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Aim. This scoping review is aimed at systematically mapping the evidence on palliative extubation in the pediatric intensive care unit. Methods. MEDLINE, EBSCO, and Cochrane databases were searched for articles published between January 2018 and December 2022, in English. Critical appraisal of sources of evidence was done using the Joanna Briggs Institute tools. PRISMA guidelines for scoping reviews were followed. Results. Six studies were included, with 366 patients, from the USA (n = 4), Brazil (n = 1), and Germany (n = 1). Three were high-quality studies, two were moderate, and one was a low-quality study. Most studies were retrospective analysis; two were narrative approaches; two were evidence-based recommendation and quality improvement project; one study was a prospective intervention. Conclusion. Symptom control is crucial pre- and postextubation. A checklist (symptom management and family support) and a postdebriefing template improve team communication and staff support postextubation. Critical care transports from the hospital are feasible to provide extubation at home. A framework addressing common planning challenges and resource management is recommended for extubation at home. The provision of pediatric palliative extubation is necessary since futile measures and prolongation of suffering violate the principle of nonmaleficence. Future research on this subject will result in more benefits for patients, parents, and professionals. [ABSTRACT FROM AUTHOR]

Background: Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide, particularly in low- and middle-income countries; however, the majority of these deaths could be avoided with adequate obstetric care. Analyzing severe maternal outcomes (SMO) has been a major approach for evaluating the quality of the obstetric care provided, since the morbid events that lead to maternal death generally occur in sequence. The objective of this study was to analyze the clinical profile, management, maternal outcomes and factors associated with SMO in women who developed PPH and were admitted to an obstetric intensive care unit (ICU) in northeastern Brazil. Methods: This retrospective cohort study included a non-probabilistic, consecutive sample of postpartum women with a diagnosis of PPH who were admitted to the obstetric ICU of the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) between January 2012 and March 2020. Sociodemographic, biological and obstetric characteristics and data regarding childbirth, the management of PPH and outcomes were collected and analyzed. The frequency of maternal near miss (MNM) and death was calculated. Multiple logistic regression analysis was performed to determine the adjusted odd ratios (AOR) and their 95% confidence intervals (95% CI) for a SMO. Results: Overall, 136 cases of SMO were identified (37.9%), with 125 cases of MNM (34.9%) and 11 cases of maternal death (3.0%). The factors that remained associated with an SMO following multivariate analysis were gestational age ≤ 34 weeks (AOR = 2.01; 95% CI: 1.12–3.64; p < 0.02), multiparity (AOR = 2.20; 95% CI: 1.10–4.68; p = 0.02) and not having delivered in the institute (AOR = 2.22; 955 CI: 1.02–4.81; p = 0.04). Conclusion: Women admitted to the obstetric ICU with a diagnosis of PPH who had had two or more previous deliveries, gestational age ≤ 34 weeks and who had delivered elsewhere were more likely to have a SMO. [ABSTRACT FROM AUTHOR]

Purpose: COVID-19 presents complex pathophysiology, and evidence collected points towards an intricate interaction between viral-dependent and individual immunological mechanisms. Identifying phenotypes through clinical and biological markers may provide a better understanding of the subjacent mechanisms and an early patient-tailored characterization of illness severity. Methods: A multicenter prospective cohort study was performed in 5 hospitals in Portugal and Brazil for one year between 2020–2021. All adult patients with an Intensive Care Unit admission with SARS-CoV-2 pneumonia were eligible. COVID-19 was diagnosed using clinical and radiologic criteria with a SARS-CoV-2 positive RT-PCR test. A two-step hierarchical cluster analysis was made using several class-defining variables. Results: 814 patients were included. The cluster analysis revealed a three-class model, allowing for the definition of three distinct COVID-19 phenotypes: 407 patients in phenotype A, 244 patients in phenotype B, and 163 patients in phenotype C. Patients included in phenotype A were significantly older, with higher baseline inflammatory biomarkers profile, and a significantly higher requirement of organ support and mortality rate. Phenotypes B and C demonstrated some overlapping clinical characteristics but different outcomes. Phenotype C patients presented a lower mortality rate, with consistently lower C-reactive protein, but higher procalcitonin and interleukin-6 serum levels, describing an immunological profile significantly different from phenotype B. Conclusions: Severe COVID-19 patients exhibit three different clinical phenotypes with distinct profiles and outcomes. Their identification could have an impact on patients' care, justifying different therapy responses and inconsistencies identified across different randomized control trial results. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease (COVID-19) survivors exhibit multisystemic alterations after hospitalization. Little is known about long-term imaging and pulmonary function of hospitalized patients intensive care unit (ICU) who survive COVID-19. We aimed to investigate long-term consequences of COVID-19 on the respiratory system of patients discharged from hospital ICU and identify risk factors associated with chest computed tomography (CT) lesion severity. Methods: A prospective cohort study of COVID-19 patients admitted to a tertiary hospital ICU in Brazil (March-August/2020), and followed-up six-twelve months after hospital admission. Initial assessment included: modified Medical Research Council dyspnea scale, SpO2 evaluation, forced vital capacity, and chest X-Ray. Patients with alterations in at least one of these examinations were eligible for CT and pulmonary function tests (PFTs) approximately 16 months after hospital admission. Primary outcome: CT lesion severity (fibrotic-like or non-fibrotic-like). Baseline clinical variables were used to build a machine learning model (ML) to predict the severity of CT lesion. Results: In total, 326 patients (72%) were eligible for CT and PFTs. COVID-19 CT lesions were identified in 81.8% of patients, and half of them showed mild restrictive lung impairment and impaired lung diffusion capacity. Patients with COVID-19 CT findings were stratified into two categories of lesion severity: non-fibrotic-like (50.8%-ground-glass opacities/reticulations) and fibrotic-like (49.2%-traction bronchiectasis/architectural distortion). No association between CT feature severity and altered lung diffusion or functional restrictive/obstructive patterns was found. The ML detected that male sex, ICU and invasive mechanic ventilation (IMV) period, tracheostomy and vasoactive drug need during hospitalization were predictors of CT lesion severity(sensitivity,0.78±0.02;specificity,0.79±0.01;F1-score,0.78±0.02;positive predictive rate,0.78±0.02; accuracy,0.78±0.02; and area under the curve,0.83±0.01). Conclusion: ICU hospitalization due to COVID-19 led to respiratory system alterations six-twelve months after hospital admission. Male sex and critical disease acute phase, characterized by a longer ICU and IMV period, and need for tracheostomy and vasoactive drugs, were risk factors for severe CT lesions six-twelve months after hospital admission. [ABSTRACT FROM AUTHOR]

