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In the backdrop of the global obesity pandemic, recognized as a notable risk factor for coronavirus disease 2019 (COVID-19) complications, the study aims to explore clinical and epidemiological attributes of hospitalized COVID-19 patients throughout 2021 in Brazil. Focused on four distinct age cohorts, the investigation scrutinizes parameters such as intensive care unit (ICU) admission frequency, invasive mechanical ventilation (IMV) usage, and in-hospital mortality among individuals with and without obesity. Using a comprehensive cross-sectional study methodology, encompassing adult COVID-19 cases, data sourced from the Influenza Epidemiological Surveillance Information System comprises 329 206 hospitalized patients. Of these individuals, 26.3% were affected by obesity. Analysis reveals elevated rates of ICU admissions, increased dependence on IMV, and heightened in-hospital mortality among the individuals with obesity across all age groups (p < .001). Logistic regression, adjusting for confounding variables, underscores a progressively rising odds ratio for mortality in younger age brackets: 1.2 (95%CI 1.1-1.3) for those under 50 years, 1.1 (95%CI 1.0-1.2) for the 50-59 age group, and 1.1 (95%CI 1.0-1.2) for the 60-69 age group. Conversely, no significant mortality difference is observed for patients over 70 years (OR: 0.972, 95%CI 0.9-1.1). In summary, hospitalized COVID-19 patients with obesity, particularly in younger age groups, exhibit elevated rates of ICU admission, IMV requirement, and in-hospital mortality compared with the control group. Notably, the 'obesity paradox' is not evident among hospitalized COVID-19 patients in 2021.

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OBJECTIVE: To evaluate the predictive ability of mortality prediction scales in cancer patients admitted to intensive care units (ICUs). DESIGN: A systematic review of the literature was conducted using a search algorithm in October 2022. The following databases were searched: PubMed, Scopus, Virtual Health Library (BVS), and Medrxiv. The risk of bias was assessed using the QUADAS-2 scale. SETTING: ICUs admitting cancer patients. PARTICIPANTS: Studies that included adult patients with an active cancer diagnosis who were admitted to the ICU. INTERVENTIONS: Integrative study without interventions. MAIN VARIABLES OF INTEREST: Mortality prediction, standardized mortality, discrimination, and calibration. RESULTS: Seven mortality risk prediction models were analyzed in cancer patients in the ICU. Most models (APACHE II, APACHE IV, SOFA, SAPS-II, SAPS-III, and MPM II) underestimated mortality, while the ICMM overestimated it. The APACHE II had the SMR (Standardized Mortality Ratio) value closest to 1, suggesting a better prognostic ability compared to the other models. CONCLUSIONS: Predicting mortality in ICU cancer patients remains an intricate challenge due to the lack of a definitive superior model and the inherent limitations of available prediction tools. For evidence-based informed clinical decision-making, it is crucial to consider the healthcare team's familiarity with each tool and its inherent limitations. Developing novel instruments or conducting large-scale validation studies is essential to enhance prediction accuracy and optimize patient care in this population.

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Objetivo: O objetivo deste estudo foi identificar e descrever os cuidados essenciais que os enfermeiros devem ter ao atuar em uma Unidade de Terapia Intensiva (UTI). Métodos: Realizou-se uma revisão bibliográfica da literatura, com uma abordagem qualitativa, descritiva e exploratória. As buscas foram realizadas PubMed, SciELO, LILACS e BIREME. Resultados: Os cuidados de enfermagem desempenham um papel crucial na recuperação e bem-estar dos pacientes em estado crítico na UTI. As intervenções dos enfermeiros devem ser embasadas em conhecimento científico, empatia e habilidades técnicas avançadas. Discute-se a importância da monitorização rigorosa, controle de infecções, prevenção de complicações da imobilidade, abordagem holística ao paciente e comunicação efetiva na UTI. Conclusão: Conclui-se que os enfermeiros devem basear suas intervenções em conhecimento científico, empatia e habilidades técnicas avançadas, destacando-se a importância da monitorização, controle de infecções, prevenção de complicações da imobilidade, abordagem holística ao paciente e comunicação efetiva na UTI.(AU)

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Objectives: The objective of this study was to identify and describe the essential care that nurses must take when working in an Intensive Care Unit (ICU). Methods: A bibliographical review of the literature was carried out, with a qualitative, descriptive and exploratory approach. The searches were carried out in PubMed, SciELO, LILACS and BIREME. Results: Nursing care plays a crucial role in the recovery and well-being of critically ill patients in the ICU. Nurses' interventions must be based on scientifi c knowledge, empathy and advanced technical skills. The importance of rigorous monitoring, infection control, prevention of immobility complications, a holistic approach to the patient and effective communication in the ICU are discussed. Conclusion: It is concluded that nurses must base their interventions on scientifi c knowledge, empathy and advanced technical skills, highlighting the importance of monitoring, infection control, prevention of immobility complications, a holistic approach to the patient and effective communication in the ICU.(AU)

