ABSTRACT
The objective of this review was to evaluate current knowledge regarding terminal illness and palliative care in the intensive care unit, to identify the major challenges involved and propose a research agenda on these issues The Brazilian Critical Care Association organized a specific forum on terminally ill patients, to which were invited experienced and skilled professionals on critical care. These professionals were divided in three groups: communication in the intensive care unit, the decision making process when faced with a terminally ill patient and palliative actions and care in the intensive care unit. Data and bibliographic references were stored in a restricted website. During a twelve hour meeting and following a modified Delphi methodology, the groups prepared the final document. Consensual definition regarding terminality was reached. Good communication was considered the cornerstone to define the best treatment for a terminally ill patient. Accordingly some communication barriers were described that should be avoided as well as some approaches that should be pursued. Criteria for palliative care and palliative action in the intensive care unit were defined. Acceptance of death as a natural event as well as respect for the patient's autonomy and the nonmaleficence principles were stressed. A recommendation was made to withdraw the futile treatment that prolongs the dying process and to elected analgesia and measures that alleviate suffering in terminally ill patients. To deliver palliative care to terminally ill patients and their relatives some principles and guides should be followed, respecting individual necessities and beliefs. The intensive care unit staff involved with the treatment of terminally ill patients is subject to stress and tension. Availability of a continuous education program on palliative care is desirable.
ABSTRACT
BACKGROUND AND OBJECTIVES: Sepsis represents the major cause of death in the ICUs all over the world. Many studies have shown an increasing incidence over time and only a slight reduce in mortality. Many new treatment strategies are arising and we should define the incidence and features of sepsis in Brazil. METHODS: Prospective cohort study in sixty-five hospitals all over Brazil. The patients who were admitted or who developed sepsis during the month of September, 2003 were enrolled. They were followed until the 28th day and/or until their discharge. The diagnoses were made in accordance to the criteria proposed by ACCP/SCCM. It were evaluated demographic features, APACHE II score, SOFA (Sepsis-related Organ Failure Assessment) score, mortality, sources of infections, microbiology, morbidities and length of stay (LOS). RESULTS: Seventy-five ICUs from all regions of Brazil took part in the study.3128 patients were identified and 521 (16.7%) filled the criteria of sepsis, severe sepsis or septic shock. Mean age was 61.7 (IQR 39-79), 293 (55.7%) were males, and the overall 28-day mortality rate was 46.6%. Average APACHE II score was 20 and SOFA score on the first day was 7 (IQR 4-10). SOFA score in the mortality group was higher on day 1 (8, IQR 5-11), and had increased on day 3 (9, IQR 6-12). The mortality rate for sepsis, severe sepsis and septic shock was 16.7%, 34.4% and 65.3%, respectively. The average LOS was 15 days (IQR 5-22). The two main sources of infection were the respiratory tract (69%) and the abdomen one (23.1%). Gram-negative bacilli were more prevalent (40.1%). Gram-positive cocci were identified in 32.8% and fungi infections in 5%. Mechanical ventilation was observed in 82.1% of the patients, Swan-Ganz catheter in 18.8%, vasopressors in 66.2% and hemotransfusion in 44.7%. CONCLUSIONS: It was observed a high mortality of sepsis in the ICUs in Brazil. The high frequency of septic shock demonstrated a group at high risk of death. In order to have a better use of the resources and reduce in mortality during the next 5 years, it is very important to identify our specific features related to this syndrome.
