Effects of physical therapy with neuromuscular electrical stimulation in acute and late septic shock patients: A randomised crossover clinical trial.

BACKGROUND: Patients with sepsis and immobility in the intensive care unit are associated with muscle weakness, and early mobilisation can counteract it. However, during septic shock, mobilisation is often delayed due to the severity of the illness. Neuromuscular electrical stimulation (NMES) may be an alternative to mobilise these patients early. This study aims to identify whether NMES performed within the first 72 hours of septic shock diagnosis or later is safe from a metabolic perspective. METHODS: This is the analysis of two randomised controlled crossover studies. Patients with acute septic shock (within the first 72 hours of diagnosis) and sepsis and septic shock in the late phase (after 72 hours of diagnosis) were eligible. Patients were submitted in a random order to the intervention protocol (dorsal decubitus position with the lower limbs raised and NMES) and control (dorsal decubitus position with the lower limbs raised without NMES). The patients were allocated in group 1 (intervention and control) or group 2 (control and intervention) with a wash-out period of 4 to 6 hours. Metabolic variables were evaluated by indirect calorimetry. RESULTS: Sixteen patients were analysed in the acute septic shock study and 21 in the late sepsis/septic shock study. There were no significant differences between Oxygen Consumption (VO2) values in the acute phase of septic shock when the baseline period, intervention, and control protocols were compared (186.59 ± 46.10; 183.64 ± 41.39; 188.97 ± 44.88, p>0.05- expressed in mL/Kg/min). The same was observed when the VO2 values in the late phase were compared (224.22 ± 53.09; 226.20 ± 49.64; 226.79 ± 58.25, p>0.05). The other metabolic variables followed the same pattern, with no significant differences between the protocols. When metabolic variables were compared between acute to late phase, significant differences were observed (p<0.05). CONCLUSIONS: As metabolic rates in septic shock patients had no increase during NMES, either in the first 72 hours of diagnosis or later, NMES can be considered safe from a metabolic viewpoint, even despite the higher metabolic demand in the acute phase of shock. TRIAL REGISTRATION: NCT03193164; NCT03815994. Registered on June 5, 2017; November 13, 2018 (clinicaltrials.gov/).

The use of distributed random forest model to quantify risk predictors for tracheostomy requirements in septic patients: A retrospective cohort study.

The search for early clinical risk factors in the intensive care setting may improve the outcome of critically ill patients. The objective of this retrospective study is to identify and quantify early predictors for patients who would require tracheostomy. Five hundred and forty four septic patients were divided in 2 groups: non-tracheostomized (NT) (n = 484) and tracheostomized (T) (n = 60). The patients consisted of 241 males (49.8%) in NT and 27 (45%) in T group, respectively (P = .4971). The median and interquartile range difference of age of NT group was of 72 years [59-82] and T of 75 [55.0-83.5] (P = .4687). The SAPS 3 for the group NTxT was 70 [55-85] and 85.5 [77-91] (P = .0001), the SOFA of 9 [6-13] and 12 [10-14] (P = .0002). The comparison of logistic regression analysis for predictors of non-tracheostomy and tracheostomy groups showed an adjusted odds ratio (OR) for SAPS 3 range between 74 and 87 of 18.14 (95%CI = 3.36-97.84) and between 88 and 116 of 27.77 (95%CI = 4.43-174.24) (P < .05). For SOFA, the adjusted OR between 10 and 13 was 12.23 (95%CI = 2.46-60.81) and between 14 and 20 was 8.45 (95%CI = 1.58-45.29) (P < .05). The need for blood transfusions and dialysis presented an OR of 2.74 (95%CI = 1.23-6.08) and 3.33 (95%CI = 1.43-7.73) (P < .05), respectively. Our data shows that SAPS 3 ≥ 74, SOFA ≥ 11, blood transfusions and the need for dialysis were independently associated and could be considered major predictors for tracheostomy requirements in septic patients.

Comparison of International Consensus Conference guidelines and WIND classification for weaning from mechanical ventilation in Brazilian critically ill patients: A retrospective cohort study.

