Ciro Leite Mendes

Early Determinants of Death Due to Multiple Organ Failure After Noncardiac Surgery in High-Risk Patients

BACKGROUND:Prediction of perioperative cardiac complications is important in the medical management of patients undergoing noncardiac surgery. However, these patients frequently die as a consequence of primary or secondary multiple organ failure (MOF), often as a result of sepsis. We investigated the early perioperative risk factors for in-hospital death due to MOF in surgical patients. METHODS:This was a prospective, multicenter, observational cohort study performed in 21 Brazilian intensive care units (ICUs). Adult patients undergoing noncardiac surgery who were admitted to the ICU within 24 hours after operation were evaluated. MOF was characterized by the presence of at least 2 organ failures. To determine the relative risk (RR) of in-hospital death due to MOF, we performed a logistic regression multivariate analysis. RESULTS:A total of 587 patients were included (mean age, 62.4 ± 17 years). ICU and hospital mortality rates were 15% and 20.6%, respectively. The main cause of death was MOF (53%). Peritonitis (RR 4.17, 95% confidence interval [CI] 1.38–12.6), diabetes (RR 3.63, 95% CI 1.17–11.2), unplanned surgery (RR 3.62, 95% CI 1.18–11.0), age (RR 1.04, 95% CI 1 0.01–1.08), and elevated serum lactate concentrations (RR 1.52, 95% CI 1.14–2.02), a high central venous pressure (RR 1.12, 95% CI 1.04–1.22), a fast heart rate (RR 3.63, 95% CI 1.17–11.2) and pH (RR 0.04, 95% CI 0.0005–0.38) on the day of admission were independent predictors of death due to MOF. CONCLUSIONS:MOF is the main cause of death after surgery in high-risk patients. Awareness of the risk factors for death due to MOF may be important in risk stratification and can suggest routes for therapy.

Optimizing perioperative hemodynamics: what is new?

Purpose of reviewUsing perioperative goal-directed therapy (GDT) or peroperative hemodynamic optimization significantly reduces postoperative complications and risk of death in patients undergoing noncardiac major surgeries. In this review, we discuss the main changes in the field of perioperative optimization over the last few years. Recent findingsOne of the key aspects that has changed in the last decade is the shift from invasive monitoring with pulmonary artery catheters (PACs) to less or minimally invasive monitoring systems. The evaluation of intravascular fluid volume deficits has also changed dramatically from the use of static indices to the assessment of fluid responsiveness using either dynamic indices or functional hemodynamic. Finally, attention has been directed toward more restrictive strategies of crystalloids as maintenance fluids. SummaryGDT is safe and more likely to tailor the amount of fluids given to the amount of fluids actually needed. This approach includes assessment of fluid responsiveness and, if necessary, the use of inotropes; moreover, this approach can be coupled with a restrictive strategy for maintenance fluids. These strategies have been increasingly incorporated into protocols for perioperative hemodynamic optimization in high-risk patients undergoing major surgery, resulting in more appropriate use of fluids, vasopressors, and inotropes.

Epidemiologia e desfecho de pacientes cirúrgicos não cardíacos em unidades de terapia intensiva no Brasil

OBJECTIVES: Due to the dramatic medical breakthroughs and an increasingly ageing population, the proportion of patients who are at risk of dying following surgery is increasing over time. The aim of this study was to evaluate the outcomes and the epidemiology of non-cardiac surgical patients admitted to the intensive care unit. METHODS: A multicenter, prospective, observational, cohort study was carried out in 21 intensive care units. A total of 885 adult surgical patients admitted to a participating intensive care unit from April to June 2006 were evaluated and 587 patients were enrolled. Exclusion criteria were trauma, cardiac, neurological, gynecologic, obstetric and palliative surgeries. The main outcome measures were postoperative complications and intensive care unit and 90-day mortality rates. RESULTS: Major and urgent surgeries were performed in 66.4% and 31.7% of the patients, respectively. The intensive care unit mortality rate was 15%, and 38% of the patients had postoperative complications. The most common complication was infection or sepsis (24.7%). Myocardial ischemia was diagnosed in only 1.9% of the patients. A total of 94 % of the patients who died after surgery had co-morbidities at the time of surgery (3.4 ± 2.2). Multiple organ failure was the main cause of death (53%). CONCLUSION: Sepsis is the predominant cause of morbidity in patients undergoing non-cardiac surgery. In this patient population, multiple organ failure prevailed as the most frequent cause of death in the hospital.

