Bruno Adler Maccagnan Pinheiro Besen

Comparison between ultrasound- and bronchoscopy-guided percutaneous dilational tracheostomy in critically ill patients: a retrospective cohort study.

INTRODUCTION Percutaneous dilational tracheostomy (PDT) is routinely performed in the intensive care unit with bronchoscopic guidance. Recently, ultrasound (US) has emerged as a new safety adjunct tool to increase the efficacy of PDT. However, the available data are limited to case series without any control group. Hence, a retrospective cohort study was designed to evaluate the efficacy of US-guided PDT compared with bronchoscopy-guided PDT. METHODS All patients who were submitted to PDT after the standardization of US-guided PDT technique in our institution were analyzed. Demographic and procedure-related variables, complications, and clinical outcomes were collected and compared in patients undergoing US- or bronchoscopy-guided PDT. RESULTS Sixty patients who had been submitted to PDT were studied, including 11 under bronchoscopy guidance and 49 under US guidance. No surgical conversion was necessary in any of the procedures, and bronchoscopy assistance was only required in 1 case in the US group. The procedure length was shorter in the US group than in the bronchoscopy group (12 vs 15 minutes, P = .028). None of the patients had any major complications. The minor complication rates were not significantly different between the groups, nor was the probability of breathing without assistance within 28 days, intensive care unit length of stay, or hospital mortality. CONCLUSION Ultrasound-guided PDT is effective, safe, and associated with similar complication rates and clinical outcomes compared with bronchoscopy-guided PDT.

One-year survival and resource use after critical illness: impact of organ failure and residual organ dysfunction in a cohort study in Brazil

IntroductionIn this study, we evaluated the impacts of organ failure and residual dysfunction on 1-year survival and health care resource use using Intensive Care Unit (ICU) discharge as the starting point.MethodsWe conducted a historical cohort study, including all adult patients discharged alive after at least 72 h of ICU stay in a tertiary teaching hospital in Brazil. The starting point of follow-up was ICU discharge. Organ failure was defined as a value of 3 or 4 in its corresponding component of the Sequential Organ Failure Assessment score, and residual organ dysfunction was defined as a score of 1 or 2. We fit a multivariate flexible Cox model to predict 1-year survival.ResultsWe analyzed 690 patients. Mortality at 1 year after discharge was 27 %. Using multivariate modeling, age, chronic obstructive pulmonary disease, cancer, organ dysfunctions and albumin at ICU discharge were the main determinants of 1-year survival. Age and organ failure were non-linearly associated with survival, and the impact of organ failure diminished over time. We conducted a subset analysis with 561 patients (81 %) discharged without organ failure within the previous 24 h of discharge, and the number of residual organs in dysfunction remained strongly associated with reduced 1-year survival. The use of health care resources among hospital survivors was substantial within 1 year: 40 % of the patients were rehospitalized, 52 % visited the emergency department, 90 % were seen at the outpatient clinic, 14 % attended rehabilitation outpatient services, 11 % were followed by the psychological or psychiatric service and 7 % used the day hospital facility. Use of health care resources up to 30 days after hospital discharge was associated with the number of organs in dysfunction at ICU discharge.ConclusionsOrgan failure was an important determinant of 1-year outcome of critically ill survivors. Nevertheless, the impact of organ failure tended to diminish over time. Resource use after critical illness was elevated among ICU survivors, and a targeted action is needed to deliver appropriate care and to reduce the late critical illness burden.

Negative Fluid Balance in Sepsis: When and How?

ABSTRACT Fluid resuscitation plays a fundamental role in the treatment of septic shock. Administration of inappropriately large quantities of fluid may lead to volume overload, which is increasingly recognized as an independent risk factor for morbidity and mortality in critical illness. In the early treatment of sepsis, timely fluid challenges should be given to optimize organ perfusion, but continuous positive fluid balance is discouraged. In fact, achievement of a negative fluid balance during treatment of sepsis is associated with better outcomes. This review will discuss the relationship between fluid overload and unfavorable outcomes in sepsis, and how fluid overload can be prevented and managed.

