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Giovanetti JN, Libera PHD, da Silva MLF, Boszczowski Í, Junior LCMC, de Albuquerque Pessoa Dos Santos Y, Forte DN, de Nardi R, Zigaib R, Park M. Eleven years impact of a stepwise educational program on healthcare associated infections and antibiotics consumption in an intensive care unit of a tertiary hospital in Brazil. J Crit Care 2024; 82:154783. [PMID: 38507842 DOI: 10.1016/j.jcrc.2024.154783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/26/2023] [Accepted: 03/10/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Hospital acquired infections (HAI) and liberal use of broad-spectrum antibiotics are common in intensive care unit(ICU)s of low-middle income countries. We investigated the long-term association of a stepwise multifaceted educational program with the incidence of HAIs and antibiotics use in a Brazilian ICU. We also evaluated the program's cost impact. METHODS We retrieved data from a prospective daily collected database of a twelve bedrooms ICU, all admitted patients within a period of eleven years were enrolled. FINDINGS From 03/15/2007 to 09/11/2019, we admitted 3059 patients where 2406 (79%) survived the ICU stay. Median age was 51 years-old, and median SAPS3 was 53. The initial density of catheter related blood infection (4.3 events / 1000 patients-day), urinary tract infection (9.2 event / 1000 patients-day) and ventilator associated pneumonia (54.9 events / 1000 patients-day) felt during the observed period to (0.35 events / 1000 patients-day), (0 events / 1000 patients-day), and (1.5 events / 1000 patients-day) respectively. The days of antibiotic therapy also decreased from 797.9 days of therapy / 1000 patients day to 292.3 days of therapy / 1000 patients day. The total cost per patient also decreased. The adjusted mortality rate was steady during the studied period from 23.2% to 22.9%. INTERPRETATION A stepwise multifaceted educational program is an effective way to reduce hospital-associated infections, improve the rational use of antibiotics, and reduce costs. This impact occurred in a long term, and is probably consistent.
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Affiliation(s)
- Jakeline Neves Giovanetti
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Pedro Henrique Della Libera
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Ícaro Boszczowski
- Infection Control Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | | | - Daniel Neves Forte
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Raquel de Nardi
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Rogerio Zigaib
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Marcelo Park
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.
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2
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Liu N, Han X, Huang R, Yu C, Fang M, Yang W, Zha Y, Shao M. Intensivist-Led Transportation of Patients on Extracorporeal Membrane Oxygenation: A Single Center Experience. ASAIO J 2023; 69:490-495. [PMID: 37126229 DOI: 10.1097/mat.0000000000001867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
This study evaluated the suitability, feasibility, safety, and outcomes of transport of the ECMO-dependent patient (EDP) by EDP transport team (EDPTT) in China. Eighty-two EDPs (forty-one cases on VV ECMO and forty-one cases on VA ECMO) received transport between June 2018 and June 2021 and were retrospectively analyzed. ECMO circulation was performed by the outlying hospital, mainly using percutaneous ECMO cannulation. The EDPTT consists of three intensive therapists, one of whom serves as a team leader, and one intensive care unit nurse. Of these, 81 (98.8%) patients were transferred by ambulance, no deaths occurred during transport, the EDP-related complications were 19% (n = 16); bleeding at the cannula site (n = 7, 8.5%) was the most prominent; equipment-related problems accounted for 14.6% of the problems requiring urgent intervention, with hand cranking being the most common (9.7%). The survival rate during transport was 100%, with 36 (43.9%) patients surviving to discharge. The ECMO weaning rate was 61% for VV ECMO and 63.7% for VA ECMO. The results demonstrated the suitability, feasibility, and safety of transporting EDP in a team led by an intensivist, with few complications and no deaths during transport. This may be the recommended staffing model for EDP transport in developing countries.
