1
|
Tavares CDAM, de Azevedo LCP, Rea-Neto Á, Campos NS, Amendola CP, Bergo RR, Kozesinski-Nakatani AC, David-João PG, Westphal GA, Guimarães Júnior MRR, Lobo SMA, Tavares MS, Dracoulakis MDA, de Souza GM, de Almeida GMB, Gebara OCE, Tomba PO, Albuquerque CSN, Silva MCR, Pereira AJ, Damiani LP, Corrêa TD, Serpa-Neto A, Berwanger O, Zampieri FG. Dapagliflozin in patients with critical illness: rationale and design of the DEFENDER study. Crit Care Sci 2023; 35:256-265. [PMID: 38133155 PMCID: PMC10734800 DOI: 10.5935/2965-2774.20230129-en] [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] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/09/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Critical illness is a major ongoing health care burden worldwide and is associated with high mortality rates. Sodium-glucose cotransporter-2 inhibitors have consistently shown benefits in cardiovascular and renal outcomes. The effects of sodium-glucose cotransporter-2 inhibitors in acute illness have not been properly investigated. METHODS DEFENDER is an investigator-initiated, multicenter, randomized, open-label trial designed to evaluate the efficacy and safety of dapagliflozin in 500 adult participants with acute organ dysfunction who are hospitalized in the intensive care unit. Eligible participants will be randomized 1:1 to receive dapagliflozin 10mg plus standard of care for up to 14 days or standard of care alone. The primary outcome is a hierarchical composite of hospital mortality, initiation of kidney replacement therapy, and intensive care unit length of stay, up to 28 days. Safety will be strictly monitored throughout the study. CONCLUSION DEFENDER is the first study designed to investigate the use of a sodium-glucose cotransporter-2 inhibitor in general intensive care unit patients with acute organ dysfunction. It will provide relevant information on the use of drugs of this promising class in critically ill patients. CLINICALTRIALS.GOV REGISTRY NCT05558098.
Collapse
Affiliation(s)
| | | | - Álvaro Rea-Neto
- Centro de Estudos e de Pesquisas em Terapia Intensiva - Curitiba
(PR), Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ary Serpa-Neto
- Hospital Israelita Albert Einstein - São Paulo (SP),
Brazil
| | | | | |
Collapse
|
2
|
Westphal GA, Besen BAMP, de Andrade J, Sardinha LA, Franke CA. Brazilian Contributions on Standardized Education for Brain Death Determination. Neurocrit Care 2023; 39:740-741. [PMID: 37752296 DOI: 10.1007/s12028-023-01850-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 09/28/2023]
Affiliation(s)
- Glauco Adrieno Westphal
- Organ Procurement Organization of Santa Catarina, Rua Esteves Júnior, 390, Florianópolis, SC, 88015-130, Brazil.
| | | | - Joel de Andrade
- Organ Procurement Organization of Santa Catarina, Rua Esteves Júnior, 390, Florianópolis, SC, 88015-130, Brazil
| | - Luiz Antônio Sardinha
- Medical ICU, Hospital das Clínicas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | | |
Collapse
|
3
|
Westphal GA, Fernandes RP, Pereira AB, Moerschberger MS, Pereira MR, Gonçalves ARR. Incidence of Delirium in Critically Ill Patients With and Without COVID-19. J Intensive Care Med 2023; 38:751-759. [PMID: 36939479 PMCID: PMC10030890 DOI: 10.1177/08850666231162805] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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] [Indexed: 03/21/2023]
Abstract
BACKGROUND It is known that patients with COVID-19 are at high risk of developing delirium. The aim of the study was to compare the incidence of delirium between critically ill patients with and without a diagnosis of COVID-19. METHODS This is a retrospective study conducted in a southern Brazilian hospital from March 2020 to January 2021. Patients were divided into two groups: the COVID-19 group consisted of patients with a diagnosis of COVID-19 confirmed by reverse transcription-polymerase chain reaction (RT-PCR) or serological tests who were admitted to specific ICUs. The non-COVID-19 group consisted of patients with other surgical and medical diagnoses who were admitted to non-COVID ICUs. All patients were evaluated daily using the Intensive Care Delirium Screening Checklist (ICDSC). The two cohorts were compared in terms of the diagnosis of delirium. RESULTS Of the 649 patients who remained more than 48 h in the ICU, 523 were eligible for the study (COVID-19 group: 292, non-COVID-19 group: 231). There were 119 (22.7%) patients who had at least one episode of delirium, including 96 (32.9%) in the COVID-19 group and 23 (10.0%) in the non-COVID-19 group (odds ratio [OR] 4.42; 95% confidence interval [CI], 2.69 to 7.26; p < 0.001). Among patients mechanically ventilated for two days or more, the incidence of delirium did not differ between groups (COVID-19: 89/211, 42.1% vs non-COVID-19: 19/47, 40.4%; p = 0.82). Logistic regression showed that the duration of mechanical ventilation was the only independent factor associated with delirium (p = 0.001). CONCLUSION COVID-19 can be associated with a higher incidence of delirium among critically ill patients, but there was no difference in this incidence between groups when mechanical ventilation lasted two days or more.
Collapse
Affiliation(s)
- Glauco Adrieno Westphal
- Department of Intensive Care, Centro Hospitalar Unimed de Joinville, Santa Catarina, Brazil
- Brazilian Research in Intensive Care Network, São Paulo, Brazil
| | | | - Aline Braz Pereira
- Department of Intensive Care, Centro Hospitalar Unimed de Joinville, Santa Catarina, Brazil
| | | | | | | |
Collapse
|
4
|
Tannous LA, Westphal GA, Ioshii SO, de Lima Alves GN, Pigatto RN, Pinto RL, de Carvalho KAT, Francisco JC, Guarita-Souza LC. Histological, Laboratorial, and Clinical Benefits of an Optimized Maintenance Strategy of a Potential Organ Donor-A Rabbit Experimental Model. Life (Basel) 2023; 13:1439. [PMID: 37511814 PMCID: PMC10381703 DOI: 10.3390/life13071439] [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: 05/29/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION Most transplanted organs are obtained from brain-dead donors. Inflammation results in a higher rate of rejection. Objectives: The objective of this animal model of brain death (BD) was to evaluate the effect of the progressive institution of volume expansion, norepinephrine, and combined hormone therapy on clinical, laboratory, and histological aspects. Methods: Twenty rabbits were divided: A (control), B (induction of BD + infusion of crystalloid), C (BD + infusion of crystalloid and noradrenaline (NA)), and D (BD + infusion of crystalloid + vasopressin + levothyroxine + methylprednisolone + NA). The animals were monitored for four hours with consecutives analysis of vital signs and blood samples. The organs were evaluated by a pathologist. Results: In Group D, we observed fewer number and lesser volume of infusions (p = 0.032/0.014) when compared with groups B and C. Mean arterial pressure levels were higher in group D when compared with group B (p = 0.008). Group D had better glycemic control when compared with group C (p = 0.016). Sodium values were elevated in group B in relation to groups C and D (p = 0.021). In Group D, the organ perfusion was better. Conclusion: The optimized strategy of management of BD animals is associated with better hemodynamic, glycemic, and natremia control, besides reducing early signs of ischemia.
Collapse
Affiliation(s)
- Luana Alves Tannous
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | | | - Sergio Ossamu Ioshii
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | | | - Raul Nishi Pigatto
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | - Rafael Luiz Pinto
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | | | | | - Luiz César Guarita-Souza
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| |
Collapse
|
5
|
Ramos J, Westphal C, Fezer AP, Moerschberger MS, Westphal GA. Effect of virtual information on the satisfaction for decision-making among family members of critically ill COVID-19 patients. Intensive Care Med 2022; 48:488-490. [PMID: 35089411 PMCID: PMC8795945 DOI: 10.1007/s00134-021-06616-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2021] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | | | - Glauco Adrieno Westphal
- Centro Hospitalar Unimed, Joinville, Brazil. .,Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil.
| |
Collapse
|
6
|
Maia IS, Marcadenti A, Zampieri FG, Damiani LP, Santos RHN, Negrelli KL, Gomes SPDC, Gomes JO, Carollo MBDS, Miranda TA, Santucci E, Valeis N, Laranjeira LN, Westphal GA, Horta JGA, Flato UAP, Fernandes C, Barros WC, Bolan RS, Gebara OCE, de Alencar Filho MS, Hamamoto VA, Hernandes ME, Golin NA, de Olinda RT, Machado FR, Rosa RG, Veiga VC, de Azevedo LCP, Avezum A, Lopes RD, Souza TML, Berwanger O, Cavalcanti AB. Antivirals for adult patients hospitalized with SARS-CoV-2 infection: A randomized, Phase II/III, multicenter, placebo-controlled, adaptive study, with multiple arms and stages. COALITION COVID-19 BRAZIL IX - REVOLUTIOn: protocol and statistical analysis plan. Rev Bras Ter Intensiva 2022. [PMID: 35766657 PMCID: PMC9345580 DOI: 10.5935/0103-507x.20220002-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Israel Silva Maia
- Research Institute, HCor-Hospital do Coração - São Paulo (SP), Brazil
- Division of Anesthesiology, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Corresponding author: Israel Silva Maia HCor-Hospital do Coração Rua Abílio Soares, 250, 12º andar ZIP code: 04005-002 - São Paulo (SP), Brazil E-mail:
| | - Aline Marcadenti
- Research Institute, HCor-Hospital do Coração - São Paulo (SP), Brazil
| | - Fernando Godinho Zampieri
- Research Institute, HCor-Hospital do Coração - São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
| | | | | | | | | | | | | | | | - Eliana Santucci
- Research Institute, HCor-Hospital do Coração - São Paulo (SP), Brazil
| | - Nanci Valeis
- Research Institute, HCor-Hospital do Coração - São Paulo (SP), Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Department of Anaesthesiology, Pain and Intensive Care Medicine, Universidade Federal de São Paulo (SP), Brazil
| | - Régis Goulart Rosa
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Hospital Moinhos de Vento - Porto Alegre (RS), Brazil
| | - Viviane Cordeiro Veiga
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil
| | - Luciano César Pontes de Azevedo
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Research and Education Institute, Hospital Sírio-Libanês - São Paulo (SP), Brazil
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz - São Paulo (SP), Brazil
| | - Renato Delascio Lopes
- Brazilian Clinical Research Institute (BCRI) - São Paulo (SP), Brazil
- Duke University Medical Center, Duke Clinical Research Institute - Durham, North Carolina, United States
| | - Tiago Moreno L Souza
- Laboratório de Imunofarmacologia, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz - Rio de Janeiro (RJ), Brazil
- National Institute for Science and Technology on Innovation in Diseases of Neglected Populations, Center for Technological Development in Health, Fundação Oswaldo Cruz - Rio de Janeiro (RJ), Brazil
| | | | - Alexandre Biasi Cavalcanti
- Research Institute, HCor-Hospital do Coração - São Paulo (SP), Brazil
- Division of Anesthesiology, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
| |
Collapse
|
7
|
Maia IS, Marcadenti A, Zampieri FG, Damiani LP, Santos RHN, Negrelli KL, Gomes SPDC, Gomes JO, Carollo MBDS, Miranda TA, Santucci E, Valeis N, Laranjeira LN, Westphal GA, Horta JGA, Flato UAP, Fernandes C, Barros WC, Bolan RS, Gebara OCE, Alencar Filho MSD, Hamamoto VA, Hernandes ME, Golin NA, Olinda RTD, Machado FR, Rosa RG, Veiga VC, Azevedo LCPD, Avezum A, Lopes RD, Souza TML, Berwanger O, Cavalcanti AB. Antivirals for adult patients hospitalized with SARS-CoV-2 infection: A randomized, Phase II/III, multicenter, placebo-controlled, adaptive study, with multiple arms and stages. COALITION COVID-19 BRAZIL IX - REVOLUTIOn: protocol and statistical analysis plan. Rev Bras Ter Intensiva 2022; 34:44-55. [PMID: 35766657 DOI: 10.5935/0103-507x.20220002-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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/31/2021] [Indexed: 11/20/2022] Open
Abstract
Repurposed drugs are important in resource-limited settings because the interventions are more rapidly available, have already been tested safely in other populations and are inexpensive. Repurposed drugs are an effective solution, especially for emerging diseases such as COVID-19. The REVOLUTIOn trial has the objective of evaluating three repurposed antiviral drugs, atazanavir, daclatasvir and sofosbuvir, already used for HIV- and hepatitis C virus-infected patients in a randomized, placebo-controlled, adaptive, multiarm, multistage study. The drugs will be tested simultaneously in a Phase II trial to first identify whether any of these drugs alone or in combination reduce the viral load. If they do, a Phase III trial will be initiated to investigate if these medications are capable of increasing the number of days free respiratory support. Participants must be hospitalized adults aged ≥ 18 years with initiation of symptoms ≤ 9 days and SpO2 ≤ 94% in room air or a need for supplemental oxygen to maintain an SpO2 > 94%. The expected total sample size ranges from 252 to 1,005 participants, depending on the number of stages that will be completed in the study. Hence, the protocol is described here in detail together with the statistical analysis plan. In conclusion, the REVOLUTIOn trial is designed to provide evidence on whether atazanavir, daclatasvir or sofosbuvir decrease the SARS-CoV-2 load in patients with COVID-19 and increase the number of days patients are free of respiratory support. In this protocol paper, we describe the rationale, design, and status of the trial. ClinicalTrials.gov identifier: NCT04468087.
