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Vizzacchi BA, Pezzini TR, de Souza JM, Caruso P, Nassar AP. Long-term mortality of critically ill patients with cancer and delirium who survived to discharge: a retrospective cohort study. Can J Anaesth 2023; 70:1789-1796. [PMID: 37610551 DOI: 10.1007/s12630-023-02538-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/20/2023] [Accepted: 03/20/2023] [Indexed: 08/24/2023] Open
Abstract
PURPOSE Delirium is common in critically ill patients and has been associated with lower short-term survival; however, its association with long-term survival has been scarcely evaluated and few studies have shown divergent results. METHODS We conducted a retrospective cohort study of adult patients with cancer admitted to the intensive care unit (ICU) and discharged from hospital from January 2015 to December 2018. We considered delirium present if the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) result was positive. We assessed the association between delirium during ICU stay and long-term mortality (up to three years after discharge). We also assessed the association between delirium type (hypoactive, hyperactive, and mixed) with long-term mortality. RESULTS We included 3,079 patients. Of these, 430 (14%) were considered delirious at some point during their ICU stay. Delirium was associated with one-year mortality after hospital discharge (hazard ratio [HR], 1.58; 95% confidence interval [CI], 1.36 to 1.83) after adjustment for potential confounders, but not with one to three year-mortality (HR, 0.92; 95% CI, 0.61 to 1.39). Hypoactive and mixed delirium were associated with one-year mortality (HR, 1.77; 95% CI, 1.46 to 2.14 and HR, 1.56; 95% CI, 1.21 to 2.00, respectively), but none of the delirium motor types was associated with one to three-year mortality. CONCLUSIONS We observed that delirium during ICU stay was associated with increased one-year mortality, but was not with mortality after one year. This association was observed in hypoactive and mixed delirium types but not with hyperactive delirium.
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Affiliation(s)
- Barbara A Vizzacchi
- Rehabilitation and Palliative Care Supervision, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Tainara R Pezzini
- Scientific Research Program for Undergraduates, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Jessica M de Souza
- Scientific Research Program for Undergraduates, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Pedro Caruso
- Intensive Care Unit, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Antonio Paulo Nassar
- Intensive Care Unit, A. C. Camargo Cancer Center, São Paulo, SP, Brazil.
- Program to Support Institutional Development of the Brazil's Unified Health System, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
- , Rua Professor Antonio Prudente, 211, 6th Floor, São Paulo, CEP 01509-001, Brazil.
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Affiliation(s)
- Antonio Paulo Nassar
- Department of Critical Care, A.C. Camargo Cancer Center, Rua Professor Antonio Prudente, 211, 6th Floor, Intensive Care Unit, São Paulo, SP, CEP 01509-0100, Brazil.
| | - Eugene Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, and the Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, Canada
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Silva CMD, Germano JN, Costa AKDA, Gennari GA, Caruso P, Nassar AP. Association of appropriateness for ICU admission with resource use, organ support and long-term survival in critically ill cancer patients. Intern Emerg Med 2023; 18:1191-1201. [PMID: 36800071 DOI: 10.1007/s11739-023-03216-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 02/02/2023] [Indexed: 02/18/2023]
Abstract
We aimed to evaluate the characteristics, resource use and outcomes of critically ill patients with cancer according to appropriateness of ICU admission. This was a retrospective cohort study of patients with cancer admitted to ICU from January 2017 to December 2018. Patients were classified as appropriate, potentially inappropriate, or inappropriate for ICU admission according to the Society of Critical Care Medicine guidelines. The primary outcome was ICU length of stay (LOS). Secondary outcomes were one-year, ICU, and hospital mortality, hospital LOS and utilization of ICU organ support. We used logistic regression and competing risk models accounting for relevant confounders in primary outcome analyses. From 6700 admitted patients, 5803 (86.6%) were classified as appropriate, 683 (10.2%) as potentially inappropriate and 214 (3.2%) as inappropriate for ICU admission. Potentially inappropriate and inappropriate ICU admissions had lower likelihood of being discharged from the ICU than patients with appropriate ICU admission (sHR 0.55, 95% CI 0.49-0.61 and sHR 0.65, 95% CI 0.53-0.81, respectively), and were associated with higher 1-year mortality (OR 6.39, 95% CI 5.60-7.29 and OR 11.12, 95% CI 8.33-14.83, respectively). Among patients with appropriate, potentially inappropriate, and inappropriate ICU admissions, ICU mortality was 4.8%, 32.6% and 35.0%, and in-hospital mortality was 12.2%, 71.6% and 81.3%, respectively (p < 0.01). Use of organ support was more common and longer among patients with potentially inappropriate ICU admission. The findings of our study suggest that inappropriateness for ICU admission among patients with cancer was associated with higher resource use in ICU and higher one-year mortality among ICU survivors.
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Affiliation(s)
- Carla Marchini Dias Silva
- Intensive Care Unit, A.C.Camargo Cancer Center, São Paulo, Brazil.
- Intensive Care Unit, Hospital Vila Nova Star, São Paulo, Brazil.
