Acute gastrointestinal failure is associated with worse hemodynamic and perfusion parameters over 48 h after admission in patients with septic shock: Retrospective cohort study.

BACKGROUND: This study aimed to investigate the relationship between acute gastrointestinal injury (AGI) and hemodynamic and perfusion parameters in the first week of intensive care unit (ICU) admission and evaluate the association of AGI with ICU and hospital outcomes in patients with septic shock undergoing mechanical ventilation. METHODS: This retrospective cohort study applied the criteria proposed by the European Society of Intensive Medicine to classify the participants into risk/dysfunction group (AGI grade I and II) and failure group (AGI grade III and IV). Hemodynamic and perfusion parameters data previously collected in the first 48 h after ICU admission (admission, 12, 24, 48 h) were analyzed. RESULTS: A total of 163 were included and classified into AGI grades I (n = 79), II (n = 64), III (n = 20), and IV (none). Groups consisted of AGI risk/dysfunction (n = 143, 87.8%) and AGI failure (n = 20, 12.2%) patients. Patients with AGI failure had higher heart rate and mottling score (MS) at admission, lower mean arterial pressure, and an oliguria incidence at 12 h compared with those without AGI failure. Skin MS and abdominal primary site of infection were risk factors for AGI failure. AGI failure tended to be a risk factor for ICU mortality (risk ratio [95% CI]: 1.37 [0.99-1.89]; P = 0.053). CONCLUSION: AGI was frequently observed in patients with septic shock in the first week of ICU admission. Higher heart rate and MS and lower mean arterial pressure and incidence of oliguria were identified in patients with AGI failure compared with those without. AGI failure was associated with ICU mortality.

Variations in phase angle and handgrip strength in patients undergoing cardiac surgery: Prospective cohort study.

BACKGROUND: Bioimpedance phase angle (PA) is a measure of cell membrane integrity, whereas handgrip strength (HGS) is an evaluation of functional capacity. Although both are related to the prognosis of patients undergoing cardiac surgery, their changes over time are less known. This study followed variations in PA and HGS for 1 year in these patients, determining associations with clinical outcomes. METHODS: This prospective cohort study included 272 cardiac surgery patients. PA and HGS were measured at six predetermined times. The evaluated outcomes were surgery type; bleeding; time of surgery, cardiopulmonary bypass, aortic cross-clamp, and mechanical ventilation; postoperative (PO) length of stay (LOS) in the intensive care unit (ICU) and hospital; and infections, hospital readmission, reoperation, and mortality. RESULTS: There were reductions in PA and HGS values after surgery, with total recovery beginning at 6 months for PA and 3 months for HGS. In the PA area under the curve (AUC), age, combined surgery, and sex (ß = -9.66, P < 0.001; ß = -252.85, P = 0.005; ß = -216.56, P < 0.001, respectively) were predictors for PA-AUC reduction. Stratified by sex, age (ß = -93.54, P < 0.001) and PO LOS (ß = -46.91, P = 0.003) were predictors for HGS-AUC reduction in women, but only age was a predictor in men (ß = -77.02, P = 0.010). PA and HGS had an effect in hospital LOS and ICU LOS. CONCLUSION: Age, combined surgery, and female sex were predictors of reduced PA-AUC, whereas reduced HGS-AUC was predicted by age in both sexes and PO hospital LOS in women, which suggests that these factors could interfere in prognosis.

Handgrip Strength in Preoperative Elective Cardiac Surgery Patients and Association With Body Composition and Surgical Risk.

