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OBJECTIVES:. Data on cardiac arrest survivors from developing countries are scarce. This study investigated clinical characteristics associated with in-hospital mortality in resuscitated patients following cardiac arrest in Brazil. DESIGN:. Retrospective analysis of prospectively collected data. SETTING:. Ninety-two general ICUs from 55 hospitals in Brazil between 2014 and 2015. PATIENTS:. Adult patients with cardiac arrest admitted to the ICU. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. We analyzed 2,296 patients (53% men; median 67 yr (interquartile range, 54–79 yr]). Eight-hundred patients (35%) had a primary admission diagnosis of cardiac arrest suggesting an out-of-hospital cardiac arrest; the remainder occurred after admission, comprising an in-hospital cardiac arrest cohort. Overall, in-hospital mortality was 83%, with only 6% undergoing withholding/withdrawal-of-life support. Random-effects multivariable Cox regression was used to assess associations with survival. After adjusting for age, sex, and severity scores, mortality was associated with shock (adjusted odds ratio, 1.25 [95% CI, 1.11–1.39]; p < 0.001), temperature dysregulation (adjusted odds ratio for normothermia, 0.85 [95% CI, 0.76–0.95]; p = 0.007), increased lactate levels above 4 mmol/L (adjusted odds ratio, 1.33 [95% CI, 1.1–1.6; p = 0.009), and surgical or cardiac cases (adjusted odds ratio, 0.72 [95% CI, 0.6–0.86]; p = 0.002). In addition, survival was better in patients with probable out-of-hospital cardiac arrest, unless ICU admission was delayed (adjusted odds ratio for interaction, 1.63 [95% CI, 1.21–2.21]; p = 004). CONCLUSIONS:. In a large multicenter cardiac arrest cohort from Brazil, we found a high mortality rate and infrequent withholding/withdrawal of life support. We also identified patient profiles associated with worse survival, such as those with shock/hypoperfusion and arrest secondary to nonsurgical admission diagnoses. Our findings unveil opportunities to improve postarrest care in developing countries, such as prompt ICU admission, expansion of the use of targeted temperature management, and implementation of shock reversal strategies (i.e., early coronary angiography), according to modern guidelines recommendations.

A major challenge for hospitals in low-income and middle-income countries is to improve management of patients diagnosed with sepsis. The objective of the present study was to evaluate the Institute for Healthcare Improvement (IHI) Model as a strategy to implement a managed sepsis protocol aimed at reducing sepsis mortality. We performed a longitudinal, prospective, non-randomised study using PDSA cycles for translating and implementing improvement actions and tools. Baseline case mortality/case fatality data were collected, and compliance rates were evaluated according to the Surviving Sepsis Campaign guidelines (3-hour care-bundle). Sepsis multidisciplinary work teams were designated and were responsible to develop Driver Diagrams and implement process changes in the intensive care unit, wards and emergency department. Satisfaction levels of healthcare professionals were assessed (balance variables). The study was carried out in a public quaternary hospital, in São Paulo city, Brazil (Hospital Municipal da Vila Santa Catarina). The number of patients with sepsis studied was 416 who were followed over a 15-month period. The data analyses were carried out by statistical process control. Case fatality rates were kept below a prespecified target of 25% (15.9%) during the period. Satisfaction level of the participating staff was high (95.2%) and 71% of participants reported no work overload. The IHI model was found to be a feasible and useful strategy for implementing a sepsis management clinical protocol.

ABSTRACTSevere sepsis and septic shock represent a major healthcare challenge. Much of the improvement in mortality associated with septic shock is related to early recognition combined with timely fluid resuscitation and adequate antibiotics administration. The main goals of septic shock resuscitation include intravascular replenishment, maintenance of adequate perfusion pressure and oxygen delivery to tissues. To achieve those goals, fluid responsiveness evaluation and complementary interventions - i.e. vasopressors, inotropes and blood transfusion - may be necessary. This article is a literature review of the available evidence on the initial hemodynamic support of the septic shock patients presenting to the emergency room or to the intensive care unit and the main interventions available to reach those targets, focusing on fluid and vasopressor therapy, blood transfusion and inotrope administration.

