BACKGROUND: Acute Gastrointestinal Injury (AGI) is associated with adverse clinical outcomes, including increased mortality. We aimed to investigate the potential of citrulline and intestinal fatty acid binding protein (I-FABP) as biomarkers for early AGI diagnosis and predicting outcomes in surgical patients. METHODS: Prospective cohort study involving patients who underwent non-cardiac surgeries and were admitted to Intensive Care Units. AGI diagnosis was based on specific criteria, and severity was categorised following established guidelines. Statistical analyses were performed to assess the diagnostic accuracy of the biomarkers and their association with outcomes, P significant when <0.05. RESULTS: AGI was identified in 40.3% of patients with varying severity. Mortality rates were significantly higher in the AGI group in the ICU (19.4% vs. 0%, p = 0.001) and hospital (22.6% vs. 2.17%, p = 0.003). Urinary I-FABP levels on days 3 and 7 showed reasonable and good accuracy for AGI diagnosis (AUC 0.732 and 0.813, respectively). Urinary I-FABP levels on days 2 and 3 accurately predict sepsis. Urinary citrulline levels on day one predicted mortality (AUC 0.87) furthermore urinary I-FABP levels on day 2 showed reasonable accuracy (sensitivity 83.3%, specificity 92.4%). CONCLUSION: Urinary I-FABP and citrulline levels are promising diagnostic and prognostic markers in ICU patients following non-cardiac surgeries.
Citrulline , Fatty Acid-Binding Proteins , Postoperative Complications , Humans , Biomarkers/urine , Citrulline/urine , Fatty Acid-Binding Proteins/urine , Postoperative Period , Prospective Studies , Postoperative Complications/urine
BACKGROUND AND OBJECTIVES: Patients who develop post-operative acute kidney injury (AKI) have a poor prognosis, especially when undergoing high-risk surgery. Therefore, the objective of this study was to evaluate the outcome of patients with AKI acquired after non-cardiac surgery and the possible risk factors for this complication. METHODS: A multicenter, prospective cohort study with patients admitted to intensive care units (ICUs) after non-cardiac surgery was conducted to assess whether they developed AKI. The patients who developed AKI were then compared to non-AKI patients. RESULTS: A total of 29 ICUs participated, of which 904 high-risk surgical patients were involved in the study. The occurrence of AKI in the post-operative period was 15.8%, and the mortality rate of post-operative AKI patients at 28 days was 27.6%. AKI was strongly associated with 28-day mortality (OR = 2.91; 95% CI 1.51-5.62; p = 0.001), and a higher length of ICU and hospital stay (p < 0.001). Independent factors for the risk of developing AKI were pre-operative anemia (OR = 7.01; 95% CI 1.69-29.07), elective surgery (OR = 0.45; 95% CI 0.21-0.97), SAPS 3 (OR = 1.04; 95% CI 1.02-1.06), post-operative vasopressor use (OR = 2.47; 95% CI 1.34-4.55), post-operative infection (OR = 8.82; 95% CI 2.43-32.05) and the need for reoperation (OR= 7.15; 95% CI 2.58-19.79). CONCLUSION: AKI was associated with the risk of death in surgical patients and those with anemia before surgery, who had a higher SAPS 3, needed a post-operative vasopressor, or had a post-operative infection or needed reoperation were more likely to develop AKI post-operatively.
Acute Kidney Injury/epidemiology , Elective Surgical Procedures , Intensive Care Units/statistics & numerical data , Postoperative Complications/epidemiology , Acute Kidney Injury/mortality , Acute Kidney Injury/therapy , Aged , Brazil/epidemiology , Female , Humans , Incidence , Length of Stay/statistics & numerical data , Logistic Models , Male , Middle Aged , Postoperative Complications/therapy , Prospective Studies , Reoperation , Risk Factors , Sepsis/epidemiology , Time Factors
BACKGROUND & AIMS: Survivors of critical illness experience significant skeletal muscle wasting that may predict clinical outcome. Ultrasound (US) is a noninvasive method that can measure muscle quadriceps muscle layer thickness (QMLT) at the bedside. The aim of this study was to determine the muscle loss assessed by ultrasonography (US) of the quadriceps femoris muscle in critically ill patients on mechanical ventilation and its relationship with hospital outcomes. METHODS: This study involved patients ≥18 years admitted to the intensive care unit who needed mechanical ventilation for at least 48 h. The quadriceps muscle layer thickness (QMLT) in the two-thirds of the thigh was quantified using bedside US. The QMLT of the left and right legs on the first (D1), third (D3), and seventh (D7) days were measured. RESULTS: US quadriceps thickness measurements were performed in 74 critically ill patients. The mean age was 62.3 ± 19.5 years, 54.1% of the patients were men, with a BMI of 25.5 ± 4.6 kg/m2, SAPS 3 of 55.2 ± 17.2, and NRS of 3.2 ± 1.0. The percentage muscle thickness declined at the right leg in 15% (95%CI, 10.5%-19.4%), and 12.7% (95%CI, 9.1%-16.3%) at the left leg from the first to the seventh day. Receiver operating characteristic showed cutoff value in muscle thickness of ≤1.64 cm on day 7 could predict survival (area under then curve = 0.7; 95% CI, 0.582-0.801). In Cox regression after adjusting, the probability of patients remaining on mechanical ventilation was higher with ≤1.64 cm loss of thigh muscle thickness on day 7; HR = 2.1 (95% CI 1.1-3.8, P = 0.017). The same occurred about ICU survival probability; HR = 3.7 (95% CI 1.2 to 11.5) and hospital survival probability; HR = 4.5 (95% CI 1.5 to 13.7). CONCLUSIONS: The measurement of QMLT using US showed that critically ill patients on mechanical ventilation presented with muscle wasting and greater loss of muscle thickness was associated with worse outcomes.