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Affiliation(s)
- Nian Liu
- From the Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
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3
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Oude Lansink-Hartgring A, Miranda DDR, Mandigers L, Delnoij T, Lorusso R, Maas JJ, Elzo Kraemer CV, Vlaar APJ, Raasveld SJ, Donker DW, Scholten E, Balzereit A, van den Brule J, Kuijpers M, Vermeulen KM, van den Bergh WM. Health-related quality of life, one-year costs and economic evaluation in extracorporeal membrane oxygenation in critically ill adults. J Crit Care 2023; 73:154215. [PMID: 36402123 DOI: 10.1016/j.jcrc.2022.154215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/23/2022] [Accepted: 11/03/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE This study reports on survival and health related quality of life (HRQOL) after extracorporeal membrane oxygenation (ECMO) treatment and the associated costs in the first year. MATERIALS AND METHODS Prospective observational cohort study patients receiving ECMO in the intensive care unit during August 2017 and July 2019. We analyzed all healthcare costs in the first year after index admission. Follow-up included a HRQOL analysis using the EQ-5D-5L at 6 and 12 months. RESULTS The study enrolled 428 patients with an ECMO run during their critical care admission. The one-year mortality was 50%. Follow up was available for 124 patients at 12 months. Survivors reported a favorable mean HRQOL (utility) of 0.71 (scale 0-1) at 12 months of 0.77. The overall health status (VAS, scale 0-100) was reported as 73.6 at 12 months. Mean total costs during the first year were $204,513 ± 211,590 with hospital costs as the major factor contributing to the total costs. Follow up costs were $53,752 ± 65,051 and costs of absenteeism were $7317 ± 17,036. CONCLUSIONS At one year after hospital admission requiring ECMO the health-related quality of life is favorable with substantial costs but considering the survival might be acceptable. However, our results are limited by loss of follow up. So it may be possible that only the best-recovered patients returned their questionnaires. This potential bias might lead to higher costs and worse HRQOL in a real-life scenario.
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Affiliation(s)
| | | | - Loes Mandigers
- Adult Intensive Care Unit, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Thijs Delnoij
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Jacinta J Maas
- Adult Intensive Care Unit, Leiden University Medical Center, Leiden, the Netherlands
| | - Carlos V Elzo Kraemer
- Adult Intensive Care Unit, Leiden University Medical Center, Leiden, the Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Unit, Amsterdam University Medical Centers, Academic Medical Centers, Amsterdam, the Netherlands
| | - S Jorinde Raasveld
- Department of Intensive Unit, Amsterdam University Medical Centers, Academic Medical Centers, Amsterdam, the Netherlands
| | - Dirk W Donker
- Department of Critical Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Cardiovascular and Respiratory Physiology Group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Erik Scholten
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Anja Balzereit
- Department of Critical Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Judith van den Brule
- Department of Intensive Care, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Marijn Kuijpers
- Department of Intensive Care, Isala Klinieken, Zwolle, the Netherlands
| | - Karin M Vermeulen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Huespe IA, Lockhart C, Kashyap R, Palizas F, Colombo M, Romero MDP, Prado E, Casabella García CA, Las Heras M, Carboni Bisso I. Evaluation of the discrimination and calibration of predictive scores of mortality in ECMO for patients with COVID-19. Artif Organs 2023:10.1111/aor.14493. [PMID: 36582133 PMCID: PMC9880702 DOI: 10.1111/aor.14493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/28/2022] [Accepted: 12/22/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND The criteria for the selection of COVID-19 patients that could benefit most from ECMO organ support are yet to be defined. In this study, we evaluated the predictive performance of ECMO mortality predictive models in patients with COVID-19. We also performed a cost-benefit analysis depending on the mortality predicted probability. We conducted a retrospective cohort study in COVID-19 patients who received ECMO at two tertiary care hospitals between March 2020 to July 2021. MATERIALS AND METHODS We evaluated the discrimination (C-statistic), calibration (Cox calibration), and accuracy of the prediction of death due to severe ARDS in V-V ECMO score (PRESERVE), the Respiratory Extracorporeal Membrane Oxygenation Survival Score (RESP) score, and the PREdiction of Survival on ECMO Therapy-Score (PRESET) score. In addition, we compared the RESP score with Plateau pressure instead of Peak pressure. RESULTS We included a total of 36 patients, 29 (80%) of them male and with a median (IQR) APACHE of 10 (8-15). The PRESET score had the highest discrimination (AUROCs 0.81 [95%CI 0.67-0.94]) and calibration (calibration-in-the-large 0.5 [95%CI -1.4 to 0.3]; calibration slope 2.2 [95%CI 0.7/3.7]). The RESP score with Plateau pressure had higher discrimination than the conventional RESP score. The cost per QALY in the USA, adjusted to life expectancy, was higher than USD 100 000 in patients older than 45 years with a PRESET > 10. CONCLUSION The PRESET score had the highest predictive performance and could help in the selection of patients that benefit most from this resource-demanding and highly invasive organ support.
