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De Backer D, Deutschman CS, Hellman J, Myatra SN, Ostermann M, Prescott HC, Talmor D, Antonelli M, Pontes Azevedo LC, Bauer SR, Kissoon N, Loeches IM, Nunnally M, Tissieres P, Vieillard-Baron A, Coopersmith CM. Surviving Sepsis Campaign Research Priorities 2023. Crit Care Med 2024; 52:268-296. [PMID: 38240508 DOI: 10.1097/ccm.0000000000006135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES To identify research priorities in the management, epidemiology, outcome, and pathophysiology of sepsis and septic shock. DESIGN Shortly after publication of the most recent Surviving Sepsis Campaign Guidelines, the Surviving Sepsis Research Committee, a multiprofessional group of 16 international experts representing the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, convened virtually and iteratively developed the article and recommendations, which represents an update from the 2018 Surviving Sepsis Campaign Research Priorities. METHODS Each task force member submitted five research questions on any sepsis-related subject. Committee members then independently ranked their top three priorities from the list generated. The highest rated clinical and basic science questions were developed into the current article. RESULTS A total of 81 questions were submitted. After merging similar questions, there were 34 clinical and ten basic science research questions submitted for voting. The five top clinical priorities were as follows: 1) what is the best strategy for screening and identification of patients with sepsis, and can predictive modeling assist in real-time recognition of sepsis? 2) what causes organ injury and dysfunction in sepsis, how should it be defined, and how can it be detected? 3) how should fluid resuscitation be individualized initially and beyond? 4) what is the best vasopressor approach for treating the different phases of septic shock? and 5) can a personalized/precision medicine approach identify optimal therapies to improve patient outcomes? The five top basic science priorities were as follows: 1) How can we improve animal models so that they more closely resemble sepsis in humans? 2) What outcome variables maximize correlations between human sepsis and animal models and are therefore most appropriate to use in both? 3) How does sepsis affect the brain, and how do sepsis-induced brain alterations contribute to organ dysfunction? How does sepsis affect interactions between neural, endocrine, and immune systems? 4) How does the microbiome affect sepsis pathobiology? 5) How do genetics and epigenetics influence the development of sepsis, the course of sepsis and the response to treatments for sepsis? CONCLUSIONS Knowledge advances in multiple clinical domains have been incorporated in progressive iterations of the Surviving Sepsis Campaign guidelines, allowing for evidence-based recommendations for short- and long-term management of sepsis. However, the strength of existing evidence is modest with significant knowledge gaps and mortality from sepsis remains high. The priorities identified represent a roadmap for research in sepsis and septic shock.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Clifford S Deutschman
- Department of Pediatrics, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY
- Sepsis Research Lab, the Feinstein Institutes for Medical Research, Manhasset, NY
| | - Judith Hellman
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Ignacio-Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Leinster, Dublin, Ireland
| | | | - Pierre Tissieres
- Pediatric Intensive Care, Neonatal Medicine and Pediatric Emergency, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Antoine Vieillard-Baron
- Service de Medecine Intensive Reanimation, Hopital Ambroise Pare, Universite Paris-Saclay, Le Kremlin-Bicêtre, France
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Westphal GA, Robinson CC, Giordani NE, Teixeira C, Rohden AI, Dos Passos Gimenes B, Guterres CM, Madalena IC, Andrighetto LV, Souza da Silva S, Barbosa da Silva D, Sganzerla D, Cavalcanti AB, Franke CA, Bozza FA, Machado FR, de Andrade J, Pontes Azevedo LC, Schneider S, Orlando BR, Grion CMC, Bezerra FA, Roman FR, Leite FO, Ferraz Siqueira ÍL, Oliveira JFP, de Oliveira LC, de Melo MDFRB, Leal PBGP, Diniz PC, Moraes RB, Salomão Pontes DF, Araújo Queiroz JE, Hammes LS, Meade MO, Rosa RG, Falavigna M. Evidence-Based Checklist to Delay Cardiac Arrest in Brain-Dead Potential Organ Donors: The DONORS Cluster Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2346901. [PMID: 38095899 PMCID: PMC10722341 DOI: 10.1001/jamanetworkopen.2023.46901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/25/2023] [Indexed: 12/17/2023] Open
Abstract
Importance The effectiveness of goal-directed care to reduce loss of brain-dead potential donors to cardiac arrest is unclear. Objective To evaluate the effectiveness of an evidence-based, goal-directed checklist in the clinical management of brain-dead potential donors in the intensive care unit (ICU). Design, Setting, and Participants The Donation Network to Optimize Organ Recovery Study (DONORS) was an open-label, parallel-group cluster randomized clinical trial in Brazil. Enrollment and follow-up were conducted from June 20, 2017, to November 30, 2019. Hospital ICUs that reported 10 or more brain deaths in the previous 2 years were included. Consecutive brain-dead potential donors in the ICU aged 14 to 90 years with a condition consistent with brain death after the first clinical examination were enrolled. Participants were randomized to either the intervention group or the control group. The intention-to-treat data analysis was conducted from June 15 to August 30, 2020. Interventions Hospital staff in the intervention group were instructed to administer to brain-dead potential donors in the intervention group an evidence-based checklist with 13 clinical goals and 14 corresponding actions to guide care, every 6 hours, from study enrollment to organ retrieval. The control group provided or received usual care. Main Outcomes and Measures The primary outcome was loss of brain-dead potential donors to cardiac arrest at the individual level. A prespecified sensitivity analysis assessed the effect of adherence to the checklist in the intervention group. Results Among the 1771 brain-dead potential donors screened in 63 hospitals, 1535 were included. These patients included 673 males (59.2%) and had a median (IQR) age of 51 (36.3-62.0) years. The main cause of brain injury was stroke (877 [57.1%]), followed by trauma (485 [31.6%]). Of the 63 hospitals, 31 (49.2%) were assigned to the intervention group (743 [48.4%] brain-dead potential donors) and 32 (50.8%) to the control group (792 [51.6%] brain-dead potential donors). Seventy potential donors (9.4%) at intervention hospitals and 117 (14.8%) at control hospitals met the primary outcome (risk ratio [RR], 0.70; 95% CI, 0.46-1.08; P = .11). The primary outcome rate was lower in those with adherence higher than 79.0% than in the control group (5.3% vs 14.8%; RR, 0.41; 95% CI, 0.22-0.78; P = .006). Conclusions and Relevance This cluster randomized clinical trial was inconclusive in determining whether the overall use of an evidence-based, goal-directed checklist reduced brain-dead potential donor loss to cardiac arrest. The findings suggest that use of such a checklist has limited effectiveness without adherence to the actions recommended in this checklist. Trial Registration ClinicalTrials.gov Identifier: NCT03179020.
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Affiliation(s)
- Glauco A Westphal
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
- Central Estadual de Transplantes de Santa Catarina, Rua Esteves Júnior, Florianópolis, Santa Catarina, Brazil
- Centro Hospitalar Unimed Joinville and Hospital Municipal São José, Joinville, Santa Catarina, Brazil
| | - Caroline Cabral Robinson
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Natalia Elis Giordani
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
- Postgraduate Programme in Epidemiology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Cassiano Teixeira
- Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
- Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Adriane Isabel Rohden
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Bruna Dos Passos Gimenes
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Cátia Moreira Guterres
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Itiana Cardoso Madalena
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Luiza Vitelo Andrighetto
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Sabrina Souza da Silva
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Daiana Barbosa da Silva
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Daniel Sganzerla
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Cristiano Augusto Franke
- Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
- Hospital de Pronto de Socorro (HPS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Fernando Augusto Bozza
- National Institute of Infectious Disease Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Rio de Janeiro, Brazil
- Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Rio de Janeiro, Brazil
| | - Flávia Ribeiro Machado
- Disciplina de Anestesiologia, Dor e Medicina Intensiva, Universidade Federal de São Paulo (UNIFESP), São Paulo, São Paulo, Brazil
| | - Joel de Andrade
- Central Estadual de Transplantes de Santa Catarina, Rua Esteves Júnior, Florianópolis, Santa Catarina, Brazil
| | | | - Silvana Schneider
- Department of Statistics, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
| | - Bianca Rodrigues Orlando
- Hospital Universitário São Francisco de Paula, Pelotas, Rio Grande do Sul, Brazil
- Hospital Escola, Universidade Federal de Pelotas (UFPEL), Pelotas, Rio Grande do Sul, Brazil
| | - Cintia Magalhães Carvalho Grion
- Hospital Universitário Regional do Norte do Paraná, Londrina, Paraná, Brazil
- Hospital Evangélico de Londrina, Londrina, Paraná, Brazil
| | | | | | - Francisco Olon Leite
- Hospital Regional Norte, Centro Universitário Inta (UNINTA), Sobral, Ceará, Brazil
| | | | | | | | | | | | - Pedro Carvalho Diniz
- Hospital Universitário, Universidade Federal do Vale do São Francisco (HU/UNIVASF), Petrolina, Pernambuco, Brazil
| | | | - Daniela Ferreira Salomão Pontes
- General Coordination Office, National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, Distrito Federal, Brazil
| | - Josélio Emar Araújo Queiroz
- General Coordination Office, National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, Distrito Federal, Brazil
| | - Luciano Serpa Hammes
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Maureen O Meade
- Department of Medicine, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Regis Goulart Rosa
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Maicon Falavigna
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
- National Institute for Health Technology Assessment, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
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Martimbianco ALC, Pacheco RL, Bagattini ÂM, de Fátima Carreira Moreira Padovez R, Azevedo LCP, Riera R. Vitamin C-based regimens for sepsis and septic shock: Systematic review and meta-analysis of randomized clinical trials. J Crit Care 2022; 71:154099. [PMID: 35763993 DOI: 10.1016/j.jcrc.2022.154099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/16/2022] [Accepted: 06/13/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE to critically appraise and synthesize the evidence on the effects of vitamin C-based regimens for patients with sepsis or septic shock. METHODS a broad search was performed on May 2021 to identify randomized clinical trials (RCTs) assessing vitamin C-based regimens as adjuvant therapy for adults with sepsis or septic shock. We used the Cochrane Risk of Bias table to assess the methodological quality of the included RCTs and the GRADE approach to evaluate the evidence certainty. RESULTS We included 20 RCTs (2124 participants). Evidence from low to very low certainty showed that vitamin C compared to placebo may reduce all-cause mortality up to 28 days (relative risk [RR] 0.60, 95% confidence interval (CI) 0.45 to 0.80, 4 RCTs, 335 participants). Considering the other comparisons (vitamin C alone or combined with thiamine and/or hydrocortisone, compared to placebo, standard care or hydrocortisone), there were a little to no difference or very uncertain evidence for adverse events, SOFA score, ICU length of stay, acute kidney injury, mechanical ventilation- and vasoactive drugs-free days up to 28 days. CONCLUSION Further RCTs with higher methodological quality, an increased number of participants and assessing clinically relevant outcomes are needed to provide better decision-making guidance. PROSPERO REGISTER CRD42021251786.
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Affiliation(s)
- Ana Luiza Cabrera Martimbianco
- Hospital Sírio-Libanês (HSL), São Paulo, SP, Brazil; Universidade Metropolitana de Santos (Unimes), Santos, SP, Brazil; Oxford-Brazil EBM Alliance, Brazil
| | - Rafael Leite Pacheco
- Hospital Sírio-Libanês (HSL), São Paulo, SP, Brazil; Oxford-Brazil EBM Alliance, Brazil; Centro Universitário São Camilo (CUSC), São Paulo, SP, Brazil; Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil.
| | | | | | | | - Rachel Riera
- Hospital Sírio-Libanês (HSL), São Paulo, SP, Brazil; Oxford-Brazil EBM Alliance, Brazil; Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
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Abstract
OBJECTIVES To assess the prevalence of burnout syndrome among intensive care physicians working in a tertiary private hospital as well as their perceived impact of the COVID-19 pandemic on their life. DESIGN A cross-sectional study. SETTING Intensive care units dedicated to the care of COVID-19 in Hospital Sirio-Libanes, Sao Paulo, Southeastern part of Brazil. PARTICIPANTS Intensive care physicians. INTERVENTIONS Each participant received an envelope with a questionnaire composed of demographic and occupational variables, information related to their personal and professional experiences facing the COVID-19 pandemic and the Maslach Burnout Inventory questionnaire. PRIMARY AND SECONDARY OUTCOMES MEASURES The primary outcome was to assess the prevalence of burnout syndrome among physicians working in an intensive care unit dedicated to the care of COVID-19. RESULTS A total of 51 from the universe of 63 (82%) intensive care physicians participated in the study. Nineteen (37.2%) met the criteria for burnout syndrome. In the three domains that characterise burnout syndrome, we found a low level of personal achievement in 96.1% of physicians interviewed, a high level of depersonalisation in 51.0% and 51.0% with a high level of emotional exhaustion. Decision-making conflicts between the intensive care unit team and other attending physicians were frequent (50% of all conflicts). A third of the participants had been diagnosed with COVID-19, 22 (43.1%) reported having a family member infected and 8 (15.7%) lost someone close to the COVID-19 pandemic. Participants felt that fear of infecting their loved ones was the aspect of their lives that changed most as compared with the prepandemic period. CONCLUSIONS Burnout syndrome was frequent among intensive care unit physicians treating patients with COVID-19 in a large tertiary private hospital. Future studies should expand our results to other private and public hospitals and test strategies to promote intensive care unit physicians' mental health.
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Affiliation(s)
| | - Eduardo Leite Vieira Costa
- Research and Education Institute, Hospital Sírio-Libanês, Sao Paulo, Brazil
- Cardio-Pulmonary Department, University of São Paulo, São Paulo, Brazil
| | | | - Luciano Cesar Pontes Azevedo
- Research and Education Institute, Hospital Sírio-Libanês, Sao Paulo, Brazil
- Emergency Medicine, University of São Paulo, São Paulo, Brazil
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Bitton E, Zimmerman S, Azevedo LCP, Benhamou D, Cecconi M, De Waele JJ, Lipman J, Martin-Loeches I, Pirracchio R, Scheeren TWL, Leone M, Einav S. An international survey of adherence to Surviving Sepsis Campaign Guidelines 2016 regarding fluid resuscitation and vasopressors in the initial management of septic shock. J Crit Care 2021; 68:144-154. [PMID: 34895959 DOI: 10.1016/j.jcrc.2021.11.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/13/2021] [Accepted: 11/29/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Our survey aimed to evaluate adherence to Surviving Sepsis Campaign (SSC) Guidelines 2016 among intensive care practitioners and to identify issues that remain controversial or lack clarity. METHODS Members of the European Society of Intensive Care Medicine (ESICM) were surveyed using an anonymous web-based survey written by an international group of experts. The primary outcome measure was the rate of adherence to specific recommendations. Secondary outcomes were to describe areas of controversy and lack of data and to associate specific practices with clinician characteristics. RESULTS Overall 820 questionnaires were completed. The SCC recommendations 2016 most adhered to were the choice of norepinephrine as first-line vasoactive drug (96.5%), vasopressor prescription based on therapeutic goal rather than dose (83.4%), targeting a specific mean arterial blood pressure during vasopressor use (77.9%), monitoring of blood pressure invasively (62.8%) and adding vasopressin or epinephrine as a second vasoactive agent (83.4%). We identified an internal conflict with regards to parallel versus sequential administration of fluids and vasoactive drugs and regional differences in practice that may be related to drug availabilities. CONCLUSION The use of vasopressors and fluid use in septic shock is largely compliant with current guidelines but several controversies should be addressed in future guideline iterations.
