RESUMO

BACKGROUND: To improve the diagnostic accuracy of the state of consciousness of patients with severe brain injury, Giacino et al. introduced the Coma Recovery Scale (CRS) in 1991, which underwent revision in 2004, resulting in the revised CRS scale (CRS-R). OBJECTIVE: To determine the concurrent validity, as well as inter- and intrarater agreement of the CRS-R's adaptation to Brazilian Portuguese. METHODS: This study involved a sample of 30 patients with severe brain injury. Concurrent evaluations were also performed with the Glasgow Coma Scale (GCS) and the Full Outline of UnResponsiveness (FOUR) scale. A total of seven rehabilitation experts were recruited to assess the inter- and intrarater reliability agreement. RESULTS: Interrater reliability was moderate to high for auditory, visual, motor, verbal, communication, and arousal subscales (Cohen weighted kappa = 0.765 to 0.892; p < 0.001). Significant inter and intrarater intraclass correlation coefficients were observed for the total CRS-R scores, all of which were statistically significant (p < 0.001). Also, total CRS-R scores exhibited a high correlation with the total GCS and FOUR scores, indicating acceptable concurrent validity (p < 0.001). CONCLUSION: The Brazilian Portuguese version of CRS-R can be reliably administered by trained examiners. This study demonstrated substantial to almost perfect interrater agreement for the total score and subscales, as well as high concurrent validity between the Brazilian Portuguese version of CRS-R and the other two standardized behavioral scales.

ANTECEDENTES: Para melhorar a acurácia diagnóstica do estado da consciência de pacientes com lesão cerebral severa, foi desenvolvida a Escala de Recuperação do Coma em 1991, que passou por revisão em 2004, resultando na escala revisada (CRS-R). OBJETIVO: Determinar a validade concorrente, concordância inter- e intraexaminador da adaptação da CRS-R para o português do Brasil. MéTODOS: Este estudo envolveu uma amostra de 30 pacientes com lesão cerebral grave. As avaliações concorrentes foram realizadas com a Escala de Coma de Glasgow (ECG) e a escala Full Outline of UnResponsiveness (FOUR). Um total de sete especialistas em reabilitação foram recrutados para avaliar a concordância de confiabilidade inter- e intraexaminador. RESULTADOS: A confiabilidade interexaminador foi de moderada a alta para as subescalas auditiva, visual, motora, verbal, comunicação e alerta (kappa ponderado de Cohen = 0,765 a 0,892; p < 0,001). Foram observados coeficientes de correlação intraclasse intra- e interexaminador significativos para os escores totais da CRS-R, todos estatisticamente significativos (p < 0,001). Adicionalmente, os escores totais da CRS-R apresentaram alta correlação com os escores ECG e FOUR totais, indicando validade concorrente aceitável (p < 0,001). CONCLUSãO: A versão em português do Brasil da CRS-R pode ser administrada de forma confiável por examinadores treinados. Este estudo demonstrou uma concordância de confiabilidade interexaminador substancial a quase perfeita para os escores total e de subescalas, assim como alta validade concorrente entre a versão brasileira do CRS-R e as outras duas escalas comportamentais.

RESUMO

Treating hypothyroidism can be challenging in patients with malabsorption, as they require a higher daily dose of oral levothyroxine (L-T4). Oral L-T4 absorption occurs mainly in the jejunum and the ileum and is affected by gastric acidity. As a result, absorption can be impaired by bariatric surgery. This paper presents a case of myxedema in a young man who had previously undergone biliopancreatic diversion. He was referred to the Emergency Department with deteriorated mental state, hypotension, bradycardia and hypothermia. Laboratory tests revealed severe hypothyroidism and hypokalaemia. The clinical and biochemical profile of the patient suggested myxedema coma. The tablet-based L-T4 therapy was replaced with intravenous (iv) L-T4, oral liquid L-T4 and oral liothyronine (L-T3) and inotropic agents and supportive care were also administered, resulting in a gradual improvement in clinical condition. The patient reported taking L-T4 tablets as prescribed before hospitalization. In patients with malabsorption, impaired L-T4 absorption may lead to severe forms of hypothyroidism. This case outlines the need for more frequent monitoring of serum Thyroid Stimulating Hormone in patients submitted to bariatric surgery and suggests the benefit of using liquid L-T4 in the place of tablets in cases of malabsorption.