| | | | | | - Giovanna Alves Gennari
- A.C.Camargo Cancer Center, São Paulo, Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Pedro Caruso
- Intensive Care Unit, A.C.Camargo Cancer Center, São Paulo, Brazil
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Zampieri FG, Cavalcanti AB, Taniguchi LU, Lisboa TC, Serpa-Neto A, Azevedo LCP, Nassar AP, Miranda TA, Gomes SPC, de Alencar Filho MS, da Silva RTA, Lacerda FH, Veiga VC, de Oliveira Manoel AL, Biondi RS, Maia IS, Lovato WJ, de Oliveira CD, Pizzol FD, Filho MC, Amendola CP, Westphal GA, Figueiredo RC, Caser EB, de Figueiredo LM, de Freitas FGR, Fernandes SS, Gobatto ALN, Paranhos JLR, de Melo RMV, Sousa MT, de Almeida GMB, Ferronatto BR, Ferreira DM, Ramos FJS, Thompson MM, Grion CMC, Santos RHN, Damiani LP, Machado FR. Attributable mortality due to nosocomial sepsis in Brazilian hospitals: a case-control study. Ann Intensive Care 2023; 13:32. [PMID: 37099045 PMCID: PMC10133434 DOI: 10.1186/s13613-023-01123-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/24/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Nosocomial sepsis is a major healthcare issue, but there are few data on estimates of its attributable mortality. We aimed to estimate attributable mortality fraction (AF) due to nosocomial sepsis. METHODS Matched 1:1 case-control study in 37 hospitals in Brazil. Hospitalized patients in participating hospitals were included. Cases were hospital non-survivors and controls were hospital survivors, which were matched by admission type and date of discharge. Exposure was defined as occurrence of nosocomial sepsis, defined as antibiotic prescription plus presence of organ dysfunction attributed to sepsis without an alternative reason for organ failure; alternative definitions were explored. Main outcome measurement was nosocomial sepsis-attributable fractions, estimated using inversed-weight probabilities methods using generalized mixed model considering time-dependency of sepsis occurrence. RESULTS 3588 patients from 37 hospitals were included. Mean age was 63 years and 48.8% were female at birth. 470 sepsis episodes occurred in 388 patients (311 in cases and 77 in control group), with pneumonia being the most common source of infection (44.3%). Average AF for sepsis mortality was 0.076 (95% CI 0.068-0.084) for medical admissions; 0.043 (95% CI 0.032-0.055) for elective surgical admissions; and 0.036 (95% CI 0.017-0.055) for emergency surgeries. In a time-dependent analysis, AF for sepsis rose linearly for medical admissions, reaching close to 0.12 on day 28; AF plateaued earlier for other admission types (0.04 for elective surgery and 0.07 for urgent surgery). Alternative sepsis definitions yield different estimates. CONCLUSION The impact of nosocomial sepsis on outcome is more pronounced in medical admissions and tends to increase over time. The results, however, are sensitive to sepsis definitions.
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Affiliation(s)
- Fernando G Zampieri
- HCor Research Institute, Rua Desembargador Eliseu Guilherme, 200, 8th Floor, São Paulo, Brazil.
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124E Clinical Sciences Building, 8440-112 St NW, Edmonton, AB, T6G2B7, Canada.
| | - Alexandre B Cavalcanti
- HCor Research Institute, Rua Desembargador Eliseu Guilherme, 200, 8th Floor, São Paulo, Brazil
| | - Leandro U Taniguchi
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Intensive Care Unit, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Thiago C Lisboa
- HCor Research Institute, Rua Desembargador Eliseu Guilherme, 200, 8th Floor, São Paulo, Brazil
- Unidade de Terapia Intensiva, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Ary Serpa-Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Luciano C P Azevedo
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Intensive Care Unit, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | | | - Tamiris A Miranda
- HCor Research Institute, Rua Desembargador Eliseu Guilherme, 200, 8th Floor, São Paulo, Brazil
| | - Samara P C Gomes
- HCor Research Institute, Rua Desembargador Eliseu Guilherme, 200, 8th Floor, São Paulo, Brazil
| | | | | | | | | | | | - Rodrigo S Biondi
- Instituto de Cardiologia do Distrito Federal, Brasilia, DF, Brazil
| | - Israel S Maia
- HCor Research Institute, Rua Desembargador Eliseu Guilherme, 200, 8th Floor, São Paulo, Brazil
- Hospital Nereu Ramos, Florianópolis, SC, Brazil
- Hospital Baía Sul, Florianópolis, SC, Brazil
| | - Wilson J Lovato
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | | | | | | | | | | | | | | | | | - Flávio Geraldo R de Freitas
- Hospital e Maternidade Sepaco, Sao Paulo, SP, Brazil
- Department of Anesthesiology, Pain and Critical Care-Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
| | | | | | | | | | | | | | | | - Denise M Ferreira
- Hospital das Clínicas da Universidade Federal de Goiás, Goiânia, GO, Brazil
| | | | - Marlus M Thompson
- Hospital Evangélico de Cachoeiro de Itapemirim, Cachoeiro de Itapemirim, ES, Brazil
| | - Cintia M C Grion
- Hospital Universitário Regional do Norte do Paraná, Londrina, PR, Brazil
| | | | - Lucas P Damiani
- HCor Research Institute, Rua Desembargador Eliseu Guilherme, 200, 8th Floor, São Paulo, Brazil
| | - Flavia R Machado
- Department of Anesthesiology, Pain and Critical Care-Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
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de Almeida MJ, Camandaroba MPG, Nassar AP, de Jesus VHF. Short-term survival of patients with advanced pancreatic cancer admitted to intensive care unit: a retrospective cohort study. Ecancermedicalscience 2022; 16:1475. [PMID: 36819828 PMCID: PMC9934886 DOI: 10.3332/ecancer.2022.1475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Indexed: 11/24/2022] Open
Abstract
Background Little is known about the outcomes of patients with advanced pancreatic cancer admitted to the intensive care unit (ICU) due to medical complications. We designed a study to evaluate their short-term (30-day) survival, predictors of short-term survival and chances of additional chemotherapy. Methods We reviewed all patients with advanced (stage III or IV) pancreatic adenocarcinoma admitted to an ICU in a dedicated Brazilian cancer centre from 2009 to 2018 due to medical reasons. We fitted multivariate regression models to identify predictors of 30-day survival and additional systemic chemotherapy. Results The study population consisted of 171 patients. Ninety-four patients (55.0%) had Eastern Cooperative Oncology Group (ECOG) performance status 2-4 and 146 (85.4%) had metastatic disease. Most patients (N = 75; 43.9%) were admitted to the ICU during first-line treatment. Median overall survival was 32 days (95% confidence interval (95% CI): 20-49). Survival rate at 30 days was 50.6%. ECOG performance status 2-4 was the only variable associated with lower probability of survival at 30 days in multivariate analysis (odds ratio: 0.28; 95% CI: 0.14-0.54; p < 0.001). Overall, 58 patients (33.9%) received additional chemotherapy and among all patients, 13.5% experienced clinical benefit from this treatment. Conclusion Patients with advanced pancreatic cancer admitted to the ICU for medical reasons have a dismal prognosis. Early palliative care and refined tools to establish those who would benefit from an ICU trial could help improve patients' care.
