Recomendações na aspiração do tubo endotraqueal para prevenção de eventos adversos - revisão integrativa

Introduction: The use of endotracheal suctioning is a common procedure in intensive care units, which implies various risks, namely hypoxemia, atelectasis, arterial hypertension, microbial colonization, etc. Nevertheless, healthcare professionals can adopt certain strategies to prevent these adverse events. Aim: To describe good practice relating to endotracheal suctioning in patients undergoing invasive ventilation. Materials and Methods: Integrative literature review. The research occurred in December 2015, using the databases B-on, PUBMED and RCAAP and 534 documents were found. After inclusion/exclusion and quality criteria evaluation, four studies were accepted for inclusion in this review. Results: Recommendations encountered were: suction only when necessary, pre-oxygenate, use a suction catheter with half the diameter of the endotracheal tube, avoid saline instillation, employ a closed aspiration system when FiO2 or positive end-expiratory pressure is elevated, limit the procedural duration to under 15 seconds and monitor the patient. Conclusion: The review demonstrates that some conclusions are not consensual, which represents a limitation of this study, since more experimental studies are needed, which represents a limitation of this study, since more experimental studies are needed. However, the stimulation of open debate, reflection, as well as the adoption of preventative measures, can lead to safer practice.Introdução: A aspiração endotraqueal é um procedimento bastante comum em Unidades de Cuidados Intensivos. Apesar de frequente, este procedimento implica diversos riscos, como hipoxemia, atelectasia, hipertensão arterial, colonização microbiana, entre outros. Os profissionais de saúde podem adotar estratégias para prevenir esses eventos adversos. Objetivo: Descrever as recomendações de boas práticas em relação à aspiração endotraqueal em doentes sob ventilação invasiva. Materiais e Métodos: Revisão integrativa da literatura. A pesquisa foi realizada nas bases de dados B-on, PUBMED e RCAAP em dezembro de 2015. Foram encontrados 534 documentos e, após aplicação dos critérios de inclusão e avaliação qualitativa, foram incluídos 4 estudos. Resultados: As recomendações encontradas foram: aspirar apenas quando necessário, pré-oxigenar, utilizar um cateter de aspiração com metade do diâmetro do tubo endotraqueal, usar a menor pressão de aspiração possível, aspiração superficial, evitar a instilação de solução salina, utilizar sistema de aspiração fechados quando FiO2 ou pressão positiva após expiração elevadas, duração inferior a 15 segundos e monitorizar doente. Conclusão: Alguns aspetos relacionados com a aspiração no tubo endotraqueal não são consensuais, o que representa uma limitação deste estudo, pois são necessários mais estudos experimentais. No entanto, o estímulo ao debate, à reflexão e à adoção de medidas preventivas conduzem a uma prática mais segura

Phenology and fruit production of Caryocar brasiliense Cambess. end Enterolobium gummiferum (Mart.) J. F. Macbr under different burn regimes

O conhecimento dos períodos reprodutivos e vegetativos das plantas é de extrema importância para coletas de sementes e produção de mudas. No Cerrado, as interações da biota com o fogo são de grande interesse, já que esses fatores estão intimamente relacionados e podem ser determinantes na manutenção das populações vegetais. Durante 12 meses, foi estudada a fenologia de duas espécies nativas do Cerrado (Enterolobium gummiferum (Mart.) J.F.Macbr. e Caryocar brasiliense Cambess.) em dois regimes de queima: em sítio mantido sob queima bienal modal no mês de agosto (PBM) e em sítio controle, livre de fogo há 14 anos (PC). Os testes de uniformidade foram realizados para verificar a sazonalidade das fases fenológicas. A seleção de modelos por critério de informação de Akaike foi realizada utilizando as variáveis climáticas da área de estudo para identificar quais delas são melhores preditoras das fases fenológicas. A produção de frutos foi estimada nos dois tratamentos. Praticamente, todas as fenofases apresentaram picos de produtividade, com exceção da brotação foliar de C. brasiliense em PC, queda foliar da mesma espécie nos dois tratamentos e E. gummiferum na PC. Em geral, o comportamento fenológico de ambas as espécies não diferiu de outros estudos. Porém, o fogo retardou a troca de folhas e inibiu as fases reprodutivas de C. brasiliense, o que corrobora o comportamento já observado em outras espécies nativas do Cerrado em áreas com incidência de queimadas.The knowledge of plant reproductive and vegetative periods is extremely important for seed harvesting and seedling production. Interactions between the Cerrado (Brazilian Savanna) biota and fire are of extreme interest because these factors are intimately related and could be determinant in plant populations maintenance. For 12 months, we studied the phenology of two Cerrado native species (Enterolobium gummiferum (Mart.) J.F.Macbr. and Caryocar brasiliense Cambess.) under two fire regimes: the first was burned every two years on August (PBM) in a control site without fire for 14 years (PC). Uniformity tests were made to verify seasonality of each phenological phase. The model selection with Akaike information criterion was made using climatic variables of the study region to identify which variables better describe the phenological phases. Fruit production was estimated for both treatments. Almost every phenophase showed production peaks, except for leaf sprout of C. brasiliense in PC and leaf fall of C. brasiliense in the two treatments, and E. gummiferum in PC. In general, the phenological behaviour of both species did not differ from other studies. However, fire retarded the leaf renewal and inhibited the reproductive phases of C. brasiliense, similar to previous results for other Cerrado native species in regions with burn incidence