RESUMO

BACKGROUND: The purpose of this study was to assess the prevalence of coma among patients in critical care units in Chile. We also aimed to provide insight into the demographic characteristics, etiologies, and complications associated with coma. METHODS: A single day cross-sectional study was conducted through a national survey of public and private hospitals with critical and intensive cardiac care units across Chile. Data were collected using an online questionnaire that contained questions regarding critically ill patients' information, demographic characteristics, etiology and duration of coma, medical complications, and support requirements. RESULTS: A total of 84% of all health facilities answered, accounting for a total of 2,708 patients. The overall coma prevalence was 2.9%. The median age of the comatose patients was 61 years (interquartile range 50-72) and 66.2% were male. The median coma duration was five days (interquartile range 2-9). Cerebral hemorrhage was the most common etiology, followed by severe hypoxic-ischemic encephalopathy, acute ischemic stroke, and traumatic brain injury. A total of 48.1% of coma patients experienced acute and ongoing treatment complications, with pneumonia being the most common complication, and 97.4% required support during comatose management. CONCLUSIONS: This study provides an overview of the prevalence of coma in Chilean critical and cardiac care units. Coma is a common condition. Comatose patients frequently experience medical complications during their hospitalization.

RESUMO

PURPOSE: There is a lack of clinical and epidemiological knowledge about nonconvulsive status epilepticus (NCSE) in developing countries including Mexico, which has the highest prevalence of epilepsy in the Americas. Our aim was to describe the clinical findings, EEG features, and outcomes of NCSE in a tertiary center in Mexico. METHODS: We conducted a retrospective case series study (2010-2020) including patients (≥15 years old) with NCSE according to the modified Salzburg NCSE criteria 2015 with at least 6 months of follow-up. We extracted the clinical data (age, sex, history of epilepsy, antiseizure medications, clinical manifestations, triggers, and etiology), EEG patterns of NCSE, and outcome. Descriptive statistics and multinomial logistic regression were used. RESULTS: One hundred thirty-four patients were analyzed; 74 (54.8%) women, the total mean age was 39.5 (15-85) years, and 71% had a history of epilepsy. Altered state of consciousness was found in 82% (including 27.7% in coma). A generalized NCSE pattern was the most common (32.1%). The NCSE etiology was mainly idiopathic (56%), and previous uncontrolled epilepsy was the trigger in 48% of patients. The clinical outcome was remission with clinical improvement in 54.5%. Multinomial logistic regression showed that the patient's age (P = 0.04), absence of comorbidities (P = 0.04), history of perinatal hypoxia (P = 0.04), absence of clinical manifestations (P = 0.01), and coma (P = 0.03) were negatively correlated with the outcome and only the absence of generalized slowing in the EEG (P = 0.001) had a significant positive effect on the prognosis. CONCLUSIONS: Age, history of perinatal hypoxia, coma, and focal ictal EEG pattern influence negatively the prognosis of NCSE.

RESUMO

An 82-year-old man with a history of hypertension and coronary revascularization presented with sudden-onset right hemiparesis and disorientation lasting 5 hours. On admission, he was intubated because of gasping and a Glasgow Coma Scale of 3. Hemorrhagic stroke was suspected, but ruled out by the initial head CT, which revealed old cerebellar lacunae. The following day, the comatose, now unsedated patient exhibited tetraparesis; fixed, nonreactive pupils; and corneal reflex, but no oculocephalic reflex. Rhythmic undulating tongue movements without palatal or limb involvement were first observed (Video 1). EEG revealed no epileptiform activity. Follow-up head CT showed acute ischemic lesions in the thalamocapsular region, midbrain, and pons while angiotomography revealed distal basilar artery occlusion (Figure). Involuntary tongue movements, though rare, have been associated with various conditions such as stroke, trauma, and epilepsy.1,2 These movements may result from disinhibition within the inhibitory reticular formation projecting to hypoglossal neurons, suggesting the pontine reticular formation as a central pacemaker.2.

