Fatores de risco para mortalidade em idosos admitidos em unidade de terapia intensiva de hospital público / Risk factors for mortality in geriatric patients admitted to the intensive care unit at a public hospital

OBJETIVO: Avaliar fatores de risco para mortalidade em pacientes idosos com internação em uma unidade de terapia intensiva (UTI). MÉTODOS: Foram estudados pacientes idosos admitidos em UTI, em um estudo de coorte histórica. Foi realizada amostragem de conveniência de todos os pacientes com 60 anos ou mais, internados nos 20 leitos de uma UTI de um hospital de alta complexidade. Foi realizada análise de regressão de Cox para estimar os fatores de risco associados à mortalidade. O nível de significância utilizado foi de 5%. RESULTADOS: A proporção de pacientes idosos representou 45% das admissões em UTI no período. A mortalidade hospitalar foi de 38,4%. A variável pós-operatório de cirurgia de urgência e os escores Acute Physiology and Chronic Health Evaluation (APACHE II) e Sequential Organ Failure Assessment (SOFA) da admissão foram identificados como fatores de risco independentes para mortalidade hospitalar. CONCLUSÃO: Os fatores de risco associados à mortalidade foram os escores APACHE II e SOFA da admissão e pós-operatório de cirurgia de urgência.

OBJECTIVE: To evaluate risk factors for mortality in geriatric patients admitted to an intensive care unit (ICU). METHODS: We studied older patients admitted to the ICU in a historical cohort study. Convenience sampling was performed for all patients aged 60 years or older, admitted to the 20 beds of an ICU of a highly complex hospital. Cox regression analysis was performed to estimate risk factors associated with mortality. The significance level used was 5%. RESULTS: The proportion of geriatric patients represented 45% of ICU admissions in the period. In-hospital mortality was 38.4%. The postoperative emergency surgery variable and the Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) admission scores were identified as independent risk factors for in-hospital mortality. CONCLUSION: Risk factors associated with mortality were APACHE II and SOFA scores for admission and postoperative emergency surgery.

Injúria renal aguda e hipertensão intra-abdominal em paciente queimado em terapia intensiva / Acute kidney injury and intra-abdominal hypertension in burn patients in intensive care

RESUMO Objetivo: Avaliar a frequência de hipertensão intra-abdominal no paciente grande queimado e sua associação com a ocorrência de injúria renal aguda. Métodos: Estudo de coorte prospectivo, com população de pacientes queimados internados nos leitos de unidade de terapia intensiva especializada. Realizada amostragem de conveniência de pacientes adultos internados no período de 1º de agosto de 2015 a 31 de outubro de 2016. Foram coletados dados clínicos e da queimadura, além de medidas seriadas da pressão intra-abdominal. O nível de significância utilizado foi de 5%. Resultados: Foram analisados 46 pacientes. Evoluíram com hipertensão intra-abdominal 38 pacientes (82,6%). A mediana da maior pressão intra-abdominal foi 15,0mmHg (intervalo interquartílico: 12,0 - 19,0). Desenvolveram injúria renal aguda 32 (69,9%) pacientes. A mediana do tempo para desenvolvimento de injúria renal aguda foi de 3 dias (intervalo interquartílico: 1 - 7). A análise individual de fatores de risco para injúria renal aguda apontou associação com hipertensão intra-abdominal (p = 0,041), uso de glicopeptídeos (p = 0,001), uso de vasopressor (p = 0,001) e uso de ventilação mecânica (p = 0,006). Foi evidenciada associação de injúria renal aguda com maior mortalidade em 30 dias (log-rank, p = 0,009). Conclusão: Ocorreu hipertensão intra-abdominal em grande parte dos pacientes estudados, predominantemente nos graus I e II. Os fatores de risco identificados para ocorrência de injúria renal aguda foram hipertensão intra-abdominal, uso de glicopeptídeos, vasopressor e ventilação mecânica. Injúria renal aguda esteve associada à maior mortalidade em 30 dias.

