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Editorial
Five hundred twelve years of history together… and many more years to come
Rev Bras Ter Intensiva. 2012;24(2):111-112
Abstract
EditorialFive hundred twelve years of history together… and many more years to come
Rev Bras Ter Intensiva. 2012;24(2):111-112
DOI 10.1590/S0103-507X2012000200001
Views2EDITORIAL Five hundred twelve years of history together… and many more years to come […]See moreViews2
Abstract
EditorialFive hundred twelve years of history together… and many more years to come
Rev Bras Ter Intensiva. 2012;24(2):111-112
DOI 10.1590/S0103-507X2012000200001
Views2EDITORIAL Five hundred twelve years of history together… and many more years to come […]See more -
Editorial
In ink and paper
Rev Bras Ter Intensiva. 2012;24(2):113-114
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Editorial
Infection prevalence and outcomes in Brazilians ICUs: another brick in the wall…
Rev Bras Ter Intensiva. 2012;24(2):115-116
Abstract
EditorialInfection prevalence and outcomes in Brazilians ICUs: another brick in the wall…
Rev Bras Ter Intensiva. 2012;24(2):115-116
DOI 10.1590/S0103-507X2012000200003
Views0EDITORIAL Infection prevalence and outcomes in Brazilians ICUs: another brick in the wall… […]See moreViews0Abstract
EditorialInfection prevalence and outcomes in Brazilians ICUs: another brick in the wall…
Rev Bras Ter Intensiva. 2012;24(2):115-116
DOI 10.1590/S0103-507X2012000200003
Views0EDITORIAL Infection prevalence and outcomes in Brazilians ICUs: another brick in the wall… […]See more -
Editorial
Searching for the Holy Grail: where do we go with the current biomarkers for sepsis?
Rev Bras Ter Intensiva. 2012;24(2):117-118
Abstract
EditorialSearching for the Holy Grail: where do we go with the current biomarkers for sepsis?
Rev Bras Ter Intensiva. 2012;24(2):117-118
DOI 10.1590/S0103-507X2012000200004
Views0EDITORIAL Searching for the Holy Grail: where do we go with the current biomarkers for sepsis? […]See moreViews0Abstract
EditorialSearching for the Holy Grail: where do we go with the current biomarkers for sepsis?
Rev Bras Ter Intensiva. 2012;24(2):117-118
DOI 10.1590/S0103-507X2012000200004
Views0EDITORIAL Searching for the Holy Grail: where do we go with the current biomarkers for sepsis? […]See more -
Special Article
I Brazilian guidelines for respiratory physiotherapy in pediatric and neonatal intensive care units
Rev Bras Ter Intensiva. 2012;24(2):119-129
Abstract
Special ArticleI Brazilian guidelines for respiratory physiotherapy in pediatric and neonatal intensive care units
Rev Bras Ter Intensiva. 2012;24(2):119-129
DOI 10.1590/S0103-507X2012000200005
Views0Developing guidelines for the role of the physiotherapist in neonatal and pediatric intensive care units is essential because these professionals are responsible for the rehabilitation of critically ill patients. Rehabilitation includes the evaluation and prevention of functional kinetic alterations, application of treatment interventions (respiratory and/or motor physiotherapy), control and application of medical gases, care of mechanical ventilation, weaning and extubation, tracheal gas insufflation, inflation/deflation of the endotracheal cuff protocol, and surfactant application, aiming to allow patients to have a full recovery and return to their functional activities. In this article, we present guidelines that are intended to guide the physiotherapist in some of the prevention/treatment interventions in respiratory therapy (airway clearance, lung expansion, position in bed, airway suction, drug inhalation, and cough assist), which help in the rehabilitation process of newborns and children in intensive care units during mechanical ventilation and up to 12 hours following extubation.
Keywords:ChildIntensive care, neonatalPhysical therapy modalitiesRehabilitationRespiration, artificialRespiratory therapySee moreViews0Abstract
Special ArticleI Brazilian guidelines for respiratory physiotherapy in pediatric and neonatal intensive care units
Rev Bras Ter Intensiva. 2012;24(2):119-129
DOI 10.1590/S0103-507X2012000200005
Views0Developing guidelines for the role of the physiotherapist in neonatal and pediatric intensive care units is essential because these professionals are responsible for the rehabilitation of critically ill patients. Rehabilitation includes the evaluation and prevention of functional kinetic alterations, application of treatment interventions (respiratory and/or motor physiotherapy), control and application of medical gases, care of mechanical ventilation, weaning and extubation, tracheal gas insufflation, inflation/deflation of the endotracheal cuff protocol, and surfactant application, aiming to allow patients to have a full recovery and return to their functional activities. In this article, we present guidelines that are intended to guide the physiotherapist in some of the prevention/treatment interventions in respiratory therapy (airway clearance, lung expansion, position in bed, airway suction, drug inhalation, and cough assist), which help in the rehabilitation process of newborns and children in intensive care units during mechanical ventilation and up to 12 hours following extubation.
