Acidose metabólica em pacientes cirúrgicos de alto risco: importância prognóstica / Metabolic acidosis assessment in high-risk surgical patients: prognostic importance

Justificativa e Objetivos: Acidose é uma desordem muito frequente em pacientes cirúrgicos. Neste cenário, permanecem incertas as implicações clínicas da acidose e características de cada tipo. Portanto, é relevante tentar elucidar o papel de cada tipo de acidose no prognóstico de pacientes cirúrgicos de alto risco. Método: Trata-se de estudo multicêntrico observacional prospectivo, realizado em três diferentes hospitais. Os pacientes que necessitassem no pós-operatório de cuidados intensivos foram incluídos no estudo consecutivamente. Pacientes com baixa expectativa de vida (câncer sem perspectiva de tratamento), pacientes com insuficiência hepática (child B ou C), insuficiência renal (Clearence de creatinina < 50 mL/min ou hemodiálise prévia), diagnóstico de diabetes previamente foram excluídos. Os pacientes classificados na admissão da UTI quanto ao tipo de acidose que desenvolviam no pós-operatório imediato foram acompanhados até 30 dias e alta hospitalar. Tal classificação avaliou acidose metabólica, pela quantificação da diferença de base menor que -4 mmol/L, anion gap corrigido pela albumina (AG) e lactato aumentados, quando maiores que 12 e 2 mmo/L, respectivamente. Então, os pacientes foram classificados como acidose metabólica hiperlactatemica, aumentado e normal (hipercloremica) anion gap corrigido pela albumina. Resultados: O total de 618 pacientes foram incluídos durante dois anos. A incidência de acidose metabólica foi 59,1% na UTI, porém 148 (23,9%) apresentaram hipercloremica, 131 (21,2%) revelaram hiperlactatemia, 86 (13,9%) AG aumentado e em 253 (40,9%) não ocorreu acidose metabólica. Dentre todas as cirurgias, pacientes de cirurgia gastrointestinal foram associados a maiores porcentagens de acidose metabólica 46,2% versus 19,8% sem acidose, P < 0,05. Interessantemente, acidose com hipercloremia apresentou mais altos valores de cloro na admissão da UTI 115,0 ± 5,7 meq/L (P < 0,05) e receberam maiores quantidades de solução fisiológica 0,9% no...

Background: Acidosis is a very frequent disorder in surgical patients. In this patient set there remains uncertainty the clinic implications from acidosis and characteristics postoperatively. Therefore, it is very important to evaluate the role of each acidosis type in outcome for high-risk surgical patients. Methods: Multicenter prospective observational study was performed in three different hospitals. The patients who needed postoperative ICU were involved in the study consecutively. Patients with low life expectancy (cancer without treatment), hepatic failure, renal failure, and diabetic diagnosis were excluded. The patients were followed until 30 days and hospital discharge. On ICU admission, immediately postoperative period, the patients were classified to each type of acidosis. The classification evaluated metabolic acidosis as base excess < -4 mmol/L and high albumin-corrected anion gap (AG) and hyperlactatemia, both > 12 and > 2 mmol/L, respectively. So, the metabolic acidosis classification patients were related to hyperlactatemic, high and normal (hyperchloremic) albumin-corrected anion gap. Results: The study enrolled 618 patients during 2 years. Overall, the acidosis incidence was 59.1% on ICU admission, 148 (23.9%) hyperchloremic, 131 (21.2%) hyperlactatemia, 86 (13.9%) a high anion gap and in 253 (40.9%) there was no metabolic acidosis. The hyperchloremic group presented the highest chlorine level, 115.0 ± 5.7 meq/L (P < 0.05) and highest administration of 0.9% physiologic solution intraoperatively, 3000,0 (2000,0 - 4000,0) mL (P < 0.05). However, in spite of patients didn't present difference in profile demographic and score prognostic, those who remain after 12 hours with acidosis, depend on groups classification in postoperatively showed greater ICU complications, respectively, hyperlactatemia group 68.8%; high anion gap 68.6%; hyperchloremic 65.8% and no acidosis 59.3%, P = 0.03. Cardiovascular and renal dysfunctions were the main...

