Marina Verçoza Viana

Delayed medical emergency team calls and associated outcomes.

Objective:To determine whether there was an association between delayed medical emergency team calls and mortality after a medical emergency team review. Design:This was a prospective observational study. Setting:A university-affiliated tertiary referral hospital in Porto Alegre, Brazil. Patients:All patients were reviewed by the medical emergency team from July 2008 to December 2009. Interventions:None. Measurements and Main Results:There were 1,481 calls for 1,148 patients. Delayed medical emergency team calls occurred for 246 patients (21.4%). The criterion associated with delay was typically the same criterion for the subsequent medical emergency team call. Physicians had a greater prevalence of delayed medical emergency team calls (110 of 246 [44.7%]) than timely medical emergency team calls (267 of 902 [29.6%]; p < 0.001). The mortality at 30 days after medical emergency team review was higher among patients with delayed medical emergency team activation (152 [61.8%]) than patients receiving timely medical emergency team activation (378 [41.9%]; p < 0.001). In a multivariate analysis, delayed medical emergency team calls remained significantly associated with higher mortality. Conclusions:Delayed medical emergency team calls are common and are independently associated with higher mortality. This result reaffirms the concept and need for a rapid response system.

Aldosterone secretion in patients with septic shock: a prospective study

OBJECTIVE To assess serum levels of the main factors that regulate the activation of the zona glomerulosa and aldosterone production in patients with septic shock, as well as their response to a high-dose (250 µg) adrenocorticotropic hormone (ACTH) stimulation test. SUBJECTS AND METHODS In 27 patients with septic shock, baseline levels of aldosterone, cortisol, ACTH, renin, sodium, potassium, and lactate were measured, followed by a cortrosyn test. RESULTS Renin correlated with baseline aldosterone and its variation after cortrosyn stimulation. Baseline cortisol and its variation did not correlate with ACTH. Only three patients had concomitant dysfunction of aldosterone and cortisol secretion. CONCLUSIONS Activation of the zona glomerulosa and zona fasciculata are independent. Aldosterone secretion is dependent on the integrity of the renin-angiotensin-aldosterone system, whereas cortisol secretion does not appear to depend predominantly on the hypothalamic-pituitary-adrenal axis. These results suggest that activation of the adrenal gland in critically ill patients occurs by multiple mechanisms.

Insulin Regimens to Treat Hyperglycemia in Hospitalized Patients on Nutritional Support: Systematic Review and Meta-Analyses

Background: The best insulin regimen to treat hyperglycemia in hospitalized patients on nutritional support (NS) is unclear. Methods: We searched electronic databases to identify cohort studies or randomized clinical trials in order to evaluate the efficacy of different insulin regimens used to treat hyperglycemia in hospitalized patients on NS on diverse outcomes: mean blood glucose (MBG), hypoglycemia, length of stay in hospital, and mortality. Results: Seventeen studies from a total of 5,030 were included. Enteral Group included 8 studies; 1,203 patients using rapid, glargine, NPH, or Premix insulin; MBG 108-225 mg/dL; hypoglycemia 0-13%. In indirect meta-analyses, NPH insulin ranked best for glucose control (MD 95% CI -2.50 mg/dL [2.65 to -2.35]). Parenteral Group included 4 studies; 228 patients using regular and glargine or NPH insulin; MBG 137-202 mg/dL; hypoglycemia 0-40%. In meta-analyses comparing regular insulin added to parenteral nutrition bag with glargine, MBG (MD 95% CI -3.78 mg/dL [-11.93 to 4.37]; I2 = 0%) or hypoglycemia frequency (RR 95% CI 1.37 [0.43-4.32]; I2 = 70.7%) did not differ. The description related to hospital length of stay and mortality was inconsistent between groups. Conclusions: The best insulin regimen to treat hyperglycemia in hospitalized patients on NS has not been established; best results using insulin regimens with NPH in enteral nutrition do not seem to be clinically relevant.

Comparison of cumulative incidence analysis and Kaplan-Meier for analysis of shock reversal in patients with septic shock

INTRODUCTION Kaplan-Meier (KM) has become the most used method to evaluate time-to-event analysis, although it is unsuitable in competing event situations such as death and shock reversal. Despite that the use of this methodology is not widely disseminated, cumulative incidence analysis (CIA) is more appropriate in these situations. We used CIA and KM (with 2 different techniques of censoring) to compare shock reversal in a cohort of patients with septic shock after steroid therapy. Furthermore, we have analyzed shock reversal in responders and nonresponders to high-dose cortrosyn test (250 μg). METHODS Analysis of shock reversal in a cohort of 74 patients with septic shock at a university hospital was done. RESULTS Shock reversal by the 28th day was estimated to be 88% and 72% by KM methods and 59% by CIA. In nonresponders to cortrosyn test (Δ ≤ 9 μg/dL), shock reversal was estimated in 80% and 56% according to KM and 47% according to CIA. As for responders to cortrosyn test, shock reversal was estimated in 90% and 77% according to KM and 64% according to the CIA method. CONCLUSION Kaplan-Meier overestimates shock reversal. Cumulative incidence analysis seems to be a more appropriate method to analyze shock reversal. Future trials intended to analyze shock reversal should apply CIA.

