Use of bedside echocardiography in the care of critically ill patients - a joint consensus document of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Medicina de Emergência, and Sociedade Brasileira de Medicina Hospitalar. Part 1 - Competence in bedside echocardiography.

The use of echocardiography by physicians who are not echocardiographers has become common throughout the world across highly diverse settings where the care of acutely ill patients is provided. Echocardiographic evaluation performed in a point-of-care manner can provide relevant information regarding the mechanism of causes of shock, for example, increasing the rates of correct diagnosis and allowing for faster informed decision-making than through evaluation methods. Considering that the accurate diagnosis of life-threatening situations is essential for professionals working with acutely ill patients, several international associations recommend that physicians responsible for critically ill patients acquire and develop the ability to perform bedside ultrasound examinations, including echocardiographic examinations. However, there is no consensus in the literature regarding which specific applications should be included in the list of skills for nonechocardiographer physicians. Taking into account the multiplicity of applications of echocardiography in different scenarios related to acutely ill patients; the differences in the published protocols, with regard to both the teaching methodology and competence verification; and the heterogeneity of training among highly diverse specialties responsible for their care at different levels, this consensus document aimed to reflect the position of representatives of related Brazilian medical societies on the subject and may thus serve as a starting point both for standardization among different specialties and for the transmission of knowledge and verification of the corresponding competencies.

The use of bedside echocardiography in the care of critically ill patients - a joint consensus document of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Medicina de Emergência and Sociedade Brasileira de Medicina Hospitalar. Part 2 - Technical aspects.

Echocardiography in critically ill patients has become essential in the evaluation of patients in different settings, such as the hospital. However, unlike for other matters related to the care of these patients, there are still no recommendations from national medical societies on the subject. The objective of this document was to organize and make available expert consensus opinions that may help to better incorporate echocardiography in the evaluation of critically ill patients. Thus, the Associação de Medicina Intensiva Brasileira, the Associação Brasileira de Medicina de Emergência, and the Sociedade Brasileira de Medicina Hospitalar formed a group of 17 physicians to formulate questions relevant to the topic and discuss the possibility of consensus for each of them. All questions were prepared using a five-point Likert scale. Consensus was defined a priori as at least 80% of the responses between one and two or between four and five. The consideration of the issues involved two rounds of voting and debate among all participants. The 27 questions prepared make up the present document and are divided into 4 major assessment areas: left ventricular function, right ventricular function, diagnosis of shock, and hemodynamics. At the end of the process, there were 17 positive (agreement) and 3 negative (disagreement) consensuses; another 7 questions remained without consensus. Although areas of uncertainty persist, this document brings together consensus opinions on several issues related to echocardiography in critically ill patients and may enhance its development in the national scenario.

Use of bedside echocardiography in the care of critically ill patients - a joint consensus document of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Medicina de Emergência, and Sociedade Brasileira de Medicina Hospitalar. Part 1 - Competence in bedside echocardiography / Uso da ecocardiografia à beira do leito no cuidado do paciente grave - um documento conjunto de consenso da Associação de Medicina Intensiva Brasileira, Associação Brasileira de Medicina de Emergência e Sociedade Brasileira de Medicina Hospitalar. Parte 1 - Competência em ecocardiografia à beira do leito

ABSTRACT The use of echocardiography by physicians who are not echocardiographers has become common throughout the world across highly diverse settings where the care of acutely ill patients is provided. Echocardiographic evaluation performed in a point-of-care manner can provide relevant information regarding the mechanism of causes of shock, for example, increasing the rates of correct diagnosis and allowing for faster informed decision-making than through evaluation methods. Considering that the accurate diagnosis of life-threatening situations is essential for professionals working with acutely ill patients, several international associations recommend that physicians responsible for critically ill patients acquire and develop the ability to perform bedside ultrasound examinations, including echocardiographic examinations. However, there is no consensus in the literature regarding which specific applications should be included in the list of skills for nonechocardiographer physicians. Taking into account the multiplicity of applications of echocardiography in different scenarios related to acutely ill patients; the differences in the published protocols, with regard to both the teaching methodology and competence verification; and the heterogeneity of training among highly diverse specialties responsible for their care at different levels, this consensus document aimed to reflect the position of representatives of related Brazilian medical societies on the subject and may thus serve as a starting point both for standardization among different specialties and for the transmission of knowledge and verification of the corresponding competencies.