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Affiliation(s)
- Eden Bitton
- Intensive Care Unit of the Shaare Zedek Medical Center and the Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Shmuel Zimmerman
- Intensive Care Unit of the Shaare Zedek Medical Center and the Hebrew University Faculty of Medicine, Jerusalem, Israel
| | | | - Dan Benhamou
- Département d'Anesthésie-Réanimation, Hôpital de Bicêtre, Université Paris-Saclay, Le Kremlin Bicêtre Cedex, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jeffrey Lipman
- Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia; The University of Queensland, Saint Lucia, Australia; Jamieson Trauma Institute, Saint Lucia, Australia; Nimes University Hospital, University of Montpellier, Montpellier, France
| | - Ignacio Martin-Loeches
- Department of Clinical Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital & Trinity Centre for Health Sciences, Dublin, Ireland
| | - Romain Pirracchio
- Department of Anaesthesia and Perioperative Medicine, Zuckerberg San Francisco General Hospital and Trauma Centre, University of California San Francisco, San Francisco, California, United States
| | - Thomas W L Scheeren
- Department of Anaesthesiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Marc Leone
- Aix Marseille University, Hôpitaux Universitaires de Marseille, Department of Anesthesiology and Intensive Care, Hospital Nord, Marseille, France.
| | - Sharon Einav
- Intensive Care Unit of the Shaare Zedek Medical Center and the Hebrew University Faculty of Medicine, Jerusalem, Israel
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Leite GGF, Ferreira BL, Tashima AK, Nishiduka ES, Cunha-Neto E, Brunialti MKC, Assuncao M, Azevedo LCP, Freitas F, van der Poll T, Scicluna BP, Salomão R. Combined Transcriptome and Proteome Leukocyte's Profiling Reveals Up-Regulated Module of Genes/Proteins Related to Low Density Neutrophils and Impaired Transcription and Translation Processes in Clinical Sepsis. Front Immunol 2021; 12:744799. [PMID: 34594344 PMCID: PMC8477441 DOI: 10.3389/fimmu.2021.744799] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 07/20/2021] [Accepted: 08/24/2021] [Indexed: 01/20/2023] Open
Abstract
Sepsis is a global health emergency, which is caused by various sources of infection that lead to changes in gene expression, protein-coding, and metabolism. Advancements in “omics” technologies have provided valuable tools to unravel the mechanisms involved in the pathogenesis of this disease. In this study, we performed shotgun mass spectrometry in peripheral blood mononuclear cells (PBMC) from septic patients (N=24) and healthy controls (N=9) and combined these results with two public microarray leukocytes datasets. Through combination of transcriptome and proteome profiling, we identified 170 co‐differentially expressed genes/proteins. Among these, 122 genes/proteins displayed the same expression trend. Ingenuity Pathway Analysis revealed pathways related to lymphocyte functions with decreased status, and defense processes that were predicted to be strongly increased. Protein-protein interaction network analyses revealed two densely connected regions, which mainly included down‐regulated genes/proteins that were related to the transcription of RNA, translation of proteins, and mitochondrial translation. Additionally, we identified one module comprising of up‐regulated genes/proteins, which were mainly related to low-density neutrophils (LDNs). LDNs were reported in sepsis and in COVID-19. Changes in gene expression level were validated using quantitative real-time PCR in PBMCs from patients with sepsis. To further support that the source of the upregulated module of genes/proteins found in our results were derived from LDNs, we identified an increase of this population by flow cytometry in PBMC samples obtained from the same cohort of septic patients included in the proteomic analysis. This study provides new insights into a reprioritization of biological functions in response to sepsis that involved a transcriptional and translational shutdown of genes/proteins, with exception of a set of genes/proteins related to LDNs and host‐defense system.
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Affiliation(s)
- Giuseppe Gianini Figueirêdo Leite
- Division of Infectious Diseases, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, São Paulo, Brazil
| | - Bianca Lima Ferreira
- Division of Infectious Diseases, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, São Paulo, Brazil
| | - Alexandre Keiji Tashima
- Department of Biochemistry, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, São Paulo, Brazil
| | - Erika Sayuri Nishiduka
- Department of Biochemistry, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, São Paulo, Brazil
| | - Edecio Cunha-Neto
- Laboratorio de Imunologia, Instituto do Coracao, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Milena Karina Colo Brunialti
- Division of Infectious Diseases, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, São Paulo, Brazil
| | - Murillo Assuncao
- Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Flávio Freitas
- Intensive Care Unit, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.,Division of Infectious Diseases, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Brendon P Scicluna
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.,Department of Applied Biomedical Sciences, Faculty of Health Sciences, Mater Dei hospital, University of Malta, Msida, Malta
| | - Reinaldo Salomão
- Division of Infectious Diseases, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, São Paulo, Brazil
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7
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Noritomi DT, Ranzani OT, Ferraz LJR, Dos Santos MC, Cordioli E, Albaladejo R, Serpa Neto A, Correa TD, Berwanger O, de Morais LC, Schettino G, Cavalcanti AB, Rosa RG, Biondi RS, Salluh JI, Azevedo LCP, Pereira AJ. TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE): protocol for a cluster-randomised clinical trial on adult general ICUs in Brazil. BMJ Open 2021; 11:e042302. [PMID: 34155070 PMCID: PMC8217943 DOI: 10.1136/bmjopen-2020-042302] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Daily multidisciplinary rounds (DMRs) consist of systematic patient-centred discussions aiming to establish joint therapeutic goals for the next 24 hours of intensive care unit (ICU) care. The aim of the present study protocol is to evaluate whether an intervention consisting of guided DMRs, supported by a remote specialist and audit/feedback on care performance will reduce ICU length of stay compared with a control group. METHODS AND ANALYSIS A multicentre, controlled, cluster-randomised superiority trial including 30 ICUs in Brazil (15 intervention and 15 control), from August 2019 to June 2021. In a parallel assignment, ICUs are randomised to a complex-intervention composed by daily rounds carried out through Tele-ICU by a remote ICU physician; development of local quality indicators dashboards coupled with monthly meetings with local leadership; and dissemination of evidence-based clinical protocols versus usual care. Primary outcome is ICU length of stay. Secondary outcomes include classification of the unit according to the profiles defined by the standardised resource use and the standardised mortality rate, hospital mortality, incidence of healthcare-associated infections, ventilator-free days at 28 days, patient-days receiving oral or enteral feeding, patient-days under light sedation or alert and calm, rate of patients under normoxaemia. All adult patients admitted after the beginning of the study in each participant ICU will be enrolled. Inclusion criteria (clusters): public Brazilian ICUs with a minimum of 8 ICU beds interested/committed to participating in the study. Exclusion criteria (clusters): units with fully established DMRs by an intensivist, specialised or step-down units. ETHICS AND DISSEMINATION The study protocol was approved by the institutional review board (IRB) of the coordinator centre, and by IRBs of each enrolled hospital/ICU. Statistical analysis protocol is being prepared for submission before the end of patient's enrolment. Results will be disseminated through conferences, peer-reviewed journals and to each participating unit. TRIAL REGISTRATION NUMBER NCT03920501; Pre-results.
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Affiliation(s)
- Danilo Teixeira Noritomi
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Clinical Governance, DASA, Sao Paulo, Brazil
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Otavio T Ranzani
- Pulmonary Division, Heart Institute, Hospital das Clinicas, Universidade de Sao Paulo Faculdade de Medicina Hospital das Clinicas, Sao Paulo, SP, Brazil
- ISGlobal, Barcelona Institute for Global Health, Barcelona, Catalunya, Spain
| | | | - Maura C Dos Santos
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo Cordioli
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Ary Serpa Neto
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
| | - Thiago D Correa
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
| | - Otávio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, São Paulo, Brazil
| | - Lubia Caus de Morais
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Guilherme Schettino
- Institute of Social Responsibility, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- HCor Research Institute, Sao Paulo, SP, Brazil
| | - Regis Goulart Rosa
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- Intensive Care, HMV, Porto Alegre, Rio Grande do Sul, Brazil
| | - Rodrigo Santos Biondi
- Instituto de Cardiologia do Distrito Federal, Brasília, Distrito Federal, Brazil
- Hospital Brasília, Brasília, DF, Brazil
| | - Jorge If Salluh
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, Brazil, Rio de Janeiro, Brazil
| | - Luciano Cesar Pontes Azevedo
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- Intensive Care Unit, Hospital Sírio-Libanês, São Paulo, SP, Brazil
- Emergency Medicine Department, University of Sao Paulo, Sao Paulo, São Paulo, Brazil
| | - Adriano Jose Pereira
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Postgraduate Program of Health Sciences, Universidade Federal de Lavras, Lavras, MG, Brazil
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Sterne JAC, Murthy S, Diaz JV, Slutsky AS, Villar J, Angus DC, Annane D, Azevedo LCP, Berwanger O, Cavalcanti AB, Dequin PF, Du B, Emberson J, Fisher D, Giraudeau B, Gordon AC, Granholm A, Green C, Haynes R, Heming N, Higgins JPT, Horby P, Jüni P, Landray MJ, Le Gouge A, Leclerc M, Lim WS, Machado FR, McArthur C, Meziani F, Møller MH, Perner A, Petersen MW, Savovic J, Tomazini B, Veiga VC, Webb S, Marshall JC. Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19: A Meta-analysis. JAMA 2020; 324:1330-1341. [PMID: 32876694 PMCID: PMC7489434 DOI: 10.1001/jama.2020.17023] [Citation(s) in RCA: 1531] [Impact Index Per Article: 382.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/21/2020] [Indexed: 01/28/2023]
Abstract
Importance Effective therapies for patients with coronavirus disease 2019 (COVID-19) are needed, and clinical trial data have demonstrated that low-dose dexamethasone reduced mortality in hospitalized patients with COVID-19 who required respiratory support. Objective To estimate the association between administration of corticosteroids compared with usual care or placebo and 28-day all-cause mortality. Design, Setting, and Participants Prospective meta-analysis that pooled data from 7 randomized clinical trials that evaluated the efficacy of corticosteroids in 1703 critically ill patients with COVID-19. The trials were conducted in 12 countries from February 26, 2020, to June 9, 2020, and the date of final follow-up was July 6, 2020. Pooled data were aggregated from the individual trials, overall, and in predefined subgroups. Risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool. Inconsistency among trial results was assessed using the I2 statistic. The primary analysis was an inverse variance-weighted fixed-effect meta-analysis of overall mortality, with the association between the intervention and mortality quantified using odds ratios (ORs). Random-effects meta-analyses also were conducted (with the Paule-Mandel estimate of heterogeneity and the Hartung-Knapp adjustment) and an inverse variance-weighted fixed-effect analysis using risk ratios. Exposures Patients had been randomized to receive systemic dexamethasone, hydrocortisone, or methylprednisolone (678 patients) or to receive usual care or placebo (1025 patients). Main Outcomes and Measures The primary outcome measure was all-cause mortality at 28 days after randomization. A secondary outcome was investigator-defined serious adverse events. Results A total of 1703 patients (median age, 60 years [interquartile range, 52-68 years]; 488 [29%] women) were included in the analysis. Risk of bias was assessed as "low" for 6 of the 7 mortality results and as "some concerns" in 1 trial because of the randomization method. Five trials reported mortality at 28 days, 1 trial at 21 days, and 1 trial at 30 days. There were 222 deaths among the 678 patients randomized to corticosteroids and 425 deaths among the 1025 patients randomized to usual care or placebo (summary OR, 0.66 [95% CI, 0.53-0.82]; P < .001 based on a fixed-effect meta-analysis). There was little inconsistency between the trial results (I2 = 15.6%; P = .31 for heterogeneity) and the summary OR was 0.70 (95% CI, 0.48-1.01; P = .053) based on the random-effects meta-analysis. The fixed-effect summary OR for the association with mortality was 0.64 (95% CI, 0.50-0.82; P < .001) for dexamethasone compared with usual care or placebo (3 trials, 1282 patients, and 527 deaths), the OR was 0.69 (95% CI, 0.43-1.12; P = .13) for hydrocortisone (3 trials, 374 patients, and 94 deaths), and the OR was 0.91 (95% CI, 0.29-2.87; P = .87) for methylprednisolone (1 trial, 47 patients, and 26 deaths). Among the 6 trials that reported serious adverse events, 64 events occurred among 354 patients randomized to corticosteroids and 80 events occurred among 342 patients randomized to usual care or placebo. Conclusions and Relevance In this prospective meta-analysis of clinical trials of critically ill patients with COVID-19, administration of systemic corticosteroids, compared with usual care or placebo, was associated with lower 28-day all-cause mortality.
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Affiliation(s)
- Jonathan A C Sterne
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Bristol Biomedical Research Centre, Bristol, England
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Janet V Diaz
- Clinical Unit, Health Emergencies Programme, World Health Organization, Geneva, Switzerland
| | - Arthur S Slutsky
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jesús Villar
- Research Unit, Hospital Universitario Dr Negrín, Las Palmas de Gran Canaria, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Djillali Annane
- Department of Intensive Care, Raymond Poincaré Hospital (APHP), School of Medicine Simone Veil, University Paris Saclay-UVSQ, Paris, France
| | - Luciano Cesar Pontes Azevedo
- Hospital Sírio-Libanês, São Paulo, Brazil
- Emergency Medicine Department, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Pierre-Francois Dequin
- Médecine Intensive-Réanimation, INSERM CIC1415, CHRU de Tours, Tours, France
- CRICS-TriGGERSep Network, Centre d'Etude des Pathologies Respiratoires, Université de Tours, Tours, France
| | - Bin Du
- Peking Union Medical College Hospital, Beijing, China
| | - Jonathan Emberson
- Nuffield Department of Population Health, University of Oxford, Oxford, England
- MRC Population Health Research Unit, University of Oxford, Oxford, England
| | - David Fisher
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, Faculty of Population Health Sciences, University College London, London, England
| | | | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, England
| | - Anders Granholm
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Richard Haynes
- Nuffield Department of Population Health, University of Oxford, Oxford, England
- MRC Population Health Research Unit, University of Oxford, Oxford, England
| | - Nicholas Heming
- Department of Intensive Care, Raymond Poincaré Hospital (APHP), School of Medicine Simone Veil, University Paris Saclay-UVSQ, Paris, France
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Bristol Biomedical Research Centre, Bristol, England
- NIHR Applied Research Collaboration West, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Peter Horby
- Nuffield Department of Medicine, University of Oxford, Oxford, England
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Martin J Landray
- Nuffield Department of Population Health, University of Oxford, Oxford, England
- MRC Population Health Research Unit, University of Oxford, Oxford, England
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | | | | | - Wei Shen Lim
- Respiratory Medicine Department, Nottingham University Hospitals NHS Trust, Nottingham, England
| | - Flávia R Machado
- Anesthesiology, Pain, and Intensive Care Department, Federal University of São Paulo, São Paulo, Brazil
| | - Colin McArthur
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Ferhat Meziani
- Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM UMR 1260, Regenerative Nanomedicine, FMTS, Strasbourg, France
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Marie Warrer Petersen
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jelena Savovic
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Applied Research Collaboration West, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Bruno Tomazini
- Hospital Sírio-Libanês, São Paulo, Brazil
- Department of Surgery, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Viviane C Veiga
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Steve Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- St John of God Healthcare, Subiaco, Australia
| | - John C Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Betonico GN, Azevedo LCP. Approaching COVID-19: Bedside strategies for intensive care. Eur J Clin Invest 2020:e13327. [PMID: 32562547 PMCID: PMC7323080 DOI: 10.1111/eci.13327] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/20/2020] [Accepted: 05/23/2020] [Indexed: 12/02/2022]
Abstract
The spread of novel coronavirus disease (COVID‐19) urged a never‐seen coordinated global response to prepare the health system, including primary care, hospital facilities and intensive care units (ICUs). Lessons have been learned from countries who suffered the pandemic at the beginning, helping the ones which are on different phases of the spreading curve. Currently, optimizing intensive care resources is mandatory as admittance to the ICUs remains rising exponentially. While public and private health system struggle for changing the slope of the curve, intensivists prepare the facilities for a tsunami of respiratory failure patients with COVID‐19.1
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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.
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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
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Falavigna M, Colpani V, Stein C, Azevedo LCP, Bagattini AM, de Brito GV, Chatkin JM, Cimerman S, Corradi MDFDB, da Cunha CA, de Medeiros FC, de Oliveira Junior HA, Fritscher LG, Gazzana MB, Gräf DD, Marra LP, Matuoka JY, Nunes MS, Pachito DV, Pagano CGM, Parreira PDCS, Riera R, Silva Júnior A, Tavares BDM, Zavascki AP, Rosa RG, Dal-Pizzol F. Guidelines for the pharmacological treatment of COVID-19. The task-force/consensus guideline of the Brazilian Association of Intensive Care Medicine, the Brazilian Society of Infectious Diseases and the Brazilian Society of Pulmonology and Tisiology. Rev Bras Ter Intensiva 2020; 32:166-196. [PMID: 32667444 PMCID: PMC7405746 DOI: 10.5935/0103-507x.20200039] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Different therapies are currently used, considered, or proposed for the treatment of COVID-19; for many of those therapies, no appropriate assessment of effectiveness and safety was performed. This document aims to provide scientifically available evidence-based information in a transparent interpretation, to subsidize decisions related to the pharmacological therapy of COVID-19 in Brazil. METHODS A group of 27 experts and methodologists integrated a task-force formed by professionals from the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB), the Brazilian Society of Infectious Diseases (Sociedad Brasileira de Infectologia - SBI) and the Brazilian Society of Pulmonology and Tisiology (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT). Rapid systematic reviews, updated on April 28, 2020, were conducted. The assessment of the quality of evidence and the development of recommendations followed the GRADE system. The recommendations were written on May 5, 8, and 13, 2020. RESULTS Eleven recommendations were issued based on low or very-low level evidence. We do not recommend the routine use of hydroxychloroquine, chloroquine, azithromycin, lopinavir/ritonavir, corticosteroids, or tocilizumab for the treatment of COVID-19. Prophylactic heparin should be used in hospitalized patients, however, no anticoagulation should be provided for patients without a specific clinical indication. Antibiotics and oseltamivir should only be considered for patients with suspected bacterial or influenza coinfection, respectively. CONCLUSION So far no pharmacological intervention was proven effective and safe to warrant its use in the routine treatment of COVID-19 patients; therefore such patients should ideally be treated in the context of clinical trials. The recommendations herein provided will be revised continuously aiming to capture newly generated evidence.
