Clinical characteristics and outcomes of COVID-19 patients admitted to the intensive care unit during the first year of the pandemic in Brazil: a single center retrospective cohort study / Características clínicas e desfechos de pacientes com COVID-19 admitidos em unidade de terapia intensiva durante o primeiro ano de pandemia no Brasil: um estudo de coorte retrospectivo em centro único

ABSTRACT Objective: To describe clinical characteristics, resource use, outcomes, and to identify predictors of in-hospital mortality of patients with COVID-19 admitted to the intensive care unit. Methods: Retrospective single-center cohort study conducted at a private hospital in São Paulo (SP), Brazil. All consecutive adult (≥18 years) patients admitted to the intensive care unit, between March 4, 2020 and February 28, 2021 were included in this study. Patients were categorized between survivors and non-survivors according to hospital discharge. Results: During the study period, 1,296 patients [median (interquartile range) age: 66 (53-77) years] with COVID-19 were admitted to the intensive care unit. Out of those, 170 (13.6%) died at hospital (non-survivors) and 1,078 (86.4%) were discharged (survivors). Compared to survivors, non-survivors were older [80 (70-88) versus 63 (50-74) years; p<0.001], had a higher Simplified Acute Physiology Score 3 [59 (54-66) versus 47 (42-53) points; p<0.001], and presented comorbidities more frequently. During the intensive care unit stay, 56.6% of patients received noninvasive ventilation, 32.9% received mechanical ventilation, 31.3% used high flow nasal cannula, 11.7% received renal replacement therapy, and 1.5% used extracorporeal membrane oxygenation. Independent predictors of in-hospital mortality included age, Sequential Organ Failure Assessment score, Charlson Comorbidity Index, need for mechanical ventilation, high flow nasal cannula, renal replacement therapy, and extracorporeal membrane oxygenation support. Conclusion: Patients with severe COVID-19 admitted to the intensive care unit exhibited a considerable morbidity and mortality, demanding substantial organ support, and prolonged intensive care unit and hospital stay.

RESUMO Objetivo: Descrever características clínicas, uso de recursos e desfechos e identificar preditores de mortalidade intra-hospitalar de pacientes com COVID-19 admitidos na unidade de terapia intensiva. Métodos: Estudo de coorte retrospectivo, em centro único, realizado em um hospital privado localizado em São Paulo (SP). Pacientes adultos (≥18 anos) admitidos consecutivamente na unidade de terapia intensiva, entre 4 de março de 2020 a 28 de fevereiro de 2021, foram incluídos neste estudo. Os pacientes foram classificados como sobreviventes e não sobreviventes, de acordo com a alta hospitalar. Resultados: Durante o período do estudo, 1.296 pacientes [mediana (intervalo interquartil) de idade: 66 (53-77) anos] com COVID-19 foram admitidos na unidade de terapia intensiva. Destes, 170 (13,6%) pacientes morreram no hospital (não sobreviventes), e 1.078 (86,4%) receberam alta hospitalar (sobreviventes). Comparados aos sobreviventes, os não sobreviventes eram mais idosos [80 (70-88) versus 63 (50-74) anos; p<0,001], apresentavam pontuação mais alta no sistema prognóstico Simplified Acute Physiology Score 3 [59 (54-66) versus 47 (42-53); pontos p<0,001] e tinham mais comorbidades. Durante a internação na unidade de terapia intensiva, 56,6% dos pacientes usaram ventilação não invasiva, 32,9% usaram ventilação mecânica invasiva, 31,3% usaram cateter nasal de alto fluxo, 11,7% foram submetidos à terapia renal substitutiva, e 1,5% usou oxigenação por membrana extracorpórea. Os preditores independentes de mortalidade intra-hospitalar foram idade, Sequential Organ Failure Assessment, Índice de Comorbidade de Charlson, necessidade de ventilação mecânica, uso de cateter nasal de alto fluxo, uso de terapia renal substitutiva e suporte por oxigenação por membrana extracorpórea. Conclusão: Pacientes com quadros graves da COVID-19 admitidos na unidade de terapia intensiva apresentaram considerável mortalidade e morbidade, com alta demanda de terapia de suporte e internação prolongada em unidade de terapia intensiva e hospitalar.

A new era of thromboelastometry / A nova era da tromboelastometria

ABSTRACT Severe hemorrhage with necessity of allogeneic blood transfusion is common complication in intensive care unit and is associated with increased morbidity and mortality. Prompt recognition and treatment of bleeding causes becomes essential for the effective control of hemorrhage, rationalizing the use of allogeneic blood components, and in this way, preventing an occurrence of their potential adverse effects. Conventional coagulation tests such as prothrombin time and activated partial thromboplastin time present limitations in predicting bleeding and guiding transfusion therapy in critically ill patients. Viscoelastic tests such as thromboelastography and rotational thromboelastometry allow rapid detection of coagulopathy and goal-directed therapy with specific hemostatic drugs. The new era of thromboelastometry relies on its efficacy, practicality, reproducibility and cost-effectiveness to establish itself as the main diagnostic tool and transfusion guide in patients with severe active bleeding.