Collapse
Affiliation(s)
- Israel Silva Maia
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil.,Divisão de Anestesiologia, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Brasilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
| | - Aline Marcadenti
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Fernando Godinho Zampieri
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil.,Brasilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
| | | | | | | | | | | | | | | | - Eliana Santucci
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Nanci Valeis
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Flávia Ribeiro Machado
- Brasilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Departamento de Anestesiologia, Dor e Medicina Intensiva, Universidade Federal de São Paulo (SP), Brasil
| | - Régis Goulart Rosa
- Brasilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
| | - Viviane Cordeiro Veiga
- Brasilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brasil
| | - Luciano César Pontes de Azevedo
- Brasilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Instituto de Pesquisa e Educação, Hospital Sírio-Libanês - São Paulo (SP), Brasil
| | - Alvaro Avezum
- Centro Internacional de Pesquisa, Hospital Alemão Oswaldo Cruz - São Paulo (SP), Brasil
| | - Renato Delascio Lopes
- Brazilian Clinical Research Institute (BCRI) - São Paulo (SP), Brasil.,Duke University Medical Center, Duke Clinical Research Institute - Durham, North Carolina, United States
| | - Tiago Moreno L Souza
- Laboratório de Imunofarmacologia, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz - Rio de Janeiro (RJ), Brasil.,Instituto Nacional de Ciência e Tecnologia de Inovação em Doenças de Populações Negligenciadas, Centro de Desenvolvimento Tecnológico em Saúde, Fundação Oswaldo Cruz - Rio de Janeiro (RJ), Brasil. Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | - Alexandre Biasi Cavalcanti
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil.,Divisão de Anestesiologia, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Brasilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
| |
Collapse
|
8
|
Maia IS, Marcadenti A, Zampieri FG, Damiani LP, Santos RHN, Negrelli KL, Gomes SPDC, Gomes JO, Carollo MBDS, Miranda TA, Santucci E, Valeis N, Laranjeira LN, Westphal GA, Horta JGA, Flato UAP, Fernandes C, Barros WC, Bolan RS, Gebara OCE, Alencar Filho MSD, Hamamoto VA, Hernandes ME, Golin NA, Olinda RTD, Machado FR, Rosa RG, Veiga VC, Azevedo LCPD, Avezum A, Lopes RD, Souza TML, Berwanger O, Cavalcanti AB, BRICNet CIXIAT. Antivirals for adult patients hospitalized with SARS-CoV-2 infection: A randomized, Phase II/III, multicenter, placebo-controlled, adaptive study, with multiple arms and stages. COALITION COVID-19 BRAZIL IX - REVOLUTIOn: protocol and statistical analysis plan. Rev Bras Ter Intensiva 2022. [DOI: 10.5935/0103-507x.20220002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
9
|
Freitas FGRD, Hammond N, Li Y, Azevedo LCPD, Cavalcanti AB, Taniguchi L, Gobatto A, Japiassú AM, Bafi AT, Mazza BF, Noritomi DT, Dal-Pizzol F, Bozza F, Salluh JIF, Westphal GA, Soares M, Assunção MSCD, Lisboa T, Lobo SMA, Barbosa AR, Ventura AF, Souza AFD, Silva AF, Toledo A, Reis A, Cembranel A, Rea Neto A, Gut AL, Justo APP, Santos AP, Albuquerque ACDD, Scazufka A, Rodrigues AB, Fernandino BB, Silva BG, Vidal BS, Pinheiro BV, Pinto BVC, Feijo CAR, Abreu Filho CD, Bosso CEDCN, Moreira CEN, Ramos CHF, Tavares C, Arantes C, Grion C, Mendes CL, Kmohan C, Piras C, Castro CPP, Lins C, Beraldo D, Fontes D, Boni D, Castiglioni D, Paisani DDM, Pedroso DFF, Mattos ER, Brito Sobrinho ED, Troncoso EMV, Rodrigues Filho EM, Nogueira EEF, Ferreira EL, Pacheco ES, Jodar E, Ferreira ELA, Araujo FFD, Trevisol FS, Amorim FF, Giannini FP, Santos FPM, Buarque F, Lima FG, Costa FAAD, Sad FCDA, Aranha FG, Ganem F, Callil F, Costa Filho FF, Dall Arto FTC, Moreno G, Friedman G, Moralez GM, Silva GAD, Costa G, Cavalcanti GS, Cavalcanti GS, Betônico GN, Betônico GN, Reis H, Araujo HBN, Hortiz Júnior HA, Guimaraes HP, Urbano H, Maia I, Santiago Filho IL, Farhat Júnior J, Alvarez JR, Passos JT, Paranhos JEDR, Marques JA, Moreira Filho JG, Andrade JN, Sobrinho JODC, Bezerra JTDP, Alves JA, Ferreira J, Gomes J, Sato KM, Gerent K, Teixeira KMC, Conde KAP, Martins LF, Figueirêdo L, Rezegue L, Tcherniacovsk L, Ferraz LO, Cavalcante L, Rabelo L, Miilher L, Garcia L, Tannous L, Hajjar LA, Paciência LEM, Cruz Neto LMD, Bley MV, Sousa MF, Puga ML, Romano MLP, Nobrega M, Arbex M, Rodrigues ML, Guerreiro MO, Rocha M, Alves MAP, Alves MAP, Rosa MD, Dias MD, Martins M, Oliveira MD, Moretti MMS, Matsui M, Messender O, Santarém OLDA, Silveira PJHD, Vassallo PF, Antoniazzi P, Gottardo PC, Correia P, Ferreira P, Torres P, Silva PGMDBE, Foernges R, Gomes R, Moraes R, Nonato Filho R, Borba RL, Gomes RV, Cordioli R, Lima R, López RP, Gargioni RRDO, Rosenblat R, Souza RMD, Almeida R, Narciso RC, Marco R, Waltrick R, Biondi R, Figueiredo R, Dutra RS, Batista R, Felipe R, Franco RSDS, Houly S, Faria SS, Pinto SF, Luzzi S, Sant'ana S, Fernandes SS, Yamada S, Zajac S, Vaz SM, Bezerra SAB, Farhat TBT, Santos TM, Smith T, Silva UVA, Damasceno VB, Nobre V, Dantas VCDS, Irineu VM, Bogado V, Nedel W, Campos Filho W, Dantas W, Viana W, Oliveira Filho WD, Delgadinho WM, Finfer S, Machado FR. Resuscitation fluid practices in Brazilian intensive care units: a secondary analysis of Fluid-TRIPS. Rev Bras Ter Intensiva 2021; 33:206-218. [PMID: 34231801 PMCID: PMC8275089 DOI: 10.5935/0103-507x.20210028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 12/08/2020] [Indexed: 12/16/2022] Open
Abstract
Objective To describe fluid resuscitation practices in Brazilian intensive care units and to compare them with those of other countries participating in the Fluid-TRIPS. Methods This was a prospective, international, cross-sectional, observational study in a convenience sample of intensive care units in 27 countries (including Brazil) using the Fluid-TRIPS database compiled in 2014. We described the patterns of fluid resuscitation use in Brazil compared with those in other countries and identified the factors associated with fluid choice. Results On the study day, 3,214 patients in Brazil and 3,493 patients in other countries were included, of whom 16.1% and 26.8% (p < 0.001) received fluids, respectively. The main indication for fluid resuscitation was impaired perfusion and/or low cardiac output (Brazil: 71.7% versus other countries: 56.4%, p < 0.001). In Brazil, the percentage of patients receiving crystalloid solutions was higher (97.7% versus 76.8%, p < 0.001), and 0.9% sodium chloride was the most commonly used crystalloid (62.5% versus 27.1%, p < 0.001). The multivariable analysis suggested that the albumin levels were associated with the use of both crystalloids and colloids, whereas the type of fluid prescriber was associated with crystalloid use only. Conclusion Our results suggest that crystalloids are more frequently used than colloids for fluid resuscitation in Brazil, and this discrepancy in frequencies is higher than that in other countries. Sodium chloride (0.9%) was the crystalloid most commonly prescribed. Serum albumin levels and the type of fluid prescriber were the factors associated with the choice of crystalloids or colloids for fluid resuscitation.
