Felippe Leopoldo Dexheimer Neto

Ultrassom pulmonar em pacientes críticos: uma nova ferramenta diagnóstica

The evaluation of critically ill patients using lung ultrasound, even if performed by nonspecialists, has recently garnered greater interest. Because lung ultrasound is based on the fact that every acute illness reduces lung aeration, it can provide information that complements the physical examination and clinical impression, the main advantage being that it is a bedside tool. The objective of this review was to evaluate the clinical applications of lung ultrasound by searching the PubMed and the Brazilian Virtual Library of Health databases. We used the following search terms (in Portuguese and English): ultrasound; lung; and critical care. In addition to the most relevant articles, we also reviewed specialized textbooks. The data show that lung ultrasound is useful in the differential diagnosis of pulmonary infiltrates, having good accuracy in identifying consolidations and interstitial syndrome. In addition, lung ultrasound has been widely used in the evaluation and treatment of pleural effusions, as well as in the identification of pneumothorax. This technique can also be useful in the immediate evaluation of patients with dyspnea or acute respiratory failure. Other described applications include monitoring treatment response and increasing the safety of invasive procedures. Although specific criteria regarding training and certification are still lacking, lung ultrasound is a fast, inexpensive, and widely available tool. This technique should progressively come to be more widely incorporated into the care of critically ill patients.

Diagnostic accuracy of the Bedside Lung Ultrasound in Emergency protocol for the diagnosis of acute respiratory failure in spontaneously breathing patients

Objetivo: O ultrassom pulmonar (USP) a beira do leito e uma tecnica de imagem nao invasiva e prontamente disponivel que pode complementar a avaliacao clinica. O protocolo Bedside Lung Ultrasound in Emergency (BLUE, ultrassom pulmonar a beira do leito em situacoes de emergencia) demonstrou elevado rendimento diagnostico em pacientes com insuficiencia respiratoria aguda (IRpA). Recentemente, um programa de treinamento em USP a beira do leito foi implementado na nossa UTI. O objetivo deste estudo foi avaliar a acuracia do USP baseado no protocolo BLUE, quando realizado por medicos com habilidades basicas em ultrassonografia, para orientar o diagnostico de IRpA. Metodos: Ao longo de um ano, todos os pacientes adultos consecutivos respirando espontaneamente admitidos na UTI por IRpA foram prospectivamente inclusos. Apos treinamento, 4 operadores com habilidades basicas em ultrassonografia realizaram o USP em ate 20 minutos apos a admissao na UTI, cegados para a historia do paciente. Os diagnosticos do USP foram comparados aos diagnosticos da equipe assistente ao final da internacao na UTI (padrao-ouro). Resultados: Foram inclusos na analise 37 pacientes (media etaria: 73,2 ± 14,7 anos; APACHE II: 19,2 ± 7,3). O diagnostico do USP demonstrou concordância com o diagnostico final em 84% dos casos (kappa total: 0,81). As causas mais comuns de IRpA foram pneumonia (n = 17) e edema pulmonar cardiogenico (n = 15). A sensibilidade e a especificidade do USP comparado ao diagnostico final foram de 88% e 90% para pneumonia e de 86% e 87% para edema pulmonar cardiogenico, respectivamente. Conclusoes: O USP baseado no protocolo BLUE foi reproduzivel por medicos com habilidades basicas em ultrassonografia e acurado para o diagnostico de pneumonia e de edema pulmonar cardiogenico.Objective: Bedside lung ultrasound (LUS) is a noninvasive, readily available imaging modality that can complement clinical evaluation. The Bedside Lung Ultrasound in Emergency (BLUE) protocol has demonstrated a high diagnostic accuracy in patients with acute respiratory failure (ARF). Recently, bedside LUS has been added to the medical training program of our ICU. The aim of this study was to investigate the accuracy of LUS based on the BLUE protocol, when performed by physicians who are not ultrasound experts, to guide the diagnosis of ARF. Methods: Over a one-year period, all spontaneously breathing adult patients consecutively admitted to the ICU for ARF were prospectively included. After training, 4 non-ultrasound experts performed LUS within 20 minutes of patient admission. They were blinded to patient medical history. LUS diagnosis was compared with the final clinical diagnosis made by the ICU team before patients were discharged from the ICU (gold standard). Results: Thirty-seven patients were included in the analysis (mean age, 73.2 ± 14.7 years; APACHE II, 19.2 ± 7.3). LUS diagnosis had a good agreement with the final diagnosis in 84% of patients (overall kappa, 0.81). The most common etiologies for ARF were pneumonia (n = 17) and hemodynamic lung edema (n = 15). The sensitivity and specificity of LUS as measured against the final diagnosis were, respectively, 88% and 90% for pneumonia and 86% and 87% for hemodynamic lung edema. Conclusions: LUS based on the BLUE protocol was reproducible by physicians who are not ultrasound experts and accurate for the diagnosis of pneumonia and hemodynamic lung edema.

