Measurements of I-FABP and citrulline in the postoperative period of non-cardiac surgeries with gastrointestinal complications: A prospective cohort observational study

BACKGROUND

Acute Gastrointestinal Injury (AGI) is associated with adverse clinical outcomes, including increased mortality. We aimed to investigate the potential of citrulline and intestinal fatty acid binding protein (I-FABP) as biomarkers for early AGI diagnosis and predicting outcomes in surgical patients.

METHODS

Prospective cohort study involving patients who underwent non-cardiac surgeries and were admitted to Intensive Care Units. AGI diagnosis was based on specific criteria, and severity was categorised following established guidelines. Statistical analyses were performed to assess the diagnostic accuracy of the biomarkers and their association with outcomes, P significant when <0.05.

RESULTS

AGI was identified in 40.3% of patients with varying severity. Mortality rates were significantly higher in the AGI group in the ICU (19.4% vs. 0%, p = 0.001) and hospital (22.6% vs. 2.17%, p = 0.003). Urinary I-FABP levels on days 3 and 7 showed reasonable and good accuracy for AGI diagnosis (AUC 0.732 and 0.813, respectively). Urinary I-FABP levels on days 2 and 3 accurately predict sepsis. Urinary citrulline levels on day one predicted mortality (AUC 0.87) furthermore urinary I-FABP levels on day 2 showed reasonable accuracy (sensitivity 83.3%, specificity 92.4%).

CONCLUSION

Urinary I-FABP and citrulline levels are promising diagnostic and prognostic markers in ICU patients following non-cardiac surgeries.

Improving perioperative care in low-resource settings with goal-directed therapy: a narrative review

Perioperative Goal-Directed Therapy (PGDT) has significantly showed to decrease complications and risk of death in high-risk patients according to numerous meta-analyses. The main goal of PGDT is to individualize the therapy with fluids, inotropes, and vasopressors, during and after surgery, according to patients' needs in order to prevent organic dysfunction development. In this opinion paper we aimed to focus a discussion on possible alternatives to invasive hemodynamic monitoring in low resource settings.

Prevalence, outcomes, and predictors of multidrug-resistant nosocomial lower respiratory tract infections among patients in an ICU

OBJECTIVE

To determine the prevalence, outcomes, and predictors of multidrug-resistant nosocomial lower respiratory tract infections (LRTI) in patients in an ICU.

METHODS

This was an observational cohort study involving patients with nosocomial LRTI (health care-associated pneumonia, hospital-acquired pneumonia, or ventilator-associated pneumonia). Data were prospectively collected between 2015 and 2019. The multidrug-resistant pathogens (MDRPs) identified in the isolates studied included resistant to extended-spectrum cephalosporin-resistant and carbapenem-resistant Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa, carbapenem-resistant Enterobacteriaceae, and methicillin-resistant Staphylococcus aureus at microbiological diagnosis.

RESULTS

During the study period, 267 patients in the ICU were diagnosed with LRTI, microbiological confirmation of LRTI having been obtained in 237. Of these, 146 (62%) had at least one MDRP isolate. Patients infected with MDRP were found to have poorer outcomes than patients infected with susceptible strains, such as prolonged mechanical ventilation (18.0 days vs. 12.0 days; p < 0.001), prolonged ICU length of stay (23.0 days vs.16.0 days; p < 0.001), and higher mortality (73% vs. 53%; p < 0.001) when compared with patients infected with susceptible strains. Hospital length of stay ≥ 5 days (OR = 3.20; 95% CI: 1.39-7.39; p = 0.005) and prolonged use vasoactive drugs (OR = 3.15; 95% CI: 1.42-7.01; p = 0.004) were independent predictors of LRTI caused by MDRPs (LRTI-MDRP). The presence of LRTI-MDRP was found to be an independent predictor of death (OR = 2.311; 95% CI: 1.091-4.894; p = 0.028).

CONCLUSIONS

Prolonged use of vasoactive drugs and prolonged hospital length of stay were independent predictors of LRTI-MDRP in this population of critically ill patients with very poor outcomes.

LB1529. Randomized, Controlled Phase 3 Study of anti-C5a Vilobelimab's Effect on Mortality in Critically Ill COVID-19 Patients: A Therapy for Viral Pneumonia

Background

SARS-CoV-2 induces endothelial damage and activates the complement system. In severe COVID-19 patients, complement split factor C5a is highly elevated leading to inflammation that contributes to multiorgan failure. The anti-C5a monoclonal antibody, Vilobelimab (Vilo), which preserves the membrane attack complex (MAC), was investigated in an adaptively designed, randomized double-blind, placebo (P)-controlled Phase 3 international multicenter study for survival in critically ill COVID-19 patients (pts).

Methods

COVID-19 pneumonia pts (N=368; Vilo n=177, P n=191), mechanically ventilated within 48 hrs before treatment, received up to 6, 800 mg infusions of Vilo or P on top of standard of care. The primary and main secondary endpoints were 28-day (d) and 60-d all-cause mortality.

Results

Pts enrolled in the study were on corticosteroids (97%) and anti-coagulants (98%) as standard of care. A smaller proportion (20%) were either continuing or had taken immunomodulators such as tocilizumab and baricitinib prior to receiving Vilo. The 28-d all-cause mortality was 31.7% with Vilo vs 41.6% with P (Kaplan-Meier estimates; Cox regression site-stratified, HR 0.73; 95% CI:0.50-1.06; P=0.094), representing a 23.8% relative mortality reduction. In predefined primary outcome analysis without site stratification, however, Vilo significantly reduced mortality at 28 (HR 0.67; 95% CI:0.48-0.96; P=0.027) and 60 days (HR 0.67; 95% CI:0.48-0.92; P=0.016). Vilo also significantly reduced 28-d mortality in more severe pts with baseline WHO ordinal scale score of 7 (n=237, HR 0.62; 95% CI:0.40-0.95; P=0.028), severe ARDS/PaO2/FiO2 ≤ 100 mmHg (n=98, HR 0.55; 95% CI:0.30-0.98; P=0.044) and eGFR &lt; 60 mL/min/1.73m2 (n=108, HR 0.55; 95% CI:0.31-0.96; P=0.036). Treatment-emergent AEs were 90.9% Vilo vs 91.0% P. Infections were comparable: Vilo 62.9%, P 59.3%. Infection incidence per 100 Pt days were equal. No meningococcal infections were reported. Serious AEs were 58.9% Vilo, 63.5% P.

