Rubens Costa Filho

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.

Como implementar cuidados paliativos de qualidade na unidade de terapia intensiva

JUSTIFICATIVA E OBJETIVOS: Os cuidados paliativos tem como objetivo a prevencao e o alivio do sofrimento, melhorando a comunicacao e o sinergismo com a terapeutica curativa. Esta filosofia de tratamento conjuga os valores dos pacientes e de seus familiares, facilitando as transferencias entre os varios setores intra-hospitalares, que possam estar conduzindo um paciente com grave risco de vida. CONTEUDO: Apesar de ainda estar se desenvolvendo em todo o mundo, os cuidados paliativos estao progressivamente integrando-se aos cuidados curativos, inclusive nos ambientes de terapia intensiva. Entretanto, varias evidencias tem demonstrado que esta abordagem medica ainda precisa melhorar, seja para os pacientes com sintomas de desconforto significativos ou dores fisicas, nas unidades de terapia intensiva, ou na percepcao dos familiares, que tamComo Implementar Cuidados Paliativos de Qualidade na Unidade de Terapia Intensiva*

Recomendações para o manejo de pacientes com formas graves de dengue

Dengue is the most common vector-borne viral infection worldwide. In Brazil, the incidence has increased with successive epidemics, and an increasing proportion of patients present with severe forms of the disease. The prognosis for these patients is directly influenced by the quality of medical care. These guidelines present the management of the severe forms of dengue, including the recognition of warning signs, the treatment for prompt re-establishment of euvolemia and the evaluation and appropriate care of potential complications, thus reducing morbidity and mortality of infected children and adults

Epidemiologia e desfecho de pacientes cirúrgicos não cardíacos em unidades de terapia intensiva no Brasil

OBJECTIVES: Due to the dramatic medical breakthroughs and an increasingly ageing population, the proportion of patients who are at risk of dying following surgery is increasing over time. The aim of this study was to evaluate the outcomes and the epidemiology of non-cardiac surgical patients admitted to the intensive care unit. METHODS: A multicenter, prospective, observational, cohort study was carried out in 21 intensive care units. A total of 885 adult surgical patients admitted to a participating intensive care unit from April to June 2006 were evaluated and 587 patients were enrolled. Exclusion criteria were trauma, cardiac, neurological, gynecologic, obstetric and palliative surgeries. The main outcome measures were postoperative complications and intensive care unit and 90-day mortality rates. RESULTS: Major and urgent surgeries were performed in 66.4% and 31.7% of the patients, respectively. The intensive care unit mortality rate was 15%, and 38% of the patients had postoperative complications. The most common complication was infection or sepsis (24.7%). Myocardial ischemia was diagnosed in only 1.9% of the patients. A total of 94 % of the patients who died after surgery had co-morbidities at the time of surgery (3.4 ± 2.2). Multiple organ failure was the main cause of death (53%). CONCLUSION: Sepsis is the predominant cause of morbidity in patients undergoing non-cardiac surgery. In this patient population, multiple organ failure prevailed as the most frequent cause of death in the hospital.

Parte II: monitorização hemodinâmica básica e cateter de artéria pulmonar

BACKGROUND AND OBJECTIVES: Monitoring of vital functions is one of the most important tools in the management of critically ill patients. Nowadays is possible to detect and analyze a great deal of physiologic data using a lot of invasive and non-invasive methods. The intensivist must be able to select and carry out the most appropriate monitoring technique according to the patient requirements and taking into account the benefit/risk ratio. Despite the fast development of non invasive monitoring techniques, invasive hemodynamic monitoring using Pulmonary Artery Catheter still is one of the basic procedures in Critical Care. The aim was to define recommendations about clinical utility of basic hemodynamic monitoring methods and the Use of Pulmonary Artery Catheter. METHODS: Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty-five physicians and nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MEDLINE in the period from 1996 to 2004. RESULTS: Recommendations were made based on 55 questions about the use of central venous pressure, invasive arterial pressure, pulmonary artery catheter and its indications in different settings. CONCLUSIONS: Evaluation of central venous pressure and invasive arterial pressure, besides variables obtained by the PAC allow the understanding of cardiovascular physiology that is of great value to the care of critically ill patients. However, the correct use of these tools is fundamental to achieve the benefits due to its use.

