Differential impact of on-site or telepharmacy in the intensive care unit: a controlled before-after study.

BACKGROUND: Clinical pharmacists have an important role in the intensive care unit (ICU) team but are scarce resources. Our aim was to evaluate the impact of on-site pharmacists on medical prescriptions in the ICU. METHODS: This is a retrospective, quasi-experimental, controlled before-after study in two ICUs. Interventions by pharmacists were evaluated in phase 1 (February to November 2016) and phase 2 (February to May 2017) in ICU A (intervention) and ICU B (control). In phase 1, both ICUs had a telepharmacy service in which medical prescriptions were evaluated and interventions were made remotely. In phase 2, an on-site pharmacist was implemented in ICU A, but not in ICU B. We compared the number of interventions that were accepted in phase 1 versus phase 2. RESULTS: During the study period, 8797/9603 (91.6%) prescriptions were evaluated, and 935 (10.6%) needed intervention. In phase 2, there was an increase in the proportion of interventions that were accepted by the physician in comparison to phase 1 (93.9% versus 76.8%, P < 0.001) in ICU A, but there was no change in ICU B (75.2% versus 73.9%, P = 0.845). CONCLUSION: An on-site pharmacist in the ICU was associated with an increase in the proportion of interventions that were accepted by physicians.

Ultrasound-based clinical profiles for predicting the risk of intradialytic hypotension in critically ill patients on intermittent dialysis: a prospective observational study.

BACKGROUND: Intradialytic hypotension, a complication of intermittent hemodialysis, decreases the efficacy of dialysis and increases long-term mortality. This study was aimed to determine whether different predialysis ultrasound cardiopulmonary profiles could predict intradialytic hypotension. METHODS: This prospective observational single-center study was performed in 248 critically ill patients with acute kidney injury undergoing intermittent hemodialysis. Immediately before hemodialysis, vena cava collapsibility was measured by vena cava ultrasound and pulmonary congestion by lung ultrasound. Factors predicting intradialytic hypotension were identified by multiple logistic regression analysis. RESULTS: Intradialytic hypotension was observed in 31.9% (n = 79) of the patients, interruption of dialysis because of intradialytic hypotension occurred in 6.8% (n = 31) of the sessions, and overall 28-day mortality was 20.1% (n = 50). Patients were classified in four ultrasound profiles: (A) 108 with B lines > 14 and vena cava collapsibility > 11.5 mm m-2, (B) 38 with B lines < 14 and vena cava collapsibility ≤ 11.5 mm m-2, (C) 36 with B lines > 14 and vena cava collapsibility Di ≤ 11.5 mm m-2, and (D) 66 with B lines < 14 and vena cava collapsibility > 11.5 mm m-2. There was an increased risk of intradialytic hypotension in patients receiving norepinephrine (odds ratios = 15, p = 0.001) and with profiles B (odds ratios = 12, p = 0.001) and C (odds ratios = 17, p = 0.001). CONCLUSION: In critically ill patients on intermittent hemodialysis, the absence of hypervolemia as assessed by lung and vena cava ultrasound predisposes to intradialytic hypotension and suggests alternative techniques of hemodialysis to provide better hemodynamic stability.

Inclusion and definition of acute renal dysfunction in critically ill patients in randomized controlled trials: a systematic review.

BACKGROUND: In evidence-based medicine, multicenter, prospective, randomized controlled trials (RCTs) are the gold standard for evaluating treatment benefits and ensuring the effectiveness of interventions. Patient-centered outcomes, such as mortality, are most often the preferred evaluated outcomes. While there is currently agreement on how to classify renal dysfunction in critically ill patients , the application frequency of this new classification system in RCTs has not previously been evaluated. In this study, we aim to assess the definition of renal dysfunction in multicenter RCTs involving critically ill patients that included mortality as a primary endpoint. METHODS: A comprehensive search was conducted for publications reporting multicenter randomized controlled trials (RCTs) involving adult patients in intensive care units (ICUs) that included mortality as a primary outcome. MEDLINE and PUBMED were queried for relevant articles in core clinical journals published between May 2004 and December 2017. RESULTS: Of 418 articles reviewed, 46 multicenter RCTs with a primary endpoint related to mortality were included. Thirty-six (78.3%) of the trial reports provided information on renal function in the participants. Only seven articles (15.2%) included mean or median serum creatinine levels, mean creatinine clearance or estimated glomerular filtration rates. Sequential organ failure assessment (SOFA) score was the most commonly used definition of renal dysfunction (20 studies; 43.5%). Risk, Injury, Failure, Loss, End-stage renal disease (RIFLE), Acute Kidney Injury Network (AKIN) and Kidney Disease Improving Global Outcomes (KDIGO) criteria were used in five (10.9%) trials. In thirteen trials (28.3%), no renal dysfunction criteria were reported. Only one trial excluded patients with renal dysfunction, and it used urinary output or need for renal replacement therapy (RRT) as criteria for this diagnosis. CONCLUSION: The presence of renal dysfunction was included as a baseline patient characteristic in most RCTs. The RIFLE, AKIN and KDIGO classification systems were infrequently used; renal dysfunction was generally defined using the SOFA score.