ABSTRACT
A oxigenoterapia hiperbárica consiste na respiração de oxigênio puro sob pressão maior que uma atmosfera e vem sendo empregada no tratamento adjuvante de lesões ulceradas de várias etiologias. Foram analisados retrospectivamente os prontuários de seis pacientes atendidos no Ambulatório de Reumatologia Pediátrica do Instituto da Criança do Hospital das Clínicas da FMUSP entre 1996 e 2002, submetidos à oxigenoterapia hiperbárica. Esse procedimento foi indicado pela presença de osteomielite crônica e lesões ulceradas (por vasculite ou infecção) que não responderam ao tratamento habitual. Dois pacientes apresentaram poliarterite nodosa cutânea, dois osteomielite crônica multifocal recorrente, um esclerodermia cutânea difusa e um pioderma gangrenoso. Cinco pacientes eram do sexo feminino (idade variou de 6 a 13,2 anos). As sessões de oxigenoterapia hiperbárica foram realizadas sob pressões que variaram de 2,4 a 2,8 atmosferas absolutas, com duração de duas horas. O número mínimo de sessões foi 18 e o máximo 80. Em cinco pacientes houve completa cicatrização das lesões. A paciente com esclerodermia cutânea abandonou o tratamento após a décima oitava sessão, pois retornou a sua cidade natal, com melhora parcial das lesões cutâneas. O principal evento adverso durante as sessões foi otalgia, após as primeiras sessões, que desapareceu com diminuição da pressão dentro da câmara e da duração da sessão. Não foram observados perfuração timpânica ou outros eventos adversos. A oxigenoterapia hiperbárica foi eficaz e bem tolerada nos pacientes com doenças reumatológicas e lesões vasculíticas ulceradas ou infectadas e osteomielite crônica.
Subject(s)
Humans , Male , Female , Child , Adolescent , Hyperbaric Oxygenation , Osteomyelitis , Oxygen Inhalation Therapy , Scleroderma, Systemic , VasculitisABSTRACT
Estudo retrospectivo de 1506 pacientes com lesões teciduais agudas e crônicas, submetidos a tratamento mínimo efetivo com OHB. A mortalidade foi de 5,24 por cento, menor que a de 21,26 por cento, do grupo geral de pacientes de OHB (p < 0.001). A maioria dos óbitos ocorreu antes de atingir o tratamento mínimo efetivo. Pacientes agudos necessitaram de 11 a 18 sessões e crônicos 30 sessões (p< 0,001) para a cura./Retrospective study of 1506 patients with acute and chronic tissue lesions with minimun effective HBO treatment...
Subject(s)
Humans , Male , Female , Wounds and Injuries/therapy , Treatment Outcome , Hyperbaric Oxygenation/statistics & numerical data , Hyperbaric Oxygenation/methods , Retrospective StudiesABSTRACT
As lesoes esofagicas apos abordagem anterior da coluna cervical sao raras na literatura. Os autores apresentam um caso de penetracao esofagica de parafuso usado em artrodese via anterior da coluna cervical pos fratura, com evolucao benigna em relacao a esta complicacao.
Subject(s)
Humans , Male , Adolescent , Esophagus/injuries , Fractures, Bone/complications , Spinal Injuries/surgery , Arthrodesis/adverse effects , Spinal Injuries/complicationsABSTRACT
A ofloxacina (OFX) foi empregada, por via oral, para o tratamento de infeccçöes graves, de etiologias diversas, em 25 pacientes, sendo 12 do sexo masculino e 13 do sexo feminino, com média de idade de 40,9 anos. Os pacientes receberam doses diárias entre 400 a 800 mg de ofloxacina (200 a 400 mg a cada 12 horas) por períodos de tratamento que variaram de oito a 24 dias. Os diagnósticos clínicos mais comuns foram: penumonia, pielonefrite aguda, infecçöes de partes moles e infecçäo urinária. As bactérias isoladas com maior freqüência foram as Gram-negativas (e. coli, P. aeruginosa, Klebsiella sp e Proteus sp) e Gram-positivas (S.aureus), entre outras. Houve um alto índice de cura clínica e microbiológica (92%), traduzindo-se pela erradicaçäo de bactérias como E. coli, P.aeruginosa, Klebsiela sp, Proteus sp e S. aureus. Houve persistência de três bactérias: Acinetobacter sp, Enterobacter aerogenes e Streptococcus beta-hemolítico
