125 results on '"Salluh JIF"'
Search Results
52. The resilient intensive care unit.
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Salluh JIF, Kurtz P, Bastos LSL, Quintairos A, Zampieri FG, and Bozza FA
- Abstract
Background: The COVID-19 pandemic tested the capacity of intensive care units (ICU) to respond to a crisis and demonstrated their fragility. Unsurprisingly, higher than usual mortality rates, lengths of stay (LOS), and ICU-acquired complications occurred during the pandemic. However, worse outcomes were not universal nor constant across ICUs and significant variation in outcomes was reported, demonstrating that some ICUs could adequately manage the surge of COVID-19., Methods: In the present editorial, we discuss the concept of a resilient Intensive Care Unit, including which metrics can be used to address the capacity to respond, sustain results and incorporate new practices that lead to improvement., Results: We believe that a resiliency analysis adds a component of preparedness to the usual ICU performance evaluation and outcomes metrics to be used during the crisis and in regular times., Conclusions: The COVID-19 pandemic demonstrated the need for a resilient health system. Although this concept has been discussed for health systems, it was not tested in intensive care. Future studies should evaluate this concept to improve ICU organization for standard and pandemic times., (© 2022. The Author(s).)
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- 2022
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53. Leveraging a national cloud-based intensive care registry for COVID-19 surveillance, research and case-mix evaluation in Brazil.
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Quintairos A, Rezende EAC, Soares M, Lobo SMA, and Salluh JIF
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- Brazil epidemiology, Cloud Computing, Critical Care, Humans, Registries, COVID-19
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- 2022
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54. Development of a core outcome set for general intensive care unit patients-Need for a broader context?
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Pari V, Beane A, Salluh JIF, and Dongelmans DA
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- Humans, Outcome Assessment, Health Care, Critical Care, Intensive Care Units
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- 2022
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55. Statistical analysis of a cluster-randomized clinical trial on adult general intensive care units in Brazil: TELE-critical care verSus usual Care On ICU PErformance (TELESCOPE) trial.
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Ranzani O, Pereira AJ, Santos MCD, Corrêa TD, Ferraz LJR, Cordioli E, Morbeck RA, Berwanger O, Morais LC, Schettino G, Cavalcanti AB, Rosa RG, Biondi RS, Salluh JIF, Azevedo LCP, Serpa Neto A, and Noritomi DT
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- Adult, Brazil, Critical Care, Hospital Mortality, Humans, Intensive Care Units, Telescopes
- Abstract
Objective: The TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE) trial aims to assess whether a complex telemedicine intervention in intensive care units, which focuses on daily multidisciplinary rounds performed by remote intensivists, will reduce intensive care unit length of stay compared to usual care., Methods: The TELESCOPE trial is a national, multicenter, controlled, open label, cluster randomized trial. The study tests the effectiveness of daily multidisciplinary rounds conducted by an intensivist through telemedicine in Brazilian intensive care units. The protocol was approved by the local Research Ethics Committee of the coordinating study center and by the local Research Ethics Committee from each of the 30 intensive care units, following Brazilian legislation. The trial is registered with ClinicalTrials. gov (NCT03920501). The primary outcome is intensive care unit length of stay, which will be analyzed accounting for the baseline period and cluster structure of the data and adjusted by prespecified covariates. Secondary exploratory outcomes included intensive care unit performance classification, in-hospital mortality, incidence of nosocomial infections, ventilator-free days at 28 days, rate of patients receiving oral or enteral feeding, rate of patients under light sedation or alert and calm, and rate of patients under normoxemia., Conclusion: According to the trial's best practice, we report our statistical analysis prior to locking the database and beginning analyses. We anticipate that this reporting practice will prevent analysis bias and improve the interpretation of the reported results.ClinicalTrials.gov registration: NCT03920501.
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- 2022
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56. The Limitations of Standardized Mortality Ratios for Coronavirus Disease 2019 ICU Patients.
- Author
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Quintairos A, Zampieri FG, Souza-Dantas VC, and Salluh JIF
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- Hospital Mortality, Humans, Intensive Care Units, SARS-CoV-2, COVID-19
- Abstract
Competing Interests: Dr. Salluh is founder of Epimed Solutions (Brazil), an electronic healthcare system used to collect data and track ICU quality metrics. He is supported in part by individual research grants from Conselho Nacional de Desenvolvimento Científico e Tecnológico and Fundação Carlos Chagas Filho de Amparo à Pesquisa do Rio de Janeiro. Dr. Zampieri has received grants for investigator-initiated studies from Ionis Pharmaceuticals, Bactiguard (Sweden), and Brazilian Ministry of Health, none related to the scope of this study. The remaining authors have disclosed that they do not have any potential conflicts of interest.
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- 2021
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57. What Is the Role of Steroids for Septic Shock in 2021?
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Nedel W, Lisboa T, and Salluh JIF
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- Adrenal Cortex Hormones, Glucocorticoids therapeutic use, Humans, Hydrocortisone, Vasoconstrictor Agents therapeutic use, Shock, Septic drug therapy
- Abstract
Corticosteroids have been used for decades in the adjunctive treatment of severe infections in intensive care. The most frequent scenario in intensive care is in septic shock, where low doses of glucocorticoids appear to restore vascular responsiveness to norepinephrine. There is a strong body of evidence suggesting that hydrocortisone reduces time on vasopressor, and may modulate the immune response. In this review, we explore the current evidence supporting the use of corticosteroids in septic shock, its benefits, and potential harms. In addition to landmark clinical trials, we will also describe new frontiers for the use of corticosteroids in septic shock which should be explored in future studies., Competing Interests: None declared., (Thieme. All rights reserved.)
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- 2021
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58. What every intensivist should know about light sedation for mechanically ventilated patients.
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Tanaka LMS, Serafim RB, and Salluh JIF
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- Conscious Sedation, Humans, Intensive Care Units, Hypnotics and Sedatives, Respiration, Artificial
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- 2021
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59. What intensive care registries can teach us about outcomes.
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Beane A, Salluh JIF, and Haniffa R
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- Delivery of Health Care, Humans, Outcome Assessment, Health Care, Registries, Critical Care, Critical Illness therapy
- Abstract
Purpose of Review: Critical care registries are synonymous with measurement of outcomes following critical illness. Their ability to provide longitudinal data to enable benchmarking of outcomes for comparison within units over time, and between units, both regionally and nationally is a key part of the evaluation of quality of care and ICU performance as well as a better understanding of case-mix. This review aims to summarize literature on outcome measures currently being reported in registries internationally, describe the current strengths and challenges with interpreting existing outcomes and highlight areas where registries may help improve implementation and interpretation of both existing and new outcome measures., Recent Findings: Outcomes being widely reported through ICU registries include measures of survival, events of interest, patient-reported outcomes and measures of resource utilization (including cost). Despite its increasing adoption, challenges with quality of reporting of outcomes measures remain. Measures of short-term survival are feasible but those requiring longer follow-ups are increasingly difficult to interpret given the evolving nature of critical care in the context of acute and chronic disease management. Furthermore, heterogeneity in patient populations and in healthcare organisations in different settings makes use of outcome measures for international benchmarking at best complex, requiring substantial advances in their definitions and implementation to support those seeking to improve patient care., Summary: Digital registries could help overcome some of the current challenges with implementing and interpreting ICU outcome data through standardization of reporting and harmonization of data. In addition, ICU registries could be instrumental in enabling data for feedback as part of improvement in both patient-centred outcomes and in service outcomes; notably resource utilization and efficiency., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)
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- 2021
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60. SAPS-3 performance for hospital mortality prediction in 30,571 patients with COVID-19 admitted to ICUs in Brazil.
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Kurtz P, Bastos LSL, Salluh JIF, Bozza FA, and Soares M
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- Brazil, Hospital Mortality, Humans, Intensive Care Units, Prognosis, SARS-CoV-2, Simplified Acute Physiology Score, COVID-19
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- 2021
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61. Systemic Severity and Organ Dysfunction in Subarachnoid Hemorrhage: A Large Retrospective Multicenter Cohort Study.