A clinical score to predict mortality in septic acute kidney injury patients requiring continuous renal replacement therapy: the HELENICC score.

BACKGROUND: This study aimed to identify predictors of early (7-day) mortality in patients with septic acute kidney injury (AKI) who required continuous renal replacement therapy (CRRT). METHODS: Prospective cohort of 186 septic AKI patients undergoing CRRT at a tertiary hospital, from October 2005 to November 2010. RESULTS: After multivariate adjustment, five variables were associated to early mortality: norepinephrine utilization, liver failure, medical condition, lactate level, and pre-dialysis creatinine level. These variables were combined in a score, which demonstrated good discrimination, with a C-statistic of 0.82 (95% CI = 0.76-0.88), and good calibration (χ 2 = 4.3; p = 0.83). SAPS 3, APACHE II and SOFA scores demonstrated poor performance in this population. CONCLUSIONS: The HEpatic failure, LactatE, NorepInephrine, medical Condition, and Creatinine (HELENICC) score outperformed tested generic models. Future studies should further validate this score in different cohorts.

Development of an algorithm to aid triage decisions for intensive care unit admission: a clinical vignette and retrospective cohort study.

BACKGROUND: Intensive care unit (ICU) admission triage is performed routinely and is often based solely on clinical judgment, which could mask biases. A computerized algorithm to aid ICU triage decisions was developed to classify patients into the Society of Critical Care Medicine's prioritization system. In this study, we sought to evaluate the reliability and validity of this algorithm. METHODS: Nine senior physicians evaluated forty clinical vignettes based on real patients. The reference standard was defined as the priorities ascribed by two investigators with full access to patients' records. Agreement of algorithm-based priorities with the reference standard and with intuitive priorities provided by the physicians were evaluated. Correlations between algorithm prioritization and physicians' judgment of the appropriateness of ICU admissions in scarcity and nonscarcity settings were also evaluated. Validity was further assessed by retrospectively applying this algorithm to 603 patients with requests for ICU admission for association with clinical outcomes. RESULTS: Agreement between algorithm-based priorities and the reference standard was substantial, with a median κ of 0.72 (interquartile range [IQR] 0.52-0.77). Algorithm-based priorities demonstrated higher interrater reliability (overall κ 0.61, 95% confidence interval [CI] 0.57-0.65; median percentage agreement 0.64, IQR 0.59-0.70) than physicians' intuitive prioritization (overall κ 0.51, 95% CI 0.47-0.55; median percentage agreement 0.49, IQR 0.44-0.56) (p = 0.001). Algorithm-based priorities were also associated with physicians' judgment of appropriateness of ICU admission (priorities 1, 2, 3, and 4 vignettes would be admitted to the last ICU bed in 83.7%, 61.2%, 45.2%, and 16.8% of the scenarios, respectively; p < 0.001) and with actual ICU admission, palliative care consultation, and hospital mortality in the retrospective cohort. CONCLUSIONS: This ICU admission triage algorithm demonstrated good reliability and validity. However, more studies are needed to evaluate a difference in benefit of ICU admission justifying the admission of one priority stratum over the others.

Long-term outcomes for epidemic viral pneumonia survivors after discharge from the intensive care unit: a systematic review.

