Original Article Archives - Critical Care Science (CCS)

  • Original Article

    Evaluation of the classifications of severity in acute respiratory distress syndrome in childhood by the Berlin Consensus and the Pediatric Acute Lung Injury Consensus Conference

    Crit Care Sci. 2024;36:e20240229en

    Abstract

    Original Article

    Evaluation of the classifications of severity in acute respiratory distress syndrome in childhood by the Berlin Consensus and the Pediatric Acute Lung Injury Consensus Conference

    Crit Care Sci. 2024;36:e20240229en

    DOI 10.62675/2965-2774.20240229-en

    Views57

    ABSTRACT

    Objective

    To compare two methods for defining and classifying the severity of pediatric acute respiratory distress syndrome: the Berlin classification, which uses the relationship between the partial pressure of oxygen and the fraction of inspired oxygen, and the classification of the Pediatric Acute Lung Injury Consensus Conference, which uses the oxygenation index.

    Methods

    This was a prospective study of patients aged 0 - 18 years with a diagnosis of acute respiratory distress syndrome who were invasively mechanically ventilated and provided one to three arterial blood gas samples, totaling 140 valid measurements. These measures were evaluated for correlation using the Spearman test and agreement using the kappa coefficient between the two classifications, initially using the general population of the study and then subdividing it into patients with and without bronchospasm and those with and without the use of neuromuscular blockers. The effect of these two factors (bronchospasm and neuromuscular blocking agent) separately and together on both classifications was also assessed using two-way analysis of variance.

    Results

    In the general population, who were 54 patients aged 0 - 18 years a strong negative correlation was found by Spearman’s test (ρ -0.91; p < 0.001), and strong agreement was found by the kappa coefficient (0.62; p < 0.001) in the comparison between Berlin and Pediatric Acute Lung Injury Consensus Conference. In the populations with and without bronchospasm and who did and did not use neuromuscular blockers, the correlation coefficients were similar to those of the general population, though among patients not using neuromuscular blockers, there was greater agreement between the classifications than for patients using neuromuscular blockers (kappa 0.67 versus 0.56, p < 0.001 for both). Neuromuscular blockers had a significant effect on the relationship between the partial pressure of oxygen and the fraction of inspired oxygen (analysis of variance; F: 12.9; p < 0.001) and the oxygenation index (analysis of variance; F: 8.3; p = 0.004).

    Conclusion

    There was a strong correlation and agreement between the two classifications in the general population and in the subgroups studied. Use of neuromuscular blockers had a significant effect on the severity of acute respiratory distress syndrome.

    See more
  • Original Article

    Alternative approaches to analyzing ventilator-free days, mortality and duration of ventilation in critical care research

    Crit Care Sci. 2024;36:e20240246en

    Abstract

    Original Article

    Alternative approaches to analyzing ventilator-free days, mortality and duration of ventilation in critical care research

    Crit Care Sci. 2024;36:e20240246en

    DOI 10.62675/2965-2774.20240246-en

    Views114

    ABSTRACT

    Objective:

    To discuss the strengths and limitations of ventilator-free days and to provide a comprehensive discussion of the different analytic methods for analyzing and interpreting this outcome.

    Methods:

    Using simulations, the power of different analytical methods was assessed, namely: quantile (median) regression, cumulative logistic regression, generalized pairwise comparison, conditional approach and truncated approach. Overall, 3,000 simulations of a two-arm trial with n = 300 per arm were computed using a two-sided alternative hypothesis and a type I error rate of α = 0.05.

    Results:

    When considering power, median regression did not perform well in studies where the treatment effect was mainly driven by mortality. Median regression performed better in situations with a weak effect on mortality but a strong effect on duration, duration only, and moderate mortality and duration. Cumulative logistic regression was found to produce similar power to the Wilcoxon rank-sum test across all scenarios, being the best strategy for the scenarios of moderate mortality and duration, weak mortality and strong duration, and duration only.

    Conclusion:

    In this study, we describe the relative power of new methods for analyzing ventilator-free days in critical care research. Our data provide validation and guidance for the use of the cumulative logistic model, median regression, generalized pairwise comparisons, and the conditional and truncated approach in specific scenarios.

