Elaine Aparecida Felix

The Modified Integrative Weaning Index as a Predictor of Extubation Failure

INTRODUCTION: The extubation period is one of the most challenging aspects for intensive care teams. Timely recognition of the return to spontaneous ventilation is essential for reducing costs, morbidity, and mortality. Several weaning predictors were studied in an attempt to evaluate the outcome of removing ventilatory support. The purpose of this study was to analyze the predictive performance of the modified integrative weaning index (IWI) in the extubation process. METHODS: A prospective study was performed in an ICU in a public hospital in Porto Alegre, Brazil, with 59 adult medical-surgical beds. The final population of the study comprised 153 patients receiving mechanical ventilation for over 48 h who were extubated during the period from February to November 2011. Demographic data and clinical parameters were collected in addition to extubation predictors, including static compliance of the respiratory system, ratio of breathing frequency to tidal volume, tracheal airway-occlusion pressure 0.1 s after the start of inspiratory flow, and modified IWI. RESULTS: Extubation failure was observed in 23 of the subjects (15%). Subjects with greater positive fluid balance, lower hemoglobin levels, and lower levels of bicarbonate presented a higher rate of reintubation. The 3 modified IWI values (the first and 30th minute of the spontaneous breathing trial and the difference between them), as well as the other ventilatory parameters and extubation predictors, displayed poor extubation outcome discrimination accuracy. All indexes presented small areas under the receiver operating characteristic curve, and no accurate cutoff point was identified. CONCLUSIONS: We concluded that modified IWI, similar to other extubation predictors, does not accurately predict extubation failure.

Effectiveness of diaphragmatic stimulation with single-channel electrodes in rabbits

Every year, a large number of individuals become dependent on mechanical ventilation because of a loss of diaphragm function. The most common causes are cervical spinal trauma and neuromuscular diseases. We have developed an experimental model to evaluate the performance of electrical stimulation of the diaphragm in rabbits using single-channel electrodes implanted directly into the muscle. Various current intensities (10, 16, 20, and 26 mA) produced tidal volumes above the baseline value, showing that this model is effective for the study of diaphragm performance at different levels of electrical stimulationEvery year, a large number of individuals become dependent on mechanical ventilation because of a loss of diaphragm function. The most common causes are cervical spinal trauma and neuromuscular diseases. We have developed an experimental model to evaluate the performance of electrical stimulation of the diaphragm in rabbits using single-channel electrodes implanted directly into the muscle. Various current intensities (10, 16, 20, and 26 mA) produced tidal volumes above the baseline value, showing that this model is effective for the study of diaphragm performance at different levels of electrical stimulation

Influência da estratégia ventilatória no desempenho funcional de enxertos pulmonares em um modelo experimental de transplante pulmonar unilateral de doadores após parada cardiocirculatória

OBJECTIVE: To compare the influence of two different ventilation strategies-volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV)-on the functional performance of lung grafts in a canine model of unilateral left lung transplantation using donor lungs harvested after three hours of normothermic cardiocirculatory arrest under mechanical ventilation. METHODS: The study comprised 40 mongrel dogs, randomized into two groups: VCV and PCV. Of the 20 recipients, 5 did not survive the transplant, and 5 died before the end of the post-transplant assessment period. The remaining 10 survivors (5 in each group) were evaluated for 360 min after lung transplantation. The functional performance of the grafts was evaluated regarding respiratory mechanics, gas exchange, and lung graft histology. RESULTS: There were no significant differences between the groups regarding respiratory mechanics (peak inspiratory pressure, plateau pressure, mean airway pressure, dynamic compliance, and static compliance) or gas exchange variables (PaO2, venous oxygen tension, PaCO2, venous carbon dioxide tension, and the arterial-venous oxygen content difference). The histopathological findings were consistent with nonspecific acute lung injury and did not differ between the groups. CONCLUSIONS: This model of lung transplantation showed that the functional performance of lung grafts was not influenced by the ventilation strategy employed during the first six hours after reperfusion.

Development of a new experimental model of intramuscular electrical stimulation of the diaphragm in rabbits.

PURPOSE To develop an animal model of diaphragmatic electrical stimulation able to generate an appropriate ventilatory support through the direct implantation of electrodes in the diaphragm (electroventilation). METHODS Six New Zealand female rabbits (2-3 kg) were placed on mechanical ventilation. Then, a laparotomy was performed in order to identify the motor points in each hemidiaphragm, followed by the implantation of the electrodes for diaphragmatic stimulation. We tested two types of electrodes according to the conduction of electrical stimulation: unipolar and bipolar. The electrodes were placed on different occasions in the same animals and tested with current intensities of 20, 26 and 32 mA. Each current intensity was repeated three times for 10 respiratory cycles with 1 minute interval between each cycle, and 5 minutes for new current intensity. We recorded the relationship between current intensity and inspiratory volume. RESULTS The electrodes adequately stimulate the diaphragm and obtain inspired volumes using different intensity currents. The bipolar electrode generated inspiratory volumes as high as 4.5 times of baseline while the unipolar electrode reached up to 3.5 times of baseline. CONCLUSION This model has proved to be effective for studying the performance of the diaphragm under different electrical stimulations using different set of electrodes.

