Jorge Pimentel

Challenges in end-of-life care in the ICU

The jurors identified numerous problems with end of life in the ICU including variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of health-care providers, the use of imprecise and insensitive terminology, and incomplete documentation in the medical records. The jury strongly recommends that research be conducted to improve end-of-life care. The jury advocates a “shared” approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honour decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician’s responsibility, as leader of the health-care team, to decide on the reasonableness of the planned action. In the event of conflict, the ICU team may agree to continue support for a predetermined time. Most conflicts can be resolved. If the conflict persists, however, an ethics consultation may be helpful. Nurses must be involved in the process. The patient must be assured of a pain-free death. The jury of the Consensus Conference subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this “double effect” should not detract from the primary aim to ensure comfort.

A comparison of estimates of glomerular filtration in critically ill patients with augmented renal clearance

IntroductionIncreasingly, derived estimates of glomerular filtration, such as the modification of diet in renal disease (MDRD) equation and Cockcroft-Gault (CG) formula are being employed in the intensive care unit (ICU). To date, these estimates have not been rigorously validated in those with augmented clearances, resulting in potentially inaccurate drug prescription.MethodsPost-hoc analysis of prospectively collected data in two tertiary level ICUs in Australia and Portugal. Patients with normal serum creatinine concentrations manifesting augmented renal clearance (ARC) (measured creatinine clearance (CLCR) > 130 ml/min/1.73 m2) were identified by chart review. Comparison between measured values and MDRD and CG estimates were then undertaken. Spearman correlation coefficients (rs) were calculated to determine goodness of fit, and precision and bias were assessed using Bland-Altman plots.ResultsEighty-six patients were included in analysis. The median [IQR] measured CLCR was 162 [145-190] ml/min/1.73 m2, as compared to 135 [116-171], 93 [83-110], 124[102-154], and 108 [87-135] ml/min/1.73 m2 estimated by CG, modified CG, 4-variable MDRD and 6-variable MDRD formulae. All of the equations significantly under-estimated the measured value, with CG displaying the smallest bias (39 ml/min/1.73 m2). Although a moderate correlation was noted between CLCR and CG (rs = 0.26, P = 0.017) and 4-variable MDRD (rs = 0.22, P = 0.047), neither had acceptable precision for clinical application in this setting. CG estimates had the highest sensitivity for correctly identifying patients with ARC (62%).ConclusionsDerived estimates of GFR are inaccurate in the setting of ARC, and should be interpreted with caution by the physician. A measured CLCR should be performed to accurately guide drug dosing.

Augmented renal clearance in septic patients and implications for vancomycin optimisation

The aim of this study was to evaluate the effect of augmented renal clearance (ARC) on vancomycin serum concentrations in critically ill patients. This prospective, single-centre, observational, cohort study included 93 consecutive, critically ill septic patients who started treatment that included vancomycin by continuous infusion, admitted over a 2-year period (March 2006 to February 2008). ARC was defined as 24-h creatinine clearance (CL(Cr))>130 mL/min/1.73 m(2). Two groups were analysed: Group A, 56 patients with a CL(Cr)≤130 mL/min/1.73 m(2); and Group B, 37 patients with a CL(Cr)>130 mL/min/1.73 m(2). Vancomycin therapeutic levels were assessed on the first 3 days of treatment (D(1), D(2) and D(3)). Serum vancomycin levels on D(1), D(2) and D(3), respectively, were 13.1, 16.6 and 18.6 μmol/L for Group A and 9.7, 11.7 and 13.8 μmol/L for Group B (P<0.05 per day). The correlation between CL(Cr) and serum vancomycin on D(1) was -0.57 (P<0.001). ARC was strongly associated with subtherapeutic vancomycin serum concentrations on the first 3 days of treatment.

