Impact of an inpatient multidisciplinary glucose control management program

ABSTRACT Objective: Glycemic control has been increasingly recognized as a critical element in inpatient care, but optimal management of blood glucose in the hospital setting remains challenging. The aims of this study were to describe and evaluate the impact of the implementation of an inpatient multidisciplinary glucose control management program on glucose control in hospitalized patients. Materials and methods: Retrospective analysis of medical records and glucose monitoring data obtained by point- of-care testing (POCT) in hospitalized patients before (May 2014) and after (June 2015 and May 2017) the implementation of the program. Results: We analyzed 6888, 7290, and 7669 POCTs from 389, 545, and 475 patients in May 2014, June 2015, and May 2017, respectively. Hyperglycemia (≥ 180 mg/ dL) occurred in 23.5%, 19.6%, and 19.3% POCTs in May 2014, June 2015, and May/2017, respectively (p < 0.001), while severe hyperglycemia (≥ 300 mg/dL) was observed in 2.5%, 2.2%, and 1.8% of them, respectively (p = 0.003). Hyperglycemia (≥ 180 mg/dL) reduced significantly from May 2014 to June 2015 (16.3%, p < 0.001) and from May 2014 to May 2017 (178%, p < 0.001). No significant changes occurred in hypoglycemic parameters. Conclusions: The implementation of an inpatient multidisciplinary glucose control management program led to significant reductions in hyperglycemic events. The key elements for this achievement were the development of institutional inpatient glycemic control protocols, establishment of a multidisciplinary team, and continuing educational programs for hospital personnel. Altogether, these actions resulted in improvements in care processes, patient safety, and clinical outcomes of hospitalized patients.

Low-molecular-weight heparin venous thromboprophylaxis in critically ill patients with renal dysfunction: A subgroup analysis of the PROTECT trial.

INTRODUCTION: There is concern about excessive bleeding when low-molecular-weight heparins (LMWHs) are used for venous thromboembolism (VTE) prophylaxis in renal dysfunction. Our objective was to evaluate whether LMWH VTE prophylaxis was safe and effective in critically ill patients with renal dysfunction by conducting a subgroup analysis of PROTECT, a randomized blinded trial. METHODS: We studied intensive care unit (ICU) patients with pre-ICU dialysis-dependent end-stage renal disease (ESRD; pre-specified subgroup; n = 118), or severe renal dysfunction at ICU admission (defined as ESRD or non-dialysis dependent with creatinine clearance [CrCl] <30 ml/min; post hoc subgroup; n = 590). We compared dalteparin, 5000 IU daily, with unfractionated heparin (UFH), 5000 IU twice daily, and considered outcomes of proximal leg deep vein thrombosis (DVT); pulmonary embolism (PE); any VTE; and major bleeding. Adjusted hazard ratios [HR] were calculated using Cox regression. RESULTS: In patients with ESRD, there was no significant difference in DVT (8.3% vs. 5.2%, p = 0.76), any VTE (10.0% vs. 6.9%; p = 0.39) or major bleeding (5.0% vs. 8.6%; p = 0.32) between UFH and dalteparin. In patients with severe renal dysfunction, there was no significant difference in any VTE (10.0% vs. 6.4%; p = 0.07) or major bleeding (8.9% vs. 11.0%; p = 0.66) but an increase in DVT with dalteparin (7.6% vs. 3.7%; p = 0.04). Interaction p-values for comparisons of HRs (ESRD versus not) were non-significant. CONCLUSIONS: In critically ill patients with ESRD, or severe renal dysfunction, there was no significant difference in any VTE or major bleeding between UFH and dalteparin. Patients with severe renal dysfunction who received dalteparin had more proximal DVTs than those on UFH; this finding did not hold in patients with ESRD alone.

Occult Breast Carcinoma Presenting as Scalp Metastasis.

Breast cancer is the most common tumor among women, and approximately 6% of the patients have de novo metastatic breast cancer. Occult breast cancer accounts for only 0.1-0.8% of the cases and most commonly presents with axillary lymphadenopathy. Scalp metastases are rare and have been described as a sign of progression or widespread metastatic disease. Here, we describe a rare case of de novo metastatic breast cancer to the scalp as the single site of spread and without an identifiable primary breast tumor.

Platelets: an outlook from biology through evidence-based achievements in critical care.

Since the original observations by Bizzozero and Osler, we have seen tremendous advances in the understanding of platelets far beyond haemostasis and the restoration of injured endothelium. In this mini-review on platelets, we will briefly outline their historical description and the importance of their evolution, focusing on a 450 million years old living fossil of Limulus polyphemus, a marine chelicerate arthropod, which helped researchers explain the basis for the immunity role of platelets and make correlations with platelet ultrastructure and function. In addition, the impact of the Limulus Amoebocyte Lysate (LAL) test for modern medicine is highlighted. The role of platelets in cardiovascular diseases, their relevance in arterial and venous thrombosis, and the utilization of antithrombotic drugs as therapeutic agents are also reported. Furthermore, platelet receptors are crucial in aggravating or mitigating other diseases, such as cancer and infections, which can recruit cells and have numerous interactions in a process recently coined "NETosis formation", which is also briefly depicted.

