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Background It is known that patients with COVID-19 are at high risk of developing delirium. The aim of the study was to compare the incidence of delirium between critically ill patients with and without a diagnosis of COVID-19. Methods This is a retrospective study conducted in a southern Brazilian hospital from March 2020 to January 2021. Patients were divided into two groups: the COVID-19 group consisted of patients with a diagnosis of COVID-19 confirmed by reverse transcription-polymerase chain reaction (RT-PCR) or serological tests who were admitted to specific ICUs. The non-COVID-19 group consisted of patients with other surgical and medical diagnoses who were admitted to non-COVID ICUs. All patients were evaluated daily using the Intensive Care Delirium Screening Checklist (ICDSC). The two cohorts were compared in terms of the diagnosis of delirium. Results Of the 649 patients who remained more than 48 h in the ICU, 523 were eligible for the study (COVID-19 group: 292, non-COVID-19 group: 231). There were 119 (22.7%) patients who had at least one episode of delirium, including 96 (32.9%) in the COVID-19 group and 23 (10.0%) in the non-COVID-19 group (odds ratio [OR] 4.42; 95% confidence interval [CI], 2.69 to 7.26; p Conclusion COVID-19 can be associated with a higher incidence of delirium among critically ill patients, but there was no difference in this incidence between groups when mechanical ventilation lasted two days or more.

Este estudo tem por base a premissa de que com um maior número de leitos de Unidade de Terapia Intensiva (UTI) disponíveis o tempo de espera para admissão em UTI é menor, o que resulta no melhor desfecho clínico, justificando, portanto, a importância do presente estudo. Objetivo: Avaliar se o tempo de espera no Departamento de Emergência até a admissão em UTI tem influência no desfecho clínico do paciente crítico. Metodologia: Estudo observacional, retrospectivo, do tipo antes e depois, realizado em um hospital público do município de Joinville/SC no ano de 2019. Foram incluídos os dados referentes aos pacientes adultos admitidos na UTI com até 72 horas de espera no Departamento de Emergência desde a chegada ao hospital. Comparou-se o último trimestre de 2017 (fase 1), período durante o qual havia 14 leitos de UTI no hospital, e último trimestre de 2018 (fase 2), período durante o qual havia 30 leitos de UTI. Resultados: Analisaram-se 173 prontuários elegíveis de 2017 e 2018. Houve diferença estatisticamente significativa no tempo decorrido na emergência até a admissão em UTI entre 2017 e 2018 (mediana de 22 vs. 15; p=0,0002). A diferença estatística também foi relevante para a mortalidade em até 24 horas após a admissão em UTI, comparando-se os dois anos em questão (9,61% vs. 2,47%; p=0,04). Não houve diferença estatística significante na mortalidade hospitalar entre 2017 e 2018 (34,6% vs. 35,5%; p=0,57). Também não houve diferença estatisticamente relevante entre os demais parâmetros analisados. Conclusão: Comparando-se 2017 a 2018, percebeu-se que o tempo de espera pelo leito de UTI diminuiu, bem como a mortalidade em até 24h da admissão intensiva. No entanto, isto não se refletiu na mortalidade hospitalar.

RESUMO Objetivo: Fornecer recomendações para nortear o manejo clínico do potencial doador em morte encefálica. Métodos: O presente documento foi formulado em dois painéis compostos por uma força tarefa integrada por 27 especialistas de diferentes áreas que responderam a questões dirigidas aos seguintes temas: ventilação mecânica, hemodinâmica, suporte endócrino-metabólico, infecção, temperatura corporal, transfusão sanguínea, e uso de checklists. Os desfechos considerados foram: parada cardíaca, número de órgãos retirados ou transplantados e função/sobrevida dos órgãos transplantados. A qualidade das evidências das recomendações foi avaliada pelo sistema Grading of Recommendations Assessment, Development, and Evaluation. Resultados: Foram geradas 19 recomendações a partir do painel de especialistas. Dessas, 7 foram classificadas como fortes, 11 fracas e uma foi considerada boa prática clínica. Conclusão: Apesar da concordância entre os membros do painel em relação à maior parte das recomendações, o grau de recomendação é fraco em sua maioria. Abstract Objective: To contribute to updating the recommendations for brain-dead potential organ donor management. Methods: A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, answered questions related to the following topics were divided into mechanical ventilation, hemodynamics, endocrine-metabolic management, infection, body temperature, blood transfusion, and checklists use. The outcomes considered were cardiac arrests, number of organs removed or transplanted as well as function / survival of transplanted organs. The quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system to classify the recommendations. Results: A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong, 11 as weak and 1 was considered a good clinical practice. Conclusion: Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak.