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Affiliation(s)
- Marina Junqueira de Almeida
- Medical Oncology Department, A.C. Camargo Cancer Center, Rua Prof. Antônio Prudente, 211, São Paulo, SP 01509-010, Brazil
| | | | - Antonio Paulo Nassar
- Intensive Care Medicine Department, A.C. Camargo Cancer Center, Rua Prof. Antônio Prudente, 211, São Paulo, SP 01509-010, Brazil
| | - Victor Hugo Fonseca de Jesus
- Medical Oncology Department, A.C. Camargo Cancer Center, Rua Prof. Antônio Prudente, 211, São Paulo, SP 01509-010, Brazil,https://orcid.org/0000-0003-4702-116X
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6
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Tomazini BM, Nassar AP, Lisboa TC, Azevedo LCPD, Veiga VC, Catarino DGM, Fogazzi DV, Arns B, Piastrelli FT, Dietrich C, Negrelli KL, Jesuíno IDA, Reis LFL, Mattos RRD, Pinheiro CCG, Luz MN, Spadoni CCDS, Moro EE, Bueno FR, Sampaio CSJC, Silva DP, Baldassare FP, Silva ACA, Veiga T, Barbante L, Lambauer M, Campos VB, Santos E, Santos RHN, Laranjeiras LN, Valeis N, Santucci E, Miranda TA, Patrocínio ACLD, Carvalho AD, Sousa EMCD, Sousa AHFD, Malheiro DT, Bezerra IL, Rodrigues MB, Malicia JC, Silva SSD, Gimenes BDP, Sesin GP, Zavascki AP, Sganzerla D, Medeiros GS, Santos RDRMD, Silva FKR, Cheno MY, Abrahão CF, Oliveira Junior HAD, Rocha LL, Nunes Neto PA, Pereira VC, Paciência LEM, Bueno ES, Caser EB, Ribeiro LZ, Fernandes CCF, Garcia JM, Silva VDFF, Santos AJD, Machado FR, Souza MAD, Ferronato BR, Urbano HCDA, Moreira DCA, Souza-Dantas VCD, Duarte DM, Coelho J, Figueiredo RC, Foreque F, Romano TG, Cubos D, Spirale VM, Nogueira RS, Maia IS, Zandonai CL, Lovato WJ, Cerantola RB, Toledo TGP, Tomba PO, Almeida JRD, Sanches LC, Pierini L, Cunha M, Sousa MT, Azevedo B, Dal-Pizzol F, Damasio DDC, Bainy MP, Beduhn DAV, Jatobá JDVN, Moura MTFD, Rego LRDM, Silva AVD, Oliveira LP, Sodré Filho ES, Santos SSD, Neves IDL, Leão VCDA, Paes JLL, Silva MCM, Oliveira CDD, Santiago RCB, Paranhos JLDR, Wiermann IGDS, Pedroso DFF, Sawada PY, Prestes RM, Nascimento GC, Grion CMC, Carrilho CMDDM, Dantas RLADM, Silva EP, Silva ACD, Oliveira SMBD, Golin NA, Tregnago R, Lima VP, Silva KGND, Boschi E, Buffon V, Machado AS, Capeletti L, Foernges RB, Carvalho ASD, Oliveira Junior LCD, Oliveira DCD, Silva EM, Ribeiro J, Pereira FC, Salgado FB, Deutschendorf C, Silva CFD, Gobatto ALN, Oliveira CBD, Dracoulakis MDA, Alvaia NOS, Souza RMD, Araújo LLCD, Melo RMVD, Passos LCS, Vidal CFDL, Rodrigues FLDA, Kurtz P, Shinotsuka CR, Tavares MB, Santana IDV, Gavinho LMDS, Nascimento AB, Pereira AJ, Cavalcanti AB. IMPACTO-MR: a Brazilian nationwide platform study to assess infections and multidrug resistance in intensive care units. Rev Bras Ter Intensiva 2022; 34:418-425. [PMID: 36888821 PMCID: PMC9987010 DOI: 10.5935/0103-507x.20220209-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/19/2022] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To describe the IMPACTO-MR, a Brazilian nationwide intensive care unit platform study focused on the impact of health care-associated infections due to multidrug-resistant bacteria. METHODS We described the IMPACTO-MR platform, its development, criteria for intensive care unit selection, characterization of core data collection, objectives, and future research projects to be held within the platform. RESULTS The core data were collected using the Epimed Monitor System® and consisted of demographic data, comorbidity data, functional status, clinical scores, admission diagnosis and secondary diagnoses, laboratory, clinical, and microbiological data, and organ support during intensive care unit stay, among others. From October 2019 to December 2020, 33,983 patients from 51 intensive care units were included in the core database. CONCLUSION The IMPACTO-MR platform is a nationwide Brazilian intensive care unit clinical database focused on researching the impact of health care-associated infections due to multidrug-resistant bacteria. This platform provides data for individual intensive care unit development and research and multicenter observational and prospective trials.
