Oral clinical findings and intensive care unit prognostic scores.

OBJECTIVE: Hospitalisation in intensive care unit (ICU) may cause changes in oral environment, which may influence patients' health status. The aim of this study was to evaluate the frequency of intraoral and extraoral findings observed during ICU admission, and to verify if there is an association with clinical prognosis scores. METHODS: Data regarding clinical characteristics of patients hospitalised in an ICU were collected from medical records. The prognostic scores Sepsis Related Organ Failure Assessment (SOFA) and Simplified Acute Physiology Score (SAPS 3) were estimated with data collected from admission and SOFA on the day of the oral examination as well. Data on oral mucosa lesions, saliva, dental condition and oral hygiene were evaluated during oral examinations. RESULTS: The association of oral findings with prognostic scores was statistically verified. The majority (92.2%) of the 170 evaluated patients showed extraoral or intraoral findings during ICU admission. The most frequent findings were chapped and crusted lips, coated tongue, pale mucosa, haemorrhagic lesions, candidiasis, depapillated tongue and traumatic lesions. There were significant higher prognostic scores in the presence of the following extraoral and intraoral findings: crusted and ulcerated lips, haemorrhagic lesions, jaundice, spontaneous oral bleeding, coated and depapillated tongue. Median SAPS 3 was higher in patients with poor oral hygiene. CONCLUSIONS: Oral findings were frequent in the population of patients hospitalised in the ICU and some of them were associated with worse prognostic scores. Routine oral examinations must be performed in hospitalised patients from ICUs for detection of oral markers of worse clinical prognosis.

Increased Use of Antibiotics in the Intensive Care Unit During Coronavirus Disease (COVID-19) Pandemic in a Brazilian Hospital.

Background: Microbial drug resistance is one of the biggest public health problems. Antibiotic consumption is an essential factor for the emergence and spread of multiresistant bacteria. Therefore, we aimed to analyze the antibiotics consumption in the Intensive Care Unit (ICU), identifying trends in the antibiotics use profile and microbiological isolates throughout the COVID-19 pandemic. Methods: We performed this retrospective observational study in intensive care units of a Brazilian tertiary hospital from January 2019 to December 2020. The primary outcome was antimicrobial consumption in the ICU, measured by defined daily doses (DDDs) per 100 bed-days. As a secondary outcome, bacterial infections (microbiological isolates) were calculated in the same fashion. Outcomes trends were analyzed using Joinpoint regression models, considering constant variance (homoscedasticity) and first-order autocorrelation assumptions. A monthly percent change (MPC) was estimated for each analyzed segment. Results: Seven thousand and nine hundred fifty-three patients had data available on prescribed and received medications and were included in the analyses. Overall, the use of antibiotics increased over time in the ICU. The reserve group (World Health Organization Classification) had an increasing trend (MPC = 7.24) from February to April 2020. The azithromycin consumption (J01FA) increased rapidly, with a MPC of 5.21 from January to April 2020. Polymyxin B showed a relevant increase from March to June 2020 (MPC = 6.93). The peak of the antibiotic consumption of Reserve group did not overlap with the peak of the pathogenic agents they are intended to treat. Conclusion: Overall antimicrobial consumption in ICU has increased in the context of the COVID-19 pandemic. The peaks in the antimicrobial's use were not associated with the rise of the pathogenic agents they intended to treat, indicating an empirical use, which is especially concerning in the context of treating multidrug-resistant (MDR) infections. This fact may contribute to the depletion of the therapeutic arsenal for MDR treatment.

Oral health status of patients in intensive care unit: a cross-sectional study

Introduction: Patients in intensive care unit (ICU) may present oral alterations asa result of patients' systemic conditions, the use of medications, intubation orpoor oral hygiene. Oral alterations should be detected and treated because theymay aggravate patients' condition. The objective of this study was to evaluate thetypes and frequencies of clinically detected oral alterations in inpatients of an ICU.Methods: This is a cross-sectional study in which an oral evaluation of patientshospitalized in an ICU of a public hospital was performed. Demographic, socialand clinical characteristics were collected from medical records. Oral examswere performed by two trained dentists, with reliability checked by intra-classcorrelation coefficient, while patients were lying in the hospital bed, using a frontalheadlamp, tongue depressor and sterile gauze. All data were recorded in studyprotocol forms and transferred to a data base for analysis. Results: Thirty-sevenpatients, with similar distribution between genders, withmedian age of 62 yearswere evaluated. The most frequent causes for hospitalization were postoperativecare (51.35%) and respiratory problems (29.72%). About 90% of the inpatientspresented some type of oral alterations during the hospitalization period. Themost common clinical alterations were dry lips (86.5%); coated tongue (61.1%);paleness of the oral mucosa (54.1%); oral foci of infection (37.8%) and candidiasis(13.5%). Conclusion: The majority of inpatients of the ICU presented some type oforal alteration, and the most frequent were dry lips and coated tongue. Dataobserved in this study reinforce the need of the dental team support during theperiod of hospitalization.