Transfusion therapy is associated with increased morbidity, mortality and costs. Conventional coagulation tests (CCT) are weak bleeding predictors, poorly reflecting coagulation in vivo. Thromboelastometry (ROTEM) provides early identification of coagulation disorders and can guide transfusion therapy by goals, reducing blood components transfusion.The aim of this study is to describe coagulation profile of critically ill patients using ROTEM and evaluate the association between CCT and thromboelastometry.This is a retrospective, observational study conducted in medical-surgical intensive care unit (ICU). Adult patients (≥18 years) admitted to ICU between November 2012 and December 2014, in whom ROTEM analyses were performed for bleeding management were included in this study. The first ROTEM and CCT after ICU admission were recorded simultaneously. Additionally, we collected data on blood components transfusion and hemostatic agents immediately after laboratory tests results.The study included 531 patients. Most ROTEM tests showed normal coagulation profile [INTEM (54.8%), EXTEM (54.1%) and FIBTEM (53.3%)] with divergent results in relation to CCT: low platelet count (51.8% in INTEM and 55.9% in EXTEM); prolonged aPTT (69.9% in INTEM and 63.7% in EXTEM) and higher INR (23.8% in INTEM and 27.4% in EXTEM). However 16,7% of patients with normocoagulability in ROTEM received platelet concentrates and 10% fresh frozen plasma.The predominant ROTEM profile observed in this sample of critically ill patients was normal. In contrast, CCT suggested coagulopathy leading to a possibly unnecessary allogenic blood component transfusion. ROTEM test may avoid inappropriate allogeneic blood products transfusion in these patients.

Objective: To evaluate nurses’ perception regarding three differentblood glucose control protocols for critically ill patients. Methods:As part of a randomized trial comparing three blood glucose controlprotocols in critically ill patients (Computer-Assisted Insulin Protocol, Leuven Protocol, and conventional treatment), all nurses participating in the study were asked to fill in a questionnaire to assess their perceptions of efficacy, complexity, feasibility, and safety (as to the occurrence of hypoglycemic episodes), an to indicate which protocol they would like to see adopted as the standard one in the Intensive Care Unit they worked. Results: Sixty nurses answered the questionnaires. Computer-Assisted Insulin Protocol was considered the most efficient protocol to maintain blood glucose levels within the target range by 58% of the nurses, compared to 22% for Leuven Protocol (p

OBJETIVO: Demonstrar as taxas de prevalência de infecção em unidades de terapia intensiva brasileiras e mortalidade atribuída pela análise dos dados ­obtidos pelo estudo Extended Prevalence of Infection in Intensive Care (EPIC II). MÉTODOS: O EPIC II é um estudo multicêntrico, internacional, prospectivo, de prevalência de infecção em UTIs, realizado em apenas um dia. Ele descreve as características demográficas, fisiológicas, bacteriológicas, terapêuticas, acompanhamento até o 60º dia, a prevalência de infecção, a taxa de mortalidade de todos os pacientes internados nas unidades de terapia intensiva participantes entre zero hora e meia noite do dia 8 de maio de 2007. Um total de 14.414 pacientes foram inlcuídos no estudo original, sendo que destes, 1.235 eram brasileiros provenientes de 90 unidades de terapia intensiva do país, que representaram o foco do estudo. RESULTADOS: Dos 1.235 pacientes, 61,6% apresentavam infecção no dia do estudo, sendo que o pulmão era o principal sítio de infecção (71,2%). Metade dos pacientes apresentava cultura positiva, sendo que o predomínio foi de bacilos Gram-negativos (72%). No dia do estudo, o Sequential Organ Failure Assessment (SOFA) mediano foi 5 (3-8) e o Simplified Acute Physiology Score II (SAPS II) mediano 36 (26-47). Os doentes infectados apresentaram escore SOFA significativamente maior do que os não infectados, 6 (4-9) e 3 (2-6), respectivamente. A taxa de mortalidade global na unidade de terapia intensiva foi 28,4%, sendo de 37,6% em infectados e 13,2% em não infectados (p

