Prospective, randomized, controlled trial assessing the effects of a driving pressure-limiting strategy for patients with acute respiratory distress syndrome due to community-acquired pneumonia (STAMINA trial): protocol and statistical analysis plan.

BACKGROUND: Driving pressure has been suggested to be the main driver of ventilator-induced lung injury and mortality in observational studies of acute respiratory distress syndrome. Whether a driving pressure-limiting strategy can improve clinical outcomes is unclear. OBJECTIVE: To describe the protocol and statistical analysis plan that will be used to test whether a driving pressure-limiting strategy including positive end-expiratory pressure titration according to the best respiratory compliance and reduction in tidal volume is superior to a standard strategy involving the use of the ARDSNet low-positive end-expiratory pressure table in terms of increasing the number of ventilator-free days in patients with acute respiratory distress syndrome due to community-acquired pneumonia. METHODS: The ventilator STrAtegy for coMmunIty acquired pNeumoniA (STAMINA) study is a randomized, multicenter, open-label trial that compares a driving pressure-limiting strategy to the ARDSnet low-positive end-expiratory pressure table in patients with moderate-to-severe acute respiratory distress syndrome due to community-acquired pneumonia admitted to intensive care units. We expect to recruit 500 patients from 20 Brazilian and 2 Colombian intensive care units. They will be randomized to a driving pressure-limiting strategy group or to a standard strategy using the ARDSNet low-positive end-expiratory pressure table. In the driving pressure-limiting strategy group, positive end-expiratory pressure will be titrated according to the best respiratory system compliance. OUTCOMES: The primary outcome is the number of ventilator-free days within 28 days. The secondary outcomes are in-hospital and intensive care unit mortality and the need for rescue therapies such as extracorporeal life support, recruitment maneuvers and inhaled nitric oxide. CONCLUSION: STAMINA is designed to provide evidence on whether a driving pressure-limiting strategy is superior to the ARDSNet low-positive end-expiratory pressure table strategy for increasing the number of ventilator-free days within 28 days in patients with moderate-to-severe acute respiratory distress syndrome. Here, we describe the rationale, design and status of the trial.

Improved performance of an intensive care unit after changing the admission triage model.

The aim of this study is to analyze the effect of implementing a prioritization triage model for admission to an intensive care unit on the outcome of critically ill patients. Retrospective longitudinal study of adult patients admitted to the Intensive Care Unit (ICU) carried out from January 2013 to December 2017. The primary outcome considered was vital status at hospital discharge. Patients were divided into period 1 (chronological triage) during the years 2013 and 2014 and period 2 (prioritization triage) during the years 2015-2017. A total of 1227 patients in period 1 and 2056 in period 2 were analyzed. Patients admitted in period 2 were older (59.8 years) compared to period 1 (57.3 years; p < 0.001) with less chronic diseases (13.6% vs. 19.2%; p = 0.001), and higher median APACHE II score (21.0 vs. 18.0; p < 0.001)) and TISS 28 score (28.0 vs. 27.0; p < 0.001). In period 2, patients tended to stay in the ICU for a shorter time (8.5 ± 11.8 days) compared to period 1 (9.6 ± 16.0 days; p = 0.060) and had lower mortality at ICU (32.8% vs. 36.9%; p = 0.016) and hospital discharge (44.2% vs. 47.8%; p = 0.041). The change in the triage model from a chronological model to a prioritization model resulted in improvement in the performance of the ICU and reduction in the hospital mortality rate.

Early Tracheostomy May Reduce the Length of Hospital Stay.

Introduction: There is evidence that prolonged invasive mechanical ventilation has negative consequences for critically ill patients and that performing tracheostomy (TQT) could help to reduce these consequences. The ideal period for performing TQT is still not clear in the literature since few studies have compared clinical aspects between patients undergoing early or late TQT. Objective: To compare the mortality rate, length of stay in the intensive care unit, length of hospital stay, and number of days free of mechanical ventilation in patients undergoing TQT before or after ten days of orotracheal intubation. Methods: A retrospective cohort study carried out by collecting data from patients admitted to an intensive care unit between January 2008 and December 2017. Patients who underwent TQT were divided into an early TQT group (i.e., time to TQT ≤ 10 days) or late TQT (i.e., time to TQT > 10 days) and the clinical outcomes of the two groups were compared. Results: Patients in the early TQT group had a shorter ICU stay than the late TQT group (19 ± 16 vs. 32 ± 22 days, p < 0.001), a shorter stay in the hospital (42 ± 32 vs. 52 ± 50 days, p < 0.001), a shorter duration of mechanical ventilation (17 ± 14 vs. 30 ± 18 days, p < 0.001), and a higher proportion of survivors in the ICU outcome (57% vs. 46%, p < 0.001). Conclusion: Tracheostomy performed within 10 days of mechanical ventilation provides several benefits to the patient and should be considered by the multidisciplinary team as a part of their clinical practice.