RESUMO

Clinical-electroencephalogram (EEG), as well as etiological and prognostic data on subtypes of nonconvulsive status epilepticus (NCSE) are yet to be established. Objective: Evaluate the clinical semiology and EEG findings and prognostic data of older adults with NCSE. Methodology: Characterize the clinical-EEG and prognostic data in the subtypes of NCSE in older adults consecutively admitted to the emergency room of the Pontifícia Universidade Católica de Campinas (PUC-Campinas) University Hospital. Results: When evaluating 105 older adults with altered consciousness, it was possible to diagnose NCSE in 50 (47.6%) older adults, with a mean age of 72.8 ± 8.8 years. NCSE-coma occurred in 6 cases, with NCSE-without coma in 44 cases. The etiology was structural in 41(82%) cases, metabolic in 5 cases, and unknown etiology in 4 cases. Twelve cases had a history of epileptic seizures. On the EEG, epileptiform discharges (EDs > 2.5 Hz) were present in 34(68%) cases and rhythmic delta activity /lateralized periodic patterns occurred in 35(70%) cases. There was clinical improvement after the initial pharmacological treatment in 36 cases and, within 30 days, 18 cases died. The better prognosis was associated with a good response to initial pharmacological treatment (n = 14) and with EDs > 2.5 Hz on EEG (Fisher's exact test; 26 vs 8; P = .012). Conclusion: Focal NCSE with impaired consciousness was the most frequent subtype. The most frequent finding on the EEG was the recording of focal/regional seizures. A high number of cases showed initial clinical improvement, but mortality was high. The favorable prognosis was associated with initial clinical improvement and the presence of EDs > 2.5 Hz. There was no relationship between EEG patterns and the etiology and subtypes of NCSE in older adults.

RESUMO

Introdução: A gravidade do delirium é um marcador de mau prognóstico e essa correlação foi pouco estudada na população com COVID-19 admitida na UTI. Além disso, pouco se sabe sobre o impacto a longo prazo desta condição. Objetivo: O objetivo do nosso estudo foi investigar o impacto da gravidade do delirium nos pacientes admitidos na UTI com COVID-19 e seus desfechos. Métodos: Coorte prospectiva formada por pacientes admitidos com COVID-19 na UTI de dois hospitais terciários no Rio de Janeiro, Brasil. Estes pacientes foram avaliados diariamente durante os sete primeiros dias de internação usando a escala de Richmond Agitation Sedation Scale (RASS), Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) e Confusion Assessment Method for Intensive Care Unit-7 (CAM-ICU-7). A presença do delirium e a gravidade do delirium foram correlacionadas com os seguintes desfechos: mortalidade, mortalidade tardia, chance de evolução para ventilação mecânica, chance de evolução para coma, chance de alta da UTI e chance de alta hospitalar. Resultados: Foram incluídos 277 pacientes e 101 destes pacientes apresentaram delirium na primeira semana de UTI (36,5%) e isso se associou ao maior tempo de internação em UTI em dias [IQR13(7- 25) vs 6 (4-12), p<0,001], maior mortalidade hospitalar (25,74% vs 5,11%, p< 0,001) e maior mortalidade tardia em um ano (5,3% vs 0,6%, p< 0,001). Delirium foi classificado em gravidade através da média aritmética do CAM-ICU-7 no período da análise em: leve, moderado e grave. Quanto mais grave foi o delirium, maior foi sua mortalidade (17,86% vs 34,38% vs 38,46%, IC 95%, p-valor < 0,001). A gravidade do delirium foi associada a maior risco de progressão para coma [OR 7,1 (IC 95%, 1,9-31,0), p=0,005] e para ventilação mecânica [OR 11,09 (IC 95% 2,8-58,5), p=0,002]. Conclusão: Em pacientes admitidos com COVID-19 na UTI, delirium foi um fator de risco independente de pior prognóstico, incluindo mortalidade. A gravidade do delirium avaliada pelo CAM-ICU-7 na primeira semana de UTI foi associada com pior prognóstico, incluindo progressão para coma e para ventilação mecânica.(AU)

