Epidemiology, prognostic factors, and outcome of trauma patients admitted in a Brazilian intensive care unit.

BACKGROUND: Trauma is a major cause of hospital admissions and is associated with manifold complications and high mortality rates. However, data on intensive care unit (ICU) admissions are scarce in developing and low-income countries, where its incidence has been increasing. OBJECTIVES: To analyze epidemiological and clinical factors and outcomes in adult trauma patients admitted to the ICU of a public teaching hospital in a developing country as well as to identify risk factors for complications in the ICU. PATIENTS AND METHODS: Retrospective cohort of adult trauma patients admitted to the general ICU of a public teaching hospital in southern Brazil in the year 2012. Demographic, clinical, and outcome data from the ICU were analyzed. RESULTS: During the study period, 144 trauma patients were admitted (83% male, Acute Physiology and Chronic Health Evaluation Score II =18.6±7.2, age =33.3 years, 93% required mechanical ventilation). Of these, 60.4% suffered a traffic accident (52% motorcycle), and 31.2% were victims of violence (aggressions, gunshot wounds, or stabbing); 71% had brain trauma, 37% had chest trauma, and 21% had abdominal trauma. Patients with trauma presented a high incidence of complications, such as infections, acute renal failure, acute respiratory distress syndrome, and thrombocytopenia. The ICU mortality rate was 22.9%. CONCLUSION: In a Brazilian public teaching ICU, there was a great variability of trauma etiologies (mainly traffic accidents with motorcycles and victims of violence); patients with trauma had a high incidence of complications and mortality in the ICU.

Characteristics and Outcomes of Intensive Care Unit Survivors: Experience of a Multidisciplinary Outpatient Clinic in a Teaching Hospital

OBJECTIVES: To describe the experience of an outpatient clinic with the multidisciplinary evaluation of intensive care unit survivors and to analyze their social, psychological, and physical characteristics in a low-income population and a developing country. METHODS: Retrospective cohort study. Adult survivors from a general intensive care unit were evaluated three months after discharge in a post-intensive care unit outpatient multidisciplinary clinic over a period of 6 years (2008-2014) in a University Hospital in southern Brazil. RESULTS: A total of 688 out of 1945 intensive care unit survivors received care at the clinic. Of these, 45.2% had psychological disorders (particularly depression), 49.0% had respiratory impairments (abnormal spirometry), and 24.6% had moderate to intense dyspnea during daily life activities. Patients experienced weight loss during hospitalization (mean=11.7%) but good recovery after discharge (mean gain=9.1%), and 94.6% were receiving nutrition orally. One-third of patients showed a reduction of peripheral muscular strength, and 5.7% had moderate to severe tetraparesis or tetraplegia. There was a significant impairment in quality of life (SF-36), particularly in the physical and emotional aspects and in functional capacity. The economic impacts on the affected families, which were mostly low-income families, were considerable. Most patients did not have full access to rehabilitation services, even though half of the families were receiving financial support from the government. CONCLUSIONS: A significant number of intensive care unit survivors evaluated 3 months after discharge had psychological, respiratory, motor, and socioeconomic problems; these findings highlight that strategies aimed to assist critically ill patients should be extended to the post-hospitalization period and that this problem is particularly important in low-income populations.

Characteristics and Outcomes of Intensive Care Unit Survivors: Experience of a Multidisciplinary Outpatient Clinic in a Teaching Hospital.

