Long-Term Mortality and Health-Related Quality of Life After Continuous Versus Intermittent Renal Replacement Therapy in ICU Survivors: A Secondary Analysis of the Quality of Life After ICU Study.

Purpose: We assessed long-term outcomes in intensive care unit (ICU) survivors with acute kidney injury (AKI) submitted to intermittent or continuous renal replacement therapy (RRT) for comparisons between groups. Methods: The multicenter prospective cohort study included 195 adult ICU survivors with an ICU stay >72 h in 10 ICUs that had at least one episode of AKI treated with intermittent RRT (IRRT) or continuous RRT (CRRT) during ICU stay. The main outcomes were mortality and health-related quality of life (HRQoL). Hospital readmissions and physical dependence were also assessed. Results: Regarding RRT, 83 (42.6%) patients received IRRT and 112 (57.4%) received CRRT. Despite the similarity regarding sociodemographic characteristics, pre-ICU state of health and type of admission between groups, the risk of death (23.5% vs 42.7%; P < .001), the prevalence of sepsis (60.7%) and acute respiratory distress syndrome (17%) were higher at ICU admission among CRRT patients. The severity of critical illness was higher among CRRT patients, regarding the need for mechanical ventilation (75.0% vs 50.6%, P = .002) and vasopressors (91.1% vs 63.9%, P < .001). One year after ICU discharge, 67 of 195 ICU survivors died (34.4%) and, after adjustment for confounders, there were no significant differences in mortality when comparing IRRT and CRTT patients (34.9% vs 33.9%; P = .590), on HRQoL in both physical (41.9% vs 42.2%; P = .926) and mental dimensions (57.6% vs 56.6%; P = .340), and on the number of hospital readmissions and physical dependence. Conclusions: Our study suggests that among ICU survivors RRT modality (IRRT vs CRRT) in the ICU does not impact long-term outcomes after ICU discharge.

Waiting for ICU admission may increase the risk of death-A plea for better resource organization.

BACKGROUND: Mortality is high in critically ill patients. In order to study the risk factors associated with mortality in these patients, we conducted an observational retrospective study in the general Intensive Care Unit (ICU) of Faro Hospital. METHODS: All patients discharged from the general ICU in the year 2015 were evaluated for inclusion. Mortality was characterized in the first 48 hours of ICU stay, at the time of discharge from ICU, and at discharge from hospital. Collected variables included demographic variables (age), and ICU variables: type of ICU admission (scheduled surgery, urgent surgery, medical and trauma), Simplified Acute Physiology Score (SAPS II), main diagnosis, hospital length of stay (HLS) before ICU (BICULS), in ICU (ICULS) and after ICU (AICULS). RESULTS: When comparing survivors with non-survivors, we found that age, disease severity expressed by SAPS II and BICULS were significantly higher in non-survivors. After multivariate regression analysis, BICULS was still significantly associated with mortality in the hospital. CONCLUSION: Further studies are needed to characterize whether this longer BICULS is related to non-modifiable prior conditions or whether it is related to delayed ICU admission, which is a modifiable factor.

A new global health outcome score after trauma (GHOST) for disability, cognitive impairment, and health-related quality of life: data from a prospective cross-sectional observational study.

Background:Trauma patients experience morbidity related to disability and cognitive impairment that negatively impact their health-related quality of life (HRQoL). We assessed the impact of trauma on disability, cognitive impairment and HRQoL after intensive care in patients with and without traumatic brain injury (TBI) and created a predictive score to identify patients with worse outcome. Methods:We identified 262 patients with severe trauma (ISS>15) admitted to the emergency room of a level 1 trauma center. Patients above 13 years were included. After 6 months, patients were assessed for disability, cognitive impairment, and HRQoL. A global health outcome score after trauma (GHOST) was obtained through the combination of these domains. Logistic regression analysis was considered for the effect of demographic, trauma and hospital factors on global outcome. p > 0.05. Statistics performed with SPSS 23.0. Results:Patients with the worst outcomes were older and had a longer length of Intensive Care Unit (ICU) stay. The effect of gender was found in all "GHOST dimensions". TBI was not significantly associated with worse outcome. Conclusions:No significant differences were seen on disability, cognitive impairment and decreased HRQoL in patients with or without TBI. Our GHOST score showed that female gender, older age, and longer ICU stay were significantly associated with the worst outcome. Abbreviations: AIS: Abbreviated Injury Scale; EQ-5D: EuroQol 5-dimensions; EQ-5D-3L: EuroQol 5-dimensions 3-levels; GCS: Glasgow Coma Scale; GOSE: Glasgow Outcome Scale Extended; HRQoL: Health-Related Quality of Life; ICU: Intensive Care Unit; ISS: Injury Severity Score; MMS: Mini Mental State; NICE: National Institute for Health and Care Excellence; RTS: Revised Trauma Score; TBI: Traumatic brain injury; TRISS: Trauma Injury Severity Score; VAS: Visual Analogue Scale.