Conclusion

Vilo significantly reduced mortality at 28 and 60 days in critically ill COVID-19 pts with no increase in infections suggesting the importance of targeting C5a while preserving MAC. Vilo targets inflammation which may represent an approach to treat sepsis and ARDS caused by other respiratory viruses.

Disclosures

Alexander Vlaar, MD, PhD, InflaRx GmbH: Advisor/Consultant Maria Habel, PhD, InflaRx GmbH: Stocks/Bonds Claus Thielert, PhD, InflaRx GmbH: Stocks/Bonds James Dickinson, MSc, InflaRx GmbH: Stocks/Bonds simon Rückinger, PhD, InflaRx GmbH: Advisor/Consultant Robert Zerbib, MSc, InflaRx GmbH: Stocks/Bonds Dorothee Neukirchen, PhD, InflaRx GmbH: Stocks/Bonds Korinna Pilz, MD, MSc, InflaRx GmbH: Ownership Interest|InflaRx GmbH: Stocks/Bonds Renfeng Guo, MD, InflaRx GmbH: Board Member|InflaRx GmbH: CSO|InflaRx GmbH: Ownership Interest|InflaRx GmbH: Stocks/Bonds Diederik van de Beek, MD, PhD, InflaRx GmbH: Advisor/Consultant Niels Riedemann, MD, PhD, InflaRx GmbH: Board Member|InflaRx GmbH: CEO|InflaRx GmbH: Ownership Interest|InflaRx GmbH: Stocks/Bonds.

1141. Phase 3 Trial (in progress) of the SYK Inhibitor Fostamatinib in Patients Hospitalized with COVID-19: Protocol and Study Implementation Updates

Background

Immune dysregulation associated with COVID-19 includes immune cell activation, inflammatory cytokine release, and neutrophil extracellular trap release (NETosis), which are mediated by spleen tyrosine kinase (SYK) (Fig 1). Fostamatinib, an oral spleen tyrosine kinase (SYK) inhibitor, was approved for immune thrombocytopenia (ITP) in 2018, and the Phase 3 trials showed a lower than expected rate of thrombosis.1 Clinical studies showed a reduction in IL-6 in patients with rheumatoid arthritis.2 The active metabolite of fostamatinib (R406) protected against LPS-induced acute lung injury and thrombosis in mice3,4 and reduced MUC1 in a mouse model of ALI.5 Fostamatinib demonstrated abrogation of the hyperimmune response caused by anti-spike IgG,6 including reduction in hyperactivation of platelets7 and NETosis in neutrophils8 in in vitro studies using plasma from patients with severe COVID-19.

A phase 2 study (NCT04579393) evaluated fostamatinib vs. placebo (all received standard of care [SOC]) in 59 hospitalized patients with COVID-19 and demonstrated reduction in mortality, ordinal scale scores, and number of days in the intensive care unit (ICU) as well as meeting the primary endpoint of safety.9 A phase 3 clinical study (NCT04629703) of fostamatinib for the treatment of COVID-19 is underway. Figure 1.Mechanism of Disease (COVID-19) and Role of SYK inhibition

Methods

A Phase 3, randomized, double-blind, placebo-controlled, adaptive design, multi-center study (NCT04629703) is underway to evaluate fostamatinib in 308 adult patients hospitalized with COVID-19 and on oxygen without intubation (Fig 2). Patients will receive fostamatinib 150 mg BID or placebo for 14 days; both arms receive SOC. At baseline, the clinical status score (8-point ordinal scale) had to be 5 or 6. Patients ≥ 65 years had to have ≥ 1 risk factor for severe disease and adults &lt; 65 had to have ≥ 3. The primary outcome is days on oxygen (Day 1 to 29). Other endpoints include change in clinical status score, days in the ICU, time to hospital discharge, all-cause mortality, oxygen-free status and safety. Fostamatinib is investigational for COVID-19.

Results

Blinded data from this trial in progress are as of 2 December 2021. See Fig 3.

Conclusion

Final results of this Phase 3 trial are anticipated in 2022.

Disclosures

Lucy Yan, MD, PhD, Rigel Pharmaceuticals: Employee|Rigel Pharmaceuticals: Stocks/Bonds Ziad Mallat, MD, PhD, Rigel Pharmaceuticals: Advisor/Consultant Suzana Margareth Lobo, MD, PhD, Rigel Pharmaceuticals: Grant/Research Support Anuj Malik, MD, MS, Rigel Pharmaceuticals: Grant/Research Support Wolfgang Dummer, MD, PhD, Rigel Pharmaceuticals: Employee|Rigel Pharmaceuticals: Stocks/Bonds.

Myocardial injury and cardiovascular complications in COVID-19: a cohort study in severe and critical patients

OBJECTIVE

To characterize myocardial injury and cardiovascular complications and their predictors in severe and critical COVID-19 patients admitted to the intensive care unit.

METHODS

This was an observational cohort study of severe and critical COVID-19 patients admitted to the intensive care unit. Myocardial injury was defined as blood levels of cardiac troponin above the 99th percentile upper reference limit. Cardiovascular events considered were the composite of deep vein thrombosis, pulmonary embolism, stroke, myocardial infarction, acute limb ischemia, mesenteric ischemia, heart failure and arrhythmia. Univariate and multivariate logistic regression or Cox proportional hazard models were used to determine predictors of myocardial injury.

RESULTS

Of 567 patients with severe and critical COVID-19 admitted to the intensive care unit, 273 (48.1%) had myocardial injury. Of the 374 patients with critical COVID-19, 86.1% had myocardial injury, and also showed more organ dysfunction and higher 28-day mortality (56.6% versus 27.1%, p < 0.001). Advanced age, arterial hypertension and immune modulator use were predictors of myocardial injury. Cardiovascular complications occurred in 19.9% of patients with severe and critical COVID-19 admitted to the intensive care unit, with most events occurring in patients with myocardial injury (28.2% versus 12.2%, p < 0.001). The occurrence of an early cardiovascular event during intensive care unit stay was associated with higher 28-day mortality compared with late or no events (57.1% versus 34% versus 41.8%, p = 0.01).

CONCLUSION

Myocardial injury and cardiovascular complications were commonly found in patients with severe and critical forms of COVID-19 admitted to the intensive care unit, and both were associated with increased mortality in these patients.

