Association between piperacillin/tazobactam use and acute kidney injury in critically ill patients: a retrospective multicentre cohort study.

BACKGROUND: Piperacillin/tazobactam is one of the most common antibiotics prescribed in the ICU and the combination of piperacillin/tazobactam with vancomycin has been associated with acute kidney injury (AKI) in critically ill patients. However, data on the risk of AKI with piperacillin/tazobactam, despite vancomycin co-exposure, are lacking. OBJECTIVES: To investigate the association of piperacillin/tazobactam with AKI and renal replacement therapy (RRT) among adult ICU patients. METHODS: We analysed data from patients included in two open access databases (MIMIC-IV and eICU). Critically ill patients who received piperacillin/tazobactam or cefepime (a cephalosporin with similar broad-spectrum activity to piperacillin/tazobactam) during their first ICU stay were eligible for the study. Marginal structural Cox models, accounting for time-fixed covariates and time-dependent covariates were performed. The primary outcomes were AKI and need of RRT. RESULTS: A total of 20 107 patients were included, with 11 213 in the piperacillin/tazobactam group and 8894 in the cefepime group. Exposure to piperacillin/tazobactam was associated with AKI (HR 1.77; 95% CI 1.51-2.07; P < 0.001) and with need of RRT (HR 1.31; 95% CI 1.08-1.57; P = 0.005). Tests for interaction were not statistically significant for occurrence of AKI and RRT in the subgroup of patients exposed to vancomycin or not (P = 0.26 and P = 0.6, respectively). CONCLUSIONS: In critically ill patients, exposure to piperacillin/tazobactam was associated with increased risk of AKI and with increased risk of RRT, regardless of combination therapy with vancomycin.

Adverse events leading to intensive care unit admission in a low-and-middle-income-country: A prospective cohort study and a systematic review.

INTRODUCTION: Adverse events (AE) are frequent in critical care and could be even more prevalent in LMIC due to a shortage of ICU beds and Human resources. There is limited data on how relevant AE are among the reasons for ICU admission, being all of which published by High-Income-Countries services. Our main goal is to describe the rate of adverse events-related ICU admissions and their preventability in a LMIC scenario, comparing our results with previous data. METHODS: This was a prospective cohort study, during a one-year period, in two general ICUs from a tertiary public academic hospital. Our exposure of interest was ICU admission related to an AE in adult patients, we further characterized their preventability and clinical outcomes. We also performed a systematic review to identify and compare previous published data on ICU admissions due to AE. RESULTS: Among all ICU admissions, 12.1% were related to an AE (9.8% caused by an AE, 2.3% related but not directly caused by an AE). These ICU admissions were not associated with a higher risk of death, but most of them were potentially preventable (70.9% of preventability rate, representing 8.6% of all ICU admissions). The meta-analysis resulted in a proportion of ICU admissions due to AE of 11% (95% CI 6%-16%), with a preventability rate of 54% (95% CI 42%-66%). CONCLUSIONS: In this prospective cohort, adverse events were a relevant reason for ICU admission. This result is consistent with data retrieved from non-LMIC as shown in our meta-analysis. The high preventability rate described reinforces that quality and safety programs could work as a tool to optimize scarce resources.

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.

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.

Comparison of the accuracy of residents, senior physicians and surrogate decision-makers for predicting hospital mortality of critically ill patients. / Comparação da acurácia de residentes, médicos seniores e decisores substitutos na previsão da mortalidade hospitalar de pacientes críticos.

OBJECTIVE: To compare the predictive performance of residents, senior intensive care unit physicians and surrogates early during intensive care unit stays and to evaluate whether different presentations of prognostic data (probability of survival versus probability of death) influenced their performance. METHODS: We questioned surrogates and physicians in charge of critically ill patients during the first 48 hours of intensive care unit admission on the patient's probability of hospital outcome. The question framing (i.e., probability of survival versus probability of death during hospitalization) was randomized. To evaluate the predictive performance, we compared the areas under the ROC curves (AUCs) for hospital outcome between surrogates and physicians' categories. We also stratified the results according to randomized question framing. RESULTS: We interviewed surrogates and physicians on the hospital outcomes of 118 patients. The predictive performance of surrogate decisionmakers was significantly lower than that of physicians (AUC of 0.63 for surrogates, 0.82 for residents, 0.80 for intensive care unit fellows and 0.81 for intensive care unit senior physicians). There was no increase in predictive performance related to physicians' experience (i.e., senior physicians did not predict outcomes better than junior physicians). Surrogate decisionmakers worsened their prediction performance when they were asked about probability of death instead of probability of survival, but there was no difference for physicians. CONCLUSION: Different predictive performance was observed when comparing surrogate decision-makers and physicians, with no effect of experience on health care professionals' prediction. Question framing affected the predictive performance of surrogates but not of physicians.

