Intestinal constipation in intensive care units

Constipation is a common complication identified among critically ill patients. Its incidence is highly variable due to lack of definition of such patients. Besides the already known consequences of constipation, in recent years it was observed that this complication may also be related to worse prognosis of critically ill patients. This review endeavors to describe the main available scientific evidence showing that constipation is a prognostic marker and a clinical representation of intestinal dysfunction, in addition to eventually interfering in the prognosis with treatment. Ogilvie syndrome, a major cause of morbidity and mortality in intensive care units was also reviewed. Considering the above cases it was concluded that more attention to this disorder is required in intensive care units as well as development of protocols for diagnosis and management of critically ill patients.A constipação intestinal é uma complicação comumente identificada entre pacientes graves. Sua incidência é bastante variável devido à carência de uma definição aplicável a estes pacientes. Além das consequências já conhecidas da constipação, nos últimos anos tem-se percebido que essa complicação também pode estar relacionada ao pior prognóstico de pacientes críticos. Ao longo desta revisão procurou-se descrever as principais evidências científicas disponíveis mostrando ser a constipação um marcador prognóstico e uma das representações clínicas da disfunção intestinal, além da possibilidade de interferir no prognóstico com o tratamento. Revisou-se também a síndrome de Ogilvie, importante causa de morbidade e mortalidade nas unidades de terapia intensiva. Conclui-se, por todo o exposto, ser necessária mais atenção a esse distúrbio nas unidades de terapia intensiva, com elaboração de protocolos de diagnóstico e manejo em pacientes graves.Universidade Federal de São Paulo (UNIFESP)UNIFESPSciEL

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

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

Homocysteine plasma levels as a marker of clinical severity in septic patients

OBJECTIVE: Homocysteine and sepsis are both associated with inflammation and endothelial activation. Therefore this study was aimed to evaluate if the plasma homocystein level is related with the septic patient clinical severity. METHODS: Severe sepsis or septic shock patients, with less than 48 hours from organ dysfunction start, were admitted to this prospective observational study. Homocysteine levels were determined by the time of study admission and then on the Days 3, 7 and 14. The homocysteine association with the Sequential Organ Failure Assessment (SOFA) score was evaluated using the Sperman test, and its association with mortality using the Mann-Whitney test. A p<0.05 value was considered statistically significant. RESULTS: Twenty one patients were enrolled, and 60 blood samples were collected to measure total homocysteine [median 6.92 (5.27 - 9.74 μmol/L)]. The Sperman correlation test showed no association between homocysteine and SOFA ( r=0.15 and p=0.26). Also no correlation was found for the homocysteine level by the study admission time and the difference between the Day 3 SOFA score versus by study admission (deltaSOFA) (r=0.04 and p=0.87). Homocysteine variation between the Day 3 and the study admission (deltaHmc) and SOFA score variation in the same period were not correlated (r=-0.11 and p=0.66). Homocysteine by the study admission was not correlated with death in intensive care unit rate (p= 0.46) or in-hospital death rate (p = 0.13). This was also true for deltaHmc (p=0.12 and p=0.99, respectively). CONCLUSION: Baseline homocysteine levels and its variations within the first dysfunction days were not related with septic patients' worsened organ function parameters or mortality.OBJETIVO: Homocisteína e a sepse estão ambos associados à inflamação e ativação endotelial. O objetivo desse estudo foi verificar se o nível plasmático de homocisteína está relacionado à gravidade do quadro séptico. MÉTODOS: Estudo clínico, prospectivo e observacional, incluindo pacientes com sepse grave ou choque séptico com menos de 48 horas de instalação da disfunção orgânica. Os níveis de homocisteína foram determinados no dia da inclusão no estudo e nos dias 3, 7, 14. A associação entre homocisteína com o escore Sequential Organ Failure Assessment (SOFA) foi avaliada pelo teste de Sperman e com mortalidade pelo teste de Mann-Whitney. Os resultados foram considerados significativos se p<0,05. RESULTADOS: Foram incluídos 21 pacientes e feitas 60 coletas para avaliação da homocisteina total (mediana de 6,92 (5,27 - 9,74 μmol/l). O teste de correlação Spearman não mostrou associação entre homocisteina e SOFA (r = -0,15 e p = 0,26). Também não foi encontrada correlação da medida de homocisteína na data de admissão do estudo e a diferença do SOFA obtido no 3º dia e o SOFA da admissão (deltaSOFA) (r = 0,04 e p = 0,87). A variação da homocisteína do 3º dia e a admissão no estudo (deltaHmc) e a variação do SOFA no mesmo período não estavam correlacionadas (r = -0,11 e p = 0,66). A homocisteina da admissão não se correlacionou com mortalidade na UTI (p=0,46) ou com a mortalidade hospitalar.(p=0,13). Mesmo quando foi utilizado o deltaHmc não houve correlação (p=012 e p=0,99, respectivamente). CONCLUSÃO: O nível basal de homocisteína ou sua variação nos primeiros dias da disfunção não estiveram relacionadas com a piora dos parâmetros funcionais dos sistemas orgânicos ou mortalidade nos pacientes sépticos.Universidade Federal de São Paulo (UNIFESP) Setor de Terapia Intensiva da Disciplina de Anestesiologia, Dor e Terapia IntensivaUniversidade Federal de São Paulo (UNIFESP)UNIFESP, Setor de Terapia Intensiva da Disciplina de Anestesiologia, Dor e Terapia IntensivaUNIFESPSciEL

