Practical use of a risk assessment model for complications after cardiac surgery

FUNDAMENTO: Identificar os fatores de risco para complicações pós-operatórias do paciente cardiopata com indicação cirúrgica que podem influenciar na decisão sobre a conduta terapêutica. OBJETIVO: Descrever a experiência de um hospital de Cardiologia na validação e uso prático de um escore de risco pré-operatório. MÉTODOS: Para validação do escore escolhido (Tuman), avaliaram-se consecutiva e prospectivamente 300 pacientes adultos antes da cirurgia cardíaca eletiva com o uso de circulação extracorpórea (CEC). Pacientes com escore de 0 a 5 foram considerados de baixo risco; de 6 a 9 como risco moderado; e maior que 10, como alto risco para complicações cardíacas, infecciosas, neurológicas, pulmonares e renais, além de óbito. RESULTADOS: A classificação de Tuman mostrou relação estatisticamente significante com ocorrência de complicações infecciosas (p=0,010), com outras complicações pós-operatórias (p=0,034) e com evolução para óbito (p<0,001). Infecção pulmonar foi a mais freqüente dentre as complicações infecciosas (15,3%), Os pacientes infectados tiveram maior tempo de permanência na UTI (p=0,001) e internação mais prolongada (p=0,001). Após o uso rotineiro, uma nova avaliação de 154 pacientes operados em 2005 confirmou a validade desse escore na identificação daqueles com maior risco de infecções pós-operatórias. CONCLUSÃO: Escolheu-se o escore de Tuman por envolver variáveis de fácil obtenção, por classificar no mesmo sistema as cirurgias mais freqüentemente realizadas e prever risco de complicações pós-operatórias, além da mortalidade. Seu uso continuado nesse hospital permitiu identificar o grupo de pacientes com maior risco de complicações, especialmente as infecciosas, mas não foi preciso na predição do risco individual.BACKGROUND: The identification of risk factors for postoperative complications in cardiac patients with surgical indication may influence the therapeutic decision. OBJECTIVE: To describe the experience of a Cardiology hospital in the validation and practical use of a preoperative risk score. METHODS:To validate TUMAN's score, chosen by considering morbidity and mortality, 300 adult patients were prospectively evaluated before elective cardiac surgery with the use of extracorporeal circulation (ECC). Patients with a score of zero to five were considered as being low risk; from six to nine, as moderate risk and a score higher than 10 as high risk for cardiac, infectious, neurological, pulmonary and renal complications, as well as death. RESULTS: The TUMAN classification showed a statistically significant association with the occurrence of infectious complications (p = 0.010), with the other postoperative complications (p = 0.034) and death (p <0.001). Pulmonary infection was the most frequent infectious complication (15.3%) and Infected patients had a longer ICU stay duration (p = 0.001) and more prolonged hospitalization (p = 0001). After routine use, a new review of 154 patients operated in 2005, confirmed the validity of this score in the identification of those with the highest risk of postoperative infections. CONCLUSION: TUMAN's score was chosen as it uses variables that can be promptly obtained, classifies in the same system the most frequently performed surgeries and predicts risk of postoperative complications, in addition to mortality. Its continued use in this hospital has been able to identify the group of patients with increased risk of complications, especially infectious ones, although it was not useful in the prediction of individual risk

