Pub Date : 2023-03-01DOI: 10.5935/2965-2774.20230203-en
João Paulo Arruda de Oliveira, Andreia Cristina Travassos Costa, Agnaldo José Lopes, Arthur de Sá Ferreira, Luis Felipe da Fonseca Reis
Objectives: To evaluate the factors associated with mortality in mechanically ventilated patients with acute respiratory distress syndrome due to COVID-19.
Methods: This was a retrospective, multicenter cohort study that included 425 mechanically ventilated adult patients with COVID-19 admitted to 4 intensive care units. Clinical data comprising the SOFA score, laboratory data and mechanical characteristics of the respiratory system were collected in a standardized way immediately after the start of invasive mechanical ventilation. The risk factors for death were analyzed using Cox regression to estimate the risk ratios and their respective 95%CIs.
Results: Body mass index (RR 1.17; 95%CI 1.11 - 1.20; p < 0.001), SOFA score (RR 1.39; 95%CI 1.31 - 1.49; p < 0.001) and driving pressure (RR 1.24; 95%CI 1.21 - 1.29; p < 0.001) were considered independent factors associated with mortality in mechanically ventilated patients with acute respiratory distress syndrome due to COVID-19. Respiratory system compliance (RR 0.92; 95%CI 0.90 - 0.93; p < 0.001) was associated with lower mortality. The comparative analysis of the survival curves indicated that patients with respiratory system compliance (< 30mL/cmH2O), a higher SOFA score (> 5 points) and higher driving pressure (> 14cmH2O) were more significantly associated with the outcome of death at 28 days and 60 days.
Conclusion: Patients with a body mass index > 32kg/m2, respiratory system compliance < 30mL/cmH2O, driving pressure > 14cmH2O and SOFA score > 5.8 immediately after the initiation of invasive ventilatory support had worse outcomes, and independent risk factors were associated with higher mortality in this population.
{"title":"Factors associated with mortality in mechanically ventilated patients with severe acute respiratory syndrome due to COVID-19 evolution.","authors":"João Paulo Arruda de Oliveira, Andreia Cristina Travassos Costa, Agnaldo José Lopes, Arthur de Sá Ferreira, Luis Felipe da Fonseca Reis","doi":"10.5935/2965-2774.20230203-en","DOIUrl":"https://doi.org/10.5935/2965-2774.20230203-en","url":null,"abstract":"<p><strong>Objectives: </strong>To evaluate the factors associated with mortality in mechanically ventilated patients with acute respiratory distress syndrome due to COVID-19.</p><p><strong>Methods: </strong>This was a retrospective, multicenter cohort study that included 425 mechanically ventilated adult patients with COVID-19 admitted to 4 intensive care units. Clinical data comprising the SOFA score, laboratory data and mechanical characteristics of the respiratory system were collected in a standardized way immediately after the start of invasive mechanical ventilation. The risk factors for death were analyzed using Cox regression to estimate the risk ratios and their respective 95%CIs.</p><p><strong>Results: </strong>Body mass index (RR 1.17; 95%CI 1.11 - 1.20; p < 0.001), SOFA score (RR 1.39; 95%CI 1.31 - 1.49; p < 0.001) and driving pressure (RR 1.24; 95%CI 1.21 - 1.29; p < 0.001) were considered independent factors associated with mortality in mechanically ventilated patients with acute respiratory distress syndrome due to COVID-19. Respiratory system compliance (RR 0.92; 95%CI 0.90 - 0.93; p < 0.001) was associated with lower mortality. The comparative analysis of the survival curves indicated that patients with respiratory system compliance (< 30mL/cmH2O), a higher SOFA score (> 5 points) and higher driving pressure (> 14cmH2O) were more significantly associated with the outcome of death at 28 days and 60 days.</p><p><strong>Conclusion: </strong>Patients with a body mass index > 32kg/m2, respiratory system compliance < 30mL/cmH2O, driving pressure > 14cmH2O and SOFA score > 5.8 immediately after the initiation of invasive ventilatory support had worse outcomes, and independent risk factors were associated with higher mortality in this population.</p>","PeriodicalId":72721,"journal":{"name":"Critical care science","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10275312/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10337449","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.5935/2965-2774.20230312-en
Bruno Silva Miranda, Valéria Cabral Neves, Yessa do Prado Albuquerque, Emilly Freitas de Souza, Adriana Koliski, Mônica Nunes Lima Cat, José Eduardo Carreiro
Objective: To evaluate whether a model of a daily fitness checklist for spontaneous breathing tests is able to identify predictive variables of extubation failure in pediatric patients admitted to a Brazilian intensive care unit.
Methods: This was a single-center, cross-sectional study with prospective data collection. The checklist model comprised 20 items and was applied to assess the ability to perform spontaneous breathing tests.