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

Comparação de valores de lactato obtidos em diferentes sítios e sua importância clínica em pacientes com sepse grave

CONTEXT AND OBJECTIVE: The ideal site for lactate collection has not been clearly established. This study aimed to evaluate associations between lactate levels in arterial blood (Lart), peripheral venous blood (Lper) and central venous blood (Lean) in patients with severe sepsis or septic shock.DESIGN AND SETTING: Cross-sectional analytical study in an tertiary university hospital.METHOD: Samples from patients with a central venous catheter and from healthy volunteers (control group) were collected. Blood was drawn simultaneously for measurements of Lart, Lper and Lcen, and the first sample was collected less than 24 hours after the onset of organ dysfunction. The results were analyzed using Pearson correlation, Bland-Altman and McNemar tests.RESULTS: A total of 238 samples were collected from 32 patients. The correlation results were r = 0.79 (P < 0.0001) for Lart/Lper and r = 0.84 (P < 0.0001) for Lart/Lcen. Bland-Altman showed large limits of agreement: -3.2 +/- 4.9 (-12.8 to 6.4) and -0.8 +/- 5.9 (-12.5 to 10.8), for Lper and Lcen respectively. lathe control group, there was greater correlation (r = 0.9009, P = 0.0004) and agreement: -0.7 +/- 1.2 (-3.1 to 1.7). Regarding clinical intervention, there was good agreement between Lart/Lcen (96.3%; three disagreements), with worst results for Lart/Lper (87.0%) with 10 cases of disagreement (P = 0.04). In eight patients (80.0%) Lper was higher than Lart.CONCLUSION: Lcen, and not Lper, can replace Lart with good correlation and clinical agreement. Lper tends to overestimate Lart, thus leading to unnecessary therapeutic interventions.Univ Fed Sao Paulo Escola Paulista Med Unifesp EP, Intens Care Unit, Discipline Anesthesiol Pain & Intens Care, Sao Paulo, BrazilUniv Fed Sao Paulo Escola Paulista Med Unifesp EP, Intens Care Unit, Discipline Anesthesiol Pain & Intens Care, Sao Paulo, BrazilWeb of Scienc

Central and mixed venous oxygen saturation in septic shock: is there a clinically relevant difference?

