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1.
J Crit Care ; 30(5): 914-9, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26031813

RESUMO

PURPOSE: Soluble forms of CD5 and CD6 lymphocyte surface receptors (sCD5 and sCD6) are molecules that seem to prevent experimental sepsis when exogenously administered. The aim of this study was to assess sCD5 and sCD6 levels in patients with septic syndromes. MATERIALS AND METHODS: The study population consisted of 218 patients admitted to the medical intensive care unit (ICU) presenting either septic syndromes or noninfectious systemic inflammatory response syndrome at admission or within the first 48 hours. The sCD5 and sCD6 levels were analyzed by sandwich enzyme-linked immunosorbent assay. RESULTS: Almost 50% of the patients had undetectable levels of sCD5 or sCD6, with no differences in clinical or biological variables with detectable patients. There was a correlation between the delta Sequential Organ Failure Assessment score and both sCD6 and sCD5 levels in all groups. Patients with sCD5 or sCD6 levels greater than 1500 ng/mL presented a higher in-ICU mortality (P < .05). Logistic regression analysis showed that increased sCD6 levels were associated with an increased risk of in-ICU mortality. CONCLUSIONS: Levels of sCD5 and sCD6 in critically ill patients with systemic inflammatory response syndrome present a high variation and an elevated proportion of undetectability. Levels of sCD6 are associated with an increased risk of mortality in these patients.


Assuntos
Antígenos CD/metabolismo , Antígenos de Diferenciação de Linfócitos T/metabolismo , Antígenos CD5/metabolismo , Linfócitos/imunologia , Sepse/imunologia , Síndrome de Resposta Inflamatória Sistêmica/imunologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estado Terminal , Ensaio de Imunoadsorção Enzimática , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Prognóstico , Sepse/mortalidade , Adulto Jovem
2.
Shock ; 43(6): 556-62, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25643015

RESUMO

PURPOSE: Decreased ADAMTS-13 (A Disintegrin and Metalloprotease with a ThromboSpondin type 1 motif, member 13) seems to be associated with a poor prognosis in sepsis. However, its role in different septic syndromes and other causes of systemic inflammatory response syndrome (SIRS) remains unclear. The aims of this study were to assess ADAMTS-13 levels in patients with septic syndromes or noninfectious SIRS and to determine their association with morbidity and mortality. METHODS: The study population consisted of 178 patients admitted to the medical intensive care unit presenting either septic syndromes or noninfectious SIRS. ADAMTS-13 levels were analyzed. RESULTS: Patients with septic syndromes showed significantly lower levels of ADAMTS-13 compared with those with noninfectious SIRS (P = 0.014). Patients with severe sepsis or septic shock presented lower levels than those of patients with sepsis (P = 0.086). A significant negative correlation was found between ADAMTS-13 levels and delta Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation II scores at admission in the septic patients. Patients who died had significantly lower levels of ADAMTS-13 compared with survivors, both in the whole population and among the septic patients (P = 0.002 and P = 0.009, respectively). Logistic regression analysis showed that decreased ADAMTS-13 levels were associated with an increased risk of in-intensive care unit mortality (odds ratio, 0.985; 95% confidence interval, 0.973-0.998; P = 0.023). CONCLUSIONS: Septic patients have lower levels of ADAMTS-13 than do patients with noninfectious SIRS. Levels of ADAMTS-13 are correlated with illness severity in patients with septic syndromes. ADAMTS-13 levels were associated with an increased risk of mortality in critically ill patients with SIRS especially those with septic syndromes.


Assuntos
Proteínas ADAM/sangue , Estado Terminal , Sepse/sangue , Síndrome de Resposta Inflamatória Sistêmica/sangue , Proteína ADAMTS13 , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Adulto Jovem
5.
Crit Care ; 15(2): R105, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21443796

