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Editorial
Lactate, blood pressure and infection: tied by faith, untied by man?
Rev Bras Ter Intensiva. 2013;25(4):263-264
Abstract
EditorialLactate, blood pressure and infection: tied by faith, untied by man?
Rev Bras Ter Intensiva. 2013;25(4):263-264
DOI 10.5935/0103-507X.20130045
Views0“Diseases are conceptually all alike, although each syndrome is cumbersome in its own way”. This paraphrase of the beginning sentence of Tolstoi’s Anna Kareninna emphasizes the complexity of dealing with a kaleidoscopic mix of signs and symptoms and their interplay. Syndromes are a mainstay of critical care medicine; no other medical specialty deals more regularly […]See more -
Special Article
Cardiopulmonary resuscitation and ethics
Rev Bras Ter Intensiva. 2013;25(4):265-269
Abstract
Special ArticleCardiopulmonary resuscitation and ethics
Rev Bras Ter Intensiva. 2013;25(4):265-269
DOI 10.5935/0103-507X.20130046
Views0INTRODUCTIONThe earliest documentation of cardiopulmonary resuscitation (CPR) dates to the Old Testament, which describes how the prophet Elisha resuscitated an apparently dead child by blowing air into his mouth.() Modern CPR began in 1960 with the landmark study by Kouwenhoven, Jude, and Knickerbocker, which reported combining closed chest compression, mouth-to-mouth breathing, and external defibrillation.() Since […]See more -
Original Articles
Reclassifying the spectrum of septic patients using lactate: severe sepsis, cryptic shock, vasoplegic shock and dysoxic shock
Rev Bras Ter Intensiva. 2013;25(4):270-278
Abstract
Original ArticlesReclassifying the spectrum of septic patients using lactate: severe sepsis, cryptic shock, vasoplegic shock and dysoxic shock
Rev Bras Ter Intensiva. 2013;25(4):270-278
DOI 10.5935/0103-507X.20130047
Views1See moreObjective:
The current definition of severe sepsis and septic shock includes a heterogeneous profile of patients. Although the prognostic value of hyperlactatemia is well established, hyperlactatemia is observed in patients with and without shock. The present study aimed to compare the prognosis of septic patients by stratifying them according to two factors: hyperlactatemia and persistent hypotension.
Methods:
The present study is a secondary analysis of an observational study conducted in ten hospitals in Brazil (Rede Amil – SP). Septic patients with initial lactate measurements in the first 6 hours of diagnosis were included and divided into 4 groups according to hyperlactatemia (lactate >4mmol/L) and persistent hypotension: (1) severe sepsis (without both criteria); (2) cryptic shock (hyperlactatemia without persistent hypotension); (3) vasoplegic shock (persistent hypotension without hyperlactatemia); and (4) dysoxic shock (both criteria).
Results:
In total, 1,948 patients were analyzed, and the sepsis group represented 52% of the patients, followed by 28% with vasoplegic shock, 12% with dysoxic shock and 8% with cryptic shock. Survival at 28 days differed among the groups (p<0.001). Survival was highest among the severe sepsis group (69%, p<0.001 versus others), similar in the cryptic and vasoplegic shock groups (53%, p=0.39), and lowest in the dysoxic shock group (38%, p<0.001 versus others). In the adjusted analysis, the survival at 28 days remained different among the groups (p<0.001) and the dysoxic shock group exhibited the highest hazard ratio (HR=2.99, 95%CI 2.21-4.05).
Conclusion:
The definition of sepsis includes four different profiles if we consider the presence of hyperlactatemia. Further studies are needed to better characterize septic patients, to understand the etiology and to design adequate targeted treatments.
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Original Articles
Brain death and tissue and organ transplantation: the understanding of medical students
Rev Bras Ter Intensiva. 2013;25(4):279-283
Abstract
Original ArticlesBrain death and tissue and organ transplantation: the understanding of medical students
Rev Bras Ter Intensiva. 2013;25(4):279-283
DOI 10.5935/0103-507X.20130048
Views0Objective:
To evaluate the level of knowledge of medical students about transplantation and brain death.