The knowledge of weaning ventilation period is fundamental to understand the causes and consequences of prolonged weaning. In 2007, an International Consensus Conference (ICC) defined a classification of weaning used worldwide. However, a new definition and classification of weaning (WIND) were suggested in 2017. The objective of this study was to compare the incidence and clinical relevance of weaning according to ICC and WIND classification in an intensive care unit (ICU) and establish which of the classifications fit better for severely ill patients. This study was a retrospective cohort study in an ICU in a tertiary University Hospital. Patient data, such as population characteristics, mechanical ventilation (MV) duration, weaning classification, mortality, SAPS 3, and death probability, were obtained from a medical records database of all patients, who were admitted to ICU between January 2016 and July 2017. Three hundred twenty-seven mechanically ventilated patients were analyzed. Using the ICC classification, 82% of the patients could not be classified, while 10%, 5%, and 3% were allocated in simple, difficult, and prolonged weaning, respectively. When WIND was used, 11%, 6%, 26%, and 57% of the patients were classified into short, difficult, prolonged, and no weaning groups, respectively. Patients without classification were sicker than those that could be classified by ICC. Using WIND, an increase in death probability, MV days, and tracheostomy rate was observed according to weaning difficult. Our results were able to find the clinical relevance of WIND classification, mainly in prolonged, no weaning, and severely ill patients. All mechanically ill patients were classified, even those sicker with tracheostomy and those that could not finish weaning, thereby enabling comparisons among different ICUs. Finally, it seems that the new classification fits better in the ICU routine, especially for more severe and prolonged weaning patients.

The use of APACHE II, SOFA, SAPS 3, C-reactive protein/albumin ratio, and lactate to predict mortality of surgical critically ill patients: A retrospective cohort study.

Several prognostic indices have been employed to predict the outcome of surgical critically ill patients. Among them, acute physiology and chronic health evaluation (APACHE) II, sequential organ failure assessment (SOFA) and simplified acute physiology score (SAPS 3) are widely used. It seems that biological markers such as C-reactive protein (CRP), albumin, and blood lactate levels correlate with the degree of inflammation during the immediate postoperative phase and could be used as independent predictors. The objective of this study is to compare the different predictive values of prognostic indices and biological markers in the outcome of 847 surgical patients admitted to the intensive care unit (ICU) in the postoperative phase.The patients were divided into survivors (n = 765, 57.4% males, age 61, interquartile range 51-71) and nonsurvivors (n = 82, 57.3% males, age 70, interquartile range 58-79). APACHE II, APACHE II death probability (DP), SOFA, SAPS 3, SAPS 3 DP, CRP, albumin, and lactate were recorded on ICU admission (first 24 hours). The area under the ROC curve (AUROC) and 95% confidence interval (95% CI) were used to measure the index accuracy to predict mortality.The AUROC and 95% CI for APACHE II, APACHE II DP, SOFA, SAPS 3, SAPS 3 DP, CRP/albumin ratio, CRP, albumin, and lactate were 0.850 (0.824-0.873), 0.855 (0.829-0.878), 0.791 (0.762-0.818), 0.840 (0.813-0.864), 0.840 (0.813-0.864), 0.731 (0.700-0.761), 0.708 (0.676-0.739), 0.697 (0.665-0.728), and 0.601 (0.567-0.634), respectively. The ICU and overall in-hospital mortality were 6.6 and 9.7%, respectively. The APACHE II, APACHE II DP, SAPS 3, SAPS 3 DP, and SOFA scores showed a better performance than CRP/albumin ratio, CRP, albumin, or lactate to predict in-hospital mortality of surgical critically ill patients.Even though all indices were able to discriminate septic from nonseptic patients, only APACHE II, APACHE II DP, SOFA and to a lesser extent SAPS 3, SAPS 3 DP, and blood lactate levels could predict in the first 24-hour ICU admission surgical patients who have survived sepsis.

The use of SAPS 3, SOFA, and Glasgow Coma Scale to predict mortality in patients with subarachnoid hemorrhage: A retrospective cohort study.

