Risk of deep venous thrombosis associated with peripherally inserted central catheter: A retrospective cohort study of 11.588 catheters in Brazil.

INTRODUCTION: Deep Venous Thrombosis (DVT) due to Peripherally Inserted Central Catheter (PICC) is one of the most threatening complications after device insertion. OBJECTIVE: To assess the rate of PICC-associated DVT and analyze the risk factors associated with this event in cancer and critically ill patients. METHODS: We conducted a descriptive, retrospective cohort study with 11,588 PICCs from December 2014 to December 2019. Patients ≥ 18 years receiving a PICC were included. Pre-and post-puncture variables were collected and a logistic regression was used to identify the independent factors associated with the risk of DVT. RESULTS: The DVT prevalence was 1.8% (n = 213). The median length of PICC use was 15.3 days. The median age was 75 years (18; 107) and 52% were men, 53.5% were critically ill and 29.1% oncological patients. The most common indications for PICC's were intravenous antibiotics (79.1%). Notably, 91.5% of PICC showed a catheter-to-vein ratio of no more than 33%. The tip location method with intracavitary electrocardiogram was used in 43%. Most catheters (67.9%) were electively removed at the end of intravenous therapy. After adjusting for cancer profile ou chemotherapy, regression anaysis revealed that age (OR 1.011; 95% CI 1.002-1.020), previous DVT (OR 1.96; 95% CI 1.12-3.44) and obstruction of the device (OR 1.60; 95% CI 1.05-2.42) were independent factors associated with PICC-associated DVT, whereas the use of an anticoagulant regimen was a protective variable (OR 0.73; 95% CI 0.54-0.99). CONCLUSION: PICC is a safe and suitable intravenous device for medium and long-term therapy, with low rates of DVT even in a cohort of critically ill and cancer patients.

Ninety-day outcomes in patients diagnosed with COVID-19 in São Paulo, Brazil: a cohort study.

OBJECTIVE: COVID-19 has been associated with a significant burden to those who survive the acute phase. We aimed to describe the quality of life and symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD) at 90 days after hospital discharge of COVID-19 patients. METHODS: Patients with COVID-19 admitted to a private hospital in the city of São Paulo, Brazil, between April of 2020 and April of 2021 were interviewed by telephone at 30 and 90 days after discharge to assess the quality of life and symptoms of depression, anxiety, and PTSD. RESULTS: A total of 2,138 patients were included. The mean age was 58.6 ± 15.8 years, and the median length of hospital stay was 9.0 (5.0-15.8) days. Between the two time points, depression increased from 3.1% to 7.2% (p < 0.001), anxiety increased from 3.2% to 6.2% (p < 0.001), and PTSD increased from 2.3% to 5.0% (p < 0.001). At least one physical symptom related to COVID-19 diagnosis persisted in 32% of patients at day 90. CONCLUSIONS: Persistence of physical symptoms was high even at 90 days after discharge. Although the prevalence of symptoms of anxiety, depression, and PTSD was low, these symptoms persisted for three months, with a significant increase between the time points. This finding indicates the need to identify at-risk patients so that they can be given an appropriate referral at discharge.

Ninety-day outcomes in patients diagnosed with COVID-19 in São Paulo, Brazil: a cohort study / Desfechos em 90 dias entre pacientes com diagnóstico de COVID-19 em São Paulo (SP): estudo de coorte

