Suzana Margareth Lobo

Uso de clorexidina 2% gel e escovação mecânica na higiene bucal de pacientes sob ventilação mecânica: efeitos na pneumonia associada a ventilador

Objective To evaluate the effects of oral chlorhexidine hygiene with toothbrushing on the rate of ventilator-associated pneumonia in a mixed population of critically ill patients under prolonged mechanical ventilation. Methods Prospective, randomized, and placebo-controlled pilot study. Patients who were receiving mechanical ventilation, had been admitted less than 24 hours prior, and were anticipated to require mechanical ventilation for more than 72 hours were included in the study. The patients were randomly divided into one of the following groups: chlorhexidine hygiene with toothbrushing or a placebo group (gel with the same color and consistency and toothbrushing). Results The planned interim analysis was conducted using 52 patients, and the study was terminated prematurely. In total, 28 patients were included in the chlorhexidine / toothbrushing group, and 24 patients were included in the placebo group. Ventilator-associated pneumonia occurred in 45.8% of the placebo group and in 64.3% of the chlorhexidine hygiene with toothbrushing group (RR=1.4; 95% CI=0.83-2.34; p=0.29). Conclusion Because the study was terminated due to futility, it was not possible to evaluate the impact of oral hygiene using 2% chlorhexidine and toothbrushing on the incidence of ventilator-associated pneumonia in this heterogeneous population of critical patients receiving long-term mechanical ventilation, and no beneficial effect was observed for this intervention.OBJECTIVE: To evaluate the effects of oral chlorhexidine hygiene with toothbrushing on the rate of ventilator-associated pneumonia in a mixed population of critically ill patients under prolonged mechanical ventilation. METHODS: Prospective, randomized, and placebo-controlled pilot study. Patients who were receiving mechanical ventilation, had been admitted less than 24 hours prior, and were anticipated to require mechanical ventilation for more than 72 hours were included in the study. The patients were randomly divided into one of the following groups: chlorhexidine hygiene with toothbrushing or a placebo group (gel with the same color and consistency and toothbrushing). RESULTS: The planned interim analysis was conducted using 52 patients, and the study was terminated prematurely. In total, 28 patients were included in the chlorhexidine / toothbrushing group, and 24 patients were included in the placebo group. Ventilator-associated pneumonia occurred in 45.8% of the placebo group and in 64.3% of the chlorhexidine hygiene with toothbrushing group (RR=1.4; 95% CI=0.83-2.34; p=0.29). CONCLUSION: Because the study was terminated due to futility, it was not possible to evaluate the impact of oral hygiene using 2% chlorhexidine and toothbrushing on the incidence of ventilator-associated pneumonia in this heterogeneous population of critical patients receiving long-term mechanical ventilation, and no beneficial effect was observed for this intervention.

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.

Markers and mediators of inflammatory response in infection and sepsis

BACKGROUND AND OBJECTIVES Sepsis is the expression of a complex network of mediators. Multiple organ dysfunction and septic shock indeed remain a major cause of death among ICU patients worldwide. Prompt recognition of both the diagnosis and the complicated evolution are essential, hence the importance of using biological markers. The main pro-inflammatory and anti-inflammatory cytokines as well as hundreds of others cellular markers, circulating bioactive molecules or coagulation products are potential biological markers that could help to characterize the presence of infection and sepsis. We aimed to review the main biological markers that could be used nowadays or possibly in the future, either in clinical or research fields. CONTENTS A selective review of biologic markers of sepsis focusing on markers of the coagulation cascade, C-reactive protein and procalcitonin. CONCLUSIONS Most of the available biological markers is still not a practical method to be used at the bed-side and is currently restricted to research works. Nowadays the determination of CRP or PCT serum levels can be of great help in the critically ill patient care along with the conventional parameters.