Collapse
Affiliation(s)
| | - Naomi Hammond
- Critical Care and Trauma Division, The George Institute for Global Health - Sydney, Austrália
| | - Yang Li
- Critical Care and Trauma Division, The George Institute for Global Health - Sydney, Austrália
| | - Luciano Cesar Pontes de Azevedo
- Hospital Sírio-Libanês - São Paulo (SP), Brasil.,Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - Leandro Taniguchi
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - André Gobatto
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - André Miguel Japiassú
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz - Rio de Janeiro (RJ), Brasil.,Hospital de Clínicas Mário Lioni - Rio de Janeiro (RJ), Brasil
| | - Antonio Tonete Bafi
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo - São Paulo (SP), Brasil.,Hospital do Rim e Hipertensão, Fundação Oswaldo Ramos - São Paulo (SP), Brasil
| | | | | | | | - Fernando Bozza
- Hospital de Clínicas Mário Lioni - Rio de Janeiro (RJ), Brasil.,Instituto D'Or de Ensino e Pesquisa - Rio de Janeiro (RJ), Brasil
| | | | | | - Márcio Soares
- Instituto D'Or de Ensino e Pesquisa - Rio de Janeiro (RJ), Brasil
| | | | | | | | | | | | | | | | | | - Aline Reis
- Instituto D'Or de Ensino e Pesquisa - Rio de Janeiro (RJ), Brasil
| | | | - Alvaro Rea Neto
- Hospital Ecoville - Curitiba (PR), Brasil.,Hospital do Trabalhador - Curitiba (PR), Brasil.,Hospital Vita Batel - Curitiba (PR), Brasil
| | - Ana Lúcia Gut
- Hospital das Clínicas, Faculdade de Medicina de Botucatu, Universidade Estadual "Júlio de Mesquita Filho" - Botucatu (SP), Brasil
| | | | | | | | | | | | | | | | | | - Bruno Valle Pinheiro
- Hospital Universitário, Universidade Federal de Juiz de Fora- Juiz de Fora (MG), Brasil
| | | | | | | | | | | | | | - Carmen Tavares
- Hospital Municipal Santa Isabel - João Pessoa (PA), Brasil
| | - Cidamaiá Arantes
- Hospital e Maternidade Municipal Dr. Odelmo Leão Carneiro - Uberlândia (MG), Brasil
| | - Cintia Grion
- Hospital Evangélico de Londrina - Londrina (PR), Brasil.,Universidade Estadual de Londrina - Londrina (SC), Brasil
| | | | - Claudio Kmohan
- Hospital de Caridade Astrogildo de Azevedo - Santa Maria (RS), Brasil
| | | | | | - Cyntia Lins
- Hospital do Subúrbio - Salvador (BA), Brasil
| | | | - Daniel Fontes
- Hospital Felício Rocho - Belo Horizonte (MG), Brasil
| | - Daniela Boni
- Hospital Municipal Irmã Dulce - Praia Grande (SP), Brasil
| | - Débora Castiglioni
- Hospital Universitário Júlio Müller, Universidade Federal do Mato Grosso - Cuiabá (MT), Brasil
| | | | | | | | | | | | | | | | - Eduardo Leme Ferreira
- Hospital Carlos da Silva Lacaz - Francisco Morato (SP), Brasil.,Hospital Escola, Faculdade de Medicina de Jundiaí - Jundiaí (SP), Brasil
| | - Eduardo Souza Pacheco
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo - São Paulo (SP), Brasil.,Hospital Sepaco - São Paulo (SP), Brasil
| | - Euzebio Jodar
- Hospital Professor Edmundo Vasconcelos - São Paulo (SP), Brasil
| | | | - Fabiana Fernandes de Araujo
- Clínica Dom Rodrigo - João Pessoa (PA), Brasil.,Complexo Hospitalar Ortotrauma de Mangabeira - Fortaleza (CE), Brasil
| | | | | | | | | | | | - Felipe Gallego Lima
- Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | | | | | | | - Flavio Callil
- Hospital Estadual Getúlio Vargas - Rio de Janeiro (RJ), Brasil
| | | | | | - Geovani Moreno
- Santa Casa de Misericórdia de Vitória da Conquista - Vitória da Conquista (BA), Brasil
| | - Gilberto Friedman
- Santa Casa de Misericórdia de Porto Alegre - Porto Alegre (RS), Brasil
| | | | | | | | | | | | | | | | - Hélder Reis
- Hospital de Clínicas Gaspar Vianna - Belém (PA), Brasil
| | | | | | - Helio Penna Guimaraes
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo - São Paulo (SP), Brasil
| | - Hugo Urbano
- Hospital Vila da Serra - Belo Horizonte (MG), Brasil
| | - Israel Maia
- Hospital Nereu Ramos - Florianópolis (SC), Brasil
| | | | | | - Janu Rangel Alvarez
- Santa Casa de Caridade de Don Pedrito - Dom Pedrito (RS), Brasil.,Santa Casa de Misericórdia de Santana do Livramento - Santana do Livramento (RS), Brasil
| | | | | | | | | | | | | | | | | | - Juliana Ferreira
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Jussara Gomes
- Associação Hospitalar Beneficente São Vicente de Paulo - Passo Fundo (RS), Brasil
| | - Karina Midori Sato
- Hospital do Servidor Público Municipal de São Paulo - São Paulo (SP), Brasil
| | | | | | | | | | | | | | | | | | | | - Ligia Rabelo
- Hospital Copa D'Or - Rio de Janeiro (RJ), Brasil
| | | | - Lisiane Garcia
- Hospital Universitário de Santa Maria - Santa Maria (RS), Brasil
| | - Luana Tannous
- Hospital Universitário Cajuru - Curitiba (PR), Brasil
| | - Ludhmila Abrahão Hajjar
- Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Instituto do Câncer do Estado de São Paulo - São Paulo (SP), Brasil
| | | | | | | | | | - Marcelo Lourencini Puga
- Hospital das Clínicas, Faculdade Ribeirão Preto, Universidade de São Paulo - Ribeirão Preto (SP), Brasil
| | | | - Marciano Nobrega
- Hospital Goiânia Leste - Goiânia (GO), Brasil.,Hospital Ortopédico - Goiânia (GO), Brasil.,Hospital Santa Maria - Goiânia (GO), Brasil
| | - Marcio Arbex
- Hospital Municipal Dr. Munir Rafful - Volta Redonda (RJ), Brasil.,Hospital Jardim Amália - Volta Redonda (RJ), Brasil
| | | | - Márcio Osório Guerreiro
- Hospital Universitário São Francisco de Paula, Universidade Católica de Pelotas - Pelotas (RS), Brasil
| | - Marcone Rocha
- Hospital São Joao de Deus - Divinópolis (MG), Brasil
| | | | | | | | | | - Miquéias Martins
- Hospital Geral de Vitória da Conquista - Vitória da Conquista (BA), Brasil
| | | | | | - Mirna Matsui
- Hospital Universitário, Universidade Federal da Grande Dourados - Dourados (GO), Brasil
| | | | | | | | | | - Paulo Antoniazzi
- Santa Casa de Misericórdia de Ribeirão Preto - Ribeirão Preto (SP), Brasil
| | | | - Paulo Correia
- Santa Casa de Belo Horizonte - Belo Horizonte (MG), Brasil
| | | | - Paulo Torres
- Santa Casa Maringá, Universidade Estadual Maringá - Maringá (PR), Brasil
| | | | - Rafael Foernges
- Hospital Universitário, Universidade de Santa Cruz do Sul - Santa Cruz do Sul (RS), Brasil
| | | | - Rafael Moraes
- Hospital das Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | | | | | - Renato V Gomes
- Hospital Unimed Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | | | - Ricardo Lima
- Hospital Samaritano Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | | | | | | | | | - Roberto Almeida
- Hospital Municipal Padre Germano Lauck - Foz do Iguaçu (RS), Brasil
| | | | - Roberto Marco
- Hospital Santa Izabel - São Paulo (SP), Brasil.,Santa Casa de Misericórdia de São Paulo - São Paulo (SP), Brasil
| | | | | | | | - Rodrigo Santana Dutra
- Hospital Universitário Ciências Médicas, Fundação Educacional Lucas Machado - Belo Horizonte (MG), Brasil
| | | | - Rouge Felipe
- Instituto Nacional de Cardiologia - Rio de Janeiro (RJ), Brasil
| | | | - Sandra Houly
- BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brasil
| | | | - Sergio Felix Pinto
- Hospital Universitário Maria Aparecida Pedrossian, Universidade Federal de Mato Grosso do Sul - Campo Grande (MS), Brasil
| | - Sergio Luzzi
- Hospital do Servidor Público Estadual "Francisco Morato de Oliveira" - São Paulo (SP), Brasil
| | | | | | - Sérgio Yamada
- Hospital Universitário de Maringá, Universidade Estadual de Maringá - Maringá (PR), Brasil
| | - Sérgio Zajac
- Albert Sabin Hospital e Maternidade - Juiz de Fora (MG), Brasil
| | | | | | | | - Thiago Martins Santos
- Disciplina de Emergências Clínicas, Universidade Estadual de Campinas - Campinas (SP), Brasil
| | | | - Ulysses V A Silva
- Fundação Pio XII- Hospital de Câncer de Barretos - Barretos (SP), Brasil
| | | | - Vandack Nobre
- Hospital das Clínicas, Universidade Federal de Minas Gerais - Belo Horizonte (MG), Brasil
| | | | | | - Viviane Bogado
- Santa Casa de Angra dos Reis - Angra dos Reis (RJ), Brasil
| | - Wagner Nedel
- Grupo Hospitalar Nossa Senhora da Conceição - Porto Alegre (RS), Brasil
| | - Walther Campos Filho
- Irmandade Misericórdia Hospital Santa Casa de Monte Alto - Monte Alto (SP), Brasil
| | | | | | - Wilson de Oliveira Filho
- Hospital Unimed de Manaus - Manaus (AM), Brasil.,Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas - Manaus (AM), Brasil
| | - Wilson Martins Delgadinho
- Casa de Saúde Campinas - Campinas (SP), Brasil.,Hospital e Maternidade Galileo - Valinhos (SP), Brasil
| | - Simon Finfer
- Critical Care and Trauma Division, The George Institute for Global Health - Sydney, Austrália
| | - Flavia Ribeiro Machado
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo - São Paulo (SP), Brasil
| |
Collapse
|
10
|
Westphal GA, Robinson CC, Cavalcanti AB, Gonçalves ARR, Guterres CM, Teixeira C, Stein C, Franke CA, da Silva DB, Pontes DFS, Nunes DSL, Abdala E, Dal-Pizzol F, Bozza FA, Machado FR, de Andrade J, Cruz LN, de Azevedo LCP, Machado MCV, Rosa RG, Manfro RC, Nothen RR, Lobo SM, Rech TH, Lisboa T, Colpani V, Falavigna M. 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. Ann Intensive Care 2020; 10:169. [PMID: 33315161 PMCID: PMC7736434 DOI: 10.1186/s13613-020-00787-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 08/03/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Glauco Adrieno Westphal
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil. .,Hospital Municipal São José (HMSJ), Joinville, SC, Brazil. .,Centro Hospitalar Unimed, Joinville, SC, Brazil.
| | | | | | - Anderson Ricardo Roman Gonçalves
- Universidade da Região de Joinville (UNIVILLE), R. Paulo Malschitzki, 10, Joinville, SC, 89219710, Brazil.,Clínica de Nefrologia de Joinville, R. Plácido Gomes, 370, Joinville, SC, 89202-050, Brazil
| | - Cátia Moreira Guterres
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cassiano Teixeira
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite, 245, Porto Alegre, RS, 90050-170, Brazil
| | - Cinara Stein
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cristiano Augusto Franke
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Hospital de Pronto de Socorro (HPS), Porto Alegre, RS, Brazil
| | - Daiana Barbosa da Silva
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Daniela Ferreira Salomão Pontes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Diego Silva Leite Nunes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Edson Abdala
- Faculdade de Medicina, Universidade de São Paulo (USP), Av. Dr, Arnaldo 455, Sala 3206, São Paulo, SP, 01246903, Brazil
| | - Felipe Dal-Pizzol
- Universidade do Extremo Sul Catarinense (UNESC), Av. Universitária, 1105, Criciúma, SC, 88806000, Brazil.,Intensive Care Unit, Hospital São José, R. Cel. Pedro Benedet, 630, Criciúma, SC, 88801-250, Brazil
| | - Fernando Augusto Bozza
- National Institute of Infectious Disease Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Av. Brasil, 4365, Rio de Janeiro, RJ, 21040360, Brazil.,Instituto D'Or de Pesquisa e Ensino (IDOR), R. Diniz Cordeiro, 30, Rio de Janeiro, RJ, 22281100, Brazil
| | - Flávia Ribeiro Machado
- Hospital São Paulo (HU), Universidade Federal de São Paulo (UNIFESP), R. Napoleão de Barros 737, São Paulo, SP, 04024002, Brazil
| | - Joel de Andrade
- Organização de Procura de Órgãos e Tecidos de Santa Catarina (OPO/SC), Rua Esteves Júnior, 390, Florianópolis, SC, 88015130, Brazil
| | - Luciane Nascimento Cruz
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | | | | | - Regis Goulart Rosa
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Roberto Ceratti Manfro
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Rosana Reis Nothen
- Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Suzana Margareth Lobo
- Faculdade de Medicina de São José do Rio Preto, Av Faria Lima, 5544, São José do Rio Preto, SP, 15090000, Brazil
| | - Tatiana Helena Rech
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Thiago Lisboa
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Verônica Colpani
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Maicon Falavigna
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil.,National Institute for Health Technology Assessment, UFRGS, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035903, Brazil.,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main St W, Hamilton, ON, Canada
| |
Collapse
|
11
|
Cherem S, Fernandes V, Zambonato KD, Westphal GA. Can the behavior of blood pressure after elevation of the positive end-expiratory pressure help to determine the fluid responsiveness status in patients with septic shock? Rev Bras Ter Intensiva 2020; 32:374-380. [PMID: 33053026 PMCID: PMC7595715 DOI: 10.5935/0103-507x.20200065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/16/2019] [Accepted: 02/12/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To evaluate whether the decrease in blood pressure caused by the increase in the positive end-expiratory pressure corresponds to the pulse pressure variation as an indicator of fluid responsiveness. METHODS This exploratory study prospectively included 24 patients with septic shock who were mechanically ventilated and subjected to three stages of elevation of the positive end-expiratory pressure: from 5 to 10cmH2O (positive end-expiratory pressure level 1), from 10 to 15cmH2O (positive end-expiratory pressure level 2), and from 15 to 20cmH2O (positive end-expiratory pressure level 3). Changes in systolic blood pressure, mean arterial pressure, and pulse pressure variation were evaluated during the three maneuvers. The patients were classified as responsive (pulse pressure variation ≥ 12%) or unresponsive to volume replacement (pulse pressure variation < 12%). RESULTS The best performance at identifying patients with pulse pressure variation ≥ 12% was observed at the positive end-expiratory pressure level 2: -9% systolic blood pressure variation (area under the curve 0.73; 95%CI: 0.49 - 0.79; p = 0.04), with a sensitivity of 63% and specificity of 80%. Concordance was low between the variable with the best performance (variation in systolic blood pressure) and pulse pressure variation ≥ 12% (kappa = 0.42; 95%CI: 0.19 - 0.56). The systolic blood pressure was < 90mmHg at positive end-expiratory pressure level 2 in 29.2% of cases and at positive end-expiratory pressure level 3 in 41.63% of cases. CONCLUSION Variations in blood pressure in response to the increase in positive end-expiratory pressure do not reliably reflect the behavior of the pulse pressure as a measure to identify the fluid responsiveness status.