Critical Illness , Respiration, Artificial , Adult , Aged , Aged, 80 and over , Cohort Studies , Female , Humans , Male , Middle Aged , Quadriceps Muscle/diagnostic imaging , Ultrasonography
The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.
Hospital Costs/statistics & numerical data , Length of Stay/statistics & numerical data , Perioperative Care/statistics & numerical data , Perioperative Care/trends , Brazil , Humans , Nutrition Therapy , Patient Care Team , Perioperative Care/economics , Postoperative Care , Postoperative Complications , Preoperative Care
ABSTRACT The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.
RESUMO O projeto ACERTO é um protocolo multimodal de cuidados perioperatórios. Implementado em 2005, o projeto, nos últimos 15 anos, tem disseminado a ideia de moderno protocolo de cuidados perioperatórios baseados em evidência e com atuação interprofissional. Dezenas de estudos publicados com o uso do protocolo têm mostrado benefícios como redução do tempo de internação, complicações pós-operatórias e custos hospitalares. Disseminado pelo Brasil, o projeto tem apoio do Colégio Brasileiro de Cirurgiões e da Sociedade Brasileira de Nutrição Parenteral e Enteral, entre outros. Este artigo compila publicações dos autores que compõem o grupo de pesquisa do CNPq "Acerto em Nutrição e Cirurgia", cita a experiência de outros autores nacionais em diversas especialidades cirúrgica e finalmente, delineia a evolução do projeto ACERTO ao longo da linha do tempo.
Humans , Hospital Costs/statistics & numerical data , Perioperative Care/trends , Perioperative Care/statistics & numerical data , Length of Stay/statistics & numerical data , Patient Care Team , Postoperative Care , Postoperative Complications , Brazil , Preoperative Care , Perioperative Care/economics , Nutrition Therapy
Abstract Introduction and objectives: The association pneumoperitoneum and obesity in video laparoscopy can contribute to pulmonary complications, but has not been well defined in specific groups of obese individuals. We assessed the effects of pneumoperitoneum in respiratory mechanics in Grade I obese compared to non-obese. Methods: Prospective study including 20 patients submitted to video laparoscopic cholecystectomy, normal spirometry, divided into non-obese (BMI ≤ 25 kg.m-2) and obese (BMI > 30 kg.mg-2), excluding Grade II and III obese. We measured pulmonary ventilation mechanics data before pneumoperitoneum (baseline), and five, fifteen and thirty minutes after peritoneal insufflation, and fifteen minutes after disinflation (final). Results: Mean BMI of non-obese was 22.72 ± 1.43 kg.m-2 and of the obese 31.78 ± 1.09 kg.m-2, p < 0.01. Duration of anesthesia and of peritoneal insufflation was similar between groups. Baseline pulmonary compliance (Crs) of the obese (38.3 ± 8.3 mL.cm H2O-1) was lower than of the non-obese (47.4 ± 5.7 mL.cm H2O-1), p = 0.01. After insufflation, Crs decreased in both groups and remained even lower in the obese at all moments assessed (GLM p < 0.01). Respiratory system peak pressure and plateau pressure were higher in the obese, albeit variations were similar at moments analyzed (GLM p > 0.05). The same occurred with elastic pressure, higher in the obese at all times (GLM p = 0.04), and resistive pressure showed differences in variations between groups during pneumoperitoneum (GLM p = 0,05). Conclusions: Grade I obese presented more changes in pulmonary mechanics than the non-obese during video laparoscopies and the fact requires mechanical ventilation-related care.