ABSTRACT Objective: COVID-19 has been associated with a significant burden to those who survive the acute phase. We aimed to describe the quality of life and symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD) at 90 days after hospital discharge of COVID-19 patients. Methods: Patients with COVID-19 admitted to a private hospital in the city of São Paulo, Brazil, between April of 2020 and April of 2021 were interviewed by telephone at 30 and 90 days after discharge to assess the quality of life and symptoms of depression, anxiety, and PTSD. Results: A total of 2,138 patients were included. The mean age was 58.6 ± 15.8 years, and the median length of hospital stay was 9.0 (5.0-15.8) days. Between the two time points, depression increased from 3.1% to 7.2% (p < 0.001), anxiety increased from 3.2% to 6.2% (p < 0.001), and PTSD increased from 2.3% to 5.0% (p < 0.001). At least one physical symptom related to COVID-19 diagnosis persisted in 32% of patients at day 90. Conclusions: Persistence of physical symptoms was high even at 90 days after discharge. Although the prevalence of symptoms of anxiety, depression, and PTSD was low, these symptoms persisted for three months, with a significant increase between the time points. This finding indicates the need to identify at-risk patients so that they can be given an appropriate referral at discharge.

RESUMO Objetivo: A COVID-19 tem sido associada a um fardo significativo para aqueles que sobrevivem à fase aguda. Nosso objetivo foi descrever a qualidade de vida e sintomas de ansiedade, depressão e transtorno de estresse pós-traumático (TEPT) 90 dias após a alta hospitalar em pacientes com COVID-19. Métodos: Pacientes com COVID-19 internados em um hospital privado na cidade de São Paulo (SP) entre abril de 2020 e abril de 2021 foram entrevistados por telefone 30 e 90 dias após a alta para avaliar a qualidade de vida e sintomas de depressão, ansiedade e TEPT. Resultados: Foram incluídos 2.138 pacientes. A média de idade foi de 58,6 ± 15,8 anos, e a mediana do tempo de internação hospitalar foi de 9,0 (5,0-15,8) dias. Entre os dois momentos, a depressão aumentou de 3,1% para 7,2% (p < 0,001), a ansiedade, de 3,2% para 6,2% (p < 0,001), e o TEPT, de 2,3% para 5,0% (p < 0,001). Pelo menos um sintoma físico relacionado ao diagnóstico de COVID-19 persistia em 32% dos pacientes no 90º dia. Conclusões: A persistência dos sintomas físicos foi elevada mesmo 90 dias após a alta. Embora a prevalência de sintomas de ansiedade, depressão e TEPT tenha sido baixa, esses sintomas persistiram por três meses, com aumento significativo entre os momentos. Esse achado indica a necessidade de identificar os pacientes de risco para que possam receber o encaminhamento adequado no momento da alta.

A clinical model to predict successful renal replacement therapy (RRT) discontinuation in patients with Acute Kidney Injury (AKI)

Abstract Introduction Ideal timing of Renal Replacement Therapy (RRT) discontinuation in Acute Kidney Injury (AKI) is still unknown. We aimed to study the role of creatinine-related variables in predicting RRT successful discontinuation and to propose a clinical predictive score. Methods In this single-centre retrospective study, we evaluated all AKI patients in whom RRT was interrupted for at least 48 hours. Patients who were still RRT-independent 7 days after initial RRT cessation were included in the "Success" group and opposed to the "Failure" group. We evaluated baseline characteristics and variables collected at the time of RRT interruption, as well as the Kinetic estimated Glomerular Filtration Rate (KeGFR), the simple variation in serum Creatinine (ΔsCr), and the incremental creatinine ratio on the first three days after RRT interruption. Multivariable analysis was performed to evaluate prediction of success. Internal validation using a simple binomial generalized regression model with Lasso estimation and 5-fold cross validation method was performed. Results We included 124 patients, 49 in the "Failure" group and 75 in the "Success" group. All creatinine-related variables predicted success in simple and multiple logistic regression models. The best model generated a clinical score based on the odds ratio obtained for each variable and included urine output, non-renal SOFA score, fluid balance, serum urea, serum potassium, blood pH, and the variation in sCr values after RRT discontinuation. The score presented an area under the ROC of 0.86 (95% CI 0.76‒1.00). Conclusion Creatinine variation between the first 2 consecutive days after RRT discontinuation might predict success in RRT discontinuation. The developed clinical score based on these variables might be a useful clinical decision tool to guide hemodialysis catheter safe removal.