Introduction: Delirium severity is a marker of poor prognosis and it has been understudied in COVID-19 patients admitted in ICU. The aim of our research was to study the association between delirium severity with poor outcomes. Purpose: The purpose of this study was to investigate the impact of delirium severity in critically ill COVID-19 patients and its association with outcomes. Methods: This prospective cohort was performed in two tertiary ICUs in Rio de Janeiro, Brazil. COVID-19 patients were evaluated daily during the first 7 days of ICU stay using the Richmond Agitation Sedation Scale (RASS), Confusion Assessment Method for the ICU (CAMICU) and Confusion Method Assessment for the ICU-7 (CAM-ICU-7). Delirium severity was correlated with outcomes and one-year mortality. Results: From 277 COVID-19 patients included, delirium occurred in 101 (36.5%) patients during the first 7 days of ICU stay, and it was associated with a higher length of ICU stay (ICU LOS) in days [IQR13( 7-25) vs 6(4-12), p<0.001], higher hospital mortality (25.74% vs 5.11%, p<0.001) and additional higher one-year mortality (5.3% vs 0.6%, p<0.001). Delirium was classified by CAM-ICU-7 in severity and as higher was the score, higher was the in-hospital mortality, respectively, 17.86% vs 34.38% vs 38.46%, CI 95%, p-value < 0.001. Severe delirium was associated with more risk of progression to coma [OR 7.1 (95% CI 1.9-31.0), p=0.005] and to mechanical ventilation [OR 11.09 (95% CI 2.8-58.5), p=0.002] in the multivariate analysis, adjusted by severity and frailty. Conclusion: In patients admitted with COVID-19 in ICU, delirium was an independent risk factor for worst prognosis, including mortality. The delirium severity accessed by the CAM-ICU-7 during the first week in the ICU was associated with poor outcomes, including progression to coma and to mechanical ventilation.(AU)

RESUMO

OBJECTIVE: In our study, it was aimed to compare the power of trauma scores (Glasgow Coma Score, Revised Trauma Score, Abbreviated Injury Scale, Injury Severity Score, and Trauma Score-Injury Severity Score) in order to predict mortality in patients with geriatric trauma and to determine the predictive values of these scores in mortality. METHODS: Demographic data, clinical features, etiological causes, laboratory results, and trauma scores of the patients were statistically analyzed. SPSS 20 for Windows was used for this evaluation. RESULTS: It was determined that as the Glasgow Coma Score value of the patients increased, the Abbreviated Injury Scale and Injury Severity Score scores decreased and the Trauma Score-Injury Severity Score score increased. Abbreviated Injury Scale and Injury Severity Score values increased and Revised Trauma Score and Trauma Score-Injury Severity Score values decreased as the lactate levels of the patients increased. It was determined that the Abbreviated Injury Scale and Injury Severity Score scores of the patients hospitalized in the intensive care unit were significantly higher, while their Trauma Score-Injury Severity Score scores were lower. CONCLUSION: Glasgow Coma Score, Revised Trauma Score, Trauma Score-Injury Severity Score, Abbreviated Injury Scale, and Injury Severity Score scores and blood lactate levels are important parameters that can be used in the emergency department for the early detection of high-risk patients in geriatric trauma and the evaluation of the prognosis of geriatric trauma patients.

RESUMO

INTRODUCTION: despite being a common procedure, nasally placed small-bowel feeding tube insertion is not risk-free and can compromise patient safety. Due to the fact that nasally placed small-bowel feeding tube is commonly inserted '"blindly," with the patient head in the neutral position, sometimes the process becomes difficult and traumatic, and may present higher level of complexity in physiological or induced coma and intubated patients. Therefore, adverse events (AEs) route errors can occur during this procedure. This study aimed to determine the effectiveness of different nasally placed small-bowel feeding tube insertion techniques in coma and intubated patients, in comparison with conventional method. METHODS: A prospective, randomized and controlled clinical trial will be carried out with coma and intubated patients admitted to the Intensive Care Unit (ICU). Thirty-nine patients will be randomly divided into 3 groups: group who will have the tube inserted in a conventional manner with the head in the neutral position, group with the head positioned laterally to the right, and, finally, with the head in the neutral position, with assistance of a laryngoscope. The primary endpoint will be: first, second and total attempt success rate; and time required for the first successful attempt and the sum of all attempts. Complications during insertion included tube bending, twisting, knotting, mucosal bleeding, and insertion into the trachea. Patient vital signs will be measured.

