Extubation failure and the use of noninvasive ventilation during the weaning process in critically ill COVID-19 patients.

OBJECTIVE: To assess the outcome of extubation in COVID-19 patients and the use of noninvasive ventilation in the weaning process. METHODS: This retrospective, observational, single-center study was conducted in COVID-19 patients aged 18 years or older who were admitted to an intensive care unit between April 2020 and December 2021, placed under mechanical ventilation for more than 48 hours and progressed to weaning. Early extubation was defined as extubation without a spontaneous breathing trial and immediate use of noninvasive ventilation after extubation. In patients who underwent a spontaneous breathing trial, noninvasive ventilation could be used as prophylactic ventilatory assistance when started immediately after extubation (prophylactic noninvasive ventilation) or as rescue therapy in cases of postextubation respiratory failure (therapeutic noninvasive ventilation). The primary outcome was extubation failure during the intensive care unit stay. RESULTS: Three hundred eighty-four extubated patients were included. Extubation failure was observed in 107 (27.9%) patients. Forty-seven (12.2%) patients received prophylactic noninvasive ventilation. In 26 (6.8%) patients, early extubation was performed with immediate use of noninvasive ventilation. Noninvasive ventilation for the management of postextubation respiratory failure was administered to 64 (16.7%) patients. CONCLUSION: We found that COVID-19 patients had a high rate of extubation failure. Despite the high risk of extubation failure, we observed low use of prophylactic noninvasive ventilation in these patients.

Endocarditis in critically ill patients: a review.

PURPOSE OF REVIEW: To summarize the advances in literature that support the best current practices regarding infective endocarditis (IE) in critically ill patients. RECENT FINDINGS: IE due to rheumatic diseases has decreased significantly, and in fact, the majority of cases are associated with degenerative valvopathies, prosthetic valves, and cardiovascular implantable electronic devices. The Duke criteria were recently updated, addressing the increasing incidence of new risk factors for IE, such as IE associated with the use of endovascular cardiac implantable electronic devices and transcatheter implant valves. The presence of organ dysfunction, renal replacement therapies, or extracorporeal membrane oxygenation should be considered in the choice of drug and dosage in critically ill patients with suspected or confirmed IE. As highlighted for other severe infections, monitoring of therapeutic antibiotic levels is a promising technique to improve outcomes in critically ill patients with organ dysfunction. SUMMARY: The diagnostic investigation of IE must consider the current epidemiological criteria and the diagnostic particularities that these circumstances require. A careful evaluation of these issues is necessary for the prompt clinical or surgical management of this infection.

Prognostic value of Doppler waveform analysis of common femoral vein in septic patients: a prospective cohort study.

OBJECTIVES: To assess whether there is an association between abnormal common femoral vein (CFV) Doppler waveform and intensive care unit (ICU) mortality in patients with sepsis. METHODS: Patients admitted to the ICU with sepsis were included. Pulsed-wave Doppler was performed by examining the CFV in the short axis without angle correction and in the long axis with angle correction. An abnormal CFV Doppler waveform was determined by a retrograde velocity peak (RVP) > 10 cm/s in the long axis or RVP > 50% of the antegrade velocity peak in the short axis. TAPSE < 17 mm was defined as right ventricular (RV) dysfunction. The primary outcome was ICU mortality. RESULTS: One hundred and ten patients were included. There was no association between abnormal CFV Doppler waveforms in the long (p = 0.709) and short axes (p = 0.171) and ICU mortality. TAPSE measurements were performed in 16 patients. RV dysfunction was identified in 8 (50.0%) patients. There was no association between the diagnosis of RV dysfunction based on TAPSE measurement and the identification of abnormal CFV Doppler waveforms in the long axis (p = 1.000) and in the short axis (p = 1.000). CONCLUSION: Abnormal CFV Doppler waveforms were not associated with ICU mortality in patients with sepsis. Furthermore, in the exploratory analysis, these alterations were not useful in identifying RV dysfunction in these patients.

Effect of Cyproheptadine on Ventilatory Support-free Days in Critically Ill Patients with COVID-19: An Open-label, Randomized Clinical Trial.

Background: Serotonin is a mediator of pulmonary hypoxic vasoconstriction. Experimental studies have shown that serotonin-mediated pulmonary vasoconstriction can be inhibited by cyproheptadine. The aim of this study is to assess whether treatment with cyproheptadine compared to usual care increases ventilatory support-free days during the first 28 days in patients with coronavirus disease 2019 (COVID-19) requiring ventilatory support. Materials and methods: This randomized, single-center, open-label clinical trial included patients who were admitted to the intensive care unit (ICU) requiring ventilatory support due to COVID-19. Patients allocated to the intervention group received cyproheptadine for 10 days. The primary outcome was ventilator-free days during the first 28 days. Results: Nineteen patients were randomized to receive cyproheptadine and 21 to the control group. The number of ventilatory support-free days during the first 28 days was not different between the two groups (15.0; 95% CI, 0.0-24.0 days in the control group vs 7.0; 95% CI, 0.0-19.0 days in the intervention group; p = 0.284). Conclusion: In patients with COVID-19 and in need of ventilatory support, the use of cyproheptadine plus usual care, compared with usual care alone, did not increase the number of ventilatory support-free days in 28 days. How to cite this article: Boniatti MM, Nedel WL, Rihl MF, Schwarz P, Parolo E, Moretti MMS, et al. Effect of Cyproheptadine on Ventilatory Support-free Days in Critically Ill Patients with COVID-19: An Open-label, Randomized Clinical Trial. Indian J Crit Care Med 2023;27(7):517-521.