Infections in patients submitted to hemodialysis: a systematic review

OBJETIVOS: Os procedimentos dialíticos para a correção da lesão renal têm a infecção como uma das principais complicações, com impacto significante na morbi-mortalidade em pacientes dialíticos crônicos e agudos críticos. O objetivo deste trabalho foi revisar a literatura sobre infecções em pacientes submetidos a procedimentos hemodialíticos. MÉTODOS: Foi realizado levantamento das publicações de 1990 a março de 2008 nas bases eletrônicas COCHRANE, PubMed/MEDLINE, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Banco de dados de Enfermagem. Foram utilizados os descritores em Ciências da Saúde (DeCS) e o Medical Subject Headings Section (MeSH) do PubMed/MEDLINE: infecção; infecção hospitalar; bacteremia; diálise renal; insuficiência renal crônica; insuficiência renal aguda; hemofiltração; hemodiafiltração; terapia de substituição renal. RESULTADOS: Foram selecionados 33 artigos. A maioria das publicações era americana, concentrou-se entre os anos 2001 e 2005 e a principal topografia foi infecção relacionada ao acesso vascular. Os estudos divergiram na definição de infecção e denominadores utilizados, comprometendo a comparação dos mesmos. Cinco artigos trabalharam com diferentes topografias de infecção, 16 estudaram infecção relacionada ao acesso vascular nos diferentes tipos de acessos vasculares, nove focaram especificamente nos cateteres centrais temporários para hemodiálise e apenas três estudaram infecções em pacientes de unidade de terapia intensiva. A realização de hemodiálise por cateteres centrais temporários foi o principal fator de risco identificado. CONCLUSÃO: Evidenciou-se a necessidade de estudos sobre a incidência de infecção no paciente crítico, que dialisa por cateter temporário devido à lesão renal aguda, na tentativa de estabelecer relação causal e fatores de risco, com a finalidade de direcionar medidas de prevenção e controle adequadas.OBJECTIVE: Infection is one of the main complications of dialysis procedures to correct renal injury, with a significant impact on morbidity mortality in chronic and critically acute dialysis patients. The objective of this work was to review literature on infection in patients submitted to hemodyalisis. METHODS: A survey of publications from 1990 to March 2008 was carried out in the database COCHRANE, PubMed/MEDLINE, Latin-American and Caribbean literature on Health Sciences and Nursing database. In Health Science (DECS) and Medical Subject Headings Section (MeSH) from |PubMed/MEDLINE the following descriptors were used: infection; cross infection; bacteremia; renal dialysis; renal failure;acute renal failure; hemofiltation; hemodiafiltration; renal replacement therapy. RESULTS: Thirty three articles were selected. Most publications were American, from 2001 to 2005 and mainly about vascular access-related infection. Studies diverged on the definition of infection and nomenclature, hindering comparisons. Fiver articles covered different infection topographies, 16 studied vascular access-related infections in the different types of vascular accesses, nine specifically focused on temporary central catheters for hemodialysis and only three studied infections in intensive care unit patients. Temporary central catheters for hemodialysis were identified as the principal risk factor. CONCLUSION: There is a need for studies about infection incidence in critically ill, submitted to dialysis with temporary catheters, due to acute renal injury to define a causal relationship and risk factors to orient adequate prevention and control measures