The European Union Directive on Clinical Research: present status of implementation in EU member states’ legislations with regard to the incompetent patient

A new law or an amendment to existing law has already been incorporated in national statutes or is in the process of approval in The Netherlands, France, Belgium, Italy, Denmark, Germany, Austria, and Spain (Table 1). In other countries discussions and proposals are still not complete. In some countries the proposals are limited to drug research (as was intended by the Directive); in others (Belgium, France, The Netherlands, the United Kingdom) its scope has been broadened to include all types of research (epidemiology, genetics, pathophysiology, and observational studies).

Association between Polymorphisms in the Fibrinogen α- and β-Genes on the Post-trauma Fibrinogen Increase

Fibrinogen is an acute phase reactant, and there, fore its plasma levels increase after severe injury. Polymorphisms in the fibrinogen α and β genes have been found to be associated with plasma levels of fibrinogen, and it has also been suggested that they are associated with the fibrinogen increase in acute phase situations. In forty-five consecutive patients admitted to the Intensive Care Unit after acute cranial or thoracic trauma, we investigated the influence of four polymorphisms at the fibrinogen loci (-455G/A and BclI (β gene), TaqI and T/A312 (α gene)) on the post-trauma increase of the fibrinogen levels. At admission, fibrinogen levels were comparable in the patients with the different genotypes for the four polymorphisms studied. However, patients carrying the -455A allele of the -455G/A polymorphism had a significantly wider variation and higher peak levels of fibrinogen, during their stay at the intensive care unit, than did the -455GA homozygotes (5.1 g/I (SD 1.3) and 5.9 g/1 (SD 1.0), respectively, p<0.05). Such difference was not found for the other studied polymorphisms. The present study suggests that the increase of fibrinogen level in acute phase situations like severe trauma is associated with the β-gene -455G/A polymorphism.

A case of acute poisoning by methyl demeton in a female 5 months pregnant.

During the last decade the number of poisonings by pesticides in Portugal has been steadily rising. Out of 140 patients treated in our Intensive Care Unit (I.C.U.), 86 were male and 54 were female, one of whom was 5 months pregnant. Besides all the care and surveillance required by every case of acute poisoning, pregnant females raise particular problems. Four months later, she gave birth to a normal child. Its follow-up has shown a normal morpho-physiological and psycho-motor development.

B-type natriuretic peptide predicts long-term prognosis in a cohort of critically ill patients

B-type natriuretic peptide is an important prognostic marker in heart failure. However, there are limited data for its value in non-cardiac intensive care unit patients, namely regarding long-term prognosis. We investigated the long-term prognostic value of BNP in a cohort of critically ill patients. This was a prospective and observational study, conducted in a tertiary university hospital 20-bed intensive care unit. We included 103 mechanically-ventilated patients admitted for a non-cardiac primary diagnosis; B-type natriuretic peptide samples were obtained on admission. A mean 14 (3–30) month follow up was available in 96.1% of patients who were discharged from hospital. Mean age was 60.7±19.0 years and mean APACHE II score was 16.2±7.2. APACHE II score and renal dysfunction increased with rising B-type natriuretic peptide, with more than 60% of patients having B-type natriuretic peptide levels of 100 pg/mL or over; echocardiography-derived left ventricular ejection fraction was lower in patients with higher B-type natriuretic peptide (P < 0.001). Long-term survivors had lower median B-type natriuretic peptide values (117.5[2–1668] pg/mL) compared with intensive care unit non-survivors (191.0[5–4945] pg/mL), P<0.001. After adjustment to APACHE II score, B-type natriuretic peptide levels of 300 pg/mL or over were independently associated with long-term mortality (odds-ratio 4.1 [95% CI 1.45–11.5], P=0.008). We conclude that in an unselected cohort of intensive care unit patients, admission B-type natriuretic peptide is frequently elevated, even without clinically apparent acute heart disease, and is a strong independent predictor of long-term mortality.

Pneumonia eosinofílica aguda com evolução para síndroma de dificuldade respiratória aguda: caso clínico

The Authors present a case of acute eosinophilic pneumonia (AEP) associated with severe acute respiratory distress syndrome in a previously healthy young adult, medicated with nitrofurantoin. AEP must be included in the differential diagnosis of community adquired pneumonia, as well as a cause of acute respiratory distress syndrome; its diagnosis is suggested by the presence of eosinophilic alveolitis in bronchoalveolar lavage fluid. The early diagnosis of AEP and corticosteroid therapy may be lifesaving.

