P Souza

Evaluation of maximal inspiratory pressure, tracheal airway occlusion pressure, and its ratio in the weaning outcome.

PURPOSE The objective of this study is to evaluate the predictive performance of maximal inspiratory pressure (Pimax), airway occlusion pressure (P 0.1), and its ratio (P 0.1/Pimax) in the weaning outcome. MATERIALS AND METHODS Seventy patients on mechanical ventilation for more than 24 hours, who fulfilled weaning criteria, were prospectively evaluated. Pimax less than -25 cm H(2)O, P 0.1 less than 4.2 cm H(2)O, and P 0.1/Pimax less than 0.14 were evaluated in all patients before spontaneous breathing trials. The receiver operating characteristic (ROC) curve was calculated to evaluate the predictive performance of each index. RESULTS Pimax presented the area under the ROC curves smaller than those for P 0.1 and P 0.1/Pimax (0.52 x 0.76 and 0.52 x 0.78; P = .004 and P = .0006, respectively), being the criteria of worst performance. P 0.1/Pimax presented excellent predictive performance in weaned patients, with sensitivity of 98.08, but with the area under the ROC curves only slightly larger than those for P 0.1 (0.78 x 0.76, respectively; P = .69). CONCLUSION In our study, P 0.1 and P 0.1/Pimax ratio were moderately accurate, whereas Pimax was less accurate in predicting the weaning outcome.

Sepsis-Associated Outcomes in Critically Ill Patients with Malignancies

RATIONALE Sepsis is a major cause of mortality among critically ill patients with cancer. Information about clinical outcomes and factors associated with increased risk of death in these patients is necessary to help physicians recognize those patients who are most likely to benefit from ICU therapy and identify possible targets for intervention. OBJECTIVES In this study, we evaluated cancer patients with sepsis chosen from a multicenter prospective study to characterize their clinical characteristics and to identify independent risk factors associated with hospital mortality. METHODS Subgroup analysis of a multicenter prospective cohort study conducted in 28 Brazilian intensive care units (ICUs) to evaluate adult cancer patients with severe sepsis and septic shock. We used logistic regression to identify variables associated with hospital mortality. MEASUREMENTS AND MAIN RESULTS Of the 717 patients admitted to the participating ICUs, 268 (37%) had severe sepsis (n = 142, 53%) or septic shock (n = 126, 47%). These patients comprised the population of the present study. The mean score on the third version of the Simplified Acute Physiology Score was 62.9 ± 17.7 points, and the median Sequential Organ Failure Assessment score was 9 (7-12) points. The most frequent sites of infection were the lungs (48%), intraabdominal region (25%), bloodstream as primary infection (19%), and urinary tract (17%). Half of the patients had microbiologically proven infections, and Gram-negative bacteria were the most common pathogens causing sepsis (31%). ICU and hospital mortality rates were 42% and 56%, respectively. In multivariable analysis, the number of acute organ dysfunctions (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.16-1.87), hematological malignancies (OR, 2.57; 95% CI, 1.05-6.27), performance status 2-4 (OR, 2.53; 95% CI, 1.44-4.43), and polymicrobial infections (OR, 3.74; 95% CI, 1.52-9.21) were associated with hospital mortality. CONCLUSIONS Sepsis is a common cause of critical illness in patients with cancer and remains associated with high mortality. Variables related to underlying malignancy, sepsis severity, and characteristics of infection are associated with a grim prognosis.

Alveolar recruitment maneuver in patients with subarachnoid hemorrhage and acute respiratory distress syndrome: A comparison of 2 approaches☆

PURPOSE The purpose of the study was to compare 2 alveolar recruitment maneuvers (ARMs) approaches in patients with subarachnoid hemorrhage (SAH) and acute respiratory distress syndrome (ARDS). MATERIAL AND METHODS Sixteen SAH patients with ARDS were randomized in 2 similar groups. One received ARM with continuous positive airway pressure (CPAP) of 35 cm H(2)O for 40 seconds (CPAP recruitment), whereas the other received pressure control ventilation with positive-end expiratory pressure of 15 cm H(2)O and pressure control above positive end-expiratory pressure of 35 cm H(2)O for 2 minutes (pressure control recruitment maneuver [PCRM]). Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were measured before and after ARM. The ratio of arterial oxygen tension to fraction of inspired oxygen was measured before and 1 hour after the ARM. RESULTS After ARM, ICP was higher in CPAP recruitment (20.50 ± 4.75 vs 13.13 ± 3.56 mm Hg; P = .003); and CPP was lower in CPAP recruitment (62.38 ± 9.81 vs 79.60 ± 6.8 mm Hg; P = .001). One hour after the ARM, the ratio of arterial oxygen tension to fraction of inspired oxygen increased significantly only in PCRM (108.5 to 203.6; P = .0078). CONCLUSION In SAH patients with ARDS, PCRM did not affect ICP and decreased CPP in safe levels, besides improving oxygenation.

