Original Articles - Clinical Research Archives - Critical Care Science (CCS)
Abstract
Rev Bras Ter Intensiva. 2012;24(3):258-262
DOI 10.1590/S0103-507X2012000300009
OBJECTIVE: To evaluate the influence of the understanding of brain death in relation to organ donation in patients from the Marco School Health Center, which is linked to the Universidade do Estado do Pará. METHODS: A total of 136 patients were interviewed based on a research protocol. The interview results were subsequently analyzed with regard to the understanding of brain death and organ donation in addition to the collection of sociodemographic data. RESULTS: The majority of patients were female and were in favor of organ donation, with a mean age of 39 years being observed. Only 19.9% of the patients understood the meaning of brain death, and 85.3% believed that physicians may be mistaken in confirming the status of brain death of a patient, while 18.4% trusted the diagnosis of brain death. A statistically significant (p < 0.01) correlation was observed between the degree of confidence in the diagnosis of brain death and the person's agreement to donate his/her organs after death. CONCLUSION: The majority of the population under study did not understand the meaning of brain death and had a low degree of confidence in the diagnosis of brain death. This lack of understanding and confidence negatively influences the desire to donate organs.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):258-262
DOI 10.1590/S0103-507X2012000300009
OBJECTIVE: To evaluate the influence of the understanding of brain death in relation to organ donation in patients from the Marco School Health Center, which is linked to the Universidade do Estado do Pará. METHODS: A total of 136 patients were interviewed based on a research protocol. The interview results were subsequently analyzed with regard to the understanding of brain death and organ donation in addition to the collection of sociodemographic data. RESULTS: The majority of patients were female and were in favor of organ donation, with a mean age of 39 years being observed. Only 19.9% of the patients understood the meaning of brain death, and 85.3% believed that physicians may be mistaken in confirming the status of brain death of a patient, while 18.4% trusted the diagnosis of brain death. A statistically significant (p < 0.01) correlation was observed between the degree of confidence in the diagnosis of brain death and the person's agreement to donate his/her organs after death. CONCLUSION: The majority of the population under study did not understand the meaning of brain death and had a low degree of confidence in the diagnosis of brain death. This lack of understanding and confidence negatively influences the desire to donate organs.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):263-269
DOI 10.1590/S0103-507X2012000300010
OBJECTIVE: This study evaluated the relationship between nutritional intake and protein and caloric requirements and observed clinical outcomes on the 7th day of intensive care unit stay. METHODS: This was a retrospective cohort study of 126 patients who were admitted to the intensive care unit for >7 days. The patients were categorized according to the adequacy of energy and protein intake in relation to requirements (a >60% Adequate Intake Group and a <60% Inadequate Intake Group). The length of stay, ventilator free time and mortality in the intensive care unit and hospital were evaluated. RESULTS: Enteral nutrition was used in 95.6% of the 126 included patients, and nutrition was initiated 41 hours after admission to the intensive care unit. The adequacy of intake was 84% for energy and 72.5% for protein. No differences in the length of stay [16 (11-23) versus 15 (11-21) days, p=0.862], ventilator free time [2 (0-7) versus 3 (0-6) days, p=0.985] or mortality in the intensive care unit [12 (41.4%) versus 38 (39.1%), p=0.831] and hospital [15 (51.7%) versus 44 (45.4%), p=0.348] were observed between the adequate and inadequate energy intake groups, respectively. Similar results in protein intake and the length of hospital stay [15 (12-21) versus 15 (11-21) days, p=0.996], ventilator free time [2 (0-7) versus 3 (0-6) days, p=0.846], and mortality in the intensive care unit [15 (28.3%) versus 35 (47.9%), p=0.536)] and hospital [18 (52.9%) versus 41 (44.6%), p=0.262] were observed between groups. CONCLUSION: The results did not establish that energy and protein intakes of greater or less than 60% of nutritional requirements were reliable dividers of clinical outcomes.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):263-269
DOI 10.1590/S0103-507X2012000300010
