Eliezer Silva

Delirium recognition and sedation practices in critically ill patients: a survey on the attitudes of 1015 Brazilian critical care physicians.

PURPOSEnThe aim of the study was to characterize the practices of Brazilian ICU physicians toward sedation and delirium.nnnMATERIALS AND METHODSnA cross-sectional survey was conducted among a convenience sample of critical care physicians between April and June 2008.nnnRESULTSnOne thousand fifteen critical care physicians responded. Sedation scoring systems were used by 893 (88.3%) of the respondents. The Ramsay and Richmond Agitation-Sedation Scale were used by 81.9% and 6.8% of the respondents, respectively. Most respondents did not discuss sedation targets (62.8%) or practice daily sedative interruption (68.3%) in most patients. More than half of the respondents (52.7%) used a sedation protocol, and the most used sedatives were midazolam (97.8%), fentanyl (91.5%), and propofol (55%). A significant rate of the respondents (42.7%) estimated that more than 25% of patients under mechanical ventilation have delirium, but 53.5% occasionally assessed patients for delirium. Thirteen percent used specific delirium scales, with the Confusion Assessment Method for intensive care unit (ICU) being the most applied. Delirium was often treated with haloperidol (88.1%); however, atypical antipsychotics (36.3%) and benzodiazepines (42.3%) were also used.nnnCONCLUSIONSnDespite the recent advances in knowledge of sedation and delirium, most of them are still not translated into clinical practice. Significant variation in practice is observed among ICU physicians and represents a potential target for future research and educational interventions.

Effects of volume resuscitation on splanchnic perfusion in canine model of severe sepsis induced by live Escherichia coli infusion

IntroductionWe conducted the present study to investigate whether early large-volume crystalloid infusion can restore gut mucosal blood flow and mesenteric oxygen metabolism in severe sepsis.MethodsAnesthetized and mechanically ventilated male mongrel dogs were challenged with intravenous injection of live Escherichia coli (6 × 109 colony-forming units/ml per kg over 15 min). After 90 min they were randomly assigned to one of two groups – control (no fluids; n = 13) or lactated Ringers solution (32 ml/kg per hour; n = 14) – and followed for 60 min. Cardiac index, mesenteric blood flow, mean arterial pressure, systemic and mesenteric oxygen-derived variables, blood lactate and gastric carbon dioxide tension (PCO2; by gas tonometry) were assessed throughout the study.ResultsE. coli infusion significantly decreased arterial pressure, cardiac index, mesenteric blood flow, and systemic and mesenteric oxygen delivery, and increased arterial and portal lactate, intramucosal PCO2, PCO2 gap (the difference between gastric mucosal and arterial PCO2), and systemic and mesenteric oxygen extraction ratio in both groups. The Ringers solution group had significantly higher cardiac index and systemic oxygen delivery, and lower oxygen extraction ratio and PCO2 gap at 165 min as compared with control animals. However, infusion of lactated Ringers solution was unable to restore the PCO2 gap. There were no significant differences between groups in mesenteric oxygen delivery, oxygen extraction ratio, or portal lactate at the end of study.ConclusionSignificant disturbances occur in the systemic and mesenteric beds during bacteremic severe sepsis. Although large-volume infusion of lactated Ringers solution restored systemic hemodynamic parameters, it was unable to correct gut mucosal PCO2 gap.

Sepsis: From Bench to Bedside

Sepsis is a syndrome related to severe infections. It is defined as the systemic host response to microorganisms in previously sterile tissues and is characterized by end-organ dysfunction away from the primary site of infection. The normal host response to infection is complex and aims to identify and control pathogen invasion, as well as to start immediate tissue repair. Both the cellular and humoral immune systems are activated, giving rise to both anti-inflammatory and proinflammatory responses. The chain of events that leads to sepsis is derived from the exacerbation of these mechanisms, promoting massive liberation of mediators and the progression of multiple organ dysfunction. Despite increasing knowledge about the pathophysiological pathways and processes involved in sepsis, morbidity and mortality remain unacceptably high. A large number of immunomodulatory agents have been studied in experimental and clinical settings in an attempt to find an efficacious anti-inflammatory drug that reduces mortality. Even though preclinical results had been promising, the vast majority of these trials actually showed little success in reducing the overwhelmingly high mortality rate of septic shock patients as compared with that of other critically ill intensive care unit patients. Clinical management usually begins with prompt recognition, determination of the probable infection site, early administration of antibiotics, and resuscitation protocols based on “early-goal” directed therapy. In this review, we address the research efforts that have been targeting risk factor identification, including genetics, pathophysiological mechanisms and strategies to recognize and treat these patients as early as possible.

