Clinical Characteristics and In-Hospital Mortality of Cardiac Arrest Survivors in Brazil: A Large Retrospective Multicenter Cohort Study.

OBJECTIVES: Data on cardiac arrest survivors from developing countries are scarce. This study investigated clinical characteristics associated with in-hospital mortality in resuscitated patients following cardiac arrest in Brazil. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Ninety-two general ICUs from 55 hospitals in Brazil between 2014 and 2015. PATIENTS: Adult patients with cardiac arrest admitted to the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We analyzed 2,296 patients (53% men; median 67 yr (interquartile range, 54-79 yr]). Eight-hundred patients (35%) had a primary admission diagnosis of cardiac arrest suggesting an out-of-hospital cardiac arrest; the remainder occurred after admission, comprising an in-hospital cardiac arrest cohort. Overall, in-hospital mortality was 83%, with only 6% undergoing withholding/withdrawal-of-life support. Random-effects multivariable Cox regression was used to assess associations with survival. After adjusting for age, sex, and severity scores, mortality was associated with shock (adjusted odds ratio, 1.25 [95% CI, 1.11-1.39]; p < 0.001), temperature dysregulation (adjusted odds ratio for normothermia, 0.85 [95% CI, 0.76-0.95]; p = 0.007), increased lactate levels above 4 mmol/L (adjusted odds ratio, 1.33 [95% CI, 1.1-1.6; p = 0.009), and surgical or cardiac cases (adjusted odds ratio, 0.72 [95% CI, 0.6-0.86]; p = 0.002). In addition, survival was better in patients with probable out-of-hospital cardiac arrest, unless ICU admission was delayed (adjusted odds ratio for interaction, 1.63 [95% CI, 1.21-2.21]; p = 004). CONCLUSIONS: In a large multicenter cardiac arrest cohort from Brazil, we found a high mortality rate and infrequent withholding/withdrawal of life support. We also identified patient profiles associated with worse survival, such as those with shock/hypoperfusion and arrest secondary to nonsurgical admission diagnoses. Our findings unveil opportunities to improve postarrest care in developing countries, such as prompt ICU admission, expansion of the use of targeted temperature management, and implementation of shock reversal strategies (i.e., early coronary angiography), according to modern guidelines recommendations.

Elderly patients with cancer admitted to intensive care unit: A multicenter study in a middle-income country.

BACKGROUND: Very elderly critically ill patients (ie, those older than 75 or 80 years) are an increasing population in intensive care units. However, patients with cancer have encompassed only a minority in epidemiological studies of very old critically-ill patients. We aimed to describe clinical characteristics and identify factors associated with hospital mortality in a cohort of patients aged 80 or older with cancer admitted to intensive care units (ICUs). METHODS: This was a retrospective cohort study in 94 ICUs in Brazil. We included patients aged 80 years or older with active cancer who had an unplanned admission. We performed a mixed effect logistic regression model to identify variables independently associated with hospital mortality. RESULTS: Of 4604 included patients, 1807 (39.2%) died in hospital. Solid metastatic (OR = 2.46; CI 95%, 2.01-3.00), hematological cancer (OR = 2.32; CI 95%, 1.75-3.09), moderate/severe performance status impairment (OR = 1.59; CI 95%, 1.33-1.90) and use of vasopressors (OR = 4.74; CI 95%, 3.88-5.79), mechanical ventilation (OR = 1.54; CI 95%, 1.25-1.89) and renal replacement (OR = 1.81; CI 95%, 1.29-2.55) therapy were independently associated with increased hospital mortality. Emergency surgical admissions were associated with lower mortality compared to medical admissions (OR = 0.71; CI 95%, 0.52-0.96). CONCLUSIONS: Hospital mortality rate in very elderly critically ill patients with cancer with unplanned ICU admissions are lower than expected a priori. Cancer characteristics, performance status impairment and acute organ dysfunctions are associated with increased mortality.

Characteristics and short-term outcomes of patients with esophageal cancer with unplanned intensive care unit admissions: a retrospective cohort study. / Características e desfechos em curto prazo de pacientes com câncer esofágico em admissões não planejadas a unidades de terapia intensiva: um estudo de coorte retrospectiva.