RESUMO O emprego da ecocardiografia por médicos não ecocardiografistas tem se tornado comum em todo o mundo nos mais diversos ambientes em que se dá o cuidado do paciente agudamente doente. A avaliação ecocardiográfica realizada de forma point-of-care pode fornecer informações pertinentes em relação ao mecanismo das causas de choque, por exemplo, incrementando as taxas de diagnóstico correto e possibilitando a tomada de decisão fundamentada de forma mais rápida do que por meio dos métodos tradicionais de avaliação. Considerando que o diagnóstico preciso de situações ameaçadoras à vida é indispensável a profissionais atuando junto a pacientes agudamente enfermos, diversas entidades associativas internacionais recomendam que médicos responsáveis por pacientes gravemente doentes devam adquirir e desenvolver a habilidade para realizar exames ultrassonográficos à beira do leito, inclusive ecocardiográficos. Entretanto, não há consenso na literatura acerca de quais aplicações específicas devam compor o rol de habilidades do médico não ecocardiografista. Levando-se em consideração a multiplicidade de aplicações da ecocardiografia em diversos cenários relativos ao paciente agudamente enfermo; as diferenças nos protocolos publicados, tanto no que diz respeito à metodologia de ensino como de verificação de competências, bem como a heterogeneidade da formação entre as mais diversas especialidades responsáveis pelo seu cuidado em diferentes níveis, este documento de consenso teve o objetivo de refletir o posicionamento de representantes de sociedades médicas brasileiras afins acerca do tema, podendo, assim, servir de ponto de partida para a uniformização entre diferentes especialidades, bem como para a transmissão de conhecimento e a verificação das competências correspondentes.

The use of bedside echocardiography in the care of critically ill patients - a joint consensus document of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Medicina de Emergência and Sociedade Brasileira de Medicina Hospitalar. Part 2 - Technical aspects / O uso da ecocardiografia à beira do leito no cuidado do paciente grave - um documento conjunto de consenso da Associação de Medicina Intensiva Brasileira, Associação Brasileira de Medicina de Emergência e Sociedade Brasileira de Medicina Hospitalar. Parte 2 - Aspectos técnicos

ABSTRACT Echocardiography in critically ill patients has become essential in the evaluation of patients in different settings, such as the hospital. However, unlike for other matters related to the care of these patients, there are still no recommendations from national medical societies on the subject. The objective of this document was to organize and make available expert consensus opinions that may help to better incorporate echocardiography in the evaluation of critically ill patients. Thus, the Associação de Medicina Intensiva Brasileira, the Associação Brasileira de Medicina de Emergência, and the Sociedade Brasileira de Medicina Hospitalar formed a group of 17 physicians to formulate questions relevant to the topic and discuss the possibility of consensus for each of them. All questions were prepared using a five-point Likert scale. Consensus was defined a priori as at least 80% of the responses between one and two or between four and five. The consideration of the issues involved two rounds of voting and debate among all participants. The 27 questions prepared make up the present document and are divided into 4 major assessment areas: left ventricular function, right ventricular function, diagnosis of shock, and hemodynamics. At the end of the process, there were 17 positive (agreement) and 3 negative (disagreement) consensuses; another 7 questions remained without consensus. Although areas of uncertainty persist, this document brings together consensus opinions on several issues related to echocardiography in critically ill patients and may enhance its development in the national scenario.

RESUMO A ecocardiografia do paciente grave tem se tornado fundamental na avaliação de pacientes em diferentes cenários e ambientes hospitalares. Entretanto, ao contrário de outras áreas relativas ao cuidado com esses pacientes, ainda não existem recomendações de sociedades médicas nacionais acerca do assunto. O objetivo deste documento foi organizar e disponibilizar opiniões de consenso de especialistas que possam auxiliar a melhor incorporação dessa técnica na avaliação de pacientes graves. Dessa forma, a Associação de Medicina Intensiva Brasileira, a Associação Brasileira de Medicina de Emergência e a Sociedade Brasileira de Medicina Hospitalar compuseram um grupo de 17 médicos para formular questões pertinentes ao tópico e debater a possibilidade de consenso de especialistas para cada uma delas. Todas as questões foram elaboradas no formato de escala Likert de cinco pontos. Consenso foi definido, a priori, como um somatório de, ao menos, 80% das respostas entre um e dois ou entre quatro e cinco. A apreciação das questões envolveu dois ciclos de votação e debate entre todos os participantes. As 27 questões elaboradas compõem o presente documento e estão divididas em 4 grandes áreas de avaliação: da função ventricular esquerda; da função ventricular direita; diagnóstica dos choques e hemodinâmica. Ao fim do processo, houve 17 consensos positivos (concordância) e 3 negativos (discordância); outras 7 questões persistiram sem consenso. Embora persistam áreas de incerteza, este documento reúne opiniões de consenso para diversas questões relativas à ecocardiografia do paciente grave e pode potencializar seu desenvolvimento no cenário nacional.

