Abstract
Rev Bras Ter Intensiva. 2022;34(4):507-518
DOI 10.5935/0103-507X.20220145-en
To verify strategies for the prevention and treatment of abstinence syndrome in a pediatric intensive care unit.
This is a systematic review in the PubMed database®, Lilacs, Embase, Web of Science, Cochrane, Cinahl, Cochrane Database Systematic Review and CENTRAL. A three-step search strategy was used for this review, and the protocol was approved in PROSPERO (CRD42021274670).
Twelve articles were included in the analysis. There was great heterogeneity among the studies included, especially regarding the therapeutic regimens used for sedation and analgesia. Midazolam doses ranged from 0.05mg/kg/hour to 0.3mg/kg/hour. Morphine also varied considerably, from 10mcg/kg/hour to 30mcg/kg/hour, between studies. Among the 12 selected studies, the most commonly used scale for the identification of withdrawal symptoms was the Sophia Observational Withdrawal Symptoms Scale. In three studies, there was a statistically significant difference in the prevention and management of the withdrawal syndrome due to the implementation of different protocols (p < 0.01 and p < 0.001).
There was great variation in the sedoanalgesia regimen used by the studies and the method of weaning and evaluation of withdrawal syndrome. More studies are needed to provide more robust evidence about the most appropriate treatment for the prevention and reduction of withdrawal signs and symptoms in critically ill children.
CRD 42021274670
Abstract
Rev Bras Ter Intensiva. 2022;34(2):287-294
DOI 10.5935/0103-507X.20220027-en
Ketamine is unique among anesthetics and analgesics. The drug is a rapid-acting general anesthetic that produces an anesthetic state characterized by profound analgesia, preserved pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression. Research has demonstrated the efficacy of its use on anesthesia, pain, palliative care, and intensive care. Recently, it has been used for postoperative and chronic pain, as an adjunct in psychotherapy, as a treatment for depression and posttraumatic stress disorder, as a procedural sedative, and as a treatment for respiratory and/or neurologic clinical conditions. Despite being a safe and widely used drug, many physicians, such as intensivists and those practicing in emergency care, are not aware of the current clinical applications of ketamine. The objective of this narrative literature review is to present the theoretical and practical aspects of clinical applications of ketamine in intensive care unit and emergency department settings.
Abstract
Rev Bras Ter Intensiva. 2022;34(1):176-184
DOI 10.5935/0103-507X.20220012-en
Defective management of secretions is one of the most frequent complications in invasive mechanically ventilated patients. Clearance of secretions through chest physiotherapy is a critical aspect of the treatment of these patients. Manual rib cage compression is one of the most practiced chest physiotherapy techniques in ventilated patients; however, its impact on clinical outcomes remains controversial due to methodological issues and poor understanding of its action. In this review, we present a detailed analysis of the physical principles involved in rib cage compression technique performance, as well as the physiological effects observed in experimental and clinical studies, which show that the use of brief and vigorous rib cage compression, based on increased expiratory flows (expiratory-inspiratory airflow difference of > 33L/minute), can improve mucus movement toward the glottis. On the other hand, the use of soft and gradual rib cage compression throughout the whole expiratory phase does not impact the expiratory flows, resulting in ineffective or undesired effects in some cases. More physiological studies are needed to understand the principles of the rib cage compression technique in ventilated humans. However, according to the evidence, rib cage compression has more potential benefits than risks, so its implementation should be promoted.
Abstract
Rev Bras Ter Intensiva. 2022;34(1):185-196
DOI 10.5935/0103-507X.20220013-en
Although the PaO 2/FiO 2 derived from arterial blood gas analysis remains the gold standard for the diagnosis of acute respiratory failure, the SpO2/FiO2 has been investigated as a potential substitute. The current narrative review presents the state of the preclinical and clinical literature on the SpO2/FiO2 as a possible substitute for PaO2/FiO2 and for use as a diagnostic and prognostic marker; provides an overview of pulse oximetry and its limitations, and assesses the utility of SpO2/ FiO2 as a surrogate for PaO2/FiO2 in COVID-19 patients. Overall, 49 studies comparing SpO2/FiO2 and PaO2/FiO2 were found according to a minimal search strategy. Most were conducted on neonates, some were conducted on adults with acute respiratory distress syndrome, and a few were conducted in other clinical scenarios (including a very few on COVID-19 patients). There is some evidence that the SpO2/ FiO2 criteria can be a surrogate for PaO2/FiO2 in different clinical scenarios. This is reinforced by the fact that unnecessary invasive procedures should be avoided in patients with acute respiratory failure. It is undeniable that pulse oximeters are becoming increasingly widespread and can provide costless monitoring. Hence, replacing PaO2/FiO2 with SpO2/FiO2may allow resourcelimited facilities to objectively diagnose acute respiratory failure.
