ASSESSMENT OF CHLORIDE LEVELS ON RENAL FUNCTION AFTER CARDIAC ARREST

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Mixed methods study protocol for combining stakeholder-led rapid evaluation with near real-time continuous registry data to facilitate evaluations of quality of care in intensive care units [version 1; peer review: awaiting peer review]

BACKGROUND: Improved access to healthcare in low- and middle-income countries (LMICs) has not equated to improved health outcomes. Absence or unsustained quality of care is partly to blame. Improving outcomes in intensive care units (ICUs) requires delivery of complex interventions by multiple specialties working in concert, and the simultaneous prevention of avoidable harms associated with the illness and the treatment interventions. Therefore, successful design and implementation of improvement interventions requires understanding of the behavioural, organisational, and external factors that determine care delivery and the likelihood of achieving sustained improvement. We aim to identify care processes that contribute to suboptimal clinical outcomes in ICUs located in LMICs and to establish barriers and enablers for improving the care processes. METHODS: Using rapid evaluation methods, we will use four data collection methods: 1) registry embedded indicators to assess quality of care processes and their associated outcomes; 2) process mapping to provide a preliminary framework to understand gaps between current and desired care practices; 3) structured observations of processes of interest identified from the process mapping and; 4) focus group discussions with stakeholders to identify barriers and enablers influencing the gap between current and desired care practices. We will also collect self-assessments of readiness for quality improvement. Data collection and analysis will be performed in parallel and through an iterative process across eight countries: Kenya, India, Malaysia, Nepal, Pakistan, South Africa, Uganda and Vietnam. CONCLUSIONS: The results of our study will provide essential information on where and how care processes can be improved to facilitate better quality of care to critically ill patients in LMICs; thus, reduce preventable mortality and morbidity in ICUs. Furthermore, understanding the rapid evaluation methods that will be used for this study will allow other researchers and healthcare professionals to carry out similar research in ICUs and other health services

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42\ub74% vs 44\ub72%; absolute difference \u20131\ub769 [\u20139\ub758 to 6\ub711] p=0\ub767; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5\u20138] vs 6 [5\u20138] cm H2O; p=0\ub70011). ICU mortality was higher in MICs than in HICs (30\ub75% vs 19\ub79%; p=0\ub70004; adjusted effect 16\ub741% [95% CI 9\ub752\u201323\ub752]; p<0\ub70001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0\ub780 [95% CI 0\ub775\u20130\ub786]; p<0\ub70001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding: No funding

A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

Meeting abstrac

Red cells distribution width after cardiac arrest

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Assessment of early lymphopenia after cardiac arrest

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Can red blood cell distribution width predict outcome after cardiac arrest?

BACKGROUND: In critically ill patients, high red blood cell distribution width (RDW) values have been associated with increased hospital mortality, but there are no data on the impact of RDW on outcomes of patients resuscitated from cardiac arrest (CA). The aim of this study was to investigate the relationship between RDW and long-term neurologic outcome in CA survivors. METHODS: We performed a retrospective analysis of an institutional database including all unconscious adult patients admitted to the intensive care unit (ICU) after non-traumatic CA between January 2007 and January 2015. Patients who survived <24 hours were excluded. The RDW (normal values 10.9-13.4%) was obtained daily from the day of admission to day 3. Patients with a cerebral performance category (CPC) score of 3-5 at 3 months were considered to have an unfavorable neurological outcome. RESULTS: Three hundred and ninety patients were included. The ICU mortality rate was 56% (n=220) and 64% of patients (n=251) had an unfavourable 3-month neurological outcome. The median RDW on the day of admission was 14 [13.0-15.2]% and remained stable over the observation period. Two hundred and forty-five patients (63%) had a high RDW (>13.4%) on admission. In multivariable logistic regression analysis, older age, absence of bystander cardiopulmonary resuscitation (CPR), a non-cardiac aetiology of the arrest, a non-shockable initial rhythm, high adrenaline dose during CPR and high admission RDW levels were independently associated with an unfavourable outcome at 3 months. CONCLUSIONS: High RDW values are associated with poor neurological outcome among CA survivors

Subprodutos do metabolismo da hemoglobina se associam com resposta inflamatória em pacientes com acidente vascular cerebral hemorrágico

