Guillain-Barré Syndrome After a SARS-CoV-2 Vaccine.

The worldwide mass vaccination campaign against COVID-19 has been the largest one ever undertaken. Although the short-term safety profile of the different vaccines has been well established, neuroinflammatory complications have been described, including rare cases of acute demyelinating inflammatory polyneuropathy. We report a 63-year-old man who presented to the emergency department with proximal muscle weakness and paresthesia. He had received the first dose of the AZD1222 SARS-CoV-2 vaccine (Oxford, AstraZeneca) two weeks before presentation. The diagnosis of Guillain-Barré syndrome (GBS) was confirmed by clinical features, cerebrospinal fluid analysis, and electromyography. On the second hospital day, progression to flaccid tetraplegia, cranial nerve involvement, and respiratory failure, requiring invasive mechanical ventilation, were noted, and he was admitted to the intensive care unit. Despite the prompt diagnosis and immunosuppressive treatment initiation, the patient was left with severe disability. Although the COVID-19 vaccination was generally safe and socially beneficial, individual adverse reactions, including neuroinflammatory severe complications, may occur.

A prolonged intensive care unit stay defines a worse long-term prognosis - Insights from the critically ill mortality by age (Cimba) study.

BACKGROUND: Patients with critical illness often survive the intensive care unit (ICU) at a cost of prolonged length of stay (LOS) and slow recovery. This chronic critically ill disease may lead to long-term poor outcomes, especially in older or frail patients. OBJECTIVES: The main goal of this study was to address the characteristics and outcomes of patients with prolonged ICU LOS. Mainly, short- and long-term admissions were compared to identify risk factors for persistent critical illness and to characterise the impact on ICU, hospital, and long-term mortality. METHODS: Subanalysis of a retrospective, multicentric, observational study addressing the 2-year outcome of patients admitted to Portuguese ICUs (the Cimba study). Patients were segregated according to an ICU LOS of ≥14 days. RESULTS: Data from 37 118 patients were analysed, featuring a median ICU LOS of 4 days (percentile: 25-75 2-9), and a mortality of 16.1% in the ICU, 24.0% in the hospital, and 38.7% after 2 years. A total of 5334 patients (14.4%) had an ICU LOS of ≥14 days (corresponding to 48.9% of all ICU patients/days). Patients with prolonged LOS were more often younger (52.8% vs 46.4%, were ≤65 years of age , p < 0.001), although more severe (Simplified Acute Physiology Score II: 49.1 ± 16.9 vs 41.8 ± 19.5, p < 0.001), and had higher ICU and hospital mortality (18.3% vs 15.7%, and 31.2 vs 22.8%, respectively). Prolonged ICU LOS was linked to an increased risk of dying during the 2-year follow-up (adjusted Cox proportional hazard: 1.65, p < 0.001). CONCLUSION: Prolonged LOS is associated with a long-term impact on patient prognosis. More careful planning of care should incorporate these data.

Atrial Fibrillation in Critically Ill Patients: Incidence and Outcomes.

BACKGROUND: Atrial fibrillation (AF), either chronic or new onset, is common in critically ill patients. Its epidemiology and relationship with clinical outcomes are poorly known. OBJECTIVE: To understand the burden of AF in patients admitted to the ICU and its impact on patients' outcomes. METHODS: This is a single-center, retrospective cohort study evaluating all patients with AF admitted to a non-cardiac intensive care unit over the course of 54 months. Clinical outcomes were evaluated in the short (hospital discharge) and long term (two-year follow-up). The hazard ratio (HR) with 95% CI was computed for the whole population as well as for propensity score-matched patients, with or without AF. RESULTS: A total of 1357 patients were screened (59.1% male), with a mean age of 75 ± 15.2 years, length of intensive care unit stay of 4.7 ± 5.1 days, and hospital mortality of 26%. A diagnosis of AF was found in 215 patients (15.8%), 142 of whom had chronic AF. The hospital all-cause mortality was similar in patients with chronic or new-onset AF (31% vs. 28.8%, p = 0.779). Patients with AF had higher in-hospital, one-year, and two-year crude mortality (30.2% vs. 22.9%, p = 0.024; 47.9% vs. 35.3%, p = 0.001; 52.6% vs. 38.4%, p < 0.001). However, after propensity score matching (N = 213), this difference was no longer significant for in-hospital mortality (OR: 1.17; 95% CI: 0.77-1.79), one-year mortality (OR: 1.38; 95% CI: 0.94-2.03), or two-year mortality (OR: 1.30; 95% CI: 0.89-1.90). CONCLUSIONS: In ICU patients, the prevalence of AF, either chronic or new-onset, was 15.8%, and these patients had higher crude mortality. However, after adjustment for age and severity on admission, no significant differences were found in the short- and long-term mortality.