Systemic Severity and Organ Dysfunction in Subarachnoid Hemorrhage: A Large Retrospective Multicenter Cohort Study.

BACKGROUND AND PURPOSE: Acute physiologic derangements and multiple organ dysfunction are common after subarachnoid hemorrhage. We aimed to evaluate the simplified acute physiology score 3 (SAPS-3) and the sequential organ failure assessment (SOFA) scores for the prediction of in-hospital mortality in a large multicenter cohort of SAH patients. METHODS: This was a retrospective analysis of prospectively collected data from 45 ICUs in Brazil, during 2014 and 2015. Patients admitted with non-traumatic subarachnoid hemorrhage (SAH) were included. Clinical and outcome data were retrieved from an electronic ICU quality registry. SAPS-3 and SOFA scores, without the neurological components (i.e., nSAPS-3 and nSOFA, respectively) were recorded, as well as the World Federation of Neurological Surgeons (WFNS) scale. We used multilevel logistic regression analysis to identify factors associated with in-hospital mortality. We evaluated performance using the area under the receiver operating characteristic curve (AUROC), as well as calibration belts and precision-recall plots. RESULTS: The study included 997 patients, from which 426 (43%) had poor clinical grade (WFNS 4 or 5) and in-hospital mortality was 34%. Median nSAPS-3 and nSOFA score at admission were 46 (IQR: 38-55) and 2 (0-5), respectively. Non-survivors were older, had higher nSAPS-3 and nSOFA, and more often poor grade. After adjustment for age, poor grade and withdrawal of life sustaining therapies, multivariable analysis identified nSAPS-3 and nSOFA score as independent clinical predictors of in-hospital mortality. The AUROC curve that included nSAPS-3 and nSOFA scores significantly improved the already good discrimination and calibration of age and WFNS to predict in-hospital mortality (AUROC: 0.89 for the full final model vs. 0.85 for age and WFNS; P < 0.0001). CONCLUSIONS: nSAPS-3 and nSOFA scores were independently associated with in-hospital mortality after SAH. The addition of these scores improved early prediction of hospital mortality in our cohort and should be integrated to other specific prognostic indices in the early assessment of SAH.

The use of distributed random forest model to quantify risk predictors for tracheostomy requirements in septic patients: A retrospective cohort study.

The search for early clinical risk factors in the intensive care setting may improve the outcome of critically ill patients. The objective of this retrospective study is to identify and quantify early predictors for patients who would require tracheostomy. Five hundred and forty four septic patients were divided in 2 groups: non-tracheostomized (NT) (n = 484) and tracheostomized (T) (n = 60). The patients consisted of 241 males (49.8%) in NT and 27 (45%) in T group, respectively (P = .4971). The median and interquartile range difference of age of NT group was of 72 years [59-82] and T of 75 [55.0-83.5] (P = .4687). The SAPS 3 for the group NTxT was 70 [55-85] and 85.5 [77-91] (P = .0001), the SOFA of 9 [6-13] and 12 [10-14] (P = .0002). The comparison of logistic regression analysis for predictors of non-tracheostomy and tracheostomy groups showed an adjusted odds ratio (OR) for SAPS 3 range between 74 and 87 of 18.14 (95%CI = 3.36-97.84) and between 88 and 116 of 27.77 (95%CI = 4.43-174.24) (P < .05). For SOFA, the adjusted OR between 10 and 13 was 12.23 (95%CI = 2.46-60.81) and between 14 and 20 was 8.45 (95%CI = 1.58-45.29) (P < .05). The need for blood transfusions and dialysis presented an OR of 2.74 (95%CI = 1.23-6.08) and 3.33 (95%CI = 1.43-7.73) (P < .05), respectively. Our data shows that SAPS 3 ≥ 74, SOFA ≥ 11, blood transfusions and the need for dialysis were independently associated and could be considered major predictors for tracheostomy requirements in septic patients.

