Infection as an independent risk factor for mortality in the surgical intensive care unit.

OBJECTIVES: Medical and surgical intensive care unit patients represent two different populations and require different treatment approaches. The aim of this study was to investigate the parameters associated with mortality in medical and surgical intensive care units. METHODS: This was a prospective cohort study of adult patients admitted to a medical and surgical intensive care unit teaching hospital over an 11-month period. Factors associated with mortality were explored using logistic regression analysis. RESULTS: In total, 827 admissions were observed, and 525 patients >18 years old and with a length of stay >24 h were analyzed. Of these patients, 227 were in the medical and 298 were in the surgical intensive care unit. The surgical patients were older (p<0.01) and had shorter lengths of stay (p<0.01). The mortality in the intensive care unit (35.1 vs. 26.2, p = 0.02) and hospital (48.8 vs. 35.5, p<0.01) was higher for medical patients. For patients in the surgical intensive care unit, death was independently associated with the need for mechanical ventilation, prognostic score (SAPS II), community-acquired infection, nosocomial infection, and intensive care unit-acquired infection. For patients in the medical intensive care unit, death was independently associated with the need for mechanical ventilation and prognostic score. CONCLUSIONS: Although the presence of infection is associated with a high mortality in both the medical and surgical intensive care units, the results of this prospective study suggest that infection has a greater impact in patients admitted to the surgical intensive care unit. Measures and trials to prevent and treat sepsis may be most effective in the surgical intensive care unit population.

Infection as an independent risk factor for mortality in the surgical intensive care unit

OBJECTIVES: Medical and surgical intensive care unit patients represent two different populations and require different treatment approaches. The aim of this study was to investigate the parameters associated with mortality in medical and surgical intensive care units. METHODS: This was a prospective cohort study of adult patients admitted to a medical and surgical intensive care unit teaching hospital over an 11-month period. Factors associated with mortality were explored using logistic regression analysis. RESULTS: In total, 827 admissions were observed, and 525 patients >18 years old and with a length of stay >24 h were analyzed. Of these patients, 227 were in the medical and 298 were in the surgical intensive care unit. The surgical patients were older (p<0.01) and had shorter lengths of stay (p<0.01). The mortality in the intensive care unit (35.1 vs. 26.2, p = 0.02) and hospital (48.8 vs. 35.5, p<0.01) was higher for medical patients. For patients in the surgical intensive care unit, death was independently associated with the need for mechanical ventilation, prognostic score (SAPS II), community-acquired infection, nosocomial infection, and intensive care unit-acquired infection. For patients in the medical intensive care unit, death was independently associated with the need for mechanical ventilation and prognostic score. CONCLUSIONS: Although the presence of infection is associated with a high mortality in both the medical and surgical intensive care units, the results of this prospective study suggest that infection has a greater impact in patients admitted to the surgical intensive care unit. Measures and trials to prevent and treat sepsis may be most effective in the surgical intensive care unit population. .

The epidemiology of acute respiratory failure in hospitalized patients: a Brazilian prospective cohort study.

PURPOSE: The purpose of this study was to assess risk factors associated with the development of acute respiratory failure (ARF) and death in a general intensive care unit (ICU). MATERIALS AND METHODS: Adults who were hospitalized at 12 surgical and nonsurgical ICUs were prospectively followed up. Multivariable analyses were realized to determine the risk factors for ARF and point out the prognostic factors for mortality in these patients. RESULTS: A total of 1732 patients were evaluated, with an ARF prevalence of 57%. Of the 889 patients who were admitted without ARF, 141 (16%) developed this syndrome in the ICU. The independent risk factors for developing ARF were 64 years of age or older, longer time between hospital and ICU admission, unscheduled surgical or clinical reason for ICU admission, and severity of illness. Of the 984 patients with ARF, 475 (48%) died during the ICU stay. Independent prognostic factors for death were age older than 64 years, time between hospital and ICU admission of more than 4 days, history of hematologic malignancy or AIDS, the development of ARF in ICU, acute lung injury, and severity of illness. CONCLUSIONS: Acute respiratory failure represents a large percentage of all ICU patients, and the high mortality is related to some preventable factors such as the time to ICU admission.

Age, invasive ventilatory support and outcomes in elderly patients admitted to intensive care units.