Evaluation of time to death after admission to an intensive care unit and factors associated with mortality: A retrospective longitudinal study.

Background: Among nonsurvivors admitted to the intensive care unit (ICU), some present early mortality while other patients, despite having a favorable evolution regarding the initial disease, die later due to complications related to hospitalization. This study aims to identify factors associated with the time until death after admission to an ICU of a university hospital. Methods: Retrospective longitudinal study that included adult patients admitted to the ICU between January 1, 2008, and December 31, 2017. Nonsurviving patients were divided into groups according to the length of time from admission to the ICU until death: Early (0-5 days), intermediate (6-28 days), and late (>28 days). Patients were considered septic if they had this diagnosis on admission to the ICU. Simple linear regression analysis was performed to evaluate the association between time to death over the years of the study. Multivariate cox regression was used to assess risk factors for the outcome in the ICU. Results: In total, 6596 patients were analyzed. Mortality rate was 32.9% in the ICU. Most deaths occurred in the early (42.8%) and intermediate periods (47.9%). Patients with three or more dysfunctions on admission were more likely to die early (P < 0.001). The diagnosis of sepsis was associated with a higher mortality rate. The multivariate analysis identified age >60 years (hazard ratio [HR] 1.009), male (HR 1.192), mechanical ventilation (HR 1.476), dialysis (HR 2.297), and sequential organ failure assessment >6 (HR 1.319) as risk factors for mortality. Conclusion: We found a higher proportion of early and intermediate deaths in the study period. The presence of three or more organ dysfunctions at ICU admission was associated with early death. The diagnosis of sepsis evident on ICU admission was associated with higher mortality.

Recusa de leitos e triagem de pacientes admitidos nas unidades de terapia intensiva do Brasil: estudo transversal do tipo survey nacional / Refusal of beds and triage of patients admitted to intensive care units in Brazil: a cross-sectional national survey

RESUMO Objetivo: Conhecer dados sobre recusa de leitos nas unidades intensivas no Brasil, assim como avaliar o uso de sistemas de triagem pelos profissionais atuantes. Métodos: Estudo transversal do tipo survey. Com a metodologia Delphi, foi criado um questionário contemplando os objetivos do trabalho. Foram convidados médicos e enfermeiros inscritos na rede de pesquisa da Associação de Medicina Intensiva Brasileira (AMIBnet). Uma plataforma da web (SurveyMonkey®) foi a forma de aplicação do questionário. As variáveis deste trabalho foram mensuradas em categorias e expressas como proporção. Foram usados o teste do qui-quadrado ou o teste exato de Fisher, para verificar associações. O nível de significância foi de 5%. Resultados: No total, 231 profissionais responderam o questionário, representando todas as regiões do país. As unidades intensivas nacionais tinham mais de 90% de taxa de ocupação sempre ou frequentemente para 90,8% dos participantes. Dentre os participantes, 84,4% já deixaram de admitir pacientes em leito intensivo devido à lotação da unidade. Metade das instituições brasileiras (49,7%) não possuía protocolos de triagem de leitos intensivos instituídos. Conclusão: A recusa de leito pela alta taxa de ocupação é frequente nas unidades de terapia intensiva do Brasil. Ainda assim, metade dos serviços do Brasil não adota protocolos para triagem de leitos.

ABSTRACT Objective: To obtain data on bed refusal in intensive care units in Brazil and to evaluate the use of triage systems by professionals. Methods: A cross-sectional survey. Using the Delphi methodology, a questionnaire was created contemplating the objectives of the study. Physicians and nurses enrolled in the research network of the Associação de Medicina Intensiva Brasileira (AMIBnet) were invited to participate. A web platform (SurveyMonkey®) was used to distribute the questionnaire. The variables in this study were measured in categories and expressed as proportions. The chi-square test or Fisher's exact test was used to verify associations. The significance level was set at 5%. Results: In total, 231 professionals answered the questionnaire, representing all regions of the country. The national intensive care units had an occupancy rate of more than 90% always or frequently for 90.8% of the participants. Among the participants, 84.4% had already refused admitting patients to the intensive care unit due to the capacity of the unit. Half of the Brazilian institutions (49.7%) did not have triage protocols for admission to intensive beds. Conclusions: Bed refusal due to high occupancy rates is common in Brazilian intensive care units. Even so, half of the services in Brazil do not adopt protocols for triage of beds.