OBJECTIVE: To review the long-term outcomes (functional status and psychological sequelae) of survivors of critical illnesses due to epidemic viral pneumonia before the COVID-19 pandemic and to establish a benchmark for comparison of the COVID-19 long-term outcomes. METHODS: This systematic review of clinical studies reported the long-term outcomes in adults admitted to intensive care units who were diagnosed with viral epidemic pneumonia. An electronic search was performed using databases: MEDLINE®, Web of Science™, LILACS/IBECS, and EMBASE. Additionally, complementary searches were conducted on the reference lists of eligible studies. The quality of the studies was assessed using the Newcastle-Ottawa Scale. The results were grouped into tables and textual descriptions. RESULTS: The final analysis included 15 studies from a total of 243 studies. This review included 771 patients with Influenza A, Middle East Respiratory Syndrome, and Severe Acute Respiratory Syndrome. It analyzed the quality of life, functionality, lung function, mortality, rate of return to work, rehospitalization, and psychiatric symptoms. The follow-up periods ranged from 1 to 144 months. We found that the quality of life, functional capacity, and pulmonary function were below expected standards. CONCLUSION: This review revealed great heterogeneity between studies attributed to different scales, follow-up time points, and methodologies. However, this systematic review identified negative long-term effects on patient outcomes. Given the possibility of future pandemics, it is essential to identify the long-term effects of viral pneumonia outbreaks. This review was not funded. Prospero database registration: (www.crd.york.ac.uk/prospero) under registration ID CRD42021190296.

Perception of the Disclosure of Adverse Events in a Latin American Culture: A National Survey.

Introduction: Adverse events are common and are responsible for a significant burden in the healthcare setting. Such issues can vary according to the local culture and relevant policies. The current literature on the subject primarily addresses Anglo-Saxon cultures; this study focused on understanding the perception of disclosure in a middle-income country in Latin America. Methods: In this descriptive study conducted from June-August, 2021, an online self-administered survey about disclosure practice used a convenience sample of 995 Brazilian healthcare professionals. Results: Based on two different outcomes presented following a hypothetical adverse event (outcome 1: death; outcome 2: no permanent damage), 77.9% of participants fully agree that disclosure should be performed in both scenarios. Although 67.1% claimed that disclosure changes the perception of the institution by those involved, only 8.3% fully agree that there would be a reduction in trust regarding the institution. Despite only 11.5% of participants fully agreeing that disclosure increases the chance of legal action against professionals and institutions, 92.7% fully or partially agree that judicialization was possible in scenario 1, and 72.4% agree it was possible in scenario 2. Of the participants, 64.2% claimed they already faced a "disclosure" situation, and 44.3% fully believe that the person directly involved in the adverse event should participate in the disclosure. Conclusion: In this sample of professionals from a middle-income country in Latin America, the practice of disclosure was considered ethical, and the majority of respondents affirmed that it should always be performed. Nonetheless, this call for transparency collides with participants' perception of a higher risk of legal action when disclosure is performed after a negative outcome situation.

Accountability for reasonableness and criteria for admission, triage and discharge in intensive care units: an analysis of current ethical recommendations. / Responsabilidade pela razoabilidade e critérios de admissão, triagem e alta em unidades de terapia intensiva: uma análise das recomendações éticas atuais.

Triage for intensive care unit admission is a frequent event and is associated to worse clinical outcomes. The process of triage is variable and may be influenced by biases and prejudices, which could lead to potentially unfair decisions. The Brazilian Federal Council of Medicine (Conselho Federal de Medicina) has recently released a guideline for intensive care unit admission and discharge. The aim of this paper is to evaluate the ethical dilemmas related to the implementation of this guideline, through the accountability for reasonabless approach, known as A4R, as elaborated by Norman Daniels. We conclude that the guideline contemplates A4R conditions, but we observe that there is a need for indication of A4R-concordant criteria to operationalize the guidelines.

Triagem para admissão em unidades de terapia intensiva é um evento frequente, especialmente em situações de escassez de recursos, e está associada a piores desfechos clínicos. O processo de triagem é variável e pode ser guiado por vieses e preconceitos, levando à tomada de decisão potencialmente injusta. O Conselho Federal de Medicina elaborou recentemente uma resolução com os critérios de admissão e alta em unidades de terapia intensiva. O objetivo deste artigo é avaliar os dilemas éticos associados à implementação dessa resolução, tendo como prisma a abordagem do accountability for reasonableness ("responsabilização pela razoabilidade"), conhecido como A4R, conforme parâmetros elaborados por Norman Daniels. Apesar de a resolução em si contemplar as condições do A4R, ainda há espaço para que a norma indique critérios para que a operacionalização da resolução também contemple esses parâmetros.