Keywords:ChildIntensive care, neonatalPhysical therapy modalitiesRehabilitationRespiration, artificialRespiratory therapySee more -
Original Articles – Basic Research
Interleukin-12 in children with sepsis and septic shock
Rev Bras Ter Intensiva. 2012;24(2):130-136
Abstract
Original Articles – Basic ResearchInterleukin-12 in children with sepsis and septic shock
Rev Bras Ter Intensiva. 2012;24(2):130-136
DOI 10.1590/S0103-507X2012000200006
Views0See moreOBJECTIVE: 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)
Views0Abstract
Original Articles – Basic ResearchInterleukin-12 in children with sepsis and septic shock
Rev Bras Ter Intensiva. 2012;24(2):130-136
DOI 10.1590/S0103-507X2012000200006
Views0See moreOBJECTIVE: 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)
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Original Articles – Basic Research
Acute hemodynamic, respiratory and metabolic alterations after blood contact with a volume priming and extracorporeal life support circuit: an experimental study
Rev Bras Ter Intensiva. 2012;24(2):137-142
Abstract
Original Articles – Basic ResearchAcute hemodynamic, respiratory and metabolic alterations after blood contact with a volume priming and extracorporeal life support circuit: an experimental study
Rev Bras Ter Intensiva. 2012;24(2):137-142
DOI 10.1590/S0103-507X2012000200007
Views0OBJECTIVE: To investigate the hemodynamic, respiratory and metabolic impact of blood contact with a priming volume and extracorporeal membrane oxygenation circuit, before the initiation of oxygenation and ventilation METHODS: Five animals were instrumented and submitted to extracorporeal membrane oxygenation. Data were collected at the baseline and 30 minutes after starting extracorporeal circulation, without membrane ventilatory (sweeper) flow. RESULTS: After starting extracorporeal membrane oxygenation, there was a non-significant elevation in pulmonary vascular resistance from 235 (178,303) to 379 (353,508) dyn.seg.(cm5)-1 (P=0.065), associated with an elevation in the alveolar arterial oxygen gradient from 235 (178,303) to 379 (353,508) mmHg (P=0.063). We also observed a reduction in the left ventricle stroke work from 102 (94,105) to 78 (71,87) (mL.mmHg)/beat (P=0.064), in addition to a reduction in cardiac output from 7.2 (6.8,7.6) to 5.9 (5.8,6.3) L/min (P=0.188). The right ventricle stroke work was counterbalanced between the pulmonary vascular resistance increment and the cardiac output reduction, maintaining a similar value. CONCLUSIONS: We presented an experimental model that is feasible and safe. Blood contact with the priming volume and extracorporeal membrane oxygenation circuit resulted in non-significant systemic or metabolic changes.
Keywords:acute respiratory distress syndromeExtracorporeal membrane oxygenationMultiple organ failureRespiration, artificialSwineSee moreViews0Abstract
Original Articles – Basic ResearchAcute hemodynamic, respiratory and metabolic alterations after blood contact with a volume priming and extracorporeal life support circuit: an experimental study
Rev Bras Ter Intensiva. 2012;24(2):137-142
DOI 10.1590/S0103-507X2012000200007
Views0OBJECTIVE: To investigate the hemodynamic, respiratory and metabolic impact of blood contact with a priming volume and extracorporeal membrane oxygenation circuit, before the initiation of oxygenation and ventilation METHODS: Five animals were instrumented and submitted to extracorporeal membrane oxygenation. Data were collected at the baseline and 30 minutes after starting extracorporeal circulation, without membrane ventilatory (sweeper) flow. RESULTS: After starting extracorporeal membrane oxygenation, there was a non-significant elevation in pulmonary vascular resistance from 235 (178,303) to 379 (353,508) dyn.seg.(cm5)-1 (P=0.065), associated with an elevation in the alveolar arterial oxygen gradient from 235 (178,303) to 379 (353,508) mmHg (P=0.063). We also observed a reduction in the left ventricle stroke work from 102 (94,105) to 78 (71,87) (mL.mmHg)/beat (P=0.064), in addition to a reduction in cardiac output from 7.2 (6.8,7.6) to 5.9 (5.8,6.3) L/min (P=0.188). The right ventricle stroke work was counterbalanced between the pulmonary vascular resistance increment and the cardiac output reduction, maintaining a similar value. CONCLUSIONS: We presented an experimental model that is feasible and safe. Blood contact with the priming volume and extracorporeal membrane oxygenation circuit resulted in non-significant systemic or metabolic changes.
Keywords:acute respiratory distress syndromeExtracorporeal membrane oxygenationMultiple organ failureRespiration, artificialSwineSee more
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Original Articles – Clinical Research
Prevalence and outcomes of infections in Brazilian ICUs: a subanalysis of EPIC II study
Rev Bras Ter Intensiva. 2012;24(2):143-150
Abstract
Original Articles – Clinical ResearchPrevalence and outcomes of infections in Brazilian ICUs: a subanalysis of EPIC II study
Rev Bras Ter Intensiva. 2012;24(2):143-150
DOI 10.1590/S0103-507X2012000200008
Views0See moreOBJECTIVE: To determine the prevalence of infections in Brazilian intensive care units and the associated mortality by analyzing the data obtained in the Extended Prevalence of Infection in Intensive Care (EPIC II) study. METHODS: EPIC II was a multicenter, international, cross-sectional prospective study of infection prevalence. It described the demographic, physiological, bacteriological, and therapeutic characteristics, outcome up to the 60th day, prevalence of infection, and mortality of all the patients admitted to the participating ICUs between zero hour and midnight on May 8, 2007. A total of 14,414 patients were included in the original study. Of these 14,414 patients, 1,235 were Brazilian and were hospitalized in 90 Brazilian ICUs. They represent the focus of this study. RESULTS: Among these 1,235 Brazilian patients, 61,6% had an infection on the day of the trial, and the lungs were the main site of infection (71.2%). Half of the patients had positive cultures, predominantly gram-negative bacilli (72%). On the day of the study, the median SOFA score was 5 (3-8) and the median SAPS II score was 36 (26-47). The infected patients had SOFA scores significantly higher than those of the non-infected patients 6 (4-9) and 3 (2-6), respectively). The overall ICU mortality rate was 28.4%: 37.6% in the infected patients, and 13.2% in the non-infected patients (p<0.001). Similarly, the in-hospital mortality rate was 34.2%, with a higher rate in the infected than in the non-infected patients (44.2% vs. 17.7%) (p<0.001). In the multivariate analysis, the main factors associated with infection incidence were emergency surgery (OR 2.89, 95%CI [1.72-4.86], p<0.001), mechanical ventilation (OR 2.06, 95% CI [1.5-2.82], p<0.001), and the SAPS II score (OR 1.04, 95% CI [1.03-1.06], p<0.001). The main factors related to mortality were ICC functional class III/ IV (OR 3.0, 95% CI [1.51-5.98], p<0.01), diabetes mellitus (OR 0.48, 95% CI [0.25-0.95], p<0.03), cirrhosis (OR 4.62, 95% CI [1.47-14,5], p<0.01), male gender (OR 0.68, 95% CI [0.46-1.0], p<0.05), mechanical ventilation (OR 1.87, 95% CI [1.19-2.95], p<0.01), hemodialysis (OR 1.98, 95% CI [1.05-3.75], p<0.03), and the SAPS II score (OR 1.08, 95% CI [1.06-1.10], p<0.001). CONCLUSION: The present study revealed a higher prevalence of infections in Brazilian ICUs than has been previously reported. There was a clear association between infection and mortality.