Results: The sample consisted of 126 pediatric patients (85 males (67.5%)) on invasive mechanical ventilation, for whom 1,217 daily assessments were applied at the bedside. The weighted total score of the prediction model showed the highest discriminatory power for the spontaneous breathing test, with sensitivity and specificity indices for fitness failure of 89.7% or success of 84.6%. The cutoff point suggested by the checklist was 8, with a probability of extubation failure less than 5%. Failure increased progressively with increasing score, with a maximum probability of predicting extubation failure of 85%.
Conclusion: The extubation failure rate with the use of this model was within what is acceptable in the literature. The daily checklist model for the spontaneous breathing test was able to identify predictive variables of failure in the extubation process in pediatric patients.
{"title":"Fitness checklist model for spontaneous breathing tests in pediatrics.","authors":"Bruno Silva Miranda, Valéria Cabral Neves, Yessa do Prado Albuquerque, Emilly Freitas de Souza, Adriana Koliski, Mônica Nunes Lima Cat, José Eduardo Carreiro","doi":"10.5935/2965-2774.20230312-en","DOIUrl":"10.5935/2965-2774.20230312-en","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate whether a model of a daily fitness checklist for spontaneous breathing tests is able to identify predictive variables of extubation failure in pediatric patients admitted to a Brazilian intensive care unit.</p><p><strong>Methods: </strong>This was a single-center, cross-sectional study with prospective data collection. The checklist model comprised 20 items and was applied to assess the ability to perform spontaneous breathing tests.</p><p><strong>Results: </strong>The sample consisted of 126 pediatric patients (85 males (67.5%)) on invasive mechanical ventilation, for whom 1,217 daily assessments were applied at the bedside. The weighted total score of the prediction model showed the highest discriminatory power for the spontaneous breathing test, with sensitivity and specificity indices for fitness failure of 89.7% or success of 84.6%. The cutoff point suggested by the checklist was 8, with a probability of extubation failure less than 5%. Failure increased progressively with increasing score, with a maximum probability of predicting extubation failure of 85%.</p><p><strong>Conclusion: </strong>The extubation failure rate with the use of this model was within what is acceptable in the literature. The daily checklist model for the spontaneous breathing test was able to identify predictive variables of failure in the extubation process in pediatric patients.</p>","PeriodicalId":72721,"journal":{"name":"Critical care science","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10275306/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10287274","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.5935/2965-2774.20230374-en
Augusto Garcia de Cezar, Flávia Del Castanhel, Suely Grosseman
Objective: To understand the perception of medical communication and needs of family members with loved ones in intensive care.
Methods: The study was mainly qualitative and exploratory, with thematic analysis of comments made by 92 family members with loved ones in intensive care units when answering in-person interviews comprising the Quality of Communication Questionnaire (QoC) and open-ended questions about their need for additional help, the appropriateness of the place where they received information, and additional comments.
Results: The participants' mean age was 46.8 years (SD = 11.8), and most of them were female, married and had incomplete or completed elementary education. The following themes were found: perception of characteristics of medical communication; feelings generated by communication; considerations about specific questions in the QoC; family members' needs; and strategies to overcome needs regarding communication. Characteristics that facilitated communication included attention and listening. Characteristics that made communication difficult included aspects of information sharing, such as inaccessible language; lack of clarity, objectivity, sincerity, and agreement among the team; limited time; and inadequate location. Feelings such as shame, helplessness, and sadness were cited when communication was inadequate. Family members' needs related to communication included more details about the loved one's diagnosis, prognosis, and health condition; participation in decisionmaking; and being asked about feelings, spirituality, dying and death. Others were related to longer visitation time, psychological support, social assistance, and better infrastructure.
Conclusion: It is necessary to enhance medical communication and improve hospital infrastructure to improve the quality of care for family members.