ABSTRACT Objective: To compare efficacy and safety of vancomycin versus teicoplanin in patients with proven or suspected infection. Methods: Data Sources: Cochrane Renal Group's Specialized Register, CENTRAL, MEDLINE, EMBASE, nephrology textbooks and review articles. Inclusion criteria: Randomized controlled trials in any language comparing teicoplanin to vancomycin for patients with proven or suspected infection. Data extraction: Two authors independently evaluated methodological quality and extracted data. Study investigators were contacted for unpublished information. A random effect model was used to estimate the pooled risk ratio (RR) with 95% confidence interval (CI). Results: A total of 24 studies (2,610 patients) were included. The drugs had similar rates of clinical cure (RR: 1.03; 95%CI: 0.98-1.08), microbiological cure (RR: 0.98; 95%CI: 0.93-1.03) and mortality (RR: 1.02; 95%CI: 0.79-1.30). Teicoplanin had lower rates of skin rash (RR: 0.57; 95%CI: 0.35-0.92), red man syndrome (RR: 0.21; 95%CI: 0.08-0.59) and total adverse events (RR: 0.73; 95%CI: 0.53-1.00). Teicoplanin reduced the risk of nephrotoxicity (RR: 0.66; 95%CI: 0.48-0.90). This effect was consistent for patients receiving aminoglycosides (RR: 0.51; 95%CI: 0.30-0.88) or having vancomycin doses corrected by serum levels (RR: 0.22; 95%CI: 0.10-0.52). There were no cases of acute kidney injury needing dialysis. Limitations: Studies lacked a standardized definition for nephrotoxicity. Conclusions: Teicoplanin and vancomycin are equally effective; however the incidence of nephrotoxicity and other adverse events was lower with teicoplanin. It may be reasonable to consider teicoplanin for patients at higher risk for acute kidney injury.

A desproporção entre a grande demanda por transplantes de órgãos e a baixa realização de transplantes é um grave problema de saúde pública. O reconhecimento da morte encefálica, a adequada abordagem da família e a manutenção clínica do doador falecido são fundamentais para a diminuição desta desproporção. Neste cenário, o intensivista tem importância central e a aplicação do conjunto de informações disponíveis para manutenção do potencial doador falecido está claramente associada à redução de perdas de doadores e ao aumento da qualidade e da efetivação de transplantesThere is a relative shortage of appropriate organs available for transplantation. The appropriate diagnosis of brain death, a suitable family approach and the maintenance of the deceased donor are fundamental in addressing this issue. The intensive care physician plays a key role in the maintenance of the deceased donor, thereby reducing losses and increasing the number of successful transplants

OBJECTIVE: Intravenous infusion of crystalloid solutions is a cornerstone of the treatment of hemorrhagic shock. However, crystalloid solutions can have variable metabolic acid-base effects, perpetuating or even aggravating shock-induced metabolic acidosis. The aim of this study was to compare, in a controlled volume-driven porcine model of hemorrhagic shock, the effects of three different crystalloid solutions on the hemodynamics and acid-base balance. METHODS: Controlled hemorrhagic shock (40% of the total blood volume was removed) was induced in 18 animals, which were then treated with normal saline (0.9% NaCl), Lactated Ringer's Solution or Plasma-Lyte pH 7.4, in a blinded fashion (n = 6 for each group). Using a predefined protocol, the animals received three times the volume of blood removed. RESULTS: The three different crystalloid infusions were equally capable of reversing the hemorrhage-induced low cardiac output and anuria. The Lactated Ringer's Solution and Plasma-Lyte pH 7.4 infusions resulted in an increased standard base excess and a decreased serum chloride level, whereas treatment with normal saline resulted in a decreased standard base excess and an increased serum chloride level. The Plasma-Lyte pH 7.4 infusions did not change the level of the unmeasured anions. CONCLUSION: Although the three tested crystalloid solutions were equally able to attenuate the hemodynamic and tissue perfusion disturbances, only the normal saline induced hyperchloremia and metabolic acidosis.