Views0Abstract
Original Articles – Clinical ResearchPrevalence and outcomes of infections in Brazilian ICUs: a subanalysis of EPIC II study
Rev Bras Ter Intensiva. 2012;24(2):143-150
DOI 10.1590/S0103-507X2012000200008
Views0See moreOBJECTIVE: To determine the prevalence of infections in Brazilian intensive care units and the associated mortality by analyzing the data obtained in the Extended Prevalence of Infection in Intensive Care (EPIC II) study. METHODS: EPIC II was a multicenter, international, cross-sectional prospective study of infection prevalence. It described the demographic, physiological, bacteriological, and therapeutic characteristics, outcome up to the 60th day, prevalence of infection, and mortality of all the patients admitted to the participating ICUs between zero hour and midnight on May 8, 2007. A total of 14,414 patients were included in the original study. Of these 14,414 patients, 1,235 were Brazilian and were hospitalized in 90 Brazilian ICUs. They represent the focus of this study. RESULTS: Among these 1,235 Brazilian patients, 61,6% had an infection on the day of the trial, and the lungs were the main site of infection (71.2%). Half of the patients had positive cultures, predominantly gram-negative bacilli (72%). On the day of the study, the median SOFA score was 5 (3-8) and the median SAPS II score was 36 (26-47). The infected patients had SOFA scores significantly higher than those of the non-infected patients 6 (4-9) and 3 (2-6), respectively). The overall ICU mortality rate was 28.4%: 37.6% in the infected patients, and 13.2% in the non-infected patients (p<0.001). Similarly, the in-hospital mortality rate was 34.2%, with a higher rate in the infected than in the non-infected patients (44.2% vs. 17.7%) (p<0.001). In the multivariate analysis, the main factors associated with infection incidence were emergency surgery (OR 2.89, 95%CI [1.72-4.86], p<0.001), mechanical ventilation (OR 2.06, 95% CI [1.5-2.82], p<0.001), and the SAPS II score (OR 1.04, 95% CI [1.03-1.06], p<0.001). The main factors related to mortality were ICC functional class III/ IV (OR 3.0, 95% CI [1.51-5.98], p<0.01), diabetes mellitus (OR 0.48, 95% CI [0.25-0.95], p<0.03), cirrhosis (OR 4.62, 95% CI [1.47-14,5], p<0.01), male gender (OR 0.68, 95% CI [0.46-1.0], p<0.05), mechanical ventilation (OR 1.87, 95% CI [1.19-2.95], p<0.01), hemodialysis (OR 1.98, 95% CI [1.05-3.75], p<0.03), and the SAPS II score (OR 1.08, 95% CI [1.06-1.10], p<0.001). CONCLUSION: The present study revealed a higher prevalence of infections in Brazilian ICUs than has been previously reported. There was a clear association between infection and mortality.
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Original Articles – Clinical Research
Characterization of drug prescriptions in an adult intensive care unit
Rev Bras Ter Intensiva. 2012;24(2):151-156
Abstract
Original Articles – Clinical ResearchCharacterization of drug prescriptions in an adult intensive care unit
Rev Bras Ter Intensiva. 2012;24(2):151-156
DOI 10.1590/S0103-507X2012000200009
Views0See moreOBJECTIVE:To characterize drug prescriptions in a university hospital adult intensive care unit. METHODS: Single-center, observational, descriptive, cross-sectional study conducted at an adult general intensive care unit. The study population included all of the unit’s inpatients from January to March 2011. The following characteristics for all prescriptions recorded during this period were examined: drug name (generic, brand name or abbreviation), dosage strength, pharmaceutical form, dose, route of administration, patient name, patient registration in the institution, clinic and hospital bed as well as the name, board license number, signature of the prescriber and date of the prescription. It was quantified the percentage of prescribed drugs included in the National List of Essential Drugs, the World Health Organization Model List of Essential Medicines and the University Hospital Center Pharmacotherapy Guide. The prescribed drugs were classified based on the Anatomical Therapeutic Chemical classification system (levels 1 and 2). RESULTS: Eight hundred forty-four prescriptions were reviewed from 72 patients (mean age: 59.04 ± 21.80), 54.92% of whom were female. The mean number of prescriptions per patient was 11.72 ± 11.68. The total number of drugs prescribed was 12,052 and 9,571 (79.41%) of the drugs were prescribed using the generic name. The most frequent absent information in the drug description was the pharmaceutical form of the drug (8,829/73.26%). The dosage strength was indicated in 7,231 (60%) of the prescriptions, and the prescriber and patient information were indicated in over 96% of the prescriptions. The prescribed drugs were classified in 13 therapeutic groups and 55 subgroups. Systemic antibacterials represented one of the most frequently prescribed subgroups. CONCLUSION: Most of the reviewed information was present in the prescriptions. However, the dosage strength and pharmaceutical form were absent in many prescriptions. The characterization of prescriptions at different hospital units is essential for the development of strategies that reduce drug utilization problems.
Views0Abstract
Original Articles – Clinical ResearchCharacterization of drug prescriptions in an adult intensive care unit
Rev Bras Ter Intensiva. 2012;24(2):151-156
DOI 10.1590/S0103-507X2012000200009
Views0See moreOBJECTIVE:To characterize drug prescriptions in a university hospital adult intensive care unit. METHODS: Single-center, observational, descriptive, cross-sectional study conducted at an adult general intensive care unit. The study population included all of the unit’s inpatients from January to March 2011. The following characteristics for all prescriptions recorded during this period were examined: drug name (generic, brand name or abbreviation), dosage strength, pharmaceutical form, dose, route of administration, patient name, patient registration in the institution, clinic and hospital bed as well as the name, board license number, signature of the prescriber and date of the prescription. It was quantified the percentage of prescribed drugs included in the National List of Essential Drugs, the World Health Organization Model List of Essential Medicines and the University Hospital Center Pharmacotherapy Guide. The prescribed drugs were classified based on the Anatomical Therapeutic Chemical classification system (levels 1 and 2). RESULTS: Eight hundred forty-four prescriptions were reviewed from 72 patients (mean age: 59.04 ± 21.80), 54.92% of whom were female. The mean number of prescriptions per patient was 11.72 ± 11.68. The total number of drugs prescribed was 12,052 and 9,571 (79.41%) of the drugs were prescribed using the generic name. The most frequent absent information in the drug description was the pharmaceutical form of the drug (8,829/73.26%). The dosage strength was indicated in 7,231 (60%) of the prescriptions, and the prescriber and patient information were indicated in over 96% of the prescriptions. The prescribed drugs were classified in 13 therapeutic groups and 55 subgroups. Systemic antibacterials represented one of the most frequently prescribed subgroups. CONCLUSION: Most of the reviewed information was present in the prescriptions. However, the dosage strength and pharmaceutical form were absent in many prescriptions. The characterization of prescriptions at different hospital units is essential for the development of strategies that reduce drug utilization problems.