OBJECTIVE: To depict the clinical presentation and outcomes of a cohort of critically ill patients with esophageal cancer. METHODS: We carried out a multicenter retrospective study that included patients with esophageal cancer admitted to intensive care units with acute illness between September 2009 and December 2017. We collected the demographic and clinical characteristics of all included patients, as well as organ-support measures and hospital outcomes. We performed logistic regression analysis to identify independent factors associated with in-hospital mortality. RESULTS: Of 226 patients included in the study, 131 (58.0%) patients died before hospital discharge. Squamous cell carcinoma was more frequent than adenocarcinoma, and 124 (54.9%) patients had metastatic cancer. The main reasons for admission were sepsis/septic shock and acute respiratory failure. Mechanical ventilation (OR = 6.18; 95%CI 2.86 - 13.35) and metastatic disease (OR = 7.10; 95%CI 3.35 - 15.05) were independently associated with in-hospital mortality. CONCLUSION: In this cohort of patients with esophageal cancer admitted to intensive care units with acute illness, the in-hospital mortality rate was very high. The requirement for invasive mechanical ventilation and metastatic disease were independent prognostic factors and should be considered in discussions about the short-term outcomes of these patients.

Características e desfechos em curto prazo de pacientes com câncer esofágico em admissões não planejadas a unidades de terapia intensiva: um estudo de coorte retrospectiva / Characteristics and short-term outcomes of patients with esophageal cancer with unplanned intensive care unit admissions: a retrospective cohort study

RESUMO Objetivo: Mostrar o quadro clínico e os desfechos de uma coorte de pacientes críticos com câncer esofágico. Métodos: Conduzimos um estudo multicêntrico retrospectivo que incluiu pacientes com câncer esofágico admitidos a unidades de terapia intensiva em razão de doença aguda entre setembro de 2009 e dezembro de 2017. Colhemos os dados demográficos e as características clínicas de todos os pacientes incluídos, assim como as medidas de suporte a órgãos e os desfechos no hospital. Realizamos uma análise de regressão logística para identificar os fatores associados de forma independente com mortalidade hospitalar. Resultados: Dentre os 226 pacientes incluídos no estudo, 131 (58,0%) faleceram antes de receber alta hospitalar. O carcinoma espinocelular foi mais frequente do que o adenocarcinoma, e 124 (54,9%) pacientes tinham câncer metastático. As principais razões para admissão foram sepse/choque séptico e insuficiência respiratória aguda. Uso de ventilação mecânica (RC = 6,18; IC95% 2,86 - 13,35) e doença metastática (RC = 7,10; IC95% 3,35 - 15,05) tiveram associação independente com mortalidade hospitalar. Conclusão: Nesta coorte de pacientes com câncer esofágico admitidos à unidades de terapia intensiva em razão de doença aguda, a taxa de mortalidade hospitalar foi muito elevada. A necessidade de utilizar ventilação mecânica invasiva e a presença de doença metastática foram fatores independentes de prognóstico e devem ser levados em conta nas discussões a respeito dos desfechos destes pacientes em curto prazo.

ABSTRACT Objective: To depict the clinical presentation and outcomes of a cohort of critically ill patients with esophageal cancer. Methods: We carried out a multicenter retrospective study that included patients with esophageal cancer admitted to intensive care units with acute illness between September 2009 and December 2017. We collected the demographic and clinical characteristics of all included patients, as well as organ-support measures and hospital outcomes. We performed logistic regression analysis to identify independent factors associated with in-hospital mortality. Results: Of 226 patients included in the study, 131 (58.0%) patients died before hospital discharge. Squamous cell carcinoma was more frequent than adenocarcinoma, and 124 (54.9%) patients had metastatic cancer. The main reasons for admission were sepsis/septic shock and acute respiratory failure. Mechanical ventilation (OR = 6.18; 95%CI 2.86 - 13.35) and metastatic disease (OR = 7.10; 95%CI 3.35 - 15.05) were independently associated with in-hospital mortality. Conclusion: In this cohort of patients with esophageal cancer admitted to intensive care units with acute illness, the in-hospital mortality rate was very high. The requirement for invasive mechanical ventilation and metastatic disease were independent prognostic factors and should be considered in discussions about the short-term outcomes of these patients.

Quality assessment of adult intensive care services: application of a tool adjusted to the reality of low-income countries. / Avaliação da qualidade de serviços de medicina intensiva adulto: aplicação de ferramenta ajustada à realidade de países de baixa renda.

