Artigos Originais Archives - Critical Care Science (CCS)
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):229-233
04-30-2006
DOI 10.1590/S0103-507X2006000300003
BACKGROUND AND OBJECTIVES: Gastrointestinal bleeding due to stress ulcer (GB) complicates critical disease, and must be received prophylaxis based on defined criteria. To evaluate the GB prophylaxis in Intensive Care Units (ICU), and to compare with the guidelines. METHODS: We carried out a cross-sectional multicenter study in 21 medical-surgical ICU in Brazil to investigate this issue. For data analysis, these were distributed in 3 sub-groups (high, moderate and low risk for GB). RESULTS: 235 patients were evaluated, with mean age of 57.7 ± 19.5 years and days on ICU 13 ± 19.7. The more common admission ICU diagnoses were sepsis (26%) and postoperative (16.2%) patients. Seventy-three (73%) of the patients were GB high risk, 21.5% moderate and 5.5% low risk. Of the 187 high risk patients, 139 were receiving GB prophylaxis (60% with histamine blockers (HB2) and 39% with proton pump inhibitors (PPI). Of these patients, 25.7% did not receive GU prophylaxis, although indicated it. Of the 55 moderate risk patients, 70.9% wer e receiving GU prophylaxis (22 with HB2 and 17 with PPI). Of the 14 low risk patients, 71% were using GU prophylaxis (6 with HB2 and 4 with PPI). CONCLUSIONS: Almost 80% of the patients made use of GB prophylactic drugs, with no agreement GU risk stratification. This study demonstrated the no adequate GU prophylaxis in the Brazilian ICU.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):229-233
04-30-2006
DOI 10.1590/S0103-507X2006000300003
BACKGROUND AND OBJECTIVES: Gastrointestinal bleeding due to stress ulcer (GB) complicates critical disease, and must be received prophylaxis based on defined criteria. To evaluate the GB prophylaxis in Intensive Care Units (ICU), and to compare with the guidelines. METHODS: We carried out a cross-sectional multicenter study in 21 medical-surgical ICU in Brazil to investigate this issue. For data analysis, these were distributed in 3 sub-groups (high, moderate and low risk for GB). RESULTS: 235 patients were evaluated, with mean age of 57.7 ± 19.5 years and days on ICU 13 ± 19.7. The more common admission ICU diagnoses were sepsis (26%) and postoperative (16.2%) patients. Seventy-three (73%) of the patients were GB high risk, 21.5% moderate and 5.5% low risk. Of the 187 high risk patients, 139 were receiving GB prophylaxis (60% with histamine blockers (HB2) and 39% with proton pump inhibitors (PPI). Of these patients, 25.7% did not receive GU prophylaxis, although indicated it. Of the 55 moderate risk patients, 70.9% wer e receiving GU prophylaxis (22 with HB2 and 17 with PPI). Of the 14 low risk patients, 71% were using GU prophylaxis (6 with HB2 and 4 with PPI). CONCLUSIONS: Almost 80% of the patients made use of GB prophylactic drugs, with no agreement GU risk stratification. This study demonstrated the no adequate GU prophylaxis in the Brazilian ICU.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):219-228
04-30-2006
DOI 10.1590/S0103-507X2006000300002
BACKGROUND AND OBJECTIVES: There are few epidemiological studies in mechanical ventilation, and the aim of the study is to show how this procedure is being used in Brazil. METHODS: A 1-day point prevalence study was performed in 40 ICUs, with 390 patients; 217 of these patients were in mechanical ventilation. The results evaluated were the characteristics of ventilated patients, their distribution in Brazil, the mechanical ventilation's causes, the main ventilatory modes, the more important ventilators settings, and the weaning stage of mechanical ventilation. RESULTS: The median age of the ventilated patients was 66 years old. The median APACHE II was 20, while the median time of mechanical ventilation was 11 days. Acute respiratory failure occurred in 71% of the patients, coma in 21.2%, acute exacerbation of chronic respiratory failure in 5.5%, and the neuromuscular disease in 2.3%. The volume-controlled ventilation (VCV) (30%), the pressure support