Evaluation of eleven immunochromatographic assays for SARS-CoV-2 detection: investigating the dengue cross-reaction.

COVID-19 disease is spread worldwide and diagnostic techniques have been studied in order to contain the pandemic. Immunochromatographic (IC) assays are feasible and a low-cost alternative especially in low and middle-income countries, which lack structure to perform certain diagnostic techniques. Here we evaluate the sensitivity and specificity of eleven different IC tests in 145 serum samples from confirmed cases of COVID-19 using RT-PCR and 100 negative serum samples from blood donors collected in February 2019. We also evaluated the cross-reactivity with dengue using 20 serum samples from patients with confirmed diagnosis for dengue collected in early 2019 through four different tests. We found high sensitivity (92%), specificity (100%) and an almost perfect agreement (Kappa 0.92) of IC assay, especially when we evaluated IgG and IgM combined after 10 days from the onset of symptoms with RT-PCR. However, we detected cross-reactivity between dengue and COVID-19 mainly with IgM antibodies (5 to 20% of cross-reaction) and demonstrated the need for better studies about diagnostic techniques for these diseases.

Effects of an educational intervention for rational cardiac enzyme requisitions in critically ill patients: a pre-post intervention study.

BACKGROUND: Although cardiac troponin is recommended as the biomarker of choice to evaluate myocardial injury, inappropriate low-value ordering practice is frequent, particularly routine ordering of creatine kinase-myocardial band (CK-MB) tests where troponin is available. OBJECTIVE: The aim of this study was to evaluate the impact of an educational intervention for rational request of cardiac biomarkers in the intensive care unit. METHOD: We conducted a quasi-experimental, pre-post implementation study of an educational program (expository-dialogue presentation and disclosure of a decision algorithm) for rational cardiac biomarker testing in adult critically ill patients. The study was divided into two 12-month periods: pre-intervention (September 2017-August 2018) and post-intervention (October 2018-September 2019). An interrupted time series with a segmented regression model was applied to analyze variation over time in CK-MB and troponin testing. RESULTS: We included 4429 patients: 2181 patients in the pre-intervention period and 2248 patients in the post-intervention period. A reduction in the concomitance of CK-MB and troponin testing was observed (concomitance in 1415 tests in the pre-intervention period vs 348 tests in the post-intervention period). The interrupted time series analysis demonstrated a noticeable immediate reduction in the concomitance of CK-MB with troponin after the intervention (-0.13 tests per patient, P = 0.0016) but not in the secular trend for the concomitance. The proportion of patients with the acute coronary syndrome as a discharge diagnosis was not different between the pre- and post-intervention period. CONCLUSION: Our pre-post interventional study demonstrated a significant decrease in the concomitance of CK-MB and troponin tests. A rational high-value ordering practice of cardiac biomarkers is possible in critically ill patients and might be suitable for educational interventions.

Acute pain in the critically ill patient: revisiting the literature / Dor aguda no paciente crítico: revisitando a literatura

