Epimed Monitor ICU Database®: um registro nacional baseado na nuvem, para pacientes adultos internados em unidades de terapia intensiva do Brasil / The Epimed Monitor ICU Database®: a cloud-based national registry for adult intensive care unit patients in Brazil

RESUMO Objetivo: Descrever a Epimed Monitor ICU Database®, uma base de dados brasileira cujo objetivo é a melhora da qualidade nas unidades de terapia intensiva do país. Métodos: Descrevemos a Epimed Monitor ICU Database®, inclusive sua estrutura e seus dados principais. Com utilização de estatística descritiva, apresentamos dados informativos agregados das admissões às unidades de terapia intensiva entre os anos de 2010 e 2016. Descrevemos também a expansão e o crescimento da base de dados juntamente da distribuição geográfica das unidades participantes no Brasil. Resultados: Os dados principais da base de dados incluíram informações demográficas, parâmetros administrativos e fisiológicos, assim como formulários específicos de relato para obter dados detalhados, com relação ao uso dos recursos da unidade de terapia intensiva, episódios infecciosos, eventos adversos e uma lista de verificação para adesão às melhores práticas clínicas. Até o final de 2016 tomou parte desta base de dados um total de 598 unidades de terapia intensiva para pacientes adultos, localizadas em 318 hospitais, perfazendo 8.160 leitos de terapia intensiva. Em sua maioria, as unidades participantes se localizavam em hospitais privados da Região Sudeste. O número anual de admissões apresentou um crescimento neste período, com predominância de admissões clínicas. A proporção de admissões em razão de doença cardiovascular diminuiu, enquanto as admissões por sepse ou infecções se tornaram mais comuns. Severidade da doença (Simplified Acute Physiology Score - SAPS 3 - 62 pontos), idade (média = 62 anos) e mortalidade hospitalar (cerca de 17%) permaneceram razoavelmente estáveis durante o período. Conclusão: Uma grande base de dados de pacientes críticos privados é viável e pode oferecer dados epidemiológicos abrangentes e relevantes para fins de melhoria da qualidade e comparação de resultados entre as unidades de terapia intensiva participantes. A base de dados é útil não apenas por razões administrativas, mas também por melhorar os cuidados diários, ao facilitar a adoção das melhores práticas e pode também ser utilizada em pesquisas clínicas.

ABSTRACT Objective: To describe the Epimed Monitor Database®, a Brazilian intensive care unit quality improvement database. Methods: We described the Epimed Monitor® Database, including its structure and core data. We presented aggregated informative data from intensive care unit admissions from 2010 to 2016 using descriptive statistics. We also described the expansion and growth of the database along with the geographical distribution of participating units in Brazil. Results: The core data from the database includes demographic, administrative and physiological parameters, as well as specific report forms used to gather detailed data regarding the use of intensive care unit resources, infectious episodes, adverse events and checklists for adherence to best clinical practices. As of the end of 2016, 598 adult intensive care units in 318 hospitals totaling 8,160 intensive care unit beds were participating in the database. Most units were located at private hospitals in the southeastern region of the country. The number of yearly admissions rose during this period and included a predominance of medical admissions. The proportion of admissions due to cardiovascular disease declined, while admissions due to sepsis or infections became more common. Illness severity (Simplified Acute Physiology Score - SAPS 3 - 62 points), patient age (mean = 62 years) and hospital mortality (approximately 17%) remained reasonably stable during this time period. Conclusion: A large private database of critically ill patients is feasible and may provide relevant nationwide epidemiological data for quality improvement and benchmarking purposes among the participating intensive care units. This database is useful not only for administrative reasons but also for the improvement of daily care by facilitating the adoption of best practices and use for clinical research.

The evaluation of sequential platelet counts has prognostic value for acute kidney injury patients requiring dialysis in the intensive care setting

OBJECTIVE: To evaluate the prognostic value of platelet counts in acute kidney injury patients requiring renal replacement therapy. METHODS: This prospective cohort study was performed in three tertiary-care hospitals. Platelet counts were obtained upon admission to the intensive care unit and during the first week of renal replacement therapy on days 1, 3, 5 and 7. The outcome of interest was the hospital mortality rate. With the aim of minimizing individual variation, we analyzed the relative platelet counts on days 3, 5, 7 and at the point of the largest variation during the first week of renal replacement therapy. Logistic regression analysis was used to test the prognostic value of the platelet counts. RESULTS: The study included 274 patients. The hospital mortality rate was 62%. The survivors had significantly higher platelet counts upon admission to the intensive care unit compared to the non-survivors [175.5×103/mm3 (108.5-259×103/mm3) vs. 148×103/mm3 (80−141×103/mm3)] and during the first week of renal replacement therapy. The relative platelet count reductions were significantly associated with a higher hospital mortality rate compared with the platelet count increases (70% vs. 44% at the nadir, respectively). A relative platelet count reduction >60% was significantly associated with a worse outcome (mortality rate = 82.6%). Relative platelet count variations and the percentage of reduction were independent risk factors of hospital mortality during the first week of renal replacement therapy. CONCLUSION: Platelet counts upon admission to the intensive care unit and at the beginning of renal replacement therapy as well as sequential platelet count evaluation have prognostic value in acute kidney injury patients requiring renal replacement therapy. .