Farmacocinética da cefuroxima na antibioticoprofilaxia de cirurgia cardíaca

OBJECTIVE: The objective was to investigate the plasma levels and to compare the pharmacokinetics of cefuroxime during and after surgery in adult patients with elective indication for coronary artery bypass grafting. METHODS: Seventeen patients received three 1.5-g bolus IV doses of cefuroxime, one every 12 hrs. Serial blood samples (3 mL) were collected 1, 3, 6, 9, and 12 hrs after the first dose (given during the intervention) and after the second and third doses (postsurgery). Blood samples were centrifuged and stored frozen until being assayed. For assessment of the cefuroxime plasma levels by liquid chromatography, only 200 µL of plasma were required. Determination of cefuroxime plasma levels was followed by a pharmacokinetic (PK)-modeling using PK Solutions 2.0 software. RESULTS: The kinetic parameters obtained remained unchanged after the first, second, and the third dose as follows: elimination half-life: 1.8 h, 1.9 h, and 1.8 h; clearance: 1.4, 1.5, and 1.5 mL/min/kg, respectively. Additionally, the apparent volume of distribution did not change during and after the intervention: 0.19, 0.25, and 0.22 L/kg, after the first, second, and the third dose, respectively. Since the drug has a low volume of distribution, plasma levels obtained after a 1.5-g IV bolus injection of cefuroxime decreased rapidly due to the high plasma clearance, with a consequent short half-life. CONCLUSIONS: The kinetic disposition of cefuroxime remains unaltered in patients undergoing coronary artery bypass grafting; to reduce the fluctuation in plasma concentrations so that the antibiotic prophylaxis in the peri-operative period is guaranteed, the dose regimen should be reviewed.OBJETIVO: Investigar os níveis plasmáticos e comparar a farmacocinética da cefuroxima durante e após cirurgia de revascularização do miocárdio. MÉTODOS: Dezessete pacientes receberam três doses intravenosas de 1,5 g de cefuroxima, a cada 12 horas. Foram coletadas amostras de sangue nos tempos de 1, 3, 6, 9 e 12 horas após a primeira dose (durante a cirurgia) e após a segunda e terceira dose (administradas após a cirurgia). As amostras de sangue foram centrifugadas e armazenadas congeladas até o momento da análise. Os níveis plasmáticos da cefuroxima foram determinados através de cromatografia líquida, utilizando-se apenas 200 mL de plasma. A determinação da farmacocinética da cefuroxima foi realizada utilizando o software PK-solutions 2.0. RESULTADOS: Todos os parâmetros cinéticos obtidos permaneceram inalterados após a adminstração da 1ª, 2ª e 3ª doses: meia vida de eliminação 1,8h, 1,9h and 1,8h, depuração 1,4, 1,5 and 1,5 mL/min/kg respectivamente. Adicionalmente, o volume aparente de distribuição, não se alterou durante ou após a intervenção: 0,19, 0,25 and 0,22 L/kg, após 1ª, 2ª e 3ª dose, respectivamente. Os níveis plasmáticos obtidos após administração da cefuroxima reduziram rapidamente devido à alta depuração plasmática com conseqüente curta meia-vida plasmática, atingindo valores abaixo da concentração inibitória mínima a partir da 9ª hora da administração. CONCLUSÕES: A disposição cinética da cefuroxima permanece inalterada em pacientes submetidos à cirurgia de revascularização do miocárdio, e com vistas à redução da flutuação no período perioperatório, o regime de dose para a antibioticoprofilaxia poderia ser revisto

Trichosporon asahii an emerging etiologic agent of fungal infection and colonization in heart failure patients in intensive care unit: case report and literature review