ICU staffing feature phenotypes and their relationship with patients' outcomes: an unsupervised machine learning analysis.

PURPOSE: To study whether ICU staffing features are associated with improved hospital mortality, ICU length of stay (LOS) and duration of mechanical ventilation (MV) using cluster analysis directed by machine learning. METHODS: The following variables were included in the analysis: average bed to nurse, physiotherapist and physician ratios, presence of 24/7 board-certified intensivists and dedicated pharmacists in the ICU, and nurse and physiotherapist autonomy scores. Clusters were defined using the partition around medoids method. We assessed the association between clusters and hospital mortality using logistic regression and with ICU LOS and MV duration using competing risk regression. RESULTS: Analysis included data from 129,680 patients admitted to 93 ICUs (2014-2015). Three clusters were identified. The features distinguishing between the clusters were: the presence of board-certified intensivists in the ICU 24/7 (present in Cluster 3), dedicated pharmacists (present in Clusters 2 and 3) and the extent of nurse autonomy (which increased from Clusters 1 to 3). The patients in Cluster 3 exhibited the best outcomes, with lower adjusted hospital mortality [odds ratio 0.92 (95% confidence interval (CI), 0.87-0.98)], shorter ICU LOS [subhazard ratio (SHR) for patients surviving to ICU discharge 1.24 (95% CI 1.22-1.26)] and shorter durations of MV [SHR for undergoing extubation 1.61(95% CI 1.54-1.69)]. Cluster 1 had the worst outcomes. CONCLUSION: Patients treated in ICUs combining 24/7 expert intensivist coverage, a dedicated pharmacist and nurses with greater autonomy had the best outcomes. All of these features represent achievable targets that should be considered by policy makers with an interest in promoting equal and optimal ICU care.

The use of APACHE II, SOFA, SAPS 3, C-reactive protein/albumin ratio, and lactate to predict mortality of surgical critically ill patients: A retrospective cohort study.

Several prognostic indices have been employed to predict the outcome of surgical critically ill patients. Among them, acute physiology and chronic health evaluation (APACHE) II, sequential organ failure assessment (SOFA) and simplified acute physiology score (SAPS 3) are widely used. It seems that biological markers such as C-reactive protein (CRP), albumin, and blood lactate levels correlate with the degree of inflammation during the immediate postoperative phase and could be used as independent predictors. The objective of this study is to compare the different predictive values of prognostic indices and biological markers in the outcome of 847 surgical patients admitted to the intensive care unit (ICU) in the postoperative phase.The patients were divided into survivors (n = 765, 57.4% males, age 61, interquartile range 51-71) and nonsurvivors (n = 82, 57.3% males, age 70, interquartile range 58-79). APACHE II, APACHE II death probability (DP), SOFA, SAPS 3, SAPS 3 DP, CRP, albumin, and lactate were recorded on ICU admission (first 24 hours). The area under the ROC curve (AUROC) and 95% confidence interval (95% CI) were used to measure the index accuracy to predict mortality.The AUROC and 95% CI for APACHE II, APACHE II DP, SOFA, SAPS 3, SAPS 3 DP, CRP/albumin ratio, CRP, albumin, and lactate were 0.850 (0.824-0.873), 0.855 (0.829-0.878), 0.791 (0.762-0.818), 0.840 (0.813-0.864), 0.840 (0.813-0.864), 0.731 (0.700-0.761), 0.708 (0.676-0.739), 0.697 (0.665-0.728), and 0.601 (0.567-0.634), respectively. The ICU and overall in-hospital mortality were 6.6 and 9.7%, respectively. The APACHE II, APACHE II DP, SAPS 3, SAPS 3 DP, and SOFA scores showed a better performance than CRP/albumin ratio, CRP, albumin, or lactate to predict in-hospital mortality of surgical critically ill patients.Even though all indices were able to discriminate septic from nonseptic patients, only APACHE II, APACHE II DP, SOFA and to a lesser extent SAPS 3, SAPS 3 DP, and blood lactate levels could predict in the first 24-hour ICU admission surgical patients who have survived sepsis.