Critically ill patients with high predicted mortality: Incidence and outcome.

OBJECTIVE: As calculated by the severity scores, an unknown number of patients are admitted to the Intensive Care Unit (ICU) with a very high risk of death. Clinical studies have poorly addressed this population, and their prognosis is largely unknown. DESIGN: Post hoc analysis of a multicenter, cohort, longitudinal, observational, retrospective study (CIMbA). SETTING: Sixteen Portuguese multipurpose ICUs. PATIENTS: Patients with a Simplified Acute Physiology Score II (SAPS II) predicted hospital mortality above 80% on admission to the ICU (high-risk group); A comparison with the remaining patients was obtained. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Hospital, 30 days, 1 year mortality. RESULTS: We identified 4546 patients (59.9% male), 12.2% of the whole population. Their SAPS II predicted hospital mortality was 89.0±5.8%, whilst the observed mortality was lower, 61.0%. This group had higher mortality, both during the first 30 days (aHR 3.52 [95% CI 3.34-3.71]) and from day 31 to day 365 after ICU admission (aHR 1.14 [95%CI 1.04-1.26]), respectively. However, their hospital standardized mortality ratio was similar to the other patients (0.69 vs. 0.69, P=.92). At one year of follow-up, 30% of patients in the high-risk group were alive. CONCLUSIONS: Roughly 12% of patients admitted to the ICU for more than 24h had a SAPS II score predicted mortality above 80%. Their hospital standardized mortality was similar to the less severe population and 30% were alive after one year of follow-up.

From Chronic Alcohol Consumption to Coma: Report of an Uncommon Cause.

Marchiafava-Bignami disease is a rare condition characterized by demyelination of the corpus callosum that can evolve into necrosis. It is associated with thiamine deficiency, chronic alcohol consumption, and less frequently, severe malnutrition. The diagnosis is based on clinical presentation - altered mental state and changes in a neurological examination - and on neuroimaging studies, especially magnetic resonance imaging. Treatment with parenteral thiamine is recommended. The authors present a case of a 50-year-old male, with chronic alcohol abuse and malnutrition, admitted to the hospital with an acute form of the Marchiafava-Bignami disease. An early diagnosis and treatment facilitated neurological and cognitive recovery.

Critically ill patient mortality by age: long-term follow-up (CIMbA-LT).

BACKGROUND: The past years have witnessed dramatic changes in the population admitted to the intensive care unit (ICU). Older and sicker patients are now commonly treated in this setting due to the newly available sophisticated life support. However, the short- and long-term benefit of this strategy is scarcely studied. METHODS: The Critically Ill patients' mortality by age: Long-Term follow-up (CIMbA-LT) was a multicentric, nationwide, retrospective, observational study addressing short- and long-term prognosis of patients admitted to Portuguese multipurpose ICUs, during 4 years, according to their age and disease severity. Patients were followed for two years after ICU admission. The standardized hospital mortality ratio (SMR) was calculated according to the Simplified Acute Physiology Score (SAPS) II and the follow-up risk, for patients discharged alive from the hospital, according to official demographic national data for age and gender. Survival curves were plotted according to age group. RESULTS: We included 37.118 patients, including 15.8% over 80 years old. The mean SAPS II score was 42.8 ± 19.4. The ICU all-cause mortality was 16.1% and 76% of all patients survive until hospital discharge. The SAPS II score overestimated hospital mortality [SMR at hospital discharge 0.7; 95% confidence interval (CI) 0.63-0.76] but accurately predicted one-year all-cause mortality [1-year SMR 1.01; (95% CI 0.98-1.08)]. Survival curves showed a peak in mortality, during the first 30 days, followed by a much slower survival decline thereafter. Older patients had higher short- and long-term mortality and their hospital SMR was also slightly higher (0.76 vs. 0.69). Patients discharged alive from the hospital had a 1-year relative mortality risk of 6.3; [95% CI 5.8-6.7]. This increased risk was higher for younger patients [21.1; (95% CI 15.1-39.6) vs. 2.4; (95% CI 2.2-2.7) for older patients]. CONCLUSIONS: Critically ill patients' mortality peaked in the first 30 days after ICU admission. Older critically ill patients had higher all-cause mortality, including a higher hospital SMR. A long-term increased relative mortality risk was noted in patients discharged alive from the hospital, but this was more noticeable in younger patients.