ABSTRACT BACKGROUND AND OBJECTIVES: According to the redefinition, acute pain is a somatic experience, with individual perception of physical or existential threat, comprising affective, cognitive and behavioral components. In critically ill patients, pain is a frequent and poorly controlled symptom, causing worse outcomes. The objective of this study was to explore the topic of acute pain in critically ill adult patients, focusing on some aspects of pathophysiology, in addition to updates regarding diagnosis, multimodal therapy and discussion of its control as a marker of good care practice. CONTENTS: A search strategy was performed with the descriptors previously defined in the Pubmed and Cochrane portals, in the period from 2011 to 2021, without a language restriction filter. Acute pain represents a physiological response to a nociceptive stimulus, with high relevance due to its ability to activate complex pathways (inflammatory, hormonal and immune), with systemic repercussions. Pain assessment is often performed using recognized scales, but with limited validation in patients with traumatic brain injury, burns and patients with severe delirium and/or dementia. Studies considering these patients point to the use of new technologies in an attempt to target this diagnosis, such as bedside pupillometry and the use of platforms capable of integrating multiparametric measurements. Regarding therapy, the concept of analgosedation, aiming at prioritizing analgesia in critically ill patients, presents an approach capable of improving clinical outcomes. In addition, there is a preference for multimodal therapy as a good medical practice through the association of different drugs with different mechanisms of no-ciceptive blockade as a strategy to achieve pain control and facilitate the reduction of opioid consumption. CONCLUSION: Due to its systemic effects and prevalence, acute pain is still a relevant problem in intensive care units. New diagnostic methods are being marketed with the aim of targeting this evaluation in complex patients. The approach to acute pain should prioritize the use of multimodal techniques, which present more consistent clinical responses, in addition to reducing the consumption of opioids. The existence of multidisciplinary teams specialized in pain control in the hospital environment is able to assist in difficult cases and help in quality audits.

RESUMO JUSTIFICATIVA E OBJETIVOS: Conforme redefinição, a dor aguda é uma experiência somática, com percepção individual de ameaça física ou existencial, compreendendo componentes afetivos, cognitivos e comportamentais. Em pacientes críticos, a dor representa um sintoma frequente e mal controlado, ocasionando piores desfechos. O objetivo deste estudo foi explorar a temática da dor aguda nos pacientes críticos adultos, com enfoque em alguns aspectos de fisiopatologia, além de atualizações em relação a diagnóstico, terapêutica multimodal e discussão de seu controle como um marcador de boa prática assistencial. CONTEÚDO: Foi realizada estratégia de busca com os descritores previamente definidos nos portais Pubmed e Cochrane, no período de 2011 a 2021, sem filtro de restrição para idioma. A dor aguda representa uma resposta fisiológica a um estímulo nociceptivo, tendo alta relevância por sua capacidade de ativar vias complexas (inflamatórias, hormonais e imunes), com repercussões sistêmicas. A avaliação da dor é frequentemente realizada através de escalas reconhecidas, porém com validação limitada em pacientes com trauma cranioencefálico, queimados e portadores de delirium e/ou demência acentuados. Os estudos considerando esses pacientes apontam para o uso de novas tecnologias na tentativa de objetivar esse diagnóstico, como a pupilometria à beira leito e o uso de plataformas capazes de integrar medidas multiparamétricas. Em relação à terapêutica, o conceito de analgosedação, objetivando priorização de analgesia nos pacientes críticos, apresenta abordagem capaz de melhorar desfechos clínicos. Além disso, há preferência da terapêutica multimodal como boa prática médica através da associação de diferentes fármacos com diversos mecanismos de bloqueio nociceptivo como estratégia para alcançar controle álgico e facilitar a redução do consumo de opioides. CONCLUSÃO: Por seus efeitos sistêmicos e sua prevalência, a dor aguda ainda é problemática relevante nas unidades de terapia intensiva. Novos métodos diagnósticos estão sendo comercializados com a proposta de objetivar essa avaliação em pacientes complexos. A abordagem da dor aguda deve priorizar o emprego de técnicas multimodais, que apresentam respostas clínicas mais consistentes, além de redução no consumo de opioides. A existência de equipes multidisciplinares especializadas no controle da dor no ambiente hospitalar é capaz de auxiliar em casos difíceis e ajudar nas auditorias de qualidade.

