Glauco Adrieno Westphal

Reduced mortality after the implementation of a protocol for the early detection of severe sepsis

OBJECTIVE We evaluate the impact that implementing an in-hospital protocol for the early detection of sepsis risk has on mortality from severe sepsis/septic shock. METHODS This was a prospective cohort study conducted in 2 phases at 2 general hospitals in Brazil. In phase I, patients with severe sepsis/septic shock were identified and treated in accordance with the Surviving Sepsis Campaign guidelines. Over the subsequent 12 months (phase II), patients with severe sepsis/septic shock were identified by means of active surveillance for signs of sepsis risk (SSR). We compared the 2 cohorts in terms of demographic variables, the time required for the identification of at least 2 SSRs, compliance with sepsis bundles (6- and 24-hour), and mortality rates. RESULTS We identified 217 patients with severe sepsis/septic shock (102 during phase I and 115 during phase II). There were significant differences between phases I and II in terms of the time required for the identification of at least 2 SSRs (34 ± 48 vs 11 ± 17 hours; P < .001) and in terms of in-hospital mortality (61.7% vs 38.2%; P < .001). CONCLUSION The early detection of sepsis promoted early treatment, reducing in-hospital mortality from severe sepsis/septic shock.

Randomised, controlled study of preoperative eletroacupuncture for postoperative pain control after cardiac surgery

Background This study aims to evaluate the effects of preoperative electroacupuncture (EA) on the need for opioids in the postoperative stage of conventional cardiac surgery. Methods A prospective, randomised and controlled study was conducted at Unimed Hospital Centre in Joinville, SC, Brazil. The day before the surgery, 32 patients undergoing cardiac surgery were randomised into two groups: patients from the treatment group received preoperative EA at bilateral points (LI4–LI11, LR3–ST36, PC6–TE5) for 30 min with alternating frequencies of 3 and 15 Hz. Patients from the control group received sham transcutaneous electrical nerve stimulation (TENS). Use of fentanyl during the postoperative period was measured. Results 10 patients were excluded because of hemodynamic and ventilatory instability leaving 13 (10 male) in the treatment group and 9 (4 male) in the control group. The average total doses of fentanyl given were 13.1±2.2 and 16.3±1.6 μg/kg in the treatment and control groups respectively (p<0.002). The doses of patient controlled analgesia were 4.1±2.0 and 6.9±1.7 μg/kg in the treatment and control groups respectively (p<0.003). The number of boluses issued also differed (treatment 13.9±7.0 vs control 24.8±7.0, p<0.002). Pain intensity scores differed between the groups (treatment 2.5±1.1 vs control 4.0±2.0, p<0.04). One patient from the control group experienced drowsiness that justified a change in fentanyl infusion, as decided by the anaesthetist. Conclusion Preoperative electro-acupuncture in conventional cardiac surgery may reduce the postoperative consumption of fentanyl.

Surviving sepsis campaign in Brazil.

Severe sepsis and septic shock have long been a challenge in intensive care because of their common occurrence, high associated costs of care, and significant mortality. The Surviving Sepsis Campaign (SSC) was developed in an attempt to address clinical inertia in the adoption of evidence-based strategies. The campaign relies on worldwide support from professional societies and has gained consensus on the management of patients with severe sepsis. The guidelines have subsequently been deployed into two bundles, with each bundle component sharing a common relationship in time. The widespread adoption of such evidence-based practice in clinical care has been disappointingly slow despite the quantifiable benefits regarding mortality. In Brazil, a country of continental dimensions with a heterogeneous population and unequal access to health services, this reality is no different. From 2004 to 2007, four prospective studies were published describing the countrys reality. In the multicenter Promoting Global Research Excellence in Severe Sepsis (PROGRESS) Study, the in-hospital mortality rate was higher in Brazil when compared with other countries: 56% against 30% in developed countries and 45% in other developing countries. During these 2.5 years of the campaign in Brazil, 43 hospitals have been receiving the necessary training to put in practice the recommended measures in all Brazilian regions, except for the North. The idea of the campaign is based on a 25% reduction in the relative risk of death from severe sepsis and septic shock within 5 years in the SSC-participating Brazilian hospitals. Ideally, the mortality rate should come to a 41.2% level subject to the 2009 deadline. This article aims to describe the actual scenario of the SSC implementation in Brazilian institutions and to report on some initiatives that have been used to overcome barriers.

