Carlos Eduardo Pompilio

Role of MELD Score and Serum Creatinine as Prognostic Tools for the Development of Acute Kidney Injury after Liver Transplantation

Background The role of the Model for End-Stage Liver Disease (MELD) score in predicting complications, such as Acute Kidney Injury (AKI), after orthotopic liver transplantation (OLT) has yet to be evaluated and serum creatinine may be too heavily weighted in the existing MELD formula, since it has many pitfalls in cirrhotic patients. Methods Retrospective data of the perioperative period from consecutive adult OLTs performed from January to December 2009 were recorded. Univariate and multivariate analysis were performed to analyze the risk factors for AKI and mortality after OLT. Results There were 114 OLTs performed in the study period, 22 (19,2%) were submitted to dialysis prior OLT and were excluded from the analysis for AKI. The median age was 52 years and 66% were male. Median creatinine value was 0.85mg/dL and MELD was 19. Fifty-two of the 92 patients (56,5%) developed AKI in the first 72 hours after OLT. The only independent risk factor for AKI was calculated MELD and when the components of the MELD score were analyzed, INR had a much stronger impact in predicting AKI then serum creatinine. Overall mortality rate was 32,5% and anesthesia duration was the only variable associated with higher mortality rate. Conclusions Although MELD score seems to have a good performance in predicting AKI after OLT, serum creatinine had no impact on its prediction despite its importance on MELD calculation. Modifying the MELD score, which could include novel AKI biomarkers, may improve its prognostic accuracy and provide a better tool for public health planning.

Education program on medical nutrition and length of stay of critically ill patients

BACKGROUND & AIMS To evaluate the impact of a multifaceted nutritional educational intervention on the quality of nutritional therapy and clinical outcomes in critically ill patients. METHODS We conducted a prospective, non-blinded study with a non-contemporaneous control group at a 16-bed intensive care unit (ICU) at the Hospital das Clinicas, Department of Gastroenterology, University of Sao Paulo Medical School in Sao Paulo, Brazil. There were three phases. Phase 1: the quality of NT was evaluated in 50 newly admitted intensive care unit patients in a pre-educational program (Pre-EP). Phase 2: nutritional protocols were created and an education program was implemented. Phase 3: another 50 patients were enrolled and observed in a post-educational program (Post-EP) using phase 1 methodology. Nutritional Therapy practice was evaluated through nutritional assessments, adequacy of energy requirements, duration of fasting, and use of early enteral nutrition. Intensive care unit length of stay and hospital length of stay were measured as primary end-points. RESULTS The pre-educational program and post-educational program groups did not differ in age, APACHE II score, gender, or nutritional assessment. The mean ± SD duration of fasting decreased (Pre-EP 3.8 ± 3.1 days vs. Post-EP: 2.2 ± 2.6 days; p = 0.002), the adequacy of nutritional therapy improved (Pre-EP 74.2% ± 33.3% vs. Post-EP 96.2% ± 23.8%; p < 0.001), and enteral nutrition was initiated earlier than 48 h more commonly (Pre-EP 24% vs. Post-E 60%; p = 0.001). Median intensive care unit length of stay decreased (Pre-EP: 18.5 days vs. Post-EP: 9.5 days; p < 0.001) although hospital length of stay did not. CONCLUSION Implementing a multifaceted nutritional educational intervention could improve the quality of nutritional therapy and may decrease intensive care unit length of stay in critically ill patients.

The technological invention of disease and the decline of autopsies

The medical literature has shown some concern about the steady decrease in the number of autopsies that are being performed, a well documented phenomenon in Europe, the United States and Latin America, including Brazil. This fall is evident even in countries where the procedure is mandatory, like Hungary. The frequency of autopsies performed at Hospital das Clinicas (HC), Faculdade de Medicina da Universidade de Sao Paulo (FMUSP), during the years 1996-2000 reached 75.6% of deaths (Figure 1). However, over the period 2001-2006 the proportion went down to 44.3%. These numbers are comparable with international statistics (Table 1).

The Bariatric Patient in the Intensive Care Unit: Pitfalls and Management

The increasing number of bariatric/metabolic operations as important alternatives for the treatment of obesity and type 2 diabetes brought several concerns about the intensive care of patients undergoing those procedures. Intensive Care Unit admission criteria are needed in order to better allocate resources and avoid unnecessary interventions. Furthermore, well-established protocols, helpful in many clinical situations, are not directly applicable to obese patients. Indeed, difficult airway management, mechanical ventilation, fluid therapy protocols, prophylaxis, and treatment of venous thromboembolic events have unique aspects that should be taken into consideration. Finally, new data related to planning nutrition therapy of the critically obese have been highlighted and deserve consideration. In this review, we provide an outline of recent studies related to those important aspects of the care of the bariatric/metabolic patients in critical conditions.

O silêncio dos inocentes: por um estudo narrativo da prática médica

Embora absolutamente pertinente, a relacao entre texto e medicina ainda e pouco pesquisada no meio academico brasileiro. Nao obstante, e fato que toda pratica medica e permeada de narrativas, quer sejam as dos pacientes, que contam aos medicos as historias de suas doencas, quer as dos medicos, que recontam essas historias de acordo com modelos cientificos aprendidos e com sua experiencia clinica. Inspirado na Narrative-Based Medicine, campo teorico ja consolidado no meio anglofono, e em algumas teorias provenientes dos Estudos Literarios e das Ciencias Sociais, este artigo busca discutir, introdutoriamente, algumas possibilidades para a consolidacao de um estudo interdisciplinar das narrativas relacionadas a area medica no âmbito academico brasileiro.