OBJECTIVE: This study evaluated the relationship between nutritional intake and protein and caloric requirements and observed clinical outcomes on the 7th day of intensive care unit stay. METHODS: This was a retrospective cohort study of 126 patients who were admitted to the intensive care unit for >7 days. The patients were categorized according to the adequacy of energy and protein intake in relation to requirements (a >60% Adequate Intake Group and a <60% Inadequate Intake Group). The length of stay, ventilator free time and mortality in the intensive care unit and hospital were evaluated. RESULTS: Enteral nutrition was used in 95.6% of the 126 included patients, and nutrition was initiated 41 hours after admission to the intensive care unit. The adequacy of intake was 84% for energy and 72.5% for protein. No differences in the length of stay [16 (11-23) versus 15 (11-21) days, p=0.862], ventilator free time [2 (0-7) versus 3 (0-6) days, p=0.985] or mortality in the intensive care unit [12 (41.4%) versus 38 (39.1%), p=0.831] and hospital [15 (51.7%) versus 44 (45.4%), p=0.348] were observed between the adequate and inadequate energy intake groups, respectively. Similar results in protein intake and the length of hospital stay [15 (12-21) versus 15 (11-21) days, p=0.996], ventilator free time [2 (0-7) versus 3 (0-6) days, p=0.846], and mortality in the intensive care unit [15 (28.3%) versus 35 (47.9%), p=0.536)] and hospital [18 (52.9%) versus 41 (44.6%), p=0.262] were observed between groups. CONCLUSION: The results did not establish that energy and protein intakes of greater or less than 60% of nutritional requirements were reliable dividers of clinical outcomes.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):224-229
DOI 10.1590/S0103-507X2012000300004
OBJECTIVE: This study analyzed the factors that are associated with the need for packed red blood cell transfusions in premature infants in a neonatal intensive care unit. METHODS: This study is a cross-sectional study of secondary data from premature infants who were admitted to a neonatal intensive care unit between 2008 and 2010. Premature infants with low birth weight were included. Packed red blood cell transfusion was the dependent variable. Pearson's Chi-square or Fisher's exact tests were used for data analysis, and the median, minimum, and maximum values were calculated. Prevalence ratios were calculated using the Poisson regression and Pearson correlation coefficient. Linear regression analyses were performed. P < 0.05 was considered to be significant. RESULTS: We examined 254 premature infants, and 39.4% of this sample received packed red blood cells. Transfusions were 70% less prevalent in premature infants who were born at >32 weeks of gestation, and 191% more prevalent in infants who exhibited late-onset neonatal sepsis. The number of transfusions per patient was negatively correlated with gestational age and positively correlated with late-onset neonatal sepsis. A gestational age <32 weeks and late-onset neonatal sepsis explained 45% of the transfusions (p<0.0001). CONCLUSIONS: Premature infants with a gestational age <32 weeks and who developed late-onset neonatal sepsis exhibited a greater need for packed red blood cell transfusions.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):224-229
DOI 10.1590/S0103-507X2012000300004
OBJECTIVE: This study analyzed the factors that are associated with the need for packed red blood cell transfusions in premature infants in a neonatal intensive care unit. METHODS: This study is a cross-sectional study of secondary data from premature infants who were admitted to a neonatal intensive care unit between 2008 and 2010. Premature infants with low birth weight were included. Packed red blood cell transfusion was the dependent variable. Pearson's Chi-square or Fisher's exact tests were used for data analysis, and the median, minimum, and maximum values were calculated. Prevalence ratios were calculated using the Poisson regression and Pearson correlation coefficient. Linear regression analyses were performed. P < 0.05 was considered to be significant. RESULTS: We examined 254 premature infants, and 39.4% of this sample received packed red blood cells. Transfusions were 70% less prevalent in premature infants who were born at >32 weeks of gestation, and 191% more prevalent in infants who exhibited late-onset neonatal sepsis. The number of transfusions per patient was negatively correlated with gestational age and positively correlated with late-onset neonatal sepsis. A gestational age <32 weeks and late-onset neonatal sepsis explained 45% of the transfusions (p<0.0001). CONCLUSIONS: Premature infants with a gestational age <32 weeks and who developed late-onset neonatal sepsis exhibited a greater need for packed red blood cell transfusions.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):230-235