Collapse
Affiliation(s)
- Samia Cherem
- Hospital Municipal São José - Joinville (SC), Brasil
| | | | | | | |
Collapse
|
12
|
Aguiar FP, Westphal GA, Dadam MM, Mota ECC, Pfutzenreuter F, França PHC. Characteristics and predictors of chronic critical illness in the intensive care unit. Rev Bras Ter Intensiva 2020; 31:511-520. [PMID: 31967226 PMCID: PMC7009003 DOI: 10.5935/0103-507x.20190088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 11/06/2018] [Accepted: 07/11/2019] [Indexed: 12/17/2022] Open
Abstract
Objective To characterize patients with chronic critical illness and identify predictors of development of chronic critical illness. Methods Prospective data was collected for 1 year in the intensive care unit of a general hospital in Southern Brazil. Three logistic regression models were constructed to identify factors associated with chronic critical illness. Results Among the 574 subjects admitted to the intensive care unit, 200 were submitted to mechanical ventilation. Of these patients, 85 (43.5%) developed chronic critical illness, composing 14.8% of all the patients admitted to the intensive care unit. The regression model that evaluated the association of chronic critical illness with conditions present prior to intensive care unit admission identified chronic renal failure in patients undergoing hemodialysis (OR 3.57; p = 0.04) and a neurological diagnosis at hospital admission (OR 2.25; p = 0.008) as independent factors. In the model that evaluated the association of chronic critical illness with situations that occurred during intensive care unit stay, muscle weakness (OR 2.86; p = 0.01) and pressure ulcers (OR 9.54; p < 0.001) had the strongest associations. In the global multivariate analysis (that assessed previous factors and situations that occurred in the intensive care unit), hospital admission due to neurological diseases (OR 2.61; p = 0.03) and the development of pressure ulcers (OR 9.08; p < 0.001) had the strongest associations. Conclusion The incidence of chronic critical illness in this study was similar to that observed in other studies and had a strong association with the diagnosis of neurological diseases at hospital admission and chronic renal failure in patients undergoing hemodialysis, as well as complications developed during hospitalization, such as pressure ulcers and muscle weakness.
Collapse
Affiliation(s)
- Fernanda Perito Aguiar
- Programa de Pós-Graduação em Saúde e Meio Ambiente e Departamento de Medicina, Universidade da Região de Joinville - Joinville (SC), Brasil.,Unidade de Terapia Intensiva, Hospital São José - Joinville (SC), Brasil
| | - Glauco Adrieno Westphal
- Programa de Pós-Graduação em Saúde e Meio Ambiente e Departamento de Medicina, Universidade da Região de Joinville - Joinville (SC), Brasil.,Unidade de Terapia Intensiva, Hospital São José - Joinville (SC), Brasil
| | | | - Elisa Cristina Correia Mota
- Programa de Pós-Graduação em Saúde e Meio Ambiente e Departamento de Medicina, Universidade da Região de Joinville - Joinville (SC), Brasil
| | | | - Paulo Henrique Condeixa França
- Programa de Pós-Graduação em Saúde e Meio Ambiente e Departamento de Medicina, Universidade da Região de Joinville - Joinville (SC), Brasil
| |
Collapse
|
13
|
Westphal GA, Fernandes V, Westphal V, Fonseca JC, Silva LRD, Valiatti JLDS. Use of CPAP as an alternative to the apnea test during the determination of brain death in hypoxemic patients. Report of two cases. Rev Bras Ter Intensiva 2020; 32:319-325. [PMID: 32667440 PMCID: PMC7405752 DOI: 10.5935/0103-507x.20200032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 07/19/2019] [Accepted: 12/02/2019] [Indexed: 11/20/2022] Open
Abstract
The apnea test, which involves disconnection from the mechanical ventilator, presents risks during the determination of brain death, especially in hypoxemic patients. We describe the performance of the apnea test without disconnection from the mechanical ventilator in two patients. The first case involved an 8-year-old boy admitted with severe hypoxemia due to pneumonia. He presented with cardiorespiratory arrest, followed by unresponsive coma due to hypoxic-ischemic encephalopathy. Two clinical exams revealed the absence of brainstem reflexes, and transcranial Doppler ultrasound revealed brain circulatory arrest. Three attempts were made to perform the apnea test, which were interrupted by hypoxemia; therefore, the apnea test was performed without disconnection from the mechanical ventilator, adjusting the continuous airway pressure to 10cmH2O and the inspired fraction of oxygen to 100%. The oxygen saturation was maintained at 100% for 10 minutes. Posttest blood gas analysis results were as follows: pH, 6.90; partial pressure of oxygen, 284.0mmHg; partial pressure of carbon dioxide, 94.0mmHg; and oxygen saturation, 100%. The second case involved a 43-year-old woman admitted with subarachnoid hemorrhage (Hunt-Hess V and Fisher IV). Two clinical exams revealed unresponsive coma and absence of all brainstem reflexes. Brain scintigraphy showed no radioisotope uptake into the brain parenchyma. The first attempt at the apnea test was stopped after 5 minutes due to hypothermia (34.9°C). After rewarming, the apnea test was repeated without disconnection from the mechanical ventilator, showing maintenance of the functional residual volume with electrical bioimpedance. Posttest blood gas analysis results were as follows: pH, 7.01; partial pressure of oxygen, 232.0mmHg; partial pressure of carbon dioxide, 66.9mmHg; and oxygen saturation, 99.0%. The apnea test without disconnection from the mechanical ventilator allowed the preservation of oxygenation in both cases. The use of continuous airway pressure during the apnea test seems to be a safe alternative in order to maintain alveolar recruitment and oxygenation during brain death determination.
Collapse
Affiliation(s)
| | - Veviani Fernandes
- Centro Hospitalar Unimed, Unidade de Terapia Intensiva, Joinville, SC, Brasil
| | - Verônica Westphal
- Centro Hospitalar Unimed, Unidade de Terapia Intensiva, Joinville, SC, Brasil
| | | | | | | |
Collapse
|
14
|
Giordani NE, Robinson CC, Westphal GA, Rosa RG, Sganzerla D, Cavalcanti AB, Machado FR, Azevedo LCP, Bozza FA, Teixeira C, de Andrade J, Franke CA, Guterres CM, Madalena IC, Rohden AI, da Silva SS, Andrighetto LV, Rech GS, Gimenes BDP, Hammes LS, Pontes DFS, Meade MO, Falavigna M. Statistical analysis plan for a cluster-randomised trial assessing the effectiveness of implementation of a bedside evidence-based checklist for clinical management of brain-dead potential organ donors in intensive care units: DONORS (Donation Network to Optimise Organ Recovery Study). Trials 2020; 21:540. [PMID: 32552839 PMCID: PMC7298918 DOI: 10.1186/s13063-020-04457-1] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 05/25/2020] [Indexed: 11/28/2022] Open
Abstract
Background The quality of clinical care of brain-dead potential organ donors may help reduce donor losses caused by irreversible or unreversed cardiac arrest and increase the number of organs donated. We sought to determine whether an evidence-based, goal-directed checklist for donor management in intensive care units (ICUs) can reduce donor losses to cardiac arrest. Methods/design The DONORS study is a multicentre, cluster-randomised controlled trial with a 1:1 allocation ratio designed to compare an intervention group (goal-directed checklist for brain-dead potential organ donor management) with a control group (standard ICU care). The primary outcome is loss of potential donors due to cardiac arrest. Secondary outcomes are the number of actual organ donors and the number of solid organs recovered per actual donor. Exploratory outcomes include the achievement of relevant clinical goals during the management of brain-dead potential organ donors. The present statistical analysis plan (SAP) describes all primary statistical procedures that will be used to evaluate the results and perform exploratory and sensitivity analyses of the trial. Discussion The SAP of the DONORS study aims to describe its analytic procedures, enhancing the transparency of the study. At the moment of SAP subsmission, 63 institutions have been randomised and were enrolling study participants. Thus, the analyses reported herein have been defined before the end of the study recruitment and database locking. Trial registration ClinicalTrials.gov, NCT03179020. Registered on 7 June 2017.
Collapse
Affiliation(s)
- Natalia Elis Giordani
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil. .,Postgraduate Programme in Epidemiology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.
| | - Caroline Cabral Robinson
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Glauco Adrieno Westphal
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil.,Hospital Municipal São José, Joinville, SC, Brazil.,Centro Hospitalar Unimed, Joinville, SC, Brazil
| | | | - Daniel Sganzerla
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | | | - Flávia Ribeiro Machado
- Department of Anaesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | - Fernando Augusto Bozza
- Department of Critical Care and Postgraduate Programme in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil.,Evandro Chagas National Institute of Infectious Diseases, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, RJ, Brazil
| | - Cassiano Teixeira
- Department of Internal Medicine and Postgraduate Programme in Rehabilitation Science, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Joel de Andrade
- Organ Procurement Organisation of Santa Catarina (OPO/SC), Florianópolis, SC, Brazil
| | - Cristiano Augusto Franke
- Adult Intensive Care Unit, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.,Trauma Intensive Care Unit, Hospital de Pronto de Socorro (HPS), Porto Alegre, RS, Brazil
| | - Cátia Moreira Guterres
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Itiana Cardoso Madalena
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Adriane Isabel Rohden
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Sabrina Souza da Silva
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Luiza Vitelo Andrighetto
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Gabriela Soares Rech
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Bruna Dos Passos Gimenes
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | | | | | - Maureen O Meade
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Maicon Falavigna
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil.,Postgraduate Programme in Epidemiology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| |
Collapse
|
15
|
Affiliation(s)
| | - Juliano Ramos
- Centro Hospitalar Unimed Joinville, Unidade de Terapia Intensiva, Joinville, SC, Brasil
| |
Collapse
|
16
|
Abstract
Brain death, defined as the complete and irreversible loss of brain functions, has a history that is linked to the emergence of intensive care units and the advancement of artificial ventilatory support. In Brazil, by federal law, the criteria for the diagnosis of brain death have been defined by the Federal Council of Medicine since 1997 and apply to the entire Brazilian territory. Resolution 2,173/2017 of the Federal Council of Medicine updated the criteria for diagnosing brain death. These changes include the following: the requirement for the patient to meet specific physiological prerequisites and for the physician to provide optimized care to the patient before starting the procedures for diagnosing brain death and to perform complementary tests, as well as the need for specific training for physicians who make this diagnosis. Other changes include the reduction of the time interval between the two clinical examinations, the possibility of continuing procedures in the presence of unilateral ear or eye injury, the performance of a single apnea test and the creation of a statement of brain death determination that includes the recording of all procedures in a single document. This document, despite the controversy surrounding it, increases the safety necessary when establishing a diagnosis of such importance and has positive implications that extend beyond the patient and the physician to reach the entire health system.