Resumo Justificativa e objetivos: Em videolaparoscopias, a associação de pneumoperitônio e obesidade pode contribuir para complicações pulmonares, mas não está bem definida em grupos específicos de obesos. Avaliamos os efeitos do pneumoperitônio na mecânica respiratória dos obesos Grau I em comparação aos não obesos. Métodos: Estudo prospectivo envolvendo 20 pacientes submetidos à colecistectomia videolaparoscópica, com espirometria normal, separados em não-obesos (IMC ≤ 25 kg.m-2) e obesos (IMC > 30 kg.mg-2), excluídos obesos Grau II e III. Mensuramos dados da mecânica ventilatória pulmonar antes do pneumoperitônio basal, após cinco, quinze e trinta minutos da insuflação peritoneal e quinze minutos após a desinsuflação final. Resultados: O IMC médio dos não obesos foi de 22,72 ± 1,43 kg.m-2 e dos obesos 31,78 ± 1,09 kg.m-2, p < 0,01. A duração da anestesia e da insuflação peritoneal foram semelhantes entre os grupos. A complacência pulmonar (Crs) basal dos obesos (38,3 ± 8,3 mL.cm H2O-1) foi inferior aos não obesos (47,4 ± 5,7 mL.cm H2O-1), p = 0,01. Após a insuflação, a Crs diminuiu nos dois grupos e permaneceu ainda mais baixa nos obesos em todos os momentos avaliados (GLM p < 0,01). A pressão de pico e a pressão de platô do sistema respiratório foram mais elevadas nos obesos, mas apresentaram semelhantes variações nos momentos analisados (GLM p > 0,05). O mesmo ocorreu com a pressão elástica, mais elevada nos obesos em todos tempos (GLM p = 0,04), e a pressão resistiva apresentou diferenças nas variações entre os grupos durante o pneumoperitônio (GLM p = 0,05). Conclusão: Obesos Grau I apresentam maiores alterações na mecânica pulmonar que os não obesos em videolaparoscopias e este fato recomenda cuidados relacionados a ventilação mecânica.
Humans , Female , Adult , Pneumoperitoneum, Artificial , Respiratory Mechanics , Cholecystectomy, Laparoscopic/methods , Video-Assisted Surgery , Obesity/physiopathology , Prospective Studies , Longitudinal Studies , Middle Aged
RESUMO Objetivo: Avaliar os efeitos da administração intravenosa de fluidos e sódio no primeiro dia de internação com a infusão de nutrição enteral em pacientes de terapia intensiva. Métodos: Estudo de coorte prospectivo realizado com pacientes críticos, não cirúrgicos, em ventilação mecânica internados pelo menos há 5 dias com nutrição enteral. Investigaram-se a quantidade de fluidos e sódio administrados por via venosa no primeiro dia e o volume de nutrição enteral infundido nos primeiros 5 dias. Comparou-se o volume de fluidos intravenosos do primeiro dia > 35mL/kg ou ≤ 35mL/kg de peso corporal e de sódio (acima ou abaixo do percentil 25), com o total de nutrição enteral infundida. Resultados: Estudaram-se 86 pacientes com média (± desvio padrão) de 65 ± 17 anos, sendo 54,7% do sexo feminino. Foram administrados, no primeiro dia, 3.393,7 ± 1.417,0mL de fluidos (48,2 ± 23,0mL/kg) e 12,2 ± 5,1g de sódio. Cinquenta e oito (67,4%) pacientes receberam mais de 35mL/kg de fluidos. Em 5 dias, foram ofertados 67 ± 19,8% (2.993,8 ± 1.324,4mL) da nutrição enteral. Os pacientes que receberam > 35mL/kg de fluidos intravenosos também receberam menos nutrição enteral em 5 dias (2.781,4 ± 1.337,9 versus 3.433,6 ± 1.202,2mL; p = 0,03) versus quem recebeu ≤ 35mL/kg. Pacientes com infusão de sódio intravenoso acima do percentil 25 (≥ 8,73g) no primeiro dia receberam menos volume de nutrição enteral em 5 dias (2.827,2 ± 1.398,0 versus 3.509,3 ± 911,9mL; p = 0,02). Conclusão: Os resultados deste estudo apoiam o pressuposto de que a administração de fluidos intravenosos no primeiro dia de internação > 35mL/kg e de sódio ≥ 8,73g pode contribuir para a menor infusão de nutrição enteral em pacientes críticos.