To describe the clinical characteristics, severity, and ophthalmological changes in SARS-CoV-2 patients through ophthalmological examinations performed at the reference center of the National Institute of Infectious Diseases, Brazil. This cross-sectional study assessed the examination results of SARS-CoV-2 patients from July 2020 to November 2020. In total, 150 patients were included and allocated into three groups of 50 patients depending on the disease severity. Group 1 patients were in the intensive care unit (ICU), group 2 patients were in the semi-ICU, and group 3 patients were outpatients. Ten (6.7%) patients exhibited ophthalmological changes; five (10%), four (8%), and one (2%) patients in groups 1, 2, and 3, respectively. Ophthalmological findings included candle flame hemorrhage and cotton wool exudates. We analyzed the general characteristics of the 10 patients with ophthalmological changes. Nine were hospitalized and one was seen on an outpatient basis. We observed ophthalmic changes in patients with SARS-CoV-2 infection, despite the absence of any clinical or laboratory risk factors indicative of such changes. [ABSTRACT FROM AUTHOR]

The present study aimed to evaluate the association between obesity and COVID-19 mortality and length of stay in ICU patients, and how these associations were modified by age groups. We performed a retrospective multicenter cohort study with data obtained from a hospital-based registry. The sample consisted of 8183 ICU hospitalized patients who tested positive for SARS-CoV-2. Cox proportional models were used to evaluate the association between BMI categories and COVID-19 mortality and generalized linear models for the length of stay in the ICU. After adjusting for confounders, those in the younger group with severe obesity had an increased risk of COVID-19 mortality compared to those with normal/overweight (HR 1.27; 95% CI 1.01–1.61). An increased risk of death was also observed for patients with underweight (HR 3.74; 95% CI 1.39–10.07). For patients aged ≥ 60 year, mild/moderate obesity was associated with reduced mortality risk (HR 0.87; 95% CI 0.78–0.97). For the age group < 60 year, the length of stay in ICU for those patients with severe obesity was 35% higher compared to the normal/overweight category (eβ 1.35; 95% CI 1.21–1.51). Conversely, for the survivors in the underweight category, the length of stay in ICU was 51% lower compared to the normal/overweight group (eβ 0.49; 95% CI 0.31–0.78). In the age group ≥ 60 year, mild/moderate obesity was associated with an increased length of stay in the ICU (eβ 1.10; 95% CI 1.01–1.21), adjusting for confounders. These findings could be helpful for health professionals to identify subgroups at higher risk for worse outcomes. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to assess the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in the oral cavity of pediatric patients hospitalized at an intensive care unit (ICU). Methodology: Thirty ICU patients (group 1) and 30 healthy patients (group 2), between 1 and 12 years of age, matched by sex and age, were selected from a public hospital in Brazil. After oral examinations, biological specimens (nostril swab, oral mucosa, and supragingival biofilm) were collected from both groups to verify the presence of Staphylococcus aureus. Identification occurred after growth in Tryptic Soy Broth with 7.5% of NaCl for 48 hours, growth in Mannitol Salt Agar, gram staining, catalase, and coagulase tests. S. aureus isolates were submitted to antibiotic sensitivity test. Results: Only 36.7% of patients in the ICU perform oral hygiene during the hospitalization period and 41.7% presented high level of dental biofilm accumulation. The presence of S. aureus was similar in patients from group 1 (43.3%, 13) and group 2 (50.0%, 15) (p = 0.60). Both groups presented 18 samples each that tested positive for S. aureus. However, when considering patients infected by MRSA, the prevalence was higher in group 1 (eight; 26.7%) than in group 2 (five; 16.7%) but no statistical difference was observed (p = 0.53). In group 1, nine MRSA samples were resistant to erythromycin and seven to clindamycin. In group 2, two MRSA samples were resistant to erythromycin and two to clindamycin. Conclusions: Although ICU children did not show a significant higher carriage of MRSA when compared with the healthy group in the population studied, the number of highly resistant strains in the oral cavity isolated from ICU patients adds an important risk factor to be considered by the medical team as possible source of systemic infections, extended hospital stay, and poor outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Reviewing the profile of patients admitted at the Burns Intensive Care Unit at São Paulo Hospital - UNIFESP, as well as the available literature, it becomes evident the need for tools able to predict those patients' outcomes. Distinct score models are used in different health centers, not only as prognostic models, but also as research and quality control tools. Amongst these prognostic scores, there are two strands, the burns specific scores - which consider the injury's characteristics - and the general critical patient's scores.Objective: This study aims to analyze the differences and tendencies in mortality prediction of two broadly used scores when applied to São Paulo Hospital's Burns Intensive Care Unit patients, ABSI - burns specific score - and SAPS 3 - general score for critical patients.Methods: This is an individual, observational, retrospective and comparative study, developed with medical records review. Both scores were applied to every patient admitted at São Paulo Hospital's Burns Intensive Care Unit from 2011 to 2016. Statistical analyses used the non-parametric test of Kolmogorov-Smirnov, a p-value <0.05 was considered significant.Results: 122 patients were included, the average age was 34,4 years old. 70,5% of patients were male and 49% had a total body surface area burned of 20%. 27% of the patients died. Statistical analyses do not show significant differences between ABSI and SAPS3 mortality predictions for burns patients at this health center.Conclusion: The study evidences that SAPS 3 score, frequently used at general Intensive Care Units, has a similar performance to ABSI score, which is specific for burns populations. ABSI score is easier to implement, as it is simpler and able to show instant results. [ABSTRACT FROM AUTHOR]