Modulating Influence of State Anxiety on the Effect of Midazolam on Postsurgical Pain.

Anxiety contributes to postsurgical pain, and midazolam is frequently prescribed preoperatively. Conflicting results have been described concerning the impact of midazolam on pain. This study aims to evaluate the effect of systemic midazolam on pain after open inguinal hernia repair, clarifying its relationship with preoperative anxiety. A prospective observational cohort study was conducted in three Portuguese ambulatory units between September 2018 and March 2020. Variable doses of midazolam were administered. Postsurgical pain was evaluated up to three months after surgery. We enrolled 306 patients and analyzed 281 patients. The mean preoperative anxiety Numeric Rating Scale score was 4 (3) and the mean Surgical Fear Questionnaire score was 22 (16); the mean midazolam dose was 1.7 (1.1) mg with no correlation to preoperative anxiety scores. Pain ≥4 was present in 67% of patients 24 h after surgery and in 54% at seven days; at three months, 27% were classified as having chronic postsurgical pain. Preoperative anxiety correlated to pain severity at all time points. In multivariable regression, higher midazolam doses were associated with less pain during the first week, with no apparent effect on chronic pain. However, subgroup analyses uncovered an effect modification according to preoperative anxiety: the decrease in acute pain occurred in the low-anxiety patients with no effect on the high-anxiety group. Inversely, there was an increase in chronic postsurgical pain in the very anxious patients, without any effect on the low-anxiety group. Midazolam, generally used as an anxiolytic, might impact distinctively on pain depending on anxiety.

Predictors of early and long-term mortality after ICU discharge in critically ill COVID-19 patients: A prospective cohort study.

BACKGROUND: To mitigate mortality among critically ill COVID-19 patients, both during their Intensive Care Unit (ICU) stay and following ICU discharge, it is crucial to measure its frequency, identify predictors and to establish an appropriate post-ICU follow-up strategy. METHODS: In this multicentre, prospective cohort study, we included 586 critically ill COVID-19 patients. RESULTS: We observed an overall ICU mortality of 20.1% [95%CI: 17.1% to 23.6%] (118/586) and an overall hospital mortality of 25.4% [95%CI: 22.1% to 29.1%] (149/586). For ICU survivors, 30 days (early) post-ICU mortality was 5.3% [95%CI: 3.6% to 7.8%] (25/468) and one-year (late) post-ICU mortality was 7.9% [95%CI: 5.8% to 10.8%] (37/468). Pre-existing conditions/comorbidities were identified as the main independent predictors of mortality after ICU discharge: hypertension and heart failure were independent predictors of early mortality; and hypertension, chronic kidney disease, chronic obstructive pulmonary disease and cancer were independent predictors of late mortality. CONCLUSION: Early and late post-ICU mortality exhibited an initial surge (in the first 30 days post-ICU) followed by a subsequent decline over time. Close monitoring of critically ill COVID-19 post-ICU survivors, especially those with pre-existing conditions, is crucial to prevent adverse outcomes, reduce mortality and to establish an appropriate follow-up strategy.

Sedation, analgesia, and delirium management in Portugal: a survey and point prevalence study. / Abordagem da sedação, da analgesia e do delirium em Portugal: inquérito nacional e estudo de prevalência.

OBJECTIVE: To establish current Portuguese critical care practices regarding analgesia, sedation, and delirium based on a comparison between the activities reported and daily clinical practice. METHODS: A national survey was conducted among physicians invited to report their practice toward analgesia, sedation, and delirium in intensive care units. A point prevalence study was performed to analyze daily practices. RESULTS: A total of 117 physicians answered the survey, and 192 patients were included in the point prevalence study. Survey and point prevalence studies reflect a high sedation assessment (92%; 88.5%), with the Richmond Agitated Sedation Scale being the most reported and used scale (41.7%; 58.2%) and propofol being the most reported and used medication (91.4%; 58.6%). Midazolam prescribing was reported by 68.4% of responders, but a point prevalence study revealed a use of 27.6%.Although 46.4% of responders reported oversedation, this was actually documented in 32% of the patients. The survey reports the daily assessment of pain (92%) using standardized scales (71%). The same was identified in the point prevalence study, with 91.1% of analgesia assessment mainly with the Behavioral Pain Scale. In the survey, opioids were reported as the first analgesic. In clinical practice, acetaminophen was the first option (34.6%), followed by opioids. Delirium assessment was reported by 70% of physicians but was performed in less than 10% of the patients. CONCLUSION: The results from the survey did not accurately reflect the common practices in Portuguese intensive care units, as reported in the point prevalence study. Efforts should be made specifically to avoid oversedation and to promote delirium assessment.