OBJECTIVES: To describe the experience of an outpatient clinic with the multidisciplinary evaluation of intensive care unit survivors and to analyze their social, psychological, and physical characteristics in a low-income population and a developing country. METHODS: Retrospective cohort study. Adult survivors from a general intensive care unit were evaluated three months after discharge in a post-intensive care unit outpatient multidisciplinary clinic over a period of 6 years (2008-2014) in a University Hospital in southern Brazil. RESULTS: A total of 688 out of 1945 intensive care unit survivors received care at the clinic. Of these, 45.2% had psychological disorders (particularly depression), 49.0% had respiratory impairments (abnormal spirometry), and 24.6% had moderate to intense dyspnea during daily life activities. Patients experienced weight loss during hospitalization (mean=11.7%) but good recovery after discharge (mean gain=9.1%), and 94.6% were receiving nutrition orally. One-third of patients showed a reduction of peripheral muscular strength, and 5.7% had moderate to severe tetraparesis or tetraplegia. There was a significant impairment in quality of life (SF-36), particularly in the physical and emotional aspects and in functional capacity. The economic impacts on the affected families, which were mostly low-income families, were considerable. Most patients did not have full access to rehabilitation services, even though half of the families were receiving financial support from the government. CONCLUSIONS: A significant number of intensive care unit survivors evaluated 3 months after discharge had psychological, respiratory, motor, and socioeconomic problems; these findings highlight that strategies aimed to assist critically ill patients should be extended to the post-hospitalization period and that this problem is particularly important in low-income populations.

Sedation and memories of patients subjected to mechanical ventilation in an intensive care unit.

OBJECTIVE: To investigate the relationship between sedation and the memories reported by patients subjected to mechanical ventilation following discharge from the intensive care unit. METHODS: This prospective, observational, cohort study was conducted with individuals subjected to mechanical ventilation who remained in the intensive care unit for more than 24 hours. Clinical statistics and sedation records were extracted from the participants' clinical records; the data relative to the participants' memories were collected using a specific validated instrument. Assessment was performed three months after discharge from the intensive care unit. RESULTS: A total of 128 individuals were assessed, most of whom (84.4%) reported recollections from their stay in the intensive care unit as predominantly a combination of real and illusory events. The participants subjected to sedation (67.2%) at deep levels (Richmond Agitation-Sedation Scale [RASS] -4 and -5) for more than two days and those with psychomotor agitation (33.6%) exhibited greater susceptibility to occurrence of illusory memories (p>0.001). CONCLUSION: The probability of the occurrence of illusory memories was greater among the participants who were subjected to deep sedation. Sedation seems to be an additional factor that contributed to the occurrence of illusory memories in severely ill individuals subjected to mechanical ventilation.

Sedação e memórias de pacientes submetidos à ventilação mecânica em unidade de terapia intensiva / Sedation and memories of patients subjected to mechanical ventilation in an intensive care unit

Objetivo: Investigar a relação entre sedação e as memórias relatadas por pacientes submetidos à ventilação mecânica após a alta da unidade de terapia intensiva. Métodos: Estudo de coorte prospectivo, observacional, realizado com pacientes submetidos à ventilação mecânica e que permaneceram por mais de 24 horas na unidade de terapia intensiva. Dados clínicos e de sedação foram pesquisados em prontuários, e os dados referentes às memórias do paciente foram coletados por meio de um instrumento validado para esse fim. As avaliações foram realizadas 3 meses após a alta da unidade de terapia intensiva. Resultados: Dos 128 pacientes avaliados, a maioria (84,4%) relatou lembranças do período de internação na unidade de terapia intensiva, prevalecendo uma combinação de eventos reais e ilusórios. Pacientes que permaneceram sedados (67,2%), com sedação profunda (RASS -4 e -5) durante um período maior do que 2 dias e que apresentaram agitação psicomotora (33,6%) foram mais suscetíveis a apresentarem memórias ilusórias (p>0,001). Conclusão: A probabilidade de os pacientes apresentarem memórias de ilusão foi maior naqueles com sedação profunda. A sedação, portanto, parece ser um fator adicional que contribuiu para o desenvolvimento de memórias ilusórias em pacientes gravemente enfermos e submetidos à ventilação mecânica. .

