Daniel Neves Forte

C-Reactive Protein/Albumin Ratio Predicts 90-Day Mortality of Septic Patients

Introduction Residual inflammation at ICU discharge may have impact upon long-term mortality. However, the significance of ongoing inflammation on mortality after ICU discharge is poorly described. C-reactive protein (CRP) and albumin are measured frequently in the ICU and exhibit opposing patterns during inflammation. Since infection is a potent trigger of inflammation, we hypothesized that CRP levels at discharge would correlate with long-term mortality in septic patients and that the CRP/albumin ratio would be a better marker of prognosis than CRP alone. Methods We evaluated 334 patients admitted to the ICU as a result of severe sepsis or septic shock who were discharged alive after a minimum of 72 hours in the ICU. We evaluated the performance of both CRP and CRP/albumin to predict mortality at 90 days after ICU discharge. Two multivariate logistic models were generated based on measurements at discharge: one model included CRP (Model-CRP), and the other included the CRP/albumin ratio (Model-CRP/albumin). Results There were 229 (67%) and 111 (33%) patients with severe sepsis and septic shock, respectively. During the 90 days of follow-up, 73 (22%) patients died. CRP/albumin ratios at admission and at discharge were associated with a poor outcome and showed greater accuracy than CRP alone at these time points (p = 0.0455 and p = 0.0438, respectively). CRP levels and the CRP/albumin ratio were independent predictors of mortality at 90 days (Model-CRP: adjusted OR 2.34, 95% CI 1.14–4.83, p = 0.021; Model-CRP/albumin: adjusted OR 2.18, 95% CI 1.10–4.67, p = 0.035). Both models showed similar accuracy (p = 0.2483). However, Model-CRP was not calibrated. Conclusions Residual inflammation at ICU discharge assessed using the CRP/albumin ratio is an independent risk factor for mortality at 90 days in septic patients. The use of the CRP/albumin ratio as a long-term marker of prognosis provides more consistent results than standard CRP values alone.

Failure to reduce C-reactive protein levels more than 25% in the last 24 hours before intensive care unit discharge predicts higher in-hospital mortality: A cohort study ☆,☆☆

PURPOSE To discharge a patient from the intensive care unit (ICU) is a complex decision-making process because in-hospital mortality after critical illness may be as high as up to 27%. Static C-reactive protein (CRP) values have been previously evaluated as a predictor of post-ICU mortality with conflicting results. Therefore, we evaluated the CRP ratio in the last 24 hours before ICU discharge as a predictor of in-hospital outcomes. METHODS A retrospective cohort study was performed in 409 patients from a 6-bed ICU of a university hospital. Data were prospectively collected during a 4-year period. Only patients discharged alive from the ICU with at least 72 hours of ICU length of stay were evaluated. RESULTS In-hospital mortality was 18.3% (75/409). Patients with reduction less than 25% in CRP concentrations at 24 hours as compared with 48 hours before ICU discharge had a worse prognosis, with increased mortality (23% vs 11%, P = .002) and post-ICU length of stay (26 [7-43] vs 11 [5-27] days, P = .036). Moreover, among hospital survivors (n = 334), patients with CRP reduction less than 25% were discharged later (hazard ratio, 0.750; 95% confidence interval, 0.602-0.935; P = .011). CONCLUSIONS In this large cohort of critically ill patients, failure to reduce CRP values more than 25% in the last 24 hours of ICU stay is a strong predictor of worse in-hospital outcomes.

The effects of discharge to an intermediate care unit after a critical illness: a 5-year cohort study.

