity (availability) setting, and 3) a multiple-choice or omission (status quo) vignette scenario. The primary outcome was the proportion of appropriate intensive care unit allocations, defined as concordance with the allocation decision made by the group of experts. Results: We analyzed 125 physicians. Overall, distractors had no impact on the outcome; however, there was a differential drop-out rate, with fewer physicians in the intervention arm completing the questionnaire. Intensive care unit bed availability was associated with an inappropriate allocation of vignettes deemed inappropriate for intensive care unit admission (OR = 2.47; 95%CI 1.19 - 5.11) but not of vignettes appropriate for intensive care unit admission. There was a significant interaction with the presence of distractors (p = 0.007), with intensive care unit bed availability being associated with increased intensive care unit admission of vignettes inappropriate for intensive care unit admission in the distractor (intervention) arm (OR = 9.82; 95%CI 2.68 - 25.93) but not in the control group (OR = 1.02; 95%CI 0.38 - 2.72). Multiple choices were associated with increased inappropriate allocation in comparison to the omission group (OR = 5.18; 95%CI 1.37 - 19.61). Conclusion: Intensive care unit bed availability and cognitive biases were associated with inappropriate intensive care unit allocation decisions. These findings may have implications for intensive care unit admission policies.

Responsabilidade pela razoabilidade e critérios de admissão, triagem e alta em unidades de terapia intensiva: uma análise das recomendações éticas atuais / Accountability for reasonableness and criteria for admission, triage and discharge in intensive care units: an analysis of current ethical recommendations

RESUMO Triagem para admissão em unidades de terapia intensiva é um evento frequente, especialmente em situações de escassez de recursos, e está associada a piores desfechos clínicos. O processo de triagem é variável e pode ser guiado por vieses e preconceitos, levando à tomada de decisão potencialmente injusta. O Conselho Federal de Medicina elaborou recentemente uma resolução com os critérios de admissão e alta em unidades de terapia intensiva. O objetivo deste artigo é avaliar os dilemas éticos associados à implementação dessa resolução, tendo como prisma a abordagem do accountability for reasonableness ("responsabilização pela razoabilidade"), conhecido como A4R, conforme parâmetros elaborados por Norman Daniels. Apesar de a resolução em si contemplar as condições do A4R, ainda há espaço para que a norma indique critérios para que a operacionalização da resolução também contemple esses parâmetros.

Abstract Triage for intensive care unit admission is a frequent event and is associated to worse clinical outcomes. The process of triage is variable and may be influenced by biases and prejudices, which could lead to potentially unfair decisions. The Brazilian Federal Council of Medicine (Conselho Federal de Medicina) has recently released a guideline for intensive care unit admission and discharge. The aim of this paper is to evaluate the ethical dilemmas related to the implementation of this guideline, through the accountability for reasonabless approach, known as A4R, as elaborated by Norman Daniels. We conclude that the guideline contemplates A4R conditions, but we observe that there is a need for indication of A4R-concordant criteria to operationalize the guidelines.

Retirada da ventilação mecânica como procedimento paliativo em uma unidade de terapia intensiva brasileira / Mechanical ventilation withdrawal as a palliative procedure in a Brazilian intensive care unit

RESUMO Objetivo: Descrever as características e os desfechos de pacientes submetidos à retirada da ventilação mecânica e comparar a pacientes com ventilação mecânica e limitações de terapias de suporte à vida (limitar ou retirar), porém sem remoção da ventilação mecânica. Métodos: Este foi um estudo de coorte retrospectiva realizado entre janeiro de 2014 e dezembro de 2018 com pacientes em ventilação mecânica com alguma limitação de suporte artificial de vida admitidos a uma única unidade de terapia intensiva. Foram comparados os pacientes submetidos à retirada da ventilação mecânica e os que não passaram por esse procedimento com relação à mortalidade na unidade de terapia intensiva e ao tempo de permanência no hospital, em uma análise não ajustada e em uma amostra pareada por escore de propensão. Analisou-se também o tempo desde a retirada da ventilação mecânica até o óbito. Resultados: Dentre 282 pacientes com limitações a terapias de suporte à vida, 31 (11%) foram submetidos à retirada da ventilação mecânica. Não houve diferenças iniciais entre os grupos. As taxas de mortalidade na unidade de terapia intensiva e no hospital foram, respectivamente, de 71% versus 57% e 93% versus 80%, entre os pacientes submetidos à retirada da ventilação mecânica e os que não o foram. O tempo mediano de permanência na unidade de terapia intensiva foi de 7 versus 8 dias (p = 0,6), e o tempo de permanência no hospital foi de 9 versus 15 dias (p = 0,015). A mortalidade hospitalar não foi significantemente diferente (25/31; 81% versus 29/31; 93%; p = 0,26) após o pareamento. O tempo mediano desde a retirada da ventilação mecânica até o óbito foi de 2 dias [0 - 5] e 10/31 (32%) dos pacientes morreram dentro de 24 horas após a retirada dessa ventilação. Conclusão: Neste relato brasileiro, a retirada da ventilação mecânica representou 11% de todos os pacientes com limitação do tratamento e não se associou com aumento da mortalidade hospitalar após pareamento por escore de propensão das covariáveis relevantes.