BACKGROUND: Handgrip strength (HGS) is a potential method to approximate perioperative risk in cardiothoracic surgery patients and correlates well with European System for Cardiac Operative Risk Evaluation (EuroSCORE) values. This study aimed to characterize the functional capacity in preoperative cardiac surgery patients through HGS. METHODS: This cross-sectional study investigated patients aged 18 years or older. The collected data included surgical risk (EuroSCORE), body mass index (BMI), body composition (electrical bioimpedance), and HGS. RESULTS: The mean age of the 278 participants was 62.1 ± 11.2 years, of whom 61.5% were male, 43.2% were overweight, and 26.3% were obese. The main types of surgery were myocardial revascularization (50%) and valve replacement (40.6%). HGS values differed between genders in all age groups (P < 0.05) and were approximately 40% lower than reference values for healthy individuals. The values differed with respect to operative risk (P = 0.003) and had a moderate positive correlation with fat-free mass (rs = 0.435, P < 0.001), a moderate negative correlation with fat mass (rs = -0.447, P < 0.001), and weak negative correlations with age (rs = -0.270, P < 0.01) and EuroSCORE (rs = -0.316, P < 0.01). CONCLUSIONS: The HGS values of preoperative elective cardiac surgery patients were below reference values for healthy individuals, were lower in male patients, were positively correlated with fat-free mass, and were negatively correlated with fat mass, age, and operative risk. Its preoperative use in these patients is an attractive complementary method of risk assessment in clinical practice.

Mild Therapeutic Hypothermia Increases Glutathione Levels in Postcardiac Arrest Patients.

Ischemia-reperfusion (I/R)-induced oxidative stress is one of the main mechanisms of tissue injury after cardiac arrest (CA). A decrease in antioxidant defenses may contribute to I/R injury. The present study aims to investigate the influence of mild therapeutic hypothermia (MTH) on levels of nonenzymatic antioxidants after CA. We investigated antioxidant levels at 6, 12, 36, and 72 hours after CA in central venous blood samples of patients admitted to intensive care. The sample consisted of 31 patients under controlled normothermia (36°C) and 11 patients treated with 24 hours of MTH (33°C). Erythrocyte glutathione (GSH) levels were elevated by MTH, increasing at 6, 12, 36, and 72 hours after CA in hypothermic patients (mean GSH levels in normothermic patients: 6 hours = 73.89, 12 hours = 56.45, 36 hours = 56.46, 72 hours = 61.80 vs. hypothermic patients: 6 hours = 176.89, 12 hours = 198.78, 36 hours = 186.96, and 72 hours = 173.68 µmol/g of protein). Vitamin C levels decreased significantly at 6 and 12 hours after CA in hypothermic patients (median vitamin C levels in normothermic patients: 6 hours = 7.53, 12 hours = 9.40, 36 hours = 8.56, and 72 hours = 8.51 vs. hypothermic patients: 6 hours = 5.46, 12 hours = 5.44, 36 hours = 6.10, and 72 hours = 5.89 mmol/L), coinciding with the period of therapeutic hypothermia. Vitamin E and nitric oxide levels were not altered by hypothermic treatment. These findings suggest that MTH alters nonenzymatic antioxidants differently, decreasing circulating vitamin C levels during treatment; however, MTH elevates GSH levels, possibly protecting tissues from I/R injury after CA.

Use of neuromuscular electrical stimulation to preserve the thickness of abdominal and chest muscles of critically ill patients: A randomized clinical trial.

OBJECTIVE: To evaluate and compare the effects of neuromuscular electrical stimulation combined with conventional physical therapy on muscle thickness in critically ill patients. DESIGN: Double-blind, randomized controlled trial. PATIENTS: Twenty-five patients participated in the study. METHODS: Patients on mechanical ventilation for 24-48 h were randomized to an intervention group (neuromuscular electrical stimulation + conventional physical therapy) or a conventional group (sham neuromuscular electrical stimulation + conventional physical therapy). Primary outcome was thickness of the rectus abdominis and chest muscles, determined on cross-sectional ultrasound images before and after the intervention. RESULTS: Eleven patients were included in the intervention group and 14 in the conventional group. After neuromuscular electrical stimulation, rectus abdominis muscle thickness and chest muscle thickness were preserved in the intervention group, whereas there was a significant reduction in thickness in the conventional group, with a significant difference between groups. There was a significant difference between groups in length of stay in the intensive care unit, with shorter length of stay in the intervention group. CONCLUSION: There was no change in rectus abdominis and chest muscle thickness in the intervention group. A significant decrease was found in these measures in the conventional group.

Therapeutic Hypothermia Reduces Oxidative Damage and Alters Antioxidant Defenses after Cardiac Arrest.