OBJETIVO: Determinar as práticas atuais de cuidados intensivos em Portugal quanto à analgesia, à sedação e ao delirium, com base em uma comparação entre as atividades relatadas e a prática clínica diária. MÉTODOS: Inquérito nacional em que os médicos foram convidados a relatar sua prática em relação à analgesia, à sedação e ao delirium em unidades de terapia intensiva. Para analisar a prática diária, realizou-se um estudo de prevalência pontual. RESULTADOS: Responderam ao inquérito 117 médicos, e 192 pacientes foram incluídos no estudo de prevalência pontual. O inquérito e o estudo de prevalência mostraram uma avaliação generalizada do nível de sedação (92%; 88,5%). A Escala de Agitação e Sedação de Richmond foi a mais reportada e utilizada (41,7%; 58,2%), e o propofol foi o medicamento mais reportado e utilizado (91,4%; 58,6%). A prescrição de midazolam foi relatada por 68,4% dos respondentes, mas o estudo de prevalência pontual revelou a sua utilização em 27,6%.Embora 46,4% dos respondentes tenham relatado excesso de sedação, na realidade foi documentado em 32% dos pacientes. O inquérito relatou avaliação diária de dor (92%) com uso de escalas padronizadas (71%). Identificou-se resultado semelhante no estudo de prevalência pontual, com 91,1% de avaliação da analgesia feita principalmente com a Escala Comportamental de Dor. No inquérito, os opioides foram relatados como analgésicos de primeira linha. Na prática clínica, o paracetamol foi a primeira opção (34,6%), seguido de opioides. A avaliação do delirium foi relatada por 70% dos médicos, embora tenha sido realizada em menos de 10% dos pacientes. CONCLUSÃO: Os resultados do inquérito não refletiram com precisão as práticas habituais nas unidades de terapia intensiva portuguesas, tal como relatado no estudo de prevalência pontual. Devem ser feitos esforços principalmente para evitar o excesso de sedação e promover a avaliação do delirium.

Children's Understanding of Informed Assents in Research Studies.

The assent procedure reflects an effort to enable the minor to understand, to the degree they are capable of, what their participation in the decision making process would involve. AIMS: To evaluate the minors' ability to understand the information provided to them when obtaining assent and to evaluate the opinion of the parents regarding the importance of asking the child's assent. METHODS: The sample included a total of 52 minors aged between 10 and 17 years who underwent exercise echocardiogram. The Quality of Informed Consent is divided into two parts: Part A was used to measure objective understanding and part B to measure subjective understanding. RESULTS: The results show that the minors have a high capacity to understand the information given to them when asking for assent. A positive relationship was found between the two parts of the questionnaire. No statistically significant relationship was found between age and sex and part A and part B or between both age groups (<14 years old and ≥14 years old) and the measure. In the case of the parents, 96.6% of parents consider assent as an advantage for the child's acceptance of health care. The opinion of the parents is not related to the age, sex or level of schooling. CONCLUSION: Minors showed a substantial level of understanding regarding the information provided to them. The parents considered the implementation of assent fundamental to the child's acceptance of health care.

Effectiveness of Delayed Intrapleural Alteplase Instillation for Infected Residual Traumatic Hemothorax. Case Report.

In thoracic trauma, many cases may present with hemothorax, and, of those, a portion can complicate in empyema. These cases can reveal themselves to be of difficult management, particularly in peripheral hospitals with complicated access to thoracic surgery. Intrapleural fibrinolytic instillation can be of use and has been widely reported, mostly in the case of empyema. In the literature, the use of fibrinolytics in hemothorax mostly pertained to the older fibrinolytics, such as streptokinase and urokinase. Recent studies describe the use of alteplase in these patients but mostly in the first days after the trauma, when it becomes clear that the first chest tube is not being effective. We report a case of residual traumatic hemothorax that could not be evacuated after multiple chest tubes placements and was finally cleared after instillation of alteplase late in the course of the disease.