Prognosis of critically ill patients with extreme acidosis: A retrospective study.

OBJECTIVE: This study aims to assess the impact of different subtypes of extreme acidosis on the mortality of critically ill patients. METHODS: This retrospective cohort study included critically ill patients who were admitted to the intensive care unit (ICU) with a pH level <7. Clinical data and blood gas analyses were collected from electronic medical records. The primary outcome was in-hospital mortality. The use of vasopressors, mechanical ventilation (MV), and renal replacement therapy (RRT), the duration of MV and RRT, and the length of ICU and hospital stay were secondary outcomes. The simplified Stewart approach to acid-base disorders was used to analyze the causes of acidosis. RESULTS: A total of 231 patients with 371 arterial blood gas analyses with pH < 7 were admitted from January 2012 to December 2021 and 222 were included in the study. Out of the 222 patients analyzed, respiratory acidosis was the primary disorder in 11.3% of patients (n = 25), metabolic acidosis in 33.8% (n = 75), and mixed acidosis in 55% (n = 122). Overall mortality was 42.8% (n = 95). No significant difference was observed in mortality among patients with respiratory, metabolic, or mixed acidosis (28%, 42.7%, and 45.9%, respectively; p = 0.26). The primary disorder affected the use of vasopressors and MV, the duration of MV, and the length of ICU and hospital stay. Patients with extreme acidosis due to unmeasured anions with lactate levels of 4 mmol/L or higher had higher mortality compared with patients with lactate levels <4 mmol/L (55.6% and 27.7%, respectively; p = 0.007). CONCLUSION: Among critically ill patients with extreme acidosis, the primary disorder is not associated with mortality, but it is associated with the use of vasopressors and MV, the duration of MV, and the length of ICU and hospital stay. Additionally, hyperlactatemia is a predictor of poor prognosis in patients with extreme acidosis.

VExUS Score in the Management of Patients With Acute Kidney Injury in the Intensive Care Unit: AKIVEX Study.

OBJECTIVES: Venous congestion is a potential cause of acute kidney injury (AKI) and venous excess ultrasound (VExUS) score is a potentially useful tool in this scenario. The aim of this study is to verify whether the VExUS score can serve as a guide to decongestion in patients with severe AKI and whether the modification of the score can be associated with an increase in the number of renal replacement therapy (RRT)-free days in 28 days. METHODS: This quasi-experimental study was conducted in patients admitted to the intensive care unit who developed severe AKI. The intervention was to suggest to the attending physician the use of diuretic in patients with VExUS >1. After 48 hours, a new VExUS assessment was performed. Primary outcome was RRT-free days at Day 28. RESULTS: Ninety patients were included. Patients with a VExUS score >1 (n = 36) at enrollment had a greater use of diuretics in the following 48 hours (75.0%, n = 27) than patients with a VExUS ≤1 (n = 54) at enrollment (38.9%, n = 21), P = .001. Patients who reduced the VExUS score had a significantly greater number of RRT-free days at Day 28 (28.0; 8.0-28.0) when compared with those who did not reduce (15.0; 3.0-27.5), P = .012. CONCLUSIONS: We found a higher diuretic use in patients with a higher VExUS score, and patients who reduced the VExUS in 48 hours had significantly more RRT-free days in 28 days.

Association between time of day for rapid response team activation and mortality.

PURPOSE: To evaluate the frequency of rapid response team (RRT) calls by time of day and their association with in-hospital mortality. MATERIALS AND METHODS: This was a retrospective cohort study of all RRT calls at a tertiary teaching hospital in Porto Alegre, Brazil. Patients were categorized according to the time of initial RRT activation. Activations were classified as daytime (7:00-18:59) or nighttime (19:00-6:59). The primary outcome was in-hospital mortality rate. The secondary outcome was ICU admission within 48 h of RRT assessment. RESULTS: During the study period, 4522 patients were included in the final analysis. Cardiovascular and respiratory changes were more common causes of nighttime activation, whereas neurological and laboratory changes were more common during the daytime. The in-hospital mortality rate was 23.9% (1081/4522). Nighttime RRT calls were not associated with worse outcomes than daytime calls. However, a decrease in the number of calls was observed during nursing handover periods (7:00, 13:00 and 19:00). Two time periods were associated with increased adjusted odds for mortality: 12:00-13:00 (adjusted OR 2.277; 95% CI 1.392-3.725) and 19:00-20:00 (adjusted OR 1.873; CI 1.873; 95% 1.099-3.190). CONCLUSION: We found that nighttime RRT calls were not associated with worse outcomes than daytime RRT calls. However, a decrease in the number of calls and higher mortality was observed during nursing handover periods.

