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Objective: In Brazil, there are no data on the preferences of intensivists regarding hemodynamic monitoring methods. The present study aimed to identify the methods used by national intensivists, the hemodynamic variables they consider important, the regional differences, the reasons for choosing a particular method, and the use of protocols and continued training. Methods: National intensivists were invited to answer an electronic questionnaire during three intensive care events and later, through the Associação de Medicina Intensiva Brasileira portal, between March and October 2009. Demographic data and aspects related to the respondent preferences regarding hemodynamic monitoring were researched. Results: In total, 211 professionals answered the questionnaire. Private hospitals showed higher availability of resources for hemodynamic monitoring than did public institutions. The pulmonary artery catheter was considered the most trusted by 56.9% of the respondents, followed by echocardiograms, at 22.3%. Cardiac output was considered the most important variable. Other variables also considered relevant were mixed/central venous oxygen saturation, pulmonary artery occlusion pressure, and right ventricular end-diastolic volume. Echocardiography was the most used method (64.5%), followed by pulmonary artery catheter (49.3%). Only half of respondents used treatment protocols, and 25% worked in continuing education programs in hemodynamic monitoring. Conclusion: Hemodynamic monitoring has a greater availability in intensive care units of private institutions in Brazil. Echocardiography was the most used monitoring method, but the pulmonary artery catheter remains the most reliable. The implementation of treatment protocols and continuing education programs in hemodynamic monitoring in Brazil is still insufficient. [ABSTRACT FROM AUTHOR]

Background. This study evaluated whether large venous-arterial CO2 gap (PCO2 gap) preoperatively is associated to poor outcome. Method. Prospective study which included adult high-risk surgical patients. The patients were pooled into two groups: wide [P(va) CO2] versus narrow [P(v-a)CO2]. In order to determine the best value to discriminate hospital mortality, it was applied a ROC (receiver operating characteristic) curve for the [P(v-a)CO2] values collected preoperatively, and the most accurate value was chosen as cut-off to define the groups. Results. The study included 66 patients. The [P(v-a)CO2] value preoperatively that best discriminated hospital mortality was 5.0mmHg, area = 0.73. Preoperative patients with [P(v-a)CO2] more than 5.0mmHg presented a higher hospital mortality (36.4% versus 4.5% P = 0.004), higher prevalence of circulatory shock (56.8% versus 22.7% P = 0.01) and acute renal failure postoperatively (27.3% versus 4.5% P = 0.02), and longer hospital length of stays 20.0 (14.0-30.0) versus 13.5 (9.0-25.0) days P = 0.01. Conclusions. The PCO2 gap values more than 5.0mmHg preoperatively were associated with worse postoperatively outcome. [ABSTRACT FROM AUTHOR]