How Can We Estimate Sepsis Incidence and Mortality

ABSTRACT Sepsis is one of the oldest and complex syndromes in medicine that has been in debate for over two millennia. Valid and comparable data on the population burden of sepsis constitute an essential resource for guiding health policy and resource allocation. Despite current epidemiological data suggesting that the global burden of sepsis is huge, the knowledge of its incidence, prevalence, mortality, and case-fatality rates is subject to several flaws. The objective of this narrative review is to assess how sepsis incidence and mortality can be estimated, providing examples on how it has been done so far in medical literature and discussing its possible biases. Results of recent studies suggest that sepsis incidence rates are increasing consistently during the last decades. Although estimates might be biased, this probably reflects a real increase in incidence over time. Nevertheless, case fatality rates have decreased, which is a probable reflex of advances in critical care provision to this very sick population at high risk of death. This conclusion can only be drawn with a reasonable degree of certainty for high-income countries. Conversely, adequately designed studies from middle- and low-income countries are urgently needed. In these countries, sepsis incidence and case-fatality rates could be disproportionally higher due to health care provision constraints and ineffective preventive measures.

Ultrasound-guided percutaneous dilatational tracheostomy: Going deep into the sea

We have read with greatinterest theletter from Dr. Yavuz regarding our paper. The author recently published a randomized clinical trial comparing ultrasound (US)-guided percutaneous dilatational tracheostomy (PDT) with the conventional landmark-based PDT; and in the letter, he makes an interesting comparison between the patients submitted to US-guided PDT in his trial [1] and ours [2]. The author still raises several questions we are pleased to provide answers. In our study, the procedures were performed according to standardized practices following hospital routines, available in supplemental materials published with the paper. So, as described in supplemental materials, “in ultrasound-guided PDT, a physician using aseptic technique determines the probable puncture site using anatomical landmarks. Sterile ultrasound is performed by an intensivist accompanied by an intensive care medicine resident. Cervical ultrasound is performed with a linear probe, followed by a color Doppler examination to evaluate the vascular anatomy of the anterior neck region and identify the thyroid isthmus, cricoid cartilage, and first 3 tracheal rings. The midline distance between the skin and the trachea and the tracheal diameter are measured at the second ring level. The vessels between the skin and tracheal rings are identified and avoided. The orotracheal tube is then identified and pulled under direct ultrasound guidance until the cuff is at the cricoid cartilage level to avoid cuff puncture. The puncture site is marked between the second and third tracheal rings with the ultrasound probe in the longitudinal plane and compared with the previously defined puncture site based on anatomical landmarks. The trachea is then punctured under ultrasound guidance with the probe in the transverse plane at the midline, with a catheter-overthe-needle device connected to a 10-mL syringe half-filled with distilled water. As soon as air aspiration is observed in the syringe, the catheter is advanced into the trachea and the needle is removed. A flexible guide wire is then gently introduced into the catheter, which is removed after this step. The ultrasound is then repeated to verify the adequate positioning of the guide wire. Thereafter, the procedure is completed as previously described by Griggs et al [3] or Ciaglia et al [4] according to senior physician preference and experience.” Ultrasound-guided PDT proved to be an effective method because no surgical conversion was necessary in any of the procedures and only 1 caserequired bronchoscopy assistance after early guide wire withdrawal. In this patient, the tracheal puncture was performed under US guidance, as previously described; and the trachea was dilated using the technique of Griggs et al [3]. After tracheal dilation, the guide wire was unintentionally removed along with the forceps; and the responsible physicianrequestedbronchoscopyassistancejusttoinsertthetracheostomy cannula to avoid tracheostomy misplacement. Thus, this patient was counted as 1 of the 49 patients managed with US guidance. None of the patients was described as having thyroidal pathologies or tracheal deviations. Although actively searched during US examination as part of tracheal puncture site definition, anatomical abnormalities were considered present only if previously described in patients’ imaging examinations or reported in patients’ charts. However, the retrospective nature and small sample may have limited the evaluation of anatomical abnormalities in our study.

Early Versus Late Initiation of Renal Replacement Therapy in Critically Ill Patients: Systematic Review and Meta-Analysis.

