Abstract
Crit Care Sci. 2023;35(2):117-146
DOI 10.5935/2965-2774.20230310-pt
Echocardiography in critically ill patients has become essential in the evaluation of patients in different settings, such as the hospital. However, unlike for other matters related to the care of these patients, there are still no recommendations from national medical societies on the subject. The objective of this document was to organize and make available expert consensus opinions that may help to better incorporate echocardiography in the evaluation of critically ill patients. Thus, the Associação de Medicina Intensiva Brasileira, the Associação Brasileira de Medicina de Emergência, and the Sociedade Brasileira de Medicina Hospitalar formed a group of 17 physicians to formulate questions relevant to the topic and discuss the possibility of consensus for each of them. All questions were prepared using a five-point Likert scale. Consensus was defined a priori as at least 80% of the responses between one and two or between four and five. The consideration of the issues involved two rounds of voting and debate among all participants. The 27 questions prepared make up the present document and are divided into 4 major assessment areas: left ventricular function, right ventricular function, diagnosis of shock, and hemodynamics. At the end of the process, there were 17 positive (agreement) and 3 negative (disagreement) consensuses; another 7 questions remained without consensus. Although areas of uncertainty persist, this document brings together consensus opinions on several issues related to echocardiography in critically ill patients and may enhance its development in the national scenario.
Abstract
Crit Care Sci. 2023;35(1):107-111
DOI 10.5935/2965-2774.20230305-pt
Cardiac output is an essential determinant of oxygen delivery, although unreliably measured on clinical examination and routine monitoring. Unfortunately, cardiac output monitoring is rarely performed in pediatric critical care medicine, with a limited availability of accurate methods for children. Herein, we report two pediatric cases in which noninvasive pulse-wave transit time-based cardiac output monitoring (esCCO, Nihon Kohden, Tokyo, Japan) was used. The esCCO system calculates cardiac output continuously by using the negative correlation between stroke volume and pulse wave transit time and requires only electrocardiogram monitoring, noninvasive blood pressure, and pulse oximetry signals. Before starting its use, esCCO should be calibrated, which can be done using patient information (gender, age, height, and body weight) or entering cardiac output values obtained by other methods. In both cases, when calibrations were performed using patient information, the agreement between esCCO and echocardiographic measurements was poor. However, after calibration with transthoracic echocardiography, the cardiac output values obtained by both methods remained similar after 2 hours and 18 hours. The results indicate that the esCCO system is suitable for use in children; however, further studies are needed to optimize its algorithm and determine its accuracy, precision, and trend in children.
Abstract
Rev Bras Ter Intensiva. 2022;34(4):477-483
DOI 10.5935/0103-507X.20220280-en
To create and validate a model for predicting septic or hypovolemic shock from easily obtainable variables collected from patients at admission to an intensive care unit.
A predictive modeling study with concurrent cohort data was conducted in a hospital in the interior of northeastern Brazil. Patients aged 18 years or older who were not using vasoactive drugs on the day of admission and were hospitalized from November 2020 to July 2021 were included. The Decision Tree, Random Forest, AdaBoost, Gradient Boosting and XGBoost classification algorithms were tested for use in building the model. The validation method used was k-fold cross validation. The evaluation metrics used were recall, precision and area under the Receiver Operating Characteristic curve.
A total of 720 patients were used to create and validate the model. The models showed high predictive capacity with areas under the Receiver Operating Characteristic curve of 0.979; 0.999; 0.980; 0.998 and 1.00 for the Decision Tree, Random Forest, AdaBoost, Gradient Boosting and XGBoost algorithms, respectively.
The predictive model created and validated showed a high ability to predict septic and hypovolemic shock from the time of admission of patients to the intensive care unit.
Abstract
Rev Bras Ter Intensiva. 2021;33(2):206-218
DOI 10.5935/0103-507X.20210028
To describe fluid resuscitation practices in Brazilian intensive care units and to compare them with those of other countries participating in the Fluid-TRIPS.
This was a prospective, international, cross-sectional, observational study in a convenience sample of intensive care units in 27 countries (including Brazil) using the Fluid-TRIPS database compiled in 2014. We described the patterns of fluid resuscitation use in Brazil compared with those in other countries and identified the factors associated with fluid choice.
On the study day, 3,214 patients in Brazil and 3,493 patients in other countries were included, of whom 16.1% and 26.8% (p < 0.001) received fluids, respectively. The main indication for fluid resuscitation was impaired perfusion and/or low cardiac output (Brazil: 71.7% versus other countries: 56.4%, p < 0.001). In Brazil, the percentage of patients receiving crystalloid solutions was higher (97.7% versus 76.8%, p < 0.001), and 0.9% sodium chloride was the most commonly used crystalloid (62.5% versus 27.1%, p < 0.001). The multivariable analysis suggested that the albumin levels were associated with the use of both crystalloids and colloids, whereas the type of fluid prescriber was associated with crystalloid use only.
Our results suggest that crystalloids are more frequently used than colloids for fluid resuscitation in Brazil, and this discrepancy in frequencies is higher than that in other countries. Sodium chloride (0.9%) was the crystalloid most commonly prescribed. Serum albumin levels and the type of fluid prescriber were the factors associated with the choice of crystalloids or colloids for fluid resuscitation.