Effects of positive end-expiratory pressure on brain tissue oxygen pressure of severe traumatic brain injury patients with acute respiratory distress syndrome: A pilot study

PURPOSE To verify whether high positive end-expiratory pressure levels can increase brain tissue oxygen pressure, and also their effects on pulse oxygen saturation, intracranial pressure, and cerebral perfusion pressure. MATERIAL AND METHODS Twenty traumatic brain injury patients with acute respiratory distress syndrome were submitted to positive end-expiratory pressure levels of 5, 10, and 15 cm H2O progressively. The 3 positive end-expiratory pressure levels were used during 20 minutes for each one, whereas brain tissue oxygen pressure, oxygen saturation, intracranial pressure, and cerebral perfusion pressure were recorded. RESULTS Brain tissue oxygen pressure and oxygen saturation increased significantly with increasing positive end-expiratory pressure from 5 to 10 and from 10 to 15 cm H2O (P=.0001 and P=.0001 respectively). Intracranial pressure and cerebral perfusion pressure did not differ significantly with increasing positive end-expiratory pressure from 5 to 10 and from 10 to 15 cm H2O (P=.16 and P=.79 respectively). CONCLUSIONS High positive end-expiratory pressure levels increased brain tissue oxygen pressure and oxygen saturation, without increase in intracranial pressure or decrease in cerebral perfusion pressure. High positive end-expiratory pressure levels can be used in severe traumatic brain injury patients with acute respiratory distress syndrome as a safe alternative to improve brain oxygenation.

Mensuração da pressão intra-abdominal nas unidades de tratamento intensivo: a opinião dos médicos intensivistas

BACKGROUND AND OBJECTIVES The adverse effects of intra-abdominal hypertension are known for many years. Only recently proper attention has been given to routine intra-abdominal pressure (IAP) monitoring. There is evidence that a quarter of intensive care units (ICU) do not measure IAP, due to a lack of knowledge of its importance or difficulty in results interpretation. The aim of this study is investigate the knowledge of ICU physicians about abdominal compartimental syndrome and its management. METHODS A questionnaire with 12 questions about this issue was mailed to ICU physicians. RESULTS The current knowledge of the international definitions of ACS does not seem to be linked to the number of years of medical practice, but was associated with the time spent working on intensive care. Although most physicians are aware of the existence of ACS, less than half know the present international definitions. The IAP monitoring is performed in patients at risk for ACS, by means of the intravesical filling with 25 to 100 mL of liquids, in intervals varying from of 4 to 8 hours. There was no consensus on the value of IAP values (with or without organ dysfunctions) for the clinical or surgical treatments of ACS in this survey. CONCLUSIONS The knowledge of ACS is satisfactory when we consider only physicians that devote most of their time to ICU work. However, it is necessary to improve education and knowledge of most intensive care physicians regarding the presence and severity of intra-abdominal hypertension in Rio de Janeiro.

Effects of expiratory trigger setting on respiratory parameters of nonchronic obstructive pulmonary disease patients

< 40%. Expiratory trigger was set at 1%, 25%, 50% and 70%, for at least 5-minute period each. Respiratory rate, f / Vt ratio, Vt, Ve, SpO2, and Ti / Ttot were measured in each percentage of ET. Analysis of variance for repeated measures was used to analyze variations during the four ET values and to verify variations out of the comfort zone. Bonferroni test was used to identify which values were significantly different among the multiple comparisons. A probability of less than 0.05 was considered significant. Results: Tidal volume, RR and f / Vt ratio presented significant increase in the percentage of patients that showed these parameters out of the comfort zone (p = 0.0025, p = 0.0002 and p = 0.007 respectively). No respiratory parameter presented significant variations when the comparisons were made from 1% to 25% of ET. Conclusions: In non-COPD patients, the use of ET in 1% or 25% has no effect on the respiratory parameters. The increase of ET to 50% or more can worse the respiratory parameters and lead to a rapid shallow breathing, suggesting that these values should be avoided in non-COPD patients.

Outcomes of cancer patients admitted to intensive care units with severe acute kidney injury

Critically ill cancer patients are at increased risk for acute kidney injury (AKI), but studies on these patients are scarce and were all single centered, conducted in specialized ICUs. The aim of this study was to evaluate the characteristics and outcomes in a prospective cohort of ICU cancer patients with AKI.