Estatinas na sepse: nova arma terapêutica no arsenal da medicina intensiva?

JUSTIFICATIVA E OBJETIVOS: Sepse é uma síndrome de base inflamatória; diversos fármacos que -atuam sobre as vias de ativação da inflamação vêm sendo observados. As estatinas, além do conhecido efeito hipolipemiante detêm capacidades antiinflamatórias chamados pleiotrópicas. Essa ação pode ser benéfica no tratamento da sepse. O objetivo deste estudo foi revisar as principais publicações abordando o seu uso na sepse. MÉTODO: Busca por artigos originais cruzando os unitermos sepse e estatina no MedLine entre 1990 e 2006. RESULTADOS: Diversos estudos experimentais e retrospectivos investigaram o uso de estatinas em sepse, até o momento, em sua maioria mostraram melhora de mortalidade e morbidade. Não existem estudos prospectivos, aleatórios, placebo-controlados ou metanálises, o que demonstrou que a falta de evidências sólidas e comprovadas para indicação de uso desta conduta ainda é prevalente. Portanto ainda com seu beneficio questionável, são necessários estudos clínicos aleatórios que possam comprovar a teoria em questão. CONCLUSÕES: Diversos estudos experimentais e retrospectivos têm investigado o uso de estatinas em pacientes sépticos, porém, apesar da literatura demonstrar ser esta teoria promissora, ainda necessita-se de estudos clínicos abordando maior número de pacientes, de forma aleatória, para estar-se apto a entender e, possivelmente, recomendar o uso desta medicação no tratamento de pacientes com sepse

Hematoma subdural de medula espinhal associada ao uso de anticoagulante oral Hematoma subdural de la médula espinal asociado al uso de anticoagulante oral Spine subdural hematoma: a rare complication associated with vitamin K antagonist (VKA)

O hematoma subdural de medula espinhal (HSDME) é uma complicação rara decorrente do uso de antagonistas de vitamina K (AVK) e de diagnostico difícil. Este artigo apresenta um caso com complicação ameaçadora à vida: um paciente octogenário portador de fibrilação atrial de início recente em uso de AVK. A história e o exame físico inicialmente se apresentavam normais, associados com a elevação dos valores de coagulograma supraterapêuticos (INR > 10). Após 24 horas da admissão hospitalar, o paciente apresentou tetraparesia progressiva, evidenciando na ressonância nuclear magnética (RNM) de medula espinhal um HSDME (Figura 1). Após reversão completa da hipocoagulação e intervenção neurocirúrgica o paciente obteve melhora do quadro neurológico.<br>El hematoma subdural espinal (HSE) es una complicación rara proveniente del uso de antagonistas de vitamina K (AVK) y de diagnostico difícil. Este artículo presenta un caso con complicación amenazadora para la vida: un paciente octogenario portador de fibrilación auricular de inicio reciente, en uso de AVK. Inicialmente, la historia y el examen físico se presentaban normales, asociados a la elevación de los valores de coagulograma supra terapéuticos (INR > 10). Tras 24 horas del ingreso hospitalario, el paciente presentó tetraparesia progresiva. Al realizarse una resonancia nuclear magnética (RNM) de médula espinal, se evidenció un HSE (Figura 1). Tras reversión completa de la hipocoagulación e intervención neuroquirúrgica el paciente obtuvo mejora del cuadro neurológico.<br>Spinal subdural hematoma (SSDH) is a rare condition, which is difficult to diagnose, related to Vitamin K Antagonist. This a case report of a life-threatening situation in a octogenarian patient with a history of recent atrial fibrillation that received K-Vitamin Antagonist (KVA) therapy. The history and the clinical assessment were normal at the admission, associated with increase in the coagulation parameters (INR >10). Twenty-four hours after the admission, the patient developed progressive tetraparesis and a Magnetic Resonance Imaging (MRI) was performed, disclosing the evidence of a SSDH (Figure 1). An emergency neurosurgical intervention was performed associated with normalization of the coagulation parameters. After the procedure, the patient presented improvement of the neurological symptoms

Organizational factors associated with target sedation on the first 48 h of mechanical ventilation: an analysis of checklist-ICU database

