F Machado

Predictive value of pulse pressure variation for fluid responsiveness in septic patients using lung-protective ventilation strategies

BACKGROUND The applicability of pulse pressure variation (ΔPP) to predict fluid responsiveness using lung-protective ventilation strategies is uncertain in clinical practice. We designed this study to evaluate the accuracy of this parameter in predicting the fluid responsiveness of septic patients ventilated with low tidal volumes (TV) (6 ml kg(-1)). METHODS Forty patients after the resuscitation phase of severe sepsis and septic shock who were mechanically ventilated with 6 ml kg(-1) were included. The ΔPP was obtained automatically at baseline and after a standardized fluid challenge (7 ml kg(-1)). Patients whose cardiac output increased by more than 15% were considered fluid responders. The predictive values of ΔPP and static variables [right atrial pressure (RAP) and pulmonary artery occlusion pressure (PAOP)] were evaluated through a receiver operating characteristic (ROC) curve analysis. RESULTS Thirty-four patients had characteristics consistent with acute lung injury or acute respiratory distress syndrome and were ventilated with high levels of PEEP [median (inter-quartile range) 10.0 (10.0-13.5)]. Nineteen patients were considered fluid responders. The RAP and PAOP significantly increased, and ΔPP significantly decreased after volume expansion. The ΔPP performance [ROC curve area: 0.91 (0.82-1.0)] was better than that of the RAP [ROC curve area: 0.73 (0.59-0.90)] and pulmonary artery occlusion pressure [ROC curve area: 0.58 (0.40-0.76)]. The ROC curve analysis revealed that the best cut-off for ΔPP was 6.5%, with a sensitivity of 0.89, specificity of 0.90, positive predictive value of 0.89, and negative predictive value of 0.90. CONCLUSIONS Automatized ΔPP accurately predicted fluid responsiveness in septic patients ventilated with low TV.

Implementation of sepsis' treatment protocols in an emerging country from 2005-2014: an analysis of 21,103 patients

Methods Retrospective analysis of the Latin America Sepsis Institute (LASI) database, from 2005 to 2014. Participation was voluntary. The implementation process was based on a multifaceted intervention including a local sepsis team, protocols, screening procedures, laboratory and antibiotics flowchart for emergency department (ED), wards and intensive care units (ICU), checklists, physicians and nurses training nd audit/feedback strategies. After the initial training, the institutions collect data on SSC bundles compliance and hospital outcome in patients with severe sepsis or septic shock in all hospital settings. We included only the institutions with at least 80 patients and at least one year of data collection, excluding patients admitted after the first four years of the campaign. All patients were followed until hospital discharge. We define public institutions as those with the major income coming from public sources and private as those coming from private insurances. Results We included 21,103 patients from 65 institutions being 9,032 from public institutions and 12,071 from private ones. Comparing the 1 semester with the 8 semester, compliance with the 6-hours bundle increased from 13.5% to 58.2% in the private institutions while the public ones improved from 7.4% to 15.7%. Mortality rates significantly decreased throughout the program in private institutions (1st semester: 47.6%, 8 semester: 27.2%; odds ratio (OR): 0.45; 95% confidence interval (CI): 0.32-0.64). However, there is no significant reduction in the public institutions throughout the semesters (1 semester: 61.3%; 8 semester: 54.5%, OR: 0.63; 95%CI: 0.39-1.02). The intervention reduced the mortality rates throughout the semesters in patients from all settings (1 semester vs 8 semester: ED OR: 0.55; 95%CI: 0.38 0.79; wards OR: 0.59; 95%CI: 0.42-0.83; ICU OR: 0.46; 95%CI: 0.39 0.54) although the effect was less consistent in the ICU. In patients from private ED, mortality rates decreased from 38.1 to 21.2% (p < 0.001) while in the public institutions this reduction was not significant (56.3% to 49.8%, p = 0.057).

Plasma levels of IL-6 and IL-10 in septic patients at admission and during follow-up and association with clinical outcomes

Sepsis is a systemic inflammatory syndrome triggered by infection. It has been recognized that a dynamic interaction between proinflammatory and anti-inflammatory response is present in this syndrome, which is balanced by as yet unknown mechanisms. We and others showed that inflammatory cytokines are upregulated in the early phase and downregulated in the late phases of sepsis, while anti-inflammatory cytokines are preserved. However, there are few data about the dynamics of these cytokines during follow-up of patients and their relation with clinical outcome. The aim of this study was to evaluate the plasma levels of a proinflammatory, IL-6, and an anti-inflammatory, IL-10, cytokine in septic patients.

Th17 lymphocytes and alternatively activated monocytes are upregulated in clinical sepsis

Sepsis is a systemic inflammatory response triggered by infection. Inflammatory response is modulated during sepsis and upregulation and downregulation of cellular activity is observed, depending on the cells and functions evaluated. Nevertheless, the interaction of innate and adaptative immune responses has been little studied in clinical sepsis.

Risk factors for intra-abdominal hypertension and abdominal compartment syndrome in patients admitted to the ICU

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) as well as their risk factors were defined recently by consensus. These diseases have a high incidence and morbi-mortality in patients admitted to the ICU and represent a huge problem among critically ill patients.

Incidence of delirium in three critical care units of a teaching hospital in Brazil

Delirium is a disturbance of consciousness in which there is a sharply global deficit of attention associated with change in cognition that cannot be attributed to a pre-existing dementia. Its relevance is not only due to the high incidence, but above all its consequences, such as influence on mortality, morbidity, and prolonging the period of hospitalization.

Orotracheal intubation: medical knowledge and clinical practices in ICUs

Orotracheal intubation (OT) is considered one of the main procedures in ICUs; however, it involves risks and complications. So, a deep theoretical knowledge of proper techniques is of utmost importance and, under ideal conditions, OT should follow a strict protocol. The present study aimed to evaluate medical knowledge about OT techniques and to identify the usual procedures.