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Affiliation(s)
- Maicon Falavigna
- Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
- Instituto para Avaliação de Tecnologia em Saúde, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
- Department of Health Research Methods, Evidence, and Impact, McMaster University - Hamilton, Canadá
| | - Verônica Colpani
- Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
- Programa de Pós-Graduação em Ciências Médicas: Endocrinologia, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Cinara Stein
- Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
| | - Luciano Cesar Pontes Azevedo
- Hospital Sírio-Libanês - São Paulo (SP), Brasil
- Disciplina de Emergências Clínicas, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Angela Maria Bagattini
- Hospital Sírio-Libanês - São Paulo (SP), Brasil
- Programa de Pós-Graduação em Medicina Tropical e Saúde Pública, Universidade Federal de Goiás - Goiânia (GO), Brasil
| | | | - José Miguel Chatkin
- Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
- Sociedade Brasileira de Pneumologia e Tisiologia - Brasília (DF), Brasil
| | - Sergio Cimerman
- Instituto de Infectologia Emílio Ribas - São Paulo (SP), Brasil
- Sociedade Brasileira de Infectologia - São Paulo (SP), Brasil
| | | | - Clovis Arns da Cunha
- Sociedade Brasileira de Infectologia - São Paulo (SP), Brasil
- Universidade Federal do Paraná - Curitiba (PR), Brasil
| | | | | | - Leandro Genehr Fritscher
- Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
- Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Marcelo Basso Gazzana
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
- Serviço de Pneumologia e Cirurgia Torácica, Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
| | | | - Lays Pires Marra
- Centro Internacional de Pesquisa, Hospital Alemão Oswaldo Cruz - São Paulo (SP), Brasil
| | - Jessica Yumi Matuoka
- Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | | | - Daniela Vianna Pachito
- Hospital Sírio-Libanês - São Paulo (SP), Brasil
- Fundação Getúlio Vargas - São Paulo (SP), Brasil
| | | | | | - Rachel Riera
- Hospital Sírio-Libanês - São Paulo (SP), Brasil
- Escola Paulista de Medicina, Universidade Federal de São Paulo - São Paulo (SP), Brasil
| | | | | | - Alexandre Prehn Zavascki
- Serviço de Infectologia e Controle de Infecção, Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
- Departamento de Medicina Interna, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | | | - Felipe Dal-Pizzol
- Laboratório de Fisiopatologia Experimental, Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense - Criciúma (SC), Brasil
- Serviço de Medicina Intensiva, Hospital São José - Criciúma (SC), Brasil
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Martin-Loeches I, Timsit JF, Leone M, de Waele J, Sartelli M, Kerrigan S, Azevedo LCP, Einav S. Clinical controversies in abdominal sepsis. Insights for critical care settings. J Crit Care 2019; 53:53-58. [DOI: 10.1016/j.jcrc.2019.05.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 12/27/2022]
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Zampieri FG, Kawano-Dourado L, Azevedo LCP, Corrêa TD, Cavalcanti AB. In Response. Anesth Analg 2019; 127:313-314. [PMID: 29683828 DOI: 10.1213/ane.0000000000003381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Fernando G Zampieri
- Research Institute, HCor-Hospital do Coração, São Paulo, Brazil, Intensive Care Unit, Hospital Sirio Libanes, São Paulo, Brazil, Emergency Medicine Discipline, University of São Paulo Medical School, São Paulo, Brazil Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil, Intensive Care Unit, Hospital Municipal Dr Moysés Deutsch - M'Boi Mirim, São Paulo, Brazil Research Institute, HCor-Hospital do Coração, São Paulo, Brazil
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14
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Rosa RG, Falavigna M, da Silva DB, Sganzerla D, Santos MMS, Kochhann R, de Moura RM, Eugênio CS, Haack TDSR, Barbosa MG, Robinson CC, Schneider D, de Oliveira DM, Jeffman RW, Cavalcanti AB, Machado FR, Azevedo LCP, Salluh JIF, Pellegrini JAS, Moraes RB, Foernges RB, Torelly AP, Ayres LDO, Duarte PAD, Lovato WJ, Sampaio PHS, de Oliveira Júnior LC, Paranhos JLDR, Dantas ADS, de Brito PIPGG, Paulo EAP, Gallindo MAC, Pilau J, Valentim HM, Meira Teles JM, Nobre V, Birriel DC, Corrêa e Castro L, Specht AM, Medeiros GS, Tonietto TF, Mesquita EC, da Silva NB, Korte JE, Hammes LS, Giannini A, Bozza FA, Teixeira C. Effect of Flexible Family Visitation on Delirium Among Patients in the Intensive Care Unit: The ICU Visits Randomized Clinical Trial. JAMA 2019; 322:216-228. [PMID: 31310297 PMCID: PMC6635909 DOI: 10.1001/jama.2019.8766] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE The effects of intensive care unit (ICU) visiting hours remain uncertain. OBJECTIVE To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium. DESIGN, SETTING AND PARTICIPANTS Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018. INTERVENTIONS Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation. MAIN OUTCOMES AND MEASURES Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory). RESULTS Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation. CONCLUSIONS AND RELEVANCE Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02932358.
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Affiliation(s)
- Regis Goulart Rosa
- Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
- Research Projects Office, HMV, Porto Alegre, Rio Grande do Sul, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, São Paulo
| | - Maicon Falavigna
- Research Projects Office, HMV, Porto Alegre, Rio Grande do Sul, Brazil
| | - Daiana Barbosa da Silva
- Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
- Research Projects Office, HMV, Porto Alegre, Rio Grande do Sul, Brazil
| | - Daniel Sganzerla
- Research Projects Office, HMV, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Renata Kochhann
- Research Projects Office, HMV, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Cláudia Severgnini Eugênio
- Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
- Research Projects Office, HMV, Porto Alegre, Rio Grande do Sul, Brazil
| | - Tarissa da Silva Ribeiro Haack
- Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
- Research Projects Office, HMV, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Daniel Schneider
- Research Projects Office, HMV, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, São Paulo
- HCor Research Institute, São Paulo, São Paulo, Brazil
| | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, São Paulo
- Department of Anesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo (UNIFESP), São Paulo, São Paulo, Brazil
| | - Luciano Cesar Pontes Azevedo
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, São Paulo
- Intensive Care Unit, Hospital Sírio-Libanês, São Paulo, São Paulo, Brazil
| | - Jorge Ibrain Figueira Salluh
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, São Paulo
- Department of Critical Care, Instituto D’Or de Pesquisa e Ensino, Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Rafael Barberena Moraes
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | | | - Pericles Almeida Delfino Duarte
- Intensive Care Unit, Hospital Universitário do Oeste do Paraná, Cascavel, Paraná, Brazil
- Intensive Care Unit, Hospital do Câncer de Cascavel, Cascavel, Paraná, Brazil
| | - Wilson José Lovato
- Intensive Care Unit, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, São Paulo, Brazil
| | | | | | | | - Alessandro da Silva Dantas
- Intensive Care Unit, Hospital Regional Doutor Deoclécio Marques de Lucena, Parnamirim, Rio Grande do Norte, Brazil
| | | | | | | | - Janaina Pilau
- Intensive Care Unit, Hospital da Cidade, Passo Fundo, Rio Grande do Sul, Brazil
| | | | | | - Vandack Nobre
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, São Paulo
- Intensive Care Unit, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | | | | | - Andréia Martins Specht
- Intensive Care Unit, Hospital Nossa Senhora da Conceição, Porto Alegre, Rio Grande do Sul, Brazil
| | - Gregory Saraiva Medeiros
- Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
- Research Projects Office, HMV, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Emersom Cicilini Mesquita
- Department of Critical Care, Instituto D’Or de Pesquisa e Ensino, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nilton Brandão da Silva
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Jeffrey E. Korte
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | | | - Alberto Giannini
- Unit of Pediatric Anesthesia and Intensive Care, Ospedale dei Bambini—ASST Spedali Civili, Brescia, Italy
| | - Fernando Augusto Bozza
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, São Paulo
- Department of Critical Care, Instituto D’Or de Pesquisa e Ensino, Rio de Janeiro, Rio de Janeiro, Brazil
- Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Rio de Janeiro, Brazil
| | - Cassiano Teixeira
- Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, São Paulo
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Sharma NK, Ferreira BL, Tashima AK, Brunialti MKC, Torquato RJS, Bafi A, Assuncao M, Azevedo LCP, Salomao R. Lipid metabolism impairment in patients with sepsis secondary to hospital acquired pneumonia, a proteomic analysis. Clin Proteomics 2019; 16:29. [PMID: 31341447 PMCID: PMC6631513 DOI: 10.1186/s12014-019-9252-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/10/2019] [Indexed: 12/28/2022] Open
Abstract
Background Sepsis is a dysregulated host response to infection and a major cause of death worldwide. Respiratory tract infections account for most sepsis cases and depending on the place of acquisition, i.e., community or hospital acquired infection, differ in etiology, antimicrobial resistance and outcomes. Accordingly, the host response may be different in septic patients secondary to community-acquired pneumonia and hospital acquired pneumonia (HAP). Proteomic analysis is a useful approach to evaluate broad alterations in biological pathways that take place during sepsis. Here we evaluated plasma proteome changes in sepsis secondary to HAP. Methods Plasma samples were obtained from patients (n = 27) at admission and after 7 days of follow-up, and were analyzed according to the patients’ outcomes. The patients’ proteome profiles were compared with healthy volunteers (n = 23). Pooled plasma samples were labeled with isobaric tag for relative and absolute quantitationand analyzed by LC–MS/MS. We used bioinformatics tools to find altered functions and pathways. Results were validated using biochemical estimations and ELISA tests. Results We identified 159 altered proteins in septic patients; most of them were common when comparing patients’ outcomes, both at admission and after 7 days. The top altered biological processes were acute inflammatory response, response to wounding, blood coagulation and homeostasis. Lipid metabolism emerged as the main altered function in patients, with HDL as a central node in the network analysis, interacting with downregulated proteins, such as APOA4, APOB, APOC1, APOL1, SAA4 and PON1. Validation tests showed reduced plasma levels of total cholesterol, HDL-C, LDL-C, non-HDL cholesterol, apolipoproteins ApoA1 and ApoB100, and Paraoxonase 1 in HAP patients. Conclusion Proteomic analysis pointed to impairment of lipid metabolism as a major change in septic patients secondary to HAP, which was further validated by the reduced levels of cholesterol moieties and apolipoproteins in plasma. Our results stress the involvement of lipids in the pathogenesis of sepsis, which is in accordance with previous reports supporting the role of lipid moieties in pathogen toxin clearance and in modulating inflammatory responses. Electronic supplementary material The online version of this article (10.1186/s12014-019-9252-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Narendra Kumar Sharma
- 1Division of Infectious Diseases, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo, 669, 10th Floor, Sao Paulo, SP 04039-032 Brazil.,6Present Address: Department of Bioscience and Biotechnology, Banasthali Vidyapith, Banasthali Tonk, 304022 Rajasthan India
| | - Bianca Lima Ferreira
- 1Division of Infectious Diseases, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo, 669, 10th Floor, Sao Paulo, SP 04039-032 Brazil
| | - Alexandre Keiji Tashima
- 2Department of Biochemistry, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP 04023-900 Brazil
| | - Milena Karina Colo Brunialti
- 1Division of Infectious Diseases, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo, 669, 10th Floor, Sao Paulo, SP 04039-032 Brazil
| | - Ricardo Jose Soares Torquato
- 2Department of Biochemistry, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP 04023-900 Brazil
| | - Antonio Bafi
- 3Intensive Care Unit, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, 04024-002 Brazil
| | - Murillo Assuncao
- 4Intensive Care Unit, Hospital Israelita Albert Einstein, Sao Paulo, 05652-900 Brazil
| | | | - Reinaldo Salomao
- 1Division of Infectious Diseases, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo, 669, 10th Floor, Sao Paulo, SP 04039-032 Brazil
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16
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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.
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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
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Li HY, Mendes PV, Melro LMG, Joelsons D, Besen BAMP, Costa ELV, Hirota AS, Barbosa EVS, Foronda FK, Azevedo LCP, Romano TG, Park M. Characterization of patients transported with extracorporeal respiratory and/or cardiovascular support in the State of São Paulo, Brazil. Rev Bras Ter Intensiva 2018; 30:317-326. [PMID: 30328986 PMCID: PMC6180471 DOI: 10.5935/0103-507x.20180052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 04/30/2018] [Indexed: 01/05/2023] Open
Abstract
Objective To characterize the transport of severely ill patients with extracorporeal
respiratory or cardiovascular support. Methods A series of 18 patients in the state of São Paulo, Brazil is
described. All patients were consecutively evaluated by a multidisciplinary
team at the hospital of origin. The patients were rescued, and
extracorporeal membrane oxygenation support was provided on site. The
patients were then transported to referral hospitals for extracorporeal
membrane oxygenation support. Data were retrieved from a prospectively
collected database. Results From 2011 to 2017, 18 patients aged 29 (25 - 31) years with a SAPS 3 of 84
(68 - 92) and main primary diagnosis of leptospirosis and influenza A (H1N1)
virus were transported to three referral hospitals in São Paulo. A
median distance of 39 (15 - 82) km was traveled on each rescue mission
during a period of 360 (308 - 431) min. A median of one (0 - 2) nurse, three
(2 - 3) physicians, and one (0 - 1) physical therapist was present per
rescue. Seventeen rescues were made by ambulance, and one rescue was made by
helicopter. The observed complications were interruption in the energy
supply to the pump in two cases (11%) and oxygen saturation < 70% in two
cases. Thirteen patients (72%) survived and were discharged from the
hospital. Among the nonsurvivors, there were two cases of brain death, two
cases of multiple organ dysfunction syndrome, and one case of irreversible
pulmonary fibrosis. Conclusions Transportation with extracorporeal support occurred without serious
complications, and the hospital survival rate was high.
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Affiliation(s)
- Ho Yeh Li
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Pedro Vitale Mendes
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Oncológica, Hospital São Luiz, Rede D'Or - São Paulo (SP), Brasil
| | - Livia Maria Garcia Melro
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Hospital TotalCor - São Paulo (SP), Brasil
| | - Daniel Joelsons
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Bruno Adler Maccagnan Pinheiro Besen
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Oncológica, Hospital São Luiz, Rede D'Or - São Paulo (SP), Brasil
| | - Eduardo Leite Viera Costa
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Hospital Sírio Libanês - São Paulo (SP), Brasil
| | - Adriana Sayuri Hirota
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - Flavia Krepel Foronda
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Luciano Cesar Pontes Azevedo
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Hospital Sírio Libanês - São Paulo (SP), Brasil
| | - Thiago Gomes Romano
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Oncológica, Hospital São Luiz, Rede D'Or - São Paulo (SP), Brasil
| | - Marcelo Park
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
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Azevedo LCP, Cavalcanti AB, Lisboa T, Pizzol FD, Machado FR. Sepsis is an important healthcare burden in Latin America: a call to action! Rev Bras Ter Intensiva 2018; 30:402-404. [PMID: 30570031 PMCID: PMC6334489 DOI: 10.5935/0103-507x.20180061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 12/26/2022] Open
Affiliation(s)
| | | | - Thiago Lisboa
- Instituto Latino Americano de Sepse - São Paulo (SP), Brasil
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Sganzerla D, Teixeira C, Robinson CC, Kochhann R, Santos MMS, de Moura RM, Barbosa MG, da Silva DB, Ribeiro T, Eugênio C, Schneider D, Mariani D, Jeffman RW, Bozza F, Cavalcanti AB, Azevedo LCP, Machado FR, Salluh JI, Pellegrini JAS, Moraes RB, Damiani LP, da Silva NB, Falavigna M, Rosa RG. Statistical analysis plan for a cluster-randomized crossover trial comparing the effectiveness and safety of a flexible family visitation model for delirium prevention in adult intensive care units (the ICU Visits Study). Trials 2018; 19:636. [PMID: 30454019 PMCID: PMC6245900 DOI: 10.1186/s13063-018-3006-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 10/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most adult intensive care units (ICUs) worldwide adopt restrictive family visitation models (RFVMs). However, evidence, mostly from non-randomized studies, suggests that flexible adult ICU visiting hours are safe policies that can result in benefits such as prevention of delirium and increase in satisfaction with care. Accordingly, the ICU Visits Study was designed to compare the effectiveness and safety of a flexible family visitation model (FFVM) vs. an RFVM on delirium prevention among ICU patients, and also to analyze its potential effects on family members and ICU professionals. METHODS/DESIGN The ICU Visits Study is a cluster-randomized crossover trial which compares an FFVM (12 consecutive ICU visiting hours per day) with an RFVM (< 4.5 ICU visiting hours per day) in 40 Brazilian adult ICUs. Participant ICUs are randomly assigned to either an FFVM or RFVM in a 1:1 ratio. After enrollment and follow-up of 25 patients, each ICU is crossed over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome is the cumulative incidence of delirium measured by the Confusion Assessment Method for the ICU. Secondary and tertiary outcomes include relevant measures of effectiveness and safety of ICU visiting policies among patients, family members, and ICU professionals. Herein, we describe all primary statistical procedures that will be used to evaluate the results and perform exploratory and sensitivity analyses of this study. This pre-specified statistical analysis plan was written and submitted without knowledge of the study data. DISCUSSION This a priori statistical analysis plan aims to enhance the transparency of our study, facilitating unbiased analyses of ICU visit study data, and provide guidance for statistical analysis for groups conducting studies in the same field. TRIAL REGISTRATION ClinicalTrials.gov, NCT02932358 . Registered on 11 October 2016.
