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Editorial
Use of biomarkers in sepsis: many questions, few answers
Rev Bras Ter Intensiva. 2013;25(1):1-2
Abstract
EditorialUse of biomarkers in sepsis: many questions, few answers
Rev Bras Ter Intensiva. 2013;25(1):1-2
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Special Article
The burden of sepsis: a call to action in support of World Sepsis Day 2013
Rev Bras Ter Intensiva. 2013;25(1):3-5
Abstract
Special ArticleThe burden of sepsis: a call to action in support of World Sepsis Day 2013
Rev Bras Ter Intensiva. 2013;25(1):3-5
DOI 10.1590/S0103-507X2013000100002
Views0SPECIAL ARTICLE The burden of sepsis: a call to action in support of World Sepsis Day 2013[…]See more -
Original Articles – Clinical Research
Serum C-reactive protein concentrations in early abdominal and pulmonary sepsis
Rev Bras Ter Intensiva. 2013;25(1):6-11
Abstract
Original Articles – Clinical ResearchSerum C-reactive protein concentrations in early abdominal and pulmonary sepsis
Rev Bras Ter Intensiva. 2013;25(1):6-11
DOI 10.1590/S0103-507X2013000100003
Views0See moreOBJECTIVES: To evaluate the C-reactive protein serum levels in patients with pulmonary and abdominal sepsis during the first five days of sepsis progression. METHODS: The present investigation was a retrospective cohort study conducted at the university hospital with 345 patients who were admitted to the intensive care unit and diagnosed with sepsis of pulmonary or abdominal origin. Serum C-reactive protein concentrations were measured by the turbidimetric immunoassay. For analysis of C-reactive protein, day 1 was defined as the day on which the patient was clinically diagnosed with sepsis. RESULTS: Thirty-four patients with sepsis (9.8%), 114 patients with severe sepsis (33.0%), and 197 patients with septic shock (57.2%) were evaluated. The age of the patients was 56.4±19.8 years. The serum C-reactive protein concentrations were higher on the day of sepsis diagnosis in the group with abdominal infection compared with the group with pulmonary sepsis (17.8±10.1 mg/dL versus 14.9±11.1 mg/dL, p=0.025) and remained significantly higher during the first five days of sepsis progression. CONCLUSION: The serum C-reactive protein concentrations were significantly higher in the patients with abdominal sepsis compared with the patients with pulmonary sepsis during the first five days of sepsis progression.
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Original Articles – Clinical Research
Outcomes for patients with lung cancer admitted to intensive care units
Rev Bras Ter Intensiva. 2013;25(1):12-16
Abstract
Original Articles – Clinical ResearchOutcomes for patients with lung cancer admitted to intensive care units
Rev Bras Ter Intensiva. 2013;25(1):12-16
DOI 10.1590/S0103-507X2013000100004
Views0See moreOBJECTIVE: This study aimed to evaluate the outcomes for patients with lung cancer admitted to intensive care units and assess their clinical and demographic profiles. METHODS: Retrospective, analytical, observational study, wherein the outcomes for patients diagnosed with lung cancer admitted to the intensive care unit of university hospital from January 2010 until February 2011 were evaluated. RESULTS: Thirty-four patients’ medical records were included. Twenty-six (76.5%) patients received some type of ventilatory support, of whom 21 (61.8%) used invasive mechanical ventilation and 11 (32.4%) used noninvasive ventilation at some point during their stay at the intensive care unit. Regarding mortality, 12 (35.3%) patients died during hospitalization at the intensive care unit, totaling 15 (44.1%) deaths during the entire hospitalization period; 19 (55.9%) patients were discharged from the hospital. The analysis of the variables showed that the patients who died had remained on invasive mechanical ventilation for a longer period 5.0 (0.25 to 15.0) days than the survivors (1.0 (0 to 1.0) days) (p=0.033) and underwent dialysis during their stay at the intensive care unit (p=0.014). CONCLUSIONS: The mortality of patients with lung cancer admitted to the intensive care unit is associated with the time spent on invasive mechanical ventilation and the need for dialysis.