Pressure-support ventilation or T-piece spontaneous breathing trials for patients with chronic obstructive pulmonary disease - A randomized controlled trial

Background Little is known about the best strategy for weaning patients with chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Spontaneous breathing trials (SBT) using a T-piece or pressure-support ventilation (PSV) have a central role in this process. Our aim was to compare T-piece and PSV SBTs according to the duration of mechanical ventilation (MV) in patients with COPD. Methods Patients with COPD who had at least 48 hours of invasive MV support were randomized to 30 minutes of T-piece or PSV at 10 cm H2O after being considered able to undergo a SBT. All patients were preemptively connected to non-invasive ventilation after extubation. Tracheostomized patients were excluded. The primary outcome was total invasive MV duration. Time to liberation from MV was assessed as secondary outcome. Results Between 2012 and 2016, 190 patients were randomized to T-piece (99) or PSV (91) groups. Extubation at first SBT was achieved in 78% of patients. The mean total MV duration was 10.82 ± 9.1 days for the T-piece group and 7.31 ± 4.9 days for the PSV group (p < 0.001); however, the pre-SBT duration also differed (7.35 ± 3.9 and 5.84 ± 3.3, respectively; p = 0.002). The time to liberation was 8.36 ± 11.04 days for the T-piece group and 4.06 ± 4.94 for the PSV group (univariate mean ratio = 2.06 [1.29–3.27], p = 0.003) for the subgroup of patients with difficult or prolonged weaning. The study group was independently associated with the time to liberation in this subgroup. Conclusions The SBT technique did not influence MV duration for patients with COPD. For the difficult/prolonged weaning subgroup, the T-piece may be associated with a longer time to liberation, although this should be clarified by further studies. Trial registration ClinicalTrials.gov NCT01464567, at November 3, 2011.

The Quality of End-of-Life Care after Limitations of Medical Treatment as Defined by a Rapid Response Team: A Retrospective Cohort Study

BACKGROUND Despite the increase in the identification of patients at the end of life after the introduction of rapid response team (RRT), there is doubt as to whether there has been an improvement in the quality of care offered to these patients. Proper end-of-life care is the next expected step after identifying patients who are dying. OBJECTIVE To evaluate the end-of-life care after limitations of medical treatment (LOMTs) as defined by an RRT. DESIGN This is a single-center retrospective cohort study at a tertiary teaching hospital in Porto Alegre, Brazil, from July 2014 to July 2016. SETTING/SUBJECTS We included 242 patients with an LOMT as defined by the RRT. MEASUREMENTS Outcomes of interest included symptoms and palliative measures after RRT review. RESULTS During the study period, there were 5396 calls to 2937 patients, representing 126 calls per 1000 hospital discharges. Of these calls, 4.9% (n = 242) resulted in an LOMT. The primary care team agreed with the LOMT decision proposed by the RRT in 91.7% of cases. Regarding end-of-life symptoms, 7.4% and 5.8% of patients presented with intense or moderate pain, respectively, and 62.4% of patients presented dyspnea in the last 48 hours of hospitalization. Less than 15% of patients received attention for their spiritual needs and/or received psychological support. CONCLUSIONS Our data reinforce the important role of RRTs in the identification of end-of-life patients with clinical deterioration. Despite the increase in the identification of these patients, the quality of end-of-life care needs to be improved.

Elevated red blood cell distribution width at ICU discharge is associated with readmission to the intensive care unit

BACKGROUND Red blood cell distribution width (RDW) is a predictor of mortality in critically ill patients. Our objective was to investigate the association between the RDW at ICU discharge and the risk of ICU readmission or unexpected death in the ward. METHODS A secondary analysis of prospectively collected data study was conducted including patients discharged alive from the ICU to the ward. The target variable was the RDW collected at ICU discharge. Elevated RDW was defined as an RDW > 16%. Outcomes of interest included readmission to the ICU, unexpected death in the ward and in-hospital death. Variables with a p-value <0.1 in the univariate analysis or with biological plausibility for the occurrence of the outcome were included in the Cox proportional hazards model for adjustment. RESULTS We included 813 patients. A total of 138 readmissions to the ICU and 44 unexpected deaths in the ward occurred. Elevated RDW at ICU discharge was independently associated with readmission to the ICU or unexpected death in the ward after multivariable adjustment (HR: 1.901; 95% CI 1.357-2.662). Other variables associated with this outcome included age, tracheostomy and mean corpuscular volume (MCV) at ICU discharge. Similar results were obtained after the exclusion of unexpected deaths in the ward (HR 1.940; CI 1.312-2.871) and for in-hospital deaths (HR 1.716; 95% CI 1.141-2.580). CONCLUSIONS Elevated RDW at ICU discharge is independently associated with ICU readmission and in-hospital death.