After cardiac arrest, organ damage consequent to ischemia-reperfusion has been attributed to oxidative stress. Mild therapeutic hypothermia has been applied to reduce this damage, and it may reduce oxidative damage as well. This study aimed to compare oxidative damage and antioxidant defenses in patients treated with controlled normothermia versus mild therapeutic hypothermia during postcardiac arrest syndrome. The sample consisted of 31 patients under controlled normothermia (36°C) and 11 patients treated with 24 h mild therapeutic hypothermia (33°C), victims of in- or out-of-hospital cardiac arrest. Parameters were assessed at 6, 12, 36, and 72 h after cardiac arrest in the central venous blood samples. Hypothermic and normothermic patients had similar S100B levels, a biomarker of brain injury. Xanthine oxidase activity is similar between hypothermic and normothermic patients; however, it decreases posthypothermia treatment. Xanthine oxidase activity is positively correlated with lactate and S100B and inversely correlated with pH, calcium, and sodium levels. Hypothermia reduces malondialdehyde and protein carbonyl levels, markers of oxidative damage. Concomitantly, hypothermia increases the activity of erythrocyte antioxidant enzymes superoxide dismutase, glutathione peroxidase, and glutathione S-transferase while decreasing the activity of serum paraoxonase-1. These findings suggest that mild therapeutic hypothermia reduces oxidative damage and alters antioxidant defenses in postcardiac arrest patients.

Leptospirosis as a cause of acute respiratory failure: clinical features and outcome in 35 critical care patients.

Leptospirosis may have important complications, such as acute respiratory failure (ARF) associated or not with other organic dysfunction, with a high mortality rate. We report the characteristics and evolution of severe leptospirosis associated with ARF. During 10 years, 35 consecutive adult patients admitted in two general Intensive Care Units with severe leptospirosis and ARF, were followed up. Clinical characteristics, associated organic dysfunction and mortality were analyzed. Survivors were compared with non-survivors. The most frequent clinical manifestations were dyspnea, fever, myalgia, jaundice, hemoptysis and coughing. All patients presented ARF, needing mechanical ventilation, as well as other organic dysfunctions. The mortality rate was 51%. Non-survivors were older and had a higher incidence of organic dysfunction, mainly renal, cardiovascular and neurological failures, as well as a higher level of acidosis. In conclusion, leptospirosis should be considered as a cause of severe ARF and other associated organic dysfunctions.

Is SAPS 3 better than APACHE II at predicting mortality in critically ill transplant patients?

OBJECTIVES: This study compared the accuracy of the Simplified Acute Physiology Score 3 with that of Acute Physiology and Chronic Health Evaluation II at predicting hospital mortality in patients from a transplant intensive care unit. METHOD: A total of 501 patients were enrolled in the study (152 liver transplants, 271 kidney transplants, 54 lung transplants, 24 kidney-pancreas transplants) between May 2006 and January 2007. The Simplified Acute Physiology Score 3 was calculated using the global equation (customized for South America) and the Acute Physiology and Chronic Health Evaluation II score; the scores were calculated within 24 hours of admission. A receiver-operating characteristic curve was generated, and the area under the receiver-operating characteristic curve was calculated to identify the patients at the greatest risk of death according to Simplified Acute Physiology Score 3 and Acute Physiology and Chronic Health Evaluation II scores. The Hosmer-Lemeshow goodness-of-fit test was used for statistically significant results and indicated a difference in performance over deciles. The standardized mortality ratio was used to estimate the overall model performance. RESULTS: The ability of both scores to predict hospital mortality was poor in the liver and renal transplant groups and average in the lung transplant group (area under the receiver-operating characteristic curve = 0.696 for Simplified Acute Physiology Score 3 and 0.670 for Acute Physiology and Chronic Health Evaluation II). The calibration of both scores was poor, even after customizing the Simplified Acute Physiology Score 3 score for South America. CONCLUSIONS: The low predictive accuracy of the Simplified Acute Physiology Score 3 and Acute Physiology and Chronic Health Evaluation II scores does not warrant the use of these scores in critically ill transplant patients.