Evaluation of eleven immunochromatographic assays for SARS-CoV-2 detection: investigating the dengue cross-reaction

ABSTRACT COVID-19 disease is spread worldwide and diagnostic techniques have been studied in order to contain the pandemic. Immunochromatographic (IC) assays are feasible and a low-cost alternative especially in low and middle-income countries, which lack structure to perform certain diagnostic techniques. Here we evaluate the sensitivity and specificity of eleven different IC tests in 145 serum samples from confirmed cases of COVID-19 using RT-PCR and 100 negative serum samples from blood donors collected in February 2019. We also evaluated the cross-reactivity with dengue using 20 serum samples from patients with confirmed diagnosis for dengue collected in early 2019 through four different tests. We found high sensitivity (92%), specificity (100%) and an almost perfect agreement (Kappa 0.92) of IC assay, especially when we evaluated IgG and IgM combined after 10 days from the onset of symptoms with RT-PCR. However, we detected cross-reactivity between dengue and COVID-19 mainly with IgM antibodies (5 to 20% of cross-reaction) and demonstrated the need for better studies about diagnostic techniques for these diseases.

Epidemiologia e desfecho dos pacientes de alto risco cirúrgico admitidos em unidades de terapia intensiva no Brasil / Epidemiology and outcome of high-surgical-risk patients admitted to an intensive care unit in Brazil

RESUMO Objetivo: Definir o perfil epidemiológico e os principais determinantes de morbimortalidade dos pacientes cirúrgicos não cardíacos de alto risco no Brasil. Métodos: Estudo prospectivo, observacional e multicêntrico. Todos os pacientes cirúrgicos não cardíacos admitidos nas unidades de terapia intensiva, ou seja, considerados de alto risco, no período de 1 mês, foram avaliados e acompanhados diariamente por, no máximo, 7 dias na unidade de terapia intensiva, para determinação de complicações. As taxas de mortalidade em 28 dias de pós-operatório, na unidade de terapia intensiva e hospitalar foram avaliadas. Resultados: Participaram 29 unidades de terapia intensiva onde foram realizadas cirurgias em 25.500 pacientes, dos quais 904 (3,5%) de alto risco (intervalo de confiança de 95% - IC95% 3,3% - 3,8%), tendo sido incluídos no estudo. Dos pacientes envolvidos, 48,3% eram de unidades de terapia intensiva privadas e 51,7% de públicas. O tempo de internação na unidade de terapia intensiva foi de 2,0 (1,0 - 4,0) dias e hospitalar de 9,5 (5,4 - 18,6) dias. As taxas de complicações foram 29,9% (IC95% 26,4 - 33,7) e mortalidade em 28 dias pós-cirurgia 9,6% (IC95% 7,4 - 12,1). Os fatores independentes de risco para complicações foram Simplified Acute Physiology Score 3 (SAPS 3; razão de chance − RC = 1,02; IC95% 1,01 - 1,03) e Sequential Organ Failure Assessment Score (SOFA) da admissão na unidade de terapia intensiva (RC =1,17; IC95% 1,09 - 1,25), tempo de cirurgia (RC = 1,001; IC95% 1,000 - 1,002) e cirurgias de emergências (RC = 1,93; IC95% 1,10 - 3,38). Em adição, foram associados com mortalidade em 28 dias idade (RC = 1,032; IC95% 1,011 - 1,052) SAPS 3 (RC = 1,041; IC95% 1,107 - 1,279), SOFA (RC = 1,175; IC95% 1,069 - 1,292) e cirurgias emergenciais (RC = 2,509; IC95% 1,040 - 6,051). Conclusão: Pacientes com escores prognósticos mais elevados, idosos, tempo cirúrgico e cirurgias emergenciais estiveram fortemente associados a maior mortalidade em 28 dias e mais complicações durante permanência em unidade de terapia intensiva.