Prognostic value of hyperlactatemia in infected patients admitted to intensive care units: a multicenter study

Objective: To evaluate the influence of patient characteristics on hyperlactatemia in an infected population admitted to intensive care units and the influence of hyperlactatemia severity on hospital mortality. Methods: A post hoc analysis of hyperlactatemia in the INFAUCI study, a national prospective, observational, multicenter study, was conducted in 14 Portuguese intensive care units. Infected patients admitted to intensive care units with a lactate measurement in the first 12 hours of admission were selected. Sepsis was identified according to the Sepsis-2 definition accepted at the time of data collection. The severity of hyperlactatemia was classified as mild (2 - 3.9mmol/L), moderate (4.0 - 9.9mmol/L) or severe (> 10mmol/L). Results: In a total of 1,640 patients infected on admission, hyperlactatemia occurred in 934 patients (57%), classified as mild, moderate and severe in 57.0%, 34.4% and 8.7% of patients, respectively. The presence of hyperlactatemia and a higher degree of hyperlactatemia were both associated with a higher Simplified Acute Physiology Score II, a higher Charlson Comorbidity Index and the presence of septic shock. The lactate Receiver Operating Characteristic curve for hospital mortality had an area under the curve of 0.64 (95%CI 0.61 - 0.72), which increased to 0.71 (95%CI 0.68 - 0.74) when combined with Sequential Organ Failure Assessment score. In-hospital mortality with other covariates adjusted by Simplified Acute Physiology Score II was associated with moderate and severe hyperlactatemia, with odds ratio of 1.95 (95%CI 1.4 - 2.7; p < 0.001) and 4.54 (95%CI 2.4 - 8.5; p < 0.001), respectively. Conclusion: Blood lactate levels correlate independently with in-hospital mortality for moderate and severe degrees of hyperlactatemia.This work was supported by an unrestricted grant from Grupo de Infeção e Sépsis (GIS), Porto, Portugal.info:eu-repo/semantics/publishedVersio

Ocular Complications of COVID-19 Patients Admitted to Intensive Care in Portugal

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long-term follow-up (CIMbA-LT)