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Objetivos: El objetivo de este estudio fue identifi car y describir los cuidados esenciales que deben tener las enfermeras cuando trabajan en una Unidad de Cuidados Intensivos (UCI). Métodos: Se realizó una revisión bibliográfi ca de la literatura, con un enfoque cualitativo, descriptivo y exploratorio. Las búsquedas se realizaron en PubMed, SciELO, LILACS y BIREME. Resultados: Los cuidados de enfermería juegan un papel crucial en la recuperación y el bienestar de los pacientes críticos en la UCI. Las intervenciones de las enfermeras deben basarse en el conocimiento científi co, la empatía y las habilidades técnicas avanzadas. Se discute la importancia de un seguimiento riguroso, el control de infecciones, la prevención de complicaciones de la inmovilidad, un enfoque holístico del paciente y una comunicación efi caz en la UCI. Conclusión: Se concluye que los enfermeros deben basar sus intervenciones en el conocimiento científi co, la empatía y las habilidades técnicas avanzadas, resaltando la importancia del seguimiento, control de infecciones, prevención de complicaciones de la inmovilidad, abordaje holístico del paciente y comunicación efectiva en la UCI.(AU)

Assuntos

Cuidados Críticos , Unidades de Terapia Intensiva , Equipe de Enfermagem

RESUMO

BACKGROUND: Trauma and emergency surgery are major causes of morbidity and mortality. The objective of this study was to determine whether serum levels of epinephrine and norepinephrine are associated with aging and mortality. METHODS: This was a prospective observational cohort study conducted in a surgical critical care unit. We included 90 patients who were admitted for postoperative care, because of major trauma, or both. We collected demographic and clinical variables, as well as serum levels of epinephrine and norepinephrine. RESULTS: For patients in the > 60-year age group, the use of vasoactive drugs was found to be associated with an undetectable epinephrine level (OR [95% CI] = 6.36 [1.12, 36.08]), p = 0.05). For the patients with undetectable epinephrine levels, the in-hospital mortality was higher among those with a norepinephrine level ≥ 2006.5 pg/mL (OR [95% CI] = 4.00 [1.27, 12.58]), p = 0.03). CONCLUSIONS: There is an association between age and mortality. Undetectable serum epinephrine, which is more common in older patients, could contribute to poor outcomes. The use of epinephrine might improve the clinical prognosis in older surgical patients with shock.

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OBJECTIVES: This study evaluated the association between refeeding syndrome (RFS) risk and intensive care unit (ICU)/in-hospital mortality and length of stay (LOS) and ICU readmission in critically ill patients. METHODS: This secondary analysis of a cohort study included patients aged ≥ 18 years admitted at ICU 24 h before data collection. We evaluated RFS risk based on the National Institute for Health and Clinical Excellence (NICE), stratifying it into four categories (no, low, high, and very-high risk). SETTING: Five adult ICUs in Brazil. MAIN OUTCOME MEASURES: ICU/in-hospital mortality and LOS and ICU readmission data were obtained from electronic medical records analysis, following patients until discharge (alive or not). RESULTS: The study involved 447 patients, categorized into no (19.2 %), low (28.6 %), high (48.8 %), and very-high (3.4 %) RFS risk groups. No significant differences emerged between the two groups (at RFS risk and no RFS risk) regarding the ICU death ratio (34.3 % versus 23.4 %) and LOS (5 versus 4 days), respectively. In contrast, patients at RFS risk experienced higher in-hospital mortality rates (34.3 % versus 23.4 %) prolonged hospital LOS (21 days versus 17 days), and increased ICU readmission rates (15 % versus 8.4 %) than patients without RFS risk. After adjusting for age and Sequential Organ Failure Assessment (SOFA) Score, we found no association between RFS risk and increased mortality in the ICU or hospital. Also, there was no significant association between RFS risk and prolonged LOS in the ICU or hospital setting. However, patients identified as at risk of RFS showed nearly double the odds of ICU readmission (Odds ratio, 1.90; 95 % CI 1.02-3.43). CONCLUSIONS: This study found no significant association between RFS risk and increased mortality in both the ICU and hospital settings, nor was there a significant association with prolonged LOS in the ICU or hospital among critically ill patients. However, patients at risk of RFS exhibited nearly double the odds of ICU readmission. IMPLICATIONS FOR CLINICAL PRACTICE: Our findings may contribute to understanding risks associated with ICU readmissions, highlighting the complexity of discharge decision-making through comprehensive assessments.