Refusal of beds and triage of patients admitted to intensive care units in Brazil: a cross-sectional national survey. / Recusa de leitos e triagem de pacientes admitidos nas unidades de terapia intensiva do Brasil: estudo transversal do tipo survey nacional.

OBJECTIVE: To obtain data on bed refusal in intensive care units in Brazil and to evaluate the use of triage systems by professionals. METHODS: A cross-sectional survey. Using the Delphi methodology, a questionnaire was created contemplating the objectives of the study. Physicians and nurses enrolled in the research network of the Associação de Medicina Intensiva Brasileira (AMIBnet) were invited to participate. A web platform (SurveyMonkey®) was used to distribute the questionnaire. The variables in this study were measured in categories and expressed as proportions. The chi-square test or Fisher's exact test was used to verify associations. The significance level was set at 5%. RESULTS: In total, 231 professionals answered the questionnaire, representing all regions of the country. The national intensive care units had an occupancy rate of more than 90% always or frequently for 90.8% of the participants. Among the participants, 84.4% had already refused admitting patients to the intensive care unit due to the capacity of the unit. Half of the Brazilian institutions (49.7%) did not have triage protocols for admission to intensive beds. CONCLUSIONS: Bed refusal due to high occupancy rates is common in Brazilian intensive care units. Even so, half of the services in Brazil do not adopt protocols for triage of beds.

OBJETIVO: Conhecer dados sobre recusa de leitos nas unidades intensivas no Brasil, assim como avaliar o uso de sistemas de triagem pelos profissionais atuantes. MÉTODOS: Estudo transversal do tipo survey. Com a metodologia Delphi, foi criado um questionário contemplando os objetivos do trabalho. Foram convidados médicos e enfermeiros inscritos na rede de pesquisa da Associação de Medicina Intensiva Brasileira (AMIBnet). Uma plataforma da web (SurveyMonkey®) foi a forma de aplicação do questionário. As variáveis deste trabalho foram mensuradas em categorias e expressas como proporção. Foram usados o teste do qui-quadrado ou o teste exato de Fisher, para verificar associações. O nível de significância foi de 5%. RESULTADOS: No total, 231 profissionais responderam o questionário, representando todas as regiões do país. As unidades intensivas nacionais tinham mais de 90% de taxa de ocupação sempre ou frequentemente para 90,8% dos participantes. Dentre os participantes, 84,4% já deixaram de admitir pacientes em leito intensivo devido à lotação da unidade. Metade das instituições brasileiras (49,7%) não possuía protocolos de triagem de leitos intensivos instituídos. CONCLUSÃO: A recusa de leito pela alta taxa de ocupação é frequente nas unidades de terapia intensiva do Brasil. Ainda assim, metade dos serviços do Brasil não adota protocolos para triagem de leitos.

Seasonal variation of clinical characteristics and prognostic of adult patients admitted to an intensive care unit.

OBJECTIVE: To evaluate seasonal variations of clinical characteristics, therapeutic resource use, and outcomes of critically ill patients admitted to an intensive care unit. METHODS: A retrospective cohort study conducted from January 2011 to December 2016 in adult patients admitted to the intensive care unit (ICU) of a University Hospital. Data were collected on the type of admission, APACHE II, SOFA, and TISS 28 scores at ICU admission. Length of hospital stay and vital status at hospital discharge were recorded. A significance level of 5% was adopted. RESULTS: During the study period, 3.711 patients were analyzed. Patients had a median age of 60.0 years (interquartile range = 45.0 - 73.0), and 59% were men. The independent risk factors associated with increased hospital mortality rate were age, chronic disease, seasonality, diagnostic category, need for mechanical ventilation and vasoactive drugs, presence of acute kidney injury, and sepsis at admission. CONCLUSION: It was possible to observe variations of the clinical characteristics and prognosis of patients; summer months presented a higher proportion of clinical and emergency surgery patients, with higher mortality rates. Sepsis at ICU admission did not show seasonal behavior. A seasonal pattern was found for mortality rate.