{"title":"Needs of family members of patients in intensive care and their perception of medical communication.","authors":"Augusto Garcia de Cezar, Flávia Del Castanhel, Suely Grosseman","doi":"10.5935/2965-2774.20230374-en","DOIUrl":"https://doi.org/10.5935/2965-2774.20230374-en","url":null,"abstract":"<p><strong>Objective: </strong>To understand the perception of medical communication and needs of family members with loved ones in intensive care.</p><p><strong>Methods: </strong>The study was mainly qualitative and exploratory, with thematic analysis of comments made by 92 family members with loved ones in intensive care units when answering in-person interviews comprising the Quality of Communication Questionnaire (QoC) and open-ended questions about their need for additional help, the appropriateness of the place where they received information, and additional comments.</p><p><strong>Results: </strong>The participants' mean age was 46.8 years (SD = 11.8), and most of them were female, married and had incomplete or completed elementary education. The following themes were found: perception of characteristics of medical communication; feelings generated by communication; considerations about specific questions in the QoC; family members' needs; and strategies to overcome needs regarding communication. Characteristics that facilitated communication included attention and listening. Characteristics that made communication difficult included aspects of information sharing, such as inaccessible language; lack of clarity, objectivity, sincerity, and agreement among the team; limited time; and inadequate location. Feelings such as shame, helplessness, and sadness were cited when communication was inadequate. Family members' needs related to communication included more details about the loved one's diagnosis, prognosis, and health condition; participation in decisionmaking; and being asked about feelings, spirituality, dying and death. Others were related to longer visitation time, psychological support, social assistance, and better infrastructure.</p><p><strong>Conclusion: </strong>It is necessary to enhance medical communication and improve hospital infrastructure to improve the quality of care for family members.</p>","PeriodicalId":72721,"journal":{"name":"Critical care science","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10275305/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10287273","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.5935/2965-2774.20230275-en
Melina Carrera, Jose García Urrutia, Cesar Bueno Ardariz, Maria Luz Porra, Claudio Gamarra, Ladislao Pablo Diaz Ballve
Objective To compare the diagnostic performance of maximal expiratory pressure with maximal expiratory pressure during induced cough for predicting extubation failure within 72 hours in patients who completed a spontaneous breathing trial (SBT). Methods The study was conducted between October 2018 and September 2019. All patients aged over 18 years admitted to the intensive care unit who required invasive mechanical ventilation for over 48 hours and successfully completed a spontaneous breathing trial were included. The maximal expiratory pressure was assessed with a unidirectional valve for 40 seconds, and verbal encouragement was given. The maximal expiratory pressure during induced cough was measured with slow instillation of 2mL of a 0.9% saline solution. The primary outcome variable was extubation failure. Results Eighty patients were included, of which 43 (54%) were male. Twenty-two patients [27.5% (95%CI 18.9 - 38.1)] failed extubation within 72 hours. Differences were observed in the maximal expiratory pressure during induced cough between the group who failed extubation, with a median of 0cmH2O (P25-75: 0 - 90), and the group without extubation failure, with a median of 120cmH2O (P25-75: 73 - 120); p < 0.001. Conclusion In patients who completed a spontaneous breathing trial, the maximal expiratory pressure during induced cough had a higher diagnostic performance for predicting extubation failure within 72 hours. Clinicaltrials.gov Registry: NCT04356625
{"title":"Maximal expiratory pressure compared with maximal expiratory pressure during induced cough as a predictor of extubation failure.","authors":"Melina Carrera, Jose García Urrutia, Cesar Bueno Ardariz, Maria Luz Porra, Claudio Gamarra, Ladislao Pablo Diaz Ballve","doi":"10.5935/2965-2774.20230275-en","DOIUrl":"https://doi.org/10.5935/2965-2774.20230275-en","url":null,"abstract":"Objective To compare the diagnostic performance of maximal expiratory pressure with maximal expiratory pressure during induced cough for predicting extubation failure within 72 hours in patients who completed a spontaneous breathing trial (SBT). Methods The study was conducted between October 2018 and September 2019. All patients aged over 18 years admitted to the intensive care unit who required invasive mechanical ventilation for over 48 hours and successfully completed a spontaneous breathing trial were included. The maximal expiratory pressure was assessed with a unidirectional valve for 40 seconds, and verbal encouragement was given. The maximal expiratory pressure during induced cough was measured with slow instillation of 2mL of a 0.9% saline solution. The primary outcome variable was extubation failure. Results Eighty patients were included, of which 43 (54%) were male. Twenty-two patients [27.5% (95%CI 18.9 - 38.1)] failed extubation within 72 hours. Differences were observed in the maximal expiratory pressure during induced cough between the group who failed extubation, with a median of 0cmH2O (P25-75: 0 - 90), and the group without extubation failure, with a median of 120cmH2O (P25-75: 73 - 120); p < 0.001. Conclusion In patients who completed a spontaneous breathing trial, the maximal expiratory pressure during induced cough had a higher diagnostic performance for predicting extubation failure within 72 hours. Clinicaltrials.gov Registry: NCT04356625","PeriodicalId":72721,"journal":{"name":"Critical care science","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10275301/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10287270","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.5935/2965-2774.20230340-en
Alberto Belenguer-Muncharaz, Carmen Díaz-Tormo, Estefania Granero-Gasamans, Maria-Lidón Mateu-Campos
Objective: To investigate whether protocol-directed weaning in neurocritical patients would reduce the rate of extubation failure (as a primary outcome) and the associated complications (as a secondary outcome) compared with conventional weaning.
Methods: A quasi-experimental study was conducted in a medical-surgical intensive care unit from January 2016 to December 2018. Patients aged 18 years or older with an acute neurological disease who were on mechanical ventilation > 24 hours were included. All patients included in the study were ready to wean, with no or minimal sedation, Glasgow coma score ≥ 9, spontaneous ventilatory stimulus, noradrenaline ≤ 0.2μgr/kg/ minute, fraction of inspired oxygen ≤ 0.5, positive end-expiratory pressure ≤ 5cmH2O, maximal inspiratory pressure < -20cmH2O, and occlusion pressure < 6cmH2O.