Surviving cardiac arrest: What happens after admission to the intensive care unit?

INTRODUCTION: Patients successfully resuscitated from cardiac arrest (CA) are admitted to the intensive care unit (ICU) for post-resuscitation care. These patients' prognosis remains dismal, with only a minority surviving to hospital discharge. Understanding the clinical factors involved in the management of these patients is essential to improve their prognosis. OBJECTIVES: To characterize the population admitted after successful reanimation from CA, and to analyze the factors associated with their outcomes. METHODS: We performed a retrospective descriptive study of patients admitted to an ICU after CA over a five-year period from January 2014 to December 2018. Demographic factors, CA characteristics, early management, mortality and neurologic outcomes were analyzed. RESULTS: A total of 187 patients, median age 67 years, were admitted after CA, of whom 39% suffered out-of-hospital CA; 87% had an initial non-shockable rhythm and the most frequent presumed cause was cardiac (31%). In-hospital mortality was 63%. Significant neurologic dysfunction (cerebral performance category 3 or 4) was seen in 31% of survivors at hospital discharge. Non-immediate initiation of basic life support (BLS), higher Simplified Acute Physiology Score II score and longer relative duration of vasopressor support were independent predictors of in-hospital mortality, while shockable rhythms were associated with improved survival. Higher Glasgow coma scale at ICU discharge and shorter length of ICU stay were predictors of better neurologic outcome. CONCLUSION: This study highlights the positive prognostic impact of shockable rhythms, and confirms the importance of immediate initiation of BLS and prompt defibrillation, supporting the need for better training both outside and inside hospitals.

Surviving cardiac arrest: What happens after admission to the intensive care unit?

INTRODUCTION: Patients successfully resuscitated from cardiac arrest (CA) are admitted to the intensive care unit (ICU) for post-resuscitation care. These patients' prognosis remains dismal, with only a minority surviving to hospital discharge. Understanding the clinical factors involved in the management of these patients is essential to improve their prognosis. OBJECTIVES: To characterize the population admitted after successful reanimation from CA, and to analyze the factors associated with their outcomes. METHODS: We performed a retrospective descriptive study of patients admitted to an ICU after CA over a five-year period from January 2014 to December 2018. Demographic factors, CA characteristics, early management, mortality and neurologic outcomes were analyzed. RESULTS: A total of 187 patients, median age 67 years, were admitted after CA, of whom 39% suffered out-of-hospital CA; 87% had an initial non-shockable rhythm and the most frequent presumed cause was cardiac (31%). In-hospital mortality was 63%. Significant neurologic dysfunction (cerebral performance category 3 or 4) was seen in 31% of survivors at hospital discharge. Non-immediate initiation of basic life support (BLS), higher Simplified Acute Physiology Score II score and longer relative duration of vasopressor support were independent predictors of in-hospital mortality, while shockable rhythms were associated with improved survival. Higher Glasgow coma scale at ICU discharge and shorter length of ICU stay were predictors of better neurologic outcome. CONCLUSION: This study highlights the positive prognostic impact of shockable rhythms, and confirms the importance of immediate initiation of BLS and prompt defibrillation, supporting the need for better training both outside and inside hospitals.

Gut Microbiota Diversity and C-Reactive Protein Are Predictors of Disease Severity in COVID-19 Patients.

The risk factors for coronavirus disease 2019 (COVID-19) severity are still poorly understood. Considering the pivotal role of the gut microbiota on host immune and inflammatory functions, we investigated the association between changes in the gut microbiota composition and the clinical severity of COVID-19. We conducted a multicenter cross-sectional study prospectively enrolling 115 COVID-19 patients categorized according to: (1) the WHO Clinical Progression Scale-mild, 19 (16.5%); moderate, 37 (32.2%); or severe, 59 (51.3%), and (2) the location of recovery from COVID-19-ambulatory, 14 (household isolation, 12.2%); hospitalized in ward, 40 (34.8%); or hospitalized in the intensive care unit, 61 (53.0%). Gut microbiota analysis was performed through 16S rRNA gene sequencing, and the data obtained were further related to the clinical parameters of COVID-19 patients. The risk factors for COVID-19 severity were identified by univariate and multivariable logistic regression models. In comparison to mild COVID-19 patients, the gut microbiota of moderate and severe patients have: (a) lower Firmicutes/Bacteroidetes ratio; (b) higher abundance of Proteobacteria; and (c) lower abundance of beneficial butyrate-producing bacteria such as the genera Roseburia and Lachnospira. Multivariable regression analysis showed that the Shannon diversity index [odds ratio (OR) = 2.85, 95% CI = 1.09-7.41, p = 0.032) and C-reactive protein (OR = 3.45, 95% CI = 1.33-8.91, p = 0.011) are risk factors for severe COVID-19 (a score of 6 or higher in the WHO Clinical Progression Scale). In conclusion, our results demonstrated that hospitalized patients with moderate and severe COVID-19 have microbial signatures of gut dysbiosis; for the first time, the gut microbiota diversity is pointed out as a prognostic biomarker of COVID-19 severity.

Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomised, controlled trial.

INTRODUCTION: Patients recovering from critical illness have been shown to be at risk of developing Post Traumatic Stress disorder (PTSD). This study was to evaluate whether a prospectively collected diary of a patient's intensive care unit (ICU) stay when used during convalescence following critical illness will reduce the development of new onset PTSD. METHODS: Intensive care patients with an ICU stay of more than 72 hours were recruited to a randomised controlled trial examining the effect of a diary outlining the details of the patients ICU stay on the development of acute PTSD. The intervention patients received their ICU diary at 1 month following critical care discharge and the final assessment of the development of acute PTSD was made at 3 months. RESULTS: 352 patients were randomised to the study at 1 month. The incidence of new cases of PTSD was reduced in the intervention group compared to the control patients (5% versus 13%, P = 0.02). CONCLUSIONS: The provision of an ICU diary is effective in aiding psychological recovery and reducing the incidence of new PTSD. TRIAL REGISTRATION: NCT00912613.

Immediate and long-term impact of medical emergency teams on cardiac arrest prevalence and mortality: a plea for periodic basic life-support training programs.

OBJECTIVE: To evaluate whether the introduction of a program including a medical emergency team responding to widened criteria together with the institution-wide training on basic life support of all hospital staff would decrease cardiac arrest prevalence and mortality in patients at risk, in the immediate and long-term periods after the program. DESIGN: Before-after design. SETTING: Urban general hospital with 470 beds. PATIENTS: All patients admitted in the hospital between 2002 and 2006 were eligible. All patients with a medical emergency team activation were included. We compared cardiac arrest prevalence and mortality and in-hospital mortality before (2002), after (2003-2004), and long term after (2005-2006) the program implementation. MEASUREMENTS AND MAIN RESULTS: There was a significant (p = .037) decrease of 27% (95% confidence interval, 2%-46%) in cardiac arrest occurrence, 33% decrease (p = .014) in cardiac arrest mortality (95% confidence interval, 8%-52%), and a nonsignificant (p = .152) decrease of 17% (95% confidence interval, -7%-36%) in in-hospital mortality associated with the program implementation. No significant differences were found for any of the outcome variables between before and long term after periods. The main factor associated with in-hospital mortality was cardiac arrest. Factors affecting cardiac arrest were age, comorbidities, measures started before medical emergency team arrival and the intervention/program. The effect in the prevention of cardiac arrest has an adjusted relative risk, 0.646 (95% confidence interval, 0.450-0.876) and an absolute risk reduction of adjusted relative risk, 18% (95% confidence interval, 6%-29%). The program prevented one cardiac arrest for every five medical emergency team activations. CONCLUSIONS: Widening criteria for hospital emergency calls together with an integrated training program may reduce cardiac arrest prevalence and mortality in at-risk patients. Program effectiveness was critically related to the staff education, awareness, and responsiveness to physiologic instability of the patients. Long-term effectiveness of the program may decrease in the absence of periodic and continued implementation of educational interventions.

In-hospital cardiac arrest: factors in the decision not to resuscitate. The impact of an organized in-hospital emergency system.

