Perceptions and practices regarding delirium, sedation and analgesia in critically ill patients: a narrative review

Durante a última década, foi publicado um número significativo de estudos fundamentais que aumentaram o conhecimento atual sobre a sedação em pacientes criticamente enfermos. Desse modo, muitas das práticas até então consideradas como padrão de cuidado são hoje obsoletas. Foi demonstrado que a sedação excessiva é perigosa, e que protocolos com sedação leve ou sem sedação se associaram a melhores desfechos dos pacientes. O delirium vem sendo cada vez mais reconhecido como uma forma importante de disfunção cerebral associada com mortalidade mais alta, maior duração da ventilação mecânica e maior permanência na unidade de terapia intensiva e no hospital. Apesar de todas as evidências disponíveis, a tradução da pesquisa para o cuidado ao pé do leito é uma tarefa hercúlea. Foi demonstrado, por levantamentos internacionais, que práticas como interrupção e titulação da sedação só são realizadas em uma minoria dos casos. O estabelecimento das melhores práticas é um tremendo desafio que deve também ser contemplado nas novas diretrizes. Nesta revisão, resumimos os achados de estudos a respeito de sedação e delirium nos anos recentes e discutimos a distância entre a evidência e a prática clínica, assim como as formas de estabelecer as melhores práticas ao pé do leito

Controle glicêmico em terapia intensiva 2009: sem sustos e sem surpresas Glucose control in critically ill patients in 2009: no alarms and no surprises

Na última década o controle glicêmico em pacientes críticos foi alvo de grande polêmica. Apesar de ter sido amplamente implementado na prática médica, os grandes estudos randomizados controlados obtiveram resultados bastante conflitantes, pois além de controlar a hiperglicemia, foi identificada a necessidade de se evitar os riscos da hipoglicemia, evento potencialmente grave nessa população. Dessa forma, o presente artigo se propõe a rever e avaliar de forma crítica os estudos publicados sobre controle glicêmico em terapia intensiva, propondo um novo alvo glicêmico (150 mg / dl) que seja capaz de minimizar os malefícios da hiperglicemia e ao mesmo tempo minimizar os riscos potenciais do uso de insulina de forma intensiva.Glucose control is a major issue in critical care since landmark publications from the last decade leading to widespread use of strict glucose control in the clinical practice. Subsequent trials showed discordant results that lead to several questions and concerns about benefits and risks of implementing an intensive glucose control protocol. In the midst of all recent controversy, we propose that a new glycemic target -150mg/dl) should be aimed. This target glucose level could offer protection against the deleterious effects of hyperglycemia and at the same time keep patient's safety avoiding hypoglicemia. The article presents a critical review of the current literature on intensive insulin therapy in critically ill patients

Brainstem dysfunction in critically ill patients

International audienceThe brainstem conveys sensory and motor inputs between the spinal cord and the brain, and contains nuclei of the cranial nerves. It controls the sleep-wake cycle and vital functions via the ascending reticular activating system and the autonomic nuclei, respectively. Brainstem dysfunction may lead to sensory and motor deficits, cranial nerve palsies, impairment of consciousness, dysautonomia, and respiratory failure. The brainstem is prone to various primary and secondary insults, resulting in acute or chronic dysfunction. Of particular importance for characterizing brainstem dysfunction and identifying the underlying etiology are a detailed clinical examination, MRI, neurophysiologic tests such as brainstem auditory evoked potentials, and an analysis of the cerebrospinal fluid. Detection of brainstem dysfunction is challenging but of utmost importance in comatose and deeply sedated patients both to guide therapy and to support outcome prediction. In the present review, we summarize the neuroanatomy, clinical syndromes, and diagnostic techniques of critical illness-associated brainstem dysfunction for the critical care setting

The impact of acute brain dysfunction in the outcomes of mechanically ventilated cancer patients