Objective. To characterize the epidemiological and clinical profile of individuals more likely to become infected with SARS-CoV-2 after the fully vaccination schedule in order to profile priority groups to receive a booster dose in situations of vaccine doses shortage as well as for maintenance of personal protective care. Methods. This cross-sectional study used data from hospitalized COVID-19 patients aged ≥18 years, who had been fully vaccinated and had a SARS-CoV-2 infection positive diagnosis collected from the SIVEP-Gripe database (Influenza Epidemiological Surveillance Information System) from January 18, 2021 to September 15, 2021. Demographic data, clinical symptoms and preexisting medical conditions (comorbidities) were analyzed. The primary outcome was in-hospital death. Results. The majority of hospitalized patients with vaccine breakthrough infection were ≥60 years old, male, with critical or severe COVID-19. The fatality rate was extremely high (50.27%) and more pronounced in elderly groups. The most prevalent symptoms were cough, dyspnea, respiratory distress, and low blood oxygen saturation. The most frequent comorbidities were heart disease and diabetes. High fatality rates were observed among patients admitted to the intensive care units (72.88%) and those who required invasive mechanical ventilation (87.82%). The main risk factors for an unfavorable outcome were older age, respiratory compromise, inactivated virus vaccine immunization, and preexisting medical conditions. Conclusions. We characterized the profile of hospitalized Brazilian patients with COVID-19 vaccine breakthrough infection and the risk factors for an unfavorable outcome. These data allow to identify priority groups to receive a booster dose and to continue using personal protection. [ABSTRACT FROM AUTHOR]

Background: Patients hospitalised with COVID-19 are at risk for thrombotic events after discharge; the role of extended thromboprophylaxis in this population is unknown.Methods: In this open-label, multicentre, randomised trial conducted at 14 centres in Brazil, patients hospitalised with COVID-19 at increased risk for venous thromboembolism (International Medical Prevention Registry on Venous Thromboembolism [IMPROVE] venous thromboembolism [VTE] score of ≥4 or 2-3 with a D-dimer >500 ng/mL) were randomly assigned (1:1) to receive, at hospital discharge, rivaroxaban 10 mg/day or no anticoagulation for 35 days. The primary efficacy outcome in an intention-to-treat analysis was a composite of symptomatic or fatal venous thromboembolism, asymptomatic venous thromboembolism on bilateral lower-limb venous ultrasound and CT pulmonary angiogram, symptomatic arterial thromboembolism, and cardiovascular death at day 35. Adjudication was blinded. The primary safety outcome was major bleeding. The primary and safety analyses were carried out in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT04662684.Findings: From Oct 8, 2020, to June 29, 2021, 997 patients were screened. Of these patients, 677 did not meet eligibility criteria; the remaining 320 patients were enrolled and randomly assigned to receive rivaroxaban (n=160 [50%]) or no anticoagulation (n=160 [50%]). All patients received thromboprophylaxis with standard doses of heparin during hospitalisation. 165 (52%) patients were in the intensive care unit while hospitalised. 197 (62%) patients had an IMPROVE score of 2-3 and elevated D-dimer levels and 121 (38%) had a score of 4 or more. Two patients (one in each group) were lost to follow-up due to withdrawal of consent and not included in the intention-to-treat primary analysis. The primary efficacy outcome occurred in five (3%) of 159 patients assigned to rivaroxaban and 15 (9%) of 159 patients assigned to no anticoagulation (relative risk 0·33, 95% CI 0·12-0·90; p=0·0293). No major bleeding occurred in either study group. Allergic reactions occurred in two (1%) patients in the rivaroxaban group.Interpretation: In patients at high risk discharged after hospitalisation due to COVID-19, thromboprophylaxis with rivaroxaban 10 mg/day for 35 days improved clinical outcomes compared with no extended thromboprophylaxis.Funding: Bayer. [ABSTRACT FROM AUTHOR]