JUSTIFICATIVA E OBJETIVOS: As infecções fúngicas por Trichosporon Asahii têm sido cada vez mais freqüentes nas últimas duas décadas. Quadros graves com alta mortalidade são tradicionalmente descritos em pacientes neutropênicos com câncer. Recentemente, a infecção tem ocorrido também em outros grupos de pacientes. O objetivo deste estudo foi descrever a crescente prevalência de Trichosporon asahii em unidade de terapia intensiva cardiológica (UTIC), com perfil de pacientes habitualmente não susceptíveis a tal infecção fúngica, relatar um caso clínico e revisão da literatura. RELATO DO CASO: Paciente do sexo feminino, 85 anos, com antecedentes de hipertensão arterial sistêmica, insuficiência cardíaca (fração de ejeção = 30%) e embolia pulmonar, admitida na UTI depois de parada cardiorrespiratória em fibrilação ventricular durante consulta de rotina. Evoluiu sem seqüela neurológica. O ecocardiograma não revelou alterações em relação ao exame anterior. Não houve alteração dos indicadores de necrose miocárdica. A paciente apresentou falha na extubação traqueal e desmame difícil, necessitando ventilação mecânica prolongada mesmo após traqueostomia. Houve complicações por insuficiência renal aguda e infecções recorrentes (respiratória, urinária e sistêmica), com boa resposta ao tratamento com antibióticos de amplo espectro. Após sete meses de internação na UTI, evoluiu com choque séptico, associado à infecção urinária por Trichosporon asahii, com hemoculturas identificadas pelo mesmo fungo. Iniciado tratamento com anfotericina B lipossomal (5 mg/kg/dia). Apesar do uso associado de vancomicina e imipenem, houve piora clínica progressiva. Hemoculturas colhidas no sétimo dia de uso de antifúngico revelaram-se negativas, porém a urocultura ainda revelou o crescimento de T. asahii. Evoluiu com óbito após 18 dias de tratamento, por falência de múltiplos órgãos. CONCLUSÕES: O aumento da gravidade dos pacientes internados nas UTI e o uso disseminado de antibióticos de amplo espectro têm possibilitado o surgimento de infecções por fungos incomuns. As infecções graves por Trichosporon asahii, descritas como restritas a pacientes imunossuprimidos, oncológicos e hematológicos, têm sido freqüentemente encontradas em pacientes idosos, com insuficiência cardíaca grave e com alta mortalidade intra-hospitalar, internados em UTI. Deve-se estar atento à possibilidade da emergência de infecções por fungos não usuais em pacientes com este perfil clínico.BACKGROUND AND OBJECTIVES: Infection with the non-Candida yeast species Trichosporon have been recognized with increasing frequency over the last two decades. Invasive disease due to trichosporonosis has been reported from neutropenic patients with cancer and the mortality is high. Recently, others groups of patients have become susceptible to this rare fungi. We report the emerging of infection with pathogenic Trichosporon asahii in severely ill heart failure patients in a tertiary cardiological intensive care unit (CICU). We describe our data, and report a fatal case of disseminated trichosporonosis in a patient with heart failure. We also review literature pertaining to T. asahii infections. CASE REPORT: An 85 year-old woman with a history of hypertension, heart failure (ejection fraction (EJ): 30%) and pulmonary embolism was admitted to a medical cardiological ICU after cardiac arrest (ventricular fibrillation) resuscitated during a routine consultation. There were no neurological sequelae and the echocardiogram revels no changes, neither the cardiac biomarkers. Ventricular fibrillation was considered secondary to heart failure. The patient had extubation failure and difficult weaning needing long term mechanical ventilation even after tracheostomy. Her hospital course was complicated by acute renal failure and recurrent respiratory, urinary and systemic bacterial infections, which responded to broad-spectrum antibiotics. After a temporary improvement she developed urinary infection and subsequent septic shock. Cultures of urine and blood specimens grew T. asahii. Treatment with liposome amphotericin B (5 mg/kg/day) was started. Despite receiving vancomycin and imipenem, the clinical condition of the patient deteriorates. Blood taken for culture on the seventh day of amphotericin B therapy were negative but urine specimen still grew T. asahii. On the eighteenth day of antifungal therapy, the patient died with multiorgan failure. CONCLUSIONS: The increasing of severely ill patients, and the use of broad spectrum antibiotics, has predisposed the emerging of invasive infections by rare and new opportunistic fungal pathogens. Severe infection related to T. asahii, until recently restricted to neutropenic patients with cancer, has been frequently identified in heart failure patients with advanced age. The mortality is high. These data highlights the importance of considering this group of patients as a risk group for T. asahii infection

Endocarditis due to Coxiella burnetii (Q fever): a rare or underdiagnosed disease? Case report

A febre Q é uma zoonose de distribuição mundial causada por Coxiella burnetii, sendo raros os registros da doença no Brasil. Estudos soroepidemiológicos mostraram uma freqüência relativamente elevada de anticorpos contra Coxiella burnetii em populações com exposição ocupacional. Em humanos, pode se manifestar clinicamente como doença aguda ou crônica, sendo que a endocardite é a forma crônica mais freqüente da febre Q e de maior morbi-mortalidade. Relatamos um caso grave de endocardite por Coxiella burnetii adquirida no Brasil com desfecho fatal, apesar de antibioticoterapia adequada e tratamento cirúrgico valvar.Q fever is a zoonosis of worldwide distribution that is caused by Coxiella burnetii. However, reports of this disease in Brazil are rare. Seroepidemiological studies have shown relatively high frequencies of antibodies against Coxiella burnetii in populations with occupational exposure. In humans, it can be manifested clinically as acute or chronic disease. Endocarditis is the most frequent chronic form of Q fever and the form with the greatest morbidity and mortality. We report a severe case of endocarditis due to Coxiella burnetii acquired in Brazil that had a fatal outcome, despite specific antibiotic therapy and valve surgery treatment

