Acute kidney injury developed in the intensive care unit: a population-based prospective cohort study in the Brazilian Amazon.

The Brazilian Amazon is a vast area with limited health care resources. To assess the epidemiology of critically ill acute kidney injury (AKI) patients in this area, a prospective cohort study of 1029 adult patients of the three intensive care units (ICUs) of Rio Branco city, the capital of Acre state, were evaluated from February 2014 to February 2016. The incidence of AKI was 53.3%. Risk factors for AKI included higher age, nonsurgical patients, admission to the ICU from the ward, higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores at ICU admission, and positive fluid balance > 1500 ml/24 hours in the days before AKI development in the ICU, with aOR of 1.3 (95% CI 1.03-1.23), 1.47 (95% CI 1.07-2.03), 1.96 (95% CI 1.40-2.74), 1.05 (95% CI 1.03-1.08) for each unit increase, and 1.62 (95% CI 1.16-2.26), respectively. AKI was associated with higher ICU mortality (aOR 2.03, 95% CI 1.29-3.18). AKI mortality was independently associated with higher age, nonsurgical patients, sepsis at ICU admission, presence of shock or use of vasoactive drugs, mechanical ventilation and mean positive fluid balance in the ICU > 1500 ml/24 hours, both during ICU follow-up, with aOR 1.27 (95% CI 1.14-1.43) for each 10-year increase, 1.64 (95% CI 1.07-2.52), 2.35 (95% CI 1.14-4.83), 1.88 (95% CI 1.03-3.44), 6.73 (95% CI 4.08-11.09), 2.31 (95% CI 1.52-3.53), respectively. Adjusted hazard ratios for AKI mortality 30 and 31-180 days after ICU discharge were 3.13 (95% CI 1.84-5.31) and 1.69 (95% CI 0.99-2.90), respectively. AKI incidence was strikingly high among critically ill patients in the Brazilian Amazon. The AKI etiology, risk factors and outcomes were similar to those described in high-income countries, but mortality rates were higher.

One-year survival after admission in the intensive care unit: a retrospective cohort study.

INTRODUCTION: Improving survival is the objective of intensive care units. Various factors affect long-term outcomes. The objective was to explore survival and the associated factors 1 year after admission to the intensive care unit. METHOD: This is an observational, descriptive, and analytical study in a retrospective cohort of adults admitted to an intensive care unit at a regional hospital during the first semester of 2022. Records of 218 patients from an anonymized database were analyzed. RESULTS: The average age was 61 years, and the average APACHE II score was 15 points (24% expected mortality). Survival 1 year after admission was 57.8%. Factors associated with 1-year survival in the Cox regression model were age and APACHE II. The univariate analysis showed that the cancer was significantly associated with lethality after 1 year (OR 10.55; 95%CI 1.99-55.76). CONCLUSION: One-year survival after intensive care unit decreases by 16.1%. Factors that significantly reduced survival were old age, severity, and oncologic cause at admission.

Towards better mortality prediction in cancer patients in the ICU: a comparative analysis of prognostic scales: systematic literature review.

OBJECTIVE: To evaluate the predictive ability of mortality prediction scales in cancer patients admitted to intensive care units (ICUs). DESIGN: A systematic review of the literature was conducted using a search algorithm in October 2022. The following databases were searched: PubMed, Scopus, Virtual Health Library (BVS), and Medrxiv. The risk of bias was assessed using the QUADAS-2 scale. SETTING: ICUs admitting cancer patients. PARTICIPANTS: Studies that included adult patients with an active cancer diagnosis who were admitted to the ICU. INTERVENTIONS: Integrative study without interventions. MAIN VARIABLES OF INTEREST: Mortality prediction, standardized mortality, discrimination, and calibration. RESULTS: Seven mortality risk prediction models were analyzed in cancer patients in the ICU. Most models (APACHE II, APACHE IV, SOFA, SAPS-II, SAPS-III, and MPM II) underestimated mortality, while the ICMM overestimated it. The APACHE II had the SMR (Standardized Mortality Ratio) value closest to 1, suggesting a better prognostic ability compared to the other models. CONCLUSIONS: Predicting mortality in ICU cancer patients remains an intricate challenge due to the lack of a definitive superior model and the inherent limitations of available prediction tools. For evidence-based informed clinical decision-making, it is crucial to consider the healthcare team's familiarity with each tool and its inherent limitations. Developing novel instruments or conducting large-scale validation studies is essential to enhance prediction accuracy and optimize patient care in this population.

Prediction of adverse drug reactions in geriatric patients admitted to intensive care units. / [Artículo traducido] Predicción de reacciones adversas a medicamentos en pacientes geriátricos ingresados en unidades de cuidados intensivos.