561. Phase 3 Trial of Fostamatinib for the Treatment of COVID-19: Repurposing an Immunomodulatory Drug Previously Approved for Immune Thrombocytopenia

Background

Key pathologies in severe COVID-19 include immune cell activation, inflammatory cytokine release, and neutrophil extracellular trap release (NETosis), which are mediated by spleen tyrosine kinase (SYK) (Figure 1). Fostamatinib, an oral SYK inhibitor approved for chronic immune thrombocytopenia, has shown activity in vitro using plasma from patients with severe COVID-19, by abrogating the hyperimmune response triggered by anti-spike IgG; ¹ inhibiting hyperactivation in platelets; ² and blocking NETosis in neutrophils.³ R406, active metabolite of fostamatinib, protected against LPS-induced acute lung injury and thrombosis in mice.^4,5 In clinical studies, fostamatinib reduced IL-6 in patients with rheumatoid arthritis.⁶ Therefore, a phase 2 study (NCT04579393) evaluated fostamatinib vs. placebo plus standard of care (SOC) in 59 hospitalized COVID-19 patients (manuscript pending). We initiated a phase 3 clinical study (NCT04629703) of fostamatinib for the treatment of COVID-19.

Methods

A double-blind, randomized, placebo-controlled, adaptive design, multi-center, Phase 3 study (NCT04629703) is underway to evaluate the safety and efficacy of fostamatinib in 308 adult patients with COVID-19 (Figure 2). Hospitalized patients without respiratory failure (with or without supplemental oxygen) were included. Patients with ARDS or using extracorporeal membrane oxygenation (ECMO) were excluded. Patients will receive fostamatinib 150 mg BID or placebo for 14 days; both arms receive SOC. The primary outcome will be progression to severe/critical disease (worsening in clinical status score on the 8-point ordinal scale) within 29 days of the first dose of study drug. Fostamatinib is investigational for COVID-19.

Results

Blinded update of trial in progress as of 28 April 2021. 12 patients have been randomized in North and South America. The clinical status score at Baseline was 5 (Hospitalized, requiring supplemental oxygen) in all 12 patients. Five patients had 8 adverse events (AE) (Fig 3). One AE (PE) was serious and is resolving. No deaths have been reported. At least two patients have been discharged (Day 5, Day 13) with continued dosing at home.

Conclusion

Fostamatinib has the potential to provide a treatment option for the hyperimmune complications of COVID-19.

Disclosures

Ziad Mallat, MD, PhD, Rigel Pharmaceuticals, Inc. (Consultant) Sandra Tong, MD, Rigel Pharmaceuticals, Inc. (Employee, Shareholder)

Referral to immediate postoperative care in an intensive care unit from the perspective of anesthesiologists, surgeons, and intensive care physicians: a cross-sectional questionnaire

Introduction and objective

Due to the high cost and insufficient offer, the request for Intensive Care (ICU) beds for postoperative recovery needs adequate criteria. Therefore, we studied the characteristics of patients referred to postoperative care at an ICU from the perspective of anesthesiologists, surgeons, and intensive care physicians.

Methods

A questionnaire on referrals to postoperative intensive care was applied to physicians at congresses in Brazil. Anesthesiologists, surgeons, and intensive care physicians who agreed to fill out the questionnaire were included. The questionnaire consisted of hypothetical clinical scenarios and cases for participants to choose which would be the priority for referral to the ICU.

Results

360 physicians participated in the study, with median time of 10 (5–18) years after graduation. Of the interviewees, 36.4% were anesthesiologists, 30.0% surgeons, and 33.6% intensive care physicians. We found that anesthesiologists were more conservative, and surgeons less conservative in ICU referrals. As to patients with risk of bleeding, 75.0% of the surgeons would refer them to the ICU, in contrast with 52.1% of the intensive care physicians, and 43.5% of the anesthesiologists (p < 0.001). As to elderly persons with limited reserve, 62.0% of the surgeons would refer them to the ICU, in contrast with 47.1% of the intensive care physicians, and 22.1% of the anesthesiologists (p < 0.001). As to patients with risk of respiratory complications, 64.5% of the surgeons would recommend the ICU, versus 43.0% of the intensive care physicians, and 32.1% of the anesthesiologists (p < 0.001). Intensive care physicians classified priorities better in indicating ICU, and the main risk indicator was the ASA physical status in all specialties (p < 0.001). There was no agreement among the specialties and surgeries on prioritizing post-operative intensive care.

Conclusion

Anesthesiologists, surgeons, and intensive care physicians presented different perspectives on postoperative referral to the ICU.

Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the AMIB, ABTO, BRICNet, and the General Coordination of the National Transplant System

OBJECTIVE

To contribute to updating the recommendations for brain-dead potential organ donor management.

METHOD

A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, joined a task force formed by the General Coordination Office of the National Transplant System/Brazilian Ministry of Health (CGSNT-MS), the Brazilian Association of Intensive Care Medicine (AMIB), the Brazilian Association of Organ Transplantation (ABTO), and the Brazilian Research in Intensive Care Network (BRICNet). The questions were developed within the scope of the 2011 Brazilian Guidelines for Management of Adult Potential Multiple-Organ Deceased Donors. The topics were divided into mechanical ventilation, hemodynamic support, endocrine-metabolic management, infection, body temperature, blood transfusion, and use of checklists. The outcomes considered for decision-making were cardiac arrest, number of organs recovered or transplanted per donor, and graft function/survival. Rapid systematic reviews were conducted, and the quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Two expert panels were held in November 2016 and February 2017 to classify the recommendations. A systematic review update was performed in June 2020, and the recommendations were reviewed through a Delphi process with the panelists between June and July 2020.

RESULTS

A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong (lung-protective ventilation strategy, vasopressors and combining arginine vasopressin to control blood pressure, antidiuretic hormones to control polyuria, serum potassium and magnesium control, and antibiotic use), 11 as weak (alveolar recruitment maneuvers, low-dose dopamine, low-dose corticosteroids, thyroid hormones, glycemic and serum sodium control, nutritional support, body temperature control or hypothermia, red blood cell transfusion, and goal-directed protocols), and 1 was considered a good clinical practice (volemic expansion).

CONCLUSION

Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak. The observed lack of robust evidence on the topic highlights the importance of the present guideline to improve the management of brain-dead potential organ donors.

