Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study.

BACKGROUND: End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. METHODS: In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. FINDINGS: Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation. INTERPRETATION: Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide. FUNDING: None.

Resuscitation fluid practices in Brazilian intensive care units: a secondary analysis of Fluid-TRIPS. / Práticas de ressuscitação volêmica em unidades de terapia intensiva brasileiras: uma análise secundária do estudo Fluid-TRIPS.

OBJECTIVE: To describe fluid resuscitation practices in Brazilian intensive care units and to compare them with those of other countries participating in the Fluid-TRIPS. METHODS: This was a prospective, international, cross-sectional, observational study in a convenience sample of intensive care units in 27 countries (including Brazil) using the Fluid-TRIPS database compiled in 2014. We described the patterns of fluid resuscitation use in Brazil compared with those in other countries and identified the factors associated with fluid choice. RESULTS: On the study day, 3,214 patients in Brazil and 3,493 patients in other countries were included, of whom 16.1% and 26.8% (p < 0.001) received fluids, respectively. The main indication for fluid resuscitation was impaired perfusion and/or low cardiac output (Brazil: 71.7% versus other countries: 56.4%, p < 0.001). In Brazil, the percentage of patients receiving crystalloid solutions was higher (97.7% versus 76.8%, p < 0.001), and 0.9% sodium chloride was the most commonly used crystalloid (62.5% versus 27.1%, p < 0.001). The multivariable analysis suggested that the albumin levels were associated with the use of both crystalloids and colloids, whereas the type of fluid prescriber was associated with crystalloid use only. CONCLUSION: Our results suggest that crystalloids are more frequently used than colloids for fluid resuscitation in Brazil, and this discrepancy in frequencies is higher than that in other countries. Sodium chloride (0.9%) was the crystalloid most commonly prescribed. Serum albumin levels and the type of fluid prescriber were the factors associated with the choice of crystalloids or colloids for fluid resuscitation.

OBJETIVO: Descrever as práticas de ressuscitação volêmica em unidades de terapia intensiva brasileiras e compará-las com as de outros países participantes do estudo Fluid-TRIPS. MÉTODOS: Este foi um estudo observacional transversal, prospectivo e internacional, de uma amostra de conveniência de unidades de terapia intensiva de 27 países (inclusive o Brasil), com utilização da base de dados Fluid-TRIPS compilada em 2014. Descrevemos os padrões de ressuscitação volêmica utilizados no Brasil em comparação com os de outros países e identificamos os fatores associados com a escolha dos fluidos. RESULTADOS: No dia do estudo, foram incluídos 3.214 pacientes do Brasil e 3.493 pacientes de outros países, dos quais, respectivamente, 16,1% e 26,8% (p < 0,001) receberam fluidos. A principal indicação para ressuscitação volêmica foi comprometimento da perfusão e/ou baixo débito cardíaco (Brasil 71,7% versus outros países 56,4%; p < 0,001). No Brasil, a percentagem de pacientes que receberam soluções cristaloides foi mais elevada (97,7% versus 76,8%; p < 0,001), e solução de cloreto de sódio a 0,9% foi o cristaloide mais comumente utilizado (62,5% versus 27,1%; p < 0,001). A análise multivariada sugeriu que os níveis de albumina se associaram com o uso tanto de cristaloides quanto de coloides, enquanto o tipo de prescritor dos fluidos se associou apenas com o uso de cristaloides. CONCLUSÃO: Nossos resultados sugerem que cristaloides são usados mais frequentemente do que coloides para ressuscitação no Brasil, e essa discrepância, em termos de frequências, é mais elevada do que em outros países. A solução de cloreto de sódio 0,9% foi o cristaloide mais frequentemente prescrito. Os níveis de albumina sérica e o tipo de prescritor de fluidos foram os fatores associados com a escolha de cristaloides ou coloides para a prescrição de fluidos.

Epidemiologia e desfecho dos pacientes de alto risco cirúrgico admitidos em unidades de terapia intensiva no Brasil / Epidemiology and outcome of high-surgical-risk patients admitted to an intensive care unit in Brazil