RESUMO

INTRODUCTION: Long-term outcomes of elderly patients after medical ICU care are little known. The aim of the study was to evaluate functional status and quality of life of elderly patients 12 months after discharge from a medical ICU. METHODS: We prospectively studied 112/230 healthy elderly patients (≥ 65 years surviving at least 12 months after ICU discharge) with full functional autonomy without cognitive impairment prior to ICU entry. The main diagnoses at admission using the Acute Physiology and Chronic Health Evaluation III (APACHE III) classification diagnosis and length of ICU stay and ICU scores (APACHE II, Sepsis-related Organ Failure Assessment (SOFA) and OMEGA) at admission and discharge were collected. Comprehensive geriatric assessment included the presence of the main geriatric syndromes and the application of Lawton, Barthel, and Charlson Indexes and Informant Questionnaire on Cognitive Decline to evaluate functionality, comorbidity and cognitive status, respectively. The EuroQol-5D assessed quality of life. Data were collected at baseline, during ICU and ward stay and 3, 6 and 12 months after hospital discharge. Paired or unpaired T-tests compared differences between groups (continuous variables), whereas the chi-square and Fisher exact tests were used for comparing dichotomous variables. For variables significant (P ≤ 0.1) on univariate analysis, a forward multiple regression analysis was performed. RESULTS: Only 48.9% of patients (mean age: 73.4 ± 5.5 years) were alive 12 months after discharge showing a significant decrease in functional autonomy (Lawton and Barthel Indexes) and quality of life (EuroQol-5D) compared to baseline status (P < 0.001, all). Multivariate analysis showed a higher Barthel Index and EQ-5D vas at hospital discharge to be associated factors of full functional recovery (P < 0.01, both). Thus, in patients with a Barthel Index ≥ 60 or EQ-5D vas ≥ 40 at discharge the hazard ratio for full functional recovery was 4.04 (95% CI: 1.58 to 10.33; P = 0.005) and 6.1 (95% CI: 1.9 to 19.9; P < 0.01), respectively. Geriatric syndromes increased after ICU stay and remained significantly increased during follow-up (P < 0.001). CONCLUSIONS: The survival rate of elderly medical patients 12 months after discharge from the ICU is low (49%), although functional status and quality of life remained similar to baseline in most of the survivors. However, there was a two-fold increase in the prevalence of geriatric syndromes.


Assuntos
Atividades Cotidianas , Cuidados Críticos , Qualidade de Vida , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Alta do Paciente , Estudos Prospectivos , Análise de Sobrevida , Fatores de Tempo
6.
Clin Vaccine Immunol ; 17(3): 447-53, 2010 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-20042521

RESUMO

Gene polymorphisms, giving rise to low serum levels of mannose-binding lectin (MBL) or MBL-associated protease 2 (MASP2), have been associated with an increased risk of infections. The objective of this study was to assess the outcome of intensive care unit (ICU) patients with systemic inflammatory response syndrome (SIRS) regarding the existence of functionally relevant MBL2 and MASP2 gene polymorphisms. The study included 243 ICU patients with SIRS admitted to our hospital, as well as 104 healthy control subjects. MBL2 and MASP2 single nucleotide polymorphisms were genotyped using a sequence-based typing technique. No differences were observed regarding the frequencies of low-MBL genotypes (O/O and XA/O) and MASP2 polymorphisms between patients with SIRS and healthy controls. Interestingly, ICU patients with a noninfectious SIRS had a lower frequency for low-MBL genotypes and a higher frequency for high-MBL genotypes (A/A and A/XA) than either ICU patients with an infectious SIRS or healthy controls. The existence of low- or /high-MBL genotypes or a MASP2 polymorphism had no impact on the mortality rates of the included patients. The presence of high-MBL-producing genotypes in patients with a noninfectious insult is a risk factor for SIRS and ICU admission.


Assuntos
Predisposição Genética para Doença , Lectina de Ligação a Manose/genética , Serina Proteases Associadas a Proteína de Ligação a Manose/genética , Síndrome de Resposta Inflamatória Sistêmica/genética , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Genótipo , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Reação em Cadeia da Polimerase , Polimorfismo de Nucleotídeo Único , Adulto Jovem
9.
Lancet ; 374(9695): 1082-8, 2009 Sep 26.
Artigo em Inglês | MEDLINE | ID: mdl-19682735

