Guidelines for maintenance of adult patients with brain death and potential for multiple organ donations: the Task Force of the Brazilian Association of Intensive Medicine the Brazilian Association of Organs Transplantation, and the Transplantation Center of Santa Catarina.

INTRODUCTION: The organ shortage for transplantation, the principal factor that increases waiting lists, has become a serious public health problem. In this scenario, the intensivist occupies a prominent position as one of the professionals that first has a chance to identify brain death and to be responsible for the maintenance of the potential deceased donor. OBJECTIVE: This report attempts to establish guidelines for care and maintenance of adult deceased donor organs guiding and standardizing care provided to patients with brain death. METHOD: These guidelines were composed by intensivists, transplant coordinators, professionals from various transplant teams, and used transplant center. The formulated questions were forwarded to all members and recommendations were constructed after an extensive literature review selecting articles with the highest degree of evidence. RESULTS: Guidelines were developed in the form of questions reflecting frequent experiences in clinical intensive care practices. The main questions were: Is there an optimal interval for keeping organs of deceased donors viable? What actions are considered essential for maintaining deceased donors in this period? What are the limits of body temperature? How should the patient be warmed? Which laboratory tests should be performed? What is the collection interval? What are the limits in the laboratory and the capture scenario? What are the limits of blood pressure? When and how should one use catecholamines? CONCLUSIONS: This pioneer project involved a multidisciplinary team working in organ transplantation seeking to provide treatment guidance to increase the number of viable organs from deceased adult donors.

Tight glucose control versus intermediate glucose control: a quasi-experimental study.

Intensive insulin treatment is associated with an increased risk of hypoglycaemia. The purpose of this study was to evaluate two different strategies: tight glucose control (TGC) versus intermediate glucose control (IGC). In this quasi-experimental study, 130 critically ill patients were assigned to receive either the TGC protocol (n=65), according to which blood glucose levels were maintained between 4.4 and 6.1 mmol/l, or the IGC protocol (n=65), according to which blood glucose levels were maintained between 4.4 and 8.0 mmol/l. A total of 52 subjects (40%) were diabetic and 63 (49%) were septic. In the IGC group, glucose levels were stabilised in the target range for a longer period of time when compared to the TGC group (63 vs. 41%, P < 0.001). The median capillary blood glucose level was 6.7 mmol/l in the TGC group (6.2 to 7.2) and 7.9 mmol/l (7.0 to 8.5) in the IGC group (P < 0.001). The incidence of hypoglyacemia less than 2.2 mmol/l was 21.5% in the TGC group and 1.5% in the IGC group (P < 0.001), and the incidence of hypoglycaemia less than 3.3 mmol/l was 67.7 and 26.2% (P < 0.001) in the two groups, respectively. Diabetes (odds ratio 2.88, CI 1.22 to 6.84) and the TGC protocol (odds ratio 7.39, CI 3.15 to 1735) were identified as independent risk factors for hypoglycaemia less than 3.3 mmol/l. Mechanical ventilation (odds ratio 4.33, CI 1.16 to 16.13), medical illness (odds ratio 2.88, CI 1.20 to 6.99) and hypoglycaemia (< 3.3 mmol/l) (odds ratio 299, CI 1.21 to 7.41) were independent factors associated with mortality. TGC is difficult to accomplish in routine intensive care unit settings and is associated with a significant increase in the incidence of hypoglycaemia. Hypoglycaemia < 3.3 mmol/l is an independent risk factor for in-hospital mortality.

Red blood cell transfusion does not increase oxygen consumption in critically ill septic patients.

BACKGROUND: Red blood cell (RBC) transfusion is commonly used to increase oxygen transport in patients with sepsis. However it does not consistently increase oxygen uptake at either the whole-body level, as calculated by the Fick method, or within individual organs, as assessed by gastric intra-mucosal pH. AIM: This study evaluates the hemodynamic and oxygen utilization effects of hemoglobin infusion on critically ill septic patients. METHODS: Fifteen septic patients undergoing mechanical ventilation whose hemoglobin was <10 g% were eligible. Ten patients (APACHE II: 25.5 +/- 7.6) received an infusion of 1 unit of packed RBC over 1 h while sedated and paralyzed. The remaining five control patients (APACHE II: 24.3 +/- 6.0) received a 5% albumin solution (500 ml) over 1 h. Hemodynamic data, gastric tonometry and calorimetry were obtained prior to and immediately after RBC transfusion or 5% albumin infusion. RESULTS: Transfusion of RBC was associated with an improvement in left ventricular systolic work index (38.6 +/- 12.6 to 41.1 +/- 13.0 g/min/m2; P = 0.04). In the control group there was no significant change in the left ventricular systolic work index (37.2 +/- 14.3 to 42.2 +/- 18.9 g/min/m2). An increase in pulmonary vascular resistance index (203 +/- 58 to 238 +/- 49 dyne/cm5/m2; P = 0.04) was also observed, while no change was produced by colloid infusion (237 +/- 87.8 to 226.4 +/- 57.8 dyne/cm5/m2). Oxygen utilization did not increase either by Fick equation or by indirect calorimetry in either group. Gastric intramucosal pH increased only in the control group but did not reach statistical significance. CONCLUSION: Hemoglobin increase does not improve either global or regional oxygen utilization in anemic septic patients. Furthermore, RBC transfusion may hamper right ventricular ejection by increasing the pulmonary vascular resistance index.