Hospital-acquired pneumonia is more frequent and lethal in stroke patients: A nationwide 4-year study.

We report a higher incidence of hospital-acquired pneumonia (HAP) in patients admitted with stroke (odds ratio, 5.6; 95% CI, 5.4-5.8). Patients with HAP and stroke had an elevated risk of death (odds ratio, 1.2; 95% CI, 1.1-1.3). The incidence and mortality of HAP in stroke patients increased across all age groups.

Clinical nutrition issues in 2022: What is missing to trust supplemental parenteral nutrition (SPN) in ICU patients?

A multidisciplinary group of international physicians involved in the medical nutrition therapy (MNT) of adult critically ill patients met to discuss the value, role, and open questions regarding supplemental parenteral nutrition (SPN) along with oral or enteral nutrition (EN), particularly in the intensive care unit (ICU) setting. This manuscript summarizes the discussions and results to highlight the importance of SPN as part of a comprehensive approach to MNT in critically ill adults and for researchers to generate new evidence based on well-powered randomized controlled trials (RCTs). The experts agreed on several key points: SPN has shown clinical benefits, resulting in this strategy being included in American and European guidelines. Nevertheless, its use is heterogeneous across European countries, due to the persistence of uncertainties, such as the optimal timing and the risk of overfeeding in absence of indirect calorimetry (IC), which results in divergent opinions and barriers to SPN implementation. Education is also insufficient. The experts agreed on actions needed to increase evidence quality on SPN use in specific patients at a given time point during acute critical illness or recovery.

Prognostic value of hyperlactatemia in infected patients admitted to intensive care units: a multicenter study. / Valor prognóstico da hiperlactatemia em pacientes admitidos com infecção em unidades de terapia intensiva: estudo multicêntrico.

OBJECTIVE: To evaluate the influence of patient characteristics on hyperlactatemia in an infected population admitted to intensive care units and the influence of hyperlactatemia severity on hospital mortality. METHODS: A post hoc analysis of hyperlactatemia in the INFAUCI study, a national prospective, observational, multicenter study, was conducted in 14 Portuguese intensive care units. Infected patients admitted to intensive care units with a lactate measurement in the first 12 hours of admission were selected. Sepsis was identified according to the Sepsis-2 definition accepted at the time of data collection. The severity of hyperlactatemia was classified as mild (2 - 3.9mmol/L), moderate (4.0 - 9.9mmol/L) or severe (> 10mmol/L). RESULTS: In a total of 1,640 patients infected on admission, hyperlactatemia occurred in 934 patients (57%), classified as mild, moderate and severe in 57.0%, 34.4% and 8.7% of patients, respectively. The presence of hyperlactatemia and a higher degree of hyperlactatemia were both associated with a higher Simplified Acute Physiology Score II, a higher Charlson Comorbidity Index and the presence of septic shock. The lactate Receiver Operating Characteristic curve for hospital mortality had an area under the curve of 0.64 (95%CI 0.61 - 0.72), which increased to 0.71 (95%CI 0.68 - 0.74) when combined with Sequential Organ Failure Assessment score. In-hospital mortality with other covariates adjusted by Simplified Acute Physiology Score II was associated with moderate and severe hyperlactatemia, with odds ratio of 1.95 (95%CI 1.4 - 2.7; p < 0.001) and 4.54 (95%CI 2.4 - 8.5; p < 0.001), respectively. CONCLUSION: Blood lactate levels correlate independently with in-hospital mortality for moderate and severe degrees of hyperlactatemia.