Assuntos

Estado Terminal , Unidades de Terapia Intensiva , Tempo de Internação , Readmissão do Paciente , Síndrome da Realimentação , Humanos , Tempo de Internação/estatística & dados numéricos , Feminino , Masculino , Unidades de Terapia Intensiva/estatística & dados numéricos , Unidades de Terapia Intensiva/organização & administração , Readmissão do Paciente/estatística & dados numéricos , Pessoa de Meia-Idade , Estado Terminal/mortalidade , Idoso , Brasil/epidemiologia , Estudos de Coortes , Adulto , Síndrome da Realimentação/mortalidade , Mortalidade Hospitalar/tendências , Fatores de Risco

RESUMO

Cefepime and piperacillin/tazobactam are antimicrobials recommended by IDSA/ATS guidelines for the empirical management of patients admitted to the intensive care unit (ICU) with community-acquired pneumonia (CAP). Concerns have been raised about which should be used in clinical practice. This study aims to compare the effect of cefepime and piperacillin/tazobactam in critically ill CAP patients through a targeted maximum likelihood estimation (TMLE). A total of 2026 ICU-admitted patients with CAP were included. Among them, (47%) presented respiratory failure, and (27%) developed septic shock. A total of (68%) received cefepime and (32%) piperacillin/tazobactam-based treatment. After running the TMLE, we found that cefepime and piperacillin/tazobactam-based treatments have comparable 28-day, hospital, and ICU mortality. Additionally, age, PTT, serum potassium and temperature were associated with preferring cefepime over piperacillin/tazobactam (OR 1.14 95% CI [1.01-1.27], p = 0.03), (OR 1.14 95% CI [1.03-1.26], p = 0.009), (OR 1.1 95% CI [1.01-1.22], p = 0.039) and (OR 1.13 95% CI [1.03-1.24], p = 0.014)]. Our study found a similar mortality rate among ICU-admitted CAP patients treated with cefepime and piperacillin/tazobactam. Clinicians may consider factors such as availability and safety profiles when making treatment decisions.

Assuntos

Antibacterianos , Cefepima , Infecções Comunitárias Adquiridas , Estado Terminal , Unidades de Terapia Intensiva , Combinação Piperacilina e Tazobactam , Humanos , Cefepima/uso terapêutico , Cefepima/administração & dosagem , Infecções Comunitárias Adquiridas/tratamento farmacológico , Infecções Comunitárias Adquiridas/mortalidade , Combinação Piperacilina e Tazobactam/uso terapêutico , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Antibacterianos/uso terapêutico , Funções Verossimilhança , Pneumonia/tratamento farmacológico , Pneumonia/mortalidade , Piperacilina/uso terapêutico

RESUMO

BACKGROUND: SARS-CoV-2 infection has been associated with multiple short- and long-term complications including depression, and cognitive impairment (CI). However, older adults with CI after COVID-19 have not been fully documented. OBJECTIVE: To evaluate cognitive function in Mexican adults post-recovery from SARS-CoV-2 infection. METHODS: In this prospective observational cohort study, we assess cognitive function (CF) by the Montreal Cognitive Assessment (MOCA) test with a cut-off less than 26 points, and functional status via telemedicine. Eligible patients with a history of moderate-severe COVID-19 aged ≥60 years, cognitively healthy (evaluated by Everyday Cognition Scale) and required admission to an intensive care unit (ICU) were included. Patients with history of dementia, stroke, and delirium during the cognitive evaluation were excluded. The association between CI and COVID-19 was assessed with a Cox regression model. RESULTS: From the 634 patients admitted to the ICU, 415 survived, afterward 308 were excluded and 107 were analyzed. Mean age was 70 years, 58% were female, and 53% had severe COVID. The mean MoCA score was 21±5 points, CI was present in 61 patients (57%). Infection severity (RR 1.87; 95% CI: 1.11-3.15, p<0.05), lower education (RR 0.92; 95% CI: 0.87-0.97, p<0.01), and activity daily living disability (RR 1.87; 95% CI: 1.07-3.26, p<0.05) were the main factors associated with CI (unadjusted model by age and sex). The delayed recall, orientation, and language (83.2, 77.6 and 72.9% respectively) domains were the most affected in patients with CI. CONCLUSIONS: Fifty-seven percent of patients analyzed developed CI six months post-ICU discharge due to SARS-CoV-2, and COVID severity was the main factor associated to its outcome.

Assuntos

COVID-19 , Cognição , Disfunção Cognitiva , Humanos , COVID-19/complicações , Feminino , Masculino , Idoso , México , Estudos Prospectivos , Disfunção Cognitiva/etiologia , Pessoa de Meia-Idade , Testes de Estado Mental e Demência , Fatores de Tempo , Idoso de 80 Anos ou mais , Estudos de Coortes , Unidades de Terapia Intensiva , Índice de Gravidade de Doença