Made available in DSpace on 2022-04-29T08:30:53Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-04-01 National Health and Medical Research Council 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. Discipline of Anesthesiology Pain and Intensive Care Universidade Federal de São Paulo, Rua Napoleão de Barros, 737, 6ºandar Critical Care and Trauma Division George Institute for Global Health Hospital Sírio-Libanês Hospital das Clínicas Faculdade de Medicina Universidade de São Paulo Instituto de Pesquisa HCor - Hospital do Coração Instituto de Pesquisa Clínica Evandro Chagas Fundação Oswaldo Cruz Hospital de Clínicas Mário Lioni Hospital do Rim e Hipertensão Fundação Oswaldo Ramos Hospital Samaritano Hospital Paulistano Hospital São José Instituto D’Or de Ensino e Pesquisa Hospital Municipal São José Hospital Israelita Albert Einstein Hospital Santa Rita Hospital de Base Faculdade de Medicina de São Jose do Rio Preto Hospital Unimed de Belo Horizonte Hospital Santa Lúcia Hospital Evangélico de Sorocaba Hospital PIO XII Hospital São Camilo Pompéia Hospital Alvorada Brasília Hospital Ecoville Hospital do Trabalhador Hospital Vita Batel Hospital das Clínicas Faculdade de Medicina de Botucatu Universidade Estadual “Júlio de Mesquita Filho” Hospital Geral Dr. César Cals Hospital Copa D’Or Associação Beneficente Hospital Unimar Hospital Casa de Saúde de Santos Hospital Estadual Getúlio Vargas Hospital e Maternidade Otaviano Neves Instituto Estadual do Cérebro Paulo Niemeyer Hospital Universitário Universidade Federal de Juiz de Fora Lifecenter Hospital Geral de Fortaleza Hospital Municipal Dr. Moysés Deutsch (M’Boi Mirim) Santa Casa de Misericórdia de Presidente Prudente Hospital 9 de julho Hospital Estadual Rocha Faria Hospital Municipal Santa Isabel Hospital e Maternidade Municipal Dr. Odelmo Leão Carneiro Hospital Evangélico de Londrina Universidade Estadual de Londrina Hospital Samaritano João Pessoa Hospital de Caridade Astrogildo de Azevedo Vitória Apart Hospital Instituto de Ortopedia e Traumatologia Hospital do Subúrbio Hospital Renascentista Hospital Felício Rocho Hospital Municipal Irmã Dulce Hospital Universitário Júlio Müller Universidade Federal do Mato Grosso Hospital de Urgência Hospital Geral de Goiânia Fundação Doutor Amaral Carvalho Hospital Adventista de Belém Hospital Santa Juliana Hospital Dom Vicente Scherer Hospital Primavera Hospital Carlos da Silva Lacaz Hospital Escola Faculdade de Medicina de Jundiaí Hospital Sepaco Hospital Professor Edmundo Vasconcelos Hospital Paulo Sacramento Clínica Dom Rodrigo Complexo Hospitalar Ortotrauma de Mangabeira Hospital Nossa Senhora da Conceição Hospital Regional de Samambaia Hospital São Camilo Ipiranga Hospital da Restauração Instituto do Coração Hospital das Clínicas Faculdade de Medicina Universidade de São Paulo Hospital Estadual Jayme Santos Neves Hospital SOS Cárdio Hospital da Luz Vila Mariana Hospital Maternidade e Pronto-Socorro Santa Luci Santa Casa de Misericórdia de Vitória da Conquista Santa Casa de Misericórdia de Porto Alegre Hospital São Francisco de Assis Hospital Memorial São José Hospital Regional de Jundiaí Hospital Universitário Faculdade de Medicina de Jundiaí Hospital Regional de Presidente Prudente Santa Casa de Misericórdia de Assis Hospital de Clínicas Gaspar Vianna Hospital do Coração do Brasil Hospital Hélio Anjos Ortiz Hospital Vila da Serra Hospital Nereu Ramos Hospital Santa Maria Intensibarra Santa Casa de Misericórdia de Santo Amaro Santa Casa de Caridade de Don Pedrito Santa Casa de Misericórdia de Santana do Livramento Hospital Unimed de Macaé Hospital Municipal Pedro II Hospital Federal dos Servidores do Estado Hospital São Mateus Hospital IBR Hospital Uniclinic Santa Casa de Misericórdia de Paraguaçu Paulista Associação Hospitalar Beneficente São Vicente de Paulo Hospital do Servidor Público Municipal de São Paulo Hospital Santa Isabel Hospital Municipal Dr Jose Soares Hungria Hospital Fernandes Távora Hospital Distrital Evandro Ayres de Moura Hospital Saúde da Mulher Hospital Estadual de Urgência e Emergência de Vitória Samur Hospital e Pronto-Socorro 28 de Agosto Hospital Assunção Hospital Universitário de Santa Maria Hospital Universitário Cajuru Instituto do Câncer do Estado de São Paulo Hospital Unimed de Limeira Hospital Amecor Santa Casa de Caridade de Diamantina Hospital das Clínicas Faculdade Ribeirão Preto Universidade de São Paulo HCor - Hospital do Coração Hospital Goiânia Leste Hospital Ortopédico Hospital Santa Maria Hospital Municipal Dr. Munir Rafful Hospital Jardim Amália Hospital Madre Regina Prottman Hospital Universitário São Francisco de Paula Universidade Católica de Pelotas Hospital São Joao de Deus Hospital Nossa Senhora Monte Serrat Hospital Unimed Salto Hospital Moinhos de Vento Hospital Geral de Vitória da Conquista Hospital Marcelino Champagnat Hospital São Lucas Pontifícia Universidade Católica do Rio Grande do Sul Hospital Universitário Universidade Federal da Grande Dourados Hospital Português Hospital Brigadeiro Hospital Regional de Sousa Hospital das Clínicas Universidade Federal do Espírito Santo Santa Casa de Misericórdia de Ribeirão Preto Hospital Universitário Lauro Wanderley Santa Casa de Belo Horizonte Hospital Adventista de Manaus Santa Casa Maringá Universidade Estadual Maringá Hospital Total Cor Hospital Universitário Universidade de Santa Cruz do Sul Hospital Dom Hélder Hospital das Clínicas de Porto Alegre Universidade Federal do Rio Grande do Sul Hospital Anis Rassi Instituto de Infectologia Emílio Ribas II Hospital Unimed Rio de Janeiro Hospital Alemão Oswaldo Cruz Hospital Samaritano Rio de Janeiro São Bernardo Apart Hospital Hospital Nossa Senhora dos Prazeres Hospital Unimed ABC Hospital Municipal de Paracatu Hospital Municipal Padre Germano Lauck Hospital Santa Helena Hospital Santa Izabel Santa Casa de Misericórdia de São Paulo Hospital Tereza Ramos Hospital Alvorada Taguatinga Hospital Maternidade São José Hospital Universitário Ciências Médicas Fundação Educacional Lucas Machado Santa Casa de Belém do Pará Instituto Nacional de Cardiologia Hospital Novo Atibaia BP - A Beneficência Portuguesa de São Paulo Hospital Universitário Maria Aparecida Pedrossian Universidade Federal de Mato Grosso do Sul Hospital do Servidor Público Estadual “Francisco Morato de Oliveira” Hospital Norte D’Or Hospital Estadual Ipiranga Hospital Universitário de Maringá Universidade Estadual de Maringá Albert Sabin Hospital e Maternidade Casa de Caridade de Carangola Irmandade de Misericórdia de Guaxupé Disciplina de Emergências Clínicas Universidade Estadual de Campinas Hospital São Lucas Fundação Pio XII- Hospital de Câncer de Barretos Clínica Campo Grande Hospital das Clínicas Universidade Federal de Minas Gerais Casa de Saúde Santa Lúcia Hospital Regional de Itapetininga São Camilo Santa Casa de Angra dos Reis Grupo Hospitalar Nossa Senhora da Conceição Irmandade Misericórdia Hospital Santa Casa de Monte Alto Hospital São Marcos Hospital Unimed de Manaus Hospital Universitário Getúlio Vargas Universidade Federal do Amazonas Casa de Saúde Campinas Hospital e Maternidade Galileo Hospital das Clínicas Faculdade de Medicina de Botucatu Universidade Estadual “Júlio de Mesquita Filho” National Health and Medical Research Council: APP1039312