Red blood cell transfusions worsen the outcomes even in critically ill patients undergoing a restrictive transfusion strategy / Transfusões de concentrados de hemácias pioram os resultados mesmo em pacientes graves, submetidos a estratégia restritiva de transfusão

CONTEXT AND OBJECTIVE: Anemia and blood transfusions are common in intensive care. This study aimed to evaluate epidemiology and outcomes among critically ill patients under a restrictive transfusion strategy. DESIGN AND SETTING: Prospective observational cohort study in an intensive care unit (ICU) at a tertiary hospital. METHODS: All adults admitted to the ICU over a one-year period who remained there for more than 72 hours were included, except those with acute coronary syndrome, ischemic stroke, acute hemorrhage, prior transfusion, pregnant women and Jehovah's Witnesses. The restrictive strategy consisted of transfusion indicated when hemoglobin levels were less than or equal to 7.0 g/dl. RESULTS: The study enrolled 167 patients; the acute physiology and chronic health evaluation II (APACHE II) score was 28.9 ± 6.5. The baseline hemoglobin level was 10.6 ± 2.2 g/dl and on day 28, it was 8.2 ± 1.3 g/dl (P < 0.001). Transfusions were administered to 35% of the patients. In the transfusion group, 61.1% did not survive, versus 48.6% in the non-transfusion group (P = 0.03). Transfusion was an independent risk factor for mortality (P = 0.011; odds ratio, OR = 2.67; 95% confidence interval, CI = 1.25 to 5.69). ICU stay and hospital stay were longer in the transfusion group: 20.0 (3.0-83.0) versus 8.0 (3.0-63.0) days (P < 0,001); and 24.0 (3.0-140.0) versus 14.0 (3.0-80.0) days (P = 0.002), respectively. CONCLUSIONS: In critically ill patients, there was a reduction in hemoglobin with increasing length of ICU stay. Moreover, transfusion was associated with worse prognoses.

CONTEXTO E OBJETIVO: Anemia e transfusões sanguíneas são comuns em terapia intensiva. O objetivo deste estudo foi investigar a epidemiologia e resultados em pacientes críticos sob o regime de transfusão restritiva. TIPO DE ESTUDO E LOCAL: Estudo de coorte, prospectivo e observacional em unidade de terapia intensiva de um hospital terciário. MÉTODOS: Foram incluídos todos adultos admitidos na unidade durante um ano e que permaneceram internados por mais de 72 horas, exceto pacientes com lesão coronariana aguda, isquemia cerebral aguda, hemorragia aguda, transfusão anterior, mulheres grávidas e testemunhas de Jeová. A estratégia restritiva consiste na transfusão indicada com a hemoglobina inferior ou igual a 7.0 g/dl. RESULTADOS: Totalizando 167 pacientes incluídos, APACHE II (Acute Physiology and Chronic Health disease II) foi de 28,9 ± 6,5. O valor da hemoglobina basal foi de 10,6 ± 2.2 g/dl e no 28º dia foi de 8,2 ± 1.3 g/dl (P < 0,001). 35% dos pacientes receberam transfusões. No grupo de transfusão 61,1% não sobreviveram versus 48,6% do grupo não transfusão (P = 0,03). A transfusão foi fator de risco independente de mortalidade (P = 0,011; odds ratio, OR = 2,67; intervalo de confiança, IC 95% = 1,25-5,69). A internação na unidade de terapia intensiva e hospitalar foi maior no grupo de transfusão: 20,0 (3,0-83,0) versus 8,0 (3,0-63,0) dias (P < 0,001); e 24,0 (3,0-140,0) versus 14,0 (3,0-80,0) dias (P = 0,002). CONCLUSÕES: Em pacientes graves, observou-se redução da hemoglobina com a progressão da permanência na UTI. Além disso, a transfusão foi associada com piores prognósticos.

Epidemiological and microbiological analysis of ventilator-associated pneumonia patients in a public teaching hospital

Ventilator-associated pneumonia (VAP) is the most commonly-acquired infection in patients in intensive care units. We analyzed epidemiological and microbiological characteristics and the outcome, in a cohort of critically-ill patients with confirmed diagnosis of VAP. All patients who had been on mechanical ventilation (MV) for more than 48 hours were included in our study; material collection for microbiological analysis was done within the first 24 hours after beginning treatment or after changing antibiotics. There were 55/265 (20.7 percent) VAP cases diagnosed, at a rate of 21.6 episodes per 1,000 days of mechanical ventilation. Mean age of the patients was 66 years, with a mean APACHE II score of 26.7 + 7.0; male patients were more prevalent. The mortality rates in the intensive care unit (ICU) and during the hospital stay were 71 percent and 80 percent, respectively. MV duration in patients with VAP was 17 (range 3-43) days and among patients who had not developed VAP, 6 (2-32) days (p < 0.0001). 98.2 percent of the samples were positive, with a high prevalence of Gram-negative bacteria, mainly Acinetobacter calcoaceticus. Risk factors for death included age, MV duration and surgery. VAP incidence in this sample of critically-ill patients was high, with a high mortality rate. Control and prevention strategies based on continuing education of healthcare workers, developed by a multidisciplinary team, should be encouraged to minimize morbimortality of this infection.