INTRODUCTION: Intensive Care Units (ICUs) pose challenges in managing critically-ill patients with polypharmacy, potentially leading to Adverse Drug Reactions (ADRs), particularly in the elderly. OBJECTIVE: To evaluate whether the severity and clinical prognosis scores used in ICUs correlate with the prediction of ADRs in aged patients admitted to an ICU. METHODS: A cohort study was conducted in a Brazilian University Hospital ICU. APACHE II and SAPS 3 assessed clinical prognosis, while GerontoNet ADR Risk Score and BADRI evaluated ADR risk at ICU admission. Severity of the patients' clinical conditions was evaluated daily based on the SOFA score. Adverse Drug Reaction (ADR) screening was performed daily through the identification of ADR triggers. RESULTS: 1295 triggers were identified (median 30 per patient, IQR = 28), with 15 suspected ADRs. No correlation was observed between patient severity and ADRs at admission (p=0.26), during hospitalization (p=0.91), or at follow-up (p=0.77). There was also no association between death and ADRs (p=0.28) or worse prognosis and ADRs (p>0.05). Higher BADRI scores correlated with more ADRs (p=0.001). CONCLUSIONS: The data suggest that employing the severity and clinical prognosis scores used in Intensive Care Units is not sufficient to direct active pharmacovigilance efforts, which are therefore indicated for critically ill patients.

Association of dead space fraction to mortality in patients with COVID-19-related ARDS: A historical cohort observational study.

OBJECTIVE: To assess the correlation of dead space fraction (VD/VT) measured through time capnography, corrected minute volume (CMV) and ventilation ratio (VR) with clinical outcomes in COVID-19 patients requiring invasive mechanical ventilation. DESIGN: Observational study of a historical cohort. SETTING: University hospital in Medellin, Colombia. PARTICIPANTS: Patients aged 15 and above with a confirmed COVID-19 diagnosis admitted to the ICU and requiring mechanical ventilation. INTERVENTIONS: Measurement of VD/VT, CMV, and VR in COVID-19 patients. MAIN VARIABLES OF INTEREST: VD/VT, CMV, VR, demographic data, oxygenation indices and ventilatory parameters. RESULTS: During the study period, 1047 COVID-19 patients on mechanical ventilation were analyzed, of whom 446 (42%) died. Deceased patients exhibited a higher prevalence of advanced age and obesity, elevated Charlson index, higher APACHE II and SOFA scores, as well as an increase in VD/VT ratio (0.27 in survivors and 0.31 in deceased) and minute ventilation volume on the first day of mechanical ventilation. The multivariate analysis revealed independent associations to in-hospital mortality, higher VD/VT (HR 1.24; 95%CI 1.003-1.525; p = 0.046), age (HR 1.024; 95%CI 1.014-1.034; p < 0.001), and SOFA score at onset (HR: 1.036; 95%CI: 1.001-1.07; p = 0.017). CONCLUSIONS: VD/VT demonstrated an association with mortality in COVID-19 patients with ARDS on mechanical ventilation. These findings suggest that VD/VT measurement may serve as a severity marker for the disease.

Correlation Between Early Serum Myoglobin Levels and the Incidence and Prognosis of Intensive Care Unit-Acquired Weakness (ICU-AW) in Septic Shock Patients: A Comparative Study.

Intensive Care Unit-acquired weakness (ICU-AW) is a common complication that significantly impedes patient recovery. In the study, we investigated the correlation between early serum myoglobin levels in patients with septic shock due to pneumonia, and the incidence of ICU-AW, duration of mechanical ventilation, and prognosis. Patients were classified based on the development of ICU-AW within the first 10 days of ICU admission. We measured serum myoglobin levels upon ICU entry, and analyzed demographic data, APACHE II scores, use of mechanical ventilation, and clinical outcomes, including mortality and duration of mechanical ventilation. The results indicated significantly elevated serum myoglobin levels in the ICU-AW group, correlated with prolonged mechanical ventilation and increased mortality. ROC analysis revealed myoglobin as a promising biomarker for predicting ICU-AW, with an area under the curve of 0.843 (95% CI: 0.819~0.867), demonstrating a sensitivity of 76.00% and specificity of 82.30%. These findings underscored serum myoglobin as a predictive biomarker for early ICU-AW in septic shock patients, highlighting its potential to guide clinical decision-making.

Prediction of adverse drug reactions in geriatric patients admitted to intensive care units.