PURPOSE The impact of the intermediate care unit (IMCU) on post-intensive care unit (ICU) outcomes is controversial. MATERIALS AND METHODS We analyzed admissions from January 2003 to December 2008 from a mixed ICU in a teaching hospital in Brazil with a high patient-to-nurse ratio (3.5:1 on the ICU, 11:1 on the IMCU, 20-25:1 on the ward). A retrospective propensity-matched analysis was performed with data from 690 patients who were discharged after at least 3 days of ICU stay. RESULTS Of the 690 patients, 160 (23%) were discharged to the IMCU. A total of 399 propensity-matched patients were compared: 298 were discharged to the ward and 101 were discharged to the IMCU. Ninety-day mortality rate was similar between the IMCU and ward patients (22% vs 18%, respectively, P = .37), as was the unplanned ICU readmission rate (P = .63). In a multivariate logistic regression, discharge to the IMCU had no effect on the 90-day mortality rate (P = .27). CONCLUSIONS In a resource-limited setting with a high patient-to-nurse ratio, discharge to IMCU had no impact on 90-day mortality rate and on unplanned readmission rate. The impact of discharge to the IMCU on the outcome for critically ill patients should be evaluated in further studies.

II Forum of the "End of Life Study Group of the Southern Cone of America": palliative care definitions, recommendations and integrated actions for intensive care and pediatric intensive care units

Palliative care is aimed to improve the quality of life of both patients and their family members during the course of life-threatening diseases through the prevention, early identification and treatment of the symptoms of physical, psychological, spiritual and social suffering. Palliative care should be provided to every critically ill patient; this requirement renders the training of intensive care practitioners and education initiatives fundamental. Continuing the Technical Council on End of Life and Palliative Care of the Brazilian Association of Intensive Medicine activities and considering previously established concepts, the II Forum of the End of Life Study Group of the Southern Cone of America was conducted in October 2010. The forum aimed to develop palliative care recommendations for critically ill patients.

Fagocitose por neutrófilos no Lúpus Eritematoso Sistêmico

OBJECTIVE: To evaluate the presence of immune complexes and the phagocytes by polymorphonuclear neutrophils in patients with systemic lupus erythematosus, with and without disease activity. METHODS: The peripheral blood of 55 subjects was analyzed. Ten of those subjects had disease activity, 15 had not disease activity, and 30 were healthy. We used radial immune diffusion to detect immune complexes. The phagocytic function was estimated by the ingestion of zymosan by polymorphonuclear neutrophils. RESULTS: In this study we found the presence of immune complexes formatted of IgM, IgG, IgA, and complement component C3 and C4 in LES patients. The arithmetic average of zymosan particles ingested by the neutrophils incubated with homologous human serum and autologous human serum was significantly decreased (p<0.05) in the LES activity patients when we compare with the group without activity, and the control group. CONCLUSION: We conclude that there are immune complexes in the LES patients with and without disease activity, and there is a reduction in the digestive step of the phagocytes by polymorphonuclear neutrophils in patients with disease activity. The conclusions of the present study are according with the pathogenesis of the disease and with the high mortality in these patients.

C-reactive protein/albumin ratio at ICU discharge as a predictor of post-ICU death: a new useful tool

There are classical predictors of death after ICU discharge, such as age, severity of disease and level of nursing care. CRP concentrations at discharge have also been reported as a predictor of in-hospital outcome, but with controversial results. Considering that albumin is a negative acute-phase protein and its decrease may be an indicator of disease severity, we hypothesized that the CRP/albumin ratio could be a marker of unfavorable outcomes in the post-ICU period.

Cuidados paliativos no paciente com HIV/AIDS internado na unidade de terapia intensiva.

Objective To describe the characteristics of patients with HIV/AIDS and to compare the therapeutic interventions and end-of-life care before and after evaluation by the palliative care team. Methods This retrospective cohort study included all patients with HIV/AIDS admitted to the intensive care unit of the Instituto de Infectologia Emílio Ribas who were evaluated by a palliative care team between January 2006 and December 2012. Results Of the 109 patients evaluated, 89% acquired opportunistic infections, 70% had CD4 counts lower than 100 cells/mm3, and only 19% adhered to treatment. The overall mortality rate was 88%. Among patients predicted with a terminally ill (68%), the use of highly active antiretroviral therapy decreased from 50.0% to 23.1% (p = 0.02), the use of antibiotics decreased from 100% to 63.6% (p < 0.001), the use of vasoactive drugs decreased from 62.1% to 37.8% (p = 0.009), the use of renal replacement therapy decreased from 34.8% to 23.0% (p < 0.0001), and the number of blood product transfusions decreased from 74.2% to 19.7% (p < 0.0001). Meetings with the family were held in 48 cases, and 23% of the terminally ill patients were discharged from the intensive care unit. Conclusion Palliative care was required in patients with severe illnesses and high mortality. The number of potentially inappropriate interventions in terminally ill patients monitored by the palliative care team significantly decreased, and 26% of the patients were discharged from the intensive care unit.