OBJECTIVE: To assess the quality of adult intensive care units. METHODS: This population-based, cross-sectional, observational, analytical study evaluated management type in Maranhão, Brazil. An assessment instrument was applied that assigned scores to each service (maximum 124 points). The units were categorized as insufficient (< 50% of the maximum score), typical (≥ 50% and <80% of the maximum score), or sufficient (≥ 80% of the maximum score). RESULTS: Of the 26 intensive care units in Maranhão, 23 were evaluated; 15 (65.2%) were located in the state capital, and 14 (60.9%) were public. The mean final score was 67.2 (54.2% of the maximum). The worst performance was observed with regard to processes (50.9%) in the units located outside the capital (p = 0.037) and for hospitals with 68 beds or fewer (p = 0.027). The result of the assessment categorized services as a function of the overall total points earned. Specifically, 8 (34.8%) services were assessed as insufficient, 13 (56.5%) were assessed as typical, and 2 (8.7%) were assessed as sufficient. CONCLUSION: The majority of the intensive care units in this study were assessed as typical. These services must be better qualified. The priorities are the processes of the units located outside the capital and in small hospitals.

OBJETIVO: Avaliar a qualidade de unidades de terapia intensiva adulto. MÉTODOS: Estudo populacional, transversal, observacional, analítico, do tipo avaliação para gestão, no Estado do Maranhão. Um instrumento de avaliação foi aplicado, atribuindo pontuações para cada serviço (máximo 124). As unidades foram categorizadas como insuficientes (< 50% da pontuação máxima), regulares (≥ 50% e < 80% da pontuação máxima) ou suficientes (≥ 80% da pontuação máxima). RESULTADOS: Das 26 unidades de terapia intensiva do Estado, 23 foram avaliadas; 15 (65,2%) estavam localizadas na capital, e 14 (60,9%) eram públicas. A pontuação final média foi de 67,2 (54,2% do máximo possível). O pior desempenho ocorreu nos processos (50,9%), nas unidades fora da capital (p = 0,037) e em hospitais com número de leitos ≤ 68 (p = 0,027). O resultado da avaliação consistiu na categorização dos serviços em função do total geral de pontos alcançados, a saber: 8 (34,8%) serviços receberam avaliação insuficiente, 13 (56,5%) regular e 2 (8,7%) suficiente. CONCLUSÃO: A maioria das unidades do estudo recebeu avaliação regular. Tais serviços necessitam ser melhor qualificados. As prioridades são os processos de unidades localizadas fora da capital e em hospitais de pequeno porte.

Avaliação da qualidade de serviços de medicina intensiva adulto: aplicação de ferramenta ajustada à realidade de países de baixa renda / Quality assessment of adult intensive care services: application of a tool adjusted to the reality of low-income countries

RESUMO Objetivo: Avaliar a qualidade de unidades de terapia intensiva adulto. Métodos: Estudo populacional, transversal, observacional, analítico, do tipo avaliação para gestão, no Estado do Maranhão. Um instrumento de avaliação foi aplicado, atribuindo pontuações para cada serviço (máximo 124). As unidades foram categorizadas como insuficientes (< 50% da pontuação máxima), regulares (≥ 50% e < 80% da pontuação máxima) ou suficientes (≥ 80% da pontuação máxima). Resultados: Das 26 unidades de terapia intensiva do Estado, 23 foram avaliadas; 15 (65,2%) estavam localizadas na capital, e 14 (60,9%) eram públicas. A pontuação final média foi de 67,2 (54,2% do máximo possível). O pior desempenho ocorreu nos processos (50,9%), nas unidades fora da capital (p = 0,037) e em hospitais com número de leitos ≤ 68 (p = 0,027). O resultado da avaliação consistiu na categorização dos serviços em função do total geral de pontos alcançados, a saber: 8 (34,8%) serviços receberam avaliação insuficiente, 13 (56,5%) regular e 2 (8,7%) suficiente. Conclusão: A maioria das unidades do estudo recebeu avaliação regular. Tais serviços necessitam ser melhor qualificados. As prioridades são os processos de unidades localizadas fora da capital e em hospitais de pequeno porte.