Inspiratory muscle training did not accelerate weaning from mechanical ventilation but did improve tidal volume and maximal respiratory pressures: a randomised trial.

QUESTION: Does inspiratory muscle training accelerate weaning from mechanical ventilation? Does it improve respiratory muscle strength, tidal volume, and the rapid shallow breathing index? DESIGN: Randomised trial with concealed allocation and intention-to-treat analysis. PARTICIPANTS: 92 patients receiving pressure support ventilation were included in the study and followed up until extubation, tracheostomy, or death. INTERVENTION: The experimental group received usual care and inspiratory muscle training using a threshold device, with a load of 40% of their maximal inspiratory pressure with a regimen of 5 sets of 10 breaths, twice a day, 7 days a week. The control group received usual care only. OUTCOME MEASURES: The primary outcome was the duration of the weaning period. The secondary outcomes were the changes in respiratory muscle strength, tidal volume, and the rapid shallow breathing index. RESULTS: Although the weaning period was a mean of 8 hours shorter in the experimental group, this difference was not statistically significant (95% CI -16 to 32). Maximal inspiratory and expiratory pressures increased in the experimental group and decreased in the control group, with significant mean differences of 10cmH2O (95% CI 5 to 15) and 8cmH2O (95% CI 2 to 13), respectively. The tidal volume also increased in the experimental group and decreased in the control group (mean difference 72 ml, 95% CI 17 to 128). The rapid shallow breathing index did not differ significantly between the groups. CONCLUSION: Inspiratory muscle training did not shorten the weaning period significantly but it increased respiratory muscle strength and tidal volume.

Is hyperchloremia associated with mortality in critically ill patients? A prospective cohort study.

PURPOSE: The aim of the study was to determine if acid-base variables are associated with hospital mortality. MATERIALS AND METHODS: This prospective cohort study took place in a university-affiliated hospital intensive care unit (ICU). One hundred seventy-five patients admitted to the ICU during the period of February to May 2007 were included in the study. We recorded clinical data and acid-base variables from all patients at ICU admission. A logistic regression model was constructed using Sepsis-related Organ Failure Assessment (SOFA) score, age, and the acid-base variables. RESULTS: Individually, none of the variables appear to be good predictors of hospital mortality. However, using the multivariate stepwise logistic regression, we had a model with good discrimination containing SOFA score, age, chloride, and albumin (area under receiver operating characteristic curve, 0.80; 95% confidence interval, 0.73-0.87). CONCLUSIONS: Hypoalbuminemia and hyperchloremia were associated with mortality. This result involving chloride is something new and should be tested in future studies.

Is SAPS 3 better than APACHE II at predicting mortality in critically ill transplant patients?

OBJECTIVES: This study compared the accuracy of the Simplified Acute Physiology Score 3 with that of Acute Physiology and Chronic Health Evaluation II at predicting hospital mortality in patients from a transplant intensive care unit. METHOD: A total of 501 patients were enrolled in the study (152 liver transplants, 271 kidney transplants, 54 lung transplants, 24 kidney-pancreas transplants) between May 2006 and January 2007. The Simplified Acute Physiology Score 3 was calculated using the global equation (customized for South America) and the Acute Physiology and Chronic Health Evaluation II score; the scores were calculated within 24 hours of admission. A receiver-operating characteristic curve was generated, and the area under the receiver-operating characteristic curve was calculated to identify the patients at the greatest risk of death according to Simplified Acute Physiology Score 3 and Acute Physiology and Chronic Health Evaluation II scores. The Hosmer-Lemeshow goodness-of-fit test was used for statistically significant results and indicated a difference in performance over deciles. The standardized mortality ratio was used to estimate the overall model performance. RESULTS: The ability of both scores to predict hospital mortality was poor in the liver and renal transplant groups and average in the lung transplant group (area under the receiver-operating characteristic curve = 0.696 for Simplified Acute Physiology Score 3 and 0.670 for Acute Physiology and Chronic Health Evaluation II). The calibration of both scores was poor, even after customizing the Simplified Acute Physiology Score 3 score for South America. CONCLUSIONS: The low predictive accuracy of the Simplified Acute Physiology Score 3 and Acute Physiology and Chronic Health Evaluation II scores does not warrant the use of these scores in critically ill transplant patients.