Introduction: Enteral nutrition (EN) with eicosapentaenoic acid (EPA)/γ-linolenic acid (GLA) is recommended for mechanically ventilated patients with severe lung injury. EPA/GLA has anti-inflammatory benefits, as evidenced by its association with reduction in pulmonary inflammation, improvement in oxygenation and improved clinical outcomes in patients with severe forms of acute lung injury. This study was a prospective, multicenter, randomized, double-blinded, controlled trial designed to investigate whether EPA/GLA could have an effective role in the treatment of patients with early sepsis (systemic inflammatory response syndrome with confirmed or presumed infection and without any organ dysfunction) by reducing the progression of the disease to severe sepsis (sepsis associated with at least one organ failure) or septic shock (sepsis associated with hypotension despite adequate fluid resuscitation). Secondary outcomes included the development of individual organ failure, increased ICU and hospital length of stay, need for mechanical ventilation and 28-day all-cause mortality.Methods: Randomization was concealed, and patients were allocated to receive, for seven days, either an EPA/GLA diet or an isocaloric, isonitrogenous control diet not enhanced with lipids. Patients were continuously tube-fed at a minimum of 75% of basal energy expenditure × 1.3. To evaluate the progression to severe sepsis and/or septic shock, daily screening for individual organ failure was performed. All clinical outcomes were recorded during a 28-day follow-up period.Results: A total of 115 patients in the early stages of sepsis requiring EN were included, among whom 106 were considered evaluable. Intention-to-treat (ITT) analysis demonstrated that patients fed the EPA/GLA diet developed less severe sepsis and/or septic shock than patients fed the control diet (26.3% versus 50%, respectively; P = 0.0259), with similar results observed for the evaluable patients (26.4% versus 50.9% respectively; P = 0.0217). The ITT analysis demonstrated that patients in the study group developed cardiovascular failure (36.2% versus 21%, respectively; P = 0.0381) and respiratory failure (39.6% versus 24.6%, respectively; P = 0.0362) less often than the control group. Similarly, when considering only the evaluable patients, fewer patients developed cardiovascular failure (20.7% versus 37.7%, respectively; P = 0.03) and respiratory failure (26.4% versus 39.6%, respectively; P = 0.04). The percentage of patients fed the EPA/GLA diet requiring invasive mechanical ventilation was reduced compared with controls (ITT patients: 18.9% versus 33.9%, respectively; P = 0.394; evaluable patients: 17.5% versus 34.5%, respectively; P = 0.295). Patients nourished with the EPA/GLA diet remained in the ICU fewer days than the control population (ITT patients: 21.1 ICU-free days versus 14.7 ICU-free days, respectively; P < 0.0001; evaluable patients: 20.8 ICU-free days versus 14.3 ICU-free days, respectively; P < 0.0001) and fewer days at the hospital (ITT patients: 19.5 hospital-free days versus 10.3 hospital-free days, respectively; P < 0.0001; evaluable patients: 19.1 hospital-free days versus 10.2 hospital-free days, respectively; P < 0.001) (all numbers expressed as means). No significant differences in 28-day all-cause mortality were observed (ITT patients: 26.2% EPA/GLA diet versus 27.6% control diet, respectively; P = 0.72; evaluable: 26.4 EPA/GLA diet versus 30.18 control diet, respectively; P = 0.79).Conclusions: These data suggest that EPA/GLA may play a beneficial role in the treatment of enterally fed patients in the early stages of sepsis without associated organ dysfunction by contributing to slowing the progression of sepsis-related organ dysfunction, especially with regard to cardiovascular and respiratory dysfunction.Trial Registration: ClinicalTrials.gov: NCT00981877. [ABSTRACT FROM AUTHOR]

Purpose of Review: Using perioperative goal-directed therapy (GDT) or peroperative hemodynamic optimization significantly reduces postoperative complications and risk of death in patients undergoing noncardiac major surgeries. In this review, we discuss the main changes in the field of perioperative optimization over the last few years., Recent Findings: One of the key aspects that has changed in the last decade is the shift from invasive monitoring with pulmonary artery catheters (PACs) to less or minimally invasive monitoring systems. The evaluation of intravascular fluid volume deficits has also changed dramatically from the use of static indices to the assessment of fluid responsiveness using either dynamic indices or functional hemodynamic. Finally, attention has been directed toward more restrictive strategies of crystalloids as maintenance fluids., Summary: GDT is safe and more likely to tailor the amount of fluids given to the amount of fluids actually needed. This approach includes assessment of fluid responsiveness and, if necessary, the use of inotropes; moreover, this approach can be coupled with a restrictive strategy for maintenance fluids. These strategies have been increasingly incorporated into protocols for perioperative hemodynamic optimization in high-risk patients undergoing major surgery, resulting in more appropriate use of fluids, vasopressors, and inotropes.

Objective: Appropriate nutritional support is important to the outcomes of critically ill patients. However, a significant portion of these patients experience intestinal motility problems. Administration of enteral nutrition by means of tubes placed in the post-pyloric position has been suggested to improve the nutrition tolerance. The aim of this study was to compare the rate of successful post-pyloric placement using a real-time electromagnetic positioning device to the success rate using the conventional placement method., Methods: This was a prospective, randomized and controlled study, conducted in a tertiary hospital over a period of three months. The patients were randomized to one of two groups: electromagnetically guided system group, whose patients underwent real-time monitoring of post-pyloric tube placement; or the control group, whose patients underwent tube placment using to the conventional blinded technique. The rates of successful post-pyloric placement and the procedure times were assessed and compared between the groups., Results: Thirty-seven patients were enrolled, 18 in the electromagnetic group and 19 in the control group. The final tube position was evaluated using radiography. The electromagnetic guided group showed better success rates and shorter procedure times when compared to the control group. Additionally, in the electromagnetic guided group, higher pH values were found in the fluids aspirated from the probe, suggesting successful postpyloric placement., Conclusion: The electromagnetically guided method provided better placement accuracy than did the conventional technique.