Collapse
Affiliation(s)
- Glauco Adrieno Westphal
- Central Estadual de Transplantes de Santa Catarina, Secretaria de Estado da Saúde de Santa Catarina - Florianópolis (SC), Brasil.,Unidade de Terapia Intensiva, Hospital Municipal São José - Joinville (SC), Brasil
| | - Viviane Cordeiro Veiga
- Unidade de Terapia Intensiva Neurológica, Hospital BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brasil
| | - Cristiano Augusto Franke
- Serviço de Medicina Intensiva, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva do Trauma, Hospital de Pronto Socorro de Porto Alegre - Porto Alegre (RS), Brasil
| |
Collapse
|
17
|
Westphal GA, Pereira AB, Fachin SM, Barreto ACC, Bornschein ACGJ, Caldeira Filho M, Koenig Á. Characteristics and outcomes of patients with community-acquired and hospital-acquired sepsis. Rev Bras Ter Intensiva 2019; 31:71-78. [PMID: 30970093 PMCID: PMC6443308 DOI: 10.5935/0103-507x.20190013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 12/04/2018] [Indexed: 12/29/2022] Open
Abstract
Objective To compare the clinical characteristics and outcomes of patients with
community-acquired and hospital-acquired sepsis. Methods This is a retrospective cohort study that included all patients with a
diagnosis of sepsis detected between January 2010 and December 2015 at a
private hospital in southern Brazil. Outcomes (mortality, intensive care
unit and hospital lengths of stay) were measured by analyzing electronic
records. Results There were 543 hospitalized patients with a diagnosis of sepsis, with a
frequency of 90.5 (85 to 105) cases/year. Of these, 319 (58%) cases were
classified as hospital-acquired sepsis. This group exhibited more severe
disease and had a larger number of organ dysfunctions, with higher hospital
[8 (8 - 10) versus 23 (20 - 27) days; p <
0.001] and intensive care unit [5 (4 - 7)
versus 8.5 (7 - 10); p < 0.001] lengths of
stay and higher in-hospital mortality (30.7% versus 15.6%;
p < 0.001) than those with community-acquired sepsis. After adjusting for
age, APACHE II scores, and hemodynamic and respiratory dysfunction,
hospital-acquired sepsis remained associated with increased mortality (OR
1.96; 95%CI 1.15 - 3.32, p = 0.013). Conclusion The present results contribute to the definition of the epidemiological
profile of sepsis in the sample studied, in which hospital-acquired sepsis
was more severe and was associated with higher mortality.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Álvaro Koenig
- Centro Hospitalar Unimed Joinville - Joinville (SC), Brasil
| |
Collapse
|
18
|
Westphal GA, Robinson CC, Biasi A, Machado FR, Rosa RG, Teixeira C, de Andrade J, Franke CA, Azevedo LCP, Bozza F, Guterres CM, da Silva DB, Sganzerla D, do Prado DZ, Madalena IC, Rohden AI, da Silva SS, Giordani NE, Andrighetto LV, Benck PS, Roman FR, de Melo MDFRB, Pereira TB, Grion CMC, Diniz PC, Oliveira JFP, Mecatti GC, Alves FAC, Moraes RB, Nobre V, Hammes LS, Meade MO, Nothen RR, Falavigna M. DONORS (Donation Network to Optimise Organ Recovery Study): Study protocol to evaluate the implementation of an evidence-based checklist for brain-dead potential organ donor management in intensive care units, a cluster randomised trial. BMJ Open 2019; 9:e028570. [PMID: 31243035 PMCID: PMC6597655 DOI: 10.1136/bmjopen-2018-028570] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION There is an increasing demand for multi-organ donors for organ transplantation programmes. This study protocol describes the Donation Network to Optimise Organ Recovery Study, a planned cluster randomised controlled trial that aims to evaluate the effectiveness of the implementation of an evidence-based, goal-directed checklist for brain-dead potential organ donor management in intensive care units (ICUs) in reducing the loss of potential donors due to cardiac arrest. METHODS AND ANALYSIS The study will include ICUs of at least 60 Brazilian sites with an average of ≥10 annual notifications of valid potential organ donors. Hospitals will be randomly assigned (with a 1:1 allocation ratio) to the intervention group, which will involve the implementation of an evidence-based, goal-directed checklist for potential organ donor maintenance, or the control group, which will maintain the usual care practices of the ICU. Team members from all participating ICUs will receive training on how to conduct family interviews for organ donation. The primary outcome will be loss of potential donors due to cardiac arrest. Secondary outcomes will include the number of actual organ donors and the number of organs recovered per actual donor. ETHICS AND DISSEMINATION The institutional review board (IRB) of the coordinating centre and of each participating site individually approved the study. We requested a waiver of informed consent for the IRB of each site. Study results will be disseminated to the general medical community through publications in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER NCT03179020; Pre-results.
Collapse
Affiliation(s)
- Glauco Adrieno Westphal
- Research Projects Office, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
- Hospital Municipal São José, Joinville, Santa Catarina, Brazil
- Centro Hospitalar Unimed, Joinville, Santa Catarina, Brazil
| | | | - Alexandre Biasi
- Research Institute, Hospital do Coração (HCor), São Paulo, São Paulo, Brazil
| | - Flávia Ribeiro Machado
- Department of Anaesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo (UNIFESP), São Paulo, São Paulo, Brazil
| | - Regis Goulart Rosa
- Adult Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Cassiano Teixeira
- Adult Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
- Department of Internal Medicine and Post Graduate Program in Rehabilitation Science, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Rio Grande do Sul
| | - Joel de Andrade
- Organ Procurement Organisation of Santa Catarina (OPO/SC), Florianópolis, Brazil
| | - Cristiano Augusto Franke
- Adult Intensive Care Unit, Hospital das Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Trauma Intensive Care Unit, Hospital de Pronto de Socorro (HPS), Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Fernando Bozza
- Department of Critical Care and Graduate Programme in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, Brazil, Rio de Janeiro, Brazil
- National Institute of Infectious Disease Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Daiana Barbosa da Silva
- Adult Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Daniel Sganzerla
- Research Projects Office, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
| | | | | | | | | | - Natalia Elis Giordani
- Research Projects Office, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
- Post Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | | | | | | | - Cintia Magalhães Carvalho Grion
- Adult Intensive Care Unit, Hospital Evangélico de Londrina, Londrina, Brazil
- Adult Intensive Care Unit, Hospital Universitário Regional do Norte do Paraná, Londrina, Brazil
| | - Pedro Carvalho Diniz
- Adult Intensive Care Unit, Hospital de Ensino Doutor Washington Antônio de Barros, Petrolina, Brazil
| | | | - Giovana Colozza Mecatti
- Adult Intensive Care Unit, Hospital Universitário São Francisco da Providência de Deus de Bragança Paulista, Bragança Paulista, Brazil
| | | | - Rafael Barberena Moraes
- Adult Intensive Care Unit, Hospital das Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Vandack Nobre
- Adult Intensive Care Unit, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Maureen O Meade
- Department of Medicine and Department of Health Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Rosana Reis Nothen
- General Hospital of the School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- General Coordination Office of the National Transplant System, Ministério da Saúde, Brasília, Brazil
| | - Maicon Falavigna
- Research Projects Office, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
- Post Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| |
Collapse
|
19
|
Westphal GA, Pereira AB, Fachin SM, Sperotto G, Gonçalves M, Albino L, Bittencourt R, Franzini VDR, Koenig Á. An electronic warning system helps reduce the time to diagnosis of sepsis. Rev Bras Ter Intensiva 2018; 30:414-422. [PMID: 30570029 PMCID: PMC6334482 DOI: 10.5935/0103-507x.20180059] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/30/2018] [Indexed: 12/20/2022] Open
Abstract
Objective To describe the improvements of an early warning system for the
identification of septic patients on the time to diagnosis, antibiotic
delivery, and mortality. Methods This was an observational cohort study that describes the successive
improvements made over a period of 10 years using an early warning system to
detect sepsis, including systematic active manual surveillance, electronic
alerts via a telephonist, and alerts sent directly to the mobile devices of
nurses. For all periods, after an alert was triggered, early treatment was
instituted according to the institutional sepsis guidelines. Results In total, 637 patients with sepsis were detected over the study period. The
median triage-to-diagnosis time was reduced from 19:20 (9:10 - 38:15) hours
to 12:40 (2:50 - 23:45) hours when the manual surveillance method was used
(p = 0.14), to 2:10 (1:25 - 2:20) hours when the alert was sent
automatically to the hospital telephone service (p = 0.014), and to 1:00
(0:30 - 1:10) hour when the alert was sent directly to the nurse's mobile
phone (p = 0.016). The diagnosis-to-antibiotic time was reduced to 1:00
(0:55 - 1:30) hours when the alert was sent to the telephonist and to 0:45
(0:30 - 1:00) minutes when the alert was sent directly to the nurse's mobile
phone (p = 0.02), with the maintenance of similar values over the following
years. There was no difference in the time of treatment between survivors
and non-survivors. Conclusion Electronic systems help reduce the triage-to-diagnosis time and
diagnosis-to-antibiotic time in patients with sepsis.
Collapse
|
20
|
Westphal GA, Moerschberger MS, Vollmann DD, Inácio AC, Machado MC, Sperotto G, Cavalcanti AB, Koenig Á. Effect of a 24-h extended visiting policy on delirium in critically ill patients. Intensive Care Med 2018; 44:968-970. [PMID: 29605880 DOI: 10.1007/s00134-018-5153-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Glauco Adrieno Westphal
- Centro Hospitalar Unimed de Joinville, Joinville, Santa Catarina, Brazil. .,Brazilian Research in Intensive Care Network (BRICNet), Rio de Janeiro, Brazil.
| | | | | | | | - Míriam C Machado
- Centro Hospitalar Unimed de Joinville, Joinville, Santa Catarina, Brazil
| | - Geonice Sperotto
- Centro Hospitalar Unimed de Joinville, Joinville, Santa Catarina, Brazil
| | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network (BRICNet), Rio de Janeiro, Brazil.,HCor Research Institute, São Paulo, Brazil
| | - Álvaro Koenig
- Centro Hospitalar Unimed de Joinville, Joinville, Santa Catarina, Brazil
| |
Collapse
|
21
|
Westphal GA, Garcia VD, de Souza RL, Franke CA, Vieira KD, Birckholz VRZ, Machado MC, de Almeida ERB, Machado FO, Sardinha LADC, Wanzuita R, Silvado CES, Costa G, Braatz V, Caldeira Filho M, Furtado R, Tannous LA, de Albuquerque AGN, Abdala E, Gonçalves ARR, Pacheco-Moreira LF, Dias FS, Fernandes R, Giovanni FD, de Carvalho FB, Fiorelli A, Teixeira C, Feijó C, Camargo SM, de Oliveira NE, David AI, Prinz RAD, Herranz LB, de Andrade J. Guidelines for the assessment and acceptance of potential brain-dead organ donors. Rev Bras Ter Intensiva 2017; 28:220-255. [PMID: 27737418 PMCID: PMC5051181 DOI: 10.5935/0103-507x.20160049] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Organ transplantation is the only alternative for many patients with terminal diseases. The increasing disproportion between the high demand for organ transplants and the low rate of transplants actually performed is worrisome. Some of the causes of this disproportion are errors in the identification of potential organ donors and in the determination of contraindications by the attending staff. Therefore, the aim of the present document is to provide guidelines for intensive care multi-professional staffs for the recognition, assessment and acceptance of potential organ donors.
Collapse
Affiliation(s)
- Glauco Adrieno Westphal
- Corresponding author: Glauco Adrieno Westphal, Centro
Hospitalar Unimed, Rua Orestes Guimarães, 905, Zip code: 89204-060 -
Joinville (SC), Brazil. E-mail:
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Kobs VC, Ferreira JA, Bobrowicz TA, Ferreira LE, Deglmann RC, Westphal GA, França PHCD. The role of the genetic elements bla oxa and IS Aba 1 in the Acinetobacter calcoaceticus-Acinetobacter baumannii complex in carbapenem resistance in the hospital setting. Rev Soc Bras Med Trop 2017; 49:433-40. [PMID: 27598629 DOI: 10.1590/0037-8682-0002-2016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 07/12/2016] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Members of the Acinetobacter genus are key pathogens that cause healthcare-associated infections, and they tend to spread and develop new antibiotic resistance mechanisms. Oxacillinases are primarily responsible for resistance to carbapenem antibiotics. Higher rates of carbapenem hydrolysis might be ascribed to insertion sequences, such as the ISAba1 sequence, near bla OXA genes. The present study examined the occurrence of the genetic elements bla OXA and ISAba1 and their relationship with susceptibility to carbapenems in clinical isolates of the Acinetobacter calcoaceticus-Acinetobacter baumannii complex. METHODS Isolates identified over 6 consecutive years in a general hospital in Joinville, Southern Brazil, were evaluated. The investigation of 5 families of genes encoding oxacillinases and the ISAba1 sequence location relative to bla OXA genes was conducted using polymerase chain reaction. RESULTS All isolates presented the bla OXA-51-like gene (n = 78), and 91% tested positive for the bla OXA-23-like gene (n = 71). The presence of ISAba1 was exclusively detected in isolates carrying the bla OXA-23-like gene. All isolates in which ISAba1 was found upstream of the bla OXA-23-like gene (n = 69) showed resistance to carbapenems, whereas the only isolate in which ISAba1 was not located near the bla OXA-23-like gene was susceptible to carbapenems. The ISAba1 sequence position of another bla OXA-23-like-positive isolate was inconclusive. The isolates exclusively carrying the bla OXA-51-like gene (n = 7) showed susceptibility to carbapenems. CONCLUSIONS The presence of the ISAba1 sequence upstream of the bla OXA-23-like gene was strongly associated with carbapenem resistance in isolates of the A. calcoaceticus-A. baumannii complex in the hospital center studied.