Abstract Objective: To describe the characteristics and outcomes of patients undergoing mechanical ventilation withdrawal and to compare them to mechanically ventilated patients with limitations (withhold or withdrawal) of life-sustaining therapies but who did not undergo mechanical ventilation withdrawal. Methods: This was a retrospective cohort study from January 2014 to December 2018 of mechanically ventilated patients with any organ support limitation admitted to a single intensive care unit. We compared patients who underwent mechanical ventilation withdrawal and those who did not regarding intensive care unit and hospital mortality and length of stay in both an unadjusted analysis and a propensity score matched subsample. We also analyzed the time from mechanical ventilation withdrawal to death. Results: Out of 282 patients with life-sustaining therapy limitations, 31 (11%) underwent mechanical ventilation withdrawal. There was no baseline difference between groups. Intensive care unit and hospital mortality rates were 71% versus 57% and 93% versus 80%, respectively, among patients who underwent mechanical ventilation withdrawal and those who did not. The median intensive care unit length of stay was 7 versus 8 days (p = 0.6), and the hospital length of stay was 9 versus 15 days (p = 0.015). Hospital mortality was not significantly different (25/31; 81% versus 29/31; 93%; p = 0.26) after matching. The median time from mechanical ventilation withdrawal until death was 2 days [0 - 5], and 10/31 (32%) patients died within 24 hours after mechanical ventilation withdrawal. Conclusion: In this Brazilian report, mechanical ventilation withdrawal represented 11% of all patients with treatment limitations and was not associated with increased hospital mortality after propensity score matching on relevant covariates.

Characteristics and outcomes of patients with COVID-19 admitted to the ICU in a university hospital in São Paulo, Brazil - study protocol.

OBJECTIVES: We designed a cohort study to describe characteristics and outcomes of patients with coronavirus disease (COVID-19) admitted to the intensive care unit (ICU) in the largest public hospital in Sao Paulo, Brazil, as Latin America becomes the epicenter of the pandemic. METHODS: This is the protocol for a study being conducted at an academic hospital in Brazil with 300 adult ICU beds dedicated to COVID-19 patients. We will include adult patients admitted to the ICU with suspected or confirmed COVID-19 during the study period. The main outcome is ICU survival at 28 days. Data will be collected prospectively and retrospectively by trained investigators from the hospital's electronic medical records, using an electronic data capture tool. We will collect data on demographics, comorbidities, severity of disease, and laboratorial test results at admission. Information on the need for advanced life support and ventilator parameters will be collected during ICU stay. Patients will be followed up for 28 days in the ICU and 60 days in the hospital. We will plot Kaplan-Meier curves to estimate ICU and hospital survival and perform survival analysis using the Cox proportional hazards model to identify the main risk factors for mortality. ClinicalTrials.gov: NCT04378582. RESULTS: We expect to include a large sample of patients with COVID-19 admitted to the ICU and to be able to provide data on admission characteristics, use of advanced life support, ICU survival at 28 days, and hospital survival at 60 days. CONCLUSIONS: This study will provide epidemiological data about critically ill patients with COVID-19 in Brazil, which could inform health policy and resource allocation in low- and middle-income countries.

Prognostication in urgent intensive care unit referrals: a cohort study.

OBJECTIVES: Prognostication is an essential ability to clinicians. Nevertheless, it has been shown to be quite variable in acutely ill patients, potentially leading to inappropriate care. We aimed to assess the accuracy of physician's prediction of hospital mortality in acutely deteriorating patients referred for urgent intensive care unit (ICU) admission. METHODS: Prospective cohort of acutely ill patients referred for urgent ICU admission in an academic, tertiary hospital. Physicians' prognosis assessments were recorded at ICU referral. Prognosis was assessed as survival without severe disabilities, survival with severe disabilities or no survival. Prognosis was further dichotomised in good prognosis (survival without severe disabilities) or poor prognosis (survival with severe disabilities or no survival) for prediction of hospital mortality. RESULTS: There were 2374 analysed referrals, with 2103 (88.6%) patients with complete data on mortality and physicians' prognosis. There were 593 (34.4%), 215 (66.4%) and 51 (94.4%) deaths in the groups ascribed a prognosis of survival without disabilities, survival with severe disabilities or no survival, respectively (p<0.001). Sensitivity was 31%, specificity was 91% and the area under the receiver operating characteristic curve was 0.61 for prediction of mortality. After multivariable analysis, severity of illness, performance status and ICU admission were associated with an increased likelihood of incorrect classification, while worse predicted prognosis was associated with a lower chance of incorrect classification. CONCLUSIONS: Physician's prediction was associated with hospital mortality, but overall accuracy was poor, mainly due to low sensitivity to detect risk of poor prognosis.

Mechanical ventilation withdrawal as a palliative procedure in a Brazilian intensive care unit. / Retirada da ventilação mecânica como procedimento paliativo em uma unidade de terapia intensiva brasileira.