Slowly progressive insulin-dependent diabetes mellitus in an elderly patient with Graves' disease.

We report a case of slowly progressive insulin-dependent diabetes mellitus in an elderly patient with Graves' disease. A 69-year-old man presented with apathetic thyrotoxicosis and weight loss. Laboratory findings indicated insulin-dependent diabetes mellitus (IDDM) with Graves' disease. Human leukocyte antigens DR4 and DR9, which are recognized as markers for IDDM with autoimmune thyroid disease, were detected. The clinical course of the IDDM was compatible with the slowly progressive type. Onset of this disease during old age is rare, and such cases should be analyzed with a thyroid function test because the symptom of thyrotoxicosis may be masked in the elderly.

Cardiac troponin: a new serum marker of myocardial injury in sepsis.

OBJECTIVE: Echocardiogram-derived left ventricular ejection fraction (LVEF) is usually utilized to evaluate left ventricular function, including that of septic patients. However, LVEF is greatly influenced by afterload. The aim of this study was to test the hypothesis that troponin I, a serum marker of myocardial injury, may be able to detect left ventricular involvement by the septic process, being at least as sensitive an indicator of left ventricular dysfunction as LVEF in these patients. DESIGN: Comparison of echocardiogram-derived LVEF with serum levels of troponin I in ten critically ill septic patients. SETTING: General intensive care unit in a tertiary care private hospital. PATIENTS: Ten critically ill septic patients with no previous documented heart disease. MEASUREMENTS AND RESULTS: Patients were simultaneously submitted to a two-dimensional echocardiogram and troponin I determinations. LVEFs and troponin I levels were analyzed in a two-by-two table in order to validate troponin I as a new biochemical marker of myocardial injury in sepsis. All the patients whose LVEF was < 0.5 had elevated troponin I levels (kappa = 0.61, p = 0.035). CONCLUSIONS: Identification of myocardial dysfunction in septic patients has been a challenging task. Troponin I, a serum marker of myocardial injury, may be of great help in the recognition of myocardial involvement by sepsis in a noninvasive and readily available way.

Alteraçöes cardiocirculatórias na sepse / Cardiovascular abnormalities in sepsis

O choque séptico é uma grave síndrome clínica, responsável, nos Estados Unidos, por aproximadamente 400 mil internaçöes em Unidades de Terapia Intensiva e 100 mil óbitos por ano. Em cerca de 15 'por cento' dos pacientes com hipotensão refratária constata-se quadro de depressão miocárdica, responsável por importantes alteraçöes hemodinâmicas. Vários estudos "in vitro" e "in vivo" demostraram que, após a introdução de endotoxinas existentes na parede de algumas bactérias, ocorre a indução de substâncias mediadoras e moduladoras presentes na circulação, desencadeando o processo séptico. O estudo anatomopatológico desses coraçöes demostrou diferentes graus de acometimento, variando desde inflamatória local até quadros de miocardite intersticial, abscesso intramiocárdico e necrose celular. As mais recentes pesquisas neste assunto são relacionadas às interaçöes do óxido nítrico com as estruturas celulares. O TNF, a IL-1 e outros mediadores atuam provavelmente de forma sinérgica, determinando as alteraçöes que acarretam a depressão do miocárdio nos pacientes sépticos. O uso de inibidores das enzimas formadoras de óxido nítrico tem sido motivo de estudos randomizados, com o intuito de avaliar seu benefício na reversão dessas alteraçöes cardiovasculares nos quadros sépticos.

Noncardiogenic pulmonary edema complicating diabetic ketoacidosis.