RESUMO

Acuity assessments are vital for timely interventions and fair resource allocation in critical care settings. Conventional acuity scoring systems heavily depend on subjective patient assessments, leaving room for implicit bias and errors. These assessments are often manual, time-consuming, intermittent, and challenging to interpret accurately, especially for healthcare providers. This risk of bias and error is likely most pronounced in time-constrained and high-stakes environments, such as critical care settings. Furthermore, such scores do not incorporate other information, such as patients' mobility level, which can indicate recovery or deterioration in the intensive care unit (ICU), especially at a granular level. We hypothesized that wearable sensor data could assist in assessing patient acuity granularly, especially in conjunction with clinical data from electronic health records (EHR). In this prospective study, we evaluated the impact of integrating mobility data collected from wrist-worn accelerometers with clinical data obtained from EHR for estimating acuity. Accelerometry data were collected from 87 patients wearing accelerometers on their wrists in an academic hospital setting. The data was evaluated using five deep neural network models: VGG, ResNet, MobileNet, SqueezeNet, and a custom Transformer network. These models outperformed a rule-based clinical score (Sequential Organ Failure Assessment, SOFA) used as a baseline when predicting acuity state (for ground truth we labeled as unstable patients if they needed life-supporting therapies, and as stable otherwise), particularly regarding the precision, sensitivity, and F1 score. The results demonstrate that integrating accelerometer data with demographics and clinical variables improves predictive performance compared to traditional scoring systems in healthcare. Deep learning models consistently outperformed the SOFA score baseline across various scenarios, showing notable enhancements in metrics such as the area under the receiver operating characteristic (ROC) Curve (AUC), precision, sensitivity, specificity, and F1 score. The most comprehensive scenario, leveraging accelerometer, demographics, and clinical data, achieved the highest AUC of 0.73, compared to 0.53 when using SOFA score as the baseline, with significant improvements in precision (0.80 vs. 0.23), specificity (0.79 vs. 0.73), and F1 score (0.77 vs. 0.66). This study demonstrates a novel approach beyond the simplistic differentiation between stable and unstable conditions. By incorporating mobility and comprehensive patient information, we distinguish between these states in critically ill patients and capture essential nuances in physiology and functional status. Unlike rudimentary definitions, such as equating low blood pressure with instability, our methodology delves deeper, offering a more holistic understanding and potentially valuable insights for acuity assessment.

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BACKGROUND: Alcohol misuse is overlooked frequently in hospitalized patients, but is common among patients with pneumonia and acute hypoxic respiratory failure. Investigations in hospitalized patients rely heavily on self-report surveys or chart abstraction, which lack sensitivity. Therefore, our understanding of the prevalence of alcohol misuse before and during the COVID-19 pandemic is limited. RESEARCH QUESTION: In critically ill patients with respiratory failure, did the proportion of patients with alcohol misuse, defined by the direct biomarker phosphatidylethanol, vary over a period including the COVID-19 pandemic? STUDY DESIGN AND METHODS: Patients with acute hypoxic respiratory failure receiving mechanical ventilation were enrolled prospectively from 2015 through 2019 (before the pandemic) and from 2020 through 2022 (during the pandemic). Alcohol use data, including Alcohol Use Disorders Identification Test (AUDIT)-C scores, were collected from electronic health records, and phosphatidylethanol presence was assessed at ICU admission. The relationship between clinical variables and phosphatidylethanol values was examined using multivariable ordinal regression. Dichotomized phosphatidylethanol values (≥ 25 ng/mL) defining alcohol misuse were compared with AUDIT-C scores signifying misuse before and during the pandemic, and correlations between log-transformed phosphatidylethanol levels and AUDIT-C scores were evaluated and compared by era. Multiple imputation by chained equations was used to handle missing phosphatidylethanol data. RESULTS: Compared with patients enrolled before the pandemic (n = 144), patients in the pandemic cohort (n = 92) included a substantially higher proportion with phosphatidylethanol-defined alcohol misuse (38% vs 90%; P < .001). In adjusted models, absence of diabetes, positive results for COVID-19, and enrollment during the pandemic each were associated with higher phosphatidylethanol values. The correlation between health care worker-recorded AUDIT-C score and phosphatidylethanol level was significantly lower during the pandemic. INTERPRETATION: The higher prevalence of phosphatidylethanol-defined alcohol misuse during the pandemic suggests that alcohol consumption increased during this period, identifying alcohol misuse as a potential risk factor for severe COVID-19-associated respiratory failure. Results also suggest that AUDIT-C score may be less useful in characterizing alcohol consumption during high clinical capacity.

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Sepsis continues to be a significant public health challenge despite advances in understanding its pathophysiology and management strategies. Therefore, this study evaluated the value of cell-free nuclear DNA (cf-nDNA) and cell-free mitochondrial DNA (cf-mtDNA) for assessing the severity and prognosis of sepsis. Ninety-four patients were divided into three groups: infection (n = 32), sepsis (n = 30), and septic shock (n = 32). Plasma samples were collected at the time of diagnosis, and cfDNA concentrations were determined by qPCR assay. The results showed that plasma cfDNA levels increased with the severity of the disease. To distinguish between patients with infection and those with sepsis, the biomarker L1PA290 achieved the highest AUC of 0.817 (95% CI: 0.725-0.909), demonstrating a sensitivity of 77.0% and a specificity of 79.3%. When cf-nDNA was combined with the SOFA score, there was a significant improvement in the AUC (0.916 (0.853-0.979)), sensitivity (88.1%), and specificity (80.0%). Moreover, patients admitted to the ICU after being diagnosed with sepsis had significantly higher cf-nDNA concentrations. In patients admitted to the ICU, combining cf-nDNA with the SOFA score yielded an AUC of 0.753 (0.622-0.857), with a sensitivity of 95.2% and a specificity of 50.0%. cfDNA can differentiate between patients with infection and those with sepsis. It can also identify patients who are likely to be admitted to the ICU by predicting those with indications for intensive care, suggesting its potential as a biomarker for sepsis.