OBJECTIVE: To describe the characteristics and outcomes of patients undergoing mechanical ventilation withdrawal and to compare them to mechanically ventilated patients with limitations (withhold or withdrawal) of life-sustaining therapies but who did not undergo mechanical ventilation withdrawal. METHODS: This was a retrospective cohort study from January 2014 to December 2018 of mechanically ventilated patients with any organ support limitation admitted to a single intensive care unit. We compared patients who underwent mechanical ventilation withdrawal and those who did not regarding intensive care unit and hospital mortality and length of stay in both an unadjusted analysis and a propensity score matched subsample. We also analyzed the time from mechanical ventilation withdrawal to death. RESULTS: Out of 282 patients with life-sustaining therapy limitations, 31 (11%) underwent mechanical ventilation withdrawal. There was no baseline difference between groups. Intensive care unit and hospital mortality rates were 71% versus 57% and 93% versus 80%, respectively, among patients who underwent mechanical ventilation withdrawal and those who did not. The median intensive care unit length of stay was 7 versus 8 days (p = 0.6), and the hospital length of stay was 9 versus 15 days (p = 0.015). Hospital mortality was not significantly different (25/31; 81% versus 29/31; 93%; p = 0.26) after matching. The median time from mechanical ventilation withdrawal until death was 2 days [0 - 5], and 10/31 (32%) patients died within 24 hours after mechanical ventilation withdrawal. CONCLUSION: In this Brazilian report, mechanical ventilation withdrawal represented 11% of all patients with treatment limitations and was not associated with increased hospital mortality after propensity score matching on relevant covariates.

OBJETIVO: Descrever as características e os desfechos de pacientes submetidos à retirada da ventilação mecânica e comparar a pacientes com ventilação mecânica e limitações de terapias de suporte à vida (limitar ou retirar), porém sem remoção da ventilação mecânica. MÉTODOS: Este foi um estudo de coorte retrospectiva realizado entre janeiro de 2014 e dezembro de 2018 com pacientes em ventilação mecânica com alguma limitação de suporte artificial de vida admitidos a uma única unidade de terapia intensiva. Foram comparados os pacientes submetidos à retirada da ventilação mecânica e os que não passaram por esse procedimento com relação à mortalidade na unidade de terapia intensiva e ao tempo de permanência no hospital, em uma análise não ajustada e em uma amostra pareada por escore de propensão. Analisou-se também o tempo desde a retirada da ventilação mecânica até o óbito. RESULTADOS: Dentre 282 pacientes com limitações a terapias de suporte à vida, 31 (11%) foram submetidos à retirada da ventilação mecânica. Não houve diferenças iniciais entre os grupos. As taxas de mortalidade na unidade de terapia intensiva e no hospital foram, respectivamente, de 71% versus 57% e 93% versus 80%, entre os pacientes submetidos à retirada da ventilação mecânica e os que não o foram. O tempo mediano de permanência na unidade de terapia intensiva foi de 7 versus 8 dias (p = 0,6), e o tempo de permanência no hospital foi de 9 versus 15 dias (p = 0,015). A mortalidade hospitalar não foi significantemente diferente (25/31; 81% versus 29/31; 93%; p = 0,26) após o pareamento. O tempo mediano desde a retirada da ventilação mecânica até o óbito foi de 2 dias [0 - 5] e 10/31 (32%) dos pacientes morreram dentro de 24 horas após a retirada dessa ventilação. CONCLUSÃO: Neste relato brasileiro, a retirada da ventilação mecânica representou 11% de todos os pacientes com limitação do tratamento e não se associou com aumento da mortalidade hospitalar após pareamento por escore de propensão das covariáveis relevantes.

Characteristics and outcomes of patients with COVID-19 admitted to the ICU in a university hospital in São Paulo, Brazil - study protocol

OBJECTIVES: We designed a cohort study to describe characteristics and outcomes of patients with coronavirus disease (COVID-19) admitted to the intensive care unit (ICU) in the largest public hospital in Sao Paulo, Brazil, as Latin America becomes the epicenter of the pandemic. METHODS: This is the protocol for a study being conducted at an academic hospital in Brazil with 300 adult ICU beds dedicated to COVID-19 patients. We will include adult patients admitted to the ICU with suspected or confirmed COVID-19 during the study period. The main outcome is ICU survival at 28 days. Data will be collected prospectively and retrospectively by trained investigators from the hospital's electronic medical records, using an electronic data capture tool. We will collect data on demographics, comorbidities, severity of disease, and laboratorial test results at admission. Information on the need for advanced life support and ventilator parameters will be collected during ICU stay. Patients will be followed up for 28 days in the ICU and 60 days in the hospital. We will plot Kaplan-Meier curves to estimate ICU and hospital survival and perform survival analysis using the Cox proportional hazards model to identify the main risk factors for mortality. ClinicalTrials.gov: NCT04378582. RESULTS: We expect to include a large sample of patients with COVID-19 admitted to the ICU and to be able to provide data on admission characteristics, use of advanced life support, ICU survival at 28 days, and hospital survival at 60 days. CONCLUSIONS: This study will provide epidemiological data about critically ill patients with COVID-19 in Brazil, which could inform health policy and resource allocation in low- and middle-income countries.