ABSTRACT Objective: To evaluate the frequency of intra-abdominal hypertension in major burn patients and its association with the occurrence of acute kidney injury. Methods: This was a prospective cohort study of a population of burn patients hospitalized in a specialized intensive care unit. A convenience sample was taken of adult patients hospitalized in the period from 1 August 2015 to 31 October 2016. Clinical and burn data were collected, and serial intra-abdominal pressure measurements taken. The significance level used was 5%. Results: A total of 46 patients were analyzed. Of these, 38 patients developed intra-abdominal hypertension (82.6%). The median increase in intra-abdominal pressure was 15.0mmHg (interquartile range: 12.0 to 19.0). Thirty-two patients (69.9%) developed acute kidney injury. The median time to development of acute kidney injury was 3 days (interquartile range: 1 - 7). The individual analysis of risk factors for acute kidney injury indicated an association with intra-abdominal hypertension (p = 0.041), use of glycopeptides (p = 0.001), use of vasopressors (p = 0.001) and use of mechanical ventilation (p = 0.006). Acute kidney injury was demonstrated to have an association with increased 30-day mortality (log-rank, p = 0.009). Conclusion: Intra-abdominal hypertension occurred in most patients, predominantly in grades I and II. The identified risk factors for the occurrence of acute kidney injury were intra-abdominal hypertension and use of glycopeptides, vasopressors and mechanical ventilation. Acute kidney injury was associated with increased 30-day mortality.

Caring for critically ill patients outside intensive care units due to full units: a cohort study

OBJECTIVES: This study sought to analyze the clinical and epidemiologic characteristics of critically ill patients who were denied intensive care unit admission due to the unavailability of beds and to estimate the direct costs of treatment. METHODS: A prospective cohort study was performed with critically ill patients treated in a university hospital. All consecutive patients denied intensive care unit beds due to a full unit from February 2012 to February 2013 were included. The data collected included clinical data, calculation of costs, prognostic scores, and outcomes. The patients were followed for data collection until intensive care unit admission or cancellation of the request for the intensive care unit bed. Vital status at hospital discharge was noted, and patients were classified as survivors or non-survivors considering this endpoint. RESULTS: Four hundred and fifty-four patients were analyzed. Patients were predominantly male (54.6%), and the median age was 62 (interquartile range (ITQ): 47 - 73) years. The median APACHE II score was 22.5 (ITQ: 16 - 29). Invasive mechanical ventilation was used in 298 patients (65.6%), and vasoactive drugs were used in 44.9% of patients. The median time of follow-up was 3 days (ITQ: 2 - 6); after this time, 204 patients were admitted to the intensive care unit and 250 had the intensive care unit bed request canceled. The median total cost per patient was US$ 5,945.98. CONCLUSIONS: Patients presented a high severity in terms of disease scores, had multiple organ dysfunction and needed multiple invasive therapeutic interventions. The study patients received intensive care with specialized consultation during their stay in the hospital wards and presented high costs of treatment.

Avaliação de 5 anos de atuação de um time de resposta rápida liderado por médico intensivista em hospital universitário / Evaluation of the five-year operation period of a rapid response team led by an intensive care physician at a university hospital

RESUMO Objetivo: Avaliar a implementação de time de resposta rápida multidisciplinar liderado por médico intensivista em hospital universitário. Métodos: Estudo de coorte retrospectiva realizado pela análise de fichas de atendimentos preenchidas durante os atendimentos realizados pelo time de resposta rápida do hospital universitário entre março de 2009 e fevereiro de 2014. Resultados: Foram coletados dados de 1.628 atendimentos realizados em 1.024 pacientes pelo time de resposta rápida, sendo 1.423 códigos amarelos e 205 códigos azuis. Houve maior número de atendimentos no primeiro ano, após implementação do time de resposta rápida. A análise multivariada identificou idade (OR 1,02; IC95% 1,02 - 1,03; p < 0,001), sexo masculino (OR 1,48; IC95% 1,09 - 2,01; p = 0,01), mais de um atendimento (OR 3,31; IC95% 2,32 - 4,71; p < 0,001), internação para especialidades clínicas (OR 1,77; IC95% 1,29 - 2,42; p < 0,001), pedido de vaga de unidade de terapia intensiva posterior ao código (OR 4,75; IC95% 3,43 - 6,59; p < 0,001) e admissão em unidade de terapia intensiva prévia ao código (OR 2,13, IC95% 1,41 - 3,21; p = 0,001) como fatores de risco para mortalidade hospitalar de pacientes atendidos em códigos amarelos. Conclusão: Os índices de mortalidade hospitalar foram elevados quando comparados aos da literatura e houve maior número de atendimentos no primeiro ano de atuação do time de resposta rápida. Houve maior mortalidade hospitalar entre pacientes internados para especialidades clínicas.

