Revista Brasileira de Terapia Intensiva最新文献

Objective: To verify strategies for the prevention and treatment of abstinence syndrome in a pediatric intensive care unit.

Methods: This is a systematic review in the PubMed database®, Lilacs, Embase, Web of Science, Cochrane, Cinahl, Cochrane Database Systematic Review and CENTRAL. A three-step search strategy was used for this review, and the protocol was approved in PROSPERO (CRD42021274670).

Results: Twelve articles were included in the analysis. There was great heterogeneity among the studies included, especially regarding the therapeutic regimens used for sedation and analgesia. Midazolam doses ranged from 0.05mg/kg/hour to 0.3mg/kg/hour. Morphine also varied considerably, from 10mcg/kg/hour to 30mcg/kg/hour, between studies. Among the 12 selected studies, the most commonly used scale for the identification of withdrawal symptoms was the Sophia Observational Withdrawal Symptoms Scale. In three studies, there was a statistically significant difference in the prevention and management of the withdrawal syndrome due to the implementation of different protocols (p < 0.01 and p < 0.001).

Conclusion: There was great variation in the sedoanalgesia regimen used by the studies and the method of weaning and evaluation of withdrawal syndrome. More studies are needed to provide more robust evidence about the most appropriate treatment for the prevention and reduction of withdrawal signs and symptoms in critically ill children.

Prospero register: CRD 42021274670.

Objective: To describe the effects of balanced solution use on the short-term outcomes of patients with traumatic brain injury enrolled in BaSICS trial.

Methods: Patients were randomized to receive either 0.9% saline or balanced solution during their intensive care unit stay. The primary endpoint was 90-day mortality, and the secondary outcomes were days alive and free of intensive care unit stay at 28 days. The primary endpoint was assessed using Bayesian logistic regression. The secondary endpoint was assessed using a Bayesian zero-inflated beta binomial regression.

Results: We included 483 patients (236 in the 0.9% saline arm and 247 in the balanced solution arm). A total of 338 patients (70%) with a Glasgow coma scale score ≤ 12 were enrolled. The overall probability that balanced solutions were associated with higher 90-day mortality was 0.98 (OR 1.48; 95%CrI 1.04 - 2.09); this mortality increment was particularly noticeable in patients with a Glasgow coma scale score below 6 at enrollment (probability of harm of 0.99). Balanced solutions were associated with -1.64 days alive and free of intensive care unit at 28 days (95%CrI -3.32 - 0.00) with a probability of harm of 0.97.

Conclusion: There was a high probability that balanced solutions were associated with high 90-day mortality and fewer days alive and free of intensive care units at 28 days.ClinicalTrials.gov: NCT02875873.

Objective: To investigate the influence of a passive mobilization session on endothelial function in patients with sepsis.

Methods: This was a quasi-experimental double-blind and single-arm study with a pre- and postintervention design. Twenty-five patients with a diagnosis of sepsis who were hospitalized in the intensive care unit were included. Endothelial function was assessed at baseline (preintervention) and immediately postintervention by brachial artery ultrasonography. Flow mediated dilatation, peak blood flow velocity and peak shear rate were obtained. Passive mobilization consisted of bilateral mobilization (ankles, knees, hips, wrists, elbows and shoulders), with three sets of ten repetitions each, totaling 15 minutes.

Results: After mobilization, we found increased vascular reactivity function compared to preintervention: absolute flow-mediated dilatation (0.57mm ± 0.22 versus 0.17mm ± 0.31; p < 0.001) and relative flow-mediated dilatation (17.1% ± 8.25 versus 5.08% ± 9.16; p < 0.001). Reactive hyperemia peak flow (71.8cm/s ± 29.3 versus 95.3cm/s ± 32.2; p < 0.001) and shear rate (211s ± 113 versus 288s ± 144; p < 0.001) were also increased.

Conclusion: A passive mobilization session increases endothelial function in critical patients with sepsis. Future studies should investigate whether a mobilization program can be applied as a beneficial intervention for clinical improvement of endothelial function in patients hospitalized due to sepsis.