RESUMO

OBJECTIVE: To investigate the impact of delirium severity in critically ill COVID-19 patients and its association with outcomes. METHODS: This prospective cohort study was performed in two tertiary intensive care units in Rio de Janeiro, Brazil. COVID-19 patients were evaluated daily during the first 7 days of intensive care unit stay using the Richmond Agitation Sedation Scale, Confusion Assessment Method for Intensive Care Unit (CAM-ICU) and Confusion Method Assessment for Intensive Care Unit-7 (CAM-ICU-7). Delirium severity was correlated with outcomes and one-year mortality. RESULTS: Among the 277 COVID-19 patients included, delirium occurred in 101 (36.5%) during the first 7 days of intensive care unit stay, and it was associated with a higher length of intensive care unit stay in days (IQR 13 [7 - 25] versus 6 [4 - 12]; p < 0.001), higher hospital mortality (25.74% versus 5.11%; p < 0.001) and additional higher one-year mortality (5.3% versus 0.6%, p < 0.001). Delirium was classified by CAM-ICU-7 in terms of severity, and higher scores were associated with higher in-hospital mortality (17.86% versus 34.38% versus 38.46%, 95%CI, p value < 0.001). Severe delirium was associated with a higher risk of progression to coma (OR 7.1; 95%CI 1.9 - 31.0; p = 0.005) and to mechanical ventilation (OR 11.09; 95%CI 2.8 - 58.5; p = 0.002) in the multivariate analysis, adjusted by severity and frailty. CONCLUSION: In patients admitted with COVID-19 in the intensive care unit, delirium was an independent risk factor for the worst prognosis, including mortality. The delirium severity assessed by the CAM-ICU-7 during the first week in the intensive care unit was associated with poor outcomes, including progression to coma and to mechanical ventilation.

RESUMO

INTRODUCTION: The objectives of this study were to investigate the main treatment strategies and long-term follow-up results of aortic dissection surgery after open-heart surgery (ADSOHS) and to analyze the risk factors that cause ADSOHS. METHODS: One hundred thirty-seven patients with ADSOHS hospitalized in our hospital from January 2009 to December 2018 were selected as the research object. Long-term follow-up results, complications, mortality, and changes of cardiac function before and after operation were used to explore the value of Sun's operation. RESULTS: The length of stay in intensive care unit of these 137 patients ranged from 9.5 to 623.75 hours (average of 76.41±97.29 hours), auxiliary ventilation time ranged from 6.0 to 259.83 hours (average of 46.16±55.59 hours), and hospital stay ranged from six to 85 days (average of 25.06±13.04 days). There were seven cases of postoperative low cardiac output, 18 cases of coma and stroke, and six cases of transient neurological dysfunction. A total of 33 patients died; 19 patients died during the perioperative period, 18 died during Sun's operation and one died during other operation; and 14 patients died during follow-up (January 2021), 12 cases of Sun's operation and two cases of other operations. CONCLUSION: ADSOHS treatment strategy is of high application value, and the risk of neurological complications and mortality is low. The main risk factors are postoperative low cardiac output, coma, stroke, and transient neurological dysfunction. The extracorporeal circulation time is relatively long. Short- and long-term follow-up effects are good, and it is worthy of clinical promotion.

RESUMO

This review will provide a better understanding of a set of signs known as malarial retinopathy. The discovery of this retinopathy in association with cerebral malaria is important because it best distinguishes patients with true cerebral malaria from those with coma due to other causes and incidental Plasmodium falciparum parasitemia. Identifying a comatose patient with malarial retinopathy increases the likelihood of an accurate severe or cerebral malaria diagnosis. As the World Health Organization does not specify that malarial retinopathy is one of the factors included in determining a cerebral malaria diagnosis, there are significant false-positive diagnoses of cerebral malaria. Once a cerebral malaria diagnosis is assigned, other possibilities and treatments are often excluded making an incorrect diagnosis of cerebral malaria potentially fatal. However, Plasmodium falciparum may also contribute to coma in some children with retinopathy-negative cerebral malaria, as this group is still not clinically well characterized, so all children with the WHO definition of cerebral malaria should be treated for severe malaria. Nevertheless, by raising awareness about malarial retinopathy, there could be a greater potential to accurately diagnose cerebral malaria and thus achieve more positive patient outcomes in the future. This literary review aims to raise awareness of the retinopathy by defining what it is to non-experts, explaining its pathology, clarifying the techniques needed to accurately diagnose malarial retinopathy, as well as the barriers that prevent clinicians from providing a proper diagnosis in malaria-endemic regions; and finally, discuss future directions to continue the study of malarial retinopathy.

