Advances in Extracorporeal Support Technologies in Critically Ill Children

The field of pediatric heart failure is evolving, and the patient population is growing as survival after complex congenital heart surgeries is improving. Mechanical circulatory support and extracorporeal respiratory support in critically ill children has progressed to a mainstay rescue modality in pediatric intensive care medicine. The need for mechanical circulatory support is growing, since the number of organ donors does not meet the necessity. This article aims to review the current state of available mechanical circulatory and respiratory support systems in acute care pediatrics, with an emphasis on the literature discussing the challenges associated with these complex support modalities

Application of the CBL combined with TBL based on SP teaching method in clinical teaching of department of intensive care medicine / 中华医学教育探索杂志

Objective:To study the teaching effect of the teaching method of case-based learning (CBL) combined with team-based learning (TBL) based on the standard patient (SP) in the clinical teaching of department of intensive care medicine.Methods:A total of 60 medical students clinically studying in the department of intensive care medicine were randomly divided into 2 groups, with 30 students in each group. The two groups received the clinical teaching through the lecture-based learning (LBL) teaching method and the CBL combined with TBL based on SP teaching method respectively. By evaluating the clinical synthesis ability of the students of two groups and the satisfaction survey of the two teaching methods, the teaching effect was evaluated. SPSS 19.0 statistical software was used to perform Chi-square test and t-test. Results:Compared with LBL teaching method, the students who accepted the CBL combined with TBL based on SP teaching method had significantly better clinical comprehensive ability ( P < 0.05), mainly in their clinical thinking ability [(4.18±0.55) vs. (3.66±0.47)], clinical skills [(4.03±0.61) vs. (3.59±0.52)] and communication ability with patients [(4.11±0.58) vs. (3.74±0.50)]. In addition, student satisfaction with teaching methods was also higher ( P <0.05), especially in the satisfaction of learning interest [(4.38 ± 0.72) vs. (3.65±0.56)], self-learning ability [(4.24±0.71) vs. (3.91±0.52)], clinical thinking ability [(4.09±0.66) vs. (3.22±0.54)], communication ability [(4.42±0.60) vs. (3.67±0.48)], and team cooperation spirit [(4.15±0.58) vs. (3.78±0.51)]. Conclusion:The teaching method of CBL combined with TBL based on SP is feasible and has good teaching effect in the clinical teaching of department of intensive care medicine.

Observation on effect of teaching based on cognitive load theory in the nursing teaching of intensive care medicine / 中华医学教育探索杂志

Objective:To explore the effect of teaching based on cognitive load theory (CLT) in the teaching of intensive care medicine.Methods:A total of 70 practical nursing students studying intensive care medicine in the Affiliated Hospital of Jining Medical College from January 2019 to September 2020 were taken as the research objects. The nursing students who practiced from January 2019 to November 2019 were included in the control group ( n=35), and the students from December 2019 to September 2020 were included in the observation group ( n=35). The control group was given routine teaching, and the observation group was given CLT-based teaching. The differences of training load (clinical nursing student training load survey scale), empathy ability (Jefferson empathy scale for nursing students in Chinese version), self-learning ability (self-learning ability evaluation scale for nursing students) and critical medical nursing professional ability (comprehensive evaluation scale for core competence of intensive care nursing students) were compared between the two groups at the end of teaching. Chi-square test and t-test were performed by SPSS 19.0. Results:At the end of teaching, the scores of all dimensions of the observation group's clinical nursing student training load survey scale were lower than those of the control group (all P<0.05); the scores of all dimensions of observation group's nurses Jefferson empathy scale for nursing students in Chinese version, self-learning ability evaluation scale for college nursing students, and comprehensive evaluation scale for core competence of intensive care nursing students were higher than those of the control group (all P<0.05). Conclusion:When CLT-based teaching is applied in the teaching of intensive care medical nursing, it helps to reduce the training load of learners, and promote empathy, independent learning ability, and professional ability of intensive care medical nursing skills.

Research on the application of ADDIE teaching model in the nursing teaching of intensive care medicine / 中华医学教育探索杂志

Objective:To explore the application effect of ADDIE (analyze, design, develop, implement, evaluate) teaching model in the nursing teaching of intensive care medicine.Methods:The data of 89 intern students who studied intensive care medicine in Cancer Hospital of Xinjiang Medical University between January 2016 and July 2020 were retrospectively analyzed. Intern students between January 2016 and December 2017 were included in control group ( n=43), and intern students between January 2018 and July 2020 were selected as observation group ( n=46). The interns in the control group were given regular teaching, and the interns in the observation group implemented ADDIE teaching model. The scores of core competence (comprehensive evaluation scale of core competence of intensive care nurses, CICCN), autonomous learning ability (assessment scale for autonomous learning ability of nursing college students), critical thinking ability (critical thinking disposition inventory-Chinese version, CTDI-CV) and evidence-based practice ability (Chinese version of evidence-based practice ability assessment scale for nursing students) were compared between the two groups of interns at the end of teaching. SPSS 19.0 was used for chi-square test and t test. Results:At the end of the teaching, the scores of CICCN scale, assessment scale for autonomous learning ability of nursing college students, CTDI-CV scale, and Chinese version of evidence-based practice ability assessment scale for nursing students were higher in observation group than those in control group (all P<0.05). Conclusion:The application of ADDIE teaching model in nursing teaching of intensive care medicine can effectively improve the core competence, autonomous learning ability, critical thinking ability and evidence-based practice ability of students.