Lesão renal aguda após cirurgias não cardíacas: incidência e impacto das disfunções orgânicas extra-renais nos desfechos

Introdução: A permanência de pacientes em Unidades de Terapia Intensiva (UTI) é frequentemente complicada por Lesão Renal Aguda (LRA), principalmente em casos de sepse, baixo débito cardíaco e pós-operatório de grandes cirurgias. Objetivo: Avaliar a incidência, características, desenvolvimento de outras disfunções orgânicas, e desfechos de pacientes com LRA adquirida na UTI após cirurgias não cardíacas. Métodos: Estudo de coorte, prospectivo. Todos os pacientes internados consecutivamente nas UTIs após cirurgias não cardíacas nos meses de abril e maio de 2017 foram analisados quanto ao desenvolvimento ou não de LRA, de outras disfunções orgânicas e ao balanço hídrico. Resultados: A incidência de LRA foi de 16,2%. Os pacientes que desenvolveram LRA no pós-operatório eram mais graves, e diferiram quanto à necessidade de ventilação mecânica (60% vs. 11%, p < 0,001), uso de drogas vasoativas (82% vs. 44%, p = 0,021); presença de infecção (80% vs. 21%, p < 0,001), sepse ou choque séptico (50% vs. 9%, p < 0,001) e a outras complicações pós-operatórias (91% vs. 58%, p = 0,023). Outras disfunções de órgãos e sistemas foram mais fre-quentes nos pacientes com IRA (2 [2-3] vs. 1 [0-1], p < 0,001), particularmente disfunção gas-trointestinal (73% vs. 19%, p < 0,001) e cardiovascular (73% vs. 33%, p = 0,015). O número de pacientes com duas ou mais disfunções orgânicas aumentou de 21% para 82% em pacientes com LRA (RR 3,89, IC: 2,18 – 6,90, p < 0,001). O tempo de internação (13 ± 9 vs. 5 ± 6 dias, p < 0,001) e a mortalidade hospitalar (54,5% vs. 7%, p = 0,013) foram maiores nos pacientes com LRA. Conclusão: Entre pacientes com cirurgias não cardíacas e necessidade de UTI, a incidência de LRA é elevada e associada a complicações de outros sistemas, incluindo os sistemas neurológico, gastrointestinal, respiratório e cardiovascular; somandose a isso, balanço hídrico acumulado positivo, sepse e choque, maior tempo de internação e maiores taxas de mortalidade também foram encontrados nesses pacientes. Palavras-Chave: Lesão Renal Aguda; Unidades de Terapia Intensiva; Epidemiologia; Fatores de Risco; Período Perioperatório.

Goal-directed therapy in patients with early acute kidney injury: a multicenter randomized controlled trial

OBJECTIVES

Acute kidney injury is associated with many conditions, and no interventions to improve the outcomes of established acute kidney injury have been developed. We performed this study to determine whether goal-directed therapy conducted during the early stages of acute kidney injury could change the course of the disease.

METHODS

This was a multicenter prospective randomized controlled study. Patients with early acute kidney injury in the critical care unit were randomly allocated to a standard care (control) group or a goal-directed therapy group with 8h of intensive treatment to maximize oxygen delivery, and all patients were evaluated during a period of 72h. ClinicalTrials.gov: NCT02414906.

RESULTS

A total of 143 patients were eligible for the study, and 99 patients were randomized. Central venous oxygen saturation was significantly increased and the serum lactate level significantly was decreased from baseline levels in the goal-directed therapy group (p=0.001) compared to the control group (p=0.572). No significant differences in the change in serum creatinine level (p=0.96), persistence of acute kidney injury beyond 72h (p=0.064) or the need for renal replacement therapy (p=0.82) were observed between the two groups. In-hospital mortality was significantly lower in the goal-directed therapy group than in the control group (33% vs. 51%; RR: 0.61, 95% CI: 0.37-1.00, p=0.048, number needed to treat=5).

CONCLUSIONS

Goal-directed therapy for patients in the early stages of acute kidney injury did not change the disease course.

Impact of immunosuppression on incidence, aetiology and outcome of ventilator-associated lower respiratory tract infections

The aim of this planned analysis of the prospective multinational TAVeM database was to determine the incidence, aetiology and impact on outcome of ventilator-associated lower respiratory tract infections (VA-LRTI) in immunocompromised patients.All patients receiving mechanical ventilation for >48 h were included. Immunocompromised patients (n=663) were compared with non-immunocompromised patients (n=2297).The incidence of VA-LRTI was significantly lower among immunocompromised than among non-immunocompromised patients (16.6% versus 24.2%; sub-hazard ratio 0.65, 95% CI 0.53-0.80; p<0.0001). Similar results were found regarding ventilator-associated tracheobronchitis (7.3% versus 11.6%; sub-hazard ratio 0.61, 95% CI 0.45-0.84; p=0.002) and ventilator-associated pneumonia (9.3% versus 12.7%; sub-hazard ratio 0.72, 95% CI 0.54-0.95; p=0.019). Among patients with VA-LRTI, the rates of multidrug-resistant bacteria (72% versus 59%; p=0.011) and intensive care unit mortality were significantly higher among immunocompromised than among non-immunocompromised patients (54% versus 30%; OR 2.68, 95% CI 1.78-4.02; p<0.0001). In patients with ventilator-associated pneumonia, mortality rates were higher among immunocompromised than among non-immunocompromised patients (64% versus 34%; p<0.001).Incidence of VA-LRTI was significantly lower among immunocompromised patients, but it was associated with a significantly higher mortality rate. Multidrug-resistant pathogens were more frequently found in immunocompromised patients with VA-LRTI.

Dexmedetomidine as an Anesthetic Adjuvant in Cardiac Surgery: a Cohort Study

OBJECTIVE:

α-₂-agonists cause sympathetic inhibition combined with parasympathetic activation and have other properties that could be beneficial during cardiac anesthesia. We evaluated the effects of dexmedetomidine as an anesthetic adjuvant compared to a control group during cardiac surgery.

METHODS:

We performed a retrospective analysis of prospectively collected data from all adult patients (> 18 years old) undergoing cardiac surgery. Patients were divided into two groups, regarding the use of dexmedetomidine as an adjuvant intraoperatively (DEX group) and a control group who did not receive α-₂-agonist (CON group).

RESULTS:

A total of 1302 patients who underwent cardiac surgery, either coronary artery bypass graft or valve surgery, were included; 796 in the DEX group and 506 in the CON group. Need for reoperation (2% vs. 2.8%, P=0.001), type 1 neurological injury (2% vs. 4.7%, P=0.005) and prolonged hospitalization (3.1% vs. 7.3%, P=0.001) were significantly less frequent in the DEX group than in the CON group. Thirty-day mortality rates were 3.4% in the DEX group and 9.7% in the CON group (P<0.001). Using multivariable Cox regression analysis with in hospital death as the dependent variable, dexmedetomidine was independently associated with a lower risk of 30-day mortality (odds ratio [OR]=0.39, 95% confidence interval [CI]: 0.24-0.65, P≤0.001). The Logistic EuroSCORE (OR=1.05, 95% CI: 1.02-1.10, P=0.004) and age (OR=1.03, 95% CI: 1.01-1.06, P=0.003) were independently associated with a higher risk of 30-day mortality.

