Gustavo Nobre

Changing sedative infusion from propofol to midazolam improves sublingual microcirculatory perfusion in patients with septic shock

PURPOSE The goal of this study was to explore possible microcirculatory alterations by changing sedative infusion from propofol to midazolam in patients with septic shock. MATERIALS AND METHODS Patients (n=16) were sedated with propofol during the first 24 hours after intubation, then with midazolam, following a predefined algorithm. Systemic hemodynamics, perfusion parameters, and microcirculation were assessed at 2 time points: just before stopping propofol and 30 minutes after the start of midazolam infusion. Sublingual microcirculation was evaluated by sidestream dark-field imaging. RESULTS The microvascular flow index and the proportion of perfused small vessels were greater when patients were on midazolam than when on propofol infusion (2.8 [2.4-2.9] vs 2.3 [1.9-2.6] and 96.4% [93.7%-97.6%] vs 92.7% [88.3%-94.7%], respectively; P<.005), and the flow heterogeneity index was greater with propofol than with midazolam use (0.49 [0.2-0.8] vs 0.19 [0.1-0.4], P<.05). There were no significant changes in systemic hemodynamics and perfusion parameters either during propofol use or during midazolam infusions. Data are presented as median (25th-75th percentiles). CONCLUSIONS In this study, sublingual microcirculatory perfusion improved when the infusion was changed from propofol to midazolam in patients with septic shock. This observation could not be explained by changes in systemic hemodynamics.

Complicações após cirurgia de revascularização miocárdica em pacientes idosos

PURPOSE: Due to the increasing longevity of the and high prevalence of coronary heart disease in the aged , coronary artery bypass graft surgery has become frequent in older patients. The purpose of this study is to describe operative features, length of stay, complications and short term outcomes after coronary artery bypass graft in such patients. METHODS: From February 2005 to October 2007, 269 patients underwent coronary artery bypass graft. Demographic data, comorbidities, prognostic scores, coronary artery bypass graft elective versus urgent indication, intensive care unit length of stay, postoperative complications and intensive care unit mortality were recorded. Intra-operative characteristics, such as total surgery time, use of bypass device, on-pump time, urine output, fluid balance, use of blood products and number of grafts, were analyzed. Patients were divided in four age groups: group I (< 60 n = 68), II (60 to 69 n = 86), III (70 to 79 n = 93) IV and older than 80 years (n = 22). RESULTS: Group IV patients were more frequently submitted to coronary artery bypass graft combined with valve replacement, emergency surgery, and had longer stay in the intensive care unit (p < 0.01). The incidence of at least one postoperative complication was also higher among patients older than 80 (p < 0.001). Multivariate analysis identified age and on-pump time as independent risk factors for development of complications. Mortality increased in patients older than 70 years (p = 0.03). CONCLUSIONS: Octogenarian patients undergoing coronary artery bypass graft have longer intensive care unit length of stay, incidence of complications and mortality. Age and on-pump time were independent risk factors associated with the incidence of postoperative complications.

Fatores preditores precoces de reinternação em unidade de terapia intensiva

OBJECTIVE: To predict readmission in intensive care unit analyzing the first 24 hours data after intensive care unit admission. METHODS: The first intensive care unit admission of patients was analyzed from January to May 2009 in a mixed unit. Readmission to the unit was considered those during the same hospital stay or within 3 months after intensive care unit discharge. Deaths during the first admission were excluded. Demographic data, use of mechanical ventilation, and report of stay longer than 3 days were submitted to uni and multivariate analysis for readmission. RESULTS: Five hundred seventy-seven patients were included (33 excluded deaths). The readmission group had 59 patients, while 518 patients were not readmitted. The lead time between the index admission and readmission was 9 (3-28) days (18 were readmitted in less than 3 days), and 10 died. Patients readmitted at least once to the intensive care unit had the differences below in comparison to the control group: older age: 75 (67-81) versus 67 (56-78) years, P<0.01; admission for respiratory insufficiency or sepsis: 33 versus 13%, P<0.01; medical admission: 49 versus 32%, P<0.05; higher SAPS II score: 27 (21-35) versus 23 (18-29) points, P<0.01; Charlson index: 2 (1-2) versus 1 (0-2) points, P<0.01; first ICU stay longer than 3 days: 35 versus 23%, P<0.01. After logistic regression, higher age, Charlson index and admission for respiratory and sepsis were independently associated to readmissions in intensive care unit. CONCLUSION: Age, comorbidities and respiratory- and/or sepsis-related admission are associated with increased readmission risk in the studied sample.

