Tulio Frederico Tonietto

Impacto de um protocolo de desmame de ventilação mecânica na taxa de falha de extubação em pacientes de difícil desmame

OBJECTIVE: To determine whether the predictive accuracy of clinical judgment alone can be improved by supplementing it with an objective weaning protocol as a decision support tool. METHODS: This was a multicenter prospective cohort study carried out at three medical/surgical ICUs. The study involved all consecutive difficult-to-wean ICU patients (failure in the first spontaneous breathing trial [SBT]), on mechanical ventilation (MV) for more than 48 h, admitted between January of 2002 and December of 2005. The patients in the protocol group (PG) were extubated after a T-piece weaning trial and were compared with patients who were otherwise extubated (non-protocol group, NPG). The primary outcome measure was reintubation within 48 h after extubation. RESULTS: We included 731 patients-533 (72.9%) and 198 (27.1%) in the PG and NPG, respectively. The overall reintubation rate was 17.9%. The extubation success rates in the PG and NPG were 86.7% and 69.6%, respectively (p < 0.001). There were no significant differences between the groups in terms of age, gender, severity score, or pre-inclusion time on MV. However, COPD was more common in the NPG than in the PG (44.4% vs. 17.6%; p < 0.001), whereas sepsis and being a post-operative patient were more common in the PG (23.8% vs. 11.6% and 42.4% vs. 26.4%, respectively; p < 0.001 for both). The time on MV after the failure in the first SBT was higher in the PG than in the NPG (9 ± 5 days vs. 7 ± 2 days; p < 0.001). CONCLUSIONS: In this sample of difficult-to-wean patients, the use of a weaning protocol improved the decision-making process, decreasing the possibility of extubation failure.

Effectiveness and Safety of an Extended ICU Visitation Model for Delirium Prevention: A Before and After Study.

Objectives: To evaluate the effect of an extended visitation model compared with a restricted visitation model on the occurrence of delirium among ICU patients. Design: Prospective single-center before and after study. Setting: Thirty-one–bed medical-surgical ICU. Patients: All patients greater than or equal to 18 years old with expected length of stay greater than or equal to 24 hours consecutively admitted to the ICU from May 2015 to November 2015. Interventions: Change of visitation policy from a restricted visitation model (4.5 hr/d) to an extended visitation model (12 hr/d). Measurements and Main Results: Two hundred eighty-six patients were enrolled (141 restricted visitation model, 145 extended visitation model). The primary outcome was the cumulative incidence of delirium, assessed bid using the confusion assessment method for the ICU. Predefined secondary outcomes included duration of delirium/coma; any ICU-acquired infection; ICU-acquired bloodstream infection, pneumonia, and urinary tract infection; all-cause ICU mortality; and length of ICU stay. The median duration of visits increased from 133 minutes (interquartile range, 97.7–162.0) in restricted visitation model to 245 minutes (interquartile range, 175.0–272.0) in extended visitation model (p < 0.001). Fourteen patients (9.6%) developed delirium in extended visitation model compared with 29 (20.5%) in restricted visitation model (adjusted relative risk, 0.50; 95% CI, 0.26–0.95). In comparison with restricted visitation model patients, extended visitation model patients had shorter length of delirium/coma (1.5 d [interquartile range, 1.0–3.0] vs 3.0 d [interquartile range, 2.5–5.0]; p = 0.03) and ICU stay (3.0 d [interquartile range, 2.0–4.0] vs 4.0 d [interquartile range, 2.0–6.0]; p = 0.04). The rate of ICU-acquired infections and all-cause ICU mortality did not differ significantly between the two study groups. Conclusions: In this medical-surgical ICU, an extended visitation model was associated with reduced occurrence of delirium and shorter length of delirium/coma and ICU stay.

Influence of FIO2 on PaCO2 during noninvasive ventilation in patients with COPD.