Comparison of Unplanned Intensive Care Unit Readmission Scores: A Prospective Cohort Study.

Purpose Early discharge from the intensive care unit (ICU) may constitute a strategy of resource consumption optimization; however, unplanned readmission of hospitalized patients to an ICU is associated with a worse outcome. We aimed to compare the effectiveness of the Stability and Workload Index for Transfer score (SWIFT), Sequential Organ Failure Assessment score (SOFA) and simplified Therapeutic Intervention Scoring System (TISS-28) in predicting unplanned ICU readmission or unexpected death in the first 48 hours after discharge from the ICU. Methods We conducted a prospective cohort study in a single tertiary hospital in southern Brazil. All adult patients admitted to the ICU for more than 24 hours from January 2008 to December 2009 were evaluated. SWIFT, SOFA and TISS-28 scores were calculated on the day of discharge from the ICU. A stepwise logistic regression was conducted to evaluate the effectiveness of these scores in predicting unplanned ICU readmission or unexpected death in the first 48 hours after discharge from the ICU. Moreover, we conducted a direct accuracy comparison among SWIFT, SOFA and TISS-28 scores. Results A total of 1,277 patients were discharged from the ICU during the study period. The rate of unplanned ICU readmission or unexpected death in the first 48 hours after discharge from the ICU was 15% (192 patients). In the multivariate analysis, age (P = 0.001), length of ICU stay (P = 0.01), cirrhosis (P = 0.03), SWIFT (P = 0.001), SOFA (P = 0.01) and TISS-28 (P<0.001) constituted predictors of unplanned ICU readmission or unexpected death. The SWIFT, SOFA and TISS-28 scores showed similar predictive accuracy (AUC values were 0.66, 0.65 and 0.74, respectively; P = 0.58). Conclusions SWIFT, SOFA and TISS-28 on the day of discharge from the ICU have only moderate accuracy in predicting ICU readmission or death. The present study did not find any differences in accuracy among the three scores.

Acesso venoso central guiado por ultrassom: qual a evidência?

In recent years, international health quality assurance organizations have been recommending ultrasound guidance for central venous punctures. This article reviews the evidence behind these recommendations. The MEDLINE, PubMed and SCIELO databases were searched for the following MeSH terms: central venous access, ultrasonography, and adults. The search was conducted on September 24, 2010, and selected meta-analyses, randomized clinical trials and reviews, retrieving 291 papers. The 21 most important papers were analyzed in this review. The internal jugular vein is the most studied ultrasound-guided puncture site, with meta-analysis showing lower relative risks of failure and complications. In addition, the largest available randomized clinical trial demonstrated a reduced central venous catheter-associated blood stream infection rate. There are few studies involving subclavian vein puncture; however, ultrasound was shown to be beneficial in two meta-analyses (however, with small numbers of patients). Regarding the femoral venous site, only one randomized clinical trial (20 patients) was identified, showing positive findings. In a British cost-effectiveness study, ultrasound use lead to resource savings for different sites of venous puncture. There is strong evidence for ultrasound benefit for internal jugular vein puncture. Although the method appears attractive for the other sites, the data are not sufficient to support any recommendation.