Aim: Major congenital anomalies are an important cause of death in the neonatal intensive care unit (NICU). Therapeutic interventions and the suspension of those already in place often raise ethical dilemmas in neonatal care. Methods: We analysed treatments—such as ventilatory support, vasoactive drugs, antibiotics, sedation/or analgesia, central venous access and other invasive procedures—offered up to 48 h before death to all newborns with major congenital anomalies over a 3‐year period in a NICU in Brazil. We also gathered information contained in medical records concerning conversations with the families and decisions to limit therapeutic interventions. Results: We enrolled 74 newborns who were hospitalised from 1 January 2015 to 31 December 2017. A total of 81.1% had central venous access, 74.3% were on ventilatory support, 56.8% received antibiotics and 43.2% used some sedative/analgesic drugs in their final moments. Conversations were registered in medical records in 76% of cases, and 46% of the families chose therapeutic intervention limits. Those who chose to limit therapeutic interventions asked for less exposure to vasoactive drugs (P = 0.003) and antibiotics (P = 0.003), as well as fewer invasive procedures (P = 0.046). There was no change in ventilatory support (P = 0.66), and palliative extubation was not performed for any patient. Conclusions: The therapeutic intervention was mainly characterised by maintenance of the current treatment when a terminal situation was identified with no introduction of new treatments that could increase suffering. The families' approach proved to be essential for making difficult decisions in the NICU. [ABSTRACT FROM AUTHOR]

Introduction: Central line-associated bloodstream infections are the second most frequent infection in intensive care units. It represents an adverse event of significant magnitude, thus threatening the patient safety. The aim of this study was to analyze the historical trend of central line-associated bloodstream infections in patients in intensive care units, the rate of infection, central venous catheter utilization ratio, type of pathogen and their antimicrobial resistance pattern. Methodology: This ecological study was performed at 42 intensive care units from a state capital of the Midwest region of Brazil. Central lineassociated bloodstream infections notifications were collected from two databases, the Municipal Coordination for Patient Safety and Infection Control at Healthcare Services, from 2012-2016, and the FormSUS (National Health System Data Processing Company), from 2014-2016. Results: The incidence of central line-associated bloodstream infections was high and stationary in the period (incidence rate of 2.3 to 3.2 per 1,000 catheter days, central venous catheter utilization ratio average 56,9%). The most frequent microorganisms were coagulase-negative Staphylococcus, Klebsiella pneumoniae, Acinetobacter spp. and Pseudomonas aeruginosa. Resistance to 3rd and 4th generation cephalosporins and carbapenems were detected among Gram-negative bacteria, and resistance to oxacillin among Gram-positive bacteria. Conclusions: Central line-associated bloodstream infections incidence rates were high, however the historical trend remained stationary in adult intensive care units. Infections were mostly caused by coagulase-negative Staphylococcus, K. pneumoniae, Acinetobacter spp. and Pseudomonas aeruginosa, including multi-drug resistant organisms. These findings point to the need of educational strategies addressing the adherence to established preventive measures and to the rational use of antimicrobials. [ABSTRACT FROM AUTHOR]

Importance: Slower intravenous fluid infusion rates could reduce the formation of tissue edema and organ dysfunction in critically ill patients; however, there are no data to support different infusion rates during fluid challenges for important outcomes such as mortality.Objective: To determine the effect of a slower infusion rate vs control infusion rate on 90-day survival in patients in the intensive care unit (ICU).Design, Setting, and Participants: Unblinded randomized factorial clinical trial in 75 ICUs in Brazil, involving 11 052 patients requiring at least 1 fluid challenge and with 1 risk factor for worse outcomes were randomized from May 29, 2017, to March 2, 2020. Follow-up was concluded on October 29, 2020. Patients were randomized to 2 different infusion rates (reported in this article) and 2 different fluid types (balanced fluids or saline, reported separately).Interventions: Patients were randomized to receive fluid challenges at 2 different infusion rates; 5538 to the slower rate (333 mL/h) and 5514 to the control group (999 mL/h). Patients were also randomized to receive balanced solution or 0.9% saline using a factorial design.Main Outcomes and Measures: The primary end point was 90-day survival.Results: Of all randomized patients, 10 520 (95.2%) were analyzed (mean age, 61.1 years [SD, 17.0 years]; 44.2% were women) after excluding duplicates and consent withdrawals. Patients assigned to the slower rate received a mean of 1162 mL on the first day vs 1252 mL for the control group. By day 90, 1406 of 5276 patients (26.6%) in the slower rate group had died vs 1414 of 5244 (27.0%) in the control group (adjusted hazard ratio, 1.03; 95% CI, 0.96-1.11; P = .46). There was no significant interaction between fluid type and infusion rate (P = .98).Conclusions and Relevance: Among patients in the intensive care unit requiring fluid challenges, infusing at a slower rate compared with a faster rate did not reduce 90-day mortality. These findings do not support the use of a slower infusion rate.Trial Registration: ClinicalTrials.gov Identifier: NCT02875873. [ABSTRACT FROM AUTHOR]