Guidelines for patients with subarachnoid hemorrhage (SAH) management and several grading systems or prognostic indices have been used not only to improve the quality of care but to predict also the outcome of these patients. Among them, the gold standards Fisher radiological grading scale, Hunt-Hess and the World Federation of Neurological Surgeons (WFNS) are the most employed. The objective of this study is to compare the predictive values of simplified acute physiology score (SAPS) 3, sequential organ failure assessment (SOFA), and Glasgow Coma Scale (GCS) in the outcome of patients with aneurysmal SAH.Fifty-one SAH patients (33% males and 67% females; mean age of 54.1 ±â€Š10.3 years) admitted to the intensive care units (ICU) in the post-operative phase were retrospectively studied. The patients were divided into survivors (n=37) and nonsurvivors (n = 14). SAPS 3, Fischer scale, WFNS, SOFA, and GCS were recorded on ICU admission (day 1 - D1), and 72-hours (day 3 - D3) SOFA, and GCS. The capability of each index SAPS 3, SOFA, and GCS (D1 and D3) to predict mortality was analyzed by receiver operating characteristic (ROC) curves. The area under the ROC curve (AUC) and the respective confidence interval (CI) were used to measure the index accuracy. The level of significance was set at P < .05.The mean SAPS 3, SOFA, and GCS on D1 were 13.5 ±â€Š12.7, 3.1 ±â€Š2.4, and 13.7 ±â€Š2.8 for survivors and 32.5 ±â€Š28.0, 5.6 ±â€Š4.9, and 13.5 ±â€Š1.9 for nonsurvivors, respectively. The AUC and 95% CI for SAPS 3, SOFA, and GCS on D1 were 0.735 (0.592-0.848), 0.623 (0.476-0.754), 0.565 (0.419-0.703), respectively. The AUC and 95% CI for SOFA and GCS on D3 were 0.768 (0.629-0.875) and 0.708 (0.563-0.826), respectively. The overall mortality was 37.8%.Even though SAPS 3 and Fischer scale predicted mortality better on admission (D1), both indices SOFA and GCS performed similarly to predict outcome in SAH patients on D3.

The effects of physical therapy with neuromuscular electrical stimulation in patients with septic shock: Study protocol for a randomized cross-over design.

INTRODUCTION: Septic shock is a potentially fatal organ dysfunction caused by an imbalance of the host response to infection. The changes in microcirculation during sepsis can be explained by the alterations in the endothelial barrier function. Endothelial progenitor cells (EPCs) are a potential recovery index of endothelial function and it an increase in response to neuromuscular electrical stimulation (NMES) was demonstrated. Therefore, the objective of this study is to investigate the effects of NMES in patients with septic shock. METHODS AND ANALYSIS: It is a study protocol for a randomized cross-over design in an intensive care unit of a tertiary University hospital. Thirty-one patients aged 18 to 65 years. The study will be divided in 2 phases: the phase one will be held in the first 72 hours of septic shock and the phase two after 3 days of first assessment. Patients will be randomly selected to the intervention protocol (decubitus position with the limbs raised and NMES) and control protocol (decubitus position with the limbs raised without NMES). After this procedure, the patients will be allocated in group 1 (intervention and control protocol) or group 2 (control and intervention protocol) with a wash-out period of 4 to 6 hours between them. The main outcome is mobilization of EPCs. The secondary outcome is metabolic and hemodynamic data. A linear mixed model will be used for analysis of dependent variables and estimated values of the mean of the differences of each effect.

How Mechanical Ventilation Measurement, Cutoff and Duration Affect Rapid Shallow Breathing Index Accuracy: A Randomized Trial.

BACKGROUND: Decreased accuracy of the rapid shallow breathing index (RSBI) can stem from 1) the method used to obtain this index, 2) duration of mechanical ventilation (MV), and 3) the established cutoff point. The objective was to evaluate the values of RSBI determined by three different methods, using distinct MV times and cutoff points. METHODS: This prospective study included 40 subjects. Before extubation, three different methods were employed to measure RSBI: pressure support ventilator (PSV) (PSV = 5 - 8 cm H2O; positive end-expiratory pressure (PEEP) = 5 cm H2O) (RSBI_MIN), automatic tube compensation (ATC) (PSV = 0, PEEP = 5 cm H2O, and 100% tube compensation) (RSBI_ATC), and disconnected MV (RSBI_SP). The results were analyzed according to the MV period (less than or over 72 h) and to the outcome of extubation (< 72 h, successful and failed; > 72 h successful and failed). The accuracy of each method was determined at different cutoff points (105, 78, and 50 cycles/min/L). RESULTS: The RSBI_MIN, RSBI_ATC, and RSBI_SP values in the group < 72 h were 38 ± 18, 45 ± 26 and 55 ± 22; in the group > 72 h, RSBI_SP value was higher than those of RSBI_ATC and RSBI_MIN (78 ± 29, 51 ± 19 and 39 ± 14) (P < 0.001). For patients with MV > 72 h who failed in removing MV, the RSBI_SP was higher (93 ± 28, 58 ± 18 and 41 ± 10) (P < 0.000), with greater accuracy at cutoff of 78. CONCLUSION: RSBI_SP associated with cutoff point < 78 cycles/min/L seems to be the best strategy to identify failed extubation in subjects with MV for over 72 h.