Transfusão de hemácias em terapia intensiva: controvérsias entre evidências

A anemia e um problema prevalente nas unidades de terapia intensiva. Ela surge nos primeiros dias e pode sustentar-se, ou agravar-se, durante a internacao. A etiologia normalmente e multifatorial. A transfusao de hemacias e a intervencao mais comumente utilizada para combate-la. Aproximadamente 12 milhoes de unidades de sangue sao utilizadas para transfusoes nos Estados Unidos, sendo 25% a 30% dentro das terapias intensivas. A maior seguranca com a diminuicao das infeccoes provocadas por transfusoes permitiu uma ampliacao de indicacoes clinicas. No entanto, a terapia transfusional esta associada a outros efeitos adversos, como infeccoes nosocomiais, comprometimento imunologico, injuria pulmonar, reacoes hemoliticas e aumento da incidencia de câncer. Alguns trabalhos ja tentaram demonstrar associacao entre a correcao da anemia, mortalidade e morbidade, entretanto a literatura ainda nao alcancou um consenso. Atualmente, uma das propostas de seguranca da Organizacao Mundial de Saude e a reducao de transfusoes potencialmente desnecessarias, promovendo uma postura de transfusao racional. Esta revisao narrativa pretende abordar como objetivo primario as controversias referentes ao limiar transfusional, de acordo com estudos recentes, e como objetivos secundarios citar aspectos da anemia iatrogenica e da variabilidade de atitudes entre intensivistas para a implementacao das melhores praticas relativas a transfusao. Nao faz parte de nossos objetivos discutir as complicacoes transfusionais, embora tenham sido mencionadas. Foi feita busca em fontes eletronicas da literatura medica (PubMed - Clinical Queries), e UpToDate versao 16.2 e consulta adicional em livros texto Mostrou-se que a pratica transfusional ainda e extremamente variada dentro das terapias intensivas. Sao escassas as evidencias de que a hemotransfusao de rotina em pacientes nao-hemorragicos deva ser aplicada naqueles com hemoglobina superiores a 7 g/dL. Nao existe um consenso sobre o limiar transfusional em pacientes criticos. Os pacientes com doenca cardiovascular parecem apresentar um maior risco de morte do que aqueles sem doenca cardiovascular, para qualquer nivel de hemoglobina. A transfusao guiada por niveis de hemoglobina e parâmetros fisiologicos, oxi-hemodinâmicos individualizados e contexto clinico parece ser atualmente estrategia mais aceita do que a correcao arbitraria e isolada da hemoglobina.

EFFICACY OF A LESS-INVASIVE MONITORING TOOL TO CORRECT POSTOPERATIVE TISSUE HYPOXIA IN HIGH-RISK SURGICAL PATIENTS.: 237

Introduction: The high rate of false positive or clinically not relevant alarms from patient monitoring devices is still a concern in critical care. Hypothesis: Even with modern bedside monitors a large percentage of alarms is clinically not relevant. Methods: Full disclosure monitoring data including all alarms, alarm settings and alarm silencing was collected in 38 medical ICU patients and annotated by an intensivist off-line using continuous video recordings to identify clinically relevant alarms. Clinically relevant alarms were defined as alarms resulting in or requiring actions by a caregiver in response to the alarm. Results: During 515 hours of observation 3682 alarms were recorded of which 68% were threshold alarms. While more than 54% of all alarms were technically correct the majority of alarms (82%) were clinically not relevant. There were significant differences between different physiologic variables. 44% of the alarms resulted from manipulation. Conclusions: This ongoing study confirms that even with modern monitoring systems most alarms are clinically not relevant. As the majority of alarms are simple threshold alarms, statistical methods may be suitable to help reduce the number of false positive alarms.