Objective: Patients undergo to cardiac surgery have more probability to develop thrombocytopenia. The heparin induced thrombocytopenia happens in 5% of the patients. The aim from this study was to evaluate the clinical importance from the severe thrombocytopenia in postoperative cardiac surgical patients., Methods: It was included cardiac surgical patients with platelets < 150000 cel/mm³ during firsts 24 h from postoperative. All patients underwent evaluation for four Ts score (thrombocytopenia, use preview of heparin, thrombosis and platelets decreased not related to heparin). In order to a four Ts score e" 6 was considered as suggestive of heparin induced thrombocytopenia type II. The mortality rate in intensive care (ICU) and hospital, length of stay, healthy state and incidence from thrombosis were compared in patients with score > 6 (group 1) and < 6 (group 2)., Results: It was include 120 patients who met the inclusions criterions. There was no difference between the groups in related to age, gender, time of cardiopulmonary bypass and surgery. However, the incidence of thrombosis was higher in group 1 (23% vs. 0%, P<0.0001), as well as the greater score is related to higher hospital mortality rate., Conclusion: The score > 6, in postoperative cardiac surgical patients, it is associated to higher incidence of thrombosis as well as the greater score is related to higher hospital mortality rate.

Objective: The aim of the study was to evaluate criteria used in clinical practice, for screening of patients for ICU admission., Methods: Cohort prospective study in a tertiary hospital. Four groups were compared in relation to ICU admission by ranking priorities into groups 1, 2, 3 and 4; highest priority 1, lowest priority 4., Results: Enrolled were 359 patients, 66 (53.2-75.0) years old. APACHE II was 23 (18-30). The ICU made available 70.4% of beds. Patients who were refused beds in the ICU were older, 66.2 ± 16.1 versus 61.9 ± 15.2 years of age (p= 0.02) and the priority 1 group had less refusal of beds, which means, 39.1% versus 23.8% had beds refused (p=0.01). The opposite occurred with priorities 3 and 4. Patients in priority 3 and 4 showed older ages, score system and more organ dysfunctions as well as more refusals of beds. ICU mortality rates were higher for priority groups 3 and 4 when compared to 1 and 2 priority groups, 86.7% versus 31.3% (p<0.001)., Conclusion: Age, score system and organ dysfunctions were greater in priority groups 3 and 4 and these were related with refusal from the ICU. Patients refused admission to the ICU showed higher mortality rates and these remained higher among priority groups 3 and 4 even when patients were admitted to the ICU.

Objectives: An increased lactate level is classically considered a marker for poorer prognosis, however little information is available on intraoperative lactate's kinetics and its connection with prognosis. This study aimed to evaluate the time when perioperative lactate is most relevant for prognosis., Methods: This was an observational prospective study conducted in a tertiary hospital. Patients with requested intensive care unit postoperative stay, aged > 18 years, undergoing major surgery were included. Palliative surgery patients and those with heart and/or severe liver failure were excluded. Arterial lactate levels were measured immediately before the surgery start (T0), after anesthesia induction (T1), 3 hours after the surgery start (T2), intensive care unit admission (T3) and 6 hours after the intensive care unit admission (T4)., Results: Sixty seven patients were included. The mean lactate values for the patients' T0, T1, T2 and T4 were 1.5 ± 0.8 mmol/L, 1.5 ± 0.7 mmol/L, 1.8 ± 1.2 mmol/L, 2.7 ± 1.7 mmol/L and 3.1 ± 2.0 mmol/L, respectively. The hospital mortality rate was 25.8%, and surviving and non-surviving patients lactate values in the intensive care unit were 2.5 ± 1. and 4.8 ± 2.8 mmol/L (P < 0.0001), respectively. The other times measurements showed no statistically significant differences between the groups., Conclusions: In surgical patients, intraoperative arterial lactate levels failed to show a predictive value; however during the postoperative period, this assessment was shown to be useful for hospital mortality prediction.