OBJETIVO: Avaliar a influência das características dos pacientes na hiperlactatemia em uma população admitida com infecção em unidades de terapia intensiva, bem como a influência da gravidade da hiperlactatemia na mortalidade hospitalar. METÓDOS: Foi realizada uma análise post hoc da hiperlactatemia no INFAUCI, um estudo nacional prospectivo, observacional e multicêntrico, que incluiu 14 unidades de terapia intensiva portuguesas. Foram selecionados pacientes admitidos com infecção em unidades de terapia intensiva com dosagem de lactato nas primeiras 12 horas de admissão. A sepse foi identificada de acordo com a definição Sepsis-2 aceita no momento da coleta de dados. A gravidade da hiperlactatemia foi classificada como leve (2 - 3,9mmol/L), moderada (4,0 - 9,9mmol/L) ou grave (> 10mmol/L). RESULTADOS: De 1.640 pacientes admitidos com infecção, a hiperlactatemia ocorreu em 934 (57%) e foi classificada como leve, moderada e grave em 57,0%, 34,4% e 8,7% dos pacientes, respectivamente. A presença de hiperlactatemia e um maior grau de hiperlactatemia se associaram a um maior Simplified Acute Physiology Score II, a maior Índice de Comorbidade de Charlson e à presença de choque séptico. Em relação à curva Receiver Operating Characteristic do lactato para mortalidade hospitalar, foi encontrada área sob a curva de 0,64 (IC95% 0,61 - 0,72), que aumentou para 0,71 (IC95% 0,68 - 0,74) quando se combinou o Sequential Organ Failure Assessment. A mortalidade intra-hospitalar com outras covariáveis ajustadas pelo Simplified Acute Physiology Score II se associou à hiperlactatemia moderada e grave, com razão de chances de 1,95 (IC95% 1,4 - 2,7; p < 0,001) e 4,54 (IC95% 2,4 - 8,5; p < 0,001), respectivamente. CONCLUSÃO: Os níveis de lactato sanguíneo correlacionam-se independentemente com a mortalidade intra-hospitalar para graus moderados e graves de hiperlactatemia.

Valor prognóstico da hiperlactatemia em pacientes admitidos com infecção em unidades de terapia intensiva: estudo multicêntrico / Prognostic value of hyperlactatemia in infected patients admitted to intensive care units: a multicenter study

RESUMO Objetivo: Avaliar a influência das características dos pacientes na hiperlactatemia em uma população admitida com infecção em unidades de terapia intensiva, bem como a influência da gravidade da hiperlactatemia na mortalidade hospitalar. Metódos: Foi realizada uma análise post hoc da hiperlactatemia no INFAUCI, um estudo nacional prospectivo, observacional e multicêntrico, que incluiu 14 unidades de terapia intensiva portuguesas. Foram selecionados pacientes admitidos com infecção em unidades de terapia intensiva com dosagem de lactato nas primeiras 12 horas de admissão. A sepse foi identificada de acordo com a definição Sepsis-2 aceita no momento da coleta de dados. A gravidade da hiperlactatemia foi classificada como leve (2 - 3,9mmol/L), moderada (4,0 - 9,9mmol/L) ou grave (> 10mmol/L). Resultados: De 1.640 pacientes admitidos com infecção, a hiperlactatemia ocorreu em 934 (57%) e foi classificada como leve, moderada e grave em 57,0%, 34,4% e 8,7% dos pacientes, respectivamente. A presença de hiperlactatemia e um maior grau de hiperlactatemia se associaram a um maior Simplified Acute Physiology Score II, a maior Índice de Comorbidade de Charlson e à presença de choque séptico. Em relação à curva Receiver Operating Characteristic do lactato para mortalidade hospitalar, foi encontrada área sob a curva de 0,64 (IC95% 0,61 - 0,72), que aumentou para 0,71 (IC95% 0,68 - 0,74) quando se combinou o Sequential Organ Failure Assessment. A mortalidade intra-hospitalar com outras covariáveis ajustadas pelo Simplified Acute Physiology Score II se associou à hiperlactatemia moderada e grave, com razão de chances de 1,95 (IC95% 1,4 - 2,7; p < 0,001) e 4,54 (IC95% 2,4 - 8,5; p < 0,001), respectivamente. Conclusão: Os níveis de lactato sanguíneo correlacionam-se independentemente com a mortalidade intra-hospitalar para graus moderados e graves de hiperlactatemia.

ABSTRACT Objective: To evaluate the influence of patient characteristics on hyperlactatemia in an infected population admitted to intensive care units and the influence of hyperlactatemia severity on hospital mortality. Methods: A post hoc analysis of hyperlactatemia in the INFAUCI study, a national prospective, observational, multicenter study, was conducted in 14 Portuguese intensive care units. Infected patients admitted to intensive care units with a lactate measurement in the first 12 hours of admission were selected. Sepsis was identified according to the Sepsis-2 definition accepted at the time of data collection. The severity of hyperlactatemia was classified as mild (2 - 3.9mmol/L), moderate (4.0 - 9.9mmol/L) or severe (> 10mmol/L). Results: In a total of 1,640 patients infected on admission, hyperlactatemia occurred in 934 patients (57%), classified as mild, moderate and severe in 57.0%, 34.4% and 8.7% of patients, respectively. The presence of hyperlactatemia and a higher degree of hyperlactatemia were both associated with a higher Simplified Acute Physiology Score II, a higher Charlson Comorbidity Index and the presence of septic shock. The lactate Receiver Operating Characteristic curve for hospital mortality had an area under the curve of 0.64 (95%CI 0.61 - 0.72), which increased to 0.71 (95%CI 0.68 - 0.74) when combined with Sequential Organ Failure Assessment score. In-hospital mortality with other covariates adjusted by Simplified Acute Physiology Score II was associated with moderate and severe hyperlactatemia, with odds ratio of 1.95 (95%CI 1.4 - 2.7; p < 0.001) and 4.54 (95%CI 2.4 - 8.5; p < 0.001), respectively. Conclusion: Blood lactate levels correlate independently with in-hospital mortality for moderate and severe degrees of hyperlactatemia.

