Search

Introduction: Contemporary information on mechanical ventilation (MV) use in emerging countries is limited. Moreover, most epidemiological studies on ventilatory support were carried out before significant developments, such as lung protective ventilation or broader application of non-invasive ventilation (NIV). We aimed to evaluate the clinical characteristics, outcomes and risk factors for hospital mortality and failure of NIV in patients requiring ventilatory support in Brazilian intensive care units (ICU)., Methods: In a multicenter, prospective, cohort study, a total of 773 adult patients admitted to 45 ICUs over a two-month period requiring invasive ventilation or NIV for more than 24 hours were evaluated. Causes of ventilatory support, prior chronic health status and physiological data were assessed. Multivariate analysis was used to identifiy variables associated with hospital mortality and NIV failure., Results: Invasive MV and NIV were used as initial ventilatory support in 622 (80%) and 151 (20%) patients. Failure with subsequent intubation occurred in 54% of NIV patients. The main reasons for ventilatory support were pneumonia (27%), neurologic disorders (19%) and non-pulmonary sepsis (12%). ICU and hospital mortality rates were 34% and 42%. Using the Berlin definition, acute respiratory distress syndrome (ARDS) was diagnosed in 31% of the patients with a hospital mortality of 52%. In the multivariate analysis, age (odds ratio (OR), 1.03; 95% confidence interval (CI), 1.01 to 1.03), comorbidities (OR, 2.30; 95% CI, 1.28 to 3.17), associated organ failures (OR, 1.12; 95% CI, 1.05 to 1.20), moderate (OR, 1.92; 95% CI, 1.10 to 3.35) to severe ARDS (OR, 2.12; 95% CI, 1.01 to 4.41), cumulative fluid balance over the first 72 h of ICU (OR, 2.44; 95% CI, 1.39 to 4.28), higher lactate (OR, 1.78; 95% CI, 1.27 to 2.50), invasive MV (OR, 2.67; 95% CI, 1.32 to 5.39) and NIV failure (OR, 3.95; 95% CI, 1.74 to 8.99) were independently associated with hospital mortality. The predictors of NIV failure were the severity of associated organ dysfunctions (OR, 1.20; 95% CI, 1.05 to 1.34), ARDS (OR, 2.31; 95% CI, 1.10 to 4.82) and positive fluid balance (OR, 2.09; 95% CI, 1.02 to 4.30)., Conclusions: Current mortality of ventilated patients in Brazil is elevated. Implementation of judicious fluid therapy and a watchful use and monitoring of NIV patients are potential targets to improve outcomes in this setting., Trial Registration: ClinicalTrials.gov NCT01268410.

Background: The differential diagnosis of wide QRS tachycardia is a challenge for the emergency physician. The major tool is the electrocardiogram (ECG), even though the sensitivity and specificity may be variable, depending on presentation. Additional leads could be used to improve the diagnostic accuracy of the ECG., Objective: To document the use of the Lewis lead in improving the diagnostic accuracy of the ECG in wide QRS tachycardia., Case Report: A 52-year-old woman with rheumatoid arthritis, in treatment with methotrexate, was admitted with progressive dyspnea that evolved to acute respiratory distress and shock at arrival. Pneumonia was diagnosed as the infection and she received antibiotics, and respiratory and inotropic support. She was also using amiodarone for more than 10 years, but she couldn't state the reason. On cardiac monitoring, wide QRS tachycardia was detected and ventricular tachycardia was considered on the differential diagnosis. The standard 12-lead ECG was complemented with the Lewis lead, obtained with higher speed and amplitude, demonstrating atrioventricular concordance and excluding ventricular tachycardia. The patient was treated for septic shock, and she died 2 days later., Conclusion: The Lewis lead is a simple and easy strategy to enhance atrial activity detection in wide QRS tachycardia., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Internal accumulation of the topical hemostatic agent Surgicel can mimic fluid collections that might be misdiagnosed as an abscess or a hematoma upon 3 common postoperative imaging methods. Herein, we report the unusual case of a neonate who underwent surgical repair of complex congenital heart conditions and then required early re-exploration, prompted by initial suspicion of mediastinitis on the basis of computed tomographic findings. During reoperation, it was determined that the mass on computed tomography was an accumulation of oxidized Surgicel. We discuss the capabilities and limitations of various imaging methods in the achievement of an accurate differential diagnosis.

Objectives: Septuagenarians or older patients needing heart surgery has increased in whole world. The objective of study is to know the characteristics of this group of patients and determine the risk factors for operative morbidity., Methods: We revised the medical records of 783 patients undergone heart valve surgery, myocardial revascularization or both between 2002 and 2007. The patients were divided in 'control group' (<70 years) 'septuagenarian group' (70 years old or more)., Results: One hundred ninety seven patients were at least 70 years old (mean age 74.1+/-3.9) and 61% were male. In the control group the mean age was 52.1+/-11.7 and 54% were male. In the septuagenarians group it was significantly higher the proportion of patients suffering from peripheral vascular disease (9% versus 5%, P=0.019), carotid artery obstruction (5% versus 2%, P=0.026), unstable angina (17% versus 9%, P=0.018). In both groups coronary artery bypass surgery prevailed. In the septuagenarian group 41% of the patients had a least one morbid event, versus 22% of the patients in the control group (P<0.001). Postoperative bleeding, pulmonary complications, mediastinitis, need of vasopressors, renal dysfunction and strokes were significantly higher in the septuagenarian group. The mortality was higher in the septuagenarian (19% versus 8.5%, P<0.001). The logistic regression revealed that COPD (OR: 8.6), EF < 35% (OR: 7,1), non-elective operation (OR: 17,2) and cardiopulmonary bypass time >120 min (OR: 3,4) were predictive of hospital mortality in septuagenarian or older patients., Conclusions: The hospital mortality of septuagenarians or elderly is significantly higher than younger patients.

Background: Preservation of the hemostatic system during cardiac surgery is a main concern, primarily after repeated cardiac operations., Methods: We compared the outcomes of adult patients undergoing isolated reoperative valvular surgery receiving full-dose of aprotinin (redo group, n = 70) with patients experiencing primary isolated valvular surgery not receiving aprotinin (primary group, n = 135)., Results: The mean age was lower in the redo group (45 +/- 14 years vs 50 +/- 17 years, p = 0.036). The redo group had more female patients (73% vs 51%, p = 0.003), patients in functional class IV (15% vs 4% p = 0.009), and patients with chronic atrial fibrillation (48% vs 24%, p = 0.001). The cardiopulmonary bypass duration was longer in the redo group (119 +/- 50 minutes vs 103 +/- 41 minutes, p = 0.014). However, the blood loss was significantly lower (300 +/- 279 mL vs 776 +/- 584 mL, p = 0.001) and fewer patients needed transfusions (3.0% vs 13%, p = 0.023) in the redo group. The postoperative morbidity was similar in both groups. The postoperative in-hospital mortality was 7% in the primary group and 10% in the redo group (p = 0.419). Factors associated with postoperative in-hospital mortality were the following: age greater than 60 years (p = 0.040, odds ratio [OR] 3.0), New York Heart Association class IV (p = 0.022, OR 5.0), preoperative critical state (p < 0.001, OR 12), emergent operation (p = 0.012, OR 7.0), endocarditis (p = 0.004, OR 10.0), and reoperation due to mechanical mitral prosthesis dysfunction (p = 0.009, OR 7)., Conclusions: The mortality and morbidity in redo valve surgery with aprotinin administration was comparable with primary valve surgery without aprotinin. Bleeding and transfusion requirements were significantly lower in redo patients receiving aprotinin.