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BACKGROUND: Chile rapidly implemented an extensive COVID-19 vaccination campaign, deploying a diversity of vaccines with a strategy that prioritized the elderly and individuals with comorbidities. This study aims to assess the direct impact of vaccination on the number of COVID-19 related cases, hospital admissions, ICU admissions and deaths averted during the first year and a half of the campaign. METHODS: Via Chile's transparency law, we obtained access to weekly event counts categorized by vaccination status and age. Integrating this data with publicly available census and vaccination coverage information, we conducted a comparative analysis of weekly incidence rates between vaccinated and unvaccinated groups from December 20, 2020 to July 2, 2022 to estimate the direct impact of vaccination in terms of the number of cases, hospitalizations, ICU admissions and deaths averted, using an approach that avoids the need to explicitly specify the effectiveness of each vaccine deployed. RESULTS: We estimated that, from December 20, 2020 to July 2, 2022 the vaccination campaign directly prevented 1,030,648 (95% Confidence Interval: 1,016,975-1,044,321) cases, 268,784 (95% CI: 264,524-273,045) hospitalizations, 85,830 (95% CI: 83,466-88,194) ICU admissions and 75,968 (95% CI: 73,909-78,028) deaths related to COVID-19 among individuals aged 16 years and older. This corresponds to a reduction of 26% of cases, 66% of hospital admissions, 70% of ICU admissions and 67% of deaths compared to a scenario without vaccination. Individuals 55 years old or older represented 67% of hospitalizations, 73% of ICU admissions and 89% of deaths related to COVID-19 prevented. CONCLUSIONS: This study highlights the role of Chile's vaccination campaign in reducing COVID-19 disease burden, with the most substantial reductions observed in severe outcomes.

Assuntos

Vacinas contra COVID-19 , COVID-19 , Hospitalização , Unidades de Terapia Intensiva , Humanos , Chile/epidemiologia , COVID-19/prevenção & controle , COVID-19/mortalidade , COVID-19/epidemiologia , Vacinas contra COVID-19/administração & dosagem , Hospitalização/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Pessoa de Meia-Idade , Adulto , Idoso , Adolescente , SARS-CoV-2 , Vacinação/estatística & dados numéricos , Adulto Jovem , Masculino , Feminino , Programas de Imunização/estatística & dados numéricos , Incidência , Criança

RESUMO

Objetivo: Relacionar las complicaciones y el riesgo de muerte en pacientes neurocríticos admitidos en la unidad de cuidados intensivos (UCI) del Hospital Universitario de Caracas durante un período de 5 meses. Métodos: investigación observacional, prospectiva, descriptiva. La muestra estuvo conformada por 65 pacientes neurocríticos, ≥ 18 años, con patologías médicas o quirúrgicas, ingresados en la UCI. El análisis estadístico incluyó la determinación de frecuencias, promedios, porcentajes y medias para descripción de variables y el T de Student. Resultados: La edad promedio fue 50,98 ± 16,66 años; la población masculinarepresentó el 50,76%. Entre las complicaciones, la mayor incidencia correspondió a las no infecciosas (70,77 %) y los trastornos ácido-básicos de tipo metabólico, la anemia y las alteraciones electrolíticas fueron las más frecuentes; el 29,23% de los pacientes presentaron complicaciones infecciosas, y la neumonía asociada a ventilación mecánica fue la más frecuente (73,91 %). La comorbilidad con mayor incidencia fue hipertensión arterial sistémica (53,84%). El 90.70% requirió ventilación mecánica y el tiempo en VM fue 4.29 ± 6.43 días. La estancia en UCI fue 5.96 ± 7.72 días. El 29,23% presentó un puntaje en la escala APACHE II entre 5-9; el SAPS II presentó mayor incidencia entre los 6-21 y 22-37 puntos con (66,70%); el SOFA al ingreso se reportó < 15 puntos en 98,46% y > 15 en 1,53%. La mortalidad del grupo fue 23,08 % (n=15). Conclusiones: Las complicaciones no infecciosas predominaron sobre las infecciosas las primeras íntimamente relacionadas con la mortalida(AU)

