Factors associated with variation in intracranial pressure in a model of intra-abdominal hypertension with acute lung injury

OBJETIVO: Avaliar o efeito de alterações hemodinâmicas, respiratórias e metabólicas sobre a pressão intracraniana em um modelo de lesão pulmonar aguda e síndrome compartimental abdominal. MÉTODOS: Oito porcos Agroceres foram submetidos, após a instrumentação, a cinco cenários clínicos: 1) estado basal com baixa pressão intra-abdominal e pulmão sadio; 2) pneumoperitôneo, com pressão intra-abdominal de 20 mm Hg; 3) lesão pulmonar aguda induzida por lavagem pulmonar e desativação de surfactante; 4) pneumoperitôneo com pressão intra-abdominal de 20 mm Hg na vigência de lesão pulmonar aguda e com PEEP baixo; e 5) PEEP ajustado a 27 cm H2O na vigência de pneumoperitôneo e lesão pulmonar aguda. Variáveis respiratórias e hemodinâmicas foram coletadas. Análise multivariada foi realizada buscando as variáveis associadas com elevação da pressão intracraniana nos cinco cenários estudados. RESULTADOS: Após a análise multivariada, nas situações não associadas com lesão pulmonar aguda apenas a pressão de platô das vias aéreas se correlacionou positivamente com a pressão intracraniana. Nos modelos associados com lesão pulmonar aguda, a pressão de platô de vias aéreas, a pressão arterial de CO2, o CO2 no final da expiração e a pressão venosa central se correlacionaram positivamente com incrementos da pressão intracraniana. CONCLUSÃO: Em um modelo de disfunção orgânica múltipla com situações clínicas associadas com aumento da pressão torácica e abdominal, o incremento da pressão intracraniana desencadeado pela elevação da pressão abdominal parece ser decorrente da piora da complacência do sistema respiratório e da redução do gradiente para drenagem venosa cerebral ocasionado pela elevação da pressão venosa central.OBJECTIVE: To evaluate the effects of hemodynamic, respiratory and metabolic changes on intracranial pressure in a model of acute lung injury and abdominal compartment syndrome. METHODS: Eight Agroceres pigs were submitted to five different clinical scenarios after instrumentation: 1) a baseline condition with low intra-abdominal pressure and healthy lungs; 2) pneumoperitoneum with 20 mmHg intra-abdominal pressure; 3) acute lung injury induced by pulmonary lavage with surfactant deactivation; 4) pneumoperitoneum with 20 mmHg intra-abdominal pressure with lung pulmonary injury and low positive end-expiratory pressure; and 5) 27 cmH2O positive end-expiratory pressure with pneumoperitoneum and acute lung injury. Respiratory and hemodynamic variables were collected. A multivariate analysis was conducted to search for variables associated with increased intracranial pressure in the five scenarios. RESULTS: Only plateau airway pressure showed a positive correlation with intracranial pressure in the multivariate analysis. In the models with acute lung injury, plateau airway pressure, CO2 arterial pressure, end tidal CO2 and central venous pressure were positively correlated with increased intracranial pressure. CONCLUSION: In a model of multiple organ dysfunction with associated clinical conditions causing increased intra-thoracic and abdominal pressure, increased intracranial pressure triggered by elevated intra-abdominal pressure is apparently caused by worsened respiratory system compliance and a reduced brain venous drainage gradient due to increased central venous pressure

Late recognition and illness severity are determinants of early death in severe septic patients

OBJECTIVE: To identify the independent variables associated with death within 4 days after the first sepsis-induced organ dysfunction. METHODS: In this prospective observational study, severe sepsis and septic shock patients were classified into 3 groups: Group 1, survivors; Group 2, late non-survivors; and Group 3, early non-survivors. Early death was defined as death occurring within 4 days after the first sepsis-induced organ dysfunction. Demographic, clinical and laboratory data were collected and submitted to univariate and multinomial analyses. RESULTS: The study included 414 patients: 218 (52.7%) in Group 1, 165 (39.8%) in Group 2, and 31 (7.5%) in Group 3. A multinomial logistic regression analysis showed that age, Acute Physiology and Chronic Health Evaluation II score, Sepsis-related Organ Failure Assessment score after the first 24 hours, nosocomial infection, hepatic dysfunction, and the time elapsed between the onset of organ dysfunction and the sepsis diagnosis were associated with early mortality. In contrast, Black race and a source of infection other than the urinary tract were associated with late death. Among the non-survivors, early death was associated with Acute Physiology and Chronic Health Evaluation II score, chronic renal failure, hepatic dysfunction Sepsis-related Organ Failure Assessment score after 24 hours, and the duration of organ dysfunction. CONCLUSION: Factors related to patients' intrinsic characteristics and disease severity as well as the promptness of sepsis recognition are associated with early death among severe septic patients.Fundacao de Amparo a Pesquisa do Estado de Sao PauloFederal University of São Paulo Department of Anesthesiology Pain and Critical CareLatin American Sepsis InstituteFederal University of São Paulo Department of Infectious DiseasesSírio Libanês Hospital Intensive Care UnitHospital Israelita Albert Einstein Intensive Care UnitUNIFESP, Department of Anesthesiology Pain and Critical CareUNIFESP, Department of Infectious DiseasesSciEL