Submitted by Rodrigo Senorans ([email protected]) on 2015-05-20T16:47:26Z No. of bitstreams: 1 The impact of acute brain dysfunction in the outcomes of mechanically ventilated cancer patients.pdf: 574933 bytes, checksum: 0974e11c5c5484e077d196ae7693ba88 (MD5)Approved for entry into archive by Anderson Silva ([email protected]) on 2015-05-20T17:49:03Z (GMT) No. of bitstreams: 1 The impact of acute brain dysfunction in the outcomes of mechanically ventilated cancer patients.pdf: 574933 bytes, checksum: 0974e11c5c5484e077d196ae7693ba88 (MD5)Approved for entry into archive by Anderson Silva ([email protected]) on 2015-05-21T13:00:38Z (GMT) No. of bitstreams: 1 The impact of acute brain dysfunction in the outcomes of mechanically ventilated cancer patients.pdf: 574933 bytes, checksum: 0974e11c5c5484e077d196ae7693ba88 (MD5)Made available in DSpace on 2015-05-21T16:36:41Z (GMT). No. of bitstreams: 1 The impact of acute brain dysfunction in the outcomes of mechanically ventilated cancer patients.pdf: 574933 bytes, checksum: 0974e11c5c5484e077d196ae7693ba88 (MD5) Previous issue date: 2014CNPq, FAPERJInstituto Nacional de Câncer. Unidade de Cuidados Intensivos e do Programa de Pós-Graduação. Rio de Janeiro, RJ, BrasilInstituto Nacional de Câncer. Unidade de Cuidados Intensivos e do Programa de Pós-Graduação. Rio de Janeiro, RJ, Brasil / D'Or Instituto de Ensino e Pesquisa. Rio de Janeiro, RJ, BrasilFundação Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Laboratório de Pesquisa Clínica em Medicina Intensiva. Rio de Janeiro, RJ, Brasil / D'Or Instituto de Ensino e Pesquisa. Rio de Janeiro, RJ, BrasilInstituto Nacional de Câncer. Unidade de Cuidados Intensivos e do Programa de Pós-Graduação. Rio de Janeiro, RJ, Brasil / D'Or Instituto de Ensino e Pesquisa. Rio de Janeiro, RJ, BrasilInstituto Nacional de Câncer. Unidade de Cuidados Intensivos e do Programa de Pós-Graduação. Rio de Janeiro, RJ, BrasilInstituto Nacional de Câncer. Unidade de Cuidados Intensivos e do Programa de Pós-Graduação. Rio de Janeiro, RJ, BrasilVanderbilt University School of Medicine. Nashville, TN, United States of America / Veteran’s Affairs Tennessee Valley Geriatric Research Education Clinical Center. Nashville, TN, United States of AmericaInstituto Nacional de Câncer. Unidade de Cuidados Intensivos e do Programa de Pós-Graduação. Rio de Janeiro, RJ, Brasil / D'Or Instituto de Ensino e Pesquisa. Rio de Janeiro, RJ, BrasilIntroduction: Delirium and coma are a frequent source of morbidity for ICU patients. Several factors are associated with the prognosis of mechanically ventilated (MV) cancer patients, but no studies evaluated delirium and coma (acute brain dysfunction). The present study evaluated the frequency and impact of acute brain dysfunction on mortality. Methods: The study was performed at National Cancer Institute, Rio de Janeiro, Brazil. We prospectively enrolled patients ventilated .48 h with a diagnosis of cancer. Acute brain dysfunction was assessed during the first 14 days of ICU using RASS/CAM-ICU. Patients were followed until hospital discharge. Univariate and multivariable analysis were performed to evaluate factors associated with hospital mortality. Results: 170 patients were included. 73% had solid tumors, age 65 [53–72 (median, IQR 25%–75%)] years. SAPS II score was 54[46–63] points and SOFA score was (7 [6–9]) points. Median duration of MV was 13 (6–21) days and ICU stay was 14 (7.5– 22) days. ICU mortality was 54% and hospital mortality was 66%. Acute brain dysfunction was diagnosed in 161 patients (95%). Survivors had more delirium/coma-free days [4(1,5–6) vs 1(0–2), p,0.001]. In multivariable analysis the number of days of delirium/coma-free days were associated with better outcomes as they were independent predictors of lower hospital mortality [0.771 (0.681 to 0.873), p,0.001]. Conclusions: Acute brain dysfunction in MV cancer patients is frequent and independently associated with increased hospital mortality. Future studies should investigate means of preventing or mitigating acute brain dysfunction as they may have a significant impact on clinical outcomes

Demographic and clinical variables of patients according to the presence of acute brain dysfunction.

*<p>For comparisons among patients with and without the diagnosis of acute brain dysfunction.</p><p>SAPS II - Simplified Acute Physiology Score II; SOFA - Sequential Organ Failure Assessment; ICU - intensive care unit; LOS –length of stay; Performance is status is defined according to the Eastern Cooperative Oncology Group (ECOG) scale.</p><p>Results expressed as median (25%–75% interquartile range) and number (%).</p

Multivariable analyses of factors associated with increased hospital mortality.

<p>Model containing the Delirium/Coma: Area under receiver operating characteristic curve = 0.67 (95% CI, 0.59 to 0.74).</p><p>Model containing the Delirium/Coma- Free Days: Area under receiver operating characteristic curve = 0.75 (95% CI, 0.68–0.81).</p><p>SAPSII - Simplified Acute Physiology Score II; CI – confidence interval.</p

Kaplan–Meier analysis depicting the impact of delirium/coma on hospital mortality.

<p>Kaplan–Meier analysis depicting the impact of delirium/coma on hospital mortality.</p

Study Flow Diagram.

<p>Study Flow Diagram.</p