RESUMO Objetivo: Definir o perfil epidemiológico e os principais determinantes de morbimortalidade dos pacientes cirúrgicos não cardíacos de alto risco no Brasil. Métodos: Estudo prospectivo, observacional e multicêntrico. Todos os pacientes cirúrgicos não cardíacos admitidos nas unidades de terapia intensiva, ou seja, considerados de alto risco, no período de 1 mês, foram avaliados e acompanhados diariamente por, no máximo, 7 dias na unidade de terapia intensiva, para determinação de complicações. As taxas de mortalidade em 28 dias de pós-operatório, na unidade de terapia intensiva e hospitalar foram avaliadas. Resultados: Participaram 29 unidades de terapia intensiva onde foram realizadas cirurgias em 25.500 pacientes, dos quais 904 (3,5%) de alto risco (intervalo de confiança de 95% - IC95% 3,3% - 3,8%), tendo sido incluídos no estudo. Dos pacientes envolvidos, 48,3% eram de unidades de terapia intensiva privadas e 51,7% de públicas. O tempo de internação na unidade de terapia intensiva foi de 2,0 (1,0 - 4,0) dias e hospitalar de 9,5 (5,4 - 18,6) dias. As taxas de complicações foram 29,9% (IC95% 26,4 - 33,7) e mortalidade em 28 dias pós-cirurgia 9,6% (IC95% 7,4 - 12,1). Os fatores independentes de risco para complicações foram Simplified Acute Physiology Score 3 (SAPS 3; razão de chance − RC = 1,02; IC95% 1,01 - 1,03) e Sequential Organ Failure Assessment Score (SOFA) da admissão na unidade de terapia intensiva (RC =1,17; IC95% 1,09 - 1,25), tempo de cirurgia (RC = 1,001; IC95% 1,000 - 1,002) e cirurgias de emergências (RC = 1,93; IC95% 1,10 - 3,38). Em adição, foram associados com mortalidade em 28 dias idade (RC = 1,032; IC95% 1,011 - 1,052) SAPS 3 (RC = 1,041; IC95% 1,107 - 1,279), SOFA (RC = 1,175; IC95% 1,069 - 1,292) e cirurgias emergenciais (RC = 2,509; IC95% 1,040 - 6,051). Conclusão: Pacientes com escores prognósticos mais elevados, idosos, tempo cirúrgico e cirurgias emergenciais estiveram fortemente associados a maior mortalidade em 28 dias e mais complicações durante permanência em unidade de terapia intensiva.

ABSTRACT Objective: To define the epidemiological profile and the main determinants of morbidity and mortality in noncardiac high surgical risk patients in Brazil. Methods: This was a prospective, observational and multicenter study. All noncardiac surgical patients admitted to intensive care units, i.e., those considered high risk, within a 1-month period were evaluated and monitored daily for a maximum of 7 days in the intensive care unit to determine complications. The 28-day postoperative, intensive care unit and hospital mortality rates were evaluated. Results: Twenty-nine intensive care units participated in the study. Surgeries were performed in 25,500 patients, of whom 904 (3.5%) were high-risk (95% confidence interval - 95%CI 3.3% - 3.8%) and were included in the study. Of the participating patients, 48.3% were from private intensive care units, and 51.7% were from public intensive care units. The length of stay in the intensive care unit was 2.0 (1.0 - 4.0) days, and the length of hospital stay was 9.5 (5.4 - 18.6) days. The complication rate was 29.9% (95%CI 26.4 - 33.7), and the 28-day postoperative mortality rate was 9.6% (95%CI 7.4 - 12.1). The independent risk factors for complications were the Simplified Acute Physiology Score 3 (SAPS 3; odds ratio - OR = 1.02; 95%CI 1.01 - 1.03) and Sequential Organ Failure Assessment Score (SOFA) on admission to the intensive care unit (OR = 1.17; 95%CI 1.09 - 1.25), surgical time (OR = 1.001, 95%CI 1.000 - 1.002) and emergency surgeries (OR = 1.93, 95%CI, 1.10 - 3.38). In addition, there were associations with 28-day mortality (OR = 1.032; 95%CI 1.011 - 1.052), SAPS 3 (OR = 1.041; 95%CI 1.107 - 1.279), SOFA (OR = 1.175, 95%CI 1.069 - 1.292) and emergency surgeries (OR = 2.509; 95%CI 1.040 - 6.051). Conclusion: Higher prognostic scores, elderly patients, longer surgical times and emergency surgeries were strongly associated with higher 28-day mortality and more complications during the intensive care unit stay.

Outcomes in Critically Ill Patients with Cancer-Related Complications.