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Objective: To relate complications and the risk of death in neurocritical patients admitted to the intensive care unit (ICU) of the University Hospital of Caracas during a period of 5 months. Methods: observational, prospective, descriptive research. The sample was made up of 65 neurocritical patients, ≥ 18 years old, with medical or surgical pathologies, admitted to the ICU.The statistical analysis included the determination of frequencies, averages, percentages and meansfor description of variables and Student's T.Results: The average age was 50.98 ± 16.66 years; the male population represented 50.76%. Among the complications, the highest incidence corresponded to non-infectious complications (70.77%) and metabolic acid-base disorders, anemia and electrolyte alterations were the most frequent; 29.23% of patients presented infectious complications, and pneumonia associated with mechanical ventilation was the most frequent (73.91%). The comorbidity with the highest incidence was systemic arterial hypertension (53.84%), 90.70% required mechanical ventilation and the time on MV was 4.29 ± 6.43 days. The ICU stay was 5.96 ± 7.72 days. 29.23% had a score on the APACHE II scale between 5-9; SAPS II presented the highest incidence between 6-21 and 22-37 points with (66.70%); The SOFA upon admission was reported to be < 15 points in 98.46% and > 15 in 1.53%. The mortality of the group was 23.08% (n=15). Conclusions: Non-infectious complications predominated over infectious complications, the former being closely related to mortalit(AU)

Assuntos

Humanos , Masculino , Feminino , Mortalidade , Cuidados Críticos , Anemia

RESUMO

BACKGROUND: Little is known about the incidence of delirium and its subtypes in patients admitted to different departments of university hospitals in Latin America. OBJECTIVE: To determine the incidence of delirium and the frequency of its subtypes, as well as its associated factors, in patients admitted to different departments of a university hospital in Bogotá, Colombia. METHODS: A cohort of patients over 18 years of age admitted to the internal medicine (IM), geriatrics (GU), general surgery (GSU), orthopaedics (OU) and intensive care unit (ICU) services of a university hospital was followed up between January and June 2018. To detect the presence of delirium, we used the CAM (Confusion Assessment Method) and the CAM-ICU if the patient had decreased communication skills. The delirium subtype was characterised using the RASS (Richmond Agitation and Sedation Scale). Patients were assessed on their admission date and then every two days until discharged from the hospital. Those in whom delirium was identified were referred for specialised intra-institutional interdisciplinary management. RESULTS: A total of 531 patients admitted during the period were assessed. The overall incidence of delirium was 12% (95% CI, 0.3-14.8). They represented 31.8% of patients in the GU, 15.6% in the ICU, 8.7% in IM, 5.1% in the OU, and 3.9% in the GSU. The most frequent clinical display was the mixed subtype, at 60.9%, followed by the normoactive subtype (34.4%) and the hypoactive subtype (4.7%). The factors most associated with delirium were age (adjusted RR = 1.07; 95% CI, 1.05-1.09), the presence of four or more comorbidities (adjusted RR = 2.04; 95% CI, 1.31-3.20), and being a patient in the ICU (adjusted RR = 2.02; 95% CI, 1.22-3.35). CONCLUSIONS: The incidence of delirium is heterogeneous in the different departments of the university hospital. The highest incidence occurred in patients that were admitted to the GU. The mixed subtype was the most frequent one, and the main associated factors were age, the presence of four or more comorbidities, and being an ICU patient.

Assuntos

Delírio , Hospitais Universitários , Humanos , Delírio/epidemiologia , Delírio/diagnóstico , Incidência , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Colômbia/epidemiologia , Idoso de 80 Anos ou mais , Adulto , Unidades de Terapia Intensiva/estatística & dados numéricos , Estudos de Coortes , Hospitalização/estatística & dados numéricos , Fatores de Risco

RESUMO

INTRODUCTION: Amidst the routine utilization of protocolized sedation in ventilated ICU patients, existing management guidelines exhibit a lack of unanimous recommendations for its widespread adoption. This study endeavors to comprehensively assess the effectiveness and safety of protocolized sedation in critically ill ventilated patients. OBJECTIVE: The primary objective of this study was to systematically review and conduct a meta-analysis of clinical trials comparing protocolized sedation with standard management in critically ill ventilated patients. Key outcomes under scrutiny include ICU and hospital mortality, ventilation days, duration of ICU stay, and incidents of self-extubation. The evaluation incorporates the Risk of Bias 2 (RoB2) tool to assess the quality of included studies. Data analysis utilizes a random-effects model for relative risk (RR) and mean differences. Subgroup analysis categorizes sedation protocols into algorithmic or daily interruption, addressing potential heterogeneity. Additionally, a GRADE evaluation is performed to ascertain the overall certainty of the evidence. RESULTS: From an initial pool of 1504 records, 10 studies met the inclusion criteria. Protocolized sedation demonstrated a reduced RR for mortality (RR: 0.80, 95% CI 0.68-0.93, p < 0.01, I2 = 0%) and a decrease in ventilation days (mean difference: - 1.12, 95% CI - 2.11 to - 0.14, p = 0.03, I2 = 84%). Furthermore, there was a notable reduction in ICU stay (mean difference: - 2.24, 95% CI - 3.59 to - 0.89, p < 0.01, I2 = 81%). However, incidents of self-extubation did not exhibit a significant difference (RR: 1.20, 95% CI 0.49-2.94, p = 0.69, I2 = 35%). Subgroup analyses effectively eliminated heterogeneity (I2 = 0%), and the GRADE evaluation yielded moderate results for mortality, ventilation days, and ICU duration. CONCLUSION: Protocolized sedation, whether implemented algorithmically or through daily interruption, emerges as a safe and effective approach when compared to standard management in ventilated ICU patients. The findings from this study contribute valuable insights to inform evidence-based practices in sedation management for this critical patient population.