Background: The effectiveness of evidence-based, goal-directed care to reduce losses of brain-dead potential organ donors through cardiac arrest is unclear. DONORS aimed to determine whether guiding clinical management with an evidence-based goal-directed checklist can reduce losses of potential organ donors to cardiac arrest. Methods: This open cluster randomized trial assigned adult intensive care units from hospitals across Brazil with 10 or more annual brain death reports to guide the management of potential donors with the checklist (intervention group) or to maintain usual care without the checklist (control group). Intervention group was instructed to apply a checklist with 13 clinical goals and 14 corresponding actions, every six hours, from study enrollment to organ retrieval. Consecutive potential donors between 14 and 90 years of age were included. Primary outcome was incidence of loss of brain-dead potential organ donors to cardiac arrest at the individual level. A prespecified sensitivity analysis assessed checklist adherence as an effect modifier. Findings: Among 1771 potential donors screened, 1535 were included from 63 hospitals: 31 assigned to checklist guidance (743 potential donors) and 32 to usual care (792 potential donors). Seventy (9.4%) potential donors at intervention hospitals and 117 (14.8%) at control met the primary outcome (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.53 to 1.05; P=0.09). Median checklist adherence was 79% (interquartile range, 64% to 90%). Among those with adherence greater than 79%, primary outcome rate was lower than control group (5.3% vs. 14.8%; HR, 0.45; 9% CI, 0.26 to 0.75). Among those with low adherence, primary outcome rate was comparable to the control group. Interpretation: Overall use of the checklist in preventing donor loss due to cardiac arrest was inconclusive. However, predefined subgroup analysis suggests that high adherence to the checklist may reduce donor losses to cardiac arrest. Funding: Brazilian Ministry of Health through PROADI-SUS. Declaration of Interests: The authors have no conflicts of interest to disclose. Ethics Approval Statement: In accordance with ethical principles stated in the Resolution No. 466/2012 of the Brazilian National Health Council/Ministry of Health, the Research Ethics Committee of each participating hospital approved the conduct of this study with a waiver of consent for eligible potential donors. Trial Registration: ClinicalTrials.gov number, NCT03179020 (https://clinicaltrials.gov/ct2/show/NCT03179020)

Background The quality of clinical care of brain-dead potential organ donors may help reduce donor losses caused by irreversible or unreversed cardiac arrest and increase the number of organs donated. We sought to determine whether an evidence-based, goal-directed checklist for donor management in intensive care units (ICUs) can reduce donor losses to cardiac arrest. Methods/design The DONORS study is a multicentre, cluster-randomised controlled trial with a 1:1 allocation ratio designed to compare an intervention group (goal-directed checklist for brain-dead potential organ donor management) with a control group (standard ICU care). The primary outcome is loss of potential donors due to cardiac arrest. Secondary outcomes are the number of actual organ donors and the number of solid organs recovered per actual donor. Exploratory outcomes include the achievement of relevant clinical goals during the management of brain-dead potential organ donors. The present statistical analysis plan (SAP) describes all primary statistical procedures that will be used to evaluate the results and perform exploratory and sensitivity analyses of the trial. Discussion The SAP of the DONORS study aims to describe its analytic procedures, enhancing the transparency of the study. At the moment of SAP subsmission, 63 institutions have been randomised and were enrolling study participants. Thus, the analyses reported herein have been defined before the end of the study recruitment and database locking. Trial registration ClinicalTrials.gov, NCT03179020. Registered on 7 June 2017.