INTRODUCTION: Cancer patients are at risk for severe complications related to the underlying malignancy or its treatment and, therefore, usually require admission to intensive care units (ICU). Here, we evaluated the clinical characteristics and outcomes in this subgroup of patients. MATERIALS AND METHODS: Secondary analysis of two prospective cohorts of cancer patients admitted to ICUs. We used multivariable logistic regression to identify variables associated with hospital mortality. RESULTS: Out of 2,028 patients, 456 (23%) had cancer-related complications. Compared to those without cancer-related complications, they more frequently had worse performance status (PS) (57% vs 36% with PS≥2), active malignancy (95% vs 58%), need for vasopressors (45% vs 34%), mechanical ventilation (70% vs 51%) and dialysis (12% vs 8%) (P<0.001 for all analyses). ICU (47% vs. 27%) and hospital (63% vs. 38%) mortality rates were also higher in patients with cancer-related complications (P<0.001). Chemo/radiation therapy-induced toxicity (6%), venous thromboembolism (5%), respiratory failure (4%), gastrointestinal involvement (3%) and vena cava syndrome (VCS) (2%) were the most frequent cancer-related complications. In multivariable analysis, the presence of cancer-related complications per se was not associated with mortality [odds ratio (OR) = 1.25 (95% confidence interval, 0.94-1.66), P = 0.131]. However, among the individual cancer-related complications, VCS [OR = 3.79 (1.11-12.92), P = 0.033], gastrointestinal involvement [OR = 3.05 (1.57-5.91), P = <0.001] and respiratory failure [OR = 1.96(1.04-3.71), P = 0.038] were independently associated with in-hospital mortality. CONCLUSIONS: The prognostic impact of cancer-related complications was variable. Although some complications were associated with worse outcomes, the presence of an acute cancer-related complication per se should not guide decisions to admit a patient to ICU.

Urinary tract infections due to Trichosporon spp. in severely ill patients in an intensive care unit.

OBJECTIVE: To evaluate the incidence of urinary tract infections due to Trichosporon spp. in an intensive care unit. METHODS: This descriptive observational study was conducted in an intensive care unit between 2007 and 2009. All consecutive patients admitted to the intensive care unit with a confirmed diagnosis were evaluated. RESULTS: Twenty patients presented with urinary tract infections due to Trichosporon spp. The prevalence was higher among men (65%) and among individuals > 70 years of age (55%). The mortality rate was 20%. The average intensive care unit stay was 19.8 days. The onset of infection was associated with prior use of antibiotics and was more frequent in the fall and winter. CONCLUSION: Infection due to Trichosporon spp. was more common in men and among those > 70 years of age and was associated with the use of an indwelling urinary catheter for more than 20 days and with the use of broadspectrum antibiotics for more than 14 days. In addition, patients with urinary infection due to Trichosporon spp. were most often hospitalized in intensive care units in the fall and winter periods.

Infecções urinárias causadas por Trichosporon spp. em pacientes graves internados em unidade de terapia intensiva / Urinary tract infections due to Trichosporon spp. in severely ill patients in an intensive care unit

RESUMOObjetivo:Avaliar a incidência de infecções do trato urinário por Trichosporon spp. em uma unidade de terapia intensiva.Métodos:Estudo descritivo observacional realizado em uma unidade de terapia intensiva no período de 2007 a 2009. Foram analisados todos os pacientes consecutivos que internaram na unidade de terapia intensiva e tiveram o diagnóstico confirmado.Resultados:Vinte pacientes apresentaram infecções do trato urinário por Trichosporon spp. A prevalência foi maior no sexo masculino (65%) e na faixa etária superior a 70 anos (55%). A mortalidade foi de 20%. A média de permanência na unidade de terapia intensiva foi de 19,8 dias. Seu aparecimento esteve relacionado ao uso pregresso de antibióticos e foi mais frequente no período que compreendeu o outono e o inverno.Conclusão:A infecção por Trichosporon spp. predominou no sexo masculino, de idade acima de 70 anos, com uso de sonda vesical de demora por mais de 20 dias e com uso de antibióticos de amplo espectro acima de 14 dias. Os pacientes que apresentaram a infecção urinária por Trichosporon spp. ficaram internados nos setores de terapia intensiva, com maior frequência, no período de outono e inverno.

ABSTRACTObjective:To evaluate the incidence of urinary tract infections due to Trichosporon spp. in an intensive care unit.Methods:This descriptive observational study was conducted in an intensive care unit between 2007 and 2009. All consecutive patients admitted to the intensive care unit with a confirmed diagnosis were evaluated.Results:Twenty patients presented with urinary tract infections due to Trichosporon spp. The prevalence was higher among men (65%) and among individuals > 70 years of age (55%). The mortality rate was 20%. The average intensive care unit stay was 19.8 days. The onset of infection was associated with prior use of antibiotics and was more frequent in the fall and winter.Conclusion:Infection due to Trichosporon spp. was more common in men and among those > 70 years of age and was associated with the use of an indwelling urinary catheter for more than 20 days and with the use of broadspectrum antibiotics for more than 14 days. In addition, patients with urinary infection due to Trichosporon spp. were most often hospitalized in intensive care units in the fall and winter periods.

Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study.

INTRODUCTION: Sedation overuse is frequent and possibly associated with poor outcomes in the intensive care unit (ICU) patients. However, the association of early oversedation with clinical outcomes has not been thoroughly evaluated. The aim of this study was to assess the association of early sedation strategies with outcomes of critically ill adult patients under mechanical ventilation (MV). METHODS: A secondary analysis of a multicenter prospective cohort conducted in 45 Brazilian ICUs, including adult patients requiring ventilatory support and sedation in the first 48 hours of ICU admissions, was performed. Sedation depth was evaluated after 48 hours of MV. Multivariate analysis was used to identify variables associated with hospital mortality. RESULTS: A total of 322 patients were evaluated. Overall, ICU and hospital mortality rates were 30.4% and 38.8%, respectively. Deep sedation was observed in 113 patients (35.1%). Longer duration of ventilatory support was observed (7 (4 to 10) versus 5 (3 to 9) days, P = 0.041) and more tracheostomies were performed in the deep sedation group (38.9% versus 22%, P = 0.001) despite similar PaO2/FiO2 ratios and acute respiratory distress syndrome (ARDS) severity. In a multivariate analysis, age (Odds Ratio (OR) 1.02; 95% confidence interval (CI) 1.00 to 1.03), Charlson Comorbidity Index >2 (OR 2.06; 95% CI, 1.44 to 2.94), Simplified Acute Physiology Score 3 (SAPS 3) score (OR 1.02; CI 95%, 1.00 to 1.04), severe ARDS (OR 1.44; CI 95%, 1.09 to 1.91) and deep sedation (OR 2.36; CI 95%, 1.31 to 4.25) were independently associated with increased hospital mortality. CONCLUSIONS: Early deep sedation is associated with adverse outcomes and constitutes an independent predictor of hospital mortality in mechanically ventilated patients.

Outcomes for patients with cancer admitted to the ICU requiring ventilatory support: results from a prospective multicenter study.

BACKGROUND: This study was undertaken to evaluate the clinical characteristics and outcomes of patients with cancer requiring nonpalliative ventilatory support. METHODS: This was a secondary analysis of a prospective cohort study conducted in 28 Brazilian ICUs evaluating adult patients with cancer requiring invasive mechanical ventilation (MV) or noninvasive ventilation (NIV) during the first 48 h of their ICU stay. We used logistic regression to identify the variables associated with hospital mortality. RESULTS: Of 717 patients, 263 (37%) (solid tumors = 227; hematologic malignancies = 36) received ventilatory support. NIV was initially used in 85 patients (32%), and 178 (68%) received MV. Additionally, NIV followed by MV occurred in 45 patients (53%). Hospital mortality rates were 67% in all patients, 40% in patients receiving NIV only, 69% when NIV was followed by MV, and 73% in patients receiving MV only (P < .001). Adjusting for the type of admission, newly diagnosed malignancy (OR, 3.59; 95% CI, 1.28-10.10), recurrent or progressive malignancy (OR, 3.67; 95% CI, 1.25-10.81), tumoral airway involvement (OR, 4.04; 95% CI, 1.30-12.56), performance status (PS) 2 to 4 (OR, 2.39; 95% CI, 1.24-4.59), NIV followed by MV (OR, 3.00; 95% CI, 1.09-8.18), MV as initial ventilatory strategy (OR, 3.53; 95% CI, 1.45-8.60), and Sequential Organ Failure Assessment score (each point except the respiratory domain) (OR, 1.15; 95% CI, 1.03-1.29) were associated with hospital mortality. Hospital survival in patients with good PS and nonprogressive malignancy and without tumoral airway involvement was 53%. Conversely, patients with poor functional capacity and cancer progression had unfavorable outcomes. CONCLUSIONS: Patients with cancer with good PS and nonprogressive disease requiring ventilatory support should receive full intensive care, because one-half of these patients survive. On the other hand, provision of palliative care should be considered the main goal for patients with poor PS and progressive underlying malignancy.

[Splenic auto-implant and hyperbaric oxygen therapy in rats]. / Aspectos morfológicos e funcionais dos autoimplantes esplênicos em ratos tratados com oxigenio hiperbárico.