The PALliative MUlticenter Study in Intensive Care (PalMuSIC). Results From a Multicenter Study Addressing Frailty and Palliative Care Interventions in Intensive Care Units in Portugal.

Objective: Frailty is a clinically recognizable state of increased vulnerability common in critical medicine. When underrecognized, it may lead to invasive treatments that do not serve the patients' best interest. Our aim was to evaluate the use of both palliative care consultation and invasive interventions in frail patients admitted to Intensive Care Units in Portugal. Methods: This was a prospective, observational study. All consecutive adult patients admitted for more than 24 h, over a 15-day period were enrolled. Twenty-three Portuguese Intensive Care Units were included. Informed consent was obtained from all patients or their surrogate. The doctor and nurse in charge calculated the Clinical Frailty Score as well as the reference family member Results: A total of 335 patients were included in the study (66% male). Mean age was 63.2 ± 16.8 and SAPS II score was 41.8 ± 17.4. Mean Clinical Frailty Score value was 3.5 ± 1.7. Frailty prevalence (mean score ≥ 5) was 20.9%. Frail patients were offered organ support therapy (64,3% invasive mechanical ventilation; 24,3% renal replacement therapy; 67,1% vasopressors) more often than non-frail patients. Nevertheless, limitation of therapeutic effort or a do not resuscitate order (p < 0.001) were more common in frail patients. Mortality rate by 6 months was higher among frail patients (50% vs. 32.3%, p < 0.001). Palliative Care was offered to only 15% of frail patients (3.9% overall). Conclusions: The authors suggest that palliative care should be universally consulted once frailty is identified in critical patients.

Impact of age in critically Ill infected patients: a post-hoc analysis of the INFAUCI study.

PURPOSE: Older patients are the fastest expanding subgroup of intensive care units (ICU) and are particularly susceptible to bacterial infections and sepsis. The aim of this study was to address the epidemiology and the main determinants of outcome of infection in old and very old patients admitted to ICU. METHODS: We performed a post hoc analysis of all infected patients admitted to ICU enrolled in a 1-year prospective, observational, multipurpose study. Patients aged < 65, 65-74 and ≥ 75 years were compared. RESULTS: Of the 1652 patients included, 50% were older than 65 years. There were no significant differences between young, old and very old patients in either ICU, hospital length of stay, or nosocomial infection. All-cause mortality was significantly higher in participants aged ≥ 75. Increased Gram-negative microorganisms' isolates occurred in > 65 years (25% versus 31%; p = 0.034). Multidrug-resistant (MDR) microorganisms were directly associated to inappropriate empiric antibiotic therapy (OR 4.73; 95% CI 2.99-7.47) and inversely associated with community-acquired infection (OR 0.39; 95% CI 0.19-0.83). Age (65-74 years: OR 1.10; 95% CI 0.64-1.90 and ≥ 75 years: OR 1.52; 95% CI 0.89-2.59) and sepsis severity (sepsis: OR 0.67; 95% CI 0.18-2.46; severe sepsis: OR 1.17; 95% CI 0.40-3.44; septic shock: OR 0.77; 95% CI 0.27-2.24) were not associated to MDR bacteria. CONCLUSION: Patients > 65 years accounted for 50% of infected patients admitted to an ICU. ICU and hospital length of stay, and nosocomial infection did not increase with age. Age did predispose to increased risk for infection by Gram-negatives. These findings may optimize strategies for infection management in older patients.

Passing Through a Hole: Delayed Diaphragmatic Hernia After Cytoreductive Surgery.