ABSTRACT Objective: To evaluate the implementation of a multidisciplinary rapid response team led by an intensive care physician at a university hospital. Methods: This retrospective cohort study analyzed assessment forms that were completed during the assessments made by the rapid response team of a university hospital between March 2009 and February 2014. Results: Data were collected from 1,628 assessments performed by the rapid response team for 1,024 patients and included 1,423 code yellow events and 205 code blue events. The number of assessments was higher in the first year of operation of the rapid response team. The multivariate analysis indicated that age (OR 1.02; 95%CI 1.02 - 1.03; p < 0.001), being male (OR 1.48; 95%CI 1.09 - 2.01; p = 0.01), having more than one assessment (OR 3.31; 95%CI, 2.32 - 4.71; p < 0.001), hospitalization for clinical care (OR 1.77; 95%CI 1.29 - 2.42; p < 0.001), the request of admission to the intensive care unit after the code event (OR 4.75; 95%CI 3.43 - 6.59; p < 0.001), and admission to the intensive care unit before the code event (OR 2.13; 95%CI 1.41 - 3.21; p = 0.001) were risk factors for hospital mortality in patients who were seen for code yellow events. Conclusion: The hospital mortality rates were higher than those found in previous studies. The number of assessments was higher in the first year of operation of the rapid response team. Moreover, hospital mortality was higher among patients admitted for clinical care.

Nursing Activities Score e carga de trabalho em unidade de terapia intensiva de hospital universitário / Nursing Activities Score and workload in the intensive care unit of a university hospital

Objetivo: A carga de trabalho de enfermagem é constituída pelo tempo dispendido pela equipe de enfermagem para realizar as atividades de sua responsabilidade, relacionadas direta ou indiretamente ao atendimento do paciente. O objetivo deste estudo foi avaliar a carga de trabalho de enfermagem em uma unidade de terapia intensiva adulto de hospital universitário com o uso do instrumento Nursing Activities Score (NAS). Métodos: Estudo longitudinal, prospectivo, envolvendo pacientes admitidos na unidade de terapia intensiva de um hospital universitário no período de março a dezembro de 2008. Foram coletados dados para o cálculo do NAS, do Acute Physiology and Chronic Health Evaluation (APACHE II), do Sequential Organ Failure Assessment (SOFA) e do Therapeutic Intervention Scoring System (TISS-28), diariamente até a saída da unidade de terapia intensiva adulto ou 90 dias de internação. O nível de significância adotado foi de 5%. Resultados: Foram avaliados 437 pacientes, resultando em NAS de 74,4%. O tipo de internação, tempo de permanência na unidade de terapia intensiva e condição de saída do paciente da unidade de terapia intensiva e do hospital foram variáveis associadas a diferenças na carga de trabalho da enfermagem. Houve correlação moderada do NAS médio com o escore de gravidade APACHE II (r=0,329), com o escore de disfunção orgânica SOFA médio (r=0,506) e com o TISS-28 médio (r=0,600). Conclusão: Encontramos elevada carga de trabalho de enfermagem no estudo. Esse resultado pode subsidiar planejamento para dimensionamento da equipe. A carga de trabalho sofreu influência de caraterísticas clínicas, sendo observado aumento do trabalho nos pacientes cirúrgicos de urgência e nos não sobreviventes. .