Acute massive pulmonary embolism is the most serious presentation of venous thromboembolism that can ultimately cause obstructive shock, leading to cardiac arrest and death. In this case report, the authors present a case of a 49-year-old female who successfully recovered from a massive pulmonary embolism with the combined use of venoarterial extracorporeal membrane oxygenation and pulmonary aspiration thrombectomy, with no complications from these procedures. Although evidence of benefit from mechanical support has not been established for patients with massive pulmonary embolism, the implementation of extracorporeal cardiocirculatory support during resuscitation may allow improvement of systemic organ perfusion and better chance of survival. Recent guidelines from the European Society of Cardiology state that venoarterial extracorporeal membrane oxygenation in combination with catheter-directed treatment may be considered for patients presenting with massive pulmonary embolism and refractory cardiac arrest. The use of extracorporeal membrane oxygenation as a stand-alone technique with anticoagulation remains controversial, and additional therapies, such as surgical or percutaneous embolectomy, must be considered. Since this intervention is not supported by high-quality studies, we believe it is important to report real-world successful cases. With this case report, we illustrate the benefit derived from resuscitation assisted by extracorporeal mechanical support and early aspiration thrombectomy in patients with massive pulmonary embolism. Additionally, it emphasizes the synergy that derives from integrated multidisciplinary systems for providing complex interventions, of which extracorporeal membrane oxygenation and Interventional Cardiology are clear examples.

Objective: To obtain data on bed refusal in intensive care units in Brazil and to evaluate the use of triage systems by professionals.

Methods: A cross-sectional survey. Using the Delphi methodology, a questionnaire was created contemplating the objectives of the study. Physicians and nurses enrolled in the research network of the Associação de Medicina Intensiva Brasileira (AMIBnet) were invited to participate. A web platform (SurveyMonkey®) was used to distribute the questionnaire. The variables in this study were measured in categories and expressed as proportions. The chi-square test or Fisher's exact test was used to verify associations. The significance level was set at 5%.

Results: In total, 231 professionals answered the questionnaire, representing all regions of the country. The national intensive care units had an occupancy rate of more than 90% always or frequently for 90.8% of the participants. Among the participants, 84.4% had already refused admitting patients to the intensive care unit due to the capacity of the unit. Half of the Brazilian institutions (49.7%) did not have triage protocols for admission to intensive beds.

Conclusions: Bed refusal due to high occupancy rates is common in Brazilian intensive care units. Even so, half of the services in Brazil do not adopt protocols for triage of beds.

Objective: To evaluate the prevalence and factors associated with depression in family members of people hospitalized in intensive care units.

Methods: A cross-sectional study was conducted with 980 family members of patients admitted to the intensive care units of a large public hospital in the interior of Bahia. Depression was measured using the Patient Health Questionnaire-8. The multivariate model consisted of the following variables: sex and age of the patient, sex and age of the family member, education level, religion, living with the family member, previous mental illness and anxiety.

Results: Depression had a prevalence of 43.5%. In the multivariate analysis, the model with the best representativeness indicated that factors associated with a higher prevalence of depression were being female (39%), age younger than 40 years (26%) and previous mental illness (38%). A higher education level was associated with a 19% lower prevalence of depression in family members.

Conclusion: The increase in the prevalence of depression was associated with female sex, age younger than 40 years and previous psychological problems. Such elements should be valued in actions aimed at family members of people hospitalized in intensive care.

Objective: To analyze and compare COVID-19 patient characteristics, clinical management and outcomes between the peak and plateau periods of the first pandemic wave in Portugal.

Methods: This was a multicentric ambispective cohort study including consecutive severe COVID-19 patients between March and August 2020 from 16 Portuguese intensive care units. The peak and plateau periods, respectively, weeks 10 - 16 and 17 - 34, were defined.