Prevalence of premalignant and malignant skin lesions in oculocutaneous albinism patients.

OBJECTIVE: Oculocutaneous albinism describes a group of pigmentary disorders that lead to skin sensitivity and predisposition to skin malignances. AIMS: To analyze clinical and epidemiological data in oculocutaneous albinism patients and to determine the prevalence of malignant skin lesions, assessing possible risk factors for skin cancer. METHODS: Cross-sectional study evaluating epidemiological data, habits of sun exposure and sun protection, and clinical examination of albino patients followed in a reference dermatology outpatient clinic in Brasil. Our primary outcome was the occurrence of malignant skin lesions in biopsied tissues. RESULTS: Of 74 patients analyzed, 11 (15%) had one or more suspicious lesions and were biopsied, of which 8 (72.7%) patients presented with basal cell carcinomas, 7 (63.3%) presented with squamous cell carcinoma, and 1 (9%) presented with melanoma. Moreover, 32(43%) patients presented with actinic keratosis. Age, female gender, previous history of sunburn, history of malignant lesions and history of sun exposure without photoprotection were associated with the presence of malignant lesions. LIMITATIONS: Unicentric, non-aleatory sample. CONCLUSIONS: There was a high prevalence of malignant and pre-malignant lesions in this population. Some potentially modifiable risk factors were associated with the occurrence of malignant skin lesions.

Impact of nonclinical factors on intensive care unit admission decisions: a vignette-based randomized trial (V-TRIAGE). / Impacto de fatores não clínicos nas decisões relacionadas à admissão em unidade de terapia intensiva: um ensaio randomizado com base em vinhetas (V-TRIAGE).

OBJECTIVE: To assess the impact of intensive care unit bed availability, distractors and choice framing on intensive care unit admission decisions. METHODS: This study was a randomized factorial trial using patient-based vignettes. The vignettes were deemed archetypical for intensive care unit admission or refusal, as judged by a group of experts. Intensive care unit physicians were randomized to 1) an increased distraction (intervention) or a control group, 2) an intensive care unit bed scarcity or nonscarcity (availability) setting, and 3) a multiple-choice or omission (status quo) vignette scenario. The primary outcome was the proportion of appropriate intensive care unit allocations, defined as concordance with the allocation decision made by the group of experts. RESULTS: We analyzed 125 physicians. Overall, distractors had no impact on the outcome; however, there was a differential drop-out rate, with fewer physicians in the intervention arm completing the questionnaire. Intensive care unit bed availability was associated with an inappropriate allocation of vignettes deemed inappropriate for intensive care unit admission (OR = 2.47; 95%CI 1.19 - 5.11) but not of vignettes appropriate for intensive care unit admission. There was a significant interaction with the presence of distractors (p = 0.007), with intensive care unit bed availability being associated with increased intensive care unit admission of vignettes inappropriate for intensive care unit admission in the distractor (intervention) arm (OR = 9.82; 95%CI 2.68 - 25.93) but not in the control group (OR = 1.02; 95%CI 0.38 - 2.72). Multiple choices were associated with increased inappropriate allocation in comparison to the omission group (OR = 5.18; 95%CI 1.37 - 19.61). CONCLUSION: Intensive care unit bed availability and cognitive biases were associated with inappropriate intensive care unit allocation decisions. These findings may have implications for intensive care unit admission policies.

