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1. ACUTE ABDOMEN IN INTENSIVE CARE UNIT: ETIOLOGY, COMORBIDITY AND SEVERITY OF 1,523 PATIENTS

Author

Geraldo Fernandes de ALMEIDA FILHO, Pedro Paulo Costa e SILVA, Murilo Tavares VALVERDE FILHO, Maria Clara Alves MORAIS, Paulo Bravo de Oliveira CHAGAS, Ricardo Azevedo Cruz D’OLIVEIRA, Liana CODES, and Paulo Lisboa BITTENCOURT

Subjects
Abdomen, acute, Intensive care units, Critical care, APACHE, Comorbidity, Mortality, Surgery, RD1-811, Diseases of the digestive system. Gastroenterology, RC799-869
Abstract

ABSTRACT BACKGROUND: Clinical features and outcomes of patients admitted to the intensive care unit due to acute abdomen are important to be investigated. AIMS: To evaluate the outcomes of critically ill subjects with acute abdomen according to etiology, comorbidity and severity. METHODS: Outcomes of 1,523 patients (878 women, mean age 66±18 years) consecutively admitted to a specialized gastrointestinal intensive care unit with different causes of acute abdomen from January 2012 to December 2019, were retrospectively evaluated according to etiology, comorbidity and severity. RESULTS: The most common causes of acute abdomen were obstructive and inflammatory, particularly large bowel obstruction (27%), small bowel obstruction (18%) and acute pancreatitis (17%). Overall mortality was 13%. Surgery was required in 34% of patients. Median length of stay in the hospital was 9 [1-101] days. On univariate analysis mortality was significantly associated with age, APACHE II, Charlson comorbidity index, requirement for surgery and malignancy (p

Published
2023
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2. ANALYSIS OF HEALTHCARE ASSOCIATED AND HOSPITAL ACQUIRED INFECTIONS IN CRITICALLY ILL PATIENTS WITH CIRRHOSIS

Author

Ricardo Azevedo Cruz D’OLIVEIRA, Lívia Carolina Dourado PEREIRA, Liana CODES, Mário de Seixas ROCHA, and Paulo Lisboa BITTENCOURT

Subjects
Liver cirrhosis, bacterial infections, morbidity, mortality, intensive care unit, Diseases of the digestive system. Gastroenterology, RC799-869
Abstract

ABSTRACT Background Bacterial infections occur in 43—59% of cirrhotic patients admitted to the intensive care unit with impact in morbidity and mortality. An increase in the frequency of multidrug-resistant (MDRO) and extensively drug-resistant (XDRO) organisms has been described in bacterial infections in cirrhotic patients with an adverse impact on survival. Objective To characterize community-acquired (CA), healthcare-associated (HCA), and hospital-acquired (HA) infections in cirrhotic patients and their impact in the occurrence of adverse outcomes. Methods This study included all cirrhotic patients admitted in an intensive care unit specialized in liver and gastrointestinal diseases in Brazil between January 2012 and June 2018. Frequency and topography of infections were retrospectively evaluated, as well as the frequency of MDRO and XDRO organisms, and their impact in occurrence of acute kidney injury, hepatorenal syndrome, acute-on-chronic liver failure, sepsis and mortality. Results A total of 374 infections were observed and classified as CA (22%), HCA (34%) and hospital-acquired (44%). Eighty-nine (54%) episodes of hospital-acquired infections were second infections. Spontaneous bacterial peritonitis (32%) and urinary tract infection (23%) were the most common infections. Culture-proven infections were positive in 61% of the cases, mainly gram-negative bacteria (73%). Acute kidney injury, hepatorenal syndrome and sepsis were observed, respectively, in 48%, 15% and 53% of the cases. MDRO and XDRO were seen, respectively, in 35% and 16%, mainly in HCA (48% vs 26% in CA infections, P=0.02) and hospital-acquired (58% vs 26% in CA infections, P=0.0009). Adverse outcomes were more frequently observed in subjects with hospital-acquired infections when compared to HCA and CA infections. Hospital-acquired, HCA and second infections were independently associated with in-hospital mortality. Conclusion Hospital-acquired, HCA and second infections are increasingly associated with either MDRO and/or XDRO and are independent predictors of in-hospital mortality. Their recognition and proper selection of appropriate empiric antibiotic regimens are important measures to reduce in-hospital mortality.