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Original Articles – Clinical Research
Nutritional status, hyperglycemia, early nutrition, and mortality of patients hospitalized in an intensive care unit
Rev Bras Ter Intensiva. 2012;24(2):157-161
Abstract
Original Articles – Clinical ResearchNutritional status, hyperglycemia, early nutrition, and mortality of patients hospitalized in an intensive care unit
Rev Bras Ter Intensiva. 2012;24(2):157-161
DOI 10.1590/S0103-507X2012000200010
Views0See moreOBJECTIVE: Because patients hospitalized in intensive care units are at risk for poor nutrition, and nutritional therapy is not always started at an appropriate time, the present study aimed to correlate nutritional status, early nutrition, and hyperglycemia with patient mortality in an intensive care unit. METHODS: This archival cohort study used the secondary database of 453 patients who stayed at least 48 hours in an intensive care unit and were assessed for 8 days of hospitalization. Patient nutritional status was defined according to the body mass index. Early nutrition was defined as an feeding energy within the first 48 hours of hospitalization, regardless of the administration route. Blood glucose levels were monitored using a glucometer. RESULTS: A majority of patients were male (54.2%), and approximately half of patients were overweight (48.4%). At the end of the first 48 hours, 69.4% of patients had received nutrition, and only 13.5% of patients still exhibited hyperglycemia. The patients who received early nutritional therapy exhibited lower a mortality risk (p = 0.002), regardless of the presence of other factors associated with mortality. CONCLUSIONS: The significant correlation between early nutritional therapy and survival emphasizes the importance of nutrition in severely ill patients. The low frequency of hyperglycemia found in this study might indicate that the prescription of nutritional therapy and the application of an insulin protocol are appropriate at institutional intensive care units.
Views0Abstract
Original Articles – Clinical ResearchNutritional status, hyperglycemia, early nutrition, and mortality of patients hospitalized in an intensive care unit
Rev Bras Ter Intensiva. 2012;24(2):157-161
DOI 10.1590/S0103-507X2012000200010
Views0See moreOBJECTIVE: Because patients hospitalized in intensive care units are at risk for poor nutrition, and nutritional therapy is not always started at an appropriate time, the present study aimed to correlate nutritional status, early nutrition, and hyperglycemia with patient mortality in an intensive care unit. METHODS: This archival cohort study used the secondary database of 453 patients who stayed at least 48 hours in an intensive care unit and were assessed for 8 days of hospitalization. Patient nutritional status was defined according to the body mass index. Early nutrition was defined as an feeding energy within the first 48 hours of hospitalization, regardless of the administration route. Blood glucose levels were monitored using a glucometer. RESULTS: A majority of patients were male (54.2%), and approximately half of patients were overweight (48.4%). At the end of the first 48 hours, 69.4% of patients had received nutrition, and only 13.5% of patients still exhibited hyperglycemia. The patients who received early nutritional therapy exhibited lower a mortality risk (p = 0.002), regardless of the presence of other factors associated with mortality. CONCLUSIONS: The significant correlation between early nutritional therapy and survival emphasizes the importance of nutrition in severely ill patients. The low frequency of hyperglycemia found in this study might indicate that the prescription of nutritional therapy and the application of an insulin protocol are appropriate at institutional intensive care units.
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Original Articles – Clinical Research
Arterial blood gas analysis in two different intra-hospital transport methods for postoperative cardiac surgery patients
Rev Bras Ter Intensiva. 2012;24(2):162-166
Abstract
Original Articles – Clinical ResearchArterial blood gas analysis in two different intra-hospital transport methods for postoperative cardiac surgery patients
Rev Bras Ter Intensiva. 2012;24(2):162-166
DOI 10.1590/S0103-507X2012000200011
Views0OBJECTIVE: To evaluate the effects on blood gases by two methods of ventilation (with transport ventilation or self-inflating manual resuscitator) during intra-hospital transport of patients after cardiac surgery. METHODS: Observational, longitudinal, prospective, randomized study. Two samples of arterial blood were collected at the end of the surgery and another at the end of patient transport. RESULTS: We included 23 patients: 13 in the Group with transport ventilation and 10 in the Group with self-inflating manual resuscitator. Baseline characteristics were similar between both groups, except for higher acute severity of illness in the Group with transport ventilation. We observed significant differences in comparisons of percentage variations of gasometric data: pH (transport ventilation + 4% x MR -5%, p=0.007), PaCO2 (-8% x +13%, p=0.006), PaO2 (+47% x -34%, p=0.01) and SatO2 (+0.6% x -1.7%, p=0.001). CONCLUSION: The use of mechanical ventilation results in fewer repercussions for blood gas analysis in the intra-hospital transport of cardiac surgery patients.