OBJECTIVE: To study the functional and morphological features of splenic autoimplants in rats subjected, or not, to postoperative hyperbaric oxygen therapy. METHODS: One hundred and five male Wistar rats, weighing 251.6 g ± 29.5 g, were studied ot early (11th day) and late (70th day ) postoperative periods. For each period the animals were distributed in the following groups: A (n=40), splenic manipulation; B (n=65),splenic autoimplants, not treated (nt) (A11nt--n=10, B11nt--n=21, A70nt--n=10, B70nt--n=18) and treated with hyperbaric oxygen (t) ( A11t--n=10, B11t--n=15, A70t--n=10, B70t--n=11). Blood was collected for measurement of lipids and immunoglobulins, platelet and Howell-Jolly body count before and after surgery. The spleen and autoimplants were removed for histologic analyses. RESULTS: There was an increase of total cholesterol (p=0.00068), LDL-cholesterol (p=0.002), VLDL-cholesterol and triglycerides (p=0.0033) in B11nt group. There was an increase of total cholesterol (p=0.0007) and LDL-cholesterol (p=0.0000) in B70nt group, and no alterations were observed in the other groups. IgM decreased in B groups (p=0.0000) and no changes were observed in the splenic manipulation group. Number of Howell-Jolly bodies were lesser in Bt groups than in Bnt groups (p=0.03). Platelets were increased in B11t and B11nt groups (p=0.0000) and remained unchanged in the other groups. Autoimplants microscopic viability was better in Bt groups than in Bnt. CONCLUSION: The splenic autoimplants of rats treated with hyperbaric oxygen therapy showed a better functionality and viability than those subjected to other procedures.

Aspectos morfológicos e funcionais dos autoimplantes esplênicos em ratos tratados com oxigenio hiperbárico / Splenic autoimplant and hyperbaric oxygen therapy in rats

OBJETIVO: Estudar aspectos morfológicos e funcionais dos autoimplantes esplênicos de ratos submetidos ou não à oxigenioterapia hiperbárica (OHB). MÉTODOS: Foram estudados em dois períodos distintos 105 ratos Wistar. No período mediato (n= 56) os animais foram avaliados até o 11º dia de pós-operatório, e no período tardio (n= 49), até o 70º dia. Em cada período os ratos foram distribuídos nos grupos: A- Simulação, B- Autoimplante esplênico, tratados com oxigênio hiperbárico ou não. Nos animais do Grupo A realizou-se apenas manipulação do baço. Nos animais do Grupo B realizou-se esplenectomia total e a seguir quatro fragmentos do baço foram implantados no grande omento. Em todos os animais foram dosados os lípides e imunoglobulinas e contadas as plaquetas e os corpúsculos de Howell-Jolly no pré-operatório e no 11º ou 70º dia de pós-operatório. O baço dos animais do Grupo A e os autoimplantes dos animais do Grupo B foram retirados e enviados para avaliação morfológica. RESULTADOS: No grupo B11nt houve aumento do colesterol total, LDL-colesterol, VLDL-colesterol e triglicérides. No grupo B70nt houve aumento do colesterol total e LDL-colesterol. Nos grupos tratados não houve alterações lipídicas. A IgM caiu nos grupos B e não alterou nos grupos A. Os corpúsculos de Howell - Jolly foram menos freqüentes nos grupos Bt que nos grupos Bnt. As plaquetas aumentaram nos grupos B11t e B11nt e não se alteraram nos demais grupos. A viabilidade microscópica dos grupos Bt foi melhor que a dos grupos Bnt. CONCLUSÃO: Os autoimplantes esplênicos dos animais tratados com OHB apresentaram melhor função e viabilidade do que os autoimplantes dos animais não tratados.

OBJECTIVE: To study the functional and morphological features of splenic autoimplants in rats subjected, or not, to postoperative hyperbaric oxygen therapy. METHODS: One hundred and five male Wistar rats, weighing 251.6 g ± 29.5 g, were studied ot early (11th day) and late (70th day ) postoperative periods. For each period the animals were distributed in the following groups: A (n=40), splenic manipulation; B (n=65),splenic autoimplants, not treated (nt) (A11nt- n=10, B11nt- n=21, A70nt- n= 10, B70nt-n= 18) and treated with hyperbaric oxygen (t) ( A11t- n= 10, B11t- n=15, A70t - n=10, B70t- n=11). Blood was collected for measurement of lipids and immunoglobulins , platelet and Howell-Jolly body count before and after surgery. The spleen and autoimplants were removed for histologic analyses. RESULTS: There was an increase of total cholesterol (p=0.00068), LDL-cholesterol (p=0.002), VLDL-cholesterol and triglycerides (p=0.0033) in B11nt group. There was an increase of total cholesterol (p= 0.0007) and LDL-cholesterol (p=0.0000) in B70nt group, and no alterations were observed in the other groups. IgM decreased in B groups (p=0.0000) and no changes were observed in the splenic manipulation group. Number of Howell-Jolly bodies were lesser in Bt groups than in Bnt groups( p=0.03). Platelets were increased in B11t and B11nt groups (p=0.0000) and remained unchanged in the other groups. Autoimplants microscopic viability was better in Bt groups than in Bnt. CONCLUSION: The splenic autoimplants of rats treated with hyperbaric oxygen therapy showed a better functionality and viability than those subjected to other procedures.