Interstitial Pneumonitis Secondary to Trastuzumab: A Case Report and Literature Review.

Interstitial lung disease is a rare complication of trastuzumab-based breast cancer treatment with few case reports published. Herein, we report the case of a 67-year-old female with early-stage HER2-postitive breast cancer who developed interstitial pneumonitis during cycle 5 of treatment with trastuzumab combined with carboplatin and docetaxel. After supportive care and treatment with prednisone, the patient showed rapid improvement of respiratory symptoms. Retreatment with trastuzumab as a single agent led to worsening of symptoms and required a second course of treatment with prednisone combined with cyclophosphamide, which was followed by improvement of symptoms. In conclusion, interstitial pneumonitis is a rare but life-threatening adverse event from trastuzumab breast cancer treatment.

Caixa de atividades diárias para ratos / Daily activities box for rats

Este trabalho apresenta um protótipo de caixa de condicionamento operante para ratos - batizada de Caixa de Atividades Diárias Para Ratos - que permite o registro, 24h por dia, de múltiplos operantes. O sujeito experimental pode ser remotamente monitorado (visto e ouvido em tempo real) por meio de uma webcam localizada na frente da caixa. Além disso, todas as funções do equipamento podem ser controladas remotamente via internet. Trata-se da primeira caixa experimental a reunir todas estas funções, ao menos no Brasil. Algumas sugestões de áreas de pesquisa em que o equipamento poderia ser utilizado são apresentadas...

This work presents a prototype of an operant conditioning box for mice - named Daily Activities Box for Rats -, in which multiple operants can be recorded 24 h per day. The experimental subject can be monitored remotely (seen and heard in real time) by means of a webcam located in front of the box. Furthermore, all the equipment functions can be controlled remotely via internet. This is the first experimental box to gather all these functions, at least in Brazil. Some suggestions of areas of research in which the equipment may be used are presented...

Viability of human adenovirus from hospital fomites.

The monitoring of environmental microbial contamination in healthcare facilities may be a valuable tool to determine pathogens transmission in those settings; however, such procedure is limited to bacterial indicators. Viruses are found commonly in those environments and are rarely used for these procedures. The aim of this study was to assess distribution and viability of a human DNA virus on fomites in an Adult Intensive Care Unit of a private hospital in Rio de Janeiro, Brazil. Human adenoviruses (HAdV) were investigated in 141 fomites by scraping the surface area and screening by quantitative PCR (qPCR) using TaqMan® System (Carlsbad, CA). Ten positive samples were selected for virus isolation in A549 and/or HEp2c cell lines. A total of 63 samples (44.7%) were positive and presented viral load ranging from 2.48 × 10(1) to 2.1 × 10(3) genomic copies per millilitre (gc/ml). The viability was demonstrated by integrated cell culture/nested-PCR in 5 out of 10 samples. Nucleotide sequencing confirmed all samples as HAdV and characterized one of them as specie B, serotype 3 (HAdV-3). The results indicate the risk of nosocomial transmission via contaminated fomites and point out the use of HAdV as biomarkers of environmental contamination.

Brazilian experience in EU-CORE: daptomycin registry and treatment of serious Gram-positive infections

OBJECTIVES: To collect data about non-controlled prescribing use of daptomycin and its impact among Brazilian patients with serious Gram positive bacterial infection, as well as the efficacy and safety outcomes. MATERIALS AND METHODS: This is a multi-center, retrospective, non-interventional registry (August 01, 2009 to June 30, 2011) to collect data on 120 patients (44 patients in the first year and 76 patients in the second year) who had received at least one dose of commercial daptomycin in Brazil for the treatment of serious Gram-positive bacterial infection. RESULTS: Right-sided endocarditis (15.8%), complicated skin and soft tissue infections (cSSTI)wound (15.0%) and bacteremia-catheter-related (14.2%) were the most frequent primary infections; lung (21.7%) was the most common site for infection. Daptomycin was used empirically in 76 (63.3%) patients, and methicillin-resistant Staphylococcus aureus (MRSA) was the most common suspected pathogen (86.1%). 82.5% of the cultures were obtained prior to or shortly after initiation of daptomycin therapy. Staphylococcus spp. - coagulase negative, MRSA, and methicillin-susceptible S. aureus were the most frequently identified pathogens (23.8%, 23.8% and 12.5%, respectively). The most common daptomycin dose administered for bacteremia and cSSTI was 6 mg/kg (30.6%) and 4 mg/kg (51.7%), respectively. The median duration of inpatient daptomycin therapy was 14 days. Most patients (57.1%) did not receive daptomycin while in intensive care unit. Carbapenem (22.5%) was the most commonly used antibiotic concomitantly. The patients showed clinical improvement after two days (median) following the start of daptomycin therapy. The clinical success rate was 80.8% and the overall rate of treatment failure was 10.8%. The main reasons for daptomycin discontinuation were successful end of therapy (75.8%), switched therapy (11.7%), and treatment failure (4.2%). Daptomycin demonstrated a favorable safety and tolerability profile regardless of treatment duration. CONCLUSIONS: Daptomycin had a relevant role in the treatment of Gram-positive infections in the clinical practice setting in Brazil.

