Duration of hemodynamic effects of crystalloids in patients with circulatory shock after initial resuscitation

Background: in the later stages of circulatory shock, monitoring should help to avoid fluid overload. in this setting, volume expansion is ideally indicated only for patients in whom the cardiac index (CI) is expected to increase. Crystalloids are usually the choice for fluid replacement. As previous studies evaluating the hemodynamic effect of crystalloids have not distinguished responders from non-responders, the present study was designed to evaluate the duration of the hemodynamic effects of crystalloids according to the fluid responsiveness status.Methods: This is a prospective observational study conducted after the initial resuscitation phase of circulatory shock (>6 h vasopressor use). Critically ill, sedated adult patients monitored with a pulmonary artery catheter who received a fluid challenge with crystalloids (500 mL infused over 30 min) were included. Hemodynamic variables were measured at baseline (T0) and at 30 min (T1), 60 min (T2), and 90 min (T3) after a fluid bolus, totaling 90 min of observation. the patients were analyzed according to their fluid responsiveness status (responders with CI increase >15% and non-responders <= 15% at T1). the data were analyzed by repeated measures of analysis of variance.Results: Twenty patients were included, 14 of whom had septic shock. Overall, volume expansion significantly increased the CI: 3.03 +/- 0.64 L/min/m(2) to 3.58 +/- 0.66 L/min/m(2) (p < 0.05). From this period, there was a progressive decrease: 3.23 +/- 0.65 L/min/m(2) (p < 0.05, T2 versus T1) and 3.12 +/- 0.64 L/min/m(2) (p < 0.05, period T3 versus T1). Similar behavior was observed in responders (13 patients), 2.84 +/- 0.61 L/min/m(2) to 3.57 +/- 0.65 L/min/m(2) (p < 0.05) with volume expansion, followed by a decrease, 3.19 +/- 0.69 L/min/m(2) (p < 0.05, T2 versus T1) and 3.06 +/- 0.70 L/min/m(2) (p < 0.05, T3 versus T1). Blood pressure and cardiac filling pressures also decreased significantly after T1 with similar findings in both responders and non-responders.Conclusions: the results suggest that volume expansion with crystalloids in patients with circulatory shock after the initial resuscitation has limited success, even in responders.Universidade Federal de São Paulo, Disciplina Anestesiol Dor & Terapia Intens, BR-04024900 São Paulo, BrazilUniversidade Federal de São Paulo, Disciplina Anestesiol Dor & Terapia Intens, BR-04024900 São Paulo, BrazilWeb of Scienc

Mortality Predictors in Renal Transplant Recipients with Severe Sepsis and Septic Shock

Introduction: the growing number of renal transplant recipients in a sustained immunosuppressive state is a factor that can contribute to increased incidence of sepsis. However, relatively little is known about sepsis in this population. the aim of this single-center study was to evaluate the factors associated with hospital mortality in renal transplant patients admitted to the intensive care unit (ICU) with severe sepsis and septic shock.Methods: Patient demographics and transplant-related and ICU stay data were retrospectively collected. Multiple logistic regression was conducted to identify the independent risk factors associated with hospital mortality.Results: A total of 190 patients were enrolled, 64.2% of whom received kidneys from deceased donors. the mean patient age was 51 +/- 13 years (males, 115 [60.5%]), and the median APACHE II was 20 (16-23). the majority of patients developed sepsis late after the renal transplantation (2.1 [0.6-2.3] years). the lung was the most common infection site (59.5%). Upon ICU admission, 16.4% of the patients had = 2 organ failures at admission, and 27.9% experienced septic shock within the first 24 hours of ICU admission. the overall hospital mortality rate was 38.4%. in the multivariate analysis, the independent determinants of hospital mortality were male gender (OR = 5.9; 95% CI, 1.7-19.6; p = 0.004), delta SOFA 24 h (OR = 1.7; 95% CI, 1.2-2.3; p = 0.001), mechanical ventilation (OR = 30; 95% CI, 8.8-102.2; p<0.0001), hematologic dysfunction (OR = 6.8; 95% CI, 2.0-22.6; p = 0.002), admission from the ward (OR = 3.4; 95% CI, 1.2-9.7; p = 0.02) and acute kidney injury stage 3 (OR = 5.7; 95% CI, 1.9-16.6; p = 0.002).Conclusions: Hospital mortality in renal transplant patients with severe sepsis and septic shock was associated with male gender, admission from the wards, worse SOFA scores on the first day and the presence of hematologic dysfunction, mechanical ventilation or advanced graft dysfunction.Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Hospital do RimUniversidade Federal de São Paulo, Unidade Transplante, Disciplina Nefrol, São Paulo, BrazilUniversidade Federal de São Paulo, Disciplina Anestesiol Dor & Terapia Intens, São Paulo, BrazilUniversidade Federal de São Paulo, Unidade Transplante, Disciplina Nefrol, São Paulo, BrazilUniversidade Federal de São Paulo, Disciplina Anestesiol Dor & Terapia Intens, São Paulo, BrazilWeb of Scienc