Clinical application of severe multiple trauma treatment model based on damage control strategy / 中华急诊医学杂志

Objective To study the superiority of severe multiple trauma treatment model based on damage control strategy. Methods In the intergrated injury first-aid mode, the intensive care unit-guided damage control strategy was used to treat severe multiple trauma. Results A total of 789 severe multiple damage patients were treated with damage control strategies in our hospital from December 2018 to December 2018. Sixty-nine patients died and the survival rate was 91.25％. Conclusions The intensive care unit-guided trauma control strategy has a satisfactory clinical effect in the treatment of patients with severe multiple trauma.

Connect with each other, help each other, and make progress together: thoughts on the construction of Critical Care Medicine Specialist League in Henan Province / 中华危重病急救医学

Critical care medicine has developed rapidly and has become an indispensable comprehensive subject in clinical medicine at home and abroad.In recent years,the government has vigorously implemented the "Healthy China" strategy and strived to achieve a higher level of national health.The Henan Provincial People's Hospital has set up a network of interconnected "Wisdom · Critical Care Medicine Specialist League" to meet the major strategic needs of the country,and to play a role in attracting large hospitals to promote the sinking of quality medical resources and the improvement of grassroots service capabilities.Complementary advantages and resource sharing are conducive to achieve win-win cooperation and coordinated development between the third-grade class-A hospital and grassroots hospitals.

Core knowledge and skill-based approach to subspecialty construction in critical/intensive care medicine with distinct Chinese peculiarity / 中华危重病急救医学

With the rapid development of critical care medicine (CCM) in China, there are increases in the number of intensive care units (ICUs), the scale of one center ICU and the team. Subspecialty construction of CCM is of great concerns for personnel training as well as discipline development, and is currently one of the urgent problems that need to be resolved. Experience of CCM subspecialty construction from Europe and the United States is lacking and it is necessary to propose some opinions on innovation to construct CCM subspecialties with Chinese characteristics. We believe that CCM sub-specialties construction should be based on the core knowledge (pathophysiology) and skill (organ monitoring and support). The following 7 sub-specialties can be set up: ① acute lung injury and mechanical ventilation; ② shock, hemodynamic monitoring and treatment; ③ acute kidney injury and blood purification; ④ sepsis and anti-infective therapy; ⑤ stress, sedation and analgesia; ⑥ nutrition and metabolic support; ⑦ coagulation, immune and inflammation. The core knowledge and skills of critical care medicine will constantly be updated and enriched. Therefore, sub-specialty settings should be constantly updated as well.

Application of clinical cases related problem-based-learning in critical care medical education / 中华医学教育探索杂志

Objective To evaluate the application of clinical cases related problem-based-learning (PBL) method in critical care medical standardized resident training program. Methods 84 residents were randomly divided into experimental group (n=42) and control group (n=42) by lottery way. The experimental group received PBL process during clinical case analysis while the control group learned completely through traditional teaching method . The residents' clinical competence were assessed by multiple scale mixed method including question bank examination (QBE), case-based discussion (CBD), direct observation of procedural skills (DOPS), simulation etc, and Likert-type scale questionnaire was used to evaluate the feedback of training residents. SPSS 17.0 was used to do line t test to the data of both groups. Results Finally 84 residents finished the study. There were no difference in the general conditions in two groups. The PBL group achieved higher examination score during QBE [(80.26 ±8.89) vs. (86.10 ±9.32)], CBD [(84.83±5.43) vs. (75.36±6.06)], DOPS [(88.81±6.68) vs. (82.70±6.98)], simulation [(79.86±10.09) vs.(72.71±9.30)]. Except two groups residents all gave high scores in enhancing cross connection in clinical knowledge [(4.786±0.470) vs. (4.571±0.859), P=0.16], and the questionnaire results showed that the resi-dents of PBL group gave higher points in exciting autonomous learning, improving clin-ical analysis ability, accelerating clinical thinking establish, developing independent thinking habits, improving the clinical communication skills and teamwork ability (P<0.05). Conclusion The clinical cases related PBL method can improve the training effects during critical care medical standardized resident training program. It can be used broadly after adapting modification in critical care medical education.

Intensive care management of patients with liver disease: proceedings of a single-topic conference sponsored by the Brazilian Society of Hepatology

ABSTRACT Survival rates of critically ill patients with liver disease has sharply increased in recent years due to several improvements in the management of decompensated cirrhosis and acute liver failure. This is ascribed to the incorporation of evidence-based strategies from clinical trials aiming to reduce mortality. In order to discuss the cutting-edge evidence regarding critical care of patients with liver disease, a joint single topic conference was recently sponsored by the Brazilian Society of Hepatology in cooperation with the Brazilian Society of Intensive Care Medicine and the Brazilian Association for Organ Transplantation. This paper summarizes the proceedings of the aforementioned meeting and it is intended to guide intensive care physicians, gastroenterologists and hepatologists in the care management of patients with liver disease.