Methods:
An anonymous self-administered questionnaire answered by medical students from the first through the sixth year that was based on information from the Associação Brasileira de Transplante de Órgãos e Tecidos, the Registro Brasileiro de Transplantes and the resolution that defines the criteria for brain death.
Results:
Of the 677 medical students asked, 310 (45.8%) agreed to answer the questionnaire. In total, 22 (7.0%) subjects were excluded. Of the students who participated, 41.3% reported having already attended a class on organ transplantation and 33% on brain death; 9.7% felt able to diagnose brain death (p<0.01); only 66.8% indicated the kidney as the most transplanted solid organ in Brazil.
Conclusion:
The level of knowledge of medical students at this institution regarding brain death and transplantation is limited, which may be the result of an inadequate approach during medical school.
Keywords:brain deathEducation, medicalorgan transplantationQuestionnaireStudents, medicalTissue and organ procurementSee more -
Original Articles
HLA-A*31 as a marker of genetic susceptibility to sepsis
Rev Bras Ter Intensiva. 2013;25(4):284-289
Abstract
Original ArticlesHLA-A*31 as a marker of genetic susceptibility to sepsis
Rev Bras Ter Intensiva. 2013;25(4):284-289
DOI 10.5935/0103-507X.20130049
Views0See moreObjective:
The HLA haplotype has been associated with many autoimmune diseases, but no associations have been described in sepsis. This study aims to investigate the HLA system as a possible marker of genetic sepsis susceptibility.
Methods:
This is a prospective cohort study including patients admitted to an intensive care unit and healthy controls from a list of renal transplant donors. Patients with less 18 years of age; pregnant or HIV positive patients; those with metastatic malignancies or receiving chemotherapy; or with advanced liver disease; or with end-of-life conditions were excluded. The DNA was extracted from the whole blood and HLA haplotypes determined using MiliPlex® technology.
Results:
From October 2010 to October 2012, 1,121 patients were included (1,078 kidney donors, 20 patients admitted with severe sepsis and 23 with septic shock). HLA-A*31 positive subjects had increased risk of developing sepsis (OR 2.36, 95%CI 1.26-5.35). Considering a p value <0.01, no other significant association was identified.
Conclusion:
HLA-A*31 expression is associated to risk of developing sepsis.
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Original Articles
Comparison of the RIFLE, AKIN and KDIGO criteria to predict mortality in critically ill patients
Rev Bras Ter Intensiva. 2013;25(4):290-296
Abstract
Original ArticlesComparison of the RIFLE, AKIN and KDIGO criteria to predict mortality in critically ill patients
Rev Bras Ter Intensiva. 2013;25(4):290-296
DOI 10.5935/0103-507X.20130050
Views7See moreObjective:
Acute kidney injury is a common complication in critically ill patients, and the RIFLE, AKIN and KDIGO criteria are used to classify these patients. The present study’s aim was to compare these criteria as predictors of mortality in critically ill patients.
Methods:
Prospective cohort study using medical records as the source of data. All patients admitted to the intensive care unit were included. The exclusion criteria were hospitalization for less than 24 hours and death. Patients were followed until discharge or death. Student’s t test, chi-squared analysis, a multivariate logistic regression and ROC curves were used for the data analysis.
Results:
The mean patient age was 64 years old, and the majority of patients were women of African descent. According to RIFLE, the mortality rates were 17.74%, 22.58%, 24.19% and 35.48% for patients without acute kidney injury (AKI) in stages of Risk, Injury and Failure, respectively. For AKIN, the mortality rates were 17.74%, 29.03%, 12.90% and 40.32% for patients without AKI and at stage I, stage II and stage III, respectively. For KDIGO 2012, the mortality rates were 17.74%, 29.03%, 11.29% and 41.94% for patients without AKI and at stage I, stage II and stage III, respectively. All three classification systems showed similar ROC curves for mortality.
Conclusion:
The RIFLE, AKIN and KDIGO criteria were good tools for predicting mortality in critically ill patients with no significant difference between them.
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Original Articles
Parenteral colistin for the treatment of severe infections: a single center experience
Rev Bras Ter Intensiva. 2013;25(4):297-305
Abstract
Original ArticlesParenteral colistin for the treatment of severe infections: a single center experience
Rev Bras Ter Intensiva. 2013;25(4):297-305
DOI 10.5935/0103-507X.20130051
Views2Objective:
To describe a single center experience involving the administration of colistin to treat nosocomial infections caused by multidrug-resistant Gram-negative bacteria and identify factors associated with acute kidney injury and mortality.