Shortening ventilatory support with a protocol based on daily extubation screening and noninvasive ventilation in selected patients

BACKGROUND: Prolonged invasive mechanical ventilation and reintubation are associated with adverse outcomes and increased mortality. Daily screening to identify patients able to breathe without support is recommended to reduce the length of mechanical ventilation. Noninvasive positive-pressure ventilation has been proposed as a technique to shorten the time that patients remain on invasive ventilation. METHODS: We conducted a before-and-after study to evaluate the efficacy of an intervention that combined daily screening with the use of noninvasive ventilation immediately after extubation in selected patients. The population consisted of patients who had been intubated for at least 2 days. RESULTS: The baseline characteristics were similar between the groups. The intervention group had a lower length of invasive ventilation (6 [4;9] vs. 7 [4;11.5] days, p = 0.04) and total (invasive plus noninvasive) ventilator support (7 [4;11] vs. 9 [6;8], p = 0.01). Similar reintubation rates within 72 hours were observed for both groups. In addition, a lower ICU mortality was found in the intervention group (10.8% vs. 24.3%, p = 0.03), with a higher cumulative survival probability at 60 days (p = 0.05). Multivariate analysis showed that the intervention was an independent factor associated with survival (RR: 2.77; CI 1.14-6.65; p = 0.03), whereas the opposite was found for reintubation at 72 hours (RR: 0.27; CI 0.11-0.65; p = 0.01). CONCLUSION: The intervention reduced the length of invasive ventilation and total ventilatory support without increasing the risk of reintubation and was identified as an independent factor associated with survival

Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study

Introduction: Sedation overuse is frequent and possibly associated with poor outcomes in the intensive care unit (ICU) patients. However, the association of early oversedation with clinical outcomes has not been thoroughly evaluated. the aim of this study was to assess the association of early sedation strategies with outcomes of critically ill adult patients under mechanical ventilation (MV).Methods: A secondary analysis of a multicenter prospective cohort conducted in 45 Brazilian ICUs, including adult patients requiring ventilatory support and sedation in the first 48 hours of ICU admissions, was performed. Sedation depth was evaluated after 48 hours of MV. Multivariate analysis was used to identify variables associated with hospital mortality.Results: A total of 322 patients were evaluated. Overall, ICU and hospital mortality rates were 30.4% and 38.8%, respectively. Deep sedation was observed in 113 patients (35.1%). Longer duration of ventilatory support was observed (7 (4 to 10) versus 5 (3 to 9) days, P = 0.041) and more tracheostomies were performed in the deep sedation group (38.9% versus 22%, P=0.001) despite similar PaO2/FiO(2) ratios and acute respiratory distress syndrome (ARDS) severity. in a multivariate analysis, age (Odds Ratio (OR) 1.02; 95% confidence interval (CI) 1.00 to 1.03), Charlson Comorbidity Index >2 (OR 2.06; 95% Cl, 1.44 to 2.94), Simplified Acute Physiology Score 3 (SAPS 3) score (OR 1.02; Cl 95%, 1.00 to 1.04), severe ARDS (OR 1.44; Cl 95%, 1.09 to 1.91) and deep sedation (OR 2.36; Cl 9596, 1.31 to 4.25) were independently associated with increased hospital mortality.Conclusions: Early deep sedation is associated with adverse outcomes and constitutes an independent predictor of hospital mortality in mechanically ventilated patients.Research and Education Institute from Hospital Sirio-Libanes, São PauloD'Or Institute for Research and Education, Rio de Janeiro, BrazilBrazilian Research in Intensive Care NetworkHosp Copa DOr, BR-22031010 Rio de Janeiro, BrazilHosp Sirio Libanes, Res & Educ Inst, BR-01308060 São Paulo, BrazilUniv São Paulo, Fac Med, Hosp Clin, ICU,Emergency Med Dept, BR-05403000 São Paulo, BrazilHosp Sao Camilo Pompeia, ICU, BR-05022000 São Paulo, BrazilCEPETI, BR-82530200 Curitiba, Parana, BrazilHosp Canc I, Inst Nacl Canc, ICU, BR-20230130 Rio de Janeiro, BrazilPasteur Hosp, ICU, BR-20735040 Rio de Janeiro, BrazilIrmandade Santa Casa Misericordia Porto Alegre, RIPIMI, BR-90020090 Porto Alegre, RS, BrazilVitoria Apart Hosp, ICU, BR-29161900 Serra, ES, BrazilHosp Mater Dei, ICU, BR-30140093 Belo Horizonte, MG, BrazilHosp Santa Luzia, ICU, BR-70390902 Brasilia, DF, BrazilHosp Sao Luiz, ICU, BR-04544000 São Paulo, BrazilUniversidade Federal de São Paulo, Anesthesiol Pain & Intens Care Dept, ICU, BR-04024900 São Paulo, BrazilHosp Sao Jose Criciuma, ICU, BR-88801250 Criciuma, BrazilUDI Hosp, ICU, BR-65076820 Sao Luis, BrazilUniv São Paulo, Univ Hosp, ICU, BR-05508000 São Paulo, BrazilUniv São Paulo, Fac Med, Hosp Clin, ICU,Surg Emergency Dept, BR-05403000 São Paulo, BrazilIDOR DOr Inst Res & Educ, BR-22281100 Rio de Janeiro, BrazilInst Nacl Canc, Postgrad Program, BR-20230130 Rio de Janeiro, BrazilUniversidade Federal de São Paulo, Anesthesiol Pain & Intens Care Dept, ICU, BR-04024900 São Paulo, BrazilWeb of Scienc