RESUMO A sobrevida de pacientes cirróticos críticos aumentou significantemente nos últimos anos devido a inúmeros avanços obtidos no manejo do paciente com cirrose descompensada e com insuficiência hepática aguda grave, particularmente após a incorporação na prática clínica de uma série de estratégias baseadas em evidencias com impacto reconhecido na redução de mortalidade. Com o intuito de discutir as principais evidencias disponíveis na literatura médica sobre o assunto, a Sociedade Brasileira de Hepatologia, em conjunto com a Associação de Medicina Intensiva Brasileira e a Associação Brasileira de Transplantes de Órgãos promoveu uma reunião monotemática sobre o manejo do paciente hepatopata crítico, que ocorreu em 21 de maio de 2014 na cidade do Rio de Janeiro. O relatório da reunião foi resumido no presente manuscrito com o objetivo de nortear a prática clínica de intensivistas, gastroenterologistas e hepatologistas no manejo do paciente hepatopata em ambiente de terapia intensiva.

Problemas ético del retiro o limitación de traamiento vital en unidades de cuuidados intensivos / Ethic problems bbout retirement or limitation of life-sustainin treatment in iintensive care units / Problemas étios do retiro ou limitação de tratamento vital em unidades de terapia intensiva

La medicina crítica atraviesa sus mejores momentos. Como afirma Gracia, "los cuidados intensivos han alcanzado su mayoría de edad". Nadie cuestiona dichos adelantos para pacientes que eran considerados hace relativamente poco como desahuciados. Sin embargo, también da algo de vértigo el cambio que se ha logrado en el manejo de la muerte de dichos pacientes: el tránsito de una muerte "natural" a una muerte "gobernada por el hombre". En este contexto cobran nuevo sentido conceptos como eutanasia, distanasia, futilidad, calidad de vida, muerte digna y, de manera especial, el concepto de retiro o limitación de tratamiento vital (LET). El presente artículo de reflexión analiza los problemas éticos que se generan al implementar los protocolos de LET en las unidades de cuidados intensivos (UCI). El artículo está dividido en cuatro partes: 1. Distinciones terminológicas; 2. formas de aplicación de la LET; 3. LET en casos especiales: pediatría y personas con discapacidad, y 4. los problemas éticos específicos de la LET.

Intensive Care Medicine experiences its best time. As Gracia says, "intensive care has come of age." Nobody questions such advances for patients that were considered hopeless days ago. However, it also gives some dizzying the change that has been made in the death management of such patients: the transition from a "natural" death to death "ruled by man." In this context, concepts take on new meaning as euthanasia, dysthanasia, futility, quality of life, dying with dignity and especially, the concept of retirement or limitation of life-sustaining treatment. This article discusses the ethical problems generated by implementing the limitations of life-sustaining treatment protocols in Intensive Care Units. The article is divided into 4 parts: 1. Terminological distinctions. 2. How to apply the limitation of life-sustaining treatment. 3. Limitation of life-sustaining treatment in special cases: pediatrics and disability. 4. The specific ethical problems of limitation of life-sustaining treatment.

A medicina crítica atravessa seus melhores momentos. Como Gracia diz: "os cuidados intensivos alcançaram a maioria de idade." Ninguém questiona tais avanços para os pacientes que foram consideradas até a pouco tempo como desauciados. No entanto, da um pouco de vertigem a mudança que tem-se alcançado na gestão da morte desses pacientes: a transição de uma morte "natural" à morte «governada pelo homem". Neste contexto, cobram novo sentido conceitos como eutanásia, distanásia, futilidade, qualidade de vida, morte digna e, em particular, o conceito de retiro ou limitação de tratamento vital (LET). O presente artigo de reflexão faz a análise dos problemas éticos gerados pela implementação de protocolos de LET nas unidades de terapia intensiva (UTI). O artigo está dividido em quatro partes: 1. Distinções terminológicas; 2. Formas de aplicação do LET; 3. LET em casos especiais: pediatria e pessoas com deficiência e, 4. Os problemas éticos explícitos da LET.

Risk factors and treatment of hospital-acquired pneumonia due to multi-drug-resistant organisms in intensive care unit / 中国感染控制杂志

Objective To analyze risk factors and antimicrobial use for hospital-acquired pneumonia (HAP)due to multidrug-resistant organisms (MDROs)in an intensive care unit(ICU),so as to perform risk assessment and guide antimicrobial use.Methods From January 2012 to December 2013,HAP patients were conducted retrospective co-hort study,risk factors for MDRO-HAP and rationality of antimicrobial use were analyzed.Results A total of 110 cases of HAP occurred in ICU,63 cases (57.27%)were MDR-HAP.Logistic regression analysis revealed that re-cent hospital stay ≥5 days (OR=19.94),transference from other hospitals (OR =19.33),infection type of late-onset HAP (OR=7.98),and antimicrobial use in recent 90 days (OR =3.42)were independent risk factors for MDR-HAP.Initial empirical anti-infective treatment revealed that there were no significant difference in timing of antimicrobial administration within 24 hours after clinical diagnosis was confirmed,and rationality of antimicrobial selection between MDR-HAP group and non-MDR-HAP group (both P >0.05);The isolation rate of pathogens in MDR-HAP group was lower than non-MDR-HAP group (73.02% vs 91 .49% P 0.05 );the rationality rate of therapy course in MDR-HAP group was higher than no-MDR-HAP group,but rationality rate of combination use of antimicrobial agents was slightly lower than the latter (both P < 0.05 ).Conclusion Patients in ICU should be conducted risk factor assessment,and according prevention and control measures should be formulated,so as to reduce the occurrence of MDR-HAP,health care workers should standardized the initial empirical anti-infective treatment.