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Kurtz P, Taccone FS, Bozza FA, Bastos LSL, Righy C, Gonçalves B, Turon R, Machado MM, Maia M, Ferez MA, Nassif C, Soares M, and Salluh JIF
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- Cohort Studies, Hospital Mortality, Humans, Intensive Care Units, Multiple Organ Failure, Prognosis, ROC Curve, Retrospective Studies, Subarachnoid Hemorrhage therapy
- Abstract
Background and Purpose: Acute physiologic derangements and multiple organ dysfunction are common after subarachnoid hemorrhage. We aimed to evaluate the simplified acute physiology score 3 (SAPS-3) and the sequential organ failure assessment (SOFA) scores for the prediction of in-hospital mortality in a large multicenter cohort of SAH patients., Methods: This was a retrospective analysis of prospectively collected data from 45 ICUs in Brazil, during 2014 and 2015. Patients admitted with non-traumatic subarachnoid hemorrhage (SAH) were included. Clinical and outcome data were retrieved from an electronic ICU quality registry. SAPS-3 and SOFA scores, without the neurological components (i.e., nSAPS-3 and nSOFA, respectively) were recorded, as well as the World Federation of Neurological Surgeons (WFNS) scale. We used multilevel logistic regression analysis to identify factors associated with in-hospital mortality. We evaluated performance using the area under the receiver operating characteristic curve (AUROC), as well as calibration belts and precision-recall plots., Results: The study included 997 patients, from which 426 (43%) had poor clinical grade (WFNS 4 or 5) and in-hospital mortality was 34%. Median nSAPS-3 and nSOFA score at admission were 46 (IQR: 38-55) and 2 (0-5), respectively. Non-survivors were older, had higher nSAPS-3 and nSOFA, and more often poor grade. After adjustment for age, poor grade and withdrawal of life sustaining therapies, multivariable analysis identified nSAPS-3 and nSOFA score as independent clinical predictors of in-hospital mortality. The AUROC curve that included nSAPS-3 and nSOFA scores significantly improved the already good discrimination and calibration of age and WFNS to predict in-hospital mortality (AUROC: 0.89 for the full final model vs. 0.85 for age and WFNS; P < 0.0001)., Conclusions: nSAPS-3 and nSOFA scores were independently associated with in-hospital mortality after SAH. The addition of these scores improved early prediction of hospital mortality in our cohort and should be integrated to other specific prognostic indices in the early assessment of SAH., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)
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- 2021
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62. A systematic review and meta-analysis of propofol versus midazolam sedation in adult intensive care (ICU) patients.
- Author
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Garcia R, Salluh JIF, Andrade TR, Farah D, da Silva PSL, Bastos DF, and Fonseca MCM
- Subjects
- Adult, Critical Care, Humans, Hypnotics and Sedatives, Intensive Care Units, Respiration, Artificial, Midazolam, Propofol
- Abstract
Purpose: Compare outcomes of adult patients admitted to ICU- length of ICU stay, length of mechanical ventilation (MV), and time until extubation- according to the use of propofol versus midazolam., Methods: We searched MEDLINE, EMBASE, LILACS, and Cochrane databases to retrieve RCTs that compared propofol and midazolam used as sedatives in adult ICU patients. We applied a random-effects, meta-analytic model in all calculations. We applied the Cochrane collaboration tool and GRADE. We separated patients into two groups: acute surgical patients (hospitalization up to 24 h) and critically-ill patients (hospitalization over 24 h and whose articles mostly mix surgical, medical and trauma patients)., Results: Globally, propofol was associated with a reduced MV time of 4.46 h (MD: -4.46 [95% CI -7.51 to -1.42] p = 0.004, I2 = 63%, 6 studies) and extubation time of 7.95 h (MD: -7.95 [95% CI -9.86 to -6.03] p < 0.00001, I2 = 98%, 16 studies). Acute surgical patients sedation with propofol compared to midazolam was associated with a reduced ICU stay of 5.07 h (MD: -5.07 [95% CI -8.68 to -1.45] p = 0.006, I2 = 41%, 5 studies), MV time of 4.28 h (MD: -4.28; [95% CI -4.62 to -3.94] p < 0.0001, I2 = 0%, 3 studies), extubation time of 1.92 h (MD: -1.92; [95% CI -2.71 to -1.13] p = 0.00001, I2 = 89%, 9 studies). In critically-ill patients sedation with propofol compared to midazolam was associated with a reduced extubation time of 32.68 h (MD: -32.68 [95% CI -48.37 to -16.98] p = 0.0001, I2 = 97%, 9 studies). GRADE was very low for all outcomes., Conclusions: Sedation with propofol compared to midazolam is associated with improved clinical outcomes in ICU, with reduced ICU stay MV time and extubation time in acute surgical patients and reduced extubation time in critically-ill patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)
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- 2021
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63. A cost-effectiveness analysis of propofol versus midazolam for the sedation of adult patients admitted to the intensive care unit.
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Andrade TR, Salluh JIF, Garcia R, Farah D, Silva PSLD, Bastos DF, and Fonseca MCM
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- Adult, Cost-Benefit Analysis, Hospitalization, Humans, Hypnotics and Sedatives, Intensive Care Units, Midazolam, Propofol
- Abstract
Objective: To build a cost-effectiveness model to compare the use of propofol versus midazolam in critically ill adult patients under mechanical ventilation., Methods: We built a decision tree model for critically ill patients submitted to mechanical ventilation and analyzed it from the Brazilian private health care system perspective. The time horizon was that of intensive care unit hospitalization. The outcomes were cost-effectiveness per hour of intensive care unit stay avoided and cost-effectiveness per hour of mechanical ventilation avoided. We retrieved data for the model from a previous meta-analysis. We assumed that the cost of medication was embedded in the intensive care unit cost. We conducted univariate and probabilistic sensitivity analyses., Results: Mechanically ventilated patients using propofol had their intensive care unit stay and the duration of mechanical ventilation decreased by 47.97 hours and 21.65 hours, respectively. There was an average cost reduction of US$ 2,998.971 for propofol when compared to midazolam. The cost-effectiveness per hour of intensive care unit stay and mechanical ventilation avoided were dominant 94.40% and 80.8% of the time, respectively., Conclusion: There was a significant reduction in costs associated with propofol use related to intensive care unit stay and duration of mechanical ventilation for critically ill adult patients.
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- 2021
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64. Evolving changes in mortality of 13,301 critically ill adult patients with COVID-19 over 8 months.
- Author
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Kurtz P, Bastos LSL, Dantas LF, Zampieri FG, Soares M, Hamacher S, Salluh JIF, and Bozza FA
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- Adult, Brazil epidemiology, Hospital Mortality, Humans, Intensive Care Units, Respiration, Artificial, SARS-CoV-2, COVID-19, Critical Illness
- Abstract
Purpose: Clinical characteristics and management of COVID-19 patients have evolved during the pandemic, potentially changing their outcomes. We analyzed the associations of changes in mortality rates with clinical profiles and respiratory support strategies in COVID-19 critically ill patients., Methods: A multicenter cohort of RT-PCR-confirmed COVID-19 patients admitted at 126 Brazilian intensive care units between February 27
th and October 28th , 2020. Assessing temporal changes in deaths, we identified distinct time periods. We evaluated the association of characteristics and respiratory support strategies with 60-day in-hospital mortality using random-effects multivariable Cox regression with inverse probability weighting., Results: Among the 13,301 confirmed-COVID-19 patients, 60-day in-hospital mortality was 13%. Across four time periods identified, younger patients were progressively more common, non-invasive respiratory support was increasingly used, and the 60-day in-hospital mortality decreased in the last two periods. 4188 patients received advanced respiratory support (non-invasive or invasive), from which 42% underwent only invasive mechanical ventilation, 37% only non-invasive respiratory support and 21% failed non-invasive support and were intubated. After adjusting for organ dysfunction scores and premorbid conditions, we found that younger age, absence of frailty and the use of non-invasive respiratory support (NIRS) as first support strategy were independently associated with improved survival (hazard ratio for NIRS first [95% confidence interval], 0.59 [0.54-0.65], p < 0.001)., Conclusion: Age and mortality rates have declined over the first 8 months of the pandemic. The use of NIRS as the first respiratory support measure was associated with survival, but causal inference is limited by the observational nature of our data.- Published
- 2021
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65. Resuscitation fluid practices in Brazilian intensive care units: a secondary analysis of Fluid-TRIPS.