AIM: To identify factors associated with "do-not-resuscitate" (DNR) decisions in patients who suffer cardiac arrest. METHODS: Hospital Pedro Hispano has an emergency system based on broad preset criteria of physiologic instability, which include airway compromise, bradypnea or tachypnea, bradycardia or tachycardia sustained hypotension, sudden loss of consciousness, decrease in the Glasgow coma scale, repeated and prolonged seizures, respiratory arrest and cardiac arrest. This retrospective study is based on data collected between January 2002 and August 2006. Variables studied included demographic characteristics (age and gender), comorbidities (neurological, cardiac and chronic renal disease, AIDS and cancer, classified as mild, moderate or severe), cardiac arrest variables (measures initiated before arrival of the medical emergency team [MET], including none, venous line, intravenous medication, endotracheal tube, manual ventilation, chest compressions, and external pacemaker; cause of cardiac arrest, classified as cardiac or noncardiac; and initial rhythm of cardiac arrest as shockable or non-shockable). Comparisons were made between the group of patients in which cardiopulmonary resuscitation (CPR) was performed and the group in which CPR was not performed. RESULTS: There were 649 MET calls, of which 227 were for cardiac arrest. In 91 of these patients CPR was not started or was stopped. Twenty-two (24%) of these patients had a DNR order in their clinical records, in 18 (20%) CPR was not started because it was considered futile, and in 47 (52%) CPR was stopped for the same reason. Age, cancer, and no measures having been initiated before arrival of the MET were significantly associated with the DNR decision. CONCLUSION: This is the first study aimed at identifying factors associated with DNR decisions in a Portuguese hospital with an organized emergency system. DNR decisions were taken in 33% of cases of cardiac arrest. Advanced age, cancer, and no measures initiated before arrival of the MET were associated with the DNR decision. These findings need to be confirmed in larger studies and should be taken into account when taking DNR decisions.

Understanding posttraumatic stress disorder-related symptoms after critical care: the early illness amnesia hypothesis.

OBJECTIVE: To assess the factual and delusional memories reported by intensive care unit survivors and its relationship with the development of Posttraumatic Stress Syndrome (PTSS). DESIGN: Multicenter observational cohort study. SETTING: Nine Portuguese intensive care units, as part of a multicenter study. METHODS AND PATIENTS: Between January and June 2005, 1,174 patients were admitted across the nine intensive care units. Two hundred thirty-nine patients were excluded, 14 with < 18 yrs old and 225 with a length of intensive care stay < or = 48 hrs. Thus a total of 935 patients were included in the study. One hundred ninety (20%) patients died in the intensive care unit, 90 (12%) patients died on the ward (30% in-hospital mortality rate), and another 56 (9%) died in the next 6 months after intensive care unit discharge. RESULTS: From the 599 survivors at 6 months, 313 patients answered the questionnaires (52% response rate). From the 313 respondents, 58% (n = 183) were men, median age was 59. The median Simplified Acute Physiology Score II was 37, median intensive care unit length of stay was 8 days, 57% (n = 177) of the patients were admitted for medical reasons. Forty percent (n = 116) of the respondents did not remember their admission to hospital, 48% (n = 142) did not remember the time in the hospital before intensive care unit admission, 73% (n = 220) had factual memories and 39% (n = 118) had delusional memories. Twenty-three percent (n = 66) stated that they had had intrusive memories. A higher number of "adverse" experiences were significantly associated with a higher PTSS-14 score. Eighteen percent (n = 54) of patients had a PTSS-14 score > 49, indicating a higher risk of developing posttraumatic stress disorder. A PTSS-14 score > 49 was significantly associated with not remembering the hospital stay before intensive care unit admission. CONCLUSION: Amnesia for the early period of critical illness (early amnesia) was positively associated with the level of posttraumatic stress disorder-related symptoms, which may be a proxy for severity of disease at the time of intensive care unit admission.

The emergency room--analysis and evaluation of an organizational model.

INTRODUCTION AND AIMS: The purpose of the emergency room is to treat critically ill patients and to prevent cardiac arrest in patients presenting with signs of physiological instability. This study has two main aims: 1) to describe the organizational model of the emergency room of Hospital Pedro Hispano based on 'chain of survival' principles; 2) to report an outcome analysis after the first year's operation with this organizational model. METHODS: Patients arriving at the emergency department of Hospital Pedro Hispano are processed by the Manchester Triage System. Patients presenting in a critical condition are coded red and immediately admitted to the emergency room. Patients classified as less critical but whose condition may worsen, with signs of physiological instability, are also admitted to the emergency room. This reflects the operating principles of the emergency room based on the prevention of cardiac arrest. All patients admitted to the emergency room have an emergency room chart, on which this study is based. RESULTS: Between May 1 2005 and April 30 2006, 1014 patients were admitted to the emergency room. Sixty-five percent of them were aged over 60 years. Altered consciousness was the most frequent reason for admission (17%), followed by respiratory failure (13%) and tachycardia (11%). Fifty-one patients (5%) were admitted after cardiac arrest. Sixty-six patients (7%) died in the emergency room, 57% of whom were admitted following cardiac arrest and 17% after shock of any etiology. A further 189 patients died during the course of their hospital stay after being discharged from the emergency room to other wards, which represents an overall mortality of 25%. CONCLUSION: Prevention and treatment of causes of cardiac arrest were the main reason for admission to the emergency room (altered consciousness, respiratory failure and tachycardia). Cardiac arrest was not among the main reasons for admission. However, when it occurs it has very high mortality; in the present study it was responsible for 5% of admissions and 53% of mortality. This organizational model may contribute to better use of resources as it enables re-orientation of patients to appropriate levels of care.