Collapse
Affiliation(s)
- Vanessa Cristine Kobs
- Laboratório de Análises Clínicas, Hospital Dona Helena, Joinville, Santa Catarina, Brazil
| | | | | | - Leslie Ecker Ferreira
- Departamento de Farmácia, Universidade da Região de Joinville, Joinville, Santa Catarina, Brazil.,Departamento de Medicina, Universidade da Região de Joinville, Joinville, Santa Catarina, Brazil
| | - Roseneide Campos Deglmann
- Departamento de Farmácia, Universidade da Região de Joinville, Joinville, Santa Catarina, Brazil.,Departamento de Medicina, Universidade da Região de Joinville, Joinville, Santa Catarina, Brazil
| | - Glauco Adrieno Westphal
- Departamento de Medicina, Universidade da Região de Joinville, Joinville, Santa Catarina, Brazil
| | - Paulo Henrique Condeixa de França
- Departamento de Farmácia, Universidade da Região de Joinville, Joinville, Santa Catarina, Brazil.,Departamento de Medicina, Universidade da Região de Joinville, Joinville, Santa Catarina, Brazil
| |
Collapse
|
23
|
Westphal GA, Slaviero TA, Montemezzo A, Lingiardi GT, de Souza FCC, Carnin TC, Soares DR, Hachiya AH, Ferraz LL, de Andrade J. The effect of brain death protocol duration on potential donor losses due to cardiac arrest. Clin Transplant 2016; 30:1411-1416. [PMID: 27532678 DOI: 10.1111/ctr.12830] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND The severe inflammatory reaction that occurs after brain death (BD) tends to amplify over time, contributing to cardiovascular deterioration and occurrence of cardiac arrest (CA). Our purpose is to evaluate the effect of BD protocol duration (BDPD) on potential donor losses due to CA. METHODS This retrospective analysis included potential donors reported during the period from May 2012 to April 2014. The risk of losses due to CA was analyzed to identify the chronological threshold at which the probability of loss due to CA increases. RESULTS Three hundred and eighty-four potential donors were analyzed. There was a greater chance of CA after a 30-hour threshold (OR 1.67, 95% CI: 1.38-1.83), and the lowest risk of was identified for the range from 12 to 30 hours (OR 0.32, 95% CI: 0.19-0.52). Multivariate analysis identified the following variables as being associated with lower occurrence of CA: BDPD between 12 and 30 hours, management of a potential donor inside the intensive care unit, and the adherence to a goal-directed protocol. CONCLUSION A long duration between the first clinical test for BD diagnosis and the procurement of organs may be an important risk factor for the occurrence of cardiac arrest in deceased potential donors.
Collapse
Affiliation(s)
- Glauco Adrieno Westphal
- Transplantation Center of Santa Catarina, Santa Catarina, Brazil. .,University of the Region of Joinville, Santa Catarina, Brazil.
| | | | | | | | | | | | | | | | | | - Joel de Andrade
- Transplantation Center of Santa Catarina, Santa Catarina, Brazil
| |
Collapse
|
24
|
Cortivo GD, Gutberlet A, Ferreira JA, Ferreira LE, Deglmann RC, Westphal GA, França PHCD. Antimicrobial resistance profiles and oxacillinase genes in carbapenem-resistant Acinetobacter baumannii isolated from hospitalized patients in Santa Catarina, Brazil. Rev Soc Bras Med Trop 2016; 48:699-705. [PMID: 26676494 DOI: 10.1590/0037-8682-0233-2015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 08/27/2015] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Carbapenems are the therapy of choice for treating severe infections caused by the Acinetobacter calcoaceticus-Acinetobacter baumannii complex. We aimed to assess the prevalence and antimicrobial susceptibility profiles of producers of distinct oxacillinases among nosocomial isolates of the A. calcoaceticus-A. baumannii complex in a 249-bed general hospital located in Joinville, Southern Brazil. METHODS Of the 139 A. baumannii clinical isolates with reduced susceptibility to carbapenems between 2010 and 2013, 118 isolates from varying anatomical sites and hospital sectors were selected for genotypic analysis. Five families of genes encoding oxacillinases, namely blaOXA-23-like, blaOXA-24-like, bla(OXA-51-like), bla(OXA-58-like), and blaOXA-143-like, were investigated by multiplex polymerase chain reaction (PCR). RESULTS Most (87.3%) isolates simultaneously carried the bla(OXA-23-like) and bla(OXA-51-like) genes, whereas three (2.5%) isolates harbored only blaOXA-51-like ones. The circulation of carbapenem-resistant isolates increased during the study period: from none in 2010, to 22 in 2011, 64 in 2012, and 53 in 2013. CONCLUSIONS Isolates carrying the bla(OXA-23-like) and bla(OXA-51-like) genes were widely distributed in the hospital investigated. Because of the worsening scenario, the implementation of preventive measures and effective barriers is needed.
Collapse
Affiliation(s)
- Giselle Dall Cortivo
- Laboratório de Microbiologia Clínica, Hospital Regional Hans Dieter Schmidt, Joinville, Santa Catarina, Brazil
| | - Andréia Gutberlet
- Departamento de Farmácia, Universidade da Região de Joinville, Joinville, Santa Catarina, Brazil
| | | | - Leslie Ecker Ferreira
- Departamento de Farmácia, Universidade da Região de Joinville, Joinville, Santa Catarina, Brazil
| | | | - Glauco Adrieno Westphal
- Departamento de Medicina, Universidade da Região de Joinville, Joinville, Santa Catarina, Brazil
| | | |
Collapse
|
25
|
Waltrick R, Possamai DS, de Aguiar FP, Dadam M, de Souza Filho VJ, Ramos LR, Laurett RDS, Fujiwara K, Caldeira Filho M, Koenig Á, Westphal GA. Comparison between a clinical diagnosis method and the surveillance technique of the Center for Disease Control and Prevention for identification of mechanical ventilator-associated pneumonia. Rev Bras Ter Intensiva 2016; 27:260-5. [PMID: 26465248 PMCID: PMC4592121 DOI: 10.5935/0103-507x.20150047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 05/01/2015] [Accepted: 06/19/2015] [Indexed: 01/01/2023] Open
Abstract
Objective >To evaluate the agreement between a new epidemiological surveillance method of
the Center for Disease Control and Prevention and the clinical pulmonary infection
score for mechanical ventilator-associated pneumonia detection. Methods This was a prospective cohort study that evaluated patients in the intensive care
units of two hospitals who were intubated for more than 48 hours between August
2013 and June 2014. Patients were evaluated daily by physical therapist using the
clinical pulmonary infection score. A nurse independently applied the new
surveillance method proposed by the Center for Disease Control and Prevention. The
diagnostic agreement between the methods was evaluated. A clinical pulmonary
infection score of ≥ 7 indicated a clinical diagnosis of mechanical
ventilator-associated pneumonia, and the association of a clinical pulmonary
infection score ≥ 7 with an isolated semiquantitative culture consisting of
≥ 104 colony-forming units indicated a definitive diagnosis. Results Of the 801 patients admitted to the intensive care units, 198 required mechanical
ventilation. Of these, 168 were intubated for more than 48 hours. A total of 18
(10.7%) cases of mechanical ventilation-associated infectious conditions were
identified, 14 (8.3%) of which exhibited possible or probable mechanical
ventilatorassociated pneumonia, which represented 35% (14/38) of mechanical
ventilator-associated pneumonia cases. The Center for Disease Control and
Prevention method identified cases of mechanical ventilator-associated pneumonia
with a sensitivity of 0.37, specificity of 1.0, positive predictive value of 1.0,
and negative predictive value of 0.84. The differences resulted in discrepancies
in the mechanical ventilator-associated pneumonia incidence density (CDC, 5.2/1000
days of mechanical ventilation; clinical pulmonary infection score ≥ 7,
13.1/1000 days of mechanical ventilation). Conclusion The Center for Disease Control and Prevention method failed to detect mechanical
ventilatorassociated pneumonia cases and may not be satisfactory as a surveillance
method.
Collapse
Affiliation(s)
- Renata Waltrick
- Programa de Residência em Medicina Intensiva, Hospital Municipal São José, Joinville, SC, BR
| | - Dimitri Sauter Possamai
- Programa de Residência em Medicina Intensiva, Hospital Municipal São José, Joinville, SC, BR
| | | | - Micheli Dadam
- Serviço de Fisioterapia, Centro Hospitalar Unimed, Joinville, SC, BR
| | | | - Lucas Rocker Ramos
- Faculdade de Medicina, Universidade da Região de Joinville, Joinville, SC, BR
| | | | - Kênia Fujiwara
- Comissão de Controle de Infecção Hospitalar, Centro Hospitalar Unimed, Joinville, SC, BR
| | - Milton Caldeira Filho
- Programa de Residência em Medicina Intensiva, Hospital Municipal São José, Joinville, SC, BR
| | - Álvaro Koenig
- Comissão de Controle de Infecção Hospitalar, Centro Hospitalar Unimed, Joinville, SC, BR
| | - Glauco Adrieno Westphal
- Programa de Residência em Medicina Intensiva, Hospital Municipal São José, Joinville, SC, BR
| |
Collapse
|
26
|
Westphal GA. A simple bedside approach to therapeutic goals achievement during the management of deceased organ donors - An adapted version of the “VIP” approach. Clin Transplant 2016; 30:138-44. [DOI: 10.1111/ctr.12667] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Glauco Adrieno Westphal
- Transplantation Center of Santa Catarina; Florianópolis Santa Catarina Brazil
- Centro Hospitalar Unimed; Joinville Santa Catarina Brazil
- Hospital Municipal São José; Joinville Santa Catarina Brazil
| |
Collapse
|
27
|
|
28
|
Westphal GA, Lino AS. Systematic screening is essential for early diagnosis of severe sepsis and septic shock. Rev Bras Ter Intensiva 2015; 27:96-101. [PMID: 26340147 PMCID: PMC4489775 DOI: 10.5935/0103-507x.20150018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 05/10/2015] [Indexed: 01/08/2023] Open
Affiliation(s)
- Glauco Adrieno Westphal
- Centro Hospitalar Unimed - Joinville (SC), Brazil
- Hospital Municipal São José - Joinville (SC),
Brazil
| | | |
Collapse
|
29
|
Pretto G, Westphal GA, Silva E. Clonidine for reduction of hemodynamic and psychological effects of S+ ketamine anesthesia for dressing changes in patients with major burns: An RCT. Burns 2014; 40:1300-7. [DOI: 10.1016/j.burns.2014.07.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 07/25/2014] [Accepted: 07/28/2014] [Indexed: 10/24/2022]
|
30
|
Westphal GA, Zaclikevis VR, Vieira KD, Cordeiro RDB, Horner MBW, Oliveira TPD, Duarte R, Sperotto G, Silveira GD, Caldeira Filho M, Coll E, Yus-Teruel S. A managed protocol for treatment of deceased potential donors reduces the incidence of cardiac arrest before organ explant. Rev Bras Ter Intensiva 2013; 24:334-40. [PMID: 23917929 PMCID: PMC4031811 DOI: 10.1590/s0103-507x2012000400007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [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: 09/04/2012] [Accepted: 11/20/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess the effect of the application of a managed protocol for the maintenance care of deceased potential multiple organ donors at two hospitals. METHODS A before (Phase 1)/after (Phase 2) study conducted at two general hospitals, which included consecutively potential donors admitted to two intensive care units. In Phase 1 (16 months), the data were collected retrospectively, and the maintenance care measures of the potential donors were instituted by the intensivists. In Phase 2 (12 months), the data collection was prospective, and a managed protocol was used for maintenance care. The two phases were compared in terms of their demographic variables, physiological variables at diagnosis of brain death and the end of the process, time to performance of brain death confirmatory test and end of the process, adherence to bundles of maintenance care essential measures, losses due to cardiac arrest, family refusal, contraindications, and the conversion rate of potential into actual donors. Student's t- and chi-square tests were used, and p-value < 0.05 was considered to be significant. RESULTS A total of 42 potential donors were identified (18 in Phase 1 and 24 in Phase 2). The time interval between the first clinical assessment and the recovery decreased in Phase 2 (Phase 1: 35.0±15.5 hours versus Phase 2: 24.6±6.2 hours; p = 0.023). Adherence increased to 10 out of the 19 essential items of maintenance care, and losses due to cardiac arrest also decreased in Phase 2 (Phase 1: 27.8 versus 0% in Phase 2; p = 0.006), while the convertion rate increased (Phase 1: 44.4 versus 75% in Phase 2; p = 0.044). The losses due to family refusal and medical contraindication did not vary. CONCLUSION The adoption of a managed protocol focused on the application of essential measures for the care of potential deceased donors might reduce the loss of potential donors due to cardiac arrest.