Results: Ninety-four of 314 patients admitted to the intensive care unit were included (50 in the Intervention Group and 44 in the Control Group). There was no significant difference in spontaneous breathing trial failure (18% in the Intervention Group versus 34% in the Control Group, p = 0.12). More patients in the Intervention Group were extubated than in the Control Group (100% versus 79%, p = 0.01). The rate of extubation failure was not signifiantly diffrent between the groups (18% in the Intervention Group versus 17% in the Control Group; relative risk 1.02; 95%CI 0.64 - 1.61; p = 1.00). The reintubation rate was lower in the Control Group (16% in the Intervention Group versus 11% in the Control Group; relative risk 1.15; 95%CI 0.74 - 1.82; p = 0.75). The need for tracheotomy was lower in the Intervention Group [4 (8%) versus 11 (25%) in the Control Group; relative risk 0.32; 95%CI 0.11 - 0.93; p = 0.04]. At Day 28, the patients in the Intervention Group had more ventilator-free days than those in the Control Group [28 (26 - 28) days versus 26 (19 - 28) days; p = 0.01]. The total duration of mechanical ventilation was shorter in the Intervention Group than in the Control Group [5 (2 - 13) days versus 9 (3 - 22) days; p = 0.01]. There were no diffrences in the length of intensive care unit stay, 28-day free from mechanical ventilation, hospital stay or 90-day mortality.
Conclusion: Considering the limitations of our study, the application of a weaning protocol for neurocritical patients led to a high percentage of extubation, a reduced need for tracheotomy and a shortened duration of mechanical ventilation. However, there was no reduction in extubation failure or the 28-day free of from mechanical ventilation compared with the Control Group.ClinicalTrials.gov Registry: NCT03128086.
{"title":"Protocol-directed weaning <i>versus</i> conventional weaning from mechanical ventilation for neurocritical patients in an intensive care unit: a nonrandomized quasi-experimental study.","authors":"Alberto Belenguer-Muncharaz, Carmen Díaz-Tormo, Estefania Granero-Gasamans, Maria-Lidón Mateu-Campos","doi":"10.5935/2965-2774.20230340-en","DOIUrl":"https://doi.org/10.5935/2965-2774.20230340-en","url":null,"abstract":"<p><strong>Objective: </strong>To investigate whether protocol-directed weaning in neurocritical patients would reduce the rate of extubation failure (as a primary outcome) and the associated complications (as a secondary outcome) compared with conventional weaning.</p><p><strong>Methods: </strong>A quasi-experimental study was conducted in a medical-surgical intensive care unit from January 2016 to December 2018. Patients aged 18 years or older with an acute neurological disease who were on mechanical ventilation > 24 hours were included. All patients included in the study were ready to wean, with no or minimal sedation, Glasgow coma score ≥ 9, spontaneous ventilatory stimulus, noradrenaline ≤ 0.2μgr/kg/ minute, fraction of inspired oxygen ≤ 0.5, positive end-expiratory pressure ≤ 5cmH2O, maximal inspiratory pressure < -20cmH2O, and occlusion pressure < 6cmH2O.</p><p><strong>Results: </strong>Ninety-four of 314 patients admitted to the intensive care unit were included (50 in the Intervention Group and 44 in the Control Group). There was no significant difference in spontaneous breathing trial failure (18% in the Intervention Group versus 34% in the Control Group, p = 0.12). More patients in the Intervention Group were extubated than in the Control Group (100% versus 79%, p = 0.01). The rate of extubation failure was not signifiantly diffrent between the groups (18% in the Intervention Group versus 17% in the Control Group; relative risk 1.02; 95%CI 0.64 - 1.61; p = 1.00). The reintubation rate was lower in the Control Group (16% in the Intervention Group versus 11% in the Control Group; relative risk 1.15; 95%CI 0.74 - 1.82; p = 0.75). The need for tracheotomy was lower in the Intervention Group [4 (8%) versus 11 (25%) in the Control Group; relative risk 0.32; 95%CI 0.11 - 0.93; p = 0.04]. At Day 28, the patients in the Intervention Group had more ventilator-free days than those in the Control Group [28 (26 - 28) days versus 26 (19 - 28) days; p = 0.01]. The total duration of mechanical ventilation was shorter in the Intervention Group than in the Control Group [5 (2 - 13) days versus 9 (3 - 22) days; p = 0.01]. There were no diffrences in the length of intensive care unit stay, 28-day free from mechanical ventilation, hospital stay or 90-day mortality.</p><p><strong>Conclusion: </strong>Considering the limitations of our study, the application of a weaning protocol for neurocritical patients led to a high percentage of extubation, a reduced need for tracheotomy and a shortened duration of mechanical ventilation. However, there was no reduction in extubation failure or the 28-day free of from mechanical ventilation compared with the Control Group.ClinicalTrials.gov Registry: NCT03128086.</p>","PeriodicalId":72721,"journal":{"name":"Critical care science","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10275310/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10309565","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.5935/2965-2774.20230317-en
Rebeca Mamede da Silva Alves, Rafael Casali Ribeiro
In the eyes of laypeople, intensive care may seem like a precise and objective field of study. Even to health professionals, believing that medical practice within intensive care units (ICUs) should be predominantly guided by technical decisions seems sensible and reasonable, even though there are nuances and some space for subjectivity. However, a careful look at particularities of the decision-making process in intensive care shows how different concepts and values, sometimes implicitly adopted, affect the ways intensivists think and, consequently, act. This article discusses a concept that largely intersects with the work processes in intensive care but remains poorly discussed: vulnerability.