- Author
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Freitas FGR, Hammond N, Li Y, Azevedo LCP, Cavalcanti AB, Taniguchi L, Gobatto A, Japiassú AM, Bafi AT, Mazza BF, Noritomi DT, Dal-Pizzol F, Bozza F, Salluh JIF, Westphal GA, Soares M, Assunção MSC, Lisboa T, Lobo SMA, Barbosa AR, Ventura AF, Souza AF, Silva AF, Toledo A, Reis A, Cembranel A, Rea Neto A, Gut AL, Justo APP, Santos AP, Albuquerque ACD, Scazufka A, Rodrigues AB, Fernandino BB, Silva BG, Vidal BS, Pinheiro BV, Pinto BVC, Feijo CAR, Abreu Filho C, Bosso CEDCN, Moreira CEN, Ramos CHF, Tavares C, Arantes C, Grion C, Mendes CL, Kmohan C, Piras C, Castro CPP, Lins C, Beraldo D, Fontes D, Boni D, Castiglioni D, Paisani DM, Pedroso DFF, Mattos ER, Brito Sobrinho E, Troncoso EMV, Rodrigues Filho EM, Nogueira EEF, Ferreira EL, Pacheco ES, Jodar E, Ferreira ELA, Araujo FF, Trevisol FS, Amorim FF, Giannini FP, Santos FPM, Buarque F, Lima FG, Costa FAAD, Sad FCDA, Aranha FG, Ganem F, Callil F, Costa Filho FF, Dall Arto FTC, Moreno G, Friedman G, Moralez GM, Silva GAD, Costa G, Cavalcanti GS, Cavalcanti GS, Betônico GN, Betônico GN, Reis H, Araujo HBN, Hortiz Júnior HA, Guimaraes HP, Urbano H, Maia I, Santiago Filho IL, Farhat Júnior J, Alvarez JR, Passos JT, Paranhos JEDR, Marques JA, Moreira Filho JG, Andrade JN, Sobrinho JOC, Bezerra JTP, Alves JA, Ferreira J, Gomes J, Sato KM, Gerent K, Teixeira KMC, Conde KAP, Martins LF, Figueirêdo L, Rezegue L, Tcherniacovsk L, Ferraz LO, Cavalcante L, Rabelo L, Miilher L, Garcia L, Tannous L, Hajjar LA, Paciência LEM, Cruz Neto LMD, Bley MV, Sousa MF, Puga ML, Romano MLP, Nobrega M, Arbex M, Rodrigues ML, Guerreiro MO, Rocha M, Alves MAP, Alves MAP, Rosa MD, Dias MD, Martins M, Oliveira M, Moretti MMS, Matsui M, Messender O, Santarém OLA, Silveira PJHD, Vassallo PF, Antoniazzi P, Gottardo PC, Correia P, Ferreira P, Torres P, Silva PGMBE, Foernges R, Gomes R, Moraes R, Nonato Filho R, Borba RL, Gomes RV, Cordioli R, Lima R, López RP, Gargioni RRO, Rosenblat R, Souza RM, Almeida R, Narciso RC, Marco R, Waltrick R, Biondi R, Figueiredo R, Dutra RS, Batista R, Felipe R, Franco RSDS, Houly S, Faria SS, Pinto SF, Luzzi S, Sant'ana S, Fernandes SS, Yamada S, Zajac S, Vaz SM, Bezerra SAB, Farhat TBT, Santos TM, Smith T, Silva UVA, Damasceno VB, Nobre V, Dantas VCS, Irineu VM, Bogado V, Nedel W, Campos Filho W, Dantas W, Viana W, Oliveira Filho W, Delgadinho WM, Finfer S, and Machado FR
- Subjects
- Brazil, Cross-Sectional Studies, Fluid Therapy, Humans, Intensive Care Units, Isotonic Solutions, Prospective Studies, Resuscitation, Critical Illness, Rehydration Solutions
- Abstract
Objective: To describe fluid resuscitation practices in Brazilian intensive care units and to compare them with those of other countries participating in the Fluid-TRIPS., Methods: This was a prospective, international, cross-sectional, observational study in a convenience sample of intensive care units in 27 countries (including Brazil) using the Fluid-TRIPS database compiled in 2014. We described the patterns of fluid resuscitation use in Brazil compared with those in other countries and identified the factors associated with fluid choice., Results: On the study day, 3,214 patients in Brazil and 3,493 patients in other countries were included, of whom 16.1% and 26.8% (p < 0.001) received fluids, respectively. The main indication for fluid resuscitation was impaired perfusion and/or low cardiac output (Brazil: 71.7% versus other countries: 56.4%, p < 0.001). In Brazil, the percentage of patients receiving crystalloid solutions was higher (97.7% versus 76.8%, p < 0.001), and 0.9% sodium chloride was the most commonly used crystalloid (62.5% versus 27.1%, p < 0.001). The multivariable analysis suggested that the albumin levels were associated with the use of both crystalloids and colloids, whereas the type of fluid prescriber was associated with crystalloid use only., Conclusion: Our results suggest that crystalloids are more frequently used than colloids for fluid resuscitation in Brazil, and this discrepancy in frequencies is higher than that in other countries. Sodium chloride (0.9%) was the crystalloid most commonly prescribed. Serum albumin levels and the type of fluid prescriber were the factors associated with the choice of crystalloids or colloids for fluid resuscitation.
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- 2021
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66. Prediction of intensive care units length of stay: a concise review.
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Peres IT, Hamacher S, Oliveira FLC, Bozza FA, and Salluh JIF
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- Hospital Mortality, Humans, Length of Stay, Intensive Care Units
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- 2021
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67. COVID-19 research in critical care: the good, the bad, and the ugly.
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Salluh JIF, Arabi YM, and Binnie A
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- Humans, Biomedical Research trends, COVID-19, Critical Care
- Published
- 2021
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68. Correction to: Trends in clinical profiles, organ support use and outcomes of patients with cancer requiring unplanned ICU admission: a multicenter cohort study.
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Zampieri FG, Romano TG, Salluh JIF, Taniguchi LU, Mendes PV, Nassar AP Jr, Costa R, Viana WN, Maia MO, Lima MFA, Cappi SB, Carvalho AGR, De Marco FVC, Santino MS, Perecmanis E, Miranda FG, Ramos GV, Silva AR, Hoff PM, Bozza FA, and Soares M
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- 2021
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69. Trends in clinical profiles, organ support use and outcomes of patients with cancer requiring unplanned ICU admission: a multicenter cohort study.
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Zampieri FG, Romano TG, Salluh JIF, Taniguchi LU, Mendes PV, Nassar AP Jr, Costa R, Viana WN, Maia MO, Lima MFA, Cappi SB, Carvalho AGR, De Marco FVC, Santino MS, Perecmanis E, Miranda FG, Ramos GV, Silva AR, Hoff PM, Bozza FA, and Soares M
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- Bayes Theorem, Cohort Studies, Critical Illness, Hospital Mortality, Humans, Intensive Care Units, Length of Stay, Retrospective Studies, Neoplasms therapy, Renal Dialysis
- Abstract
Purpose: To describe trends in outcomes of cancer patients with unplanned admissions to intensive-care units (ICU) according to cancer type, organ support use, and performance status (PS) over an 8-year period., Methods: We retrospectively analyzed prospectively collected data from all cancer patients admitted to 92 medical-surgical ICUs from July/2011 to June/2019. We assessed trends in mortality through a Bayesian hierarchical model adjusted for relevant clinical confounders and whether there was a reduction in ICU length-of-stay (LOS) over time using a competing risk model., Results: 32,096 patients (8.7% of all ICU admissions; solid tumors, 90%; hematological malignancies, 10%) were studied. Bed/days use by cancer patients increased up to more than 30% during the period. Overall adjusted mortality decreased by 9.2% [95% credible interval (CI), 13.1-5.6%]. The largest reductions in mortality occurred in patients without need for organ support (9.6%) and in those with need for mechanical ventilation (MV) only (11%). Smallest reductions occurred in patients requiring MV, vasopressors, and dialysis (3.9%) simultaneously. Survival gains over time decreased as PS worsened. Lung cancer patients had the lowest decrease in mortality. Each year was associated with a lower sub-hazard for ICU death [SHR 0.93 (0.91-0.94)] and a higher chance of being discharged alive from the ICU earlier [SHR 1.01 (1-1.01)]., Conclusion: Outcomes in critically ill cancer patients improved in the past 8 years, with reductions in both mortality and ICU LOS, suggesting improvements in overall care. However, outcomes remained poor in patients with lung cancer, requiring multiple organ support and compromised PS.
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- 2021
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70. Intensive care for COVID-19 in low- and middle-income countries: research opportunities and challenges.
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Salluh JIF, Burghi G, and Haniffa R
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- Humans, COVID-19, Critical Care, Developing Countries
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- 2021
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71. Biomarkers in the ICU: less is more? Not sure.
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Póvoa P, Salluh JIF, and Lisboa T
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- Biomarkers, Humans, Intensive Care Units
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- 2021
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72. Clinical course and outcomes of critically ill patients with COVID-19 infection: a systematic review.