The cost-effectiveness ratio of a managed protocol for severe sepsis

PURPOSEnSevere sepsis is a time-dependent disease, and implementation of early treatment has been associated with mortality rate reduction. However, the literature is controversial regarding cost-effectiveness analysis of this intervention. The aim was to assess the cost-effectiveness of a managed protocol for the treatment of severe sepsis.nnnMATERIALS AND METHODSnThis is a prospective cohort study involving a historical comparison (before and after the implementation of the protocol) of patients who had been hospitalized with severe sepsis and septic shock. The group of patients who were treated before the assistance routine was implemented was considered to be the control. The case-managed nurse involved with assistance protocol performed the data collection. This nurse received special training to ensure the quality of the data and to measure the intervention throughout the implementation process.nnnRESULTSnA total of 414 patients were analyzed. The mortality rates were 57% in the control group and 38% in the protocol group (P=.002). After the implementation of the protocol, the absolute risk reduction was 18%; and the relative risk reduction was 31.8%. There was a tendency for a reduction in the cost of the full hospitalization, but this trend did not reach statistical significance. Nevertheless, the cost of hospitalization in the intensive care unit was reduced significantly from US

Exercise training prevents skeletal muscle damage in an experimental sepsis model

138,237±

Sustained Gastric Mucosal Acidosis After Hemorrhage in Spite of Rapid Hemodynamic Restoration With Blood or Hypertonic/Hyperoncotic Solution

202,418 in the control group to US

The Effects of Low and High Tidal Volume and Pentoxifylline on Intestinal Blood Flow and Leukocyte-Endothelial Interactions in Mechanically Ventilated Rats

85,484±

Exercise training reduces oxidative damage in skeletal muscle of septic rats

127,471 in the protocol group (P=.003). The managed protocol for sepsis resulted in an average gain of 3.2 life-years after being discharged from the hospital (8.8±13.3 years in the control group and 12.0±14.0 years in the protocol group, P=.01).nnnCONCLUSIONSnGiven that the incremental cost was lower than or equal to zero, the effectiveness of the protocol was justified by the significant increase in the life-years saved and the reduced mortality.

Clonidine for reduction of hemodynamic and psychological effects of S+ ketamine anesthesia for dressing changes in patients with major burns: An RCT

OBJECTIVE: Oxidative stress plays an important role in skeletal muscle damage in sepsis. Aerobic exercise can decrease oxidative stress and enhance antioxidant defenses. Therefore, it was hypothesized that aerobic exercise training before a sepsis stimulus could attenuate skeletal muscle damage by modulating oxidative stress. Thus, the aim of this study was to evaluate the effects of aerobic physical preconditioning on the different mechanisms that are involved in sepsis-induced myopathy. METHODS: Male Wistar rats were randomly assigned to either the untrained or trained group. The exercise training protocol consisted of an eight-week treadmill program. After the training protocol, the animals from both groups were randomly assigned to either a sham group or a cecal ligation and perforation surgery group. Thus, the groups were as follows: sham, cecal ligation and perforation, sham trained, and cecal ligation and perforation trained. Five days after surgery, the animals were euthanized and their soleus and plantaris muscles were harvested. Fiber cross-sectional area, creatine kinase, thiobarbituric acid reactive species, carbonyl, catalase and superoxide dismutase activities were measured. RESULTS: The fiber cross-sectional area was smaller, and the creatine kinase, thiobarbituric acid reactive species and carbonyl levels were higher in both muscles in the cecal ligation and perforation group than in the sham and cecal ligation and perforation trained groups. The muscle superoxide dismutase activity was higher in the cecal ligation and perforation trained group than in the sham and cecal ligation and perforation groups. The muscle catalase activity was lower in the cecal ligation and perforation group than in the sham group. CONCLUSION: In summary, aerobic physical preconditioning prevents atrophy, lipid peroxidation and protein oxidation and improves superoxide dismutase activity in the skeletal muscles of septic rats.

Georeferencing of deaths from sepsis in the city of São Paulo

Splanchnic hypoperfusion has been implicated as the motor of multiple organ dysfunction. Hypertonic saline has shown to benefit microcirculatory blood flow. In hemorrhaged animals, we tested the hypothesis that small-volume 3% NaCl/10% dextran 40 (3%HSD) promotes global and regional improvements, including gastric mucosal acidosis reversal. Seventeen dogs (18.8 ± 1.2 kg) were bled (20 mL/min) to a mean arterial pressure of 40–45 mm Hg, which was maintained at these levels for 15 min. They were randomly assigned to two groups: Blood (n = 9), total shed blood retransfused at 40 mL/min; or a 4-min bolus injection of 3%HSD (n = 8), in a volume equivalent to 25% of total shed blood. All animals were followed for 30 min thereafter. Gastric mucosal PCO2 (gas tonometry), portal vein PCO2, superior mesenteric artery blood flow (SMA, ultrasonic flowprobes), and systemic and regional O2-derived variables were evaluated throughout the protocol. Hemorrhage induced significant reductions of arterial pressure, cardiac output, and SMA blood flow, while portal–arterial and gastric–arterial PCO2 gradients increased. Total shed blood transfusion, as well as 3%HSD bolus injection, promptly restored all parameters, except for the increased gastric–arterial PCO2 gradient. We conclude that persistent gastric mucosal acidosis cannot be adequately predicted by global and splanchnic O2 derived variables in following hemorrhage and resuscitation with total shed blood transfusion or small-volume hypertonic–hyperoncotic solution.