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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.

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.

A sepse tem alta incidência, alta letalidade e custos elevados, sendo a principal causa de mortalidade em unidades de terapia intensiva. Está claramente demonstrado que pacientes reconhecidos e tratados precocemente tem melhor prognóstico. A formulação de diretrizes de tratamento é fundamental para a adequação desse tratamento. Pacientes com claros sinais de hipoperfusão devem ser submetidos a otimização hemodinâmica. Assim, o reconhecimento dos sinais de hipoperfusão é um dos principais passos do tratamento. A presente diretriz aborda as evidências disponíveis na literatura em relação aos principais parâmetros hemodinâmicos utilizados atualmente. Sepsis is a very frequent condition and causes high mortality rates and healthcare costs; it is the main cause of death in intensive care units. Clear, improved prognosis was shown for early diagnosed and treated patients. Treatment guidelines are fundamental for appropriate therapy. It is clear that hypoperfusion patients should be hemodynamically optimized; therefore, recognition of hypoperfusion signs is one of the main therapeutic steps. This guideline discusses the current literature and available data regarding the evaluation of hemodynamic parameters.

Complicações sistêmicas são vistas frequentemente em indivíduos acometidos por hemorragia subaracnóidea. Dentre estas alterações podem ocorrer anormalidades eletrocardiográficas que simulam miocardiopatia isquêmica que podem ou não estar associadas com disfunção miocárdica. O objetivo deste é relatar um caso de associação de hemorragia subaracnóidea com disfunção miocárdica e choque cardiogênico. Mulher de 45 anos foi internada com quadro de coma secundário a hemorragia subaracnóidea. À admissão apresentava Glasgow = 7, Hunt-Hess = 5 e classificação tomográfica de Fisher = 3. O aneurisma cerebral de artéria comunicante anterior evidenciado pela arteriografia cerebral foi embolizado com sucesso no segundo dia de internação. Evoluiu com dispnéia e infiltrado pulmonar difuso. Havia alteração da repolarização ventricular em parede lateral, aumento da CK-MB (36 U/L) e hipotensão. O índice cardíaco de 2,03 L/min/m², a resistência vascular sistêmica 3728 dynes.seg/cm5/m², e a irresponsividade a volume evidenciavam o padrão hemodinâmico de choque cardiogênico. A fração de ejeção do ventrículo esquerdo era de 39%. A cineangiocoronariografia não apresentava lesões coronarianas obstrutivas. Após 6 dias a paciente foi extubada e ao oitavo dia foi possível a retirada completa da dobutamina. A fração de ejeção passou a 65%. Sucessivos exames de Doppler transcraniano não apresentaram vasoespasmo. A paciente recebeu alta da unidade de terapia intensiva no décimo quarto dia. Pacientes com hemorragia subaracnóidea podem apresentar disfunção ventricular e choque cardiogênico, aumentando o risco de isquemia cerebral. O diagnóstico e a otimização hemodinâmica são essenciais para minimizar os riscos de vasoespasmo e isquemia cerebral. Systemic complications are frequent in subarachnoid hemorrhage patients. Among these complications, electrocardiographic abnormalities simulating ischemic cardiomyopathy may occur, possibly associated with myocardial dysfunction. This manuscript aims to report a case of subarachnoid hemorrhage associated with myocardial dysfunction and cardiogenic shock. A 45 years old woman was admitted with subarachnoid hemorrhage and coma, showing Glasgow scale = 7, Hunt-Hess = 5 and Fischer computed tomography classification = 3. On the second day, the patient underwent anterior cerebral communicant artery aneurysm embolization. The clinical evaluation revealed diffuse pulmonary infiltration, dyspnea and hypotension. Additional tests showed electrocardiographic lateral wall repolarization changes and elevated creatine kinase-MB fraction (36U/L). The cardiac index was 2.03 L/minute/m², Vascular systemic resistance was 3728 dynes.sec/cm². The non-responsiveness to volume demonstrated a cardiogenic shock pattern. The ventricular ejection fraction was 39%. The coronariography was normal, showing no obstructive lesions. Six days later the patient was removed from respiratory support and after eight days the dobutamine infusion was discontinued. The ejection fraction recovered up to 65%. Serial transcranial Doppler evaluations did not show vascular spasm. After ten days the patient was discharged from the intensive care unit. Patients with subarachnoid hemorrhage may be complicated with ventricular dysfunction and cardiogenic shock, increasing the cerebral ischemia risk. Diagnosis optimization and hemodynamic stabilization are essential to minimize the risk of cerebral vasospasm and ischemia.