RESUMO A hemorragia grave com necessidade de transfusão de sangue e componentes é uma complicação frequente na unidade de terapia intensiva e está associada ao aumento da morbidade e da mortalidade. A identificação adequada e o tratamento precoce da causa específica da coagulopatia tornam-se fundamentais para o controle efetivo da hemorragia, racionalizando a utilização de sangue e componentes, e desta forma, prevenindo a ocorrência de efeitos adversos. Testes convencionais da coagulação (tempo de ativação de protrombina e tempo de tromboplastina parcial ativada) apresentam limitações para prever sangramento e guiar a terapia transfusional em pacientes graves. Testes viscoelásticos como a tromboelastografia e tromboelastometria rotacional permitem a rápida detecção da coagulopatia e orientam a terapia de forma individualizada, alvo dirigida com drogas hemostáticas específicas. A nova era da tromboelastometria confia na sua eficácia, praticidade, reprodutibilidade e custo-eficácia para se firmar como a principal ferramenta diagnóstica e guia transfusional em pacientes com sangramento ativo grave.

Infection and immune-mediated meningococcal-associated arthritis: combination features in the same patient / Artrite meningocócica mediada imunologicamente e associada à infecção: combinação de ambas características no mesmo paciente

We present a case of a 16-year-old male patient with sudden-onset, rash, arthritis and meningitis by Neisseria meningitidis one week after an acute upper respiratory infection. On the 10th day of treatment followed by neurological and arthritis clinical improvement, he presented once again a tender and swollen left knee with a moderate effusion, and active and passive range of motion was severely limited secondary to pain, and when he was submitted to surgical drainage and synovial fluid analysis he showed inflammatory characteristics. A non-steroidal anti-inflammatory drug was taken for five days with complete improvement of symptoms. The case is notable for its combination of features of septic and immune-mediated arthritis, which has rarely been reported in the same patient.

Paciente de 16 anos do sexo masculino apresentou-se ao serviço de emergência com quadro de erupção cutânea súbita, artrite e meningite por Neisseria meningitidis, uma semana após apresentar sintomas de infecção de vias aéreas superiores. No décimo dia de tratamento, seguido da melhora clínica neurológica e da artrite, ele volta a apresentar derrame articular moderado com limitação importante da amplitude dos movimentos passivo e ativo secundária à dor. Em seguida, foi submetido à drenagem cirúrgica e a análise do líquido sinovial mostra características inflamatórias. Foi iniciado tratamento com antiinflamatório não esteroidal por cinco dias com melhora completa dos sintomas. Esse caso tem como característica peculiar o fato do indivíduo apresentar tanto as características de artrite séptica pelo meningococo quanto de artrite imunomediada, o que tem sido pouco usual no mesmo paciente.

JC virus-associated central nervous system diseases in HIV-infected patients in Brazil: clinical presentations, associated factors with mortality and outcome

INTRODUCTION: Several presentations of neurologic complications caused by JC virus (JCV) in human immunodeficiency virus (HIV)-infected patients have been described and need to be distinguished from the "classic" form of progressive multifocal leukoencephalopathy (PMl). The objectives of this study were: 1) to describe the spectrum and frequency of presentations of JCV-associated central nervous system (CNS) diseases; 2) identify factors associated with in-hospital mortality of patients with JCV-associated CNS disease; and 3) to estimate the overall mortality of this population. MATERIAL AND METHODS: This was a retrospective study of HIV-infected patients admitted consecutively for JCVassociated CNS diseases in a referral teaching center in São Paulo, Brazil, from 2002 to 2007. All patients with laboratory confirmed JCV-associated CNS diseases were included using the following criteria: compatible clinical and radiological features associated with the presence of JCV DNA in the cerebrospinal fluid. JCV-associated CNS diseases were classified as follows: 1) classic PMl; 2) inflammatory PMl; and 3) JC virus granule cell neuronopathy (GCN). RESULTS: We included 47 cases. JCV-associated CNS diseases were classified as follows: 1) classic PMl: 42 (89%); 2) inflammatory PMl: three (6%); and 3) JC virus GCN: four (9%). Nosocomial pneumonia (p = 0.003), previous diagnosis of HIV infection (p = 0.03), and imaging showing cerebellar and/or brainstem involvement (p = 0.02) were associated with in-hospital mortality. overall mortality during hospitalization was 34%. CONCLUSIONS: Novel presentations of JCV-associated CNS diseases were observed in our setting; nosocomial pneumonia, previous diagnosis of HIV infection, and cerebellar and/or brainstem involvement were associated with in-hospital mortality; and overall mortality was high.