RESUMO

BACKGROUND: Non-invasive ventilation can prevent respiratory failure after extubation in individuals at increased risk of this complication, and enhanced survival in patients with hypercapnia has been recorded. We aimed to assess prospectively the effectiveness of non-invasive ventilation after extubation in patients with hypercapnia and as rescue therapy when respiratory failure develops. METHODS: We undertook a randomised controlled trial in three intensive-care units in Spain. We enrolled 106 mechanically ventilated patients with chronic respiratory disorders and hypercapnia after a successful spontaneous breathing trial. We randomly allocated participants by computer to receive after extubation either non-invasive ventilation for 24 h (n=54) or conventional oxygen treatment (n=52). The primary endpoint was avoidance of respiratory failure within 72 h after extubation. Analysis was by intention to treat. This trial is registered with clinicaltrials.gov, identifier NCT00539708. FINDINGS: Respiratory failure after extubation was less frequent in patients assigned non-invasive ventilation than in those allocated conventional oxygen therapy (8 [15%] vs 25 [48%]; odds ratio 5.32 [95% CI 2.11-13.46]; p<0.0001). In patients with respiratory failure, non-invasive ventilation as rescue therapy avoided reintubation in 17 of 27 patients. Non-invasive ventilation was independently associated with a lower risk of respiratory failure after extubation (adjusted odds ratio 0.17 [95% CI 0.06-0.44]; p<0.0001). 90-day mortality was lower in patients assigned non-invasive ventilation than in those allocated conventional oxygen (p=0.0146). INTERPRETATION: Early non-invasive ventilation after extubation diminished risk of respiratory failure and lowered 90-day mortality in patients with hypercapnia during a spontaneous breathing trial. Routine implementation of this strategy for management of mechanically ventilated patients with chronic respiratory disorders is advisable. FUNDING: IDIBAPS, CibeRes, Fondo de Investigaciones Sanitarias, European Respiratory Society.


Assuntos
Respiração com Pressão Positiva , Insuficiência Respiratória/terapia , Desmame do Respirador , Idoso , Doença Crônica , Remoção de Dispositivo , Feminino , Mortalidade Hospitalar , Humanos , Hipercapnia/complicações , Intubação Intratraqueal , Tempo de Internação , Masculino , Respiração com Pressão Positiva/efeitos adversos , Respiração Artificial/efeitos adversos , Insuficiência Respiratória/sangue , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/fisiopatologia , Resultado do Tratamento
11.
Intensive Care Med ; 35(3): 550-5, 2009 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-18982308

RESUMO

PURPOSE: The aim of this study was to assess mortality in healthy elderly patients after non-elective medical ICU admission and to identify predictive factors of mortality in these patients. METHODS: Patients >or=65 years living at home and with full-autonomy (Barthel index, BI > 60), without cognitive impairment, and non-electively admitted to a medical ICU were prospectively recruited. A full comprehensive geriatric assessment was made with validated scales. RESULTS: A total of 230 patients were included, 110 (48%) between 65 and 74 years and 120 (52%) >or=75 years. No significant differences were observed between the two groups in premorbid functional and cognitive status, main diagnosis at ICU admission, APACHE II and SOFA scores, use of mechanical ventilation or haemodialysis or length of ICU stay. Over a mean follow-up of 522 days (range 20-1,170 days) the cumulative mortality of the whole group was 55%, being significantly higher in older subjects (62 vs. 47%; P = 0.024). On multivariate analysis, only parameters related to quality of life (QOL) and functional status were independent predictors of cumulated mortality (P < 0.01, both). Thus, in patients with EQ-5D(vas) (<70) or baseline Lawton index (LI) (<5) the hazard ratio for cumulated mortality was 2.45 (95% CI: 1.15-5.25; P = 0.03) and 4.10 (95% CI: 1.53-10.99; P = 0.006), respectively, compared to those with better scores. CONCLUSIONS: Healthy elderly non-elective medical patients admitted to the ICU have a high mortality rate related to premorbid QOL. The LI and/or EQ-5D(vas) may be useful tools to identify patients with the best chance of survival.


Assuntos
Nível de Saúde , Unidades de Terapia Intensiva/estatística & dados numéricos , Mortalidade/tendências , Admissão do Paciente/estatística & dados numéricos , Idoso , Feminino , Humanos , Masculino , Qualidade de Vida/psicologia , Respiração Artificial/estatística & dados numéricos , Estados Unidos/epidemiologia
15.
J Travel Med ; 15(3): 202-5, 2008.
Artigo em Inglês | MEDLINE | ID: mdl-18494699

RESUMO

Yellow fever vaccine is a live, attenuated viral preparation from the 17D virus strain. Since 1996, 34 cases of yellow fever vaccine-associated viscerotropic disease (YEL-AVD) have been described. We report a new case of YEL-AVD. Given the potential risks associated with the vaccine, physicians should consider vaccination only for patients truly at risk for exposure to yellow fever, especially for primovaccination.