Biomarkers for prediction of mortality in left-sided infective endocarditis

Background: Evidence regarding biomarkers for risk prediction in patients with infective endocarditis (IE) is limited. We aimed to investigate the value of a panel of biomarkers for the prediction of in-hospital mortality in patients with IE. Methods: Between 2016 and 2018, consecutive IE patients admitted to the emergency department were prospectively included. Blood concentrations of nine biomarkers were measured at admission (D0) and on the seventh day (D7) of antibiotic therapy: C-reactive protein (CRP), sensitive troponin I (s-cTnI), procalcitonin, B-type natriuretic peptide (BNP), neutrophil gelatinase-associated lipocalin (NGAL), interleukin 6 (IL6), tumor necrosis factor α (TNF-α), proadrenomedullin, alpha-1-acid glycoprotein, and galectin 3. The primary endpoint was in-hospital mortality. Results: Among 97 patients, 56% underwent cardiac surgery, and in-hospital mortality was 27%. At admission, six biomarkers were independent predictors of in-hospital mortality: s-cTnI (OR 3.4; 95%CI 1.8–6.4; P < 0.001), BNP (OR 2.7; 95%CI 1.4–5.1; P = 0.002), IL-6 (OR 2.06; 95%CI 1.3–3.7; P = 0.019), procalcitonin (OR 1.9; 95%CI 1.1–3.2; P = 0.018), TNF-α (OR 1.8; 95%CI 1.1–2.9; P = 0.019), and CRP (OR 1.8; 95%CI 1.0–3.3; P = 0.037). At admission, S-cTnI provided the highest accuracy for predicting mortality (area under the ROC curve: s-cTnI 0.812, BNP 0.727, IL-6 0.734, procalcitonin 0.684, TNF-α 0.675, CRP 0.670). After 7 days of antibiotic therapy, BNP and inflammatory biomarkers improved their performance (s-cTnI 0.814, BNP 0.823, IL-6 0.695, procalcitonin 0.802, TNF-α 0.554, CRP 0.759). Conclusion: S-cTnI concentration measured at admission had the highest accuracy for mortality prediction in patients with IE

Cytomegalovirus infection in transplant recipients

Cytomegalovirus infection is a frequent complication after transplantation. This infection occurs due to transmission from the transplanted organ, due to reactivation of latent infection, or after a primary infection in seronegative patients and can be defined as follows: latent infection, active infection, viral syndrome or invasive disease. This condition occurs mainly between 30 and 90 days after transplantation. In hematopoietic stem cell transplantation in particular, infection usually occurs within the first 30 days after transplantation and in the presence of graft-versus-host disease. The major risk factors are when the recipient is cytomegalovirus seronegative and the donor is seropositive as well as when lymphocyte-depleting antibodies are used. There are two methods for the diagnosis of cytomegalovirus infection: the pp65 antigenemia assay and polymerase chain reaction. Serology has no value for the diagnosis of active disease, whereas histology of the affected tissue and bronchoalveolar lavage analysis are useful in the diagnosis of invasive disease. Cytomegalovirus disease can be prevented by prophylaxis (the administration of antiviral drugs to all or to a subgroup of patients who are at higher risk of viral replication) or by preemptive therapy (the early diagnosis of viral replication before development of the disease and prescription of antiviral treatment to prevent the appearance of clinical disease). The drug used is intravenous or oral ganciclovir; oral valganciclovir; or, less frequently, valacyclovir. Prophylaxis should continue for 90 to 180 days. Treatment is always indicated in cytomegalovirus disease, and the gold-standard drug is intravenous ganciclovir. Treatment should be given for 2 to 3 weeks and should be continued for an additional 7 days after the first negative result for viremia

A Brazilian university hospital position regarding transplantation criteria for HIV-positive patients according to the current literature

Human immunodeficiency virus (HIV) infection was considered a contraindication for solid organ transplantation (SOT) in the past. However, HIV management has improved since highly active antiretroviral therapy (HAART) became available in 1996, and the long-term survival of patients living with HIV has led many transplant programs to reevaluate their policies regarding the exclusion of patients with HIV infection. Based on the available data in the medical literature and the cumulative experience of transplantation in HIVpositive patients at our hospital, the aim of the present article is to outline the criteria for transplantation in HIVpositive patients as recommended by the Immunocompromised Host Committee of the Hospital das Clı´nicas of the University of Sa˜o Paulo