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Affiliation(s)
- Daniel Sganzerla
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Cassiano Teixeira
- Intensive Care Unit, HMV. Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Caroline Cabral Robinson
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Renata Kochhann
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Mariana Martins Siqueira Santos
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Rafaela Moraes de Moura
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Mirceli Goulart Barbosa
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Daiana Barbosa da Silva
- Intensive Care Unit, HMV. Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Tarissa Ribeiro
- Intensive Care Unit, HMV. Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Cláudia Eugênio
- Intensive Care Unit, HMV. Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Daniel Schneider
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Débora Mariani
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Rodrigo Wiltgen Jeffman
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Fernando Bozza
- Department of Critical Care, Instituto D'Or de Pesquisa e Ensino (IDOR), Rua Diniz Cordeiro, 30, Botafogo, Rio de Janeiro, RJ, 22281-100, Brazil
| | | | - Luciano Cesar Pontes Azevedo
- Intensive Care Unit, Hospital Sírio-Libanês, Rua Dona Adma Jafet, 91, Bela Vista, São Paulo, SP, 01308-050, Brazil
| | - Flávia Ribeiro Machado
- Department of Anesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 737, Vila Clementino, São Paulo, SP, 04024-900, Brazil
| | - Jorge Ibrain Salluh
- HCor Research Institute, Rua Abílio Soares, 250, Paraíso, São Paulo, SP, 04005-909, Brazil
| | - José Augusto Santos Pellegrini
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350, Santa Cecília, Porto Alegre, RS, 90035-903, Brazil
| | - Rafael Barberena Moraes
- Institute for Education and Research, HMV, Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Lucas Petri Damiani
- HCor Research Institute, Rua Abílio Soares, 250, Paraíso, São Paulo, SP, 04005-909, Brazil
| | - Nilton Brandão da Silva
- Department of Internal Medicine, School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Rua Sarmento Leite, 245, Centro Histórico, Porto Alegre, RS, 90050-170, Brazil
| | - Maicon Falavigna
- Institute for Education and Research, HMV, Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil
| | - Regis Goulart Rosa
- Intensive Care Unit, HMV. Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil.
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Rosa RG, Falavigna M, Robinson CC, da Silva DB, Kochhann R, de Moura RM, Santos MMS, Sganzerla D, Giordani NE, Eugênio C, Ribeiro T, Cavalcanti AB, Bozza F, Azevedo LCP, Machado FR, Salluh JIF, Pellegrini JAS, Moraes RB, Hochegger T, Amaral A, Teles JMM, da Luz LG, Barbosa MG, Birriel DC, Ferraz IDL, Nobre V, Valentim HM, Corrêa E Castro L, Duarte PAD, Tregnago R, Barilli SLS, Brandão N, Giannini A, Teixeira C. Study protocol to assess the effectiveness and safety of a flexible family visitation model for delirium prevention in adult intensive care units: a cluster-randomised, crossover trial (The ICU Visits Study). BMJ Open 2018; 8:e021193. [PMID: 29654049 PMCID: PMC5905750 DOI: 10.1136/bmjopen-2017-021193] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Flexible intensive care unit (ICU) visiting hours have been proposed as a means to improve patient-centred and family-centred care. However, randomised trials evaluating the effects of flexible family visitation models (FFVMs) are scarce. This study aims to compare the effectiveness and safety of an FFVM versus a restrictive family visitation model (RFVM) on delirium prevention among ICU patients, as well as to analyse its potential effects on family members and ICU professionals. METHODS AND ANALYSIS A cluster-randomised crossover trial involving adult ICU patients, family members and ICU professionals will be conducted. Forty medical-surgical Brazilian ICUs with RFVMs (<4.5 hours/day) will be randomly assigned to either an RFVM (visits according to local policies) or an FFVM (visitation during 12 consecutive hours per day) group at a 1:1 ratio. After enrolment and follow-up of 25 patients, each ICU will be switched over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome will be the cumulative incidence of delirium among ICU patients, measured twice a day using the Confusion Assessment Method for the ICU. Secondary outcome measures will include daily hazard of delirium, ventilator-free days, any ICU-acquired infections, ICU length of stay and hospital mortality among the patients; symptoms of anxiety and depression and satisfaction among the family members; and prevalence of burnout symptoms among the ICU professionals. Tertiary outcomes will include need for antipsychotic agents and/or mechanical restraints, coma-free days, unplanned loss of invasive devices and ICU-acquired pneumonia, urinary tract infection or bloodstream infection among the patients; self-perception of involvement in patient care among the family members; and satisfaction among the ICU professionals. ETHICS AND DISSEMINATION The study protocol has been approved by the research ethics committee of all participant institutions. We aim to disseminate the findings through conferences and peer-reviewed journals. TRIAL REGISTRATION NCT02932358.
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Affiliation(s)
- Regis Goulart Rosa
- Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
| | - Maicon Falavigna
- Institute for Education and Research, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
| | | | | | - Renata Kochhann
- Research Projects Office, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
| | | | | | - Daniel Sganzerla
- Research Projects Office, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
| | | | - Cláudia Eugênio
- Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
| | - Tarissa Ribeiro
- Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
| | | | - Fernando Bozza
- Department of Critical Care, Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil
| | | | - Flávia Ribeiro Machado
- Department of Anesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | | | | | | | - Taís Hochegger
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Alexandre Amaral
- Intensive Care Unit, Hospital de Urgências de Goiânia, Goiânia, Brazil
| | | | | | | | | | - Iris de Lima Ferraz
- Intensive Care Unit, Hospital de Urgência e Emergência de Rio Branco, Rio Branco, Brazil
| | - Vandack Nobre
- Intensive Care Unit, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Péricles Almeida Delfino Duarte
- Intensive Care Unit, Hospital do Câncer de Cascavel, Cascavel, Brazil
- Intensive Care, Hospital Universitário do Oeste do Paraná, Cascavel, Brazil
| | | | | | - Nilton Brandão
- Department of Internal Medicine, School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Alberto Giannini
- Unit of Pediatric Anesthesia and Intensive Care, Ospedale dei Bambini - ASST Spedali Civili, Brescia, Italy
| | - Cassiano Teixeira
- Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
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21
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Real JM, Ferreira LRP, Esteves GH, Koyama FC, Dias MVS, Bezerra-Neto JE, Cunha-Neto E, Machado FR, Salomão R, Azevedo LCP. Exosomes from patients with septic shock convey miRNAs related to inflammation and cell cycle regulation: new signaling pathways in sepsis? Crit Care 2018. [PMID: 29540208 PMCID: PMC5852953 DOI: 10.1186/s13054-018-2003-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Exosomes isolated from plasma of patients with sepsis may induce vascular apoptosis and myocardial dysfunction by mechanisms related to inflammation and oxidative stress. Despite previous studies demonstrating that these vesicles contain genetic material related to cellular communication, their molecular cargo during sepsis is relatively unknown. In this study, we evaluated the presence of microRNAs (miRNAs) and messenger RNAs (mRNAs) related to inflammatory response and redox metabolism in exosomes of patients with septic shock. Methods Blood samples were collected from 24 patients with septic shock at ICU admission and after 7 days of treatment. Twelve healthy volunteers were used as control subjects. Exosomes were isolated by ultracentrifugation, and their miRNA and mRNA content was evaluated by qRT-PCR array. Results As compared with healthy volunteers, exosomes from patients with sepsis had significant changes in 65 exosomal miRNAs. Twenty-eight miRNAs were differentially expressed, both at enrollment and after 7 days, with similar kinetics (18 miRNAs upregulated and 10 downregulated). At enrollment, 35 differentially expressed miRNAs clustered patients with sepsis according to survival. The pathways enriched by the miRNAs of patients with sepsis compared with control subjects were related mostly to inflammatory response. The comparison of miRNAs from patients with sepsis according to hospital survival demonstrated pathways related mostly to cell cycle regulation. At enrollment, sepsis was associated with significant increases in the expression of mRNAs related to redox metabolism (myeloperoxidase, 64-fold; PRDX3, 2.6-fold; SOD2, 2.2-fold) and redox-responsive genes (FOXM1, 21-fold; SELS, 16-fold; GLRX2, 3.4-fold). The expression of myeloperoxidase mRNA remained elevated after 7 days (65-fold). Conclusions Exosomes from patients with septic shock convey miRNAs and mRNAs related to pathogenic pathways, including inflammatory response, oxidative stress, and cell cycle regulation. Exosomes may represent a novel mechanism for intercellular communication during sepsis. Electronic supplementary material The online version of this article (10.1186/s13054-018-2003-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Juliana Monte Real
- Research and Education Institute, Hospital Sirio-Libanes, Rua Professor Daher Cutait 69, São Paulo, SP, 01539-001, Brazil.,Sao Paulo State Cancer Institute, University of São Paulo, São Paulo, Brazil.,Hospital do Servidor Publico Estadual de São Paulo, São Paulo, Brazil
| | - Ludmila Rodrigues Pinto Ferreira
- Morphology Department, Instituto de Ciencias Biologicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Laboratory of Immunology, Heart Institute, University of São Paulo, School of Medicine, São Paulo, Brazil
| | | | - Fernanda Christtanini Koyama
- Research and Education Institute, Hospital Sirio-Libanes, Rua Professor Daher Cutait 69, São Paulo, SP, 01539-001, Brazil.,Ludwig Institute for Cancer Research, São Paulo, Brazil
| | | | | | - Edécio Cunha-Neto
- Laboratory of Immunology, Heart Institute, University of São Paulo, School of Medicine, São Paulo, Brazil.,Division of Clinical Immunology and Allergy, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | | | - Luciano Cesar Pontes Azevedo
- Research and Education Institute, Hospital Sirio-Libanes, Rua Professor Daher Cutait 69, São Paulo, SP, 01539-001, Brazil. .,Emergency Medicine, University of São Paulo, São Paulo, Brazil.
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22
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Cavalcanti AB, Azevedo LCP, Machado FR. Use of prevalence data to study sepsis incidence and mortality in intensive care units - Authors' reply. Lancet Infect Dis 2018; 18:252-253. [PMID: 29485091 DOI: 10.1016/s1473-3099(18)30082-3] [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] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 01/29/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Alexandre Biasi Cavalcanti
- Latin America Sepsis Institute, São Paulo, 04039-002, Brazil; Research Institute, Hospital do Coração, São Paulo, Brazil
| | - Luciano Cesar Pontes Azevedo
- Latin America Sepsis Institute, São Paulo, 04039-002, Brazil; Research and Education Institute, Hospital Sírio Libanes, São Paulo, Brazil
| | - Flavia R Machado
- Latin America Sepsis Institute, São Paulo, 04039-002, Brazil; Anesthesiology, Pain, and Intensive Care Department, Universidade Federal de São Paulo, São Paulo, Brazil.
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23
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Nascente APM, Freitas FGR, Bakker J, Bafi AT, Ladeira RT, Azevedo LCP, Lima A, Machado FR. Microcirculation improvement after short-term infusion of vasopressin in septic shock is dependent on noradrenaline. Clinics (Sao Paulo) 2017; 72:750-757. [PMID: 29319721 PMCID: PMC5738558 DOI: 10.6061/clinics/2017(12)06] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/11/2017] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To assess the impact of vasopressin on the microcirculation and to develop a predictive model to estimate the probability of microcirculatory recruitment in patients with septic shock. METHODS This prospective interventional study included patients with septic shock receiving noradrenaline for less than 48 hours. We infused vasopressin at 0.04 U/min for one hour. Hemodynamic measurements, including sidestream dark-field imaging, were obtained immediately before vasopressin infusion, 1 hour after vasopressin infusion and 1 hour after vasopressin withdrawal. We defined patients with more than a 10% increase in total vascular density and perfused vascular density as responders. ClinicalTrials.gov: NCT02053675. RESULTS Eighteen patients were included, and nine (50%) showed improved microcirculation after infusion of vasopressin. The noradrenaline dose was significantly reduced after vasopressin (p=0.001) and was higher both at baseline and during vasopressin infusion in the responders than in the non-responders. The strongest predictor for a favorable microcirculatory response was the dose of noradrenaline at baseline (OR=4.5; 95% CI: 1.2-17.0; p=0.027). For patients using a noradrenaline dose higher than 0.38 mcg/kg/min, the probability that microcirculatory perfusion would be improved with vasopressin was 53% (sensitivity 78%, specificity 77%). CONCLUSIONS In patients with septic shock for no longer than 48 h, administration of vasopressin is likely to result in an improvement in microcirculation when the baseline noradrenaline dose is higher than 0.38 mcg/kg/min.
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Affiliation(s)
- Ana Paula Metran Nascente
- Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
| | | | - Jan Bakker
- Department of Intensive Care Adults, Erasmus MC - University Hospital Rotterdam, the Netherlands
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine. College of Physicians & Surgeons of Columbia, University of New York, USA
| | - Antônio Tonete Bafi
- Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
| | - Renata Teixeira Ladeira
- Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
| | | | - Alexandre Lima
- Department of Intensive Care Adults, Erasmus MC - University Hospital Rotterdam, the Netherlands
| | - Flavia Ribeiro Machado
- Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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Biagini S, Dale CS, Real JM, Moreira ES, Carvalho CRR, Schettino GPP, Wendel S, Azevedo LCP. Short-term effects of stored homologous red blood cell transfusion on cardiorespiratory function and inflammation: an experimental study in a hypovolemia model. ACTA ACUST UNITED AC 2017; 51:e6258. [PMID: 29185590 PMCID: PMC5685056 DOI: 10.1590/1414-431x20176258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 02/26/2017] [Accepted: 08/11/2017] [Indexed: 01/08/2023]
Abstract
The pathophysiological mechanisms associated with the effects of red blood cell (RBC) transfusion on cardiopulmonary function and inflammation are unclear. We developed an experimental model of homologous 14-days stored RBC transfusion in hypovolemic swine to evaluate the short-term effects of transfusion on cardiopulmonary system and inflammation. Sixteen healthy male anesthetized swine (68±3.3 kg) were submitted to controlled hemorrhage (25% of blood volume). Two units of non-filtered RBC from each animal were stored under blood bank conditions for 14 days. After 30 min of hypovolemia, the control group (n=8) received an infusion of lactated Ringer's solution (three times the removed volume). The transfusion group (n=8) received two units of homologous 14-days stored RBC and lactated Ringer's solution in a volume that was three times the difference between blood removed and blood transfusion infused. Both groups were followed up for 6 h after resuscitation with collection of hemodynamic and respiratory data. Cytokines and RNA expression were measured in plasma and lung tissue. Stored RBC transfusion significantly increased mixed oxygen venous saturation and arterial oxygen content. Transfusion was not associated with alterations on pulmonary function. Pulmonary concentrations of cytokines were not different between groups. Gene expression for lung cytokines demonstrated a 2-fold increase in mRNA level for inducible nitric oxide synthase and a 0.5-fold decrease in mRNA content for IL-21 in the transfused group. Thus, stored homologous RBC transfusion in a hypovolemia model improved cardiovascular parameters but did not induce significant effects on microcirculation, pulmonary inflammation and respiratory function up to 6 h after transfusion.