CONCLUSION:

Dexmedetomidine used as an anesthetic adjuvant was associated with better outcomes in patients undergoing coronary artery bypass graft and valve surgery. Randomized prospective controlled trials are warranted to confirm our results.

Pulmonary complications after non-cardiac surgeries: temporal patterns and risk factors

BACKGROUND

Postoperative complications are the primary determinants of survival following major surgery. We aimed to characterize the early perioperative risk factors for postoperative pulmonary complications (POPCs) in patients undergoing major non-cardiac surgeries.

METHODS

This study utilized a multicenter prospective observational cohort design. Adult patients undergoing non-cardiac surgeries and admitted to 21 Brazilian ICUs were screened for inclusion in the study. POPCs were defined as the presence of acute pulmonary oedema, nosocomial pneumonia, and extubation failure in the postoperative period.

RESULTS

Of the 581 patients enrolled, 110 (19%) had at least one POPC, of whom 5% had acute pulmonary oedema, 10% extubation failure while 10% had pneumonia. Most cases of pulmonary oedema occurred in the first week after surgery, while pneumonia was more frequently a later occurrence. The mortality rate was significantly higher in the group with POPCs compared to the group of patients without POPCs (62% vs. 11%, RR: 5.1, 95% CI: 4.23-7.69; P < 0.001). A low functional capacity (RR: 4.6, 95% CI: 2.1-10.0), major surgery (RR: 3.6, 95% CI: 1.2-10.7), preoperative hemodynamic instability (RR: 3.4, 95% CI: 1.1-10.6), alcoholism (RR: 3.3, 95% CI: 1.0-10.7), unplanned surgery (RR: 2.3, 95% CI: 1.0-5.2), the SOFA score (RR: 1.1, 95% CI: 1.0-1.2), and increased central venous pressure (RR: 1.1, 95% CI: 1.0-1.1) were independent predictors of POPCs.

CONCLUSIONS

Pulmonary complications are common in intensive care units after major non-cardiac surgeries. Awareness of the risk factors for POPCs may help multidisciplinary teams develop strategies to prevent these complications.

FUNCIONALIDADE E COMPLICAÇÕES EM PACIENTES GRAVEMENTE ENFERMOS REINTERNADOS NO HOSPITAL

Introdução: Pacientes com longo tempo de internação em Unidade de Terapia Intensiva, especialmente os que necessitam de sedação e de suporte ventilatório prolongado, estão sujeitos a maior perda de massa muscular e óssea. Objetivos: Avaliar a funcionalidade, as complicações decorrentes do processo de hospitalização em pacientes reinternados e com necessidade de suporte ventilatório após alta da Unidade de Terapia Intensiva e descrever intervenções possíveis da Terapia Ocupacional. Casuística e Métodos: Estudo de coorte prospectivo realizado no Hospital de Base de São José do Rio Preto – SP, entre os meses de Junho e Outubro de 2014. Foram incluídos pacientes adultos readmitidos no hospital e que em algum momento da internação atual fizeram uso da ventilação mecânica em unidades de cuidados intensivos. Foi elaborado um questionário sobre as Atividades de Vida Diária, capacidade de deambulação e complicações decorrentes do processo de hospitalização. Resultados: O total de internações, em enfermarias, foi de 11.979 pacientes, dos quais 544 (4,5%) eram reinternados. Destes, um total de 200 pacientes fizeram uso de ventilação mecânica invasiva em algum momento da hospitalização e foram incluídos no estudo. Após a alta das Unidades de Terapia Intensiva mais de 80 % dos pacientes apresentavam dependência funcional parcial ou total para as Atividades de Vida Diária. Verificou-se ainda alta prevalência de perda de peso (51%), 13% desenvolveram lesão cutânea por pressão, 12% necessitaram de sonda enteral para suporte nutricional e 11% precisaram de traqueostomia. Mais da metade dos pacientes apresentaram tempo de internação prolongada. Conclusão: A maioria dos pacientes reinternados e que necessitaram de ventilação mecânica apresentaram complicações e importante comprometimento funcional após alta da Unidade de Terapia Intensiva. É relevante refletir sobre a inserção da equipe multidisciplinar na assistência hospitalar durante a internação, entre eles o terapeuta ocupacional, objetivando reduzir complicações secundárias, novas reinternações e os custos desse processo.

The use of 2% chlorhexidine gel and toothbrushing for oral hygiene of patients receiving mechanical ventilation: effects on ventilator-associated pneumonia

Objective

To evaluate the effects of oral chlorhexidine hygiene with toothbrushing on the rate of ventilator-associated pneumonia in a mixed population of critically ill patients under prolonged mechanical ventilation.

Methods

Prospective, randomized, and placebo-controlled pilot study. Patients who were receiving mechanical ventilation, had been admitted less than 24 hours prior, and were anticipated to require mechanical ventilation for more than 72 hours were included in the study. The patients were randomly divided into one of the following groups: chlorhexidine hygiene with toothbrushing or a placebo group (gel with the same color and consistency and toothbrushing).

Results

The planned interim analysis was conducted using 52 patients, and the study was terminated prematurely. In total, 28 patients were included in the chlorhexidine / toothbrushing group, and 24 patients were included in the placebo group. Ventilator-associated pneumonia occurred in 45.8% of the placebo group and in 64.3% of the chlorhexidine hygiene with toothbrushing group (RR=1.4; 95% CI=0.83-2.34; p=0.29).

Conclusion

Because the study was terminated due to futility, it was not possible to evaluate the impact of oral hygiene using 2% chlorhexidine and toothbrushing on the incidence of ventilator-associated pneumonia in this heterogeneous population of critical patients receiving long-term mechanical ventilation, and no beneficial effect was observed for this intervention.

Markers and mediators of inflammatory response in infection and sepsis

BACKGROUND AND OBJECTIVES

Sepsis is the expression of a complex network of mediators. Multiple organ dysfunction and septic shock indeed remain a major cause of death among ICU patients worldwide. Prompt recognition of both the diagnosis and the complicated evolution are essential, hence the importance of using biological markers. The main pro-inflammatory and anti-inflammatory cytokines as well as hundreds of others cellular markers, circulating bioactive molecules or coagulation products are potential biological markers that could help to characterize the presence of infection and sepsis. We aimed to review the main biological markers that could be used nowadays or possibly in the future, either in clinical or research fields.