{"title":"Intensive care and the different meanings of vulnerability.","authors":"Rebeca Mamede da Silva Alves, Rafael Casali Ribeiro","doi":"10.5935/2965-2774.20230317-en","DOIUrl":"https://doi.org/10.5935/2965-2774.20230317-en","url":null,"abstract":"In the eyes of laypeople, intensive care may seem like a precise and objective field of study. Even to health professionals, believing that medical practice within intensive care units (ICUs) should be predominantly guided by technical decisions seems sensible and reasonable, even though there are nuances and some space for subjectivity. However, a careful look at particularities of the decision-making process in intensive care shows how different concepts and values, sometimes implicitly adopted, affect the ways intensivists think and, consequently, act. This article discusses a concept that largely intersects with the work processes in intensive care but remains poorly discussed: vulnerability.","PeriodicalId":72721,"journal":{"name":"Critical care science","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10275309/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10287271","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.5935/2965-2774.20230405-en
Fernanda Chohfi Atallah, Pedro Caruso, Antonio Paulo Nassar, Andre Peretti Torelly, Cristina Prata Amendola, Jorge Ibrain Figueira Salluh, Thiago Gomes Romano
The number of patients with cancer requiring intensive care unit admission is increasing around the world. The improvement in the pathophysiological understanding of this group of patients, as well as the increasingly better and more targeted treatment options for their underlying disease, has led to a significant increase in their survival over the past three decades. Within the organizational concepts, it is necessary to know what adds value in the care of critical oncohematological patients. Practices in medicine that do not benefit patients and possibly cause harm are called low-value practices, while high-value practices are defined as high-quality care at relatively low cost. In this article, we discuss ten domains with high-value evidence in the care of cancer patients: (1) intensive care unit admission policies; (2) intensive care unit organization; (3) etiological investigation of hypoxemia; (4) management of acute respiratory failure; (5) management of febrile neutropenia; (6) urgent chemotherapy treatment in critically ill patients; (7) patient and family experience; (8) palliative care; (9) care of intensive care unit staff; and (10) long-term impact of critical disease on the cancer population. The disclosure of such policies is expected to have the potential to change health care standards. We understand that it is a lengthy process, and initiatives such as this paper are one of the first steps in raising awareness and beginning a discussion about high-value care in various health scenarios.
{"title":"High-value care for critically ill oncohematological patients: what do we know thus far?","authors":"Fernanda Chohfi Atallah, Pedro Caruso, Antonio Paulo Nassar, Andre Peretti Torelly, Cristina Prata Amendola, Jorge Ibrain Figueira Salluh, Thiago Gomes Romano","doi":"10.5935/2965-2774.20230405-en","DOIUrl":"https://doi.org/10.5935/2965-2774.20230405-en","url":null,"abstract":"<p><p>The number of patients with cancer requiring intensive care unit admission is increasing around the world. The improvement in the pathophysiological understanding of this group of patients, as well as the increasingly better and more targeted treatment options for their underlying disease, has led to a significant increase in their survival over the past three decades. Within the organizational concepts, it is necessary to know what adds value in the care of critical oncohematological patients. Practices in medicine that do not benefit patients and possibly cause harm are called low-value practices, while high-value practices are defined as high-quality care at relatively low cost. In this article, we discuss ten domains with high-value evidence in the care of cancer patients: (1) intensive care unit admission policies; (2) intensive care unit organization; (3) etiological investigation of hypoxemia; (4) management of acute respiratory failure; (5) management of febrile neutropenia; (6) urgent chemotherapy treatment in critically ill patients; (7) patient and family experience; (8) palliative care; (9) care of intensive care unit staff; and (10) long-term impact of critical disease on the cancer population. The disclosure of such policies is expected to have the potential to change health care standards. We understand that it is a lengthy process, and initiatives such as this paper are one of the first steps in raising awareness and beginning a discussion about high-value care in various health scenarios.</p>","PeriodicalId":72721,"journal":{"name":"Critical care science","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10275311/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10309566","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.5935/2965-2774.20230394-en
Fernando José da Silva Ramos, Mauricio Henrique Claro Dos Santos, Laerte Pastore
