Transfusion practices in brazilian Intensive Care Units (pelo FUNDO-AMIB)

BACKGROUND AND OBJECTIVES: Anemia of critical illness is a multifactorial condition caused by blood loss, frequent phlebotomies and inadequate production of red blood cells (RBC). Controversy surrounds the most appropriate hemoglobin concentration trigger for transfusion of RBC. We aimed to evaluate transfusion practices in Brazilian ICUs. METHODS: A prospective study throughout a 2-week period in 19 Brazilian ICUs. Hemoglobin (Hb) level, transfusion rate, organ dysfunction assessment and 28-day mortality were evaluated. Primary indication for transfusion and pretransfusion hemoglobin level were collected for each transfusion. RESULTS: Two hundred thirty-one patients with an ICU length of stay longer than 48h were included. An Hb level lower than 10 g/dL was found in 33% on admission in the ICU. A total of 348 RBC units were transfused in 86 patients (36.5%). The mean pretransfusion hemoglobin level was 7.7 ± 1.1 g/dL. Transfused-patients had significantly higher SOFA score (7.9 ± 4.6 vs 5.6 ± 3.8, p < 0.05, respectively), days on mechanical ventilation (10.7 ± 8.2 vs 7.2 ± 6.4, p < 0.05) and days on vasoactive drugs (6.7 ± 6.4 vs 4.2 ± 4.0, p < 0.05) than non-transfused patients despite similar APACHE II scores (15.2 ± 8.1 vs 14.2 ± 8.1, NS). Transfused patients had higher mortality rate (43.5%) than non-transfused patients (36.3%) (RR 0.60-1.15, NS). Only one patient (0.28%) had febrile non-hemolytic transfusion and urticarial reactions. CONCLUSIONS: Anemia is common in critically ill patients.It seems from the present study that transfusion practices in Brazil have had a more restrictive approach with a lower limit transfusion trigger.JUSTIFICATIVA E OBJETIVOS: A anemia é uma condição comum em pacientes graves. A transfusão de hemoderivados aumenta de forma significativa o risco de transmissão de agentes infecciosos e afeta o perfil imunológico. O objetivo deste estudo foi avaliar a incidência de anemia e a prática de transfusão de hemácias em UTI brasileiras. MÉTODO: Estudo prospectivo, multicêntrico, realizado em 19 UTI em um período de duas semanas. A presença de anemia, as indicações e a utilização de concentrados de hemácias, foram avaliadas diariamente. As complicações que ocorreram durante a internação na UTI e após a transfusão da primeira unidade de concentrado de hemácias foram registradas. RESULTADOS: Um total de 33% apresentava anemia na admissão na UTI e esta proporção aumentou para 55% no final de sete dias de internação. Um total de 348 unidades de concentrado de hemácias foi transfundido em 86 pacientes (36,5%). A média de suas unidades por paciente foi 4,1 ± 3,3 U. O nível de hemoglobina limiar para a transfusão de CH foi 7,7 ± 1,1 g/dL. Pacientes transfundidos tinham mais disfunções orgânicas avaliadas pelo escore SOFA (7,9 ± 4,6 versus 5,6 ± 3,8, transfundidos versus não transfundidos, p < 0,05). As taxas de mortalidade foram 43,5% e 36,3% em pacientes transfundidos e não transfundidos, respectivamente (RR 0,61-11,7, NS). Pacientes transfundidos tiveram número maior de complicações (1,58 ± 0,66 versus 1,33 ± 0,49, p = 0,0001). CONCLUSÕES: A anemia é comum em UTI brasileiras. O limiar transfusional de hemoglobina foi menor do que o observado em outros paises.Faculdade de Medicina de São José do Rio PretoUniversidade de São PauloUFRGS Departamento de Medicina Interna HC de Porto AlegreUniversidade Paris VIUFRJ CTI dos Hospitais Cardiotrauma Ipanema e São LucasAMIBUniversidade Estadual de LondrinaUFRGS FAMED HCPAFaculdade de Medicina de CatanduvaUNIFESP-EPMFundação Padre Albino UTI do Complexo HospitalarUniversidade Federal de São Paulo (UNIFESP) Disciplina de Anestesiologia, Dor e Terapia Intensiva Setor de TerapiaSanta Casa de Misericórdia de São PauloHospital Unimed de LimeiraUTI do Hospital Regional de AssisAMIB Departamento de MedicinaAmerican CollegeFundação Getúlio VargasHospital Pró CardíacoUNIRIOFGVHospital Santa Helena de GoiâniaHospital evangélico de Cachoeiro de Itapemirim Unidade coronarianaSBNHospital Evangélico Cachoeiro de Itapemirim UTI Adulto e CoronarianaUFRJUFRN Hospital Onofre Lopes UTIHospital Novo AtibaiaUNIFESP, EPMUNIFESP, Disciplina de Anestesiologia, Dor e Terapia Intensiva Setor de TerapiaSciEL

Epidemiology and outcomes of non-cardiac surgical patients in Brazilian intensive care units