Seasonal variation of clinical characteristics and prognostic of adult patients admitted to an intensive care unit

SUMMARY OBJECTIVE: To evaluate seasonal variations of clinical characteristics, therapeutic resource use, and outcomes of critically ill patients admitted to an intensive care unit. METHODS: A retrospective cohort study conducted from January 2011 to December 2016 in adult patients admitted to the intensive care unit (ICU) of a University Hospital. Data were collected on the type of admission, APACHE II, SOFA, and TISS 28 scores at ICU admission. Length of hospital stay and vital status at hospital discharge were recorded. A significance level of 5% was adopted. RESULTS: During the study period, 3.711 patients were analyzed. Patients had a median age of 60.0 years (interquartile range = 45.0 − 73.0), and 59% were men. The independent risk factors associated with increased hospital mortality rate were age, chronic disease, seasonality, diagnostic category, need for mechanical ventilation and vasoactive drugs, presence of acute kidney injury, and sepsis at admission. CONCLUSION: It was possible to observe variations of the clinical characteristics and prognosis of patients; summer months presented a higher proportion of clinical and emergency surgery patients, with higher mortality rates. Sepsis at ICU admission did not show seasonal behavior. A seasonal pattern was found for mortality rate.

RESUMO OBJETIVO: Analisar variações sazonais dos padrões clínicos, uso de recursos terapêuticos e resultados da internação de pacientes adultos admitidos na unidade de terapia intensiva. MÉTODOS: Estudo de coorte retrospectivo realizado de janeiro de 2011 a dezembro de 2016 em pacientes adultos na unidade de terapia intensiva (UTI) de Hospital Universitário. Foram coletados dados do tipo de admissão, escores Apache II, Sofa e Tiss 28 da admissão na UTI. O tempo de permanência e o desfecho na saída hospitalar foram registrados. O nível de significância adotado foi de 5%. RESULTADOS: Foram analisados 3.711 pacientes no período do estudo. Os pacientes apresentaram mediana de idade de 60,0 anos (intervalo interqualítico = 45,0 − 73,0), sendo 59% homens. Os fatores independentes associados ao aumento de taxa de mortalidade hospitalar foram idade, doença crônica, sazonalidade, categoria diagnóstica, necessidade de ventilação mecânica e uso de drogas vasoativas, diagnóstico de injúria renal aguda e sepse na admissão. Pela análise de série temporal, a sazonalidade para sepse não foi significativa, enquanto a sazonalidade para óbitos foi significativa. CONCLUSÕES: Foi possível observar variação do perfil clínico e de prognóstico dos pacientes admitidos, sendo que os meses de verão apresentam maior proporção de pacientes clínicos e cirúrgicos de urgência, com maiores taxas de mortalidade. Sepse na admissão da UTI não apresentou comportamento sazonal. Foi encontrado padrão sazonal para a taxa de mortalidade.

The Effect of Support Surfaces on the Incidence of Pressure Injuries in Critically Ill Patients: A Randomized Clinical Trial.

PURPOSE: To analyze whether a viscoelastic mattress support surface can reduce the incidence of stage 2 pressure injuries compared to a standard hospital mattress with pyramidal overlay in critically ill patients. METHOD: A randomized clinical trial with intention-to-treat analysis was carried out recruiting patients with Braden scale ≤14 on intensive care unit admission from April 2016 to April 2017. Patients were allocated into two groups: intervention group (viscoelastic mattress) and control group (standard mattress with pyramidal overlay). The level of significance adopted was 5%. RESULTS: A total of 62 patients were included in the study. There was a predominance of males (53%) and the mean age was 67.9 (SD 18.8) years. There were no differences in clinical or severity characteristics between the patients in the control group and the intervention group. Pressure injuries occurred in 35 patients, with a median time of 7 days (ITQ 4-10) from admission. The frequency of pressure injuries was higher in the control group (80.6%) compared to the intervention group (32.2%; p < 0.001). CONCLUSIONS: Viscoelastic support surfaces reduced the incidence of pressure injuries in moderate or higher risk critically ill patients when compared to pyramidal support surfaces.

Evaluation of the five-year operation period of a rapid response team led by an intensive care physician at a university hospital. / Avaliação de 5 anos de atuação de um time de resposta rápida liderado por médico intensivista em hospital universitário.