ERM for Health Care Organizations: An Economic Enterprise Risk Management Innovation Program (E2RMhealth care)

BACKGROUND In recent years, health care organizations have looked to enterprise risk management (ERM) for novel systems to obtain more accurate data on which to base risk strategies. OBJECTIVE This study proposes a conceptual ERM framework specifically designed for health care organizations. METHODS We explore how hospitals in the United States and Brazil are structuring and implementing ERM processes within their management structure. This study incorporates interviews with 15 chief risk officers (8 from the United States and 7 from Brazil) with qualitative data analysis using NVivo (QSR International software). RESULTS The interviews confirm that adopting ERM for health care organizations has gained momentum and become a priority, and that the demand for risk economic assessment orientation is common among health care risk managers. CONCLUSION We propose an ERM model for health care (Economic Enterprise Risk Management in Health Care) divided into four maturity levels and complemented by an implementation timeline. The model is accompanied by guidelines to orient the gradual implementation of ERM, including orientation to perform risk economic assessment.

A proposed enterprise risk management model for health organizations

Abstract Health care organizations are environments with high management complexity and subject to a constant exposure to risks. Enterprise risk management (ERM) has been studied and applied in different economic environments with the aim of improving organizational performance. However, the health sector still suffers from a lack of attention in this context, in particular with regard to the need for a high degree of financial transparency and for the establishment of process-orientated management, and this provides the motivation for the study described in this paper. An ERM model for health organizations is proposed, based on a systematic literature review and on seven case studies in Brazilian hospitals. An approach to economic risk assessment using indicators such as the cash flow at risk and the variability of costs and receipts from the proposed model is suggested. The health organizations involved in the case studies all interpret ERM as a source of information contributing to corporate governance, and the indicators listed provide constructive data for improvement-driven decision-making. Given the interest expressed by the organizations involved, further application and validation of the proposed model in subsequent studies is suggested.

Preditores de mortalidade intra‐hospitalar em pacientes submetidos a cirurgias não eletivas em um hospital universitário: uma coorte prospectiva

INTRODUCTION Morbidity and mortality associated with urgent or emergency surgeries are high compared to elective procedures. Perioperative risk scores identify the non-elective character as an independent factor of complications and death. The present study aims to characterize the population undergoing non-elective surgeries at the Hospital de Clínicas de Porto Alegre and identify the clinical and surgical factors associated with death within 30 days postoperatively. METHODOLOGY A prospective cohort study of 187 patients undergoing elective surgeries between April and May 2014 at the Hospital de Clínicas, Porto Alegre. Patient-related data, pre-operative risk situations, and surgical information were evaluated. Death in 30 days was the primary outcome measured. RESULTS The mean age of the sample was 48.5 years, and 84.4% of the subjects had comorbidities. The primary endpoint was observed in 14.4% of the cases, with exploratory laparotomy being the procedure with the highest mortality (47.7%). After multivariate logistic regression, age (odds ratio [OR] 1.0360, p <0.05), anemia (OR 3.961, p <0.05), acute or chronic renal insufficiency (OR 6.075, p <0.05), sepsis (OR 7.027, p <0.05), and patient-related risk factors for mortality, in addition to the large surgery category (OR 7.502, p <0.05) were identified. CONCLUSION The high mortality rate found may reflect the high complexity of the institutions patients. Knowing the profile of the patients assisted helps in the definition of management priorities, suggesting the need to create specific care lines for groups identified as high risk in order to reduce perioperative complications and deaths.

Perioperative mortality related to anesthesia within 48 h and up to 30 days following surgery: A retrospective cohort study of 11,562 anesthetic procedures

STUDY OBJECTIVE Studying postoperative in-hospital mortality is crucial to the understanding of the perioperative process failures and to the implementation of strategies to improve patient outcomes. We intend to classify the causes of perioperative deaths up to 30 days after procedures requiring anesthesia and to evaluate the risk factors for early (48 h) or late (30 day) mortality. DESIGN Retrospective cohort study. SETTING A quaternary University Hospital from South Brazil. PATIENTS The information related to the perioperative care was collected from surgeries performed between January 2012 and December 2011. INTERVENTIONS None (observational study). MEASUREMENTS Three anesthesiologists classified the causes of deaths according to the ANZCA (Australian and New Zealand College of Anesthetists) classification, used in the report of Anesthesia-Related Mortality in Australia since 1985, which defines eight death categories. The risk factors for early or late death were analyzed in a regression model. MAIN RESULTS 11.562 surgeries were performed, with a mortality incidence of 2.75% within 30 days (319 deaths). Most deaths were inevitable (50.7%), as they were related to advanced illnesses and would occur regardless of anesthetic or surgical procedures. The second most common cause was related to surgical complications (25%). The death rate having anesthesia as a likely contributor was 1.72:10.000 procedures, and as a potential contributor 7.78:10.000. These deaths occurred significantly earlier (<48 h) when compared to deaths from other causes. Transoperative vasopressor, extremes of age and out-of-hour surgery were independent variables associated to early deaths. CONCLUSIONS The study confirms that postoperative mortality in which anesthesia was involved occurred earlier in the perioperative period. In addition, it was revealed that this involvement of anesthesia as a morbidity contributor shows higher frequency when considering the anesthesiologist perioperative role, and when assessing the mortality in the long term (30 days).