Diseño de indicadores para el cuidado respiratorio y movilización temprana en una unidad de cuidado intensivo / Design Indicators for Respiratory Care and Early Mobilization in the Intensive Care Unit / Criação de indicadores para o cuidado respiratório e mobilização precoce em uma unidade de cuidado

Objetivo: Diseñar indicadores para medir procesos y resultados de algunas intervenciones del cuidado respiratorio y movilización temprana en la unidad de cuidado intensivo (UCI). Método: Se llevó a cabo un estudio descriptivo con tres fases: 1) diseño de indicadores, 2) prueba piloto de los indicadores propuestos y 3) validación y ajuste. En este documento se presentan los resultados de la primera fase del estudio. Se realizó revisión de la literatura, discusión con panel de expertos y fisioterapeutas con experiencia en la atención del paciente críticamente enfermo, se consideró la validez de constructo y la validez de criterio. Resultados: Se diseñaron quince indicadores de efectividad (ocho relacionados con el cuidado respiratorio y siete relacionados con la movilización temprana). El 66% fueron indicadores de resultado. Conclusiones: Los indicadores propuestos consideran la medición de los procesos y resultados de algunas intervenciones de cuidado respiratorio y de movilización temprana del paciente crítico, por lo tanto, permitirán mejorar la evaluación e intervención en UCI con la consecuente mejoría en la calidad de la atención.

Objective: To design indicators for measuring processes and outcomes of some respiratory care interventions, and the early mobilization in the intensive care unit (ICU). Method: A descriptive study was conducted in three phases: i) design of the indicators, ii) pilot test of the proposed indicators, and iii) validation and adjustment. This document presents the results of the first phase of the study. The selected literature was reviewed, and a discussion with a panel of experts and physiotherapists with experience in caring for critically ill patients was held. Construct validity and criterion validity were considered. Results: The study designed 15 effectiveness indicators (eight related to respiratory care and seven related to early mobilization). 66% were result indicators. Conclusions: The proposed indicators consider measuring processes and outcomes of some respiratory care interventions and early mobilization of critically ill patients, thus enhancing assessment and intervention in ICU with a consequent improvement in the quality of care.

Objetivo: criar indicadores para medir processos e resultados de algumas intervenções do cuidado respiratório e mobilização precoce na unidade de cuidado intensivo (UCI). Materiais e metodos: levou-se a cabo um estudo descritivo com três fases 1) criação de indicadores, 2) prova piloto dos indicadores propostos e 3) validação e ajuste. Neste documento apresentam-se os resultados da primeira fase do estudo. Realizou-se revisão da literatura, discussão com painel de expertos e isioterapeutas com experiência na atenção do paciente criticamente doente, se considerou a validez de constructo e a validez de critério. Resultados: criaram-se quinze indicadores de efetividade (oito relacionados com o cuidado respiratório e sete relacionados com a mobilização precoce). O 66% foram indicadores de resultado. Conclusões: os indicadores propostos consideram a medição dos processos e resultados de algumas intervenções de cuidado respiratório e de mobilização precoce do paciente crítico, portanto, permitiram melhorar a avaliação e intervenção em UCI com a consequente melhoria na qualidade da atenção.

Analysis of projects received and funded in fields of emergency and intensive care medicine/trauma/burns/plastic surgery from National Natural Science Foundation of China during 2010-2013 / 中华危重病急救医学

Objective To summarized the projects received and funded in the fields of emergency and intensive care medicine/trauma/burns/plastic surgery from National Natural Science Foundation of China (NSFC) during 2010-2013,put forward the thinking and perspective of this future trend in these fields.Methods The number of the funded project and total funding in the fields of emergency and intensive care medicine/trauma/burns/plastic surgery from NSFC during 2010-2013 had been statistical analyzed,in the meantime,the overview situation of various branches in basic research and further preliminary analysis the research frontier and hot issues have been analyzed.Results ① The number of funded project were 581 in H 15 of NSFC during 2010-2013,total funding reached to 277.13 million RMB,including 117 projects in H 1511 (emergency and intensive care medicine/trauma/burns/plastic surgery and other science issue),96 projects in H1507 (wound healing and scar),88 projects in H1502 (multi-organ failure),71 projects in H 1505 (burn),61 projects in H 1504 (trauma) ② The top 10 working unit for project funding in the field of Emergency and intensive care medicine/trauma/burns/plastic surgery present as Third Military Medical University (70),Shanghai Jiao tong University (69),Second Military Medical University (40),Chinese PLA General Hospital (36),Forth Military Medical University (35),Zhejiang University (22),Sun Yat-Sen University (18),Southern Medical University (14),China Medical University (11),Capital Medical University (11) respectively,the number of funded project positive correlated with funding.③ The funded research field in H15 covered almost all important organs and system injury or repair research,our scientists reached a fairly high level in some research field,for example,sepsis,trauma,repair,et al.Sepsis was funded 112 projects in H15 for 4 years,the growth rate became rapid and stable comparing to shock,burns and cardiopulmonary resuscitation funded projects' number.emergency and intensive care medicine/trauma/burns research fields related to heart,lung,bone/cartilage/muscle,stomach/intestinal/liver,brain/spinal cord/peripheral nerve and other tissues/organs.The number of funded projects in plastic surgery related research fields in angioma and flap related projects were down below to 3 projects,but the number of funded project in wounds,scar repair related research field were more than other fields relatively.④ In frontier and research hot issue,the funded rate represent as 23.8％,21.4％,19.0％ and 23.9％ in stem cell related research fields in 4 years respectively.The funded rate average to 20.9％ in epigenetic related research fields for four years,the funded rate achieved to break through zero in autophagy related research fields,the total rate raised to 32.6％ from 2011 to 2013.Conclusions The funded number and funding were raised rapidly in the fields of emergency and intensive care medicine/trauma/burns/plastic surgery from NSFC.The application for each proposal should be focus on concise or upgrade the scientific issues to improve the quality.The depth or systematic in content and interdisciplinary research fields (e.g.immunology) should be paid attention to.Sepsis,trauma and burns will be the main stream direction in future in the fields of emergency and intensive care medicine/trauma/burns/plastic surgery.The fields of wound healing and scar,surface organ defects,damage,repair and regeneration,surface tissue/organ transplantation and reconstruction,craniofacial deformities and correction are important develop directions in future work.