INTRODUCTION: Intensive care units (ICUs) pose challenges in managing critically ill patients with polypharmacy, potentially leading to adverse drug reactions (ADRs), particularly in the elderly. OBJECTIVE: To evaluate whether the severity and clinical prognosis scores used in ICUs correlate with the prediction of ADRs in aged patients admitted to an ICU. METHODS: A cohort study was conducted in a Brazilian University Hospital ICU. APACHE II and SAPS 3 assessed clinical prognosis, while GerontoNet ADR Risk Score and BADRI evaluated ADR risk at ICU admission. Severity of the patients' clinical conditions was evaluated daily based on the SOFA score. ADR screening was performed daily through the identification of ADR triggers. RESULTS: 1295 triggers were identified (median 30 per patient, IQR=28), with 15 suspected ADRs. No correlation was observed between patient severity and ADRs at admission (p=0.26), during hospitalization (p=0.91), or at follow-up (p=0.77). There was also no association between death and ADRs (p=0.28) or worse prognosis and ADRs (p>0.05). Higher BADRI scores correlated with more ADRs (p=0.001). CONCLUSIONS: These data suggest that employing the severity and clinical prognosis scores used in ICUs is not sufficient to direct active pharmacovigilance efforts, which are therefore indicated for critically ill patients.

Effectiveness of Helmet-CPAP in mild to moderate coronavirus type 2 hypoxemia: An observational study.

OBJECTIVE: To determine the relative effectiveness of Helmet-CPAP (H_CPAP) with respect to high-flow nasal cannula oxygen therapy (HFNO) in avoiding greater need for intubation or mortality in a medium complexity hospital in Chile during the year 2021. DESIGN: Cohort analytical study, single center. SETTING: Units other than intensive care units. PATIENTS: Records of adults with mild to moderate hypoxemia due to coronavirus type 2. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Need for intubation or mortality. RESULTS: 159 patients were included in the study, with a ratio by support of 2:10 (H_CPAP:HFNO). The 46.5% were women, with no significant differences by sex according to support (p = 0.99, Fisher test). The APACHE II score, for HFNO, had a median of 10.5, 3.5 units higher than H_CPAP (p < 0.01, Wilcoxon rank sum). The risk of intubation in HFNO was 42.1% and in H_CPAP 3.8%, with a significant risk reduction of 91% (95% CI: 36.9%-98.7%; p < 0.01). APACHE II does not modify or confound the support and intubation relationship (p > 0.2, binomial regression); however, it does confound the support and mortality relationship (p = 0.82, RR homogeneity test). Despite a 79.1% reduction in mortality risk with H_CPAP, this reduction was not statistically significant (p = 0.11, binomial regression). CONCLUSIONS: The use of Helmet CPAP, when compared to HFNO, was an effective therapeutic ventilatory support strategy to reduce the risk of intubation in patients with mild to moderate hypoxemia caused by coronavirus type 2 in inpatient units other than intensive care. The limitations associated with the difference in size, age and severity between the arms could generate bias.

Factors associated with extubation failure in an intensive care unit: a case-control study / Fatores associados à falha de extubação em unidade de terapia intensiva: estudo de caso-controle / Factores asociados al fracaso de la extubación en unidad de cuidados intensivos: estudio de caso y control

Abstract Objective: to investigate the factors associated with extubation failure of patients in the intensive care unit. Method: unpaired, longitudinal, retrospective and quantitative case-control with the participation of 480 patients through clinical parameters for ventilator weaning. Data were analyzed by: Fisher's exact test or the chi-square test; unpaired two-tailed Student's t test; and Mann-Whitney test. Significant P values lower than or equal to 0.05 were admitted. Results: of the patients, 415 (86.5%) were successful and 65 (13.5%) failed. Success group: the most negative fluid balance, APACHE II in 20 (14-25), weak cough in 58 (13.9%). Failure group: the most positive fluid balance, APACHE II in 23 (19-29), weak cough in 31 (47.7%), abundant amount of pulmonary secretions in 47.7%. Conclusion: positive fluid balance and the presence of inefficient cough or inability to clear the airway were predictors of extubation failure.

Resumo Objetivo: investigar os fatores associados à falha de extubação de pacientes na unidade de terapia intensiva. Método: caso-controle não pareado, longitudinal, retrospectivo e quantitativo com a participação de 480 pacientes por meio de parâmetros clínicos para desmame ventilatório. Dados analisados por: Teste Exato de Fisher ou o teste Qui-quadrado; teste t de Student bicaudal não pareado; e teste de Mann-Whitney. Admitiram-se significantes valores de P menores ou iguais a 0,05. Resultados: dos pacientes, 415 (86,5%) tiveram sucesso e 65 (13,5%) falharam. Grupo sucesso: balanço hídrico mais negativo, APACHE II em 20 (14-25), tosse fraca em 58 (13,9%). Grupo falha: balanço hídrico mais positivo, APACHE II em 23 (19-29), tosse fraca em 31 (47,7 %), quantidade abundante de secreção pulmonar em 47,7 %. Conclusão: o balanço hídrico positivo e a presença de tosse ineficiente ou incapacidade de higienizar a via aérea foram preditores de falhas de extubação.