ABSTRACT Objective: To evaluate the effects of intravenous infusion of fluids and sodium on the first day of admission on infusion of enteral nutrition in the first 5 days in intensive care patients. Methods: A prospective cohort study was conducted with critical nonsurgical patients admitted for at least 5 days who were on mechanical ventilation and receiving enteral nutrition. The amount of intravenous fluids and sodium infused on the first day and the volume of enteral nutrition infused in the first 5 days were investigated. The volume of intravenous fluids > 35mL/kg or ≤ 35mL/kg of body weight and sodium (above or below the 25th percentile) infused on the first day was compared with infused enteral nutrition. Results: A total of 86 patients were studied, with a mean (± standard deviation) of 65 ± 17 years, of which 54.7% were female. On the first day, 3,393.7 ± 1,417.0mL of fluid (48.2 ± 23.0mL/kg) and 12.2 ± 5.1g of sodium were administered. Fifty-eight (67.4%) patients received more than 35mL/kg of fluids. In 5 days, 67 ± 19.8% (2,993.8 ± 1,324.4mL) of the prescribed enteral nutrition was received. Patients who received > 35mL/kg of intravenous fluids also received less enteral nutrition in 5 days (2,781.4 ± 1,337.9 versus 3,433.6 ± 1,202.2mL; p = 0.03) versus those who received ≤ 35mL/kg. Patients with intravenous sodium infusion above the 25th percentile (≥ 8.73g) on the first day received less enteral nutrition volume in 5 days (2,827.2 ± 1,398.0 versus 3,509.3 ± 911.9mL; p = 0.02). Conclusion: The results of this study support the assumption that the administration of intravenous fluids > 35mL/kg and sodium ≥ 8.73g on the first day of hospitalization may contribute to the lower infusion of enteral nutrition in critically ill patients.
Humans , Male , Female , Aged , Aged, 80 and over , Sodium/administration & dosage , Enteral Nutrition/methods , Critical Care/methods , Fluid Therapy/methods , Respiration, Artificial , Infusions, Intravenous , Prospective Studies , Cohort Studies , Critical Illness , Fluid Therapy/adverse effects , Middle Aged
BACKGROUND AND OBJECTIVES: Elderly individuals have a greater sensitivity to sedation, and the most commonly used drugs for sedation are benzodiazepines, which exhibit some complication. Therefore, this study aimed to compare the use of dexmedetomidine and midazolam regarding proper sedation and postoperative complications in elderly individuals who require intraoperative sedation. METHODS: This study was a parallel-randomized clinical trial, which included 120 patients aged >70 years undergoing regional anesthesia and sedation. The exclusion criteria consisted of bradycardia, heart failure, respiratory failure, a Glasgow Coma Scale ≤14, liver failure and refusal to participate. Patients were divided into two groups: the first group received midazolam (MDZ), while the second group received dexmedetomidine (DEX). The doses were titrated to achieve an intraoperative Richmond Agitation-Sedation Scale (RASS) score between -3 and -1. Incidences of complications were recorded. RESULTS: During a 120 min follow-up, the depth of sedation (RASS score) revealed variations less often in the DEX group (p=0.002). Patients in the DEX group (n=67) had lower rates of intraoperative complications (19.4% vs 73.6%, p<0.001). Intraoperatively, the incidence rates of psychomotor agitation (15.1% vs 1.5%, p=0.005), arterial hypotension (28.3% vs 3.0%, p<0.001) and respiratory depression (73.6% vs 0%, p<0.001) were higher in the MDZ group (n=53). During postanesthesia care, the incidence rates of shivering (p<0.001), residual sedation (p=0.04) and use of supplemental oxygen (p<0.001) were significantly lower in the DEX group. CONCLUSIONS: The use of DEX for sedation during surgery provides better control over the depth of sedation and produces fewer complications in elderly individuals. TRIAL REGISTRATION NUMBER: NCT02878837.
Benzodiazepines/administration & dosage , Dexmedetomidine/administration & dosage , Hypnotics and Sedatives/administration & dosage , Intraoperative Care/methods , Postoperative Complications/prevention & control , Aged , Aged, 80 and over , Double-Blind Method , Female , Humans , Intraoperative Care/adverse effects , Male , Postoperative Complications/chemically induced , Postoperative Complications/diagnosis
OBJECTIVES: Acute kidney injury is associated with many conditions, and no interventions to improve the outcomes of established acute kidney injury have been developed. We performed this study to determine whether goal-directed therapy conducted during the early stages of acute kidney injury could change the course of the disease. METHODS: This was a multicenter prospective randomized controlled study. Patients with early acute kidney injury in the critical care unit were randomly allocated to a standard care (control) group or a goal-directed therapy group with 8h of intensive treatment to maximize oxygen delivery, and all patients were evaluated during a period of 72h. ClinicalTrials.gov: NCT02414906. RESULTS: A total of 143 patients were eligible for the study, and 99 patients were randomized. Central venous oxygen saturation was significantly increased and the serum lactate level significantly was decreased from baseline levels in the goal-directed therapy group (p=0.001) compared to the control group (p=0.572). No significant differences in the change in serum creatinine level (p=0.96), persistence of acute kidney injury beyond 72h (p=0.064) or the need for renal replacement therapy (p=0.82) were observed between the two groups. In-hospital mortality was significantly lower in the goal-directed therapy group than in the control group (33% vs. 51%; RR: 0.61, 95% CI: 0.37-1.00, p=0.048, number needed to treat=5). CONCLUSIONS: Goal-directed therapy for patients in the early stages of acute kidney injury did not change the disease course.