Keywords:blood gas analysisIntensive carePatient transferPulmonary gas exchangeRespiration, artificialTransportation of patientsSee moreViews0Abstract
Original Articles – Clinical ResearchArterial blood gas analysis in two different intra-hospital transport methods for postoperative cardiac surgery patients
Rev Bras Ter Intensiva. 2012;24(2):162-166
DOI 10.1590/S0103-507X2012000200011
Views0OBJECTIVE: To evaluate the effects on blood gases by two methods of ventilation (with transport ventilation or self-inflating manual resuscitator) during intra-hospital transport of patients after cardiac surgery. METHODS: Observational, longitudinal, prospective, randomized study. Two samples of arterial blood were collected at the end of the surgery and another at the end of patient transport. RESULTS: We included 23 patients: 13 in the Group with transport ventilation and 10 in the Group with self-inflating manual resuscitator. Baseline characteristics were similar between both groups, except for higher acute severity of illness in the Group with transport ventilation. We observed significant differences in comparisons of percentage variations of gasometric data: pH (transport ventilation + 4% x MR -5%, p=0.007), PaCO2 (-8% x +13%, p=0.006), PaO2 (+47% x -34%, p=0.01) and SatO2 (+0.6% x -1.7%, p=0.001). CONCLUSION: The use of mechanical ventilation results in fewer repercussions for blood gas analysis in the intra-hospital transport of cardiac surgery patients.
Keywords:blood gas analysisIntensive carePatient transferPulmonary gas exchangeRespiration, artificialTransportation of patientsSee more
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Original Articles – Clinical Research
Use of a noninvasive ventilation device following tracheotomy: an alternative to facilitate ICU discharge?
Rev Bras Ter Intensiva. 2012;24(2):167-172
Abstract
Original Articles – Clinical ResearchUse of a noninvasive ventilation device following tracheotomy: an alternative to facilitate ICU discharge?
Rev Bras Ter Intensiva. 2012;24(2):167-172
DOI 10.1590/S0103-507X2012000200012
Views0See moreOBJECTIVE: We aimed to assess the use of noninvasive ventilation devices in patients with prolonged weaning following tracheotomy. METHODS: We performed a retrospective observational study using data collected from the clinical records of tracheotomized patients diagnosed with prolonged weaning. The participants were hospitalized in the adult intensive care unit of Moinhos de Vento Hospital, Porto Alegre (RS) between December 2007 and December 2008. RESULTS: In the data collection period, 1,482 patients were admitted to the intensive care unit. In total, 126 patients underwent tracheotomies, and 26 of these patients met the inclusion criteria for participating in the study. The average age of the patients in our sample was 73 ± 12 years. In our sample, 57.7% of the participants were female, and 80.8% were admitted as a result of acute hypoxemic respiratory failure. After the tracheotomy, the patients remained under mechanical ventilation for an average of 29.8 days. After the initiation of the experimental protocol, the tracheotomized patients remained under ventilation for an average of 53.5 days on a portable noninvasive device connected to the tracheotomy. There were three possible outcomes for the patients. They were discharged, were weaned from the noninvasive ventilation, or died in the intensive care unit or hospital ward. In total, 76.9% (20/26) of the patients were discharged from the intensive care unit, and 53.8% (14/26) of the patients were discharged from the hospital. CONCLUSION: The use of noninvasive portable ventilators connected to the tracheotomy may represent an alternative for discontinuing ventilationand discharging tracheotomized patients with prolonged ventilatory weaning from intensive care unit.
Views0Abstract
Original Articles – Clinical ResearchUse of a noninvasive ventilation device following tracheotomy: an alternative to facilitate ICU discharge?
Rev Bras Ter Intensiva. 2012;24(2):167-172
DOI 10.1590/S0103-507X2012000200012
Views0See moreOBJECTIVE: We aimed to assess the use of noninvasive ventilation devices in patients with prolonged weaning following tracheotomy. METHODS: We performed a retrospective observational study using data collected from the clinical records of tracheotomized patients diagnosed with prolonged weaning. The participants were hospitalized in the adult intensive care unit of Moinhos de Vento Hospital, Porto Alegre (RS) between December 2007 and December 2008. RESULTS: In the data collection period, 1,482 patients were admitted to the intensive care unit. In total, 126 patients underwent tracheotomies, and 26 of these patients met the inclusion criteria for participating in the study. The average age of the patients in our sample was 73 ± 12 years. In our sample, 57.7% of the participants were female, and 80.8% were admitted as a result of acute hypoxemic respiratory failure. After the tracheotomy, the patients remained under mechanical ventilation for an average of 29.8 days. After the initiation of the experimental protocol, the tracheotomized patients remained under ventilation for an average of 53.5 days on a portable noninvasive device connected to the tracheotomy. There were three possible outcomes for the patients. They were discharged, were weaned from the noninvasive ventilation, or died in the intensive care unit or hospital ward. In total, 76.9% (20/26) of the patients were discharged from the intensive care unit, and 53.8% (14/26) of the patients were discharged from the hospital. CONCLUSION: The use of noninvasive portable ventilators connected to the tracheotomy may represent an alternative for discontinuing ventilationand discharging tracheotomized patients with prolonged ventilatory weaning from intensive care unit.
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Original Articles – Clinical Research
Influence of early mobilization on respiratory and peripheral muscle strength in critically ill patients
Rev Bras Ter Intensiva. 2012;24(2):173-178
Abstract
Original Articles – Clinical ResearchInfluence of early mobilization on respiratory and peripheral muscle strength in critically ill patients
Rev Bras Ter Intensiva. 2012;24(2):173-178
DOI 10.1590/S0103-507X2012000200013
Views8See moreOBJECTIVE:To evaluate the effects of an early mobilization protocol on respiratory and peripheral muscles in critically ill patients. METHODS: A randomized controlled clinical trial was conducted with 59 male and female patients on mechanical ventilation. The patients were divided into a conventional physical therapy group (control group, n=14) that received the sector’s standard physical therapy program and an early mobilization group (n=14) that received a systematic early mobilization protocol. Peripheral muscle strength was assessed with the Medical Research Council score, and respiratory muscle strength (determined by the maximal inspiratory and expiratory pressures) was measured using a vacuum manometer with a unidirectional valve. Systematic early mobilization was performed on five levels. RESULTS: Significant increases were observed for values for maximal inspiratory pressure and the Medical Research Council score in the early mobilization group. However, no statistically significant improvement was observed for maximal expiratory pressure or MV duration (days), length of stay in the intensive care unit (days), and length of hospital stay (days). CONCLUSION: The early mobilization group showed gains in inspiratory and peripheral muscle strength.