Resumen Objetivo: investigar los factores asociados al fracaso de la extubación de pacientes en la unidad de cuidados intensivos. Método: caso y control no apareado, longitudinal, retrospectivo y cuantitativo con la participación de 480 pacientes mediante parámetros clínicos para el destete de la ventilación. Datos analizados por: Prueba Exacta de Fisher o prueba de Chi-cuadrado; prueba t de Student de dos colas para datos no apareados; y prueba de Mann-Whitney. Se admitieron valores de P significativos menores o iguales a 0,05. Resultados: de los pacientes, 415 (86,5%) tuvieron éxito y 65 (13,5%) fracasaron. Grupo de éxito: balance hídrico más negativo, APACHE II en 20 (14-25), tos débil en 58 (13,9%). Grupo de fracaso: balance de líquidos más positivo, APACHE II en 23 (19-29), tos débil en 31 (47,7%), abundante cantidad de secreciones pulmonares en 47,7%. Conclusión: el balance hídrico positivo y la presencia de tos ineficaz o incapacidad para higienizar la vía aérea fueron predictores de fracaso de la extubación.

Improved performance of an intensive care unit after changing the admission triage model.

The aim of this study is to analyze the effect of implementing a prioritization triage model for admission to an intensive care unit on the outcome of critically ill patients. Retrospective longitudinal study of adult patients admitted to the Intensive Care Unit (ICU) carried out from January 2013 to December 2017. The primary outcome considered was vital status at hospital discharge. Patients were divided into period 1 (chronological triage) during the years 2013 and 2014 and period 2 (prioritization triage) during the years 2015-2017. A total of 1227 patients in period 1 and 2056 in period 2 were analyzed. Patients admitted in period 2 were older (59.8 years) compared to period 1 (57.3 years; p < 0.001) with less chronic diseases (13.6% vs. 19.2%; p = 0.001), and higher median APACHE II score (21.0 vs. 18.0; p < 0.001)) and TISS 28 score (28.0 vs. 27.0; p < 0.001). In period 2, patients tended to stay in the ICU for a shorter time (8.5 ± 11.8 days) compared to period 1 (9.6 ± 16.0 days; p = 0.060) and had lower mortality at ICU (32.8% vs. 36.9%; p = 0.016) and hospital discharge (44.2% vs. 47.8%; p = 0.041). The change in the triage model from a chronological model to a prioritization model resulted in improvement in the performance of the ICU and reduction in the hospital mortality rate.

Asociación entre índice de masa corporal y mortalidad en pacientes críticos con choque séptico / Association between body mass index and mortality in critical ill patients with septic shock

INTRODUCCIÓN. La paradoja de la obesidad propone que, en determinadas enfermedades, los enfermos con obesidad tienen menor mortalidad. OBJETIVO. Asociar el índice de masa corporal con la mortalidad a 30 días en adultos con choque séptico. MATERIALES Y MÉTODOS. Estudio observacional, analítico, retrospectivo, multicéntrico. Se analizaron 673 pacientes con choque séptico, ingresados en terapia intensiva de dos hospitales de la ciudad de la ciudad de Quito ­ Ecuador, durante enero 2017 - diciembre 2019. Criterios de inclusión: Mayores a 18 años, choque séptico, registro de peso, talla y condición vital al día 30. Criterios de exclusión: Orden de no reanimación, embarazadas, protocolo de donación de órganos, cuidados paliativos. Las variables se recolectaron a partir de las historias clínicas digitales y físicas de los centros participantes. Las estimaciones de riesgo calculadas se presentaron como OR (Odds Ratio) en el análisis bivariado y OR Adj (OR ajustado) para el análisis multivariado. Un valor de p <0.05 se consideró estadísticamente significativo. Todos los análisis estadísticos se realizaron usando el software estadístico R® (Versión 4.1.2). RESULTADOS. La edad promedio fue de 65 años, índice de masa corporal promedio 25,9 Kg/m2 (+4,9 Kg/m2). El 54,3% tuvo índice de masa corporal > 25 Kg/m2. La mortalidad general fue 49.2%. Sujetos con sobrepeso y obesidad tuvieron menor mortalidad, OR: 0,48 (IC 95%: 0.34, 0.68; p <0.0001) y OR 0.45 (IC 95 %: 0.28, 0.70; p =0.001) respectivamente, con similar tendencia en el análisis multivariado. Los sujetos con peso bajo tuvieron la mayor mortalidad (OR: 2.12. IC 95%: 0.91 - 5.54. p: 0.097). DISCUSIÓN. Los resultados obtenidos apoyan la teoría de paradoja de obesidad, sin embargo, no se realizó evaluación según los niveles de obesidad. CONCLUSIÓN. La mortalidad en choque séptico es menor en sujetos con sobrepeso y obesidad comparada con sujetos con peso normal o bajo peso.