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Original Articles – Clinical Research
Enteral nutritional therapy in septic patients in the intensive care unit: compliance with nutritional guidelines for critically ill patients
Rev Bras Ter Intensiva. 2013;25(1):17-24
Abstract
Original Articles – Clinical ResearchEnteral nutritional therapy in septic patients in the intensive care unit: compliance with nutritional guidelines for critically ill patients
Rev Bras Ter Intensiva. 2013;25(1):17-24
DOI 10.1590/S0103-507X2013000100005
Views0OBJECTIVE: Evaluate the compliance of septic patients’ nutritional management with enteral nutrition guidelines for critically ill patients. METHODS: Prospective cohort study with 92 septic patients, age ≥18 years, hospitalized in an intensive care unit, under enteral nutrition, evaluated according to enteral nutrition guidelines for critically ill patients, compliance with caloric and protein goals, and reasons for not starting enteral nutrition early or for discontinuing it. Prognostic scores, length of intensive care unit stay, clinical progression, and nutritional status were also analyzed. RESULTS: The patients had a mean age of 63.4±15.1 years, were predominantly male, were diagnosed predominantly with septic shock (56.5%), had a mean intensive care unit stay of 11 (7.2 to 18.0) days, had 8.2±4.2 SOFA and 24.1±9.6 APACHE II scores, and had 39.1% mortality. Enteral nutrition was initiated early in 63% of patients. Approximately 50% met the caloric and protein goals on the third day of intensive care unit stay, a percentage that decreased to 30% at day 7. Reasons for the late start of enteral nutrition included gastrointestinal tract complications (35.3%) and hemodynamic instability (32.3%). Clinical procedures were the most frequent reason to discontinue enteral nutrition (44.1%). There was no association between compliance with the guidelines and nutritional status, length of intensive care unit stay, severity, or progression. CONCLUSION: Although the number of septic patients under early enteral nutrition was significant, caloric and protein goals at day 3 of intensive care unit stay were met by only half of them, a percentage that decreased at day 7.
Keywords:enteral nutritionGuidelines as topicIntensive careIntensive care unitsnutrition therapySepsisSee more -
Original Articles – Clinical Research
Bioelectrical impedance phase angle in septic patients admitted to intensive care units
Rev Bras Ter Intensiva. 2013;25(1):25-31
Abstract
Original Articles – Clinical ResearchBioelectrical impedance phase angle in septic patients admitted to intensive care units
Rev Bras Ter Intensiva. 2013;25(1):25-31
DOI 10.1590/S0103-507X2013000100006
Views0See moreOBJECTIVE: To calculate the values of the phase angle of septic patients using bioelectrical impedance analysis, correlate the values with clinical and biochemical variables, and compare them to reference values. METHODS: Cohort study conducted with 50 septic patients aged ≥18 years old, admitted to intensive care units, and assessed according to prognostic indexes (APACHE II and SOFA), clinical progression (mortality, severity of sepsis, length of stay in intensive care unit), biochemical parameters (albumin and C-reactive protein), and the phase angle. RESULTS: The average age of the sample was 65.6±16.5 years. Most patients were male (58%) and suffering from septic shock (60%). The average APACHE II and SOFA scores were 22.98±7.1 and 7.5±3.4, respectively. The patients who survived stayed nine days on average (five to 13) in the intensive care unit, and the mortality rate was 30%. The average value of the phase angle was 5.4±2.6° in the total sample and was smaller among the females compared with the males (p=0.01). The phase angle measures did not exhibit an association with the severity of the sepsis, mortality, gender, and age or correlate with the length of hospitalization or the biochemical parameters. The participants’ phase angle values adjusted per gender and age were 1.1 to 1.9 times lower compared with the values for a normal population. CONCLUSION: The average value of the phase angle of septic patients was lower compared with the reference values for a healthy population. The phase angle measures did not exhibit association with the clinical and biochemical variables, which might be explained by the sample homogeneity.