Assessment of the accuracy of the CALCULATE scale for pressure injury in critically ill patients.

INTRODUCTION: Pressure injury is damage to the skin and underlying soft tissue that occurs in response to intense and/or prolonged skin pressure. The Braden scale is the most used in health services to assess pressure injury. However, this scale was not specifically developed for critically ill patients. The Critical Care Pressure Ulcer Assessment Tool Made Easy (CALCULATE) scale was developed for patients in intensive care units. OBJECTIVE: The objective of this study was to compare the accuracy of the CALCULATE scale with that of Braden in predicting the risk of pressure injury in critically ill patients. METHODS: This was a prospective cohort study, involving patients who did not have pressure injury on admission to the intensive care unit of a tertiary hospital in the city of Porto Alegre, Brazil. Data collection took place between January and July 2020 using the Braden and CALCULATE scales, in addition to clinical and sociodemographic variables. Patients were followed up until discharge from the intensive care unit or death. RESULTS: Fifty-one patients were included in the study. Of these, 29 (56.9%) developed pressure injury. To predict pressure injury onset, the areas under the receiver operator characteristic curve of the Braden scale on the first day and the lowest score during the first 3 days were 0.71 (0.56-0.86) and 0.70 (0.53-0.87), respectively. The areas under the receiver operator characteristic curve of the CALCULATE scale on the first day and the highest score during the first 3 days were 0.91 (0.82-0.99) and 0.92 (0.85-1.00), respectively. In the logistic regression analysis, the CALCULATE scale on the first day remained an independent predictor of pressure injury onset after controlling for age and length of stay in the intensive care unit. CONCLUSION: We found that the CALCULATE scale may be more accurate than the Braden scale as a tool to assess the risk of developing pressure injury in critically ill patients.

Extubation failure and the use of noninvasive ventilation during the weaning process in critically ill COVID-19 patients / Falha de extubação e uso de ventilação não invasiva durante o processo de desmame em pacientes críticos com COVID-19

ABSTRACT Objective: To assess the outcome of extubation in COVID-19 patients and the use of noninvasive ventilation in the weaning process. Methods: This retrospective, observational, single-center study was conducted in COVID-19 patients aged 18 years or older who were admitted to an intensive care unit between April 2020 and December 2021, placed under mechanical ventilation for more than 48 hours and progressed to weaning. Early extubation was defined as extubation without a spontaneous breathing trial and immediate use of noninvasive ventilation after extubation. In patients who underwent a spontaneous breathing trial, noninvasive ventilation could be used as prophylactic ventilatory assistance when started immediately after extubation (prophylactic noninvasive ventilation) or as rescue therapy in cases of postextubation respiratory failure (therapeutic noninvasive ventilation). The primary outcome was extubation failure during the intensive care unit stay. Results: Three hundred eighty-four extubated patients were included. Extubation failure was observed in 107 (27.9%) patients. Forty-seven (12.2%) patients received prophylactic noninvasive ventilation. In 26 (6.8%) patients, early extubation was performed with immediate use of noninvasive ventilation. Noninvasive ventilation for the management of postextubation respiratory failure was administered to 64 (16.7%) patients. Conclusion: We found that COVID-19 patients had a high rate of extubation failure. Despite the high risk of extubation failure, we observed low use of prophylactic noninvasive ventilation in these patients.

RESUMO Objetivo: Avaliar o desfecho da extubação em pacientes com COVID-19 e o uso da ventilação não invasiva no processo de desmame. Métodos: Este estudo retrospectivo, observacional e unicêntrico foi realizado em pacientes com COVID-19 com 18 anos ou mais, internados em uma unidade de terapia intensiva entre abril de 2020 e dezembro de 2021, colocados sob ventilação mecânica por mais de 48 horas com progressão para o desmame. A extubação precoce foi definida como a extubação sem um teste de ventilação espontânea e com uso imediato de ventilação não invasiva após a extubação. Em pacientes submetidos a um teste de ventilação espontânea, a ventilação não invasiva poderia ser usada como assistência ventilatória profilática, quando iniciada imediatamente após a extubação (ventilação não invasiva profilática), ou como terapia de resgate em casos de insuficiência respiratória pós-extubação (ventilação não invasiva terapêutica). O desfecho primário foi falha de extubação durante a internação na unidade de terapia intensiva. Resultados: Foram incluídos 384 pacientes extubados. A falha de extubação foi observada em 107 (27,9%) pacientes. Quarenta e sete (12,2%) pacientes receberam ventilação não invasiva profilática. Em 26 (6,8%) pacientes, a extubação precoce foi realizada com o uso imediato de ventilação não invasiva. A ventilação não invasiva para o manejo da insuficiência respiratória pós-extubação foi administrada em 64 (16,7%) pacientes. Conclusão: Os pacientes com COVID-19 apresentaram alta taxa de falha de extubação. Apesar do alto risco de falha de extubação, observamos baixo uso de ventilação não invasiva profilática nesses pacientes.