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Affiliation(s)
- Ivan Alfredo Huespe
- Unidad de Terapia Intensiva Adultos, Hospital Italiano de Buenos AiresBuenos AiresArgentina,Área de investigación en medicina InternaHospital Italiano de Buenos AiresBuenos AiresArgentina,Universidad de Buenos AiresBuenos AiresArgentina,Global Clinical Scholars Research TraineeHarvard Medical SchoolBostonMassachusettsUSA
| | - Carolina Lockhart
- Unidad de Terapia Intensiva Adultos, Hospital Italiano de Buenos AiresBuenos AiresArgentina
| | - Rahul Kashyap
- Global Clinical Scholars Research TraineeHarvard Medical SchoolBostonMassachusettsUSA,Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMinnesotaUSA,Department of ResearchWellSpan HealthYorkPennsylvaniaUSA
| | - Fernando Palizas
- Unidad de Terapia Intensiva Adultos, Clínica BazterricaBuenos AiresArgentina
| | - Malena Colombo
- Instituto Universitario del Hospital ItalianoBuenos AiresArgentina
| | | | - Eduardo Prado
- Unidad de Terapia Intensiva Adultos, Hospital Italiano de Buenos AiresBuenos AiresArgentina
| | | | - Marcos Las Heras
- Unidad de Terapia Intensiva Adultos, Hospital Italiano de Buenos AiresBuenos AiresArgentina
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5
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The Cost of ARDS: A Systematic Review. Chest 2021; 161:684-696. [PMID: 34478719 DOI: 10.1016/j.chest.2021.08.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 08/08/2021] [Accepted: 08/10/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND ARDS is an inflammatory condition of the lungs and is a common condition in adult ICUs. The resources required and costs of care for patients with ARDS are significant because of the severity of the illness and extended ICU lengths of stay. RESEARCH QUESTION What are the costs associated with ARDS? STUDY DESIGN AND METHODS We systematically searched the literature through April 29, 2021, for articles relevant to ARDS and costs. MEDLINE, Embase, Central, and EconLit databases were searched, and articles that reported on cost data from an original publication in adult patients with ARDS were included. Two authors independently assessed articles for inclusion and extracted data elements related to costs, methodology, health-care system type, economic perspective, and clinical data. Publication quality was assessed using a modified version of the Quality of Health Economic Studies Instrument. RESULTS Four thousand six hundred sixty-three publications were found, of which 110 were included for full-text review (κ = 0.72). A total of 22 publications (49,483 patients) were suitable for data extraction. The publications represented a broad range of health-care systems, economic perspectives, costing methodology, and time frames. Mean inpatient costs ranged from $8,476 (2021 US dollars [USD]) to $547,974 (2021 USD) and were highest in publications of lower quality and in American health systems and were associated with trauma cohorts. Outpatient costs were highest in publications with higher readmission rates, longer durations of follow-up, and in American health systems. INTERPRETATION A wide range of costing data is available for ARDS. A comprehensive synthesis of this literature frames the reasons for this and allows estimates to reflect the context in which they were assessed. This information will be of value to researchers and administrators interested in the economics of caring for patients with ARDS. TRIAL REGISTRY PROSPERO; No.: CRD42020192487.