A diaphragmatic hernia is a protrusion of abdominal contents into the thoracic cavity. Although it is commonly congenital, diaphragmatic hernias can also be acquired. Blunt or penetrating trauma are among the most frequent causes, although spontaneous or iatrogenic cases have been reported. Recently, some case reports related to diaphragmatic hernia after debulking surgery for advanced ovarian cancer have been described. This is an exceedingly rare but life-threatening complication, being prompt recognition and surgical correction critical. We report a case of a delayed diaphragmatic hernia in a 19-year-old female resulting from cytoreductive surgery for advanced ovarian cancer. Rapid evolution from gastrointestinal symptoms to hypovolemic shock occurred, and intensive care admission was required. Immediate surgery was critical to improving the patient outcome. This case highlights this uncommon but life-threatening complication, the challenges of diagnosing and managing those patients, and the need for early recognition, support, and surgical correction.

Evidence Associated with the Use of Oxazolidinones for the Treatment of Skin and Skin Structure Infections: A Retrospective Study.

INTRODUCTION: Skin and skin structure infections are an increasing cause of hospitalization. Although mortality is relatively low, skin and skin structure infections are associated with prolonged hospital length of stay and high costs. Oxazolidinones have been suggested as a tool to treat infected patients in the ambulatory setting in order to decrease hospital length of stay. We wanted to address the evidence associated with the use of oxazolidinones in the treatment of skin and skin structure infections. MATERIAL AND METHODS: In this observational retrospective study we analyzed the anonymized diagnosis related group coded information from the Portuguese database for hospital admissions, that included all adult patients with a diagnosis of oxazolidinone use and a SSSI, discharged between 2010 and 2015. RESULTS: During the study period, a total of 5518 patients had a diagnosis of oxazolidinone treatment. We selected 483 of those who were also diagnosed with a skin and skin structure infections. Their mean age was 64.9 years and 62.7% were male. The median hospital length of stay was 27 days (Inter quartile range 13 - 56) and the mortality rate was 12.6%. The prevalence of secondary anemia and of thrombocytopenia in the whole group treated with oxazolidinones was 2.5% and 3%, respectively. DISCUSSION: Despite the high bioavailability of oxazolidinones, we were not able to find evidence that its use was associated with a decrease of mortality or hospital length of stay (due to early discharge) of patients with skin and skin structure infections. CONCLUSION: In this study we were not able to find evidence that oxazolidinones had any clinically significant benefit. A structured approach, including antibiotics with favorable pharmacokinetic and safety profile as well as a carefully planned ambulatory follow up may be needed.

Introdução: As infeções da pele e das estruturas da pele são uma causa crescente de hospitalização. Apesar da baixa mortalidade, as infeções da pele e das estruturas da pele estão associadas a internamentos prolongados e a custos elevados. O uso de oxazolidinonas foi proposto como estratégia para o tratamento ambulatório destes doentes como forma de reduzir a duração do internamento. Pretendeu-se avaliar a evidência associada ao uso de oxazolidinonas no tratamento de infeções da pele e das estruturas da pele. Material e Métodos: Neste estudo retrospectivo observacional analisámos a base de dados portuguesa anonimizada, codificada por grupos de diagnóstico homogéneos. Incluímos adultos com alta hospitalar entre 2010 a 2015 com diagnóstico de alta de utilização de oxazolidinonas. Nesse grupo selecionamos os que apresentavam diagnóstico concomitante de infeções da pele e das estruturas da pele. Resultados: Durante o período em estudo 5518 doentes receberam o diagnóstico de tratamento com oxazolidinona. Destes selecionámos 483 com diagnóstico concomitante de infeções da pele e das estruturas da pele. Destes, 62,7% eram homens e a idade média foi de 64,9 anos. A duração mediana do internamento hospitalar foi de 27 dias (intervalo interquartil 13 ­ 56) e a taxa de mortalidade foi 12,6%. A prevalência de anemia secundária, nos 5518 doentes tratados com oxazolidinonas, foi de 2,5% e a de trombocitopénia foi de 3%. Discussão: Apesar da elevada biodisponibilidade das oxazolidinonas, neste estudo não conseguimos identificar evidência que o seu uso estivesse associado a diminuição da mortalidade ou da demora média hospitalar (relacionado com alta precoce) dos doentes com infeções da pele e das estruturas da pele. Conclusão: Neste estudo não encontramos evidência de que a utilização de oxazolidinonas esteja associada a benefícios clínicos significativos. Estratégias integradas, incluindo antibióticos com bom perfil de segurança e de farmacocinética, bem como planeamento adequado para seguimento em ambulatório parecem ser necessários.

Hidden hospital mortality in patients with sepsis discharged from the intensive care unit. / Mortalidade oculta em pacientes sépticos após alta da unidade de terapia intensiva.