OBJETIVO: Avaliar o impacto da disponibilidade de leitos em unidade de terapia intensiva, distratores e formatação da escolha, nas decisões de admissão na unidade de terapia intensiva. MÉTODOS: Este estudo foi um ensaio randomizado fatorial, com utilização de vinhetas baseadas em pacientes. As vinhetas foram consideradas arquetípicas para admissão ou recusa de admissão na unidade de terapia intensiva, conforme julgado por um grupo de especialistas. Médicos de unidade de terapia intensiva foram randomizados para um grupo com distrações (intervenção) ou um grupo controle; a um ambiente de escassez ou de disponibilidade de leitos em unidade de terapia intensiva (disponibilidade) e a uma vinheta com cenário de múltipla escolha ou omissão (status quo). O desfecho primário foi a proporção de alocações adequadas à unidade de terapia intensiva, definida como concordância com as decisões de alocação acordadas pelo grupo de especialistas. RESULTADOS: Analisamos 125 médicos. Em termos gerais, os distratores não tiveram impacto sobre o desfecho; contudo, houve taxa diferenciada de desistências, com menos médicos no grupo intervenção tendo respondido completamente ao questionário. A disponibilidade de leitos em unidade de terapia intensiva se associou com alocações inadequadas de vinhetas consideradas não adequadas para admissão na unidade de terapia intensiva (RC = 2,47; IC95% 1,19 - 5,11), porém não com vinhetas apropriadas para admissão na unidade de terapia intensiva. Ocorreu interação significante com a presença de distratores (p = 0,007), sendo a disponibilidade de leitos na unidade de terapia intensiva associada com maior admissão na unidade de terapia intensiva de vinhetas não apropriadas para admissão na unidade de terapia intensiva no braço com distratores (intervenção) (RC = 9,82; IC95% 2,68 - 25,93), porém não no grupo controle (RC = 5,18; IC95% 1,37 - 19,61). CONCLUSÃO: A disponibilidade de leitos em unidade de terapia intensiva e vieses cognitivos se associaram com decisões inadequadas de alocação à unidade de terapia intensiva. Esses achados podem ter implicações para políticas de admissão na unidade de terapia intensiva.

Prediction of hemodynamic tolerance of intermittent hemodialysis in critically ill patients: a cohort study.

The evaluation and management of fluid balance are key challenges when caring for critically ill patients requiring renal replacement therapy. The aim of this study was to assess the ability of clinical judgment and other variables to predict the occurrence of hypotension during intermittent hemodialysis (IHD) in critically ill patients. This was a prospective, observational, single-center study involving critically ill patients undergoing IHD. The clinical judgment of hypervolemia was determined by the managing nephrologists and critical care physicians in charge of the patients on the basis of the clinical data used to calculate the ultrafiltration volume and rate for each dialysis treatment. Seventy-nine (31.9%) patients presented with hypotension during IHD. Patients were perceived as being hypervolemic in 109 (43.9%) of the cases by nephrologists and in 107 (43.1%) by intensivists. The agreement between nephrologists and intensivists was weak (kappa = 0.561). Receiver operating characteristic curve analysis yielded an AUC of 0.81 (95% CI 0.75 to 0.84; P < 0.0001), and a cutoff value of 70 mm for the vascular pedicle width (VPW) had the highest accuracy for the prediction of the absence of hypotension. The clinical judgment of hypervolemia did not predict hypotension during IHD. The high predictive ability of the VPW may assist clinicians with critical thinking.

Unplanned Transfers From Intermediate Care Units to Intensive Care Units: A Cohort Study.

This study evaluated unplanned transfers from the intermediate care unit (IMCU) to the intensive care unit (ICU) among urgent admissions. This retrospective, observational study was conducted in 2 ICUs and 1 IMCU. Three patterns of urgent admission were assessed: admissions to the ICU only, admissions to the IMCU only, and admissions to the IMCU with subsequent transfer to the ICU. Of 5296 admissions analyzed, 1396 patients (26.4%) were initially admitted to the IMCU. Of these, 172 (12.3%) were transferred from the IMCU to the ICU. Mortality was higher in patients transferred from the IMCU to the ICU than in the 3900 ICU-only patients (odds ratio, 3.22; 95% CI, 1.52-6.80). Most transfers from the IMCU to the ICU (135; 78.5%) were due to deterioration of the condition for which the patient was admitted. Patient transfers from the IMCU to the ICU were common, were associated with increased hospital mortality, and were mostly due to deterioration in the condition that was the reason for admission.

Realistic simulation is associated with healthcare professionals' increased self-perception of confidence in providing acute stroke care: a before-after controlled study.