Development of an enterprise risk inventory for healthcare

BackgroundThe first phase of an enterprise risk management (ERM) program is the identification of risks. Accurate identification is essential to a proactive and effective ERM function. The authors identified a lack of such risk identification in the literature and in practical cases when interviewing the chief risk officers from healthcare organizations. A risk inventory specific to healthcare organizations that includes detailed risk scenarios and risk impacts currently does not exist. Thus, the objective of this research is to develop an enterprise risk inventory for healthcare organizations to create a common understanding of how each type of risk impacts a healthcare organization.MethodERM guidelines and data from 15 interviews with chief risk officers were analyzed to create the risk inventory. The identified risks were confirmed through a survey of risk managers from a range of global healthcare organizations during the ASHRM conference in 2017. Descriptive statistics were developed and cluster analysis was performed using the survey results.ResultsThe risk inventory includes 28 risks and their specific risk scenarios. Cyberattack was ranked as the principal risk by the participants, followed by sentinel events and risks associated with human capital management (organizational culture, use of electronic medical records and physician wellness). The data analysis showed that the specific characteristics of the survey participants, such as the length of time working in risk management, the size of the organization, and the presence of a school of medicine, do not impact an individual’s opinion of the importance of the risks identified. A personal background in risk management (clinical or enterprise) was a characteristic that showed a small difference in the perceived importance of the risks from the proposed risk inventory.ConclusionsIn addition to defining specific risk scenarios, the enterprise risk inventory presented in this research can contribute to guiding the risk identification phase of an ERM program and thereby support the development of a risk culture. Patient data security in hospitals that operate with high levels of technology is fundamental to delivering high quality and safe care to patients. At the top of the risk ranking, the identification of cyberattacks reflects the importance that healthcare risk managers place on this risk by allocating time and other resources. Exploring opportunities to improve cyber risk management and evaluating the benefits of using the risk inventory at the beginning of the risk identification phase in an ERM program are suggestions for future studies.

Evaluation of cytokines levels and lung function in patients undergoing coronary artery bypass

Dear Editor, First, we congratulate the authors for the article entitled “Evaluation of cytokines levels and lung function in patients undergoing coronary artery bypass,” recently published in the Revista Brasileira de Anestesiologia 1. The importance of knowing the inflammatory status of patients undergoing cardiac surgery post-operatively is due to the fact that it can influence – besides the variables outlined in the study – the duration of mechanical ventilation and ICU stay, which was demonstrated by Kilger et al. 2 The authors found that patients who received doses of hydrocortisone in postoperative period of cardiac surgery had low levels of IL-6 and shorter ICU stay compared to those who received no treatment. However, the preoperative evaluation of brain natriuretic peptide (BNP) has been shown to be a better predictor of clinical outcomes in patients undergoing cardiac surgery, compared to inflammatory markers. This result is evident in the study by Ganem et al. 3, which evaluated the levels of BNP, IL-6, IL-8, P-selectin, ICAM, and C-reactive protein and correlated them with immediate clinical outcomes in patients undergoing cardiac surgery. The study showed that elevated BNP levels correlate with longer ICU stay, duration of mechanical ventilation, and use of dobutamine. Plasma levels of BNP > 190 pg.mL-1 are an independent predictor of ICU stay for longer than five days, which is not seen in this same period with the use of inflammatory factors. Therefore, the inclusion of BNP evaluation during the postoperative period in future studies is interesting to correlate it with ECC time. Similarly to the finding of Machado et al. 1 that the increase in the absolute values of IL-6 are related to a longer ECC and varying levels of IL-8 are related to a longer duration of surgery, Liu et al. 4 correlated such inflammatory markers with the duration of mechanical ventilation in children with renal failure undergoing cardiac surgery and found levels of IL-6 and IL-8 significantly higher in patients who required a longer time on mechanical ventilation. Another important and influential factor regarding the inflammatory levels in these patients is the ventilation system used. Oliveira et al. 5 compared cytokine levels in bronchoalveolar lavage in two groups of patients without lung disease who were mechanically ventilated at the ICU after surgery. One group used low tidal volume ventilation (5-7 mL.kg-1) and the other high tidal volume (10-12 mL.kg-1). The study showed that using a high tidal volume significantly increases the levels of IL-8 and TNF-α. Thus, we conclude that despite these elevated inflammatory markers present primarily regarding CEC, since the tidal volume ranged between 6 and 8 mL.kg-1 in patients undergoing cardiac surgery, other factors such as duration of mechanical ventilation during surgery and ventilation strategy adopted may also contribute to changes in absolute levels of these cytokines, as well as clinical outcomes in the immediate postoperative period.