ventilation (PSV) (29.5%), and the pressure-controlled ventilation (PCV) (18%) were the ventilatory modes most used; the PSV had been the main mode in weaning (63.5%). The median of tidal volume (8 mL/kg) was higher in VCV. The median of maximal inspiratory pression (30 cmH2O) and the median of positive end-expiration pressure (PEEP) (8 cmH2O) were higher in PCV. CONCLUSIONS: The predominance of ventilated patients in ICUs was marked by clinical severity of them, and a longer hospital stay time; acute respiratory failure was the principal mechanical ventilation cause; VCV and PSV ventilated more patients, with PSV being more used in weaning patients.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):219-228
04-30-2006
DOI 10.1590/S0103-507X2006000300002
BACKGROUND AND OBJECTIVES: There are few epidemiological studies in mechanical ventilation, and the aim of the study is to show how this procedure is being used in Brazil. METHODS: A 1-day point prevalence study was performed in 40 ICUs, with 390 patients; 217 of these patients were in mechanical ventilation. The results evaluated were the characteristics of ventilated patients, their distribution in Brazil, the mechanical ventilation's causes, the main ventilatory modes, the more important ventilators settings, and the weaning stage of mechanical ventilation. RESULTS: The median age of the ventilated patients was 66 years old. The median APACHE II was 20, while the median time of mechanical ventilation was 11 days. Acute respiratory failure occurred in 71% of the patients, coma in 21.2%, acute exacerbation of chronic respiratory failure in 5.5%, and the neuromuscular disease in 2.3%. The volume-controlled ventilation (VCV) (30%), the pressure support ventilation (PSV) (29.5%), and the pressure-controlled ventilation (PCV) (18%) were the ventilatory modes most used; the PSV had been the main mode in weaning (63.5%). The median of tidal volume (8 mL/kg) was higher in VCV. The median of maximal inspiratory pression (30 cmH2O) and the median of positive end-expiration pressure (PEEP) (8 cmH2O) were higher in PCV. CONCLUSIONS: The predominance of ventilated patients in ICUs was marked by clinical severity of them, and a longer hospital stay time; acute respiratory failure was the principal mechanical ventilation cause; VCV and PSV ventilated more patients, with PSV being more used in weaning patients.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):276-281
04-30-2006
DOI 10.1590/S0103-507X2006000300010
BACKGROUND AND OBJECTIVES: ICU is the hospital sectors that have interrupt assistance. Assistance with quality is a challenge for those who run human resources. It is also important to know the risk of the patient to the better use of resources. The aim of this study is to identify most used severity indexes in intensive care and classify them according with their finality METHODS: Library research (medline), using the key words: "Scoring systems and ICU". The articles were selected in the period from March to May 2005. Books and thesis were also used. RESULTS: We identify seven indexes evaluating nursing workload: TISS, TISS-28, TOSS, NEMS, NAS, NCR11, and Omega. We identify 21 indexes evaluating clinical status: Killip Glasgow CRI APACHE II e III, Ransom, SS, SSS, SAPS, MLR, MPM, LIS, ARPI, SAPS (II), MPM II, ODIN, Ontario, MODS, SOFA, LOD, and PSI). CONCLUSIONS: Although indexes evaluating nursing workload are in a lower number, they are also fundamental to preview the need for material and human resources.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):276-281
04-30-2006
DOI 10.1590/S0103-507X2006000300010