BACKGROUND: although advancing age is associated with worse outcomes on mechanically ventilated elderly patients admitted to intensive care units (ICU), this relation has not been extensively investigated on patients not requiring invasive ventilatory support. OBJECTIVE: to determine the relationship between age and in-hospital mortality of elderly patients, admitted to ICU, requiring and not requiring invasive ventilatory support. DESIGN: prospective observational cohort study conducted over a period of 11 months. SETTING: medical-surgical ICU at a Brazilian university hospital. SUBJECTS: a total of 840 patients aged 55 years and older were admitted to ICU. METHODS: in-hospital death rates for patients requiring and not requiring invasive ventilatory support were compared across three successive age intervals (55-64; 65-74 and 75 or more years), adjusting for severity of illness using the Acute Physiologic Score. RESULTS: age was strongly correlated with mortality among the invasively ventilated subgroup of patients and the multivariate adjusted odds ratios increased progressively with every age increment (OR = 1.60, 95% CI = 1.01-2.54 for 65-74 years old and OR = 2.68, 95% CI = 1.58-4.56 for > or =75 years). For the patients not submitted to invasive ventilatory support, age was not independently associated with in-hospital mortality (OR = 2.28, 95% CI = 0.99-5.25 for 65-74 years old and OR = 1.95, 95% CI = 0.82-4.62 for > or =75 years old). CONCLUSIONS: the combination of age and invasive mechanical ventilation is strongly associated with in-hospital mortality. Age should not be considered as a factor related to in-hospital mortality of elderly patients not requiring invasive ventilatory support in ICU.

Continuous positive airway pressure increases inspiratory capacity of COPD patients.

BACKGROUND AND OBJECTIVE: Hyperinflation with a decrease in inspiratory capacity (IC) is a common presentation for both unstable and stable COPD patients. As CPAP can reduce inspiratory load, possibly secondary to a reduction in hyperinflation, this study examined whether CPAP would increase IC in stable COPD patients. METHODS: Twenty-one stable COPD patients (nine emphysema, 12 chronic bronchitis) received a trial of CPAP for 5 min at 4, 7 and 11 cmH(2)O. Fast and slow VC (SVC) were measured before and after each CPAP trial. In patients in whom all three CPAP levels resulted in a decreased IC, an additional trial of CPAP at 2 cmH(2)O was conducted. For each patient, a 'best CPAP' level was defined as the one associated with the greatest IC. This pressure was then applied for an additional 10 min followed by spirometry. RESULTS: Following application of the 'best CPAP', the IC and SVC increased in 15 patients (nine emphysema, six chronic bronchitis). The mean change in IC was 159 mL (95% CI: 80-237 mL) and the mean change in SVC was 240 mL (95% CI: 97-386 mL). Among these patients, those with emphysema demonstrated a mean increase in IC of 216 mL (95% CI: 94-337 mL). Six patients (all with chronic bronchitis) did not demonstrate any improvement in IC. CONCLUSIONS: The best individualized CPAP can increase inspiratory capacity in patients with stable COPD, especially in those with emphysema.

Ventilação mecânica na lesão pulmonar aguda / síndrome do desconforto respiratório agudo / Mechanical ventilation in the acute lung injury/acute respiratory distress syndrome

JUSTIFICATIVA E OBJETIVOS: Em 2000, foi publicado o II Consenso Brasileiro de Ventilação Mecânica. Desde então, o conhecimento na área da ventilação mecânica avançou rapidamente, com a publicação de inúmeros estudos clínicos que acrescentaram informações importantes para o manuseio de pacientes críticos em ventilação artificial. Além disso, a expansão do conceito de Medicina Baseada em Evidências determinou a hierarquização das recomendações clínicas, segundo o rigor metodológico dos estudos que as embasaram. Essa abordagem explícita vem ampliando a compreensão e a aplicação das recomendações clínicas. Por esses motivos, a AMIB - Associação de Medicina Intensiva Brasileira - e a SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - julgaram conveniente a atualização das recomendações descritas no Consenso anterior. Dentre os tópicos selecionados a Ventilação Mecânica na Síndrome do Desconforto Respiratório Agudo (SDRA) foi um dos temas propostos. O objetivo foi descrever os pontos mais importantes relacionados à ventilação mecânica na Síndrome do Desconforto Respiratório Agudo e discutir o papel das estratégias protetoras aplicada a esses pacientes. MÉTODO: Objetivou-se chegar a um documento suficientemente sintético, que refletisse a melhor evidência disponível na literatura. A revisão bibliográfica baseou-se na busca de estudos através de palavras-chave e em sua gradação conforme níveis de evidência. As palavras-chave utilizadas para a busca foram: mechanical ventilation e acute respiratory distress syndrome. RESULTADOS: São apresentadas recomendações quanto à utilização das estratégias protetoras (uso de baixos volumes-correntes e limitação da pressão de platô inspiratório), assim como, o estado atual da aplicação da PEEP e o papel das manobras de recrutamento. CONCLUSÕES: A ventilação mecânica na SDRA apresentou muitas mudanças nesses últimos anos e o uso de estratégias ventilatórias que preservem a micro-arquitetura pulmonar...