BACKGROUND: Simulations are becoming widely used in medical education, but there is little evidence of their effectiveness on neurocritical care. Because acute stroke is a neurological emergency demanding prompt attention, it is a promising candidate for simulation training. OBJECTIVE: To assess the impact of a stroke realistic simulation course on clinicians' self-perception of confidence in the management of acute stroke. METHODS: We conducted a controlled, before-after study. For our intervention, 17 healthcare professionals participated in a stroke realistic simulation course. As controls, participants were chosen from a convenience sample of attendees to the courses Emergency Neurologic Life Support (ENLS) (18 participants) and Neurosonology (20 participants). All participants responded pre- and post-test questionnaires evaluating their self-perception of confidence in acute stroke care, ranging from 10 to 50 points. We evaluated the variation between pre- and post-test results to assess the change on trainees' self-perception of confidence in the management of acute stroke. Multivariate analysis was performed to control for potential confounders. RESULTS: Forty-six (83.63%) subjects completed both questionnaires. The post-test scores were higher than those from the pretests in the stroke realistic simulation course group [pretest median (interquartile range - IQR): 41.5 (36.7-46.5) and post-test median (IQR): 47 (44.7-48); p=0.033], but not in the neurosonology [pretest median (IQR): 46 (44-47) and post-test median (IQR): 46 (44-47); p=0.739] or the ENLS [pretest median (IQR): 46.5 (39-48.2), post-test median (IQR): 47 (40.2-49); p=0.317] groups. Results were maintained after adjustment for covariates. CONCLUSIONS: This stroke realistic simulation course was associated with an improvement on trainees' self-perception of confidence in providing acute stroke care.

Efficacy of Brazilian green propolis (EPP-AF®) as an adjunct treatment for hospitalized COVID-19 patients: A randomized, controlled clinical trial.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) promotes challenging immune and inflammatory phenomena. Though various therapeutic possibilities have been tested against coronavirus disease 2019 (COVID-19), the most adequate treatment has not yet been established. Propolis is a natural product with considerable evidence of immunoregulatory and anti-inflammatory activities, and experimental data point to potential against viral targets. We hypothesized that propolis can reduce the negative effects of COVID-19. METHODS: In a randomized, controlled, open-label, single-center trial, hospitalized adult COVID-19 patients were treated with a standardized green propolis extract (EPP-AF®ï¸) as an adjunct therapy. Patients were allocated to receive standard care plus an oral dose of 400 mg or 800 mg/day of green propolis for seven days, or standard care alone. Standard care included all necessary interventions, as determined by the attending physician. The primary end point was the time to clinical improvement, defined as the length of hospital stay or oxygen therapy dependency duration. Secondary outcomes included acute kidney injury and need for intensive care or vasoactive drugs. Patients were followed for 28 days after admission. RESULTS: We enrolled 124 patients; 40 were assigned to EPP-AF®ï¸ 400 mg/day, 42 to EPP-AF®ï¸ 800 mg/day, and 42 to the control group. The length of hospital stay post-intervention was shorter in both propolis groups than in the control group; lower dose, median 7 days versus 12 days (95% confidence interval [CI] -6.23 to -0.07; p = 0.049) and higher dose, median 6 days versus 12 days (95% CI -7.00 to -1.09; p = 0.009). Propolis did not significantly affect the need for oxygen supplementation. In the high dose propolis group, there was a lower rate of acute kidney injury than in the controls (4.8 vs 23.8%), (odds ratio [OR] 0.18; 95% CI 0.03-0.84; p = 0.048). No patient had propolis treatment discontinued due to adverse events. CONCLUSIONS: Addition of propolis to the standard care procedures resulted in clinical benefits for the hospitalized COVID-19 patients, especially evidenced by a reduction in the length of hospital stay. Consequently, we conclude that propolis can reduce the impact of COVID-19.

Neuromuscular blockade and airway management during endotracheal intubation in Brazilian intensive care units: a national survey. / Bloqueio neuromuscular e manuseio das vias aéreas na intubação endotraqueal em unidades de terapia intensiva brasileiras: um levantamento nacional.

OBJECTIVE: To describe the use of neuromuscular blockade as well as other practices among Brazilian physicians in adult intensive care units. METHODS: An online national survey was designed and administered to Brazilian intensivists. Questions were selected using the Delphi method and assessed physicians' demographic data, intensive care unit characteristics, practices regarding airway management, use of neuromuscular blockade and sedation during endotracheal intubation in the intensive care unit. As a secondary outcome, we applied a multivariate analysis to evaluate factors associated with the use of neuromuscular blockade. RESULTS: Five hundred sixty-five intensivists from all Brazilian regions responded to the questionnaire. The majority of respondents were male (65%), with a mean age of 38 ( 8.4 years, and 58.5% had a board certification in critical care. Only 40.7% of the intensivists reported the use of neuromuscular blockade during all or in more than 75% of endotracheal intubations. In the multivariate analysis, the number of intubations performed monthly and physician specialization in anesthesiology were directly associated with frequent use of neuromuscular blockade. Etomidate and ketamine were more commonly used in the clinical situation of hypotension and shock, while propofol and midazolam were more commonly prescribed in the situation of clinical stability. CONCLUSION: The reported use of neuromuscular blockade was low among intensivists, and sedative drugs were chosen in accordance with patient hemodynamic stability. These results may help the design of future studies regarding airway management in Brazil.