Collapse
|
31
|
Westphal GA, Caldeira Filho M, Fiorelli A, Vieira KD, Zaclikevis V, Bartz M, Wanzuita R, Teixeira C, Franke C, Machado FO, Friedman G, Andrade J, Matos JD, Lamgaro DM, Silva E, Costa G, Coelho ME, Oliveira MC, Youssef NCM, Akamine N, Duarte P, Lisboa R, Mazzali M, Ferraz Neto BH. Guidelines for maintenance of adult patients with brain death and potential for multiple organ donations: the Task Force of the Brazilian Association of Intensive Medicine the Brazilian Association of Organs Transplantation, and the Transplantation Center of Santa Catarina. Transplant Proc 2013; 44:2260-7. [PMID: 23026569 DOI: 10.1016/j.transproceed.2012.07.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The organ shortage for transplantation, the principal factor that increases waiting lists, has become a serious public health problem. In this scenario, the intensivist occupies a prominent position as one of the professionals that first has a chance to identify brain death and to be responsible for the maintenance of the potential deceased donor. OBJECTIVE This report attempts to establish guidelines for care and maintenance of adult deceased donor organs guiding and standardizing care provided to patients with brain death. METHOD These guidelines were composed by intensivists, transplant coordinators, professionals from various transplant teams, and used transplant center. The formulated questions were forwarded to all members and recommendations were constructed after an extensive literature review selecting articles with the highest degree of evidence. RESULTS Guidelines were developed in the form of questions reflecting frequent experiences in clinical intensive care practices. The main questions were: Is there an optimal interval for keeping organs of deceased donors viable? What actions are considered essential for maintaining deceased donors in this period? What are the limits of body temperature? How should the patient be warmed? Which laboratory tests should be performed? What is the collection interval? What are the limits in the laboratory and the capture scenario? What are the limits of blood pressure? When and how should one use catecholamines? CONCLUSIONS This pioneer project involved a multidisciplinary team working in organ transplantation seeking to provide treatment guidance to increase the number of viable organs from deceased adult donors.
Collapse
Affiliation(s)
- G A Westphal
- Brazilian Association of Intensive Medicine, the Brazilian Association of Organ Transplants (ABTO), and the Transplantation Center of Santa Catarina (SC-Tx), Santa Catarina, Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Westphal GA, Vieira KD, Orzechowski R, Kaefer KM, Zaclikevis VR, Mastroeni MF. [Analysis of quality of life following hospital discharge among survivors of severe sepsis and septic shock]. Rev Panam Salud Publica 2012; 31:499-505. [PMID: 22858817 DOI: 10.1590/s1020-49892012000600008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 03/08/2012] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE Describe the impact of severe sepsis and septic shock on patients' quality of life following hospital discharge. METHODS A controlled study conducted in two general hospitals of Joinville, Santa Catarina, Brazil, of in-patients with severe sepsis or septic shock during the period of August 2005 through November 2007. The patients were contacted by telephone between June and November 2009. The study group responded to Short Form-36, a questionnaire on the quality of life, two years after being discharged from hospital. The questionnaire was also answered by a control group composed of people who lived at the same residence as the study subjects, had no recent hospitalization, and were close in age. RESULTS Of 217 patients with severe sepsis or septic shock, 112 (51.6%) survived hospitalization. The survival rate after hospital discharge was 41.02% at 180 days, 37.4% at one year, 34.3% at 18 months, and 32.3% in two years. Thirty-six survivors responded to Short Form-36. There were declines in the quality of life for survivors (No. = 36) in comparison to the control group (No. = 36) in the following areas: physical functioning (59 ± 32 versus 91 ± 18; P < 0.001), vitality (48 ± 13 versus 59 ± 14; P < 0.008), mental health (48 ± 13 versus 59 ± 14; P < 0.03), bodily pain (50 ± 26 versus 76 ± 16; P < 0.001), general health perceptions (53 ± 18 versus 67 ± 13; P < 0.004), physical role functioning (67 ± 45 versus 85 ± 34; P < 0.05), and social role functioning (70 ± 28 versus 90. ± 16; P < 0.05). CONCLUSIONS Severe sepsis or septic shock can result in significant negative effects on the quality of life, in addition to reducing long-term survival probability.
Collapse
|
33
|
Wanzuita R, Poli-de-Figueiredo LF, Pfuetzenreiter F, Cavalcanti AB, Westphal GA. Replacement of fentanyl infusion by enteral methadone decreases the weaning time from mechanical ventilation: a randomized controlled trial. Crit Care 2012; 16:R49. [PMID: 22420584 PMCID: PMC3681375 DOI: 10.1186/cc11250] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 10/29/2011] [Accepted: 03/15/2012] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Patients undergoing mechanical ventilation (MV) are frequently administered prolonged and/or high doses of opioids which when removed can cause a withdrawal syndrome and difficulty in weaning from MV. We tested the hypothesis that the introduction of enteral methadone during weaning from sedation and analgesia in critically ill adult patients on MV would decrease the weaning time from MV. METHODS A double-blind randomized controlled trial was conducted in the adult intensive care units (ICUs) of four general hospitals in Brazil. The 75 patients, who met the criteria for weaning from MV and had been using fentanyl for more than five consecutive days, were randomized to the methadone (MG) or control group (CG). Within the first 24 hours after study enrollment, both groups received 80% of the original dose of fentanyl, the MG received enteral methadone and the CG received an enteral placebo. After the first 24 hours, the MG received an intravenous (IV) saline solution (placebo), while the CG received IV fentanyl. For both groups, the IV solution was reduced by 20% every 24 hours. The groups were compared by evaluating the MV weaning time and the duration of MV, as well as the ICU stay and the hospital stay. RESULTS Of the 75 patients randomized, seven were excluded and 68 were analyzed: 37 from the MG and 31 from the CG. There was a higher probability of early extubation in the MG, but the difference was not significant (hazard ratio: 1.52 (95% confidence interval (CI) 0.87 to 2.64; P = 0.11). The probability of successful weaning by the fifth day was significantly higher in the MG (hazard ratio: 2.64 (95% CI: 1.22 to 5.69; P < 0.02). Among the 54 patients who were successfully weaned (29 from the MG and 25 from the CG), the MV weaning time was significantly lower in the MG (hazard ratio: 2.06; 95% CI 1.17 to 3.63; P < 0.004). CONCLUSIONS The introduction of enteral methadone during weaning from sedation and analgesia in mechanically ventilated patients resulted in a decrease in the weaning time from MV.
Collapse
Affiliation(s)
- Raquel Wanzuita
- Adult ICU, Centro Hospitalar Unimed, Rua Orestes Guimarães-905, Joinville, 89204-060, Brazil
- Adult ICU, Hospital Regional Hans Dieter Schmidt, Rua Xavier arp-1, Joinville, 89227-680, Brazil
| | - Luiz F Poli-de-Figueiredo
- LIM-08, Hospital das Clínicas, University of São Paulo, Avenida Doutor Arnaldo-455, São Paulo, 01246-903, Brazil
| | - Felipe Pfuetzenreiter
- Adult ICU, Centro Hospitalar Unimed, Rua Orestes Guimarães-905, Joinville, 89204-060, Brazil
- Adult ICU, Hospital Municipal São José, Avenida Getúlio Vargas-238, Joinville, 89202-000, Brazil
| | | | - Glauco Adrieno Westphal
- Adult ICU, Centro Hospitalar Unimed, Rua Orestes Guimarães-905, Joinville, 89204-060, Brazil
- Adult ICU, Hospital Municipal São José, Avenida Getúlio Vargas-238, Joinville, 89202-000, Brazil
| |
Collapse
|
34
|
Oliveira ELD, Westphal GA, Mastroeni MF. Demographic and clinical characteristics of patients undergoing coronary artery bypass graft surgery and their relation to mortality. Braz J Cardiovasc Surg 2012; 27:52-60. [PMID: 22729301 DOI: 10.5935/1678-9741.20120009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 01/20/2012] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To describe the demographic and clinical characteristics and to test their relation to mortality in patients undergoing to coronary artery bypass graft surgery (CABG). METHODS It is a retrospective study developed from the medical records of 655 patients undergoing CABG from May 2002 to April 2010. RESULTS Hospital mortality was 12.1%. Mortality was significantly (P<0.05) higher in females (17.3%), aged less than 70 years (22.8%), in emergency surgery (36.4%), in cases of readmission to the intensive care unit (ICU) (33.3%), when the stay in the ICU was less than three days (16.3%), undergoing longer cardiopulmonary bypass (CPB) and with more comorbidities (15.4%). Predictor variables of death identified with logistic regression analysis were: female (OR=2.04), age >70 years (OR=2.69), emergency surgery (OR=15.43) and urgency (OR=3.81), performance of CPB (OR=2.19) and re-admission to the ICU (OR=4.33). CONCLUSION Variables such as gender, age, type of surgery, readmission to the ICU, ICU stay, comorbidities and time of CPB influence the outcome death in patients undergoing to CABG. Thus, such aspects should be considered to reduce hospital mortality in patients undergoing such surgery.
Collapse
|
35
|
Westphal GA, Caldeira Filho M, Vieira KD, Zaclikevis VR, Bartz MCM, Wanzuita R, Réa-Neto Á, Teixeira C, Franke C, Machado FO, Andrade JD, Matos JDD, Gerent KB, Fiorelli A, Gonçalves ARR, Ferraz Neto BH, Dias FS, Carvalho FBD, Costa G, Camargo JJ, Teles JMM, Maia M, Nogara M, Coelho ME, Mazzali M, Youssef NCM, Duarte P, Souza RLD, Fernandes R, Camargo S, Garcia VD. Diretrizes para manutenção de múltiplos órgãos no potencial doador adulto falecido: Parte III. Recomendações órgãos específicas. Rev Bras Ter Intensiva 2011. [DOI: 10.1590/s0103-507x2011000400005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
36
|
Westphal GA, Caldeira Filho M, Vieira KD, Zaclikevis VR, Bartz MCM, Wanzuita R, Réa-Neto A, Teixeira C, Franke C, Machado FO, Andrade JD, Matos JDD, Gerent KB, Fiorelli A, Gonçalves ARR, Ferraz Neto BH, Dias FS, Carvalho FBD, Costa G, Camargo JJ, Teles JMM, Maia M, Nogara M, Coelho ME, Mazzali M, Youssef NCM, Duarte P, Souza RLD, Fernandes R, Camargo S, Garcia VD. Guidelines for potential multiple organ donors (adult). Part III: organ-specific recommendations. Rev Bras Ter Intensiva 2011; 23:410-425. [PMID: 23949454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
Brain death (BD) alters the pathophysiology of patients and may damage the kidneys, the lungs, the heart and the liver. To obtain better quality transplant organs, intensive care physicians in charge of the maintenance of deceased donors should attentively monitor these organs. Careful hemodynamic, ventilatory and bronchial clearance management minimizes the loss of kidneys and lungs. The evaluation of cardiac function and morphology supports the transplant viability assessment of the heart. The monitoring of liver function, the management of the patient's metabolic status and the evaluation of viral serology are fundamental for organ selection by the transplant teams and for the care of the transplant recipient.
Collapse
|
37
|
Westphal GA, Caldeira Filho M, Vieira KD, Zaclikevis VR, Bartz MCM, Wanzuita R, Teixeira C, Franke C, Machado FO, Friedman G, Andrade JD, Matos JDD, Lamgaro DM, Silva E, Costa G, Coelho ME, Oliveira MCD, Youssef NCM, Akamine N, Souza RLD. Guidelines for potential multiple organ donors (adult): part I. Overview and hemodynamic support. Rev Bras Ter Intensiva 2011; 23:255-268. [PMID: 23949397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2011] [Indexed: 06/02/2023] Open
Abstract
There is a relative shortage of appropriate organs available for transplantation. The appropriate diagnosis of brain death, a suitable family approach and the maintenance of the deceased donor are fundamental in addressing this issue. The intensive care physician plays a key role in the maintenance of the deceased donor, thereby reducing losses and increasing the number of successful transplants.