BACKGROUND AND OBJECTIVES: The II Brazilian Consensus Conference on Mechanical Ventilation was published in 2000. Knowledge on the field of mechanical ventilation evolved rapidly since then, with the publication of numerous clinical studies with potential impact on the ventilatory management of critically ill patients. Moreover, the evolving concept of evidence - based medicine determined the grading of clinical recommendations according to the methodological value of the studies on which they are based. This explicit approach has broadened the understanding and adoption of clinical recommendations. For these reasons, AMIB - Associação de Medicina Intensiva Brasileira and SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - decided to update the recommendations of the II Brazilian Consensus. Acute Respiratory Distress Syndrome (ARDS) has been one of the updated topics. This objective was described the most important topics related to mechanical ventilation in patients with acute respiratory distress syndrome. METHODS: Systematic review of the published literature and gradation of the studies in levels of evidence, using the key words mechanical ventilation and acute respiratory distress syndrome. RESULTS: Recommendations on the use of lung protective strategies during mechanical ventilation based on reduced tidal volumes and limitation of plateau pressure. The state of the art of recruitment maneuvers and PEEP titration is also discussed. CONCLUSIONS: The mechanical ventilation of patients with ADRS changed in the last few years. We presented the role of lung protective strategies that could be applied to these patients.

Ventilação mecânica no intra-operatório / Intraoperative mechanical ventilation

JUSTIFICATIVA E OBJETIVOS: Em 2000, foi publicado o II Consenso Brasileiro de Ventilação Mecânica. Desde então, o conhecimento na área da ventilação mecânica avançou rapidamente, com a publicação de inúmeros estudos clínicos que acrescentaram informações importantes para o manuseio de pacientes críticos em ventilação artificial. Além disso, a expansão do conceito de Medicina Baseada em Evidências determinou a hierarquização das recomendações clínicas, segundo o rigor do método dos estudos que os embasaram. Essa abordagem explícita vem ampliando a compreensão e a aplicação das recomendações clínicas. Por esses motivos, a AMIB - Associação de Medicina Intensiva Brasileira - e a SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - julgaram conveniente a atualização das recomendações descritas no Consenso anterior. Dentre os tópicos selecionados a Ventilação Mecânica no Intra-Operatório foi um dos temas propostos. O objetivo foi descrever os pontos mais importantes relacionados à ventilação mecânica no período intra-operatório. MÉTODO: Objetivou-se chegar a um documento suficientemente sintético, que refletisse a melhor evidência disponível na literatura. A revisão bibliográfica baseou-se na busca de estudos através de palavras-chave e em sua gradação conforme níveis de evidência. As palavras-chave utilizadas para a busca foram: mechanical ventilation, perioperative e anesthesia. RESULTADOS: São apresentadas recomendações quanto à prevenção de complicações, as modalidades ventilatórias que podem ser aplicadas durante a anestesia e as manobras pós-operatórias para aumento do volume pulmonar. CONCLUSÕES: A atelectasia pulmonar tem se mostrado uma complicação freqüente no intra-operatório, assim técnicas de ventilação mecânica têm sido introduzidas visando a redução nessas complicações.