Methods:
This retrospective longitudinal study evaluates critically ill patients with infections caused by multidrug-resistant Gram-negative bacteria. All adult patients who required treatment with intravenous colistin (colistimethate sodium) from January to December 2008 were considered eligible for the study. Data include demographics, diagnosis, duration of treatment, presence of acute kidney injury and 30-day mortality.
Results:
Colistin was used to treat an infection in 109 (13.8%) of the 789 patients admitted to the intensive care unit. The 30-day mortality observed in these patients was 71.6%. Twenty-nine patients (26.6%) presented kidney injury prior to colistin treatment, and six of these patients were able to recover kidney function even during colistin treatment. Twenty-one patients (19.2%) developed acute kidney injury while taking colistin, and 11 of these patients required dialysis. The variable independently associated with the presence of acute kidney injury was the Sequential Organ Failure Assessment at the beginning of colistin treatment (OR 1.46; 95%CI 1.20-1.79; p<0.001). The factors age (OR 1.03; 95%CI 1.00-1.05; p=0.02) and vasopressor use (OR 12.48; 95%CI 4.49-34.70; p<0.001) were associated with death in the logistic-regression model.
Conclusions:
Organ dysfunction at the beginning of colistin treatment was associated with acute kidney injury. In a small group of patients, we were able to observe an improvement of kidney function during colistin treatment. Age and vasopressor use were associated with death.
Keywords:Acinetobacter baumanniiAcute kidney injuryColistin/therapeutic useCross infection/drug therapyDeathIntensive carePseudomonas aeruginosaSee more -
Original Articles
A comparison of gradual sedation levels using the Comfort-B scale and bispectral index in children on mechanical ventilation in the pediatric intensive care unit
Rev Bras Ter Intensiva. 2013;25(4):306-311
Abstract
Original ArticlesA comparison of gradual sedation levels using the Comfort-B scale and bispectral index in children on mechanical ventilation in the pediatric intensive care unit
Rev Bras Ter Intensiva. 2013;25(4):306-311
DOI 10.5935/0103-507X.20130052
Views0Objective:
Compare the scores resulting from the Comfort-B scale with the bispectral index in children in an intensive care unit.
Methods:
Eleven children between the ages of 1 month and 16 years requiring mechanical ventilation and sedation were simultaneously classified based on the bispectral index and the Comfort-B scale. Their behavior was recorded using digital photography, and the record was later evaluated by three independent evaluators. Agreement tests (Bland-Altman and Kappa) were then performed. The correlation between the two methods (Pearson correlation) was tested.
Results:
In total, 35 observations were performed on 11 patients. Based on the Kappa coefficient, the agreement among evaluators ranged from 0.56 to 0.75 (p<0.001). There was a positive and consistent association between the bispectral index and the Comfort-B scale [r=0.424 (p=0.011) to r=0.498 (p=0.002)].
Conclusion:
Due to the strong correlation between the independent evaluators and the consistent correlation between the two methods, the results suggest that the Comfort-B scale is reproducible and useful in classifying the level of sedation in children requiring mechanical ventilation.
Keywords:ChildConscious sedationElectroencephalography/instrumentationIntensive care units, pediatricMonitoring, physiologic/instrumentationRespiration, artificial/methodsSee more -
Review Articles
Alveolar recruitment maneuver and perioperative ventilatory support in obese patients undergoing abdominal surgery
Rev Bras Ter Intensiva. 2013;25(4):312-318
Abstract
Review ArticlesAlveolar recruitment maneuver and perioperative ventilatory support in obese patients undergoing abdominal surgery
Rev Bras Ter Intensiva. 2013;25(4):312-318
DOI 10.5935/0103-507X.20130053
Views0The development of abdominal surgery represents an alternative therapy for the morbidly obese; however, patients undergoing this surgical procedure often experience postoperative pulmonary complications. The use of alveolar recruitment maneuvers and/or perioperative ventilatory strategies is a possible alternative to reduce these complications, focusing on the reduction of postoperative pulmonary complications. In this review, the benefits of perioperative ventilatory strategies and the implementation of alveolar recruitment maneuvers in obese patients undergoing abdominal surgery are described.