CONTENTS

A selective review of biologic markers of sepsis focusing on markers of the coagulation cascade, C-reactive protein and procalcitonin.

CONCLUSIONS

Most of the available biological markers is still not a practical method to be used at the bed-side and is currently restricted to research works. Nowadays the determination of CRP or PCT serum levels can be of great help in the critically ill patient care along with the conventional parameters.

Severe virus influenza A H1N1 related pneumonia and community-acquired pneumonia: differences in the evolution

OBJECTIVE

To analyze the clinical, laboratory and evolution data of patients with severe influenza A H1N1 pneumonia and compare the data with that of patients with severe community-acquired bacterial pneumonia.

METHODS

Cohort and retrospective study. All patients admitted to the intensive care unit between May 2009 and December 2010 with a diagnosis of severe pneumonia caused by the influenza A H1N1 virus were included in the study. Thirty patients with severe community-acquired pneumonia admitted within the same period were used as a control group. Severe community-acquired pneumonia was defined as the presence of at least one major severity criteria (ventilator or vasopressor use) or two minor criteria.

RESULTS

The data of 45 patients were evaluated. Of these patients, 15 were infected with H1N1. When compared to the group with community-acquired pneumonia, patients from the H1N1 group had significantly lower leukocyte counts on admission (6,728±4,070 versus 16,038±7,863; p<0.05) and lower C-reactive protein levels (Day 2: 15.1±8.1 versus 22.1±10.9 mg/dL; p<0.05). The PaO2/FiO2 ratio values were lower in the first week in patients with H1N1. Patients who did not survive the H1N1 severe pneumonia had significantly higher levels of C-reactive protein and higher serum creatinine levels compared with patients who survived. The mortality rate was significantly higher in the H1N1 group than in the control group (53% versus 20%; p=0.056, respectivelly).

CONCLUSION

Differences in the leukocyte count, C-reactive protein concentrations and oxygenation profiles may contribute to the diagnosis and prognosis of patients with severe influenza A H1N1 virus-related pneumonia and community-acquired pneumonia.

Serum C-reactive protein concentrations in early abdominal and pulmonary sepsis

Objectives

To evaluate the C-reactive protein serum levels in patients with pulmonary and abdominal sepsis during the first five days of sepsis progression.

Methods

The present investigation was a retrospective cohort study conducted at the university hospital with 345 patients who were admitted to the intensive care unit and diagnosed with sepsis of pulmonary or abdominal origin. Serum C-reactive protein concentrations were measured by the turbidimetric immunoassay. For analysis of C-reactive protein, day 1 was defined as the day on which the patient was clinically diagnosed with sepsis.

Results

Thirty-four patients with sepsis (9.8%), 114 patients with severe sepsis (33.0%), and 197 patients with septic shock (57.2%) were evaluated. The age of the patients was 56.4±19.8 years. The serum C-reactive protein concentrations were higher on the day of sepsis diagnosis in the group with abdominal infection compared with the group with pulmonary sepsis (17.8±10.1 mg/dL versus 14.9±11.1 mg/dL, p=0.025) and remained significantly higher during the first five days of sepsis progression.

Conclusion

The serum C-reactive protein concentrations were significantly higher in the patients with abdominal sepsis compared with the patients with pulmonary sepsis during the first five days of sepsis progression.

Differences in sepsis treatment and outcomes between public and private hospitals in Brazil: a multicenter observational study

Background

Previous studies showed higher sepsis mortality rates in Brazil compared to other developed or developing countries. Moreover, another trial demonstrated an increased mortality rate in public hospitals compared to private hospitals in Brazil. The reasons for these findings may include delayed recognition and inadequate treatment of sepsis in public facilities. We designed this study to evaluate the factors associated with mortality in septic patients admitted to intensive care units in a network of public and private institutions.

Materials and Methods

This study is a retrospective analysis of a prospective cohort of sepsis patients in 19 private and public institutions in Brazil. We analyzed data from the original database and collected additional data to assess compliance to the treatment guidelines and to determine the time from the onset of organ dysfunction and the sepsis diagnosis by the healthcare team.

Results

A total of 396 patients were analyzed. Patients in public hospitals were younger, had a greater number of dysfunctional organs at baseline and a lower chance to have sepsis diagnosed within two hours of the onset of organ dysfunction. Private hospitals had a better compliance to lactate and blood culture sampling and maintenance of glycemic control. The multivariate analysis showed that age, disease severity at baseline and being treated at a public hospital were independent risk factors for mortality. A delay in the sepsis diagnosis of longer than two hours was associated with mortality only in the public setting.

Conclusions

We confirmed a lower sepsis mortality rate in the private hospitals of this network. Being treated in a public hospital was an independent factor for mortality. Delayed recognition of sepsis was more frequent in public institutions and this might have been associated with a higher mortality. Improving sepsis recognition and early diagnosis may be important targets in public institutions.

Sequential C-reactive protein measurements in patients with serious infections: does it help?

C-reactive protein (CRP) is a marker of inflammation traditionally used as a complementary tool to support the clinical diagnosis and as a marker of severity of disease. CRP is an acute-phase protein synthesized by the liver after stimulus by cytokines and its serum levels increase markedly within hours after the onset of infection, inflammation or tissue injury. Dynamic serial measurement of CRP has been widely used to help therapeutic decision-making. Decreasing plasma concentrations of this biomarker have been used as an indicator for resolution of infection or sepsis.

Clinical-pathological discrepancies in critically ill patients with difficult premortem diagnoses

INTRODUCTION

The importance of autopsies is a common theme of discussions both in Brazil and around the world as it elucidates causes of death and has wide ranging social value. However this is a practice that is gradually being considered unnecessary and there have been a decline in the number of postmortems examinations.

OBJECTIVES

To compare clinical and pathological diagnosis in critically ill patients with difficult premortem diagnosis.

METHODS

All autopsy cases (total of 98) from any of the three general medical/surgical intensive care units (78 beds in total) affiliated to the medical school from January 2003 to December 2006 were analyzed. We analyzed the clinical and pathological diagnosis based on the Goldman criteria.

RESULTS

In 49 (50%) cases, there were class I and II of Goldman. In contrast, only 30 (30.6%) had a complete agreement between premortem and postmortem diagnosis and were classified as class V. Infections had a significantly greater rate of concordant diagnosis than cardiovascular diseases.

CONCLUSION

We found significant discrepancies between clinical and pathological findings, reinforcing the value of postmortem examination.