BACKGROUND AND OBJECTIVES: The II Brazilian Consensus Conference on Mechanical Ventilation was published in 2000. Knowledge on the field of mechanical ventilation evolved rapidly since then, with the publication of numerous clinical studies with potential impact on the ventilatory management of critically ill patients. Moreover, the evolving concept of evidence - based Medicine determined the grading of clinical recommendations according to the methodological value of the studies on which they are based. This explicit approach has broadened the understanding and adoption of clinical recommendations. For these reasons, AMIB - Associação de Medicina Intensiva Brasileira and SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - decided to update the recommendations of the II Brazilian Consensus. Intraoperative mechanical ventilation has been one of the updated topics. This objective was described the most important topics on the intraoperative mechanical ventilation. METHODS: Systematic review of the published literature and gradation of the studies in levels of evidence, using the key words: mechanical ventilation, intraoperative and anesthesia. RESULTS: Recommendations on how to prevent pulmonary complications during anesthesia/postoperative period and which are the best intraoperative ventilatory techniques. CONCLUSIONS: Pulmonary atelectasis is a common complication observed in the postoperative period, thus ventilatory techniques has been adapted to prevent these complications.

Ventilação mecânica não-invasiva com pressão positiva / Noninvasive mechanical ventilation with positive pressure

JUSTIFICATIVA E OBJETIVOS: Em 2000, foi publicado o II Consenso Brasileiro de Ventilação Mecânica. Desde então, o conhecimento na área da ventilação mecânica avançou rapidamente, com a publicação de numerosos estudos clínicos que acrescentaram informações importantes para o manejo de pacientes críticos em ventilação artificial. Além disso, a expansão do conceito de Medicina Baseada em Evidências determinou a hierarquização das recomendações clínicas, segundo o rigor metodológico dos estudos que as embasaram. Essa abordagem explícita vem ampliando a compreensão e a aplicação das recomendações clínicas. Por esses motivos, a AMIB - Associação de Medicina Intensiva Brasileira - e a SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - julgaram conveniente a atualização das recomendações descritas no Consenso anterior. Dentre os tópicos selecionados a Ventilação Mecânica Não-Invasiva foi um dos temas propostos. O objetivo deste estudo foi descrever os pontos mais importantes relacionados à ventilação mecânica na forma não-invasiva (VMNI) e sugerir as principais indicações dessa modalidade. MÉTODO: Objetivou-se chegar a um documento suficientemente sintético, que refletisse a melhor evidência disponível na literatura. A revisão bibliográfica baseou-se na busca de estudos através de palavras-chave e em sua gradação conforme níveis de evidência. As palavras-chave utilizadas para a busca foram: Ventilação mecânica não invasiva: Non-invasive mechanical ventilation. RESULTADOS: São apresentadas recomendações quanto à utilização da VMNI nas diversas formas de insuficiência respiratória e no desmame da ventilação mecânica. CONCLUSÕES: A VMNI está indicada como o tratamento preferencial na exacerbação da DPOC, assim como, na assistência de pacientes em edema agudo de pulmão.

BACKGROUND AND OBJECTIVES: The II Brazilian Consensus Conference on Mechanical Ventilation was published in 2000. Knowledge on the field of mechanical ventilation evolved rapidly since then, with the publication of numerous clinical studies with potential impact on the ventilatory management of critically ill patients. Moreover, the evolving concept of evidence - based medicine determined the grading of clinical recommendations according to the methodological value of the studies on which they are based. This explicit approach has broadened the understanding and adoption of clinical recommendations. For these reasons, AMIB - Associação de Medicina Intensiva Brasileira and SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - decided to update the recommendations of the II Brazilian Consensus. Non-Invasive Mechanical ventilation has been one of the updated topics. Describe the most important topics on the non-invasive mechanical ventilation and suggest the main therapeutic approaches of this modality. METHODS: Systematic review of the published literature and gradation of the studies in levels of evidence, using the keywords "non-invasive mechanical ventilation". RESULTS: Recommendations on the non-invasive mechanical ventilation during respiratory failure and weaning are presented. CONCLUSIONS: Non-invasive mechanical ventilation is the main form of ventilatory support during exacerbation of chronic obstructive pulmonary disease and in acute pulmonary edema patients.

