Francisco Albano de Meneses

Terminalidade e cuidados paliativos na unidade de terapia intensiva

The objective of this review was to evaluate current knowledge regarding terminal illness and palliative care in the intensive care unit, to identify the major challenges involved and propose a research agenda on these issues The Brazilian Critical Care Association organized a specific forum on terminally ill patients, to which were invited experienced and skilled professionals on critical care. These professionals were divided in three groups: communication in the intensive care unit, the decision making process when faced with a terminally ill patient and palliative actions and care in the intensive care unit. Data and bibliographic references were stored in a restricted website. During a twelve hour meeting and following a modified Delphi methodology, the groups prepared the final document. Consensual definition regarding terminality was reached. Good communication was considered the cornerstone to define the best treatment for a terminally ill patient. Accordingly some communication barriers were described that should be avoided as well as some approaches that should be pursued. Criteria for palliative care and palliative action in the intensive care unit were defined. Acceptance of death as a natural event as well as respect for the patients autonomy and the nonmaleficence principles were stressed. A recommendation was made to withdraw the futile treatment that prolongs the dying process and to elected analgesia and measures that alleviate suffering in terminally ill patients. To deliver palliative care to terminally ill patients and their relatives some principles and guides should be followed, respecting individual necessities and beliefs. The intensive care unit staff involved with the treatment of terminally ill patients is subject to stress and tension. Availability of a continuous education program on palliative care is desirable.

Gravidade dos pacientes admitidos à Unidade de Terapia Intensiva de um hospital universitário brasileiro

JUSTIFICATIVA E OBJETIVOS: Analisar a gravidade de pacientes internados na Unidade de Terapia Intensiva (UTI) de um hospital universitario, utilizando o escore APACHE II. METODO: Foi realizado estudo descritivo, retrospectivo, com analise de 300 pacientes admitidos a UTI, no periodo de marco de 2004 a julho de 2005. RESULTADOS: Dos 300 pacientes estudados, 51,7% eram do sexo masculino, com media idade de 54,2 ± 19,57) anos. Houve maior prevalencia de pacientes acima de 60 anos (43%). Quanto a procedencia, 78% foram provenientes das enfermarias do proprio hospital. De acordo com o sistema acometido, as principais disfuncoes foram respiratorias e cardiovasculares. A media de permanencia na UTI foi de 7,51 ± 8,21) dias. A media geral de APACHE II foi de 16,48 ± 7,67), com significativa diferenca entre sobreviventes e falecidos. A mortalidade total na UTI foi de 32,7%, sem diferenca significativa entre os pacientes falecidos com menos ou mais de 48 horas. A razao de mortalidade padronizada foi 1,1. CONCLUSOES: Apesar da gravidade dos pacientes admitidos, a razao de mortalidade padronizada sugere satisfatoria qualidade no servico em apreco.

Morbimortalidade do idoso internado na Unidade de Terapia Intensiva de Hospital Universitário de Fortaleza

BACKGROUND AND OBJECTIVES: To identify the severity of elderly patients admitted to the intensive care unit (ICU) in a university hospital, relating it to the in-ICU mortality. METHODS: Retrospective study, with analysis of 130 patients admitted to ICU from March 2004 to July 2005. RESULTS: Of the 130 patients, there was a predominance of women, and mean 72.2 ± 7.3 years. There were more patients between 65 and 74 years old. More than 80% of the patients had come from the university hospital itself. The main dysfunctions were from the cardiocirculatory and respiratory systems. Sepsis caused 23.8% of the admissions. Length of stay in ICU was 8.2 ± 7.6 days. The mean of APACHE II was 18.2 ± 7.2. Lesser values of APACHE II, length of stay and mortality were observed in patients with cardiocirculatory dysfunction. The in-ICU mortality was 33.9%, 6.2% before 48 hours. The standardized mortality ratio (SMR) was 0.988. CONCLUSIONS: The age groups did not determine difference between values of APACHE II. They were related neither to higher mortality rate, nor to higher ICU length of stay. Patients with cardiocirculatory dysfunctions had lesser values of APACHE II, ICU length of stay and in-ICU mortality.

Perfil dos pacientes com lúpus eritematoso sistêmico, internados na unidade de terapia intensiva de um hospital universitário de Fortaleza

OBJECTIVES: Due to the high incidence in our service, we did object on this study describe the features and outcome of patients with systemic lupus erythematosus (SLE) admitted to the intensive care unit of Walter Cantidio University Hospital METHODS: Patients were restrospectively characterized according to demography parameters, time of diagnosis of SLE, organ dysfunction and laboratorial parameters at admission, supportive therapies during their stay, length of stay in the hospital before admission, length of stay in the unit, readmission to the unit and outcome. We also evaluated Systemic Lupus Erythematosus Disease Activity (SLEDAI) score, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, expected mortality and standardized mortality ratio. RESULTS: From November 2003 to October 2006, 1,052 patients were admitted to the intensive care unit. Fifty patients had SLE and were included in this retrospective study. Of the 50 patients with SLE admitted to the ICU, 88.2% were female. The mean age was 30.3 ± 12.8 years. The median time of diagnosis of SLE was 67 months. The most common organ dysfunctions were renal (70.6%), cardiovascular (61.8%), respiratory (55.9%) and neurological (55.9%). The main reasons for admission to the ICU were respiratory (38.2%), cardiologic (29.4%) and neurological (29.4%) dysfunctions. Among the intensive care therapies, 44.1% of the patients needed blood products, 41.2% vasopressor agents and 35.3% mechanical ventilation, 23.5% dialysis. The mean SLEDAI score was 15.0 ± 12.2. The mean APACHE II score was 19.3 ± 6.8, with a predicted mortality rate of 37.6%. The actual mortality rate in ICU was 29.4%, with 8.8% before 48 hours. The standardized mortality ratio was 0.78. Patients with APACHE II > 18, with more than 3 acute organ involvements, leukopenia (< 4000 cells/mm3) and gastrointestinal or metabolic involvement had higher mortality in the intensive care unit. CONCLUSION: Although the severity of patients at admission to the ICU, demonstrated by APACHE II and the acute dysfunctions, the outcomes of analysed patients sugest susceptibility to the therapy.