Effects of early changes in organ dysfunctions on the outcomes of critically ill patients in need of renal replacement therapy

INTRODUCTION: Acute kidney injury usually develops in critically ill patients in the context of multiple organ dysfunctions. OBJECTIVE: To evaluate the effect of changes in associated organ dysfunctions over the first three days of renal replacement therapy on the outcomes of patients with acute kidney injury. METHODS: Over a 19-month period, we evaluated 260 patients admitted to the intensive care units of three tertiary-care hospitals who required renal replacement therapy for > 48 h. Organ dysfunctions were evaluated by SOFA score (excluding renal points) on the first (D1) and third (D3) days of renal replacement therapy. Absolute (A-SOFA) and relative (D-SOFA) changes in SOFA scores were also calculated. RESULTS: Hospital mortality rate was 75 percent. Organ dysfunctions worsened (A-SOFA>0) in 53 percent, remained unchanged (A-SOFA=0) in 17 percent and improved (A-SOFA<0) in 30 percent of patients; and mortality was lower in the last group (80 percent vs. 84 percent vs. 61 percent, p=0.003). SOFA on D1 (p<0.001), SOFA on D3 (p<0.001), A-SOFA (p=0.019) and D-SOFA (p=0.016) were higher in non-survivors. However, neither A-SOFA nor D-SOFA discriminated survivors from non-survivors on an individual basis. Adjusting for other covariates (including SOFA on D1), A-SOFA and D-SOFA were associated with increased mortality, and patients in whom SOFA scores worsened or remained unchanged had poorer outcomes. CONCLUSIONS: In addition to baseline values, early changes in SOFA score after the start of renal replacement therapy were associated with hospital mortality. However, no prognostic score should be used as the only parameter to predict individual outcomes.

Pacientes clínicos referenciados, mas não internados na Unidade de Terapia Intensiva: prevalência, características clínicas e prognóstico / Referred medical patients not admitted to the Intensive Care Unit: prevalence, clinical characteristics and prognosis

JUSTIFICATIVA E OBJETIVOS: A evolução dos pacientes cuja internação é negada nos centros de terapia intensiva (CTI) é pouco conhecida. Os objetivos deste estudo foram comparar as características dos pacientes internados com aqueles que não foram internados em CTI e identificar os fatores associados com o processo de triagem para a internação. MÉTODO: Foi realizado um estudo do tipo coorte prospectiva e observacional durante 26 meses. Os dados dos pacientes foram coletados através de um formulário padronizado para a solicitação de internação no CTI. Os desfechos de interesse do estudo foram a internação no CTI e a evolução hospitalar. RESULTADOS: Foram estudados 455 pacientes dos quais 254 (56 por cento) foram internados e 201 (44 por cento) não; a maioria destes, por falta de vagas (82 por cento). Os pacientes não internados apresentaram maior letalidade (85 por cento versus 61 por cento; p < 0,001). Na análise multivariada, foram identificados os seguintes fatores associados à não internação dos pacientes no CTI [razão de chances, (intervalo de confiança 95 por cento)]: neoplasia metastática [5,6(1,7-18,7)], pressão arterial sistólica < 90 mmHg [5,2(3,0-8,8)], idade >70 anos [4,0(2,4-6,5)], cirrose hepática [3,7(1,8-7,5)], e escala de coma de Glasgow < 5 [3,6(1,9-6,9)]. Por outro lado, os pacientes em ventilação mecânica [0,5(0,3-0,7)] e aqueles com cardiopatia isquêmica [0,1(0,03-0,6)] apresentaram maior probabilidade de internação no CTI. CONCLUSÕES: A recusa de pacientes no CTI é freqüente e ocorre geralmente por falta de vagas. Os pacientes não internados apresentaram maior letalidade. Foram identificadas características dos pacientes que estão associadas ao processo de seleção de pacientes para internação na unidade de terapia intensiva.

