C-reactive protein, an early marker of community-acquired sepsis resolution: a multi-center prospective observational study.

INTRODUCTION: C-reactive protein (CRP) has been shown to be a valuable marker in the diagnosis of infection and in monitoring its response to antibiotics. Our objective was to evaluate serial CRP measurements after prescription of antibiotics to describe the clinical course of Community-Acquired Sepsis admitted to intensive care units (ICU). METHODS: During a 12-month period a multi-center, prospective, observational study was conducted, segregating adults with Community-Acquired Sepsis. Patients were followed-up during the first five ICU days, day of ICU discharge or death and hospital outcome. CRP-ratio was calculated in relation to Day 1 CRP concentration. Patients were classified according to the pattern of CRP-ratio response to antibiotics: fast response if Day 5 CRP-ratio was < 0.4, slow response if Day 5 CRP-ratio was between 0.4 and 0.8, and no response if Day 5 CRP-ratio was > 0.8. Comparison between survivors and non-survivors was performed. RESULTS: A total of 891 patients (age 60 ± 17 yrs, hospital mortality 38%) were studied. There were no significant differences between the CRP of survivors and non-survivors until Day 2 of antibiotic therapy. On the following three days, CRP of survivors was significantly lower (P < 0.001). After adjusting for the Simplified Acute Physiology Score II and severity of sepsis, the CRP course was significantly associated with mortality (ORCRP-ratio = 1.03, confidence interval 95%= (1.02, 1.04), P < 0.001). The hospital mortality of patients with fast response, slow response and no response patterns was 23%, 30% and 41%, respectively (P = 0.001). No responders had a significant increase on the odds of death (OR = 2.5, CI95% = (1.6, 4.0), P < 0.001) when compared with fast responders. CONCLUSIONS: Daily CRP measurements after antibiotic prescription were useful as early as Day 3 in identification of Community-Acquired Sepsis patients with poor outcome. The rate of CRP decline during the first five ICU days was markedly associated with prognosis. The identification of the pattern of CRP-ratio response was useful in the recognition of the individual clinical course.

[SYSVENT: Proof of Concept Study of a Prototype to Ventilate Critical Care Patients]. / SYSVENT: Prova de Conceito de um Protótipo para Ventilar Doentes em Cuidados Intensivos.

INTRODUCTION: The new coronavirus pandemic has led to scarcity of invasive ventilation resources in hospitals in several countries. In this context, the Portuguese Medical Association invited intensive care physicians who, in collaboration with SYSADVANCE S.A., developed SYSVENT OM1, a ventilator capable of operating in controlled and assisted modes (volume and pressure) and able to treat patients admitted to intensive care units. In this study we do the proof of concept comparing programmed tidal volume, inspiratory pressure and positive end-expiratory pressure with those measured by the ventilator and an external measuring equipment. MATERIAL AND METHODS: We set up the ventilator in tandem with an artificial lung and a flow analyzer. We measured expiratory tidal volume, and inspiratory pressure against three levels of compliance, each with six steps of tidal volume. Positive end-expiratory pressure was measured at 2 cmH2O incremental along eight steps. For each measurement, we performed three readings. RESULTS: Considering each of the three single variables, the mean value of the highest difference between programmed values and measured values is, for all of them, within what we considered to be acceptable for a prototype model (tidal volume = -28.1 mL, inspiratory pressure = 0.8 cmH2O and positive end-expiratory pressure = -1.1 cmH2O). This difference is greater when evaluated with the external measuring equipment in comparison with the ventilator. DISCUSSION: The results showed a good monitoring and accuracy performance. Technical limitations related with the artificial lung and the flow analyzer have been documented, which do not compromise the results, but limit their amplitude. CONCLUSION: For tested parameters, the ventilator has a good operating performance, is in accordance with the initial premises and has potential for clinical use.

Introdução: A pandemia pelo novo coronavírus provocou rotura em hospitais de vários países por falta de recursos para ventilaçãoinvasiva. Assim, a Ordem dos Médicos convidou intensivistas que, em colaboração com a SYSADVANCE S.A., desenvolveram o SYSVENT OM1, um ventilador capaz de operar em modos controlados e assistidos (volume e pressão) e apto para tratar doentes em cuidados intensivos. Neste estudo fazemos a prova de conceito, comparando volume-corrente, pressão inspiratória e pressão positiva tele-expiratória programados, com os valores medidos pelo ventilador e por um equipamento de medição externo.Material e Métodos: Montámos o ventilador em série com um pulmão artificial e um analisador de fluxos. Medimos o volume-corrente expiratório e a pressão inspiratória, em três níveis de compliance e seis patamares de volume-corrente. A pressão positiva tele-expiratória foi medida com incrementos de 2 cmH2O ao longo de oito patamares. Para cada medição realizámos três leituras.Resultados: Considerando cada uma das três variáveis isoladamente, a média da diferença máxima entre os valores programados e os valores medidos situa-se, para todas elas, dentro do que considerámos ser aceitável para um modelo protótipo (volume-corrente = -28,1 mL, pressão inspiratória = 0,8 cmH2O e pressão positiva tele-expiratória = -1,1 cmH2O). Essa diferença é maior quando avaliada com o equipamento de medição externa comparativamente com o ventilador.Discussão: Os resultados mostraram uma boa capacidade de monitorização e de precisão. Documentaram-se limitações técnicas relacionadas com o pulmão artificial e com o analisador de fluxos que não desvirtuam os resultados, mas limitam a sua amplitude.Conclusão: Para os parâmetros testados, o ventilador apresenta boa performance de funcionamento, está de acordo com as premissasiniciais e tem potencial para uso clínico.