OBJECTIVE: To alert physicians to the possibility of pulmonary edema as a complication of diabetic ketoacidosis. METHODS: We report a case of adult respiratory distress syndrome after resuscitative efforts to compensate the first episode of diabetic ketoacidosis in a previously healthy young woman. RESULTS: In a 26-year-old woman with a 3-day history of malaise, polyuria, nausea, and vomiting, severe hypoxia and rales developed, and intubation and mechanical ventilation became necessary. Hemodynamic evaluation and striking electron microscopic findings on open-lung biopsy confirmed the diagnosis of adult respiratory distress syndrome. Despite adequate ventilatory support and hemodynamic management, death ensued and was attributed to irresponsive and progressive acute respiratory failure due to increased pulmonary capillary permeability edema. CONCLUSION: Clinicians should be aware of this possibly fatal pulmonary complication of diabetic ketoacidosis.

[Hemodynamic impact of thrombolytic therapy in acute pulmonary thromboembolism]. / Repercussões hemodinâmicas da terapia trombolítica no tromboembolismo pulmonar agudo.

PURPOSE: To evaluate pre and post-hemodynamic changes after thrombolytic therapy in patients with acute pulmonary embolism with multiple pulmonary segments compromised. METHODS: Nine patients, 5 females, aged between 27 and 83 (mean 62 +/- 16) years, with the onset of symptoms preceding 7 days, were submitted to thrombolytic therapy, administered after baseline perfusion-ventilation lung scan, echodopplercardiography (ECO) and hemodynamic measurements with a Swan-Ganz thermodilution catheter. The same procedures were done after the thrombolytic infusion. Streptokinase (SK) was used in 7 (78%) cases and recombinant human tissue-type plasminogen activator (rt-PA, alteplase) in 2 with the following doses: SK-250,000 i.u. infusion over 30 min, then 100,000 i.v/h over 24 to 72 h and rt-PA-20 mg in bolus infusion, then 80 mg over 6 h. Thrombolytic was infused in pulmonary artery trunk in 8 (88%) cases and a peripheral vein in 1 (12%) case, until mean pulmonary artery pressure (PAP) reached 20 mmHg. All patients received i.v. heparin and oral anticoagulation after thrombolytic therapy. RESULTS: A significant (p < 0.05) decrease in right atrial pressure (12 +/- 3 vs 8 +/- 2 mmHg), PAP (32 +/- 5 vs 19 +/- 2 mmHg), pulmonary vascular resistance (397 +/- 125 vs 87 +/- 24 dyne.s/cm5) and increase in cardiac output (3.4 +/- 0.5 vs 5.5 +/- 1.0 l/min) and stroke volume (30 +/- 5 vs 57 +/- 10 ml/beat) were observed after thrombolytic infusion. Two patients died as a result of pulmonary infection unrelated to the embolic event or thrombolysis. Minor bleeding complications occurred in two cases and major in one patient with orthopedic prosthesis. CONCLUSION: Thrombolytic therapy exert desirable effects on hemodynamic abnormalities, achieving lungs scan and ECO improvement in patients with acute pulmonary embolism.

Comparative study of intensive care unit (ICU) performance.

It is possible to evaluate ICU performance using severity-of-illness systems, but are these systems objective enough to draw comparison between different units? A software was developed to allow data collection and calculation of the score APACHE II [1] and administrative hospital indicators. To provide homogeneity, all data were collected following the same protocol and verified by one author.

[Diagnosis of papillary muscle rupture in acute myocardial infarction by transesophageal Doppler echocardiography]. / Diagnóstico da rotura do músculo papilar no infarto agudo do miocárdio através do ecodopplercardiograma transesofágico.

Three patients, two females, ages ranging from 62 to 78 years were studied, evolving with hypotension, acute pulmonary edema and cardiogenic shock. One had anterior myocardial infarction, and in two, infero-posterior. Due to severe hemodynamic instability and necessity of vasoactive drug therapy to maintain adequate arterial pressure, coronary angiography was performed in two, showing total occlusion of the circumflex artery and severe mitral regurgitation. In one case, angioplasty on the circumflex artery was successfully achieved. No hemodynamic improvement was observed, however. Doppler echocardiography depicted mild to moderate mitral regurgitation in the three cases. Transesophageal echo confirmed the clinical suspicion of papillary muscle rupture: total rupture of antero-lateral papillary muscle in one patient, as well as total and partial rupture of the postero-medial papillary muscle in the other two patients. Two patients were submitted to mitral valve replacement, and the surgical findings confirmed the transesophageal echo conclusions. One of them died in the immediate pos-operative period, whereas the other was discharged from the hospital and is doing well. The third patient died before operation. Differential diagnosis of acute mitral regurgitation due to papillary muscle dysfunction or rupture was not possible by left ventriculography or by transthoracic echo. Transesophageal echo was the only exam to clearly confirm papillary muscle rupture, as should be done promptly after clinical suspicion of this severe condition arises.