A adequada comunicação entre os profissionais médicos reduz a mortalidade no centro de tratamento intensivo

OBJETIVOS: A falha de comunicacao entre os profissionais de saude em centros de tratamento intensivo pode estar relacionada ao aumento de mortalidade dos pacientes criticamente doentes. Este estudo teve como objetivo avaliar se falhas de comunicacao entre os medicos assistentes e os medicos rotineiros do centro de tratamento intensivo teriam impacto na morbidade e mortalidade dos pacientes criticos. METODOS: Estudo de coorte incluindo pacientes nao consecutivos admitidos no centro de tratamento intensivo durante 18 meses. Os pacientes foram divididos em 3 grupos conforme o habito de comunicacao de seus medicos assistentes com os medicos rotineiros: CD - comunicacao diaria da conduta (>75% dos dias); CE - comunicacao eventual (25 a 75% dos dias); RC - rara comunicacao (<25% dos dias). Foram coletados dados demograficos, escores de gravidade, motivo de internacao no centro de tratamento intensivo, tempo de internacao no centro de tratamento intensivo e intervencoes realizadas nos pacientes. Foram analisadas as consequencias da falha na comunicacao entre os profissionais medicos (atraso na realizacao de procedimentos, na realizacao de exames diagnosticos, no inicio de antibioticoterapia, no desmame do suporte ventilatorio e no uso de vasopressores) e inadequacoes de prescricao medica (ausencia de cabeceira elevada, ausencia de profilaxia medicamentosa para ulcera de estresse e para trombose venosa profunda) relacionando-as com o desfecho dos pacientes. RESULTADOS: Foram incluidos 792 pacientes no estudo, sendo agrupados da seguinte maneira: CD (n =529), CE (n =187) e RC (n =76). A mortalidade foi maior nos pacientes pertencentes ao grupo RC (26,3%) comparada aos demais (CD =13,6% e CE =17,1%; p <0,05). A analise multivariada demonstrou que o atraso no inicio de antibioticos [RR 1,83 (IC95%: 1,36 - 2,25)], o atraso no inicio do desmame ventilatorio [RR 1,63 (IC95%: 1,25 - 2,04)] e a nao prescricao de profilaxia para trombose venosa profunda [RR 1,98 (IC95%: 1,43 - 3,12)] contribuiram de forma independente para o aumento de mortalidade dos pacientes. CONCLUSAO: A falta de comunicacao entre medicos assistentes e rotineiros do centro de tratamento intensivo pode aumentar a mortalidade dos pacientes, principalmente devido ao atraso no inicio de antibioticos e no desmame da ventilacao mecânica e a nao prescricao de profilaxia para trombose venosa profunda.

Mortality of Adult Critically Ill Subjects With Cancer

BACKGROUND: Cancer patients may require intensive care support for postoperative care, complications associated with underlying malignancy, or toxicities related to cancer therapy. The higher mortality rates found in this population than in the population of ICU patients without cancer may be attributable to confounding due to a higher prevalence of multiple organic dysfunctions at ICU admission in patients with malignancy; however, data regarding this hypothesis are scarce. Accordingly, we performed the present study to compare the crude and propensity score-matched mortality rates between adult subjects with and without cancer admitted to a mixed medical-surgical ICU. METHODS: We conducted a retrospective analysis of a comprehensive longitudinal ICU database in a tertiary referral hospital in Southern Brazil. All adult subjects who were admitted to the ICU from January 2008 to December 2014 were evaluated. Crude and propensity score-matched all-cause 30-d mortality rates of critically ill subjects with cancer were compared with those of critically ill subjects without cancer. RESULTS: A total of 4,221 subjects were evaluated. The survival analysis revealed that the crude mortality rate was higher among subjects with cancer than among subjects without cancer (18.7% vs 10.2%, P < .001). However, after matching by propensity score, the 30-d mortality rates of subjects with and without cancer were similar (18.5% vs 15.2%, P = .17). CONCLUSIONS: The present study failed to show an association between malignancy and all-cause 30-d mortality rate in adult subjects admitted to a mixed medical-surgical ICU. The propensity score-matched analysis showed no evidence of excessive mortality due to cancer diagnosis.