Association of frailty with short-term outcomes, organ support and resource use in critically ill patients.

PURPOSE: Frail patients are known to experience poor outcomes. Nevertheless, we know less about how frailty manifests itself in patients' physiology during critical illness and how it affects resource use in intensive care units (ICU). We aimed to assess the association of frailty with short-term outcomes and organ support used by critically ill patients. METHODS: Retrospective analysis of prospective collected data from 93 ICUs in Brazil from 2014 to 2015. We assessed frailty using the modified frailty index (MFI). The primary outcome was in-hospital mortality. Secondary outcomes were discharge home without need for nursing care, ICU and hospital length of stay (LOS), and utilization of ICU organ support and transfusion. We used mixed logistic regression and competing risk models accounting for relevant confounders in outcome analyses. RESULTS: The analysis consisted of 129,680 eligible patients. There were 40,779 (31.4%) non-frail (MFI = 0), 64,407 (49.7%) pre-frail (MFI = 1-2) and 24,494 (18.9%) frail (MFI ≥ 3) patients. After adjusted analysis, frailty was associated with higher in-hospital mortality (OR 2.42, 95% CI 1.89-3.08), particularly in patients admitted with lower SOFA scores. Frail patients were less likely to be discharged home (OR 0.36, 95% CI 0.54-0.79) and had higher hospital and ICU LOS than non-frail patients. Use of all forms of organ support (mechanical ventilation, non-invasive ventilation, vasopressors, dialysis and transfusions) were more common in frail patients and increased as MFI increased. CONCLUSIONS: Frailty, as assessed by MFI, was associated with several patient-centered endpoints including not only survival, but also ICU LOS and organ support.

Role of organisational factors on the 'weekend effect' in critically ill patients in Brazil: a retrospective cohort analysis.

INTRODUCTION: Higher mortality for patients admitted to intensive care units (ICUs) during the weekends has been occasionally reported with conflicting results that could be related to organisational factors. We investigated the effects of ICU organisational and staffing patterns on the potential association between weekend admission and outcomes in critically ill patients. METHODS: We included 59 614 patients admitted to 78 ICUs participating during 2013. We defined 'weekend admission' as any ICU admission from Friday 19:00 until Monday 07:00. We assessed the association between weekend admission with hospital mortality using a mixed logistic regression model controlling for both patient-level (illness severity, age, comorbidities, performance status and admission type) and ICU-level (decrease in nurse/bed ratio on weekend, full-time intensivist coverage, use of checklists on weekends and number of institutional protocols) confounders. We performed secondary analyses in the subgroup of scheduled surgical admissions. RESULTS: A total of 41 894 patients (70.3%) were admitted on weekdays and 17 720 patients (29.7%) on weekends. In univariable analysis, weekend admitted patients had higher ICU (10.9% vs 9.0%, P<0.001) and hospital (16.5% vs 13.5%, P<0.001) mortality. After adjusting for confounders, weekend admission was not associated with higher hospital mortality (OR 1.05, 95% CI 0.99 to 1.12, P=0.095). However, a 'weekend effect' was still observed in scheduled surgical admissions, as well as in ICUs not using checklists during the weekends. For unscheduled admissions, no 'weekend effect' was observed regardless of ICU's characteristics. For scheduled surgical admissions, a 'weekend effect' was present only in ICUs with a low number of implemented protocols and those with a reduction in the nurse/bed ratio and not applying checklists during weekends. CONCLUSIONS: ICU organisational factors, such as decreased nurse-to-patient ratio, absence of checklists and fewer standardised protocols, may explain, in part, increases in mortality in patients admitted to the ICU mortality on weekends.

Thrombosed aneurysm of saphenous vein coronary artery bypass grafting.

We describe the case of a male patient, aged 76 years, referred for cardiac investigation due to retrosternal chest pain and dyspnea. He had a history of acute myocardial infarction and angioplasties in the last 30 years, including a saphenous vein coronary artery bypass grafting (SVCABG). Echocardiogram showed hypoechoic oval formation near the right ventricle, suggesting a pericardial cyst. Computed angiotomography revealed a predominantly fusiform and thrombosed aneurysmal dilation of the SVCABG to the right coronary artery. SVCABG aneurysms are very rare and potentially fatal. They usually appear in the late postoperative period, and patients are often asymptomatic. On radiography, it is frequently presented as enlargement of the mediastinum, with echocardiography, computed tomography and magnetic resonance imaging being very useful for diagnosis. Coronary angiography is the gold standard to detect these cases. Our report illustrates a rare situation arising late from a relatively common surgery. Due to its severity, proper recognition in the routine assessment of patients with a similar history is essential.