Short-term effects of passive mobilization on the sublingual microcirculation and on the systemic circulation in patients with septic shock

Background: Active mobilization is not possible in patients under deep sedation and unable to follow commands. In this scenario, passive therapy is an interesting alternative. However, in patients with septic shock, passive mobilization may have risks related to increased oxygen consumption. Our objective was to evaluate the impact of passive mobilization on sublingual microcirculation and systemic hemodynamics in patients with septic shock. Methods: We included patients who were older than 18 years, who presented with septic shock, and who were under sedation and mechanical ventilation. Passive exercise was applied for 20 min with 30 repetitions per minute. Systemic hemodynamic and microcirculatory variables were compared before (T0) and up to 10 min after (T1) passive exercise. p values <0.05 were considered significant. Results: We included 35 patients (median age [IQR 25-75%]: 68 [49.0-78.0] years mean (+/- SD) Simplified Acute Physiologic Score (SAPS) 3 score: 66.7 +/- 12.1 median [IQR 25-75%] Sequential Organ Failure Assessment (SOFA) score: 9 [7.0-12.0]). After passive mobilization, there was a slight but significant increase in proportion of perfused vessels (PPV) (T0 [IQR 25-75%]: 78.2 [70.9-81.9%] T1 [IQR 25-75%]: 80.0 [75.2-85.1] % p = 0.029), without any change in other microcirculatory variables. There was a reduction in heart rate (HR) (T0 (mean +/- SD): 95.6 +/- 22.0 bpm T1 (mean +/- SD): 93.8 +/- 22.0 bpm p < 0.040) and body temperature (T0 (mean +/- SD): 36.9 +/- 1.1 degrees C T1 (mean +/- SD): 36.7 +/- 1.2 degrees C p < 0.002) with no change in other systemic hemodynamic variables. There was no significant correlation between PPV variation and HR (r = -0.010, p = 0.955), cardiac index (r = 0.218, p = 0.215) or mean arterial pressure (r = 0.276, p = 0.109) variation. Conclusions: In patients with septic shock after the initial phase of hemodynamic resuscitation, passive exercise is not associated with relevant changes in sublingual microcirculation or systemic hemodynamics.Fundacao de Apoio a Pesquisa do Estado de Sao Paulo FAPESPUniv Fed Sao Paulo, Anesthesiol Pain & Intens Care Dept, Napoleao Barros 737, BR-04024002 Sao Paulo, SP, BrazilUniv Fed Sao Paulo, Anesthesiol Pain & Intens Care Dept, Napoleao Barros 737, BR-04024002 Sao Paulo, SP, BrazilFAPESP: 2012 19 051-1Web of Scienc

Association between perfusion and microcirculation variables and outcomes in patients admitted to intensive care units

