Abstract
Rev Bras Ter Intensiva. 2012;24(2):137-142
DOI 10.1590/S0103-507X2012000200007
OBJECTIVE: To investigate the hemodynamic, respiratory and metabolic impact of blood contact with a priming volume and extracorporeal membrane oxygenation circuit, before the initiation of oxygenation and ventilation METHODS: Five animals were instrumented and submitted to extracorporeal membrane oxygenation. Data were collected at the baseline and 30 minutes after starting extracorporeal circulation, without membrane ventilatory (sweeper) flow. RESULTS: After starting extracorporeal membrane oxygenation, there was a non-significant elevation in pulmonary vascular resistance from 235 (178,303) to 379 (353,508) dyn.seg.(cm5)-1 (P=0.065), associated with an elevation in the alveolar arterial oxygen gradient from 235 (178,303) to 379 (353,508) mmHg (P=0.063). We also observed a reduction in the left ventricle stroke work from 102 (94,105) to 78 (71,87) (mL.mmHg)/beat (P=0.064), in addition to a reduction in cardiac output from 7.2 (6.8,7.6) to 5.9 (5.8,6.3) L/min (P=0.188). The right ventricle stroke work was counterbalanced between the pulmonary vascular resistance increment and the cardiac output reduction, maintaining a similar value. CONCLUSIONS: We presented an experimental model that is feasible and safe. Blood contact with the priming volume and extracorporeal membrane oxygenation circuit resulted in non-significant systemic or metabolic changes.
Abstract
Rev Bras Ter Intensiva. 2011;23(4):426-433
DOI 10.1590/S0103-507X2011000400006
OBJECTIVE: To investigate the correlation of organ dysfunction and its progression with inflammatory response during the early phases of septic shock by assessing baseline cytokine concentrations. METHODS: This study included patients over 18 years old with septic shock within the first 48 hours after the onset of organ dysfunction. Interleukin 6 (IL-6), interleukin 8 (IL-8), interleukin 10 (IL-10) and C-reactive protein levels were assessed at inclusion and after 24 hours, and the differences between these values were calculated. The progression of organ dysfunction was assessed using the Sequential Organ Failure Assessment (SOFA) score upon admission and 24 hours later for a delta-SOFA determination and were categorized as either worsened or improved. The results were expressed as means + standard deviation or median (25-75% percentiles). Values with descriptive p values of 0.05 or less were considered significant. RESULTS: Overall, we included 41 patients with median SOFA scores of 8.0 (6.5-10.0) upon admission (T0) and 8.0 (6.0-10.0) 24 hours later (T1). Worsened, improved or unchanged SOFA scores were observed in 11 (Group 1), 17 (Group 2) and 13 (Group 3) patients, respectively. For Group 1, the baseline IL-6, IL-8 and IL-10 values were higher, and a significant increase of IL-8 levels was found after 24 hours. The change in the SOFA score after 24 hours was significantly, although weakly, correlated with baseline IL-6 and IL-8 concentrations. CONCLUSIONS: Higher baseline IL-6, IL-8 and IL-10 levels are associated with unfavorable organ dysfunction outcomes. Increased IL-8 levels within the first 24 hours are correlated with a worsening dysfunction.
Abstract
Rev Bras Ter Intensiva. 2010;22(4):399-402
DOI 10.1590/S0103-507X2010000400014
Ophidian accidents are not rare in Brazil. Its frequency is of about 30,000 cases/year in Brazil, although ranging between different regions. The gender Bothrops, which includes snakes popularly known as 'jararaca', is by far the most frequently involved, followed by the gender Crotalus, mainly represented by the rattlesnake. Other genders as Micrurus and Lachesis have lower epidemiological relevance. Critical cases are uncommon, and the most severe complications include renal failure and blood coagulation disorders. Adult respiratory distress syndrome and multi-organ systems failure are described, although rare. This report is aims to describe a case involving a Bothrops ophidian accident progressing to adult respiratory distress syndrome and multi-organ and systems failure, and to discuss the therapy used.