OBJETIVO: Descrever o uso do bloqueio neuromuscular e de outras práticas entre os médicos brasileiros atuantes em unidades de terapia intensiva para pacientes adultos. MÉTODOS: Um levantamento nacional on-line foi aplicado a intensivistas brasileiros. As questões foram selecionadas utilizando o método Delphi e avaliavam os dados demográficos dos médicos, as características da unidade de terapia intensiva, as práticas relativas ao manuseio das vias aéreas e o uso de bloqueio neuromuscular e sedação durante a intubação endotraqueal na unidade de terapia intensiva. Como desfecho secundário, aplicamos uma análise multivariada para avaliar fatores associados com o uso do bloqueio neuromuscular. RESULTADOS: Responderam ao questionário 565 intensivistas de todas as regiões do país. A maioria dos que responderam era homens (65%), com média de idade de 38 ± 8,4 anos, e 58,5% dos participantes tinham título de especialista em terapia intensiva. Apenas 40,7% dos intensivistas relataram o uso de bloqueio neuromuscular durante todas ou em mais de 75% das intubações endotraqueais. Na análise multivariada, o número de intubações realizadas por mês e a especialização do médico em anestesiologia se associaram diretamente com o uso frequente de bloqueio neuromuscular. Etomidato e cetamina foram utilizados mais comumente na situação clínica de hipotensão e choque, enquanto propofol e midazolam foram mais comumente prescritos em situações de estabilidade hemodinâmica. CONCLUSÃO: O relato de uso de bloqueio neuromuscular foi baixo entre intensivistas, e os fármacos sedativos foram escolhidos segundo a estabilidade hemodinâmica do paciente. Estes resultados podem ajudar no delineamento de futuros estudos relativos ao manuseio das vias aéreas no Brasil.

Prognostication in urgent intensive care unit referrals: a cohort study.

OBJECTIVES: Prognostication is an essential ability to clinicians. Nevertheless, it has been shown to be quite variable in acutely ill patients, potentially leading to inappropriate care. We aimed to assess the accuracy of physician's prediction of hospital mortality in acutely deteriorating patients referred for urgent intensive care unit (ICU) admission. METHODS: Prospective cohort of acutely ill patients referred for urgent ICU admission in an academic, tertiary hospital. Physicians' prognosis assessments were recorded at ICU referral. Prognosis was assessed as survival without severe disabilities, survival with severe disabilities or no survival. Prognosis was further dichotomised in good prognosis (survival without severe disabilities) or poor prognosis (survival with severe disabilities or no survival) for prediction of hospital mortality. RESULTS: There were 2374 analysed referrals, with 2103 (88.6%) patients with complete data on mortality and physicians' prognosis. There were 593 (34.4%), 215 (66.4%) and 51 (94.4%) deaths in the groups ascribed a prognosis of survival without disabilities, survival with severe disabilities or no survival, respectively (p<0.001). Sensitivity was 31%, specificity was 91% and the area under the receiver operating characteristic curve was 0.61 for prediction of mortality. After multivariable analysis, severity of illness, performance status and ICU admission were associated with an increased likelihood of incorrect classification, while worse predicted prognosis was associated with a lower chance of incorrect classification. CONCLUSIONS: Physician's prediction was associated with hospital mortality, but overall accuracy was poor, mainly due to low sensitivity to detect risk of poor prognosis.

Efficacy and safety of milrinone in the treatment of cerebral vasospasm after subarachnoid hemorrhage: a systematic review. / Eficácia e segurança da milrinona no tratamento do vasoespasmo cerebral após hemorragia subaracnóidea: uma revisão sistemática.