The objective of this study is to evaluate blood glucose (BG) control efficacy and safety of 3 insulin protocols in medical intensive care unit (MICU) patients.This was a multicenter randomized controlled trial involving 167 MICU patients with at least one BG measurementor=150 mg/dL and one or more of the following: mechanical ventilation, systemic inflammatory response syndrome, trauma, or burns. The interventions were computer-assisted insulin protocol (CAIP), with insulin infusion maintaining BG between 100 and 130 mg/dL; Leuven protocol, with insulin maintaining BG between 80 and 110 mg/dL; or conventional treatment-subcutaneous insulin if glucose150 mg/dL. The main efficacy outcome was the mean of patients' median BG, and the safety outcome was the incidence of hypoglycemia (or=40 mg/dL).The mean of patients' median BG was 125.0, 127.1, and 158.5 mg/dL for CAIP, Leuven, and conventional treatment, respectively (P = .34, CAIP vs Leuven; P.001, CAIP vs conventional). In CAIP, 12 patients (21.4%) had at least one episode of hypoglycemia vs 24 (41.4%) in Leuven and 2 (3.8%) in conventional treatment (P = .02, CAIP vs Leuven; P = .006, CAIP vs conventional).The CAIP is safer than and as effective as the standard strict protocol for controlling glucose in MICU patients. Hypoglycemia was rare under conventional treatment. However, BG levels were higher than with IV insulin protocols.

The National Healthcare Safety Network/Center for Disease Control and Prevention (NHSN/CDC) published in 2013 a new surveillance protocol in order to standardize the ventilator-associated pneumonia (VAP) confirmation criteria and, consequently, to increase the reliability of indicators in different institutions.

We tested the hypothesis that the dynamic evaluation of central venous pressure (CVP) amplitude could be a reliable predictor of fluid responsiveness in patients under mechanical ventilation, similar to the variation of arterial pulse pressure (DeltaPp). Thirty postcardiac surgery patients, under mechanical ventilation, were evaluated. The percentual difference between inspiratory (Ppins) and expiratory pulse pressure (Ppins) was so calculated: DeltaPp (%) = 100 x (Ppins - Ppexp)/[(Ppins + Ppexp)/2]. The respiratory variation of CVP curves amplitude were calculated by determining the percentual difference between inspiratory (CVPpins) and expiratory (CVPpexp) variation using vena cava "pressure" collapsibility index according the following formula: Cvci (%) = [(CVPpexp - CVPpins)/CVPpexp] x 100. There was a correlation between DeltaPp and Cvci (Pearson correlation coefficient, r = 0.45). Receiver operating characteristic curves showed that the Cvci value more than or equal to 5% predicted DeltaPp more than or equal to 13% with 91% specificity, 89% sensitivity, and AUC of 0.90. Therefore, Cvci presented a good agreement with DeltaPp (kappa = 0.76) to identify potential fluid responders (patients with DeltaPp > or =13%). In 9 potential fluid responders, both DeltaPp and Cvci significantly decreased from 18% +/- 8% to 8% +/- 6% (P < 0.004) and 23% +/- 15% to 7% +/- 6% (P < 0.004), respectively, after fluid replacement. Our findings suggest that vena cava "pressure" collapsibility index can be used as a marker of fluid responsiveness in postcardiac surgery patients under mechanical ventilation, such as arterial pulse pressure respiratory variation.