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Affiliation(s)
- S Biagini
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | - C S Dale
- Laboratorio de Neuromodulação e Dor Experimental, Departamento de Anatomia, Universidade de São Paulo, São Paulo, SP, Brasil
| | - J M Real
- Associação TUCCA para Crianças e Adolescentes com Câncer, Departamento de Oncologia Pediátrica, Hospital Santa Marcelina, São Paulo, Brasil.,Centro de Investigação Translacional em Oncologia, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, SP, Brasil.,Hospital do Servidor Público Estadual de São Paulo (IAMSPE), São Paulo, SP, Brasil
| | - E S Moreira
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil.,Evidências - Kantar Health, São Paulo, SP, Brasil
| | - C R R Carvalho
- Departamento de Cardiopneumologia, Instituto do Coração, Universidade de São Paulo, São Paulo, SP, Brasil
| | - G P P Schettino
- Departamento de Cardiopneumologia, Instituto do Coração, Universidade de São Paulo, São Paulo, SP, Brasil.,Hospital Municipal da Vila Santa Catarina, Sociedade Beneficente Israelita Albert Einstein, São Paulo, SP, Brasil
| | - S Wendel
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil.,Banco de Sangue, Hospital Sirio-Libanes, São Paulo, SP, Brasil
| | - L C P Azevedo
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil.,Disciplina de Emergências Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
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Machado FR, Cavalcanti AB, Bozza FA, Ferreira EM, Angotti Carrara FS, Sousa JL, Caixeta N, Salomao R, Angus DC, Pontes Azevedo LC. The epidemiology of sepsis in Brazilian intensive care units (the Sepsis PREvalence Assessment Database, SPREAD): an observational study. Lancet Infect Dis 2017; 17:1180-1189. [PMID: 28826588 DOI: 10.1016/s1473-3099(17)30322-5] [Citation(s) in RCA: 170] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/24/2017] [Accepted: 04/19/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND The sepsis burden on acute care services in middle-income countries is a cause for concern. We estimated incidence, prevalence, and mortality of sepsis in adult Brazilian intensive care units (ICUs) and association of ICU organisational factors with outcome. METHODS We did a 1-day point prevalence study with follow-up of patients in ICU with sepsis in a nationally representative pseudo-random sample. We produced a sampling frame initially stratified by geographical region. Each stratum was then stratified by hospitals' main source of income (serving general public vs privately insured individuals) and ICU size (ten or fewer beds vs more than ten beds), finally generating 40 strata. In each stratum we selected a random sample of ICUs so as to enrol the total required beds in 1690 Brazilian adult ICUs. We followed up patients until hospital discharge censored at 60 days, estimated incidence from prevalence and length of stay, and generated national estimates. We assessed mortality prognostic factors using random-effects logistic regression models. FINDINGS On Feb 27, 2014, 227 (72%) of 317 ICUs that were randomly selected provided data on 2632 patients, of whom 794 had sepsis (30·2 septic patients per 100 ICU beds, 95% CI 28·4-31·9). The ICU sepsis incidence was 36·3 per 1000 patient-days (95% CI 29·8-44·0) and mortality was observed in 439 (55·7%) of 788 patients (95% CI 52·2-59·2). Low availability of resources (odds ratio [OR] 1·67, 95% CI 1·02-2·75, p=0·045) and adequacy of treatment (OR 0·56, 0·37-0·84, p=0·006) were independently associated with mortality. The projected incidence rate is 290 per 100 000 population (95% CI 237·9-351·2) of adult cases of ICU-treated sepsis per year, which yields about 420 000 cases annually, of whom 230 000 die in hospital. INTERPRETATION The incidence, prevalence, and mortality of ICU-treated sepsis is high in Brazil. Outcome varies considerably, and is associated with access to adequate resources and treatment. Our results show the burden of sepsis in resource-limited settings, highlighting the need to establish programmes aiming for sepsis prevention, early diagnosis, and adequate treatment. FUNDING Fundação de Apoio a Pesquisa do Estado de São Paulo (FAPESP).
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Affiliation(s)
- Flavia R Machado
- Anesthesiology, Pain, and Intensive Care Department, Universidade Federal de São Paulo, São Paulo, Brazil; Latin America Sepsis Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil.
| | - Alexandre Biasi Cavalcanti
- Latin America Sepsis Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; Research Institute, Hospital do Coração (HCor), São Paulo, Brazil
| | - Fernando Augusto Bozza
- Latin America Sepsis Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil
| | | | | | | | | | - Reinaldo Salomao
- Infectious Disease Department, Universidade Federal de São Paulo, São Paulo, Brazil; Latin America Sepsis Institute, São Paulo, Brazil
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Luciano Cesar Pontes Azevedo
- Latin America Sepsis Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; Hospital Sírio Libanes, São Paulo, Brazil
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26
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Machado FR, Ferreira EM, Schippers P, de Paula IC, Saes LSV, de Oliveira FI, Tuma P, Nogueira Filho W, Piza F, Guare S, Mangini C, Guth GZ, Azevedo LCP, Freitas FGR, do Amaral JLG, Mansur NS, Salomão R. Implementation of sepsis bundles in public hospitals in Brazil: a prospective study with heterogeneous results. Crit Care 2017; 21:268. [PMID: 29089025 PMCID: PMC5664817 DOI: 10.1186/s13054-017-1858-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 10/05/2017] [Indexed: 01/21/2023]
Abstract
Background Public hospitals in emerging countries pose a challenge to quality improvement initiatives in sepsis. Our objective was to evaluate the results of a quality improvement initiative in sepsis in a network of public institutions and to assess potential differences between institutions that did or did not achieve a reduction in mortality. Methods We conducted a prospective study of patients with sepsis or septic shock. We collected baseline data on compliance with the Surviving Sepsis Campaign 6-h bundles and mortality. Afterward, we initiated a multifaceted quality improvement initiative for patients with sepsis or septic shock in all hospital sectors. The primary outcome was hospital mortality over time. The secondary outcomes were the time to sepsis diagnosis and compliance with the entire 6-h bundles throughout the intervention. We defined successful institutions as those where the mortality rates decreased significantly over time, using a logistic regression model. We analyzed differences over time in the secondary outcomes by comparing the successful institutions with the nonsuccessful ones. We assessed the predictors of in-hospital mortality using logistic regression models. All tests were two-sided, and a p value less than 0.05 indicated statistical significance. Results We included 3435 patients from the emergency departments (50.7%), wards (34.1%), and intensive care units (15.2%) of 9 institutions. Throughout the intervention, there was an overall reduction in the risk of death, in the proportion of septic shock, and the time to sepsis diagnosis, as well as an improvement in compliance with the 6-h bundle. The time to sepsis diagnosis, but not the compliance with bundles, was associated with a reduction in the risk of death. However, there was a significant reduction in mortality in only two institutions. The reduction in the time to sepsis diagnosis was greater in the successful institutions. By contrast, the nonsuccessful sites had a greater increase in compliance with the 6-h bundle. Conclusions Quality improvement initiatives reduced sepsis mortality in public Brazilian institutions, although not in all of them. Early recognition seems to be a more relevant factor than compliance with the 6-h bundle. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1858-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Flavia Ribeiro Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil. .,Latin American Sepsis Institute, São Paulo, SP, Brazil. .,Latin American Sepsis Institute, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 6° andar, Vila Clementino, 04024-002, São Paulo, SP, Brazil.
| | | | | | | | | | | | - Paula Tuma
- Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | | | - Felipe Piza
- Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | - Sandra Guare
- Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | - Cláudia Mangini
- Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | | | | | - Flavio Geraldo Resende Freitas
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil.,Latin American Sepsis Institute, São Paulo, SP, Brazil
| | - Jose Luiz Gomes do Amaral
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil.,Latin American Sepsis Institute, São Paulo, SP, Brazil.,Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | | | - Reinaldo Salomão
- Latin American Sepsis Institute, São Paulo, SP, Brazil.,Infectious Disease Department, Federal University of São Paulo, São Paulo, SP, Brazil
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Cordioli RL, Costa ELV, Azevedo LCP, Gomes S, Amato MBP, Park M. Physiologic effects of alveolar recruitment and inspiratory pauses during moderately-high-frequency ventilation delivered by a conventional ventilator in a severe lung injury model. PLoS One 2017; 12:e0185769. [PMID: 28961282 PMCID: PMC5621701 DOI: 10.1371/journal.pone.0185769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 04/05/2017] [Accepted: 09/19/2017] [Indexed: 11/18/2022] Open
Abstract
Background and aims To investigate whether performing alveolar recruitment or adding inspiratory pauses could promote physiologic benefits (VT) during moderately-high-frequency positive pressure ventilation (MHFPPV) delivered by a conventional ventilator in a porcine model of severe acute respiratory distress syndrome (ARDS). Methods Prospective experimental laboratory study with eight pigs. Induction of acute lung injury with sequential pulmonary lavages and injurious ventilation was initially performed. Then, animals were ventilated on a conventional mechanical ventilator with a respiratory rate (RR) = 60 breaths/minute and PEEP titrated according to ARDS Network table. The first two steps consisted of a randomized order of inspiratory pauses of 10 and 30% of inspiratory time. In final step, we removed the inspiratory pause and titrated PEEP, after lung recruitment, with the aid of electrical impedance tomography. At each step, PaCO2 was allowed to stabilize between 57–63 mmHg for 30 minutes. Results The step with RR of 60 after lung recruitment had the highest PEEP when compared with all other steps (17 [16,19] vs 14 [10, 17]cmH2O), but had lower driving pressures (13 [13,11] vs 16 [14, 17]cmH2O), higher P/F ratios (212 [191,243] vs 141 [105, 184] mmHg), lower shunt (23 [20, 23] vs 32 [27, 49]%), lower dead space ventilation (10 [0, 15] vs 30 [20, 37]%), and a more homogeneous alveolar ventilation distribution. There were no detrimental effects in terms of lung mechanics, hemodynamics, or gas exchange. Neither the addition of inspiratory pauses or the alveolar recruitment maneuver followed by decremental PEEP titration resulted in further reductions in VT. Conclusions During MHFPPV set with RR of 60 bpm delivered by a conventional ventilator in severe ARDS swine model, neither the inspiratory pauses or PEEP titration after recruitment maneuver allowed reduction of VT significantly, however the last strategy decreased driving pressures and improved both shunt and dead space.
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Affiliation(s)
- Ricardo Luiz Cordioli
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
- Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), University of São Paulo, São Paulo, Brazil
- Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- * E-mail:
| | - Eduardo Leite Vieira Costa
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
- Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), University of São Paulo, São Paulo, Brazil
| | - Luciano Cesar Pontes Azevedo
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
- Emergency Medicine Discipline, Universidade de São Paulo, São Paulo, Brazil
| | - Susimeire Gomes
- Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), University of São Paulo, São Paulo, Brazil
| | - Marcelo Britto Passos Amato
- Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), University of São Paulo, São Paulo, Brazil
| | - Marcelo Park
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
- Emergency Medicine Discipline, Universidade de São Paulo, São Paulo, Brazil
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Romano TG, Azevedo LCP, Mendes PV, Costa ELV, Park M. Effect of continuous dialysis on blood ph in acidemic hypercapnic animals with severe acute kidney injury: a randomized experimental study comparing high vs. low bicarbonate affluent. Intensive Care Med Exp 2017; 5:28. [PMID: 28560615 PMCID: PMC5449359 DOI: 10.1186/s40635-017-0141-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/17/2017] [Indexed: 11/10/2022] Open
Abstract
Background Controlling blood pH during acute ventilatory failure and hypercapnia in individuals suffering from severe acute kidney injury (AKI) and undergoing continuous renal replacement therapy (CRRT) is of paramount importance in critical care settings. In this situation, the optimal concentration of sodium bicarbonate in the dialysate is still an unsolved question in critical care since high concentrations may worsen carbon dioxide levels and low concentrations may not be as effective in controlling pH. Methods We performed a randomized, non-blinded, experimental study. AKI was induced in 12 female pigs via renal hilum ligation and hypoventilation by reducing the tidal volume during mechanical ventilation with the goal of achieving a pH between 7.10–7.15. After achieving the target pH, animals were randomized to undergo isovolemic hemodialysis with one of two bicarbonate concentrations in the dialysate (40 mEq/L [group 40] vs. 20 mEq/L [group 20]). Results Hemodynamic, respiratory, and laboratory data were collected. The median pH value at CRRT initiation was 7.14 [7.12, 7.15] in group 20 and 7.13 [7.09, 7.14] in group 40 (P = ns). The median baseline PaCO2 was 74 [72, 81] mmHg in group 20 vs. 79 [63, 85] mmHg in group 40 (P = ns). After 3 h of CRRT, the pH value was 7.05 [6.95, 7.09] in group 20 and 7.12 [7.1, 7.14] in group 40 (P < 0.05), with corresponding values of PaCO2 of 85 [79, 88] mmHg vs. 81 [63, 100] mmHg (P = ns). The difference in pH after 3 h was due to a metabolic component [standard base excess −10.4 [−12.5, −9.5] mEq/L in group 20 vs. –7.6 [−9.2, −5.1] mEq/L in group 40) (P < 0.05)]. Despite the increased infusion of bicarbonate in group 40, the blood CO2 content did not change during the experiment. The 12-h survival rate was higher in group 40 (67% vs. 0, P = 0.032). Conclusions A higher bicarbonate concentration in the dialysate of animals undergoing hypercapnic respiratory failure was associated with improved blood pH control without increasing the PaCO2 levels. Electronic supplementary material The online version of this article (doi:10.1186/s40635-017-0141-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thiago Gomes Romano
- Nephrology Department, ABC Medical School, Av. Príncipe de Gales, 821, Príncipe de Gales, Santo André, São Paulo, 09060-650, Brazil. .,Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil.
| | - Luciano Cesar Pontes Azevedo
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil.,Emergency Medicine Discipline, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - Pedro Vitale Mendes
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil.,Emergency Medicine Discipline, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - Eduardo Leite Vieira Costa
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil.,Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), University of São Paulo, São Paulo, Brazil
| | - Marcelo Park
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil.,Emergency Medicine Discipline, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
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29
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Esquerdo KF, Sharma NK, Brunialti MKC, Baggio-Zappia GL, Assunção M, Azevedo LCP, Bafi AT, Salomao R. Inflammasome gene profile is modulated in septic patients, with a greater magnitude in non-survivors. Clin Exp Immunol 2017; 189:232-240. [PMID: 28369745 DOI: 10.1111/cei.12971] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [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: 03/16/2017] [Indexed: 01/08/2023] Open
Abstract
Inflammasome signalling induces the processing and secretion of interleukin (IL)-1β and IL-18 which, coupled with pyroptosis, activate further the inflammatory response. In the present study we evaluated the expression of genes involved in inflammasome signalling pathways in septic patients, their interaction networks and the predicted functions modulated in survivors and non-survivors. Twenty-seven patients with sepsis secondary to community-acquired pneumonia admitted to intensive care units from three general hospitals in São Paulo were included into the study. We performed a polymerase chain reaction (PCR) array encompassing 35 genes related to the nucleotide-binding oligomerization domain and leucine-rich repeat-containing (NLR)-inflammasome in peripheral blood mononuclear cells obtained at admission and after 7 days of follow-up. Eleven healthy volunteers were used as the reference group. Increased NLRC4 and NLRP3 and decreased nucleotide-binding oligomerization domain (NOD1), and NLRP1 expression was observed in septic patients compared to healthy individuals; the IL-1β and IL-18 expression levels were also high in the patients. The gene expression changes followed the same patterns in surviving and non-surviving patients, with higher magnitudes observed in non-survivors. Functional analyses revealed, however, that activation and inhibition intensity for representing functions were different in survivors and non-survivors, as for production of reactive oxygen species, synthesis of nitric oxide and for the control of bacterial infections. Our results showed that the genes involved in the activation of the NLR-inflammasome cascades were altered substantially in septic patients, with a higher number of altered genes and a higher intensity in the disturbance of gene expression found among patients dying of sepsis.