To compare the clinical characteristics and outcomes of patients with community-acquired and hospital-acquired sepsis.This is a retrospective cohort study that included all patients with a diagnosis of sepsis detected between January 2010 and December 2015 at a private hospital in southern Brazil. Outcomes (mortality, intensive care unit and hospital lengths of stay) were measured by analyzing electronic records.There were 543 hospitalized patients with a diagnosis of sepsis, with a frequency of 90.5 (85 to 105) cases/year. Of these, 319 (58%) cases were classified as hospital-acquired sepsis. This group exhibited more severe disease and had a larger number of organ dysfunctions, with higher hospital [8 (8 - 10) versus 23 (20 - 27) days; p0.001] and intensive care unit [5 (4 - 7) versus 8.5 (7 - 10); p0.001] lengths of stay and higher in-hospital mortality (30.7% versus 15.6%; p0.001) than those with community-acquired sepsis. After adjusting for age, APACHE II scores, and hemodynamic and respiratory dysfunction, hospital-acquired sepsis remained associated with increased mortality (OR 1.96; 95%CI 1.15 - 3.32, p = 0.013).The present results contribute to the definition of the epidemiological profile of sepsis in the sample studied, in which hospital-acquired sepsis was more severe and was associated with higher mortality.Comparar as características clínicas e os desfechos de pacientes com sepse adquirida na comunidade ou no hospital.Trata-se de estudo retrospectivo de coorte, que incluiu todos os pacientes com diagnóstico de sepse detectada entre janeiro de 2010 e dezembro de 2015 em um hospital privado localizado na Região Sul do Brasil. Os desfechos (mortalidade, tempo de permanência na unidade de terapia intensiva e no hospital) foram avaliados por meio da análise dos registros eletrônicos.Foram hospitalizados, no total, 543 pacientes com diagnóstico de sepse, com frequência de 90,5 (85 a 105) casos por ano. Destes, 319 (58%) casos foram classificados como sepse adquirida no hospital. Este grupo apresentava doença mais grave e tinha um maior número de disfunções de órgãos, assim como teve um tempo maior de permanência no hospital [8 (8 - 10) versus 23 (20 - 27) dias; p0,001] e na unidade de terapia intensiva [5 (4 - 7) versus 8,5 (7 - 10); p0,001] do aqueles que apresentavam sepse adquirida na comunidade. Após ajustar quanto à idade, escore APACHE II e disfunção hemodinâmica e respiratória, a sepse adquirida no hospital persistiu associada com maior mortalidade (OR 1,96; IC95% 1,15 - 3,32, p = 0,013).Nossos resultados contribuem para a definição do perfil epidemiológico da sepse na amostra estudada, na qual a sepse adquirida no hospital foi mais grave e associada com mortalidade mais alta.

Brain death, defined as the complete and irreversible loss of brain functions, has a history that is linked to the emergence of intensive care units and the advancement of artificial ventilatory support. In Brazil, by federal law, the criteria for the diagnosis of brain death have been defined by the Federal Council of Medicine since 1997 and apply to the entire Brazilian territory. Resolution 2,173/2017 of the Federal Council of Medicine updated the criteria for diagnosing brain death. These changes include the following: the requirement for the patient to meet specific physiological prerequisites and for the physician to provide optimized care to the patient before starting the procedures for diagnosing brain death and to perform complementary tests, as well as the need for specific training for physicians who make this diagnosis. Other changes include the reduction of the time interval between the two clinical examinations, the possibility of continuing procedures in the presence of unilateral ear or eye injury, the performance of a single apnea test and the creation of a statement of brain death determination that includes the recording of all procedures in a single document. This document, despite the controversy surrounding it, increases the safety necessary when establishing a diagnosis of such importance and has positive implications that extend beyond the patient and the physician to reach the entire health system.Definida como a perda completa e irreversível das funções encefálicas, a morte encefálica tem sua história vinculada ao surgimento das unidades de terapia intensiva e do avanço do suporte ventilatório artificial. No Brasil, por determinação de lei federal, os critérios para determinação da morte encefálica são definidos pelo Conselho Federal de Medicina desde 1997, sendo válidos para todo o território nacional. A resolução 2.173/2017 do Conselho Federal de Medicina atualizou a metodologia para determinação da morte encefálica. Fazem parte dessas mudanças: a obrigatoriedade da observação de pré-requisitos fisiológicos, do atendimento otimizado ao paciente antes de iniciar os procedimentos para determinar a morte encefálica e da realização de exames complementares, bem como a necessidade de capacitação específica dos médicos que realizam tal diagnóstico. Também fazem parte das novidades a redução do intervalo de tempo entre os dois exames clínicos, a possibilidade de prosseguir os procedimentos mediante lesão unilateral de olho ou ouvido, a realização de um único teste de apneia e a criação de um termo de determinação de morte encefálica que contempla o registro de todos os procedimentos em um documento único. É evidente, nesse documento, ainda que existam controvérsias, o aprimoramento da segurança para definição de um diagnóstico de tamanha importância, com implicações positivas que se estendem para além do paciente e do médico, e abrangem todo o sistema de saúde.