Thrombosed aneurysm of saphenous vein coronary artery bypass grafting / Aneurisma trombosado de bypass aortocoronariano de veia safena

Summary We describe the case of a male patient, aged 76 years, referred for cardiac investigation due to retrosternal chest pain and dyspnea. He had a history of acute myocardial infarction and angioplasties in the last 30 years, including a saphenous vein coronary artery bypass grafting (SVCABG). Echocardiogram showed hypoechoic oval formation near the right ventricle, suggesting a pericardial cyst. Computed angiotomography revealed a predominantly fusiform and thrombosed aneurysmal dilation of the SVCABG to the right coronary artery. SVCABG aneurysms are very rare and potentially fatal. They usually appear in the late postoperative period, and patients are often asymptomatic. On radiography, it is frequently presented as enlargement of the mediastinum, with echocardiography, computed tomography and magnetic resonance imaging being very useful for diagnosis. Coronary angiography is the gold standard to detect these cases. Our report illustrates a rare situation arising late from a relatively common surgery. Due to its severity, proper recognition in the routine assessment of patients with a similar history is essential.

Resumo Descrevemos o caso de paciente do sexo masculino, 76 anos, em avaliação cardiológica em razão de dor torácica retroesternal e dispneia. Antecedente de infartos agudos do miocárdio e angioplastias nos últimos 30 anos, incluindo um bypass aortocoronário de veia safena (BACVS) ou "ponte de safena". Em ecocardiograma, observou-se formação ovalada alongada hipoecoica junto ao ventrículo direito, podendo sugerir um cisto pericárdico. Angiotomografia computadorizada do tórax evidenciou uma dilatação aneurismática predominantemente fusiforme e trombosada de "ponte de safena" para artéria coronária direita. Aneurismas de BACVS são raríssimos e potencialmente fatais. Geralmente, surgem em um período tardio pós-cirúrgico, sendo seus portadores muitas vezes assintomáticos. Na radiografia, frequentemente se apresentam como alargamento do mediastino, sendo a ecocardiografia, a tomografia computadorizada e a ressonância magnética muito úteis no diagnóstico. A angiografia coronariana é o padrão-ouro na detecção. Este relato ilustra uma situação rara decorrente tardiamente de uma cirurgia relativamente comum, e por causa de sua gravidade torna-se essencial o seu reconhecimento na rotina de avaliação de pacientes com antecedentes semelhantes.

Effects of Organizational Characteristics on Outcomes and Resource Use in Patients With Cancer Admitted to Intensive Care Units.

PURPOSE: To investigate the impact of organizational characteristics and processes of care on hospital mortality and resource use in patients with cancer admitted to intensive care units (ICUs). PATIENTS AND METHODS: We performed a retrospective cohort study of 9,946 patients with cancer (solid, n = 8,956; hematologic, n = 990) admitted to 70 ICUs (51 located in general hospitals and 19 in cancer centers) during 2013. We retrieved patients' clinical and outcome data from an electronic ICU quality registry. We surveyed ICUs regarding structure, organization, staffing patterns, and processes of care. We used mixed multivariable logistic regression analysis to identify characteristics associated with hospital mortality and efficient resource use in the ICU. RESULTS: Median number of patients with cancer per center was 110 (interquartile range, 58 to 154), corresponding to 17.9% of all ICU admissions. ICU and hospital mortality rates were 15.9% and 25.4%, respectively. After adjusting for relevant patient characteristics, presence of clinical pharmacists in the ICU (odds ratio [OR], 0.67; 95% CI, 0.49 to 0.90), number of protocols (OR, 0.92; 95% CI, 0.87 to 0.98), and daily meetings between oncologists and intensivists for care planning (OR, 0.69; 95% CI, 0.52 to 0.91) were associated with lower mortality. Implementation of protocols (OR, 1.52; 95% CI, 1.11 to 2.07) and meetings between oncologists and intensivists (OR, 4.70; 95% CI, 1.15 to 19.22) were also independently associated with more efficient resource use. Neither admission to ICUs in cancer centers compared with general hospitals nor annual case volume had an impact on mortality or resource use. CONCLUSION: Organizational aspects, namely the implementation of protocols and presence of clinical pharmacists in the ICU, and close collaboration between oncologists and ICU teams are targets to improve mortality and resource use in critically ill patients with cancer.