Abstract
Rev Bras Ter Intensiva. 2019;31(1):47-56
DOI 10.5935/0103-507X.20190011
To determine the association between the primary site of infection and in-hospital mortality as the main outcome, or the need for admission to the intensive care unit as a secondary outcome, in patients with sepsis admitted to the emergency department.
This was a secondary analysis of a multicenter prospective cohort. Patients included in the study were older than 18 years with a diagnosis of severe sepsis or septic shock who were admitted to the emergency departments of three tertiary care hospitals. Of the 5022 eligible participants, 2510 were included. Multiple logistic regression analysis was performed for mortality.
The most common site of infection was the urinary tract, present in 27.8% of the cases, followed by pneumonia (27.5%) and intra-abdominal focus (10.8%). In 5.4% of the cases, no definite site of infection was identified on admission. Logistic regression revealed a significant association between the following sites of infection and in-hospital mortality when using the urinary infection group as a reference: pneumonia (OR 3.4; 95%CI, 2.2 - 5.2; p < 0.001), skin and soft tissues (OR 2.6; 95%CI, 1.4 - 5.0; p = 0.003), bloodstream (OR 2.0; 95%CI, 1.1 - 3.6; p = 0.018), without specific focus (OR 2.0; 95%CI, 1.1 - 3.8; p = 0.028), and intra-abdominal focus (OR 1.9; 95%CI, 1.1 - 3.3; p = 0.024).
There is a significant association between the different sites of infection and in-hospital mortality or the need for admission to an intensive care unit in patients with sepsis or septic shock. Urinary tract infection shows the lowest risk, which should be considered in prognostic models of these conditions.
Abstract
Rev Bras Ter Intensiva. 2017;29(2):238-247
DOI 10.5935/0103-507X.20170033
Parameters related to macrocirculation, such as the mean arterial pressure, central venous pressure, cardiac output, mixed venous saturation and central oxygen saturation, are commonly used in the hemodynamic assessment of critically ill patients. However, several studies have shown that there is a dissociation between these parameters and the state of microcirculation in this group of patients. Techniques that allow direct viewing of the microcirculation are not completely disseminated, nor are they incorporated into the clinical management of patients in shock. The numerous techniques developed for microcirculation assessment include clinical assessment (e.g., peripheral perfusion index and temperature gradient), laser Doppler flowmetry, tissue oxygen assessment electrodes, videomicroscopy (orthogonal polarization spectral imaging, sidestream dark field imaging or incident dark field illumination) and near infrared spectroscopy. In the near future, the monitoring and optimization of tissue perfusion by direct viewing and microcirculation assessment may become a goal to be achieved in the hemodynamic resuscitation of critically ill patients.
Abstract
Rev Bras Ter Intensiva. 2013;25(4):270-278
DOI 10.5935/0103-507X.20130047
The current definition of severe sepsis and septic shock includes a heterogeneous profile of patients. Although the prognostic value of hyperlactatemia is well established, hyperlactatemia is observed in patients with and without shock. The present study aimed to compare the prognosis of septic patients by stratifying them according to two factors: hyperlactatemia and persistent hypotension.
The present study is a secondary analysis of an observational study conducted in ten hospitals in Brazil (Rede Amil - SP). Septic patients with initial lactate measurements in the first 6 hours of diagnosis were included and divided into 4 groups according to hyperlactatemia (lactate >4mmol/L) and persistent hypotension: (1) severe sepsis (without both criteria); (2) cryptic shock (hyperlactatemia without persistent hypotension); (3) vasoplegic shock (persistent hypotension without hyperlactatemia); and (4) dysoxic shock (both criteria).
In total, 1,948 patients were analyzed, and the sepsis group represented 52% of the patients, followed by 28% with vasoplegic shock, 12% with dysoxic shock and 8% with cryptic shock. Survival at 28 days differed among the groups (p<0.001). Survival was highest among the severe sepsis group (69%, p<0.001 versus others), similar in the cryptic and vasoplegic shock groups (53%, p=0.39), and lowest in the dysoxic shock group (38%, p<0.001 versus others). In the adjusted analysis, the survival at 28 days remained different among the groups (p<0.001) and the dysoxic shock group exhibited the highest hazard ratio (HR=2.99, 95%CI 2.21-4.05).
The definition of sepsis includes four different profiles if we consider the presence of hyperlactatemia. Further studies are needed to better characterize septic patients, to understand the etiology and to design adequate targeted treatments.
Abstract
Rev Bras Ter Intensiva. 2012;24(2):130-136
DOI 10.1590/S0103-507X2012000200006
OBJECTIVE: To examine the behavior of interleukin-12 and verify whether it can be used to differentiate septic conditions in children. METHODS: Septic children aged between 28 days and 14 years, prospectively enrolled from 01/2004 to 12/2005, were divided into sepsis (SG; n=47) and septic shock (SSG; n=43) groups. Interleukin-12 levels were measured at admission (T0) and 12 hours later (T12). Disease severity was assessed by the PRISM score. RESULTS: Interleukin-12 levels did not differentiate children with sepsis from those with septic shock at admission [SSG: 0.24 (0-226.4)=SG: 1.23 (0-511.6); p=0.135)] and T12 [SG: 6.11 (0-230.5)=SSG: 1.32 (0-61.0); p=0.1239)]. Comparing time points, no significant difference was observed in the SG [SG, T0: 1.23 (0-511.6)=T12: 6.11 (0-230.5); p=0.075]. In SSG however, interleukin-12 increased from T0 to T12 (SSG, T0: 0.24 (0-226.4)