Since December 2019, when the first cases were described in China, the coronavirus disease 2019 (COVID-19) pandemic has impacted health systems around the world. A significant number of patients have the severe form of the disease, requiring admission to the intensive care unit (ICU).(1) The shortage of beds, equipment and drugs represented an even greater challenge in the management of these patients. The improvised use of operating rooms, which served as ICU beds, and the use of anesthesia equipment for sedation and mechanical ventilation have been described and were employed as heroic measures in the management of these patients.(2-4) In this context, the use of volatile anesthetics (VAs) has reappeared as an option for the sedation of critically ill patients.(3) The use of VAs in the ICU has been described for more than 2 decades and is mainly used in Europe and Canada;(5) however, the equipment to administer VAs was only recently approved for use in Brazil. The main VAs used as sedatives in the ICU are sevoflurane and isoflurane. The development of equipment with compact vaporizers adapted for mechanical ventilators in ICUs made it possible to use these agents as an option for sedation. Among the main advantages of using VAs rather than opioids in critically ill patients are earlier awakening, lower use of opioids and shorter time on mechanical ventilation. Other reported benefits of VAs are bronchodilator effects and improved oxygenation, especially in patients with acute respiratory distress syndrome (ARDS). Among the contraindications and limitations of VAs are a personal or family history of malignant hyperthermia, suspected or confirmed intracranial hypertension, severe hemodynamic instability and significant pulmonary secretion with the need for frequent aspiration due to the risk of system obstruction.(5) Three meta-analyses showed that compared to venous sedation, the use of VAs in the ICU resulted in faster awakening and extubation times.(6-8) More recently, Meiser et al., in a multicenter noninferiority study of isoflurane compared to propofol, showed that isoflurane was an effective and safe option. Additionally, in the isoflurane group, opioid consumption was lower.(9) Experimental studies have shown that sevoflurane has the ability to reduce lung inflammation in ARDS models.(10,11) Jabaudon et al., in a randomized study, demonstrated that compared with midazolam, the use of sevoflurane in patients with ARDS for a period of 48 hours was related to improved oxygenation and reduced markers of lung epithelial lesions.(12) The use of VAs in the ICU has been more frequently reported in populations of surgical patients. Although there are no contraindications for VAs use in other populations of critically ill patients (e.g., patients with sepsis), further studies are needed.
{"title":"Sedation with volatile anesthetics in the intensive care unit: a new option with old agents.","authors":"Fernando José da Silva Ramos, Mauricio Henrique Claro Dos Santos, Laerte Pastore","doi":"10.5935/2965-2774.20230394-en","DOIUrl":"https://doi.org/10.5935/2965-2774.20230394-en","url":null,"abstract":"Since December 2019, when the first cases were described in China, the coronavirus disease 2019 (COVID-19) pandemic has impacted health systems around the world. A significant number of patients have the severe form of the disease, requiring admission to the intensive care unit (ICU).(1) The shortage of beds, equipment and drugs represented an even greater challenge in the management of these patients. The improvised use of operating rooms, which served as ICU beds, and the use of anesthesia equipment for sedation and mechanical ventilation have been described and were employed as heroic measures in the management of these patients.(2-4) In this context, the use of volatile anesthetics (VAs) has reappeared as an option for the sedation of critically ill patients.(3) The use of VAs in the ICU has been described for more than 2 decades and is mainly used in Europe and Canada;(5) however, the equipment to administer VAs was only recently approved for use in Brazil. The main VAs used as sedatives in the ICU are sevoflurane and isoflurane. The development of equipment with compact vaporizers adapted for mechanical ventilators in ICUs made it possible to use these agents as an option for sedation. Among the main advantages of using VAs rather than opioids in critically ill patients are earlier awakening, lower use of opioids and shorter time on mechanical ventilation. Other reported benefits of VAs are bronchodilator effects and improved oxygenation, especially in patients with acute respiratory distress syndrome (ARDS). Among the contraindications and limitations of VAs are a personal or family history of malignant hyperthermia, suspected or confirmed intracranial hypertension, severe hemodynamic instability and significant pulmonary secretion with the need for frequent aspiration due to the risk of system obstruction.(5) Three meta-analyses showed that compared to venous sedation, the use of VAs in the ICU resulted in faster awakening and extubation times.(6-8) More recently, Meiser et al., in a multicenter noninferiority study of isoflurane compared to propofol, showed that isoflurane was an effective and safe option. Additionally, in the isoflurane group, opioid consumption was lower.(9) Experimental studies have shown that sevoflurane has the ability to reduce lung inflammation in ARDS models.(10,11) Jabaudon et al., in a randomized study, demonstrated that compared with midazolam, the use of sevoflurane in patients with ARDS for a period of 48 hours was related to improved oxygenation and reduced markers of lung epithelial lesions.(12) The use of VAs in the ICU has been more frequently reported in populations of surgical patients. Although there are no contraindications for VAs use in other populations of critically ill patients (e.g., patients with sepsis), further studies are needed.","PeriodicalId":72721,"journal":{"name":"Critical care science","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10275303/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10337447","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.5935/2965-2774.20230350-en
José Colleti, Arnaldo Prata-Barbosa, Orlei Ribeiro Araujo, Cristian Tedesco Tonial, Felipe Rezende Caino de Oliveira, Daniela Carla de Souza, Fernanda Lima-Setta, Thiago Silveira Jannuzzi de Oliveira, Mary Lucy Ferraz Maia Fiuza de Mello, Carolina Amoretti, Paulo Ramos David João, Cinara Carneiro Neves, Norma Suely Oliveira, Cira Ferreira Antunes Costa, Daniel Garros
Objective: To assess Brazilian pediatric intensivists' general knowledge of extracorporeal membrane oxygenation, including evidence for its use, the national funding model, indications, and complications.