OBJECTIVE: To evaluate the implementation of a multidisciplinary rapid response team led by an intensive care physician at a university hospital. METHODS: This retrospective cohort study analyzed assessment forms that were completed during the assessments made by the rapid response team of a university hospital between March 2009 and February 2014. RESULTS: Data were collected from 1,628 assessments performed by the rapid response team for 1,024 patients and included 1,423 code yellow events and 205 code blue events. The number of assessments was higher in the first year of operation of the rapid response team. The multivariate analysis indicated that age (OR 1.02; 95%CI 1.02 - 1.03; p < 0.001), being male (OR 1.48; 95%CI 1.09 - 2.01; p = 0.01), having more than one assessment (OR 3.31; 95%CI, 2.32 - 4.71; p < 0.001), hospitalization for clinical care (OR 1.77; 95%CI 1.29 - 2.42; p < 0.001), the request of admission to the intensive care unit after the code event (OR 4.75; 95%CI 3.43 - 6.59; p < 0.001), and admission to the intensive care unit before the code event (OR 2.13; 95%CI 1.41 - 3.21; p = 0.001) were risk factors for hospital mortality in patients who were seen for code yellow events. CONCLUSION: The hospital mortality rates were higher than those found in previous studies. The number of assessments was higher in the first year of operation of the rapid response team. Moreover, hospital mortality was higher among patients admitted for clinical care.

Avaliação de 5 anos de atuação de um time de resposta rápida liderado por médico intensivista em hospital universitário / Evaluation of the five-year operation period of a rapid response team led by an intensive care physician at a university hospital

RESUMO Objetivo: Avaliar a implementação de time de resposta rápida multidisciplinar liderado por médico intensivista em hospital universitário. Métodos: Estudo de coorte retrospectiva realizado pela análise de fichas de atendimentos preenchidas durante os atendimentos realizados pelo time de resposta rápida do hospital universitário entre março de 2009 e fevereiro de 2014. Resultados: Foram coletados dados de 1.628 atendimentos realizados em 1.024 pacientes pelo time de resposta rápida, sendo 1.423 códigos amarelos e 205 códigos azuis. Houve maior número de atendimentos no primeiro ano, após implementação do time de resposta rápida. A análise multivariada identificou idade (OR 1,02; IC95% 1,02 - 1,03; p < 0,001), sexo masculino (OR 1,48; IC95% 1,09 - 2,01; p = 0,01), mais de um atendimento (OR 3,31; IC95% 2,32 - 4,71; p < 0,001), internação para especialidades clínicas (OR 1,77; IC95% 1,29 - 2,42; p < 0,001), pedido de vaga de unidade de terapia intensiva posterior ao código (OR 4,75; IC95% 3,43 - 6,59; p < 0,001) e admissão em unidade de terapia intensiva prévia ao código (OR 2,13, IC95% 1,41 - 3,21; p = 0,001) como fatores de risco para mortalidade hospitalar de pacientes atendidos em códigos amarelos. Conclusão: Os índices de mortalidade hospitalar foram elevados quando comparados aos da literatura e houve maior número de atendimentos no primeiro ano de atuação do time de resposta rápida. Houve maior mortalidade hospitalar entre pacientes internados para especialidades clínicas.

ABSTRACT Objective: To evaluate the implementation of a multidisciplinary rapid response team led by an intensive care physician at a university hospital. Methods: This retrospective cohort study analyzed assessment forms that were completed during the assessments made by the rapid response team of a university hospital between March 2009 and February 2014. Results: Data were collected from 1,628 assessments performed by the rapid response team for 1,024 patients and included 1,423 code yellow events and 205 code blue events. The number of assessments was higher in the first year of operation of the rapid response team. The multivariate analysis indicated that age (OR 1.02; 95%CI 1.02 - 1.03; p < 0.001), being male (OR 1.48; 95%CI 1.09 - 2.01; p = 0.01), having more than one assessment (OR 3.31; 95%CI, 2.32 - 4.71; p < 0.001), hospitalization for clinical care (OR 1.77; 95%CI 1.29 - 2.42; p < 0.001), the request of admission to the intensive care unit after the code event (OR 4.75; 95%CI 3.43 - 6.59; p < 0.001), and admission to the intensive care unit before the code event (OR 2.13; 95%CI 1.41 - 3.21; p = 0.001) were risk factors for hospital mortality in patients who were seen for code yellow events. Conclusion: The hospital mortality rates were higher than those found in previous studies. The number of assessments was higher in the first year of operation of the rapid response team. Moreover, hospital mortality was higher among patients admitted for clinical care.