Results: Five hundred forty-one adult patients with a median age of 65 [57 - 74] years, mostly male (71.2%), were included. There were no significant differences in median age (p = 0.3), Simplified Acute Physiology Score II (40 versus 39; p = 0.8), partial arterial oxygen pressure/fraction of inspired oxygen ratio (139 versus 136; p = 0.6), antibiotic therapy (57% versus 64%; p = 0.2) at admission, or 28-day mortality (24.4% versus 22.8%; p = 0.7) between the peak and plateau periods. During the peak period, patients had fewer comorbidities (1 [0 - 3] versus 2 [0 - 5]; p = 0.002) and presented a higher use of vasopressors (47% versus 36%; p < 0.001) and invasive mechanical ventilation (58.1 versus 49.2%; p < 0.001) at admission, prone positioning (45% versus 36%; p = 0.04), and hydroxychloroquine (59% versus 10%; p < 0.001) and lopinavir/ritonavir (41% versus 10%; p < 0.001) prescriptions. However, a greater use of high-flow nasal cannulas (5% versus 16%, p < 0.001) on admission, remdesivir (0.3% versus 15%; p < 0.001) and corticosteroid (29% versus 52%, p < 0.001) therapy, and a shorter ICU length of stay (12 days versus 8, p < 0.001) were observed during the plateau.

Conclusion: There were significant changes in patient comorbidities, intensive care unit therapies and length of stay between the peak and plateau periods of the first COVID-19 wave.

Objective: To verify the relationship between the rectus femoris cross-sectional area and diaphragmatic excursion with successful weaning from mechanical ventilation in chronic critically tracheostomized patients.

Methods: This was a prospective observational cohort study. We included chronic critically ill patients (those who underwent tracheostomy placement after 10 days under mechanical ventilation). The rectus femoris cross-sectional area and diaphragmatic excursion were obtained by ultrasonography performed within the first 48 hours after tracheostomy. We measured rectus femoris cross-sectional area and diaphragmatic excursion to assess their association with weaning from mechanical ventilation, including their potential to predict successful weaning and survival throughout the intensive care unit stay.

Results: Eighty-one patients were included. Forty-five patients (55%) were weaned from mechanical ventilation. The mortality rates were 42% and 61.7% in the intensive care unit and hospital, respectively. The fail group in relation to the success group at weaning presented a lower rectus femoris cross-sectional area (1.4 [0.8] versus 1.84 [0.76]cm2, p = 0.014) and lower diaphragmatic excursion (1.29 ± 0.62 versus 1.62 ± 0.51cm, p = 0.019). When rectus femoris cross-sectional area ≥ 1.80cm2 and diaphragmatic excursion ≥ 1.25cm was a combined condition, it had a strong association with successful weaning (adjusted OR = 20.81, 95%CI 2.38 - 182.28; p = 0.006) but not with intensive care unit survival (adjusted OR = 0.19, 95%CI 0.03 - 1.08; p = 0.061).

Conclusion: Successful weaning from mechanical ventilation in chronic critically ill patients was associated with higher measurements of rectus femoris cross-sectional area and diaphragmatic excursion.

Objective: To create and validate a model for predicting septic or hypovolemic shock from easily obtainable variables collected from patients at admission to an intensive care unit.

Methods: A predictive modeling study with concurrent cohort data was conducted in a hospital in the interior of northeastern Brazil. Patients aged 18 years or older who were not using vasoactive drugs on the day of admission and were hospitalized from November 2020 to July 2021 were included. The Decision Tree, Random Forest, AdaBoost, Gradient Boosting and XGBoost classification algorithms were tested for use in building the model. The validation method used was k-fold cross validation. The evaluation metrics used were recall, precision and area under the Receiver Operating Characteristic curve.

Results: A total of 720 patients were used to create and validate the model. The models showed high predictive capacity with areas under the Receiver Operating Characteristic curve of 0.979; 0.999; 0.980; 0.998 and 1.00 for the Decision Tree, Random Forest, AdaBoost, Gradient Boosting and XGBoost algorithms, respectively.

Conclusion: The predictive model created and validated showed a high ability to predict septic and hypovolemic shock from the time of admission of patients to the intensive care unit.