Late recognition and illness severity are determinants of early death in severe septic patients

OBJECTIVE: To identify the independent variables associated with death within 4 days after the first sepsis-induced organ dysfunction. METHODS: In this prospective observational study, severe sepsis and septic shock patients were classified into 3 groups: Group 1, survivors; Group 2, late non-survivors; and Group 3, early non-survivors. Early death was defined as death occurring within 4 days after the first sepsis-induced organ dysfunction. Demographic, clinical and laboratory data were collected and submitted to univariate and multinomial analyses. RESULTS: The study included 414 patients: 218 (52.7%) in Group 1, 165 (39.8%) in Group 2, and 31 (7.5%) in Group 3. A multinomial logistic regression analysis showed that age, Acute Physiology and Chronic Health Evaluation II score, Sepsis-related Organ Failure Assessment score after the first 24 hours, nosocomial infection, hepatic dysfunction, and the time elapsed between the onset of organ dysfunction and the sepsis diagnosis were associated with early mortality. In contrast, Black race and a source of infection other than the urinary tract were associated with late death. Among the non-survivors, early death was associated with Acute Physiology and Chronic Health Evaluation II score, chronic renal failure, hepatic dysfunction Sepsis-related Organ Failure Assessment score after 24 hours, and the duration of organ dysfunction. CONCLUSION: Factors related to patients' intrinsic characteristics and disease severity as well as the promptness of sepsis recognition are associated with early death among severe septic patients

Evaluation of quality of life and ergonomic risks in workers of the furniture sector in Southeastern Brazil

This study evaluated ergonomically the workers of a furniture industry making sofa structures, located in the city of Visconde do Rio Branco, Minas Gerais State, between August 2016 and December 2016, aiming to evaluate the quality of life and the ergonomic risks of the workers present. It was evaluated a population of 66 workers, including assemblers of sofa structures and carpentry machine operators, both males. Initially, all of these were submitted to the pain test, performed by means of questions regarding the greatest and least muscular discomfort, with the help of a map of the musculature of the human body. A sample of the workers with the highest rates of muscular pain was withdrawn from this population. The sample was submitted to WHOQOL-Bref (World Health Organization Quality of Life - Bref) questionnaire, which evaluates the perception of quality of life; After the kinesiological analysis of the work, observing the positions adopted and the assembly time of the structures of the sofa; the RULA method (Rapid Upper Limb Assessment), responsible for evaluate possible damage to limbs, such as the arm, forearm, wrist, neck, trunk and legs; and finally the biomechanical evaluation of static and postural forces, using 3DSSPP software (3D Static Strength Prediction Program). The results of WHOQOL-Bref questionnaire revealed that, in general, the perception of the sample about quality of life at work was classified as "very satisfactory" and the "physical environment was the one with the lowest degree of satisfaction. The kinesiological and biomechanical analyzes showed that the factors most critical to the work routine are related to wrist flexion, ulnar deviation and flexion of the indicator. However, based on static and postural forces, this activity can be developed without health risks by 97% of the workers. The load on workers during the working day did not prove to be crucial for triggering musculoskeletal disorders, so most workers are able to develop their work activities without health risks

Severe hypoxemia during veno-venous extracorporeal membrane oxygenation: exploring the limits of extracorporeal respiratory support

OBJECTIVE: Veno-venous extracorporeal oxygenation for respiratory support has emerged as a rescue alternative for patients with hypoxemia. However, in some patients with more severe lung injury, extracorporeal support fails to restore arterial oxygenation. Based on four clinical vignettes, the aims of this article were to describe the pathophysiology of this concerning problem and to discuss possibilities for hypoxemia resolution. METHODS: Considering the main reasons and rationale for hypoxemia during veno-venous extracorporeal membrane oxygenation, some possible bedside solutions must be considered: 1) optimization of extracorporeal membrane oxygenation blood flow; 2) identification of recirculation and cannula repositioning if necessary; 3) optimization of residual lung function and consideration of blood transfusion; 4) diagnosis of oxygenator dysfunction and consideration of its replacement; and finally 5) optimization of the ratio of extracorporeal membrane oxygenation blood flow to cardiac output, based on the reduction of cardiac output. CONCLUSION: Therefore, based on the pathophysiology of hypoxemia during veno-venous extracorporeal oxygenation support, we propose a stepwise approach to help guide specific interventions