Published
2022
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3. Epidemiologia e desfecho dos pacientes de alto risco cirúrgico admitidos em unidades de terapia intensiva no Brasil

Author

João Manoel Silva Júnior, Renato Carneiro de Freitas Chaves, Thiago Domingos Corrêa, Murillo Santucci Cesar de Assunção, Henrique Tadashi Katayama, Fabio Eduardo Bosso, Cristina Prata Amendola, Ary Serpa Neto, Luiz Marcelo Sá Malbouisson, Neymar Elias de Oliveira, Viviane Cordeiro Veiga, Salomón Soriano Ordinola Rojas, Natalia Fioravante Postalli, Thais Kawagoe Alvarisa, Bruno Melo Nobrega de Lucena, Raphael Augusto Gomes de Oliveira, Luciana Coelho Sanches, Ulysses Vasconcellos de Andrade e Silva, Antonio Paulo Nassar Junior, Álvaro Réa-Neto, Alexandre Amaral, José Mário Teles, Flávio Geraldo Rezende de Freitas, Antônio Tonete Bafi, Eduardo Souza Pacheco, Fernando José Ramos, José Mauro Vieira Júnior, Maria Augusta Santos Rahe Pereira, Fábio Sartori Schwerz, Giovanna Padoa de Menezes, Danielle Dourado Magalhães, Cristine Pilati Pileggi Castro, Sabrina Frighetto Henrich, Diogo Oliveira Toledo, Bruna Fernanda Camargo Silva Parra, Fernando Suparregui Dias, Luiza Zerman, Fernanda Formolo, Marciano de Sousa Nobrega, Claudio Piras, Stéphanie de Barros Piras, Rodrigo Conti, Paulo Lisboa Bittencourt, Ricardo Azevedo Cruz D’Oliveira, André Ricardo de Oliveira Estrela, Mirella Cristine de Oliveira, Fernanda Baeumle Reese, Jarbas da Silva Motta Júnior, Bruna Martins Dzivielevski da Câmara, Paula Geraldes David-João, Luana Alves Tannous, Viviane Bernardes de Oliveira Chaiben, Lorena Macedo Araújo Miranda, José Arthur dos Santos Brasil, Rafael Alexandre de Oliveira Deucher, Marcos Henrique Borges Ferreira, Denner Luiz Vilela, Guilherme Cincinato de Almeida, Wagner Luis Nedel, Matheus Golenia dos Passos, Luiz Gustavo Marin, Wilson de Oliveira Filho, Raoni Machado Coutinho, Michele Cristina Lima de Oliveira, Gilberto Friedman, André Meregalli, Jorge Amilton Höher, Afonso José Celente Soares, and Suzana Margareth Ajeje Lobo

Subjects
Procedimentos cirúrgicos operatórios/ epidemiologia, Procedimentos cirúrgicos operatórios/mortalidade, Cuidados pós-operatórios, Complicações pós-operatórias/mortalidade, Unidades de terapia intensiva, Brasil, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

RESUMO Objetivo: Definir o perfil epidemiológico e os principais determinantes de morbimortalidade dos pacientes cirúrgicos não cardíacos de alto risco no Brasil. Métodos: Estudo prospectivo, observacional e multicêntrico. Todos os pacientes cirúrgicos não cardíacos admitidos nas unidades de terapia intensiva, ou seja, considerados de alto risco, no período de 1 mês, foram avaliados e acompanhados diariamente por, no máximo, 7 dias na unidade de terapia intensiva, para determinação de complicações. As taxas de mortalidade em 28 dias de pós-operatório, na unidade de terapia intensiva e hospitalar foram avaliadas. Resultados: Participaram 29 unidades de terapia intensiva onde foram realizadas cirurgias em 25.500 pacientes, dos quais 904 (3,5%) de alto risco (intervalo de confiança de 95% - IC95% 3,3% - 3,8%), tendo sido incluídos no estudo. Dos pacientes envolvidos, 48,3% eram de unidades de terapia intensiva privadas e 51,7% de públicas. O tempo de internação na unidade de terapia intensiva foi de 2,0 (1,0 - 4,0) dias e hospitalar de 9,5 (5,4 - 18,6) dias. As taxas de complicações foram 29,9% (IC95% 26,4 - 33,7) e mortalidade em 28 dias pós-cirurgia 9,6% (IC95% 7,4 - 12,1). Os fatores independentes de risco para complicações foram Simplified Acute Physiology Score 3 (SAPS 3; razão de chance − RC = 1,02; IC95% 1,01 - 1,03) e Sequential Organ Failure Assessment Score (SOFA) da admissão na unidade de terapia intensiva (RC =1,17; IC95% 1,09 - 1,25), tempo de cirurgia (RC = 1,001; IC95% 1,000 - 1,002) e cirurgias de emergências (RC = 1,93; IC95% 1,10 - 3,38). Em adição, foram associados com mortalidade em 28 dias idade (RC = 1,032; IC95% 1,011 - 1,052) SAPS 3 (RC = 1,041; IC95% 1,107 - 1,279), SOFA (RC = 1,175; IC95% 1,069 - 1,292) e cirurgias emergenciais (RC = 2,509; IC95% 1,040 - 6,051). Conclusão: Pacientes com escores prognósticos mais elevados, idosos, tempo cirúrgico e cirurgias emergenciais estiveram fortemente associados a maior mortalidade em 28 dias e mais complicações durante permanência em unidade de terapia intensiva.