DOI 10.1590/S0103-507X2012000300005
OBJECTIVE: This study established the incidence and primary causes of unplanned extubation in newborns in the neonatal intensive care units of the Hospital Sofia Feldman, Belo Horizonte (Minas Gerais). METHODS: This retrospective study was conducted between July 1, 2009 and April 30, 2010. Unplanned extubations and their primary causes were assessed using an adverse events form. The following variables were assessed: gender, corrected age, present weight, duration of mechanical ventilation time, and motives/causes of the event on the day of the unplanned extubation event. RESULTS: Fifty-four unplanned extubations occurred, which corresponded to an incidence of 1.0 event/100 days of mechanical ventilation. This rate was higher among newborns with a corrected age of 30 to 36 weeks and weight < 1,000 g. The primary causes of unplanned extubations included patient agitation, inappropriate handling of patients during the performance of procedures, and inappropriate fixation and positioning of the endotracheal tube. CONCLUSION: The incidence of unplanned extubation in the investigated neonatal intensive care units was low during the study period compared to previously reported data. Nevertheless, the assessment of the quality of procedures, the continuous follow-up of newborns, and the monitoring of the causes of extubation are required to further reduce this incidence.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):230-235
DOI 10.1590/S0103-507X2012000300005
OBJECTIVE: This study established the incidence and primary causes of unplanned extubation in newborns in the neonatal intensive care units of the Hospital Sofia Feldman, Belo Horizonte (Minas Gerais). METHODS: This retrospective study was conducted between July 1, 2009 and April 30, 2010. Unplanned extubations and their primary causes were assessed using an adverse events form. The following variables were assessed: gender, corrected age, present weight, duration of mechanical ventilation time, and motives/causes of the event on the day of the unplanned extubation event. RESULTS: Fifty-four unplanned extubations occurred, which corresponded to an incidence of 1.0 event/100 days of mechanical ventilation. This rate was higher among newborns with a corrected age of 30 to 36 weeks and weight < 1,000 g. The primary causes of unplanned extubations included patient agitation, inappropriate handling of patients during the performance of procedures, and inappropriate fixation and positioning of the endotracheal tube. CONCLUSION: The incidence of unplanned extubation in the investigated neonatal intensive care units was low during the study period compared to previously reported data. Nevertheless, the assessment of the quality of procedures, the continuous follow-up of newborns, and the monitoring of the causes of extubation are required to further reduce this incidence.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):270-277
DOI 10.1590/S0103-507X2012000300011
OBJECTIVE: Given the inaccessibility of indirect calorimetry, intensive care units generally use predictive equations or recommendations that are established by international societies to determine energy expenditure. The aim of the present study was to compare the energy expenditure of critically ill patients, as determined using indirect calorimetry, to the values obtained using the Harris-Benedict equation. METHODS: A retrospective observational study was conducted at the Intensive Care Unit 1 of the Centro Hospitalar do Porto. The energy requirements of hospitalized critically ill patients as determined using indirect calorimetry were assessed between January 2003 and April 2012. The accuracy (± 10% difference between the measured and estimated values), the mean differences and the limits of agreement were determined for the studied equations. RESULTS: Eighty-five patients were assessed using 288 indirect calorimetry measurements. The following energy requirement values were obtained for the different methods: 1,753.98±391.13 kcal/day (24.48 ± 5.95 kcal/kg/day) for indirect calorimetry and 1,504.11 ± 266.99 kcal/day (20.72±2.43 kcal/kg/day) for the Harris-Benedict equation. The equation had a precision of 31.76% with a mean difference of -259.86 kcal/day and limits of agreement between -858.84 and 339.12 kcal/day. Sex (p=0.023), temperature (p=0.009) and body mass index (p<0.001) were found to significantly affect energy expenditure. CONCLUSION: The Harris-Benedict equation is inaccurate and tends to underestimate energy expenditure. In addition, the Harris-Benedict equation is associated with significant differences between the predicted and true energy expenditure at an individual level.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):270-277