BACKGROUND: The administration of a high FIO2 to COPD patients breathing spontaneously may result in hypercapnia, due to reversal of preexisting regional hypoxic pulmonary vasoconstriction, resulting in a greater dead space. Arterial blood gas trends have not been reported in these patients. In a 31-bed medical ICU in a teaching hospital we prospectively investigated the response of 17 CO2-retaining COPD patients, after acute respiratory crisis stabilization with noninvasive ventilation, to an FIO2 of 1.0 for 40 min, after having been noninvasively ventilated with an FIO2 of ≤ 0.50 for 40 min. RESULTS: The mean ± SD baseline findings were: PaO2 101.4 ± 21.7 mm Hg, PaCO2 52.6 ± 10.4 mm Hg, breathing frequency 17.8 ± 3.7 breaths/min, tidal volume 601 ± 8 mL, and Glasgow coma score of 14.8 ± 0.3. PaO2 significantly increased (P < .001) when FIO2 was increased to 1.0, but there was no significant change in PaCO2, breathing frequency, tidal volume, or Glasgow coma score. CONCLUSIONS: During noninvasive ventilation with an FIO2 sufficient to maintain a normal PaO2, a further increase in FIO2 did not increase PaCO2 in our CO2-retaining COPD patients.

Mortality of Adult Critically Ill Subjects With Cancer

BACKGROUND: Cancer patients may require intensive care support for postoperative care, complications associated with underlying malignancy, or toxicities related to cancer therapy. The higher mortality rates found in this population than in the population of ICU patients without cancer may be attributable to confounding due to a higher prevalence of multiple organic dysfunctions at ICU admission in patients with malignancy; however, data regarding this hypothesis are scarce. Accordingly, we performed the present study to compare the crude and propensity score-matched mortality rates between adult subjects with and without cancer admitted to a mixed medical-surgical ICU. METHODS: We conducted a retrospective analysis of a comprehensive longitudinal ICU database in a tertiary referral hospital in Southern Brazil. All adult subjects who were admitted to the ICU from January 2008 to December 2014 were evaluated. Crude and propensity score-matched all-cause 30-d mortality rates of critically ill subjects with cancer were compared with those of critically ill subjects without cancer. RESULTS: A total of 4,221 subjects were evaluated. The survival analysis revealed that the crude mortality rate was higher among subjects with cancer than among subjects without cancer (18.7% vs 10.2%, P < .001). However, after matching by propensity score, the 30-d mortality rates of subjects with and without cancer were similar (18.5% vs 15.2%, P = .17). CONCLUSIONS: The present study failed to show an association between malignancy and all-cause 30-d mortality rate in adult subjects admitted to a mixed medical-surgical ICU. The propensity score-matched analysis showed no evidence of excessive mortality due to cancer diagnosis.

Mechanical ventilation weaning protocol improves medical adherence and results

Introduction: Implementation of a weaning protocol is related to better patient prognosis. However, new approaches may take several years to become the standard of care in daily practice. We conducted a prospective cohort study to investigate the effectiveness of a multifaceted strategy to implement a protocol to wean patients from mechanical ventilation (MV) and to evaluate the weaning success rate as well as practitioner adherence to the protocol. Methods: We investigated all consecutive MV‐dependent subjects admitted to a medical‐surgical intensive care unit (ICU) for > 24 h over 7 years. The multifaceted strategy consisted of continuing education of attending physicians and ICU staff and regular feedback regarding patient outcomes. The study was conducted in three phases: protocol development, protocol and multifaceted strategy implementation, and protocol monitoring. Data regarding weaning outcomes and physician adherence to the weaning protocol were collected during all phases. Results: We enrolled 2469 subjects over 7 years, with 1,943 subjects (78.7%) experiencing weaning success. Physician adherence to the protocol increased during the years of protocol and multifaceted strategy implementation (from 38% to 86%, p < 0.01) and decreased in the protocol monitoring phase (from 73.9% to 50.0%, p < 0.01). However, during the study years, the weaning success of all subjects increased (from 73.1% to 85.4%, p < 0.001). When the weaning protocol was evaluated step‐by‐step, we found high adherence for noninvasive ventilation use (95%) and weaning predictor measurement (91%) and lower adherence for control of fluid balance (57%) and daily interruption of sedation (24%). Weaning success was higher in patients who had undergone the weaning protocol compared to those who had undergone weaning based in clinical practice (85.6% vs. 67.7%, p < 0.001). Conclusions: A multifaceted strategy consisting of continuing education and regular feedback can increase physician adherence to a weaning protocol for mechanical ventilation. HIGHLIGHTSA multifaceted strategy consisting of continuing education and regular feedback can increase physician adherence to a weaning protocol for mechanical ventilation.There was good medical acceptance of the implementation of the protocol for some factors, including multidisciplinary guidance and education of the ICU staff; additionally, a weaning program was developed that included leadership, education, and supervision.