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6
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Sady ERR, Junqueira L, Veiga VC, Rojas SSO. Apnea test for brain death diagnosis in adults on extracorporeal membrane oxygenation: a review. Rev Bras Ter Intensiva 2020; 32:312-318. [PMID: 32667442 PMCID: PMC7405745 DOI: 10.5935/0103-507x.20200048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/28/2020] [Indexed: 12/05/2022] Open
Abstract
Among the potential complications of extracorporeal membrane oxygenation, neurological dysfunctions, including brain death, are not negligible. In Brazil, the diagnostic process of brain death is regulated by Federal Council of Medicine resolution 2,173 of 2017. Diagnostic tests for brain death include the apnea test, which assesses the presence of a ventilatory response to hypercapnic stimulus. However, gas exchange, including carbon dioxide removal, is maintained under extracorporeal membrane oxygenation, making the test challenging. In addition to the fact that the aforementioned resolution does not consider the specificities of the diagnostic process under extracorporeal membrane oxygenation, studies on the subject are scarce. This review aims to identify case studies (and/or case series) published in the PubMed® and Cochrane databases describing the process of brain death diagnosis. A total of 17 publications (2011 - 2019) were identified. The practical strategies described were to provide pretest supplemental oxygenation via mechanical ventilation and extracorporeal membrane oxygenation (fraction of inspired oxygen = 1.0) and, at the beginning of the test, titrate the sweep flow (0.5 - 1.0L/minute) to minimize carbon dioxide removal. It is also recommended to increase blood flow and/or sweep flow in the presence of hypoxemia and/or hypotension, which may be combined with fluid infusion and/or the escalation of inotropic/vasoactive drugs. If the partial pressure of carbon dioxide threshold is not reached, repeating the test under supplementation of carbon dioxide exogenous to the circuit is an alternative. Last, in cases of venoarterial extracorporeal membrane oxygenation, to measure gas variation and exclude differential hypoxia, blood samples of the native and extracorporeal (post-oxygenator) circulations are recommended.
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Affiliation(s)
| | - Lígia Junqueira
- Unidade de Terapia Intensiva Neurológica, Hospital Beneficência Portuguesa, São Paulo, SP, Brasil
| | - Viviane Cordeiro Veiga
- Unidade de Terapia Intensiva Neurológica, Hospital Beneficência Portuguesa, São Paulo, SP, Brasil
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Assy J, Skouri H, Charafeddine L, Majdalani M, Younes K, Bulbul Z, Sfeir P, Bourgi J, Hallal A, Rifai K, Zaatari R, Bitar F, Rassi IE. Establishing an ECMO program in a developing country: challenges and lessons learned. Perfusion 2019; 34:508-515. [DOI: 10.1177/0267659119834489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim: The ECMO (extracorporeal membrane oxygenation) Program at the American University of Beirut Medical Center was established in November 2015 as the first program serving adult and pediatric population in a low-resource setting. The aim of the study is to describe the challenges faced during the establishment of the program and factors leading to its success. Methods: The program establishment is described. The preparation phase, included the strategic, financial, and clinical planning by administration, nursing, and a multidisciplinary team of physicians. The training and education phase included all the involved nurses, perfusionists, and physicians. Concerns were heard from various stakeholders, and the challenges were analyzed and discussed. Results: The preparation committee chose the adequate equipment, responded to the concerns, defined roles and responsibilities through credentialing and privileging, wrote policies and protocols, and established a strategy to decide for the ECMO indication. Selected team of nurses, physicians, and perfusionists are identified and trained locally, and abroad. A full-time ECMO physician was recruited to launch the program. Twelve patients (6 adults, 3 children, and 3 neonates) were supported by ECMO, for cardiac and respiratory indications. Eleven patients were supported by veno-arterial ECMO, and 1 patient (a neonate) with veno-venous ECMO. Overall, 75% survived to decannulation and 41% survived to discharge. Conclusion: With limited human and financial resources, new ECMO centers need to carefully establish selection criteria that may differ from those used in developed countries. Indications should be discussed on a case by case basis, taking into account clinical, social, and financial issues. This experience might help other institutions in developing countries to build their own program despite financial and human limitations.