INTERSEPT study: we still need more clarity

In recent issues of Critical Care, we read with concern the article by Pontes-Arruda and colleagues [1] and the fi rst author’s reply to the letter from Machado (the latter two of which appear in [2]). Th e article and subsequent letters address eicosapentaenoic acid/gamma-linolenic acid (EPA/GLA) use in sepsis patients in the INTERSEPT (Investigating Nutritional Th erapy with EPA, GLA and Antioxidants Role in Sepsis Treatment) study. We served as the principal investigators of this trial and come from sites that did not successfully include any patients or that included only a small number of patients. From this vantage point, we believe that Pontes-Arruda’s reply to Machado’s comments [2] did not clarify several important points. As stated in the article [1], only fi ve of the 12 sites successfully enrolled patients. However, the fi rst author’s site was responsible for the inclusion of about 100 of the 106 patients. We believe that this imbalance is relevant and that readers of Critical Care need to be aware of it. We disagree with Pontes-Arruda’s response [2] that all relevant limitations were already mentioned in the Discussion [1]. We found it diffi cult to understand his affi rmation that the results were unaff ected by the unbalanced distribution pattern of the patients, as any statistical analysis of the few patients from the other four sites would obviously be under powered. We also think he should clearly state the strategies that were used at his site to successfully enroll patients given that the 11 other sites, most of which are very skilled at performing intervention studies, failed to enroll similar numbers of patients. Th e author’s explanation [2] of the Sequential Organ Failure Assessment (SOFA) fi ndings is also not clear. We agree that it is perfectly possible for some patients to have a high SOFA score that may be insuffi cient to fulfi ll the inclusion criteria. However, the median and inter quartile values shown in Table 3 [1] indicate that 75% of all patients had a SOFA score of more than 4. Th is would be a very unusual fi nding in sepsis patients without signifi cant organ dysfunction. Moreover, the interquartile interval in Table 3 indicates that at least 75% of the patients had platelet levels of more than 144 × 10 9 cells per liter, a bilirubin level of less than 1.5 mg/dL, and a creatinine level of less than 1.6 mg/dL; as stated in the text [1], no patients had an arterial partial pressure of oxygen/ fraction of inspired oxygen (PaO 2 /FiO 2 ) ratio of less than 300. Th e high median and inter quartile values for the SOFA scores would be possible only in the presence of severe neurological or hemo dynamic dys func tion in the majority of the patients; this point, there fore, requires further explanation. Moreover, at least 50% of the patients had lactate levels of higher than 3.7 mmol/L, and this suggests that many patients already had signs of hypoperfusion (that is, severe sepsis) at inclusion. We believe that this paper needs more clarity as all of the above aspects are relevant for readers of Critical Care.

Doses baixas de dobutamina e fluidos no pós-operatório de pacientes de alto risco: efeitos sobre a oxigenação tecidual, resposta inflamatória e morbidade

JUSTIFICATIVA E OBJETIVOS: A dobutamina e um agente inotropico com propriedade adrenergica b-1 predominante e frequentemente usado para aumentar o fluxo sanguineo em pacientes criticos. Dobutamina pode ter um papel no aumento da perfusao esplâncnica, desse modo protegendo esta area de lesao isquemica. O objetivo deste estudo foi investigar os efeitos de baixas doses de dobutamina (5 mg/kg/min) sobre a oxigenacao tecidual, resposta inflamatoria e complicacoes pos-operatoria em pacientes de alto risco. METODO: Estudo prospectivo, aleatorio, encoberto e placebo-controlado. Cem pacientes cirurgicos admitidos em Unidade Semi-Intensiva foram avaliados e 82 pacientes foram incluidos, 42 pacientes no grupo controle (solucao fisiologica) e 40 no grupo tratamento (5 mg/kg/min) de dobutamina por 24 horas). Os mesmos procedimentos terapeuticos foram usados nos dois grupos. A infusao de liquidos deveria ser realizada em caso de taquicardia ou hipotensao apos a infusao de dobutamina, pela possibilidade de hipovolemia. RESULTADOS: O volume total de fluidos administrado foi significativamente maior no grupo dobutamina do que no grupo controle (7351 ± 2082 mL versus 6074 ± 2386 mL, respectivamente, p < 0,05). Saturacao venosa central de oxigenio (SvcO2), lactato serico e proteina C-reativa foram similares em ambos os grupos. Complicacoes ocorreram em 35% e 50% dos pacientes nos grupos dobutamina e controle, respectivamente (RR 0,70 IC 95% 0,41 - 1,17; NS). CONCLUSOES: Baixas doses de dobutamina e fluidos apos trauma cirurgico nao tiveram efeitos na prevalencia de complicacoes pos-operatoria em pacientes cirurgicos de alto risco.

Consenso brasileiro de monitorização e suporte hemodinâmico - Parte V: suporte hemodinâmico

BACKGROUND AND OBJECTIVES Shock occurs when the circulatory system cannot maintain adequate cellular perfusion. If this condition is not reverted irreversible cellular injury establishes. Shock treatment has as its initial priority the fast and vigorous correction of mean arterial pressure and cardiac output to maintain life and avoid or lessen organic dysfunctions. Fluid challenge and vasoactive drugs are necessary to warrant an adequate tissue perfusion and maintenance of function of different organs and systems, always guided by cardiovascular monitorization. The recommendations built in this consensus are aimed to guide hemodynamic support needed to maintain adequate tisular perfusion. 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 physician and two 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 answering 17 questions about hemodynamic support with focus on fluid challenge, red blood cell transfusions, vasoactive drugs and perioperative hemodynamic optimization. CONCLUSIONS Hemodynamic monitoring by itself does not reduce the mortality of critically ill patients, however, we believe that the correct interpretation of the data obtained by the hemodynamic monitoring and the use of hemodynamic support protocols based on well defined tissue perfusion goals can improve the outcome of these patients.