Introdução: Pacientes em unidade de terapia intensiva (UTI) podem apresentaralterações orais como resultado das condições sistêmicas dos pacientes, uso demedicamentos, intubação ou falta de higiene bucal. Alterações orais devem serdetectadas e tratadas, pois podem agravar a condição do paciente. O objetivodeste estudo foi avaliar os tipos e frequências de alterações orais clinicamentedetectadas em pacientes internados em uma UTI. Métodos: Estudo transversalem que foi realizada avaliação oral de pacientes internados em uma UTI de umhospital público. Características demográficas, sociais e clínicas foram coletadasdos prontuários médicos. Os exames orais foram realizados por dois dentistastreinados, com confiabilidade verificada pelo coeficiente de correlação intra-classe, enquanto os pacientes estavam deitados na cama do hospital, utilizandofrontal, abaixador de língua e gaze estéril. Todos os dados foram registrados emformulários de protocolo do estudo e transferidos para uma base de dados paraanálise. Resultados: Foram avaliados 37 pacientes, com distribuição semelhanteentre os sexos, com mediana de idade de 62 anos. As causas mais frequentes deinternação foram cuidados pós-operatórios (51,35%) e problemas respiratórios(29,72%). Cerca de 90% dos pacientes internados apresentaram algum tipo dealteração bucal durante o período de internação. As alterações clínicas maiscomuns foram lábios secos (86,5%); língua (61,1%); palidez da mucosa oral (54,1%);focos orais de infecção (37,8%) e candidíase (13,5%). Conclusão: A maioria dospacientes internados em UTI apresentou algum tipo de alteração oral, sendo osmais frequentes lábios secos e língua. Os dados observados neste estudo reforçama necessidade do apoio da equipe odontológica durante o período de internação.

Avaliação da microcirculação: uma nova arma no manejo da sepse? / Microcirculatory assessment: a new weapon in the treatment of sepsis?

A evolução para disfunção de múltiplos órgãos ainda é comum na sepse e está relacionada diretamente com a disfunção microcirculatória. Através de pesquisa nas bases de dados PubMed, empregando-se os unitermos microcirculação e sepse, vinte e seis artigos foram selecionados para esta revisão, bem como citações consideradas relevantes extraídas de artigos de revisão. Com o advento da técnica de imagem obtida através de polarização ortogonal, que permite a observação à beira do leito da microcirculação em pacientes críticos, é possível estabelecer uma relação entre disfunção microvascular e prognóstico, além de observar diretamente o efeito de diferentes intervenções terapêuticas. No entanto, a relação causal entre disfunção microcirculatória e prognóstico adverso na sepse, bem como os efeitos de terapias dirigidas para correção destas anormalidades microcirculatórias ainda precisam ser melhor definidos.

The progression into multi-organ failure continues to be a common feature of sepsis and is directly related to microcirculatory dysfunction. Based on a PubMed database search using the key words microcirculation and sepsis, twenty-six articles were selected for this review. The relevant references from these articles were also selected and included in this analysis. Orthogonal polarization spectral imaging allows for the bedside assessment of the microcirculation of critically ill patients. Such imaging has established a correlation between microvascular dysfunction and patient outcomes, which allows practitioners to directly assess the effects of therapeutic interventions. However, the causal relationships between microcirculatory dysfunction, adverse outcomes, and the effects of therapies aimed at these microcirculatory changes in sepsis, are not clear.

Microcirculatory assessment: a new weapon in the treatment of sepsis? / Avaliação da microcirculação: uma nova arma no manejo da sepse?