OBJETIVO: Comparar o desempenho preditivo de residentes, médicos seniores de unidades de terapia intensiva e decisores substitutos dos pacientes logo no início da internação na unidade de terapia intensiva e avaliar se diferentes apresentações de prognóstico (probabilidade de sobrevida versus probabilidade de óbito) influenciaram seus desempenhos. MÉTODOS: Os decisores substitutos e os médicos responsáveis pelos pacientes críticos foram questionados durante as primeiras 48 horas de internação na unidade de terapia intensiva sobre a probabilidade do desfecho hospitalar do paciente. O enquadramento da pergunta (isto é, a probabilidade de sobrevida versus a probabilidade de óbito durante a internação) foi randomizado. Para avaliar o desempenho preditivo, comparou-se a área sob a curva ROC para desfecho hospitalar entre as categorias decisores substitutos e médicos. Também estratificaram-se os resultados de acordo com o enquadramento da pergunta randomizado. RESULTADOS: Entrevistaram-se decisores substitutos e médicos sobre os desfechos hospitalares de 118 pacientes. O desempenho preditivo dos decisores substitutos foi significativamente inferior ao dos médicos (área sob a curva de 0,63 para decisores substitutos, 0,82 para residentes, 0,80 para residentes de medicina intensiva e 0,81 para médicos seniores de unidade de terapia intensiva). Não houve aumento no desempenho preditivo quanto à experiência dos médicos (ou seja, médicos seniores não previram desfechos melhor que médicos juniores). Os decisores substitutos pioraram seu desempenho de previsão quando perguntados sobre a probabilidade de óbito ao invés da probabilidade de sobrevida, mas não houve diferença entre os médicos. CONCLUSÃO: Observou-se desempenho preditivo diferente ao comparar decisores substitutos e médicos, sem qualquer efeito da experiência no prognóstico dos profissionais de saúde. O enquadramento da pergunta afetou o desempenho preditivo dos substitutos, mas não o dos médicos.

Performance of NUTRIC score to predict 28-day mortality in critically ill patients after replacing APACHE II with SAPS 3.

OBJECTIVES: The Nutrition Risk in the Critically Ill (NUTRIC) score has been advocated as a screening tool for nutrition risk assessment in critically ill patients. It was developed and validated to predict 28-day mortality using Acute Physiology and Chronic Health Evaluation II (APACHE II) score as one of its components. However, nowadays the Simplified Acute Physiology Score 3 (SAPS 3) demonstrates better performance. We aimed to test the performance of NUTRIC score in predicting 28-day mortality after replacement of APACHE II by SAPS 3, and the interaction between nutrition adequacy and mortality. METHODS: Adult patients who received nutrition therapy and remained >3 days in intensive care unit were retrospectively evaluated. In order to replace APACHE II component, we used ranges of SAPS 3 with similar predicted mortality. Discrimination between these tools in predicting 28-day mortality was assessed using the ROC curve, calibration was evaluated with calibration belt, and correlation with intraclass correlation. The relationship between nutritional adequacy and mortality was assessed in a subgroup with available data. RESULTS: 542 patients were analyzed (median age of 78 years old, 73.4% admitted for non-surgical reasons and 28-day mortality was 18.1%). Mortality prediction discrimination did not differ between tools (p>0.05), but showed a good agreement (intraclass correlation 0.86) with good calibration. In the subgroup analysis for nutritional adequacy (n = 99), no association with mortality was observed. CONCLUSION: Performance of NUTRIC score with SAPS 3 is similar to the original tool. Therefore, it might be used in settings where APACHE II is not available.