Objetivo - Analisar se existe associação entre as variáveis microcirculatórias no momento da admissão dos pacientes na unidade de terapia intensiva (UTI) e mortalidade e gravidade da disfunção orgânica, bem como avaliar possíveis associações com variáveis da circulação sistêmica e de perfusão. Método - Tratou-se de estudo clínico unicêntrico, prospectivo e observacional. Os pacientes admitidos na UTI entre 2ª e 6ª feira das 7 às 19 horas foram consecutivamente incluídos em até 3 horas da admissão, com avaliação de imagens da microcirculação sublingual por videomicroscopia com o CytoCam®, e coleta de parâmetros de circulação sistêmica e de perfusão. Foram excluídos pacientes com impossibilidade técnica para a microscopia sublingual e sob cuidados paliativos exclusivos. Regressão logística foi utilizada para avaliar fatores associados a mortalidade e a disfunção orgânica. Correlações entre variáveis contínuas foram testadas utilizando-se o teste de Spearman. Resultados - Entre julho e dezembro de 2015 foram incluídos 140 pacientes. A média do Escore Fisiológico Agudo Simplificado 3 (SAPS 3) foi de 42,4 ± 14,6, a mediana do escore de Avaliação Sequencial de Falência de Órgãos (SOFA) na admissão de 2,0 [1,0; 3,2] e a mortalidade na UTI foi de 7,1%. A frequência cardíaca (sobreviventes: [80,1 ± 18,2] bpm vs. não sobreviventes: [99,3 ± 21,6] bpm; p = 0,02) e o tempo de enchimento capilar (sobreviventes: 2,0 [2,0; 3,0] segundos vs. não sobreviventes: 3,0 [3,0; 4,0] segundos; p = 0,04) foram significativamente maiores em não sobreviventes quando comparados a sobreviventes. Quanto às variáveis de microcirculação, a mediana do índice de fluxo microcirculatório (MFI) foi de 2,8 [2,7;2,8], a densidade vascular total (TVD) de 20,0 ± 3,0 mm/mm2; a densidade vascular perfundida (PVD) de 14,6 ± 2,7 mm/mm2 e a proporção de vasos perfundidos (PPV) de 73,1 ± 9,9%. Não encontramos diferenças estatisticamente significativas nas variáveis de microcirculação entre sobreviventes e não sobreviventes ou associação com o escore SOFA de admissão. No modelo logístico, somente o SOFA na admissão e os níveis de lactato tiveram associação independente com maior mortalidade na UTI. Conclusão - Não observamos associação entre as variáveis microcirculatórias obtidas na admissão e mortalidade, intensidade da disfunção orgânica ou correlação relevante com as variáveis de circulação sistêmica. Somente a intensidade da disfunção orgânica na admissão e os níveis de lactato tiveram associação independente com maior mortalidade na UTI.Objective - To analyze the association between the microcirculatory variables at intensive care unit (ICU) admission and mortality and severity of organ dysfunction, as well as to evaluate the possible association with systemic circulatory variables and perfusion in critically ill patients. Methods - This was a single center, prospective and observational clinical study. Patients admitted to the ICU from Monday to Friday from 7:00 am to 7:00 pm were consecutively included within 3 hours of admission, with evaluation of the sublingual microcirculation by videomicroscopy with CytoCam® and of the systemic circulation and perfusion. Patients with technical impossibility for sublingual microscopy and under exclusive palliative care were excluded. Logistic regression was used to assess factors associated with mortality and organ dysfunction. Correlations between continuous variables were tested using the Spearman test. Results - From July to December 2015, 140 patients were included. The mean Simplified Acute Physiology Score 3 (SAPS 3) was 42.4 ± 14.6, the median Sequential Organ Failure Assessment (SOFA) score on admission 2.0 [1.0; 3.2] and ICU mortality was 7.1%. The heart rate (survivors: [80.1 ± 18.2] bpm vs. non-survivors: [99.3 ± 21.6] bpm; p = 0.02), and capillary refill time (survivors: 2.0 [2.0; 3.0] seconds vs. non-survivors: 3.0 [3.0; 4.0] seconds; p = 0.04) were both significantly higher in non-survivors as compared with survivors. As for the microcirculation variables, the median microvascular flow index (MFI) was 2,8 [2,7;2,8], the total vessel density (TVD) 20,0 ± 3,0 mm/mm2; the perfused vessel density (PVD) 14,6 ± 2,7 mm/mm2 and the proportion of perfused vessels (PPV) 73,1 ± 9,9%. There were no statistically significant differences in the microcirculation variables between survivors and non-survivors or association with the SOFA at admission. In the logistic model, only SOFA at admission and lactate levels were independently associated with higher ICU mortality. Conclusion - We did not observe any association between admission microcirculatory variables and mortality, degree of organ dysfunction or relevant correlations with systemic circulation variables. Only the degree of organ dysfunction on admission and lactate levels were independent associated with higher ICU mortality.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

Serum concentrations of vitamin D and organ dysfunction in patients with severe sepsis and septic shock