The progression into multi-organ failure continues to be a common feature of sepsis and is directly related to microcirculatory dysfunction. Based on a PubMed database search using the key words microcirculation and sepsis, twenty-six articles were selected for this review. The relevant references from these articles were also selected and included in this analysis. Orthogonal polarization spectral imaging allows for the bedside assessment of the microcirculation of critically ill patients. Such imaging has established a correlation between microvascular dysfunction and patient outcomes, which allows practitioners to directly assess the effects of therapeutic interventions. However, the causal relationships between microcirculatory dysfunction, adverse outcomes, and the effects of therapies aimed at these microcirculatory changes in sepsis, are not clear.

Microcirculatory assessment in daily clinical practice - not yet ready but not too far! / Avaliação da microcirculação na prática clínica diária - ainda não disponível, mas não tão longe!

Shock is characterized by an alteration in tissue perfusion that may lead to tissue hypoxia. Recent guidelines recommend aggressive and early resuscitation therapy, but mortality rate is still unacceptably high. Unfortunately, traditional clinical surrogates used to guide resuscitation therapy poorly correlate with microcirculatory blood flow, a key determinant of tissue perfusion. New techniques that directly assess microcirculatory perfusion at the bedside have emerged as a complement to traditional macrohemodynamic parameters. These techniques have been supported by several studies showing microcirculatory alterations in different clinical settings. In addition, these microcirculatory alterations are related with outcome and persist regardless of arterial pressure normalization, being a better predictor of organ dysfunction and mortality than global hemodynamic and laboratory parameters. These findings allowed the concept of "microcirculatory-goal directed therapy", which is now in its preliminary phase, as the impact of many interventions still needs to be assessed. Finally, microcirculation assessment has also been explored in other medical s such as perioperative, systemic arterial hypertension, heart failure, and hyperviscosity syndromes. In this review, we shortly present the characteristics of microcirculation and the main determinants of capillary blood flow, and we discuss advantages and limitations of some recently available techniques to evaluate microcirculation at the bedside, and how they could be useful for the general clinician in daily practice.

O choque é caracterizado por uma alteração na perfusão tecidual que pode levar à hipóxia tecidual. Diretrizes recentes recomendam uma terapia de ressuscitação hemodinâmica precoce e agressiva nos estados de choque, mas a taxa de mortalidade ainda é inaceitavelmente alta. Os parâmetros clínicos habituais usados para orientar a terapia de reanimação correlacionam-se mal com o fluxo sanguíneo capilar, um determinante essencial da perfusão tecidual. Novas técnicas que avaliam diretamente a perfusão da microcirculação à beira do leito surgem como um complemento aos parâmetros macro-hemodinâmicos tradicionais. Estas técnicas foram testadas em vários estudos que mostraram alterações microcirculatórias em diferentes situações clínicas de choque. Além disso, estas alterações microcirculatórias estão relacionadas ao prognóstico, e persistem independentemente da normalização da pressão arterial, sendo um melhor preditor de disfunção orgânica e mortalidade do que os parâmetros hemodinâmicos globais e laboratoriais. Estes achados permitiram lançar o conceito de "terapia dirigida por parâmetros microcirculatórios", atualmente em fase preliminar, uma vez que o impacto de muitas intervenções ainda precisa ser avaliado. Finalmente, a avaliação da microcirculação também foi explorada em outras áreas que não o choque, como o período perioperatório, hipertensão arterial sistêmica, insuficiência cardíaca e síndromes de hiperviscosidade. Nesta revisão, apresentamos sucintamente as características da microcirculação e os principais determinantes do fluxo sanguíneo capilar e discutimos as vantagens e limitações de algumas tecnologias recentes disponíveis para avaliar a microcirculação à beira do leito e como podem ser úteis ao clínico geral na prática diária.

Microcirculatory assessment in daily clinical practice - not yet ready but not too far!

Shock is characterized by an alteration in tissue perfusion that may lead to tissue hypoxia. Recent guidelines recommend aggressive and early resuscitation therapy, but mortality rate is still unacceptably high. Unfortunately, traditional clinical surrogates used to guide resuscitation therapy poorly correlate with microcirculatory blood flow, a key determinant of tissue perfusion. New techniques that directly assess microcirculatory perfusion at the bedside have emerged as a complement to traditional macrohemodynamic parameters. These techniques have been supported by several studies showing microcirculatory alterations in different clinical settings. In addition, these microcirculatory alterations are related with outcome and persist regardless of arterial pressure normalization, being a better predictor of organ dysfunction and mortality than global hemodynamic and laboratory parameters. These findings allowed the concept of "microcirculatory-goal directed therapy", which is now in its preliminary phase, as the impact of many interventions still needs to be assessed. Finally, microcirculation assessment has also been explored in other medical fields such as perioperative, systemic arterial hypertension, heart failure, and hyperviscosity syndromes. In this review, we shortly present the characteristics of microcirculation and the main determinants of capillary blood flow, and we discuss advantages and limitations of some recently available techniques to evaluate microcirculation at the bedside, and how they could be useful for the general clinician in daily practice.