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Affiliation(s)
- Bruno M Tomazini
- Hospital Sírio-Libanês - São Paulo (SP), Brasil.,Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
| | - Antonio Paulo Nassar
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Hospital A. C. Camargo Cancer Center - São Paulo (SP), Brasil
| | - Thiago Costa Lisboa
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Luciano César Pontes de Azevedo
- Hospital Sírio-Libanês - São Paulo (SP), Brasil.,Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
| | - Viviane Cordeiro Veiga
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brasil
| | | | | | - Beatriz Arns
- Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Thabata Veiga
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Leticia Barbante
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Marianne Lambauer
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | | | - Elton Santos
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | | | | | - Nanci Valeis
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Eliana Santucci
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo - São Paulo (SP), Brasil
| | - Maria Aparecida de Souza
- Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo - São Paulo (SP), Brasil
| | | | | | | | - Vicente Cés de Souza-Dantas
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | - Diego Meireles Duarte
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | - Juliana Coelho
- BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brasil
| | | | | | | | - Daniel Cubos
- Hospital e Maternidade São Luiz Itaim - São Paulo (SP), Brasil
| | | | | | - Israel Silva Maia
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital Nereu Ramos - Florianópolis (SC), Brasil
| | | | - Wilson José Lovato
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo - Ribeirão Preto (SP), Brasil
| | - Rodrigo Barbosa Cerantola
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo - Ribeirão Preto (SP), Brasil
| | | | | | | | | | | | | | | | - Bruna Azevedo
- Fundação Hospitalar São Francisco de Assis - Belo Horizonte (MG), Brasil
| | - Felipe Dal-Pizzol
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital São José - Criciúma (SC), Brasil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Cintia Magalhães Carvalho Grion
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital Universitário, Universidade Estadual de Londrina - Londrina (PR), Brasil
| | | | | | - Eliane Pereira Silva
- Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte - Natal (RN), Brasil
| | | | | | | | | | - Valéria Paes Lima
- Hospital Universitário de Brasília, Universidade de Brasília - Brasília (DF), Brasil
| | | | - Emerson Boschi
- Hospital Geral de Caxias do Sul - Caxias do Sul (RS), Brasil
| | - Viviane Buffon
- Hospital Geral de Caxias do Sul - Caxias do Sul (RS), Brasil
| | | | | | | | | | | | | | | | | | | | | | - Caroline Deutschendorf
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Cristofer Farias da Silva
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | | | | | | | | | | | | | | | | | | | | | - Pedro Kurtz
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Instituto Estadual do Cérebro Paulo Niemeyer - Rio de Janeiro (RJ), Brasil
| | - Cássia Righy Shinotsuka
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Instituto Estadual do Cérebro Paulo Niemeyer - Rio de Janeiro (RJ), Brasil
| | | | | | | | | | - Adriano J Pereira
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
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Archanjo LVF, Caruso P, Nassar AP. One-year mortality of hematopoietic stem cell recipients admitted to an intensive care unit in a dedicated Brazilian cancer center: a retrospective cohort study. SAO PAULO MED J 2022; 141:107-113. [PMID: 35920534 PMCID: PMC10005466 DOI: 10.1590/1516-3180.2021.0986.r1.11052022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/11/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) recipients requiring intensive care unit (ICU) admission early after transplantation have a poor prognosis. However, many studies have only focused on allogeneic HSCT recipients. OBJECTIVES To describe the characteristics of HSCT recipients admitted to the ICU shortly after transplantation and assess differences in 1-year mortality between autologous and allogeneic HSCT recipients. DESIGN AND SETTING A single-center retrospective cohort study in a cancer center in Brazil. METHODS We included all consecutive patients who underwent HSCT less than a year before ICU admission between 2009 and 2018. We collected clinical and demographic data and assessed the 1-year mortality of all patients. The effect of allogeneic HSCT compared with autologous HSCT on 1-year mortality risk was evaluated in an unadjusted model and an adjusted Cox proportional hazard model for age and Sequential Organ Failure Assessment (SOFA) at admission. RESULTS Of the 942 patients who underwent HSCT during the study period, 83 (8.8%) were included in the study (autologous HSCT = 57 [68.7%], allogeneic HSCT = 26 [31.3%]). At 1 year after ICU admission, 21 (36.8%) and 18 (69.2%) patients who underwent autologous and allogeneic HSCT, respectively, had died. Allogeneic HSCT was associated with increased 1-year mortality (unadjusted hazard ratio, HR = 2.79 [confidence interval, CI, 95%, 1.48-5.26]; adjusted HR = 2.62 [CI 95%, 1.29-5.31]). CONCLUSION Allogeneic HSCT recipients admitted to the ICU had higher short- and long-term mortality rates than autologous HSCT recipients, even after adjusting for age and severity at ICU admission.
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Affiliation(s)
| | - Pedro Caruso
- MD, PhD. Physician and ICU coordinator, Professor. A.C. Camargo
Cancer Center, São Paulo (SP), Brazil. Professor, Discipline of Pulmonology,
Universidade de São Paulo (USP), São Paulo (SP), Brazil
| | - Antonio Paulo Nassar
- MD, PhD. Attending Physician and Professor, Intensive Care Unit,
A.C. Camargo Cancer Center, São Paulo (SP) Brazil
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Midega TD, Leite Filho NCV, Nassar AP, Alencar RM, Capone Neto A, Ferraz LJR, Corrêa TD. Impact of intensive care unit admission during handover on mortality: propensity matched cohort study. Einstein (Sao Paulo) 2021; 19:eAO5748. [PMID: 34161436 PMCID: PMC8225264 DOI: 10.31744/einstein_journal/2021ao5748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 12/06/2020] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To investigate the impact of intensive care unit admission during medical handover on mortality. METHODS Post-hoc analysis of data extracted from a prior study aimed at addressing the impacts of intensive care unit readmission on clinical outcomes. This retrospective, single-center, propensity-matched cohort study was conducted in a 41-bed general open-model intensive care unit. Patients were assigned to one of two cohorts according to time of intensive care unit admission: Handover Group (intensive care unit admission between 6:30 am and 7:30 am or 6:30 pm and 7:30 pm) or Control Group (intensive care unit admission between 7:31 am and 6:29 pm or 7:31 pm and 6:29 am). Patients in the Handover Group were propensity-matched to patients in the Control Group at a 1:2 ratio. RESULTS A total of 6,650 adult patients were admitted to the intensive care unit between June 1st 2013 and May 31st 2015. Following exclusion of non-eligible participants, 5,779 patients (389; 6.7% and 5,390; 93.3%, Handover and Control Group) were deemed eligible for propensity score matching. Of these, 1,166 were successfully matched (389; 33.4% and 777; 66.6%, Handover and Control Group). Following propensity-score matching, intensive care unit admission during handover was not associated with increased risk of intensive care unit (OR: 1.40; 95%CI: 0.92-2.11; p=0.113) or in-hospital (OR: 1.23; 95%CI: 0.85-1.75; p=0.265) mortality. CONCLUSION Intensive care unit admission during medical handover did not affect in-hospital mortality in this propensity-matched, single-center cohort study.