Phenotypes of sickle cell intensive care admissions: an unsupervised machine learning approach in a single-center retrospective cohort.

Sickle cell disease (SCD) is associated with multiple known complications and increased mortality. This study aims to further understand the profile of intensive care unit (ICU) admissions of SCD patients. In this single-center retrospective cohort (approval number 0926-11), we evaluated SCD-related ICU admissions at our hospital in São Paulo, Brazil. Admissions were clustered using clinical data and organ dysfunction at ICU admission. A hierarchical clustering method was used to distinguish phenotypes. From 140 admissions obtained, 125 were included. The mean age was 30 years, 48% were male, and SS genotype was predominant (71.2%). Non-surgical causes of admissions accounted for 85.6% (n = 107). The mean Sequential Organ Failure Assessment score (SOFA) was 4 (IQR 2-7). Vasopressors were required by 12% and mechanical ventilation by 17.6%. After analysis of the average silhouette width, the optimal number of clusters was 3: cluster 1 (n = 69), cluster 2 (n = 25), cluster 3 (n = 31). Cluster 1 had a mean age of 29 years, 87% of SS genotype, and mean SOFA of 4. Cluster 2 had a mean age of 37 years, 80% of SS genotype, and mean SOFA of 8. Cluster 3 had a mean age of 26 years, 29% of SS genotype, and mean SOFA of 3. The need for mechanical ventilation was 11.6%, 44%, and 9.7%, respectively. Mortality was significantly higher in cluster 2 (44%, p = 0.012). This cohort of critical SCD admissions suggested the presence of three different profiles. This can be informative in the ICU setting to identify SCD patients at higher risk of worse outcomes.

Association of Frailty, Organ Support, and Long-Term Survival in Critically Ill Patients With COVID-19.

Few studies have explored the effect of frailty on the long-term survival of COVID-19 patients after ICU admission. Furthermore, the Clinical Frailty Scale (CFS) validity in critical care patients remains debated. We investigated the association between frailty and 6-month survival in critically ill COVID-19 patients. We also explored whether ICU resource utilization varied according to frailty status and examined the concurrent validity of the CFS in this setting. DESIGN: Ancillary study of a longitudinal prospective cohort. SETTING: University hospital in São Paulo. PATIENTS: Patients with severe COVID-19 admitted to ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We assessed baseline frailty using the CFS (1-9; frail ≥ 5) and used validated procedures to compute a Frailty Index (0-1; frail > 0.25). We used Cox models to estimate associations of frailty status with 6-month survival after ICU admission and area under the receiver operating characteristic curves (AUCs) to estimate CFS's accuracy in identifying frailty according to Frailty Index. We included 1,028 patients (mean age, 66 yr; male, 61%). Overall, 224 (22%) patients were frail (CFS ≥ 5), and 608 (59%) died over the 6-month follow-up. Frailty was independently associated with lower 6-month survival and further stratified mortality in patients with similar age and Sequential Organ Failure Assessment scores. We additionally verified that the CFS was highly accurate in identifying frailty as defined by the Frailty Index (AUC, 0.91; 95% CI, 0.89-0.93). Although treatment modalities did not diverge according to frailty status, higher CFS scores were associated with withholding organ support due to refractory organ failure. CONCLUSIONS: One in five COVID-19 patients admitted to the ICU was frail. CFS scores greater than or equal to 5 were associated with lower long-term survival and decisions on withholding further escalation of invasive support for multiple organ failure in the ICU. Clinicians should consider frailty alongside sociodemographic and clinical measures to have a fuller picture of COVID-19 prognosis in critical care.