BACKGROUND AND OBJECTIVES: Information on the outcomes of patients who were refused to the ICU is limited. The aims of this study were to compare the clinical characteristics of patients who were admitted with those of patients who were refused to the ICU and to identify clinical parameters associated with triage procedures. METHODS: Observational prospective cohort study. The following data were collected using a standard questionnaire: comorbidities, acute illness, vital status, laboratory data and APACHE II score. The end-points of interest were admission to the ICU and vital status at hospital discharge. RESULTS: A total of 455 patients were studied; 254 (56 percent) were admitted and 201 (44 percent) were not. The main reason for the refuse of admission was the lack of ICU beds (82 percent). Patients who were not admitted had a higher mortality (85 percent vs. 61 percent; p < 0.001). In multivariable analysis, the following variables were associated to non-admission [odds ratio, (95 percent confidence interval)]: metastatic cancer [5.6(1.7-18.7)], arterial systolic pressure < 90 mmHg [5.2(3.0-8.8)], age > 70 years [4.0(2.4-6.5)], hepatic cirrhosis [3.7(1.8-7.6)], and Glasgow coma scale < 5 [3.6(1.9-6.9)]. The variables associated with ICU admission were: mechanical ventilation [0.5(0.3-0.7)] and acute coronary syndromes [0.1(0.03-0.6)]. CONCLUSIONS: Refusal of ICU admission is frequent and generally as a consequence of ICU beds shortage. Patients who were not admitted had a higher mortality. Clinical characteristics associated with the refusal of admission were identified suggesting that they are used in clinical decision-making for ICU triage.

Avaliação da morbidade acumulada (DANO) em uma população de pacientes com lupus eritematoso sistêmico do ambulatório de colagenoses do HUCFF

A sobrevida no lupus eritematose sistêmicos (LES) aumentou e a morbidade acumulada (dano) tornou-se um importante parâmetro de avaliação prognostica. O índice de danos (ID) é um instrumento desenvolvido e validado para mensurar o dano, que tem extensão e distribuição variáveis nas diversas coortes. Avalia a extensão, as características e os fatores relacionados com dano numa população de pacientes ambulatoriais com LES. Foram estudados pacientes com diagnostico provável ou definido de LES e anotados os seus dados clínicos e do tratamento de LES. O ID foi aplicado através de entrevista, exame clinico e consulta do prontuário médico. Foram incluídos 105 pacientes com idade de 41 (31,5-49) anos, tempo de diagnóstico da doença de 127 (64,5-200) meses, dos quais 96 (91,4%) eram mullheres; 86 (81,9%) pacientes tiveram dano e o valor do ID foi 2 (1-4). Os domínios cutâneo (50,5%), muscular-esqueletico (35,2%), neuro-psiquiatrico (22,9%) e ocular (21,9%) foram os mais acometidos. A presença de dano foi relacionada a um maiior numero de critérios de LES (RC=2,32, IC95%=1,23-4, 37). Síndrome do anticorpo antifosfolipidio (SAF) (RC=9,82, IC95%=2,74- 35,23), PULSOTERAPIA COM METILPREDNISOLONA (MPD) (RC=1,07, IC95%=1,19-12,81) e idade (RC=1,01, IC95%=1,01-1,13) e tempo de corticoterapia oral ( RC=3.91,IC95%=1,00-1,02) maiores foram associados com dano mais extenso (ID4³). Hipertensão arterial sistêmica (HAS) foi relacionada com a presença de dano renal, aterosclerótico e cardíaco, e a pulsoterapia com ciclofosfamida com menopausa precoce. A freqüência e extensão do dano foram elevadas na amostra. A presença de SAF foi o principal determinante de dano mais grave. O controle da HAS e estratégias que reduzam o uso de corticóides podem contribuir para minimizar o desenvolvimento de dano

Survival in systemic lupus erythematosus (SLE) has improved, and accrued chronic morbidity (damage) has become a major prognostic measure in lupus patients. The SLICC/ACR-DI is a validated instrument specifically designed to ascertain damage. The rate and pattern of damage have been shown to vary among cohorts. To assess rate, pattern and factors related to accrued damage, using the SLICC/ACR-DI, in a population of SLE outpatients. Patients with probable and definite diagnosis of SLE were studied. Clinical data and those related to SLE treatment were collected. Damage was assessed using SLICC/ACR-DI by interview, clinical exam and chart review. One hundred and five patients were studied and 96 (91,4%) were female. Their median age was 41 (31.5-49) years and median SLE duration was 127 (64.5-200) months. The most involved domains were: skin (50.5%), musculoskeletal (35.2%), neuropsychiatric (22.9%) and ocular (21.9%). Damage was associated with higher number of ACR classification criteria for SLE (OR=2.32, CI95%=1.23-4.37). Antiphospholipid syndrome (APS) (OR=9.82, CI95%=2.74-35.23), intravenous pulses with methylprednisolone (OR=1.07, CI95%=1.19-12.81), higher age (OR=1.01, CI95%=1.01-1.13) and prolonged therapy with oral steroids (OR=3.91, CI95%=1.00-1.02) were related to severe degrees of damage. Hypertension was associated with renal, cardiac and atherosclerotic damage. Treatment with pulses of cyclophosphamide was associated with premature gonadal failure. Prevalence and extension of damage were very high on studied sample of SLE outpatients. APS was the major contributor to the development of severe damage. Control of hypertension and strategies to reduce corticosteroid use may contribute to minimize morbidity related to SLE and its treatment