Acute Kidney Injury/therapy , Early Goal-Directed Therapy , Acute Kidney Injury/mortality , Aged , Case-Control Studies , Female , Hospital Mortality , Humans , Male , Middle Aged , Patient Care Planning , Prospective Studies , Treatment Outcome
Introduction: intravenous fluid overload may lead to dysmotility that may impair early enteral nutrition delivery in critically ill patients. Objectives: this study aimed to compare the volume of intravenous fluids (IF) with the occurrence of caloric and protein deficits in Intensive Care Unit (ICU) patients. Methods: this cohort study included critically ill patients with mechanical ventilation and receiving early enteral nutrition (target: 25-30 kcal/kg/day and 1.25-2.0 g of protein/kg/day). Over the first five days the volume of IF infused and caloric/protein deficits were calculated. Results: eighty-six critically ill patients (SAPS III score: 62 ± 10) with a mean age of 68 (18-91) years were enrolled. Patients received a median of 2,969 (920-5,960) ml/day of IF, which corresponded to a median of 41.6 (17.0-88.2) ml/kg/day and 10.7 (3.31-21.45) g of sodium/day. All patients had a caloric deficit (mean: 1,812 ± 850 kcal over five days) and in 23 (27%) this deficit exceeded 480 kcal/day. The mean protein deficit was 94.6 ± 5.9 g over five days, and 34 patients (40%) had more than 20 g of deficit/day. Patients with caloric deficit greater than 480 kcal/day received approximately 1.5 l of IF and 10 g of NaCl more than the other patients. Similarly, patients with protein deficit greater than 20 g/day received approximately 3 l of IF and 25 g of NaCl more than the other patients. Mortality was greater in patients with critical protein deficit (69% vs 41.1%; p = 0.01).Conclusion: in critically ill patients receiving enteral nutrition, the volume of intravenous fluids infused affected nutrition delivery and increased caloric and protein déficits
Introducción: la sobrecarga de líquidos por vía intravenosa puede provocar dismotilidad que puede afectar el suministro de nutrición enteral temprana en pacientes críticos. Objetivos: este estudio tuvo como objetivo comparar el volumen de líquidos por vía intravenosa (IF) con la aparición de défi cit calórico y proteico en pacientes de la Unidad de Cuidados Intensivos (UCI). Métodos: este estudio de cohorte incluyó a pacientes críticamente enfermos con ventilación mecánica que recibían nutrición enteral temprana (target: 25-30 kcal/kg/día y 1,25-2,0 g de proteína/kg/día. Durante los primeros cinco días calculamos el volumen de IF y el déficit calórico/ proteico. Resultados: ochenta y seis pacientes críticamente enfermos (SAPS III: 62 ± 10) con una edad media de 68 (18-91) años fueron estudiados. Los pacientes recibieron una mediana de 2.969 (920-5.960) ml/día de IF, que correspondió a una mediana de 41,6 (17,0-88,2) ml/kg/día y a 10,7 (3,31-21,45) g de sodio/día. Todos los pacientes tenían déficit calórico (media: 1.812 ± 850 kcal en cinco días) y en 23 (27%) este défi cit excedía las 480 kcal/día. El défi cit medio de proteínas fue de 94,6 ± 5,9 g en cinco días y 34 pacientes (40%) tuvieron más de 20 g de déficit/ día. Los pacientes con un déficit calórico superior a 480 kcal/día recibieron aproximadamente 1,5 l de IF y 10 g de NaCl más que los otros pacientes. De forma similar, los pacientes con un déficit de proteínas mayor de 20 g/día recibieron aproximadamente 3 l de IF y 25 g de NaCl más que los otros pacientes. La mortalidad fue mayor en pacientes con défi cit proteico crítico (69% vs. 41,1%; p = 0,01). Conclusión: en pacientes críticamente enfermos que reciben nutrición enteral, el volumen de líquidos intravenosos infundidos afecta el suministro de nutrición y aumenta el déficit de calorías y proteínas
Humans , Male , Female , Adolescent , Young Adult , Adult , Middle Aged , Aged , Aged, 80 and over , Critical Illness/therapy , Energy Intake , Fluid Therapy/adverse effects , Hypoprothrombinemias/etiology , Administration, Intravenous , Cohort Studies , Prospective Studies
OBJECTIVES: Acute kidney injury is associated with many conditions, and no interventions to improve the outcomes of established acute kidney injury have been developed. We performed this study to determine whether goal-directed therapy conducted during the early stages of acute kidney injury could change the course of the disease. METHODS: This was a multicenter prospective randomized controlled study. Patients with early acute kidney injury in the critical care unit were randomly allocated to a standard care (control) group or a goal-directed therapy group with 8h of intensive treatment to maximize oxygen delivery, and all patients were evaluated during a period of 72h. ClinicalTrials.gov: NCT02414906. RESULTS: A total of 143 patients were eligible for the study, and 99 patients were randomized. Central venous oxygen saturation was significantly increased and the serum lactate level significantly was decreased from baseline levels in the goal-directed therapy group (p=0.001) compared to the control group (p=0.572). No significant differences in the change in serum creatinine level (p=0.96), persistence of acute kidney injury beyond 72h (p=0.064) or the need for renal replacement therapy (p=0.82) were observed between the two groups. In-hospital mortality was significantly lower in the goal-directed therapy group than in the control group (33% vs. 51%; RR: 0.61, 95% CI: 0.37-1.00, p=0.048, number needed to treat=5). CONCLUSIONS: Goal-directed therapy for patients in the early stages of acute kidney injury did not change the disease course.