Comparação da acurácia de residentes, médicos seniores e decisores substitutos na previsão da mortalidade hospitalar de pacientes críticos / Comparison of the accuracy of residents, senior physicians and surrogate decision-makers for predicting hospital mortality of critically ill patients

RESUMO Objetivo: Comparar o desempenho preditivo de residentes, médicos seniores de unidades de terapia intensiva e decisores substitutos dos pacientes logo no início da internação na unidade de terapia intensiva e avaliar se diferentes apresentações de prognóstico (probabilidade de sobrevida versus probabilidade de óbito) influenciaram seus desempenhos. Métodos: Os decisores substitutos e os médicos responsáveis pelos pacientes críticos foram questionados durante as primeiras 48 horas de internação na unidade de terapia intensiva sobre a probabilidade do desfecho hospitalar do paciente. O enquadramento da pergunta (isto é, a probabilidade de sobrevida versus a probabilidade de óbito durante a internação) foi randomizado. Para avaliar o desempenho preditivo, comparou-se a área sob a curva ROC para desfecho hospitalar entre as categorias decisores substitutos e médicos. Também estratificaram-se os resultados de acordo com o enquadramento da pergunta randomizado. Resultados: Entrevistaram-se decisores substitutos e médicos sobre os desfechos hospitalares de 118 pacientes. O desempenho preditivo dos decisores substitutos foi significativamente inferior ao dos médicos (área sob a curva de 0,63 para decisores substitutos, 0,82 para residentes, 0,80 para residentes de medicina intensiva e 0,81 para médicos seniores de unidade de terapia intensiva). Não houve aumento no desempenho preditivo quanto à experiência dos médicos (ou seja, médicos seniores não previram desfechos melhor que médicos juniores). Os decisores substitutos pioraram seu desempenho de previsão quando perguntados sobre a probabilidade de óbito ao invés da probabilidade de sobrevida, mas não houve diferença entre os médicos. Conclusão: Observou-se desempenho preditivo diferente ao comparar decisores substitutos e médicos, sem qualquer efeito da experiência no prognóstico dos profissionais de saúde. O enquadramento da pergunta afetou o desempenho preditivo dos substitutos, mas não o dos médicos.

ABSTRACT Objective: To compare the predictive performance of residents, senior intensive care unit physicians and surrogates early during intensive care unit stays and to evaluate whether different presentations of prognostic data (probability of survival versus probability of death) influenced their performance. Methods: We questioned surrogates and physicians in charge of critically ill patients during the first 48 hours of intensive care unit admission on the patient's probability of hospital outcome. The question framing (i.e., probability of survival versus probability of death during hospitalization) was randomized. To evaluate the predictive performance, we compared the areas under the ROC curves (AUCs) for hospital outcome between surrogates and physicians' categories. We also stratified the results according to randomized question framing. Results: We interviewed surrogates and physicians on the hospital outcomes of 118 patients. The predictive performance of surrogate decisionmakers was significantly lower than that of physicians (AUC of 0.63 for surrogates, 0.82 for residents, 0.80 for intensive care unit fellows and 0.81 for intensive care unit senior physicians). There was no increase in predictive performance related to physicians' experience (i.e., senior physicians did not predict outcomes better than junior physicians). Surrogate decisionmakers worsened their prediction performance when they were asked about probability of death instead of probability of survival, but there was no difference for physicians. Conclusion: Different predictive performance was observed when comparing surrogate decision-makers and physicians, with no effect of experience on health care professionals' prediction. Question framing affected the predictive performance of surrogates but not of physicians.

Patient-Centered Outcomes Following COVID-19: Frailty and Disability Transitions in Critical Care Survivors.

OBJECTIVES: As the pandemic advances, the interest in the long-lasting consequences of COVID-19 increases. However, a few studies have explored patient-centered outcomes in critical care survivors. We aimed to investigate frailty and disability transitions in COVID-19 patients admitted to ICUs. DESIGN: Prospective cohort study. SETTING: University hospital in Sao Paulo. PATIENTS: Survivors of COVID-19 ICU admissions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We assessed frailty using the Clinical Frailty Scale (CFS). We also evaluated 15 basic, instrumental, and mobility activities. Baseline frailty and disability were defined by clinical conditions 2-4 weeks before COVID-19, and post-COVID-19 was characterized 90 days (day 90) after hospital discharge. We used alluvial flow diagrams to visualize transitions in frailty status, Venn diagrams to describe the overlap between frailty and disabilities in activities of daily living, and linear mixed models to explore the occurrence of new disabilities following critical care in COVID-19. We included 428 participants with a mean age of 64 years, 57% males, and a median Simplified Acute Physiology Score-3 score of 59. Overall, 14% were frail at baseline. We found that 124/394 participants (31%) were frail at day 90, 70% of whom were previously non-frail. The number of disabilities also increased (mean difference, 2.46; 95% CI, 2.06-2.86), mainly in participants who were non-frail before COVID-19. Higher pre-COVID-19 CFS scores were independently associated with new-onset disabilities. At day 90, 135 patients (34%) were either frail or disabled. CONCLUSIONS: Frailty and disability were more frequent 90 days after hospital discharge compared with baseline in COVID-19 patients admitted to the ICU. Our results show that most COVID-19 critical care survivors transition to poorer health status, highlighting the importance of long-term medical follow-up for this population.