Methods: This was a multicenter cross-sectional survey including 45 Brazilian pediatric intensive care units. A convenience sample of 654 intensivists was surveyed regarding their knowledge on managing patients on extracorporeal membrane oxygenation, its indications, complications, funding, and literature evidence.
Results: The survey addressed questions regarding the knowledge and experience of pediatric intensivists with extracorporeal membrane oxygenation, including two clinical cases and 6 optional questions about the management of patients on extracorporeal membrane oxygenation. Of the 45 invited centers, 42 (91%) participated in the study, and 412 of 654 (63%) pediatric intensivists responded to the survey. Most pediatric intensive care units were from the Southeast region of Brazil (59.5%), and private/for-profit hospitals represented 28.6% of the participating centers. The average age of respondents was 41.4 (standard deviation 9.1) years, and the majority (77%) were women. Only 12.4% of respondents had taken an extracorporeal membrane oxygenation course. Only 19% of surveyed hospitals have an extracorporeal membrane oxygenation program, and only 27% of intensivists reported having already managed patients on extracorporeal membrane oxygenation. Specific extracorporeal membrane oxygenation management questions were responded to by only 64 physicians (15.5%), who had a fair/good correct response rate (median 63.4%; range 32.8% to 91.9%).
Conclusion: Most Brazilian pediatric intensivists demonstrated limited knowledge regarding extracorporeal membrane oxygenation, including its indications and complications. Extracorporeal membrane oxygenation is not yet widely available in Brazil, with few intensivists prepared to manage patients on extracorporeal membrane oxygenation and even fewer intensivists recognizing when to refer patients to extracorporeal membrane oxygenation centers.
{"title":"Knowledge regarding extracorporeal membrane oxygenation management among Brazilian pediatric intensivists: a cross-sectional survey.","authors":"José Colleti, Arnaldo Prata-Barbosa, Orlei Ribeiro Araujo, Cristian Tedesco Tonial, Felipe Rezende Caino de Oliveira, Daniela Carla de Souza, Fernanda Lima-Setta, Thiago Silveira Jannuzzi de Oliveira, Mary Lucy Ferraz Maia Fiuza de Mello, Carolina Amoretti, Paulo Ramos David João, Cinara Carneiro Neves, Norma Suely Oliveira, Cira Ferreira Antunes Costa, Daniel Garros","doi":"10.5935/2965-2774.20230350-en","DOIUrl":"https://doi.org/10.5935/2965-2774.20230350-en","url":null,"abstract":"<p><strong>Objective: </strong>To assess Brazilian pediatric intensivists' general knowledge of extracorporeal membrane oxygenation, including evidence for its use, the national funding model, indications, and complications.</p><p><strong>Methods: </strong>This was a multicenter cross-sectional survey including 45 Brazilian pediatric intensive care units. A convenience sample of 654 intensivists was surveyed regarding their knowledge on managing patients on extracorporeal membrane oxygenation, its indications, complications, funding, and literature evidence.</p><p><strong>Results: </strong>The survey addressed questions regarding the knowledge and experience of pediatric intensivists with extracorporeal membrane oxygenation, including two clinical cases and 6 optional questions about the management of patients on extracorporeal membrane oxygenation. Of the 45 invited centers, 42 (91%) participated in the study, and 412 of 654 (63%) pediatric intensivists responded to the survey. Most pediatric intensive care units were from the Southeast region of Brazil (59.5%), and private/for-profit hospitals represented 28.6% of the participating centers. The average age of respondents was 41.4 (standard deviation 9.1) years, and the majority (77%) were women. Only 12.4% of respondents had taken an extracorporeal membrane oxygenation course. Only 19% of surveyed hospitals have an extracorporeal membrane oxygenation program, and only 27% of intensivists reported having already managed patients on extracorporeal membrane oxygenation. Specific extracorporeal membrane oxygenation management questions were responded to by only 64 physicians (15.5%), who had a fair/good correct response rate (median 63.4%; range 32.8% to 91.9%).</p><p><strong>Conclusion: </strong>Most Brazilian pediatric intensivists demonstrated limited knowledge regarding extracorporeal membrane oxygenation, including its indications and complications. Extracorporeal membrane oxygenation is not yet widely available in Brazil, with few intensivists prepared to manage patients on extracorporeal membrane oxygenation and even fewer intensivists recognizing when to refer patients to extracorporeal membrane oxygenation centers.</p>","PeriodicalId":72721,"journal":{"name":"Critical care science","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10275299/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10288715","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.5935/2965-2774.20230307-en