Objective: To investigate the relationship between sedation and the memories reported by patients subjected to mechanical ventilation following discharge from the intensive care unit. Methods: This prospective, observational, cohort study was conducted with individuals subjected to mechanical ventilation who remained in the intensive care unit for more than 24 hours. Clinical statistics and sedation records were extracted from the participants' clinical records; the data relative to the participants' memories were collected using a specific validated instrument. Assessment was performed three months after discharge from the intensive care unit. Results: A total of 128 individuals were assessed, most of whom (84.4%) reported recollections from their stay in the intensive care unit as predominantly a combination of real and illusory events. The participants subjected to sedation (67.2%) at deep levels (Richmond Agitation-Sedation Scale [RASS] -4 and -5) for more than two days and those with psychomotor agitation (33.6%) exhibited greater susceptibility to occurrence of illusory memories (p>0.001). Conclusion: The probability of the occurrence of illusory memories was greater among the participants who were subjected to deep sedation. Sedation seems to be an additional factor that contributed to the occurrence of illusory memories in severely ill individuals subjected to mechanical ventilation. .

Pró-calcitonina como biomarcador inflamatório e prognóstico de mortalidade à admissão na unidade de terapia intensiva: experiência de um hospital universitário / Procalcitonin as an inflammatory and prognostic biomarker of mortality at intensive care unit admission: experience at an university hospital

Introdução: A Pró-calcitonina (PCT) é um dos principais biomarcadores inflamatórios a ser avaliado no paciente critico. Seu papel discriminatório entre etiologias bacterianas e virais, bem como no acompanhamento do tratamento anti-infeccioso é bem estabelecido. O objetivo deste estudo foi avaliar se os níveis séricos de PCT na admissão em UTI eram preditores de mortalidade em pacientes adultos. Métodos: Estudo de coorte histórica. Foram avaliados os prontuários de pacientes consecutivos admitidos na UTI Geral de adultos de um Hospital Universitário, com diferentes diagnósticos etiológicos. Foi acompanhado o desfecho de saída (mortalidade), e comparado com outros marcadores inflamatórios e de prognóstico. Resultados: Incluídos 108 pacientes. Nos pacientes com sepse na admissão, os níveis de PCT foram significativamente maiores. Em todos os grupos, houve tendência a valores maiores dos níveis de PCT entre os pacientes que evoluíram para o óbito na UTI. Valores acima de 3,0 ng/ml foram preditores de mortalidade. Conclusões: Níveis séricos elevados de PCT na admissão em UTI, além de auxílio discriminatório de infecção e sepse, podem ser preditivos de mortalidade (AU)

Introduction: Procalcitonin (PCT) is one of the main inflammatory biomarkers to be evaluated in critically ill patients. Its discriminatory role among bacterial and viral etiologies, as well as in the monitoring of anti-infective treatment, is well established. The aim of this study was to evaluate whether serum PCT levels at admission to ICU were predictors of mortality in adult patients. Methods: A historical cohort study. The medical records of consecutive patients with different etiological diagnoses admitted to the General ICU of a University Hospital were assessed. The outcome (mortality) was accompanied and compared with other inflammatory and prognostic markers. Results: The study comprised 108 patients. In patients with sepsis on admission , PCT levels were signifi cantly higher. In all groups, there was a trend to higher levels of PCT in patients who eventually died in ICU. Values above 3.0 ng/ml were predictors of mortality. Conclusions: Elevated serum PCT levels on ICU admission, besides the discriminatory aid of infection and sepsis, may be predictive of mortality (AU)

Epidemiologia, estratégias e evolução de pacientes submetidos à ventilação mecânica / Epidemiology, strategies and outcome of patients submitted to mechanical ventilation