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Serafim RB, Póvoa P, Souza-Dantas V, Kalil AC, and Salluh JIF
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- COVID-19 mortality, COVID-19 therapy, Critical Illness, Extracorporeal Membrane Oxygenation statistics & numerical data, Female, Humans, Intensive Care Units, Length of Stay statistics & numerical data, Male, Middle Aged, Renal Replacement Therapy statistics & numerical data, Respiration, Artificial statistics & numerical data, Severity of Illness Index, Survival Analysis, Treatment Outcome, Vasoconstrictor Agents therapeutic use, COVID-19 epidemiology, COVID-19 pathology, Critical Care methods, SARS-CoV-2 pathogenicity
- Abstract
Objectives: Coronavirus disease 19 (COVID-19) is a major cause of hospital admission and represents a challenge for patient management during intensive care unit (ICU) stay. We aimed to describe the clinical course and outcomes of COVID-19 pneumonia in critically ill patients., Methods: We performed a systematic search of peer-reviewed publications in MEDLINE, EMBASE and the Cochrane Library up to 15th August 2020. Preprints and reports were also included if they met the inclusion criteria. Study eligibility criteria were full-text prospective, retrospective or registry-based publications describing outcomes in patients admitted to the ICU for COVID-19, using a validated test. Participants were critically ill patients admitted in the ICU with COVID-19 infection., Results: From 32 articles included, a total of 69 093 patients were admitted to the ICU and were evaluated. Most patients included in the studies were male (76 165/128 168, 59%, 26 studies) and the mean patient age was 56 (95%CI 48.5-59.8) years. Studies described high ICU mortality (21 145/65 383, 32.3%, 15 studies). The median length of ICU stay was 9.0 (95%CI 6.5-11.2) days, described in five studies. More than half the patients admitted to the ICU required mechanical ventilation (31 213/53 465, 58%, 23 studies) and among them mortality was very high (27 972/47 632, 59%, six studies). The duration of mechanical ventilation was 8.4 (95%CI 1.6-13.7) days. The main interventions described were the use of non-invasive ventilation, extracorporeal membrane oxygenation, renal replacement therapy and vasopressors., Conclusions: This systematic review, including approximately 69 000 ICU patients, demonstrates that COVID-19 infection in critically ill patients is associated with great need for life-sustaining interventions, high mortality, and prolonged length of ICU stay., (Copyright © 2020 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)
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- 2021
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73. Linking of global intensive care (LOGIC): An international benchmarking in critical care initiative.
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Dongelmans DA, Pilcher D, Beane A, Soares M, Del Pilar Arias Lopez M, Fernandez A, Guidet B, Haniffa R, and Salluh JIF
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- Critical Care economics, Databases, Factual, Female, Humans, Male, Middle Aged, Patient Admission, Benchmarking methods, Critical Care methods, Delivery of Health Care methods, Intensive Care Units, Registries
- Abstract
Benchmarking is a common and effective method for measuring and analyzing ICU performance. With the existence of national registries, objective information can now be obtained to allow benchmarking of ICU care within and between countries. The present manuscript briefly describes the current status of benchmarking in healthcare and critical care and presents the LOGIC project, an initiative to promote international benchmarking for intensive care units. Currently 13 registries have joined LOGIC. We showed large differences in the utilization of ICU as well as resources and in outcomes. Despite the need for careful interpretation of differences due to variation in definitions and limited risk adjustment, LOGIC is a growing worldwide initiative that allows access to insightful epidemiologic data from ICUs in multiple databases and registries., Competing Interests: Declaration of Competing Interest Drs Salluh and Soares are co-founders and shareholders of Epimed Solutions, a cloud-based analytics company., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)
- Published
- 2020
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74. Data-driven ICU management: Using Big Data and algorithms to improve outcomes.
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Carra G, Salluh JIF, da Silva Ramos FJ, and Meyfroidt G
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- Data Mining methods, Forecasting, Humans, Retrospective Studies, Big Data, Biomedical Research, Intensive Care Units organization & administration, Intensive Care Units trends, Machine Learning
- Abstract
The digitalization of the Intensive Care Unit (ICU) led to an increasing amount of clinical data being collected at the bedside. The term "Big Data" can be used to refer to the analysis of these datasets that collect enormous amount of data of different origin and format. Complexity and variety define the value of Big Data. In fact, the retrospective analysis of these datasets allows to generate new knowledge, with consequent potential improvements in the clinical practice. Despite the promising start of Big Data analysis in medical research, which has seen a rising number of peer-reviewed articles, very limited applications have been used in ICU clinical practice. A close future effort should be done to validate the knowledge extracted from clinical Big Data and implement it in the clinic. In this article, we provide an introduction to Big Data in the ICU, from data collection and data analysis, to the main successful examples of prognostic, predictive and classification models based on ICU data. In addition, we focus on the main challenges that these models face to reach the bedside and effectively improve ICU care., Competing Interests: Declaration of Competing Interest GC receives funding from the Research Foundation Flanders (FWO) as a PhD fellow (fellowship number: 1S28120N). GM is supported by the Research Foundation Flanders (FWO) as senior clinical investigator (fellowship number: 1843118N). GM receives project funding from the KU Leuven (C2 project (C24/17/072): A Neuromonitor for the 21st century)). dSRFJ, GM, GC – declare no conflicts of interests; SJIF is founder and shareholder at Epimed Solutions, the provider of a cloud-based healthcare analytics and performance evaluation software., (Copyright © 2020. Published by Elsevier Inc.)
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- 2020
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75. Structure and process associated with the efficiency of intensive care units in low-resource settings: An analysis of the CHECKLIST-ICU trial database.
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Bastos LSL, Hamacher S, Zampieri FG, Cavalcanti AB, Salluh JIF, and Bozza FA
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- Brazil, Catheters, Indwelling adverse effects, Checklist, Critical Illness, Cross Infection epidemiology, Female, Humans, Incidence, Male, Pneumonia, Ventilator-Associated etiology, Intensive Care Units organization & administration, Respiration, Artificial adverse effects
- Abstract
Purpose: Characteristics of structure and process impact ICU performance and the outcomes of critically ill patients. We sought to identify organizational characteristics associated with efficient ICUs in low-resource settings., Materials and Methods: This is a secondary analysis of a multicenter cluster-randomized clinical trial in Brazil (CHECKLIST-ICU). Efficient units were defined by standardized mortality ratio (SMR) and standardized resource use (SRU) lower than the overall medians and non-efficient otherwise. We used a regularized logistic regression model to evaluate associations between organizational factors and efficiency., Results: From 118 ICUs (13,635 patients), 47 units were considered efficient and 71 non-efficient. Efficient units presented lower incidence rates (median[IQR]) of central line-associated bloodstream infections (4.95[0.00-22.0] vs 6.29[0.00-25.6], p = .04), utilization rates of mechanical ventilation (0.41[0.07-0.73] vs 0.58[0.19-0.82], p < .001), central venous catheter (0.67[0.15-0.98] vs 0.78[0.33-0.98], p = .04), and indwelling urinary catheter (0.62[0.22-0.95] vs 0.76[0.32-0.98], p < .01) than non-efficient units. The reported active surveillance of ventilator-associated pneumonia (OR = 1.72; 95%CI, 1.16-2.57) and utilization of central venous catheters (OR = 1.94; 95%CI, 1.32-2.94) were associated with efficient ICUs., Conclusions: In low-resource settings, active surveillance of nosocomial infections and the utilization of invasive devices were associated with efficiency, supporting the management and evaluation of performance indicators as a starting point for improvement in ICU., Competing Interests: Declaration of Competing Interest The authors declare no competing interests., (Copyright © 2020. Published by Elsevier Inc.)
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- 2020
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76. Pediatric Sepsis: Subphenotypes to Enrich Clinical Trial Entry Criteria.
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Lanziotti VS and Salluh JIF
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- Child, Humans, Inflammation, Phenotype, Multiple Organ Failure, Sepsis
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- 2020
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77. Customization and external validation of the Simplified Mortality Score for the Intensive Care Unit (SMS-ICU) in Brazilian critically ill patients.
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Zampieri FG, Granholm A, Møller MH, Scotti AV, Alves A, Cabral MM, Sousa MF, Balieiro HM, Hortala CC Jr, Filho EMR, Perecmanis E, de Magalhães Menezes MA, Moreira CEN, Moralez GM, Bafi AT, de Carvalho CB, Salluh JIF, Bozza FA, Perner A, and Soares M
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- Adult, Aged, Aged, 80 and over, Brazil, Calibration, Cohort Studies, Critical Illness mortality, Female, Hospitalization, Humans, Male, Middle Aged, Severity of Illness Index, Simplified Acute Physiology Score, Hospital Mortality, Intensive Care Units statistics & numerical data
- Abstract
Purpose: To customize and externally validate the recently proposed Simplified Mortality Score for the ICU (SMS-ICU, a simple score for 90-day mortality that has no need for ancillary testing results) for in-hospital mortality and to compare its performance to SAPS 3., Material and Methods: We used data from two distinct large cohorts of adult Brazilian patients with unplanned ICU admissions to perform a first-level customization (43,017 patients admitted to 78 ICUs) of the original SMS-ICU score for in-hospital mortality and, sequentially, externally validate it (313,365 patients admitted to 99 ICUs). Performance of SMS-ICU was assessed through measurements of discrimination and calibration and compared with SAPS 3., Results: In the validation cohort, median SMS-ICU was 13 (IQR 8-16) points and median SAPS 3 was 44 (IQR 36-51). Discrimination of SMS-ICU was good (AUC 0.817; 95% CI 0.814-0.819) but slightly lower than of SAPS 3 (AUC 0.845; 95% CI 0.843-0.848;). The customized SMS-ICU predictions were comparable to SAPS 3 in terms of calibration., Conclusion: In this external validation of the SMS-ICU in a large Brazilian cohort, we observed good discrimination of SMS-ICU and acceptable calibration after first-level customization. SMS-ICU can be used as a measure of illness severity for acutely admitted ICU patients in clinical studies., Competing Interests: Declaration of Competing Interest MS and JIFS are proprietary and founder of Epimed Solutions®, a cloud-based registry for intensive care units that was used for the ORCHESTRA database. AG, AP, and MHM were involved in the development of the SMS-ICU. The ICU, Rigshospitalet receives fund for other research projects from Ferring Pharmaceuticals, Denmark, and the Novo Nordisk Foundation, Denmark., (Copyright © 2020 Elsevier Inc. All rights reserved.)