Ritmo circadiano em óbitos hospitalares: comparação entre unidade de tratamento intensivo e unidade de tratamento não intensivo / Circadian rhythm of hospital deaths: comparison between intensive care unit and non-intensive care unit

OBJETIVO: A demonstração de que a mortalidade cardiovascular segue um ritmo circadiano fez com que fosse verificado se pacientes que falecem em unidade de tratamento intensivo (UTI) e unidade clínica (UC) obedecem a este ritmo. MÉTODOS: Foram analisados todos os óbitos hospitalares ocorridos entre 1º de janeiro de 2006 e 31 de julho de 2010. O padrão circadiano dos óbitos foi analisado dividindo-se as 24 horas do dia em períodos de 2 horas. Utilizou-se o teste do qui-quadrado para comparação de variáveis categóricas e o teste t de Student ou a análise da variância fator único para comparação de variáveis contínuas. Um valor de p < 0,05 foi considerado estatisticamente significante. RESULTADOS: No período estudado, foram registrados 700 óbitos, 211 (30,1 por cento) na UTI e 88 (12,6 por cento) na UC. Houve mais óbitos nas primeiras horas do dia, entre 6 e 12 h, na UC, em comparação à UTI (38 por cento vs. 21 por cento; p = 0,004). Na UTI, 21 por cento dos óbitos ocorreram entre 6 e 12 h, 30 por cento entre 12 e 18 h, 26 por cento entre 18 e 24 h e 24 por cento entre 24 e 6 h (p = 0,13). Enquanto, na UC, 38 por cento ocorreram entre 6 e 12 h, 18 por cento entre 12 e 18h, 19 por cento entre 18 e 24 h e 25 por cento entre 24 e 6 h (p = 0,005). CONCLUSÃO: Na UC, os óbitos ocorrem com maior frequência no período da manhã e seguem um padrão circadiano, enquanto na UTI esse fenômeno não ocorre.

OBJECTIVE: The demonstration that cardiovascular mortality follows a circadian rhythm led us to verify whether patients dying at the intensive unit care (ICU) and at the non-intensive unit care (non-ICU) follow that rhythm. METHODS: All hospital's deaths occurring between January 1, 2006 and July 31, 2010 were analyzed. The circadian pattern of the time of death was analyzed in twelve 2 hour intervals. The Chi-square test was used to compare proportions, and Student's t test or ANOVA single factor to compare continuous variables. A p-value < 0.05 was considered statistically significant. RESULTS: During the study period 700 deaths occurred in the hospital, 211 (30.1 percent) at the ICU and 88 (12.6 percent) at the non-ICU. There were more deaths in the first hours of the day, between 6 am and 12 am, at the non-ICU in comparison to the ICU (38 percent vs. 21 percent; p = 0.004). In the ICU, we observed that 21 percent of the deaths occurred between 6 am and 12 pm, 30 percent between 12 pm and 6 pm, 26 percent between 6 pm and 12 am and 24 percent between 12 am and 6 am (p = 0.13), whereas, at the non-ICU, 38 percent of the deaths occurred between 6 am and 12 pm, 18 percent between 12 pm and 6 pm, 19 percent between 6 pm and 12 am and 25 percent between 12 am and 6 am (p = 0.005). CONCLUSION: At the non-ICU, deaths occur more often in the morning period and follow a circadian rhythm, which does not occur at the ICU.

Recomendações para o manejo de pacientes com formas graves de dengue / Guidelines for the management of patients with severe forms of dengue

A dengue é a infecção viral transmitida por mosquito mais frequente no planeta. No Brasil a incidência vem aumentando em sucessivas epidemias, com uma proporção crescente de casos graves. A qualidade da assistência prestada influencia diretamente o prognóstico da doença. Estas recomendações apresentam o manejo das formas graves de dengue, incluindo o reconhecimento de sinais de alerta, o tratamento visando o pronto re-estabelecimento da euvolemia e a avaliação e cuidado das potenciais complicações, no intuito de reduzir a morbi-mortalidade de crianças e adultos infectados.

Dengue is the most common vector-borne viral infection worldwide. In Brazil, the incidence has increased with successive epidemics, and an increasing proportion of patients present with severe forms of the disease. The prognosis for these patients is directly influenced by the quality of medical care. These guidelines present the management of the severe forms of dengue, including the recognition of warning signs, the treatment for prompt re-establishment of euvolemia and the evaluation and appropriate care of potential complications, thus reducing morbidity and mortality of infected children and adults.