Humans , Male , Female , Middle Aged , Aged , Early Goal-Directed Therapy , Patient Care Planning , Case-Control Studies , Prospective Studies , Treatment Outcome , Hospital Mortality , Acute Kidney Injury/mortality , Acute Kidney Injury/therapy
Objetivo: Caracterizar os fatores de risco para lesão renal aguda em pacientes submetidos a cirurgias não cardíacas na unidade de terapia intensiva e sua influência na evolução clínica no pós-operatório. Métodos: Estudo clínico, prospectivo, observacional com 98 pacientes na unidade de terapia intensiva de pós-operatório do Hospital Servidor Público Estadual entre novembro de 2012 e fevereiro de 2013. As variáveis estudadas foram idade, sexo, risco pré-operatório, tipo de cirurgia e anestesia, comorbidades, necessidade de ventilação mecânica, drogas vasoativas, transfusão, diálise e sobrevida em 30 dias. O diagnóstico da lesão renal aguda foi estabelecido pelos critérios Acute Kidney Injury Network (AKIN). Na análise estatística, variáveis categóricas foram avaliadas pelo teste qui quadrado e níveis de p<0,05 foram considerados significantes. Resultados: Os pacientes apresentavam idade de 70,7±13,8 anos, 57,1% eram do sexo masculino e 88,8% estavam em pós-operatório de cirurgia eletiva. Desenvolveram lesão renal aguda 35 (35,7%) pacientes e, destes, 20 (59,2%) eram AKIN 1, (3) 8,6% AKIN 2 e 12 (34,2%) AKIN 3. Necessitaram de diálise 24 (68,57%) pacientes. Risco anestésico elevado nas cirurgias eletivas, intercorrências no intraoperatório e presença da doença renal crônica foram fatores que influenciaram no aparecimento da lesão renal aguda especialmente nos idosos. A mortalidade nos pacientes com lesão renal aguda foi 46% vs. 11% daqueles sem lesão renal aguda. Conclusão: A lesão renal aguda apresentou alta mortalidade em idosos submetidos à cirurgia eletiva com risco pré-operatório elevado e doença renal crônica prévia. É importante a identificação precoce destes fatores de risco e da lesão renal aguda nesses pacientes.
Objectives: To characterize risk factors for acute kidney injury in patients undergoing non-cardiac surgeries in Intensive Care Unit (ICU), and their influence on clinical outcomes postoperatively. Methods: Clinical, prospective, observational study of 98 patients admitted to the Intensive Care Unit after surgery at Hospital do Servidor Público Estadual from November/2012 to February/2013. The variables studied were: age, gender, preoperative anesthetic risk, type of surgery and anesthesia, comorbidities, need for mechanical ventilation, use of vasoactive drugs, need for blood transfusion, renal replacement therapy (RRT) and survival at 30 days. The diagnosis of acute kidney injury has been established through the Acute Kidney Injury Network (AKIN) criteria. At statistical analysis, categorical variables were analyzed using the chi-square test and p levels <0.05 were considered significant. Results: Patients were 70.7 ± 13.8 years old; 57.1% were male, and 88.8% were in postoperative period of elective surgery. Thirty-five patients (35.7%) had an acute kidney injury, with 20 (59.2%) being AKIN1, 8.6% AKIN2 (3), and 12 (34.2%) AKIN3. High anesthetic risk in elective surgeries, complications during surgery, and the presence of chronic kidney disease were factors that influenced the onset of acute kidney injury, especially in the elderly. Mortality in patients with acute kidney injury was of 46%, versus 11% of those without acute kidney injury. Conclusion: Acute kidney injury showed high mortality in the elderly patients undergoing elective surgery with a high preoperative risk and previous chronic kidney disease. The early identification of these risk factors, as well as the early diagnosis of acute kidney injury in these patients is important.