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Original Articles – Clinical Research
Readmissions and deaths following ICU discharge: a challenge for intensive care
Rev Bras Ter Intensiva. 2013;25(1):32-38
Abstract
Original Articles – Clinical ResearchReadmissions and deaths following ICU discharge: a challenge for intensive care
Rev Bras Ter Intensiva. 2013;25(1):32-38
DOI 10.1590/S0103-507X2013000100007
Views0OBJECTIVES: Identify patients at risk for intensive care unit readmission, the reasons for and rates of readmission, and mortality after their stay in the intensive care unit; describe the sensitivity and specificity of the Stability and Workload Index for Transfer scale as a criterion for discharge from the intensive care unit. METHODS: Adult, critical patients from intensive care units from two public hospitals in Porto Alegre, Brazil, comprised the sample. The patients’ clinical and demographic characteristics were collected within 24 hours of admission. They were monitored until their final outcome on the intensive care unit (death or discharge) to apply the Stability and Workload Index for Transfer. The deaths during the first intensive care unit admission were disregarded, and we continued monitoring the other patients using the hospitals’ electronic systems to identify the discharges, deaths, and readmissions. RESULTS: Readmission rates were 13.7% in intensive care unit 1 (medical-surgical, ICU1) and 9.3% in intensive care unit 2 (trauma and neurosurgery, ICU2). The death rate following discharge was 12.5% from ICU1 and 4.2% from ICU2. There was a statistically significant difference in Stability and Workload Index for Transfer (p<0.05) regarding the ICU1 patients' outcome, which was not found in the ICU2 patients. In ICU1, 46.5% (N=20) of patients were readmitted very early (within 48 hours of discharge). Mortality was high among those readmitted: 69.7% in ICU1 and 48.5% in ICU2. CONCLUSIONS: The Stability and Workload Index for Transfer scale showed greater efficacy in identifying patients more prone to readmission and death following discharge from a medical-surgical intensive care unit. The patients' intensive care unit readmission during the same hospitalization resulted in increased morbidity, mortality, length of stay, and total costs.
Keywords:HospitalizationIntensive care unitsMortality ratePatient dischargePatient readmissionQuality of health careSee more -
Original Articles – Clinical Research
Characterization of the use of a cycle ergometer to assist in the physical therapy treatment of critically ill patients
Rev Bras Ter Intensiva. 2013;25(1):39-43
Abstract
Original Articles – Clinical ResearchCharacterization of the use of a cycle ergometer to assist in the physical therapy treatment of critically ill patients
Rev Bras Ter Intensiva. 2013;25(1):39-43
DOI 10.1590/S0103-507X2013000100008
Views0See moreOBJECTIVE: The objective of this study was to use a cycle ergometer to assess cardiorespiratory changes during active exercise and to verify patients’ satisfaction with this type of activity. METHODS: A single intervention involving active lower limb exercise was performed with a cycle ergometer (without load) for 5 minutes. The following variables were measured before, during and immediately after exercise: heart rate, blood pressure, respiratory rate, peripheral oxygen saturation and the Borg dyspnea scale score. Following the exercise, the patients answered a questionnaire to evaluate their satisfaction with this type of activity. RESULTS: A total of 38 patients (65% male) with a mean age of 48 ± 16 years old participated in the study. Enrolled patients presented a sequential organ failure assessment (SOFA) score of 2 (0 – 5 scale). During the exercise, 16% of the patients used ventilation support and 55% of them were breathing at room air. A comparison of the initial and final values of the variables indicated increases in the heart rate (92±17 beats/min vs. 95±18 beats/min; p<0.05), the respiratory rate (19 ± 8 breaths/min vs. 23±8 breaths/min; p<0.05) and the Borg dyspnea scale score (1.3±1.8 vs. 2.8±2.2; p<0.05). In addition, 85% of the patients reported enjoying the activity. Only 25% of the patients reported some discomfort, and 100% of the patients wanted to repeat this type of activity in future treatments. CONCLUSION: During the cycle ergometer exercises, minor cardiorespiratory changes were observed in the patients. The evaluated patients reported high satisfaction with this type of activity.