Keywords:AnesthesiaObesity/surgeryPostoperative complicationsPostoperative periodPulmonary alveoli/physiopathologyRespiration, artificialRespiratory mechanicsSee more -
Review Articles
Ventilator-induced lung injury in preterm infants
Rev Bras Ter Intensiva. 2013;25(4):319-326
Abstract
Review ArticlesVentilator-induced lung injury in preterm infants
Rev Bras Ter Intensiva. 2013;25(4):319-326
DOI 10.5935/0103-507X.20130054
Views0In preterm infants, the need for intubation and mechanical ventilation is associated with ventilator-induced lung injuries and subsequent bronchopulmonary dysplasia. The aim of the present review was to improve the understanding of the mechanisms of injury that involve cytokine-mediated inflammation to contribute to the development of new preventive strategies. Relevant articles were retrieved from the PubMed database using the search terms “ventilator-induced lung injury preterm”, “continuous positive airway pressure”, “preterm”, and “bronchopulmonary dysplasia”. The resulting data and other relevant information were divided into several topics to ensure a thorough, critical view of ventilation-induced lung injury and its consequences in preterm infants. The role of pro-inflammatory cytokines (particularly interleukins 6 and 8 and tumor necrosis factor alpha) as mediators of lung injury was assessed. Evidence from studies conducted with animals and human newborns is described. This evidence shows that brief periods of mechanical ventilation is sufficient to induce the release of pro-inflammatory cytokines. Other forms of mechanical and non-invasive ventilation were also analyzed as protective alternatives to conventional mechanical ventilation. It was concluded that non-invasive ventilation, intubation followed by early surfactant administration and quick extubation for nasal continuous positive airway pressure, and strategies that regulate tidal volume and avoid volutrauma (such as volume guarantee ventilation) protect against ventilator-induced lung injury in preterm infants.
Keywords:Bronchopulmonary dysplasiaContinuous positive airway pressureCytokinesInfant, pretermRespiration, artificialVentilator-induced lung injurySee more -
Review Articles
Chest physiotherapy on intracranial pressure of critically ill patients admitted to the intensive care unit: a systematic review
Rev Bras Ter Intensiva. 2013;25(4):327-333
Abstract
Review ArticlesChest physiotherapy on intracranial pressure of critically ill patients admitted to the intensive care unit: a systematic review
Rev Bras Ter Intensiva. 2013;25(4):327-333
DOI 10.5935/0103-507X.20130055
Views0See moreObjective:
To analyze the outcomes of increased or decreased intracranial pressure and/or the decrease in cerebral perfusion pressure resulting from respiratory physiotherapy on critically ill patients admitted to the intensive care unit.
Methods:
Through a systematic review of the literature, clinical trials published between 2002 and 2012 were selected. The search involved the LILACS, SciELO, MedLine and PEDro databases using the keywords “physical therapy”, “physiotherapy”, “respiratory therapy” and “randomized controlled trials” combined with the keyword “intracranial pressure”.
Results:
In total, five studies, including a total of 164 patients between 25 and 65 years of age, reporting that respiratory physiotherapy maneuvers significantly increased intracranial pressure without changing the cerebral perfusion pressure were included. The articles addressed several techniques including vibration, vibrocompression, tapping, postural drainage, and the endotracheal aspiration maneuver. All patients required invasive mechanical ventilation.
Conclusion:
Respiratory physiotherapy leads to increased intracranial pressure. Studies suggest that there are no short-term hemodynamic or respiratory repercussions or changes in the cerebral perfusion pressure. However, none of the studies evaluated the clinical outcomes or ensured the safety of the maneuvers.
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Review Articles
Sepsis and pregnancy: do we know how to treat this situation?
Rev Bras Ter Intensiva. 2013;25(4):334-344
Abstract
Review ArticlesSepsis and pregnancy: do we know how to treat this situation?