OBJECTIVES: Due to the dramatic medical breakthroughs and an increasingly ageing population, the proportion of patients who are at risk of dying following surgery is increasing over time. The aim of this study was to evaluate the outcomes and the epidemiology of non-cardiac surgical patients admitted to the intensive care unit. METHODS: A multicenter, prospective, observational, cohort study was carried out in 21 intensive care units. A total of 885 adult surgical patients admitted to a participating intensive care unit from April to June 2006 were evaluated and 587 patients were enrolled. Exclusion criteria were trauma, cardiac, neurological, gynecologic, obstetric and palliative surgeries. The main outcome measures were postoperative complications and intensive care unit and 90-day mortality rates. RESULTS: Major and urgent surgeries were performed in 66.4% and 31.7% of the patients, respectively. The intensive care unit mortality rate was 15%, and 38% of the patients had postoperative complications. The most common complication was infection or sepsis (24.7%). Myocardial ischemia was diagnosed in only 1.9% of the patients. A total of 94 % of the patients who died after surgery had co-morbidities at the time of surgery (3.4 ± 2.2). Multiple organ failure was the main cause of death (53%). CONCLUSION: Sepsis is the predominant cause of morbidity in patients undergoing non-cardiac surgery. In this patient population, multiple organ failure prevailed as the most frequent cause of death in the hospital.OBJETIVO: Devido aos avanços da medicina e ao envelhecimento da população, a proporção de pacientes em risco de morte após cirurgias está aumentando. Nosso objetivo foi avaliar o desfecho e a epidemiologia de cirurgias não cardíacas em pacientes admitidos em unidade de terapia intensiva. MÉTODOS: Estudo prospectivo, observacional, de coorte, realizado em 21 unidades de terapia intensiva. Um total de 885 pacientes adultos, cirúrgicos, consecutivamente admitidos em unidades de terapia intensiva no período de abril a junho de 2006 foi avaliado e destes, 587 foram incluídos. Os critérios de exclusão foram; trauma, cirurgias cardíacas, neurológicas, ginecológicas, obstétricas e paliativas. Os principais desfechos foram complicações pós-cirúrgicas e mortalidade na unidade de terapia intensiva e 90 dias após a cirurgia. RESULTADOS: Cirurgias de grande porte e de urgência foram realizadas em 66,4% e 31,7%, dos pacientes, respectivamente. A taxa de mortalidade na unidade de terapia intensiva foi de 15%, e 38% dos pacientes tiveram complicações no pós-operatório. A complicação mais comum foi infecção ou sepse (24,7%). Isquemia miocárdica foi diagnosticada em apenas 1,9%. Um total de 94 % dos pacientes que morreram após a cirurgia tinha co-morbidades associadas (3,4 ± 2,2). A principal causa de óbito foi disfunção de múltiplos órgãos (53%). CONCLUSÃO: Sepse é a causa predominante de morbidade em pacientes submetidos a cirurgias não cardíacas. A grande maioria dos óbitos no pós-operatório ocorreu por disfunção de múltiplos órgãos.Faculdade de Medicina de São José do Rio PretoServidor Público Estadual Serviço de Terapia IntensivaHospital São Lucas Unidade Coronariana IntensivaHospital Moinhos de Vento Centro de Terapia IntensivaClínica Sorocaba Centro de Terapia IntensivaClínica São Vicente Centro de Terapia IntensivaUniversidade Federal da Paraíba Hospital Universitário Unidade de Terapia Intensiva de AdultosUniversidade Federal de São Paulo (UNIFESP)Hospital Pró-Cardíaco Centro de Terapia IntensivaUniversidade Federal do Mato Grosso do Sul Hospital Universitário Centro de Terapia Intensiva AdultoUniversidade Estadual de LondrinaHospital de Terapia IntensivaUniversidade Estadual do PiauíHospital Santa Luzia Centro de Terapia IntensivaUniversidade Estadual do Oeste do ParanáFaculdade de Medicina de São José do Rio Preto Hospital de BaseHospital do Servidor Público EstadualHospital Cardiotrauma IpanemaSanta Casa de Misericórdia Centro de Terapia IntensivaUNIFESPSciEL

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&lt;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&lt;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

Haff disease associated with the ingestion of the freshwater fish Mylossoma duriventre (pacu-manteiga)

A rabdomiólise associada à doença de Haff é correlacionada com a ingestão de certos peixes e crustáceos de água doce, sendo causada por uma toxina não identificada. Relatamos o caso de um paciente que apresentou rabdomiólise cerca de 2 horas após ingerir o peixe de água doce Mylossoma duriventre (pacu-manteiga) cerca de 3 anos após o relato de um surto de doença de Haff em Manaus

Pulmonary complications after non-cardiac surgeries: temporal patterns and risk factors

BACKGROUND: Postoperative complications are the primary determinants of survival following major surgery. We aimed to characterize the early perioperative risk factors for postoperative pulmonary complications (POPCs) in patients undergoing major non-cardiac surgeries. METHODS: This study utilized a multicenter prospective observational cohort design. Adult patients undergoing non-cardiac surgeries and admitted to 21 Brazilian ICUs were screened for inclusion in the study. POPCs were defined as the presence of acute pulmonary oedema, nosocomial pneumonia, and extubation failure in the postoperative period. RESULTS: Of the 581 patients enrolled, 110 (19%) had at least one POPC, of whom 5% had acute pulmonary oedema, 10% extubation failure while 10% had pneumonia. Most cases of pulmonary oedema occurred in the first week after surgery, while pneumonia was more frequently a later occurrence. The mortality rate was significantly higher in the group with POPCs compared to the group of patients without POPCs (62% vs. 11%, RR: 5.1, 95% CI: 4.23–7.69; P < 0.001). A low functional capacity (RR: 4.6, 95% CI: 2.1–10.0), major surgery (RR: 3.6, 95% CI: 1.2–10.7), preoperative hemodynamic instability (RR: 3.4, 95% CI: 1.1–10.6), alcoholism (RR: 3.3, 95% CI: 1.0–10.7), unplanned surgery (RR: 2.3, 95% CI: 1.0–5.2), the SOFA score (RR: 1.1, 95% CI: 1.0–1.2), and increased central venous pressure (RR: 1.1, 95% CI: 1.0–1.1) were independent predictors of POPCs. CONCLUSIONS: Pulmonary complications are common in intensive care units after major non-cardiac surgeries. Awareness of the risk factors for POPCs may help multidisciplinary teams develop strategies to prevent these complications