Cancer symptoms: do patients, family caregivers and professionals agree?

OBJECTIVES: To assess the level of agreement among patients, their family caregivers and health professionals regarding the symptoms presented by patients with cancer. METHODS: This is a cross-sectional study carried out in patients with cancer admitted to a hospital in Brazil from December 2019 to July 2020. One family caregiver for each patient was included in the study. In addition, nurses and physicians involved in patient care were included. Patients, family caregivers and health professionals responded to the Palliative Outcome Scale (POS). RESULTS: Sixty-one patients with their family caregivers, 18 nurses and 8 physicians were included. Physicians reported a lower mean POS score than patients (p=0.008). In general, physicians and nurses underestimated the anxiety of the patient and the anxiety of the family caregivers and how much the patient feels that his or her life is worthwhile. Intraclass correlation coefficient showed moderate and good levels of agreement between patients' and family caregivers' responses (0.61). Agreement between patient and nurse (0.02) and physician (0.21) responses was poor. CONCLUSIONS: The level of agreement between patients and healthcare professionals was very poor regarding patients' symptoms. However, the caregiver's perception of the patient's symptoms can be a reliable source of information.

Coping with complexity in the COVID pandemic: An exploratory study of intensive care units.

Although the COVID pandemic has challenged the resilience of health services in general, this impact has been most visible in intensive care units (ICUs). This paper presents an exploratory study of how ICUs in Brazil have coped with the complexity stemming from the pandemic. Five guidelines for coping with complexity were adopted as analytical framework. The guidelines were concerned with slack resources, diversity of perspectives, visibility, work-as-done, and unintended consequences. There were three main sources of data: (i) a survey with respondents from 33 ICUs, which indicated their agreement with 23 statements related to the use of the complexity guidelines; (ii) semistructured interviews with seven survey respondents and two public health officials; and (iii) 20 h of observations of the meetings of a municipal bed management committee. Seventy resilience practices were identified from these data sources. Most of these practices (n = 30) were related to the guideline on slack resources, which were commonly obtained from other hospital units. As for the survey data, the statement related to the availability of extra or standby human resources obtained the lowest score, reinforcing the key role of slack resources. Five lessons learned for coping with complexity in ICUs were drawn from our data; one lesson for each guideline. Furthermore, the survey questionnaire is a potential ICU assessment tool, which can be adapted to other health services.

Comparison of a modified Story approach to traditional evaluation of acid-base disturbances in patients with shock: a cohort study.

To compare whether the diagnostic evaluation of metabolic acidosis can be improved by using a modified Story method compared to the traditional evaluation in a population of critically ill patients with shock. This prospective cohort study included shock patients admitted to the ICU of a tertiary hospital in Brazil between May 2018 and November 2019. We collected laboratory data necessary for traditional evaluation and the simplified Stewart's method. During the study period, 149 patients were included in the final analysis. Of the 17 patients with a normal SBE and AGcorrected, 13 (76.5%) presented with metabolic acidosis according to the modified Story assessment. Therefore, of the 149 patients included in the study, the traditional approach failed to identify metabolic acidosis that was identified by the modified Story assessment in 13 (8.7%) patients. In addition, the determination of the severity of metabolic acidosis also differed between the two methods by a mean of - 7.8 mEq/L. We found that a modified Story method can identify and quantify metabolic acidosis in patients with disorders that were not revealed by the traditional approach.

Fever is associated with earlier antibiotic onset and reduced mortality in patients with sepsis admitted to the ICU.

To evaluate the association of body temperature with mortality in septic patients admitted to the ICU from the ward. In addition, we intend to investigate whether the timing of antibiotic administration was different between febrile and afebrile patients and whether this difference contributed to mortality. This is a retrospective cohort study that included sepsis patients admitted to the ICU from the ward between July 2017 and July 2019. Antibiotic administration was defined as the initiation of antimicrobial treatment or the expansion of the antimicrobial spectrum within 48 h prior to admission to the ICU. Regarding vital signs, the most altered vital sign in the 48 h prior to admission to the ICU was considered. Two hundred and eight patients were included in the final analysis. Antibiotic administration occurred earlier in patients with fever than in patients without fever. Antibiotic administration occurred before admission to the ICU in 27 (90.0%) patients with fever and in 101 (64.7%) patients without fever (p = 0.006). The mortality rate in the ICU was 88 in 176 (50.0%; 95% CI 42.5-57.5%) patients without fever and 7 in 32 (21.9%; 95% CI 6.7-37.0%) patients with fever (p = 0.004). In the multivariate analysis, absence of fever significantly increased the risk of ICU mortality (OR 3.462; 95% CI 1.293-9.272). We found an inverse association between body temperature and mortality in patients with sepsis admitted to the ICU from the ward. Although antibiotic administration was earlier in patients with fever and precocity was associated with reduced mortality, the time of antibiotic administration did not fully explain the lower mortality in these patients.