Humans , Male , Female , Aged , Acute Kidney Injury/surgery , Postoperative Complications , Renal Insufficiency, Chronic/complications , Intensive Care Units , Intraoperative Complications , Risk Factors , Surgical Procedures, Operative
Objetivo: No Brasil, não há dados sobre as preferências do intensivista em relação aos métodos de monitorização hemodinâmica. Este estudo procurou identificar os métodos utilizados por intensivistas nacionais, as variáveis hemodinâmicas por eles consideradas importantes, as diferenças regionais, as razões para escolha de um determinado método, o emprego de protocolos e treinamento continuado. Métodos: Intensivistas nacionais foram convidados a responder um questionário em formato eletrônico durante três eventos de medicina intensiva e, posteriormente, por meio do portal da Associação de Medicina Intensiva Brasileira, entre março e outubro de 2009. Foram pesquisados dados demográficos e aspectos relacionados às preferências do entrevistado em relação à monitorização hemodinâmica. Resultados: Responderam ao questionário 211 profissionais. Nos hospitais privados, foi evidenciada maior disponibilidade de recursos de monitorização hemodinâmica do que nas instituições públicas. O cateter de artéria pulmonar foi considerado o mais fidedigno por 56,9%, seguido do ecocardiograma, com 22,3%. O débito cardíaco foi considerado a variável mais importante. Outras variáveis também julgadas relevantes foram débito cardíaco, saturação de oxigênio venoso misto/saturação de oxigênio venoso central, pressão ...
Objective: In Brazil, there are no data on the preferences of intensivists regarding hemodynamic monitoring methods. The present study aimed to identify the methods used by national intensivists, the hemodynamic variables they consider important, the regional differences, the reasons for choosing a particular method, and the use of protocols and continued training. Methods: National intensivists were invited to answer an electronic questionnaire during three intensive care events and later, through the Associação de Medicina Intensiva Brasileira portal, between March and October 2009. Demographic data and aspects related to the respondent preferences regarding hemodynamic monitoring were researched. Results: In total, 211 professionals answered the questionnaire. Private hospitals showed higher availability of resources for hemodynamic monitoring than did public institutions. The pulmonary artery catheter was considered the most trusted by 56.9% of the respondents, followed by echocardiograms, at 22.3%. Cardiac output was considered the most important variable. Other variables also considered relevant were mixed/central venous oxygen saturation, pulmonary artery occlusion pressure, and right ventricular end-diastolic volume. Echocardiography was the most used method (64.5%), followed by pulmonary artery catheter (49.3%). Only half of respondents used treatment protocols, and 25% worked in continuing education programs in hemodynamic monitoring. ...
Adult , Female , Humans , Male , Middle Aged , Critical Care/methods , Intensive Care Units/statistics & numerical data , Monitoring, Physiologic/methods , Attitude of Health Personnel , Brazil , Catheterization, Swan-Ganz/statistics & numerical data , Critical Care/statistics & numerical data , Echocardiography/statistics & numerical data , Health Care Surveys , Hemodynamics/physiology , Hospitals, Private/statistics & numerical data , Hospitals, Public/statistics & numerical data , Surveys and Questionnaires
JUSTIFICATIVA E OBJETIVOS: A medicina endoscópica está cada vez mais sendo usada atualmente, porém não é isenta de riscos. Portanto, este estudo avaliou os fatores associados com complicações perioperatórias em cirurgias endoscópicas com irrigação intraoperatória. MÉTODO: Estudo de coorte durante seis meses. Foram incluídos pacientes com > 18 anos, submetidos a cirurgias endoscópicas que usariam fluidos de irrigação no intraoperatório. Pacientes em uso de diuréticos, com insuficiência renal, distúrbios cognitivos, hiponatremia prévia a cirurgia, gestantes e moribundos foram excluídos. Foram alocados em dois grupos os pacientes que apresentaram complicações ou não no período perioperatório. As complicações avaliadas estavam relacionadas a alterações neurológicas, cardiovasculares, renais e sangramentos no perioperatório. RESULTADOS: Foram incluídos 181 pacientes e 39 excluídos, portanto 142 preencheram os critérios. Apresentaram complicações 21,8% dos pacientes, com maior ocorrência em cirurgias endoscópicas de próstata, seguidas de histeroscopias, bexiga, artroscopia de joelho e ombro, respectivamente 58,1%, 36,9%, 19,4%, 3,8% e 3,2%. Comparando os grupos, apresentaram associação com complicações na análise univariada; idade, sexo, tabagismo, cardiopatia, ASA, sódio sérico no fim da cirurgia, total de fluido de irrigação administrado, ressecção transuretral de próstata, histeroscopia. Entretanto, apenas idade (OR = 1,048), sódio sérico (OR = 0,962) e volume de fluido de irrigação administrado no intraoperatório (OR = 1,001) foram variáveis independentes para complicações na regressão múltipla. CONCLUSÃO: Graves complicações em cirurgias endoscópicas têm grande ocorrência. O sódio sérico no fim da operação, a quantidade de fluido de irrigação e a idade foram fortes fatores independentes associados ao problema. Dessa forma, tais fatores devem ser levados em consideração nesses tipos de cirurgias.