C-reactive protein: a tool in the follow-up of nosocomial pneumonia

OBJECTIVES

The aim of this study was to examine the clinical usefulness of serial C-reactive protein (CRP) dosages in patients with nosocomial pneumonia (NP).

METHODS

Prospective and observational study performed in a 24-beds Intensive Care Unit. Sixty four patients with NP, including non-ventilated patients and those with ventilator-associated pneumonia were included. Daily measurements of CRP were performed and CRP ratios were calculated from the day of antibiotic prescription (D0) until day 10. Patients were than classified according to the CRP ratios in 2 groups: 'good' response (CRP ratios lower than 0.67 at day 10) and 'poor' response (non-response or bi-phasic response).

RESULTS

The poor response group (n = 34) had a mortality rate of 53% in comparison to 20% in the good response group (n = 30) (RR = 2.65; 95% CI, 1.21-5.79, p = 0.01). Significant differences between the two groups were found on CRP ratios at Day 4 (p = 0.01). The adequacy of antibiotic therapy was much lower in the group poor response in comparison to the group good response, 14% vs. 67% (p = 0.008), respectively.

CONCLUSIONS

Daily CRP measurements in patients with nosocomial pneumonia may be useful in the identification of patients with poor outcome, as early as day 4, and detect patients with inappropriate antimicrobial therapy.

Prolonged gastrointestinal dysfunction in critically ill patients

OBJECTIVE

We aimed to investigate the prevalence and independent predictors of prolonged gastrointestinal dysfunction in critically ill patients admitted to the intensive care unit.

METHODS

Retrospective and observational cohort study performed in a mixed 24 beds intensive care unit in a tertiary center. Patients admitted in the intensive care unit between August 2003 and January 2004, who had a length of stay in the intensive care unit greater than 4 days were enrolled. Gastrointestinal function was evaluated daily according to a classification that considered physical examination (bowel sounds or distension) and the nutritional support progress.

RESULTS

Were included 128 patients. The mean age was 56 ± 19 years, 63.3% were male and 77.3% were surgical patients. Prolonged gastrointestinal dysfunction occurred in 35% of patients, with prevalence 3.3 times higher in surgical patients (27%) than in medical patients (8%). Endoscopies were performed in 38 patients (29.7%), and in three quarters of them erosive lesions and or bleeding were observed. Gastrointestinal dysfunction was more frequent in patients presenting moderate or severe edema (51%) than in patients without edema (22.5%) (p<0.05). In the logistic regression analysis, a serum lactate level higher than 5.2 mEq/L (RR 6.69 95%CI 15-38.7, P = 0.034) and the presence of a low oxygenation index (RR 12.4 95%CI 2.18-70.8, p = 0.005) were predictive of gastrointestinal dysfunction.

CONCLUSION

Prolonged gastrointestinal dysfunction was highly prevalent in this heterogeneous population of critically ill patients. Admission high serum lactate levels and a low oxygenation index were predictive of prolonged gastrointestinal dysfunction.

Chryseobacterium indologenes infection: a case report

A case of Chryseobacterium indologenes infection is reported, identified in an invasive mechanic ventilation patient's tracheal aspiration material. Epidemiological, microbiological, and intensive care unit therapy aspects are discussed. The patient was a 30 years-old male, admitted with idiopathic medullary aplasia and febrile neutropenia, referred to the intensive care unit with severe bronchopneumonia and sepsis of pulmonary origin. Most of the previously reported Chryseobacterium indologenes infection cases were associated with severe diseases and polymicrobial infections which could make difficult interpreting antimicrobial therapy options against this agent.

RF tumour ablation: Computer simulation and mathematical modelling of the effects of electrical and thermal conductivity

This study determined the effects of thermal conductivity on RF ablation tissue heating using mathematical modelling and computer simulations of RF heating coupled to thermal transport. Computer simulation of the Bio-Heat equation coupled with temperature-dependent solutions for RF electric fields (ETherm) was used to generate temperature profiles 2 cm away from a 3 cm internally-cooled electrode. Multiple conditions of clinically relevant electrical conductivities (0.07-12 S m-1) and 'tumour' radius (5-30 mm) at a given background electrical conductivity (0.12 S m-1) were studied. Temperature response surfaces were plotted for six thermal conductivities, ranging from 0.3-2 W m-1 degrees C (the range of anticipated clinical and experimental systems). A temperature response surface was obtained for each thermal conductivity at 25 electrical conductivities and 17 radii (n=425 temperature data points). The simulated temperature response was fit to a mathematical model derived from prior phantom data. This mathematical model is of the form (T=a+bRc exp(dR) s(f) exp(g)(s)) for RF generator-energy dependent situations and (T=h+k exp(mR)+n?exp(p)(s)) for RF generator-current limited situations, where T is the temperature (degrees C) 2 cm from the electrode and a, b, c, d, f, g, h, k, m, n and p are fitting parameters. For each of the thermal conductivity temperature profiles generated, the mathematical model fit the response surface to an r2 of 0.97-0.99. Parameters a, b, c, d, f, k and m were highly correlated to thermal conductivity (r2=0.96-0.99). The monotonic progression of fitting parameters permitted their mathematical expression using simple functions. Additionally, the effect of thermal conductivity simplified the above equation to the extent that g, h, n and p were found to be invariant. Thus, representation of the temperature response surface could be accurately expressed as a function of electrical conductivity, radius and thermal conductivity. As a result, the non-linear temperature response of RF induced heating can be adequately expressed mathematically as a function of electrical conductivity, radius and thermal conductivity. Hence, thermal conductivity accounts for some of the previously unexplained variance. Furthermore, the addition of this variable into the mathematical model substantially simplifies the equations and, as such, it is expected that this will permit improved prediction of RF ablation induced temperatures in clinical practice.

Effects of respiratory physiotherapy on intracranial pressure and cerebral perfusion pressure in severe traumatic brain injury patients

OBJECTIVE

After brain injury intracranial hypertension is the major cause of mortality, in addition to the possibility of functional, behavioral and cognitive sequels. Scarcity of studies on the effects of respiratory physiotherapy on these patients may lead to contradictory performances. This study aimed to assess the effects of customary respiratory physiotherapy maneuvers on intracranial and cerebral perfusion pressures in patients with severe brain injury.

METHODS

Clinical, prospective trial with patients with severe traumatic brain injury, mechanically ventilated and with a continued measurement of intracranial pressure. The effects of manual vibrocompression maneuvers and intratracheal aspiration with or without saline infusion on the measurements of intracranial and cerebral perfusion pressures, between the first and third day after cerebral injury were evaluated.