Purpose: To assess how preexisting disabling comorbidities (DC) affect the recovery rate of quality of life (QOL) over time in sepsis survivors. Methods: A prospective study was conducted on sepsis survivors who answered the 36-Item Short Form Health Survey (SF-36) 7 days after discharge from the intensive care unit. Subsequent interviews were held at 3, 6, and 12 months. The results of the physical component score (PCS) and mental component score (MCS) of the SF-36 were evaluated. Patients were divided into 2 groups to compare patients with DC (DC group) and without DC (no-DC group). Quantile regression was used to model changes in PCS and MCS between different time points. Results: Seventy-nine sepsis survivors were enrolled. After controlling for baseline age and QOL, the QOL scores were lower among patients with DC than in no-DC patients. The QOL of DC group got worse when compared to no-DC group. Recovery rate of PCS and MCS was higher in the DC group than in the no-DC group (PCS: 20.51 vs 16.96, P < .01; MCS: 19.24 vs 9.66, P < .01). Their baseline QOL was recovered only by 6 months after the sepsis episode. Conclusion: Quality-of-life impairment and its recovery rhythm in patients with sepsis appear to be conditioned by coexisting DC.

RESUMO Objetivo: Caracterizar os pacientes com doença crítica crônica e identificar os preditores relacionados à evolução para doença crítica crônica. Métodos: Coleta prospectiva de dados por 1 ano realizada na unidade de terapia intensiva de um hospital geral localizado na Região Sul do país. Construíram-se três modelos de regressão logística para identificar os fatores associados com doença crítica crônica. Resultados: Dentre os 574 pacientes admitidos à unidade de terapia intensiva durante o período do estudo, 200 foram submetidos à ventilação mecânica. Destes, 85 (43,5%) pacientes desenvolveram doença crítica crônica, totalizando 14,8% de todos os pacientes admitidos à unidade de terapia intensiva. O modelo de regressão que avaliou os fatores prévios à admissão à unidade de terapia intensiva associados com doença crítica crônica identificou insuficiência renal crônica submetida à diálise (OR 3,57; p = 0,04) e diagnóstico neurológico quando da admissão ao hospital (OR 2,25; p = 0,008) como fatores independentes. No modelo que avaliou a associação de doença crítica crônica com situações ocorridas durante a permanência na unidade de terapia intensiva, destacaram-se fraqueza muscular (OR 2,86; p = 0,01) e úlceras por pressão (OR 9,54; p < 0,001). Na análise multivariada global (fatores prévios e situações ocorridas durante a permanência na unidade de terapia intensiva), destacaram-se admissão ao hospital por doenças neurológicas (OR 2,61; p = 0,03) e desenvolvimento de úlceras por pressão (OR 9,08; p < 0,001). Conclusão: A incidência de doença crítica crônica foi similar à observada em outros estudos e teve associação mais forte com o diagnóstico de doenças neurológicas quando da admissão ao hospital e insuficiência renal crônica submetida à hemodiálise, assim como com complicações desenvolvidas durante a hospitalização, como úlceras por pressão e fraqueza muscular. ABSTRACT Objective: To characterize patients with chronic critical illness and identify predictors of development of chronic critical illness. Methods: Prospective data was collected for 1 year in the intensive care unit of a general hospital in Southern Brazil. Three logistic regression models were constructed to identify factors associated with chronic critical illness. Results: Among the 574 subjects admitted to the intensive care unit, 200 were submitted to mechanical ventilation. Of these patients, 85 (43.5%) developed chronic critical illness, composing 14.8% of all the patients admitted to the intensive care unit. The regression model that evaluated the association of chronic critical illness with conditions present prior to intensive care unit admission identified chronic renal failure in patients undergoing hemodialysis (OR 3.57; p = 0.04) and a neurological diagnosis at hospital admission (OR 2.25; p = 0.008) as independent factors. In the model that evaluated the association of chronic critical illness with situations that occurred during intensive care unit stay, muscle weakness (OR 2.86; p = 0.01) and pressure ulcers (OR 9.54; p < 0.001) had the strongest associations. In the global multivariate analysis (that assessed previous factors and situations that occurred in the intensive care unit), hospital admission due to neurological diseases (OR 2.61; p = 0.03) and the development of pressure ulcers (OR 9.08; p < 0.001) had the strongest associations. Conclusion: The incidence of chronic critical illness in this study was similar to that observed in other studies and had a strong association with the diagnosis of neurological diseases at hospital admission and chronic renal failure in patients undergoing hemodialysis, as well as complications developed during hospitalization, such as pressure ulcers and muscle weakness.

Rationale: Although proposed as a clinical prompt to sepsis based on predictive validity for mortality, the Quick Sepsis-related Organ Failure Assessment (qSOFA) score is often used as a screening tool, which requires high sensitivity.Objectives: To assess the predictive accuracy of qSOFA for mortality in Brazil, focusing on sensitivity.Methods: We prospectively collected data from two cohorts of emergency department and ward patients. Cohort 1 included patients with suspected infection but without organ dysfunction or sepsis (22 hospitals: 3 public and 19 private). Cohort 2 included patients with sepsis (54 hospitals: 24 public and 28 private). The primary outcome was in-hospital mortality. The predictive accuracy of qSOFA was examined considering only the worst values before the suspicion of infection or sepsis.Measurements and Main Results: Cohort 1 contained 5,460 patients (mortality rate, 14.0%; 95% confidence interval [CI], 13.1-15.0), among whom 78.3% had a qSOFA score less than or equal to 1 (mortality rate, 8.3%; 95% CI, 7.5-9.1). The sensitivity of a qSOFA score greater than or equal to 2 for predicting mortality was 53.9% and the 95% CI was 50.3 to 57.5. The sensitivity was higher for a qSOFA greater than or equal to 1 (84.9%; 95% CI, 82.1-87.3), a qSOFA score greater than or equal to 1 or lactate greater than 2 mmol/L (91.3%; 95% CI, 89.0-93.2), and systemic inflammatory response syndrome plus organ dysfunction (68.7%; 95% CI, 65.2-71.9). Cohort 2 contained 4,711 patients, among whom 62.3% had a qSOFA score less than or equal to 1 (mortality rate, 17.3%; 95% CI, 15.9-18.7), whereas in public hospitals the mortality rate was 39.3% (95% CI, 35.5-43.3).Conclusions: A qSOFA score greater than or equal to 2 has low sensitivity for predicting death in patients with suspected infection in a developing country. Using a qSOFA score greater than or equal to 2 as a screening tool for sepsis may miss patients who ultimately die. Using a qSOFA score greater than or equal to 1 or adding lactate to a qSOFA score greater than or equal to 1 may improve sensitivity.Clinical trial registered with www.clinicaltrials.gov (NCT03158493).