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Affiliation(s)
| | | | | | - Roger Monteiro Alencar
- Hospital Municipal Dr. Moysés Deutsch; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Midega TD, Bozza FA, Machado FR, Guimarães HP, Salluh JI, Nassar AP, Normílio-Silva K, Schultz MJ, Cavalcanti AB, Serpa Neto A. Organizational factors associated with adherence to low tidal volume ventilation: a secondary analysis of the CHECKLIST-ICU database. Ann Intensive Care 2020; 10:68. [PMID: 32488524 PMCID: PMC7266115 DOI: 10.1186/s13613-020-00687-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/25/2020] [Indexed: 12/15/2022] Open
Abstract
Background Survival benefit from low tidal volume (VT) ventilation (LTVV) has been demonstrated for patients with acute respiratory distress syndrome (ARDS), and patients not having ARDS could also benefit from this strategy. Organizational factors may play a role on adherence to LTVV. The present study aimed to identify organizational factors with an independent association with adherence to LTVV. Methods Secondary analysis of the database of a multicenter two-phase study (prospective cohort followed by a cluster-randomized trial) performed in 118 Brazilian intensive care units. Patients under mechanical ventilation at day 2 were included. LTVV was defined as a VT ≤ 8 ml/kg PBW on the second day of ventilation. Data on the type and number of beds of the hospital, teaching status, nursing, respiratory therapists and physician staffing, use of structured checklist, and presence of protocols were tested. A multivariable mixed-effect model was used to assess the association between organizational factors and adherence to LTVV. Results The study included 5719 patients; 3340 (58%) patients received LTVV. A greater number of hospital beds (absolute difference 7.43% [95% confidence interval 0.61–14.24%]; p = 0.038), use of structured checklist during multidisciplinary rounds (5.10% [0.55–9.81%]; p = 0.030), and presence of at least one nurse per 10 patients during all shifts (17.24% [0.85–33.60%]; p = 0.045) were the only three factors that had an independent association with adherence to LTVV. Conclusions Number of hospital beds, use of a structured checklist during multidisciplinary rounds, and nurse staffing are organizational factors associated with adherence to LTVV. These findings shed light on organizational factors that may improve ventilation in critically ill patients.
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Affiliation(s)
- Thais Dias Midega
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil
| | - Fernando A Bozza
- Research Institute, Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil.,Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Flávia Ribeiro Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, Brazil
| | - Helio Penna Guimarães
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil.,Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jorge I Salluh
- Graduate Program in Translational Medicine and Department of Critical Care, Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil.,Post Graduate Program in Internal Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Antonio Paulo Nassar
- Intensive Care Unit and Postgraduate Program, A.C. Camargo Cancer Center, São Paulo, Brazil
| | | | - Marcus J Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil. .,Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands.
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Nassar AP, Nassif BN, Santos DVVD, Caruso P. Procalcitonin Clearance at 24, 48, 72, and 96 Hours and Mortality in Patients With Cancer and Sepsis: A Retrospective Cohort Study. J Intensive Care Med 2019; 35:1297-1301. [PMID: 31284812 DOI: 10.1177/0885066619861588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Previous studies have evaluated procalcitonin clearance (PCTc) as a marker of sepsis severity but at different time points and cutoffs. We aimed to assess the predictive performance of PCTc at different time points of sepsis management in patients with cancer. METHODS This retrospective cohort study included patients with cancer admitted to an intensive care unit between 2013 and 2016. We calculated PCTc at 24, 48, 72, and 96 hours after admission. Its predictive performance for hospital and 90-day mortality was analyzed with receiver operating characteristic curves and areas under the curves (AUCs). Sensitivity and specificity were calculated for different time points using different cutoffs. RESULTS We included 301 patients. Areas under the curves ranged from 0.62 for PCTc at 24 hours to 0.68 for PCTc at 72 and 96 hours for hospital mortality prediction, and from 0.61 for PCTc at 24 hours to 0.68 for PCTc at 72 hours for 90-day mortality prediction. For hospital mortality prediction, PCTc at 72 hours ≤80% showed the best sensitivity (96.0%; 95% confidence interval [CI]: 90.8%-98.7%), and PCTc at 96 hours ≤50% showed the best specificity (70.7%; 95% CI: 54.5%-83.9%). CONCLUSIONS Procalcitonin clearance at 24, 48, 72, and 96 hours poorly predicted hospital and 90-day mortality. Therefore, daily PCT measurement should not be used to predict mortality for patients with cancer and sepsis.
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Affiliation(s)
| | | | | | - Pedro Caruso
- Intensive Care Unit, 139300A.C. Camargo Cancer Center, São Paulo, Brazil.,Intensive Care Unit, Discipline of Pulmonology, University of São Paulo, São Paulo, Brazil
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Nassar AP, Zampieri FG, Salluh JI, Bozza FA, Machado FR, Guimarães HP, Damiani LP, Cavalcanti AB. Organizational factors associated with target sedation on the first 48 h of mechanical ventilation: an analysis of checklist-ICU database. Crit Care 2019; 23:34. [PMID: 30696474 PMCID: PMC6352335 DOI: 10.1186/s13054-019-2323-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/11/2019] [Indexed: 12/24/2022]
Abstract
Background Although light sedation levels are associated with several beneficial outcomes for critically ill patients on mechanical ventilation, the majority of patients are still deeply sedated. Organizational factors may play a role on adherence to light sedation levels. We aimed to identify organizational factors associated with a moderate to light sedation target on the first 48 h of mechanical ventilation, as well as the association between early achievement of within-target sedation and mortality. Methods This study is a secondary analysis of a multicenter two-phase study (prospective cohort followed by a cluster-randomized controlled trial) performed in 118 Brazilian ICUs. We included all critically ill patients who were on mechanical ventilation 48 h after ICU admission. A moderate to light level of sedation or being alert and calm (i.e., the Richmond Agitation-Sedation Scale of − 3 to 0) was the target for all patients on mechanical ventilation during the study period. We collected data on the type of hospital (public, private, profit and private, nonprofit), hospital teaching status, nursing and physician staffing, and presence of sedation, analgesia, and weaning protocols. We used multivariate random-effects regression with ICU and study phase as random-effects and correction for patients’ Simplified Acute Physiology Score 3 and Sequential Organ Failure Assessment. We also performed a mediation analysis to explore whether sedation level was just a mediator of the association between organizational factors and mortality. Results We included 5719 patients. Only 1710 (29.9%) were on target sedation levels on day 2. Board-certified intensivists on the morning and afternoon shifts were associated with an adequate sedation level on day 2 (OR = 2.43; CI 95%, 1.09–5.38). Target sedation levels were associated with reduced hospital mortality (OR = 0.63; CI 95%, 0.55–0.72). Mediation analysis also suggested such an association, but did not suggest a relationship between the physician staffing model and hospital mortality. Conclusions Board-certified intensivists on morning and afternoon shifts were associated with an increased number of patients achieving lighter sedation goals. These findings reinforce the importance of organizational factors, such as intensivists’ presence, as a modifiable quality improvement target. Electronic supplementary material The online version of this article (10.1186/s13054-019-2323-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antonio Paulo Nassar
- Intensive Care Unit and Postgraduate Program, A.C. Camargo Cancer Center, São Paulo, Brazil.