Objective: Anemia is common in severely ill patients, and blood sampling plays a relevant causative role. Consequently, blood transfusions are frequent an related to several complications. Trying to reduce the transfusion-related risk, minimizing blood loss is mandatory. Thus, this work aimed to evaluate a closed blood sampling system as a strategy to spare unnecessary blood losses and transfusions., Methods: This was a prospective, randomized, controlled, multicenter, 6 months, clinical trial. The patients were assigned to either VAMP (Venous Arterial Blood Management Protection) group, using a closed blood sampling system, or control group. The groups' transfusion rate, as well as hemoglobin (Hb) and Hematocrit (Ht) changes were compared for 14 days., Results: Were included 127 patients, 65 assigned to the control group, and 62 to VAMP. During the intensive care unit stay, both groups experienced both hemoglobin and hematocrit drops. However, when the final Ht and Hb were compared between the groups, a difference was identified with higher values in the VAMP group (p=0.03; p=0.006, respectively). No statistical difference was found for both groups transfusion rates, although the VAMP group had an absolute 12% blood transfusion reduction., Conclusion: The use of a closed blood sampling system was able to minimize blood count values changes, however failed to reduce transfusions rate.

Background and Objectives: The SAPS 3 (Simplified Acute Physiology Score 3) prognostic system is composed of 20 parameters, represented by an acute physiology score and assessment of the previous status, aimed at establishing a predictive mortality index for patients admitted to intensive care units (ICU). The objective of this study was to validate this system and determine its discriminatory power in surgical patients in Brazil., Methods: This is a prospective study undertaken in two surgical ICUs of two different hospitals over a one-year period; patients younger than 16 years, who stay at the ICU for less than 24 hours, readmitted to the unit, and those admitted for dialysis were excluded from the study. The predictive ability of the SAPS 3 index to differentiate survivors and non-survivors was determined by the ROC curve and calibration by the Hosmer-Lemeshow goodness-of-fit test., Results: One thousand three-hundred and ten patients were included in the study. Gastrointestinal surgeries predominated (34.9%). Eighteen was the lower SAPS 3 index and the highest was 154, with a mean of 48.5 +/- 18.1. The predicted and real hospital mortality was 10.3% and 10.8%, respectively; the standardized mortality ratio (SMR) was 1.04 (95%CI = 1.03-1.07). Calibration by the Hosmer and Lemeshow method showed X(2) = 10.47 p = 0.234. The SAPS 3 score that better discriminated survivors and non-survivors was 57, with sensitivity of 75.8% and specificity 86%. Among the patients with SAPS 3 index higher than 57, 73.5% did not survive versus 26.5% who survived (OR= 1.32, 95%CI 1.23-1.42, p < 0.0001)., Conclusions: The SAPS 3 system is valid for the Brazilian population of surgical patients, being a useful indicator of critical patients and to determine greater care in this group.

Unlabelled: Currently, aging of the population is a widespread global phenomenon. Therefore, the assessment of prognosis in elderly patients is needed. This study aims to identify risk factors in a population of elderly patients admitted in the intensive care unit, Methods: A prospective study in the intensive care unit of a general tertiary hospital was carried out for five months. Patients with 65 years or more of age, who stayed in the intensive care unit for 24 hours or more were included and those at the-end-of-life, patients readmitted to intensive care unit during the same hospital stay were excluded., Results: In this study 199 patients were involved, with a mean age of 75.4±6.8 years, and 58.8% were female. Mortality was 57.3%. The mean APACHE II, SOFA, MODS and Katz index (assessment of daily activities) were respectively 20.0±5.8, 6.8±3.9, 2.4±1.9 and 5.3±1.6. Most patients were postoperative 59.3% and 41.6% were under invasive mechanical ventilation. At regression analysis, the independent determinants of higher mortality were: older age (76.9±6.7 years death versus 73.3±6.5 years discharge, P<0.001, OR=1.08, CI 95% 1.01-1. 16), the Katz index (4.9±1.9 deaths versus 5.7±0.9 discharge, p=0.001, OR=0.66, CI 95% 0.45-0.98), hyperglycemia (158.1±69.0 death versus 139.6±48.5 discharge p=0.041; OR=1.02; CI 95% 1.01-1.03) and need for mechanical ventilation at admission to the intensive care unit (57.0% death versus 20.5% discharge p <0.001, OR=3.57, CI 95% 1.24-10.3)., Conclusion: Elderly patients admitted to the intensive care unit that have difficulties in performing daily activities, hyperglycemia and who are under invasive mechanical ventilation had a worse hospital prognosis.