Assuntos
Insuficiência de Múltiplos Órgãos/etiologia , Vacina contra Febre Amarela/efeitos adversos , Febre Amarela/prevenção & controle , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/imunologia , Insuficiência de Múltiplos Órgãos/terapia , Síndrome do Desconforto Respiratório do Adulto/etiologia , Fatores de Risco , Espanha , Síndrome de Resposta Inflamatória Sistêmica/etiologia , Resultado do Tratamento , Vacinas Atenuadas/efeitos adversos , Febre Amarela/imunologia , Vacina contra Febre Amarela/administração & dosagem
16.
Intensive Care Med ; 33(8): 1354-62, 2007 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-17541549

RESUMO

OBJECTIVE: To evaluate the effect of the 4G/5G PAI-1 gene polymorphism on the development of organ failure and outcome in critically ill patients with septic syndromes. DESIGN AND SETTING: Prospective, observational study in a medical intensive care unit of a university hospital. PATIENTS: 224 consecutively admitted patients. INTERVENTIONS: Epidemiological data, severity scores, and the primary site of infection were recorded. DNA genotyping of the PAI-1, TNF-beta, and IL1-ra genes, and measurement of plasma PAI-1 antigen and D-dimer were carried out. MEASUREMENTS: The primary outcome variables were organ dysfunction and mortality. RESULTS: Eighty-eight subjects had septic shock at ICU entry or within 48 h from admission. Homozygotes for the 4G allele exhibited higher plasma concentrations of PAI-1 antigen and D-dimer than 4G/5G and 5G/5G subjects). ICU mortality was 44.0% in patients with 4G/4G, 23.4% in 4G/5G and 12.5% in 5G/5G, mainly due to multiorgan failure. After adjusting for SAPS II at admission the genotypes independently associated with ICU mortality in septic shock were TNF-B2/B2 (OR 2.83, 1.04-7.67) and 4G/4G of PAI-1 (OR 2.23, 1.02-4.85). The PAI-1 genotype did not determine susceptibility to infection or the outcome in nonseptic systemic inflammatory response syndrome, sepsis, severe sepsis, and nosocomial septic shock. CONCLUSIONS: Homozygosity for 4G of the PAI-1 gene confers an increase in the risk of mortality in adult patients with septic shock due to a greater organ failure.


Assuntos
Grupo com Ancestrais do Continente Europeu/genética , Inibidor 1 de Ativador de Plasminogênio/genética , Choque Séptico/mortalidade , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Masculino , Registros Médicos , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/genética , Polimorfismo Genético , Choque Séptico/genética , Espanha
17.
Alcohol Clin Exp Res ; 31(7): 1099-105, 2007 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-17488323

RESUMO

BACKGROUND: Excessive ethanol intake is one of the most frequent causes of acquired dilated cardiomyopathy in developed countries. L-type Ca(2+) channels, involved in excitation-contraction coupling, are disturbed in animal models of persistent ethanol consumption. This study was designed to evaluate the density and function of myocardial L-type Ca(2+) channel receptors in organ donors with chronic alcoholism and controls. METHODS: The protein expression of L-type Ca(2+) channels was determined with (3)H-(+)-PN 200-110-binding experiments using a specific antibody against the alpha(1)-subunit in homogenate samples of left-ventricle apex from organ donors: healthy controls (n=11), chronic alcoholic without cardiomyopathy (n=12), and alcoholics with cardiomyopathy (n=11). Morphometric measurements of cardiomyocytes were performed. RESULTS: Binding experiments proved an up-regulation of L-type Ca(2+) channels expression in alcoholic patients compared with controls (B(max) 2.61 +/- 1.10 vs 1.33 +/- 0.49 fmol/mg, respectively; p<0.001). This up-regulation was present in the group of alcoholic subjects without cardiomyopathy, and was not seen in those with cardiomyopathy (3.39 +/- 2.20 vs 1.77 +/- 0.53 fmol/mg, respectively; p=0.02). The cross-sectional area and perimeter of the cells were greater in alcoholic patients with cardiomyopathy compared with controls and alcoholic patients without cardiomyopathy (500 +/- 87 vs 307 +/- 74 and 255 +/- 25 microm(2), respectively; p<0.001 both) as was the perimeter (78.7 +/- 7.7 vs 61.5 +/- 7.2 and 56.5 +/- 2.8 microm, respectively; p<0.001 both). Binding results did not change after adjusting receptor measurements for cross-sectional area and cell perimeter. CONCLUSIONS: Chronic alcoholism causes an up-regulation of myocardial L-type Ca(2+) channel receptors, which decreases when cardiomyopathy is present.