Análise das UTIs do Estado de Santa Catarina e avaliação do perfil dos pacientes internados nesses setores / Analyzes of ICUs in the state of Santa Catarina and the over all evaluation of patients admitted in these sectors

Objetivo: Analisar as UTIs no Estado de Santa Catarina e o perfil dos pacientes internados nesses setores. Método: Corte transversal, realizado com o apoio do CREMESC e SOCATI. Foi enviado um questionário estruturado aos chefes das UTIs cadastradas no CREMESC (n=60), sendo anotadas as características dos hospitais e das UTIs, os recursos humanos, materiais e os dados terapêuticos referentes aos pacientes internados nas UTIs. Para análise estatísticas foram utilizados os teste X2 e ANOVA (significância 5%). Resultados: Houve a resposta de 80% dos questionários (n=48). Foram apontados 689 leitos de UTI, 63% atendiam adultos, 20% crianças e/ou recém--nascidos e 17% eram unidades mistas (adulto e infantil). A taxa de ocupação nessas unidades foi de, respectivamente, 77.8%, 60.7% e 92.4%. Foram apontados mais profissionais com título de especialista nas UTIs pediá-tricas em comparação com as UTIs de adulto (p<0.001). As UTIs possuíam a maioria dos materiais indispensá-veis. Foram anotados 0.8 ventiladores mecânicos/leito, sendo menos prevalentes o cateter de Swan Gans e o capnógrafo. Cerca de 60% dos pacientes adultos e 28% dos pediátricos estava sob ventilação mecânica. Drogas vaso ativas eram administradas em 30% dos pacientes adultos e 23% dos pediátricos. Quanto aos fármacos sedoanalgésicos, os pacientes pediátricos receberam mais midazolam. Os adultos receberam mais fentanil e outros fármacos (clonidina, propofol). Conclusão: A maioria das UTIs de Santa Catarina possui material básico adequado e bom índice de profissionais titulados trabalham nesses setores. No que concerne a administração de fármacos sedoanalgésicos, drogas vaso ativas e nutrição parenteral, as condutas tomadas com os pacientes pediátricos foram diferentes daquelas aplicadas aos adultos.

Objective: To analyze the ICUs in the state of Santa Catarina and the profile of patients admitted in these sectors. Method: Cross section study, conducted with the support of CREMESC and SOCATI. A structured questionnaire was sent to heads of ICUs enrolled in CREMESC (n=60), and noted the general characteristics of hospitals and ICUs, human resources, materials and therapeutic data concerning patients admitted to ICUs. Statistical analysis used ANOVA and x2 tests (significance 5%).Results: Eighty percent of the respondents answered the questionnaires (n=48). Were appointed 689 ICU beds, 63% used in the treatment of adults, 20% send to children and/or newborns and 17% mixed (adult/child). The occupancy rate in these units was respectively 77.8%, 60.7% and 92.4%. Respective to the professionals expertise, were appointed more diploma of specialist within pediatric ICUs compared to adult ICUs (p<0.001). The ICU had the majority of essential materials. Were recorded 0.8 mechanical ventilator for bed. The Swan Ganz catheter and capnography were the least availa-ble technologies. About 60% of adult patients and 28% of children were on mechanical ventilation. Vasoactive drugs were administered in 30% of adult patients and 23% of children. Midazolan was the more used drug for sedoanalgesic in pediatric patients, while adults received more fentanyl and other drugs (clonidine/propofol). Conclusion: The majority of ICUs in Santa Catarina has adequate basic material and adequate index of specialist working in these sectors. Regarding the administration of sedoanalgesic drugs, vasoactive drugs and parenteral nutrition, medical decisions taken with the pediatric patients were different from those applied to adults.