Objective: Early initiation of renal replacement therapy (RRT) effect on survival and renal recovery of critically ill patients is still uncertain. We aimed to systematically review current evidence comparing outcomes of early versus late initiation of RRT in critically ill patients. Methods: We searched the Medline (via Pubmed), LILACS, Science Direct, and CENTRAL databases from inception until November 2016 for randomized clinical trials (RCTs) or observational studies comparing early versus late initiation of RRT in critically ill patients. The primary outcome was mortality. Duration of mechanical ventilation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and renal function recovery were secondary outcomes. Meta-analysis and trial sequential analysis (TSA) were used for the primary outcome. Results: Sixty-two studies were retrieved and analyzed, including 11 RCTs. There was no difference in mortality between early and late initiation of RRT among RCTs (odds ratio [OR] = 0.78; 95% confidence interval [CI]: 0.52-1.19; I2 = 63.1%). Trial sequential analysis of mortality across all RCTs achieved futility boundaries at both 1% and 5% type I error rates, although a subgroup analysis of studies including only acute kidney injury patients was not conclusive. There was also no difference in time on mechanical ventilation, ICU and hospital LOS, or renal recovery among studies. Early initiation of RRT was associated with reduced mortality among prospective (OR = 0.69; 95% CI: 0.49-0.96; I2 = 85.9%) and retrospective (OR = 0.61; 95% CI: 0.41-0.92; I2 = 90.9%) observational studies, both with substantial heterogeneity. However, subgroup analysis excluding low-quality observational studies did not achieve statistical significance. Conclusion: Pooled analysis of randomized trials indicates early initiation of RRT is not associated with lower mortality rates. The potential benefit of reduced mortality associated with early initiation of RRT was limited to low-quality observational studies.

Timing of Initiation of Renal Replacement Therapy in Critically Ill Patients With Acute Kidney Injury

Discussion | The monthly patient censuses for buprenorphineprescribing physicians were substantially below patient limits at the time; more than 20% treated 3 or fewer patients, and fewer than 10% treated more than 75 patients. The median treatment duration (53 days) was lower than expected given clinical recommendations of maintenance treatment for up to 12 months3 and evidencelinkinglongertreatmenttobetteroutcomes.1,4 Thefindings are limited in that prescriber waiver status is unknown as is patient clinical status; we cannot exclude the possibility that buprenorphine was prescribed off-label for pain. Novice prescribers cite insufficient access to more experienced prescribers and insufficient access to substance abuse counseling for patients as barriers to treating more patients.5 Such barriers might be addressed by web-based or telecounseling for patients and by programs providing mentoring and telephone consultation from more experienced prescribers.6 Strategies to help current prescribers treat more patients safely and effectively could complement policy initiatives designed to increase access to treatment by increasing patient limits and number of waivered prescribers.

Methodological Reasons for the Association Between Hypocalcemia and Worse Outcomes in Intracranial Hemorrhage

Dear Editor, We read with interest the manuscript recently published in Neurocritical Care journal by Tu et al. [1] regarding the association of hypocalcemia with worse outcomes in patients admitted for intracranial hemorrhage. We are, however, concerned with the reporting and interpretation of the findings. The authors introduced selection bias by excluding patients who died from reasons that were not directly related to the hemorrhage. Many patients in neurocritical care die of medical complications, such as aspiration or venous thromboembolism, which are related to the severity of the neurological insult and are not reasonable exclusion criteria. The reported interpretation of correlation between ionized calcium levels and other variables—blood pressure, coagulation markers, and hematoma volume—is also of concern. By examining the scatter plots and the correlation coefficient, we conclude there is negligible correlation and the statistically significant p values merely reflect the large sample size, and not a meaningful positive association [2]. After considering these issues—selection bias and negligible correlation with hematoma expansion and coagulation markers—the association between low ionized calcium levels and poor outcome is difficult to interpret. Actually, it seems much more credible that this association reflects critical illness associated hypocalcemia, a known prognostic marker of worse outcomes—for which a treatment aiming at euboxia (i.e., normalization of physiological parameters) is not recommended [3]. Furthermore, the authors do not report variable selection for the Cox proportional hazards model, how the model was built, what was the final model fit, and whether the assumption of proportionality of hazards was evaluated any time during statistical analysis [4]. As a final criticism, modeling a continuous variable such as serum calcium levels as a binary variable should be viewed with much caution since it may also lead to substantial bias in the analysis and interpretation of results [5]. Given these concerns, we disagree with the authors’ conclusion that “Decreased serum calcium level on admission indicates 90-day poor prognosis.” These results were based on a biased sample and a poorly reported statistical analysis. Rather, if the results of the regression model are indeed true, this probably reflects acute illness associated hypocalcemia and not any mechanism related to calcium-induced coagulation abnormalities.