Uso da tomografia por impedância elétrica torácica como ferramenta de auxílio às manobras de recrutamento alveolar na síndrome do desconforto respiratório agudo: relato de caso e breve revisão da literatura

Thoracic electrical impedance tomography is a real-time, noninvasive monitoring tool of the regional pulmonary ventilation distribution. Its bedside use in patients with acute respiratory distress syndrome has the potential to aid in alveolar recruitment maneuvers, which are often necessary in cases of refractory hypoxemia. In this case report, we describe the monitoring results and interpretation of thoracic electrical impedance tomography used during alveolar recruitment maneuvers in a patient with acute respiratory distress syndrome, with transient application of high alveolar pressures and optimal positive end-expiratory pressure titration. Furthermore, we provide a brief literature review regarding the use of alveolar recruitment maneuvers and monitoring using thoracic electrical impedance tomography in patients with acute respiratory distress syndrome.

Out-of-bed extubation: a feasibility study

Objective In clinical intensive care practice, weaning from mechanical ventilation is accompanied by concurrent early patient mobilization. The aim of this study was to compare the success of extubation performed with patients seated in an armchair compared to extubation with patients in a supine position. Methods A retrospective study, observational and non-randomized was conducted in a mixed-gender, 23-bed intensive care unit. The primary study outcome was success of extubation, which was defined as the patient tolerating the removal of the endotracheal tube for at least 48 hours. The differences between the study groups were assessed using Students t-test and chi-squared analysis. Results Ninety-one patients were included from December 2010 and June 2011. The study population had a mean age of 71 years ± 12 months, a mean APACHE II score of 21±7.6, and a mean length of mechanical ventilation of 2.6±2 days. Extubation was performed in 33 patients who were seated in an armchair (36%) and in 58 patients in a supine position (64%). There were no significant differences in age, mean APACHE II score or length of mechanical ventilation between the two groups, and a similar extubation success rate was observed (82%, seated group versus 85%, supine group, p>0.05). Furthermore, no significant differences were found between the two groups in terms of post-extubation distress, need for tracheostomy, duration of mechanical ventilation weaning, or intensive care unit stay. Conclusion Our results suggest that the clinical outcomes of patients extubated in a seated position are similar to those of patients extubated in a supine position. This new practice of seated extubation was not associated with adverse events and allowed extubation to occur simultaneously with early mobilization.

Public versus Private Healthcare Systems following Discharge from the ICU: A Propensity Score-Matched Comparison of Outcomes

Purpose. The long-term outcomes of patients after discharge from tertiary ICUs as they relate to the public versus private healthcare systems in Brazil have not yet been evaluated. Materials and Methods. A multicenter prospective cohort study was conducted to compare the all-cause mortality and the physical functional status (PFS) 24 months after discharge from the ICU between adult patients treated in the public and private healthcare systems. A propensity score- (PS-) matched comparison of all causes of mortality and PFS 24 months after discharge from the ICU was performed. Results. In total, 928 patients were discharged from the ICU including 172 (18.6%) patients in the public and 756 (81.4%) patients in the private healthcare system. The results of the PS-matched comparison of all-cause mortality revealed higher mortality rates among the patients of the public healthcare system compared to those of the private healthcare system (47.3% versus 27.6%, P = 0.003). The comparison of the PS-matched Karnofsky performance and Lawton activities of daily living scores between the ICU survivors of the public and private healthcare systems revealed no significant differences. Conclusions. The patients of private healthcare system exhibited significantly greater survival rates than the patients of the public healthcare system with similar PFS following ICU discharge.

Platypnea-orthodeoxia syndrome in patients presenting enlarged aortic root: case report and literature review

We describe herein a case of a patient who, when in orthostatic positions, had severe hypoxemia and ventilatory dysfunction. Although the severity of symptoms required hospitalization in an intensive care setting, the initial tests only identified the presence of enlarged aortic root, which did not explain the condition. The association of these events with an unusual etiology, namely intracardiac shunt, characterized the diagnosis of platypnea-orthodeoxia syndrome. The literature review shows that, with advancing research methods, there was a progressive increase in the identification of this condition, and this association should be part of the differential diagnosis of dyspnea in patients with enlarged aortic root.