Objective To contribute to updating the recommendations for brain-dead potential organ donor management. Method A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, joined a task force formed by the General Coordination Office of the National Transplant System/Brazilian Ministry of Health (CGSNT-MS), the Brazilian Association of Intensive Care Medicine (AMIB), the Brazilian Association of Organ Transplantation (ABTO), and the Brazilian Research in Intensive Care Network (BRICNet). The questions were developed within the scope of the 2011 Brazilian Guidelines for Management of Adult Potential Multiple-Organ Deceased Donors. The topics were divided into mechanical ventilation, hemodynamic support, endocrine-metabolic management, infection, body temperature, blood transfusion, and use of checklists. The outcomes considered for decision-making were cardiac arrest, number of organs recovered or transplanted per donor, and graft function/survival. Rapid systematic reviews were conducted, and the quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Two expert panels were held in November 2016 and February 2017 to classify the recommendations. A systematic review update was performed in June 2020, and the recommendations were reviewed through a Delphi process with the panelists between June and July 2020. Results A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong (lung-protective ventilation strategy, vasopressors and combining arginine vasopressin to control blood pressure, antidiuretic hormones to control polyuria, serum potassium and magnesium control, and antibiotic use), 11 as weak (alveolar recruitment maneuvers, low-dose dopamine, low-dose corticosteroids, thyroid hormones, glycemic and serum sodium control, nutritional support, body temperature control or hypothermia, red blood cell transfusion, and goal-directed protocols), and 1 was considered a good clinical practice (volemic expansion). Conclusion Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak. The observed lack of robust evidence on the topic highlights the importance of the present guideline to improve the management of brain-dead potential organ donors.

The apnea test, which involves disconnection from the mechanical ventilator, presents risks during the determination of brain death, especially in hypoxemic patients. We describe the performance of the apnea test without disconnection from the mechanical ventilator in two patients. The first case involved an 8-year-old boy admitted with severe hypoxemia due to pneumonia. He presented with cardiorespiratory arrest, followed by unresponsive coma due to hypoxic-ischemic encephalopathy. Two clinical exams revealed the absence of brainstem reflexes, and transcranial Doppler ultrasound revealed brain circulatory arrest. Three attempts were made to perform the apnea test, which were interrupted by hypoxemia; therefore, the apnea test was performed without disconnection from the mechanical ventilator, adjusting the continuous airway pressure to 10cmH2O and the inspired fraction of oxygen to 100%. The oxygen saturation was maintained at 100% for 10 minutes. Posttest blood gas analysis results were as follows: pH, 6.90; partial pressure of oxygen, 284.0mmHg; partial pressure of carbon dioxide, 94.0mmHg; and oxygen saturation, 100%. The second case involved a 43-year-old woman admitted with subarachnoid hemorrhage (Hunt-Hess V and Fisher IV). Two clinical exams revealed unresponsive coma and absence of all brainstem reflexes. Brain scintigraphy showed no radioisotope uptake into the brain parenchyma. The first attempt at the apnea test was stopped after 5 minutes due to hypothermia (34.9°C). After rewarming, the apnea test was repeated without disconnection from the mechanical ventilator, showing maintenance of the functional residual volume with electrical bioimpedance. Posttest blood gas analysis results were as follows: pH, 7.01; partial pressure of oxygen, 232.0mmHg; partial pressure of carbon dioxide, 66.9mmHg; and oxygen saturation, 99.0%. The apnea test without disconnection from the mechanical ventilator allowed the preservation of oxygenation in both cases. The use of continuous airway pressure during the apnea test seems to be a safe alternative in order to maintain alveolar recruitment and oxygenation during brain death determination.