A importância de se avaliar a função dos ventrículos direito e esquerdo na síndrome do desconforto respiratório agudo / The importance of evaluating right and left ventricular function in acute respiratory distress syndrome

Este artigo de revisão examina as evidências que ligam a síndrome de desconforto respiratório agudo com a hipertensão arterial pulmonar e a consequente interferência sobre a performance ventricular. Destaca-se a importância de se avaliar as alterações do ventrículo direito e esquerdo à luz da fisiopatologia, somados ao impacto no desfecho clínico. Uma ampla busca no PubMed foi realizada utilizando os descritores válidos do Medical Subject Headings (MeSH) da seguinte maneira: “Ventricular Function, Right”[MeSH] OR “Ventricular Function, Left”[MeSH] AND “Respiratory Distress Syndrome, Adult”[MeSH], com a finalidade de seleção de artigos que abordem esse tema, incluindo revisões. Os autores fazem considerações sobre a importância de uma “visão protetora ampla”, não somente aquelas restritas às ações terapêuticas sobre a injúria pulmonar, que envolvem, por exemplo, diferentes estratégias ventilatórias menos lesivas, mas também destacam a importância de se identificar e manusear precocemente os desequilíbrios cardiocirculatórios presentes nesse cenário.

This review article examines the best scientific evidence related to acute respiratory distress syndrome and acute pulmonary hypertension, with an emphasis on how right ventricular function should be managed in this scenario, especially in terms of its effect on left ventricular function. We conducted a search of the Medline (PubMed) database, employing search strings such as “Ventricular Function, Right”[MeSH] OR “Ventricular Function, Left”[MeSH]) AND “Respiratory Distress Syndrome, Adult”[MeSH]. A broad range of articles were identified, and we selected the main articles highlighting the subject under study, including other review articles. On the basis of the data reviewed, we believe that it is crucial to adopt a “wider view of protection” that is not restricted to therapeutic interventions for pulmonary injury such as distinct open-lung strategies, that cause less harm. In addition, the early identification and monitoring of cardiovascular dysfunction, often present in these settings, is of great importance.

Qualidade em terapia intensiva / Intensive care unit quality

JUSTIFICATIVA E OBJETIVOS: A Unidade de Terapia Intensiva é um setor de alta complexidade no ambiente hospitalar. A monitoração da qualidade de serviços prestados torna-se a cada dia fundamental para segurança do paciente crítico. O objetivo deste estudo foi realizar uma revisão de conceitos e práticas úteis na melhoria contínua do atendimento do paciente grave. CONTEÚDO: Revisão de literatura sobre qualidade e segurança em Medicina Intensiva, incluindo modelos de outras áreas de conhecimento agora aplicados na gestão de uma Unidade de Terapia Intensiva. CONCLUSÃO: A utilização de conceitos e práticas que envolvem análise de processos e desfechos é fundamentalno processo de melhoria contínua e na segurança do atendimento do paciente crítico. Modelos vindos de áreas como administração e engenharia de produção podem ser adaptados em Medicina Intensiva, facilitando fluxos internos e equilibrando uma boa prática médica com controle adequado de custos.

Transfusão de hemácias em terapia intensiva: controvérsias entre evidências / Red blood cell transfusion in the intensive care setting: controversies amongst evidence

A anemia é um problema prevalente nas unidades de terapia intensiva. Ela surge nos primeiros dias e pode sustentar-se, ou agravar-se, durante a internação. A etiologia normalmente é multifatorial. A transfusão de hemácias é a intervenção mais comumente utilizada para combatê-la. Aproximadamente 12 milhões de unidades de sangue são utilizadas para transfusões nos Estados Unidos, sendo 25 por cento a 30 por cento dentro das terapias intensivas. A maior segurança com a diminuição das infecções provocadas por transfusões permitiu uma ampliação de indicações clínicas. No entanto, a terapia transfusional está associada a outros efeitos adversos, como infecções nosocomiais, comprometimento imunológico, injúria pulmonar, reações hemolíticas e aumento da incidência de câncer. Alguns trabalhos já tentaram demonstrar associação entre a correção da anemia, mortalidade e morbidade, entretanto a literatura ainda não alcançou um consenso. Atualmente, uma das propostas de segurança da Organização Mundial de Saúde é a redução de transfusões potencialmente desnecessárias, promovendo uma postura de transfusão racional. Esta revisão narrativa pretende abordar como objetivo primário as controvérsias referentes ao limiar transfusional, de acordo com estudos recentes, e como objetivos secundários citar aspectos da anemia iatrogênica e da variabilidade de atitudes entre intensivistas para a implementação das melhores práticas relativas à transfusão. Não faz parte de nossos objetivos discutir as complicações transfusionais, embora tenham sido mencionadas. Foi feita busca em fontes eletrônicas da literatura médica (PubMed - Clinical Queries), e UpToDate versão 16.2 e consulta adicional em livros texto Mostrou-se que a prática transfusional ainda é extremamente variada dentro das terapias intensivas. São escassas as evidências de que a hemotransfusão de rotina em pacientes não-hemorrágicos deva ser aplicada naqueles com hemoglobina superiores a 7 g/dL. Não existe ...