Assuntos
Alcoolismo/metabolismo , Canais de Cálcio Tipo L/metabolismo , Regulação para Cima , Consumo de Bebidas Alcoólicas/metabolismo , Alcoolismo/epidemiologia , Cardiomiopatia Alcoólica/epidemiologia , Cardiomiopatia Alcoólica/metabolismo , Cardiomiopatia Alcoólica/patologia , Comorbidade , Etanol/farmacologia , Feminino , Transplante de Coração , Humanos , Masculino , Pessoa de Meia-Idade , Contração Miocárdica/efeitos dos fármacos , Miocárdio/metabolismo , Miocárdio/patologia , Preservação de Órgãos , Rianodina/farmacologia , Canal de Liberação de Cálcio do Receptor de Rianodina/efeitos dos fármacos , Retículo Sarcoplasmático , Doadores de Tecidos , Regulação para Cima/efeitos dos fármacos
18.
Crit Care Med ; 35(6): 1543-9, 2007 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-17452937

RESUMO

OBJECTIVE: The aspiration of subglottic secretions colonized by bacteria pooled around the tracheal tube cuff due to inadvertent deflation (<20 cm H2O) of the cuff plays a relevant role in the pathogenesis of ventilator-associated pneumonia. We assessed the efficacy of an automatic, validated device for the continuous regulation of tracheal tube cuff pressure in preventing ventilator-associated pneumonia. DESIGN: Prospective randomized controlled trial. SETTING: Respiratory intensive care unit and general medical intensive care unit. PATIENTS: One hundred and forty-two mechanically ventilated patients (age, 64 +/- 17 yrs; Acute Physiology and Chronic Health Evaluation II score, 18 +/- 6) without pneumonia or aspiration at admission. INTERVENTIONS: Within 24 hrs of intubation, patients were randomly allocated to undergo continuous regulation of the cuff pressure with the automatic device (n = 73) or routine care of the cuff pressure (control group, n = 69). Patients remained in a semirecumbent position in bed. MEASUREMENTS AND MAIN RESULTS: The primary end point variable was the incidence of ventilator-associated pneumonia. Main causes for intubation were decreased consciousness (43, 30%) and exacerbation of chronic respiratory diseases (38, 27%). Cuff pressure <20 cm H2O was more frequently observed in the control than the automatic group (45.3 vs. 0.7% determinations, p < .001). However, the rate of ventilator-associated pneumonia with clinical criteria (16, 22% vs. 20, 29%) and microbiological confirmation (11, 15% vs. 10, 15%), the distribution of early and late onset, the causative microorganisms, and intensive care unit (20, 27% vs. 16, 23%) and hospital mortality (30, 41% vs. 23, 33%) were similar for the automatic and control groups, respectively. CONCLUSIONS: Cuff pressure is better controlled with the automatic device. However, it did not result in additional benefits to the semirecumbent position in preventing ventilator-associated pneumonia.