Pulse oximetry wave variation as a noninvasive tool to assess volume status in cardiac surgery

OBJECTIVE: To compare variations of plethysmographic wave amplitude (ΔPpleth) and to determine the percent difference between inspiratory and expiratory pulse pressure (ΔPp) cutoff values for volume responsiveness in a homogenous population of postoperative cardiac surgery patients. INTRODUCTION: Intra-thoracic pressure variations interfere with stroke volume variation. Pulse pressure variations through arterial lines during mechanical ventilation have been recommended for the estimation of fluid responsiveness. Pulse oximetry may offer a non-invasive plethysmographic method to evaluate pulse pressure; this may be useful for guiding fluid replacement. METHODS: Controlled, prospective study in cardiac surgery patients under controlled ventilation. Simultaneous digital recordings of arterial pressure and plethysmographic waves were performed. ΔPp, systolic pressure (ΔPs), ΔPpleth, and systolic component (ΔSpleth) were calculated. A ΔPp ≥ 13% identified fluid-responsive patients. Volume expansion was performed in responsive subjects. Systolic and amplitude components of pressure and plethysmographic waves were compared. RESULTS: In 50 measurements from 43 patients, ΔPp was correlated with (Ppleth (r=0.90, p<0.001), (Ps (r=0.90, p<0.001), and (Spleth (r=0.73, p<0.001). An aArea under ROC curve (AUC) identified the fluid responsiveness thresholds: (Ppleth of 11% (AUC = 0.95±0.04), (Ps of 8% (AUC=0.93±0.05), and (Spleth of 32% (AUC=0.82±0.07). A (Ppleth value ≥ 11% predicted (Pp ≥ 13% with 100% specificity and 91% sensitivity. Volume expansion, performed in 20 patients, changed (Pp, (Ppleth, (Ps and (Spleth significantly (p<0.008). CONCLUSIONS: ΔPpleth is well correlated with ΔPp and constitutes a simple and non-invasive method for assessing fluid responsiveness in patients following cardiac surgery.

Características clínico-demográficas de pacientes submetidos a cirurgia de revascularização do miocárdio e sua relação com a mortalidade

OBJECTIVE To describe the demographic and clinical characteristics and to test their relation to mortality in patients undergoing to coronary artery bypass graft surgery (CABG). METHODS It is a retrospective study developed from the medical records of 655 patients undergoing CABG from May 2002 to April 2010. RESULTS Hospital mortality was 12.1%. Mortality was significantly (P<0.05) higher in females (17.3%), aged less than 70 years (22.8%), in emergency surgery (36.4%), in cases of readmission to the intensive care unit (ICU) (33.3%), when the stay in the ICU was less than three days (16.3%), undergoing longer cardiopulmonary bypass (CPB) and with more comorbidities (15.4%). Predictor variables of death identified with logistic regression analysis were: female (OR=2.04), age >70 years (OR=2.69), emergency surgery (OR=15.43) and urgency (OR=3.81), performance of CPB (OR=2.19) and re-admission to the ICU (OR=4.33). CONCLUSION Variables such as gender, age, type of surgery, readmission to the ICU, ICU stay, comorbidities and time of CPB influence the outcome death in patients undergoing to CABG. Thus, such aspects should be considered to reduce hospital mortality in patients undergoing such surgery.

Replacement of fentanyl infusion by enteral methadone decreases the weaning time from mechanical ventilation: a randomized controlled trial.

IntroductionPatients undergoing mechanical ventilation (MV) are frequently administered prolonged and/or high doses of opioids which when removed can cause a withdrawal syndrome and difficulty in weaning from MV. We tested the hypothesis that the introduction of enteral methadone during weaning from sedation and analgesia in critically ill adult patients on MV would decrease the weaning time from MV.MethodsA double-blind randomized controlled trial was conducted in the adult intensive care units (ICUs) of four general hospitals in Brazil. The 75 patients, who met the criteria for weaning from MV and had been using fentanyl for more than five consecutive days, were randomized to the methadone (MG) or control group (CG). Within the first 24 hours after study enrollment, both groups received 80% of the original dose of fentanyl, the MG received enteral methadone and the CG received an enteral placebo. After the first 24 hours, the MG received an intravenous (IV) saline solution (placebo), while the CG received IV fentanyl. For both groups, the IV solution was reduced by 20% every 24 hours. The groups were compared by evaluating the MV weaning time and the duration of MV, as well as the ICU stay and the hospital stay.ResultsOf the 75 patients randomized, seven were excluded and 68 were analyzed: 37 from the MG and 31 from the CG. There was a higher probability of early extubation in the MG, but the difference was not significant (hazard ratio: 1.52 (95% confidence interval (CI) 0.87 to 2.64; P = 0.11). The probability of successful weaning by the fifth day was significantly higher in the MG (hazard ratio: 2.64 (95% CI: 1.22 to 5.69; P < 0.02). Among the 54 patients who were successfully weaned (29 from the MG and 25 from the CG), the MV weaning time was significantly lower in the MG (hazard ratio: 2.06; 95% CI 1.17 to 3.63; P < 0.004).ConclusionsThe introduction of enteral methadone during weaning from sedation and analgesia in mechanically ventilated patients resulted in a decrease in the weaning time from MV.