Rev Bras Ter Intensiva. 2013;25(4):334-344
DOI 10.5935/0103-507X.20130056
Views0See moreSepsis is defined as an acute inflammatory response syndrome secondary to an infectious focus. It has a high incidence, morbidity and mortality, causing substantial financial costs, especially due to complications such as septic shock and multiple organ dysfunction. The pathogen toxins associated with individual susceptibility culminate with cytokine release, which promotes a systemic inflammatory response that can progress to multiple organ dysfunction and eventual patient death.
Specifically, sepsis incidence, morbidity and mortality are lower in pregnant women, as this group is typically younger with fewer comorbidities having a polymicrobial etiology resulting in sepsis.
Pregnant women exhibit physiological characteristics that may confer specific clinical presentation and laboratory patterns during the sepsis course. Thus, a better understanding of these changes is critical for better identification and management of these patients. The presence of a fetus also requires unique approaches in a pregnant woman with sepsis.
Sepsis treatment is based on certain guidelines that were established after major clinical trials, which, unfortunately, all classified pregnancy as a exclusion criteria.
Thus, the treatment of sepsis in the general population has been extrapolated to the pregnant population, with the following main goals: maintenance of tissue perfusion with fluid replacement and vasoactive drugs (initial resuscitation), adequate oxygenation, control of the infection source and an early start of antibiotic therapy, corticosteroid infusion and blood transfusion when properly indicated, prophylaxis, and specifically monitoring and maintenance of fetal heath.
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Case Reports
Aortic luminal thrombus and intramural hematoma after cardiopulmonary resuscitation
Rev Bras Ter Intensiva. 2013;25(4):345-347
Abstract
Case ReportsAortic luminal thrombus and intramural hematoma after cardiopulmonary resuscitation
Rev Bras Ter Intensiva. 2013;25(4):345-347
DOI 10.5935/0103-507X.20130057
Views0We describe the case of a patient with an intramural hematoma and floating thrombus after cardiopulmonary resuscitation. The 92-year old man had a cardiac arrest due to ventricular fibrillation and witnesses immediately initiated manual cardiopulmonary resuscitation. Transesophageal echocardiography was performed immediately on hospital admission because the patient was in cardiogenic shock. In addition to an akinetic anterior wall, examination of the descending thoracic aorta demonstrated an intramural hematoma and a floating intra-aortic thrombus at a distance of 40cm from the dental arch. There was no aortic dissection. The thrombus was attributed to aortic compression during cardiopulmonary resuscitation. Although the aortic thrombus and intramural hematoma were not associated with any complications in this patient, insertion of an intra-aortic balloon may have led to aortic rupture or embolic events. Transesophageal echocardiography should be performed, when available, prior to insertion of an intra-aortic balloon for counterpulsation in patients who have undergone cardiopulmonary resuscitation.
Keywords:Anticoagulants/therapeutic useCardiopulmonary resuscitation/complicationsCase reportsEchocardiographyHematoma/etiologyThrombosis/etiologySee more -
Case Reports
Haff disease associated with the ingestion of the freshwater fish Mylossoma duriventre (pacu-manteiga)
Rev Bras Ter Intensiva. 2013;25(4):348-351
Abstract
Case ReportsHaff disease associated with the ingestion of the freshwater fish Mylossoma duriventre (pacu-manteiga)
Rev Bras Ter Intensiva. 2013;25(4):348-351
DOI 10.5935/0103-507X.20130058
Views1See moreHaff disease associated rhabdomyolysis is correlated with the ingestion of certain freshwater fish and shellfish and is caused by an unidentified toxin. We report the case of a patient who experienced rhabdomyolysis approximately 2 hours after ingestion of the freshwater fish Mylossoma duriventre (pacu-manteiga) approximately 3 years after an outbreak had been reported in Manaus, Brazilian Amazon.
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Letter to the Editor
To: Use of a noninvasive ventilation device following tracheotomy: an alternative to facilitate ICU discharge?
Rev Bras Ter Intensiva. 2013;25(4):352-354
Abstract
Letter to the EditorTo: Use of a noninvasive ventilation device following tracheotomy: an alternative to facilitate ICU discharge?
Rev Bras Ter Intensiva. 2013;25(4):352-354
DOI 10.5935/0103-507X.20130059
Views2To the EditorIn intensive care units (ICUs), the incidence clinical conditions that make it difficult to wean patients from mechanical ventilation is approximately 30% worldwide.[…]See more