DOI 10.1590/S0103-507X2012000300011
OBJECTIVE: Given the inaccessibility of indirect calorimetry, intensive care units generally use predictive equations or recommendations that are established by international societies to determine energy expenditure. The aim of the present study was to compare the energy expenditure of critically ill patients, as determined using indirect calorimetry, to the values obtained using the Harris-Benedict equation. METHODS: A retrospective observational study was conducted at the Intensive Care Unit 1 of the Centro Hospitalar do Porto. The energy requirements of hospitalized critically ill patients as determined using indirect calorimetry were assessed between January 2003 and April 2012. The accuracy (± 10% difference between the measured and estimated values), the mean differences and the limits of agreement were determined for the studied equations. RESULTS: Eighty-five patients were assessed using 288 indirect calorimetry measurements. The following energy requirement values were obtained for the different methods: 1,753.98±391.13 kcal/day (24.48 ± 5.95 kcal/kg/day) for indirect calorimetry and 1,504.11 ± 266.99 kcal/day (20.72±2.43 kcal/kg/day) for the Harris-Benedict equation. The equation had a precision of 31.76% with a mean difference of -259.86 kcal/day and limits of agreement between -858.84 and 339.12 kcal/day. Sex (p=0.023), temperature (p=0.009) and body mass index (p<0.001) were found to significantly affect energy expenditure. CONCLUSION: The Harris-Benedict equation is inaccurate and tends to underestimate energy expenditure. In addition, the Harris-Benedict equation is associated with significant differences between the predicted and true energy expenditure at an individual level.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):278-283
DOI 10.1590/S0103-507X2012000300012
OBJECTIVE: This study analyzed acute respiratory failure caused by acute pulmonary edema, as well as chronic obstructive pulmonary disease exacerbation, that was treated with non-invasive mechanical ventilation to identify the factors that are associated with the success or failure non-invasive mechanical ventilation in urgent and emergency service. METHODS: This study was a prospective, descriptive and analytical study. We included patients of both genders aged >18 years who used non-invasive mechanical ventilation due to acute respiratory failure that was secondary to acute pulmonary edema or chronic obstructive pulmonary disease exacerbation. Patients with acute respiratory failure that was secondary to pathologies other than acute pulmonary edema and chronic obstructive pulmonary disease or who presented with contraindications for the technique were excluded. Expiratory pressures between 5 and 8 cmH2O and inspiratory pressures between 10 and 12 cmH2O were used. Supplemental oxygen maintained peripheral oxygen saturation at >90%. The primary outcome was endotracheal intubation. RESULTS: A total of 152 patients were included. The median non-invasive mechanical ventilation time was 6 hours (range 1 - 32 hours) for chronic obstructive pulmonary disease patients (n=60) and 5 hours (range 2 - 32 hours) for acute pulmonary edema patients (n=92). Most (75.7%) patients progressed successfully. However, reduced APACHE II scores and lower peripheral oxygen saturation were observed. These results were statistically significant in patients who progressed to intubation (p<0.001). BiPAP (Bi-level Positive Airway Pressure portable ventilator), as continuous positive airway pressure use increased the probability of endotracheal intubation 2.3 times (p=0.032). Patients with acute pulmonary edema and elevated GCS scores also increased the probability of success. CONCLUSION: Respiratory frequency >25 rpm, higher APACHE II scores, BiPAP use and chronic obstructive pulmonary disease diagnosis were associated with endotracheal intubation. Higher GCS and SpO2 values were associated with NIV success. Non-invasive mechanical ventilation can be used in emergency services in acute respiratory failure cases caused by acute pulmonary edema and chronic obstructive pulmonary disease exacerbation, but patients with variables related to a higher percentage of endotracheal intubation should be specially monitored.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):278-283
DOI 10.1590/S0103-507X2012000300012