    See more
  • Original Article

    Goal-directed therapy guided by the FloTrac sensor in major surgery: a systematic review and meta-analysis

    Crit Care Sci. 2024;36:e20240196en

    Abstract

    Original Article

    Goal-directed therapy guided by the FloTrac sensor in major surgery: a systematic review and meta-analysis

    Crit Care Sci. 2024;36:e20240196en

    DOI 10.62675/2965-2774.20240196-en

    Views115

    ABSTRACT

    Objective

    To provide insights into the potential benefits of goal-directed therapy guided by FloTrac in reducing postoperative complications and improving outcomes.

    Methods

    We performed a systematic review and meta-analysis of randomized controlled trials to evaluate goal-directed therapy guided by FloTrac in major surgery, comparing goal-directed therapy with usual care or invasive monitoring in cardiac and noncardiac surgery subgroups. The quality of the articles and evidence were evaluated with a risk of bias tool and GRADE.

    Results

    We included 29 randomized controlled trials with 3,468 patients. Goal-directed therapy significantly reduced the duration of hospital stay (mean difference -1.43 days; 95%CI 2.07 to -0.79; I2 81%), intensive care unit stay (mean difference -0.77 days; 95%CI -1.18 to -0.36; I2 93%), and mechanical ventilation (mean difference -2.48 hours, 95%CI -4.10 to -0.86, I2 63%). There was no statistically significant difference in mortality, myocardial infarction, acute kidney injury or hypotension, but goal-directed therapy significantly reduced the risk of heart failure or pulmonary edema (RR 0.46; 95%CI 0.23 - 0.92; I2 0%).

    Conclusion

    Goal-directed therapy guided by the FloTrac sensor improved clinical outcomes and shortened the length of stay in the hospital and intensive care unit in patients undergoing major surgery. Further research can validate these results using specific protocols and better understand the potential benefits of FloTrac beyond these outcomes.

    See more
  • Original Article

    Driving pressure, as opposed to tidal volume based on predicted body weight, is associated with mortality: results from a prospective cohort of COVID-19 acute respiratory distress syndrome patients

    Crit Care Sci. 2024;36:e20240208en

    Abstract

    Original Article

    Driving pressure, as opposed to tidal volume based on predicted body weight, is associated with mortality: results from a prospective cohort of COVID-19 acute respiratory distress syndrome patients

    Crit Care Sci. 2024;36:e20240208en

    DOI 10.62675/2965-2774.20240208-en

    Views164

    ABSTRACT

    Objective:

    To evaluate the association between driving pressure and tidal volume based on predicted body weight and mortality in a cohort of patients with acute respiratory distress syndrome caused by COVID-19.

    Methods:

    This was a prospective, observational study that included patients with acute respiratory distress syndrome due to COVID-19 admitted to two intensive care units. We performed multivariable analyses to determine whether driving pressure and tidal volume/kg predicted body weight on the first day of mechanical ventilation, as independent variables, are associated with hospital mortality.

    Results:

    We included 231 patients. The mean age was 64 (53 - 74) years, and the mean Simplified Acute and Physiology Score 3 score was 45 (39 - 54). The hospital mortality rate was 51.9%. Driving pressure was independently associated with hospital mortality (odds ratio 1.21, 95%CI 1.04 - 1.41 for each cm H2O increase in driving pressure, p = 0.01). Based on a double stratification analysis, we found that for the same level of tidal volume/kg predicted body weight, the risk of hospital death increased with increasing driving pressure. However, changes in tidal volume/kg predicted body weight were not associated with mortality when they did not lead to an increase in driving pressure.

    Conclusion:

    In patients with acute respiratory distress syndrome caused by COVID-19, exposure to higher driving pressure, as opposed to higher tidal volume/kg predicted body weight, is associated with greater mortality. These results suggest that driving pressure might be a primary target for lung-protective mechanical ventilation in these patients.

    See more
    Driving pressure, as opposed to tidal volume based on predicted body weight, is associated with mortality: results from a prospective cohort of COVID-19 acute respiratory distress syndrome patients
  • Original Article

    A comprehensive physical functional assessment of survivors of critical care unit stay due to COVID-19

    Crit Care Sci. 2024;36:e20240284en

    Abstract

    Original Article

    A comprehensive physical functional assessment of survivors of critical care unit stay due to COVID-19

    Crit Care Sci. 2024;36:e20240284en

    DOI 10.62675/2965-2774.20240284-en

    Views125

    ABSTRACT

    Objective:

    To examine the physical function and respiratory muscle strength of patients - who recovered from critical COVID-19 – after intensive care unit discharge to the ward on Days one (D1) and seven (D7), and to investigate variables associated with functional impairment.