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Affiliation(s)
- Jana Assy
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hadi Skouri
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Lama Charafeddine
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marianne Majdalani
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Khaled Younes
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ziad Bulbul
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Pierre Sfeir
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jamil Bourgi
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Hallal
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Khaled Rifai
- Department of Nursing and Perfusion, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rafika Zaatari
- Department of Nursing and Perfusion, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi Bitar
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Issam El Rassi
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
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Li HY, Mendes PV, Melro LMG, Joelsons D, Besen BAMP, Costa ELV, Hirota AS, Barbosa EVS, Foronda FK, Azevedo LCP, Romano TG, Park M. Characterization of patients transported with extracorporeal respiratory and/or cardiovascular support in the State of São Paulo, Brazil. Rev Bras Ter Intensiva 2018; 30:317-326. [PMID: 30328986 PMCID: PMC6180471 DOI: 10.5935/0103-507x.20180052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 04/30/2018] [Indexed: 01/05/2023] Open
Abstract
Objective To characterize the transport of severely ill patients with extracorporeal
respiratory or cardiovascular support. Methods A series of 18 patients in the state of São Paulo, Brazil is
described. All patients were consecutively evaluated by a multidisciplinary
team at the hospital of origin. The patients were rescued, and
extracorporeal membrane oxygenation support was provided on site. The
patients were then transported to referral hospitals for extracorporeal
membrane oxygenation support. Data were retrieved from a prospectively
collected database. Results From 2011 to 2017, 18 patients aged 29 (25 - 31) years with a SAPS 3 of 84
(68 - 92) and main primary diagnosis of leptospirosis and influenza A (H1N1)
virus were transported to three referral hospitals in São Paulo. A
median distance of 39 (15 - 82) km was traveled on each rescue mission
during a period of 360 (308 - 431) min. A median of one (0 - 2) nurse, three
(2 - 3) physicians, and one (0 - 1) physical therapist was present per
rescue. Seventeen rescues were made by ambulance, and one rescue was made by
helicopter. The observed complications were interruption in the energy
supply to the pump in two cases (11%) and oxygen saturation < 70% in two
cases. Thirteen patients (72%) survived and were discharged from the
hospital. Among the nonsurvivors, there were two cases of brain death, two
cases of multiple organ dysfunction syndrome, and one case of irreversible
pulmonary fibrosis. Conclusions Transportation with extracorporeal support occurred without serious
complications, and the hospital survival rate was high.
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Affiliation(s)
- Ho Yeh Li
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Pedro Vitale Mendes
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Oncológica, Hospital São Luiz, Rede D'Or - São Paulo (SP), Brasil
| | - Livia Maria Garcia Melro
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Hospital TotalCor - São Paulo (SP), Brasil
| | - Daniel Joelsons
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Bruno Adler Maccagnan Pinheiro Besen
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Oncológica, Hospital São Luiz, Rede D'Or - São Paulo (SP), Brasil
| | - Eduardo Leite Viera Costa
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Hospital Sírio Libanês - São Paulo (SP), Brasil
| | - Adriana Sayuri Hirota
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - Flavia Krepel Foronda
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Luciano Cesar Pontes Azevedo
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Hospital Sírio Libanês - São Paulo (SP), Brasil
| | - Thiago Gomes Romano
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Oncológica, Hospital São Luiz, Rede D'Or - São Paulo (SP), Brasil
| | - Marcelo Park
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
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Moraz G, Garcez ADS, de Assis EM, dos Santos JP, Barcellos NT, Kroeff LR. [Cost-effectiveness in health in Brazil: a systematic review]. CIENCIA & SAUDE COLETIVA 2017; 20:3211-29. [PMID: 26465862 DOI: 10.1590/1413-812320152010.00962015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 05/30/2015] [Indexed: 12/13/2022] Open
Abstract
A systematic review was performed with the aim of describing the landscape and evolution of cost-effectiveness studies in health in Brazil. The search for articles on cost-effectiveness was performed in the main electronic health databases. The review identified 83 cost-effectiveness studies conducted nationwide. Between the years 1990-2005 there were few studies published on cost-effectiveness, though between 2006 and 2014 there was a significant increase in the number of publications. As for the themes and objectives of the studies, the chronic degenerative diseases and infectious/contagious diseases reflect the epidemiological diversity of Brazil. A predominance of studies on health intervention/treatment was identified. Thus, this review reveals a compatible Brazilian epidemiological reality scenario, indicating a need to increase research and investment of funds in the area of preventive health.
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Affiliation(s)
- Gabriele Moraz
- Universidade do Vale do Rio dos Sinos, São Leopoldo, RS, Brasil,
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10
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Romano TG, Mendes PV, Park M, Costa ELV. Extracorporeal respiratory support in adult patients. J Bras Pneumol 2017; 43:60-70. [PMID: 28380189 PMCID: PMC5790677 DOI: 10.1590/s1806-37562016000000299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/05/2017] [Indexed: 01/19/2023] Open
Abstract
In patients with severe respiratory failure, either hypoxemic or hypercapnic, life support with mechanical ventilation alone can be insufficient to meet their needs, especially if one tries to avoid ventilator settings that can cause injury to the lungs. In those patients, extracorporeal membrane oxygenation (ECMO), which is also very effective in removing carbon dioxide from the blood, can provide life support, allowing the application of protective lung ventilation. In this review article, we aim to explore some of the most relevant aspects of using ECMO for respiratory support. We discuss the history of respiratory support using ECMO in adults, as well as the clinical evidence; costs; indications; installation of the equipment; ventilator settings; daily care of the patient and the system; common troubleshooting; weaning; and discontinuation.