[Correction to the article "SYSVENT: Proof of Concept Study of a Prototype to Ventilate Critical Care Patients", Published on Acta Med Port 2021 Jan;34(1):12-19.] / Errata ao artigo "SYSVENT: Prova de Conceito de um Protótipo para Ventilar Doentes em Cuidados Intensivos", Publicado em Acta Med Port 2021 Jan;34(1):12-19.

On page 13, in Table 1, first line on the third column (under 'Amplitude'), where it reads: "[0,21; 1].", It should read: "[21; 100]". Article published with errors: https://www.actamedicaportuguesa.com/revista/index.php/amp/article/view/14516.

Na página 13, Tabela 1, primeira linha da terceira coluna (intitulada 'Amplitude') onde se lê: "[0,21; 1]"Deverá ler-se: "[21; 100]". Artigo publicado com erros: https://www.actamedicaportuguesa.com/revista/index.php/amp/article/view/14516.

Influence of vasopressor agent in septic shock mortality. Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI study).

OBJECTIVE: Guidelines for the adrenergic support of septic shock are controversial. In patients with community-acquired septic shock, we assessed the impact of the choice of vasopressor support on mortality. DESIGN: Cohort, multiple center, observational study. SETTING: Seventeen Portuguese intensive care units (ICUs). PATIENTS: All adult patients admitted to a participating ICU between December 2004 and November 2005. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were followed up during the first five ICU days, the day of discharge or death, and hospital outcome. Eight hundred ninety-seven consecutive patients with community-acquired sepsis (median age, 63 years; 577 men; and hospital mortality, 38%) were studied. Of the 458 patients with septic shock, 73% received norepinephrine and 50.5% dopamine. The norepinephrine group had a higher hospital mortality (52% vs. 38.5%, p = 0.002). A Kaplan-Meier survival curve showed diminished 28-day survival in the norepinephrine group (log-rank = 22.6, p < 0.001). A Cox proportional hazard analysis revealed that the administration of norepinephrine was associated with an increased risk of death (adjusted hazard ratio, 2.501; 95% confidence interval, 1.413-4.425; p = 0.002). In a multivariate analysis with ICU mortality as the dependent factor, Simplified Acute Physiology Score II and norepinephrine administration were independent risk factors for ICU mortality in patients with septic shock. CONCLUSIONS: In patients with community-acquired septic shock, our data suggest that norepinephrine administration could be associated with worse outcome.

A case-control study on risk factors for early-onset respiratory tract infection in patients admitted in ICU.

BACKGROUND: Respiratory tract infections are common in intensive care units (ICU), with incidences reported from 10 to 65%, and case fatality rates over 20% in pneumonia. This study was designed to identify risk factors for the development of an early onset respiratory tract infection (ERI) and to review the microbiological profile and the effectiveness of first intention antibiotic therapy. METHODS: Case-control, retrospective clinical study of the patients admitted to the Intensive Care Unit (ICU) of our hospital, a teaching and tertiary care facility, from January to September 2000 who had a respiratory tract infection diagnosed in the first 5 days of hospital stay. RESULTS: Of the 385 patients admitted to our unit: 129 (33,5%) had a diagnosis of ERI and 86 patients were admitted to the control group. Documented aspiration (adjusted OR = 5,265; 95% CI = 1,155 - 24,007) and fractured ribs (adjusted OR = 12,150; 95% CI = 1,571 - 93,941) were found to be independent risk factors for the development of ERI (multiple logistic regression model performed with the diagnostic group as dependent variable and adjusted for age, sex, SAPS II, documented aspiration, non-elective oro-tracheal intubation (OTI), fractured ribs, pneumothorax and pleural effusion).A total of 78 organisms were isolated in 61 patients (47%). The normal flora of the upper airway (Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenza and Moraxella catharralis) accounted for 72% of all isolations achieved, polimicrobian infections were responsible for 25% of all microbiological documented infections. First intention treatment was, in 62% of the patients, the association amoxacillin+clavulanate, being effective in 75% of the patients to whom it was administered. The patients with ERI needed more days of OTI (6 vs 2, p < 0,001) and mechanical ventilation (6 vs 2, p < 0,001) and had a longer ICU (7 vs 2, p < 0,001) and hospital length of stay (17 vs 11, p = 0,018), when compared with controls. CONCLUSION: In this study documented tracheobronchial aspiration and fractured ribs were identified as independent risk factors for ERI. Microbiological profile was dominated by sensitive micro-organisms. The choice amoxacilin+clavulanate revealed to be a good option with an effectiveness rate of 77% in the patients in whom it was used.

Adrenergic support in septic shock: a critical review.

The definition of septic shock includes sepsis-induced hypotension despite adequate fluid resuscitation, along with the presence of organ perfusion abnormalities, and ultimately cell dysfunction. To restore adequate organ perfusion and cell homeostasis, cardiac output should be restored with volume infusion plus vasopressor agents as indicated. Appropriate arterial pressure for each individual patient and proper arterial oxygen content are key elements to restoring perfusion. Tissue perfusion can be monitored by markers of organ and mitochondrial function, namely urine output, level of consciousness, peripheral skin perfusion, central or mixed venous oxygen saturation, and lactate. The hemodynamic effects of the different vasopressor agents depend on the relative affinity to adrenergic receptors. Those with predominant alpha-agonist activity produce more vasoconstriction (inoconstrictors) while those with predominant beta-agonist stimulation increase cardiac performance (inodilators). The debate about whether one vasopressor agent is superior to another is still ongoing. The Surviving Sepsis Campaign guidelines refer to either norepinephrine or dopamine as the first-choice vasopressor agent to correct hypotension in septic shock. However, recent data from observational and controlled trials have challenged these recommendations concerning different adrenergic agents. As a result, our view on the prescription of vasopressors has changed from a probably oversimplified "one-size-fits-all" approach to a multimodal approach in vasopressor selection.