Lactato como prognóstico de mortalidade e falência orgânica em pacientes com síndrome da resposta inflamatória sistêmica / Lactate as a predictor of mortality and multiple organ failure in patients with the systemic inflammatory response syndrome

JUSTIFICATIVA E OBJETIVOS: A síndrome da resposta inflamatória sistêmica (SRIS) é comum em pacientes em estado crítico no pós-operatório. O objetivo deste estudo foi investigar a correlação entre dosagem de lactato, disfunção de múltiplos órgãos e mortalidade em pacientes com diagnóstico de SRIS. MÉTODO: Estudo prospectivo que avaliou 24 pacientes com diagnóstico de SRIS (Colégio Americano de Cirurgiões Torácicos/Sociedade Americana de Medicina Intensiva) no pós-operatório em UTI cirúrgica. O lactato foi dosado nas primeiras 24 horas após o diagnóstico de SRIS e diariamente durante 7 dias. Os pacientes foram divididos em dois grupos: Grupo LE (lactato > 2 mmol.L-1) e Grupo LN (lactato < 2 mmol.L-1). A falência de múltiplos órgãos foi avaliada pelo escore SOFA (Sequential Organ Failure Assessment) diariamente por sete dias. Após o seguimento por sete dias, os pacientes foram acompanhados até sua alta hospitalar ou óbito em 28 dias. RESULTADOS: Treze pacientes foram incluídos no Grupo LE após o diagnóstico de SRIS e 11 pacientes no Grupo LN. O risco relativo (RR) de óbito em sete dias para o Grupo LE foi 4,23 (IC 95 por cento 2,25-7,95) vezes maior que o Grupo LN, no primeiro dia do estudo. O RR de óbito em 28 dias foi 1,7 vezes maior para o Grupo LE (IC 95 por cento 0,84-3,46). Os grupos foram similares com relação ao SOFA durante o estudo. CONCLUSÕES: Os pacientes com lactato elevado nas primeiras 24 horas após o diagnóstico de SRIS não apresentaram mais disfunção orgânica do que os pacientes com lactato normal, porém tiveram risco aumentado de óbito em sete dias.

BACKGROUND AND OBJECTIVES: The systemic inflammatory response syndrome (SIRS) is common in the postoperative period of critically ill patients. The objective of this study was to investigate the correlation between lactate level, multiple organ dysfunction, and mortality in patients with SIRS. METHODS: This prospective study evaluated 24 patients with a postoperative diagnosis of SIRS (American College of Chest Physicians/Society of Critical Care Medicine) in the surgical ICU. Lactate levels were determined in the first 24 hours after the diagnosis of SIRS and daily, for 7 days. Patients were divided in 2 groups: LE Group (lactate > 2 mmol.L-1) and LN Group (lactate < 2 mmol.L-1). Multiple organ failure was evaluated by the SOFA (Sequential Organ Failure Assessment) score daily, for 7 days. After the 7-day follow-up period patients were followed for up to 28 days, until discharge from the hospital or death. RESULTS: Thirteen patients were included in the LE Group after the diagnosis of SIRS and 11 patients in the LN Group. The relative risk (RR) of death in 7 days for the LE Group was 4.23 (CI 95 percent 2.25-7.95) times greater than in the LN Group in the first day of the study. The RR of death in 28 days was 1.7 times greater for the LE Group (CI 95 percent 0.84-3.46). The SOFA score was similar in both groups. CONCLUSIONS: Patients with elevated lactate in the first 24 hours after the diagnosis of SIRS did not have more organic dysfunction than patients with normal lactate levels, but they had an increased risk of death in 7 days.

JUSTIFICATIVA Y OBJETIVOS: El síndrome de la respuesta inflamatoria sistémica (SRIS) es común en pacientes en estado crítico en el postoperatorio. El objetivo de este estudio fue investigar la correlación entre dosificación de lactato, disfunción de múltiplos órganos y mortalidad en pacientes con diagnóstico de SRIS. MÉTODO: Estudio prospectivo que evaluó 24 pacientes con diagnóstico de SRIS (Colegio Americano de Cirujanos Torácicos/Sociedad Americana de Medicina Intensiva) en el postoperatorio en UTI quirúrgica. El lactato fue dosificado en las primeras 24 horas después del diagnóstico de SIRS y diariamente durante 7 días. Los pacientes fueron divididos en 2 grupos: Grupo LE (lactato > 2 mmol.L-1) y Grupo LN (lactato < 2 mmol.L-1). La falencia de múltiples órganos se evaluó por la puntuación SOFA (Sequential Organ Failure Assessment) diariamente por 7 días. Después del seguimiento por 7 días, los pacientes fueron acompañados hasta su alta u óbito en 28 días. RESULTADOS: Trece pacientes fueron incluidos en el Grupo LE después del diagnóstico de SRIS y 11 pacientes en el Grupo LN. El riesgo relativo (RR) de óbito en 7 días para el Grupo LE fue 4.23 (IC 95 por ciento 2.25-7.95) veces mayor que el Grupo LN, el primero día del estudio. El RR de óbito en 28 días fue 1.7 veces mayor para el Grupo LE (IC 95 por ciento 0.84-3.46). Los grupos fueron similares con relación al SOFA durante el estudio. CONCLUSIONES: Los pacientes con lactato elevado en las primeras 24 horas después del diagnóstico de SRIS no presentaron más disfunción orgánica que los pacientes con lactato normal, pero tuvieron riesgo aumentado de óbito en 7 días.