Objetivo:Avaliar a concordância entre um novo metodo de vigilância epidemiologica do Center for Disease Control and Prevention e o Clinical Pulmonary Infection Score para deteccao de pneumonia associada a ventilacao mecânica.Metodos:Coorte prospectiva que avaliou pacientes internados nas unidades de terapia intensiva de dois hospitais que permaneceram intubados por mais de 48 horas no periodo de agosto de 2013 a junho de 2014. Os pacientes foram avaliados diariamente pelos fisioterapeutas com o Clinical Pulmonary Infection Score. De forma independente, um enfermeiro aplicou o novo metodo de vigilância proposto pelo Center for Disease Control and Prevention. Avaliou-se a concordância diagnostica entre os metodos. Clinical Pulmonary Infection Score ≥ 7 foi considerado diagnostico clinico de pneumonia associada a ventilacao mecânica, considerando-se diagnostico definitivo a associacao de Clinical Pulmonary Infection Score ≥ 7 com germe isolado em cultura semiquantitativa ≥ 104 unidades formadoras de colonias.Resultados:De 801 pacientes admitidos nas unidades de terapia intensiva, 198 estiveram sob ventilacao mecânica. Destes, 168 permaneceram intubados por mais de 48 horas. Identificaram-se 18 (10,7%) condicoes infecciosas associadas a ventilacao mecânica e 14 (8,3%) pneumonias associadas a ventilacao mecânica possiveis ou provaveis, representando 35% (14/38) diagnosticos clinicos de pneumonia associada a ventilacao mecânica. O metodo do Center for Disease Control and Prevention identificou casos de pneumonia associada a ventilacao mecânica com sensibilidade de 0,37 e especificidade de 1,0, com valor preditivo positivo de 1,0 e negativo de 0,84. As diferencas implicaram em discrepâncias na densidade de incidencia de pneumonia associada a ventilacao mecânica (CDC: 5,2/1000 dias de ventilacao mecânica; Clinical Pulmonary Infection Score ≥ 7: 13,1/1000 dias de ventilacao mecânica).Conclusao:O metodo do Center for Disease Control and Prevention falhou na deteccao de casos de pneumonia associada a ventilacao mecânica e pode nao ser satisfatorio como metodo de vigilância.Objective: To evaluate the agreement between a new epidemiological surveillance method of the Center for Disease Control and Prevention and the clinical pulmonary infection score for mechanical ventilator-associated pneumonia detection.

Brain death (BD) alters the pathophysiology of patients and may damage the kidneys, the lungs, the heart and the liver. To obtain better quality transplant organs, intensive care physicians in charge of the maintenance of deceased donors should attentively monitor these organs. Careful hemodynamic, ventilatory and bronchial clearance management minimizes the loss of kidneys and lungs. The evaluation of cardiac function and morphology supports the transplant viability assessment of the heart. The monitoring of liver function, the management of the patient's metabolic status and the evaluation of viral serology are fundamental for organ selection by the transplant teams and for the care of the transplant recipient.

OBJETIVO: Avaliar o efeito da aplicação de um protocolo gerenciado de manutenção de potenciais doadores falecidos de múltiplos órgãos em duas unidades hospitalares. MÉTODOS: Estudo antes (Fase 1)/depois (Fase 2) realizado em dois hospitais gerais que incluiu, consecutivamente, os potenciais doadores ingressados em duas unidades de terapia intensiva. Na Fase 1 (16 meses), os dados foram coletados retrospectivamente e as medidas de manutenção do potencial doador foram instituídas a critério do intensivista. Na Fase 2 (12 meses), a coleta de dados foi prospectiva e a manutenção foi guiada por um protocolo gerenciado. As duas fases foram comparadas entre si de acordo com variáveis demográficas, variáveis fisiológicas no diagnóstico da morte encefálica e ao final do processo, tempo necessário para realização do exame confirmatório de morte encefálica e final do processo, aderência aos conjuntos de medidas essenciais de manutenção (pacotes), perdas por parada cardíaca, perdas por negativa familiar, perdas por contraindicação e taxa de conversão de potenciais doadores em doadores reais. Foram aplicados os testes de t-Student e do qui-quadrado, e o valor de p