Harris-Benedict Equation and Resting Energy Expenditure Estimates in Critically Ill Ventilator Patients.

BACKGROUND: In routine practice, assessment of the nutritional status of critically ill patients still relies on traditional methods such as anthropometric measurements, biochemical markers, and predictive equations. OBJECTIVE: To compare resting energy expenditure measured by indirect calorimetry (REEIC) with REE calculated by using the Harris-Benedict equation with 3 different sources of body weight (from bed scale, REEHB1; ideal body weight, REEHB2; and predicted body weight, REEHB3). METHODS: This study included 205 critically ill patients (115 men, 90 women) evaluated within the first 48 hours of admission and undergoing mechanical ventilation. REE was measured by indirect calorimetry for 30 minutes and calculated by using the Harris-Benedict equation with the 3 sources of body weight. Data were compared by the Bland-Altman method. RESULTS: The values based on ideal and predicted body weight (REEHB2 and REEHB3) did not agree with REEIC. Bland-Altman analysis showed that the limits of agreement varied from +796.1 kcal/d to -559.6 kcal/d for REEHB2 and from +809.2 kcal/d to -564.7 kcal/d for REEHB3. REEIC and REEHB1 (body weight determined by bed scale) agreed the best; the bias was -18.8 kcal/d. However, REEHB1 still overestimated REEIC by +555.3 kcal/d and underestimated it by -593.0 kcal/d. CONCLUSION: For measuring REE in critically ill patients undergoing mechanical ventilation, calculation via the Harris-Benedict equation, regardless of the source of body weight, cannot be substituted for indirect calorimetry.

Are the Dysnatremias a Permanent Threat to the Critically Ill Patients?

BACKGROUD: The dysnatremias (hyponatremia and hypernatremia) are relatively common findings on admission of intensive care unit (ICU) patients and may represent a major risk. The aim of the study was to assess the ability of serum sodium levels and the Acute Physiology and Chronic Health Evaluation II (APACHE II) to predict mortality of surgical critically ill patients. METHODS: One hundred and ninety-five surgical patients (62% males and 38% females; mean age of 51.8 ± 17.3 years) admitted to the ICU in the postoperative phase were retrospectively studied. The patients were divided into survivors (n = 152) and non-survivors (n = 43). APACHE II, and serum sodium levels at admission, 48 h and discharge were analyzed by generation of receiver operating characteristic (ROC) curves. RESULTS: The mean APACHE II was 16.3 ± 8.3 (13.6 ± 6.1 for survivors and 25.5 ± 8.5 for non-survivors). The area under the ROC curve for APACHE II was 0.841 (0.782 - 0.889) and 0.721 (0.653 - 0.783), 0.754 (0.653 - 0.783) and 0.720 (0.687 - 0.812) for serum sodium level at admission, 48 h and discharge, respectively. CONCLUSION: Even though APACHE II scoring system was the most effective index to predict mortality in the surgical critically ill patients, the serum sodium levels on admission may also be used as an independent predictor of outcome.

Comparison of Energy Expenditure and Oxygen Consumption of Spontaneous Breathing Trial Conducted With and Without Automatic Tube Compensation.