RESUMO Objetivo: Avaliar as concentrações séricas e a variação de vitamina D em pacientes com sepse grave ou choque séptico e indivíduos controles na admissão e após 7 dias de internação na unidade de terapia intensiva, correlacionando-os com a gravidade da disfunção orgânica. Métodos: Estudo caso-controle, prospectivo e observacional em pacientes com mais de 18 anos com sepse grave ou choque séptico pareados com grupo controle. Foi realizada dosagem sérica de vitamina D na inclusão (D0) e no sétimo dia (D7). Definiu-se deficiência grave se vitamina D < 10ng/mL, deficiência se entre 10 e 20ng/mL, insuficiência se entre 20 e 30ng/mL e suficiência se ≥ 30ng/mL. Consideramos melhora a modificação para qualquer classificação mais elevada, associada ao incremento de 50% dos valores absolutos. Resultados: Incluímos 51 pacientes (26 sépticos e 25 controles). A prevalência de concentrações de vitamina D ≤ 30ng/mL foi de 98%. Não houve correlação entre a concentração sérica de vitamina D no D0 e o escore SOFA no D0 ou com sua variação após 7 dias, tanto na população geral quanto nos sépticos. Pacientes com melhora da deficiência tiveram melhora no escore SOFA no D7 (p = 0,013). Conclusão: Na população estudada, os pacientes sépticos apresentaram melhora das concentrações séricas de vitamina D no sétimo dia em comparação com controles. Encontramos associação entre a melhora das concentrações de vitamina D e a maior redução da intensidade de disfunção orgânica

Diabetes mellitus e intolerância à glicose são subdiagnosticados nas unidades de terapia intensiva

OBJETIVO: Avaliar a presença de diabetes mellitus e a intolerância à glicose em pacientes internados em unidades de terapia intensiva. MÉTODOS: Foram incluídos pacientes clínicos, em pós-operatório de cirurgias eletivas e de urgência, e excluídos aqueles com história de diabetes mellitus. Para o diagnóstico de alterações prévias da glicemia, utilizou-se a dosagem da hemoglobina glicada (HbA1c) na admissão do paciente, sendo classificado em normal (<5,7%), intolerante à glicose (5,7-6,4%) ou diabético (&gt;6,4%). Durante os 3 primeiros dias da internação, foram avaliados o controle glicêmico e as complicações clínicas. A evolução para óbito foi acompanhada por 28 dias. Para as análises estatísticas, utilizaram-se testes do qui-quadrado, ANOVA, teste t de Student, Kruskall-Wallis ou Mann Whitney. RESULTADOS: Foram incluídos 30 pacientes, 53% do gênero feminino, idade de 53,4±19,7 anos e APACHE II de 13,6±6,6. A maioria dos pacientes foi admitida por sepse grave ou choque séptico, seguido por pós-operatório de cirurgias eletivas, oncológicas, politraumatismo e cirurgia de urgência. Ao classificar esses pacientes segundo a HbA1c, apesar da ausência prévia de história de diabetes mellitus, apenas 13,3% tinham HbA1c normal, 23,3% tinham níveis compatíveis com o diagnóstico de diabetes mellitus e 63,3% eram compatíveis com intolerância à glicose. Houve associação significativa entre o diagnóstico de diabetes mellitus ou intolerância a glicose e o uso de droga vasoativa (p=0,04). CONCLUSÃO: Foi encontrada alta prevalência de diabetes mellitus e intolerância à glicose, sem diagnóstico prévio, em pacientes internados em uma unidade de terapia intensiva geral

Factors associated with hospital mortality in renal transplant patients admitted to the intensive care unit with acute respiratory failure

Abstract Introduction: The lungs are often involved in a variety of complications after kidney transplantation. Acute respiratory failure (ARF) is one of the most serious manifestations of pulmonary involvement. Objective: To describe the main causes of ARF in kidney transplant patients who require intensive care and identify the factors associated with mortality. Methods: This retrospective study evaluated adult patients with ARF admitted to the intensive care unit of a center with high volume of transplants from August 2013 to August 2015. Demographic, clinical, and transplant characteristics were analyzed. Multivariate logistic regression analysis was performed to identify factors associated with hospital mortality. Results: 183 patients were included with age of 55.32 ± 13.56 years. 126 (68.8%) were deceased-donor transplant, and 37 (20.2%) patients had previous history of rejection. The ICU admission SAPS3 and SOFA score were 54.39 ± 10.32 and 4.81 ± 2.32, respectively. The main cause of hospitalization was community-acquired pneumonia (18.6%), followed by acute pulmonary edema (15.3%). Opportunistic infections were common: PCP (9.3%), tuberculosis (2.7%), and cytomegalovirus (2.2%). Factors associated with mortality were requirement for vasopressor (OD 8.13, CI 2.83 to 23.35, p < 0.001), invasive mechanical ventilation (OD 3.87, CI: 1.29 to 11.66, p = 0.016), and SAPS3 (OD 1.04, CI 1.0 to 1.08, p = 0.045). Conclusion: Bacterial pneumonia is the leading cause of ARF requiring intensive care, followed by acute pulmonary edema. Requirement for vasopressor, invasive mechanical ventilation and SAP3 were associated with hospital mortality