Urinary sodium excretion is low prior to acute kidney injury in patients in the intensive care unit.

Background: The incidence of acute kidney injury (AKI) is high in intensive care units (ICUs), and a better understanding of AKI is needed. Early chronic kidney disease is associated with urinary concentration inability and AKI recovery with increased urinary solutes in humans. Whether the inability of the kidneys to concentrate urine and excrete solutes at appropriate levels could occur prior to the diagnosis of AKI is still uncertain, and the associated mechanisms have not been studied. Methods: In this single-center prospective observational study, high AKI risk in ICU patients was followed up for 7 days or until ICU discharge. They were grouped as "AKI" or "No AKI" according to their AKI status throughout admission. We collected daily urine samples to measure solute concentrations and osmolality. Data were analyzed 1 day before AKI, or from the first to the fifth day of admission in the "No AKI" group. We used logistic regression models to evaluate the influence of the variables on future AKI diagnosis. The expression of kidney transporters in urine was evaluated by Western blotting. Results: We identified 29 patients as "No AKI" and 23 patients as "AKI," the latter being mostly low severity AKI. Urinary sodium excretion was lower in "AKI" patients prior to AKI diagnosis, particularly in septic patients. The expression of Na+/H+ exchanger (NHE3), a urinary sodium transporter, was higher in "AKI" patients. Conclusions: Urinary sodium excretion is low before an AKI episode in ICU patients, and high expressions of proximal tubule sodium transporters might contribute to this.

Protective ventilation and outcomes of critically ill patients with COVID-19: a cohort study.

BACKGROUND: Approximately 5% of COVID-19 patients develop respiratory failure and need ventilatory support, yet little is known about the impact of mechanical ventilation strategy in COVID-19. Our objective was to describe baseline characteristics, ventilatory parameters, and outcomes of critically ill patients in the largest referral center for COVID-19 in Sao Paulo, Brazil, during the first surge of the pandemic. METHODS: This cohort included COVID-19 patients admitted to the intensive care units (ICUs) of an academic hospital with 94 ICU beds, a number expanded to 300 during the pandemic as part of a state preparedness plan. Data included demographics, advanced life support therapies, and ventilator parameters. The main outcome was 28-day survival. We used a multivariate Cox model to test the association between protective ventilation and survival, adjusting for PF ratio, pH, compliance, and PEEP. RESULTS: We included 1503 patients from March 30 to June 30, 2020. The mean age was 60 ± 15 years, and 59% were male. During 28-day follow-up, 1180 (79%) patients needed invasive ventilation and 666 (44%) died. For the 984 patients who were receiving mechanical ventilation in the first 24 h of ICU stay, mean tidal volume was 6.5 ± 1.3 mL/kg of ideal body weight, plateau pressure was 24 ± 5 cmH2O, respiratory system compliance was 31.9 (24.4-40.9) mL/cmH2O, and 82% of patients were ventilated with protective ventilation. Noninvasive ventilation was used in 21% of patients, and prone, in 36%. Compliance was associated with survival and did not show a bimodal pattern that would support the presence of two phenotypes. In the multivariable model, protective ventilation (aHR 0.73 [95%CI 0.57-0.94]), adjusted for PF ratio, compliance, PEEP, and arterial pH, was independently associated with survival. CONCLUSIONS: During the peak of the epidemic in Sao Paulo, critically ill patients with COVID-19 often required mechanical ventilation and mortality was high. Our findings revealed an association between mechanical ventilation strategy and mortality, highlighting the importance of protective ventilation for patients with COVID-19.