Venous drainage from the tail of the pancreas to the lienal vein and its relationship with the distal splenorenal shunt selectivity.

PURPOSE: To identify the veins draining from the pancreatic tail to the lienal vein and its possible relationship with the loss of the distal splenorenal shunt selectivity. METHODS: Thirty eight human blocks including stomach, duodenum, spleen, colon and pancreas, removed from fresh corpses, were studied with the replenish and corrosion technique, using vinilic resin and posterior corrosion of the organic tissue with commercial hydrochloric acid, in order to study the lienal vein and its tributaries. RESULTS: The number of veins flowing directly to the splenic vein varied from seven to twenty two (14.52 + or - 3.53). Pancreatic branches of the pancreatic tail flowing to the segmentary veins of the spleen were found in 25 of the anatomical pieces studied (65.79%). These branches varied from one to four, predominating one branch (60%) and two branches (24%). CONCLUSIONS: In 65.79% of the anatomical pieces studied, the veins of the pancreatic tail flowed in segmentary branches of the splenic vein. These branches could be responsible for the loss of distal splenorenal shunt selectivity. The complete disconnection of the pancreatic tail could increase the selectivity in this procedure.

Venous drainage from the tail of the pancreas to the lienal vein and its relationship with the distal splenorenal shunt selectivity / Drenagem venosa da cauda do pâncreas para a veia lienal e sua relação com a seletividade da anastomose esplenorrenal

PURPOSE: To identify the veins draining from the pancreatic tail to the lienal vein and its possible relationship with the loss of the distal splenorenal shunt selectivity. METHODS: Thirty eight human blocks including stomach, duodenum, spleen, colon and pancreas, removed from fresh corpses, were studied with the replenish and corrosion technique, using vinilic resin and posterior corrosion of the organic tissue with commercial hydrochloric acid, in order to study the lienal vein and its tributaries. RESULTS: The number of veins flowing directly to the splenic vein varied from seven to twenty two (14.52 ± 3.53). Pancreatic branches of the pancreatic tail flowing to the segmentary veins of the spleen were found in 25 of the anatomical pieces studied (65.79 percent). These branches varied from one to four, predominating one branch (60 percent) and two branches (24 percent). CONCLUSIONS: In 65.79 percent of the anatomical pieces studied, the veins of the pancreatic tail flowed in segmentary branches of the splenic vein. These branches could be responsible for the loss of distal splenorenal shunt selectivity. The complete disconnection of the pancreatic tail could increase the selectivity in this procedure.

OBJETIVO: Identificar as veias da cauda do pâncreas afluentes da veia lienal e a possível relação destes ramos com a perda de seletividade da derivação esplenorrenal distal. MÉTODOS: Foram estudadas 38 peças humanas, retiradas de cadáveres, contendo estômago, duodeno, baço, cólon e pâncreas, utilizando-se a técnica de repleção vascular com resina vinílica e posterior corrosão do tecido orgânico com o objetivo de se estudar o molde vascular da veia lienal e seus afluentes. RESULTADOS: O número de veias afluindo diretamente para a veia esplênica variou de sete a vinte dois (MA 14.52±3.53). Ramos pancreáticos da cauda do pâncreas afluindo para as veias segmentares do baço estavam presentes em 25 das peças estudadas (65,79 por cento). Estes ramos variaram de um a quatro, predominando um ramo (60 por cento) e dois ramos (24 por cento). CONCLUSÕES: Em 65,79 por cento das peças veias da cauda do pâncreas desembocavam em ramos segmentares da veia esplênica. Estes ramos poderiam ser responsáveis pela perda de seletividade da derivação esplenorrenal distal e a esqueletização completa da cauda do pâncreas poderia aumentar a seletividade neste procedimento.

Characteristics and outcomes of patients with cancer requiring admission to intensive care units: a prospective multicenter study.