OBJECTIVE: To systematically review the current evidence on the efficacy of milrinone in the treatment of cerebral vasospasm after subarachnoid hemorrhage. METHODS: The Pubmed®, Cochrane and Embase databases were screened for articles published from April 2001 to February 2019. Two independent reviewers performed the methodological quality screening and data extraction of the studies. RESULTS: Twenty-two studies were found to be relevant, and only one of these was a randomized control trial. Studies showed marked heterogeneity and weaknesses in key methodological criteria. Most patients presented with moderate to severe vasospasm. Angiography was the main method of diagnosing vasospasm. Intra-arterial administration of milrinone was performed in three studies, intravenous administration was performed in nine studies, and both routes of administration in six studies; the intrathecal route was used in two studies, the cisternal route in one study and endovascular administration in one study. The side effects of milrinone were described in six studies. Twenty-one studies indicated resolution of vasospasm. CONCLUSION: The current evidence indicates that milrinone may have a role in treatment of vasospasm after aneurysmal subarachnoid hemorrhage. However, only one randomized control trial was performed, with a low quality level. Our findings indicate the need for future randomized control trials with patient-centered outcomes to provide definitive recommendations.

OBJETIVO: Revisar sistematicamente a evidência atual da eficácia de milrinona no tratamento do vasoespasmo cerebral após hemorragia subaracnóidea. MÉTODOS: Triaram-se as bases de dados Pubmed®, Cochrane e Embase quanto a artigos publicados entre abril de 2001 e fevereiro de 2019. Dois revisores independentes realizaram uma triagem metodológica da qualidade e a extração dos dados dos estudos. RESULTADOS: Encontraram-se 22 estudos considerados relevantes, sendo que apenas um deles era um ensaio randomizado controlado. Os estudos demonstraram acentuada heterogeneidade e debilidade de seus critérios metodológicos. A maioria dos pacientes apresentava vasoespasmo moderado a grave. O principal método para diagnóstico do vasoespasmo foi a angiografia. Em três estudos, realizou-se administração de milrinona por via intra-arterial; em nove estudos, a administração foi endovenosa, e, em seis estudos, utilizaram-se ambas as vias de administração. A via intratecal foi utilizada em dois estudos, em um estudo, a administração foi realizada via cisterna e, em um estudo, a via de administração foi a endovascular. Os efeitos colaterais de milrinona foram descritos em seis estudos. Vinte e um estudos indicaram a resolução do vasoespasmo. CONCLUSÃO: A evidência atual indica que o uso de milrinona teve um papel no tratamento do vasoespasmo após hemorragia subaracnóidea aneurismática. Contudo, só foi realizado um ensaio randomizado controlado, com baixo nível de qualidade. Nossos achados indicam a necessidade de futuros estudos randomizados controlados com desfechos centrados no paciente, com o fim de proporcionar recomendações definitivas.

There is no association between weekend admissions and delays in antibiotic administration for patients admitted to the emergency department with suspicion of sepsis: A retrospective cohort study.

Admission to the emergency department (ED) on weekends has been associated with an increase in mortality and poor outcomes, but the associated findings are not consistent. It has been hypothesized that this association may be due to lower adherence to standards of care.This study was conducted to evaluate whether weekend admissions to the ED increases the time to antibiotic administration in septic patients.A retrospective cohort study of adult patients who were included in the sepsis protocol at a tertiary ED between January 2015 and December 2017 was performed. The sepsis protocol was activated for all patients with suspected severe infection.A total of 831 patients with a mean age of 59 ±â€Š21 years were evaluated, of whom 217 (26.1%) were admitted on weekends. In addition, 391 (47.1%) patients were male, and 84 (10.1%) died in the hospital. Overall, the mean sequential organ failure assessment score was 2 ±â€Š1.9, and the mean Charlson comorbidity index was 3.7 ±â€Š3. The time to antibiotic administration was similar between patients admitted on weekends (36.29 ±â€Š50 minutes CI 95%) and patients admitted on weekdays (44.44 ±â€Š69 minutes CI 95%), P = .06; U = 60174.0. Additionally, mortality was similar in both groups of patients, with a 10.3% mortality rate on weekdays and a 9.8% mortality rate on weekends, P = 821.In this cohort of patients with suspicion of sepsis in the ED, admission on weekends was not associated with increased delays in antibiotic therapy or higher mortality rates.