A morte encefálica induz várias alterações fisiopatológicas que podem causar lesões em rins, pulmões, coração e fígado. Portanto, a atuação do intensivista durante a manutenção do potencial doador falecido exige cuidados específicos com estes órgãos visando sua maior viabilidade para transplantes. O manejo hemodinâmico cuidadoso, os cuidados ventilatórios e de higiene brônquica minimizam a perda de rins e pulmões para o transplante. A avaliação da condição morfológica e funcional do coração auxilia na avaliação do potencial transplantável deste órgão. Por fim, a avaliação da função hepática, assim como o controle metabólico e a realização de sorologias virais são fundamentais para a orientação das equipes transplantadoras na seleção do órgão a ser doado e no cuidado com o receptor. Brain death (BD) alters the pathophysiology of patients and may damage the kidneys, the lungs, the heart and the liver. To obtain better quality transplant organs, intensive care physicians in charge of the maintenance of deceased donors should attentively monitor these organs. Careful hemodynamic, ventilatory and bronchial clearance management minimizes the loss of kidneys and lungs. The evaluation of cardiac function and morphology supports the transplant viability assessment of the heart. The monitoring of liver function, the management of the patient's metabolic status and the evaluation of viral serology are fundamental for organ selection by the transplant teams and for the care of the transplant recipient

A atuacao do intensivista durante a manutencao do potencial doador falecido na busca da reducao de perdas de doadores e do aumento da efetivacao de transplantes nao se restringe aos aspectos hemodinâmicos. O adequado controle endocrino-metabolico e essencial para a manutencao do aporte energetico aos tecidos e do controle hidro-eletrolitico, favorecendo inclusive a estabilidade hemodinâmica. A abordagem das alteracoes hematologicas e igualmente importante considerando as implicacoes da pratica transfusional inapropriada. Ressalta-se ainda o papel da ventilacao protetora na modulacao inflamatoria e consequente aumento do aproveitamento de pulmoes para transplante. Por fim, assinala-se a relevância da avaliacao criteriosa das evidencias de atividade infecciosa e da antibioticoterapia na busca do maior utilizacao de orgaos de potenciais doadores falecidos

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 transplantes There 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

There 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.

Systemic complications are frequent in subarachnoid hemorrhage patients. Among these complications, electrocardiographic abnormalities simulating ischemic cardiomyopathy may occur, possibly associated with myocardial dysfunction. This manuscript aims to report a case of subarachnoid hemorrhage associated with myocardial dysfunction and cardiogenic shock. A 45 years old woman was admitted with subarachnoid hemorrhage and coma, showing Glasgow scale = 7, Hunt-Hess = 5 and Fischer computed tomography classification = 3. On the second day, the patient underwent anterior cerebral communicant artery aneurysm embolization. The clinical evaluation revealed diffuse pulmonary infiltration, dyspnea and hypotension. Additional tests showed electrocardiographic lateral wall repolarization changes and elevated creatine kinase-MB fraction (36U/L). The cardiac index was 2.03 L/minute/m², Vascular systemic resistance was 3728 dynes.sec/cm². The non-responsiveness to volume demonstrated a cardiogenic shock pattern. The ventricular ejection fraction was 39%. The coronariography was normal, showing no obstructive lesions. Six days later the patient was removed from respiratory support and after eight days the dobutamine infusion was discontinued. The ejection fraction recovered up to 65%. Serial transcranial Doppler evaluations did not show vascular spasm. After ten days the patient was discharged from the intensive care unit. Patients with subarachnoid hemorrhage may be complicated with ventricular dysfunction and cardiogenic shock, increasing the cerebral ischemia risk. Diagnosis optimization and hemodynamic stabilization are essential to minimize the risk of cerebral vasospasm and ischemia.

