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Revista Brasileira de Terapia Intensiva. 01-01-2014;26(3):215-239
DOI 10.5935/0103-507X.20140034
Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.
Abstract
Revista Brasileira de Terapia Intensiva. 01-01-2014;26(3):215-239
DOI 10.5935/0103-507X.20140034
Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.
Abstract
Revista Brasileira de Terapia Intensiva. 01-01-2014;26(2):89-121
DOI 10.5935/0103-507X.20140017
Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.
Abstract
Revista Brasileira de Terapia Intensiva. 01-01-2014;26(2):89-121
DOI 10.5935/0103-507X.20140017
Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.
Abstract
Revista Brasileira de Terapia Intensiva. 01-01-2013;25(4):334-344
DOI 10.5935/0103-507X.20130056
Sepsis is defined as an acute inflammatory response syndrome secondary to an infectious focus. It has a high incidence, morbidity and mortality, causing substantial financial costs, especially due to complications such as septic shock and multiple organ dysfunction. The pathogen toxins associated with individual susceptibility culminate with cytokine release, which promotes a systemic inflammatory response that can progress to multiple organ dysfunction and eventual patient death.
Specifically, sepsis incidence, morbidity and mortality are lower in pregnant women, as this group is typically younger with fewer comorbidities having a polymicrobial etiology resulting in sepsis.
Pregnant women exhibit physiological characteristics that may confer specific clinical presentation and laboratory patterns during the sepsis course. Thus, a better understanding of these changes is critical for better identification and management of these patients. The presence of a fetus also requires unique approaches in a pregnant woman with sepsis.
Sepsis treatment is based on certain guidelines that were established after major clinical trials, which, unfortunately, all classified pregnancy as a exclusion criteria.
Thus, the treatment of sepsis in the general population has been extrapolated to the pregnant population, with the following main goals: maintenance of tissue perfusion with fluid replacement and vasoactive drugs (initial resuscitation), adequate oxygenation, control of the infection source and an early start of antibiotic therapy, corticosteroid infusion and blood transfusion when properly indicated, prophylaxis, and specifically monitoring and maintenance of fetal heath.
Abstract
Revista Brasileira de Terapia Intensiva. 01-01-2013;25(4):334-344
DOI 10.5935/0103-507X.20130056
Sepsis is defined as an acute inflammatory response syndrome secondary to an infectious focus. It has a high incidence, morbidity and mortality, causing substantial financial costs, especially due to complications such as septic shock and multiple organ dysfunction. The pathogen toxins associated with individual susceptibility culminate with cytokine release, which promotes a systemic inflammatory response that can progress to multiple organ dysfunction and eventual patient death.
Specifically, sepsis incidence, morbidity and mortality are lower in pregnant women, as this group is typically younger with fewer comorbidities having a polymicrobial etiology resulting in sepsis.
Pregnant women exhibit physiological characteristics that may confer specific clinical presentation and laboratory patterns during the sepsis course. Thus, a better understanding of these changes is critical for better identification and management of these patients. The presence of a fetus also requires unique approaches in a pregnant woman with sepsis.
Sepsis treatment is based on certain guidelines that were established after major clinical trials, which, unfortunately, all classified pregnancy as a exclusion criteria.
Thus, the treatment of sepsis in the general population has been extrapolated to the pregnant population, with the following main goals: maintenance of tissue perfusion with fluid replacement and vasoactive drugs (initial resuscitation), adequate oxygenation, control of the infection source and an early start of antibiotic therapy, corticosteroid infusion and blood transfusion when properly indicated, prophylaxis, and specifically monitoring and maintenance of fetal heath.