To evaluate whether the decrease in blood pressure caused by the increase in the positive end-expiratory pressure corresponds to the pulse pressure variation as an indicator of fluid responsiveness.This exploratory study prospectively included 24 patients with septic shock who were mechanically ventilated and subjected to three stages of elevation of the positive end-expiratory pressure: from 5 to 10cmH2O (positive end-expiratory pressure level 1), from 10 to 15cmH2O (positive end-expiratory pressure level 2), and from 15 to 20cmH2O (positive end-expiratory pressure level 3). Changes in systolic blood pressure, mean arterial pressure, and pulse pressure variation were evaluated during the three maneuvers. The patients were classified as responsive (pulse pressure variation ≥ 12%) or unresponsive to volume replacement (pulse pressure variation12%).The best performance at identifying patients with pulse pressure variation ≥ 12% was observed at the positive end-expiratory pressure level 2: -9% systolic blood pressure variation (area under the curve 0.73; 95%CI: 0.49 - 0.79; p = 0.04), with a sensitivity of 63% and specificity of 80%. Concordance was low between the variable with the best performance (variation in systolic blood pressure) and pulse pressure variation ≥ 12% (kappa = 0.42; 95%CI: 0.19 - 0.56). The systolic blood pressure was90mmHg at positive end-expiratory pressure level 2 in 29.2% of cases and at positive end-expiratory pressure level 3 in 41.63% of cases.Variations in blood pressure in response to the increase in positive end-expiratory pressure do not reliably reflect the behavior of the pulse pressure as a measure to identify the fluid responsiveness status.Avaliar se a diminuição da pressão arterial provocada pela elevação da pressão parcial positiva final corresponde à variação da pressão de pulso como indicador de fluido-responsividade.Estudo de caráter exploratório que incluiu prospectivamente 24 pacientes com choque séptico ventilados mecanicamente e submetidos a três etapas de elevação da pressão parcial positiva final: de 5 para 10cmH2O (nível da pressão parcial positiva final 1), de 10 para 15cmH2O (nível da pressão parcial positiva final 2) e de 15 para 20cmH2O (nível da pressão parcial positiva final 3). Alterações da pressão arterial sistólica, da pressão arterial média e da variação da pressão de pulso foram avaliadas durante as três manobras. Os pacientes foram classificados como responsivos (variação da pressão de pulso ≥ 12%) e não responsivos a volume (variação da pressão de pulso12%).O melhor desempenho para identificar pacientes com variação da pressão de pulso ≥ 12% foi observado no nível da pressão parcial positiva final 2: variação de pressão arterial sistólica de -9% (área sob a curva de 0,73; IC95%: 0,49 - 0,79; p = 0,04), com sensibilidade de 63% e especificidade de 80%. A concordância foi baixa entre a variável de melhor desempenho (variação de pressão arterial sistólica) e a variação da pressão de pulso ≥ 12% (kappa = 0,42; IC95%: 0,19 - 0,56). A pressão arterial sistólica foi90mmHg no nível da pressão parcial positiva final 2 em 29,2% dos casos e em 41,6,3% no nível da pressão parcial positiva final 3.Variações da pressão arterial em resposta à elevação da pressão parcial positiva final não refletem de modo confiável o comportamento da variação da pressão de pulso para identificar o status da fluido-responsividade.

RESUMO Objetivo: Caracterizar os pacientes com doença crítica crônica e identificar os preditores relacionados à evolução para doença crítica crônica. Métodos: Coleta prospectiva de dados por 1 ano realizada na unidade de terapia intensiva de um hospital geral localizado na Região Sul do país. Construíram-se três modelos de regressão logística para identificar os fatores associados com doença crítica crônica. Resultados: Dentre os 574 pacientes admitidos à unidade de terapia intensiva durante o período do estudo, 200 foram submetidos à ventilação mecânica. Destes, 85 (43,5%) pacientes desenvolveram doença crítica crônica, totalizando 14,8% de todos os pacientes admitidos à unidade de terapia intensiva. O modelo de regressão que avaliou os fatores prévios à admissão à unidade de terapia intensiva associados com doença crítica crônica identificou insuficiência renal crônica submetida à diálise (OR 3,57; p = 0,04) e diagnóstico neurológico quando da admissão ao hospital (OR 2,25; p = 0,008) como fatores independentes. No modelo que avaliou a associação de doença crítica crônica com situações ocorridas durante a permanência na unidade de terapia intensiva, destacaram-se fraqueza muscular (OR 2,86; p = 0,01) e úlceras por pressão (OR 9,54; p < 0,001). Na análise multivariada global (fatores prévios e situações ocorridas durante a permanência na unidade de terapia intensiva), destacaram-se admissão ao hospital por doenças neurológicas (OR 2,61; p = 0,03) e desenvolvimento de úlceras por pressão (OR 9,08; p < 0,001). Conclusão: A incidência de doença crítica crônica foi similar à observada em outros estudos e teve associação mais forte com o diagnóstico de doenças neurológicas quando da admissão ao hospital e insuficiência renal crônica submetida à hemodiálise, assim como com complicações desenvolvidas durante a hospitalização, como úlceras por pressão e fraqueza muscular.

IntroductionThere is an increasing demand for multi-organ donors for organ transplantation programmes. This study protocol describes the Donation Network to Optimise Organ Recovery Study, a planned cluster randomised controlled trial that aims to evaluate the effectiveness of the implementation of an evidence-based, goal-directed checklist for brain-dead potential organ donor management in intensive care units (ICUs) in reducing the loss of potential donors due to cardiac arrest.Methods and analysisThe study will include ICUs of at least 60 Brazilian sites with an average of ≥10 annual notifications of valid potential organ donors. Hospitals will be randomly assigned (with a 1:1 allocation ratio) to the intervention group, which will involve the implementation of an evidence-based, goal-directed checklist for potential organ donor maintenance, or the control group, which will maintain the usual care practices of the ICU. Team members from all participating ICUs will receive training on how to conduct family interviews for organ donation. The primary outcome will be loss of potential donors due to cardiac arrest. Secondary outcomes will include the number of actual organ donors and the number of organs recovered per actual donor.Ethics and disseminationThe institutional review board (IRB) of the coordinating centre and of each participating site individually approved the study. We requested a waiver of informed consent for the IRB of each site. Study results will be disseminated to the general medical community through publications in peer-reviewed medical journals.Trial registration numberNCT03179020; Pre-results.