O balanço hídrico pós-extubação se associa com falha da extubação: um estudo de coorte / Postextubation fluid balance is associated with extubation failure: a cohort study

RESUMO Objetivo: Avaliar se há associação entre o balanço hídrico nas 48 horas após a extubação e a falha da extubação. Métodos: Este é um estudo de coorte prospectiva que incluiu os pacientes admitidos à unidade de terapia intensiva de um hospital terciário no sul do Brasil entre março e dezembro de 2019. Incluíram-se os pacientes que necessitaram de ventilação mecânica por pelo menos 24 horas e foram extubados durante o período do estudo. O desfecho primário foi falha da extubação, considerada como necessidade de reintubar dentro das primeiras 72 horas após a extubação. O desfecho secundário foi um desfecho combinado de falha da extubação ou necessidade de ventilação não invasiva terapêutica. Resultados: Foram incluídos 101 pacientes. Observou-se falha da extubação em 29 (28,7%) deles. Na análise univariada, pacientes com balanço hídrico negativo acima de 1L no período de 48 horas após a extubação tiveram menor taxa de falha da extubação (12,0%), em comparação a pacientes com balanço hídrico negativo nas 48 horas após a extubação menor que 1L (34,2%; p = 0,033). A duração da ventilação mecânica e o balanço hídrico negativo nas 48 horas após a extubação inferior a 1L se associaram com falha da extubação na análise multivariada quando corrigido pelo Simplified Acute Physiology Score 3. Quando avaliou-se o desfecho combinado, apenas o balanço hídrico nas 48 horas pós-extubação inferior a 1L manteve associação, quando corrigido pelo Simplified Acute Physiology Score 3 e duração da ventilação mecânica. Conclusão: O balanço hídrico nas 48 horas após a extubação se associa com falha da extubação. São necessários mais estudos para avaliar se evitar um balanço hídrico positivo nesse período poderia melhorar os desfechos do desmame.

ABSTRACT Objective: To assess whether there is an association between 48-hour postextubation fluid balance and extubation failure. Methods: This was a prospective cohort study that included patients admitted to the intensive care unit of a tertiary hospital in southern Brazil from March 2019 to December 2019. Patients who required mechanical ventilation for at least 24 hours and who were extubated during the study period were included. The primary outcome was extubation failure, considered as the need for reintubation in the first 72 hours after extubation. The secondary outcome was a combined outcome with extubation failure or the need for therapeutic noninvasive ventilation. Results: A total of 101 patients were included. Extubation failure was observed in 29 (28.7%) patients. In univariate analysis, patients with a negative 48-hour postextubation fluid balance higher than one liter had a lower rate of extubation failure (12.0%) than patients with a negative 48-hour postextubation fluid balance lower than 1L (34.2%; p = 0.033). Mechanical ventilation duration and negative 48-hour postextubation fluid balance lower than one liter were associated with extubation failure when corrected for Simplified Acute Physiology Score 3 in multivariate analysis. When we evaluated the combined outcome, only negative 48-hour postextubation lower than 1L maintained an association when corrected for for Simplified Acute Physiology Score 3 and mechanical ventilation duration. Conclusion: The 48-hour postextubation fluid balance is associated with extubation failure. Further studies are necessary to assess whether avoiding positive fluid balance in this period might improve weaning outcomes.

O idoso, a desospitalização e a família: os desafios para pratica do cuidado domiciliar / Personas mayores, deshospitalización y familia: los desafíos para la práctica de cuidado en casa / The elderly, de-hospitalization and the family: challenges for the practice of home care

O envelhecimento da população tem exigido uma maior sobrecarga de cuidados por parte dos sistemas de saúde e familiares dos idosos, principalmente após a hospitalização. Os profissionais de saúde, em especial os enfermeiros, são responsáveis pela educação em saúde, para que a reabilitação seja segura e o cuidado seja exitoso. O objetivo deste estudo é relatar a experiência de educação em saúde realizada com familiares (cuidadores) e idosos após a alta para prevenir quedas no domicílio. Trata-se de um relato de experiência oriundo de visitas domiciliares realizadas três meses após a alta hospitalar de idosos que receberam tratamento cirúrgico de fratura de membros inferiores em um hospital público de Porto Alegre-RS. Realizamos a pesquisa de campo em três etapas, que são descritas a seguir: contato telefônico prévio para agendamento da visita, durante a visita iniciamos a abordagem baseada no diálogo informal, resgatando as vivências relacionadas ao ato de cuidar do idoso por conta própria. despesas, retorno ao domicílio e, por fim, orientações sobre cuidados domiciliares para prevenção de novas quedas. Foram realizadas 55 visitas domiciliares em Porto Alegre e região metropolitana. A educação em saúde utilizou o calendário como recurso para a discussão das melhores práticas na atenção domiciliar para prevenir o risco de quedas e promover a autonomia e independência dos idosos. Esta intervenção conseguiu reabilitar a autoconfiança, autonomia e independência do idoso, promovendo qualidade de vida e reinserção social, além de tornar o familiar solidariamente responsável por um cuidado seguro.