Introduction: The COVID‐19 pandemic continues, with a late hyperinflammatory phase. The immunosuppressive therapy used in heart transplant patients, in theory, could reduce inflammation, thus benefitting patients with COVID‐19. So far, however, there is still very little literature on this subject. Methods: This is a single‐center retrospective study. We described laboratory parameters and clinical outcomes from 11 heart transplant patients with COVID‐19 assisted at Dante Pazzanese Institute of Cardiology between March and July 2020. Results: Patients with ages of between 35 and 79 years were enrolled, and heart transplantation ranged from 3 to 264 months. The main comorbidities were diabetes mellitus (9/11; 81.8%), hypertension (10/11; 90.9%), and chronic renal disease (6/11; 54.5%). Cyclosporine A was used in 10 (90.9%) patients, mycophenolate mofetil in 9 (81.8%) patients, and mTOR inhibitor in 5 (45.5%) patients. Fever and cough were observed in 8 (72.7%) patients, and dyspnea and gastrointestinal symptoms in 5 (45.5%) patients. Lymphopenia was observed in 10 (90.9%) patients and thrombocytopenia in 5 (45.5%) patients. The higher level of troponin associated with chest tomography above 50% of bilateral pulmonary infiltrates with ground‐glass opacity (GGO) was observed in those with the worst outcomes. Nine patients needed intensive care, and hospital stay ranged from 4 to 21 days, with 2 (18.2%) patients requiring vasopressor drugs and mechanical ventilation, and three (27.3%) patients dying due to COVID‐19 complications. Conclusion: Heart transplant patients had similar symptoms and outcomes as the general population; immunosuppressive therapy seems not to have protected them. Patients who presented higher levels of troponin and D‐dimer, associated with greater GGO pulmonary infiltrates, had worse outcomes. More studies with larger cohorts may clarify immunosuppressive effects on COVID‐19 outcomes. [ABSTRACT FROM AUTHOR]

• Laboratory results from 178 887 Brazilian COVID-19 patients and controls were evaluated. • Distinct disease profiles influenced by age and sex were detected. • Such profiles may underly the occurrence of severe disease. The progression and severity of COVID-19 vary significantly in the population. While the hallmarks of SARS-CoV-2 and severe COVID-19 within routine laboratory parameters are emerging, the impact of sex and age on these profiles is still unknown. A multidimensional analysis was performed involving millions of records of laboratory parameters and diagnostic tests for 178 887 individuals from Brazil, of whom 33 266 tested positive for SARS-CoV-2. Analyzed data included those relating to complete blood cell count, electrolytes, metabolites, arterial blood gases, enzymes, hormones, cancer biomarkers, and others. COVID-19 induced similar alterations in laboratory parameters in males and females. CRP and ferritin were increased, especially in older men with COVID-19, whereas abnormal liver function tests were common across several age groups, except for young women. Low peripheral blood basophils and eosinophils were more common in the elderly with COVID-19. Both male and female COVID-19 patients admitted to intensive care units displayed alterations in the coagulation system, and higher values for neutrophils, CRP, and lactate dehydrogenase. Our study uncovered the laboratory profiles of a large cohort of COVID-19 patients, which formed the basis of discrepancies influenced by aging and biological sex. These profiles directly linked COVID-19 disease presentation to an intricate interplay between sex, age, and immune activation. [ABSTRACT FROM AUTHOR]

Background: Highly active antiretroviral therapy (HAART) has reduced HIV-related morbidity and mortality at all stages of infection and reduced transmission of HIV. Currently, the immediate start of HAART is recommended for all HIV patients, regardless of the CD4 count. There are several concerns, however, about starting treatment in critically ill patients. Unpredictable absorption of medication by the gastrointestinal tract, drug toxicity, drug interactions, limited reserve to tolerate the dysfunction of other organs resulting from hypersensitivity to drugs or immune reconstitution syndrome, and the possibility that subtherapeutic levels of drug may lead to viral resistance are the main concerns. The objective of our study was to compare the early onset (up to 5 days) with late onset (after discharge from the ICU) of HAART in HIV-infected patients admitted to the ICU. Methods: This was a randomized, open-label clinical trial enrolling HIV-infected patients admitted to the ICU of a public hospital in southern Brazil. Patients randomized to the intervention group had to start treatment with HAART within 5 days of ICU admission. For patients in the control group, treatment should begin after discharge from the ICU. The patients were followed up to determine mortality in the ICU, in the hospital and at 6 months. The primary outcome was hospital mortality. The secondary outcome was mortality at 6 months. Results: The calculated sample size was 344 patients. Unfortunately, we decided to discontinue the study due to a progressively slower recruitment rate. A total of 115 patients were randomized. The majority of admissions were for AIDS-defining illnesses and low CD4. The main cause of admission was respiratory failure. Regarding the early and late study groups, there was no difference in hospital (66.7% and 63.8%, p = 0.75) or 6-month (68.4% and 79.2%, p = 0.20) mortality. After multivariate analysis, the only independent predictors of in-hospital mortality were shock and dialysis during the ICU stay. For the mortality outcome at 6 months, the independent variables were shock and dialysis during the ICU stay and tuberculosis at ICU admission. Conclusions: Although the early termination of the study precludes definitive conclusions being made, early HAART administration for HIV-infected patients admitted to the ICU compared to late administration did not show benefit in hospital mortality or 6-month mortality. ClinicalTrials.gov, NCT01455688. Registered 20 October 2011, https://clinicaltrials.gov/show/NCT01455688 [ABSTRACT FROM AUTHOR]