Cuidados intensivos para pacientes em pós-operatório de cirurgia bariátrica / Intensive care of postoperative patients in bariatric surgery

JUSTIFICATIVA E OBJETIVOS: A obesidade é considerada uma epidemia e afeta mais de 300 milhões de pessoas no mundo. A sua prevalência vem aumentando significativamente nos últimos anos e a mortalidade do paciente obeso crítico, em alguns estudos, mostra-se maior, especialmente em pacientes cirúrgicos que necessitam de UTI. Este estudo teve como objetivo ressaltar as particularidades das condutas em Medicina Intensiva no pós-operatório do paciente obeso submetido à cirurgia bariátrica. CONTEÚDO: A taxa dos pacientes obesos na UTI é de 9 por cento a 26 por cento e o aumento no número de cirurgias bariáðtricas tem elevado o fluxo de obesos internados em UTI. A obesidade tem várias particularidades fisiopatológicas que devem ser conhecidas para melhor manuseio pós-operatório. Entre elas estão as restrições pulmonares, que leva ao aumento do número de complicações, o fator de risco para síndrome coronariana aguda eventos trombóticos. CONCLUSÕES: O número de pacientes submetidos à cirurgia bariátrica está aumentando, o que leva a maior número de pacientes obesos internados na UTI. As alterações fisiológicas da obesidade, juntamente com as complicações de um paciente crítico, são desafios para a prática médica. Portanto, é relevante conhecer a fisiopatologia da obesidade, o tratamento rotineiro das complicações no pós-operatório de cirurgia bariátrica.

BACKGROUND AND OBJECTIVES: Obesity is an epidemic disease reaching more than 300 million people all over the world. Its prevalence has increased during the past few years and according to some studies its mortality in the critically ill patient seems to be much higher, especially among patients who were submitted to surgery. This study has as objective to discuss some particularities of managing obese patients in the intensive care unit after bariatric surgery. CONTENTS: The rate of obese patient in the ICU ranges from 9 percent to 26 percent and the increase in the number of bariatric surgeries has raised the number of obese patients in the ICU. It is important to know the physiopathology of obesity and to treat its particularities during the postoperative care. Such as pulmonary restriction, that causes an increase in pulmonary complications, coronary artery disease and thromboembolic events. CONCLUSIONS: The number of patients that undergo to bariatric surgery has increased; therefore, the number of obese patients in the ICU has also risen. Different physiological events and complications in obese patients are challenges to clinical practice. The knowledge of obese physiopathology helps in the managing routine procedures and complications after bariatric surgery.

Avaliação da qualidade e satisfação de vida dos pacientes antes da internação na Unidade de Terapia Intensiva e após a alta hospitalar / Evaluation the quality and satisfaction of life of patients, before admission in Intensive Care Unit and after hospital discharge

JUSTIFICATIVA E OBJETIVOS: Analisar a qualidade e satisfação de vida (QSV) dos pacientes antes da internação na UTI e após a alta hospitalar. O objetivo deste estudo foi verificar se as características demográficas, clínicas e terapêuticas interferiram nessa QSV. MÉTODO: Foi realizado um estudo do tipo coorte prospectivo, com abordagem quanti-qualitativa. Foram analisados os pacientes internados na UTI do Hospital Universitário da Universidade Federal de Santa Catarina, por mais de 24 horas, entre os meses de abril e julho de 2005. Coletaram-se dados referentes a QSV dos pacientes antes da internação na UTI, assim como suas características demográficas, clínicas e terapêuticas. Posteriormente, aplicou-se, por telefone, 7, 90 e 180 dias após a alta hospitalar, um questionário que avaliou os dados sobre a QSV dos pacientes; subdivididos em 2 grupos: QSV melhor/inalterada e piora da QSV. Para a análise estatística foram utilizados os testes t de Student e Qui-quadrado. Foi considerado significativo < 0,05. RESULTADOS: Sessenta e oito pacientes preencheram os critérios de admissão, 21 completaram o estudo. A comparação entre a QSV de 7, 90 e 180 dias após a alta hospitalar revelou que a qualidade de vida (QV) dos pacientes melhorou e que 90,5 por cento estavam satisfeitos. Os pacientes cuja QV foi melhor/inalterada foram os mais idosos. Os grupos foram semelhantes, em relação ao sexo, escolaridade, escore APACHE II médio, tempo de internação, uso de ventilação mecânica e fármaco vasoativo. Sessenta por cento dos pacientes havia retornado ao trabalho após 180 dias. CONCLUSÕES: Houve uma tendência de os pacientes sentirem-se satisfeitos após a alta hospitalar, bem como a melhora da qualidade de vida com o decorrer do tempo. Mesmo aqueles que referiram piora, encontravam-se bem para retomar suas atividades laborativas.

BACKGROUND AND OBJETIVES: To evaluate the quality and satisfaction of life (QSL) of patients before admission in ICU, and after hospital discharge. To verify the influence of the patient's demographic/clinic/therapeutic factors in the QSL. METHODS: Prospective cohort study with quali-quantitative approach. All patients admitted in ICU/HU/UFSC from April-July 2005, who's stayed more than 24 hours were included. Initially, the data of QSL before ICU admission, patient's demographics/clinics/therapeutics features were recorded. Afterwards, by telephone, 7, 90 and 180 days after hospital discharge, the patients answered the questionnaires about QSL. In the sequence, all patients were subdivided into 2 main groups: unchanged or better, and worse QSL. Data were analyzed using t Student and Chi-square tests (p-value < 0.05). RESULTS: Sixty eight patients were enrolled into the study. Completed questionnaires were obtained from 21 of them. A comparison of 7, 90 and 180 days after hospital discharge showed that QSL of patients was unchanged or better at 90 and 180 days. The majority of patients expressed more satisfaction in that moment. Unchanged or better QSL was associated with advanced age. However, there were no statistical significant differences in sex, schooling, APACHE II score, length of stay, mechanical ventilation and used drugs. Sixty percent returned to their previous work. CONCLUSIONS: There was a tendency for patients who felt themselves satisfied after hospital discharge to have their QSL improved as time went bye. Better QSL was associated with advanced age. Even when patients reported worse QSL they returned to their previous work.