Abstract
Rev Bras Ter Intensiva. 2021;33(4):600-615
DOI 10.5935/0103-507X.20210087
Cardiac, ventilatory and kidney management in the critical care setting has been optimized over the past decades. Cognition and sedation represent one of the last remaning challenges. As conventional sedation is suboptimal and as the sedation evoked by alpha-2 adrenergic agonists (“cooperative” sedation with dexmedetomidine, clonidine or guanfacine) represents a valuable alternative, this manuscript covers three practical topics for which evidence-based medicine is lacking: a) Switching from conventional to cooperative sedation (“switching”): the short answer is the abrupt withdrawal of conventional sedation, immediate implementation of alpha-2 agonist infusion and the use of “rescue sedation” (midazolam bolus[es]) or “breakthrough sedation” (haloperidol bolus[es]) to stabilize cooperative sedation. b) Switching from conventional to cooperative sedation in unstable patients (e.g., refractory delirium tremens, septic shock, acute respiratory distress syndrome, etc.): to avoid hypotension and bradycardia evoked by sympathetic deactivation, the short answer is to maintain the stroke volume through volume loading, vasopressors and inotropes. c) To avoid these switches and associated difficulties, alpha-2 agonists may be considered first-line sedatives. The short answer is to administer alpha-2 agonists slowly from admission or endotracheal intubation up to stabilized cooperative sedation. The “take home” message is as follows: a) alpha-2 agonists are jointly sympathetic deactivators and sedative agents; b) sympathetic deactivation implies maintaining the stroke volume and iterative assessment of volemia. Evidence-based medicine should document our propositions.
Abstract
Rev Bras Ter Intensiva. 2021;33(4):616-623
DOI 10.5935/0103-507X.20210071
Manual hyperinflation is used in neonatal and pediatric intensive care units to promote expiratory flow bias, but there is no consensus on the benefits of the technique. Thus, a review that presents supporting evidence is necessary. This study aims to review the literature on the manual hyperinflation maneuver in neonatal and pediatric intensive care units to analyze the evidence for this technique in terms of the forms of application (associated with other techniques or not), its safety, the performance of manual resuscitators and the influence of the physical therapist’s experience, in addition to evaluating the methodological quality of the identified articles. A search was performed in the following databases: Web of Science, ScienceDirect, PubMedⓇ, Scopus, CINAHL and SciELO. Two researchers independently selected the articles. Duplicate studies were assessed, evaluated by title and abstract and then read in full. The quality of the articles was analyzed using the PEDro scale. Six articles were included, two of which had high methodological quality. The main results provided information on the contribution of the positive end-expiratory pressure valve to increasing lung volumes and the use of chest compressions to optimize expiratory flow bias, the negative influence of operator experience on the increase in peak inspiratory flow, the performance of different manual resuscitators when used with the technique and the safety of application in terms of maintaining hemodynamic stability and increasing peripheral oxygen saturation. The available studies point to a positive effect of the manual hyperinflation maneuver in children who are admitted to intensive care units.
Registration PROSPERO: CRD42018108056.
Abstract
Rev Bras Ter Intensiva. 2021;33(4):624-634
DOI 10.5935/0103-507X.20210088
To identify the clinical and epidemiological profile of adult intensive care units in Brazil.
A systematic review was performed using a comprehensive strategy to search PubMed®, Embase, SciELO, and the Biblioteca Virtual em Saúde. The eligibility criteria for this review were observational studies that described the epidemiological and/or clinical profile of critically ill patients admitted to Brazilian intensive care units and were published between 2007 and 2020.
From the 4,457 identified studies, 27 were eligible for this review, constituting an analysis of 113 intensive care units and a final sample of 75,280 individuals. There was a predominance of male and elderly patients. Cardiovascular diseases were the main cause of admission to the intensive care unit. The Acute Physiology and Chronic Health Evaluation II score was the most widely used disease severity assessment system. The length of stay and mortality in the intensive care unit varied widely between institutions.
These results can help guide the planning and organization of intensive care units, providing support for decision-making and the implementation of interventions that ensure better quality patient care.
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Case reports (56) Child (53) Coronavirus infections (34) COVID-19 (46) Critical care (116) Critical illness (54) Extracorporeal membrane oxygenation (26) Infant, newborn (27) Intensive care (72) Intensive care units (256) Intensive care units, pediatric (31) mechanical ventilation (38) Mortality (76) Physical therapy modalities (28) Prognosis (61) Respiration, artificial (119) Respiratory insufficiency (26) risk factors (34) SARS-CoV-2 (28) Sepsis (98)