Assuntos

Hipnóticos e Sedativos , Unidades de Terapia Intensiva , Respiração Artificial , Humanos , Respiração Artificial/métodos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/uso terapêutico , Cuidados Críticos/métodos , Cuidados Críticos/normas , Estado Terminal/mortalidade , Estado Terminal/terapia , Sedação Consciente/métodos , Mortalidade Hospitalar , Tempo de Internação , Protocolos Clínicos

Assuntos

Cuidados Críticos , Sistema de Registros , Humanos

RESUMO

Severe community-acquired pneumonia (sCAP) remains one of the leading causes of admission to the intensive care unit, thus consuming a large share of resources and is associated with high mortality rates worldwide. The evidence generated by clinical studies in the last decade was translated into recommendations according to the first published guidelines focusing on severe community-acquired pneumonia. Despite the advances proposed by the present guidelines, several challenges preclude the prompt implementation of these diagnostic and therapeutic measures. The present article discusses the challenges for the broad implementation of the sCAP guidelines and proposes solutions when applicable.

Assuntos

Infecções Comunitárias Adquiridas , Pneumonia , Humanos , Pneumonia/terapia , Pneumonia/tratamento farmacológico , Infecções Comunitárias Adquiridas/terapia , Infecções Comunitárias Adquiridas/tratamento farmacológico , Unidades de Terapia Intensiva , Hospitalização

RESUMO

Staphylococcus capitis has been recognized as a relevant opportunistic pathogen, particularly its persistence in neonatal ICUs around the world. Therefore, the aim of this study was to describe the epidemiological profile of clinical isolates of S. capitis and to characterize the factors involved in the persistence and pathogenesis of these strains isolated from blood cultures collected in a hospital in the interior of the state of São Paulo, Brazil. A total of 141 S. capitis strains were submitted to detection of the mecA gene and SCCmec typing by multiplex PCR. Genes involved in biofilm production and genes encoding enterotoxins and hemolysins were detected by conventional PCR. Biofilm formation was evaluated by the polystyrene plate adherence test and phenotypic resistance was investigated by the disk diffusion method. Finally, pulsed-field gel electrophoresis (PFGE) was used to analyze the clonal relationship between isolates. The mecA gene was detected in 99 (70.2%) isolates, with this percentage reaching 100% in the neonatal ICU. SCCmec type III was the most prevalent type, detected in 31 (31.3%) isolates and co-occurrence of SCCmec was also observed. In vitro biofilm formation was detected in 46 (32.6%) isolates but was not correlated with the presence of the ica operon genes. Furthermore, biofilm production in ICU isolates was favored by hyperosmotic conditions, which are common in ICUs because of the frequent parenteral nutrition. Analysis of the clonal relationship between the isolates investigated in the present study confirms a homogeneous profile of S. capitis and the persistence of clones that are prevalent in the neonatal ICU and disseminated across the hospital. This study highlights the adaptation of isolates to specific hospital environments and their high clonality.

RESUMO

Intracranial hypertension (IH) is a life-threating condition especially for the brain injured patient. In such cases, an external ventricular drain (EVD) or an intraparenchymal bolt are the conventional gold standard for intracranial pressure (ICPi) monitoring. However, these techniques have several limitations. Therefore, identifying an ideal screening method for IH is important to avoid the unnecessary placement of ICPi and expedite its introduction in patients who require it. A potential screening tool is the ICP wave morphology (ICPW) which changes according to the intracranial volume-pressure curve. Specifically, the P2/P1 ratio of the ICPW has shown promise as a triage test to indicate normal ICP. In this study, we propose evaluating the noninvasive ICPW (nICPW-B4C sensor) as a screening method for ICPi monitoring in patients with moderate to high probability of IH. This is a retrospective analysis of a prospective, multicenter study that recruited adult patients requiring ICPi monitoring from both Federal University of São Paulo and University of São Paulo Medical School Hospitals. ICPi values and the nICPW parameters were obtained from both the invasive and the noninvasive methods simultaneously 5 min after the closure of the EVD drainage. ICP assessment was performed using a catheter inserted into the ventricle and connected to a pressure transducer and a drainage system. The B4C sensor was positioned on the patient's scalp without the need for trichotomy, surgical incision or trepanation, and the morphology of the ICP waves acquired through a strain sensor that can detect and monitor skull bone deformations caused by changes in ICP. All patients were monitored using this noninvasive system for at least 10 min per session. The area under the curve (AUC) was used to describe discriminatory power of the P2/P1 ratio for IH, with emphasis in the Negative Predictive value (NPV), based on the Youden index, and the negative likelihood ratio [LR-]. Recruitment occurred from August 2017 to March 2020. A total of 69 patients fulfilled inclusion and exclusion criteria in the two centers and a total of 111 monitorizations were performed. The mean P2/P1 ratio value in the sample was 1.12. The mean P2/P1 value in the no IH population was 1.01 meanwhile in the IH population was 1.32 (p < 0.01). The best Youden index for the mean P2/P1 ratio was with a cut-off value of 1.13 showing a sensitivity of 93%, specificity of 60%, and a NPV of 97%, as well as an AUC of 0.83 to predict IH. With the 1.13 cut-off value for P2/P1 ratio, the LR- for IH was 0.11, corresponding to a strong performance in ruling out the condition (IH), with an approximate 45% reduction in condition probability after a negative test (ICPW). To conclude, the P2/P1 ratio of the noninvasive ICP waveform showed in this study a high Negative Predictive Value and Likelihood Ratio in different acute neurological conditions to rule out IH. As a result, this parameter may be beneficial in situations where invasive methods are not feasible or unavailable and to screen high-risk patients for potential invasive ICP monitoring.Trial registration: At clinicaltrials.gov under numbers NCT05121155 (Registered 16 November 2021-retrospectively registered) and NCT03144219 (Registered 30 September 2022-retrospectively registered).