Objective: We evaluate the impact that implementing an in-hospital protocol for the early detection of sepsis risk has on mortality from severe sepsis/septic shock. Methods: This was a prospective cohort study conducted in 2 phases at 2 general hospitals in Brazil. In phase I, patients with severe sepsis/septic shock were identified and treated in accordance with the Surviving Sepsis Campaign guidelines. Over the subsequent 12 months (phase II), patients with severe sepsis/septic shock were identified by means of active surveillance for signs of sepsis risk (SSR). We compared the 2 cohorts in terms of demographic variables, the time required for the identification of at least 2 SSRs, compliance with sepsis bundles (6- and 24-hour), and mortality rates. Results: We identified 217 patients with severe sepsis/septic shock (102 during phase I and 115 during phase II). There were significant differences between phases I and II in terms of the time required for the identification of at least 2 SSRs (34 ± 48 vs 11 ± 17 hours; P b .001) and in terms of in-hospital mortality (61.7% vs 38.2%; P b .001). Conclusion: The early detection of sepsis promoted early treatment, reducing in-hospital mortality from severe sepsis/septic shock.

Sepsis is a very frequent condition and causes high mortality rates and healthcare costs; it is the main cause of death in intensive care units. Clear, improved prognosis was shown for early diagnosed and treated patients. Treatment guidelines are fundamental for appropriate therapy. It is clear that hypoperfusion patients should be hemodynamically optimized; therefore, recognition of hypoperfusion signs is one of the main therapeutic steps. This guideline discusses the current literature and available data regarding the evaluation of hemodynamic parameters.

OBJETIVO: Avaliar o impacto da aplicação de uma política institucional para detecção da sepse grave ou choque séptico. MÉTODOS: Estudo antes (fase I)/depois (fase II) com coleta prospectiva de dados em hospital público de 195 leitos. Fase I: Pacientes com sepse grave ou choque séptico foram incluídos consecutivamente durante 15 meses e tratados conforme diretrizes da Campanha Sobrevivendo à Sepse. Fase II: Nos 10 meses subseqüentes, pacientes com sepse grave ou choque séptico foram arrolados a partir da busca ativa de sinais sugestivos de infecção nos pacientes internados. As duas fases foram comparadas entre si no que diz respeito às variáveis demográficas, tempo necessário para reconhecimento de pelo menos dois sinais sugestivos de infecção (Δt-SSI), aderência aos pacotes de 6 e 24 horas, e mortalidade. RESULTADOS: Foram identificados 124 pacientes com sepse grave ou choque séptico, 68 na fase I e 56 na fase II. As variáveis demográficas foram semelhantes nas fases. O Δt-SSI foi de 34 ± 54 horas na fase I e 7 ± 8,4 horas na fase II (p < 0,001). Não houve diferença na aderência aos pacotes de tratamento. Paralelamente, observou-se redução significativa das taxas de mortalidade ao 28º dia (54,4% na fase I versus 30% na fase II; p < 0,02) e hospitalar (67,6% na fase I versus 41% na fase II; p < 0,003). CONCLUSÃO: A estratégia utilizada contribuiu para a identificação antecipada do risco de sepse e resultou em diminuição da mortalidade associada à sepse grave e ao choque séptico. OBJECTIVE: To evaluate the impact of implementing an institutional policy for detection of severe sepsis and septic shock. METHODS: Study before (stage I), after (stage II) with prospective data collection in a 195 bed public hospital.. Stage I: Patients with severe sepsis or septic shock were included consecutively over 15 months and treated according to the Surviving Sepsis Campaign guidelines. Stage II: In the 10 subsequent months, patients with severe sepsis or septic shock were enrolled based on an active search for signs suggesting infection (SSI) in hospitalized patients. The two stages were compared for demographic variables, time needed for recognition of at least two signs suggesting infection (SSI-Δt), compliance to the bundles of 6 and 24 hours and mortality. RESULTS: We identified 124 patients with severe sepsis or septic shock, 68 in stage I and 56 in stage II. The demographic variables were similar in both stages. The Δt-SSI was 34 ± 54 hours in stage I and 7 ± 8.4 hours in stage II (p