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- 2020
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78. Challenges for the care delivery for critically ill COVID-19 patients in developing countries: the Brazilian perspective.
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Salluh JIF, Lisboa T, and Bozza FA
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- Betacoronavirus, Brazil epidemiology, COVID-19, Coronavirus Infections epidemiology, Developing Countries, Humans, Intensive Care Units organization & administration, Pandemics, Pneumonia, Viral epidemiology, SARS-CoV-2, Coronavirus Infections therapy, Critical Illness, Delivery of Health Care organization & administration, Pneumonia, Viral therapy
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- 2020
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79. Elderly patients with cancer admitted to intensive care unit: A multicenter study in a middle-income country.
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Nassar Junior AP, Trevisani MDS, Bettim BB, Zampieri FG, Carvalho JA Jr, Silva A Jr, de Freitas FGR, Pinto JEDSS, Romano E, Ramos SR, Faria GBA, Silva UVAE, Santos RC, Tommasi EO, de Moraes APP, Cruz BAD, Bozza FA, Caruso P, Salluh JIF, and Soares M
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- APACHE, Aged, 80 and over, Brazil, Cohort Studies, Female, Hematologic Neoplasms mortality, Hematologic Neoplasms pathology, Hospitalization, Humans, Intensive Care Units, Logistic Models, Male, Neoplasms pathology, Retrospective Studies, Risk Factors, Critical Illness mortality, Hospital Mortality trends, Neoplasms mortality
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Background: Very elderly critically ill patients (ie, those older than 75 or 80 years) are an increasing population in intensive care units. However, patients with cancer have encompassed only a minority in epidemiological studies of very old critically-ill patients. We aimed to describe clinical characteristics and identify factors associated with hospital mortality in a cohort of patients aged 80 or older with cancer admitted to intensive care units (ICUs)., Methods: This was a retrospective cohort study in 94 ICUs in Brazil. We included patients aged 80 years or older with active cancer who had an unplanned admission. We performed a mixed effect logistic regression model to identify variables independently associated with hospital mortality., Results: Of 4604 included patients, 1807 (39.2%) died in hospital. Solid metastatic (OR = 2.46; CI 95%, 2.01-3.00), hematological cancer (OR = 2.32; CI 95%, 1.75-3.09), moderate/severe performance status impairment (OR = 1.59; CI 95%, 1.33-1.90) and use of vasopressors (OR = 4.74; CI 95%, 3.88-5.79), mechanical ventilation (OR = 1.54; CI 95%, 1.25-1.89) and renal replacement (OR = 1.81; CI 95%, 1.29-2.55) therapy were independently associated with increased hospital mortality. Emergency surgical admissions were associated with lower mortality compared to medical admissions (OR = 0.71; CI 95%, 0.52-0.96)., Conclusions: Hospital mortality rate in very elderly critically ill patients with cancer with unplanned ICU admissions are lower than expected a priori. Cancer characteristics, performance status impairment and acute organ dysfunctions are associated with increased mortality., Competing Interests: Dr. Soares and Dr. Salluh are founders and equity shareholders of Epimed Solutions®, which commercializes the Epimed Monitor System®, a cloud-based software for ICU management and benchmarking. The other authors declare that they have no conflict of interest. Dr. Zampieri has received grant for an investigator-initiated clinical trial from Bactiguard®, Sweden, which is unrelated to the aspects of this work. These do not alter our adherence to Plos One policies on sharing data and materials.
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- 2020
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80. Delivering evidence-based critical care for mechanically ventilated patients with COVID-19.
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Salluh JIF, Ramos F, and Chiche JD
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- Betacoronavirus, COVID-19, Coronavirus Infections virology, Critical Care standards, Delivery of Health Care standards, Evidence-Based Medicine standards, Humans, Pandemics, Pneumonia, Viral virology, Respiration, Artificial standards, SARS-CoV-2, Standard of Care, Coronavirus Infections therapy, Critical Care methods, Delivery of Health Care methods, Evidence-Based Medicine methods, Pneumonia, Viral therapy, Respiration, Artificial methods
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- 2020
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81. How to evaluate intensive care unit performance during the COVID-19 pandemic.
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Zampieri FG, Soares M, and Salluh JIF
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- Adult, Betacoronavirus, COVID-19, Critical Illness, Humans, Intensive Care Units, SARS-CoV-2, Coronavirus, Coronavirus Infections, Pandemics, Pneumonia, Viral, Sepsis
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- 2020
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82. What every intensivist must know about antimicrobial stewardship: its pitfalls and its challenges.
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Paiva JA, Mergulhão P, and Salluh JIF
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- Critical Care methods, Drug Resistance, Microbial, Drug Resistance, Multiple, Humans, Anti-Infective Agents administration & dosage, Antimicrobial Stewardship methods, Intensive Care Units
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- 2020
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83. Identification of distinct clinical phenotypes in mechanically ventilated patients with acute brain dysfunction using cluster analysis.
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Souza-Dantas VC, Dal-Pizzol F, Tomasi CD, Spector N, Soares M, Bozza FA, Póvoa P, and Salluh JIF
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- APACHE, Academic Medical Centers, Aged, Biomarkers, C-Reactive Protein analysis, Cluster Analysis, Comorbidity, Female, Humans, Hypnotics and Sedatives administration & dosage, Male, Middle Aged, Phenotype, Prospective Studies, Risk Assessment, Risk Factors, Sepsis epidemiology, Socioeconomic Factors, Time Factors, Coma epidemiology, Delirium epidemiology, Intensive Care Units statistics & numerical data, Respiration, Artificial statistics & numerical data
- Abstract
Acute brain dysfunction (ABD) is a frequent and severe syndrome occurring in critically ill patients and early identification of high-risk patients is paramount. In the present analysis, we propose a clinically applicable model for early phenotype identification of ABD at the bedside in mechanically ventilated patients, improving the recognition of patients with prolonged ABD.Prospective cohort with 629 mechanically ventilated patients in two medical-surgical intensive care units at academic centers. We applied cluster analysis to identify phenotypes using clinical and biological data. We then tested the association of phenotypes and its respective clinical outcomes. We performed a validation on a new cohort of patients select on subsequent patients admitted to the participants intensive care units.A model with 3 phenotypes best described the study population. A 4-variable model including medical admission, sepsis diagnosis, simplified acute physiologic score II and basal serum C-reactive protein (CRP) accurately classified each phenotype (area under curve 0.82; 95% CI, 0.79-0.86). Phenotype A had the shorter duration of ABD (median, 1 day), while phenotypes B and C had progressively longer duration of ABD (median, 3 and 6 days, respectively; P < .0001). There was an association between the duration of ABD and the baseline CRP levels and simplified acute physiology score II score (sensitivity and specificity of 80%). To increase the sensitivity of the model, we added CRP kinetics. By day 1, a CRP < 1.0 times the initial level was associated with a shorter duration of ABD (specificity 0.98).A model based on widely available clinical variables could provide phenotypes associated with the duration of ABD. Phenotypes with longer duration of ABD (phenotypes B and C) are characterized by more severe inflammation and by significantly worse clinical outcomes.
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- 2020
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84. Factors associated with mortality in severe community-acquired pneumonia: A multicenter cohort study - Response to letter.
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Espinoza R and Salluh JIF
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- Cohort Studies, Humans, Community-Acquired Infections, Pneumonia
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- 2019
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85. ICU staffing feature phenotypes and their relationship with patients' outcomes: an unsupervised machine learning analysis.