BACKGROUND: Weaning from mechanical ventilation is defined as the process of release of ventilatory support and how the evaluation of this phase is conducted in the spontaneous breathing trial (SBT). One of the most used modes of SBT is the continuous positive airway pressure (CPAP), which applies a continuous positive pressure in both inspiration and expiration. However, together with the mechanical ventilation modes, the automatic tube compensation (ATC) can be used, which compensates the resistance imposed by the endotracheal tube. The objective of this study was to compare oxygen consumption (VO2) and energy expenditure (EE) during SBT conducted with and without ATC. METHODS: The study was prospective, randomized and crossover. Forty mechanically ventilated patients were admitted to an intensive care unit of a university tertiary hospital. The participants were randomly allocated in group 1, in which SBT was initiated with CPAP and ATC, followed by CPAP without ATC or in group 2, in which SBT was initiated with CPAP without ATC, followed by CPAP with ATC. Indirect calorimetry helped to measure VO2 and EE during SBT. RESULTS: The differences between VO2 and EE obtained during SBT with ATC and without ATC were -1.6 mL/kg/min (95% CI: -4.36 - 1.07) and 5.4 kcal/day (95% CI: -21.67 - 10.79), respectively. CONCLUSIONS: We concluded that VO2 and EE obtained during SBT with and without ATC were not different.

Energy expenditure in critically ill surgical patients. Comparative analysis of predictive equation and indirect calorimetry.

PURPOSE: The aim of this investigation was to compare the resting energy expenditure (REE) calculated by the Harris-Benedict equation (REE HB) with the REE measured by indirect calorimetry (REE IC) in critically ill surgical patients under mechanical ventilation. METHODS: Thirty patients were included in this work. REE was calculated by the Harris-Benedict equation (REE HB) using real body weight, and it was also measured by indirect calorimetry (REE IC), which was performed for 30 minutes. RESULTS: REE HB had significant (p < 0.0005) but low correlation (Spearman r = 0.57) with REE IC, with a mean bias of 12 kcal.d-1 and limits of agreement ranging from - 599.7 to 623.7 kcal.d-1 as detected by the Bland-Altman analysis. CONCLUSION: These findings suggest that REE IC seems to be more appropriate than REE HB for accurate measurement of REE in critically ill surgical patients under mechanical ventilation.

Energy expenditure in critically ill surgical patients. Comparative analysis of predictive equation and indirect calorimetry / Gasto energético em pacientes cirúrgicos. Análise comparativa entre equação preditiva e calorimetria indireta

PURPOSE: The aim of this investigation was to compare the resting energy expenditure (REE) calculated by the Harris-Benedict equation (REE HB) with the REE measured by indirect calorimetry (REE IC) in critically ill surgical patients under mechanical ventilation. METHODS: Thirty patients were included in this work. REE was calculated by the Harris-Benedict equation (REE HB) using real body weight, and it was also measured by indirect calorimetry (REE IC), which was performed for 30 minutes. RESULTS: REE HB had significant (p < 0.0005) but low correlation (Spearman r = 0.57) with REE IC, with a mean bias of 12 kcal.d-1 and limits of agreement ranging from - 599.7 to 623.7 kcal.d-1 as detected by the Bland-Altman analysis. CONCLUSION: These findings suggest that REE IC seems to be more appropriate than REE HB for accurate measurement of REE in critically ill surgical patients under mechanical ventilation.

OBJETIVO: O objetivo deste estudo foi comparar o gasto energético de repouso (GER), calculado pela equação de Harris-Benedict (GER HB) com o GER medido pela calorimetria indireta (GER CI) em pacientes cirúrgicos gravemente enfermos em ventilação mecânica. MÉTODOS: Trinta pacientes foram incluídos nesta investigação. O gasto energético de repouso foi calculado pela equação de Harris-Benedict (GER HB) utilizando o peso corporal real e medido pela calorimetria indireta (GER CI). A calorimetria indireta foi realizada durante 30 minutos. RESULTADOS: O gasto energético de repouso calculado pela equação de Harris-Benedict mostrou uma correlação significativa (p < 0,0005), porém fraca (Spearman r = 0,57) com GER CI, com um viés médio de 12 kcal.d-1 e os limites de concordância variando de - 599,7 a -623,7 kcal.d-1 como detectados pela análise de Bland-Altman. CONCLUSÃO: Estes achados sugerem que a calorimetria indireta parece ser mais apropriada do que a equação de Harris Benedict para a medida exata do GER em pacientes cirúrgicos gravemente enfermos em ventilação mecânica.