JUSTIFICATIVA E OBJETIVOS: A epidemiologia e uso de estratégias ventilatórias variam amplamente entre pacientes submetidos à ventilação mecânica (VM). O objetivo deste estudo foi avaliar o perfil dos pacientes submetidos à VM em diferentes instituições, bem como as estratégias ventilatórias e complicações.MÉTODO: Estudo de coorte prospectivo de pacientes submetidos à VM por período maior de 24h em cinco unidades de terapia intensiva (UTI) de três cidades da região Oeste do estado do Paraná. Foram analisados dados clínico-demográficos,complicações durante o período de VM e desfechos clínicos. As estratégias ventilatórias, de desmame e tratamento clínico geral ficaram a critério de cada UTI. RESULTADOS: Foram avaliados 242 pacientes (idade mediana de 49 anos; 65,7% do sexo masculino), que ficaram em VM por um período mediano de 8 dias. A etiologia mais frequente foi trauma e clínico/cardiológico. O modo ventilatório mais utilizado foi assistido-controlado ciclado a volume. Traqueostomia foi realizada em 36,8%, no 8º dia de VM. Pneumonia associada à VM ocorreu em 35,1% dos pacientes. A mortalidade na UTI foi de 45,0%, sendo de 47,5% nos pacientes com síndrome do desconforto respiratório agudo. Houve grande variabilidade na utilização de estratégias e nos resultados entre as instituições e de acordo com a etiologia. CONCLUSÃO: As características clínicas e utilização de estratégias ventilatórias variam amplamente entre os pacientes com insuficiência respiratória e VM. O conhecimento da epidemiologia e das condutas clínicas utilizadas pode contribuir para redução de complicações e melhor evolução entre estes pacientes.

BACKGROUND AND OBJECTIVES: Epidemiology and ventilatory strategies vary widely among patients undergoin gmechanical ventilation (MV). The objective of this study was to evaluate the profile of patients submitted to MV in different institutions, as well as ventilation strategies and complications. METHOD: Prospective cohort study of patients undergoing MV for longer than 24 hours in five intensive care units (ICU) of three cities in Paraná state, southern Brazil. We analyzed clinical and demographic data, complications during mechanical ventilation and clinical outcomes. Ventilatory strategies, weaning and clinical management were kept according of each ICU. RESULTS: It was evaluated 242 patients (median age 49 years; 65.7% male) who remained on MV for a median of 8 days.The most frequent etiologies were trauma and clinical/cardiology. Most used ventilatory mode was assisted controlled cycled volume. Tracheostomy was performed in 36.8%, at 8th day of MV. Ventilator-associated pneumonia occurred in 35.1% of patients.The ICU mortality was 45.0% (being 47.5% in patients with acute respiratory distress syndrome. There was great variability in the use of strategies and outcomes between institutions as well as according to the etiology. CONCLUSION: Clinical features and use of ventilatory strategies varies widely among patients with respiratory failure and MV. Knowledge of the epidemiology and clinical procedures used may contribute to reducing complications and better outcomes among these patients.

Procalcitonin in patients with influenza A (H1N1) infection and acute respiratory failure / Pró-calcitonina em pacientes com infecção por influenza A (H1N1) e insuficiência respiratória aguda

ABSTRACT Objective: To verify serum procalcitonin levels of patients with acute respiratory failure secondary to influenza A (H1N1) upon their admission to the Intensive Care Unit and to compare these results to values found in patients with sepsis and trauma admitted to the same unit. Methods: Analysis of records of patients infected with influenza A (H1N1) and respiratory failure admitted to the General Intensive Care Unit during in a period of 60 days. The values of serum procalcitonin and clinical and laboratory data were compared to those of all patients admitted with sepsis or trauma in the previous year. Results: Among patients with influenza A (H1N1) (n = 16), the median serum procalcitonin level upon admission was 0.11 ng/mL, lower than in the sepsis group (p < 0.001) and slightly lower than in trauma patients. Although the mean values were low, serum procalcitonin was a strong predictor of hospital mortality in patients with influenza A (H1N1). Conclusion: Patients with influenza A (H1N1) with severe acute respiratory failure presented with low serum procalcitonin values upon admission, although their serum levels are predictors of hospital mortality. The kinetics study of this biomarker may be a useful tool in the management of this group of patients.