RESUMO

BACKGROUND: In-hospital cardiac arrest is a common situation in hospital settings. Therefore, healthcare providers should understand the reasons that could affect the results of cardiopulmonary resuscitation. We aimed to determine the independent predictors for poor outcomes after the return of spontaneous circulation in in-hospital cardiac arrest patients, and also look for a relationship between patient...s background parameters and the status at intensive care unit. METHODS: We did a retrospective cohort study using cardiac arrest patients admitted to the intensive care unit after successful cardiopulmonary resuscitation between 2011...2015. PATIENTS: .. data were gathered from hospital database. Estimated probabilities of survival were computed using the Kaplan-Meier method. Cox proportional hazard models were used to determine associated risk factors for mortality. RESULTS: In total, 197 cardiac arrest patients were admitted to anesthesia intensive care unit after successful cardiopulmonary resuscitation in a 4-years period. Of 197 patients, 170 (86.3%) died in intensive care unit. Median of survival days was 4 days. Comorbidity (p.ß=.ß0.01), higher duration of cardiopulmonary resuscitation (p.ß=.ß0.02), lower Glasgow Coma Score (p.ß=.ß0.00), abnormal lactate level (p.ß=.ß0.00), and abnormal mean blood pressure (p.ß=.ß0.01) were the main predictors for increased mortality in cardiac arrest patients after intensive care unit admission. CONCLUSION: The consequent clinical status of the patients is affected by the physiological state after return of spontaneous circulation. Comorbidity, higher duration of cardiopulmonary resuscitation, lower arrival Glasgow Coma Score, abnormal lactate level, and abnormal mean blood pressure were the main predictors for increased mortality in patients admitted to the intensive care unit after successful cardiopulmonary resuscitation.

RESUMO

Objetivo: analisar o conhecimento da Escala de Coma de Glasgow em acadêmicos de enfermagem cursando o último e penúltimo semestres do Centro Universitário Planalto do Distrito Federal Campus Águas Claras.Método: Este estudo utilizou-se abordagem quantitativa com o método descritivo, utilizando para coleta de dados um questionário com seis questões objetivas.Resultado: A pesquisa realizada com uma amostra de 20 acadêmicos de enfermagem, evidenciou que 80% demonstraram saber o que é avaliado na escala, porém constatou-se que apenas 20% entendem como utilizar de forma correta a escala de coma de Glasgow.Conclusão: a maioria dos acadêmicospossui conhecimento teórico sobre a Escala de Coma de Glasgow, entretanto possuem déficit na aplicação da escala

Objective:to analyze the knowledge of the Glasgow Coma Scale in nursing students in the last and penultimate semesters of Centro Universitário Planalto do Distrito Federal Campus Águas Claras. Method:This study used a quantitative approach with the descriptive method, using a questionnaire with six objective questions for data collection. Results:The research carried out with a sample of 20 nursing students showed that 80% demonstrated that they know what is evaluated on the scale, but it was found that only 20% understand how to correctly use the Glasgow Coma Scale. Conclusion:most students have theoretical knowledge about the Glasgow Coma Scale, but they have deficits in the application of the scale.

Objetivo:Analizar el conocimiento de la Escala de Coma de Glasgow en estudiantes de enfermería que cursan el último y penúltimo semestre del Centro Universitario Planalto del Distrito Federal Campus Águas Claras. Método:Este estudio utilizó un enfoque cuantitativo con el método descriptivo, utilizando un cuestionario con seis preguntas objetivas para la recolección de datos. Resultados:La investigación realizada con una muestra de 20 estudiantes de enfermería mostró que el 80% demostró saber lo que se evalúa en la escala, pero se encontró que solo el 20% entiende cómo utilizar correctamente la Escala de Coma de Glasgow. Conclusión:la mayoría de los estudiantes tienen conocimientos teóricos sobre la Escala de Coma de Glasgow, pero tienen déficits en la aplicación de la escala.