Objectives: To describe the population of aged as compared to young patients under mechanical ventilation and to analyze the mortality risk factors of this group in an intensive care unit., Methods: This was a prospective observational trial in patients over 18 years of age, admitted in an intensive care unit and under mechanical ventilation, during one year. Patients were divided into two groups according to age: Group 1 - patients over 65 years old; and Group 2, 65 years old or younger., Results: eighty one mechanic ventilation patients were included, 62 aged and 18 younger, mean ages from aged was 76 years, while in the younger it was 56 years. As compared to the control, aged patients had longer mechanic ventilation time , higher intensive care unit and hospital mortality: 63.1% versus 26.3% and 74.2% versus 47.4% (P<0.05), respectively. In addition, the aged under mechanic ventilation had increased desintubation failures, difficult ventilatory weaning and deaths directly related to respiratory dysfunction. The mechanic ventilation time was an independent risk factor for death in the intensive care unit in aged patients (OR= 2.7, p=0.02). The area under the ROC curve of mechanic ventilation about intensive care unit death was 0.92 (95% CI 0.85-0.97, p (area 0.5)=0.0001), cutoff point of 4 days, sensitivity 89.4% and specificity 77.1%., Conclusions: Mechanic ventilation patients over 65years of age have a worse prognosis than the younger, and the longer the mechanic ventilation time, the higher will be intensive care mortality.

Objectives: Due to the dramatic medical breakthroughs and an increasingly ageing population, the proportion of patients who are at risk of dying following surgery is increasing over time. The aim of this study was to evaluate the outcomes and the epidemiology of non-cardiac surgical patients admitted to the intensive care unit., Methods: A multicenter, prospective, observational, cohort study was carried out in 21 intensive care units. A total of 885 adult surgical patients admitted to a participating intensive care unit from April to June 2006 were evaluated and 587 patients were enrolled. Exclusion criteria were trauma, cardiac, neurological, gynecologic, obstetric and palliative surgeries. The main outcome measures were postoperative complications and intensive care unit and 90-day mortality rates., Results: Major and urgent surgeries were performed in 66.4% and 31.7% of the patients, respectively. The intensive care unit mortality rate was 15%, and 38% of the patients had postoperative complications. The most common complication was infection or sepsis (24.7%). Myocardial ischemia was diagnosed in only 1.9% of the patients. A total of 94 % of the patients who died after surgery had co-morbidities at the time of surgery (3.4 ± 2.2). Multiple organ failure was the main cause of death (53%)., Conclusion: Sepsis is the predominant cause of morbidity in patients undergoing non-cardiac surgery. In this patient population, multiple organ failure prevailed as the most frequent cause of death in the hospital.

Ventilator-associated pneumonia (VAP) is the most commonly-acquired infection in patients in intensive care units. We analyzed epidemiological and microbiological characteristics and the outcome, in a cohort of critically-ill patients with confirmed diagnosis of VAP. All patients who had been on mechanical ventilation (MV) for more than 48 hours were included in our study; material collection for microbiological analysis was done within the first 24 hours after beginning treatment or after changing antibiotics. There were 55/265 (20.7%) VAP cases diagnosed, at a rate of 21.6 episodes per 1,000 days of mechanical ventilation. Mean age of the patients was 66 years, with a mean APACHE II score of 26.7 + 7.0; male patients were more prevalent. The mortality rates in the intensive care unit (ICU) and during the hospital stay were 71% and 80%, respectively. MV duration in patients with VAP was 17 (range 3-43) days and among patients who had not developed VAP, 6 (2-32) days (p < 0.0001). 98.2% of the samples were positive, with a high prevalence of Gram-negative bacteria, mainly Acinetobacter calcoaceticus. Risk factors for death included age, MV duration and surgery. VAP incidence in this sample of critically-ill patients was high, with a high mortality rate. Control and prevention strategies based on continuing education of healthcare workers, developed by a multidisciplinary team, should be encouraged to minimize morbimortality of this infection.