BACKGROUND AND OBJECTIVES: ICU is the hospital sectors that have interrupt assistance. Assistance with quality is a challenge for those who run human resources. It is also important to know the risk of the patient to the better use of resources. The aim of this study is to identify most used severity indexes in intensive care and classify them according with their finality METHODS: Library research (medline), using the key words: "Scoring systems and ICU". The articles were selected in the period from March to May 2005. Books and thesis were also used. RESULTS: We identify seven indexes evaluating nursing workload: TISS, TISS-28, TOSS, NEMS, NAS, NCR11, and Omega. We identify 21 indexes evaluating clinical status: Killip Glasgow CRI APACHE II e III, Ransom, SS, SSS, SAPS, MLR, MPM, LIS, ARPI, SAPS (II), MPM II, ODIN, Ontario, MODS, SOFA, LOD, and PSI). CONCLUSIONS: Although indexes evaluating nursing workload are in a lower number, they are also fundamental to preview the need for material and human resources.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):268-275
04-30-2006
DOI 10.1590/S0103-507X2006000300009
BACKGROUND AND OBJECTIVES: Actually tight glycemic control is a major concern in critical care. The objective of this study was to evaluate effectiveness and safety of Yale insulin infusion protocol in a Brazilian medical and surgical intensive care unit. METHODS: Retrospective, before-after cohort study. Selected end-points were mean blood glucose levels, time-to-reach target range of 80 - 140 mg/dL, and percent of blood glucose in target range and hypoglycemia incidence. RESULTS: Were studied 112 patients: 60 in control group (CG) and 52 in protocol group (PG). Bedside blood glucose was measured 5392 times for a mean value of 131.2 ± 14.7 mg/dL in the PG versus 2485 times for a mean value of 181.7 ± 36.1 mg/dL in the CG. Blood glucose values were in the target range 65% and 32% of the times, respectively for PG and CG groups (p < 0.001). The median time to reach glucose target range was 7 h (range 4 -10 h) for PG and 96 hr (range 46 - 278 h) for CG (p < 0.001). Incidence of severe hypoglycemia did not reach difference statistically significant: 4 patients in PG versus 2 patients in CG. CONCLUSIONS: Yale insulin infusion protocol was effective and safe to improve blood glucose control in a Brazilian medical and surgical intensive care unit.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):268-275
04-30-2006
DOI 10.1590/S0103-507X2006000300009
BACKGROUND AND OBJECTIVES: Actually tight glycemic control is a major concern in critical care. The objective of this study was to evaluate effectiveness and safety of Yale insulin infusion protocol in a Brazilian medical and surgical intensive care unit. METHODS: Retrospective, before-after cohort study. Selected end-points were mean blood glucose levels, time-to-reach target range of 80 - 140 mg/dL, and percent of blood glucose in target range and hypoglycemia incidence. RESULTS: Were studied 112 patients: 60 in control group (CG) and 52 in protocol group (PG). Bedside blood glucose was measured 5392 times for a mean value of 131.2 ± 14.7 mg/dL in the PG versus 2485 times for a mean value of 181.7 ± 36.1 mg/dL in the CG. Blood glucose values were in the target range 65% and 32% of the times, respectively for PG and CG groups (p < 0.001). The median time to reach glucose target range was 7 h (range 4 -10 h) for PG and 96 hr (range 46 - 278 h) for CG (p < 0.001). Incidence of severe hypoglycemia did not reach difference statistically significant: 4 patients in PG versus 2 patients in CG. CONCLUSIONS: Yale insulin infusion protocol was effective and safe to improve blood glucose control in a Brazilian medical and surgical intensive care unit.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):263-267
04-30-2006
DOI 10.1590/S0103-507X2006000300008
BACKGROUND AND OBJECTIVES: To identify the severity of elderly patients admitted to the intensive care unit (ICU) in a university hospital, relating it to the in-ICU mortality. METHODS: Retrospective study, with analysis of 130 patients admitted to ICU from March 2004 to July 2005. RESULTS: Of the 130 patients, there was a predominance of women, and mean 72.2 ± 7.3 years. There were more patients between 65 and 74 years old. More than 80% of the patients had come from the university hospital itself. The main dysfunctions were from the cardiocirculatory and respiratory systems. Sepsis caused 23.8% of the admissions. Length of stay in ICU was 8.2 ± 7.6 days. The mean of APACHE II was 18.2 ± 7.2. Lesser values of APACHE II, length of stay and mortality were observed in patients with cardiocirculatory dysfunction. The in-ICU mortality was 33.9%, 6.2% before 48 hours. The standardized mortality ratio (SMR) was 0.988. CONCLUSIONS: The age groups did not determine difference between values of APACHE II. They were related neither to higher mortality rate, nor to higher ICU length of stay. Patients with cardiocirculatory dysfunctions had lesser values of APACHE II, ICU length of stay and in-ICU mortality.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):263-267