Escalas de Ramsay e Richmond são equivalentes para a avaliação do nível de sedação em pacientes gravemente enfermos

OBJECTIVE The main purpose of this study was to compare performance of the Ramsay and Richmond sedation scores on mechanically ventilated critically ill patients, in a university-affiliated hospital. METHODS This was a 4-month prospective study, which included a total of 45 patients mechanically ventilated, with at least 48 hours stay in the intensive care unit. Each patient was assessed daily for sedation mode, sedative and analgesic doses and sedation level using the Ramsay and Richmond scores. Statistical analysis was made using Students t-test, Pearsons and Spearmans correlation, and constructing ROC-curves. RESULTS A high general mortality of 60% was observed. The length of sedation and daily dose of medication did not correlate with mortality. Deep sedation (Ramsay > 4 or Richmond < -3) was positively correlated with probability of death with an AUC > 0.78. An adequate level of sedation (Ramsay 2 to 4 or Richmond 0 to -3) was sensitively correlated with probability of survival with an AUC > 0.80. A low level of sedation was observed in 63 days evaluated (8.64%), and no correlation was found between occurrence of agitation and unfavorable outcomes. Correlation between Ramsay and Richmond scores (Pearsons > 0.810 - p<0.0001) was good. CONCLUSION In this study, Ramsay and Richmond sedation scores were similar for the assessment of deep, insufficient and adequate sedation. Both have good correlation with mortality in over sedated patients.OBJETIVO: O objetivo principal deste estudo foi comparar o desempenho das escalas de sedacao de Ramsay e Richmond em pacientes criticos sob ventilacao mecânica em um hospital universitario. METODOS: Estudo prospectivo onde foram incluidos todos os pacientes sob ventilacao mecânica com pelo menos 48 horas de internacao, durante quatro meses, totalizando 45 pacientes. Foram avaliados diariamente a modalidade de sedacao, dose dos sedativos e analgesicos e o nivel de sedacao atraves das escalas de Ramsay e Richmond. O teste T de Student, os indices de correlacao de Pearson e Spearman, e a elaboracao de curvas Receiver Operating Characteristic (ROC) foram utilizados para a analise estatistica. RESULTADOS: A mortalidade geral observada foi de 60%. Nesta serie, o tempo de sedacao e a dose de sedativos utilizada nao se correlacionaram com a mortalidade. Sedacao profunda (Ramsay > 4 ou Richmond 0,78. Niveis adequados de sedacao (Ramsay 2 a 4 ou Richmond 0 a -3) correlacionaram-se sensivelmente a probabilidade de sobrevivencia, com uma ASC > 0,80. Em 63 evolucoes (8,64%) foram observados niveis baixos de sedacao, porem nao se evidenciou nenhuma correlacao entre a ocorrencia de agitacao e prognosticos desfavoraveis. Houve uma boa correlacao entre as escalas Ramsay e Richmond (Pearson > 0,810 - p<0,0001). CONCLUSAO: Neste estudo, as escalas de Ramsay e Richmond mostraram-se equivalentes para a avaliacao de sedacoes profunda, insuficiente e adequada e ambos demonstraram boa correlacao com mortalidade em pacientes excessivamente sedados.

Parte II: monitorização hemodinâmica básica e cateter de artéria pulmonar

BACKGROUND AND OBJECTIVES: Monitoring of vital functions is one of the most important tools in the management of critically ill patients. Nowadays is possible to detect and analyze a great deal of physiologic data using a lot of invasive and non-invasive methods. The intensivist must be able to select and carry out the most appropriate monitoring technique according to the patient requirements and taking into account the benefit/risk ratio. Despite the fast development of non invasive monitoring techniques, invasive hemodynamic monitoring using Pulmonary Artery Catheter still is one of the basic procedures in Critical Care. The aim was to define recommendations about clinical utility of basic hemodynamic monitoring methods and the Use of Pulmonary Artery Catheter. METHODS: Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty-five physicians and nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MEDLINE in the period from 1996 to 2004. RESULTS: Recommendations were made based on 55 questions about the use of central venous pressure, invasive arterial pressure, pulmonary artery catheter and its indications in different settings. CONCLUSIONS: Evaluation of central venous pressure and invasive arterial pressure, besides variables obtained by the PAC allow the understanding of cardiovascular physiology that is of great value to the care of critically ill patients. However, the correct use of these tools is fundamental to achieve the benefits due to its use.

INTERSEPT study: we still need more clarity

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.

Monitorização hemodinâmica em unidade de terapia intensiva: uma perspectiva do Brasil