José Augusto Santos Pellegrini, Ciro Leite Mendes, Paulo César Gottardo, Khalil Feitosa, Josiane França John, Ana Cláudia Tonelli de Oliveira, Alexandre Jorge de Andrade Negri, Ana Burigo Grumann, Dalton de Souza Barros, Fátima Elizabeth Fonseca de Oliveira Negri, Gérson Luiz de Macedo, Júlio Leal Bandeira Neves, Márcio da Silveira Rodrigues, Marcio Fernando Spagnól, Marcus Antonio Ferez, Ricardo Ávila Chalhub, Ricardo Luiz Cordioli
The use of echocardiography by physicians who are not echocardiographers has become common throughout the world across highly diverse settings where the care of acutely ill patients is provided. Echocardiographic evaluation performed in a point-of-care manner can provide relevant information regarding the mechanism of causes of shock, for example, increasing the rates of correct diagnosis and allowing for faster informed decision-making than through evaluation methods. Considering that the accurate diagnosis of life-threatening situations is essential for professionals working with acutely ill patients, several international associations recommend that physicians responsible for critically ill patients acquire and develop the ability to perform bedside ultrasound examinations, including echocardiographic examinations. However, there is no consensus in the literature regarding which specific applications should be included in the list of skills for nonechocardiographer physicians. Taking into account the multiplicity of applications of echocardiography in different scenarios related to acutely ill patients; the differences in the published protocols, with regard to both the teaching methodology and competence verification; and the heterogeneity of training among highly diverse specialties responsible for their care at different levels, this consensus document aimed to reflect the position of representatives of related Brazilian medical societies on the subject and may thus serve as a starting point both for standardization among different specialties and for the transmission of knowledge and verification of the corresponding competencies.
{"title":"Use of bedside echocardiography in the care of critically ill patients - a joint consensus document of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Medicina de Emergência, and Sociedade Brasileira de Medicina Hospitalar. Part 1 - Competence in bedside echocardiography.","authors":"José Augusto Santos Pellegrini, Ciro Leite Mendes, Paulo César Gottardo, Khalil Feitosa, Josiane França John, Ana Cláudia Tonelli de Oliveira, Alexandre Jorge de Andrade Negri, Ana Burigo Grumann, Dalton de Souza Barros, Fátima Elizabeth Fonseca de Oliveira Negri, Gérson Luiz de Macedo, Júlio Leal Bandeira Neves, Márcio da Silveira Rodrigues, Marcio Fernando Spagnól, Marcus Antonio Ferez, Ricardo Ávila Chalhub, Ricardo Luiz Cordioli","doi":"10.5935/2965-2774.20230307-en","DOIUrl":"10.5935/2965-2774.20230307-en","url":null,"abstract":"<p><p>The use of echocardiography by physicians who are not echocardiographers has become common throughout the world across highly diverse settings where the care of acutely ill patients is provided. Echocardiographic evaluation performed in a point-of-care manner can provide relevant information regarding the mechanism of causes of shock, for example, increasing the rates of correct diagnosis and allowing for faster informed decision-making than through evaluation methods. Considering that the accurate diagnosis of life-threatening situations is essential for professionals working with acutely ill patients, several international associations recommend that physicians responsible for critically ill patients acquire and develop the ability to perform bedside ultrasound examinations, including echocardiographic examinations. However, there is no consensus in the literature regarding which specific applications should be included in the list of skills for nonechocardiographer physicians. Taking into account the multiplicity of applications of echocardiography in different scenarios related to acutely ill patients; the differences in the published protocols, with regard to both the teaching methodology and competence verification; and the heterogeneity of training among highly diverse specialties responsible for their care at different levels, this consensus document aimed to reflect the position of representatives of related Brazilian medical societies on the subject and may thus serve as a starting point both for standardization among different specialties and for the transmission of knowledge and verification of the corresponding competencies.</p>","PeriodicalId":72721,"journal":{"name":"Critical care science","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10275308/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10287265","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}