The obesity paradox proposes that, in certain diseases, patients with obesity have lower mortality. OBJECTIVE. To associate body mass index with 30-day mortality in adults with septic shock. MATERIALS AND METHODS. Observational, analytical, retrospective, multicenter, retrospective study. We analyzed 673 patients with septic shock, admitted to intensive care in two hospitals in the city of Quito - Ecuador, during January 2017 - December 2019. Inclusion criteria: older than 18 years, septic shock, weight, height and vital condition at day 30. Exclusion criteria: Do not resuscitate order, pregnant women, organ donation protocol, palliative care. Variables were collected from the digital and physical medical records of the participating centers. Calculated risk estimates were presented as OR (Odds Ratio) in bivariate analysis and OR Adj (adjusted OR) for multivariate analysis. A p value <0.05 was considered statistically significant. All statistical analyses were performed using R® statistical software (Version 4.1.2). RESULTS. The mean age was 65 years, mean body mass index 25.9 kg/m2 (+4.9 kg/m2). Body mass index > 25 kg/m2 was 54.3%. Overall mortality was 49.2%. Overweight and obese subjects had lower mortality, OR: 0.48 (95% CI: 0.34, 0.68; p<0.0001) and OR 0.45 (95 % CI: 0.28, 0.70; p=0.001) respectively, with similar trend in multivariate analysis. Underweight subjects had the highest mortality (OR: 2.12. 95% CI: 0.91 - 5.54. p: 0.097). DISCUSSION. The results obtained support the obesity paradox theory, however, assessment according to obesity levels was not performed. CONCLUSIONS. Mortality in septic shock is lower in overweight and obese subjects compared to normal weight or underweight subjects.

Factores asociados a mortalidad en pacientes críticos con COVID-19 en un centro universitario de Paraguay / Factors associated with mortality in critical patients with COVID-19 in an university center in Paraguay

INTRODUCCIÓN: La pandemia por COVID-19 es un problema de salud mundial. Habitualmente cursa con sintomatología leve y 5% de los afectados evoluciona a cuadros graves que requieren de cuidados intensivos. OBJETIVO: Determinar el perfil clínico, la mortalidad y factores asociados a la misma en pacientes con COVID-19 ingresados al Departamento de Cuidados Intensivos de Adultos, del Hospital de Clínicas de la Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Paraguay, entre agosto de 2020 a agosto de 2021. PACIENTES Y MÉTODO: Se realizó un estudio observacional analítico de corte transverso. Los datos se obtuvieron a partir de las historias clínicas de los pacientes. RESULTADOS: Se incluyeron 214 pacientes críticos entre 21 y 85 años de edad (mediana 54 años), 57,9% del sexo masculino, 85% provenientes del Departamento Central y Asunción. La mortalidad global fue de 38,3%. Se asociaron significativamente con la mortalidad una edad ≥ 60 años, las comorbilidades (diabetes mellitus, cardiopatía, enfermedad renal crónica), los índices de gravedad (APACHE II, SOFA, inicial), procalcitonina elevada, utilización de vasopresor, asistencia respiratoria mecánica y utilización del decúbito prono; así como la presencia de SDRA y el requerimiento de depuración extrarenal. En el análisis multivariado (por regresión logística) los factores de riesgo de mortalidad independientes fueron: la edad mayor de 60 años, la utilización de noradrenalina y depuración extra-renal durante la hospitalización. CONCLUSIÓN: Nuestra mortalidad es similar a la reportada internacionalmente. Los factores de riesgo de mortalidad identificados muestran una población con mayores posibilidades de un desenlace desfavorable.

BACKGROUND: The COVID-19 pandemic is a world health issue. Generally, it is with mild and around 5% evolves to a severe disease that requires intensive care. AIM: To determine the clinical profile, mortality and associated factors in COVID-19 patients admitted at the Adult Intensive Care Department at the Hospital de Clinicas, between August 2020 and August 2021. METHODS: Cross-section observational analytic study. Data was obtained from clinical charts. RESULTS: 214 patients were included, with an average age of 54 years, 57.9% male. Overall mortality was 38.3%. Factors associated significantly with mortality were: ≥60 years of age, comorbidity (diabetes mellitus, heart disease, chronic renal disease), severity index (APACHE II, initial SOFA), high procalcitonin, use of vasopressor, mechanical respiratory assistance and prone decubitus; as well as the presence of acute respiratory distress syndrome and hemodialysis. Multi varied analysis identified as mortality risk factors: ≥60 years of age, noradrenaline use and hemodialysis. CONCLUSION: Mortality rate is similar to that reported worldwide. Mortality risk factors identified show a population with higher possibilities for unfavorable outcome.