Anemia is a prevalent issue in intensive care units. It appears in the first days, and may continue or worsen during hospital stay. Its etiology is generally multifactorial. Red blood cell transfusion is the most common intervention for treating anemia. Approximately 12 million blood units are used for transfusions in the United States, 25 percent to 30 percent in the intensive care units. Due to reduction of transfusion infections the increased safety has allowed an expansion of clinical indications. However, transfusion therapy is associated with other adverse effects such as nosocomial infections, immunological impairment, lung injury, hemolytic reactions and higher cancer incidence. Various papers have tried to show an association between correction of anemia and mortality-morbidity, but no consensus has been reached in literature. One of the current World Health Organization's proposals is to reduce potentially unnecessary transfusions, promoting a rational transfusion attitude. The primary objective of this narrative review is to approach controversies regarding the transfusion threshold according to recent studies, and as a secondary objective, it aims to discuss iatrogenic anemia aspects and the different behaviors among intensivists on the best practices for implementation of transfusion practices. It is not within our objectives to discuss transfusion complications, although they are mentioned. A search was conducted on electronic literature databases (PubMed - Clinical Queries), and UpToDate 16.2, and additional consultation to textbooks. It became clear that transfusion practices are widely variable among intensive care units. Evidence is scarce that routine transfusion in non-hemorrhagic patients should be used in those with > 7 g/dL hemoglobin. There is no consensus on the transfusion threshold in critically ill patients. Cardiovascular disease patients seem to present a higher risk of death than non-cardiovascular patients, ...

Red blood cell transfusion in the intensive care setting: controversies amongst evidence. / Transfusão de hemácias em terapia intensiva: controvérsias entre evidências.

Anemia is a prevalent issue in intensive care units. It appears in the first days, and may continue or worsen during hospital stay. Its etiology is generally multifactorial. Red blood cell transfusion is the most common intervention for treating anemia. Approximately 12 million blood units are used for transfusions in the United States, 25% to 30% in the intensive care units. Due to reduction of transfusion infections the increased safety has allowed an expansion of clinical indications. However, transfusion therapy is associated with other adverse effects such as nosocomial infections, immunological impairment, lung injury, hemolytic reactions and higher cancer incidence. Various papers have tried to show an association between correction of anemia and mortality-morbidity, but no consensus has been reached in literature. One of the current World Health Organization's proposals is to reduce potentially unnecessary transfusions, promoting a rational transfusion attitude. The primary objective of this narrative review is to approach controversies regarding the transfusion threshold according to recent studies, and as a secondary objective, it aims to discuss iatrogenic anemia aspects and the different behaviors among intensivists on the best practices for implementation of transfusion practices. It is not within our objectives to discuss transfusion complications, although they are mentioned. A search was conducted on electronic literature databases (PubMed - Clinical Queries), and UpToDate 16.2, and additional consultation to textbooks. It became clear that transfusion practices are widely variable among intensive care units. Evidence is scarce that routine transfusion in non-hemorrhagic patients should be used in those with > 7 g/dL hemoglobin. There is no consensus on the transfusion threshold in critically ill patients. Cardiovascular disease patients seem to present a higher risk of death than non-cardiovascular patients, for any level of hemoglobin. Transfusion guided by hemoglobin levels and individual oxy-hemodynamic physiologic parameters and clinical context is apparently, the current best accepted strategy, rather than arbitrary and isolated hemoglobin correction.

Epidemiologia e desfecho de pacientes cirúrgicos não cardíacos em unidades de terapia intensiva no Brasil / Epidemiology and outcomes of non-cardiac surgical patients in Brazilian intensive care units

OBJETIVO: Devido aos avanços da medicina e ao envelhecimento da população, a proporção de pacientes em risco de morte após cirurgias está aumentando. Nosso objetivo foi avaliar o desfecho e a epidemiologia de cirurgias não cardíacas em pacientes admitidos em unidade de terapia intensiva. MÉTODOS: Estudo prospectivo, observacional, de coorte, realizado em 21 unidades de terapia intensiva. Um total de 885 pacientes adultos, cirúrgicos, consecutivamente admitidos em unidades de terapia intensiva no período de abril a junho de 2006 foi avaliado e destes, 587 foram incluídos. Os critérios de exclusão foram; trauma, cirurgias cardíacas, neurológicas, ginecológicas, obstétricas e paliativas. Os principais desfechos foram complicações pós-cirúrgicas e mortalidade na unidade de terapia intensiva e 90 dias após a cirurgia. RESULTADOS: Cirurgias de grande porte e de urgência foram realizadas em 66,4 por cento e 31,7 por cento, dos pacientes, respectivamente. A taxa de mortalidade na unidade de terapia intensiva foi de 15 por cento, e 38 por cento dos pacientes tiveram complicações no pós-operatório. A complicação mais comum foi infecção ou sepse (24,7 por cento). Isquemia miocárdica foi diagnosticada em apenas 1,9 por cento. Um total de 94 por cento dos pacientes que morreram após a cirurgia tinha co-morbidades associadas (3,4 ± 2,2). A principal causa de óbito foi disfunção de múltiplos órgãos (53 por cento). CONCLUSÃO: Sepse é a causa predominante de morbidade em pacientes submetidos a cirurgias não cardíacas. A grande maioria dos óbitos no pós-operatório ocorreu por disfunção de múltiplos órgãos.