Abstract
Rev Bras Ter Intensiva. 2010;22(2):118-124
DOI 10.1590/S0103-507X2010000200004
OBJECTIVE: We aimed to investigate the prevalence and independent predictors of prolonged gastrointestinal dysfunction in critically ill patients admitted to the intensive care unit. METHODS: Retrospective and observational cohort study performed in a mixed 24 beds intensive care unit in a tertiary center. Patients admitted in the intensive care unit between August 2003 and January 2004, who had a length of stay in the intensive care unit greater than 4 days were enrolled. Gastrointestinal function was evaluated daily according to a classification that considered physical examination (bowel sounds or distension) and the nutritional support progress. RESULTS: Were included 128 patients. The mean age was 56 ± 19 years, 63.3% were male and 77.3% were surgical patients. Prolonged gastrointestinal dysfunction occurred in 35% of patients, with prevalence 3.3 times higher in surgical patients (27%) than in medical patients (8%). Endoscopies were performed in 38 patients (29.7%), and in three quarters of them erosive lesions and or bleeding were observed. Gastrointestinal dysfunction was more frequent in patients presenting moderate or severe edema (51%) than in patients without edema (22.5%) (p<0.05). In the logistic regression analysis, a serum lactate level higher than 5.2 mEq/L (RR 6.69 95%CI 15-38.7, P = 0.034) and the presence of a low oxygenation index (RR 12.4 95%CI 2.18-70.8, p = 0.005) were predictive of gastrointestinal dysfunction. CONCLUSION: Prolonged gastrointestinal dysfunction was highly prevalent in this heterogeneous population of critically ill patients. Admission high serum lactate levels and a low oxygenation index were predictive of prolonged gastrointestinal dysfunction.
Abstract
Rev Bras Ter Intensiva. 2010;22(1):64-68
DOI 10.1590/S0103-507X2010000100011
A sepsis staging system focused on predisposition, insult, host response and organ failure may provide a useful basis for risk stratification. Knowledge on interactions among predisposing factors, insult characteristics and host response might help us to improve our understanding on sepsis pathophysiology and allow more individual therapeutic approach. Recent clinical studies documented the clinical importance of PIRO approach for severity stratification in septic patients in intensive care unit, and also for specific conditions such as community acquired pneumonia and ventilator associated pneumonia , with a good performance for outcome prediction. In this review we describe how this new concept can be used in clinical practice and provide some insights on its usefulness to facilitate the stratification and potential for enrollment in clinical trials of sepsis therapies.
Abstract
Rev Bras Ter Intensiva. 2009;21(4):425-431
DOI 10.1590/S0103-507X2009000400013
Despite recent advances in diagnosis and care of critically ill patients sepsis related mortality rate remains unacceptably high. Therefore, new methods of evaluation are necessary to provide an earlier and more accurate characterization of septic patients. Based on the (oncologic) TNM system, the PIRO concept was introduced as a new staging system for sepsis in order to assess risk and predict prognosis, with potential to assist in inclusion of patients in clinical studies and estimate the probability of response of patients to specific therapeutic interventions.
Abstract
Rev Bras Ter Intensiva. 2008;20(4):376-384
DOI 10.1590/S0103-507X2008000400010
OBJECTIVES: Due to the dramatic medical breakthroughs and an increasingly ageing population, the proportion of patients who are at risk of dying following surgery is increasing over time. The aim of this study was to evaluate the outcomes and the epidemiology of non-cardiac surgical patients admitted to the intensive care unit. METHODS: A multicenter, prospective, observational, cohort study was carried out in 21 intensive care units. A total of 885 adult surgical patients admitted to a participating intensive care unit from April to June 2006 were evaluated and 587 patients were enrolled. Exclusion criteria were trauma, cardiac, neurological, gynecologic, obstetric and palliative surgeries. The main outcome measures were postoperative complications and intensive care unit and 90-day mortality rates. RESULTS: Major and urgent surgeries were performed in 66.4% and 31.7% of the patients, respectively. The intensive care unit mortality rate was 15%, and 38% of the patients had postoperative complications. The most common complication was infection or sepsis (24.7%). Myocardial ischemia was diagnosed in only 1.9% of the patients. A total of 94 % of the patients who died after surgery had co-morbidities at the time of surgery (3.4 ± 2.2). Multiple organ failure was the main cause of death (53%). CONCLUSION: Sepsis is the predominant cause of morbidity in patients undergoing non-cardiac surgery. In this patient population, multiple organ failure prevailed as the most frequent cause of death in the hospital.