INTRODUCTION: Central venous oxygen saturation (SvcO2) has been proposed as an alternative for mixed venous oxygen saturation (SvO2), with a variable level of acceptance according to available data. This study aimed to evaluate possible differences between SvO2 and SvcO2 or atrial venous saturation (SvaO2), with emphasis on the role of cardiac output and their impact on clinical management of the septic patient. METHODS: This is an observational, prospective study of patients with septic shock monitored by pulmonary artery catheter. Blood was obtained simultaneously for SvcO2, SvO2 and SvaO2 determination. Linear correlation (significant if p<0.05) and agreement analysis (Bland-Altman) were performed with samples and subgroups according to cardiac output. Moreover, agreement about clinical management based on these samples was evaluated. RESULTS: Sixty one measurements from 23 patients were obtained, median age of 65.0 (49.0-75.0) years and mean APACHE II of 27.7±6.3. Mean values of SvO2, SvcO2 and SvaO2 were 72.20±8.26%, 74.61±7.60% and 74.64±8.47%. Linear correlation test showed a weak correlation between SvO2 and SvcO2 (r=0.61, p<0.0001) and also between SvO2 and SvaO2 (r=0.70, p<0.0001). Agreements between SvcO2/SvO2 and SvaO2/SvO2 were -2.40±1.96 (-16.20 and 11.40) and -2.40±1.96 (-15.10 and 10.20), respectively, with no difference in the cardiac output subgroups. No agreement was found in clinical management for 27.8% of the cases, both for SvcO2/SvO2 and for SvaO2/SvO2. CONCLUSION: This study showed that the correlation and agreement between SvO2 and SvcO2 is weak and may lead to different clinical management.INTRODUÇÃO: A medida da saturação venosa central de oxigênio (SvcO2) tem sido proposta como alternativa a saturação venosa mista (SvO2), com grau de concordância variável nos dados atualmente disponíveis. Esse estudo objetivou avaliar as possíveis diferenças entre a SvO2 e a SvcO2 ou saturação venosa atrial de oxigênio (SvaO2), com ênfase na interferência do débito cardíaco, e o impacto delas no manejo clínico do paciente séptico. MÉTODOS: Estudo prospectivo observacional em pacientes com choque séptico monitorizados com cateter de artéria pulmonar. Foi obtido sangue simultaneamente para determinação da SvcO2, SvO2 e SvaO2. Realizado testes de correlação linear (significativos se p<0,05) e análise de concordância (Bland-Altman) entre as amostras e nos subgupos de débito cardíaco. Além disso, foi avaliada a concordância entre condutas clínicas baseadas nessas medidas. RESULTADOS: Foram obtidas 61 medidas de 23 pacientes, mediana de idade de 65,0 (49,0-75,0) anos, APACHE II médio de 27,7±6,3. Os valores médios encontrados foram 72,20±8,26%, 74,61±7,60% e 74,64±8,47% para SvO2, SvcO2 e SvaO2. O teste de correlação linear mostrou baixa correlação tanto entre a SvO2 e a SvcO2 (r=0,61, p<0,0001) quanto entre a SvO2 e a SvaO2 (r=0,70, p<0,0001). As concordâncias entre SvcO2/SvO2 e SvaO2/SvO2 foram, respectivamente, de -2,40±1,96 (-16,20 e 11,40) e -2,40±1,96 (-15,10 e 10,20), sem diferença nos subgrupos de débito cardíaco. Não houve concordância na conduta clínica em 27,8% dos casos, tanto entre SvcO2/SvO2 como de SvaO2/SvO2. CONCLUSÃO: Esse estudo mostra que a correlação e a concordância entre SvO2 e SvcO2 é baixa e pode levar a condutas clínicas diferentes.Universidade Federal de São Paulo (UNIFESP)Universidade Federal de São Paulo (UNIFESP) Setor de Terapia Intensiva da Disciplina de Anestesiologia, Dor e Terapia IntensivaUNIFESP, Setor de Terapia Intensiva da Disciplina de Anestesiologia, Dor e Terapia IntensivaSciEL

Predictive value of pulse pressure variation for fluid resposiveness in septic patients using lung-protective ventilation strategies

Objetivos. A aplicabilidade da variacao de pressao de pulso (&#916;PP) em predizer a resposta a infusao de fluidos em pacientes sob estrategia ventilatoria invasiva protetora e incerta na pratica clinica. Desenhamos esse estudo para avaliar a acuracia deste parametro em pacientes septicos ventilando com baixos volumes correntes (6ml.kg-1). Metodos. Foram incluidos quarenta pacientes apos a fase de ressuscitacao da sepse grave e choque septico que estavam ventilados com volume corrente de 6ml.kg-1. O &#916;PP foi calculado automaticamente no baseline e apos prova de volume (7ml.kg-1). Pacientes que apresentaram incremento do debito cardiaco acima de 15% foram considerados respondedores. O valor preditivo do &#916;PP e das variaveis estaticas (pressao atrial direita e pressao ocluida de arteria pulmonar) foi avaliado atraves da analise da curva ROC (receiver operating characteristics). Resultados. Trinta e quatro pacientes apresentavam caracteristicas consistentes com lesao pulmonar aguda ou sindrome de angustia respiratoria aguda (LPA / SDRA) e foram ventilados com altos niveis de PEEP [10.0 (10.0-13.5)]. Dezenove pacientes foram considerados respondedores. A pressao atrial direita e pressao ocluida de arteria pulmonar aumentaram significativamente e o &#916;PP diminuiu significativamente apos infusao de fluidos. O desempenho do &#916;PP [area da curva ROC: 0,91 (0,82-1,0)] foi superior a pressao atrial direita [area da curva ROC: 0,73 (0,59-0,90)] e a pressao ocluida de arteria pulmonar [area da curva ROC: 0,58 (0,40-0,76)]. A analise da curva ROC revelou que o melhor ponto de corte para o &#916;PP foi de 6,5%, com uma sensibilidade de 0,89, especificidade de 0,90, valor preditivo positivo de 0,89 e valor preditivo negativo de 0,90. Conclusao. O &#916;PP automatizado prediz com exatidao a resposta a infusao de fluidos em pacientes septicos ventilados com baixos volumes correntesBV UNIFESP: Teses e dissertaçõe