Abordagem da sedação, da analgesia e do delirium em Portugal: inquérito nacional e estudo de prevalência / Sedation, analgesia, and delirium management in Portugal: a survey and point prevalence study

RESUMO Objetivo: Determinar as práticas atuais de cuidados intensivos em Portugal quanto à analgesia, à sedação e ao delirium, com base em uma comparação entre as atividades relatadas e a prática clínica diária. Métodos: Inquérito nacional em que os médicos foram convidados a relatar sua prática em relação à analgesia, à sedação e ao delirium em unidades de terapia intensiva. Para analisar a prática diária, realizou-se um estudo de prevalência pontual. Resultados: Responderam ao inquérito 117 médicos, e 192 pacientes foram incluídos no estudo de prevalência pontual. O inquérito e o estudo de prevalência mostraram uma avaliação generalizada do nível de sedação (92%; 88,5%). A Escala de Agitação e Sedação de Richmond foi a mais reportada e utilizada (41,7%; 58,2%), e o propofol foi o medicamento mais reportado e utilizado (91,4%; 58,6%). A prescrição de midazolam foi relatada por 68,4% dos respondentes, mas o estudo de prevalência pontual revelou a sua utilização em 27,6%. Embora 46,4% dos respondentes tenham relatado excesso de sedação, na realidade foi documentado em 32% dos pacientes. O inquérito relatou avaliação diária de dor (92%) com uso de escalas padronizadas (71%). Identificou-se resultado semelhante no estudo de prevalência pontual, com 91,1% de avaliação da analgesia feita principalmente com a Escala Comportamental de Dor. No inquérito, os opioides foram relatados como analgésicos de primeira linha. Na prática clínica, o paracetamol foi a primeira opção (34,6%), seguido de opioides. A avaliação do delirium foi relatada por 70% dos médicos, embora tenha sido realizada em menos de 10% dos pacientes. Conclusão: Os resultados do inquérito não refletiram com precisão as práticas habituais nas unidades de terapia intensiva portuguesas, tal como relatado no estudo de prevalência pontual. Devem ser feitos esforços principalmente para evitar o excesso de sedação e promover a avaliação do delirium.

ABSTRACT Objective: To establish current Portuguese critical care practices regarding analgesia, sedation, and delirium based on a comparison between the activities reported and daily clinical practice. Methods: A national survey was conducted among physicians invited to report their practice toward analgesia, sedation, and delirium in intensive care units. A point prevalence study was performed to analyze daily practices. Results: A total of 117 physicians answered the survey, and 192 patients were included in the point prevalence study. Survey and point prevalence studies reflect a high sedation assessment (92%; 88.5%), with the Richmond Agitated Sedation Scale being the most reported and used scale (41.7%; 58.2%) and propofol being the most reported and used medication (91.4%; 58.6%). Midazolam prescribing was reported by 68.4% of responders, but a point prevalence study revealed a use of 27.6%. Although 46.4% of responders reported oversedation, this was actually documented in 32% of the patients. The survey reports the daily assessment of pain (92%) using standardized scales (71%). The same was identified in the point prevalence study, with 91.1% of analgesia assessment mainly with the Behavioral Pain Scale. In the survey, opioids were reported as the first analgesic. In clinical practice, acetaminophen was the first option (34.6%), followed by opioids. Delirium assessment was reported by 70% of physicians but was performed in less than 10% of the patients. Conclusion: The results from the survey did not accurately reflect the common practices in Portuguese intensive care units, as reported in the point prevalence study. Efforts should be made specifically to avoid oversedation and to promote delirium assessment.

The role of memories on health-related quality of life after intensive care unit care: an unforgettable controversy?