OBJECTIVE: To evaluate the impact of the presence of sepsis on in-hospital mortality after intensive care unit discharge. METHODS: Retrospective, observational, single-center study. All consecutive patients discharged alive from the intensive care unit of Hospital Vila Franca de Xira (Portugal) from January 1 to December 31, 2015 (N = 473) were included and followed until death or hospital discharge. In-hospital mortality after intensive care unit discharge was calculated for septic and non-septic patients. RESULTS: A total of 61 patients (12.9%) died in the hospital after being discharged alive from the intensive care unit. This rate was higher among the patients with sepsis on admission, 21.4%, whereas the in-hospital, post-intensive care unit mortality rate for the remaining patients was nearly half that, 9.3% (p < 0.001). Other patient characteristics associated with mortality were advanced age (p = 0.02), male sex (p < 0.001), lower body mass index (p = 0.02), end-stage renal disease (p = 0.04) and high Simplified Acute Physiology Score II (SAPS II) at intensive care unit admission (p < 0.001), the presence of shock (p < 0.001) and medical admission (p < 0.001). We developed a logistic regression model and identified the independent predictors of in-hospital mortality after intensive care unit discharge. CONCLUSION: Admission to the intensive care unit with a sepsis diagnosis is associated with an increased risk of dying in the hospital, not only in the intensive care unit but also after resolution of the acute process and discharge from the intensive care unit.

OBJETIVO: Avaliar o impacto da presença de sepse na mortalidade hospitalar após alta da unidade de terapia intensiva. MÉTODOS: Ensaio retrospectivo, observacional, em centro único. Todos os pacientes que consecutivamente receberam alta vivos da unidade de terapia intensiva do Hospital Vila Franca de Xira (Portugal) entre 1º de janeiro e 31 de dezembro de 2015 (N = 473) foram incluídos e acompanhados até o óbito ou alta do hospital. A mortalidade hospitalar após alta da unidade de terapia intensiva foi calculada para pacientes sépticos e não sépticos. RESULTADOS: Um total de 61 pacientes (12,9%) faleceu no hospital após receber alta vivos da unidade de terapia intensiva. Esta taxa foi mais elevada entre os pacientes que tinham sepse quando da admissão (21,4%), enquanto a taxa de mortalidade hospitalar após alta da unidade de terapia intensiva para os demais pacientes foi aproximadamente a metade (9,3%), com p < 0,001. Outras características dos pacientes associadas com mortalidade foram idade avançada (p = 0,02), sexo masculino (p < 0,001), índice mais baixo de massa corporal (p = 0,02), nefropatia terminal (p = 0,04) e, quando da admissão à unidade de terapia intensiva, escore elevado segundo o Simplified Acute Physiology Score (SAPS II); p < 0,001, presença de choque (p < 0,001) e admissão por causas clínicas (p < 0,001). Desenvolvemos um modelo de regressão logística e identificamos os preditores independentes de mortalidade hospitalar após alta da unidade de terapia intensiva. CONCLUSÃO: A admissão à unidade de terapia intensiva com diagnóstico de sepse se associa com maior risco de morrer no hospital, não apenas na unidade de terapia intensiva quanto também após a resolução do processo agudo e alta da unidade de terapia intensiva.

Mortalidade oculta em pacientes sépticos após alta da unidade de terapia intensiva / Hidden hospital mortality in patients with sepsis discharged from the intensive care unit

RESUMO Objetivo: Avaliar o impacto da presença de sepse na mortalidade hospitalar após alta da unidade de terapia intensiva. Métodos: Ensaio retrospectivo, observacional, em centro único. Todos os pacientes que consecutivamente receberam alta vivos da unidade de terapia intensiva do Hospital Vila Franca de Xira (Portugal) entre 1º de janeiro e 31 de dezembro de 2015 (N = 473) foram incluídos e acompanhados até o óbito ou alta do hospital. A mortalidade hospitalar após alta da unidade de terapia intensiva foi calculada para pacientes sépticos e não sépticos. Resultados: Um total de 61 pacientes (12,9%) faleceu no hospital após receber alta vivos da unidade de terapia intensiva. Esta taxa foi mais elevada entre os pacientes que tinham sepse quando da admissão (21,4%), enquanto a taxa de mortalidade hospitalar após alta da unidade de terapia intensiva para os demais pacientes foi aproximadamente a metade (9,3%), com p < 0,001. Outras características dos pacientes associadas com mortalidade foram idade avançada (p = 0,02), sexo masculino (p < 0,001), índice mais baixo de massa corporal (p = 0,02), nefropatia terminal (p = 0,04) e, quando da admissão à unidade de terapia intensiva, escore elevado segundo o Simplified Acute Physiology Score (SAPS II); p < 0,001, presença de choque (p < 0,001) e admissão por causas clínicas (p < 0,001). Desenvolvemos um modelo de regressão logística e identificamos os preditores independentes de mortalidade hospitalar após alta da unidade de terapia intensiva. Conclusão: A admissão à unidade de terapia intensiva com diagnóstico de sepse se associa com maior risco de morrer no hospital, não apenas na unidade de terapia intensiva quanto também após a resolução do processo agudo e alta da unidade de terapia intensiva.