To evaluate the impact of implementing an institutional policy for detection of severe sepsis and septic shock.Study before (stage I), after (stage II) with prospective data collection in a 195 bed public hospital.. Stage I: Patients with severe sepsis or septic shock were included consecutively over 15 months and treated according to the Surviving Sepsis Campaign guidelines. Stage II: In the 10 subsequent months, patients with severe sepsis or septic shock were enrolled based on an active search for signs suggesting infection (SSI) in hospitalized patients. The two stages were compared for demographic variables, time needed for recognition of at least two signs suggesting infection (SSI-Δt), compliance to the bundles of 6 and 24 hours and mortality.We identified 124 patients with severe sepsis or septic shock, 68 in stage I and 56 in stage II. The demographic variables were similar in both stages. The Δt-SSI was 34 ± 54 hours in stage I and 7 ± 8.4 hours in stage II (p0.001). There was no difference in compliance to the bundles. In parallel there was significant reduction of mortality rates at 28 days (54.4% versus 30%, p0.02) and hospital (67.6% versus 41%, p0.003).The strategy used helped to identify early risk of sepsis and resulted in decreased mortality associated with severe sepsis and septic shock.

In recent issues of Critical Care, we read with concern the article by Pontes-Arruda and colleagues [1] and the fi rst author’s reply to the letter from Machado (the latter two of which appear in [2]). Th e article and subsequent letters address eicosapentaenoic acid/gamma-linolenic acid (EPA/GLA) use in sepsis patients in the INTERSEPT (Investigating Nutritional Th erapy with EPA, GLA and Antioxidants Role in Sepsis Treatment) study. We served as the principal investigators of this trial and come from sites that did not successfully include any patients or that included only a small number of patients. From this vantage point, we believe that Pontes-Arruda’s reply to Machado’s comments [2] did not clarify several important points. As stated in the article [1], only fi ve of the 12 sites successfully enrolled patients. However, the fi rst author’s site was responsible for the inclusion of about 100 of the 106 patients. We believe that this imbalance is relevant and that readers of Critical Care need to be aware of it. We disagree with Pontes-Arruda’s response [2] that all relevant limitations were already mentioned in the Discussion [1]. We found it diffi cult to understand his affi rmation that the results were unaff ected by the unbalanced distribution pattern of the patients, as any statistical analysis of the few patients from the other four sites would obviously be under powered. We also think he should clearly state the strategies that were used at his site to successfully enroll patients given that the 11 other sites, most of which are very skilled at performing intervention studies, failed to enroll similar numbers of patients. Th e author’s explanation [2] of the Sequential Organ Failure Assessment (SOFA) fi ndings is also not clear. We agree that it is perfectly possible for some patients to have a high SOFA score that may be insuffi cient to fulfi ll the inclusion criteria. However, the median and inter quartile values shown in Table 3 [1] indicate that 75% of all patients had a SOFA score of more than 4. Th is would be a very unusual fi nding in sepsis patients without signifi cant organ dysfunction. Moreover, the interquartile interval in Table 3 indicates that at least 75% of the patients had platelet levels of more than 144 × 10 9 cells per liter, a bilirubin level of less than 1.5 mg/dL, and a creatinine level of less than 1.6 mg/dL; as stated in the text [1], no patients had an arterial partial pressure of oxygen/ fraction of inspired oxygen (PaO 2 /FiO 2 ) ratio of less than 300. Th e high median and inter quartile values for the SOFA scores would be possible only in the presence of severe neurological or hemo dynamic dys func tion in the majority of the patients; this point, there fore, requires further explanation. Moreover, at least 50% of the patients had lactate levels of higher than 3.7 mmol/L, and this suggests that many patients already had signs of hypoperfusion (that is, severe sepsis) at inclusion. We believe that this paper needs more clarity as all of the above aspects are relevant for readers of Critical Care.