Submitted by Sandra Infurna ([email protected]) on 2019-01-30T11:32:43Z No. of bitstreams: 1 hugocairec_Neto_etal_IOC_2018.pdf: 135869 bytes, checksum: d4dede578cd6cc8caf028aa89f8ce25f (MD5)Approved for entry into archive by Sandra Infurna ([email protected]) on 2019-01-31T15:13:19Z (GMT) No. of bitstreams: 1 hugocairec_Neto_etal_IOC_2018.pdf: 135869 bytes, checksum: d4dede578cd6cc8caf028aa89f8ce25f (MD5)Made available in DSpace on 2019-01-31T15:13:19Z (GMT). No. of bitstreams: 1 hugocairec_Neto_etal_IOC_2018.pdf: 135869 bytes, checksum: d4dede578cd6cc8caf028aa89f8ce25f (MD5) Previous issue date: 2018Fundação Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Laboratório de Pesquisa Clínica em Medicina Intensiva. Rio de Janeiro, RJ. Brasil / Instituto Estadual do Cérebro Paulo Niemeyer. Rio de Janeiro, RJ, Brasil.Instituto Estadual do Cérebro Paulo Niemeyer. Rio de Janeiro, RJ, Brasil / Complexo Hospitalar de Niterói. Niterói, RJ, Brasil.Universidade Federal Fluminense. Hospital Universitário Antônio Pedro. Niterói, RJ, Brasil / Hospital Quinta D`Or. Rio de Janeiro, TJ, Brasil.Fundação Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Laboratório de Pesquisa Clínica em Medicina Intensiva. Rio de Janeiro, RJ. Brasil.Fundação Oswaldo Cruz. Instituto Oswaldo Cruz. Laboratório de Imunofarmacologia. Rio de Janeiro, RJ. Brasil.Universidade Federal do Rio de Janeiro. Instituto de Microbiologia Paulo de Góes. Departamento de Imunologia. Rio de Janeiro, RJ, Brasil.Universidade Federal do Rio de Janeiro. Instituto de Bioquímica Médica. Laboratório de Bioquímica de Resposta ao Estresse. Rio de Janeiro, RJ, Brasil.Fundação Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Laboratório de Pesquisa Clínica em Medicina Intensiva. Rio de Janeiro, RJ. Brasil / Instituto D’Or de Pesquisa e Ensino. Rio de Janeiro, RJ, Brasil.Objective: To evaluate the relationships of brain iron and heme with the inflammatory response of the systemic and central nervous systems and to investigate the role of defensive systems against the toxicity of iron and heme in the central nervous system. Methods: We assessed a prospective cohort of patients presenting with intracerebral and subarachnoid hemorrhage. We assayed plasma and cerebrospinal fluid samples for the presence of iron, heme, hemopexin, haptoglobin, enolase, S100-β and cytokines for the first three days following hemorrhagic stroke. We also analyzed the dynamic changes in these components within both fluids and their relationship with early mortality rates. Results: Hemopexin and haptoglobin concentrations were nearly negligible in the brain after intracerebral and subarachnoid hemorrhage. Cerebrospinal fluid iron and heme concentrations correlated with a proinflammatory response in the central nervous system, and plasmatic and cerebrospinal fluid inflammatory profiles on the third day after hemorrhagic stroke were related to early mortality rates. Interleukin 4 levels within the cerebrospinal fluid during the first 24 hours after hemorrhagic stroke were found to be higher in survivors than in non-survivors. Conclusion: Iron and heme are associated with a pro-inflammatory response in the central nervous system following hemorrhagic stroke, and protections against hemoglobin and heme are lacking within the human brain. Patient inflammatory profiles were associated with a poorer prognosis, and local anti-inflammatory responses appeared to have a protective role

The impact of acute brain dysfunction in the outcomes of mechanically ventilated cancer patients