ABSTRACT Objective: To assess the quality of adult intensive care units. Methods: This population-based, cross-sectional, observational, analytical study evaluated management type in Maranhão, Brazil. An assessment instrument was applied that assigned scores to each service (maximum 124 points). The units were categorized as insufficient (< 50% of the maximum score), typical (≥ 50% and <80% of the maximum score), or sufficient (≥ 80% of the maximum score). Results: Of the 26 intensive care units in Maranhão, 23 were evaluated; 15 (65.2%) were located in the state capital, and 14 (60.9%) were public. The mean final score was 67.2 (54.2% of the maximum). The worst performance was observed with regard to processes (50.9%) in the units located outside the capital (p = 0.037) and for hospitals with 68 beds or fewer (p = 0.027). The result of the assessment categorized services as a function of the overall total points earned. Specifically, 8 (34.8%) services were assessed as insufficient, 13 (56.5%) were assessed as typical, and 2 (8.7%) were assessed as sufficient. Conclusion: The majority of the intensive care units in this study were assessed as typical. These services must be better qualified. The priorities are the processes of the units located outside the capital and in small hospitals.

Quality in intensive care units: proposal of an assessment instrument.

BACKGROUND: There is an increasing need for standardized instruments for quality assessment that are able to reflect the actual conditions of the intensive care practices, especially in low and middle-income countries. The aim of this article is to describe the preparation of an instrument for quality assessment of adult intensive care services adapted to the actual conditions of intensive care in a middle-income country and comprising indicators validated in the literature. METHODS: The study consisted of five steps: (1) a literature survey; (2) a discussion with specialists by consensus method; (3) a pilot field test; (4) a description of indicators; and (5) an elaboration of the final version of the instrument. Each generated indicator was attributed a score ("out of standard" = 0; "below standard" = 1; "standard" = 2) that allowed calculation of the total score for each service assessed. RESULTS: A total of 62 indicators were constructed, distributed as follows: 38 structure indicators (physical structure: 4; human resources: 14; continued education and training: 2; protocols and routines: 12; material resources: 6); 17 process indicators (safety: 7; work: 10); and seven outcome indicators. The maximum possible total score was 124. CONCLUSIONS: Possible future applications of the instrument for the assessment of intensive care units that was constructed in the present study include benchmarking, multicenter studies, self-assessment of intensive care units, and evaluation of changes resulting from interventions.

Severe maternal morbidity: a case-control study in Maranhao, Brazil.

BACKGROUND: Maternal mortality and morbidity are among the top public health priorities in Brazil, being quite high, especially among the most disadvantage women. A case control study was developed to identify risk factors for severe maternal morbidity in Sao Luis, one of the poorest Brazilian State Capitals. METHODS: The case-control study was carried out between 01/03/2009 and 28/02/2010 in two public high-risk maternities facilities and in two intensive care units (ICUs) for referral of obstetric cases. All cases hospitalized due to complications during gestation period, childbirth or up to 42 days of puerperium and who fulfilled any of Mantel's and/or Waterstone's criteria were identified. Two controls per case were randomly selected among patients of the same clinics discharged for other reasons. Data were obtained through a structured interview as well as from medical charts and prenatal cards and included sociodemographic variables, clinical and obstetric histories, behavioral factors and exposure to stress factors during pregnancy, pre-natal assistance and obstetric complication and childbirth care. RESULTS: In the final model of the unconditional logistic regression analysis, being older than 35 years (OR=3.11; 95% CI:1.53-6.31), previous hypertension (OR=2.52; 95% CI:1.09-5.80), history of abortion (OR=1.61; 95% CI:0.97-2.68), 4-5 pre-natal consultations (OR=1.78; 95% CI:1.05-3.01) and 1-3 pre-natal consultations (OR=1.89; 95% CI:1.03-3.49) were independently associated with severe maternal morbidity. CONCLUSIONS: The results corroborate the importance of reproductive healthcare, of identifying a high-risk pregnancy and of a qualified and complete prenatal care to prevent severe morbid events.

Incidence and main causes of severe maternal morbidity in São Luís, Maranhão, Brazil: a longitudinal study.