OBJECTIVE: This study analyzed acute respiratory failure caused by acute pulmonary edema, as well as chronic obstructive pulmonary disease exacerbation, that was treated with non-invasive mechanical ventilation to identify the factors that are associated with the success or failure non-invasive mechanical ventilation in urgent and emergency service. METHODS: This study was a prospective, descriptive and analytical study. We included patients of both genders aged >18 years who used non-invasive mechanical ventilation due to acute respiratory failure that was secondary to acute pulmonary edema or chronic obstructive pulmonary disease exacerbation. Patients with acute respiratory failure that was secondary to pathologies other than acute pulmonary edema and chronic obstructive pulmonary disease or who presented with contraindications for the technique were excluded. Expiratory pressures between 5 and 8 cmH2O and inspiratory pressures between 10 and 12 cmH2O were used. Supplemental oxygen maintained peripheral oxygen saturation at >90%. The primary outcome was endotracheal intubation. RESULTS: A total of 152 patients were included. The median non-invasive mechanical ventilation time was 6 hours (range 1 - 32 hours) for chronic obstructive pulmonary disease patients (n=60) and 5 hours (range 2 - 32 hours) for acute pulmonary edema patients (n=92). Most (75.7%) patients progressed successfully. However, reduced APACHE II scores and lower peripheral oxygen saturation were observed. These results were statistically significant in patients who progressed to intubation (p<0.001). BiPAP (Bi-level Positive Airway Pressure portable ventilator), as continuous positive airway pressure use increased the probability of endotracheal intubation 2.3 times (p=0.032). Patients with acute pulmonary edema and elevated GCS scores also increased the probability of success. CONCLUSION: Respiratory frequency >25 rpm, higher APACHE II scores, BiPAP use and chronic obstructive pulmonary disease diagnosis were associated with endotracheal intubation. Higher GCS and SpO2 values were associated with NIV success. Non-invasive mechanical ventilation can be used in emergency services in acute respiratory failure cases caused by acute pulmonary edema and chronic obstructive pulmonary disease exacerbation, but patients with variables related to a higher percentage of endotracheal intubation should be specially monitored.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):236-245
DOI 10.1590/S0103-507X2012000300006
OBJECTIVE: Intensive care unit survivors and non-survivors have distinct acid-base profiles. The kidney's regulation of urinary electrolytes and the urinary strong ion difference plays a major role in acid-base homeostasis. The aim of this study was to evaluate the potential utility of daily spot urinary electrolyte measurement in acid-base and renal function monitoring. METHODS: We prospectively recorded daily plasma acid-base parameters and traditional markers of renal function in parallel with spot urinary electrolyte measurements in patients with urinary catheters admitted to our intensive care unit. Patients who remained in the intensive care unit for at least 4 days with a urinary catheter were included in the study. RESULTS: Of the 50 patients included in the study, 22% died during their intensive care unit stay. The incidence of acute kidney injury was significantly higher in non-survivors during the 4-day observation period (64% vs. 18% in survivors). Urinary chloride and sodium were lower and urinary strong ion difference was higher on day 1 in patients who developed acute kidney injury among both survivors and non-survivors. Both groups had similar urine output, although non-survivors had persistently higher urinary strong ion difference on all days. Survivors had a progressive improvement in metabolic acid-base profile due to increases in the plasma strong ion difference and decreases in weak acids. These changes were concomitant with decreases in urinary strong ion difference. In non-survivors, acid-base parameters did not significantly change during follow-up. CONCLUSIONS: Daily assessment of spot urinary electrolytes and strong ion difference are useful components of acid-base and renal function evaluations in critically ill patients, having distinct profiles between intensive care unit survivors and non-survivors.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):236-245
DOI 10.1590/S0103-507X2012000300006