OBJETIVOS: Pacientes com câncer criticamente enfermos têm maior risco de lesão renal aguda, mas estudos envolvendo estes pacientes são escassos, e todos em centros únicos e realizados em unidades de terapia intensiva especializadas. O objetivo deste estudo foi avaliar as características e desfechos em uma coorte prospectiva de pacientes de câncer internados em diversas unidades de terapia intensiva com lesão renal aguda. MÉTODOS: Estudo prospectivo multicêntrico de coorte realizado em unidades de terapia intensiva de 28 hospitais brasileiros em um período de dois meses. Foram utilizadas regressões logísticas univariada e multivariada para identificar os fatores associados a mortalidade hospitalar. RESULTADOS: Dentre todas as 717 internações a unidades de terapia intensiva, 87 (12%) tiveram lesão renal aguda e 36% deles receberam terapia de substituição renal. A lesão renal se desenvolveu mais frequentemente em pacientes com neoplasias hematológicas do que em pacientes com tumores sólidos (26% x 11%; p=0,003). Isquemia/choque (76%) e sepse (67%) foram os principais fatores associados à lesão renal, e esta foi multifatorial em 79% dos pacientes. A letalidade hospitalar foi de 71%. Os escores de gravidade gerais e específicos para pacientes com lesão renal, foram imprecisos para predizer o prognóstico nestes pacientes. Na análise multivariada, a duração da internação hospitalar antes da unidade de terapia intensiva, disfunções orgânicas agudas, necessidade de ventilação mecânica e um performance status comprometido associaram-se à maior letalidade. Mais ainda, características relacionadas ao câncer não se associaram com os desfechos. CONCLUSÕES: O presente estudo demonstra que internação na unidade de terapia intensiva e suporte avançado à vida devem ser considerados em pacientes selecionados de câncer criticamente enfermos com lesão renal.OBJECTIVES: Critically ill cancer patients are at increased risk for acute kidney injury, but studies on these patients are scarce and were all single centered conducted in specialized intensive care units. The objective was to evaluate the characteristics and outcomes in a prospective cohort of cancer patients admitted to several intensive care units with acute kidney injury. METHODS: Prospective multicenter cohort study conducted in intensive care units from 28 hospitals in Brazil over a two-month period. Univariate and multivariate logistic regression were used to identify factors associated with hospital mortality. RESULTS: Out of all 717 intensive care unit admissions, 87 (12%) had acute kidney injury and 36% of them received renal replacement therapy. Kidney injury developed more frequently in patients with hematological malignancies than in patients with solid tumors (26% vs. 11%, P=0.003). Ischemia/shock (76%) and sepsis (67%) were the main contributing factor for and kidney injury was multifactorial in 79% of the patients. Hospital mortality was 71%. General and renal-specific severity-of-illness scores were inaccurate in predicting outcomes for these patients. In a multivariate analysis, length of hospital stay prior to intensive care unit, acute organ dysfunctions, need for mechanical ventilation and a poor performance status were associated with increased mortality. Moreover, cancer-related characteristics were not associated with outcomes. CONCLUSIONS: The present study demonstrates that intensive care units admission and advanced life-support should be considered in selected critically ill cancer patients with kidney injury.

Objective: Despite the existence of evidence-based guidelines forthe management of patients with severe sepsis and septic shock,there is much variation among individual treatments. Methods: Abefore-after study with prospective data collection was performedat the emergency department and intensive care unit of a 485-bed,private, tertiary, general hospital. A total of 160 patients were enrolled(94 in a “pre-protocol phase” and 66 in a “post-protocol phase”). Aresuscitation bundle for the first six hours and a management bundlefor 24 hours were used. Additional quality indicators were alsoproposed and evaluated. The outcomes analyzed included hospitalmortality, hospital and intensive care unit length of stay, compliancewith bundles and performance related to quality indicators. Results:From the “pre-protocol” to “post-protocol” phase, the diagnosismoved from the intensive care unit (52.0 to 18.2%) to the emergencydepartment (26.6 to 40.9%) and to the wards (17.0 to 36.4%).Number of blood cultures prior to antibiotics, administration ofactivated drotrecogin alfa, use of corticosteroids and compliancewith six-hour and 24-hour sepsis bundles were significantly higherafter protocol implementation. Patients in the “post-protocol” grouphad a statistically lower risk of in-hospital mortality (56.4 versus36.4%, p = 0.01). The greatest decrease in mortality rate occurredamong the most critically ill patients (67.7 to 40.7%, p = 0.004).Conclusions: Adopting an institutional protocol focused on behavioralchanges and using quality improvement tools led to reduced hospitalmortality and generated changes in healthcare team practice. Thisresult adds to the growing evidence that optimized process-of-careby implementing managed protocols for sepsis patients can reducemortality. Therefore, similar strategies should be routinely employed.