    Methods:

    This was a prospective cohort study of adult patients with COVID-19 who needed invasive mechanical ventilation, non-invasive ventilation or high-flow nasal cannula and were discharged from the intensive care unit to the ward. Participants were submitted to Medical Research Council sum-score, handgrip strength, maximal inspiratory pressure, maximal expiratory pressure, and short physical performance battery tests. Participants were grouped into two groups according to their need for invasive ventilation: the Invasive Mechanical Ventilation Group (IMV Group) and the Non-Invasive Mechanical Ventilation Group (Non-IMV Group).

    Results:

    Patients in the IMV Group (n = 31) were younger and had higher Sequential Organ Failure Assessment scores than those in the Non-IMV Group (n = 33). The short physical performance battery scores (range 0 - 12) on D1 and D7 were 6.1 ± 4.3 and 7.3 ± 3.8, respectively for the Non-Invasive Mechanical Ventilation Group, and 1.3 ± 2.5 and 2.6 ± 3.7, respectively for the IMV Group. The prevalence of intensive care unit-acquired weakness on D7 was 13% for the Non-IMV Group and 72% for the IMV Group. The maximal inspiratory pressure, maximal expiratory pressure, and handgrip strength increased on D7 in both groups, but the maximal expiratory pressure and handgrip strength were still weak. Only maximal inspiratory pressure was recovered (i.e., > 80% of the predicted value) in the Non-IMV Group. Female sex, and the need and duration of invasive mechanical were independently and negatively associated with the short physical performance battery score and handgrip strength.

    Conclusion:

    Patients who recovered from critical COVID-19 and who received invasive mechanical ventilation presented greater disability than those who were not invasively ventilated. However, they both showed marginal functional improvement during early recovery, regardless of the need for invasive mechanical ventilation. This might highlight the severity of disability caused by SARS-CoV-2.

    See more
    A comprehensive physical functional assessment of survivors of critical care unit stay due to COVID-19
  • Original Article

    Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial

    Crit Care Sci. 2024;36:e20240144en

    Abstract

    Original Article

    Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial

    Crit Care Sci. 2024;36:e20240144en

    DOI 10.62675/2965-2774.20240144-pt

    Views1,044

    ABSTRACT

    Objective:

    To determine whether enteral melatonin decreases the incidence of delirium in critically ill adults.

    Methods:

    In this randomized controlled trial, adults were admitted to the intensive care unit and received either usual standard care alone (Control Group) or in combination with 3mg of enteral melatonin once a day at 9 PM (Melatonin Group). Concealment of allocation was done by serially numbered opaque sealed envelopes. The intensivist assessing delirium and the investigator performing the data analysis were blinded to the group allocation. The primary outcome was the incidence of delirium within 24 hours of the intensive care unit stay. The secondary outcomes were the incidence of delirium on Days 3 and 7, intensive care unit mortality, length of intensive care unit stay, duration of mechanical ventilation and Glasgow outcome score (at discharge).

    Results:

    We included 108 patients in the final analysis, with 54 patients in each group. At 24 hours of intensive care unit stay, there was no difference in the incidence of delirium between Melatonin and Control Groups (29.6 versus 46.2%; RR = 0.6; 95%CI 0.38 - 1.05; p = 0.11). No secondary outcome showed a statistically significant difference.

    Conclusion:

    Enteral melatonin 3mg is not more effective at decreasing the incidence of delirium than standard care is in critically ill adults.

    See more
    Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial
  • Original Article

    Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis

    Crit Care Sci. 2024;36:e20240176en

    Abstract

    Original Article

    Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis

    Crit Care Sci. 2024;36:e20240176en

    DOI 10.62675/2965-2774.20240176-en

    Views283

    ABSTRACT

    Objective:

    To systematically review the effect of the prone position on endotracheal intubation and mortality in nonintubated COVID-19 patients with acute respiratory distress syndrome.

    Methods:

    We registered the protocol (CRD42021286711) and searched for four databases and gray literature from inception to December 31, 2022. We included observational studies and clinical trials. There was no limit by date or the language of publication. We excluded case reports, case series, studies not available in full text, and those studies that included children < 18-years-old.