Abstract
Revista Brasileira de Terapia Intensiva. 08-01-2012;24(2):143-150
DOI 10.1590/S0103-507X2012000200008
OBJECTIVE: To determine the prevalence of infections in Brazilian intensive care units and the associated mortality by analyzing the data obtained in the Extended Prevalence of Infection in Intensive Care (EPIC II) study. METHODS: EPIC II was a multicenter, international, cross-sectional prospective study of infection prevalence. It described the demographic, physiological, bacteriological, and therapeutic characteristics, outcome up to the 60th day, prevalence of infection, and mortality of all the patients admitted to the participating ICUs between zero hour and midnight on May 8, 2007. A total of 14,414 patients were included in the original study. Of these 14,414 patients, 1,235 were Brazilian and were hospitalized in 90 Brazilian ICUs. They represent the focus of this study. RESULTS: Among these 1,235 Brazilian patients, 61,6% had an infection on the day of the trial, and the lungs were the main site of infection (71.2%). Half of the patients had positive cultures, predominantly gram-negative bacilli (72%). On the day of the study, the median SOFA score was 5 (3-8) and the median SAPS II score was 36 (26-47). The infected patients had SOFA scores significantly higher than those of the non-infected patients 6 (4-9) and 3 (2-6), respectively). The overall ICU mortality rate was 28.4%: 37.6% in the infected patients, and 13.2% in the non-infected patients (p<0.001). Similarly, the in-hospital mortality rate was 34.2%, with a higher rate in the infected than in the non-infected patients (44.2% vs. 17.7%) (p<0.001). In the multivariate analysis, the main factors associated with infection incidence were emergency surgery (OR 2.89, 95%CI [1.72-4.86], p<0.001), mechanical ventilation (OR 2.06, 95% CI [1.5-2.82], p<0.001), and the SAPS II score (OR 1.04, 95% CI [1.03-1.06], p<0.001). The main factors related to mortality were ICC functional class III/ IV (OR 3.0, 95% CI [1.51-5.98], p<0.01), diabetes mellitus (OR 0.48, 95% CI [0.25-0.95], p<0.03), cirrhosis (OR 4.62, 95% CI [1.47-14,5], p<0.01), male gender (OR 0.68, 95% CI [0.46-1.0], p<0.05), mechanical ventilation (OR 1.87, 95% CI [1.19-2.95], p<0.01), hemodialysis (OR 1.98, 95% CI [1.05-3.75], p<0.03), and the SAPS II score (OR 1.08, 95% CI [1.06-1.10], p<0.001). CONCLUSION: The present study revealed a higher prevalence of infections in Brazilian ICUs than has been previously reported. There was a clear association between infection and mortality.
Abstract
Revista Brasileira de Terapia Intensiva. 08-01-2012;24(2):143-150
DOI 10.1590/S0103-507X2012000200008
OBJECTIVE: To determine the prevalence of infections in Brazilian intensive care units and the associated mortality by analyzing the data obtained in the Extended Prevalence of Infection in Intensive Care (EPIC II) study. METHODS: EPIC II was a multicenter, international, cross-sectional prospective study of infection prevalence. It described the demographic, physiological, bacteriological, and therapeutic characteristics, outcome up to the 60th day, prevalence of infection, and mortality of all the patients admitted to the participating ICUs between zero hour and midnight on May 8, 2007. A total of 14,414 patients were included in the original study. Of these 14,414 patients, 1,235 were Brazilian and were hospitalized in 90 Brazilian ICUs. They represent the focus of this study. RESULTS: Among these 1,235 Brazilian patients, 61,6% had an infection on the day of the trial, and the lungs were the main site of infection (71.2%). Half of the patients had positive cultures, predominantly gram-negative bacilli (72%). On the day of the study, the median SOFA score was 5 (3-8) and the median SAPS II score was 36 (26-47). The infected patients had SOFA scores significantly higher than those of the non-infected patients 6 (4-9) and 3 (2-6), respectively). The overall ICU mortality rate was 28.4%: 37.6% in the infected patients, and 13.2% in the non-infected patients (p<0.001). Similarly, the in-hospital mortality rate was 34.2%, with a higher rate in the infected than in the non-infected patients (44.2% vs. 17.7%) (p<0.001). In the multivariate analysis, the main factors associated with infection incidence were emergency surgery (OR 2.89, 95%CI [1.72-4.86], p<0.001), mechanical ventilation (OR 2.06, 95% CI [1.5-2.82], p<0.001), and the SAPS II score (OR 1.04, 95% CI [1.03-1.06], p<0.001). The main factors related to mortality were ICC functional class III/ IV (OR 3.0, 95% CI [1.51-5.98], p<0.01), diabetes mellitus (OR 0.48, 95% CI [0.25-0.95], p<0.03), cirrhosis (OR 4.62, 95% CI [1.47-14,5], p<0.01), male gender (OR 0.68, 95% CI [0.46-1.0], p<0.05), mechanical ventilation (OR 1.87, 95% CI [1.19-2.95], p<0.01), hemodialysis (OR 1.98, 95% CI [1.05-3.75], p<0.03), and the SAPS II score (OR 1.08, 95% CI [1.06-1.10], p<0.001). CONCLUSION: The present study revealed a higher prevalence of infections in Brazilian ICUs than has been previously reported. There was a clear association between infection and mortality.