Brazilian Consensus on perioperative hemodynamic therapy goal guided in patients undergoing noncardiac surgery: fluid management strategy - produced by the São Paulo State Society of Anesthesiology (Sociedade de Anestesiologia do Estado de São Paulo - SAESP)

Enis Donizetti Silvaa,b,c, Albert Carl Perrinod, Alexandre Teruyae,f,g, Bobbie Jean Sweitzerh, Chiara Scaglioni Tessmer Gatto i, Claudia Marquez Simõesa,b,j, Ederlon Alves Carvalho Rezendek, Filomena Regina Barbosa Gomes Galas j, Francisco Ricardo Lobol,m, João Manoel da Silva Juniork, Leandro Ultino Taniguchin,o, Luciano Cesar Pontes de Azevedoa,o,p, Ludhmila Abrahão Hajjara,i,j, Luiz Antônio Mondadoriq, Marcelo Gama de Abreur, Marcelo Vaz Perezs,t, Regina El Dibu, Paulo do Nascimento Junioru, Roseny dos Reis Rodrigues f,p, Suzana Margareth Lobol,m,v, Rogean Rodrigues Nunesc,w,x, Murillo Santucci Cesar de Assunçãof,∗

Consenso Brasileiro sobre terapia hemodinâmica perioperatória guiada por objetivos em pacientes submetidos a cirurgias não cardíacas: estratégia de gerenciamento de fluidos – produzido pela Sociedade de Anestesiologia do Estado de São Paulo (SAESP)

Enis Donizetti Silva , Albert Carl Perrino, Alexandre Teruya, Bobbie Jean Sweitzer, Chiara Scaglioni Tessmer Gatto , Claudia Marquez Simões , Ederlon Alves Carvalho Rezende , Filomena Regina Barbosa Gomes Galas , Francisco Ricardo Lobo , João Manoel da Silva Junior , Leandro Ultino Taniguchi, Luciano Cesar Pontes de Azevedo , Ludhmila Abrahão Hajjar , Luiz Antônio Mondadori, Marcelo Gama de Abreu , Marcelo Vaz Perez , Regina El Dib, Paulo do Nascimento Junior, Roseny dos Reis Rodrigues , Suzana Margareth Lobo , Rogean Rodrigues Nunes c,w,x e Murillo Santucci Cesar de Assunção f,∗

Disfunção do trato gastrointestinal prolongada em pacientes admitidos na terapia intensiva.

OBJECTIVE: We aimed to investigate the prevalence and independent predictors of prolonged gastrointestinal dysfunction in critically ill patients admitted to the intensive care unit. METHODS: Retrospective and observational cohort study performed in a mixed 24 beds intensive care unit in a tertiary center. Patients admitted in the intensive care unit between August 2003 and January 2004, who had a length of stay in the intensive care unit greater than 4 days were enrolled. Gastrointestinal function was evaluated daily according to a classification that considered physical examination (bowel sounds or distension) and the nutritional support progress. RESULTS: Were included 128 patients. The mean age was 56 ± 19 years, 63.3% were male and 77.3% were surgical patients. Prolonged gastrointestinal dysfunction occurred in 35% of patients, with prevalence 3.3 times higher in surgical patients (27%) than in medical patients (8%). Endoscopies were performed in 38 patients (29.7%), and in three quarters of them erosive lesions and or bleeding were observed. Gastrointestinal dysfunction was more frequent in patients presenting moderate or severe edema (51%) than in patients without edema (22.5%) (p<0.05). In the logistic regression analysis, a serum lactate level higher than 5.2 mEq/L (RR 6.69 95%CI 15-38.7, P = 0.034) and the presence of a low oxygenation index (RR 12.4 95%CI 2.18-70.8, p = 0.005) were predictive of gastrointestinal dysfunction. CONCLUSION: Prolonged gastrointestinal dysfunction was highly prevalent in this heterogeneous population of critically ill patients. Admission high serum lactate levels and a low oxygenation index were predictive of prolonged gastrointestinal dysfunction.

Early Optimization of Oxygen Delivery in High-risk Surgical Patients

Total tissue perfusion relies on adequate arterial oxygen saturation, cardiac output, and hemoglobin concentration, and global perfusion is usually assessed by calculation of the oxygen delivery index (DO2I) [1]. More than 20 years ago Shoemaker et al. reported that perioperative alterations in DO2 were closely correlated to the development of multiple organ failure (MOF) and death [2]. Since then goal-directed therapy, defined as the use of the cardiac output or a surrogate to guide intravenous fluid and inotropic therapy, has been used in an attempt to improve outcome in surgical patients [1].