BACKGROUND AND OBJECTIVES: Currently, endoscopic medicine is being increasingly used, albeit not without risks. Therefore, this study evaluated the factors associated with perioperative complications in endoscopic surgery with intraoperative irrigation. METHOD: A cohort study of six months duration. Patients aged > 18 years undergoing endoscopic surgery with the use of irrigation fluids during the intraoperative period were included. Exclusion criteria were: use of diuretics, kidney failure, cognitive impairment, hyponatremia prior to surgery, pregnancy, and critically ill. The patients who presented with or without complications during the perioperative period were allocated into two groups. Complications evaluated were related to neurological, cardiovascular and renal changes, and perioperative bleeding. RESULTS: In total, 181 patients were enrolled and 39 excluded; therefore, 142 patients met the study criteria. Patients with complications amounted to 21.8%, with higher prevalence in endoscopic prostate surgery, followed by hysteroscopy, bladder, knee, and shoulder arthroscopy (58.1%, 36.9%, 19.4%, 3.8%, 3.2% respectively). When comparing both groups, we found association with complications in univariate analysis: age, sex, smoking, heart disease, ASA, serum sodium at the end of surgery, total irrigation fluid administered, TURP, and hysteroscopy. However, in multiple regression analysis for complications, only age (OR = 1.048), serum sodium (OR = 0.962), and volume of irrigation fluid administered during surgery (OR = 1.001) were independent variables. CONCLUSION: The incidence of serious complications in endoscopic surgeries is high. Serum sodium at the end of the operation, amount of irrigation fluid, and age were strong independent factors associated with the problem. Thus, these factors must be taken into account in these surgeries.
JUSTIFICATIVA Y OBJETIVOS: Hoy por hoy, la medicina endoscópica se usa cada vez más aunque no esté exenta de riesgos. Por eso, este estudio evaluó los factores que están asociados con las complicaciones perioperatorias en las cirugías endoscópicas con irrigación intraoperatória. MÉTODO: Estudio de cohorte durante seis meses. Se incluyeron pacientes con > 18 años, sometidos a cirugías endoscópicas que usarían fluidos de irrigación en el intraoperatorio. Pacientes que usaban diuréticos, que tenían insuficiencia renal, trastornos cognitivos, hiponatremia previa a la cirugía, gestantes y moribundos quedaron fuera del estudio. Fueron divididos en dos grupos los pacientes que tenían complicaciones o no en el período perioperatorio. Las complicaciones evaluadas estaban relacionadas con las alteraciones neurológicas, cardiovasculares, renales y con los sangramientos en el perioperatorio. RESULTADOS: Fueron incluidos 181 pacientes quedando fuera 39, por tanto 142 respetaron los criterios. Tenían complicaciones el 21,8% de los pacientes, con una incidencia mayor en las cirugías endoscópicas de próstata, seguidas de histeroscopias, vejiga, artroscopia de rodilla y de hombro, respectivamente 58,1%, 36,9%, 19,4%, 3,8% y 3,2%. Comparando los grupos, tenían una asociación con las complicaciones en el análisis univariado; edad, sexo, tabaquismo, cardiopatía, ASA, sodio sérico al final de la cirugía, total de fluido de irrigación administrado, resección transuretral de próstata, histeroscopia. Sin embargo, solamente la edad (OR = 1,048), sodio sérico (OR = 0,962) y el volumen de fluido de irrigación administrado en el intraoperatorio (OR = 1,001), fueron variables independientes para las complicaciones en la regresión múltiple. CONCLUSIONES: Las graves complicaciones en las cirugías endoscópicas tienen un gran porcentaje de incidencia. El sodio sérico al final de la operación, la cantidad de fluido de irrigación y la edad, fueron fuertes factores independientes asociados al problema. Tales factores deben ser tenidos en cuenta en esos tipos de cirugías.
Aged , Female , Humans , Male , Middle Aged , Endoscopy/adverse effects , Therapeutic Irrigation/adverse effects , Cohort Studies , Incidence , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Risk Assessment , Risk Factors