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Zampieri FG, Salluh JIF, Azevedo LCP, Kahn JM, Damiani LP, Borges LP, Viana WN, Costa R, Corrêa TD, Araya DES, Maia MO, Ferez MA, Carvalho AGR, Knibel MF, Melo UO, Santino MS, Lisboa T, Caser EB, Besen BAMP, Bozza FA, Angus DC, and Soares M
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- Brazil, Cluster Analysis, Hospital Bed Capacity statistics & numerical data, Humans, Intensive Care Units organization & administration, Intensive Care Units statistics & numerical data, Length of Stay statistics & numerical data, Length of Stay trends, Logistic Models, Nurses statistics & numerical data, Nurses supply & distribution, Odds Ratio, Organ Dysfunction Scores, Personnel Staffing and Scheduling classification, Personnel Staffing and Scheduling statistics & numerical data, Physical Therapists statistics & numerical data, Physical Therapists supply & distribution, Physicians statistics & numerical data, Physicians supply & distribution, Retrospective Studies, Time Factors, Hospital Mortality trends, Personnel Staffing and Scheduling standards, Unsupervised Machine Learning trends
- Abstract
Purpose: To study whether ICU staffing features are associated with improved hospital mortality, ICU length of stay (LOS) and duration of mechanical ventilation (MV) using cluster analysis directed by machine learning., Methods: The following variables were included in the analysis: average bed to nurse, physiotherapist and physician ratios, presence of 24/7 board-certified intensivists and dedicated pharmacists in the ICU, and nurse and physiotherapist autonomy scores. Clusters were defined using the partition around medoids method. We assessed the association between clusters and hospital mortality using logistic regression and with ICU LOS and MV duration using competing risk regression., Results: Analysis included data from 129,680 patients admitted to 93 ICUs (2014-2015). Three clusters were identified. The features distinguishing between the clusters were: the presence of board-certified intensivists in the ICU 24/7 (present in Cluster 3), dedicated pharmacists (present in Clusters 2 and 3) and the extent of nurse autonomy (which increased from Clusters 1 to 3). The patients in Cluster 3 exhibited the best outcomes, with lower adjusted hospital mortality [odds ratio 0.92 (95% confidence interval (CI), 0.87-0.98)], shorter ICU LOS [subhazard ratio (SHR) for patients surviving to ICU discharge 1.24 (95% CI 1.22-1.26)] and shorter durations of MV [SHR for undergoing extubation 1.61(95% CI 1.54-1.69)]. Cluster 1 had the worst outcomes., Conclusion: Patients treated in ICUs combining 24/7 expert intensivist coverage, a dedicated pharmacist and nurses with greater autonomy had the best outcomes. All of these features represent achievable targets that should be considered by policy makers with an interest in promoting equal and optimal ICU care.
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- 2019
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86. Ventilator-associated tracheobronchitis: an update.
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Salluh JIF, Souza-Dantas VC, Martin-Loeches I, Lisboa TC, Rabello LSCF, Nseir S, and Póvoa P
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- Anti-Bacterial Agents administration & dosage, Bronchitis epidemiology, Humans, Pneumonia, Ventilator-Associated epidemiology, Respiration, Artificial methods, Respiratory Tract Infections epidemiology, Respiratory Tract Infections etiology, Tracheitis epidemiology, Bronchitis etiology, Respiration, Artificial adverse effects, Tracheitis etiology
- Abstract
Ventilator-associated lower respiratory tract infection is one of the most frequent complications in mechanically ventilated patients. Ventilator-associated tracheobronchitis has been considered a disease that does not warrant antibiotic treatment by the medical community for many years. In the last decade, several studies have shown that tracheobronchitis could be considered an intermediate process that leads to ventilator-associated pneumonia. Furthermore, ventilator-associated tracheobronchitis has a limited impact on overall mortality but shows a significant association with increased patient costs, length of stay, antibiotic use, and duration of mechanical ventilation. Although we still need clear evidence, especially concerning treatment modalities, the present study on ventilator-associated tracheobronchitis highlights that there are important impacts of including this condition in clinical management and epidemiological and infection surveillance.
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- 2019
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87. Modulators of systemic inflammatory response syndrome presence in patients admitted to intensive care units with acute infection: a Bayesian network approach.
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Zampieri FG, Aguiar FJ, Bozza FA, Salluh JIF, and Soares M
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- Bayes Theorem, Humans, Infections physiopathology, Intensive Care Units organization & administration, Organ Dysfunction Scores, Systemic Inflammatory Response Syndrome physiopathology, Infections complications, Systemic Inflammatory Response Syndrome etiology
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- 2019
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88. Effect of Flexible Family Visitation on Delirium Among Patients in the Intensive Care Unit: The ICU Visits Randomized Clinical Trial.
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Rosa RG, Falavigna M, da Silva DB, Sganzerla D, Santos MMS, Kochhann R, de Moura RM, Eugênio CS, Haack TDSR, Barbosa MG, Robinson CC, Schneider D, de Oliveira DM, Jeffman RW, Cavalcanti AB, Machado FR, Azevedo LCP, Salluh JIF, Pellegrini JAS, Moraes RB, Foernges RB, Torelly AP, Ayres LO, Duarte PAD, Lovato WJ, Sampaio PHS, de Oliveira Júnior LC, Paranhos JLDR, Dantas ADS, de Brito PIPGG, Paulo EAP, Gallindo MAC, Pilau J, Valentim HM, Meira Teles JM, Nobre V, Birriel DC, Corrêa E Castro L, Specht AM, Medeiros GS, Tonietto TF, Mesquita EC, da Silva NB, Korte JE, Hammes LS, Giannini A, Bozza FA, and Teixeira C
- Subjects
- Anxiety, Brazil, Burnout, Professional, Critical Care psychology, Cross-Over Studies, Depression, Female, Health Education, Hospitalization, Humans, Incidence, Male, Middle Aged, Time Factors, Delirium prevention & control, Family psychology, Intensive Care Units organization & administration, Visitors to Patients
- Abstract
Importance: The effects of intensive care unit (ICU) visiting hours remain uncertain., Objective: To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium., Design, Setting and Participants: Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018., Interventions: Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation., Main Outcomes and Measures: Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory)., Results: Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation., Conclusions and Relevance: Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium., Trial Registration: ClinicalTrials.gov Identifier: NCT02932358.
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- 2019
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89. Does this critically ill patient with delirium require any drug treatment?
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Salluh JIF and Latronico N
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- Critical Illness therapy, Humans, Intensive Care Units organization & administration, Pharmacology methods, Delirium drug therapy, Medical Overuse prevention & control, Pharmacology standards
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- 2019
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90. A Comparison of Mortality From Sepsis in Brazil and England: The Impact of Heterogeneity in General and Sepsis-Specific Patient Characteristics.
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Ranzani OT, Shankar-Hari M, Harrison DA, Rabello LS, Salluh JIF, Rowan KM, and Soares M
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- Age Distribution, Aged, Brazil epidemiology, Cardiovascular Diseases epidemiology, Cohort Studies, Comorbidity, Datasets as Topic, England epidemiology, Female, Hospital Mortality, Humans, Length of Stay statistics & numerical data, Logistic Models, Male, Middle Aged, Organ Dysfunction Scores, Respiratory Tract Diseases epidemiology, Intensive Care Units, Sepsis mortality
- Abstract
Objectives: To test whether differences in both general and sepsis-specific patient characteristics explain the observed differences in sepsis mortality between countries, using two national critical care (ICU) databases., Design: Cohort study., Setting: We analyzed 62 and 164 ICUs in Brazil and England, respectively., Patients: Twenty-two-thousand four-hundred twenty-six adult ICU admissions from January 2013 to December 2013., Interventions: None., Measurements and Main Results: After harmonizing relevant variables, we merged the first ICU episode of adult medical admissions from Brazil (ORganizational CHaractEeriSTics in cRitical cAre study) and England (Intensive Care National Audit & Research Centre Case Mix Programme). Sepsis-3 definition was used, and the primary outcome was hospital mortality. We used multilevel logistic regression models to evaluate the impact of country (Brazil vs England) on mortality, after adjustment for general (age, sex, comorbidities, functional status, admission source, time to admission) and sepsis-specific (site of infection, organ dysfunction type and number) patient characteristics. Of medical ICU admissions, 13.2% (4,505/34,150) in Brazil and 30.7% (17,921/58,316) in England met the sepsis definition. The Brazil cohort was older, had greater prevalence of severe comorbidities and dependency compared with England. Respiratory was the most common infection site in both countries. The most common organ dysfunction was cardiovascular in Brazil (41.2%) and respiratory in England (85.8%). Crude hospital mortality was similar (Brazil 41.4% vs England 39.3%; odds ratio, 1.12 [0.98-1.30]). After adjusting for general patient characteristics, there was an important change in the point-estimate of the odds ratio (0.88 [0.75-1.02]). However, after adjusting for sepsis-specific patient characteristics, the direction of effect reversed again with Brazil having higher risk-adjusted mortality (odds ratio, 1.22 [1.05-1.43])., Conclusions: Patients with sepsis admitted to ICUs in Brazil and England have important differences in general and sepsis-specific characteristics, from source of admission to organ dysfunctions. We show that comparing crude mortality from sepsis patients admitted to the ICU between countries, as currently performed, is not reliable and that the adjustment for both general and sepsis-specific patient characteristics is essential for valid international comparisons of mortality amongst sepsis patients admitted to critical care units.
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- 2019
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91. Association of frailty with short-term outcomes, organ support and resource use in critically ill patients.