Background and Objectives: One of the greatest challenges found by the intensivists in their daily activities is tissue hipoperfusion control. Blood lactate is generally accepted as a marker of tissular hypoxia and several studies have demonstrated good correlation between blood lactate and prognosis during shock and resuscitation. The aim of this study was to evaluate the clinical utility of arterial blood lactate as a marker of morbidity and mortality in critically ill patients in the post-operative period of high risk non-cardiac surgeries., Methods: Prospective and observational cohort study realized in an ICU of a tertiary hospital during a four month period. Demographic data of the patients submitted to high risk surgeries were collected, besides arterial lactate measures and number and type of complications in the post-operative period. To the statistic analysis was considered as significant a p < 0.05. The predictive ability of the indexes to differentiate survivors from non-survivors was tested using ROC curves. Lenght of ICU stay estimation where calculated by Kaplan Meier method., Results: Were included 202 patients. 50.2% were female and their mean age was 66.5 ± 13.6 years. APACHE II score was 17.4 ± 3.0 and the median of MODS score was 4 (2-6). Median lenght of surgeries was 4h (3-6h). 70.7% of the surgeries were elective ones. ICU and hospital mortality were 15.6% and 33.7%, respectively. The best lactate value to discriminate mortality was 3.2 mmol/L, with sensitivity of 62.5%, specificity of 78.8% and an area under the curve of 0.7. 62.5% of patients with lactate > 3.2 did not survive versus 21.2% of survivors (OR = 2.95 IC95% 1.98- 4.38, p < 0.0001). ICU lenght of stay was greater when > 3.2 mmol/L (log rank 0.007) lactate., Conclusions: High risk patients submitted to non cardiac surgeries and admitted to the ICU with hiperlactatemia, defined as an arterial lactate > 3.2 mmol/L, are prone to a longer ICU lenght of stay and to die.

Background and Objectives: Oncologic diseases are conditions that have influence in the treatment offered to affected patients. The aim of this study was to compare hospitalar outcome of oncologic and non oncologic patients submitted to high risk elective surgery., Methods: Prospective, observational cohort study realized in an ICU of a tertiary hospital during the period between 04/01/2005 and 07/31/2005. Demographic data, APACHE II and MODS scores and laboratorial and hemodynamic variables were collected and complications like re-intervention need for mechanical ventilation, red blood cell transfusions and pulmonary artery catheter use during the post-operative period were evaluated. All patients were followed until hospital discharge or death. T student and Mann Whitney tests were used to compare numerical variables. Chi-square test was used to compare categorical variables. A p < 0.05 was considered as significant., Results: 119 patients were included in the study. 43 were oncologic and 76 were non-oncologic. 52.9% were female. Mean age was 65.1 ± 14.1 years. Mean APACHE II score was 16.5 ± 5.8 and MODS median was 3 (2-6). Median length of surgery was 5 (3.3-7) hours and ICU and hospital mortality were 10.9% and 25.2%, respectively. Oncologic patients had greater length of hospital stay and length of stay before surgery. These results were statistically significant. Hospital mortality of oncologic patients was not greater than non-oncologic patients (22.4% versus 30.2%, p = 0.32)., Conclusions: In this series, oncologic patients submitted to high risk surgery had the same mortality rate as non-onconlogic patients with similar disease severity.