Complicaçöes de cateteres venosos centrais: estudo prospectivo / Complications of central venous catheters: prospective study

A inserçäo de cateteres venosos centrais (CVC) é um procedimento muito comum em UTI. Este trabalho visou a determinaçäo de via de colocaçäo do CVC que tem a melhor possibilidade de uma boa locaçäo da ponta do cateter. Foram analisados 563 CVCs que foram colocados por punçäo (excluídos por fio-guia) e que tiveram controle radiológico após o procedimento. A via mais escolhida foi a infraclavicular com 303 CVCs (54//), seguida pela via jugular, 142 CVCs (25//), e supraclavicular, 118 CVCs (21//). A taxa de má-locaçäo da ponta foi 17//, 6// e 9//, respectivamente. Houve diferença estatística quando se compara a via infraclavicular com a via jugular (p < 0,05). Ocorreram nove (1,4//) pneumotórax. Dos 127 CVCs enviados para cultura, 26(20//) demonstraram crescimento de mais de 15 unidades formadoras de colônias. Os agentes mais freqüentemente isolados foram: Candida spp (7), S. aureus (5), S. epidermidis (4) e P. aeruginosa (3)

[Complications of central venous catheters: prospective study]. / Complicações de cateteres venosos centrais: estudo prospectivo.

The insertion of central venous catheters (CVC) represent a very common procedure in intensive care units. The purpose of this study was to determine the via that provide the best chance for a good location of the tip of a CVC. The 563 CVCs that were inserted percutaneously and that had a radiology control were analyzed. The infraclavicular via was used for 303 (25%) CVCs; the jugular via had 142 (25%) CVCs and the supraclavicular via was used in 118 (21%) CVCs. The rate of bad location of the tip of the CVC were 17%, 6% and 9%, respectively. There was a significant difference when the insertion through infraclavicular via and jugular via were compared. There were 9 pneumothorax (1.4%). 127 CVCs were sent to microbiology laboratory, 26 (20%) had positive culture (> 15 colony forming units). The most frequent agents isolates were: Candida spp (7), S. aureus (5), S. epidermidis (4) and P. aeruginosa (3).

[Post infarction ventricular septal defect. Echocardiographic analysis of patients treated with positive end-expiratory pressure]. / Comunicação interventricular após infarto do miocárdio. Análise ecocardiografica de pacientes submetidos a pressão expiratória final positiva.

Interventricular septal rupture is a life-threatening complication occurring in 0.5 to 1.0% of patients following acute myocardial infarction and often results in right and left ventricular failure. This study aimed at evaluating the echocardiographic effects of PEEP on right (RV) and left (LV) ventricular dimension in three patients who developed a postinfarction septal defect and in whom acute respiratory failure was a preterminal event. The effects of PEPP on the heart remain controversial. We observed in all three patients a sudden large increase in RV dimensions and hence, probably through ventricular interdependence, a proportional decrease in LV dimensions. The progressive leftward septal displacement with increasing levels of PEEP probably contributed to reduce LV compliance. We concluded that PEEP therapy in this group of patients had no proven beneficial effects and probably contributed to further RV dilatation and failure.

[Staphylococcus aureus endocarditis in a puerperal woman with mitral and tricuspid valve prolapse]. / Endocardite por Staphylococcus aureus no puerpério de portadora de prolapso de valvas mitral e tricúspide.

A 17-year-old woman with mitral and tricuspid valve prolapse and myxomatous degeneration presented puerperal infection by Staphylococcus aureus with clinical picture of sepsis and multiple septic embolism (right eye, left thumb, spleen, and left calf). She underwent total hysterectomy on the 10th day postdelivery and right eye enucleation on the 16th. Temporary total AV block occurred on the 14th day with temporary external pacing during the next couple of days. Acute endocarditis with acute mitral regurgitation was diagnosed on the 13th day, demanding immediate valve replacement. On the 46th day she developed moderate tricuspid valve regurgitation due to another episode of endocarditis. Final clinical discharge took place on the 62nd day after antibiotic therapy completion.

Reliability of right atrial pressure monitoring to assess left ventricular preload in critically ill septic patients.

Right atrial pressure (RAP) can be used as a guide to fluid therapy in critical care settings. RAP and pulmonary capillary wedge pressure (WP) were measured in 27 septic patients without cardiac disease and on mechanical ventilation. An r of .61 was obtained with a regression line defined by the equation WP = 7.38 + (0.53 x RAP) +/- 3.15. However, a large SD of data points can invalidate the clinical usefulness of this equation. The reliability of various RAP interval values in predicting optimal WP was then studied in these patients. We concluded that RAP values less than or equal to 5 mm Hg were highly specific (97%) in predicting low or normal WP (less than or equal to 12 mm Hg).