RESULTS

Data were collected from 11 patients, 41 years of age (median) and APACHE II of 19.5 ± 5. The manual vibrocompression maneuver did not cause an increase of intracranial pressure on any of the days assessed. Intracranial pressure significantly increased after intratracheal aspiration maneuvers in relation to the basal measurement (day1, 9.5 ± 0.9 mm Hg vs 18.0 ± 3.2 mm Hg; day 2, 10.6 ± 1.7 mm Hg vs 21.4 ± 3.8 mm Hg; day 3, 14.4 ± 1.0 vs 24.9 ± 2.7 mm Hg; p<0.05 for all). However, these elevations were transient (about 27 seconds) and accompanied by compensatory increases of the cerebral perfusion pressure.

CONCLUSION

The manual vibrocompression maneuver did not increase intracranial pressure or cerebral perfusion pressure in patients with severe brain injury. Intratracheal aspiration induced a significant and transient increase of the intracranial and cerebral perfusion pressures.

Epidemiology and outcomes of non-cardiac surgical patients in Brazilian intensive care units

OBJECTIVES

Due to the dramatic medical breakthroughs and an increasingly ageing population, the proportion of patients who are at risk of dying following surgery is increasing over time. The aim of this study was to evaluate the outcomes and the epidemiology of non-cardiac surgical patients admitted to the intensive care unit.

METHODS

A multicenter, prospective, observational, cohort study was carried out in 21 intensive care units. A total of 885 adult surgical patients admitted to a participating intensive care unit from April to June 2006 were evaluated and 587 patients were enrolled. Exclusion criteria were trauma, cardiac, neurological, gynecologic, obstetric and palliative surgeries. The main outcome measures were postoperative complications and intensive care unit and 90-day mortality rates.

RESULTS

Major and urgent surgeries were performed in 66.4% and 31.7% of the patients, respectively. The intensive care unit mortality rate was 15%, and 38% of the patients had postoperative complications. The most common complication was infection or sepsis (24.7%). Myocardial ischemia was diagnosed in only 1.9% of the patients. A total of 94 % of the patients who died after surgery had co-morbidities at the time of surgery (3.4 ± 2.2). Multiple organ failure was the main cause of death (53%).

CONCLUSION

Sepsis is the predominant cause of morbidity in patients undergoing non-cardiac surgery. In this patient population, multiple organ failure prevailed as the most frequent cause of death in the hospital.

Efficacy and safety of doripenem versus piperacillin/tazobactam in nosocomial pneumonia: a randomized, open-label, multicenter study

OBJECTIVE

Doripenem is a new carbapenem that has broad-spectrum activity against bacterial pathogens commonly responsible for nosocomial pneumonia (NP). It has several advantages over currently available carbapenems and other classes of drugs used in this indication. This prospective, randomized, open-label, multicenter study was designed to establish whether doripenem was noninferior to piperacillin/tazobactam in NP.

METHODS

Adults (n=448) with signs and symptoms of NP, including non-ventilated patients and those ventilated for <5 days, were stratified by ventilation mode, illness severity (Acute Physiology and Chronic Health Evaluation II score), and geographic region and then randomly allocated to treatment with doripenem 500 mg every 8 h by a 1-h intravenous (IV) infusion or piperacillin/tazobactam 4.5 g every 6 h by 30-min IV infusion. After receiving IV study drug for at least 72 h, eligible patients could be switched to oral levofloxacin 750 mg once daily. Antibiotic therapy was continued for a total of 7-14 days. The primary endpoint was the clinical cure rate, assessed 7-14 days after treatment completion, in clinically evaluable patients and in the clinical modified intent-to-treat population (cMITT).

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00211003.

RESULTS

Doripenem was noninferior to piperacillin/tazobactam. Clinical cure rates in clinically evaluable patients (n=253) were 81.3% in the doripenem arm and 79.8% in the piperacillin/tazobactam arm (between-treatment difference: 1.5%; 95% confidence interval [CI], -9.1 to 12.1%) and in the cMITT population 69.5% and 64.1%, respectively, (between-treatment difference: 5.4%; 95% CI, -4.1 to 14.8%). Baseline resistance of Klebsiella pneumoniae and Pseudomonas aeruginosa to piperacillin/tazobactam was 44% and 26.9%, respectively; a doripenem minimum inhibitory concentration (MIC) >8 mug/mL occurred in 0% and 7.7%, respectively. Favorable microbiological outcome rates against Gram-negative pathogens were numerically higher with doripenem than with piperacillin/tazobactam, but the difference was not statistically significant. Both study drugs were generally well tolerated, as only 16.1% and 17.6% of patients receiving doripenem and piperacillin/tazobactam, respectively, had a drug-related adverse event. Study limitations included the open-label design, the low rate of monotherapy (adjunctive use of aminoglycoside was required when P. aeruginosa was suspected), and the exclusion of the most critically ill and immunocompromized patients.

CONCLUSIONS

Doripenem was clinically and microbiologically effective in patents with NP, including those with early-onset ventilator-associated pneumonia, and was therapeutically noninferior to piperacillin/tazobactam.

[Hantavirus pulmonary syndrome with multiple organ dysfunctions: case report]

BACKGROUND AND OBJECTIVES

Hantavirus infection is a zoonose with worldwide distribution. The transmission is related to the intimal contact with rodents. It causes two syndromes: hemorrhagic fever with renal syndrome (HFRS), endemic in Asia and Europe and the Hantavirus pulmonary syndrome (HPS), found in the American continent, including Brazil, with high mortality rates. The aim of this study is to report a case of HPS with multiple organ failure, managed with early goal-directed therapy guided by flow and tissue perfusion parameters.

CASE REPORT

A 36 year-old male had fever with progressive dispnea, severe hypoxia and acute respiratory failure. Diffuse interstitial alveolar infiltrates were seen in the chest X-Ray. He developed multiple organ dysfunction syndromes (pulmonary, renal, coagulation, cardiovascular and metabolic). Treatment and invasive hemodynamic monitoring with pulmonary artery catheter was early instituted. The most important laboratory findings were thrombocytopenia, elevated hematocrit and hemoglobin concentrations, elevated liver enzymes, elevated lactate dehydrogenase and a positive sorology for Hantavirus (ELISA IgM positive). Organ dysfunctions reverted to normal and he was discharged after 21 days in hospital.

CONCLUSIONS

An early and adequate resuscitation with goal-directed therapy enabled the reversion of the multiple organ failure syndromes and a favorable outcome, despite the severity of the disease.