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Original Articles – Clinical Research
Impact of tongue biofilm removal on mechanically ventilated patients
Rev Bras Ter Intensiva. 2013;25(1):44-48
Abstract
Original Articles – Clinical ResearchImpact of tongue biofilm removal on mechanically ventilated patients
Rev Bras Ter Intensiva. 2013;25(1):44-48
DOI 10.1590/S0103-507X2013000100009
Views0See moreOBJECTIVE: To evaluate the effectiveness of a tongue cleaner in the removal of tongue biofilm in mechanically ventilated patients. METHODS: Tongue biofilm and tracheal secretion samples were collected from a total of 50 patients: 27 in the study group (SG) who were intubated or tracheostomized under assisted ventilation and treated with the tongue cleaner and 23 in the control group (CG) who did not undergo tongue cleaning. Oral and tracheal secretion cultures of the SG (initially and after 5 days) and the CG (at a single time-point) were performed to evaluate the changes in bacterial flora. RESULTS: The median age of the SG patients was 77 years (45-99 years), and that of the CG patients was 79 years (21-94 years). The length of hospital stay ranged from 17-1,370 days for the SG with a median stay of 425 days and from 4-240 days for the CG with a median stay of 120 days. No significant differences were found when the dental plaque indexes were compared between the SG and the CG. There was no correlation between the index and the length of hospital stay. The same bacterial flora was found in the dental plaque of 9 of the 27 SG patients before and after the tongue scraper was used for 5 days compared with the CG (p=0.683). Overall, 7 of the 27 SG patients had positive bacterial cultures for the same strains in both tongue biofilm and tracheal secretions compared with the CG (p=0.003). Significant similarities in strain resistance and susceptibility of the assessed microorganisms were observed between oral and tracheal microflora in 6/23 cases in the CG (p=0.006). CONCLUSION: The use of a tongue cleaner is effective at reducing tongue biofilm in patients on mechanical ventilation and facilitates oral hygiene interventions performed by caregivers.
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Review Articles
Protein requirements, morbidity and mortality in critically ill patients: fundamentals and applications
Rev Bras Ter Intensiva. 2013;25(1):49-55
Abstract
Review ArticlesProtein requirements, morbidity and mortality in critically ill patients: fundamentals and applications
Rev Bras Ter Intensiva. 2013;25(1):49-55
DOI 10.1590/S0103-507X2013000100010
Views0Recent evidence suggests that a negative protein balance secondary to severe disease is associated with increased morbidity. A loss of total body protein is inevitable in this scenario, even with an aggressive nutritional approach, primarily due to the catabolism of skeletal muscle fibers. The ubiquitin-proteasome system is the primary metabolic and biochemical mechanism involved in this process; paradoxically, this system consumes adenosine triphosphate as its energy source. It is possible that a neutral protein balance in these clinical situations is important for improving outcomes and achieving the caloric goals estimated or measured by indirect calorimetry. Recent studies have suggested that the use of higher protein concentrations in nutritional therapy for critically ill patients may help to reduce mortality. The purpose of this study was to review some of the nutrition therapy principles related to protein metabolism, evaluate the main assertions of the guidelines of specialty societies and review the recent studies that address these issues using critical insights from the authors’ clinical experience.
Keywords:Dietary proteinsenteral nutritionIntensive caremorbidityMortalityNitrogennutrition therapyparenteral nutritionSee more -
Review Articles
Biomarkers in septic encephalopathy: a systematic review of clinical studies
Rev Bras Ter Intensiva. 2013;25(1):56-62
Abstract
Review ArticlesBiomarkers in septic encephalopathy: a systematic review of clinical studies
Rev Bras Ter Intensiva. 2013;25(1):56-62
DOI 10.1590/S0103-507X2013000100011
Views0See moreOBJECTIVE: The aim of this study was to systematically review the importance of neuron-specific enolase and S100 beta for diagnosing and monitoring septic encephalopathy. METHODS: A PubMed database search was performed to identify studies that evaluated S100 beta and neuron-specific enolase serum levels in patients with sepsis and that were published between January 2000 and April 2012. Only human studies that employed an additional method of neurological assessment were selected. RESULTS: Nine studies were identified, seven of which associated high concentrations of S100 beta and neuron-specific enolase with the development of septic encephalopathy. Four studies also associated these concentrations with increased mortality. However, two studies did not find such an association when they evaluated S100 beta levels, and one of these studies did not observe a correlation between neuron-specific enolase and septic encephalopathy. CONCLUSION: S100 beta and neuron-specific enolase are promising biomarkers for diagnosing and monitoring patients with septic encephalopathy, but more research is necessary.