[Traumatic diaphragmatic hernias: retrospective analysis].

AIMS This study classifies cases of traumatic diaphragmatic hernias (TDH) in patients admitted to the Intensive Care Unit (ICU) of the Coimbra University Hospitals (HUC) from 1990 to 2004. METHODS Retrospective analysis of 34 cases of TDH, studying anatomical location, place and time of diagnosis, complementary tests aiding diagnosis, herniated organs, associated traumatism, morbidity and mortality. RESULTS Twenty-eight male and six female patients with an average age of 40.5 years +/- 20.5, average SAPS score 38.8. Average length of stay was 19.1 +/- 13.6 days, all suffered from closed traumatism and were put on artificial ventilation. The left-side diaphragm was more frequently affected (94.1%) then the right. Diagnosis in 19 cases was made up in the first six hours following the diagnosis of traumatism, in four cases within 12 hours and in the remaining cases between 48 hours and 16 years after traumatism. In 13 patients the diagnosis was established intra-operatively. The stomach was typically one of the herniated organs. The most frequently associated lesions at the thoracic level were pulmonary contusion, haemothorax and pneumothorax, and at the abdominal level, haemoperitoneum and splenic lesion. The rates for complications and mortality were 55.8% and 11.7% respectively. CONCLUSIONS TDH mainly occurs on the left side through closed thoraco-abdominal trauma following road traffic accidents. This group of patients, on average younger than others admitted to ICU, presents a longer average hospitalisation period, but has lower rates of mortality and lower SAPS severity scores. The most commonly herniated organ was the stomach and the most frequently encountered lesions were cranial-encephalic, splenic and pleural traumatisms. Pre-operative diagnosis of diaphragmatic injuries is difficult and a high index of clinical suspicion is needed after thoraco-abdominal trauma. This diagnosis should always be considered a possibility in cases of closed thoraco-abdominal traumas.

Intestinal dysfunction in the critical trauma patients – An early and frequent event

BACKGROUND Small-bowel dysfunction exerts a relevant prognostic impact in the critically ill patients. Citrullinemia has been used in the evaluation of the intestinal function and it is considered an objective parameter of the functional enterocyte mass. Present study proposes to determine the intestinal dysfunction prevalence and the citrullinemia kinetic profile in severe trauma patients and to investigate its correlation with severity indicators and clinical outcome. METHODS A prospective study including 23 critical trauma patients was performed. Aminoacidemias were quantified, by ion exchange chromatography, at the admission and at the first and third days. Severity and outcome parameters were registered. RESULTS In severe trauma patients, severe hypocitrullinemia (< 20 μmol/L) prevalence at admission was high (69.6%) and mean citrullinemia was low (19.5 ± 11.1 μmol/L). Baseline citrullinemia was inversely and significantly correlated with shock index (r = -55.1%, p = 0.008) and extent of invasive ventilation support (r = -42.7%, p = 0.042). Citrullinemia < 13.7 μmol/L at admission, observed in 17.4% of patients, was associated with higher shock index (1.27 ± 0.10 versus 0.75 ± 0.18, p = 0.0001) and longer duration of invasive ventilation support (20.3 ± 7 versus 11.2 ± 7.1 days, p = 0.029) and intensive care unit stay (22 ± 5.9 versus 12.2 ± 8.8 days, p = 0.048). A citrullinemia decrease in the first day after admittance superior to 12.7% constituted a significant predictive factor of in-hospital mortality (75 versus 14.3%, p = 0.044; odds ratio = 7.8; accuracy = 65.2%; specificity = 92.3%; negative predictive value = 85.7%] and lower actuarial survival (69.8 ± 41.6 versus 278.1 ± 37.4 days, p = 0.034). CONCLUSIONS Those results confirm the high prevalence and the prognostic relevance of hypocitrullinemia, considered a biomarker of enterocyte dysfunction, in severe trauma patients.