Objective: The nursing workload consists of the time spent by the nursing staff to perform the activities for which they are responsible, whether directly or indirectly related to patient care. The aim of this study was to evaluate the nursing workload in an adult intensive care unit at a university hospital using the Nursing Activities Score (NAS) instrument. Methods: A longitudinal, prospective study that involved the patients admitted to the intensive care unit of a university hospital between March and December 2008. The data were collected daily to calculate the NAS, the Acute Physiology and Chronic Health Evaluation (APACHE II), the Sequential Organ Failure Assessment (SOFA) and the Therapeutic Intervention Scoring System (TISS-28) of patients until they left the adult intensive care unit or after 90 days of hospitalization. The level of significance was set at 5%. Results: In total, 437 patients were evaluated, which resulted in an NAS of 74.4%. The type of admission, length of stay in the intensive care unit and the patients' condition when leaving the intensive care unit and hospital were variables associated with differences in the nursing workload. There was a moderate correlation between the mean NAS and APACHE II severity score (r=0.329), the mean organic dysfunction SOFA score (r=0.506) and the mean TISS-28 score (r=0.600). Conclusion: We observed a high nursing workload in this study. These results can assist in planning the size of the staff required. The workload was influenced by clinical characteristics, including an increased workload required for emergency surgical patients and patients who died. .

Colistina parenteral no tratamento de infeccoes graves: experiencia em centro unico / Parenteral colistin for the treatment of severe infections: a single center experience

Objetivo: Descrever a experiência de um único centro com o uso de colistina para tratar infecções hospitalares causadas por bactérias Gram-negativas resistentes a múltiplos fármacos e identificar fatores associados com lesão renal aguda e mortalidade. Métodos: Estudo longitudinal retrospectivo que avaliou pacientes gravemente enfermos, com infecções causadas por bactérias Gram-negativas resistentes a múltiplos fármacos. Foram considerados elegíveis para este estudo, durante o período compreendido entre janeiro e dezembro de 2008, todos os pacientes adultos com necessidade de tratamento com colistina endovenosa (colistimetato de sódio). As informações coletadas incluem dados demográficos, diagnóstico, duração do tratamento, presença de lesão renal aguda e mortalidade em 30 dias. Resultados: A colistina foi utilizada para tratar uma infecção em 109 de 789 pacientes (13,8%) admitidos à unidade de terapia intensiva. A mortalidade em 30 dias observada nestes pacientes foi de 71,6%. Vinte e nove pacientes (26,6%) tinham lesão renal prévia ao tratamento com colistina, sendo que seis deles conseguiram recuperar a função renal, mesmo durante o tratamento com colistina. Vinte e um pacientes (19,2%) desenvolveram lesão renal aguda durante o tratamento com colistina, sendo que 11 destes pacientes necessitaram ser submetidos à diálise. A variável independentemente associada com a presença de lesão renal aguda foi a pontuação segundo o sistema Sequential Organ Failure Assessment no início do tratamento com colistina (OR=1,46; IC95%=1,20-1,79; p<0,001). Idade (OR=1,03; IC95%=1,00-1,05; p=0,02) e uso de vasopressores (OR=12,48; IC95%=4,49-34,70; p<0,001) foram fatores associados a óbito, segundo um modelo de regressão logística. ...

Objective: To describe a single center experience involving the administration of colistin to treat nosocomial infections caused by multidrug-resistant Gram-negative bacteria and identify factors associated with acute kidney injury and mortality. Methods: This retrospective longitudinal study evaluates critically ill patients with infections caused by multidrug-resistant Gram-negative bacteria. All adult patients who required treatment with intravenous colistin (colistimethate sodium) from January to December 2008 were considered eligible for the study. Data include demographics, diagnosis, duration of treatment, presence of acute kidney injury and 30-day mortality. Results: Colistin was used to treat an infection in 109 (13.8%) of the 789 patients admitted to the intensive care unit. The 30-day mortality observed in these patients was 71.6%. Twenty-nine patients (26.6%) presented kidney injury prior to colistin treatment, and six of these patients were able to recover kidney function even during colistin treatment. Twenty-one patients (19.2%) developed acute kidney injury while taking colistin, and 11 of these patients required dialysis. The variable independently associated with the presence of acute kidney injury was the Sequential Organ Failure Assessment at the beginning of colistin treatment (OR 1.46; 95%CI 1.20-1.79; p<0.001). The factors age (OR 1.03; 95%CI 1.00-1.05; p=0.02) and vasopressor use (OR 12.48; 95%CI 4.49-34.70; p<0.001) were associated with death in the logistic-regression model. Conclusions: Organ dysfunction at the beginning of colistin treatment was associated with acute kidney injury. In a small group of patients, we were able to observe an improvement of kidney function during colistin treatment. Age and vasopressor use were associated with death. .