[Correlation between the shock index and the anaerobic index]. / Correlación entre el índice de choque y el índice anaerobio.

Background: Shock is defined as an acute circulatory insufficiency that causes cellular dysfunction. The shock index (SI) and the anaerobic index or the relationship between the veno-arterial gradient of carbon dioxide and the difference between the arterial and venous content of O2 [∆P(v-a)CO2/ΔC(a-v)O2] are markers of systemic hypoperfusion. Objective: To determine if there is a correlation between the SI and the anaerobic index in patients with circulatory shock. Material and methods: Observational and prospective study in patients with circulatory shock. The SI and the anaerobic index were calculated at admission to the intensive care unit (ICU) and during their stay. Pearson's correlation coefficient was calculated and the association of SI with mortality was explored with bivariate logistic regression. Results: 59 patients aged 55.5 (± 16.5) years, 54.3% men, were analyzed. The most frequent type of shock was hypovolemic (40.7%). They had SOFA score: 8.4 (± 3.2) and APACHE II: 18.5 (± 6). The SI was: 0.93 (± 0.32) and the anaerobic index: 2.3 (± 1.3). Global correlation was r = 0.15; at admission r = 0.29; after 6 hours: r = 0.19; after 24 hours: r = 0.18; after 48 hours: r = 0.44, and after 72 hours: r = 0.66. The SI > 1 at ICU admission had an OR 3.8 (95% CI: 1.31-11.02), p = 0.01. Conclusions: The SI and the anaerobic index have a weak positive correlation during the first 48 hours of circulatory shock. The SI > 1 is a possible risk factor for death in patients with circulatory shock.

Introducción: el choque se define como una insuficiencia circulatoria aguda que ocasiona disfunción celular. El índice de choque (ICh) y el índice anaerobio o relación entre el gradiente veno-arterial de dióxido de carbono y la diferencia entre el contenido arterial y venoso de O2 [∆P(v-a)CO2/ΔC(a-v)O2] son marcadores de hipoperfusión sistémica. Objetivo: determinar si existe correlación entre el ICh y el índice anaerobio en pacientes con choque circulatorio. Material y métodos: estudio observacional y prospectivo en pacientes con choque circulatorio. Se calcularon el ICh y el índice anaerobio al ingreso a la unidad de cuidados intensivos (UCI) y durante su estancia. Se calculó el coeficiente de correlación de Pearson y se exploró la asociación del ICh con la mortalidad con una regresión logística bivariada. Resultados: se analizaron 59 pacientes de 55.5 (± 16.5) años, 54.3% hombres. El tipo de choque más frecuente fue el hipovolémico (40.7%). Tuvieron puntaje SOFA: 8.4 (± 3.2) y APACHE II: 18.5 (± 6). El ICh fue: 0.93 (± 0.32) y el índice anaerobio: 2.3 (± 1.3). La correlación global fue r = 0.15; al ingreso: r = 0.29; a las 6 horas: r = 0.19; a las 24 horas: r = 0.18; a las 48 horas: r = 0.44, y a las 72 horas: r = 0.66. El ICh > 1 al ingreso a la UCI tuvo una RM 3.8 (IC 95%: 1.31-11.02), p = 0.01. Conclusiones: el ICh y el índice anaerobio tienen una correlación positiva débil durante las primeras 48 horas del choque circulatorio. El ICh > 1 es un posible factor de riesgo de muerte en pacientes con choque circulatorio.

Predictors of short-term mortality in HIV-infected patients admitted to intensive care unit / Fatores preditores de mortalidade de curto prazo em pacientes infectados com HIV admitidos em unidade de terapia intensiva

INTRODUCTIONn: Historically, complications of HIV infection have been related to admissions to the Intensive Care Unit (ICU). Despite therapeutic advances, the results of the analysis of prognostic factors in patients with HIV/AIDS have varied, including late diagnosis and failure to adhere to antiretroviral treatment. OBJECTIVE: To evaluate the predictors of short-term mortality in HIV-infected patients admitted to the ICU, as well as their sociodemographic and clinical characteristics. METHODS: A retrospective cohort study including patients admitted to the ICU of a teaching hospital from 2003 through 2012. Data were collected from medical records after the Institutional Review Board approval. RESULTS: 148 HIV-infected patients were identified and 131 were eligible. Among included patients, 42.75% were HIV new diagnoses and 5.34% had no information about the time of diagnosis. The main reasons for admission to the ICU were respiratory failure and sepsis while mortality was 70.23% between 2003 and 2012. Among the risk factors for mortality were low albumin, high APACHE, low CD4+ T lymphocyte count, and not using antiretroviral therapy. CONCLUSION: Despite the availability of diagnosis and treatment for HIV-infected individuals, the number of new cases of advanced Aids diagnosed in high-complexity services such as ICU is high, as well as the non-use of combination antiretroviral therapy. It is necessary to strengthen anti-HIV screening to detect and treat more cases in the early stages.