ABSTRACT Objective: To define the epidemiological profile and the main determinants of morbidity and mortality in noncardiac high surgical risk patients in Brazil. Methods: This was a prospective, observational and multicenter study. All noncardiac surgical patients admitted to intensive care units, i.e., those considered high risk, within a 1-month period were evaluated and monitored daily for a maximum of 7 days in the intensive care unit to determine complications. The 28-day postoperative, intensive care unit and hospital mortality rates were evaluated. Results: Twenty-nine intensive care units participated in the study. Surgeries were performed in 25,500 patients, of whom 904 (3.5%) were high-risk (95% confidence interval - 95%CI 3.3% - 3.8%) and were included in the study. Of the participating patients, 48.3% were from private intensive care units, and 51.7% were from public intensive care units. The length of stay in the intensive care unit was 2.0 (1.0 - 4.0) days, and the length of hospital stay was 9.5 (5.4 - 18.6) days. The complication rate was 29.9% (95%CI 26.4 - 33.7), and the 28-day postoperative mortality rate was 9.6% (95%CI 7.4 - 12.1). The independent risk factors for complications were the Simplified Acute Physiology Score 3 (SAPS 3; odds ratio - OR = 1.02; 95%CI 1.01 - 1.03) and Sequential Organ Failure Assessment Score (SOFA) on admission to the intensive care unit (OR = 1.17; 95%CI 1.09 - 1.25), surgical time (OR = 1.001, 95%CI 1.000 - 1.002) and emergency surgeries (OR = 1.93, 95%CI, 1.10 - 3.38). In addition, there were associations with 28-day mortality (OR = 1.032; 95%CI 1.011 - 1.052), SAPS 3 (OR = 1.041; 95%CI 1.107 - 1.279), SOFA (OR = 1.175, 95%CI 1.069 - 1.292) and emergency surgeries (OR = 2.509; 95%CI 1.040 - 6.051). Conclusion: Higher prognostic scores, elderly patients, longer surgical times and emergency surgeries were strongly associated with higher 28-day mortality and more complications during the intensive care unit stay.

Moral distress and its contribution to the development of burnout syndrome among critical care providers.

BACKGROUND: Burnout appears to be common among critical care providers. It is characterized by three components: emotional exhaustion, depersonalization and personal accomplishment. Moral distress is the inability of a moral agent to act according to his or her core values and perceived obligations due to internal and external constraints. We aimed to estimate the correlation between moral distress and burnout among all intensive care unit (ICU) and the step-down unit (SDU) providers (physicians, nurses, nurse technicians and respiratory therapists). METHODS: A survey was conducted from August to September 2015. For data collection, a self-administered questionnaire for each critical care provider was used including basic demographic data, the Maslach Burnout Inventory (MBI) and the Moral Distress Scale-Revised (MDS-R). Correlation analysis between MBI domains and moral distress score and regression analysis to assess independent variables associated with burnout were performed. RESULTS: A total of 283 out of 389 (72.7%) critical care providers agreed to participate. The same team of physicians attended both ICU and SDU, and severe burnout was identified in 18.2% of them. Considering all others critical care providers of both units, we identified that overall 23.1% (95% CI 18.0-28.8%) presented severe burnout, and it did not differ between professional categories. The mean MDS-R rate for all ICU and SDU respondents was 111.5 and 104.5, respectively, p = 0.446. Many questions from MDS-R questionnaire were significantly associated with burnout, and those respondents with high MDS-R score (>100 points) were more likely to suffer from burnout (28.9 vs 14.4%, p = 0.010). After regression analysis, moral distress was independently associated with burnout (OR 2.4, CI 1.19-4.82, p = 0.014). CONCLUSIONS: Moral distress, resulting from therapeutic obstinacy and the provision of futile care, is an important issue among critical care providers' team, and it was significantly associated with severe burnout.

Do Biliary Salts Have Role on Acute Kidney Injury Development?

Acute kidney injury (AKI) is a major complication in patients with acute liver failure and chronic liver disease. Hemodynamic changes appear to be the principal alterations in these conditions, therefore there should be no known structural abnormalities responsible for AKI. On the other hand, several authors have published data on structural changes known as bile cast nephropathy or cholemic nephrosis, which basically consist of the presence of bile casts in tubular lumen analogous to those observed in myeloma. Although these findings are well documented, there is a lack of reproducibility by other authors. This paper aims to discuss, through evidence-based medical literature, the role of biliary salts on kidney injury development.