Collapse
|
38
|
Westphal GA, Caldeira Filho M, Vieira KD, Zaclikevis VR, Bartz MCM, Wanzuita R, Teixeira C, Franke C, Machado FO, Friedman G, Andrade JD, Matos JDD, Lamgaro DM, Silva E, Costa G, Coelho ME, Oliveira MCD, Youssef NCM, Akamine N, Souza RLD. Diretrizes para manutenção de múltiplos órgãos no potencial doador adulto falecido: parte I. Aspectos gerais e suporte hemodinâmico. Rev Bras Ter Intensiva 2011. [DOI: 10.1590/s0103-507x2011000300003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
39
|
Westphal GA, Caldeira Filho M, Vieira KD, Zaclikevis VR, Bartz MCM, Wanzuita R, Réa-Neto A, Teixeira C, Franke C, Machado FO, Andrade JD, Matos JDD, Fiorelli A, Lamgaro DM, Nagel F, Dal-Pizzol F, Costa G, Teles JM, Melo LH, Coelho ME, Youssef NCM, Duarte P, Souza RLD. Guidelines for potential multiple organ donors (adult): part II. Mechanical ventilation, endocrine metabolic management, hematological and infectious aspects. Rev Bras Ter Intensiva 2011; 23:269-282. [PMID: 23949398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Indexed: 06/02/2023] Open
Abstract
The role of intensive care specialists in the maintenance of deceased potential donors is not restricted to hemodynamics. Appropriate endocrine-metabolic management is fundamental to maintaining energy support and hydroelectrolytic control, which cooperate for hemodynamic stability. Hematological changes are also important, especially considering the issues caused by inappropriate transfusions. In addition, this article discusses the role of appropriate protective ventilation to prevent inflammatory responses and to provide more transplantable lungs. Finally, judicious assessment of infections and antibiotic therapy is discussed.
Collapse
|
40
|
Westphal GA, Caldeira Filho M, Vieira KD, Zaclikevis VR, Bartz MCM, Wanzuita R, Réa-Neto Á, Teixeira C, Franke C, Machado FO, Andrade JD, Matos JDD, Fiorelli A, Lamgaro DM, Nagel F, Dal-Pizzol F, Costa G, Teles JM, Melo LH, Coelho ME, Youssef NCM, Duarte P, Souza RLD. Diretrizes para manutenção de múltiplos órgãos no potencial doador adulto falecido: parte II. Ventilação mecânica, controle endócrino metabólico e aspectos hematológicos e infecciosos. Rev Bras Ter Intensiva 2011. [DOI: 10.1590/s0103-507x2011000300004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
41
|
Coura LEF, Manoel CHU, Poffo R, Bedin A, Westphal GA. Randomised, controlled study of preoperative electroacupuncture for postoperative pain control after cardiac surgery. Acupunct Med 2011; 29:16-20. [PMID: 21383391 DOI: 10.1136/aim.2010.003251] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND This study aims to evaluate the effects of preoperative electroacupuncture (EA) on the need for opioids in the postoperative stage of conventional cardiac surgery. METHODS A prospective, randomised and controlled study was conducted at Unimed Hospital Centre in Joinville, SC, Brazil. The day before the surgery, 32 patients undergoing cardiac surgery were randomised into two groups: patients from the treatment group received preoperative EA at bilateral points (LI4-LI11, LR3-ST36, PC6-TE5) for 30 min with alternating frequencies of 3 and 15 Hz. Patients from the control group received sham transcutaneous electrical nerve stimulation (TENS). Use of fentanyl during the postoperative period was measured. RESULTS 10 patients were excluded because of hemodynamic and ventilatory instability leaving 13 (10 male) in the treatment group and 9 (4 male) in the control group. The average total doses of fentanyl given were 13.1±2.2 and 16.3±1.6 μg/kg in the treatment and control groups respectively (p<0.002). The doses of patient controlled analgesia were 4.1±2.0 and 6.9±1.7 μg/kg in the treatment and control groups respectively (p<0.003). The number of boluses issued also differed (treatment 13.9±7.0 vs control 24.8±7.0, p<0.002). Pain intensity scores differed between the groups (treatment 2.5±1.1 vs control 4.0±2.0, p<0.04). One patient from the control group experienced drowsiness that justified a change in fentanyl infusion, as decided by the anaesthetist. CONCLUSION Preoperative electro-acupuncture in conventional cardiac surgery may reduce the postoperative consumption of fentanyl.
Collapse
|
42
|
Coelho CW, Jannig PR, Souza AB, Fronza H, Westphal GA, Petronilho F, Silva PM, Dal-Pizzol F, Silva E. Exercise training reduces oxidative damage in skeletal muscle of septic rats. Crit Care 2011. [PMCID: PMC3124152 DOI: 10.1186/cc10150] [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: 11/25/2022] Open
|
43
|
Ferreira LE, Dalposso K, Hackbarth BB, Gonçalves AR, Westphal GA, França PHCD, Pinho MDSL. Painel molecular para detecção de microrganismos associados à sepse. Rev Bras Ter Intensiva 2011. [DOI: 10.1590/s0103-507x2011000100007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
44
|
Ferreira LE, Dalposso K, Hackbarth BB, Gonçalves AR, Westphal GA, França PHCD, Pinho MDSL. Molecular panel for detection of sepsis-related microorganisms. Rev Bras Ter Intensiva 2011; 23:36-40. [PMID: 25299552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 02/10/2011] [Indexed: 06/04/2023] Open
Abstract
INTRODUCTION Sepsis is a systemic inflammatory response related to high mortality rates in the hospital environment. Delayed etiological diagnosis and inadequate antimicrobial therapy are associated with treatment failures. Molecular tests based on polymerase chain reaction are regarded as faster and more accurate procedures than culture techniques for microbial identification, providing a higher rate of therapeutic success. OBJECTIVE To develop a panel of primers for DNA fragments of sepsis-related microorganisms. METHODS Primers for amplification of Enterobacter spp., Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus and Candida spp. were designed and tested for sensitivity and specificity on the basis of their respective standard strains. RESULTS The intended specificity was obtained for P. aeruginosa, S. aureus and Candida spp primers. Sensitivity tests showed a threshold for detection from 5 ng to 500 fg in blood samples contaminated with microbial DNA. CONCLUSIONS The molecular panel presented offers the advantage of a flexible 'open' system when compared to other multiplex detection methods.
Collapse
Affiliation(s)
- Leslie Ecker Ferreira
- Programa de Pós-graduação em Saúde e Meio Ambiente, Universidade da Região de Joinville, Joinville, SC, Brasil
| | - Karilene Dalposso
- Departamento de Farmácia, Universidade da Região de Joinville, Joinville, SC, Brasil
| | | | - Anderson R Gonçalves
- Departamento de Medicina, Universidade da Região de Joinville, Joinville, SC, Brasil
| | | | | | - Mauro de Souza Leite Pinho
- Programa de Pós-graduação em Saúde e Meio Ambiente, Universidade da Região de Joinville, Joinville, SC, Brasil
| |
Collapse
|
45
|
Westphal GA, Gonçalves AR, Caldeira Filho M, Silva E, Salomão R, Bernardo WM, Machado FR. Guidelines for treatment of severe sepsis/septic shock: tissue perfusion assessment. Rev Bras Ter Intensiva 2011; 23:6-12. [PMID: 25299548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2009] [Accepted: 12/08/2010] [Indexed: 06/04/2023] Open
Abstract
Sepsis is a very frequent condition and causes high mortality rates and healthcare costs; it is the main cause of death in intensive care units. Clear, improved prognosis was shown for early diagnosed and treated patients. Treatment guidelines are fundamental for appropriate therapy. It is clear that hypoperfusion patients should be hemodynamically optimized; therefore, recognition of hypoperfusion signs is one of the main therapeutic steps. This guideline discusses the current literature and available data regarding the evaluation of hemodynamic parameters.
Collapse
|
46
|
Westphal GA, Gonçalves AR, Caldeira Filho M, Silva E, Salomão R, Bernardo WM, Machado FR. Diretrizes para tratamento da sepse grave/choque séptico: avaliação da perfusão tecidual. Rev Bras Ter Intensiva 2011. [DOI: 10.1590/s0103-507x2011000100003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
47
|
Westphal GA, Silva E, Salomão R, Bernardo WM, Machado FR. Diretrizes para tratamento da sepse grave/choque séptico: ressuscitação hemodinâmica. Rev Bras Ter Intensiva 2011. [DOI: 10.1590/s0103-507x2011000100004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
48
|
Westphal GA, Silva E, Salomão R, Bernardo WM, Machado FR. Guidelines for the treatment of severe sepsis and septic shock: hemodynamic resuscitation. Rev Bras Ter Intensiva 2011; 23:13-23. [PMID: 25299549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 12/01/2010] [Indexed: 06/04/2023] Open
Abstract
Sepsis has a high incidence, mortality and cost and is the main cause of death in intensive care units. Early recognition and treatment have been clearly associated with a better prognosis. Establishing new guidelines is a fundamental step for improving treatment. Patients with clear signs of hypoperfusion should undergo hemodynamic optimization. This guideline addresses the main strategies in the literature that are clinically available.
Collapse
|
49
|
Koenig A, Picon PD, Feijó J, Silva E, Westphal GA. Estimate of the economic impact of implementing an in hospital protocol for the early detection and treatment of severe sepsis in public and private hospitals in southern Brazil. Rev Bras Ter Intensiva 2010; 22:213-219. [PMID: 25302426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Accepted: 09/20/2010] [Indexed: 06/04/2023] Open
Abstract
OBJECTIVE To analyze the economic impact of an early sepsis detection protocol in two general hospitals. METHODS We analyzed data collected from a prospective study of septic patients before and after the implementation of a protocol for early diagnosis of severe sepsis. We conducted a cost-effectiveness analysis comparing: mortality rate, cost of sepsis treatment and indirect costs attributed to years of productive life lost to premature death in both phases. RESULTS Two hundred seventeen patients were included, 102 in phase I and 115 in phase II. After protocol implementation, in private and public hospital, mortality rates decreased from 50% to 32.2% and from 67.6% to 41% (p < 0.05). The mean years of productive life lost due to sepsis decreased from 3.18 to 0.80 and 9.81 to 4.65 (p < 0.05), with a mean gain of 2.38 and 5.16 years of productive life, for each septic patient. Considering Brazilian gross domestic product per capita, estimated productivity loss due to sepsis decreased between 3.2 and 9.7 billion US dollars, varying based on the incidence of sepsis. Hospital costs were similar in both phases. CONCLUSION A protocol for early detection and treatment of in-hospital septic patients is highly cost-effective from a societal perspective.
Collapse
Affiliation(s)
| | | | | | - Eliezer Silva
- Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
| | | |
Collapse
|
50
|
Westphal GA, Costa G, Gouvêa S, Kaefer KM, Silva RSD, Caldeira Filho M. Cardiogenic shock associated with subarachnoid hemorrhage. Rev Bras Ter Intensiva 2010; 22:310-314. [PMID: 25302440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Accepted: 07/08/2010] [Indexed: 06/04/2023] Open
Abstract
Systemic complications are frequent in subarachnoid hemorrhage patients. Among these complications, electrocardiographic abnormalities simulating ischemic cardiomyopathy may occur, possibly associated with myocardial dysfunction. This manuscript aims to report a case of subarachnoid hemorrhage associated with myocardial dysfunction and cardiogenic shock. A 45 years old woman was admitted with subarachnoid hemorrhage and coma, showing Glasgow scale = 7, Hunt-Hess = 5 and Fischer computed tomography classification = 3. On the second day, the patient underwent anterior cerebral communicant artery aneurysm embolization. The clinical evaluation revealed diffuse pulmonary infiltration, dyspnea and hypotension. Additional tests showed electrocardiographic lateral wall repolarization changes and elevated creatine kinase-MB fraction (36U/L). The cardiac index was 2.03 L/minute/m², Vascular systemic resistance was 3728 dynes.sec/cm². The non-responsiveness to volume demonstrated a cardiogenic shock pattern. The ventricular ejection fraction was 39%. The coronariography was normal, showing no obstructive lesions. Six days later the patient was removed from respiratory support and after eight days the dobutamine infusion was discontinued. The ejection fraction recovered up to 65%. Serial transcranial Doppler evaluations did not show vascular spasm. After ten days the patient was discharged from the intensive care unit. Patients with subarachnoid hemorrhage may be complicated with ventricular dysfunction and cardiogenic shock, increasing the cerebral ischemia risk. Diagnosis optimization and hemodynamic stabilization are essential to minimize the risk of cerebral vasospasm and ischemia.
Collapse
|