OBJECTIVES: Due to the dramatic medical breakthroughs and an increasingly ageing population, the proportion of patients who are at risk of dying following surgery is increasing over time. The aim of this study was to evaluate the outcomes and the epidemiology of non-cardiac surgical patients admitted to the intensive care unit. METHODS: A multicenter, prospective, observational, cohort study was carried out in 21 intensive care units. A total of 885 adult surgical patients admitted to a participating intensive care unit from April to June 2006 were evaluated and 587 patients were enrolled. Exclusion criteria were trauma, cardiac, neurological, gynecologic, obstetric and palliative surgeries. The main outcome measures were postoperative complications and intensive care unit and 90-day mortality rates. RESULTS: Major and urgent surgeries were performed in 66.4 percent and 31.7 percent of the patients, respectively. The intensive care unit mortality rate was 15 percent, and 38 percent of the patients had postoperative complications. The most common complication was infection or sepsis (24.7 percent). Myocardial ischemia was diagnosed in only 1.9 percent of the patients. A total of 94 percent of the patients who died after surgery had co-morbidities at the time of surgery (3.4 ± 2.2). Multiple organ failure was the main cause of death (53 percent). CONCLUSION: Sepsis is the predominant cause of morbidity in patients undergoing non-cardiac surgery. In this patient population, multiple organ failure prevailed as the most frequent cause of death in the hospital.

Como implementar cuidados paliativos de qualidade na unidade de terapia intensiva / How to implement quality in palliative care at intensive care unit

JUSTIFICATIVA E OBJETIVOS: Os cuidados paliativos têm como objetivo a prevenção e o alívio do sofrimento, melhorando a comunicação e o sinergismo com a terapêutica curativa. Esta filosofia de tratamento conjuga os valores dos pacientes e de seus familiares, facilitando as transferências entre os vários setores intra-hospitalares, que possam estar conduzindo um paciente com grave risco de vida. CONTEÚDO: Apesar de ainda estar se desenvolvendo em todo o mundo, os cuidados paliativos estão progressivamente integrando-se aos cuidados curativos, inclusive nos ambientes de terapia intensiva. Entretanto, várias evidências têm demonstrado que esta abordagem médica ainda precisa melhorar, seja para os pacientes com sintomas de desconforto significativos ou dores físicas, nas unidades de terapia intensiva, ou na percepção dos familiares, que também é falha, sobretudo no que cerne às recomendações básicas como as intervenções diagnósticas, prognósticas e terapêuticas. CONCLUSÕES: O desenvolvimento de pesquisa nesta área promoverá indicadores de desempenho, o que nos garantirá eficiência, qualidade operacional, e melhoria constante desses cuidados. Este artigo destaca a importância da medicina paliativa e propõe alternativas e planos para promoção de uma abordagem paliativa em tempo apropriado, no sentido de tornar a medicina geral mais próxima dos valores e dignidade humana.

BACKGROUND AND OBJECTIVES: Palliative care has the objective of preventing and relieving suffering by improving communication and synergism with curative therapy. This philosophy of treatment combines the patients' values and their families and facilitates the movement in various hospital departments, which might occur with critically ill patients. CONTENTS: Though still little developed in the world, palliative care is gradually integrating curative care in intensive care units. However, various pieces of evidence have been showing that there is still a necessity to improve, especially for patients with symptoms of discomfort and pain, in intensive care environments. The patients' families still have a poor understanding of the basic recommendations: diagnostic, prognostic and therapeutic interventions. CONCLUSIONS: Development of research in this area can promote performance indicators trying to ensure efficiency, operational quality, and constant improvement of care. This article highlights the importance of palliative medicine and proposes alternatives to promoting an appropriate time approach, bringing general medicine closer to human values.

Epidemiology and outcomes of non-cardiac surgical patients in Brazilian intensive care units. / Epidemiologia e desfecho de pacientes cirúrgicos não cardíacos em unidades de terapia intensiva no Brasil.

OBJECTIVES: Due to the dramatic medical breakthroughs and an increasingly ageing population, the proportion of patients who are at risk of dying following surgery is increasing over time. The aim of this study was to evaluate the outcomes and the epidemiology of non-cardiac surgical patients admitted to the intensive care unit. METHODS: A multicenter, prospective, observational, cohort study was carried out in 21 intensive care units. A total of 885 adult surgical patients admitted to a participating intensive care unit from April to June 2006 were evaluated and 587 patients were enrolled. Exclusion criteria were trauma, cardiac, neurological, gynecologic, obstetric and palliative surgeries. The main outcome measures were postoperative complications and intensive care unit and 90-day mortality rates. RESULTS: Major and urgent surgeries were performed in 66.4% and 31.7% of the patients, respectively. The intensive care unit mortality rate was 15%, and 38% of the patients had postoperative complications. The most common complication was infection or sepsis (24.7%). Myocardial ischemia was diagnosed in only 1.9% of the patients. A total of 94 % of the patients who died after surgery had co-morbidities at the time of surgery (3.4 ± 2.2). Multiple organ failure was the main cause of death (53%). CONCLUSION: Sepsis is the predominant cause of morbidity in patients undergoing non-cardiac surgery. In this patient population, multiple organ failure prevailed as the most frequent cause of death in the hospital.