Background The severe inflammatory reaction that occurs after brain death (BD) tends to amplify over time contributing to cardiovascular deterioration and occurrence of cardiac arrest (CA). Our purpose is to evaluate the effect of BD protocol duration (BDPD) on potential donor losses due to CA Methods This retrospective analysis included potential donors reported during the period from May 2012 to April 2014. The risk of losses due to CA was analyzed to identify the chronological threshold at which the probability of loss due to CA increases Results 384 potential donors were analyzed. There was a greater chance of CA after a 30-hour threshold (OR 1.67, 95% CI: 1.38-1.83), and the lowest risk of was identified for the range from 12 to 30 hours (OR 0.32, 95% CI: 0.19-0.52). Multivariate analysis identified the following variables as being associated with CA: BDPD between 12 and 30 hours, management of a potential donor outside the intensive care unit (ICU) and the adherence to a goal-directed protocol Conclusion A long duration between the first clinical test for BD diagnosis and the procurement of organs may be an important risk factor for the occurrence of cardiac arrest in deceased potential donors. This article is protected by copyright. All rights reserved.

INTRODUCTION: Members of the Acinetobacter genus are key pathogens that cause healthcare-associated infections, and they tend to spread and develop new antibiotic resistance mechanisms. Oxacillinases are primarily responsible for resistance to carbapenem antibiotics. Higher rates of carbapenem hydrolysis might be ascribed to insertion sequences, such as the ISAba1 sequence, near bla OXA genes. The present study examined the occurrence of the genetic elements bla OXA and ISAba1 and their relationship with susceptibility to carbapenems in clinical isolates of the Acinetobacter calcoaceticus-Acinetobacter baumannii complex. METHODS: Isolates identified over 6 consecutive years in a general hospital in Joinville, Southern Brazil, were evaluated. The investigation of 5 families of genes encoding oxacillinases and the ISAba1 sequence location relative to bla OXA genes was conducted using polymerase chain reaction. RESULTS: All isolates presented the bla OXA-51-like gene (n = 78), and 91% tested positive for the bla OXA-23-like gene (n = 71). The presence of ISAba1 was exclusively detected in isolates carrying the bla OXA-23-like gene. All isolates in which ISAba1 was found upstream of the bla OXA-23-like gene (n = 69) showed resistance to carbapenems, whereas the only isolate in which ISAba1 was not located near the bla OXA-23-like gene was susceptible to carbapenems. The ISAba1 sequence position of another bla OXA-23-like-positive isolate was inconclusive. The isolates exclusively carrying the bla OXA-51-like gene (n = 7) showed susceptibility to carbapenems. CONCLUSIONS: The presence of the ISAba1 sequence upstream of the bla OXA-23-like gene was strongly associated with carbapenem resistance in isolates of the A. calcoaceticus-A. baumannii complex in the hospital center studied.

Purpose The purpose of the study is to characterize the practices of Brazilian intensivists toward acute kidney injury (AKI) definition and management. Methods A cross-sectional survey was conducted among 36 Brazilian hospitals. Results Of 731 ICU physicians invited to participate, 310 (42%) responded to the survey. Nearly half of the intensive care unit (ICU) physicians (146/310) do not apply AKIN and/or RIFLE definitions to their ICU patients. Most of the respondents prescribe intravenous fluids as a first-line therapeutic intervention for AKI patients. Although 38% of the surveyed physicians considered worsening of respiratory parameters to be the main criterion for stopping fluid infusion, only 15% considered daily net fluid balance as a criterion. Most of the respondents believed in the benefits of early renal replacement therapy (RRT) and considered worsening acidosis the most important criteria for starting early RRT. The main reason for a nephrologist referral was an urgently needed RRT. Conclusions Despite recent advances in AKI definition and management, most of the surveyed ICU physicians in Brazil have not incorporated them in their clinical practice. Important differences in the management of AKI patients were observed among Brazilian ICU physicians, which is relevant for educational interventions and future research.

The disproportion between the supply and demand of transplant organs could be alleviated by improving the quality of clinical management of deceased potential donors. As a large number of donor losses by cardiac arrest occur due to hemodynamic instability, without instituting all essential maintenance measures, it is likely that the application of simplified potential donor maintenance protocols will help to decrease potential donor losses and increase the supply of organs for transplantation. The Ventilation, Infusion and Pumping (VIP) strategy is a mnemonic method that brings together key aspects of the restoration of oxygen delivery to tissues during hemodynamic instability: adequate mechanical Ventilation, volume Infusion and evaluation of heart Pump effectiveness. The inclusion of the additional initials, "P" and "S," refers to Pharmacological treatment and Specificities involved in the etiology of shock. The use of simplified care standards can assist in adhering to essential potential donor management measures. Therefore, using a simplified method as the adapted VIP approach can contribute to improving management standards of potential organ donors and increasing the supply of organs for transplantation.

RESUMO O transplante de órgãos é a única alternativa para muitos pacientes portadores de algumas doenças terminais. Ao mesmo tempo, é preocupante a crescente desproporção entre a alta demanda por transplantes de órgãos e o baixo índice de transplantes efetivados. Dentre as diferentes causas que alimentam essa desproporção, estão os equívocos na identificação do potencial doador de órgãos e as contraindicações mal atribuídas pela equipe assistente. Assim, o presente documento pretende fornecer subsídios à equipe multiprofissional da terapia intensiva para o reconhecimento, a avaliação e a validação do potencial doador de órgãos. ABSTRACT Organ transplantation is the only alternative for many patients with terminal diseases. The increasing disproportion between the high demand for organ transplants and the low rate of transplants actually performed is worrisome. Some of the causes of this disproportion are errors in the identification of potential organ donors and in the determination of contraindications by the attending staff. Therefore, the aim of the present document is to provide guidelines for intensive care multi-professional staffs for the recognition, assessment and acceptance of potential organ donors.