Ventilação mecânica na doença pulmonar obstrutiva crônica / Mechanical ventilation in chronic obstructive pulmonary disease

JUSTIFICATIVA E OBJETIVOS: Em 2000, foi publicado o II Consenso Brasileiro de Ventilação Mecânica. Desde então, o conhecimento na área da ventilação mecânica avançou rapidamente, com a publicação de numerosos estudos clínicos que acrescentaram informações importantes para o manejo de pacientes críticos em ventilação artificial. Além disso, a expansão do conceito de Medicina Baseada em Evidências determinou a hierarquização das recomendações clínicas, segundo o rigor metodológico dos estudos que as embasaram. Essa abordagem explícita vem ampliando a compreensão e a aplicação das recomendações clínicas. Por esses motivos, a AMIB - Associação de Medicina Intensiva Brasileira - e a SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - julgaram conveniente a atualização das recomendações descritas no Consenso anterior. Dentre os tópicos selecionados a Ventilação Mecânica na Agudização da DPOC foi um dos temas propostos. O objetivo deste estudo foi descrever os pontos mais importantes relacionados à ventilação mecânica durante a agudização da doença pulmonar obstrutiva crônica (DPOC) e sugerir as principais abordagens terapêuticas. MÉTODO: Objetivou-se chegar a um documento suficientemente sintético, que refletisse a melhor evidência disponível na literatura. A revisão bibliográfica baseou-se na busca de estudos através de palavras-chave e em sua gradação conforme níveis de evidência. As palavras-chave utilizadas para a busca foram: ventilação mecânica na DPOC: COPD and mechanical ventilation. RESULTADOS: São apresentadas recomendações quanto aos modos ventilatórios e aos parâmetros a serem aplicados quando do ajuste do ventilador, além da monitoração recomendada. Apresentam-se ainda, técnicas alternativas que possam ser utilizadas. CONCLUSÕES: Estratégias protetoras de ventilação mecânica são recomendadas durante a ventilação mecânica de um paciente DPOC agudizado.

BACKGROUND AND OBJECTIVES: The II Brazilian Consensus Conference on Mechanical Ventilation was published in 2000. Knowledge on the field of mechanical ventilation evolved rapidly since then, with the publication of numerous clinical studies with potential impact on the ventilatory management of critically ill patients. Moreover, the evolving concept of evidence - based medicine determined the grading of clinical recommendations according to the methodological value of the studies on which they are based. This explicit approach has broadened the understanding and adoption of clinical recommendations. For these reasons, AMIB - Associação de Medicina Intensiva Brasileira and SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - decided to update the recommendations of the II Brazilian Consensus. Mechanical ventilation in COPD exacerbation has been one of the updated topics. Describe the most important topics on the mechanical ventilation during the COPD exacerbation and suggest the main therapeutic approaches. METHODS: Systematic review of the published literature and gradation of the studies in levels of evidence, using the keywords "mechanical ventilation" and "COPD". RESULTS: We present recommendations on the ventilatory modes and settings to be adopted when ventilating a patient during an asthma attack, as well as the recommended monitoring. Alternative ventilation techniques are also presented. CONCLUSIONS: Protective ventilatory strategies are recommended when ventilating a patient during a.

[Mechanical ventilation in the acute lung injury/acute respiratory distress syndrome]. / Ventilação mecânica na lesão pulmonar aguda / síndrome do desconforto respiratório agudo.

BACKGROUND AND OBJECTIVES: The II Brazilian Consensus Conference on Mechanical Ventilation was published in 2000. Knowledge on the field of mechanical ventilation evolved rapidly since then, with the publication of numerous clinical studies with potential impact on the ventilatory management of critically ill patients. Moreover, the evolving concept of evidence - based medicine determined the grading of clinical recommendations according to the methodological value of the studies on which they are based. This explicit approach has broadened the understanding and adoption of clinical recommendations. For these reasons, AMIB - Associação de Medicina Intensiva Brasileira and SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - decided to update the recommendations of the II Brazilian Consensus. Acute Respiratory Distress Syndrome (ARDS) has been one of the updated topics. This objective was described the most important topics related to mechanical ventilation in patients with acute respiratory distress syndrome. METHODS: Systematic review of the published literature and gradation of the studies in levels of evidence, using the key words mechanical ventilation and acute respiratory distress syndrome. RESULTS: Recommendations on the use of lung protective strategies during mechanical ventilation based on reduced tidal volumes and limitation of plateau pressure. The state of the art of recruitment maneuvers and PEEP titration is also discussed. CONCLUSIONS: The mechanical ventilation of patients with ADRS changed in the last few years. We presented the role of lung protective strategies that could be applied to these patients.