INTRODUÇÃO: Historicamente, as complicações da infecção pelo HIV estavam relacionadas às internações em Unidade de Terapia Intensiva (UTI). Apesar dos avanços terapêuticos, os fatores prognósticos em pacientes com HIV/AIDS têm variado, incluindo diagnóstico tardio e não adesão ao tratamento antirretroviral. OBJETIVO: Avaliar os fatores preditores de mortalidade a curto prazo em pacientes infectados pelo HIV internados em UTI, bem como suas características sociodemográficas e clínicas. MÉTODOS: Estudo de coorte retrospectivo incluindo pacientes internados na UTI de um hospital universitário entre 2003 a 2012. Os dados foram coletados dos prontuários médicos após a aprovação pelo Comitê de Ética em Pesquisa com Seres Humanos. RESULTADOS: 148 pacientes infectados pelo HIV foram identificados e 131 eram elegíveis. Entre os pacientes incluídos, 42,75% possuíam diagnósticos recente de HIV e 5,34% não possuíam informação sobre o momento do diagnóstico. Os principais motivos de admissão na UTI foram insuficiência respiratória e sepse, enquanto a mortalidade foi 70,23% entre 2003 e 2012. Entre os fatores de risco para mortalidade identificou-se albumina baixa, APACHE alto, baixa contagem de linfócitos T CD4+ e não uso de terapia antirretroviral. CONCLUSÃO: Apesar da disponibilidade de diagnóstico e tratamento para indivíduos infectados pelo HIV, é elevado o número de casos novos em estágio avançado de Aids diagnosticados em serviços de alta complexidade, como UTI, e o não uso de terapia antirretroviral combinada. É necessário fortalecer a triagem anti-HIV, bem como aumentar a repetição da testagem anti-HIV para detectar e tratar mais casos em estágios iniciais.

Typical phenotypes of patients with acute respiratory failure with and without COVID-19 and their relationship with outcomes: a cohort study.

OBJECTIVE: To compare, within a cohort of patients with acute respiratory failure, the phenotypes of patients with and without COVID-19 in the context of the pandemic and evaluate whether COVID-19 is an independent predictor of intensive care unit mortality. METHODS: This historical cohort study evaluated 1001 acute respiratory failure patients with suspected COVID-19 admitted to the intensive care unit of 8 hospitals. Patients were classified as COVID-19 cases and non-COVID-19 cases according to real-time polymerase chain reaction results. Data on clinical and demographic characteristics were collected on intensive care unit admission, as well as daily clinical and laboratory data and intensive care unit outcomes. RESULTS: Although the groups did not differ in terms of APACHE II or SOFA scores at admission, the COVID-19 group had more initial symptoms of fever, myalgia and diarrhea, had a longer duration of symptoms, and had a higher prevalence of obesity. They also had a lower PaO2/FiO2 ratio, lower platelet levels than non-COVID-19 patients, and more metabolic changes, such as higher levels of blood glucose, C-reactive protein, and lactic dehydrogenase. Patients with non-COVID-19 acute respiratory failure had a higher prevalence of chronic obstructive pulmonary disease/asthma and cardiopathy. Patients with COVID-19 stayed in the hospital longer and had more complications, such as acute kidney failure, severe acute respiratory distress syndrome and severe infection. The all-cause mortality rate was also higher in this group (43.7% in the COVID-19 group versus 27.4% in the non-COVID-19 group). The diagnosis of COVID-19 was a predictor of intensive care unit mortality (odds ratio, 2.77; 95%CI, 1.89 - 4.07; p < 0.001), regardless of age or Charlson Comorbidity Index score. CONCLUSION: In a prospective cohort of patients admitted with acute respiratory failure, patients with COVID-19 had a clearly different phenotype and a higher mortality than non-COVID-19 patients. This may help to outline more accurate screening and appropriate and timely treatment for these patients.

Procalcitonin and High APACHE (Acute Physiological and Chronic Health Evaluation) Level Are Associated with the Course of Acute Kidney Injury in Patients with SARS-CoV-2.