Assuntos

Lesões Encefálicas , Hipertensão Intracraniana , Pressão Intracraniana , Humanos , Feminino , Masculino , Adulto , Pessoa de Meia-Idade , Hipertensão Intracraniana/diagnóstico , Estudos Retrospectivos , Monitorização Fisiológica/métodos , Lesões Encefálicas/complicações , Lesões Encefálicas/diagnóstico , Estudos Prospectivos , Curva ROC , Idoso

RESUMO

Objective: This study aims to develop a predictive model using artificial intelligence to estimate the ICU length of stay (LOS) for Congenital Heart Defects (CHD) patients after surgery, improving care planning and resource management. Design: We analyze clinical data from 2240 CHD surgery patients to create and validate the predictive model. Twenty AI models are developed and evaluated for accuracy and reliability. Setting: The study is conducted in a Brazilian hospital's Cardiovascular Surgery Department, focusing on transplants and cardiopulmonary surgeries. Participants: Retrospective analysis is conducted on data from 2240 consecutive CHD patients undergoing surgery. Interventions: Ninety-three pre and intraoperative variables are used as ICU LOS predictors. Measurements and main results: Utilizing regression and clustering methodologies for ICU LOS (ICU Length of Stay) estimation, the Light Gradient Boosting Machine, using regression, achieved a Mean Squared Error (MSE) of 15.4, 11.8, and 15.2 days for training, testing, and unseen data. Key predictors included metrics such as "Mechanical Ventilation Duration", "Weight on Surgery Date", and "Vasoactive-Inotropic Score". Meanwhile, the clustering model, Cat Boost Classifier, attained an accuracy of 0.6917 and AUC of 0.8559 with similar key predictors. Conclusions: Patients with higher ventilation times, vasoactive-inotropic scores, anoxia time, cardiopulmonary bypass time, and lower weight, height, BMI, age, hematocrit, and presurgical oxygen saturation have longer ICU stays, aligning with existing literature.

RESUMO

Background: The COVID-19 pandemic has had a severe impact on the Latin American subcontinent, particularly in areas with limited hospital resources and a restricted Intensive Care Unit (ICU) capacity. This study aimed to provide a comprehensive description of the clinical characteristics, outcomes, and factors associated with survival of COVID-19 hospitalized patients in Honduras. Research question: What were the characteristics and outcomes of COVID-19 patients in a large referral center in Honduras? Study design and methods: This study employed a retrospective cohort design conducted in a single center in San Pedro Sula, Honduras, between October 2020 to March 2021. All hospitalized cases of confirmed COVID-19 during this timeframe were included in the analysis. Univariable and multivariable survival analysis were performed using Kaplan-Meier curves and Cox proportional hazards model aiming to identify factors associated with decreased 30 day in-hospital survival, using a priori-selected factors. Results: A total of 929 confirmed cases were identified in this cohort, with males accounting for 55.4 % of cases. The case fatality rate among the hospitalized patients was found to be 50.1 % corresponding to 466 deaths. Patients with comorbidities such as hypertension, diabetes, obesity, chronic kidney disease, chronic obstructive pulmonary disease and cardiovascular disease had a higher likelihood of mortality. Additionally, non-survivors had a significantly longer time from illness onset to hospital admission compared to survivors (8.2 days vs 4.7 days). Among the cohort, 306 patients (32.9 %) met criteria for ICU admission. However, due to limited capacity, only 60 patients (19·6 %) were admitted to the ICU. Importantly, patients that were unable to receive level-appropriate care had lower likelihood of survival compared to those who received level-appropriate care (hazard ratio: 1.84). Interpretation: This study represents, the largest investigation of in-hospital COVID-19 cases in Honduras and Central America. The findings highlight a substantial case fatality rate among hospitalized patients. In this study, patients who couldn't receive level-appropriate care (ICU admission) had a significantly lower likelihood of survival when compared to those who did. These results underscore the significant impact of healthcare access during the pandemic, particularly in low- and middle-income countries.