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Affiliation(s)
- Thiago Gomes Romano
- . Disciplina de Nefrologia, Faculdade de Medicina do ABC, Santo André (SP) Brasil.,. Hospital Sírio-Libanês, São Paulo (SP) Brasil
| | - Pedro Vitale Mendes
- . Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil.,. Hospital Sírio-Libanês, São Paulo (SP) Brasil
| | - Marcelo Park
- . Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Eduardo Leite Vieira Costa
- . Hospital Sírio-Libanês, São Paulo (SP) Brasil.,. UTI Respiratória, Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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11
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Mendes PV, de Albuquerque Gallo C, Besen BAMP, Hirota AS, de Oliveira Nardi R, Dos Santos EV, Li HY, Joelsons D, Costa ELV, Foronda FK, Azevedo LCP, Park M. Transportation of patients on extracorporeal membrane oxygenation: a tertiary medical center experience and systematic review of the literature. Ann Intensive Care 2017; 7:14. [PMID: 28176223 PMCID: PMC5296266 DOI: 10.1186/s13613-016-0232-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 12/25/2016] [Indexed: 12/29/2022] Open
Abstract
Background Utilization of extracorporeal membrane oxygenation (ECMO) has increased worldwide, but its use remains restricted to severely ill patients, and few referral centers are properly structured to offer this support. Inter-hospital transfer of patients on ECMO support can be life-threatening. In this study, we report a single-center experience and a systematic review of the available published data on complications and mortality associated with ECMO transportation. Methods We reported single-center data regarding complications and mortality associated with the transportation of patients on ECMO support. Additionally, we searched multiple databases for case series, observational studies, and randomized controlled trials regarding mortality of patients transferred on ECMO support. Results were analyzed independently for pediatric (under 12 years old) and adult populations. We pooled mortality rates using a random-effects model. Complications and transportation data were also described. Results A total of 38 manuscripts, including our series, were included in the final analysis, totaling 1481 patients transported on ECMO support. A total of 951 patients survived to hospital discharge. The pooled survival rates for adult and pediatric patients were 62% (95% CI 57–68) and 68% (95% CI 60–75), respectively. Two deaths occurred during patient transportation. No other complication resulting in adverse outcome was reported. Conclusion Using the available pooled data, we found that patient transfer to a referral institution while on ECMO support seems to be safe and adds no significant risk of mortality to ECMO patients. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0232-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pedro Vitale Mendes
- Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Rua Dr. Enéas Carvalho de Aguiar, 255, Sala 5023, São Paulo, SP, 05403000, Brazil. .,Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil.
| | | | | | | | | | | | - Ho Yeh Li
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Daniel Joelsons
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Eduardo Leite Vieira Costa
- Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Rua Dr. Enéas Carvalho de Aguiar, 255, Sala 5023, São Paulo, SP, 05403000, Brazil.,Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | | | - Luciano Cesar Pontes Azevedo
- Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Rua Dr. Enéas Carvalho de Aguiar, 255, Sala 5023, São Paulo, SP, 05403000, Brazil.,Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Marcelo Park
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
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Durães AR, Figueira FAMDS, Lafayette AR, Martins JDCS, de Sá JC. Use of venoarterial extracorporeal membrane oxygenation in fulminant chagasic myocarditis as a bridge to heart transplant. Rev Bras Ter Intensiva 2016; 27:397-401. [PMID: 26761479 PMCID: PMC4738827 DOI: 10.5935/0103-507x.20150066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 11/12/2015] [Indexed: 01/20/2023] Open
Abstract
A 17-year-old Brazilian male presented with progressive dyspnea for 15 days,
worsening in the last 24 hours, and was admitted in respiratory failure and
cardiogenic shock, with multiple organ dysfunctions. Echocardiography
showed a left ventricle ejection fraction of 11%, severe diffuse
hypokinesia, and a systolic pulmonary artery pressure of 50mmHg, resulting
in the need for hemodynamic support with dobutamine (20mcg/kg/min) and
noradrenaline (1.7mcg/kg/min). After 48 hours with no clinical or
hemodynamic improvement, an extracorporeal membrane oxygenation was
implanted. The patient presented with hemodynamic, systemic perfusion and
renal and liver function improvements; however, his cardiac function did
not recover after 72 hours, and he was transfer to another hospital. Air
transport was conducted from Salvador to Recife in Brazil. A heart
transplant was performed with rapid recovery of both liver and kidney
functions, as well as good graft function. Histopathology of the explanted
heart showed chronic active myocarditis and amastigotes of
Trypanosoma cruzi. The estimated global prevalence of
T. cruzi infections declined from 18 million in 1991,
when the first regional control initiative began, to 5.7 million in 2010.