Para: Hipotermia terapêutica após parada cardíaca: preditores de prognóstico

Determining the neurological prognosis of patients who have suffered cardiac arrest is extremely important because it allows the physician to inform the family about the life expectancy of their beloved relative, as well as to wisely plan for the allocation of available resources. We read with great interest the study performed by Leão et al., who assessed factors associated with worse neurological outcomes after cardiac arrest.(1) The study conducted by Leão et al. showed the ability of hypoxic-ischemic injuries viewed using magnetic resonance imaging of the brain to predict, in 72 hours, the prognosis of cardiac arrest survivors who had undergone therapeutic hypothermia (odds ratio OR 19.8; 95% confidence interval 95%CI: 1.7 229.6).(1) This result reinforces the recommendations by the American Heart Association in regard to magnetic resonance imaging of the brain for neurological prognosis evaluation after cardiac arrest.(2) The time from the return of spontaneous circulation until the target temperature was reached was also associated with the neurological prognosis. Patients who reached the target temperature more quickly presented worse neurological outcomes. However, we would like to highlight some important issues. First, the authors do not describe the initial temperature of the patients before they underwent therapeutic hypothermia. In addition, although hypothermia may reduce coronary perfusion, the fact that patients with more severe neurological damage were less reactive to low temperatures may make this finding a marker of worse prognosis and not necessarily its cause. The authors, as well as the editorial,(3) also state that such results corroborate the findings of the randomized clinical trial performed by Kim et al. However, it is necessary to emphasize that this study was conducted only in out-of-hospital cardiac arrest and that induction of pre-hospital hypothermia increased the time spent by the team on site, possibly delaying interventions, such as cardiac catheterization, and increasing the number of cardiac arrests during transport.(4) It is also important to note that the study population was heterogeneous (e.g., multiple initial cardiac arrest rhythms, distinct causes, in-hospital and out-of-hospital settings). These issues may have influenced patient outcomes. Moreover, the authors did not evaluate whether patients with findings suggestive of worse prognosis had any limitations with regard to treatment or withdrawal of support, leading to self-fulfilling prophecies. Lastly, the editorial(3) considers that the findings of Leão et al.(1) corroborate the maintenance of a temperature close to 36oC. However, it was not the aim of the study to evaluate the impact of temperature control on cardiac arrest survivors, Conflicts of interest: None.

Comment on Okabayashi et al. Intensive Versus Intermediate Glucose Control in Surgical Intensive Care Unit Patients. Diabetes Care 2014;37:1516–1524

Hyperglycemia is a major concern in critically ill patients, especially in surgical patients. The optimal target of glucose control in this population and the best method to achieve this goal in order to avoid hypoglycemia is unknown. Okabayashi et al. (1) demonstrated that intensive glucose control (glucose target 80–110 mg/dL) compared with intermediate glucose control (glucose target 140–180 mg/dL) in a selected group of patients who underwent hepato-biliary-pancreatic surgery was feasible using a closed-loop glycemic sensor, without hypoglycemic events and, more important, with a decreased number of surgical site infections and shorter hospitalization length. The result of this trial reinforces the need for new trials using …

Prophylactic haloperidol: too early to lose hope

Delirium is a very prevalent syndrome and an important independent predictor of negative outcome in patients in the intensive-care unit (ICU), but there is no proven pharmacological intervention to prevent or treat this disorder. Therefore, the study by Valerie J Page and colleagues, which provided an assessment of the use of haloperidol in the ICU setting, was needed. However, the results of this trial should not be classed as defi nitive because the study has some limitations. First, haloperidol was used as both a prophylaxis and treatment, and the number of patients with delirium at enrolment was not stated. We would expect that the dose needed to treat a patient with delirium would be higher than the prophylactic dose. Also, the criteria for stopping the drug should be reconsidered, since although patients might be 2 days free of delirium, they still could be at risk of developing delirium. Second, regarding the statistical analysis, the primary outcome was the number of delirium-free and comafree days in the first 14 days after randomisation, but patients who died before day 14 were recorded as having zero days free of delirium and coma, restricting the analysis to survivors, and correcting the incidence of the main outcome (delirium) according to the competing event (death). When analysing time-to-event data and competing outcomes, a technique known as cumulative incidence analysis can be used to assess the actual incidence of delirium. This type of analysis would have provided more accurate results in Page and colleagues’ study, and should be used in future trials that intend to address delirium incidence. Last, the study authors conclude that their results do not support the use of haloperidol in patients needing mechanical ventilation, irrespective of whether patients screen positive for delirium or are in a coma. They believe that haloperidol should be reserved for short-term management of acute agitation; however, we think it is too soon to come to this conclusion.