BACKGROUND: Decreased health-related quality of life (HRQoL) is a significant problem after an intensive care stay and is affected by several known factors such as age, sex, and previous health-state. The objective of this study was to assess the association between memory and self-reported perceived HRQoL of patients discharged from the intensive care unit (ICU). METHODS: A prospective, multicenter study involving nine general ICUs in Portugal. All adult patients with a length of stay >48 hours were invited to participate in a 6-month follow-up after ICU discharge by answering a set of structured questionnaires, including EuroQol 5-Dimensions and ICU memory tool. RESULTS: A total of 313 (52% of the eligible) patients agreed to enter the study. The median age of patients was 60 years old, 58% were males, the median Simplified Acute Physiology Score II (SAPS II) was 38, and the median length of stay was 8 days for ICU and 21 days for total hospital stay. Eighty-nine percent (n=276) of the admissions were emergencies. Seventy-eight percent (n=234) of the patients had memories associated with the ICU stay. Patients with no memories had 2.1 higher chances (P=0.011) of being in the bottom half of the HRQoL score (<0.5 Euro-Qol 5-Dimensions index score). Even after adjusting for pre-admission characteristics, having memories was associated with higher perceived HRQoL (adjusted odds ratio =2.1, P=0.022). CONCLUSION: This study suggests that most of the ICU survivors have memories of their ICU stay. For the ICU survivors, having memories of the ICU stay is associated with a higher perceived HRQoL 6 months after ICU discharge.

Patients' recollections of experiences in the intensive care unit may affect their quality of life.

INTRODUCTION: We wished to obtain the experiences felt by patients during their ICU stay using an original questionnaire and to correlate the memories of those experiences with health-related quality of life (HR-QOL). METHODS: We conducted a prospective study in 10 Portuguese intensive care units (ICUs). Six months after ICU discharge, an original questionnaire on experiences of patients during their ICU stay, the recollection questionnaire, was delivered. HR-QOL was evaluated simultaneously, with the EQ-5D questionnaire. Between 1 September 2002 and 31 March 2003 1433 adult patients were admitted. ICU and hospital mortalities were 21% and 28%, respectively. Six months after ICU discharge, 464 patients completed the recollection questionnaire. RESULTS: Thirty-eight percent of the patients stated they did not remember any moment of their ICU stay. The ICU environment was described as friendly and calm by 93% of the patients. Sleep was described as being good and enough by 73%. The experiences reported as being more stressful were tracheal tube aspiration (81%), nose tube (75%), family worries (71%) and pain (64%). Of respondents, 51% experienced dreams and nightmares during their ICU stay; of these, 14% stated that those dreams and nightmares disturb their present daily life and they exhibit a worse HR-QOL. Forty-one percent of patients reported current sleep disturbances, 38% difficulties in concentrating in current daily activities and 36% difficulties in remembering recent events. More than half of the patients reported more fatigue than before the ICU stay. Multiple and linear regression analysis showed that older age, longer ICU stay, higher Simplified Acute Physiology Score II, non-scheduled surgery and multiple trauma diagnostic categories, present sleep disturbances, daily disturbances by dreams and nightmares, difficulties in concentrating and difficulties in remembering recent events were independent predictors of worse HR-QOL. Multicollinearity analysis showed that, with the exception of the correlation between admission diagnostic categories and length of ICU stay (0.47), all other correlations between the independent variables and coefficient estimates included in the regression models were weak (below 0.30). CONCLUSION: This study suggests that neuropsychological consequences of critical illness, in particular the recollection of ICU experiences, may influence subsequent HR-QOL.

Quality of life in acute respiratory distress syndrome survivors may be no worst than in other ICU survivors.

OBJECTIVE: To compare the health-related quality of life (HR-QOL) in acute respiratory distress syndrome (ARDS) survivors with that in a matched control group of non-ARDS survivors. DESIGN AND SETTING: Prospective, matched, parallel cohort study, comparing HR-QOL between intensive care unit (ICU) survivors with ARDS and a control group in a tertiary care hospital. PATIENTS: Between May 1997 and December 2000, all ARDS adult patients of an eight-bed medical/surgical unit of a tertiary care hospital were enrolled and a control group of non-ARDS survivors, matched for severity of disease and for previous health state, was selected. The study included 29 ARDS survivors who answered the EQ-5D questionnaire and had lung function evaluated. MEASUREMENTS AND RESULTS: A follow-up appointment was performed 6 months after ICU discharge consisting of: (a) evaluation of HR-QOL using EQ-5D and (b) lung function tests and measure of diffusing capacity. Among ARDS survivors 41% had normal lung function and 59% mild to moderate lung function impairments. Nearly a one-third of ARDS survivors reported problems in one or more of the five dimensions of the EQ-5D, and 48% reported feeling worse at the interview than 6 month before ICU admission. No significant differences were found in HR-QOL between ARDS survivors and other ICU survivors with similar age and matched for previous health state and severity of disease. CONCLUSIONS: This study suggests that impairments in HR-QOL among ARDS survivors may not be distinguishable from that among other ICU survivors.