Views8Abstract
Original Articles – Clinical ResearchInfluence of early mobilization on respiratory and peripheral muscle strength in critically ill patients
Rev Bras Ter Intensiva. 2012;24(2):173-178
DOI 10.1590/S0103-507X2012000200013
Views8See moreOBJECTIVE:To evaluate the effects of an early mobilization protocol on respiratory and peripheral muscles in critically ill patients. METHODS: A randomized controlled clinical trial was conducted with 59 male and female patients on mechanical ventilation. The patients were divided into a conventional physical therapy group (control group, n=14) that received the sector’s standard physical therapy program and an early mobilization group (n=14) that received a systematic early mobilization protocol. Peripheral muscle strength was assessed with the Medical Research Council score, and respiratory muscle strength (determined by the maximal inspiratory and expiratory pressures) was measured using a vacuum manometer with a unidirectional valve. Systematic early mobilization was performed on five levels. RESULTS: Significant increases were observed for values for maximal inspiratory pressure and the Medical Research Council score in the early mobilization group. However, no statistically significant improvement was observed for maximal expiratory pressure or MV duration (days), length of stay in the intensive care unit (days), and length of hospital stay (days). CONCLUSION: The early mobilization group showed gains in inspiratory and peripheral muscle strength.
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Original Articles – Clinical Research
Prevalence and factors associated with bronchopulmonary dysplasia in a referral hospital in Minas Gerais, Brazil
Rev Bras Ter Intensiva. 2012;24(2):179-183
Abstract
Original Articles – Clinical ResearchPrevalence and factors associated with bronchopulmonary dysplasia in a referral hospital in Minas Gerais, Brazil
Rev Bras Ter Intensiva. 2012;24(2):179-183
DOI 10.1590/S0103-507X2012000200014
Views0OBJECTIVE:The aim of the present study was to evaluate the prevalence and factors associated with bronchopulmonary dysplasia at a neonatal intensive care unit. METHODS: The study was a cross-sectional study that used secondary data from premature infants who were born with less than 32 weeks of gestational age and were admitted to a neonatal intensive care unit. Chi-square, Mann-Whitney and multivariate tests were used. Significance was set at p<0.05. RESULTS: A total of 88 premature infants were included in the study. Bronchopulmonary dysplasia occurred in 27.3% of the infants and was related to having a gestational age below 28 weeks (OR: 4.80; 95% CI: 1.50-15.34; p=0.008) and a patent ductus arteriosus (OR: 3.44; 95% CI: 1.10-10.76; p=0.034). The group with bronchopulmonary dysplasia used mechanical ventilation for a longer duration, with a median of 24.5 days (p<0.0001). At discharge, the corrected and chronological ages were higher in the group with bronchopulmonary dysplasia (p<0.0001), with respective medians of 38.4 weeks and 70.5 days. CONCLUSIONS: In this study, the prevalence of bronchopulmonary dysplasia was high; the high prevalence was related to extreme prematurity, patent ductus arteriosus, a longer period under mechanical ventilation and prolonged hospitalization. The increased survival of infants with low gestational age makes this disorder a public health issue.
Keywords:Bronchopulmonary dysplasiaInfant, low birth weightInfant, prematureInfant, premature, diseasesSee moreViews0Abstract
Original Articles – Clinical ResearchPrevalence and factors associated with bronchopulmonary dysplasia in a referral hospital in Minas Gerais, Brazil
Rev Bras Ter Intensiva. 2012;24(2):179-183
DOI 10.1590/S0103-507X2012000200014
Views0OBJECTIVE:The aim of the present study was to evaluate the prevalence and factors associated with bronchopulmonary dysplasia at a neonatal intensive care unit. METHODS: The study was a cross-sectional study that used secondary data from premature infants who were born with less than 32 weeks of gestational age and were admitted to a neonatal intensive care unit. Chi-square, Mann-Whitney and multivariate tests were used. Significance was set at p<0.05. RESULTS: A total of 88 premature infants were included in the study. Bronchopulmonary dysplasia occurred in 27.3% of the infants and was related to having a gestational age below 28 weeks (OR: 4.80; 95% CI: 1.50-15.34; p=0.008) and a patent ductus arteriosus (OR: 3.44; 95% CI: 1.10-10.76; p=0.034). The group with bronchopulmonary dysplasia used mechanical ventilation for a longer duration, with a median of 24.5 days (p<0.0001). At discharge, the corrected and chronological ages were higher in the group with bronchopulmonary dysplasia (p<0.0001), with respective medians of 38.4 weeks and 70.5 days. CONCLUSIONS: In this study, the prevalence of bronchopulmonary dysplasia was high; the high prevalence was related to extreme prematurity, patent ductus arteriosus, a longer period under mechanical ventilation and prolonged hospitalization. The increased survival of infants with low gestational age makes this disorder a public health issue.
Keywords:Bronchopulmonary dysplasiaInfant, low birth weightInfant, prematureInfant, premature, diseasesSee more -
Original Articles – Clinical Research
The correlation between plasma lactate concentrations and early neonatal mortality
Rev Bras Ter Intensiva. 2012;24(2):184-187
Abstract
Original Articles – Clinical ResearchThe correlation between plasma lactate concentrations and early neonatal mortality
Rev Bras Ter Intensiva. 2012;24(2):184-187
DOI 10.1590/S0103-507X2012000200015
Views0See moreOBJECTIVE: To assess the correlation between plasma lactate concentrations in the first 6 hours of life and early neonatal mortality. METHODS: The patients were divided in 2 groups based on the cutoff point, obtained from a receiver operating characteristic (ROC) curve, of the plasma lactate concentration that best predicted neonatal mortality during the first 3 days of life. The differences between groups and the correlations between the investigated variables and the plasma lactate concentrations measured in the first 6 hours of life were analyzed using the Chi-square, Student’s t, or Mann-Whitney tests and logistic regression. RESULTS: The best cutoff point of the plasma lactate concentration as determined by the ROC curve for death during the first 3 days of life was 4.2 mmol/L. The investigated groups differed with regards to the average birth weight, which was lower in the group with serum lactate levels > 4.2 mmol/L, and the match between birth weight and gestational age, where the group with serum lactate levels > 4.2 mmol/L exhibited a higher number of newborns small for their gestational age. Seizures, intracranial hemorrhage, and death during the first 3 days of life occurred more frequently in the group with serum lactate levels > 4.2 mmol/L. CONCLUSION: In the investigated samples, the presence of plasma lactate concentrations > 4.2 mmol/L in the first 6 hours of life correlated with neonatal death during the first 3 days of life, a higher frequency of neurologic morbidity, and newborns that were small for their gestational age.