Objective: To assess the impact of each measure in the six and 24-hour bundles of a Managed Care Program in the care of a cohort of hospitalized severe sepsis / septic shock patients. Methods: A prospective study was carried out with 316 consecutive patients with severe sepsis / septic shock, assessing the impact on mortality by calculating the Odds Ratio of each single action (significance level of 5%). Rresults: In the sample there were 57% males, the mean age was 65.24 years, the APACHE II score was over 25 in 39.2%; 71.8% had a diagnosis of septic shock, and 65.5% required mechanical ventilation. Furthermore, 88.9% of patients had at least two organ dysfunctions upon the initial presentation. Only the blood culture collected before starting antibiotics: OR = 0.54 (95% CI: 0.33-0.87; p < 0.009) and the introduction of antibiotics by no later than 120 minutes after the diagnosis: OR = 0.44 (95% CI: 0.23-0.87; p < 0.009) were significant. Other six-hour bundle items tended towards a worse outcome. Results were superior in the 24-hour bundles with interventions in all four items, although without statistical significance. Cconclusions: The single impact of all interventions in the bundles occurred due to only two items: collecting blood cultures before starting antibiotics and early use (by 120 minutes) of antibiotics. Future evaluations in larger databases including multivariate analysis may support these findings.

Sepsis is a syndrome related to severe infections. It is defined as the systemic host response to microorganisms in previously sterile tissues and is characterized by end-organ dysfunction away from the primary site of infection. The normal host response to infection is complex and aims to identify and control pathogen invasion, as well as to start immediate tissue repair. Both the cellular and humoral immune systems are activated, giving rise to both anti-inflammatory and proinflammatory responses. The chain of events that leads to sepsis is derived from the exacerbation of these mechanisms, promoting massive liberation of mediators and the progression of multiple organ dysfunction. Despite increasing knowledge about the pathophysiological pathways and processes involved in sepsis, morbidity and mortality remain unacceptably high. A large number of immunomodulatory agents have been studied in experimental and clinical settings in an attempt to find an efficacious anti-inflammatory drug that reduces mortality. Even though preclinical results had been promising, the vast majority of these trials actually showed little success in reducing the overwhelmingly high mortality rate of septic shock patients as compared with that of other critically ill intensive care unit patients. Clinical management usually begins with prompt recognition, determination of the probable infection site, early administration of antibiotics, and resuscitation protocols based on "early-goal" directed therapy. In this review, we address the research efforts that have been targeting risk factor identification, including genetics, pathophysiological mechanisms and strategies to recognize and treat these patients as early as possible.

JUSTIFICATIVA E OBJETIVOS: A interpretação do débito cardíaco e da pré-carga como números absolutos não traz grandes informações sobre a hemodinâmica do paciente crítico. Em contrapartida, a monitorização da resposta do débito cardíaco à expansão volêmica ou suporte inotrópico é uma ferramenta muito útil na unidade de terapia intensiva, quando o paciente apresenta algum sinal de má perfusão tecidual. Apesar do CAP ser considerado como " padrão-ouro" na avaliação destes parâmetros, foram desenvolvidas tecnologias alternativas bastante confiáveis para a sua monitorização. MÉTODO: O processo de desenvolvimento de recomendações utilizou o método Delphi modificado para criar e quantificar o consenso entre os participantes. A AMIB determinou um coordenador para o consenso, o qual escolheu seis especialistas para comporem o comitê consultivo. Outros 18 peritos de diferentes regiões do país foram selecionados para completar o painel de 25 especialistas, médicos e enfermeiros. Um levantamento bibliográfico na MEDLINE de artigos na língua inglesa foi realizado no período de 1966 a 2004. RESULTADOS: Foram apresentadas recomendações referentes à análise da variação da pressão arterial durante ventilação mecânica, débito cardíaco contínuo por contorno de pulso arterial, débito cardíaco por diluição do lítio, Doppler transesofágico, bioimpedância transtorácica, ecocardiografia e reinalação parcial de gás carbônico. CONCLUSÕES: As novas e menos invasivas técnicas para medida do débito cardíaco, pré-carga e fluidoresponsividade apresentam adequada precisão e podem ser uma alternativa ao uso do CAP em pacientes graves.BACKGROUND AND OBJECTIVES: Cardiac output and preload as absolute data do not offer helpful information about the hemodynamic of critically ill patients. However, monitoring the response of these variables to volume challenge or inotropic drugs is a very useful tool in the critical care setting, particularly for patients with signs of tissue hypoperfusion. Although PAC remains the " gold standard" to measure cardiac output and preload, new and alternative technologies were developed to evaluate these hemodynamic variables. 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 three 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 regarding the use of arterial pulse pressure variation during mechanical ventilation, continuous arterial pulse contour and lithium dilution cardiac output measurements, esophageal Doppler waveform, thoracic electrical bioimpedance, echocardiography and partial CO2 rebreathing for monitoring cardiac output and preload were created. CONCLUSIONS: The new and less invasive techniques for the measurement of cardiac output, preload or fluid responsiveness are accurate and may be an alternative to PAC in critically ill patients.