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Zampieri FG, Iwashyna TJ, Viglianti EM, Taniguchi LU, Viana WN, Costa R, Corrêa TD, Moreira CEN, Maia MO, Moralez GM, Lisboa T, Ferez MA, Freitas CEF, de Carvalho CB, Mazza BF, Lima MFA, Ramos GV, Silva AR, Bozza FA, Salluh JIF, and Soares M
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- Aged, Blood Transfusion statistics & numerical data, Brazil epidemiology, Critical Illness mortality, Facilities and Services Utilization, Frail Elderly statistics & numerical data, Health Resources statistics & numerical data, Hospital Mortality, Humans, Intensive Care Units, Length of Stay statistics & numerical data, Prospective Studies, Retrospective Studies, Severity of Illness Index, Critical Care statistics & numerical data, Critical Illness therapy, Frailty therapy
- Abstract
Purpose: Frail patients are known to experience poor outcomes. Nevertheless, we know less about how frailty manifests itself in patients' physiology during critical illness and how it affects resource use in intensive care units (ICU). We aimed to assess the association of frailty with short-term outcomes and organ support used by critically ill patients., Methods: Retrospective analysis of prospective collected data from 93 ICUs in Brazil from 2014 to 2015. We assessed frailty using the modified frailty index (MFI). The primary outcome was in-hospital mortality. Secondary outcomes were discharge home without need for nursing care, ICU and hospital length of stay (LOS), and utilization of ICU organ support and transfusion. We used mixed logistic regression and competing risk models accounting for relevant confounders in outcome analyses., Results: The analysis consisted of 129,680 eligible patients. There were 40,779 (31.4%) non-frail (MFI = 0), 64,407 (49.7%) pre-frail (MFI = 1-2) and 24,494 (18.9%) frail (MFI ≥ 3) patients. After adjusted analysis, frailty was associated with higher in-hospital mortality (OR 2.42, 95% CI 1.89-3.08), particularly in patients admitted with lower SOFA scores. Frail patients were less likely to be discharged home (OR 0.36, 95% CI 0.54-0.79) and had higher hospital and ICU LOS than non-frail patients. Use of all forms of organ support (mechanical ventilation, non-invasive ventilation, vasopressors, dialysis and transfusions) were more common in frail patients and increased as MFI increased., Conclusions: Frailty, as assessed by MFI, was associated with several patient-centered endpoints including not only survival, but also ICU LOS and organ support.
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- 2018
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92. Study protocol to assess the effectiveness and safety of a flexible family visitation model for delirium prevention in adult intensive care units: a cluster-randomised, crossover trial (The ICU Visits Study).
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Rosa RG, Falavigna M, Robinson CC, da Silva DB, Kochhann R, de Moura RM, Santos MMS, Sganzerla D, Giordani NE, Eugênio C, Ribeiro T, Cavalcanti AB, Bozza F, Azevedo LCP, Machado FR, Salluh JIF, Pellegrini JAS, Moraes RB, Hochegger T, Amaral A, Teles JMM, da Luz LG, Barbosa MG, Birriel DC, Ferraz IL, Nobre V, Valentim HM, Corrêa E Castro L, Duarte PAD, Tregnago R, Barilli SLS, Brandão N, Giannini A, and Teixeira C
- Subjects
- Adult, Brazil, Cross-Over Studies, Humans, Randomized Controlled Trials as Topic, Reproducibility of Results, Delirium prevention & control, Family Relations, Intensive Care Units, Visitors to Patients
- Abstract
Introduction: Flexible intensive care unit (ICU) visiting hours have been proposed as a means to improve patient-centred and family-centred care. However, randomised trials evaluating the effects of flexible family visitation models (FFVMs) are scarce. This study aims to compare the effectiveness and safety of an FFVM versus a restrictive family visitation model (RFVM) on delirium prevention among ICU patients, as well as to analyse its potential effects on family members and ICU professionals., Methods and Analysis: A cluster-randomised crossover trial involving adult ICU patients, family members and ICU professionals will be conducted. Forty medical-surgical Brazilian ICUs with RFVMs (<4.5 hours/day) will be randomly assigned to either an RFVM (visits according to local policies) or an FFVM (visitation during 12 consecutive hours per day) group at a 1:1 ratio. After enrolment and follow-up of 25 patients, each ICU will be switched over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome will be the cumulative incidence of delirium among ICU patients, measured twice a day using the Confusion Assessment Method for the ICU. Secondary outcome measures will include daily hazard of delirium, ventilator-free days, any ICU-acquired infections, ICU length of stay and hospital mortality among the patients; symptoms of anxiety and depression and satisfaction among the family members; and prevalence of burnout symptoms among the ICU professionals. Tertiary outcomes will include need for antipsychotic agents and/or mechanical restraints, coma-free days, unplanned loss of invasive devices and ICU-acquired pneumonia, urinary tract infection or bloodstream infection among the patients; self-perception of involvement in patient care among the family members; and satisfaction among the ICU professionals., Ethics and Dissemination: The study protocol has been approved by the research ethics committee of all participant institutions. We aim to disseminate the findings through conferences and peer-reviewed journals., Trial Registration: NCT02932358., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)
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- 2018
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93. Patterns of C-reactive protein ratio response to antibiotics in pediatric sepsis: A prospective cohort study.
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Lanziotti VS, Póvoa P, Prata-Barbosa A, Pulcheri LB, Rabello LSCF, Lapa E Silva JR, Soares M, and Salluh JIF
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- Child, Child, Preschool, Cohort Studies, Female, Humans, Infant, Infant, Newborn, Intensive Care Units, Pediatric, Male, Portugal, Prospective Studies, Sepsis blood, Sepsis microbiology, Sepsis mortality, Anti-Bacterial Agents therapeutic use, Biomarkers blood, C-Reactive Protein metabolism, Child, Hospitalized, Sepsis drug therapy
- Abstract
Purpose: Evaluate sequential C-reactive protein (CRP) measurements and patterns of CRP-ratio response to antibiotic therapy during first 7days in Pediatric Intensive Care Unit (PICU) of septic children., Methods: Prospective, cohort study of children (1month-12years) admitted at 3 PICUs, with diagnosis of sepsis with <72h course. CRP-ratio was calculated in relation to D0_CRP value. Children were classified according to an individual pattern of CRP-ratio response: fast - CRP_D4 of therapy was <0.4 of D0_CRP; slow - continuous but slow decrease of CRP; non - CRP remained ≥0.8 of D0_CRP; biphasic - initial CRP decrease to levels <0.8 of D0_CRP followed by secondary rise ≥0.8., Results: 103 septic children (age-median: 2yrs; 54% male) were prospectively included (infection focus: 65% respiratory, 12.5% central nervous system). Overall PICU mortality was 11.7%. 102 children could be classified according to a predefined CRP-ratio response pattern. Time-dependent analysis of CRP-ratio and CRP course of the different patterns were significantly different. Besides, PICU mortality rate was significantly different according CRP-ratio response patterns: fast response 4.5%; slow response 5.8%; non-response 29.4%; biphasic response 42.8%., Conclusions: In pediatric sepsis, CRP-ratio serial evaluation was useful in early identification of patients with poor outcome., (Copyright © 2017 Elsevier Inc. All rights reserved.)
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- 2018
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94. New perspectives to improve critical care benchmarking.
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Salluh JIF, Chiche JD, Reis CE, and Soares M
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- 2018
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95. Role of organisational factors on the 'weekend effect' in critically ill patients in Brazil: a retrospective cohort analysis.
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Zampieri FG, Lisboa TC, Correa TD, Bozza FA, Ferez M, Fernandes HS, Japiassú AM, Verdeal JCR, Carvalho ACP, Knibel MF, Mazza BF, Colombari F, Vieira JM, Viana WN, Costa R, Godoy MM, Maia MO, Caser EB, Salluh JIF, and Soares M
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- Adult, Aged, Aged, 80 and over, Brazil, Critical Illness therapy, Female, Humans, Logistic Models, Male, Middle Aged, Multivariate Analysis, Propensity Score, Retrospective Studies, Time Factors, Workforce, Critical Illness mortality, Hospital Mortality trends, Intensive Care Units organization & administration, Patient Admission statistics & numerical data
- Abstract
Introduction: Higher mortality for patients admitted to intensive care units (ICUs) during the weekends has been occasionally reported with conflicting results that could be related to organisational factors. We investigated the effects of ICU organisational and staffing patterns on the potential association between weekend admission and outcomes in critically ill patients., Methods: We included 59 614 patients admitted to 78 ICUs participating during 2013. We defined 'weekend admission' as any ICU admission from Friday 19:00 until Monday 07:00. We assessed the association between weekend admission with hospital mortality using a mixed logistic regression model controlling for both patient-level (illness severity, age, comorbidities, performance status and admission type) and ICU-level (decrease in nurse/bed ratio on weekend, full-time intensivist coverage, use of checklists on weekends and number of institutional protocols) confounders. We performed secondary analyses in the subgroup of scheduled surgical admissions., Results: A total of 41 894 patients (70.3%) were admitted on weekdays and 17 720 patients (29.7%) on weekends. In univariable analysis, weekend admitted patients had higher ICU (10.9% vs 9.0%, P<0.001) and hospital (16.5% vs 13.5%, P<0.001) mortality. After adjusting for confounders, weekend admission was not associated with higher hospital mortality (OR 1.05, 95% CI 0.99 to 1.12, P=0.095). However, a 'weekend effect' was still observed in scheduled surgical admissions, as well as in ICUs not using checklists during the weekends. For unscheduled admissions, no 'weekend effect' was observed regardless of ICU's characteristics. For scheduled surgical admissions, a 'weekend effect' was present only in ICUs with a low number of implemented protocols and those with a reduction in the nurse/bed ratio and not applying checklists during weekends., Conclusions: ICU organisational factors, such as decreased nurse-to-patient ratio, absence of checklists and fewer standardised protocols, may explain, in part, increases in mortality in patients admitted to the ICU mortality on weekends., Competing Interests: Competing interests: MS and JIFS are founders and equity shareholders of Epimed Solutions, which commercialises the Epimed Monitor System, a cloud-based software for ICU management and benchmarking. The other authors declare that they have no conflict of interest., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)
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- 2018
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96. Patterns of C-reactive protein ratio predicts outcomes in healthcare-associated pneumonia in critically ill patients with cancer.