OBJECTIVE: To evaluate the characteristics and outcomes of patients with cancer admitted to several intensive care units. Knowledge on patients with cancer requiring intensive care is mostly restricted to single-center studies. DESIGN: : Prospective, multicenter, cohort study. SETTING: Intensive care units from 28 hospitals in Brazil. PATIENTS: A total of 717 consecutive patients included over a 2-mo period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 667 (93%) patients with solid tumors and 50 (7%) patients had hematologic malignancies. The main reasons for intensive care unit admission were postoperative care (57%), sepsis (15%), and respiratory failure (10%). Overall hospital mortality rate was 30% and was higher in patients admitted because of medical complications (58%) than in emergency (37%) and scheduled (11%) surgical patients (p < .001). Adjusting for covariates other than the type of admission, the number of hospital days before intensive care unit admission (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.01-1.37), higher Sequential Organ Failure Assessment scores (OR, 1.25; 95% CI, 1.17-1.34), poor performance status (OR, 3.40; 95% CI, 2.19 -5.26), the need for mechanical ventilation (OR, 2.42; 95% CI, 1.51-3.87), and active underlying malignancy in recurrence or progression (OR, 2.42; 95% CI, 1.51-3.87) were associated with increased hospital mortality in multivariate analysis. CONCLUSIONS: This large multicenter study reports encouraging survival rates for patients with cancer requiring intensive care. In these patients, mortality was mostly dependent on the severity of organ failures, performance status, and need for mechanical ventilation rather than cancer-related characteristics, such as the type of malignancy or the presence of neutropenia.

Sepse Brasil: estudo epidemiológico da sepse em Unidades de Terapia Intensiva brasileiras / An epidemiological study of sepsis in Intensive Care Units: Sepsis Brazil study

JUSTIFICATIVA E OBJETIVOS: A sepse representa a principal causa de morte nas UTI em todo o mundo. Muitos estudos têm demonstrado um aumento da incidência ao longo do tempo e apenas uma leve redução na mortalidade. MÉTODO: Foi realizado um estudo prospectivo em 65 hospitais de todas as regiões do Brasil. Os pacientes que foram admitidos com sepse ou que desenvolveram sepse no mês de setembro de 2003 foram incluídos. O acompanhamento foi feito até o 28º dia de internação e/ou até a alta da UTI. O diagnóstico seguiu os critérios clássicos propostos na convenção de 1991. Foram avaliados dados demográficos, escore APACHE II, escore SOFA, mortalidade, fonte de infecção, microbiologia, comorbidades, tempo de internação, uso de ventilação mecânica, cateter de Swan-Ganz, vasopressores e hemotransfusão. RESULTADOS: Setenta e cinco unidades de terapia intensiva de todas as regiões do Brasil participaram do estudo. Foram identificados 3128 pacientes e 521 (16,7 por cento) foram diagnosticados como tendo o diagnóstico de sepse, sepse grave ou choque séptico. A idade média foi de 61,7 (IQR 39-79), 293 (55,7 por cento) corresponderam ao sexo masculino, e a mortalidade global em 28 dias foi de 46,6 por cento. O escore APACHE II médio foi de 20 e o escore SOFA no D1 foi de 7 (IQR 4-10). O escore SOFA no grupo dos não-sobreviventes foi maior no D1 (8, IQR 5-11), e aumentou no D3 (9, IQR 6-12). A mortalidade na sepse, sepse grave e choque séptico foi de 16,7 por cento, 34,4 por cento e 65,3 por cento, respectivamente. O tempo médio de internação foi de 15 dias (IQR 5-22). As duas principais fontes de infecção foram o trato respiratório (69 por cento) e o abdômen (23,1 por cento). Os bacilos gram-negativos foram mais prevalentes (40,1 por cento). Os cocos gram-positivos foram identificados em 32,8 por cento e as infecções fúngicas em 5 por cento. A ventilação mecânica ocorreu em 82,1 por cento dos casos, uso de cateter de Swan-Ganz em 18,8 por cento, vasopressores...