Objetivo: No Brasil, nao ha dados sobre as preferencias do intensivista em relacao aos metodos de monitorizacao hemodinâmica. Este estudo procurou identificar os metodos utilizados por intensivistas nacionais, as variaveis hemodinâmicas por eles consideradas importantes, as diferencas regionais, as razoes para escolha de um determinado metodo, o emprego de protocolos e treinamento continuado. Metodos: Intensivistas nacionais foram convidados a responder um questionario em formato eletronico durante tres eventos de medicina intensiva e, posteriormente, por meio do portal da Associacao de Medicina Intensiva Brasileira, entre marco e outubro de 2009. Foram pesquisados dados demograficos e aspectos relacionados as preferencias do entrevistado em relacao a monitorizacao hemodinâmica. Resultados: Responderam ao questionario 211 profissionais. Nos hospitais privados, foi evidenciada maior disponibilidade de recursos de monitorizacao hemodinâmica do que nas instituicoes publicas. O cateter de arteria pulmonar foi considerado o mais fidedigno por 56,9%, seguido do ecocardiograma, com 22,3%. O debito cardiaco foi considerado a variavel mais importante. Outras variaveis tambem julgadas relevantes foram debito cardiaco, saturacao de oxigenio venoso misto/saturacao de oxigenio venoso central, pressao de oclusao da arteria pulmonar e volume diastolico final do ventriculo direito. O ecocardiograma foi apontado como o metodo mais utilizado (64,5%), seguido pelo cateter de arteria pulmonar (49,3%). Apenas metade dos entrevistados utilizava protocolos de tratamento e 25% trabalhava com programas de educacao continuada em monitorizacao hemodinâmica. Conclusao: A monitorizacao hemodinâmica e mais disponivel nas unidades de terapia intensiva de instituicoes privadas do Brasil. O ecocardiograma foi apontado como metodo de monitorizacao mais utilizado, porem o cateter de arteria pulmonar permanece o mais confiavel. A implantacao de protocolos de tratamento e de programas de educacao continuada em monitorizacao hemodinâmica no Brasil ainda e insuficiente.Objective In Brazil, there are no data on the preferences of intensivists regarding hemodynamic monitoring methods. The present study aimed to identify the methods used by national intensivists, the hemodynamic variables they consider important, the regional differences, the reasons for choosing a particular method, and the use of protocols and continued training. Methods National intensivists were invited to answer an electronic questionnaire during three intensive care events and later, through the Associação de Medicina Intensiva Brasileira portal, between March and October 2009. Demographic data and aspects related to the respondent preferences regarding hemodynamic monitoring were researched. Results In total, 211 professionals answered the questionnaire. Private hospitals showed higher availability of resources for hemodynamic monitoring than did public institutions. The pulmonary artery catheter was considered the most trusted by 56.9% of the respondents, followed by echocardiograms, at 22.3%. Cardiac output was considered the most important variable. Other variables also considered relevant were mixed/central venous oxygen saturation, pulmonary artery occlusion pressure, and right ventricular end-diastolic volume. Echocardiography was the most used method (64.5%), followed by pulmonary artery catheter (49.3%). Only half of respondents used treatment protocols, and 25% worked in continuing education programs in hemodynamic monitoring. Conclusion Hemodynamic monitoring has a greater availability in intensive care units of private institutions in Brazil. Echocardiography was the most used monitoring method, but the pulmonary artery catheter remains the most reliable. The implementation of treatment protocols and continuing education programs in hemodynamic monitoring in Brazil is still insufficient.

Avaliação da variabilidade de intervenções baseadas no cateter de artéria pulmonar: experiência brasileira

BACKGROUND AND OBJECTIVES: Use of Pulmonary Artery Catheter (PAC) is still a debatable issue, mainly due to questions raised about its security and efficacy. This study reproduced in a sample of Brazilian physicians, another one conducted amidst American doctors, in which was pointed out the heterogeneity of clinical decisions guided by data obtained from PAC. METHODS: During the Brazilian Congress of Intensive Care Medicine (Curitiba 2004), doctors were asked to answer a survey form with three vignettes. Each of them contained PAC data and one half of the surveys contained echocardiographic information. Every doctor was asked to select one of six interventions for each vignette. A homogeneous answer was considered when it was selected by at least 80% of the respondents. RESULTS: Two hundred and thirty seven doctors answered the questionnaires. They selected completely different therapeutic interventions in all three vignettes and none of the interventions achieved more than 80% agreement. Variability persisted with the choices guided by echocardiography. CONCLUSIONS: As in the original study, we observed total heterogeneity of therapeutic interventions guided by CAP and echocardiography. These results could be caused by lack of knowledge about basic pathophysiologic concepts and maybe we had to improve its teaching at the medical school benches.

Consenso brasileiro de monitorização e suporte hemodinâmico - Parte V: suporte hemodinâmico

BACKGROUND AND OBJECTIVES Shock occurs when the circulatory system cannot maintain adequate cellular perfusion. If this condition is not reverted irreversible cellular injury establishes. Shock treatment has as its initial priority the fast and vigorous correction of mean arterial pressure and cardiac output to maintain life and avoid or lessen organic dysfunctions. Fluid challenge and vasoactive drugs are necessary to warrant an adequate tissue perfusion and maintenance of function of different organs and systems, always guided by cardiovascular monitorization. The recommendations built in this consensus are aimed to guide hemodynamic support needed to maintain adequate tisular perfusion. METHODS Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty five physician and two nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MEDLINE in the period from 1996 to 2004. RESULTS Recommendations were made answering 17 questions about hemodynamic support with focus on fluid challenge, red blood cell transfusions, vasoactive drugs and perioperative hemodynamic optimization. CONCLUSIONS Hemodynamic monitoring by itself does not reduce the mortality of critically ill patients, however, we believe that the correct interpretation of the data obtained by the hemodynamic monitoring and the use of hemodynamic support protocols based on well defined tissue perfusion goals can improve the outcome of these patients.

Cardiac tamponade in a patient with severe dengue fever

A 26-year-old postpartum female presented with symptoms characteristic of dengue fever on the 16th day of puerperium. On the third day of the illness, the patient presented a clinical picture consistent with shock. Tests determined primary infection with dengue virus serotype 2. Cardiac tamponade was confirmed by echocardiography. This rare manifestation is described in a patient without any associated comorbidity.