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Rabello LSCF, Póvoa P, Lapa E Silva JR, Azevedo LCP, da Silva Ramos FJ, Lisboa T, Soares M, and Salluh JIF
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- Adult, Aged, Anti-Bacterial Agents therapeutic use, Biomarkers metabolism, Critical Care, Critical Illness, Cross Infection complications, Cross Infection prevention & control, Female, Hospital Mortality, Humans, Intensive Care Units, Middle Aged, Neoplasms complications, Pneumonia, Bacterial complications, Pneumonia, Bacterial prevention & control, Prospective Studies, Respiration, Artificial statistics & numerical data, Shock, Septic blood, Shock, Septic mortality, C-Reactive Protein metabolism, Cross Infection blood, Neoplasms blood, Pneumonia, Bacterial blood
- Abstract
Purpose: Describe the patterns of C-reactive protein relative changes in response to antibiotic therapy in critically ill cancer patients with healthcare-associated pneumonia (HCAP) and its ability to predict outcome., Methods: Secondary analysis of a prospective cohort of critically ill cancer patients with HCAP. CRP was sampled every other day from D0 to D6 of antibiotic therapy. Patients were classified according to an individual pattern of CRP-ratio response: fast - CRP at D4 of therapy was <0.4 of D0 CRP; slow - a continuous but slow decrease of CRP; non - CRP remained ≥0.8 of D0 CRP; biphasic - initial CRP decrease to levels <0.8 of the D0 CRP followed by a secondary rise ≥0.8., Results: 129 patients were included and septic shock was present in 74% and invasive mechanical ventilation was used in 73%. Intensive care unit (ICU) and hospital mortality rates were 47% and 64%, respectively. By D4, both CRP and CRP-ratio of survivors were significantly lower than in nonsurvivors (p<0.001 and p=0.004, respectively). Both time-dependent analysis of CRP-ratio of the four previously defined patterns (p<0.001) as ICU mortality were consistently different [fast 12.9%, slow 43.2%, biphasic 66.7% and non 71.8% (p<0.001)]., Conclusion: CRP-ratio was useful in the early prediction of poor outcomes in cancer patients with HCAP., (Copyright © 2017 Elsevier Inc. All rights reserved.)
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- 2017
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97. External validation of SAPS 3 and MPM 0 -III scores in 48,816 patients from 72 Brazilian ICUs.
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Moralez GM, Rabello LSCF, Lisboa TC, Lima MDFA, Hatum RM, De Marco FVC, Alves A, Pinto JEDSS, de Araújo HBN, Ramos GV, Silva AR, Fernandes GC, Faria GBA, Mendes CL, Ramos Filho RÁ, de Souza VP, do Brasil PEAA, Bozza FA, Salluh JIF, and Soares M
- Abstract
Background: The performance of severity-of-illness scores varies in different scenarios and must be validated prior of being used in a specific settings and geographic regions. Moreover, models' calibration may deteriorate overtime and performance of such instruments should be reassessed regularly. Therefore, we aimed at to validate the SAPS 3 in a large contemporary cohort of patients admitted to Brazilian ICUs. In addition, we also compared the performance of the SAPS 3 with the MPM
0 -III., Methods: This is a retrospective cohort study in which 48,816 (medical admissions = 67.9%) adult patients are admitted to 72 Brazilian ICUs during 2013. We evaluated models' discrimination using the area under the receiver operating characteristic curve (AUROC). We applied the calibration belt to evaluate the agreement between observed and expected mortality rates (calibration)., Results: Mean SAPS 3 score was 44.3 ± 15.4 points. ICU and hospital mortality rates were 11.0 and 16.5%. We estimated predicted mortality using both standard (SE) and Central and South American (CSA) customized equations. Predicted mortality rates were 16.4 ± 19.3% (SAPS 3-SE), 21.7 ± 23.2% (SAPS 3-CSA) and 14.3 ± 14.0% (MPM0 -III). Standardized mortality ratios (SMR) obtained for each model were: 1.00 (95% CI, 0.98-0.102) for the SAPS 3-SE, 0.75 (0.74-0.77) for the SAPS 3-CSA and 1.15 (1.13-1.18) for the MPM0 -III. Discrimination was better for SAPS 3 models (AUROC = 0.85) than for MPM0 -III (AUROC = 0.80) (p < 0.001). We applied the calibration belt to evaluate the agreement between observed and expected mortality rates (calibration): the SAPS 3-CSA overestimated mortality throughout all risk classes while the MPM0 -III underestimated it uniformly. The SAPS 3-SE did not show relevant deviations from ideal calibration., Conclusions: In a large contemporary database, the SAPS 3-SE was accurate in predicting outcomes, supporting its use for performance evaluation and benchmarking in Brazilian ICUs.- Published
- 2017
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98. Understanding intensive care unit benchmarking.
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Salluh JIF, Soares M, and Keegan MT
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- Benchmarking, Intensive Care Units standards
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- 2017
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99. Worldwide Survey of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment" (ABCDEF) Bundle.
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Morandi A, Piva S, Ely EW, Myatra SN, Salluh JIF, Amare D, Azoulay E, Bellelli G, Csomos A, Fan E, Fagoni N, Girard TD, Heras La Calle G, Inoue S, Lim CM, Kaps R, Kotfis K, Koh Y, Misango D, Pandharipande PP, Permpikul C, Cheng Tan C, Wang DX, Sharshar T, Shehabi Y, Skrobik Y, Singh JM, Slooter A, Smith M, Tsuruta R, and Latronico N
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- Adult, Aged, Cross-Sectional Studies, Delirium diagnosis, Delirium therapy, Early Ambulation statistics & numerical data, Family, Humans, Medicine statistics & numerical data, Middle Aged, Pain Management, Pain Measurement, Respiration, Intensive Care Units statistics & numerical data, Knowledge, Patient Care Bundles methods, Patient Care Bundles statistics & numerical data, Physicians statistics & numerical data
- Abstract
Objectives: To assess the knowledge and use of the Assessment, prevention, and management of pain; spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle to implement the Pain, Agitation, Delirium guidelines., Design: Worldwide online survey., Setting: Intensive care., Intervention: A cross-sectional online survey using the Delphi method was administered to intensivists worldwide, to assess the knowledge and use of all aspects of the ABCDEF bundle., Measurement and Main Results: There were 1,521 respondents from 47 countries, 57% had implemented the ABCDEF bundle, with varying degrees of compliance across continents. Most of the respondents (83%) used a scale to evaluate pain. Spontaneous awakening trials and spontaneous breathing trials are performed in 66% and 67% of the responder ICUs, respectively. Sedation scale was used in 89% of ICUs. Delirium monitoring was implemented in 70% of ICUs, but only 42% used a validated delirium tool. Likewise, early mobilization was "prescribed" by most, but 69% had no mobility team and 79% used no formal mobility scale. Only 36% of the respondents assessed ICU-acquired weakness. Family members were actively involved in 67% of ICUs; however, only 33% used dedicated staff to support families and only 35% reported that their unit was open 24 hr/d for family visits., Conclusions: The current implementation of the ABCDEF bundle varies across individual components and regions. We identified specific targets for quality improvement and adoption of the ABCDEF bundle. Our data reflect a significant but incomplete shift toward patient- and family-centered ICU care in accordance with the Pain, Agitation, Delirium guidelines.
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- 2017
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100. Intensive Care Medicine in 2050: global perspectives.
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Arabi YM, Schultz MJ, and Salluh JIF
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- Forecasting, Humans, Intensive Care Units, Medicine, Critical Care trends
- Published
- 2017
- Full Text
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