Myocarditis is an inflammatory disease due to infectious or non-infectious
conditions. Clinical manifestation is variable, ranging from subclinical
presentation to refractory heart failure and cardiogenic shock. Several
reports suggest that the use of extracorporeal membrane oxygenation in
patients presenting with severe refractory myocarditis is a potential
bridging therapy to heart transplant when there is no spontaneous recovery
of ventricular function. In a 6-month follow-up outpatient consult, the
patient presented well and was asymptomatic.
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13
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Antoniali F. There is one more thing to be done: ECMO! Braz J Cardiovasc Surg 2016; 30:IV-VI. [PMID: 27163432 PMCID: PMC4614922 DOI: 10.5935/1678-9741.20150066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Fernando Antoniali
- ECMO group of Campinas, Cardio Surgical Clinic, PUC-Campinas, Campinas, SP, Brazil
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14
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Park M, Mendes PV, Hirota AS, dos Santos EV, Costa ELV, Azevedo LCP. Blood flow/pump rotation ratio as an artificial lung performance monitoring tool during extracorporeal respiratory support using centrifugal pumps. Rev Bras Ter Intensiva 2015; 27:178-84. [PMID: 26340159 PMCID: PMC4489787 DOI: 10.5935/0103-507x.20150030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 05/10/2015] [Indexed: 01/19/2023] Open
Abstract
Objective To analyze the correlations of the blood flow/pump rotation ratio and the
transmembrane pressure, CO2 and O2 transfer during the
extracorporeal respiratory support. Methods Five animals were instrumented and submitted to extracorporeal membrane
oxygenation in a five-step protocol, including abdominal sepsis and lung
injury. Results This study showed that blood flow/pump rotations ratio variations are dependent on
extracorporeal membrane oxygenation blood flow in a positive logarithmic fashion.
Blood flow/pump rotation ratio variations are negatively associated with
transmembrane pressure (R2 = 0.5 for blood flow = 1500mL/minute and
R2 = 0.4 for blood flow = 3500mL/minute, both with p < 0.001) and
positively associated with CO2 transfer variations (R2 = 0.2
for sweep gas flow ≤ 6L/minute, p < 0.001, and R2 = 0.1 for
sweep gas flow > 6L/minute, p = 0.006), and the blood flow/pump rotation ratio
is not associated with O2 transfer variations (R2 = 0.01 for
blood flow = 1500mL/minute, p = 0.19, and R2 = - 0.01 for blood flow =
3500 mL/minute, p = 0.46). Conclusion Blood flow/pump rotation ratio variation is negatively associated with
transmembrane pressure and positively associated with CO2 transfer in
this animal model. According to the clinical situation, a decrease in the blood
flow/pump rotation ratio can indicate artificial lung dysfunction without the
occurrence of hypoxemia.
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Affiliation(s)
- Marcelo Park
- Departamento de Emergências Clínicas, Unidade de Terapia Intensiva, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - Pedro Vitale Mendes
- Departamento de Emergências Clínicas, Unidade de Terapia Intensiva, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - Adriana Sayuri Hirota
- Departamento de Emergências Clínicas, Unidade de Terapia Intensiva, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | | | | | - Luciano Cesar Pontes Azevedo
- Departamento de Emergências Clínicas, Unidade de Terapia Intensiva, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
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Zigaib R, Noritomi DT. Critical care medicine: extracorporeal oxygenation is feasible in Brazil? Rev Bras Ter Intensiva 2014; 26:200-2. [PMID: 25295812 PMCID: PMC4188454 DOI: 10.5935/0103-507x.20140029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Rogério Zigaib
- Intensive Care Unit, Hospital Paulistano - São Paulo (SP),
Brazil
- Intensive Care Unit, Discipline of Clinical Emergency, Hospital das
Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
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