CONTEXT AND OBJECTIVE: Evaluation of severe maternal morbidity has been used in monitoring of maternal health. The objective of this study was to estimate its incidence and main causes in São Luís, Maranhão, Brazil. DESIGN AND SETTING: Prospective longitudinal study, carried out in two public high-risk maternity hospitals and two public intensive care units (ICUs) for referral of obstetric cases from the municipality. METHODS: Between March 1, 2009, and February 28,2010, all cases of severe maternal morbidity according to the Mantel and Waterstone criteria were identified. The sociodemographic and healthcare characteristics of the extremely severe cases were compared with the less severe cases, using the Fisher, χ(2), Student t and Mann-Whitney tests, with a significance level of < 0.05. RESULTS: 127 cases of severe maternal morbidity were identified among 8,493 deliveries, i.e. an incidence of 15.0/1000 deliveries. Out of 122 cases interviewed, 121 cases were within the Waterstone criteria and 29 were within the Mantel criteria, corresponding to incidences of 14.1/1000 and 3.4/1000 deliveries, respectively. These rates were lower than those described in the literature, possibly due to case loss. The main causes were hypertension during pregnancy, which was more frequent in less severe cases (P = 0.001) and obstetric hemorrhage, which was more common among extremely severe cases (P = 0.01). CONCLUSIONS: Direct obstetric disorders were the main causes of severe maternal morbidity in São Luís, Maranhão. Investigation and monitoring of severe morbidity may contribute towards improving obstetric care in the municipality.

Incidence and main causes of severe maternal morbidity in São Luís, Maranhão, Brazil: a longitudinal study / Incidência e principais causas de morbidade materna grave em São Luís, Maranhão, Brasil: estudo longitudinal

CONTEXT AND OBJECTIVE: Evaluation of severe maternal morbidity has been used in monitoring of maternal health. The objective of this study was to estimate its incidence and main causes in São Luís, Maranhão, Brazil. DESIGN AND SETTING: Prospective longitudinal study, carried out in two public high-risk maternity hospitals and two public intensive care units (ICUs) for referral of obstetric cases from the municipality. METHODS: Between March 1, 2009, and February 28, 2010, all cases of severe maternal morbidity according to the Mantel and Waterstone criteria were identified. The sociodemographic and healthcare characteristics of the extremely severe cases were compared with the less severe cases, using the Fisher, Χ2, Student t and Mann-Whitney tests, with a significance level of < 0.05. RESULTS: 127 cases of severe maternal morbidity were identified among 8,493 deliveries, i.e. an incidence of 15.0/1000 deliveries. Out of 122 cases interviewed, 121 cases were within the Waterstone criteria and 29 were within the Mantel criteria, corresponding to incidences of 14.1/1000 and 3.4/1000 deliveries, respectively. These rates were lower than those described in the literature, possibly due to case loss. The main causes were hypertension during pregnancy, which was more frequent in less severe cases (P = 0.001) and obstetric hemorrhage, which was more common among extremely severe cases (P = 0.01). CONCLUSIONS: Direct obstetric disorders were the main causes of severe maternal morbidity in São Luís, Maranhão. Investigation and monitoring of severe morbidity may contribute towards improving obstetric care in the municipality.

CONTEXTO E OBJETIVO: A avaliação da morbidade materna grave tem sido utilizada na vigilância à saúde materna. O objetivo deste estudo é estimar esta incidência e as suas principais causas em São Luís, Maranhão, Brasil. TIPO DE ESTUDO E LOCAL: Estudo longitudinal prospectivo, desenvolvido nas duas maternidades públicas de alto risco e nas duas unidades de terapia intensivas (UTIs) públicas de referência para casos obstétricos do município. MÉTODOS: Entre 1º de março de 2009 e 28 de fevereiro de 2010, foram identificados todos os casos de morbidade materna grave segundo os critérios de Mantel e Waterstone. As variáveis sociodemográficas e de atenção à saúde dos casos de extrema gravidade foram comparados aos casos de menor gravidade utilizando os testes de Fisher, Χ², t Student e Mann-Whitney, com nível de significância de 0,05. RESULTADOS: Foram identificados 127 casos de morbidade materna grave em 8.493 partos, gerando uma incidência de 15,0/1000 partos. Dos 122 casos entrevistados, 121 se incluíam nos critérios de Waterstone e 29 se incluíam nos critérios de Mantel, correspondendo a incidências de 14,1/1000 e 3,4/1000 partos, respectivamente. Estas taxas estão abaixo da descrita na literatura possivelmente por perda de casos. As principais causas foram a hipertensão na gravidez, mais presente nos casos de menor gravidade (P = 0,001) e a hemorragia obstétrica, mais comum nos casos de extrema gravidade (P = 0,01). CONCLUSÃO: As desordens obstétricas diretas são as principais causas da morbidade materna grave em São Luís, Maranhão. Investigar e monitorar a morbidade grave pode contribuir para a melhoria da assistência obstétrica no município.