Modulation of the renin-angiotensin-aldosterone system in sepsis: a new therapeutic approach?

IMPORTANCE OF THE FIELD: Severe sepsis is characterized by relative hypotension associated with a high cardiac output, peripheral vasodilation, and organ dysfunction. The renin-angiotensin-aldosterone system (RAAS) is primarily activated to increase blood pressure, but recently potential pro-inflammatory effects of angiotensin II have attracted interest because of the reported association between angiotensin II levels and organ failure and mortality in sepsis. RAAS antagonists could represent a new therapeutic option in this setting. AREAS COVERED IN THIS REVIEW: The role of RAAS activation in severe sepsis and septic shock, and the potential benefits (and risks) of using RAAS antagonists. WHAT THE READER WILL GAIN: Insight into RAAS function in severe sepsis and the potential for RAAS inhibitors to be used as an adjunctive therapy in patients with severe sepsis, with discussion of promising results from animal models of sepsis. TAKE HOME MESSAGE: Use of RAAS antagonists is an emerging therapeutic option in severe sepsis because these agents may reduce endothelial damage, organ failure, and mortality. However, timing of administration of RAAS antagonists is important because reduced RAAS function may contribute to refractive hypotension later on in septic shock and benefits of RAAS antagonists seem to be restricted to the early phases of sepsis.

Adrenal function testing in patients with septic shock.

INTRODUCTION: Adrenal failure (AF) is associated with increased mortality in septic patients. Nonetheless, there is no agreement regarding the best diagnostic criteria for AF. We compared the diagnosis of AF considering different baseline total cortisol cutoff values and Deltamax values after low (1 microg) and high (249 microg) doses of corticotropin, we analyzed the impact of serum albumin on AF identification and we correlated laboratorial AF with norepinephrine removal. METHODS: A prospective noninterventional study was performed in an intensive care unit from May 2002 to May 2005, including septic shock patients over 18 years old without previous steroid usage. After measurement of serum albumin and baseline total cortisol, the patients were sequentially submitted to 1 microg and 249 microg corticotropin tests with a 60-minute interval between doses. Post-stimuli cortisol levels were drawn 60 minutes after each test (cortisol 60 and cortisol 120). The cortisol 60 and cortisol 120 values minus baseline were called Deltamax1 and Deltamax249, respectively. Adrenal failure was defined as Deltamax249 < or = 9 microg/dl or baseline cortisol < or = 10 microg/dl. Other baseline cortisol cutoff values referred to as AF in other studies (< or =15, < or =20, < or =25 and < or =34 mug/dl) were compared with Deltamax249 < or = 9 microg/dl and serum albumin influence. Norepinephrine removal was compared with the baseline cortisol values and Deltamax249 values. RESULTS: We enrolled 102 patients (43 male). AF was diagnosed in 22.5% (23/102). Patients with albumin < or =2.5 g/dl presented a lower baseline total cortisol level (15.5 microg/dl vs 22.4 microg/dl, P = 0.04) and a higher frequency of baseline cortisol < or =25 microg/dl (84% vs 58.3%, P = 0.05) than those with albumin > 2.5 g/dl. The Deltamax249 levels and Deltamax249 < or = 9, however, were not affected by serum albumin (14.5 microg/dl vs 18.8 microg/dl, P = 0.48 and 24% vs 25%, P = 1.0). Baseline cortisol < or = 23.6 microg/dl was the most accurate diagnostic threshold to determine norepinephrine removal according to the receiver operating characteristic curve. CONCLUSION: AF was identified in 22.5% of the studied population. Since Deltamax249 < or = 9 microg/dl results were not affected by serum albumin and since the baseline serum total cortisol varied directly with albumin levels, we propose that Deltamax249 < or = 9 microg/dl, which means Deltamax after high corticotropin dose may be a better option for AF diagnosis whenever measurement of free cortisol is not available. Baseline cortisol < or =23.6 microg/dl was the best value for predicting norepinephrine removal in patients without corticosteroid treatment.