| | - Fernando G Zampieri
- Research Institute, HCor-Hospital do Coração, São Paulo, Brazil.,Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Jorge I Salluh
- Graduate Program in Translational Medicine and Department of Critical Care, D'Or Institute for Research and Education, Rio De Janeiro, Brazil.,Programa de Pós-Graduação em Clinica médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fernando A Bozza
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil
| | - Flávia Ribeiro Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, Brazil
| | - Helio Penna Guimarães
- Research Institute, HCor-Hospital do Coração, São Paulo, Brazil.,Federal univeristy of São Paulo, São Paulo, Brazil
| | - Lucas P Damiani
- Research Institute, HCor-Hospital do Coração, São Paulo, Brazil
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Affiliation(s)
- Rui P Moreno
- Hospital de São José, Centro Hospitalar de Lisboa Central - Lisboa, Portugal
| | - Antonio Paulo Nassar
- Unidade de Terapia Intensiva, A.C. Camargo Cancer Center - São Paulo (SP), Brasil
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Taniguchi LU, Zampieri FG, Nassar AP. Applicability of respiratory variations in stroke volume and its surrogates for dynamic fluid responsiveness prediction in critically ill patients: a systematic review of the prevalence of required conditions. Rev Bras Ter Intensiva 2018; 29:70-76. [PMID: 28444075 PMCID: PMC5385988 DOI: 10.5935/0103-507x.20170011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 08/17/2016] [Indexed: 12/16/2022] Open
Abstract
Objective The present systematic review searched for published data on the prevalence
of required conditions for proper assessment in critically ill patients. Methods The Medline, Scopus and Web of Science databases were searched to identify
studies that evaluated the prevalence of validated conditions for the fluid
responsiveness assessment using respiratory variations in the stroke volume
or another surrogate in adult critically ill patients. The primary outcome
was the suitability of the fluid responsiveness evaluation. The secondary
objectives were the type and prevalence of pre-requisites evaluated to
define the suitability. Results Five studies were included (14,804 patients). High clinical and statistical
heterogeneity was observed (I2 = 98.6%), which prevented us from
pooling the results into a meaningful summary conclusion. The most frequent
limitation identified is the absence of invasive mechanical ventilation with
a tidal volume ≥ 8mL/kg. The final suitability for the fluid
responsiveness assessment was low (in four studies, it varied between 1.9 to
8.3%, in one study, it was 42.4%). Conclusion Applicability of the dynamic indices of preload responsiveness requiring
heart-lung interactions might be limited in daily practice.
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Affiliation(s)
- Leandro Utino Taniguchi
- Disciplina de Emergências Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês - São Paulo (SP), Brasil
| | - Fernando Godinho Zampieri
- Disciplina de Emergências Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital Alemão Oswaldo Cruz - São Paulo (SP), Brasil
| | - Antonio Paulo Nassar
- Disciplina de Emergências Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva de Adultos, A.C. Camargo Cancer Center - São Paulo (SP), Brasil
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Besen BAMP, Park M, Nassar AP. Accounting for single center effects in systematic reviews cannot be overlooked. Crit Care 2017; 21:241. [PMID: 28915905 PMCID: PMC5602911 DOI: 10.1186/s13054-017-1804-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Nassar AP, Caruso P, Costa RT. Performance status is an independent predictor of mortality in cancer septic patients admitted to the intensive care unit. J Crit Care 2017. [DOI: 10.1016/j.jcrc.2017.09.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Nassar AP, Dettino ALA, Amendola CP, Dos Santos RA, Forte DN, Caruso P. Oncologists' and Intensivists' Attitudes Toward the Care of Critically Ill Patients with Cancer. J Intensive Care Med 2017; 34:811-817. [PMID: 28675982 DOI: 10.1177/0885066617716105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Patients with cancer represent an important proportion of intensive care unit (ICU) admissions. Oncologists and intensivists have distinct knowledge backgrounds, and conflicts about the appropriate management of these patients may emerge. METHODS We surveyed oncologists and intensivists at 2 academic cancer centers regarding their management of 2 hypothetical patients with different cancer types (metastatic pancreatic cancer and metastatic breast cancer with positive receptors for estrogen, progesterone, and HER-2) who develop septic shock and multiple organ failure. RESULTS Sixty intensivists and 46 oncologists responded to the survey. Oncologists and intensivists similarly favored withdrawal of life support measures for the patient with pancreatic cancer (33/46 [72%] vs 48/60 [80%], P = .45). On the other hand, intensivists favored more withdrawal of life support measures for the patient with breast cancer compared to oncologists (32/59 [54%] vs 9/44 [21%], P < .001). In the multinomial logistic regression, the oncology specialists were more likely to advocate for a full-code status for the patient with breast cancer (OR = 5.931; CI 95%, 1.762-19.956; P = .004). CONCLUSIONS Oncologists and intensivists share different views regarding life support measures in critically ill patients with cancer. Oncologists tend to focus on the cancer characteristics, whereas intensivists focus on multiple organ failure when weighing in on the same decisions. Regular meetings between oncologists and intensivists may reduce possible conflicts regarding the critical care of patients with cancer.