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Affiliation(s)
- K F Esquerdo
- Escola Paulista de Medicina, Hospital São Paulo, Universidade Federal de Sao Paulo, São Paulo, Brazil
| | - N K Sharma
- Escola Paulista de Medicina, Hospital São Paulo, Universidade Federal de Sao Paulo, São Paulo, Brazil
| | - M K C Brunialti
- Escola Paulista de Medicina, Hospital São Paulo, Universidade Federal de Sao Paulo, São Paulo, Brazil
| | - G L Baggio-Zappia
- Escola Paulista de Medicina, Hospital São Paulo, Universidade Federal de Sao Paulo, São Paulo, Brazil
| | - M Assunção
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - A T Bafi
- Escola Paulista de Medicina, Hospital São Paulo, Universidade Federal de Sao Paulo, São Paulo, Brazil
| | - R Salomao
- Escola Paulista de Medicina, Hospital São Paulo, Universidade Federal de Sao Paulo, São Paulo, Brazil
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30
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Mendes PV, de Albuquerque Gallo C, Besen BAMP, Hirota AS, de Oliveira Nardi R, Dos Santos EV, Li HY, Joelsons D, Costa ELV, Foronda FK, Azevedo LCP, Park M. Transportation of patients on extracorporeal membrane oxygenation: a tertiary medical center experience and systematic review of the literature. Ann Intensive Care 2017; 7:14. [PMID: 28176223 PMCID: PMC5296266 DOI: 10.1186/s13613-016-0232-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [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: 08/18/2016] [Accepted: 12/25/2016] [Indexed: 12/29/2022] Open
Abstract
Background Utilization of extracorporeal membrane oxygenation (ECMO) has increased worldwide, but its use remains restricted to severely ill patients, and few referral centers are properly structured to offer this support. Inter-hospital transfer of patients on ECMO support can be life-threatening. In this study, we report a single-center experience and a systematic review of the available published data on complications and mortality associated with ECMO transportation. Methods We reported single-center data regarding complications and mortality associated with the transportation of patients on ECMO support. Additionally, we searched multiple databases for case series, observational studies, and randomized controlled trials regarding mortality of patients transferred on ECMO support. Results were analyzed independently for pediatric (under 12 years old) and adult populations. We pooled mortality rates using a random-effects model. Complications and transportation data were also described. Results A total of 38 manuscripts, including our series, were included in the final analysis, totaling 1481 patients transported on ECMO support. A total of 951 patients survived to hospital discharge. The pooled survival rates for adult and pediatric patients were 62% (95% CI 57–68) and 68% (95% CI 60–75), respectively. Two deaths occurred during patient transportation. No other complication resulting in adverse outcome was reported. Conclusion Using the available pooled data, we found that patient transfer to a referral institution while on ECMO support seems to be safe and adds no significant risk of mortality to ECMO patients. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0232-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pedro Vitale Mendes
- Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Rua Dr. Enéas Carvalho de Aguiar, 255, Sala 5023, São Paulo, SP, 05403000, Brazil. .,Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil.
| | | | | | | | | | | | - Ho Yeh Li
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Daniel Joelsons
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Eduardo Leite Vieira Costa
- Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Rua Dr. Enéas Carvalho de Aguiar, 255, Sala 5023, São Paulo, SP, 05403000, Brazil.,Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | | | - Luciano Cesar Pontes Azevedo
- Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Rua Dr. Enéas Carvalho de Aguiar, 255, Sala 5023, São Paulo, SP, 05403000, Brazil.,Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Marcelo Park
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
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31
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Alves FS, Freitas FGR, Bafi AT, Azevedo LCP, Machado FR. Serum concentrations of vitamin D and organ dysfunction in patients with severe sepsis and septic shock. Rev Bras Ter Intensiva 2016; 27:376-82. [PMID: 26761476 PMCID: PMC4738824 DOI: 10.5935/0103-507x.20150063] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 11/03/2015] [Accepted: 11/23/2015] [Indexed: 12/31/2022] Open
Abstract
Objectives To evaluate the serum concentrations of vitamin D and their variations
in patients with severe sepsis or septic shock and in control subjects
upon admission and after 7 days of hospitalization in the intensive
care unit and to correlate these concentrations with the severity of
organ dysfunction. Methods This case-control, prospective, observational study involved patients
aged > 18 years with severe sepsis or septic shock paired with a
control group. Serum vitamin D concentrations were measured at
inclusion (D0) and on the seventh day after inclusion (D7). Severe
deficiency was defined as vitamin D levels < 10ng/ml, deficiency as
levels between 10 and 20ng/ml, insufficiency as levels between 20 and
30ng/ml, and sufficiency as levels ≥ 30ng/mL. We considered a
change to a higher ranking, together with a 50% increase in the
absolute concentration, to represent an improvement. Results We included 51 patients (26 with septic shock and 25 controls). The
prevalence of vitamin D concentration ≤ 30ng/ml was 98%. There
was no correlation between the serum concentration of vitamin D at D0
and the SOFA score at D0 or D7 either in the general population or in
the group with septic shock. Patients with improvement in vitamin D
deficiency had an improved SOFA score at D7 (p = 0.013). Conclusion In the population studied, patients with septic shock showed improvement
in the serum concentrations of vitamin D on the seventh day compared
with the controls. We also found a correlation between higher vitamin
D concentrations and a greater decrease in the severity of organ
dysfunction.
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Affiliation(s)
- Fernanda Sampaio Alves
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | - Antonio Tonete Bafi
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | - Flavia Ribeiro Machado
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Besen BAMP, Romano TG, Nassar AP, Taniguchi LU, Azevedo LCP, Mendes PV, Zampieri FG, Park M. Sepsis-3 definitions predict ICU mortality in a low-middle-income country. Ann Intensive Care 2016; 6:107. [PMID: 27807819 PMCID: PMC5093106 DOI: 10.1186/s13613-016-0204-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 10/17/2016] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis-3 definitions were published recently and validated only in high-income countries. The aim of this study was to assess the new criteria’s accuracy in stratifying mortality as compared to its predecessor (Sepsis-2) in a Brazilian public intensive care unit (ICU) and to investigate whether the addition of lactate values would improve stratification. Methods Retrospective cohort study conducted between 2010 and 2015 in a public university’s 19-bed ICU. Data from patients admitted to the ICU with sepsis were retrieved from a prospectively collected database. ICU mortality was compared across categories of both Sepsis-2 definitions (sepsis, severe sepsis and septic shock) and Sepsis-3 definitions (infection, sepsis and septic shock). Area under the receiving operator characteristic curves were constructed, and the net reclassification index and integrated discrimination index for the addition of lactate as a categorical variable to each stratum of definition were evaluated. Results The medical records of 957 patients were retrieved from a prospectively collected database. Mean age was 52 ± 19 years, median SAPS 3 was 65 [50,79], respiratory tract infection was the most common cause (42%, 402 patients), and 311 (32%) patients died in ICU. The ICU mortality rate was progressively higher across categories of sepsis as defined by the Sepsis-3 consensus: infection with no organ dysfunction—7/103 (7%); sepsis—106/419 (25%); and septic shock—198/435 (46%) (P < 0.001). For Sepsis-2 definitions, ICU mortality was different only across the categories of severe sepsis [43/252-(17%)] and septic shock [250/572-(44%)] (P < 0.001); sepsis had a mortality of 18/135-(13%) (P = 0.430 vs. severe sepsis). When combined with lactate, the definitions’ accuracy in stratifying ICU mortality only improved with lactate levels above 4 mmol/L. This improvement occurred in the severe sepsis and septic shock groups (Sepsis-2) and the no-dysfunction and septic shock groups (Sepsis-3). Multivariate analysis demonstrated similar findings. Conclusions In a Brazilian ICU, the new Sepsis-3 definitions were accurate in stratifying mortality and were superior to the previous definitions. We also observed that the new definitions’ accuracy improved progressively with severity. Serum lactate improved accuracy for values higher than 4 mmol/L in the no-dysfunction and septic shock groups. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0204-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bruno Adler Maccagnan Pinheiro Besen
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil. .,Hospital da Luz, Amil, São Paulo, Brazil.
| | - Thiago Gomes Romano
- Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil.,Nephrology Department, ABC Medical School, Santo Andre, Brazil
| | - Antonio Paulo Nassar
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil.,A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Leandro Utino Taniguchi
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil.,Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Luciano Cesar Pontes Azevedo
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil.,Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Pedro Vitale Mendes
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil.,Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Fernando Godinho Zampieri
- Research Institute, HCor-Hospital do Coração, São Paulo, Brazil.,Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Marcelo Park
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil
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Park M, Mendes PV, Costa ELV, Barbosa EVS, Hirota AS, Azevedo LCP. Factors associated with blood oxygen partial pressure and carbon dioxide partial pressure regulation during respiratory extracorporeal membrane oxygenation support: data from a swine model. Rev Bras Ter Intensiva 2016; 28:11-8. [PMID: 27096671 PMCID: PMC4828086 DOI: 10.5935/0103-507x.20160006] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 01/06/2016] [Indexed: 12/17/2022] Open
Abstract
Objective The aim of this study was to explore the factors associated with blood oxygen
partial pressure and carbon dioxide partial pressure. Methods The factors associated with oxygen - and carbon dioxide regulation were
investigated in an apneic pig model under veno-venous extracorporeal
membrane oxygenation support. A predefined sequence of blood and sweep flows
was tested. Results Oxygenation was mainly associated with extracorporeal membrane oxygenation
blood flow (beta coefficient = 0.036mmHg/mL/min), cardiac output (beta
coefficient = -11.970mmHg/L/min) and pulmonary shunting (beta coefficient =
-0.232mmHg/%). Furthermore, the initial oxygen partial pressure and carbon
dioxide partial pressure measurements were also associated with oxygenation,
with beta coefficients of 0.160 and 0.442mmHg/mmHg, respectively. Carbon
dioxide partial pressure was associated with cardiac output (beta
coefficient = 3.578mmHg/L/min), sweep gas flow (beta coefficient =
-2.635mmHg/L/min), temperature (beta coefficient = 4.514mmHg/ºC), initial pH
(beta coefficient = -66.065mmHg/0.01 unit) and hemoglobin (beta coefficient
= 6.635mmHg/g/dL). Conclusion In conclusion, elevations in blood and sweep gas flows in an apneic
veno-venous extracorporeal membrane oxygenation model resulted in an
increase in oxygen partial pressure and a reduction in carbon dioxide
partial pressure 2, respectively. Furthermore, without the possibility of
causal inference, oxygen partial pressure was negatively associated with
pulmonary shunting and cardiac output, and carbon dioxide partial pressure
was positively associated with cardiac output, core temperature and initial
hemoglobin.
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Affiliation(s)
- Marcelo Park
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Pedro Vitale Mendes
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | | | | | - Adriana Sayuri Hirota
- Unidade de Terapia Intensiva, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Park M, Mendes PV, Zampieri FG, Azevedo LCP, Costa ELV, Antoniali F, Ribeiro GCDA, Caneo LF, da Cruz Neto LM, Carvalho CRR, Trindade EM. The economic effect of extracorporeal membrane oxygenation to support adults with severe respiratory failure in Brazil: a hypothetical analysis. Rev Bras Ter Intensiva 2016; 26:253-62. [PMID: 25295819 PMCID: PMC4188461 DOI: 10.5935/0103-507x.20140036] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 12/12/2013] [Accepted: 05/05/2014] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To analyze the cost-utility of using extracorporeal oxygenation for patients with severe acute respiratory distress syndrome in Brazil. METHODS A decision tree was constructed using databases from previously published studies. Costs were taken from the average price paid by the Brazilian Unified Health System (Sistema Único de Saúde; SUS) over three months in 2011. Using the data of 10,000,000 simulated patients with predetermined outcomes and costs, an analysis was performed of the ratio between cost increase and years of life gained, adjusted for quality (cost-utility), with survival rates of 40 and 60% for patients using extracorporeal membrane oxygenation. RESULTS The decision tree resulted in 16 outcomes with different life support techniques. With survival rates of 40 and 60%, respectively, the increased costs were R$=-301.00/-14.00, with a cost of R$=-30,913.00/-1,752.00 paid per six-month quality-adjusted life-year gained and R$=-2,386.00/-90.00 per quality-adjusted life-year gained until the end of life, when all patients with severe ARDS were analyzed. Analyzing only patients with severe hypoxemia (i.e., a ratio of partial oxygen pressure in the blood to the fraction of inspired oxygen <100 mmHg), the increased cost was R$=-5,714.00/272.00, with a cost per six-month quality-adjusted life-year gained of R$=-9,521.00/293.00 and a cost of R$=-280.00/7.00 per quality-adjusted life-year gained. CONCLUSION The cost-utility ratio associated with the use of extracorporeal membrane oxygenation in Brazil is potentially acceptable according to this hypothetical study.
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Affiliation(s)
- Marcelo Park
- Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Pedro Vitale Mendes
- Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | | | | | | | | | | | - Luiz Fernando Caneo
- Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
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35
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Mendes PV, Park M, Maciel AT, E Silva DP, Friedrich N, Barbosa EVS, Hirota AS, Schettino GPP, Azevedo LCP, Costa ELV. Kinetics of arterial carbon dioxide during veno-venous extracorporeal membrane oxygenation support in an apnoeic porcine model. Intensive Care Med Exp 2016; 4:1. [PMID: 26738486 PMCID: PMC4703593 DOI: 10.1186/s40635-015-0074-x] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 12/20/2015] [Indexed: 01/19/2023] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is a technique widely used worldwide to improve gas exchange. Changes in ECMO settings affect both oxygen and carbon dioxide. The impact on oxygenation can be followed closely by continuous pulse oximeter. Conversely, carbon dioxide equilibrates much slower and is not usually monitored directly. Methods We investigated the time to stabilization of arterial carbon dioxide partial pressure (PaCO2) following step changes in ECMO settings in 5 apnoeic porcine models under veno-venous ECMO support with polymethylpentene membranes. We collected sequential arterial blood gases at a pre-specified interval of 50 min using a sequence of standardized blood and sweep gas flow combinations. Results Following the changes in ECMO parameters, the kinetics of carbon dioxide was dependent on sweep gas and ECMO blood flow. With a blood flow of 1500 mL/min, PaCO2 takes longer than 50 min to equilibrate following the changes in sweep gas flow. Furthermore, the sweep gas flow from 3.0 to 10.0 L/min did not significantly affect PaCO2. However, with a blood flow of 3500 mL/min, 50 min was enough for PaCO2 to reach the equilibrium and every increment of sweep gas flow (up to 10.0 L/min) resulted in additional reductions of PaCO2. Conclusions Fifty minutes was enough to reach the equilibrium of PaCO2 after ECMO initiation or after changes in blood and sweep gas flow with an ECMO blood flow of 3500 ml/min. Longer periods may be necessary with lower ECMO blood flows.
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Affiliation(s)
- Pedro Vitale Mendes
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil. .,Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Sixth floor-room 6040, Rua Dr. Eneas Carvalho de Aguiar, 255, São Paulo, 05623-010, Brazil.
| | - Marcelo Park
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil. .,Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Sixth floor-room 6040, Rua Dr. Eneas Carvalho de Aguiar, 255, São Paulo, 05623-010, Brazil.
| | - Alexandre Toledo Maciel
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil. .,Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Sixth floor-room 6040, Rua Dr. Eneas Carvalho de Aguiar, 255, São Paulo, 05623-010, Brazil.
| | - Débora Prudêncio E Silva
- Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Sixth floor-room 6040, Rua Dr. Eneas Carvalho de Aguiar, 255, São Paulo, 05623-010, Brazil.
| | - Natalia Friedrich
- Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Sixth floor-room 6040, Rua Dr. Eneas Carvalho de Aguiar, 255, São Paulo, 05623-010, Brazil.
| | - Edzangela Vasconcelos Santos Barbosa
- Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Sixth floor-room 6040, Rua Dr. Eneas Carvalho de Aguiar, 255, São Paulo, 05623-010, Brazil.
| | - Adriana Sayuri Hirota
- Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Sixth floor-room 6040, Rua Dr. Eneas Carvalho de Aguiar, 255, São Paulo, 05623-010, Brazil.
| | | | - Luciano Cesar Pontes Azevedo
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil. .,Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Sixth floor-room 6040, Rua Dr. Eneas Carvalho de Aguiar, 255, São Paulo, 05623-010, Brazil.
| | - Eduardo Leite Vieira Costa
- Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil. .,Intensive Care Unit, Hospital das Clinicas, University of São Paulo School of Medicine, Sixth floor-room 6040, Rua Dr. Eneas Carvalho de Aguiar, 255, São Paulo, 05623-010, Brazil.
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Torres VBL, Vassalo JRL, Spector N, Bozza FA, Azevedo LCP, Salluh JIF, Soares M. Outcomes in critically ill patients with cancer-related complications. Intensive Care Med Exp 2015. [PMCID: PMC4798169 DOI: 10.1186/2197-425x-3-s1-a251] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Park M, Mendes PV, Hirota AS, dos Santos EV, Costa ELV, Azevedo LCP. Blood flow/pump rotation ratio as an artificial lung performance monitoring tool during extracorporeal respiratory support using centrifugal pumps. Rev Bras Ter Intensiva 2015; 27:178-84. [PMID: 26340159 PMCID: PMC4489787 DOI: 10.5935/0103-507x.20150030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 05/10/2015] [Indexed: 01/19/2023] Open
Abstract
Objective To analyze the correlations of the blood flow/pump rotation ratio and the
transmembrane pressure, CO2 and O2 transfer during the
extracorporeal respiratory support. Methods Five animals were instrumented and submitted to extracorporeal membrane
oxygenation in a five-step protocol, including abdominal sepsis and lung
injury. Results This study showed that blood flow/pump rotations ratio variations are dependent on
extracorporeal membrane oxygenation blood flow in a positive logarithmic fashion.
Blood flow/pump rotation ratio variations are negatively associated with
transmembrane pressure (R2 = 0.5 for blood flow = 1500mL/minute and
R2 = 0.4 for blood flow = 3500mL/minute, both with p < 0.001) and
positively associated with CO2 transfer variations (R2 = 0.2
for sweep gas flow ≤ 6L/minute, p < 0.001, and R2 = 0.1 for
sweep gas flow > 6L/minute, p = 0.006), and the blood flow/pump rotation ratio
is not associated with O2 transfer variations (R2 = 0.01 for
blood flow = 1500mL/minute, p = 0.19, and R2 = - 0.01 for blood flow =
3500 mL/minute, p = 0.46). Conclusion Blood flow/pump rotation ratio variation is negatively associated with
transmembrane pressure and positively associated with CO2 transfer in
this animal model. According to the clinical situation, a decrease in the blood
flow/pump rotation ratio can indicate artificial lung dysfunction without the
occurrence of hypoxemia.