El envejecimiento de la población ha exigido una mayor carga asistencial por parte de los sistemas de salud de las personas mayores y de los familiares, especialmente después de la hospitalización. Los profesionales de la salud, especialmente las enfermeras, son responsables de la educación sanitaria, para que la rehabilitación sea segura y la atención sea exitosa. El objetivo de este estudio es relatar la experiencia de educación sanitaria realizada con familiares (cuidadores) y personas mayores tras el alta para prevenir caídas en el domicilio. Se trata de un relato de experiencia derivada de las visitas domiciliarias realizadas tres meses después del alta hospitalaria de ancianos que recibieron tratamiento quirúrgico por fracturas de miembros inferiores en un hospital público de Porto Alegre-RS. Realizamos la investigación de campo en tres etapas, las cuales se describen a continuación: contacto telefónico previo a programar la visita, durante la visita iniciamos el abordaje basado en el diálogo informal, rescatando las experiencias relacionadas con el acto de cuidar al adulto mayor por su cuenta. gastos, regreso a casa y, fi nalmente, orientación sobre cuidados domiciliarios para evitar nuevas caídas. Se realizaron 55 visitas domiciliarias en Porto Alegre y su región metropolitana. La educación para la salud utilizó el calendario como un recurso para discutir las mejores prácticas en la atención domiciliaria para prevenir el riesgo de caídas y promover la autonomía e independencia de las personas mayores. Esta intervención logró rehabilitar la autoconfianza, autonomía e independencia de las personas mayores, promoviendo la calidad de vida y la reinserción social, además de responsabilizar solidariamente al familiar de un cuidado seguro.

The aging of the population has demanded a greater burden of care on the part of the elderly's health systems and family members, especially after hospitalization. Health professionals, especially nurses, are responsible for health education, so that rehabilitation is safe and care is successful. The aim of this study is to report the experience of health education carried out with family members (caregivers) and elderly people after discharge to prevent falls at home. This is an experience report arising from home visits carried out three months after hospital discharge of elderly people who received surgical treatment for fractures of the lower limbs in a public hospital in Porto Alegre-RS. We carried out the field research in three stages, which are described below telephone contact prior to scheduling the visit, during the visit we started the approach based on informal dialogue, rescuing the experiences related to the act of caring for the elderly on their own. Expenses, return home and, finally, guidance on home care to prevent further falls. 55 home visits were carried out in Porto Alegre and its metropolitan region. Health education used the calendar as a resource for discussing best practices in home care to prevent the risk of falls and promote the autonomy and independence of the elderly. The intervention managed to rehabilitate the elderly's self-confidence, autonomy and independence, promoting quality of life and social reintegration, in addition to making the family member jointly responsible for safe care.

Changes in cardiac arrest profiles after the implementation of a Rapid Response Team. / Modificações no perfil de paradas cardíacas após implantação de um Time de Resposta Rápida.

OBJECTIVE: To evaluate changes in the characteristics of in-hospital cardiac arrest after the implementation of a Rapid Response Team. METHODS: This was a prospective observational study of in-hospital cardiac arrest that occurred from January 2013 to December 2017. The exclusion criterion was in-hospital cardiac arrest in the intensive care unit, emergency room or operating room. The Rapid Response Team was implemented in July 2014 in the study hospital. Patients were classified into two groups: a Pre-Rapid Response Team (in-hospital cardiac arrest before Rapid Response Team implementation) and a Post-Rapid Response Team (in-hospital cardiac arrest after Rapid Response Team implementation). Patients were followed until hospital discharge or death. RESULTS: We had a total of 308 cardiac arrests (64.6 ± 15.2 years, 60.3% men, 13.9% with initial shockable rhythm). There was a decrease from 4.2 to 2.5 in-hospital cardiac arrest/1000 admissions after implementation of the Rapid Response Team, and we had approximately 124 calls/1000 admissions. Pre-Rapid Response Team cardiac arrest was associated with more hypoxia (29.4 versus 14.3%; p = 0.006) and an altered respiratory rate (14.7 versus 4.2%; p = 0.004) compared with post-Rapid Response Team cardiac arrest. Cardiac arrest due to hypoxia was more common before Rapid Response Team implementation (61.2 versus 38.1%, p < 0.001). In multivariate analysis, return of spontaneous circulation was associated with shockable rhythm (OR 2.97; IC95% 1.04 - 8.43) and witnessed cardiac arrest (OR 2.52; IC95% 1.39 - 4.59) but not with Rapid Response Team implementation (OR 1.40; IC95% 0.70 - 2.81) or premonitory signs (OR 0.71; IC95% 0.39 - 1.28). In multivariate analysis, in-hospital mortality was associated with non-shockable rhythm (OR 5.34; IC95% 2.28 - 12.53) and age (OR 1.03; IC95% 1.01 - 1.05) but not with Rapid Response Team implementation (OR 0.89; IC95% 0.40 - 2.02). CONCLUSION: Even though Rapid Response Team implementation is associated with a reduction in in-hospital cardiac arrest, it was not associated with the mortality of in-hospital cardiac arrest victims. A significant decrease in cardiac arrests due to respiratory causes was noted after Rapid Response Team implementation.