Abstract Background Although light sedation levels are associated with several beneficial outcomes for critically ill patients on mechanical ventilation, the majority of patients are still deeply sedated. Organizational factors may play a role on adherence to light sedation levels. We aimed to identify organizational factors associated with a moderate to light sedation target on the first 48 h of mechanical ventilation, as well as the association between early achievement of within-target sedation and mortality. Methods This study is a secondary analysis of a multicenter two-phase study (prospective cohort followed by a cluster-randomized controlled trial) performed in 118 Brazilian ICUs. We included all critically ill patients who were on mechanical ventilation 48 h after ICU admission. A moderate to light level of sedation or being alert and calm (i.e., the Richmond Agitation-Sedation Scale of − 3 to 0) was the target for all patients on mechanical ventilation during the study period. We collected data on the type of hospital (public, private, profit and private, nonprofit), hospital teaching status, nursing and physician staffing, and presence of sedation, analgesia, and weaning protocols. We used multivariate random-effects regression with ICU and study phase as random-effects and correction for patients’ Simplified Acute Physiology Score 3 and Sequential Organ Failure Assessment. We also performed a mediation analysis to explore whether sedation level was just a mediator of the association between organizational factors and mortality. Results We included 5719 patients. Only 1710 (29.9%) were on target sedation levels on day 2. Board-certified intensivists on the morning and afternoon shifts were associated with an adequate sedation level on day 2 (OR = 2.43; CI 95%, 1.09–5.38). Target sedation levels were associated with reduced hospital mortality (OR = 0.63; CI 95%, 0.55–0.72). Mediation analysis also suggested such an association, but did not suggest a relationship between the physician staffing model and hospital mortality. Conclusions Board-certified intensivists on morning and afternoon shifts were associated with an increased number of patients achieving lighter sedation goals. These findings reinforce the importance of organizational factors, such as intensivists’ presence, as a modifiable quality improvement target

A cluster randomized trial of a multifaceted quality improvement intervention in Brazilian intensive care units: study protocol