Perception of usefulness of laboratory tests ordering by internal medicine residents in ambulatory setting: A single-center prospective cohort study.

The demand for high value health care uncovered a steady trend in laboratory tests ordering and inappropriate testing practices. Residents' training in laboratory ordering practice provides an opportunity for quality improvement. We collected information on demographics, the main reason for the appointment, preexisting medical conditions and presence of co-morbidities from first-visit patients to the internal medicine outpatient service of our university general hospital. We also collected information on all laboratory tests ordered by the attending medical residents. At a follow-up visit, we recorded residents' subjective perception on the usefulness of each ordered laboratory test for the purposes of diagnosis, prognosis, treatment or screening. We observed that 17.3% of all ordered tests had no perceived utility by the attending resident. Tests were usually ordered to exclude differential diagnoses (26.7%) and to help prognosis estimation (19.1%). Age and co-morbidity influenced the chosen category to legitimate usefulness of tests ordering. This study suggests that clinical objectives (diagnosis, prognosis, treatment or prevention) as well as personalization to age and previous health conditions should be considered before test ordering to allow a more appropriate laboratory tests ordering, but further studies are necessary to examine this framework beyond this medical training scenario.

Comparação do desempenho do SAPS 3 em pacientes com e sem tumor sólido admitidos a uma unidade de terapia intensiva no Brasil: um estudo de coorte retrospectiva / Comparison of SAPS 3 performance in patients with and without solid tumor admitted to an intensive care unit in Brazil: a retrospective cohort study

RESUMO Objetivo: Comparar o desempenho do Simplified Acute Physiology Score 3 (SAPS 3) em pacientes com e sem tumor sólido admitidos à unidade de terapia intensiva de um hospital oncológico. Métodos: Realizamos a análise de uma coorte retrospectiva em nossa base de dados administrativa da primeira admissão de pacientes adultos à unidade de terapia intensiva entre 2012 e 2016. Os pacientes foram classificados segundo a presença de tumor sólido. Avaliamos a discriminação utilizando a área sob a curva Características de Operação do Receptor (ASC COR) e a calibração com uso da abordagem com faixa de calibração. Resultados: Incluímos 7.254 pacientes (41,5% tinham câncer e 12,1% morreram durante a hospitalização). Os pacientes oncológicos tiveram maior mortalidade hospitalar do que os não oncológicos (respectivamente, 14,1% e 10,6%; p < 0,001). A discriminação do SAPS 3 foi melhor para os pacientes oncológicos (ASC COR = 0,85) do que para os não oncológicos (ASC COR = 0,79) (p < 0,001). Após aplicar a abordagem com faixa de calibração para pacientes oncológicos, o SAPS 3 atingiu as taxas médias observadas com intervalo de confiança de 95%. Em pacientes não oncológicos, o SAPS 3 superestimou a mortalidade nos pacientes com risco baixo a moderado. A calibração foi afetada pelo tempo apenas nos casos de pacientes não oncológicos. Conclusão: O SAPS 3 teve desempenho distinto para pacientes oncológicos e não oncológicos em nossa coorte de um único centro, observando-se variação (principalmente da calibração) ao longo do tempo. Esses achados devem ser levados em consideração ao avaliar o desempenho de escore de doença grave.

ABSTRACT Objective: To compare the performance of the Simplified Acute Physiology Score 3 (SAPS 3) in patients with and without solid cancer who were admitted to the intensive care unit of a comprehensive oncological hospital in Brazil. Methods: We performed a retrospective cohort analysis of our administrative database of the first admission of adult patients to the intensive care unit from 2012 to 2016. The patients were categorized according to the presence of solid cancer. We evaluated discrimination using the area under the Receiver Operating Characteristic curve (AUROC) and calibration using the calibration belt approach. Results: We included 7,254 patients (41.5% had cancer, and 12.1% died during hospitalization). Oncological patients had higher hospital mortality than nononcological patients (14.1% versus 10.6%, respectively; p < 0.001). SAPS 3 discrimination was better for oncological patients (AUROC = 0.85) than for nononcological patients (AUROC = 0.79) (p < 0.001). After we applied the calibration belt in oncological patients, the SAPS 3 matched the average observed rates with a confidence level of 95%. In nononcological patients, the SAPS 3 overestimated mortality in those with a low-middle risk. Calibration was affected by the time period only for nononcological patients. Conclusion: SAPS 3 performed differently between oncological and nononcological patients in our single-center cohort, and variation over time (mainly calibration) was observed. This finding should be taken into account when evaluating severity-of-illness score performance.