OBJECTIVE: Intensive care unit survivors and non-survivors have distinct acid-base profiles. The kidney's regulation of urinary electrolytes and the urinary strong ion difference plays a major role in acid-base homeostasis. The aim of this study was to evaluate the potential utility of daily spot urinary electrolyte measurement in acid-base and renal function monitoring. METHODS: We prospectively recorded daily plasma acid-base parameters and traditional markers of renal function in parallel with spot urinary electrolyte measurements in patients with urinary catheters admitted to our intensive care unit. Patients who remained in the intensive care unit for at least 4 days with a urinary catheter were included in the study. RESULTS: Of the 50 patients included in the study, 22% died during their intensive care unit stay. The incidence of acute kidney injury was significantly higher in non-survivors during the 4-day observation period (64% vs. 18% in survivors). Urinary chloride and sodium were lower and urinary strong ion difference was higher on day 1 in patients who developed acute kidney injury among both survivors and non-survivors. Both groups had similar urine output, although non-survivors had persistently higher urinary strong ion difference on all days. Survivors had a progressive improvement in metabolic acid-base profile due to increases in the plasma strong ion difference and decreases in weak acids. These changes were concomitant with decreases in urinary strong ion difference. In non-survivors, acid-base parameters did not significantly change during follow-up. CONCLUSIONS: Daily assessment of spot urinary electrolytes and strong ion difference are useful components of acid-base and renal function evaluations in critically ill patients, having distinct profiles between intensive care unit survivors and non-survivors.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):246-251
DOI 10.1590/S0103-507X2012000300007
OBJECTIVE: This study compared the general and specific severity indices to assess the prognosis of severe acute pancreatitis at a polyvalent intensive care unit. METHODS: This retrospective study included 108 patients who were diagnosed with severe acute pancreatitis from July 1, 1999 to March 31, 2012. Their demographic and clinical data were collected, and the following severity indices were calculated: Ranson, Osborne, Blamey and Imrie, Balthazar, POP, APACHE II, SAPS II, and SOFA. The discriminative power of these indices with regard to mortality at the intensive care unit and hospital was assessed using the area under the ROC curve. RESULTS: The demographic data of the surviving and deceased patients did not significantly differ at baseline. The mortality rates were 27% and 39% at the intensive care unit and hospital, respectively. The severity indices that exhibited the greatest discriminative power with regard to mortality at the intensive care unit and hospital were the POP 0, POP 24, SOFA (at admission, 24 hours, 48 hours, and discharge), SAPS II, and APACHE II. CONCLUSION: The POP performed better than the other indices (aROC>0.8) at admission and 24 hours later (as originally described). The general physiological dysfunction indices also exhibited reasonable discriminative power (aROC=0.75-0.8), which was unlike the remaining pancreatitis specific indices, whose discriminative power was lower.
Abstract
Rev Bras Ter Intensiva. 2012;24(3):246-251
DOI 10.1590/S0103-507X2012000300007
OBJECTIVE: This study compared the general and specific severity indices to assess the prognosis of severe acute pancreatitis at a polyvalent intensive care unit. METHODS: This retrospective study included 108 patients who were diagnosed with severe acute pancreatitis from July 1, 1999 to March 31, 2012. Their demographic and clinical data were collected, and the following severity indices were calculated: Ranson, Osborne, Blamey and Imrie, Balthazar, POP, APACHE II, SAPS II, and SOFA. The discriminative power of these indices with regard to mortality at the intensive care unit and hospital was assessed using the area under the ROC curve. RESULTS: The demographic data of the surviving and deceased patients did not significantly differ at baseline. The mortality rates were 27% and 39% at the intensive care unit and hospital, respectively. The severity indices that exhibited the greatest discriminative power with regard to mortality at the intensive care unit and hospital were the POP 0, POP 24, SOFA (at admission, 24 hours, 48 hours, and discharge), SAPS II, and APACHE II. CONCLUSION: The POP performed better than the other indices (aROC>0.8) at admission and 24 hours later (as originally described). The general physiological dysfunction indices also exhibited reasonable discriminative power (aROC=0.75-0.8), which was unlike the remaining pancreatitis specific indices, whose discriminative power was lower.