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Case Reports
Pseudo-acute myocardial infarction due to transient apical ventricular dysfunction syndrome (Takotsubo syndrome)
Rev Bras Ter Intensiva. 2013;25(1):63-67
Abstract
Case ReportsPseudo-acute myocardial infarction due to transient apical ventricular dysfunction syndrome (Takotsubo syndrome)
Rev Bras Ter Intensiva. 2013;25(1):63-67
DOI 10.1590/S0103-507X2013000100012
Views0Takotsubo syndrome is characterized by predominantly medial-apical transient left ventricular dysfunction, which is typically triggered by physical or emotional stress. The present article reports the case of a 61-year-old female patient presenting with dizziness, excessive sweating, and sudden state of ill feeling following an episode involving intense emotional stress. The physical examination and electrocardiogram were normal upon admission, but the troponin I and creatine kinase-MB concentrations were increased. Acute myocardial infarction without ST segment elevation was suspected, and coronary angiography was immediately performed, which showed severe diffuse left ventricular hypokinesia, medial-apical systolic ballooning, and a lack of significant coronary injury. The patient was referred to the intensive care unit and was successfully treated with supportive therapy. As this case shows, Takotsubo syndrome might simulate the clinical manifestations of acute myocardial infarction, and coronary angiography is necessary to distinguish between both myocardial infarction and myocardial infarction in the acute stage. The present patient progressed with spontaneous resolution of the ventricular dysfunction without any sequelae.
Keywords:Case reportsHemodynamicsIntensive careShock, cardiogenicStress, psychologicalTakotsubo, cardiomyopathyVentricular dysfunction, leftSee more -
Case Reports
Marchiafava-Bignami disease: a rare entity with a poor outcome
Rev Bras Ter Intensiva. 2013;25(1):68-72
Abstract
Case ReportsMarchiafava-Bignami disease: a rare entity with a poor outcome
Rev Bras Ter Intensiva. 2013;25(1):68-72
DOI 10.1590/S0103-507X2013000100013
Views0Marchiafava-Bignami disease is a rare affliction characterized by primary degeneration of the corpus callosum associated with chronic consumption of ethanol. The disease may occasionally occur in patients who are not alcoholics but are chronically malnourished. A complex deficiency of group B vitamins is the main etiopathogenic hypothesis, and many patients improve after the administration of these compounds. However, a good response is not always observed. The definitive diagnosis of Marchiafava-Bignami disease can be problematic and is based on features of neuroimaging studies, especially magnetic resonance imaging. Its treatment is still controversial and shows variable results. Because nutritional factors are implicated, as in Wernicke’s encephalopathy, some authors claim that replacement of B vitamins is beneficial. The present article is a case report of a severe acute form of Marchiafava-Bignami disease in an alcohol-dependent male patient who improved after the administration of parenteral B vitamins. As a consequence of his neurological and immunologic conditions, he developed multiple pulmonary infections and had a protracted course in the intensive care unit. He eventually died of sepsis associated with an uncommon fungus, Rhodotorula mucilaginosa. The present article reports the clinical and neuroimaging data from this patient and contains a review of Marchiafava-Bignami disease and Rhodotorula infections in the intensive care unit.
Keywords:AlchoolismBrain diseasesCase reportsinfectionMagnetic resonance imagingMarchiafava-Bignami diseaseSee more