Neuromuscular blockade and airway management during endotracheal intubation in Brazilian intensive care units: a national survey. / Bloqueio neuromuscular e manuseio das vias aéreas na intubação endotraqueal em unidades de terapia intensiva brasileiras: um levantamento nacional.

OBJECTIVE: To describe the use of neuromuscular blockade as well as other practices among Brazilian physicians in adult intensive care units. METHODS: An online national survey was designed and administered to Brazilian intensivists. Questions were selected using the Delphi method and assessed physicians' demographic data, intensive care unit characteristics, practices regarding airway management, use of neuromuscular blockade and sedation during endotracheal intubation in the intensive care unit. As a secondary outcome, we applied a multivariate analysis to evaluate factors associated with the use of neuromuscular blockade. RESULTS: Five hundred sixty-five intensivists from all Brazilian regions responded to the questionnaire. The majority of respondents were male (65%), with a mean age of 38 ( 8.4 years, and 58.5% had a board certification in critical care. Only 40.7% of the intensivists reported the use of neuromuscular blockade during all or in more than 75% of endotracheal intubations. In the multivariate analysis, the number of intubations performed monthly and physician specialization in anesthesiology were directly associated with frequent use of neuromuscular blockade. Etomidate and ketamine were more commonly used in the clinical situation of hypotension and shock, while propofol and midazolam were more commonly prescribed in the situation of clinical stability. CONCLUSION: The reported use of neuromuscular blockade was low among intensivists, and sedative drugs were chosen in accordance with patient hemodynamic stability. These results may help the design of future studies regarding airway management in Brazil.

OBJETIVO: Descrever o uso do bloqueio neuromuscular e de outras práticas entre os médicos brasileiros atuantes em unidades de terapia intensiva para pacientes adultos. MÉTODOS: Um levantamento nacional on-line foi aplicado a intensivistas brasileiros. As questões foram selecionadas utilizando o método Delphi e avaliavam os dados demográficos dos médicos, as características da unidade de terapia intensiva, as práticas relativas ao manuseio das vias aéreas e o uso de bloqueio neuromuscular e sedação durante a intubação endotraqueal na unidade de terapia intensiva. Como desfecho secundário, aplicamos uma análise multivariada para avaliar fatores associados com o uso do bloqueio neuromuscular. RESULTADOS: Responderam ao questionário 565 intensivistas de todas as regiões do país. A maioria dos que responderam era homens (65%), com média de idade de 38 ± 8,4 anos, e 58,5% dos participantes tinham título de especialista em terapia intensiva. Apenas 40,7% dos intensivistas relataram o uso de bloqueio neuromuscular durante todas ou em mais de 75% das intubações endotraqueais. Na análise multivariada, o número de intubações realizadas por mês e a especialização do médico em anestesiologia se associaram diretamente com o uso frequente de bloqueio neuromuscular. Etomidato e cetamina foram utilizados mais comumente na situação clínica de hipotensão e choque, enquanto propofol e midazolam foram mais comumente prescritos em situações de estabilidade hemodinâmica. CONCLUSÃO: O relato de uso de bloqueio neuromuscular foi baixo entre intensivistas, e os fármacos sedativos foram escolhidos segundo a estabilidade hemodinâmica do paciente. Estes resultados podem ajudar no delineamento de futuros estudos relativos ao manuseio das vias aéreas no Brasil.

Practices for promoting sleep in intensive care units in Brazil: a national survey. / Práticas de promoção de sono em unidades de terapia intensiva no Brasil: um inquérito nacional.