Utilização de sistema fechado para coleta de sangue e necessidade de transfusão em pacientes graves / Closed system for blood sampling and transfusion in critically ill patients

OBJETIVO: A anemia é desordem comum em pacientes graves e as coletas de sangue ocupam papel de destaque como causa. Consequentemente, a transfusão de sangue é freqüente e está relacionada a várias complicações. Na tentativa de reduzir o risco associado à transfusão é necessário minimizar as perdas sanguíneas e para tal, este estudo avaliou o sistema fechado para coleta de sangue como estratégia para diminuir perdas desnecessárias e transfusão sanguínea. MÉTODOS: Estudo clínico prospectivo, randomizado, controlado, multicêntrico, durante 6 meses. Os pacientes foram alocados em dois grupos, grupo VAMP (Venous Arterial Blood Management Protection) que utilizou sistema fechado para coleta de sangue e o grupo controle que não utilizou. O percentual de pacientes transfundidos, assim como a variação da hemoglobina (Hb) e hematócrito (Ht), foram comparados entre os grupos na ao longo de 14 dias. RESULTADOS: Foram incluídos 127 pacientes, sendo 65 controles e 62 VAMP. Durante a internação na unidade de terapia intensiva, ambos os grupos apresentaram queda nos valores de hemoglobina e hematócrito. Entretanto, quando comparados o Ht final e Hb final entre os grupos houve diferença, com maiores valores no grupo VAMP (p=0,03; p=0,006). Não houve diferença estatística entre a proporção de pacientes transfundidos nos dois grupos, embora o grupo VAMP tenha apresentado redução absoluta de 12 por cento na transfusão sanguínea. CONCLUSÃO: A utilização de sistema fechado para coleta de sangue conseguiu minimizar a queda nos valores hematimétricos sem, contudo, reduzir o número de transfusões.

OBJECTIVE: Anemia is common in severely ill patients, and blood sampling plays a relevant causative role. Consequently, blood transfusions are frequent an related to several complications. Trying to reduce the transfusion-related risk, minimizing blood loss is mandatory. Thus, this work aimed to evaluate a closed blood sampling system as a strategy to spare unnecessary blood losses and transfusions. METHODS: This was a prospective, randomized, controlled, multicenter, 6 months, clinical trial. The patients were assigned to either VAMP (Venous Arterial Blood Management Protection) group, using a closed blood sampling system, or control group. The groups' transfusion rate, as well as hemoglobin (Hb) and Hematocrit (Ht) changes were compared for 14 days. RESULTS: Were included 127 patients, 65 assigned to the control group, and 62 to VAMP. During the intensive care unit stay, both groups experienced both hemoglobin and hematocrit drops. However, when the final Ht and Hb were compared between the groups, a difference was identified with higher values in the VAMP group (p=0.03; p=0.006, respectively). No statistical difference was found for both groups transfusion rates, although the VAMP group had an absolute 12 percent blood transfusion reduction. CONCLUSION: The use of a closed blood sampling system was able to minimize blood count values changes, however failed to reduce transfusions rate.

Closed system for blood sampling and transfusion in critically ill patients. / Utilização de sistema fechado para coleta de sangue e necessidade de transfusão em pacientes graves.