OBJETIVO: Avaliar as modificações nas características das paradas cardíacas no hospital após a implantação de um Time de Resposta Rápida. MÉTODOS: Este foi um estudo observacional prospectivo de paradas cardíacas ocorridas no hospital entre janeiro de 2013 e dezembro de 2017. O critério de exclusão foi parada cardíaca na unidade de terapia intensiva, na emergência ou na sala cirúrgica. O Time de Resposta Rápida foi introduzido no hospital do estudo em julho de 2014. Os pacientes foram classificados em dois grupos: Pré-Time de Resposta Rápida (parada cardíaca no hospital antes da implantação do Time de Resposta Rápida) e Pós- Time de Resposta Rápida (parada cardíaca no hospital após a implantação do Time de Resposta Rápida). Os pacientes foram seguidos até a alta hospitalar ou óbito. RESULTADOS: Ocorreram 308 paradas cardíacas (64,6 ± 15,2 anos; 60,3% homens; 13,9% com ritmo inicial chocável). Houve diminuição de 4,2 para 2,5 no índice de parada cardíaca no hospital por 1.000 admissões após o início da atuação do Time de Resposta Rápida, além de cerca de 124 chamados por 1.000 admissões. A parada antes da implantação do Time de Resposta Rápida se associou com hipóxia (29,4 versus 14,3%; p = 0,006) e alteração da frequência respiratória (14,7 versus 4,2%; p = 0,004) em comparação aos dados referentes à parada cardíaca após a implantação do Time de Resposta Rápida. Parada cardíaca por hipóxia foi mais comum antes da implantação do Time de Resposta Rápida (61,2 versus 38,1%; p < 0,001). Na análise multivariada, o retorno à circulação espontânea se associou com ritmo chocável (RC 2,97; IC95% 1,04 - 8,43) e parada cardíaca testemunhada (RC 2,52; IC95% 1,39 - 4,59) mas não com a implantação do Time de Resposta Rápida (RC 1,40; IC95% 0,70 - 2,81) ou sinais premonitórios (RC 0,71; IC95% 0,39 - 1,28). Na análise multivariada, a mortalidade hospitalar se associou com ritmo não chocável (RC 5,34; IC95% 2,28 - 12,53) e idade (RC 1,03; IC95% 1,01 - 1,05), porém não com a implantação do Time de Resposta Rápida (RC 0,89; IC95% 0,40 - 2,02). CONCLUSÃO: Apesar de a implantação de um Time de Resposta Rápida se associar com redução na incidência de parada cardíaca no hospital, ela não se associou com a redução da mortalidade das vítimas de parada cardíaca no hospital. Observou-se significante diminuição nas paradas cardíacas devidas a causas respiratórias após a implantação do Time de Resposta Rápida.

Postextubation fluid balance is associated with extubation failure: a cohort study. / O balanço hídrico pós-extubação se associa com falha da extubação: um estudo de coorte.

OBJECTIVE: To assess whether there is an association between 48-hour postextubation fluid balance and extubation failure. METHODS: This was a prospective cohort study that included patients admitted to the intensive care unit of a tertiary hospital in southern Brazil from March 2019 to December 2019. Patients who required mechanical ventilation for at least 24 hours and who were extubated during the study period were included. The primary outcome was extubation failure, considered as the need for reintubation in the first 72 hours after extubation. The secondary outcome was a combined outcome with extubation failure or the need for therapeutic noninvasive ventilation. RESULTS: A total of 101 patients were included. Extubation failure was observed in 29 (28.7%) patients. In univariate analysis, patients with a negative 48-hour postextubation fluid balance higher than one liter had a lower rate of extubation failure (12.0%) than patients with a negative 48-hour postextubation fluid balance lower than 1L (34.2%; p = 0.033). Mechanical ventilation duration and negative 48-hour postextubation fluid balance lower than one liter were associated with extubation failure when corrected for Simplified Acute Physiology Score 3 in multivariate analysis. When we evaluated the combined outcome, only negative 48-hour postextubation lower than 1L maintained an association when corrected for for Simplified Acute Physiology Score 3 and mechanical ventilation duration. CONCLUSION: The 48-hour postextubation fluid balance is associated with extubation failure. Further studies are necessary to assess whether avoiding positive fluid balance in this period might improve weaning outcomes.