ABSTRACT Objective: To evaluate the impact of the presence of sepsis on in-hospital mortality after intensive care unit discharge. Methods: Retrospective, observational, single-center study. All consecutive patients discharged alive from the intensive care unit of Hospital Vila Franca de Xira (Portugal) from January 1 to December 31, 2015 (N = 473) were included and followed until death or hospital discharge. In-hospital mortality after intensive care unit discharge was calculated for septic and non-septic patients. Results: A total of 61 patients (12.9%) died in the hospital after being discharged alive from the intensive care unit. This rate was higher among the patients with sepsis on admission, 21.4%, whereas the in-hospital, post-intensive care unit mortality rate for the remaining patients was nearly half that, 9.3% (p < 0.001). Other patient characteristics associated with mortality were advanced age (p = 0.02), male sex (p < 0.001), lower body mass index (p = 0.02), end-stage renal disease (p = 0.04) and high Simplified Acute Physiology Score II (SAPS II) at intensive care unit admission (p < 0.001), the presence of shock (p < 0.001) and medical admission (p < 0.001). We developed a logistic regression model and identified the independent predictors of in-hospital mortality after intensive care unit discharge. Conclusion: Admission to the intensive care unit with a sepsis diagnosis is associated with an increased risk of dying in the hospital, not only in the intensive care unit but also after resolution of the acute process and discharge from the intensive care unit.

Assessment of pharmacokinetic changes of meropenem during therapy in septic critically ill patients.

BACKGROUND: Meropenem is a carbapenem antibiotic commonly used in critically ill patients to treat severe infections. The available pharmacokinetic (PK) data has been mostly obtained from healthy volunteers as well as from clinical studies addressing selected populations, often excluding the elderly and also patients with renal failure. Our aim was to study PK of meropenem in a broader population of septic critically ill patients. METHODS: We characterized the PK of meropenem in 15 critically ill patients during the first 36 hrs of therapy. Aditionally, whenever possible, we collected a second set of late plasma samples after 5 days of therapy to evaluate PK intra-patient variability and its correlation with clinical course.Patients received meropenem (1 g every 8 hrs IV). Drug plasma profiles were determined by high-performance liquid chromatography. The PK of meropenem was characterized and compared with clinical parameters. RESULTS: Fifteen septic critically ill patients (8 male, median age 73 yrs) were included. The geometric mean of the volume of distribution at the steady state (Vss)/weight was 0.20 (0.15-0.27) L/kg. No correlation of Vss/weight with severity or comorbidity scores was found. However the Sequential Organ Failure Assessment score correlated with the Vss/weight of the peripheral compartment (r2 = 0.55, p = 0.021). The median meropenem clearance (Cl) was 73.3 (45-120) mL/min correlated with the creatinine (Cr) Cl (r2 = 0.35, p = 0.033).After 5 days (N = 7) although Vss remained stable, a decrease in the proportion of the peripheral compartment (Vss2) was found, from 61.3 (42.5-88.5)% to 51.7 (36.6-73.1)%. No drug accumulation was noted. CONCLUSIONS: In this cohort of septic, unselected, critically ill patients, large meropenem PK heterogeneity was noted, although neither underdosing nor accumulation was found. However, Cr Cl correlated to meropenem Cl and the Vss2 decreased with patient's improvement.

Antibiotics and extracorporeal circulation--one size does not fit all.

Dosing of antibiotics in critically ill patients is a significant challenge. The increasing number of patients undergoing extracorporeal membrane oxygenation further complicates the issue due to inflammatory activation and to drug sequestration in the circuit. Since patients receiving extracorporeal membrane oxygenation commonly face severe infections, appropriate antibiotic selection and correct dosing is of paramount importance to improve survival. Therapeutic drug monitoring (whenever available) or population pharmacokinetics, based on readily available clinical and laboratory data, should help tailor antibiotic dosing to the individual patient.