Views0Abstract
Original Articles – Clinical ResearchThe correlation between plasma lactate concentrations and early neonatal mortality
Rev Bras Ter Intensiva. 2012;24(2):184-187
DOI 10.1590/S0103-507X2012000200015
Views0See moreOBJECTIVE: To assess the correlation between plasma lactate concentrations in the first 6 hours of life and early neonatal mortality. METHODS: The patients were divided in 2 groups based on the cutoff point, obtained from a receiver operating characteristic (ROC) curve, of the plasma lactate concentration that best predicted neonatal mortality during the first 3 days of life. The differences between groups and the correlations between the investigated variables and the plasma lactate concentrations measured in the first 6 hours of life were analyzed using the Chi-square, Student’s t, or Mann-Whitney tests and logistic regression. RESULTS: The best cutoff point of the plasma lactate concentration as determined by the ROC curve for death during the first 3 days of life was 4.2 mmol/L. The investigated groups differed with regards to the average birth weight, which was lower in the group with serum lactate levels > 4.2 mmol/L, and the match between birth weight and gestational age, where the group with serum lactate levels > 4.2 mmol/L exhibited a higher number of newborns small for their gestational age. Seizures, intracranial hemorrhage, and death during the first 3 days of life occurred more frequently in the group with serum lactate levels > 4.2 mmol/L. CONCLUSION: In the investigated samples, the presence of plasma lactate concentrations > 4.2 mmol/L in the first 6 hours of life correlated with neonatal death during the first 3 days of life, a higher frequency of neurologic morbidity, and newborns that were small for their gestational age.
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Review Articles
Motor physical therapy in hospitalized patients in an intensive care unit: a systematic review
Rev Bras Ter Intensiva. 2012;24(2):188-196
Abstract
Review ArticlesMotor physical therapy in hospitalized patients in an intensive care unit: a systematic review
Rev Bras Ter Intensiva. 2012;24(2):188-196
DOI 10.1590/S0103-507X2012000200016
Views0See moreOBJECTIVE: To analyze the outcomes achieved by motor physical therapy in critically ill patients admitted to intensive care units. METHODS: A systematic literature review was performed, and clinical trials published between 2002 and 2011 were included in the study. The search involved the LILACS, SciELO, MedLine, EMBASE and Cochrane databases, using the keywords “intensive care unit”, “physiotherapy”, “physical therapy”, “mobility”, “mobilization” and “randomized controlled trials.” Two researchers screened the articles independently and included works that addressed the effect of physical therapy on critically ill patients. RESULTS: From an initial analysis of 67 potentially relevant articles, only 8 met the selection criteria and addressed the outcomes of electrostimulation, cycle ergometry and kinesiotherapy techniques. The sample sizes ranged from 8 to 101 subjects, with mean ages between 52 and 79 years. All patients were undergoing invasive mechanical ventilation. Among the analyzed articles, 6 reported significant benefits of motor physical therapy, such as improvement in peripheral muscle strength, respiratory capacity and functionality, in critically ill patients. CONCLUSION: With this systematic review, it is possible to conclude that motor physical therapy is a feasible and safe therapy for critically ill patients and can minimize the deleterious effects of prolonged immobilization. Approaches involving electrostimulation, cycle ergometry and kinesiotherapy showed positive responses in patients under intensive care. Available evidence regarding the impact of motor physical therapy on length of stay in intensive care units and on mortality is still scarce, and further study in this area is warranted.
Views0Abstract
Review ArticlesMotor physical therapy in hospitalized patients in an intensive care unit: a systematic review
Rev Bras Ter Intensiva. 2012;24(2):188-196
DOI 10.1590/S0103-507X2012000200016
Views0See moreOBJECTIVE: To analyze the outcomes achieved by motor physical therapy in critically ill patients admitted to intensive care units. METHODS: A systematic literature review was performed, and clinical trials published between 2002 and 2011 were included in the study. The search involved the LILACS, SciELO, MedLine, EMBASE and Cochrane databases, using the keywords “intensive care unit”, “physiotherapy”, “physical therapy”, “mobility”, “mobilization” and “randomized controlled trials.” Two researchers screened the articles independently and included works that addressed the effect of physical therapy on critically ill patients. RESULTS: From an initial analysis of 67 potentially relevant articles, only 8 met the selection criteria and addressed the outcomes of electrostimulation, cycle ergometry and kinesiotherapy techniques. The sample sizes ranged from 8 to 101 subjects, with mean ages between 52 and 79 years. All patients were undergoing invasive mechanical ventilation. Among the analyzed articles, 6 reported significant benefits of motor physical therapy, such as improvement in peripheral muscle strength, respiratory capacity and functionality, in critically ill patients. CONCLUSION: With this systematic review, it is possible to conclude that motor physical therapy is a feasible and safe therapy for critically ill patients and can minimize the deleterious effects of prolonged immobilization. Approaches involving electrostimulation, cycle ergometry and kinesiotherapy showed positive responses in patients under intensive care. Available evidence regarding the impact of motor physical therapy on length of stay in intensive care units and on mortality is still scarce, and further study in this area is warranted.