Low spatial resolution computed tomography underestimates lung overinflation resulting from positive pressure ventilation.

OBJECTIVE: In acute lung injury, lung overinflation resulting from mechanical ventilation with positive end-expiratory pressure (PEEP) can be assessed using lung computed tomography. The goal of this study was to compare lung overinflation measured on low and high spatial resolution computed tomography sections. DESIGN: Lung overinflation was measured on thick (10-mm) and thin (1.5-mm) computed tomography sections obtained at zero end-expiratory pressure (ZEEP) and PEEP 10 cm H2O using a software including a color-coding system. SETTING: A 20-bed surgical intensive care unit of a university hospital. PATIENTS: Thirty mechanically ventilated patients with acute lung injury. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Overinflated lung volume was measured as the end-expiratory volume of lung regions with computed tomography attenuations <-900 Hounsfield units. Lung overinflation, expressed in percentage of the total lung volume, was significantly underestimated by thick computed tomography sections compared with thin computed tomography sections (0.4 +/- 1.6% vs. 3.0 +/- 4.0% in ZEEP and 1.9 +/- 4% vs. 6.8 +/- 7.3% in PEEP, p < .01). In patients with a diffuse loss of aeration, the overinflated lung volumes of thick and thin computed tomography sections were, respectively, 0.6 +/- 0.8 mL vs. 16 +/- 10 mL in ZEEP (p < .01) and 8 +/- 9 mL vs. 73 +/- 62 mL in PEEP (p < .05). In patients with a focal loss of aeration, this underestimation was more pronounced: 18 +/- 56 mL vs. 127 +/- 140 mL in ZEEP (p < .01) and 85 +/- 161 mL vs. 322 +/- 292 mL in PEEP (p < .01). CONCLUSIONS: In patients with acute lung injury, an accurate computed tomography estimation of lung overinflation resulting from positive pressure mechanical ventilation requires high spatial resolution computed tomography sections, particularly when the lung morphology shows a focal loss of aeration.

Leptospirosis as a cause of acute respiratory failure: clinical features and outcome in 35 critical care patients

Leptospirosis may have important complications, such as acute respiratory failure (ARF) associated or not with other organic dysfunction, with a high mortality rate. We report the characteristics and evolution of severe leptospirosis associated with ARF. During 10 years, 35 consecutive adult patients admitted in two general Intensive Care Units with severe leptospirosis and ARF, were followed up. Clinical characteristics, associated organic dysfunction and mortality were analyzed. Survivors were compared with non-survivors. The most frequent clinical manifestations were dyspnea, fever, myalgia, jaundice, hemoptysis and coughing. All patients presented ARF, needing mechanical ventilation, as well as other organic dysfunctions. The mortality rate was 51. Non-survivors were older and had a higher incidence of organic dysfunction, mainly renal, cardiovascular and neurological failures, as well as a higher level of acidosis. In conclusion, leptospirosis should be considered as a cause of severe ARF and other associated organic dysfunctions.

Múltipla recorrência de mixomas cardíacos com embolia pulmonar aguda / Multiple recurrences of cardiac myxomas with acute tumoral pulmonary embolism

We report the case of a 42-year-old female with a second recurrence of cardiac myxoma. Her first diagnosis was at the age of 24 years, when cardiac tumors were withdrawn from her right ventricle and left atrium. Her first recurrence was at the age of 36 years, when tumors were removed from the left and right atria, and the right ventricle. Six years later, the patient was admitted to the Hospital das Clínicas de Porto Alegre complaining of sudden dyspnea, dry cough, and pain in the right hypochondrium, which bore no relation to breathing. The transesophageal echocardiography showed a small tumor in the interatrial septum, close to the superior vena cava, and 2 larger tumors in the right ventricle, 1 close to the outflow tract and the other almost completely obstructing the right branch of the pulmonary artery. The patient was referred to surgery, in which myxomas were removed from the right atrium and ventricle with extension to the right pulmonary artery. The postoperative period was uneventful