    Results:

    We included ten observational studies, eight clinical trials, 3,969 patients, 1,120 endotracheal intubation events, and 843 deaths. All of the studies had a low risk of bias (Newcastle-Ottawa Scale and Risk of Bias 2 tools). We found that the conscious prone position decreased the odds of endotracheal intubation by 44% (OR 0.56; 95%CI 0.40 - 0.78) and mortality by 43% (OR 0.57; 95%CI 0.39 - 0.84) in nonintubated COVID-19 patients with acute respiratory distress syndrome. This protective effect on endotracheal intubation and mortality was more robust in those who spent > 8 hours/day in the conscious prone position (OR 0.43; 95%CI 0.26 - 0.72 and OR 0.38; 95%CI 0.24 - 0.60, respectively). The certainty of the evidence according to the GRADE criteria was moderate.

    Conclusion:

    The conscious prone position decreased the odds of endotracheal intubation and mortality, especially when patients spent over 8 hours/day in the conscious prone position and treatment in the intensive care unit. However, our results should be cautiously interpreted due to limitations in evaluating randomized clinical trials, nonrandomized clinical trials and observational studies. However, despite systematic reviews with meta-analyses of randomized clinical trials, we must keep in mind that these studies remain heterogeneous from a clinical and methodological point of view.

    See more
    Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis
  • Original Article

    Association of biomarkers with successful ventilatory weaning in COVID-19 patients: an observational study

    Crit Care Sci. 2024;36:e20240158en

    Abstract

    Original Article

    Association of biomarkers with successful ventilatory weaning in COVID-19 patients: an observational study

    Crit Care Sci. 2024;36:e20240158en

    DOI 10.62675/2965-2774.20240158-en

    Views74

    ABSTRACT

    Objective:

    To evaluate the association of biomarkers with successful ventilatory weaning in COVID-19 patients.

    Methods:

    An observational, retrospective, and single-center study was conducted between March 2020 and April 2021. C-reactive protein, total lymphocytes, and the neutrophil/lymphocyte ratio were evaluated during attrition and extubation, and the variation in these biomarker values was measured. The primary outcome was successful extubation. ROC curves were drawn to find the best cutoff points for the biomarkers based on sensitivity and specificity. Statistical analysis was performed using logistic regression.

    Results:

    Of the 2,377 patients admitted to the intensive care unit, 458 were included in the analysis, 356 in the Successful Weaning Group and 102 in the Failure Group. The cutoff points found from the ROC curves were −62.4% for C-reactive protein, +45.7% for total lymphocytes, and −32.9% for neutrophil/lymphocyte ratio. These points were significantly associated with greater extubation success. In the multivariate analysis, only C-reactive protein variation remained statistically significant (OR 2.6; 95%CI 1.51 – 4.5; p < 0.001).

    Conclusion:

    In this study, a decrease in C-reactive protein levels was associated with successful extubation in COVID-19 patients. Total lymphocytes and the neutrophil/lymphocyte ratio did not maintain the association after multivariate analysis. However, a decrease in C-reactive protein levels should not be used as a sole variable to identify COVID-19 patients suitable for weaning; as in our study, the area under the ROC curve demonstrated poor accuracy in discriminating extubation outcomes, with low sensitivity and specificity.

    See more
    Association of biomarkers with successful ventilatory weaning in COVID-19 patients: an observational study

Search

Search in:

Article type
article-commentary
brief-report
case-report
correction
editorial
editorial
letter
letter
other
rapid-communication
reply
research-article
review-article
review-article
Section
Articles
Artigo de Revisão de Pediatria
Artigo Original
Artigo Original de Pediatria
Artigo Original Destaque
Artigos de Revisão
Artigos de Revisão
Artigos originais
Author's Response
Brief Communication
Case Report
Case Reports
Clinical Report
Comentários
Commentaries
Commentary
Consenso Brasileiro de Monitorização e Suporte Hemodinâmico
Correspondence
Editoriais
Editorial
Editorials
Erratum
Letter to the Editor
Letters to the Editor
Original Article
Original Article - Basic Research
Original Article - Neonatologia
Original Articles
Original Articles - Basic Research
Original Articles - Clinical Research
Relato de Caso
Relatos de Caso
Research Letter
Review
Review Article
Special Article
Special Articles
Viewpoint
Year / Volume
2024; v.36
2023; v.35
2022; v.34
2021; v.33
2020; v.32
2019; v.31
2018; v.30
2017; v.29
2016; v.28
2015; v.27
2014; v.26
2013; v.25
2012; v.24
2011; v.23
2010; v.22
2009; v.21
2008; v.20
2007; v.19
2006; v.18
ISSUE