BACKGROUND AND OBJECTIVES: Sepsis represents the major cause of death in the ICUs all over the world. Many studies have shown an increasing incidence over time and only a slight reduce in mortality. Many new treatment strategies are arising and we should define the incidence and features of sepsis in Brazil. METHODS: Prospective cohort study in sixty-five hospitals all over Brazil. The patients who were admitted or who developed sepsis during the month of September, 2003 were enrolled. They were followed until the 28th day and/or until their discharge. The diagnoses were made in accordance to the criteria proposed by ACCP/SCCM. It were evaluated demographic features, APACHE II score, SOFA (Sepsis-related Organ Failure Assessment) score, mortality, sources of infections, microbiology, morbidities and length of stay (LOS). RESULTS: Seventy-five ICUs from all regions of Brazil took part in the study.3128 patients were identified and 521 (16.7 percent) filled the criteria of sepsis, severe sepsis or septic shock. Mean age was 61.7 (IQR 39-79), 293 (55.7 percent) were males, and the overall 28-day mortality rate was 46.6 percent. Average APACHE II score was 20 and SOFA score on the first day was 7 (IQR 4-10). SOFA score in the mortality group was higher on day 1 (8, IQR 5-11), and had increased on day 3 (9, IQR 6-12). The mortality rate for sepsis, severe sepsis and septic shock was 16.7 percent, 34.4 percent and 65.3 percent, respectively. The average LOS was 15 days (IQR 5-22). The two main sources of infection were the respiratory tract (69 percent) and the abdomen one (23.1 percent). Gram-negative bacilli were more prevalent (40.1 percent). Gram-positive cocci were identified in 32.8 percent and fungi infections in 5 percent. Mechanical ventilation was observed in 82.1 percent of the patients, Swan-Ganz catheter in 18.8 percent, vasopressors in 66.2 percent and hemotransfusion in 44.7 percent. CONCLUSIONS: It was observed a high mortality...

[An epidemiological study of sepsis in Intensive Care Units: Sepsis Brazil study]. / Sepse Brasil: estudo epidemiológico da sepse em Unidades de Terapia Intensiva brasileiras.

BACKGROUND AND OBJECTIVES: Sepsis represents the major cause of death in the ICUs all over the world. Many studies have shown an increasing incidence over time and only a slight reduce in mortality. Many new treatment strategies are arising and we should define the incidence and features of sepsis in Brazil. METHODS: Prospective cohort study in sixty-five hospitals all over Brazil. The patients who were admitted or who developed sepsis during the month of September, 2003 were enrolled. They were followed until the 28th day and/or until their discharge. The diagnoses were made in accordance to the criteria proposed by ACCP/SCCM. It were evaluated demographic features, APACHE II score, SOFA (Sepsis-related Organ Failure Assessment) score, mortality, sources of infections, microbiology, morbidities and length of stay (LOS). RESULTS: Seventy-five ICUs from all regions of Brazil took part in the study.3128 patients were identified and 521 (16.7%) filled the criteria of sepsis, severe sepsis or septic shock. Mean age was 61.7 (IQR 39-79), 293 (55.7%) were males, and the overall 28-day mortality rate was 46.6%. Average APACHE II score was 20 and SOFA score on the first day was 7 (IQR 4-10). SOFA score in the mortality group was higher on day 1 (8, IQR 5-11), and had increased on day 3 (9, IQR 6-12). The mortality rate for sepsis, severe sepsis and septic shock was 16.7%, 34.4% and 65.3%, respectively. The average LOS was 15 days (IQR 5-22). The two main sources of infection were the respiratory tract (69%) and the abdomen one (23.1%). Gram-negative bacilli were more prevalent (40.1%). Gram-positive cocci were identified in 32.8% and fungi infections in 5%. Mechanical ventilation was observed in 82.1% of the patients, Swan-Ganz catheter in 18.8%, vasopressors in 66.2% and hemotransfusion in 44.7%. CONCLUSIONS: It was observed a high mortality of sepsis in the ICUs in Brazil. The high frequency of septic shock demonstrated a group at high risk of death. In order to have a better use of the resources and reduce in mortality during the next 5 years, it is very important to identify our specific features related to this syndrome.

Afluência da veia esplênica e sua importância nas derivações esplenorrenais seletivas / Splenic tributaries and their importance on selective splenorenal shunts

Os autores realizaram estudo da afluência da veia esplênica utilizando 38 moldes de duodeno, estômago, pâncreas e baço, por meio da técnica de repleção e corrosão, com vinilite corado com azul da Prússia. Os afluentes encontrados foram: ramos pancreáticos em todas as peças, variando de 7 a 22 ramos, com média de 14,52 ñ 3,53; a veia gástrica esquerda, em 36,84 por cento das peças; a veia mesentérica inferior em 44,74 por cento das peças; ramo gástrico (gástrica posterior), proveniente do fundo gástrico, em 57,89 por cento das peças, e ramos pancreáticos, provenientes da cauda do pâncreas e desembocando em ramos segmentares da veia esplênica, em 65,79 por cento das peças. Os ramos pancreáticos variaram em número de um a quatro, com média de 1,64 ñ 0,95. Os autores concluem que o conhecimento dos afluentes da veia esplênica seria importante na realização das derivações esplenorrenais distais, quando associadas à desconexão esplenopancreática