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4. Análise das infecções relacionadas aos cuidados de saúde e hospitalares nos pacientes cirróticos críticos

Author

Ricardo Azevedo Cruz D’OLIVEIRA, Lívia Carolina Dourado PEREIRA, Liana CODES, Mário de Seixas ROCHA, and Paulo Lisboa BITTENCOURT

Subjects
Liver Cirrhosis, Male, Hepatorenal Syndrome, Critical Illness, morbidity, intensive care unit, unidade de terapia intensivo, Sepsis, Humans, morbidade, Retrospective Studies, mortalidade, Cross Infection, Gastroenterology, Bacterial Infections, Acute Kidney Injury, mortality, Hospitals, Anti-Bacterial Agents, Community-Acquired Infections, infecções bacterianas, bacterial infections, Liver cirrhosis, Female, Delivery of Health Care, Cirrose hepática
Abstract

Background Bacterial infections occur in 43—59% of cirrhotic patients admitted to the intensive care unit with impact in morbidity and mortality. An increase in the frequency of multidrug-resistant (MDRO) and extensively drug-resistant (XDRO) organisms has been described in bacterial infections in cirrhotic patients with an adverse impact on survival. Objective To characterize community-acquired (CA), healthcare-associated (HCA), and hospital-acquired (HA) infections in cirrhotic patients and their impact in the occurrence of adverse outcomes. Methods This study included all cirrhotic patients admitted in an intensive care unit specialized in liver and gastrointestinal diseases in Brazil between January 2012 and June 2018. Frequency and topography of infections were retrospectively evaluated, as well as the frequency of MDRO and XDRO organisms, and their impact in occurrence of acute kidney injury, hepatorenal syndrome, acute-on-chronic liver failure, sepsis and mortality. Results A total of 374 infections were observed and classified as CA (22%), HCA (34%) and hospital-acquired (44%). Eighty-nine (54%) episodes of hospital-acquired infections were second infections. Spontaneous bacterial peritonitis (32%) and urinary tract infection (23%) were the most common infections. Culture-proven infections were positive in 61% of the cases, mainly gram-negative bacteria (73%). Acute kidney injury, hepatorenal syndrome and sepsis were observed, respectively, in 48%, 15% and 53% of the cases. MDRO and XDRO were seen, respectively, in 35% and 16%, mainly in HCA (48% vs 26% in CA infections, P=0.02) and hospital-acquired (58% vs 26% in CA infections, P=0.0009). Adverse outcomes were more frequently observed in subjects with hospital-acquired infections when compared to HCA and CA infections. Hospital-acquired, HCA and second infections were independently associated with in-hospital mortality. Conclusion Hospital-acquired, HCA and second infections are increasingly associated with either MDRO and/or XDRO and are independent predictors of in-hospital mortality. Their recognition and proper selection of appropriate empiric antibiotic regimens are important measures to reduce in-hospital mortality. RESUMO Contexto As infecções bacterianas ocorrem em 43—59% dos pacientes cirróticos internados em unidade de terapia intensiva com impacto na morbimortalidade. Um aumento na frequência de bactérias multirresistentes e com resistência estendida foi descrito em infecções bacterianas em pacientes cirróticos, com um impacto adverso na sobrevida. Objetivo Caracterizar as infecções adquiridas na comunidade, relacionadas aos cuidados de saúde (RCS) e hospitalares em pacientes cirróticos e seu impacto na ocorrência de desfechos adversos. Métodos Este estudo incluiu todos os pacientes cirróticos internados em uma unidade de terapia intensiva especializada em doenças hepáticas e gastrointestinais no Brasil entre janeiro de 2012 e junho de 2018. A frequência e topografia das infecções foram avaliadas retrospectivamente, bem como a frequência de bactérias multirresistentes e resistência estendida, e seu impacto na ocorrência de lesão renal aguda, síndrome hepatorrenal, insuficiência hepática crônica agudizada, sepse e mortalidade. Resultados Um total de 374 infecções foram observadas e classificadas como infecções adquiridas na comunidade (22%), RCS (34%) e infecções hospitalares (44%). Oitenta e nove (54%) episódios de infecções hospitalares foram identificadas como segunda infecção. Peritonite bacteriana espontânea (32%) e infecção do trato urinário (23%) foram as infecções mais comuns. As infecções comprovadas por cultura foram positivas em 61% dos casos, principalmente ocasionadas por bactérias gram-negativas (73%). Lesão renal aguda, síndrome hepatorrenal e sepse foram observados respectivamente, em 48%, 15% e 53% dos casos. Bactérias multirresistentes e resistência estendida foram observadas respectivamente, em 35% e 16%, principalmente nos RCS (48% vs 26% em infecções adquiridas na comunidade, P=0,02) e infecções hospitalares (58% vs 26% em infecções adquiridas na comunidade, P=0,0009). Os resultados adversos foram observados com mais frequência em indivíduos com infecções nosocomiais em comparação com infecções relacionadas aos cuidados de saúde e comunitárias. Infecções hospitalares, RCS e ocorrência de uma segunda infecção foram independentemente associadas à mortalidade intra-hospitalar. Conclusão Infecções hospitalares, relacionadas aos cuidados de saúde e reinfecções estão cada vez mais associadas a bactérias multirresistentes e/ou resistência estendida e são preditores independentes de mortalidade intra-hospitalar. Seu reconhecimento e seleção adequada de regimes antibióticos empíricos apropriados são medidas importantes para reduzir a mortalidade intra-hospitalar.