RESUMO Objetivo: Verificar os níveis de pró-calcitonina sérica em pacientes com insuficiência respiratória aguda secundária à influenza A (H1N1) admitidos à Unidade de Terapia Intensiva, e comparar esses resultados com valores encontrados em pacientes com sepse e trauma admitidos na mesma unidade. Métodos: Análise de prontuários de pacientes infectados com influenza A (H1N1) e insuficiência respiratória aguda admitidos na Unidade de Terapia Intensiva Geral em um período de 60 dias. Os valores de pró-calcitonina sérica e os dados clínicos e laboratoriais foram comparados com todos pacientes admitidos com sepse ou trauma no ano anterior. Resultados: Entre os pacientes com influenza A (H1N1) (n = 16), a mediana de pró-calcitonina sérica na admissão foi 0,11 ng/mL, menor do que o grupo de sepse (p < 0,01) e levemente menor do que os com trauma. Embora os valores médios tenham sido baixos, o nível sérico de pró-calcitonina foi um poderoso preditor de mortalidade hospitalar em pacientes com influenza A (H1N1). Conclusão: Pacientes com influenza A (H1N1) com insuficiência respiratória aguda grave tiveram baixos níveis de pró-calcitonina à admissão, embora seu nível sérico seja preditor de mortalidade hospitalar. A cinética desse biomarcador poderia ser uma ferramenta útil para o manejo desses pacientes.

Procalcitonin in patients with influenza A (H1N1) infection and acute respiratory failure.

OBJECTIVE: To verify serum procalcitonin levels of patients with acute respiratory failure secondary to influenza A (H1N1) upon their admission to the Intensive Care Unit and to compare these results to values found in patients with sepsis and trauma admitted to the same unit. METHODS: Analysis of records of patients infected with influenza A (H1N1) and respiratory failure admitted to the General Intensive Care Unit during in a period of 60 days. The values of serum procalcitonin and clinical and laboratory data were compared to those of all patients admitted with sepsis or trauma in the previous year. RESULTS: Among patients with influenza A (H1N1) (n = 16), the median serum procalcitonin level upon admission was 0.11 ng/mL, lower than in the sepsis group (p < 0.001) and slightly lower than in trauma patients. Although the mean values were low, serum procalcitonin was a strong predictor of hospital mortality in patients with influenza A (H1N1). CONCLUSION: Patients with influenza A (H1N1) with severe acute respiratory failure presented with low serum procalcitonin values upon admission, although their serum levels are predictors of hospital mortality. The kinetics study of this biomarker may be a useful tool in the management of this group of patients.

Tratamento cirúrgico de massas tumorais cardíacas: experiência inicial / Surgical treatment of cardiac tumors: initial experience

Apresenta a experiência inicial do Serviço de Cirurgia Cardíaca do Instituto de Moléstias Cardiovasculares de Cascavel, no tratamento cirúrgico de massas tumorais intracardíacas. Dentre 808 procedimentos cirúrgicos para tratamento de cardiopatias, num período de 55 meses, quatro foram retiradas cirúrgicas de tumores intracardíacos. Em todos os casos o diagnóstico, de massa tumoral, do tipo mixoma, foi efetuado através da acocardiografia transtorácica, sendo em um caso realizada a suspeita de trombo, com confirmaçäo histológica, após retirada cirúrgica. Os quatro pacientes tiveram uma evoluçäo muito boa a curto prazo, sem apresentarem morbi-mortalidade hospitalar. Na evoluçäo a médio prazo todos os pacientes encontram-se em classe funcional I da NYHA. Conclui-se que após diagnóstico ecocardiográfico de massas tumorais intracardíacas, a sua retirada deve ser imediata, porque os resultados a curto e médio prazo säo muito bons(AB)

Dupla origem do ramo descendente anterior--das coronárias esquerda e direita--associada a origem anômala à direita do ramo circunflexo / Origin of Anterior Descending Artery - from the Left and Right Coronary Arteries - Associated with Anomalous Origin of the Circunflex Artery

A 65 year-old white man, with typical angina pectoris, underwent coronary angiography that showed dual left anterior descending artery (LAD), originating from the right coronary artery (RCA), associated with anomalous origin of the left circumflex artery (LCX) also from the RCA. This an extremely rare coronary artery anomaly and, it is the first case reported, so far. This rareness and clinical significance are emphasized.