04-30-2006
DOI 10.1590/S0103-507X2006000300008
BACKGROUND AND OBJECTIVES: To identify the severity of elderly patients admitted to the intensive care unit (ICU) in a university hospital, relating it to the in-ICU mortality. METHODS: Retrospective study, with analysis of 130 patients admitted to ICU from March 2004 to July 2005. RESULTS: Of the 130 patients, there was a predominance of women, and mean 72.2 ± 7.3 years. There were more patients between 65 and 74 years old. More than 80% of the patients had come from the university hospital itself. The main dysfunctions were from the cardiocirculatory and respiratory systems. Sepsis caused 23.8% of the admissions. Length of stay in ICU was 8.2 ± 7.6 days. The mean of APACHE II was 18.2 ± 7.2. Lesser values of APACHE II, length of stay and mortality were observed in patients with cardiocirculatory dysfunction. The in-ICU mortality was 33.9%, 6.2% before 48 hours. The standardized mortality ratio (SMR) was 0.988. CONCLUSIONS: The age groups did not determine difference between values of APACHE II. They were related neither to higher mortality rate, nor to higher ICU length of stay. Patients with cardiocirculatory dysfunctions had lesser values of APACHE II, ICU length of stay and in-ICU mortality.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):256-262
04-30-2006
DOI 10.1590/S0103-507X2006000300007
BACKGROUND AND OBJECTIVES: There is no literature consensus about the time of airway occlusion sufficient enough to get a true PImax during weaning from mechanical ventilation (MV). So, the main objectives of the present study were to compare two methods PImax measurement and to evaluate the influence of patients' level of conscience on them. METHODS: The population was composed by 28 general ICU patients, with MV > 48h, in a weaning process, divided into two groups according to Glasgow coma scale score: with (GCS < 15) and without (GCS = 15) alterations of conscience level. The airway was occluded by using an unidirectional valve for 20s (PImaxT20), or for a maximum time of one minute if a plateau of inspiratory pressure was not observed during three consecutive inspirations (PImaxTid). RESULTS: PImaxT20 (mean ± SD, cmH2O) values were similar in both groups (44 ± 16 vs42 ± 15, p = 0.52). However, PImaxTid values, as long as the time needed to their attainment, were greater in GCS < 15 group (65 ± 24 vs 47 ± 23cmH2O and 37 ± 10 vs24 ± 8s, p = 0.04 and 0.0019, respectively). CONCLUSIONS: The method commonly used of 20s airway occlusion seems to be inadequate to get the true PImax in patients with alterations of the level of conscience. Additional studies, now in a more homogeneous group (e. g.: patients with structural brain lesion), are needed to clarify these findings.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):256-262
04-30-2006
DOI 10.1590/S0103-507X2006000300007
BACKGROUND AND OBJECTIVES: There is no literature consensus about the time of airway occlusion sufficient enough to get a true PImax during weaning from mechanical ventilation (MV). So, the main objectives of the present study were to compare two methods PImax measurement and to evaluate the influence of patients' level of conscience on them. METHODS: The population was composed by 28 general ICU patients, with MV > 48h, in a weaning process, divided into two groups according to Glasgow coma scale score: with (GCS < 15) and without (GCS = 15) alterations of conscience level. The airway was occluded by using an unidirectional valve for 20s (PImaxT20), or