RESUMO

Abstract Background In-hospital cardiac arrest is a common situation in hospital settings. Therefore, healthcare providers should understand the reasons that could affect the results of cardiopulmonary resuscitation. We aimed to determine the independent predictors for poor outcomes after the return of spontaneous circulation in in-hospital cardiac arrest patients, and also look for a relationship between patient's background parameters and the status at intensive care unit. Methods We did a retrospective cohort study using cardiac arrest patients admitted to the intensive care unit after successful cardiopulmonary resuscitation between 2011-2015. Patients' data were gathered from hospital database. Estimated probabilities of survival were computed using the Kaplan-Meier method. Cox proportional hazard models were used to determine associated risk factors for mortality. Results In total, 197 cardiac arrest patients were admitted to anesthesia intensive care unit after successful cardiopulmonary resuscitation in a 4-years period. Of 197 patients, 170 (86.3%) died in intensive care unit. Median of survival days was 4 days. Comorbidity (p= 0.01), higher duration of cardiopulmonary resuscitation (p= 0.02), lower Glasgow Coma Score (p= 0.00), abnormal lactate level (p= 0.00), and abnormal mean blood pressure (p= 0.01) were the main predictors for increased mortality in cardiac arrest patients after intensive care unit admission. Conclusion The consequent clinical status of the patients is affected by the physiological state after return of spontaneous circulation. Comorbidity, higher duration of cardiopulmonary resuscitation, lower arrival Glasgow Coma Score, abnormal lactate level, and abnormal mean blood pressure were the main predictors for increased mortality in patients admitted to the intensive care unit after successful cardiopulmonary resuscitation.

RESUMO

Insulin antibodies (IAs) induced by exogenous insulin rarely cause hypoglycemia. However, insulin autoantibodies (IAAs) in insulin autoimmune syndrome (IAS) can cause hypoglycemia. The typical manifestations of IAS are fasting or postprandial hypoglycemia, elevated insulin level, decreased C-peptide levels, and positive IAA. We report a 45-year-old male with type 1 diabetes mellitus (T1DM) treated with insulin analogues suffering from recurrent hypoglycemic coma and diabetic ketoacidosis (DKA). His symptoms were caused by exogenous insulin and were similar to IAS. A possible reason was that exogenous insulin induced IA. IA titers were 61.95% (normal: < 5%), and the concentrations of insulin and C-peptide were > 300 mU/L and < 0.02 nmol/L when hypoglycemia occurred. Based on his clinical symptoms and other examinations, he was diagnosed with hyperinsulinemic hypoglycemia caused by IA. His symptoms improved after changing insulin regimens from insulin lispro plus insulin detemir to recombinant human insulin (Gensulin R) and starting prednisone.

RESUMO

ABSTRACT Insulin antibodies (IAs) induced by exogenous insulin rarely cause hypoglycemia. However, insulin autoantibodies (IAAs) in insulin autoimmune syndrome (IAS) can cause hypoglycemia. The typical manifestations of IAS are fasting or postprandial hypoglycemia, elevated insulin level, decreased C-peptide levels, and positive IAA. We report a 45-year-old male with type 1 diabetes mellitus (T1DM) treated with insulin analogues suffering from recurrent hypoglycemic coma and diabetic ketoacidosis (DKA). His symptoms were caused by exogenous insulin and were similar to IAS. A possible reason was that exogenous insulin induced IA. IA titers were 61.95% (normal: 300 mU/L and < 0.02 nmol/L when hypoglycemia occurred. Based on his clinical symptoms and other examinations, he was diagnosed with hyperinsulinemic hypoglycemia caused by IA. His symptoms improved after changing insulin regimens from insulin lispro plus insulin detemir to recombinant human insulin (Gensulin R) and starting prednisone.