JUSTIFICATIVA E OBJETIVOS: A monitorização de funções vitais é uma das mais importantes e essenciais ferramentas no manuseio de pacientes críticos na UTI. Hoje é possível detectar e analisar uma grande variedade de sinais fisiológicos através de diferentes técnicas, invasivas e não-invasivas. O intensivista deve ser capaz de selecionar e executar o método de monitorização mais apropriado de acordo com as necessidades individuais do paciente, considerando a relação risco-benefício da técnica. Apesar do rápido desenvolvimento de técnicas de monitorização não-invasiva, a monitorização hemodinâmica invasiva com o uso do cateter de artéria pulmonar (CAP) ainda é um dos procedimentos fundamentais em UTI. O objetivo destas recomendações é estabelecer diretrizes para o uso adequado dos métodos básicos de monitorização hemodinâmica e CAP. MÉTODO: O processo de desenvolvimento de recomendações utilizou o método Delphi modificado para criar e quantificar o consenso entre os participantes. A AMIB determinou um coordenador para o consenso, o qual escolheu seis especialistas para comporem o comitê consultivo. Outros 18 peritos de diferentes regiões do país foram selecionados para completar o painel de 25 especialistas, médicos e enfermeiros. Um levantamento bibliográfico na MedLine de artigos na língua inglesa foi realizado no período de 1966 a 2004. RESULTADOS: Foram apresentadas recomendações referentes a 55 questões sobre monitorização da pressão venosa central, pressão arterial invasiva e cateter de artéria pulmonar. Com relação ao CAP, além de recomendações quanto ao uso correto foram discutidas as indicações em diferentes situações clínicas. CONCLUSÕES: A avaliação da pressão venosa central e da pressão arterial, além das variáveis obtidas com o CAP permite o entendimento da fisiologia indispensável para o cuidado de pacientes graves. Entretanto, a correta utilização dessas ferramentas é fundamental para os possíveis benefícios decorrentes do uso.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.

Current guidelines and consensus recommend arterial and venous samples as equally acceptable for blood glucose assessment in point-of-care devices, but there is limited evidence to support this recommendation. We evaluated the accuracy of two devices for bedside point-of-care blood glucose measurements using arterial, fingerstick and catheter venous blood samples in ICU patients, and assessed which factors could impair their accuracy.145 patients from a 41-bed adult mixed-ICU, in a tertiary care hospital were prospectively enrolled. Fingerstick, central venous (catheter) and arterial blood (indwelling catheter) samples were simultaneously collected, once per patient. Arterial measurements obtained with Precision PCx, and arterial, fingerstick and venous measurements obtained with Accu-chek Advantage II were compared to arterial central lab measurements. Agreement between point-of-care and laboratory measurements were evaluated with Bland-Altman, and multiple linear regression models were used to investigate interference of associated factors.Mean difference between Accu-chek arterial samples versus central lab was 10.7 mg/dL (95% LA -21.3 to 42.7 mg/dL), and between Precision PCx versus central lab was 18.6 mg/dL (95% LA -12.6 to 49.5 mg/dL). Accu-chek fingerstick versus central lab arterial samples presented a similar bias (10.0 mg/dL) but a wider 95% LA (-31.8 to 51.8 mg/dL). Agreement between venous samples with arterial central lab was the poorest (mean bias 15.1 mg/dL; 95% LA -51.7 to 81.9). Hyperglycemia, low hematocrit, and acidosis were associated with larger differences between arterial and venous blood measurements with the two glucometers and central lab. Vasopressor administration was associated with increased error for fingerstick measurements.Sampling from central venous catheters should not be used for glycemic control in ICU patients. In addition, reliability of the two evaluated glucometers was insufficient. Error with Accu-chek Advantage II increases mostly with central venous samples. Hyperglycemia, lower hematocrit, acidosis, and vasopressor administration increase measurement error.