Funding Information: Collaborators of the CIMBA-LT study: Hospital Vila Franca de Xira: André Oliveira; João Gonçalves-Pereira; Joaquim Lima. Centro Hospitalar de Médio Tejo (Abrantes): Rui Assis; Joana Monteiro. Hospital Nélio Mendonça (Funchal): André Simões; Catarina Lume. Centro Hospitalar de Trás-os-Montes e Alto Douro (Vila Real): Maria João Pinto. Centro Hospitalar de Vila Nova de Gaia: Sara Pipa. Hospital de Braga: Laura Costa. Hospital de Bragança: Cristina Nunes. Hospital do Divino Espírito Santo (S. Miguel): Manuela Henriques; Luís Tavares. Hospital de Leiria: Filipa Sequeira. Centro Hospitalar Universitário de S.João (Porto): José-Artur Paiva; Tatiana Santos Vieira; Núria Jorge. Centro Hospital Universitário de Lisboa Norte (Lisboa): Ana Bento Rodrigues; Susana Fernandes; João Ribeiro. Hospital S.Francisco Xavier (Lisboa): Rui Morais; Pedro Póvoa; Luís Coelho. Centro Hospitalar Universitário de Coimbra: Ana Martinho; Iolanda Santos. Hospital Egas Moniz (Lisboa): Gabriela Almeida. Hospital de Beja: Alexandra Paula; Filipe Morais de Almeida. Centro Hospitalar Universitário do Algarve (Faro): Sofia Ribeiro. Publisher Copyright: © 2023, The Author(s).Background: The past years have witnessed dramatic changes in the population admitted to the intensive care unit (ICU). Older and sicker patients are now commonly treated in this setting due to the newly available sophisticated life support. However, the short- and long-term benefit of this strategy is scarcely studied. Methods: The Critically Ill patients’ mortality by age: Long-Term follow-up (CIMbA-LT) was a multicentric, nationwide, retrospective, observational study addressing short- and long-term prognosis of patients admitted to Portuguese multipurpose ICUs, during 4 years, according to their age and disease severity. Patients were followed for two years after ICU admission. The standardized hospital mortality ratio (SMR) was calculated according to the Simplified Acute Physiology Score (SAPS) II and the follow-up risk, for patients discharged alive from the hospital, according to official demographic national data for age and gender. Survival curves were plotted according to age group. Results: We included 37.118 patients, including 15.8% over 80 years old. The mean SAPS II score was 42.8 ± 19.4. The ICU all-cause mortality was 16.1% and 76% of all patients survive until hospital discharge. The SAPS II score overestimated hospital mortality [SMR at hospital discharge 0.7; 95% confidence interval (CI) 0.63–0.76] but accurately predicted one-year all-cause mortality [1-year SMR 1.01; (95% CI 0.98–1.08)]. Survival curves showed a peak in mortality, during the first 30 days, followed by a much slower survival decline thereafter. Older patients had higher short- and long-term mortality and their hospital SMR was also slightly higher (0.76 vs. 0.69). Patients discharged alive from the hospital had a 1-year relative mortality risk of 6.3; [95% CI 5.8–6.7]. This increased risk was higher for younger patients [21.1; (95% CI 15.1–39.6) vs. 2.4; (95% CI 2.2–2.7) for older patients]. Conclusions: Critically ill patients’ mortality peaked in the first 30 days after ICU admission. Older critically ill patients had higher all-cause mortality, including a higher hospital SMR. A long-term increased relative mortality risk was noted in patients discharged alive from the hospital, but this was more noticeable in younger patients.publishersversionpublishe

Epidemiology of invasive aspergillosis in critically ill patients : clinical presentation, underlying conditions, and outcome

Introduction: Invasive aspergillosis (IA) is a fungal infection that particularly affects immunocompromised hosts. Recently, several studies have indicated a high incidence of IA in intensive care unit (ICU) patients. However, few data are available on the epidemiology and outcome of patients with IA in this setting. Methods: An observational study including all patients with a positive Aspergillus culture during ICU stay was performed in 30 ICUs in 8 countries. Cases were classified as proven IA, putative IA or Aspergillus colonization according to recently validated criteria. Demographic, microbiologic and diagnostic data were collected. Outcome was recorded 12 weeks after Aspergillus isolation. Results: A total of 563 patients were included, of whom 266 were colonized (47%), 203 had putative IA (36%) and 94 had proven IA (17%). The lung was the most frequent site of infection (94%), and Aspergillus fumigatus the most commonly isolated species (92%). Patients with IA had higher incidences of cancer and organ transplantation than those with colonization. Compared with other patients, they were more frequently diagnosed with sepsis on ICU admission and more frequently received vasopressors and renal replacement therapy (RRT) during the ICU stay. Mortality was 38% among colonized patients, 67% in those with putative IA and 79% in those with proven IA (P < 0.001). Independent risk factors for death among patients with IA included older age, history of bone marrow transplantation, and mechanical ventilation, RRT and higher Sequential Organ Failure Assessment score at diagnosis. Conclusions: IA among critically ill patients is associated with high mortality. Patients diagnosed with proven or putative IA had greater severity of illness and more frequently needed organ support than those with Aspergillus spp colonization

Frequency and functional activity of Th17, Tc17 and other T-cell subsets in Systemic Lupus Erythematosus

To compare frequency and functional activity of peripheral blood (PB) Th(c)17, Th(c)1 and Treg cells and the amount of type 2 cytokines mRNA we recruited SLE patients in active (n = 15) and inactive disease (n = 19) and healthy age- and gender-matched controls (n = 15). The study of Th(c)17, Th(c)1 and Treg cells was done by flow cytometry and cytokine mRNA by real-time PCR. Compared to NC, SLE patients present an increased proportion of Th(c)17 cells, but with lower amounts of IL-17 per cell and also a decreased frequency of Treg, but with increased production of TGF-b and FoxP3 mRNA. In active compared to inactive SLE, there is a marked decreased in frequency of Th(c)1 cells, an increased production of type 2 cytokines mRNA and a distinct functional profile of Th(c)17 cells. Our findings suggest a functional disequilibrium of T-cell subsets in SLE which may contribute to the inflammatory process and disease pathogenesis