Background: Acute kidney injury (AKI) is associated with poor outcomes in patients infected with SARS-CoV-2. Sepsis, direct injury to kidney cells by the virus, and severe systemic inflammation are mechanisms implicated in its development. We investigated the association between inflammatory markers (C-reactive protein, procalcitonin, D-dimer, lactate dehydrogenase, and ferritin) in patients infected with SARS-CoV-2 and the development of AKI. Methods: A prospective cohort study performed at the Civil Hospital (Dr. Juan I. Menchaca) Guadalajara, Mexico, included patients aged >18 years with a diagnosis of SARS-CoV-2 pneumonia confirmed by RT-PCR and who did or did not present with AKI (KDIGO) while hospitalized. Biomarkers of inflammation were recorded, and kidney function was estimated using the CKD-EPI formula. Results: 291 patients were included (68% males; average age, 57 years). The incidence of AKI was 40.5% (118 patients); 21% developed stage 1 AKI, 6% developed stage 2 AKI, and 14% developed stage 3 AKI. The development of AKI was associated with higher phosphate (p = 0.002) (RR 1.39, CI 95% 1.13-1.72), high procalcitonin levels at hospital admission (p = 0.005) (RR 2.09, CI 95% 1.26-3.50), and high APACHE scores (p = 0.011) (RR 2.0, CI 95% 1.17-3.40). The survival analysis free of AKI according to procalcitonin levels and APACHE scores demonstrated a lower survival in patients with procalcitonin >0.5 ng/ml (p = 0.001) and APACHE >15 points (p = 0.004). Conclusions: Phosphate, high procalcitonin levels, and APACHE levels >15 were predictors of AKI development in patients hospitalized with COVID-19.

Nursing Team Workload and the Apache Index of Gravity of Patients Post Liver Transplantation: A Cohort Study.

BACKGROUND: Liver transplantation is a complex treatment that demands a high workload from the nursing team. This study evaluated the nursing workload and its relationship with the severity of patients after liver transplantation. MATERIAL AND METHODS: A retrospective cohort study, with a review of 286 medical records of liver transplant patients from January 2014 to June 2018 in a hospital in southern Brazil was performed. Demographic and clinical characteristics were analyzed, as well as the outcome and the scores Model for End-Stage Liver Disease (MELD), Nursing Activity Score (NAS), and Acute Physiology and Chronic Health Evaluation IV (APACHE IV). RESULTS: Men represented 68.9% of the sample, the mean age was 57.6 years (±10), and the MELD and APACHE IV scores respectively showed means of 24.3 (±5.6) and 58.9 (±23.7). The length of stay in the intensive care unit was 5 days (range, 3-7) and mortality was 9.1%. There was a gradual reduction in the mean NAS in 24 hours (94.9 ± 18.5), 48 hours (87.2 ± 17.0), 72 hours (83.3 ± 19.6) and at discharge (82.3 ± 18.0). Associations of NAS with MELD (P ˂ .05), APACHE IV (P ˂ .001), length of stay in the intensive care unit (P ˂ .001), and death outcome (P ˂ .001) were observed. The greatest workload was in checking vital signs, water balance, and administrative tasks (P ˂ .001). CONCLUSIONS: The nursing workload in the postoperative period of liver transplantation exceeds what is recommended and is related to the severity of the patients.

Performance of NUTRIC score to predict 28-day mortality in critically ill patients after replacing APACHE II with SAPS 3.

OBJECTIVES: The Nutrition Risk in the Critically Ill (NUTRIC) score has been advocated as a screening tool for nutrition risk assessment in critically ill patients. It was developed and validated to predict 28-day mortality using Acute Physiology and Chronic Health Evaluation II (APACHE II) score as one of its components. However, nowadays the Simplified Acute Physiology Score 3 (SAPS 3) demonstrates better performance. We aimed to test the performance of NUTRIC score in predicting 28-day mortality after replacement of APACHE II by SAPS 3, and the interaction between nutrition adequacy and mortality. METHODS: Adult patients who received nutrition therapy and remained >3 days in intensive care unit were retrospectively evaluated. In order to replace APACHE II component, we used ranges of SAPS 3 with similar predicted mortality. Discrimination between these tools in predicting 28-day mortality was assessed using the ROC curve, calibration was evaluated with calibration belt, and correlation with intraclass correlation. The relationship between nutritional adequacy and mortality was assessed in a subgroup with available data. RESULTS: 542 patients were analyzed (median age of 78 years old, 73.4% admitted for non-surgical reasons and 28-day mortality was 18.1%). Mortality prediction discrimination did not differ between tools (p>0.05), but showed a good agreement (intraclass correlation 0.86) with good calibration. In the subgroup analysis for nutritional adequacy (n = 99), no association with mortality was observed. CONCLUSION: Performance of NUTRIC score with SAPS 3 is similar to the original tool. Therefore, it might be used in settings where APACHE II is not available.