OBJECTIVE: To conduct a national survey of intensive care professionals to identify the practices for promoting sleep in adult intensive care units in Brazil and describe the professionals' perceptions of the importance of sleep for patients. METHODS: An electronic questionnaire was distributed by the clinical research cooperation network of the Associação de Medicina Intensiva Brasileira and by the Brazilian Research in Intensive Care Network to physicians and nurses registered with the association. The questionnaire evaluated the profile of the respondents, the profile of their intensive care units, whether protocols for promoting sleep were present, the pharmacological and nonpharmacological measures typically employed in the unit, and the professionals' perceptions regarding sleep in critically ill patients. RESULTS: A total of 118 questionnaires were evaluated. The Southeast region of the country was the most represented (50 questionnaires, 42.4%). The majority of units had a clinical-surgical profile (93 questionnaires; 78.8%), and 26 had a continuous visitation policy (22.0%). Only 18 intensive care units (15.3%) reported having protocols for promoting sleep. The most cited measure for sleep promotion was reducing light during the night (95 questionnaires; 80.5%), which was more often performed in private intensive care units. Almost all of the responders (99%) believed that poor-quality sleep has a negative impact on patient recovery. CONCLUSION: The responses to this Brazilian survey revealed that few intensive care units had a program for promoting sleep, although almost all participants recognized the importance of sleep in patient recovery.

Práticas de promoção de sono em unidades de terapia intensiva no Brasil: um inquérito nacional / Practices for promoting sleep in intensive care units in Brazil: a national survey

RESUMO Objetivo: Realizar um inquérito nacional com profissionais de terapia intensiva para determinar as práticas de promoção do sono em unidades de terapia intensiva para adultos no Brasil, e descrever suas percepções sobre a importância do sono para os pacientes. Métodos: Um questionário eletrônico foi distribuído pela rede de cooperação em pesquisa clínica da Associação de Medicina Intensiva Brasileira aos médicos e enfermeiros registrados na associação e pela Brazilian Research in Intensive Care Network. O questionário avaliou o perfil dos respondedores, de suas unidades de terapia intensiva, se estavam presentes protocolos de promoção do sono, quais as medidas farmacológicas e não farmacológicas usualmente empregadas na unidade e a percepção dos profissionais em relação ao sono nos pacientes críticos. Resultados: Foram avaliados 118 questionários. A Região Sudeste foi a mais representada (50 questionários; 42,4%). A maioria apresentava perfil clínico-cirúrgico (93 questionários; 78,8%) e 26 possuíam política de visita contínua (22,0%). Apenas 18 unidades de terapia intensiva (15,3%) referiram apresentar protocolos de promoção do sono. A medida mais citada para promoção de sono foi a redução da luminosidade no período noturno (95 questionários; 80,5%), sendo mais executada em unidades de terapia intensiva privadas. Quase a totalidade dos respondedores (99%) acreditou que o sono com qualidade ruim tinha impacto negativo na recuperação do paciente. Conclusão: Nas respostas deste inquérito brasileiro, poucas unidades apresentaram um programa de promoção de sono na unidade de terapia intensiva, embora a quase totalidade dos participantes reconhecesse a importância do sono na recuperação do paciente.

ABSTRACT Objective: To conduct a national survey of intensive care professionals to identify the practices for promoting sleep in adult intensive care units in Brazil and describe the professionals' perceptions of the importance of sleep for patients. Methods: An electronic questionnaire was distributed by the clinical research cooperation network of the Associação de Medicina Intensiva Brasileira and by the Brazilian Research in Intensive Care Network to physicians and nurses registered with the association. The questionnaire evaluated the profile of the respondents, the profile of their intensive care units, whether protocols for promoting sleep were present, the pharmacological and nonpharmacological measures typically employed in the unit, and the professionals' perceptions regarding sleep in critically ill patients. Results: A total of 118 questionnaires were evaluated. The Southeast region of the country was the most represented (50 questionnaires, 42.4%). The majority of units had a clinical-surgical profile (93 questionnaires; 78.8%), and 26 had a continuous visitation policy (22.0%). Only 18 intensive care units (15.3%) reported having protocols for promoting sleep. The most cited measure for sleep promotion was reducing light during the night (95 questionnaires; 80.5%), which was more often performed in private intensive care units. Almost all of the responders (99%) believed that poor-quality sleep has a negative impact on patient recovery. Conclusion: The responses to this Brazilian survey revealed that few intensive care units had a program for promoting sleep, although almost all participants recognized the importance of sleep in patient recovery.