Prevenção e tratamento de náuseas e vômitos no período pós-operatório

Postoperative nausea and vomiting are common and can be prevented. Complications of this condition cause higher rates of morbidity and mortality. A review of literature was carried out on MEDLINE, with focus on controlled clinical trials. Pathophysiology is complex, with many afferent and efferent pathways, and its comprehension facilitate the choice of medication. Risk factors are presented, with a stratified score of chance to develop postoperative nausea and vomiting. An algorithm for identification of higher risk patients was elaborated and classified the level of prevention/treatment recommended to avoid excessive use of drugs and their side effects. Postoperative nausea and vomiting must be prevented, because of the involved complications and discomfort for patients. A systematic approach with analysis of preoperative risk factors and prescription of medication can be effective for prevention.

Age and acute-severity illness portend daily activity dysfunction 6 months after hospital discharge.

assessment of participants without dementia for the first three follow-ups (n = 573). The resulting composite score was validated against the CDR score by calculating the correlation between the composite score and CDR of the samples of the first (total n 5 1,099, with dementia n 5 235) and second (total n 5 683, with dementia n 5 190) followups and by calculating the correlation of the changes in both scores between the first and second follow-up. Participants without demenita were assigned a CDR score of 0. The Pearson correlation coefficient between the composite score and CDR was 0.88 at the first follow-up, 0.83 at the second follow-up, and 0.62 for in scores between the first and second follow-ups. All correlation coefficients were significant at Po.001. The composite score interquartile range (IQR) was ( 0.66–0.32) for participants with a CDR of 0, ( 2.58 to 0.90) for a CDR of 1, ( 5.50 to 2.56) for a CDR of 2, and ( 9.61 to 5.23) for a CDR of 3. The results indicate high correlations between the Composite Cognitive and ADL Functioning Score and the CDR score at one point in time. Changes over time in the composite score also correlated highly with change in CDR. These observations support the validity of the composite score that was developed. The fact that the IQRs of the composite scores per CDR score overlapped little shows that the composite score could accurately separate CDR categories. This supports the clinical relevance and provides information for the clinical interpretation of the Composite Cognitive and ADL Functioning Score. Based on the validation by CDR scores in this study population, the Composite Cognitive and ADL Functioning Score is easy to use and interpret and clinically relevant, and because it reduces the need for clinical judgment of each individual required in comparable composite measures, it is highly useful for large population-based studies.

Avaliação da microcirculação: uma nova arma no manejo da sepse?

The progression into multi-organ failure continues to be a common feature of sepsis and is directly related to microcirculatory dysfunction. Based on a PubMed database search using the key words microcirculation and sepsis, twenty-six articles were selected for this review. The relevant references from these articles were also selected and included in this analysis. Orthogonal polarization spectral imaging allows for the bedside assessment of the microcirculation of critically ill patients. Such imaging has established a correlation between microvascular dysfunction and patient outcomes, which allows practitioners to directly assess the effects of therapeutic interventions. However, the causal relationships between microcirculatory dysfunction, adverse outcomes, and the effects of therapies aimed at these microcirculatory changes in sepsis, are not clear.The progression into multi-organ failure continues to be a common feature of sepsis and is directly related to microcirculatory dysfunction. Based on a PubMed database search using the key words microcirculation and sepsis, twenty-six articles were selected for this review. The relevant references from these articles were also selected and included in this analysis. Orthogonal polarization spectral imaging allows for the bedside assessment of the microcirculation of critically ill patients. Such imaging has established a correlation between microvascular dysfunction and patient outcomes, which allows practitioners to directly assess the effects of therapeutic interventions. However, the causal relationships between microcirculatory dysfunction, adverse outcomes, and the effects of therapies aimed at these microcirculatory changes in sepsis, are not clear.

Complicações pós-operatórias de pacientes com dissecção de aorta ascendente tratados cirurgicamente

OBJECTIVES: Ascending aortic dissection has a poor prognosis if it is not promptly corrected surgically. Even with surgical correction, postoperative management is feared because of its complicated course. Our aim was to describe the incidence of postoperative complications and identify the 1 and 6-month mortality rate of our ascending aortic dissection surgical cohort. Secondarily, a comparison was made between ascending aortic dissection patients and paired-matched patients who received urgent coronary artery bypass graft surgery. METHODS: A retrospective analysis of a prospectively-collected database from February 2005 through June 2008 revealed 12 ascending aortic dissection and 10 elective ascending aortic aneurysm repair patients. These patients were analyzed for demographic and perioperative characteristics. Ascending aortic dissection patients were compared to paired-matched coronary artery bypass graft surgery patients according to age (± 3 years), gender, elective/urgent procedure and surgical team. The main outcome was in-hospital morbidity, defined by postoperative complications, intensive care unit admission and hospital length of stay. RESULTS: Twenty-two patients received operations to correct ascending aortic dissections and ascending aortic aneurysms, while 246 patients received coronary artery bypass graft surgeries. Ascending aortic dissection patients were notably similar to ascending aortic aneurysm brackets, except for longer mechanical ventilation times and lengths of stay in the hospital. After matching coronary artery bypass graft surgery patients to an ascending aortic dissection group, the following significantly worse results were found for the Aorta group: higher incidence of postoperative complications (91% vs. 45%, p=0.03), and longer hospital length of stay (19 [11-41] vs. 12.5 [8.5-13] days, p=0.05). No difference in mortality was found at the 1-month (8.3%) or 6-month (16.6%) postoperative care date. CONCLUSION: Ascending aortic dissection correction is associated with an increased incidence of postoperative complications and an increased hospital length of stay, but 1 and 6-month mortality is similar to that of paired-matched coronary artery bypass graft surgery patients.