Diretrizes para manutenção de múltiplos órgãos no potencial doador adulto falecido: parte I. Aspectos gerais e suporte hemodinâmico

There is a relative shortage of appropriate organs available for transplantation. The appropriate diagnosis of brain death, a suitable family approach and the maintenance of the deceased donor are fundamental in addressing this issue. The intensive care physician plays a key role in the maintenance of the deceased donor, thereby reducing losses and increasing the number of successful transplants

Análise da qualidade de vida após a alta hospitalar em sobreviventes de sepse grave e choque séptico

OBJETIVO: Descrever a repercussao da sepse grave e do choque septico sobre a qualidade de vida apos a alta hospitalar. METODOS: Estudo controlado realizado em dois hospitais gerais de Joinville, Santa Catarina, Brasil, envolvendo pacientes internados com sepse grave ou choque septico no periodo de agosto de 2005 a novembro de 2007. Os pacientes foram contatados por telefone entre junho e novembro de 2009. Os sobreviventes responderam ao Short Form-36, um questionario de qualidade de vida, dois anos apos a alta. O questionario tambem foi respondido por um grupo controle composto de pessoas que habitavam o mesmo domicilio dos sobreviventes, sem internacao recente e com idade mais proxima possivel a do paciente. RESULTADOS: De 217 pacientes com sepse grave ou choque septico, 112 (51,6%) sobreviveram a internacao. A sobrevida pos-alta hospitalar foi de 41,02% em 180 dias, 37,4% apos um ano, 34i3% em 18 meses e 32,3% em dois anos. Trinta e seis sobreviventes responderam ao Short Form-36. Houve comprometimento da qualidade de vida dos sobreviventes (No. = 36) em relacao ao grupo controle (No. = 36) nos dominios: capacidade funcional (59 ± 32 versus 91 ± 18; P 0,002), vitalidade (48 ± 13 versus 59 ± 14; P 0,008), saude mental (48 ± 13 versus 59 ± 14; P 0,03), dor (50 ± 26 versus 76 ± 16; P 0,001), estado geral de saude (53 ±18 versus 67 ± 13; P 0,004), aspectos fisicos (67 ± 45 versus 85 ± 34; P 0,05) e aspectos sociais (70 ±28 versus 90 ± 16; P 0,05). CONCLUSOES: Sepse grave ou choque septico podem resultar em comprometimento significativo da qualidade de vida, assim como limitar a probabilidade de sobrevida a longo prazo.(AU)

Vasodilation increases pulse pressure variation, mimicking hypovolemic status in rabbits

OBJECTIVE To test the hypothesis that pulse pressure respiratory variation (PPV) amplification, observed in hypovolemia, can also be observed during sodium nitroprusside (SNP)-induced vasodilation. INTRODUCTION PPV is largely used for early identification of cardiac responsiveness, especially when hypovolemia is suspected. PPV results from respiratory variation in transpulmonary blood flow and reflects the left ventricular preload variations during respiratory cycles. Any factor that decreases left ventricular preload can be associated with PPV amplification, as seen in hypovolemia. METHODS Ten anesthetized and mechanically ventilated rabbits underwent progressive hypotension by either controlled hemorrhage (Group 1) or intravenous SNP infusion (Group 2). Animals in Group 1 (n = 5) had graded hemorrhage induced at 10% steps until 50% of the total volume was bled. Mean arterial pressure (MAP) steps were registered and assumed as pressure targets to be reached in Group 2. Group 2 (n = 5) was subjected to a progressive SNP infusion to reach similar pressure targets as those defined in Group 1. Heart rate (HR), systolic pressure variation (SPV) and PPV were measured at each MAP step, and the values were compared between the groups. RESULTS SPV and PPV were similar between the experimental models in all steps (p > 0.16). SPV increased earlier in Group 2. CONCLUSION Both pharmacologic vasodilation and graded hemorrhage induced PPV amplification similar to that observed in hypovolemia, reinforcing the idea that amplified arterial pressure variation does not necessarily represent hypovolemic status but rather potential cardiovascular responsiveness to fluid infusion.

Diretrizes para avaliação e validação do potencial doador de órgãos em morte encefálica

O transplante de orgaos e a unica alternativa para muitos pacientes portadores de algumas doencas terminais. Ao mesmo tempo, e preocupante a crescente desproporcao entre a alta demanda por transplantes de orgaos e o baixo indice de transplantes efetivados. Dentre as diferentes causas que alimentam essa desproporcao, estao os equivocos na identificacao do potencial doador de orgaos e as contraindicacoes mal atribuidas pela equipe assistente. Assim, o presente documento pretende fornecer subsidios a equipe multiprofissional da terapia intensiva para o reconhecimento, a avaliacao e a validacao do potencial doador de orgaos.Organ transplantation is the only alternative for many patients with terminal diseases. The increasing disproportion between the high demand for organ transplants and the low rate of transplants actually performed is worrisome. Some of the causes of this disproportion are errors in the identification of potential organ donors and in the determination of contraindications by the attending staff. Therefore, the aim of the present document is to provide guidelines for intensive care multi-professional staffs for the recognition, assessment and acceptance of potential organ donors.