Fernando Bozza. Fundação Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Documento produzido em parceria ou por autor vinculado à Fiocruz, mas não consta a informação no documento.Submitted by Janaína Nascimento ([email protected]) on 2019-08-19T13:05:05Z No. of bitstreams: 1 ve_Cavalcanti_Alexandre_etal_INI_2015.pdf: 1589962 bytes, checksum: be64c1ea1aceb6f5e90621f36e19234b (MD5)Approved for entry into archive by Janaína Nascimento ([email protected]) on 2019-08-19T13:39:07Z (GMT) No. of bitstreams: 1 ve_Cavalcanti_Alexandre_etal_INI_2015.pdf: 1589962 bytes, checksum: be64c1ea1aceb6f5e90621f36e19234b (MD5)Made available in DSpace on 2019-08-19T13:39:07Z (GMT). No. of bitstreams: 1 ve_Cavalcanti_Alexandre_etal_INI_2015.pdf: 1589962 bytes, checksum: be64c1ea1aceb6f5e90621f36e19234b (MD5) Previous issue date: 2015Hospital do Coração. Research Institute. São Paulo, SP, Brazil.Universidade Federal de São Paulo. Hospital Universitário. São Paulo, SP, Brazil / Latin American Sepsis Institute. São Paulo, SP, Brazil.D’Or Institute for Research and Education. Rio de Janeiro, RJ, Brazil / Fundação Oswaldo Cruz. Rio de Janeiro, RJ, Brasil.D’Or Institute for Research and Education. Rio de Janeiro, RJ, Brazil.Hospital Samaritano. São Paulo, SP, Brazil.Hospital do Coração. Research Institute. São Paulo, SP, Brazil.Hospital do Coração. Research Institute. São Paulo, SP, Brazil.Hospital do Coração. Research Institute. São Paulo, SP, Brazil.Hospital Samaritano. São Paulo, SP, Brazil.Latin American Sepsis Institute. São Paulo, SP, Brazil.Latin American Sepsis Institute. São Paulo, SP, Brazil.D’Or Institute for Research and Education. Rio de Janeiro, RJ, Brazil.D’Or Institute for Research and Education. Rio de Janeiro, RJ, Brazil.Hospital do Coração. Research Institute. São Paulo, SP, Brazil.Hospital do Coração. Research Institute. São Paulo, SP, Brazil.Hospital Moinhos de Vento. Porto Alegre, RS, Brasil.Hospital Moinhos de Vento. Porto Alegre, RS, Brasil.University of Pittsburgh. School of Medicine. Division of General Internal Medicine. Pittsburgh, PA, USA.University of Pittsburgh. School of Medicine. Department of Critical Care Medicine. CRISMA Center. Pittsburgh, PA, USA.Hospital do Coração. Research Institute. São Paulo, SP, Brazil.Background: The uptake of evidence-based therapies in the intensive care environment is suboptimal, particularly in limited-resource countries. Checklists, daily goal assessments, and clinician prompts may improve compliance with best practice processes of care and, in turn, improve clinical outcomes. However, the available evidence on the effectiveness of checklists is unreliable and inconclusive, and the mechanisms are poorly understood. We aim to evaluate whether the use of a multifaceted quality improvement intervention, including the use of a checklist and the definition of daily care goals during multidisciplinary daily rounds and clinician prompts, can improve the in-hospital mortality of patients admitted to intensive care units (ICUs). Our secondary objectives are to assess the effects of the study intervention on specific processes of care, clinical outcomes, and the safety culture and to determine which factors (the processes of care and/or safety culture) mediate the effect of the study intervention on mortality. Methods/design: This is a cluster randomized trial involving 118 ICUs in Brazil conducted in two phases. In the observational preparatory phase, we collect baseline data on processes of care and clinical outcomes from 60 consecutive patients with lengths of ICU stay longer than 48 h and apply the Safety Attitudes Questionnaire (SAQ) to 75% or more of the health care staff in each ICU. In the randomized phase, we assign ICUs to the experimental or control arm and repeat data collection. Experimental arm ICUs receive the multifaceted quality improvement intervention, including a checklist and definition of daily care goals during daily multidisciplinary rounds, clinician prompting, and feedback on rates of adherence to selected care processes. Control arm ICUs maintain usual care. The primary outcome is in-hospital mortality, truncated at 60 days. Secondary outcomes include the rates of adherence to appropriate care processes, rates of other clinical outcomes, and scores on the SAQ domains. Analysis follows the intention-to-treat principle, and the primary outcome is analyzed using mixed effects logistic regression. Discussion: This is a large scale, pragmatic cluster-randomized trial evaluating whether a multifaceted quality improvement intervention, including checklists applied during the multidisciplinary daily rounds and clinician prompting, can improve the adoption of proven therapies and decrease the mortality of critically ill patients. If this study finds that the intervention reduces mortality, it may be widely adopted in intensive care units, even those in limited-resource settings

Organizational factors associated with adherence to low tidal volume ventilation: a secondary analysis of the CHECKLIST-ICU database

Background: Survival benefit from low tidal volume (VT) ventilation (LTVV) has been demonstrated for patients with acute respiratory distress syndrome (ARDS), and patients not having ARDS could also benefit from this strategy. Organizational factors may play a role on adherence to LTVV. The present study aimed to identify organizational factors with an independent association with adherence to LTVV. Methods: Secondary analysis of the database of a multicenter two-phase study (prospective cohort followed by a cluster-randomized trial) performed in 118 Brazilian intensive care units. Patients under mechanical ventilation at day 2 were included. LTVV was defined as a VT ≤ 8 ml/kg PBW on the second day of ventilation. Data on the type and number of beds of the hospital, teaching status, nursing, respiratory therapists and physician staffing, use of structured checklist, and presence of protocols were tested. A multivariable mixed-effect model was used to assess the association between organizational factors and adherence to LTVV. Results: The study included 5719 patients; 3340 (58%) patients received LTVV. A greater number of hospital beds (absolute difference 7.43% [95% confidence interval 0.61–14.24%]; p = 0.038), use of structured checklist during multidisciplinary rounds (5.10% [0.55–9.81%]; p = 0.030), and presence of at least one nurse per 10 patients during all shifts (17.24% [0.85–33.60%]; p = 0.045) were the only three factors that had an independent association with adherence to LTVV. Conclusions: Number of hospital beds, use of a structured checklist during multidisciplinary rounds, and nurse staffing are organizational factors associated with adherence to LTVV. These findings shed light on organizational factors that may improve ventilation in critically ill patients