for a maximum time of one minute if a plateau of inspiratory pressure was not observed during three consecutive inspirations (PImaxTid). RESULTS: PImaxT20 (mean ± SD, cmH2O) values were similar in both groups (44 ± 16 vs42 ± 15, p = 0.52). However, PImaxTid values, as long as the time needed to their attainment, were greater in GCS < 15 group (65 ± 24 vs 47 ± 23cmH2O and 37 ± 10 vs24 ± 8s, p = 0.04 and 0.0019, respectively). CONCLUSIONS: The method commonly used of 20s airway occlusion seems to be inadequate to get the true PImax in patients with alterations of the level of conscience. Additional studies, now in a more homogeneous group (e. g.: patients with structural brain lesion), are needed to clarify these findings.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):251-255
04-30-2006
DOI 10.1590/S0103-507X2006000300006
BACKGROUND AND OBJECTIVES: Oncologic diseases are conditions that have influence in the treatment offered to affected patients. The aim of this study was to compare hospitalar outcome of oncologic and non oncologic patients submitted to high risk elective surgery. METHODS: Prospective, observational cohort study realized in an ICU of a tertiary hospital during the period between 04/01/2005 and 07/31/2005. Demographic data, APACHE II and MODS scores and laboratorial and hemodynamic variables were collected and complications like re-intervention need for mechanical ventilation, red blood cell transfusions and pulmonary artery catheter use during the post-operative period were evaluated. All patients were followed until hospital discharge or death. T student and Mann Whitney tests were used to compare numerical variables. Chi-square test was used to compare categorical variables. A p < 0.05 was considered as significant. RESULTS: 119 patients were included in the study. 43 were oncologic and 76 were non-oncologic. 52.9% were female. Mean age was 65.1 ± 14.1 years. Mean APACHE II score was 16.5 ± 5.8 and MODS median was 3 (2-6). Median length of surgery was 5 (3.3-7) hours and ICU and hospital mortality were 10.9% and 25.2%, respectively. Oncologic patients had greater length of hospital stay and length of stay before surgery. These results were statistically significant. Hospital mortality of oncologic patients was not greater than non-oncologic patients (22.4% versus 30.2%, p = 0.32). CONCLUSIONS: In this series, oncologic patients submitted to high risk surgery had the same mortality rate as non-onconlogic patients with similar disease severity.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):251-255
04-30-2006
DOI 10.1590/S0103-507X2006000300006
BACKGROUND AND OBJECTIVES: Oncologic diseases are conditions that have influence in the treatment offered to affected patients. The aim of this study was to compare hospitalar outcome of oncologic and non oncologic patients submitted to high risk elective surgery. METHODS: Prospective, observational cohort study realized in an ICU of a tertiary hospital during the period between 04/01/2005 and 07/31/2005. Demographic data, APACHE II and MODS scores and laboratorial and hemodynamic variables were collected and complications like re-intervention need for mechanical ventilation, red blood cell transfusions and pulmonary artery catheter use during the post-operative period were evaluated. All patients were followed until hospital discharge or death. T student and Mann Whitney tests were used to compare numerical variables. Chi-square test was used to compare categorical variables. A p < 0.05 was considered as significant. RESULTS: 119 patients were included in the study. 43 were oncologic and 76 were non-oncologic. 52.9% were female. Mean age was 65.1 ± 14.1 years. Mean APACHE II score was 16.5 ± 5.8 and MODS median was 3 (2-6). Median length of surgery was 5 (3.3-7) hours and ICU and hospital mortality were 10.9% and 25.2%, respectively. Oncologic patients had greater length of hospital stay and length of stay before surgery. These results were statistically significant. Hospital mortality of oncologic patients was not greater than non-oncologic patients (22.4% versus 30.2%, p = 0.32). CONCLUSIONS: In this series, oncologic patients submitted to high risk surgery had the same mortality rate as non-onconlogic patients with similar disease severity.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):242-250