Assuntos
Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Respiração Artificial/métodos , Traqueia , APACHE , Desenho de Equipamento , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial/instrumentação
19.
Crit Care Med ; 34(2): 329-36, 2006 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-16424711

RESUMO

OBJECTIVE: To compare a mixing vs. a cycling strategy of use of anti-Pseudomonas antibiotics on the acquisition of resistant Gram-negative bacilli in the critical care setting. DESIGN: Prospective, open, comparative study of two strategies of antibiotic use. SETTING: Two medical intensive care units of a university hospital. PATIENTS: A total of 346 patients admitted for >or=48 hrs to two separate medical intensive care units during an 8-month period. INTERVENTIONS: Patients, who according to the attending physician's judgment required an anti-Pseudomonas regimen, were assigned to receive cefepime/ceftazidime, ciprofloxacin, a carbapemen, or piperacillin-tazobactam in this order. "Cycling" was accomplished by prescribing one of these antibiotics during 1 month each. "Mixing" was accomplished by using the same order of antibiotic administration on consecutive patients. Interventions were carried out during two successive 4-month periods, starting with mixing in one unit and cycling in the other. MEASUREMENTS AND MAIN RESULTS: Swabbing of nares, pharynx, and rectum and culture of respiratory secretions were obtained thrice weekly. The main outcome variable was the proportion of patients acquiring enteric or nonfermentative Gram-negative bacilli resistant to the antibiotics under intervention. The scheduled cycling of antibiotics was only partially successful. Although the expected antibiotic was the most prevalent anti-Pseudomonas agent used within the corresponding period, it never accounted for >45% of all anti-Pseudomonas antimicrobials administered. During mixing, a significantly higher proportion of patients acquired a strain of Pseudomonas aeruginosa resistant to cefepime (9% vs. 3%, p = .01), and there was a trend toward a more frequent acquisition of resistance to ceftazidime (p = .06), imipenem (p = .06), and meropenem (p = .07). No differences in the rate of acquisition of potentially resistant Gram-negative bacilli or incidence of intensive care unit-acquired infections and infections due to particular organisms were observed. CONCLUSIONS: In critically ill medical patients, a strategy of monthly rotation of anti-Pseudomonas beta-lactams and ciprofloxacin may perform better than a strategy of mixing in the acquisition of P. aeruginosa resistant to selected beta-lactams.


Assuntos
Antibacterianos/uso terapêutico , Infecções Bacterianas/tratamento farmacológico , Infecção Hospitalar/tratamento farmacológico , Unidades de Terapia Intensiva , Infecções por Pseudomonas/tratamento farmacológico , APACHE , Antibacterianos/administração & dosagem , Infecções Bacterianas/classificação , Esquema de Medicação , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Infecções por Pseudomonas/classificação
20.
Am J Respir Crit Care Med ; 173(2): 164-70, 2006 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-16224108

RESUMO

RATIONALE: Respiratory failure after extubation and reintubation is associated with increased morbidity and mortality. OBJECTIVES: To assess the efficacy of noninvasive ventilation in averting respiratory failure after extubation in patients at increased risk. METHODS: A prospective randomized controlled trial was conducted in 162 mechanically ventilated patients who tolerated a spontaneous breathing trial after recovery from the acute episode but had increased risk for respiratory failure after extubation. Patients were randomly allocated after extubation to receive noninvasive ventilation for 24 h (n = 79), or conventional management with oxygen therapy (control group, n = 83). MEASUREMENTS AND MAIN RESULTS: The primary end-point variable was the decrease in respiratory failure after extubation. In the noninvasive ventilation group, respiratory failure after extubation was less frequent (13, 16 vs. 27, 33%; p = 0.029) and the intensive care unit mortality was lower (2, 3 versus 12, 14%; p = 0.015). However, 90-d survival did not change significantly between groups. Separate analyses of patients without and with hypercapnia (arterial CO(2) tension greater than 45 mm Hg) during the spontaneous breathing trial showed that noninvasive ventilation improved intensive care unit mortality (0 vs. 4, 18%; p = 0.035) and 90-d survival (p = 0.006) in hypercapnic patients only; of them, 98% had chronic respiratory disorders. CONCLUSIONS: The early use of noninvasive ventilation averted respiratory failure after extubation and decreased intensive care unit mortality among patients at increased risk. The beneficial effect of noninvasive ventilation in improving survival of hypercapnic patients with chronic respiratory disorders warrants a new prospective clinical trial.


Assuntos
Intubação Intratraqueal/métodos , Respiração Artificial/métodos , Insuficiência Respiratória/prevenção & controle , Idoso , Feminino , Humanos , Hipercapnia/complicações , Tempo de Internação/estatística & dados numéricos , Masculino , Estudos Prospectivos , Insuficiência Respiratória/complicações , Fatores de Risco , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento
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