OBJECTIVE: Anemia is common in severely ill patients, and blood sampling plays a relevant causative role. Consequently, blood transfusions are frequent an related to several complications. Trying to reduce the transfusion-related risk, minimizing blood loss is mandatory. Thus, this work aimed to evaluate a closed blood sampling system as a strategy to spare unnecessary blood losses and transfusions. METHODS: This was a prospective, randomized, controlled, multicenter, 6 months, clinical trial. The patients were assigned to either VAMP (Venous Arterial Blood Management Protection) group, using a closed blood sampling system, or control group. The groups' transfusion rate, as well as hemoglobin (Hb) and Hematocrit (Ht) changes were compared for 14 days. RESULTS: Were included 127 patients, 65 assigned to the control group, and 62 to VAMP. During the intensive care unit stay, both groups experienced both hemoglobin and hematocrit drops. However, when the final Ht and Hb were compared between the groups, a difference was identified with higher values in the VAMP group (p=0.03; p=0.006, respectively). No statistical difference was found for both groups transfusion rates, although the VAMP group had an absolute 12% blood transfusion reduction. CONCLUSION: The use of a closed blood sampling system was able to minimize blood count values changes, however failed to reduce transfusions rate.

Auditory brainstem response: prognostic value in patients with a score of 3 on the Glasgow Coma Scale.

OBJECTIVE: To evaluate the prognostic value of auditory brainstem response (ABR) recorded in comatose patients presenting a score of 3 on the Glasgow Coma Scale (GCS = 3). PATIENTS: One hundred thirty-eight patients in coma at GCS = 3 due to various etiologic agents. INTERVENTION: To record and analyze tracings of ABR. MAIN OUTCOME MEASURE: Tracings from ABR were classified into four types (B1, B2, B3, and B4) on the basis of synchrony of waves. RESULTS: The Fischer's exact test used for comparison between death proportions revealed that B1 is different from B2, B3, or B4 and the association B2 + B3 + B4. CONCLUSION: Auditory brainstem response is a useful tool with prognostic value for patients in coma with GCS = 3. It was demonstrated in our series that once the patient presented an abnormal ABR (B2, B3, or B4), he had a greater probability of dying than a patient with a normal ABR (B1).

O BERA como instrumento de avaliação funcional do tronco cerebral em cirurgias com hipotermia profunda e parada circulatória total / The ABR as a tool in the evaluation of brainstem function in surgeries with deep hypothermia and total cardiac arrest

OBJETIVO: Monitoramento do tronco cerebral através da análise dos traçados do BERA em cirurgia cardíaca com hipotermia profunda e parada circulatória total (PCT), registrando a recuperaçäo funcional (eletrofisiológica) do tronco cerebral. FORMA DE ESTUDO: Coorte Longitudinal. MATERIAL E MÉTODO: Foram estudados o comportamento do traçado do BERA de 8 pacientes submetidos a cirurgia cardíaca com hipotermia profunda e PCT para correçäo de aneurisma de aorta torácica. Etapas: resfriamento corporal até 18ºC C; PCT por até 60 minutos; reaquecimento. Registros do BERA: 35ºC, 32ºC, 26ºC, 18ºC, 27ºC, 35ºC. RESULTADOS: Os traçados iniciais (35ºC) se apresentavam normais. Aos 26ºC há o desaparecimento de todas as ondas. Aos 18ºC o traçado do BERA mostrava um padräo isoelétrico. Aos 27ºC, recuperaçäo das ondas I, III e V. A partir de 35ºC as latências das ondas retornam ao normal. CONCLUSÄO: O BERA constitui-se em competente instrumento de monitoramento da integridade funcional do tronco cerebral em cirurgia cardíaca com hipotermia profunda e PCT. As ondas desaparecem no período de resfriamento corporal, atingem um padräo isoelétrico a 18ºC, e reaparecem durante o reaquecimento. No final do procedimento, os médicos anestesistas näo dispöem de exame clínico fidedigno para acessar a integridade funcional do tronco cerebral, devido ao uso de drogas depressoras do SNC. O reaparecimento das ondas do BERA é o parâmetro proposto para este fim. A manutençäo do padräo isoelétrico após o reaquecimento corporal sugere grave comprometimento funcional do tronco cerebral

Distúrbios do equilíbrio hidroeletrolítico e do equilíbrio acidobásico: uma revisäo prática / Fluid, electrolyte and acid-base disorders: a practical review

O equilíbrio hidroeletrolítico e o equilíbrio acidobásico säo assuntos de importância para todas as especialidades. Porém, seu entendimento prático é, por vezes, revestido de variados graus de dificuldades. No presente texto apresenta-se o assunto apenas como uma visäo prática, adquirida em mais de vinte (20) anos de ensino para estudantes, médicos residentes e médicos pós-graduandos. O texto tem apenas a pretensäo didática, sem nenhuma preocupaçäo acadêmica