04-30-2006
DOI 10.1590/S0103-507X2006000300005
BACKGROUND AND OBJECTIVES: Packed red blood cell (PRBC) transfusion is frequent in intensive care unit (ICU). However, the consequences of anemia in ICU patients are poorly understood. Our aim was to evaluate the prevalence, indications, pre-transfusion hematocrit and hemoglobin levels, and outcomes of ICU patients transfused with PRBC. METHODS: Prospective cohort study conducted at a medical-surgical ICU of a teaching hospital during a 16-month period. Patients' demographic, clinical, laboratory and transfusion-related data were collected. Logistic regression was used after univariate analyses. RESULTS: A total of 698 patients were evaluated and 244 (35%) received PRBC, mainly within the first four days of ICU (82.4%). Transfusion was more frequent in medical and emergency surgical patients. The mean pre-transfusion hematocrit and hemoglobin were 22.8% ± 4.5% and 7.9 ± 1.4 g/dL, respectively. Transfused patients received 4.4 ± 3.7 PRBC during ICU stay and 2.2 ± 1 PRBC at each transfusion. The ICU (39.8% versus 13.2%; p < 0.0001) and hospital (48.8% versus 20.3%; p < 0.0001) mortality rates were higher in transfused patients. Mortality increased as the number of transfused PRBC increased (R² = 0.91). In logistic regression, predictive factors for PRBC transfusion were hepatic cirrhosis, mechanical ventilation (MV), type and duration of ICU admission, and hematocrit. The independent factors associated to hospital mortality were MV, transfusions of more than five PRBC and SAPS II score. CONCLUSIONS: PRBC transfusions are frequent in ICU patients, especially in those with medical and emergency surgical complications, longer ICU stay, and hepatic cirrhosis and in need of MV. Pre-transfusion hemoglobin levels were lower than those previously reported. In our study, PRBC transfusion was associated with increased mortality.
Abstract
Revista Brasileira de Terapia Intensiva. 2006;18(3):242-250
04-30-2006
DOI 10.1590/S0103-507X2006000300005
BACKGROUND AND OBJECTIVES: Packed red blood cell (PRBC) transfusion is frequent in intensive care unit (ICU). However, the consequences of anemia in ICU patients are poorly understood. Our aim was to evaluate the prevalence, indications, pre-transfusion hematocrit and hemoglobin levels, and outcomes of ICU patients transfused with PRBC. METHODS: Prospective cohort study conducted at a medical-surgical ICU of a teaching hospital during a 16-month period. Patients' demographic, clinical, laboratory and transfusion-related data were collected. Logistic regression was used after univariate analyses. RESULTS: A total of 698 patients were evaluated and 244 (35%) received PRBC, mainly within the first four days of ICU (82.4%). Transfusion was more frequent in medical and emergency surgical patients. The mean pre-transfusion hematocrit and hemoglobin were 22.8% ± 4.5% and 7.9 ± 1.4 g/dL, respectively. Transfused patients received 4.4 ± 3.7 PRBC during ICU stay and 2.2 ± 1 PRBC at each transfusion. The ICU (39.8% versus 13.2%; p < 0.0001) and hospital (48.8% versus 20.3%; p < 0.0001) mortality rates were higher in transfused patients. Mortality increased as the number of transfused PRBC increased (R² = 0.91). In logistic regression, predictive factors for PRBC transfusion were hepatic cirrhosis, mechanical ventilation (MV), type and duration of ICU admission, and hematocrit. The independent factors associated to hospital mortality were MV, transfusions of more than five PRBC and SAPS II score. CONCLUSIONS: PRBC transfusions are frequent in ICU patients, especially in those with medical and emergency surgical complications, longer ICU stay, and hepatic cirrhosis and in need of MV. Pre-transfusion hemoglobin levels were lower than those previously reported. In our study, PRBC transfusion was associated with increased mortality.