Mechanisms governing the inflammatory response during sepsis have been shown to be complex, involving cross-talk between diverse signaling pathways. Current knowledge regarding the mechanisms underlying sepsis provides an incomplete picture of the syndrome, justifying additional efforts to understand this condition. Microarray-based expression profiling is a powerful approach for the investigation of complex clinical conditions such as sepsis. In this study, we investigate whole-genome expression profiles in mononuclear cells from survivors (n = 5) and non-survivors (n = 5) of sepsis. To circumvent the heterogeneity of septic patients, only patients admitted with sepsis caused by community-acquired pneumonia were included. Blood samples were collected at the time of sepsis diagnosis and seven days later to evaluate the role of biological processes or genes possibly involved in patient recovery. Principal Components Analysis (PCA) profiling discriminated between patients with early sepsis and healthy individuals. Genes with differential expression were grouped according to Gene Ontology, and most genes related to immune defense were up-regulated in septic patients. Additionally, PCA in the early stage was able to distinguish survivors from non-survivors. Differences in oxidative phosphorylation seem to be associated with clinical outcome because significant differences in the expression profile of genes related to mitochondrial electron transport chain (ETC) I-V were observed between survivors and non-survivors at the time of patient enrollment. Global gene expression profiles after seven days of sepsis progression seem to reproduce, to a certain extent, patterns collected at the time of diagnosis. Gene expression profiles comparing admission and follow-up samples differed between survivors and non-survivors, with decreased expression of genes related to immune functions in non-survivors. In conclusion, genes related to host defense and inflammatory response ontology were up-regulated during sepsis, consistent with the need for a host response to infection, and the sustainability of their expression in follow-up samples was associated with outcomes.

Apesar das diversas inovações tecnológicas e do melhor entendimento fisiopatológico dos estados de choque, esta condição permanece com elevada taxa de morbimortalidade. Uma das explicações mais aceitas para a taxa elevada é o desenvolvimento da síndrome de disfunção de múltiplos órgãos (SDMO), secundária à hipoperfusão tecidual persistente. Assim, é evidente a importância da avaliação da perfusão tecidual em tais quadros, bem como possíveis interferências terapêuticas a partir da avaliação. Nesta revisão, são abordadas noções básicas sobre a monitorização clínica e laboratorial da perfusão tecidual no choque, incluindo transporte de O2, consumo e taxa de extração de O2 saturação venosa mista de O2, lactato e gradiente gastroarterial de CO2. Tais dados são fundamentais para a correta interpretação e melhor intervenção terapêutica, visando adequar o desequilíbrio presente entre oferta/consumo de O2 e, desta forma, interromper a série de eventos fisiopatológicos que resulta em SDMO e, em muitas condições, em morte. Nesse contexto, algumas metas devem ser alcançadas durante a ressuscitação de pacientes com síndrome do choque, a saber: pressão arterial média > 65 mmHg; diurese ³ 1 ml/kg/hora; débito cardíaco suficiente para manter uma SvO2 >65%; lactato sérico < 2 mmol/L, destacando que, mesmo quando normalizadas as variáveis sistêmicas de oxigenação, graves distúrbios perfusionais regionais ainda podem existir, sendo necessário recorrer à monitorização regional através da avaliação do pCO2-gap.

OBJETIVO: Avaliar a percepção de enfermeiros a respeito de três protocolos para controle glicêmico em pacientes críticos. MÉTODOS: Como parte complementar de um estudo randomizado comparando três protocolos de controle glicêmico em pacientes críticos (Protocolo de Insulina Assistido por Computador, Protocolo de Leuven e tratamento convencional), todos os enfermeiros participantes do estudo foram convidados a preencher um questionário a fim de avaliar suas percepções a respeito da eficácia, complexidade, viabilidade e segurança (em razão da ocorrência de episódios de hipoglicemia), e indicar qual dos três protocolos eles gostariam que fosse adotado na Unidade de Terapia Intensiva em que trabalhavam. RESULTADOS: Os questionários foram respondidos por 60 enfermeiros. O Protocolo de Insulina Assistido por Computador foi considerado o protocolo mais eficiente para a manutenção do nível de glicemia dentro da faixa-alvo por 58% dos enfermeiros, comparado a 22% para PL (p