Background: Mortality in the intensive care unit (ICU) has been associated to an array of risk factors. Identification of risk factors potentially contribute to predict and reduce mortality rates in the ICU. The objectives of the study were to determine the prevalence and the factors associated with the mortality and to analyze the survival.Method: A cross-sectional study conducted in two clinical and surgical ICU in the state of Sergipe, northeastern Brazil. We enrolled 316 patients with at least 48 h of hospitalization, minimum age of 18 years old, sedated or weaned, with RASS ≥ -3, between July 2017 and April 2018. We categorized data in (1) age and gender, (2) clinical condition, and (3) prevalence of delirium. Data from enrolled patients were collected from enrollment until death or ICU discharge. Patients' outcomes were categorized in (1) death and (2) nondeath (discharge).Results: Twenty-one percent of participants died. Age (53 ± 17 years vs. 45 ± 18 years, p < 0.01), electrolyte disturbance (30.3% vs 18.1%, p=0.029), glycemic index (33.3% vs 18.2%, p=0.008), tube feeding (83.3% vs 67.1%, p=0.01), mechanical ventilation (50% vs 35.7%, p=0.035), sedation with fentanyl (24.2 vs 13.6, p=0.035), use of insulin (33.8% vs 21.7%, p=0.042), and higher Charlson score (2.61 vs 2.17, p=0.041) were significantly associated with death on the adjusted model. However, the regression model indicated that patients admitted from the emergency (HR = 0.40, p=0.006) and glycemic index alterations (HR = 1.68, p=0.047) were associated with mortality. There was no statistically significant difference (p=0.540) in survival between patients with and without delirium, based on the survival analysis and length of hospitalization.Conclusion: The prevalence of death was 21%, and age, electrolyte disturbance, glycemic index, tube feeding, mechanical ventilation, sedation with fentanyl, use of insulin, and higher Charlson score were associated with mortality. [ABSTRACT FROM AUTHOR]

Carbapenem-resistant Enterobacteriaceae (CRE) colonization is common in hospital patients admitted to intensive care units (ICU) from the emergency department. We evaluated the effect of previous hospitalization in the emergency department on CRE colonization at ICU admission. Our case-control study included 103 cases and 201 controls; cases were patients colonized by CRE at admission to ICU and controls were patients admitted to ICU and not colonized. Risk factors were emergency department stay, use of carbapenem, Simplified Acute Physiology Score, upper digestive endoscopy, and transfer from another hospital. We found that ED stay before ICU admission was associated with CRE colonization at admission to the ICU. Our findings indicate that addressing infection control problems in EDs will help to control carbapenem resistance in ICUs. [ABSTRACT FROM AUTHOR]

• Among 114 intensive care patients studied with YF, mortality rate was 47.4%. • Prothrombin time, encephalopathy and APACHE 2 were associated with YF mortality. • Early evolution to liver failure predicts higher mortality in YF. • Markers of hepatic inflammation were not independently associated with YF mortality. Yellow fever (YF) is a viral hemorrhagic disease caused by an arbovirus from the Flaviviridae family. Data on the clinical profile of severe YF in intensive care units (ICUs) are scarce. This study aimed to evaluate factors associated with YF mortality in patients admitted to a Brazilian ICU during the YF outbreaks of 2017 and 2018. This was a longitudinal cohort case series study that included YF patients admitted to the ICU. Demographics, clinical and laboratory data were analyzed. Cox regression identified independent predictors of death risk. A total of 114 patients were studied. The median age was 48 years, and 92.1% were males. In univariate analysis, jaundice, leukopenia, bradycardia, prothrombin time, expressed as a ratio to the international normalized ratio-(PT-INR), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, lactate, arterial pH and bicarbonate, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score 3 (SAPS 3) severity scores, transfusion of fresh frozen plasma, acute renal failure (Acute Kidney Injury Network stage III (AKIN III)), hemodialysis, cumulative fluid balance at 72 h of ICU, vasopressor use, seizures and grade IV encephalopathy were significantly associated with mortality. In multivariate analysis, factors independently associated with YF mortality were PT-INR, APACHE II, and grade IV hepatic encephalopathy. In the large outbreak in Brazil, factors independently associated with death risk in YF were: PT-INR, APACHE II, and grade IV hepatic encephalopathy. Early identification of patients with YF mortality risk factors may be very useful. Once these patients with a poor prognosis have been identified, proper management should be promptly implemented. [ABSTRACT FROM AUTHOR]