“Can We Discuss About RRT Starting Time Before We Have a Recovery Biomarker”—Yes, We Can

We agree with the rationale of doctor Coelho’s point of view, but our answer to her question is: Yes, we can! As a matter of fact, we need to discuss the timing of renal replacement therapy (RRT) initiation in critical care before a renal recovery biomarker is available. Renal replacement therapy is costly, associated with adverse events and may increase the burden of care for critical care nurses. In an ideal scenario, we would be able to forecast which patients would develop severe and persistent acute kidney injury (AKI) from those whose AKI is transient, in which case RRT would not be necessary. Indeed, some progress has been achieved in this field. Renal angina is a recently developed concept. Cruz et al, through a clinical classification, categorized patients into very high, high, or moderate risk of AKI development. His results showed that high-risk patients that raised 0.3 mg/dL of their serum creatinine had higher probability to develop severe AKI, with a sensitivity of 92%. Another bedside clinical tool is the furosemide stress test (FST). Koyner et al have shown that the urine output after 2 hours of an FST (1-1.5 mg/kg) outperformed urinary biomarkers and predicted RRT need with a reasonable accuracy, which yielded an area under curve of 0.86. Biomarkers, though, have not thrived so far. We agree with Vanmassenhove statement: AKI in critical care is often “not a single hit at a well-defined time point.” Therefore, the utilization of biomarkers raises many questions such as sampling timing, specificity, correlation of damage with clinically relevant AKI, and interpretation of biomarkers in the presence of chronic kidney disease. Even in situations where the renal hit is known, as cardiac surgery, the performance of biomarkers such as plasma neutrophil gelatinase–associated lipocalin (NGAL) is not that enthusiastic. The predictive performance of biomarkers does not bring more hope in this matter either. The AKINESIS study showed that NGAL did not have better performance than serum creatinine to predict stage 2 AKI in patients admitted with decompensated heart failure. The lack of specificity is also observed in sepsis since NGAL is associated with inflammation. Our conclusion, in response to Dr Coelho’s letter, is that it would be ideal to predict organs dysfunction time course, not only for AKI but also for lungs, liver, hemodynamics, and so on; but from the point we are now, biomarkers are far away from that capacity. Nevertheless, other tools such as the FST are available right now that can help the physician decisionmaking process, while others are a matter of debate and investigation.

Ultrasound-Guided Percutaneous Dilational Tracheostomy: A Systematic Review of Randomized Controlled Trials and Meta-Analysis.

Introduction: Percutaneous dilational tracheostomy (PDT) is a common and increasingly used procedure in the intensive care unit (ICU). It is usually performed with bronchoscopy guidance. Ultrasound has emerged as a useful tool in order to assist PDT, potentially improving its success rate and reducing procedural-related complications. Objective: To investigate whether the ultrasound-guided PDT is equivalent or superior to the bronchoscopy-guided or anatomical landmarks–guided PDT with regard to procedural-related and clinical complications. Methods: A systematic review of randomized clinical trials was conducted comparing an ultrasound-guided PDT to the control groups (either a bronchoscopy-guided PDT or an anatomical landmark–guided PDT) in patients undergoing a PDT in the ICU. The primary outcome was the incidence of major procedural-related and clinical complication rates. The secondary outcome was the incidence of minor complication rates. Random-effect meta-analyzes were used to pool the results. Results: Four studies fulfilled the inclusion criteria and they were analyzed. The studies included 588 participants. There were no differences in the major complication rates between the patients who were assigned to the ultrasound-guided PDT when compared to the control groups (pooled risk ratio [RR]: 0.48; 95% confidence interval [CI]: 0.13-1.71, I2 = 0%). The minor complication rates were not different between the groups, but they had a high heterogeneity (pooled RR: 0.49; 95% CI 0.16-1.50; I2 = 85%). The sensitivity analyzes that only included the randomized controlled trials that used a landmark-guided PDT as the control group showed lower rates of minor complications in the ultrasound-guided PDT group (pooled RR: 0.55; 95% CI: 0.31-0.98, I2 = 0%). Conclusion: The ultrasound-guided PDT seems to be safe and it is comparable to the bronchoscopy-guided PDT regarding the major and minor procedural-related or clinical complications. It also seems to reduce the minor complications when compared to the anatomical landmark–guided PDT.