Submitted by Rodrigo Senorans ([email protected]) on 2015-05-20T16:47:26Z No. of bitstreams: 1 The impact of acute brain dysfunction in the outcomes of mechanically ventilated cancer patients.pdf: 574933 bytes, checksum: 0974e11c5c5484e077d196ae7693ba88 (MD5)Approved for entry into archive by Anderson Silva ([email protected]) on 2015-05-20T17:49:03Z (GMT) No. of bitstreams: 1 The impact of acute brain dysfunction in the outcomes of mechanically ventilated cancer patients.pdf: 574933 bytes, checksum: 0974e11c5c5484e077d196ae7693ba88 (MD5)Approved for entry into archive by Anderson Silva ([email protected]) on 2015-05-21T13:00:38Z (GMT) No. of bitstreams: 1 The impact of acute brain dysfunction in the outcomes of mechanically ventilated cancer patients.pdf: 574933 bytes, checksum: 0974e11c5c5484e077d196ae7693ba88 (MD5)Made available in DSpace on 2015-05-21T16:36:41Z (GMT). No. of bitstreams: 1 The impact of acute brain dysfunction in the outcomes of mechanically ventilated cancer patients.pdf: 574933 bytes, checksum: 0974e11c5c5484e077d196ae7693ba88 (MD5) Previous issue date: 2014CNPq, FAPERJInstituto Nacional de Câncer. Unidade de Cuidados Intensivos e do Programa de Pós-Graduação. Rio de Janeiro, RJ, BrasilInstituto Nacional de Câncer. Unidade de Cuidados Intensivos e do Programa de Pós-Graduação. Rio de Janeiro, RJ, Brasil / D'Or Instituto de Ensino e Pesquisa. Rio de Janeiro, RJ, BrasilFundação Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Laboratório de Pesquisa Clínica em Medicina Intensiva. Rio de Janeiro, RJ, Brasil / D'Or Instituto de Ensino e Pesquisa. Rio de Janeiro, RJ, BrasilInstituto Nacional de Câncer. Unidade de Cuidados Intensivos e do Programa de Pós-Graduação. Rio de Janeiro, RJ, Brasil / D'Or Instituto de Ensino e Pesquisa. Rio de Janeiro, RJ, BrasilInstituto Nacional de Câncer. Unidade de Cuidados Intensivos e do Programa de Pós-Graduação. Rio de Janeiro, RJ, BrasilInstituto Nacional de Câncer. Unidade de Cuidados Intensivos e do Programa de Pós-Graduação. Rio de Janeiro, RJ, BrasilVanderbilt University School of Medicine. Nashville, TN, United States of America / Veteran’s Affairs Tennessee Valley Geriatric Research Education Clinical Center. Nashville, TN, United States of AmericaInstituto Nacional de Câncer. Unidade de Cuidados Intensivos e do Programa de Pós-Graduação. Rio de Janeiro, RJ, Brasil / D'Or Instituto de Ensino e Pesquisa. Rio de Janeiro, RJ, BrasilIntroduction: Delirium and coma are a frequent source of morbidity for ICU patients. Several factors are associated with the prognosis of mechanically ventilated (MV) cancer patients, but no studies evaluated delirium and coma (acute brain dysfunction). The present study evaluated the frequency and impact of acute brain dysfunction on mortality. Methods: The study was performed at National Cancer Institute, Rio de Janeiro, Brazil. We prospectively enrolled patients ventilated .48 h with a diagnosis of cancer. Acute brain dysfunction was assessed during the first 14 days of ICU using RASS/CAM-ICU. Patients were followed until hospital discharge. Univariate and multivariable analysis were performed to evaluate factors associated with hospital mortality. Results: 170 patients were included. 73% had solid tumors, age 65 [53–72 (median, IQR 25%–75%)] years. SAPS II score was 54[46–63] points and SOFA score was (7 [6–9]) points. Median duration of MV was 13 (6–21) days and ICU stay was 14 (7.5– 22) days. ICU mortality was 54% and hospital mortality was 66%. Acute brain dysfunction was diagnosed in 161 patients (95%). Survivors had more delirium/coma-free days [4(1,5–6) vs 1(0–2), p,0.001]. In multivariable analysis the number of days of delirium/coma-free days were associated with better outcomes as they were independent predictors of lower hospital mortality [0.771 (0.681 to 0.873), p,0.001]. Conclusions: Acute brain dysfunction in MV cancer patients is frequent and independently associated with increased hospital mortality. Future studies should investigate means of preventing or mitigating acute brain dysfunction as they may have a significant impact on clinical outcomes