OBJETIVO: Avaliar se há associação entre o balanço hídrico nas 48 horas após a extubação e a falha da extubação. MÉTODOS: Este é um estudo de coorte prospectiva que incluiu os pacientes admitidos à unidade de terapia intensiva de um hospital terciário no sul do Brasil entre março e dezembro de 2019. Incluíram-se os pacientes que necessitaram de ventilação mecânica por pelo menos 24 horas e foram extubados durante o período do estudo. O desfecho primário foi falha da extubação, considerada como necessidade de reintubar dentro das primeiras 72 horas após a extubação. O desfecho secundário foi um desfecho combinado de falha da extubação ou necessidade de ventilação não invasiva terapêutica. RESULTADOS: Foram incluídos 101 pacientes. Observou-se falha da extubação em 29 (28,7%) deles. Na análise univariada, pacientes com balanço hídrico negativo acima de 1L no período de 48 horas após a extubação tiveram menor taxa de falha da extubação (12,0%), em comparação a pacientes com balanço hídrico negativo nas 48 horas após a extubação menor que 1L (34,2%; p = 0,033). A duração da ventilação mecânica e o balanço hídrico negativo nas 48 horas após a extubação inferior a 1L se associaram com falha da extubação na análise multivariada quando corrigido pelo Simplified Acute Physiology Score 3. Quando avaliou-se o desfecho combinado, apenas o balanço hídrico nas 48 horas pós-extubação inferior a 1L manteve associação, quando corrigido pelo Simplified Acute Physiology Score 3 e duração da ventilação mecânica. CONCLUSÃO: O balanço hídrico nas 48 horas após a extubação se associa com falha da extubação. São necessários mais estudos para avaliar se evitar um balanço hídrico positivo nesse período poderia melhorar os desfechos do desmame.

Delirium and quality of life in critically ill patients: a prospective cohort study. / Delirium e qualidade de vida em pacientes críticos: um estudo de coorte prospectivo.

OBJECTIVE: To evaluate the association between the incidence of delirium in the intensive care unit and quality of life 1 month after hospital discharge. METHODS: This was a prospective cohort study conducted in the intensive care units of two medium-complexity hospitals from December 2015 to December 2016. Delirium was identified using the Confusion Assessment Method for the Intensive Care Unit scale. At the time of hospital discharge, functional capacity and cognition were assessed with the Barthel index and the Mini Mental State Examination, respectively. Thirty days after patient discharge, the World Health Organization Quality of Life-BREF questionnaire was administered by telephone. RESULTS: A total of 216 patients were included. Delirium was identified in 127 (58.8%) of them. Patients with delirium exhibited greater functional dependence (median Barthel index 50.0 [21.2 - 70.0] versus 80.0 [60.0 - 95.0]; p < 0.001) and lower cognition (Mini Mental State Examination score 12.9 ± 7.5 versus 20.7 ± 9.8; p < 0.001) at hospital discharge. There was no difference in any of the quality-of-life domains evaluated 1 month after hospital discharge between patients with and without delirium. CONCLUSION: Our findings suggest that patients with delirium in the intensive care unit do not have worse quality of life 1 month after hospital discharge, despite presenting greater cognitive impairment and functional disability at the time of hospital discharge.

OBJETIVO: Avaliar a associação entre a incidência de delirium na unidade de terapia intensiva e qualidade de vida 1 mês após a alta hospitalar. MÉTODOS: Trata-se de estudo de coorte prospectivo desenvolvido em unidades de terapia intensiva de dois hospitais de média complexidade durante o período de dezembro de 2015 a dezembro de 2016. Delirium foi identificado por meio da escala Confusion Assessment Method for the Intensive Care Unit. No momento da alta hospitalar, foram avaliadas capacidade funcional e cognição por meio do índice de Barthel e da escala de Mini Exame do Estado Mental, respectivamente. Após 30 dias da alta hospitalar do paciente, por meio de contato telefônico, aplicou-se o questionário World Health Organization Quality of Life-Bref. RESULTADOS: Foram incluídos 216 pacientes. Delirium foi identificado em 127 (58,8%) deles. Os pacientes com delirium apresentaram maior dependência funcional (mediana do índice de Barthel 50,0 [21,2 - 70,0] versus 80,0 [60,0 - 95,0]; p < 0,001) e menor cognição (escore do Mini Exame do Estado Mental 12,9 ± 7,5 versus 20,7 ± 9,8; p < 0,001) na alta hospitalar. Com relação à qualidade de vida, avaliada 1 mês após alta hospitalar, não houve diferença, em nenhum dos domínios, entre os pacientes com e sem delirium. CONCLUSÃO: Nossos achados sugerem que os pacientes com delirium na unidade de terapia intensiva não apresentam piora da qualidade de vida 1 mês após a alta hospitalar, apesar de apresentarem maior prejuízo cognitivo e incapacidade funcional no momento da alta hospitalar.