Anemia e transfusões de concentrados de hemácias em pacientes graves nas UTI brasileiras (pelo FUNDO-AMIB) / Transfusion practices in brazilian Intensive Care Units (pelo FUNDO-AMIB)

JUSTIFICATIVA E OBJETIVOS: A anemia é uma condição comum em pacientes graves. A transfusão de hemoderivados aumenta de forma significativa o risco de transmissão de agentes infecciosos e afeta o perfil imunológico. O objetivo deste estudo foi avaliar a incidência de anemia e a prática de transfusão de hemácias em UTI brasileiras. MÉTODO: Estudo prospectivo, multicêntrico, realizado em 19 UTI em um período de duas semanas. A presença de anemia, as indicações e a utilização de concentrados de hemácias, foram avaliadas diariamente. As complicações que ocorreram durante a internação na UTI e após a transfusão da primeira unidade de concentrado de hemácias foram registradas. RESULTADOS: Um total de 33 por cento apresentava anemia na admissão na UTI e esta proporção aumentou para 55 por cento no final de sete dias de internação. Um total de 348 unidades de concentrado de hemácias foi transfundido em 86 pacientes (36,5 por cento). A média de suas unidades por paciente foi 4,1 ± 3,3 U. O nível de hemoglobina limiar para a transfusão de CH foi 7,7 ± 1,1 g/dL. Pacientes transfundidos tinham mais disfunções orgânicas avaliadas pelo escore SOFA (7,9 ± 4,6 versus 5,6 ± 3,8, transfundidos versus não transfundidos, p < 0,05). As taxas de mortalidade foram 43,5 por cento e 36,3 por cento em pacientes transfundidos e não transfundidos, respectivamente (RR 0,61-11,7, NS). Pacientes transfundidos tiveram número maior de complicações (1,58 ± 0,66 versus 1,33 ± 0,49, p = 0,0001). CONCLUSÕES: A anemia é comum em UTI brasileiras. O limiar transfusional de hemoglobina foi menor do que o observado em outros paises.

BACKGROUND AND OBJECTIVES: Anemia of critical illness is a multifactorial condition caused by blood loss, frequent phlebotomies and inadequate production of red blood cells (RBC). Controversy surrounds the most appropriate hemoglobin concentration "trigger" for transfusion of RBC. We aimed to evaluate transfusion practices in Brazilian ICUs. METHODS: A prospective study throughout a 2-week period in 19 Brazilian ICUs. Hemoglobin (Hb) level, transfusion rate, organ dysfunction assessment and 28-day mortality were evaluated. Primary indication for transfusion and pretransfusion hemoglobin level were collected for each transfusion. RESULTS: Two hundred thirty-one patients with an ICU length of stay longer than 48h were included. An Hb level lower than 10 g/dL was found in 33 percent on admission in the ICU. A total of 348 RBC units were transfused in 86 patients (36.5 percent). The mean pretransfusion hemoglobin level was 7.7 ± 1.1 g/dL. Transfused-patients had significantly higher SOFA score (7.9 ± 4.6 vs 5.6 ± 3.8, p < 0.05, respectively), days on mechanical ventilation (10.7 ± 8.2 vs 7.2 ± 6.4, p < 0.05) and days on vasoactive drugs (6.7 ± 6.4 vs 4.2 ± 4.0, p < 0.05) than non-transfused patients despite similar APACHE II scores (15.2 ± 8.1 vs 14.2 ± 8.1, NS). Transfused patients had higher mortality rate (43.5 percent) than non-transfused patients (36.3 percent) (RR 0.60-1.15, NS). Only one patient (0.28 percent) had febrile non-hemolytic transfusion and urticarial reactions. CONCLUSIONS: Anemia is common in critically ill patients.It seems from the present study that transfusion practices in Brazil have had a more restrictive approach with a lower limit "transfusion trigger".

Parte II: monitorização hemodinâmica básica e cateter de artéria pulmonar / Part II: basic hemodynamic monitoring and the use of pulmonary artery catheter