EFFECT OF TYPE OF ADMISSION ON SHORT‐ AND LONG‐TERM OUTCOME OF NONAGENARIANS ADMITTED TO AN INTENSIVE CARE UNIT

ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Author Contributions: Paula Ramı́rez designed the study. Paula Ramı́rez, David Arizo, Concepcion Cortes, Gema Salinas, and Alberto Marquez de la Plata acquired data. Miguel Angel Garcia analyzed the data. Paula Ramı́rez, Monica Talavera, and Juan Bonatre prepared the manuscript. Sponsor’s Role: There was no sponsor for this study.

Cateter venoso profundo recoberto com antibiótico para reduzir infecção: estudo piloto

BACKGROUND AND OBJECTIVES Nosocomial catheter related bloodstream infections (CR-BSI) increase morbidity and mortality in critically ill patients. Central venous catheters (CVC) coated with rifampin and minocycline (RM) decrease rates of colonization and CR-BSI. However, recent trials challenged the clinical impact of such catheters. We designed this trial to compare rates of colonization and CR-BSI in RM catheters and controls in a cohort of critically ill patients in Brazil. METHODS Prospective, controlled trial conducted in one medico-surgical ICU. Patients were assigned to receive a control or RM CVC. After removal, tips were cultured in association with blood cultures. Rates of colonization and CR-BSI were recorded. RESULTS Among 120 catheters inserted, 100 could be evaluated, 49 in the uncoated and 51 in the coated group. Clinical characteristics of patients were similar in the two groups. Two cases of CR-BSI (3.9%) occurred in patients who received RM catheters compared with 5 (10.2%) in the uncoated group (p = 0.26). Six RM catheters (11.8%) were colonized compared with 14 (28.6%) control catheters (p = 0.036). Kaplan-Meier analysis showed no significant differences in the risk of colonization or CR-BSI. Rates of CR-BSI were 4.7 per 1000 catheter-days in the RM coated group compared to 11.4 per 1000 catheter days in the uncoated group (p = 0.45). CONCLUSIONS In this pilot study, we showed lower rates of colonization in RM coated when compared with uncoated catheters. Incidence and rates of CR-BSI were similar in the two groups.

Comparação entre as variações respiratórias da amplitude de onda pletismográfica da oximetria de pulso e do pulso arterial em pacientes com e sem uso de norepinefrina

OBJECTIVES: Arterial pulse pressure respiratory variation is a good predictor of fluid response in ventilated patients. Recently, it was shown that respiratory variation in arterial pulse pressure correlates with variation in pulse oximetry plethysmographic waveform amplitude. We wanted to evaluate the correlation between respiratory variation in arterial pulse pressure and respiratory variation in pulse oximetry plethysmographic waveform amplitude, and to determine whether this correlation was influenced by norepinephrine administration. METHODS: Prospective study of sixty patients with normal sinus rhythm on mechanical ventilation, profoundly sedated and with stable hemodynamics. Oxygenation index and invasive arterial pressure were monitored. Respiratory variation in arterial pulse pressure and respiratory variation in pulse oximetry plethysmographic waveform amplitude were recorded simultaneously in a beat-to-beat evaluation, and were compared using the Pearson coefficient of agreement and linear regression. RESULTS: Thirty patients (50%) required norepinephrine. There was a significant correlation (K = 0.66; p < 0.001) between respiratory variation in arterial pulse pressure and respiratory variation in pulse oximetry plethysmographic waveform amplitude. Area under the ROC curve was 0.88 (range, 0.79 - 0.97), with a best cutoff value of 14% to predict a respiratory variation in arterial pulse pressure of 13. The use of norepinephrine did not influence the correlation (K = 0.63, p = 0.001, respectively). CONCLUSIONS: Respiratory variation in arterial pulse pressure above 13% can be accurately predicted by a respiratory variation in pulse oximetry plethysmographic waveform amplitude of 14%. The use of norepinephrine does not alter this relationship.