Associação entre sexo e mortalidade em pacientes com sepse: os hormônios sexuais influenciam o desfecho?

OBJETIVO: Analise comparativa da mortalidade em dois subgrupos de pacientes com sepse, diferenciados pela idade e sexo, admitidos na unidade de cuidados intensivos de um hospital de ensino. METODOS: De dezembro de 2005 a abril de 2008, de um total de 628 pacientes admitidos na unidade de cuidados intensivos, 133 tinham o diagnostico de sepse e foram separados em dois subgrupos com base na idade: subgrupo G1, com idades entre 14 - 40 anos e subgrupo G2, com idade acima de 50 anos. Os pacientes com idades entre 41 e 50 anos (n = 8) foram excluidos. Os subgrupos foram caracterizados quanto aos dados demograficos, indicadores prognosticos (escore APACHE II, disfuncao orgânica e choque circulatorio) e desfecho (mortalidade). RESULTADOS: O subgrupo G1 (n = 44) tinha 27 (61,4%) pacientes do sexo feminino e o subgrupo G2 (n = 81) tinha 40 (49,4%) pacientes do sexo feminino. A media do escore APACHE II, incidencia de disfuncao de multiplos orgaos e progressao para choque circulatorio nao foram estatisticamente diferente entre pacientes femininos e masculinos em ambos os subgrupos. A taxa de mortalidade geral foi menor em mulheres do que em homens do subgrupo G1 (P = 0,04); no subgrupo G2 foi observada uma tendencia inversa. CONCLUSOES: Em pacientes com sepse, mulheres abaixo dos quarenta anos de idade, portanto em periodo fertil, tiveram menor mortalidade do que homens; houve uma tendencia para menor mortalidade entre homens com mais de 50 anos.

Validação de um escore de alerta precoce pré-admissão na unidade de terapia intensiva

BACKGROUND AND OBJECTIVES: Prognosis of patients in the intensive care unit (ICU) has a relation with their severity just before admission. The Modified Early Warning Score (MEWS) was used to evaluate the severe condition of patients 12, 24 and 72 hours before admission in the ICU, assess the most prevalent parameters and correlate the MEWS before ICU with the outcome (survival versus death). METHODS: Retrospective analyses of 65 patients consecutively admitted to the ICU from July to October, 2006 evaluating the physiological parameters 72 hours prior to admission. RESULTS: APACHE II mean was 22.2 ± 7.9 points, mortality was 54.6% and standardized mortality ratio means was 1.24. MEWS means were 3.7 ± 0.2; 4.0 ± 0.2 and 5.1 ± 0.2 points, calculated 72, 48 and 24 hours previous to ICU admission, respectively. An increasing percentage of patients with MEWS > 3 points within 72, 48 and 24 hours before admission - 43.8%, 59.4% and 73.4%, respectively was recorded. Among the included physiological parameters respiratory rate contributed the most to the MEWS. Highest mortality was found in patients with MEWS > 3 points already found 72 hours before admission. Patients who died presented with a significant increase in the MEWS 24 hours prior to admission to the ICU (in relation to the MEWS recorded 72 hours before) but the situation was not identified in survivors. CONCLUSIONS: MEWS closely identified the severity of patients admitted to the ICU, suggesting that it can be a reliable score, useful in the situations preceding the ICU.

Association between sex and mortality in patients with sepsis admitted to the ICU: gender and sex hormones influence the response to sepsis?

Studies have demonstrated an impact of gender dimorphism on immune and organ responsiveness and in the susceptibility to and morbidity from shock, trauma, and sepsis. We performed a comparative analysis of mortality in two subgroups of patients with sepsis, differentiated by age and sex, admitted to the ICU (UTI) of a teaching hospital.

Déficit de base à admissão na unidade de terapia intensiva: um indicador de mortalidade precoce

BACKGROUND AND OBJECTIVES: Base deficit is considered an indicator of tissue injury, shock and resuscitation. The objective of this study was to establish an association between base deficit obtained on the admission of patients in intensive care unit (ICU) and their prognosis. METHODS: A retrospective study with analysis of 110 patients admitted consecutively in the ICU, during the period of June to December 2006. RESULTS: There was a predominance of women, with age mean 54.2 ± 18.7 years old. Length of stay in ICU was 6.5 ± 7.4 days and the mean APACHE II score was 21 ± 8.1 points. The standardized mortality ratio was 0.715. Mortality was higher in patients with base deficit > 6 mEq/L (38.9%) than in those with base deficit 6 mEq/L is a marker of significant mortality.

Neither too much, neither too little! Positive fluid balance and ICU outcome

The fluid balance of critically ill patients has emerged as a potential marker of disease severity. This is associated with worse outcome and prolonged time of use of intensive care support in the ICU.

Mechanical ventilation: does the moment of initial use or length of stay on mechanical ventilation have any relation to severity of illness and outcome?

In the modern ICU, technologies are able to keep patients alive for prolonged periods of time, even despite ongoing life-threatening illness. Mechanical ventilation (MV) is crucial in most cases, although invasive MV, when prolonged, may be associated with increased morbidity and mortality.