JUSTIFICATIVA E OBJETIVOS: A monitorização de funções vitais é uma das mais importantes e essenciais ferramentas no manuseio de pacientes críticos na UTI. Hoje é possível detectar e analisar uma grande variedade de sinais fisiológicos através de diferentes técnicas, invasivas e não-invasivas. O intensivista deve ser capaz de selecionar e executar o método de monitorização mais apropriado de acordo com as necessidades individuais do paciente, considerando a relação risco-benefício da técnica. Apesar do rápido desenvolvimento de técnicas de monitorização não-invasiva, a monitorização hemodinâmica invasiva com o uso do cateter de artéria pulmonar (CAP) ainda é um dos procedimentos fundamentais em UTI. O objetivo destas recomendações é estabelecer diretrizes para o uso adequado dos métodos básicos de monitorização hemodinâmica e CAP. MÉTODO: O processo de desenvolvimento de recomendações utilizou o método Delphi modificado para criar e quantificar o consenso entre os participantes. A AMIB determinou um coordenador para o consenso, o qual escolheu seis especialistas para comporem o comitê consultivo. Outros 18 peritos de diferentes regiões do país foram selecionados para completar o painel de 25 especialistas, médicos e enfermeiros. Um levantamento bibliográfico na MedLine de artigos na língua inglesa foi realizado no período de 1966 a 2004. RESULTADOS: Foram apresentadas recomendações referentes a 55 questões sobre monitorização da pressão venosa central, pressão arterial invasiva e cateter de artéria pulmonar. Com relação ao CAP, além de recomendações quanto ao uso correto foram discutidas as indicações em diferentes situações clínicas. CONCLUSÕES: A avaliação da pressão venosa central e da pressão arterial, além das variáveis obtidas com o CAP permite o entendimento da fisiologia indispensável para o cuidado de pacientes graves. Entretanto, a correta utilização dessas ferramentas é fundamental para os possíveis benefícios decorrentes do uso.

BACKGROUND AND OBJECTIVES: Monitoring of vital functions is one of the most important tools in the management of critically ill patients. Nowadays is possible to detect and analyze a great deal of physiologic data using a lot of invasive and non-invasive methods. The intensivist must be able to select and carry out the most appropriate monitoring technique according to the patient requirements and taking into account the benefit/risk ratio. Despite the fast development of non invasive monitoring techniques, invasive hemodynamic monitoring using Pulmonary Artery Catheter still is one of the basic procedures in Critical Care. The aim was to define recommendations about clinical utility of basic hemodynamic monitoring methods and the Use of Pulmonary Artery Catheter. METHODS: Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty-five physicians and nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MEDLINE in the period from 1996 to 2004. RESULTS: Recommendations were made based on 55 questions about the use of central venous pressure, invasive arterial pressure, pulmonary artery catheter and its indications in different settings. CONCLUSIONS: Evaluation of central venous pressure and invasive arterial pressure, besides variables obtained by the PAC allow the understanding of cardiovascular physiology that is of great value to the care of critically ill patients. However, the correct use of these tools is fundamental to achieve the benefits due to its use.

Consenso brasileiro de monitorização e suporte hemodinâmico - parte III: métodos alternativos de monitorização do débito cardíaco e da volemia / Brazilian consensus of monitoring and hemodynamic support - part III: alternative methods for cardiac output monitoring and volemia estimation

JUSTIFICATIVA E OBJETIVOS: A interpretação do débito cardíaco e da pré-carga como números absolutos não traz grandes informações sobre a hemodinâmica do paciente crítico. Em contrapartida, a monitorização da resposta do débito cardíaco à expansão volêmica ou suporte inotrópico é uma ferramenta muito útil na unidade de terapia intensiva, quando o paciente apresenta algum sinal de má perfusão tecidual. Apesar do CAP ser considerado como " padrão-ouro" na avaliação destes parâmetros, foram desenvolvidas tecnologias alternativas bastante confiáveis para a sua monitorização. MÉTODO: O processo de desenvolvimento de recomendações utilizou o método Delphi modificado para criar e quantificar o consenso entre os participantes. A AMIB determinou um coordenador para o consenso, o qual escolheu seis especialistas para comporem o comitê consultivo. Outros 18 peritos de diferentes regiões do país foram selecionados para completar o painel de 25 especialistas, médicos e enfermeiros. Um levantamento bibliográfico na MEDLINE de artigos na língua inglesa foi realizado no período de 1966 a 2004. RESULTADOS: Foram apresentadas recomendações referentes à análise da variação da pressão arterial durante ventilação mecânica, débito cardíaco contínuo por contorno de pulso arterial, débito cardíaco por diluição do lítio, Doppler transesofágico, bioimpedância transtorácica, ecocardiografia e reinalação parcial de gás carbônico. CONCLUSÕES: As novas e menos invasivas técnicas para medida do débito cardíaco, pré-carga e fluidoresponsividade apresentam adequada precisão e podem ser uma alternativa ao uso do CAP em pacientes graves.

BACKGROUND AND OBJECTIVES: Cardiac output and preload as absolute data do not offer helpful information about the hemodynamic of critically ill patients. However, monitoring the response of these variables to volume challenge or inotropic drugs is a very useful tool in the critical care setting, particularly for patients with signs of tissue hypoperfusion. Although PAC remains the " gold standard" to measure cardiac output and preload, new and alternative technologies were developed to evaluate these hemodynamic variables. METHODS: Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty three physician and two nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MEDLINE in the period from 1996 to 2004. RESULTS: Recommendations regarding the use of arterial pulse pressure variation during mechanical ventilation, continuous arterial pulse contour and lithium dilution cardiac output measurements, esophageal Doppler waveform, thoracic electrical bioimpedance, echocardiography and partial CO2 rebreathing for monitoring cardiac output and preload were created. CONCLUSIONS: The new and less invasive techniques for the measurement of cardiac output, preload or fluid responsiveness are accurate and may be an alternative to PAC in critically ill patients.