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Review Articles
Palliative care of elderly patients in intensive care units: a systematic review
Rev Bras Ter Intensiva. 2012;24(2):197-206
Abstract
Review ArticlesPalliative care of elderly patients in intensive care units: a systematic review
Rev Bras Ter Intensiva. 2012;24(2):197-206
DOI 10.1590/S0103-507X2012000200017
Views0See moreOBJECTIVE: The use of interventionist medical technology in terminal elderly patients must be associated with palliative care as a measure of clinical support in intensive care units. Palliative care is an important component of end-of-life care, and the assistance provided by the healthcare team should be guided by decisions made by patients and their family members. Prolongation of life not accompanied by therapies aimed at relieving symptoms, such as pain and dyspnea, contributes to patient and family member stress suffering. The aim of the present study was to survey advances made in the application of palliative care in intensive care units. METHODS: Medline and Bireme were used to perform a systematic literature review of intensive care units-based palliative care for elderly patients. RESULTS: A total of 29 articles describing palliative care in intensive care units were analyzed according to the variables “satisfaction of relatives when they participate in the discussions on palliative care” and “difficulties to implement such type of care due to lack of technical skills of the health caregivers.” CONCLUSION: Palliative care for elderly patients in intensive care units must be more thoroughly investigated to improve the relationships and communication among patients, their relatives, and the healthcare team. As greater numbers of elderly patients are admitted to intensive care units, the skills of health caregivers must improve to meet the challenges posed by the end-of-life care.
Views0Abstract
Review ArticlesPalliative care of elderly patients in intensive care units: a systematic review
Rev Bras Ter Intensiva. 2012;24(2):197-206
DOI 10.1590/S0103-507X2012000200017
Views0See moreOBJECTIVE: The use of interventionist medical technology in terminal elderly patients must be associated with palliative care as a measure of clinical support in intensive care units. Palliative care is an important component of end-of-life care, and the assistance provided by the healthcare team should be guided by decisions made by patients and their family members. Prolongation of life not accompanied by therapies aimed at relieving symptoms, such as pain and dyspnea, contributes to patient and family member stress suffering. The aim of the present study was to survey advances made in the application of palliative care in intensive care units. METHODS: Medline and Bireme were used to perform a systematic literature review of intensive care units-based palliative care for elderly patients. RESULTS: A total of 29 articles describing palliative care in intensive care units were analyzed according to the variables “satisfaction of relatives when they participate in the discussions on palliative care” and “difficulties to implement such type of care due to lack of technical skills of the health caregivers.” CONCLUSION: Palliative care for elderly patients in intensive care units must be more thoroughly investigated to improve the relationships and communication among patients, their relatives, and the healthcare team. As greater numbers of elderly patients are admitted to intensive care units, the skills of health caregivers must improve to meet the challenges posed by the end-of-life care.
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Case Report
ProSealTM laryngeal mask airway for surfactant administration in the treatment of respiratory distress syndrome in a premature infant
Rev Bras Ter Intensiva. 2012;24(2):207-210
Abstract
Case ReportProSealTM laryngeal mask airway for surfactant administration in the treatment of respiratory distress syndrome in a premature infant
Rev Bras Ter Intensiva. 2012;24(2):207-210
DOI 10.1590/S0103-507X2012000200018
Views0The administration of surfactant via tracheal cannula with mechanical ventilation is the conventional treatment for infant respiratory distress syndrome. Hemodynamic and respiratory changes due to tracheal intubation and the need for premedication justify the search for less invasive alternatives of surfactant administration. The objective of this study was to describe the use of the ProSealTM laryngeal mask airway as an option for the treatment of respiratory distress syndrome in a premature infant born at 31 weeks of gestation, at 1335 g, with respiratory difficulty after the first hour of life and exhibiting the clinical and radiologic features of respiratory distress syndrome. The surfactant was administered with the use of the ProSealTM laryngeal mask airway at 3.5 hours of life. It was well tolerated, with no need for tracheal intubation. Normal gasometry and radiologic improvement were observed after three and six hours of administration. Oxygen administration was suspended after eight days, with no comorbidities at discharge. The laryngeal mask airway seems to be a painless and less invasive alternative to treat respiratory distress syndrome and may reduce the need for tracheal intubation and mechanical ventilation. The efficacy and advantages of this route of treatment should be confirmed in a study of an adequate sample.
Keywords:administration & dosagedrug therapyInfant, prematureLaryngeal masksRespiratory distress syndrome, newbornSurface-active agentsutilizationSee moreViews0Abstract
Case ReportProSealTM laryngeal mask airway for surfactant administration in the treatment of respiratory distress syndrome in a premature infant
Rev Bras Ter Intensiva. 2012;24(2):207-210
DOI 10.1590/S0103-507X2012000200018
Views0The administration of surfactant via tracheal cannula with mechanical ventilation is the conventional treatment for infant respiratory distress syndrome. Hemodynamic and respiratory changes due to tracheal intubation and the need for premedication justify the search for less invasive alternatives of surfactant administration. The objective of this study was to describe the use of the ProSealTM laryngeal mask airway as an option for the treatment of respiratory distress syndrome in a premature infant born at 31 weeks of gestation, at 1335 g, with respiratory difficulty after the first hour of life and exhibiting the clinical and radiologic features of respiratory distress syndrome. The surfactant was administered with the use of the ProSealTM laryngeal mask airway at 3.5 hours of life. It was well tolerated, with no need for tracheal intubation. Normal gasometry and radiologic improvement were observed after three and six hours of administration. Oxygen administration was suspended after eight days, with no comorbidities at discharge. The laryngeal mask airway seems to be a painless and less invasive alternative to treat respiratory distress syndrome and may reduce the need for tracheal intubation and mechanical ventilation. The efficacy and advantages of this route of treatment should be confirmed in a study of an adequate sample.
Keywords:administration & dosagedrug therapyInfant, prematureLaryngeal masksRespiratory distress syndrome, newbornSurface-active agentsutilizationSee more
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Erratum Rev Bras Ter Intensiva. 2012;24(2):211-211
Abstract
ErratumRev Bras Ter Intensiva. 2012;24(2):211-211
DOI 10.1590/S0103-507X2012000200019
Views0ERRATUM In the article Multidisciplinary care in the intensive care unit for a patient with Prader-Willi syndrome: a dental approach. RBTI 2012;24(1):106-110 the correct legend are:[…]See moreViews0Abstract
ErratumRev Bras Ter Intensiva. 2012;24(2):211-211
DOI 10.1590/S0103-507X2012000200019
Views0ERRATUM In the article Multidisciplinary care in the intensive care unit for a patient with Prader-Willi syndrome: a dental approach. RBTI 2012;24(1):106-110 the correct legend are:[…]See more
Volume Articles - Critical Care Science (CCS)