The early recognition and treatment of severe sepsis and septic shock is the key to a successful outcome. The longer the delay in starting treatment, the worse the prognosis due to persistent tissue hypoperfusion and consequent development and worsening of organ dysfunction. One of the main mechanisms responsible for the development of cellular dysfunction is tissue hypoxia. The adjustments necessary for adequate tissue blood flow and therefore of oxygen supply to metabolic demand according to the assessment of the cardiac index and oxygen extraction rate should be performed during resuscitation period, especially in high complexity patients. New technologies, easily handled at the bedside, and new studies that directly assess the impact of macro-hemodynamic parameter optimization on microcirculation and in the clinical outcome of septic patients, are needed.

Objective To compare outcomes between elderly (≥65 years old) and non-elderly (

CONTEXT AND OBJECTIVE: Prognostic models reflect the population characteristics of the countries from which they originate. Predictive models should be customized to fit the general population where they will be used. The aim here was to perform external validation on two predictive models and compare their performance in a mixed population of critically ill patients in Brazil.DESIGN AND SETTING: Retrospective study in a Brazilian general intensive care unit (ICU).METHODS: This was a retrospective review of all patients admitted to a 41-bed mixed ICU from August 2011 to September 2012. Calibration (assessed using the Hosmer-Lemeshow goodness-of-fit test) and discrimination (assessed using area under the curve) of APACHE II and SAPS III were compared. The standardized mortality ratio (SMR) was calculated by dividing the number of observed deaths by the number of expected deaths.RESULTS: A total of 3,333 ICU patients were enrolled. The Hosmer-Lemeshow goodness-of-fit test showed good calibration for all models in relation to hospital mortality. For in-hospital mortality there was a worse fit for APACHE II in clinical patients. Discrimination was better for SAPS III for in-ICU and in-hospital mortality (P = 0.042). The SMRs for the whole population were 0.27 (confidence interval [CI]: 0.23 - 0.33) for APACHE II and 0.28 (CI: 0.22 - 0.36) for SAPS III.CONCLUSIONS: In this group of critically ill patients, SAPS III was a better prognostic score, with higher discrimination and calibration power.

Early resuscitation of septic shock patients reduces the sepsis-related morbidity and mortality. The main goals of septic shock resuscitation include volemic expansion, maintenance of adequate tissue perfusion and oxygen delivery, guided by central venous pressure, mean arterial pressure, mixed or central venous oxygen saturation and arterial lactate levels. An aggressive fluid resuscitation, possibly in association with vasopressors, inotropes and red blood cell concentrate transfusion may be necessary to achieve those hemodynamic goals. Nonetheless, even though fluid administration is one of the most common interventions offered to critically ill patients, the most appropriate type of fluid to be used remains controversial. According to recently published clinical trials, crystalloid solutions seem to be the most appropriate type of fluids for initial resuscitation of septic shock patients. Balanced crystalloids have theoretical advantages over the classic solutions, but there is not enough evidence to indicate it as first-line treatment. Additionally, when large amounts of fluids are necessary to restore the hemodynamic stability, albumin solutions may be a safe and effective alternative. Hydroxyethyl starches solutions must be avoided in septic patients due to the increased risk of acute renal failure, increased need for renal replacement therapy and increased mortality. Our objective was to present a narrative review of the literature regarding the major types of fluids and their main drawbacks in the initial resuscitation of the septic shock patients.

ABSTRACT Objective To verify the impact of the Lean Six Sigma methodology in reducing incorrect entries of non-appropriated revenues and expenses. Methods Process for the review and application of the Lean Six Sigma methodology between December 2015 and September 2016, in a high-complexity general hospital in the city of São Paulo (SP). Results A total of 3,756,814 (100%) entries were audited between December 2015 and September 2016. The Sigma level evolved over the course of the process and increased from 3.44 Sigma in December 2015 to 5.92 Sigma in September 2016. Entries classified as non-appropriated revenues and expenses were brought down to 0% at the end of the study. Conclusion The use of the Lean Six Sigma methodology was efficient in reducing incorrect entries, calculating costs, ensuring compliance in rendering of accounts and accurately determining cost-outcome ratios.