Among onco-hematological patients with acute respiratory failure (ARpF), surgical lung biopsy (SLB) could contribute to the medical management, by guiding initiation, maintenance or discontinuation of diagnostic and therapeutic interventions. The aim of the present study was to evaluate the results of SLB in these patients in an oncological center from a medium-income country, as well as analyze if this procedure is clinically useful in this context, and its impact on complications and mortality. This observational retrospective study analyzed onco-hematological patients with ARpF in the Intensive Care Unit (ICU) of a cancer center in southern Brazil between 2010–2016, who required mechanical ventilation and were submitted to open SLB. Among the studied population (n=17), the most commonly found etiology was infectious, present in ~50% of the biopsies, followed by unspecific inflammatory infiltrate acute respiratory distress syndrome and interstitial fibrosis, alveolar hemorrhage, neoplastic infiltrate and pulmonary embolism. Biopsy has led to a change of management in 63.3% of patients that were alive when results were available; however, 35% of patients succumbed prior to the pathological result. There was no requirement for re-operation or mortality attributable to the procedure. However, ICU mortality was elevated (88%). SLB in onco-hematological patients mechanically ventilated in the ICU is a safe procedure with few severe complications and that contributes for diagnosis and management in the majority of cases. Due to the high mortality of this population, controlled trials may be required to establish its benefit in mortality and ICU outcomes. [ABSTRACT FROM AUTHOR]

Purpose: We assessed the prevalence and variables associated with haloperidol use for delirium in ICU patients and explored any associations of haloperidol use with 90-day mortality.Methods: All acutely admitted, adult ICU patients were screened during a 2-week inception period. We followed the patient throughout their ICU stay and assessed 90-day mortality. We assessed patients and their variables in the first 24 and 72 h in ICU and studied their association together with that of ICU characteristics with haloperidol use.Results: We included 1260 patients from 99 ICUs in 13 countries. Delirium occurred in 314/1260 patients [25% (95% confidence interval 23-27)] of whom 145 received haloperidol [46% (41-52)]. Other interventions for delirium were benzodiazepines in 36% (31-42), dexmedetomidine in 21% (17-26), quetiapine in 19% (14-23) and olanzapine in 9% (6-12) of the patients with delirium. In the first 24 h in the ICU, all subtypes of delirium [hyperactive, adjusted odds ratio (aOR) 29.7 (12.9-74.5); mixed 10.0 (5.0-20.2); hypoactive 3.0 (1.2-6.7)] and circulatory support 2.7 (1.7-4.3) were associated with haloperidol use. At 72 h after ICU admission, circulatory support remained associated with subsequent use of haloperidol, aOR 2.6 (1.1-6.9). Haloperidol use within 0-24 h and within 0-72 h of ICU admission was not associated with 90-day mortality [aOR 1.2 (0.5-2.5); p = 0.66] and [aOR 1.9 (1.0-3.9); p = 0.07], respectively.Conclusions: In our study, haloperidol was the main pharmacological agent used for delirium in adult patients regardless of delirium subtype. Benzodiazepines, other anti-psychotics and dexmedetomidine were other frequently used agents. Haloperidol use was not statistically significantly associated with increased 90-day mortality. [ABSTRACT FROM AUTHOR]

Objective: To assess the functional status of post-ICU patients using the Barthel Index (BI) and the Katz Index (KI) and to assess which is more suitable for this population.Design: Retrospective longitudinal study.Setting: Public tertiary hospital in São Paulo (Brazil).Participants: Patients aged ≥18 years old, admitted to ICU, who were treated with mechanical ventilation (MV) ≥ 24 h and were discharged to ward.Exclusion Criteria: Inability to answer the BI and the KI; limiting neurological or orthopaedic conditions; ICU stay ≥90 days. Patients transferred to or from other hospitals or who died in the wards were not analysed.Intervention: BI and KI were scored pre-ICU and post-ICU and the variation was calculated.Main Outcome Measures: BI and KI scores were compared using analysis based on item response theory (IRT), using degree of difficulty and discriminating items as parameters.Results: Median age was 52 years old, median APACHE II score was 15. Median ICU stay was 11 days and median MV duration was 4 days. BI variation was 44% and KI variation was 55%. In IRT analysis, BI considered a larger number of items with different levels of difficulty.Conclusion: Both the BI and the KI revealed significant deterioration of functional status after ICU discharge. The IRT analysis suggested that the Barthel Index might be a better scale than the Katz Index for the assessment of functional status of patients discharged from ICU, since it presented better discrimination of the ability to carry out the tasks. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the effect of an extended visitation model compared with a restricted visitation model on the occurrence of delirium among ICU patients.Design: Prospective single-center before and after study.Setting: Thirty-one-bed medical-surgical ICU.Patients: All patients greater than or equal to 18 years old with expected length of stay greater than or equal to 24 hours consecutively admitted to the ICU from May 2015 to November 2015.Interventions: Change of visitation policy from a restricted visitation model (4.5 hr/d) to an extended visitation model (12 hr/d).Measurements and Main Results: Two hundred eighty-six patients were enrolled (141 restricted visitation model, 145 extended visitation model). The primary outcome was the cumulative incidence of delirium, assessed bid using the confusion assessment method for the ICU. Predefined secondary outcomes included duration of delirium/coma; any ICU-acquired infection; ICU-acquired bloodstream infection, pneumonia, and urinary tract infection; all-cause ICU mortality; and length of ICU stay. The median duration of visits increased from 133 minutes (interquartile range, 97.7-162.0) in restricted visitation model to 245 minutes (interquartile range, 175.0-272.0) in extended visitation model (p < 0.001). Fourteen patients (9.6%) developed delirium in extended visitation model compared with 29 (20.5%) in restricted visitation model (adjusted relative risk, 0.50; 95% CI, 0.26-0.95). In comparison with restricted visitation model patients, extended visitation model patients had shorter length of delirium/coma (1.5 d [interquartile range, 1.0-3.0] vs 3.0 d [interquartile range, 2.5-5.0]; p = 0.03) and ICU stay (3.0 d [interquartile range, 2.0-4.0] vs 4.0 d [interquartile range, 2.0-6.0]; p = 0.04). The rate of ICU-acquired infections and all-cause ICU mortality did not differ significantly between the two study groups.Conclusions: In this medical-surgical ICU, an extended visitation model was associated with reduced occurrence of delirium and shorter length of delirium/coma and ICU stay. [ABSTRACT FROM AUTHOR]