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Affiliation(s)
- Marcelo Park
- Departamento de Emergências Clínicas, Unidade de Terapia Intensiva, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - Pedro Vitale Mendes
- Departamento de Emergências Clínicas, Unidade de Terapia Intensiva, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - Adriana Sayuri Hirota
- Departamento de Emergências Clínicas, Unidade de Terapia Intensiva, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | | | | | - Luciano Cesar Pontes Azevedo
- Departamento de Emergências Clínicas, Unidade de Terapia Intensiva, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
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Mazza BF, Freitas FGR, Barros MMO, Azevedo LCP, Machado FR. Blood transfusions in septic shock: is 7.0 g/dL really the appropriate threshold? Rev Bras Ter Intensiva 2015; 27:36-43. [PMID: 25909311 PMCID: PMC4396895 DOI: 10.5935/0103-507x.20150007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [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: 11/11/2014] [Accepted: 02/02/2015] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To evaluate the immediate effects of red blood cell transfusion on central venous oxygen saturation and lactate levels in septic shock patients with different transfusion triggers. METHODS We included patients with a diagnosis of septic shock within the last 48 hours and hemoglobin levels below 9.0 g/dL Patients were randomized for immediate transfusion with hemoglobin concentrations maintained above 9.0 g/dL (Group Hb9) or to withhold transfusion unless hemoglobin felt bellow 7.0 g/dL (Group Hb7). Hemoglobin, lactate, central venous oxygen saturation levels were determined before and one hour after each transfusion. RESULTS We included 46 patients and 74 transfusions. Patients in Group Hb7 had a significant reduction in median lactate from 2.44 (2.00 - 3.22) mMol/L to 2.21 (1.80 - 2.79) mMol/L, p = 0.005, which was not observed in Group Hb9 [1.90 (1.80 - 2.65) mMol/L to 2.00 (1.70 - 2.41) mMol/L, p = 0.23]. Central venous oxygen saturation levels increased in Group Hb7 [68.0 (64.0 - 72.0)% to 72.0 (69.0 - 75.0)%, p < 0.0001] but not in Group Hb9 [72.0 (69.0 - 74.0)% to 72.0 (71.0 - 73.0)%, p = 0.98]. Patients with elevated lactate or central venous oxygen saturation < 70% at baseline had a significant increase in these variables, regardless of baseline hemoglobin levels. Patients with normal values did not show a decrease in either group. CONCLUSION Red blood cell transfusion increased central venous oxygen saturation and decreased lactate levels in patients with hypoperfusion regardless of their baseline hemoglobin levels. Transfusion did not appear to impair these variables in patients without hypoperfusion. ClinicalTrials.gov NCT01611753.
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Affiliation(s)
- Bruno Franco Mazza
- Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | | | | | - Luciano Cesar Pontes Azevedo
- Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Flavia Ribeiro Machado
- Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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Biagini S, Costa PA, Wendel S, Schettino G, Azevedo LCP. In vitro and in vivo validation of stored swine erythrocyte viability to establish an experimental model of homologous red blood cell transfusion: a pilot study. Rev Bras Ter Intensiva 2014; 26:287-91. [PMID: 25295823 PMCID: PMC4188465 DOI: 10.5935/0103-507x.20140040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Accepted: 06/04/2014] [Indexed: 01/20/2023] Open
Abstract
Objective To develop experimental models of erythrocyte transfusion, the first step is to
ensure the viability of the red blood cells transfused. In this pilot study, we
assessed the viability of transfused red blood cells with validation in vitro and
in vivo of homologous swine erythrocytes stored for 14 days. Methods Blood collected from one Agroceres® swine was stored in two red blood
cell units. In vivo validation was performed by labeling the red blood cells with
Na251CrO4 and recovering the viable
erythrocytes after 24 hours of infusion in one autologous and four homologous
animals. In vitro validation was performed at baseline and after 14 days in
sixteen red blood cell units by measuring hemoglobin, hematocrit, hemolysis index
and free hemoglobin. A post-mortem splenectomy was performed to evaluate the
splenic sequestration of erythrocytes, and the radioactivity of the supernatant
samples was counted to evaluate intravascular hemolysis. Results After 14 days of storage, the red blood cell units had lower volumes and
equivalent total concentrations of hemoglobin and hematocrit compared to human
standards. The free hemoglobin concentration increased from 31.0±9.3 to
112.4±31.4mg/dL (p<0.001), and the hemolysis index increased from 0.1±0.1 to
0.5±0.1% (p<0.001). However, these tests were within the acceptable range for
human standards. The percentage of radioactivity in supernatant samples was
similar at baseline and after 24 hours, thus excluding significant hemolysis. No
evidence of splenic sequestration of radioactive erythrocytes was found. Conclusion Swine red blood cells stored for 14 days are viable and can be used in
experimental studies of transfusion. These validation experiments are important to
aid investigators in establishing experimental models of transfusion.
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Affiliation(s)
- Silvana Biagini
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | - Paulo Aguirre Costa
- Departamento de Medicina Nuclear, Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | - Silvano Wendel
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | - Guilherme Schettino
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, SP, Brasil
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Soares M, Toffart AC, Timsit JF, Burghi G, Irrazábal C, Pattison N, Tobar E, Almeida BFC, Silva UVA, Azevedo LCP, Rabbat A, Lamer C, Parrot A, Souza-Dantas VC, Wallet F, Blot F, Bourdin G, Piras C, Delemazure J, Durand M, Tejera D, Salluh JIF, Azoulay E. Intensive care in patients with lung cancer: a multinational study. Ann Oncol 2014; 25:1829-1835. [PMID: 24950981 DOI: 10.1093/annonc/mdu234] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [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: 11/14/2022] Open
Abstract
BACKGROUND Detailed information about lung cancer patients requiring admission to intensive care units (ICUs) is mostly restricted to single-center studies. Our aim was to evaluate the clinical characteristics and outcomes of lung cancer patients admitted to ICUs. PATIENTS AND METHODS Prospective multicenter study in 449 patients with lung cancer (small cell, n = 55; non-small cell, n = 394) admitted to 22 ICUs in six countries in Europe and South America during 2011. Multivariate Cox proportional hazards frailty models were built to identify characteristics associated with 30-day and 6-month mortality. RESULTS Most of the patients (71%) had newly diagnosed cancer. Cancer-related complications occurred in 56% of patients; the most common was tumoral airway involvement (26%). Ventilatory support was required in 53% of patients. Overall hospital, 30-day, and 6-month mortality rates were 39%, 41%, and 55%, respectively. After adjustment for type of admission and early treatment-limitation decisions, determinants of mortality were organ dysfunction severity, poor performance status (PS), recurrent/progressive cancer, and cancer-related complications. Mortality rates were far lower in the patient subset with nonrecurrent/progressive cancer and a good PS, even those with sepsis, multiple organ dysfunctions, and need for ventilatory support. Mortality was also lower in high-volume centers. Poor PS predicted failure to receive the initially planned cancer treatment after hospital discharge. CONCLUSIONS ICU admission was associated with meaningful survival in lung cancer patients with good PS and non-recurrent/progressive disease. Conversely, mortality rates were very high in patients not fit for anticancer treatment and poor PS. In this subgroup, palliative care may be the best option.
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Affiliation(s)
- M Soares
- Post-Graduation Program, Instituto Nacional de Câncer, Rio de Janeiro; Department of Clinical Research, D'Or Institute for Research and Education, Rio de Janeiro, Brazil.
| | | | - J-F Timsit
- Medical Intensive Care Unit (ICU), Hôpital A. Michallon Chu de Grenoble, Grenoble, France
| | - G Burghi
- ICU, Hospital Maciel, Montevideo, Uruguay
| | - C Irrazábal
- ICU, Instituto Medico Especializado Alexander Fleming, Buenos Aires, Argentina
| | - N Pattison
- ICU, Royal Brompton NHS Foundation Trust, London; ICU, Royal Marsden Hospital, London, UK
| | - E Tobar
- ICU, Hospital Clinico Universidad de Chile, Santiago, Chile
| | | | - U V A Silva
- ICU, Fundação Pio XII-Hospital do Câncer de Barretos, Barretos
| | | | | | - C Lamer
- ICU, Institut Mutualiste Montsouris, Paris
| | - A Parrot
- Medical ICU, APHP-Hopital Tenon, Paris, France
| | - V C Souza-Dantas
- ICU, Instituto Nacional de Câncer-Hospital do Câncer I, Rio de Janeiro, Brazil
| | - F Wallet
- Medical-Surgical ICU, Hospices Civils de Lyon Centre Hospitalier Lyon Sud, Lyon
| | - F Blot
- ICU, Gustave Roussy, Villejuif
| | - G Bourdin
- Medical ICU, Hôpital de la Croix-Rousse, Lyon, France
| | - C Piras
- ICU, Vitória Apart Hospital, Vitória, Brazil
| | - J Delemazure
- Medical ICU, Groupe Hospitalier Pitié Salpêtrière, Paris
| | - M Durand
- Surgical ICU, Hôpital A. Michallon Chu de Grenoble, Grenoble, France
| | - D Tejera
- ICU, Hospital de Clínicas, Montevideo, Uruguay
| | - J I F Salluh
- Post-Graduation Program, Instituto Nacional de Câncer, Rio de Janeiro; Department of Clinical Research, D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - E Azoulay
- Medical ICU, Saint-Louis Teaching Hospital, Paris, France
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Tanaka LMS, Azevedo LCP, Park M, Schettino G, Nassar AP, Réa-Neto A, Tannous L, de Souza-Dantas VC, Torelly A, Lisboa T, Piras C, Carvalho FB, Maia MDO, Giannini FP, Machado FR, Dal-Pizzol F, de Carvalho AGR, dos Santos RB, Tierno PFGMM, Soares M, Salluh JIF. Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. Crit Care 2014; 18:R156. [PMID: 25047960 PMCID: PMC4223597 DOI: 10.1186/cc13995] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 06/23/2014] [Indexed: 12/13/2022]
Abstract
Introduction Sedation overuse is frequent and possibly associated with poor outcomes in the intensive care unit (ICU) patients. However, the association of early oversedation with clinical outcomes has not been thoroughly evaluated. The aim of this study was to assess the association of early sedation strategies with outcomes of critically ill adult patients under mechanical ventilation (MV). Methods A secondary analysis of a multicenter prospective cohort conducted in 45 Brazilian ICUs, including adult patients requiring ventilatory support and sedation in the first 48 hours of ICU admissions, was performed. Sedation depth was evaluated after 48 hours of MV. Multivariate analysis was used to identify variables associated with hospital mortality. Results A total of 322 patients were evaluated. Overall, ICU and hospital mortality rates were 30.4% and 38.8%, respectively. Deep sedation was observed in 113 patients (35.1%). Longer duration of ventilatory support was observed (7 (4 to 10) versus 5 (3 to 9) days, P = 0.041) and more tracheostomies were performed in the deep sedation group (38.9% versus 22%, P = 0.001) despite similar PaO2/FiO2 ratios and acute respiratory distress syndrome (ARDS) severity. In a multivariate analysis, age (Odds Ratio (OR) 1.02; 95% confidence interval (CI) 1.00 to 1.03), Charlson Comorbidity Index >2 (OR 2.06; 95% CI, 1.44 to 2.94), Simplified Acute Physiology Score 3 (SAPS 3) score (OR 1.02; CI 95%, 1.00 to 1.04), severe ARDS (OR 1.44; CI 95%, 1.09 to 1.91) and deep sedation (OR 2.36; CI 95%, 1.31 to 4.25) were independently associated with increased hospital mortality. Conclusions Early deep sedation is associated with adverse outcomes and constitutes an independent predictor of hospital mortality in mechanically ventilated patients.
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Sanches LC, Pontes Azevedo LC, Salomão R, Noguti MA, Brunialti M, Lourenço DM, Machado FR. Association between early glycemic control and improvements in markers of coagulation and fibrinolysis in patients with septic shock-induced stress hyperglycemia. J Crit Care 2014; 29:884.e1-6. [PMID: 24891151 DOI: 10.1016/j.jcrc.2014.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 11/11/2013] [Revised: 03/25/2014] [Accepted: 04/21/2014] [Indexed: 12/29/2022]
Abstract
PURPOSE The purpose of this study is to evaluate the coagulation and inflammatory profiles in septic shock patients with baseline hyperglycemia under glycemic control. METHODS Prospective, observational study conducted in an intensive care unit of a university hospital, including 41 septic shock nondiabetic patients with hyperglycemia (n = 21) or normoglycemia (n = 20) profiles at baseline. Hyperglycemic patients received a glucose control protocol (target glycemia, <150 mg/dL). Metabolic, inflammatory, and coagulation markers were measured at baseline and after 24 hours. RESULTS Median glycemic values between groups were different at baseline but not after 24 hours. Baseline coagulation profile was similar in both groups with elevated levels of coagulation markers, reduced factor VII, protein C, and antithrombin activities and fibrinolysis impairment. Normoglycemic patients had unchanged coagulation markers after 24 hours. After treatment, previously hyperglycemic patients exhibited increased plasminogen concentrations (P = .03) and reduced levels of plasminogen activator inhibitor 1 (P = .01) and tissue plasminogen activator (P = .03) as compared with baseline. They also had higher factor VII (P = .03), protein C (P = .04), and antithrombin (P = .04) activities than normoglycemic patients. Inflammatory markers were elevated in both groups and improved after 24 hours, independently of the glycemic profile. CONCLUSIONS Glycemic control during septic shock is associated with improvements in coagulation and fibrinolysis parameters compared with baseline and normoglycemic patients.
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Affiliation(s)
- Luciana Coelho Sanches
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo-UNIFESP, São Paulo, Brazil
| | | | - Reinaldo Salomão
- Infectious Disease Department, Federal University of São Paulo-UNIFESP, São Paulo, Brazil
| | - Maria Aparecida Noguti
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo-UNIFESP, São Paulo, Brazil
| | - Milena Brunialti
- Infectious Disease Department, Federal University of São Paulo-UNIFESP, São Paulo, Brazil
| | - Dayse M Lourenço
- Hematology Department, Federal University of São Paulo-UNIFESP, São Paulo, Brazil
| | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo-UNIFESP, São Paulo, Brazil.
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Cordioli RL, Park M, Costa ELV, Gomes S, Brochard L, Amato MBP, Azevedo LCP. Moderately high frequency ventilation with a conventional ventilator allows reduction of tidal volume without increasing mean airway pressure. Intensive Care Med Exp 2014; 2:13. [PMID: 26266914 PMCID: PMC4512987 DOI: 10.1186/2197-425x-2-13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 11/18/2013] [Accepted: 03/21/2014] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study was to explore if positive-pressure ventilation delivered by a conventional ICU ventilator at a moderately high frequency (HFPPV) allows a safe reduction of tidal volume (VT) below 6 mL/kg in a porcine model of severe acute respiratory distress syndrome (ARDS) and at a lower mean airway pressure than high-frequency oscillatory ventilation (HFOV). Methods This is a prospective study. In eight pigs (median weight 34 [29,36] kg), ARDS was induced by pulmonary lavage and injurious ventilation. The animals were ventilated with a randomized sequence of respiratory rates: 30, 60, 90, 120, 150, followed by HFOV at 5 Hz. At each step, VT was adjusted to allow partial pressure of arterial carbon dioxide (PaCO2) to stabilize between 57 and 63 mmHg. Data are shown as median [P25th,P75th]. Results After lung injury, the PaO2/FiO2 (P/F) ratio was 92 [63,118] mmHg, pulmonary shunt 26 [17,31]%, and static compliance 11 [8,14] mL/cmH2O. Positive end-expiratory pressure (PEEP) was 14 [10,17] cmH2O. At 30 breaths/min, VT was higher than 6 (7.5 [6.8,10.2]) mL/kg, but at all higher frequencies, VT could be reduced and PaCO2 maintained, leading to reductions in plateau pressures and driving pressures. For frequencies of 60 to 150/min, VT progressively fell from 5.2 [5.1,5.9] to 3.8 [3.7,4.2] mL/kg (p < 0.001). There were no detrimental effects in terms of lung mechanics, auto-PEEP generation, hemodynamics, or gas exchange. Mean airway pressure was maintained constant and was increased only during HFOV. Conclusions During protective mechanical ventilation, HFPPV delivered by a conventional ventilator in a severe ARDS swine model safely allows further tidal volume reductions. This strategy also allowed decreasing airway pressures while maintaining stable PaCO2 levels.