Abstract
Revista Brasileira de Terapia Intensiva. 10-24-2011;23(3):255-268
DOI 10.1590/S0103-507X2011000300003
There is a relative shortage of appropriate organs available for transplantation. The appropriate diagnosis of brain death, a suitable family approach and the maintenance of the deceased donor are fundamental in addressing this issue. The intensive care physician plays a key role in the maintenance of the deceased donor, thereby reducing losses and increasing the number of successful transplants
Abstract
Revista Brasileira de Terapia Intensiva. 10-24-2011;23(3):255-268
DOI 10.1590/S0103-507X2011000300003
There is a relative shortage of appropriate organs available for transplantation. The appropriate diagnosis of brain death, a suitable family approach and the maintenance of the deceased donor are fundamental in addressing this issue. The intensive care physician plays a key role in the maintenance of the deceased donor, thereby reducing losses and increasing the number of successful transplants
Abstract
Revista Brasileira de Terapia Intensiva. 08-01-2011;23(2):134-144
DOI 10.1590/S0103-507X2011000200005
Sepsis is a common and lethal condition that carries a substantial financial burden and is the primary cause of death in intensive care units. Early diagnosis and treatment of patients has been clearly shown to improve prognosis. Therefore, early diagnosis of infections and control of the primary infection site are fundamental to improving patients' prognosis. This guideline reviews the available evidence concerning the primary strategies for the diagnosis of infection
Abstract
Revista Brasileira de Terapia Intensiva. 08-01-2011;23(2):134-144
DOI 10.1590/S0103-507X2011000200005
Sepsis is a common and lethal condition that carries a substantial financial burden and is the primary cause of death in intensive care units. Early diagnosis and treatment of patients has been clearly shown to improve prognosis. Therefore, early diagnosis of infections and control of the primary infection site are fundamental to improving patients' prognosis. This guideline reviews the available evidence concerning the primary strategies for the diagnosis of infection
Abstract
Revista Brasileira de Terapia Intensiva. 08-01-2011;23(2):145-157
DOI 10.1590/S0103-507X2011000200006
Sepsis is a common and lethal condition that carries a substantial financial burden. In addition, it is the main cause of death in intensive care units. Early diagnosis and treatment of patients has been clearly shown to improve prognosis. Therefore, early diagnosis of the infecting agent, control of the primary infection site and the use of appropriate antibiotic therapy are fundamental to improving outcomes. This guideline reviews the available evidence in the literature concerning infection control and therapy strategies
Abstract
Revista Brasileira de Terapia Intensiva. 08-01-2011;23(2):145-157
DOI 10.1590/S0103-507X2011000200006
Sepsis is a common and lethal condition that carries a substantial financial burden. In addition, it is the main cause of death in intensive care units. Early diagnosis and treatment of patients has been clearly shown to improve prognosis. Therefore, early diagnosis of the infecting agent, control of the primary infection site and the use of appropriate antibiotic therapy are fundamental to improving outcomes. This guideline reviews the available evidence in the literature concerning infection control and therapy strategies