Checking procalcitonin suitability for prognosis and antimicrobial therapy monitoring in burn patients

Due to greater infection susceptibility, sepsis is the main cause of death in burn patients. Quick diagnosis and patient stratification, early and appropriated antimicrobial therapy, and focus control are crucial for patients' survival. On the other hand, superfluous extension of therapy is associated with adverse events and arousal of microbial resistance. The use of biomarkers, necessarily coupled with close clinical examination, may predict outcomes, stratifying patients who need more intensive care, and monitor the efficacy of antimicrobial therapy, allowing faster de-escalation or stop, reducing the development of resistance and possibly the financial burden, without increasing mortality. The aim of this work is to check the suitability of procalcitonin (PCT) to fulfill these goals in a large sample of septic burn patients.publishe

Co-ingestion of amatoxins and isoxazoles-containing mushrooms and successful treatment: A case report

Mushroom poisonings occur when ingestion of wild mushrooms containing toxins takes place, placing the consumers at life-threatening risk. In the present case report, an unusual multiple poisoning with isoxazoles- and amatoxins-containing mushrooms in a context of altered mental state and poorly controlled hypertension is presented. A 68-year-old female was presented to São João hospital (Portugal) with complaints of extreme dizziness, hallucinations, vertigo and imbalance, 3 h after consuming a stew of wild mushrooms. The first observations revealed altered mental state and elevated blood pressure. The examination of cooked mushroom fragments allowed a preliminary identification of Amanita pantherina. Gas chromatography-mass spectrometry (GC-MS) showed the presence of muscimol in urine. Moreover, through high-performance liquid chromatography-ultraviolet detection (HPLC-UV) analysis of the gastric juice, the presence of α-amanitin was found, showing that amatoxins-containing mushrooms were also included in the stew. After 4 days of supportive treatment, activated charcoal, silybin and N-acetylcysteine, the patient recovered being discharged 10 days post-ingestion with no organ complications. The prompt and appropriate therapy protocol for life-threatening amatoxins toxicity probably saved the patient's life as oral absorption was decreased and also supportive care was immediately started.This work received financial support from the European Union (FEDER funds through COMPETE) and National Funds (FCT, Fundação para a Ciência e Tecnologia) through project Pest-C/EQB/LA0006/2013. Juliana Garcia and Vera Marisa Costa thank FCT e Foundation for Science and Technology e for their PhD grant (SFRH/BD/74979/2010) and Post-doc grant (SFRH/BPD/63746/2009), respectively.info:eu-repo/semantics/publishedVersio

Phenotypic identification of subclones in multiple myeloma with different chemoresistant, cytogenetic and clonogenic potential

Knowledge about clonal diversity and selection is critical to understand multiple myeloma (MM) pathogenesis, chemoresistance and progression. If targeted therapy becomes reality, identification and monitoring of intraclonal plasma cell (PC) heterogeneity would become increasingly demanded. Here we investigated the kinetics of intraclonal heterogeneity among 116 MM patients using 23-marker multidimensional flow cytometry (MFC) and principal component analysis, at diagnosis and during minimal residual disease (MRD) monitoring. Distinct phenotypic subclones were observed in 35116 (30%) newly diagnosed MM patients. In 1035 patients, persistent MRD was detected after 9 induction cycles, and longitudinal comparison of patient-paired diagnostic vs MRD samples unraveled phenotypic clonal tiding after therapy in half (510) of the patients. After demonstrating selection of distinct phenotypic subsets by therapeutic pressure, we investigated whether distinct fluorescence-activated cell-sorted PC subclones had different clonogenic and cytogenetic profiles. In half (510) of the patients analyzed, distinct phenotypic subclones showed different clonogenic potential when co-cultured with stromal cells, and in 611 cases distinct phenotypic subclones displayed unique cytogenetic profiles by interphase fluorescence in situ hybridization, including selective del(17p13). Collectively, we unravel potential therapeutic selection of preexisting diagnostic phenotypic subclones during MRD monitoring; because phenotypically distinct PCs may show different clonogenic and cytogenetic profiles, identification and follow-up of unique phenotypic-genetic myeloma PC subclones may become relevant for tailored therapy.Peer Reviewe