Published
2022

5. Cumulative positive fluid balance is a risk factor for acute kidney injury and requirement for renal replacement therapy after liver transplantation

Author

Liana Codes, Jorge Luiz Andrade Bastos, Paulo Lisboa Bittencourt, Ygor Gomes de Souza, and Ricardo Azevedo Cruz D'Oliveira

Subjects
Transplantation, medicine.medical_specialty, Liver transplantation, business.industry, medicine.medical_treatment, Urology, Acute kidney injury, Observational Study, 030208 emergency & critical care medicine, medicine.disease, Fluid balance, 03 medical and health sciences, 0302 clinical medicine, Positive fluid balance, mental disorders, medicine, 030212 general & internal medicine, Renal replacement therapy, Risk factor, business
Abstract

AIM To analyze whether fluid overload is an independent risk factor of adverse outcomes after liver transplantation (LT). METHODS One hundred and twenty-one patients submitted to LT were retrospectively evaluated. Data regarding perioperative and postoperative variables previously associated with adverse outcomes after LT were reviewed. Cumulative fluid balance (FB) in the first 12 h and 4 d after surgery were compared with major adverse outcomes after LT. RESULTS Most of the patients were submitted to a liberal approach of fluid administration with a mean cumulative FB over 5 L and 10 L, respectively, in the first 12 h and 4 d after LT. Cumulative FB in 4 d was independently associated with occurrence of both AKI and requirement for renal replacement therapy (RRT) (OR = 2.3; 95%CI: 1.37-3.86, P = 0.02 and OR = 2.89; 95%CI: 1.52-5.49, P = 0.001 respectively). Other variables on multivariate analysis associated with AKI and RRT were, respectively, male sex and Acute Physiology and Chronic Health Disease Classification System (APACHE II) levels and sepsis or septic shock. Mortality was shown to be independently related to AST and APACHE II levels (OR = 2.35; 95%CI: 1.1-5.05, P = 0.02 and 2.63; 95%CI: 1.0-6.87, P = 0.04 respectively), probably reflecting the degree of graft dysfunction and severity of early postoperative course of LT. No effect of FB on mortality after LT was disclosed. CONCLUSION Cumulative positive FB over 4 d after LT is independently associated with the development of AKI and the requirement of RRT. Survival was not independently related to FB, but to surrogate markers of graft dysfunction and severity of postoperative course of LT.

Published
2018

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