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Affiliation(s)
- Ricardo Luiz Cordioli
- Research and Education Institute, Hospital Sírio-Libanês, Rua Dona Adma Jafet, 91, Bela Vista, São Paulo, 01308-050, Brazil,
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Silva SC, Baggio-Zappia GL, Brunialti MKC, Assunçao MSC, Azevedo LCP, Machado FR, Salomao R. Evaluation of Toll-like, chemokine, and integrin receptors on monocytes and neutrophils from peripheral blood of septic patients and their correlation with clinical outcomes. ACTA ACUST UNITED AC 2014; 47:384-93. [PMID: 24728213 PMCID: PMC4075306 DOI: 10.1590/1414-431x20143190] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 02/10/2014] [Indexed: 11/21/2022]
Abstract
Recognition of pathogens is performed by specific receptors in cells of the innate immune system, which may undergo modulation during the continuum of clinical manifestations of sepsis. Monocytes and neutrophils play a key role in host defense by sensing and destroying microorganisms. This study aimed to evaluate the expression of CD14 receptors on monocytes; CD66b and CXCR2 receptors on neutrophils; and TLR2, TLR4, TLR5, TLR9, and CD11b receptors on both cell types of septic patients. Seventy-seven septic patients (SP) and 40 healthy volunteers (HV) were included in the study, and blood samples were collected on day zero (D0) and after 7 days of therapy (D7). Evaluation of the cellular receptors was carried out by flow cytometry. Expression of CD14 on monocytes and of CD11b and CXCR2 on neutrophils from SP was lower than that from HV. Conversely, expression of TLR5 on monocytes and neutrophils was higher in SP compared with HV. Expression of TLR2 on the surface of neutrophils and that of TLR5 on monocytes and neutrophils of SP was lower at D7 than at D0. In addition, SP who survived showed reduced expression of TLR2 and TLR4 on the surface of neutrophils at D7 compared to D0. Expression of CXCR2 for surviving patients was higher at follow-up compared to baseline. We conclude that expression of recognition and cell signaling receptors is differentially regulated between SP and HV depending on the receptor being evaluated.
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Affiliation(s)
- S C Silva
- Disciplina de Infectologia, Departamento de Medicina, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - G L Baggio-Zappia
- Disciplina de Infectologia, Departamento de Medicina, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - M K C Brunialti
- Disciplina de Infectologia, Departamento de Medicina, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - M S C Assunçao
- Unidade de Terapia Intensiva, Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
| | - L C P Azevedo
- Unidade de Terapia Intensiva, Hospital Sírio Libanês, São Paulo, SP, Brasil
| | - F R Machado
- Disciplina de Anestesiologia, Departamento de Cirurgia, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - R Salomao
- Disciplina de Infectologia, Departamento de Medicina, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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Park M, Costa ELV, Maciel AT, Barbosa EVS, Hirota AS, Schettino G, Azevedo LCP. Effect of flow rate and temperature on transmembrane blood pressure drop in an extracorporeal artificial lung. Perfusion 2014; 29:517-25. [DOI: 10.1177/0267659114525986] [Citation(s) in RCA: 5] [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] [Indexed: 01/19/2023]
Abstract
Introduction: Transmembrane pressure drop reflects the resistance of an artificial lung system to blood transit. Decreased resistance (low transmembrane pressure drop) enhances blood flow through the oxygenator, thereby, enhancing gas exchange efficiency. This study is part of a previous one where we observed the behaviour and the modulation of blood pressure drop during the passage of blood through artificial lung membranes. Methods: Before and after the induction of multi-organ dysfunction, the animals were instrumented and analysed for venous-venous extracorporeal membrane oxygenation, using a pre-defined sequence of blood flows. Results: Blood flow and revolutions per minute (RPM) of the centrifugal pump varied in a linear fashion. At a blood flow of 5.5 L/min, pre- and post-pump blood pressures reached -120 and 450 mmHg, respectively. Transmembrane pressures showed a significant spread, particularly at blood flows above 2 L/min; over the entire range of blood flow rates, there was a positive association of pressure drop with blood flow (0.005 mmHg/mL/minute of blood flow ) and a negative association of pressure drop with temperature (-4.828 mmHg/oCelsius). These associations were similar when blood flows of below and above 2000 mL/minute were examined. Conclusions: During its passage through the extracorporeal system, blood is exposed to pressure variations from -120 to 450 mmHg. At high blood flows (above 2 L/min), the drop in transmembrane pressure becomes unpredictable and highly variable. Over the entire range of blood flows investigated (0 – 5500 mL/min), the drop in transmembrane pressure was positively associated with blood flow and negatively associated with body temperature.
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Affiliation(s)
- M Park
- Research and Education Institute, Sírio Libanês Hospital, São Paulo, Brazil
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, São Paulo, Brazil
| | - ELV Costa
- Research and Education Institute, Sírio Libanês Hospital, São Paulo, Brazil
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, São Paulo, Brazil
| | - AT Maciel
- Research and Education Institute, Sírio Libanês Hospital, São Paulo, Brazil
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, São Paulo, Brazil
| | - EVS Barbosa
- Research and Education Institute, Sírio Libanês Hospital, São Paulo, Brazil
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, São Paulo, Brazil
| | - AS Hirota
- Research and Education Institute, Sírio Libanês Hospital, São Paulo, Brazil
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, São Paulo, Brazil
| | - GdeP Schettino
- Research and Education Institute, Sírio Libanês Hospital, São Paulo, Brazil
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, São Paulo, Brazil
| | - LCP Azevedo
- Research and Education Institute, Sírio Libanês Hospital, São Paulo, Brazil
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, São Paulo, Brazil
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Nunes LB, Mendes PV, Hirota AS, Barbosa EV, Maciel AT, Schettino GPP, Costa ELV, Azevedo LCP, Park M. Severe hypoxemia during veno-venous extracorporeal membrane oxygenation: exploring the limits of extracorporeal respiratory support. Clinics (Sao Paulo) 2014; 69:173-8. [PMID: 24626942 PMCID: PMC3935134 DOI: 10.6061/clinics/2014(03)05] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 08/15/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Veno-venous extracorporeal oxygenation for respiratory support has emerged as a rescue alternative for patients with hypoxemia. However, in some patients with more severe lung injury, extracorporeal support fails to restore arterial oxygenation. Based on four clinical vignettes, the aims of this article were to describe the pathophysiology of this concerning problem and to discuss possibilities for hypoxemia resolution. METHODS Considering the main reasons and rationale for hypoxemia during veno-venous extracorporeal membrane oxygenation, some possible bedside solutions must be considered: 1) optimization of extracorporeal membrane oxygenation blood flow; 2) identification of recirculation and cannula repositioning if necessary; 3) optimization of residual lung function and consideration of blood transfusion; 4) diagnosis of oxygenator dysfunction and consideration of its replacement; and finally 5) optimization of the ratio of extracorporeal membrane oxygenation blood flow to cardiac output, based on the reduction of cardiac output. CONCLUSION Therefore, based on the pathophysiology of hypoxemia during veno-venous extracorporeal oxygenation support, we propose a stepwise approach to help guide specific interventions.
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Affiliation(s)
- Liane Brescovici Nunes
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Emergency Department, Intensive Care Unit, São PauloSP, Brazil, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Emergency Department, Intensive Care Unit, São Paulo/SP, Brazil
| | - Pedro Vitale Mendes
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Emergency Department, Intensive Care Unit, São PauloSP, Brazil, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Emergency Department, Intensive Care Unit, São Paulo/SP, Brazil
| | - Adriana Sayuri Hirota
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Emergency Department, Intensive Care Unit, São PauloSP, Brazil, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Emergency Department, Intensive Care Unit, São Paulo/SP, Brazil
| | - Edzangela Vasconcelos Barbosa
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Emergency Department, Intensive Care Unit, São PauloSP, Brazil, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Emergency Department, Intensive Care Unit, São Paulo/SP, Brazil
| | - Alexandre Toledo Maciel
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Emergency Department, Intensive Care Unit, São PauloSP, Brazil, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Emergency Department, Intensive Care Unit, São Paulo/SP, Brazil
| | - Guilherme Pinto Paula Schettino
- Hospital Sírio Libanês, Intensive Care Unit, São PauloSP, Brazil, Hospital Sírio Libanês, Intensive Care Unit, São Paulo/SP, Brazil
| | - Eduardo Leite Vieira Costa
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Respiratory Intensive Care Unit, São PauloSP, Brazil, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Respiratory Intensive Care Unit, São Paulo/SP, Brazil
| | - Luciano Cesar Pontes Azevedo
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Emergency Department, Intensive Care Unit, São PauloSP, Brazil, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Emergency Department, Intensive Care Unit, São Paulo/SP, Brazil
| | - Marcelo Park
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Emergency Department, Intensive Care Unit, São PauloSP, Brazil, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Emergency Department, Intensive Care Unit, São Paulo/SP, Brazil
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Honda CKY, Freitas FGR, Stanich P, Mazza BF, Castro I, Nascente APM, Bafi AT, Azevedo LCP, Machado FR. Nurse to bed ratio and nutrition support in critically ill patients. Am J Crit Care 2013; 22:e71-8. [PMID: 24186828 DOI: 10.4037/ajcc2013610] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Inadequate nutrition support is common among critically ill patients, and identification of risk factors for such inadequacy might help in improving nutrition support. OBJECTIVE To determine how often daily calorie goals are met and the factors responsible for inadequate nutrition support. Methods A single-center prospective cohort study. Each patient's demographic and clinical characteristics, the need for ventilatory support, the use and dosage of medications, the number of nursing staff per bed, the time elapsed from admission to the intensive care unit until the effective start of enteral feeding, and the causes for nonadministration were recorded. Achievement of daily calorie goals was determined and correlated with risk factors. RESULTS A total of 262 daily evaluations were done in 40 patients. Daily calorie goal was achieved in only 46.2% of the evaluations (n = 121), with a mean of 74.8% of the prescribed volume of enteral nutrition infused daily. Risk factors for inadequate nutrition support were the use of midazolam (odds ratio, 1.58; 95% CI, 1.18-2.11) and fewer nursing professionals per bed (odds ratio, 2.56; 95% CI, 1.43-4.57). Conclusion Achievement of daily calorie goals was inadequate, and the main factors associated with this failure were the use and dosage of midazolam and the number of nurses available.
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Affiliation(s)
- Carolina Keiko Yamamoto Honda
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Flávio Geraldo Rezende Freitas
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Patricia Stanich
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Bruno Franco Mazza
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Isac Castro
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Ana Paula Metran Nascente
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Antonio Toneti Bafi
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Luciano Cesar Pontes Azevedo
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Flávia Ribeiro Machado
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
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da Silva Ramos FJ, Fumis RRL, Azevedo LCP, Schettino G. Perceptions of an open visitation policy by intensive care unit workers. Ann Intensive Care 2013; 3:34. [PMID: 24135292 PMCID: PMC3854481 DOI: 10.1186/2110-5820-3-34] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [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: 07/17/2013] [Accepted: 09/22/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An intensive care unit (ICU) admission is a stressful event for the patient and the patient's family. Several studies demonstrated symptoms of anxiety, depression, and posttraumatic stress disorder in family members of patients admitted to ICU. Some studies recognize that the open visitation policy (OVP) is related to a reduction in symptoms of anxiety and depression for the patient and an improvement in family satisfaction. However, some issues have been presented as barriers for the adoption of that strategy. This study was designed to evaluate perceptions of physicians, nurses, and respiratory therapists (RTs) of an OVP and to quantify visiting times in a Brazilian private intensive care unit (ICU). METHODS This observational and descriptive study was performed in the medical-surgical (22 beds) and neurologic ICU (8 beds) of Sírio-Libanês Hospital (HSL), São Paulo, Brazil. All physicians, nurses, and RTs from ICU were invited to participate in the study. A questionnaire was applied to all ICU workers who accepted to participate in the study. The questionnaire consisted of 22 questions about the visiting policy. During five consecutive days, we evaluated the time that the visitors stayed in the patient room, as well as the type of visitor. RESULTS A total of 106 ICU workers participated in this study (42 physicians, 39 nurses, and 25 RTs). Only three of the questions exposed a negative perception of the visiting policy: 53.3% of the participants do not think that the OVP consistently increases family satisfaction with patient's care; 59.4% of ICU workers think that the OVP impairs the organization of the patient's care; 72.7% of participants believe that their work suffers more interruptions because of the OVP. The median visiting time per day was 11.5 hours. CONCLUSIONS According to physicians, nurses, and respiratory therapists, the greatest impact of OVP is the benefit to the patients rather than to the family or to the staff. Furthermore, they feel that they need communication training to better interact with family members who are present in the ICU 24 hours per day.
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Affiliation(s)
- Fernando José da Silva Ramos
- Research Laboratory of Anesthesiology and Intensive Care Medicine, Research and Education Institute of Sírio-Libanês Hospital, Cel Nicolau dos Santos 69, São Paulo 01308-060, Brazil.
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Zampieri FG, Mendes PV, Ranzani OT, Taniguchi LU, Pontes Azevedo LC, Vieira Costa EL, Park M. Extracorporeal membrane oxygenation for severe respiratory failure in adult patients: a systematic review and meta-analysis of current evidence. J Crit Care 2013; 28:998-1005. [PMID: 23954453 DOI: 10.1016/j.jcrc.2013.07.047] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 07/07/2013] [Accepted: 07/08/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) for acute respiratory failure is still a matter of debate. METHODS We performed a structured search on Pubmed, EMBASE, Lilacs, and the Cochrane Library for randomized controlled trials and observational case-control studies with severity-paired patients, evaluating the use of ECMO on severe acute respiratory failure in adult patients. A random-effect model using DerSimonian and Laird method for variance estimator was performed to evaluate the effect of ECMO use on hospital mortality. Heterogeneity between studies was assessed with Cochran's Q statistic and Higgin's I(2). RESULTS Three studies were included on the metanalysis, comprising 353 patients in the main analysis, in which 179 patients were ECMO supported. One study was a randomized controlled trial and two were observational studies with a propensity score matching. The most common reason for acute respiratory failure was influenza H1N1 pneumonia (45%) and pneumonia (33%). ECMO was not associated with a reduction in hospital mortality (OR = 0.71; CI 95% = 0.34 - 1.47; P = 0.358). If alternative severity-pairing method presented by the two observational studies was included, a total of 478 cases were included, in which 228 received ECMO support. In the former analysis, ECMO had a benefit on hospital mortality (OR = 0.52; CI 95% = 0.35 - 0.76; P < 0.001). CONCLUSION Extracorporeal membrane oxygenation benefit on hospital mortality is unclear. Results were sensitive to statistical analysis, and no definitive conclusion can be drawn from the available data. More studies are needed before the widespread use of ECMO can be recommended.
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Affiliation(s)
- Fernando Godinho Zampieri
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil.
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Azevedo LCP, Toscano CM, Bierrenbach AL. Bacterial Meningitis in Brazil: Baseline Epidemiologic Assessment of the Decade Prior to the Introduction of Pneumococcal and Meningococcal Vaccines. PLoS One 2013; 8:e64524. [PMID: 23823579 PMCID: PMC3688798 DOI: 10.1371/journal.pone.0064524] [Citation(s) in RCA: 31] [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: 01/28/2013] [Accepted: 04/16/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Bacterial meningitis is associated with significant burden in Brazil. In 2010, both 10-valent pneumococcal conjugate vaccine and meningococcal capsular group C conjugate vaccine were introduced into the routine vaccination schedule. Haemophilus influenzae type b vaccine was previously introduced in 1999. This study presents trends in demographics, microbiological characteristics and seasonality patterns of bacterial meningitis cases in Brazil from 2000 to 2010. METHODS AND FINDINGS All meningitis cases confirmed by clinical and/or laboratory criteria notified to the national information system for notifiable diseases between 2000 and 2010 were analyzed. Proportions of bacterial meningitis cases by demographic characteristics, criteria used for confirmation and etiology were calculated. We estimated disease rates per 100,000 population and trends for the study period, with emphasis on H. influenzae, N. meningitidis and S. pneumoniae cases. In the decade, 341,805 cases of meningitis were notified in Brazil. Of the 251,853 cases with defined etiology, 110,264 (43.8%) were due to bacterial meningitis (excluding tuberculosis). Of these, 34,997 (31.7%) were due to meningococcal disease. The incidence of bacterial meningitis significantly decreased from 3.1/100,000 population in 2000-2002 to 2.14/100,000 in 2009-2010 (p<0.01). Among cases of meningococcal disease, the proportion of those associated with group C increased from 41% in 2007 to 61.7% in 2010, while the proportion of group B disease progressively declined. Throughout the study period, an increased number of cases occurred during winter. CONCLUSIONS Despite the reduction in bacterial meningitis incidence during the last decade, it remains a significant healthcare issue in Brazil. Meningococcal disease is responsible for the majority of the cases with group C the most common capsular type. Our study demonstrates the appropriateness of introduction of meningococcal vaccination in Brazil. Furthermore, this study provides a baseline for future evaluation of the impact of the vaccines introduction in Brazil and changes in disease epidemiology.
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Affiliation(s)
- Luciano Cesar Pontes Azevedo
- Research and Education Institute (IEP), Hospital Sírio-Libanês, São Paulo, Brazil
- Emergency Medicine Department, University of São Paulo, Brazil
| | | | - Ana Luiza Bierrenbach
- Research and Education Institute (IEP), Hospital Sírio-Libanês, São Paulo, Brazil
- Department of Collective Health, Federal University of Goiás, Goiânia, Brazil
- Sanas Epidemiology and Research, São Paulo, Brazil
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