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Affiliation(s)
- Antonio Paulo Nassar
- 1 Intensive Care Unit, A.C. Camargo Cancer Center, São Paulo, Brazil.,2 Intensive Care Unit, Discipline of Medical Emergencies, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | | | | | - Rodrigo Alves Dos Santos
- 4 Intensive Care Unit, Pio XII Foundation, Barretos Cancer Hospital, Barretos, Brazil.,5 Barretos School of Health Sciences, Barretos, Brazil
| | - Daniel Neves Forte
- 2 Intensive Care Unit, Discipline of Medical Emergencies, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.,6 Department of Palliative Care, Hospital Sírio Libanês, São Paulo, Brazil
| | - Pedro Caruso
- 1 Intensive Care Unit, A.C. Camargo Cancer Center, São Paulo, Brazil.,7 Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Besen BAMP, Romano TG, Mendes PV, Gallo CA, Zampieri FG, Nassar AP, Park M. Early Versus Late Initiation of Renal Replacement Therapy in Critically Ill Patients: Systematic Review and Meta-Analysis. J Intensive Care Med 2017; 34:714-722. [PMID: 28569129 DOI: 10.1177/0885066617710914] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Early initiation of renal replacement therapy (RRT) effect on survival and renal recovery of critically ill patients is still uncertain. We aimed to systematically review current evidence comparing outcomes of early versus late initiation of RRT in critically ill patients. METHODS We searched the Medline (via Pubmed), LILACS, Science Direct, and CENTRAL databases from inception until November 2016 for randomized clinical trials (RCTs) or observational studies comparing early versus late initiation of RRT in critically ill patients. The primary outcome was mortality. Duration of mechanical ventilation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and renal function recovery were secondary outcomes. Meta-analysis and trial sequential analysis (TSA) were used for the primary outcome. RESULTS Sixty-two studies were retrieved and analyzed, including 11 RCTs. There was no difference in mortality between early and late initiation of RRT among RCTs (odds ratio [OR] = 0.78; 95% confidence interval [CI]: 0.52-1.19; I2 = 63.1%). Trial sequential analysis of mortality across all RCTs achieved futility boundaries at both 1% and 5% type I error rates, although a subgroup analysis of studies including only acute kidney injury patients was not conclusive. There was also no difference in time on mechanical ventilation, ICU and hospital LOS, or renal recovery among studies. Early initiation of RRT was associated with reduced mortality among prospective (OR = 0.69; 95% CI: 0.49-0.96; I2 = 85.9%) and retrospective (OR = 0.61; 95% CI: 0.41-0.92; I2 = 90.9%) observational studies, both with substantial heterogeneity. However, subgroup analysis excluding low-quality observational studies did not achieve statistical significance. CONCLUSION Pooled analysis of randomized trials indicates early initiation of RRT is not associated with lower mortality rates. The potential benefit of reduced mortality associated with early initiation of RRT was limited to low-quality observational studies.
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Affiliation(s)
- Bruno Adler Maccagnan Pinheiro Besen
- 1 Intensive Care Unit, Emergency department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.,2 Intensive Care Unit, Hospital da Luz, Amil, São Paulo, Brazil
| | - Thiago Gomes Romano
- 3 Nephrology Department, ABC Medical School, Santo Andre, Brazil.,4 Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Pedro Vitale Mendes
- 1 Intensive Care Unit, Emergency department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.,4 Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Cesar Albuquerque Gallo
- 1 Intensive Care Unit, Emergency department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Fernando Godinho Zampieri
- 5 Research Institute, HCor-Hospital do Coração, São Paulo, Brazil.,6 Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Antonio Paulo Nassar
- 1 Intensive Care Unit, Emergency department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.,7 Intensive Care Unit, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Marcelo Park
- 1 Intensive Care Unit, Emergency department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.,4 Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
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Besen BAMP, Romano TG, Nassar AP, Taniguchi LU, Azevedo LCP, Mendes PV, Zampieri FG, Park M. Sepsis-3 definitions predict ICU mortality in a low-middle-income country. Ann Intensive Care 2016; 6:107. [PMID: 27807819 PMCID: PMC5093106 DOI: 10.1186/s13613-016-0204-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 10/17/2016] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis-3 definitions were published recently and validated only in high-income countries. The aim of this study was to assess the new criteria’s accuracy in stratifying mortality as compared to its predecessor (Sepsis-2) in a Brazilian public intensive care unit (ICU) and to investigate whether the addition of lactate values would improve stratification. Methods Retrospective cohort study conducted between 2010 and 2015 in a public university’s 19-bed ICU. Data from patients admitted to the ICU with sepsis were retrieved from a prospectively collected database. ICU mortality was compared across categories of both Sepsis-2 definitions (sepsis, severe sepsis and septic shock) and Sepsis-3 definitions (infection, sepsis and septic shock). Area under the receiving operator characteristic curves were constructed, and the net reclassification index and integrated discrimination index for the addition of lactate as a categorical variable to each stratum of definition were evaluated. Results The medical records of 957 patients were retrieved from a prospectively collected database. Mean age was 52 ± 19 years, median SAPS 3 was 65 [50,79], respiratory tract infection was the most common cause (42%, 402 patients), and 311 (32%) patients died in ICU. The ICU mortality rate was progressively higher across categories of sepsis as defined by the Sepsis-3 consensus: infection with no organ dysfunction—7/103 (7%); sepsis—106/419 (25%); and septic shock—198/435 (46%) (P < 0.001). For Sepsis-2 definitions, ICU mortality was different only across the categories of severe sepsis [43/252-(17%)] and septic shock [250/572-(44%)] (P < 0.001); sepsis had a mortality of 18/135-(13%) (P = 0.430 vs. severe sepsis). When combined with lactate, the definitions’ accuracy in stratifying ICU mortality only improved with lactate levels above 4 mmol/L. This improvement occurred in the severe sepsis and septic shock groups (Sepsis-2) and the no-dysfunction and septic shock groups (Sepsis-3). Multivariate analysis demonstrated similar findings. Conclusions In a Brazilian ICU, the new Sepsis-3 definitions were accurate in stratifying mortality and were superior to the previous definitions. We also observed that the new definitions’ accuracy improved progressively with severity. Serum lactate improved accuracy for values higher than 4 mmol/L in the no-dysfunction and septic shock groups. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0204-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bruno Adler Maccagnan Pinheiro Besen
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil. .,Hospital da Luz, Amil, São Paulo, Brazil.