APACHE II and SOFA scores for intensive care and hospital outcome prediction in oncologic patients

The number of acute organ failures has been shown to be an important determinant of prognosis in critically ill cancer patients admitted to an ICU [1]. Although the SOFA score is useful in analyzing the number and the severity of acute organ failures related to ICU mortality, it is not validated to predict outcomes in the ICU. On the other hand, general prognostic models have failed to accurately predict outcomes in the oncologic population [2,3]. Given this, we propose to analyze the ability of the SOFA score compared with the APACHE II score in predicting ICU and inhospital mortality in oncologic patients.

SOFA-derived variables and sepsis survival in a Brazilian university hospital intensive care unit

Organ dysfunction is a major determinant of morbidity and mortality in the critically ill septic patient. We tried to establish the mortality prediction accuracy of SOFA-derived variables (maximum SOFA, 48-hour ΔSOFA and highest SOFA) in a Brazilian sample of ICU patients.

Differences in attitudes towards end-of-life care among intensivists, oncologists and prosecutors in Brazil: a nationwide survey

There is great variability in end-of-life care [1] and the legal context may interfere with decisions on limitation of medical treatment [2]. In Brazil, end-of-life care was initially regulated in 2006, but legal controversies still continue [3]. Even though physicians do not need authorization from the Judiciary system to act, those controversies may cause uncertainty regarding seemingly competing professional duties (caring for patients’ best interests versus maintenance of life), possibly hampering good medical care [4]. In this study, we sought to compare the attitudes of physicians (intensivists and oncologists) and prosecutors from the Ministerio Publico da Uniao (MPU) towards common concepts in end-of-life care in Brazil, such as patient autonomy and withholding/withdrawal of care. We evaluated MPU prosecutors because they may be responsible for investigation of deaths due to limitation of medical treatment. After ethics approval, we sent an electronic survey (SurveyMonkey Inc., USA) to intensivists, oncologists and prosecutors practicing in the 27 federative units of Brazil (see Additional file 1 for more details of methods and Brazilian judiciary and health systems). Participants were asked to rate 11 questions in a Likert scale from 1 (completely disagree) to 10 (completely agree). Responses were categorized in three groups, accordingly to the Likert scale: disagree (1–4), neutral (5–6) and agree (7–10). Categorical and continuous variables were analyzed with chi-square and Kruskal-Wallis tests, respectively, and a p value < 0.05 was considered as significant. Outcome was the difference in agreement between groups of respondents. From February 2018 to May 2018 there were 661 respondents, comprising 24/27 (88.8%) federative units of Brazil, of which 467 (71%) were intensivists, 89 (13%) were oncologists and 105 (16%) were prosecutors. The characteristics of the respondents are provided in Table 1. There were significant differences in responses between physicians and prosecutors for all 11 questions, except for question 10 (Fig. 1 and Additional file 1: Table S1). Prosecutors were less likely to agree with paternalistic decision-making by physicians, more likely to agree with the maintenance of life-sustaining treatments in patients with poor prognosis and more likely to agree with the concepts of euthanasia and physician-assisted suicide, whereas physicians responded in the opposite direction. Our results suggest that there is variation in attitudes towards end-of-life care between physicians and prosecutors. However, responses did not reflect an absolute dominance of the principle of maintenance of life over other principles. Similar variations in attitudes have been shown before [5] and may reflect professional ethics and other values. Those differences should encourage actions to reduce heterogeneity in attitudes toward end-of-life care, possibly through greater interaction between physicians and prosecutors, ensuring that patients’ wishes are respected and that clinicians are protected in their practice.