Background and Objectives: The main cardiovascular function is to maintain the adequate perfusion e oxygen delivery to the cells. Physiologically, this is controlled by the cellular metabolic rate. The critically ill patients are in high danger of tissue hipoperfusion and this is directly related to cellular injury and organ dysfunction. Therefore, the tissue perfusion monitoring makes part and is indissociated of hemodynamic evaluation of the critically ill patient and is indicated to all this patients. The objective was to define recommendations about clinical utility of different tolls to bedside perfusion monitoring., Methods: Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty five physician and two nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MedLine in the period from 1996 to 2004., Results: Recommendations were done about the utility of clinical monitoring of tissue perfusion, temperature gradient and transcutaneous oxygen monitoring, serum lactate, base excess, SvO² and ScvO², gastric and sublingual capnometry, CO² venous-arterial gradient and Orthogonal Polarization Spectral (OPS)., Conclusions: The homodynamic compensation of a critically ill patient isn’t complete unless the tissue perfusion is corrected. Many different methods of monitoring is available and are useful in clinical practice, however, none has accuracy and effectiveness characteristics to be used independently of clinical context.

Background and Objectives: Use of Pulmonary Artery Catheter (PAC) is still a debatable issue, mainly due to questions raised about its security and efficacy. This study reproduced in a sample of Brazilian physicians, another one conducted amidst American doctors, in which was pointed out the heterogeneity of clinical decisions guided by data obtained from PAC., Methods: During the Brazilian Congress of Intensive Care Medicine (Curitiba 2004), doctors were asked to answer a survey form with three vignettes. Each of them contained PAC data and one half of the surveys contained echocardiographic information. Every doctor was asked to select one of six interventions for each vignette. A homogeneous answer was considered when it was selected by at least 80% of the respondents., Results: Two hundred and thirty seven doctors answered the questionnaires. They selected completely different therapeutic interventions in all three vignettes and none of the interventions achieved more than 80% agreement. Variability persisted with the choices guided by echocardiography., Conclusions: As in the original study, we observed total heterogeneity of therapeutic interventions guided by CAP and echocardiography. These results could be caused by lack of knowledge about basic pathophysiologic concepts and maybe we had to improve its teaching at the medical school benches.

Background and Objectives: Shock occurs when the circulatory system cannot maintain adequate cellular perfusion. If this condition is not reverted irreversible cellular injury establishes. Shock treatment has as its initial priority the fast and vigorous correction of mean arterial pressure and cardiac output to maintain life and avoid or lessen organic dysfunctions. Fluid challenge and vasoactive drugs are necessary to warrant an adequate tissue perfusion and maintenance of function of different organs and systems, always guided by cardiovascular monitorization. The recommendations built in this consensus are aimed to guide hemodynamic support needed to maintain adequate tisular perfusion., Methods: Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty five physician and two nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MEDLINE in the period from 1996 to 2004., Results: Recommendations were made answering 17 questions about hemodynamic support with focus on fluid challenge, red blood cell transfusions, vasoactive drugs and perioperative hemodynamic optimization., Conclusions: Hemodynamic monitoring by itself does not reduce the mortality of critically ill patients, however, we believe that the correct interpretation of the data obtained by the hemodynamic monitoring and the use of hemodynamic support protocols based on well defined tissue perfusion goals can improve the outcome of these patients.

Background and Objectives: Monitoring of vital functions is one of the most important tools in the management of critically ill patients. Nowadays is possible to detect and analyze a great deal of physiologic data using a lot of invasive and non-invasive methods. The intensivist must be able to select and carry out the most appropriate monitoring technique according to the patient requirements and taking into account the benefit/risk ratio. Despite the fast development of non invasive monitoring techniques, invasive hemodynamic monitoring using Pulmonary Artery Catheter still is one of the basic procedures in Critical Care. The aim was to define recommendations about clinical utility of basic hemodynamic monitoring methods and the Use of Pulmonary Artery Catheter., Methods: Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty-five physicians and nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MEDLINE in the period from 1996 to 2004., Results: Recommendations were made based on 55 questions about the use of central venous pressure, invasive arterial pressure, pulmonary artery catheter and its indications in different settings., Conclusions: Evaluation of central venous pressure and invasive arterial pressure, besides variables obtained by the PAC allow the understanding of cardiovascular physiology that is of great value to the care of critically ill patients. However, the correct use of these tools is fundamental to achieve the benefits due to its use.