Here, we evaluated the frequency of C. difficile colonization and its impact on clinical outcomes in patients admitted to intensive care units in Brazil. From ninety-two patients screened 16 (17.3%) were colonized by C. difficile. Colonized patients had higher Simplified Acute Physiology Score III (SAPS III), however there was no association between C. difficile colonization with diarrhea or mortality. The C. difficile strains sequenced belonged to clade 1 and presented high vancomycin-resistant rates. 1. Prospective cohort study in adult ICUs of two tertiary teaching hospitals in Brazil 2. Evaluate the C. difficile colonization, variables associated, and the clinical course of colonized patients 3. The colonization rate was 17.3% and it was associated with higher SAPS III score 4. All recovered strains belonged to clade 1 and presented high resistance levels to vancomycin [ABSTRACT FROM AUTHOR]

Objective: To analyze existing technologies for changing dressings in intensive care patients. Methods: Descriptive and exploratory study, bibliographical research. Results: In this study, seven articles were chosen for the analysis of data on types of wounds and dressings and the respective technologies applicable to each lesion. They were selected for meeting the inclusion criteria and for presenting relevance to the proposed topic for the discussion and presentation of the results obtained. Conclusion: It is concluded through the study that there are already cutting-edge technologies used in intensive care patients such as venous ulcers, traumatic injury, diabetic foot and treatment of milder chronic wounds. However, in Brazil there is still a need to carry out more studies on the applicability of the technologies mentioned in this article. Recommendation: Thus, it is recommended the implementation and planning of a nursing care plan for patients in intensive care regarding the treatment of wounds and dressing change that is humanized and mediated by available technologies. [ABSTRACT FROM AUTHOR]

The global spread of carbapenemase-producing organisms (CPO) has been considered by international health authorities as a critical public health concern. Brazil has a high CPO prevalence according to distinct publications but many routine microbiology laboratories have only phenotypic resources to evaluate this epidemiological situation, which is time-consuming and detects only carbapenem-resistant isolates missing CPO susceptible expressing a slightly decreased susceptibility. New molecular platforms can detect CPO faster but a local evaluation is essential. To evaluate the performance of CPO detection direct from rectal swabs with the Xpert Carba-R™ assay (Cepheid, Sunnyvale, CA) in the largest Brazilian University Hospital. A prospective diagnostic accuracy study of CPO was performed with the collection of rectal swabs from patients admitted into the Intensive Care Unit (ICU) and into the Emergency Department (ED) between April and July 2016. The Xpert Carba-R™ assay results were compared with carbapenem-resistant Enterobacterales (CRE) surveillance cultures plus in-house PCR carbapenemase detection (reference method). In case of discordant results between methods, additional tests were performed. The limit of detection (LoD) for the CRE culture and the Xpert Carba-R™ assay were performed with contrived isolates of known carbapenemases genes. A total of 921 clinical rectal swabs were analyzed being 21% (196/921) from the ICU and 79% (725/921) from the ED. Overall, the Xpert Carba-R™ assay detected 9.9% (91/921) of CPOs being 9.5% (87/921) positive only for bla KPC and 0.4% (4/921) positive only for bla NDM. The reference method detected 9.1% (84/921) CPO being 77 (8.4%) bla KPC, 5 bla VIM (0.5%) and 2 bla NDM (0.2%). No IMP or OXA-48 like gene was detected. Overall, twelve samples, 1.3% (10 bla KPC , 2 bla NDM) were Xpert Carba-R™ positive but negative by the reference method. Five isolates (0.5%) were positive for bla VIM only by in-house PCR and confirmed to be bla VIM-2 by DNA sequencing. The Kappa value, sensitivity, specificity, positive/negative predictive values and accuracy of the Xpert Carba-R™ assay were; 0.893 (95% confidence interval [CI], 0.842–0.944), 94% (86.7–98.0), 98.6% (97.5–99.3), 86.8% (78.1–93.0), 99.4% (98.6–99.8) and 98.2% (97.3–99.1), respectively. The LoD for bla KPC of the Xpert Carba-R™ assay and the CRE cultures were 101 CFU/swab. The Xpert Carba-R™ assay is an accurate test to detect CPO directly from the rectal swabs with significant lower turnaround time (TAT) when compared to the reference method (CRE culture plus in-house PCR). Xpert Carba-R™ may, therefore, be regarded as a good and fast epidemiological tool. • Xpert Carba-R™ is an accurate epidemiological tool for carbapenemase gene detection. • Xpert Carba-R™ showed high sensitivity and specificity for KPC detection. • Xpert Carba-R™ can be implemented in routine laboratories with less workload. • Fast detection of carbapenemases genes directly from the rectal swabs. [ABSTRACT FROM AUTHOR]