Colite por Clostridium difficile e Citomegalovirus após cirurgia báriatrica: relato de caso

Although controversial, chronic critical illness may be best defined as prolonged dependence of intensive care unit and/ or mechanical ventilation, carrying on not wellunderstood physiopathological processes that affect individual consciousness, respiration, nutrition, neuromuscular and hormonal function. It is becoming a large and growing issue in worldwide health systems, counting for excessive costs and caregivers burden15. Clostridium difficile associated to diarrhea has become one of the most common healthcare infections4. Cytomegalovirus infection is an important cause of morbidity and mortality among immunosuppressed patients in contexts such as organ transplantation, malignant hematologic disease, Aids and complicated inflammatory bowel disease21. Colitis co-infection by Clostridium difficile and Cytomegalovirus has been reported especially in those scenarios as well. Here is described a unique case of concomitant infection in a chronic critically ill patient with no other previous immunosuppressive condition.

More than the tip of the iceberg: association between disabilities and inability to attend a clinic-based post-ICU follow-up and how it may impact on health inequalities

Regis Goulart Rosa, Renata Kochhann, Paula Berto, Livia Biason, Juçara Gasparetto Maccari, Patrícia De Leon, Francine Dutra, Sâmia Faria da Silva, Daniel Sganzerla, Daniel Schneider, Paulo Ricardo Cardoso, Frederico Klein Gomes, Vitória Homem Machado, Gregory Medeiros, Tulio Frederico Tonietto, Luciana Tagliari, Mariana Mattioni, Luisa Anzolin, Maicon Oliveira, Juliana Mara Stormovski de Andrade, Maicon Falavigna, Caroline Cabral Robinson and Cassiano Teixeira

The impact of critical care transition programs on outcomes after intensive care unit (ICU) discharge: can we get there from here?

Although sometimes underestimated, the transition of care from the intensive care unit (ICU) to a medical or surgical hospital ward is a complex process with many potential challenges. Despite recovery from critical illnesses that lead to ICU admission, patients discharged from ICU remain at risk for successive clinical worsening during the hospital stay, which may result in readmission to ICU or even death (1-3). Moreover, ICU readmission is associated with poorer outcomes, such as lower ICU and hospital survival rates, prolonged hospitalisation, higher costs related to patient care, higher degrees of disability after ICU discharge and more emotional stress to patients and their families (1,2,4-6).

Factors associated with mortality and functional status among neurocritical care adult patients: a prospective cohort study

Neurocritical care patients are at risk for the development of poor clinical outcomes during intensive care unit (ICU) stay. However, few data regarding the impact of specific factors on mortality and poor functional status in this population are available.

Comparing mortality between cancer and non-cancer critically ill patients: a propensity score matched analysis

Intensive care unit (ICU) admission may be required in cancer patients for management of acute illnessess associated with underlying malignancy or complications of cancer therapy. The higher mortality rates found in this population, in comparison to non-cancer critically ill patients, may be attributable to confounding bias due to a higher incidence of multiple organic dysfunction in those patiens with malignant neoplasms; however data regarding this hypothesis are scarce.