Los anticuerpos contra la insulina (AI) inducidos por la insulina exógena raramente causan hipoglucemia. No obstante, los autoanticuerpos contra la insulina (AIA) en el síndrome autoinmune de insulina (SAI) pueden causar hipoglucemia. Las manifestaciones típicas del SAI son la hipoglucemia en ayunas o posprandial, niveles elevados de insulina, la disminución del nivel de péptido C y AIA positivos. Presentamos un paciente hombre de 45 años con diabetes mellitus de tipo 1 (DMT1) tratado con análogos de insulina, que sufría comas hipoglucémicos recurrentes y cetoacidosis diabética (CAD). Sus síntomas fueron causados por la insulina exógena y fueron similares al SAI. La posible razón fue que la insulina exógena indujo AI. El título de AI era del 61,95% (Normal: 300 mU/L y < 0,02 nmol/L cuando se producía la hipoglucemia. Basados en sus síntomas clínicos y otros exámenes, se le diagnosticó hipoglucemia hiperinsulinémica causada por la AI. Sus síntomas mejoraron después de cambiar el régimen de insulina de lispro más insulina detemir a insulina humana recombinante (Gensulin R) y de empezar a tomar prednisona.

RESUMO

BACKGROUND: Intensive care unit-acquired atrophy and weakness are associated with high mortality, a reduction in physical function, and quality of life. Passive mobilization (PM) and neuromuscular electrical stimulation were applied in comatose patients; however, evidence is inconclusive regarding atrophy and weakness prevention. Blood flow restriction (BFR) associated with PM (BFRp) or with electrical stimulation (BFRpE) was able to reduce atrophy and increase muscle mass in spinal cord-injured patients, respectively. Bulky venous return occurs after releasing BFR, which can cause unknown repercussions on the cardiovascular system. Hence, the aim of this study was to investigate the effect of BFRp and BFRpE on cardiovascular safety and applicability, neuromuscular adaptations, physical function, and quality of life in comatose patients in intensive care units (ICUs). METHODS: Thirty-nine patients will be assessed at baseline (T0-18 h of coma) and randomly assigned to the PM (control group), BFRp, or BFRpE groups. The training protocol will be applied in both legs alternately, twice a day with a 4-h interval until coma awake, death, or ICU discharge. Cardiovascular safety and applicability will be evaluated at the first training session (T1). At T0 and 12 h after the last session (T2), muscle thickness and quality will be assessed. Global muscle strength and physical function will be assessed 12 h after T2 and ICU and hospital discharge for those who wake up from coma. Six and 12 months after hospital discharge, physical function and quality of life will be re-assessed. DISCUSSION: In view of applicability, the data will be used to inform the design and sample size of a prospective trial to clarify the effect of BFRpE on preventing muscle atrophy and weakness and to exert the greatest beneficial effects on physical function and quality of life compared to BFRp in comatose patients in the ICU. TRIAL REGISTRATION: Universal Trial Number (UTN) Registry UTN U1111-1241-4344. Retrospectively registered on 2 October 2019. Brazilian Clinical Trials Registry (ReBec) RBR-2qpyxf . Retrospectively registered on 21 January 2020, http://ensaiosclinicos.gov.br/rg/RBR-2qpyxf/.

RESUMO

To determine the role of early acquisition of blood oxygen level-dependent (BOLD) signals and diffusion tensor imaging (DTI) for analysis of the connectivity of the ascending arousal network (AAN) in predicting neurological outcomes after acute traumatic brain injury (TBI), cardiopulmonary arrest (CPA), or stroke. A prospective analysis of 50 comatose patients was performed during their ICU stay. Image processing was conducted to assess structural and functional connectivity of the AAN. Outcomes were evaluated after 3 and 6 months. Nineteen patients (38%) had stroke, 18 (36%) CPA, and 13 (26%) TBI. Twenty-three patients were comatose (44%), 11 were in a minimally conscious state (20%), and 16 had unresponsive wakefulness syndrome (32%). Univariate analysis demonstrated that measurements of diffusivity, functional connectivity, and numbers of fibers in the gray matter, white matter, whole brain, midbrain reticular formation, and pontis oralis nucleus may serve as predictive biomarkers of outcome depending on the diagnosis. Multivariate analysis demonstrated a correlation of the predicted value and the real outcome for each separate diagnosis and for all the etiologies together. Findings suggest that the above imaging biomarkers may have a predictive role for the outcome of comatose patients after acute TBI, CPA, or stroke.