| | - Thiago Gomes Romano
- Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil.,Nephrology Department, ABC Medical School, Santo Andre, Brazil
| | - Antonio Paulo Nassar
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil.,A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Leandro Utino Taniguchi
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil.,Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Luciano Cesar Pontes Azevedo
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil.,Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Pedro Vitale Mendes
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil.,Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Fernando Godinho Zampieri
- Research Institute, HCor-Hospital do Coração, São Paulo, Brazil.,Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Marcelo Park
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil
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Maciel AT, Nassar AP, Vitorio D. Very Transient Cases of Acute Kidney Injury in the Early Postoperative Period After Cardiac Surgery: The Relevance of More Frequent Serum Creatinine Assessment and Concomitant Urinary Biochemistry Evaluation. J Cardiothorac Vasc Anesth 2016; 30:56-63. [DOI: 10.1053/j.jvca.2015.04.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Indexed: 11/11/2022]
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Nassar AP, Caruso P. ICU physicians are unable to accurately predict length of stay at admission: a prospective study. Int J Qual Health Care 2015; 28:99-103. [DOI: 10.1093/intqhc/mzv112] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2015] [Indexed: 12/12/2022] Open
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Tanaka LMS, Azevedo LCP, Park M, Schettino G, Nassar AP, Réa-Neto A, Tannous L, de Souza-Dantas VC, Torelly A, Lisboa T, Piras C, Carvalho FB, Maia MDO, Giannini FP, Machado FR, Dal-Pizzol F, de Carvalho AGR, dos Santos RB, Tierno PFGMM, Soares M, Salluh JIF. Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. Crit Care 2014; 18:R156. [PMID: 25047960 PMCID: PMC4223597 DOI: 10.1186/cc13995] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 06/23/2014] [Indexed: 12/13/2022]
Abstract
Introduction Sedation overuse is frequent and possibly associated with poor outcomes in the intensive care unit (ICU) patients. However, the association of early oversedation with clinical outcomes has not been thoroughly evaluated. The aim of this study was to assess the association of early sedation strategies with outcomes of critically ill adult patients under mechanical ventilation (MV). Methods A secondary analysis of a multicenter prospective cohort conducted in 45 Brazilian ICUs, including adult patients requiring ventilatory support and sedation in the first 48 hours of ICU admissions, was performed. Sedation depth was evaluated after 48 hours of MV. Multivariate analysis was used to identify variables associated with hospital mortality. Results A total of 322 patients were evaluated. Overall, ICU and hospital mortality rates were 30.4% and 38.8%, respectively. Deep sedation was observed in 113 patients (35.1%). Longer duration of ventilatory support was observed (7 (4 to 10) versus 5 (3 to 9) days, P = 0.041) and more tracheostomies were performed in the deep sedation group (38.9% versus 22%, P = 0.001) despite similar PaO2/FiO2 ratios and acute respiratory distress syndrome (ARDS) severity. In a multivariate analysis, age (Odds Ratio (OR) 1.02; 95% confidence interval (CI) 1.00 to 1.03), Charlson Comorbidity Index >2 (OR 2.06; 95% CI, 1.44 to 2.94), Simplified Acute Physiology Score 3 (SAPS 3) score (OR 1.02; CI 95%, 1.00 to 1.04), severe ARDS (OR 1.44; CI 95%, 1.09 to 1.91) and deep sedation (OR 2.36; CI 95%, 1.31 to 4.25) were independently associated with increased hospital mortality. Conclusions Early deep sedation is associated with adverse outcomes and constitutes an independent predictor of hospital mortality in mechanically ventilated patients.
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Nassar AP, Malbouisson LMS, Moreno R. Evaluation of Simplified Acute Physiology Score 3 performance: a systematic review of external validation studies. Crit Care 2014; 18:R117. [PMID: 24906651 PMCID: PMC4230997 DOI: 10.1186/cc13911] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 05/21/2014] [Indexed: 11/30/2022]
Abstract
Introduction Simplified Acute Physiology Score 3 (SAPS 3) was the first critical care prognostic model developed from worldwide data. We aimed to systematically review studies that assessed the prognostic performance of SAPS 3 general and customized models for predicting hospital mortality in adult patients admitted to the ICU. Methods Medline, Lilacs, Scielo and Google Scholar were searched to identify studies which assessed calibration and discrimination of general and customized SAPS 3 equations. Additionally, we decided to evaluate the correlation between trial size (number of included patients) and the Hosmer-Lemeshow (H-L) statistics value of the SAPS 3 models. Results A total of 28 studies were included. Of these, 11 studies (42.8%) did not find statistically significant mis-calibration for the SAPS 3 general equation. There was a positive correlation between number of included patients and higher H-L statistics, that is, a statistically significant mis-calibration of the model (r = 0.747, P <0.001). Customized equations for major geographic regions did not have statistically significant departures from perfect calibration in 9 of 19 studies. Five studies (17.9%) developed a regional customization and in all of them this new model was not statistically different from a perfect calibration for their populations. Discrimination was at least very good in 24 studies (85.7%). Conclusions Statistically significant departure from perfect calibration for the SAPS 3 general equation was common in validation studies and was correlated with larger studies, as should be expected, since H-L statistics (both C and H) are strongly dependent on sample size This finding was also present when major geographic customized equations were evaluated. Local customizations, on the other hand, improved SAPS 3 calibration. Discrimination was almost always very good or excellent, which gives excellent perspectives for local customization when a precise local estimate is needed.
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Nassar AP, da Silva FMQ, de Cleva R. Constipation in intensive care unit: Incidence and risk factors. J Crit Care 2009; 24:630.e9-12. [DOI: 10.1016/j.jcrc.2009.03.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Revised: 03/26/2009] [Accepted: 03/28/2009] [Indexed: 12/26/2022]
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Nassar AP, Figueiredo W, Neto RCP, Lima DM, Park M. Applicability of four sedation/agitation scales in Portuguese. Crit Care 2007. [PMCID: PMC3301202 DOI: 10.1186/cc5862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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