Avaliação da necessidade da solicitação de exames complementares para pacientes internados em unidade de terapia intensiva de hospital universitário / Laboratory exams necessity for patients admitted to an university hospital intensive care unity

JUSTIFICATIVA E OBJETIVOS: O aumento progressivo nos recursos diagnósticos tem aumentado a qualidade e a quantidade dos exames de laboratório realizados nas Unidades de Terapia Intensiva (UTI). A influência deste aumento sobre a morbidade e mortalidade não está bem definida. O objetivo deste estudo foi avaliar a freqüência da solicitação de exames na UTI do HU e verificar se houve ou não relação entre a quantidade de exames solicitados e a idade dos pacientes, o seu desfecho e a gravidade das doenças. MÉTODO: Coorte prospectiva, com abordagem quantitativa. Foram analisados os exames dos pacientes internados na UTI, dos meses de julho a dezembro, 2005. Foram coletados dados clínicos e demográficos dos pacientes e quantificados diariamente os exames mais freqüentemente solicitados na UTI. Seqüencialmente a média diária de exames foi calculada para todo o período de internação. Para fins de análise os pacientes foram divididos obedecendo três critérios: faixa etária, desfecho de saída da UTI e gravidade. Para a análise estatística foram utilizados os testes Exato de Fisher, Qui-quadrado e ANOVA. RESULTADOS: Foram admitidos 113 pacientes durante o período de estudo. A taxa média foi de 11,5 exames por dia de internação. Estes valores não apresentaram diferença estatística quando comparados entre os pacientes com idade acima ou abaixo de 60 anos, entre os que sobreviveram e os que foram a óbito e entre aqueles que tiveram taxa de óbito estimada em menos que 50 por cento ou mais que 50 por cento. CONCLUSÕES: Os exames solicitados não guardam correlação clínica e prognóstica com sua solicitação. Não houve estatística significativa quando a taxa diária média de exames foi relacionada à idade do paciente, ao desfecho e à gravidade.

BACKGROUND AND OBJECTIVES: The progressive increasing diagnostic resources had influenced the quality and quantity of laboratory exams. It is not clear if the amount of exams performed influence the morbidity and mortality in the ICU patients. The purpose of this study was to appraise the frequency of the most ordering tests in the ICU of HU-UFSC and to check if there was connection between them and the age, the destiny until the ICU discharge and the estimate severity of their diseases. METHODS: Prospective cohort study with qualitative approach. The blood samples of admitted patients were analyzed, from July to December 2005. Clinical and demographic features were collected and the most frequently blood-samples were quantified per day. In the sequence the daily rate of exams were calculated during all the admission period. The patients were analyzed according to three criterions: age, destiny until the ICU discharge and estimate severity according to APACHE II index. Data were analyzed using Fisher Exact, Chi-square and ANOVA tests. RESULTS: One hundred and thirteen patients were enrolled to this study. The average test-ordering was 11.50 per day. These numbers didn't have statistical difference when they were compared between survivor and non-survivor patients, and between those whose the death estimated tax was bigger or smaller than 50 per cent. CONCLUSIONS: The test-ordering didn't show clinical and prognostic relation to its request. There were no statistic relation between the patient's age, ICU discharge and the estimate severity.

Síndrome de Stevens-Johnson e necrólise epidérmica tóxica em medicina intensiva: [revisão] / Stevens-Johnson syndrome and toxical epidermal necrolysis in intensive care medicine: [review]

JUSTIFICATIVA E OBJETIVOS: A Síndrome de Stevens Johnson (SSJ) e Necrólise Epidérmica Tóxica (NET) são reações cutâneas graves, com potencial para morbidade e mortalidade elevadas acometendo a pele e a membrana mucosa necessitando de cuidados de medicina intensiva. O objetivo deste artigo foi apresentar revisão da literatura sobre SSJ e NET. CONTEÚDO: Este artigo revisa os conceitos básicos, diagnóstico, quadro clínico e o princípio de tratamento em Unidade de Terapia Intensiva da SSJ e NET. CONCLUSÕES: Estas doenças caracterizam emergências dermatológicas e seu adequado manuseio e cuidado deve fazer parte do conhecimento rotineiro do médico intensivista.

BACKGROUND AND OBJECTIVES: The Stevens Johnson Syndrome (SJS) and Toxical Epidermal Necrolisys (TEN) are important skin and mucosal lesions that need intensive care treatment. The aim of this article is to show a literature review about SJS and TEN. CONTENTS: This article reviews the concepts, diagnostic topics, clinical presentation and the principle of basic treatment in Intensive Care Unit for SJS and TEN. CONCLUSIONS: These illnesses are characterized as dermatological emergencies and its adequate management and cares must be part of the routine knowledge of the intensive care doctors.

Sedação em medicina intensiva: uso de remifentanil na prática clínica / Sedation in intensive care unit: the use of remifentanil in clinical practice

JUSTIFICATIVA E OBJETIVOS: Os pacientes em terapia intensiva freqüentemente necessitam receber sedação e analgesia para diversos procedimentos como parte fundamental do tratamento. A Medicina intensiva tem como desafio escolher o melhor fármaco analgésico para o paciente, produzindo poucos efeitos colaterais. O objetivo deste estudo foi descrever os principais fundamentos para o uso do remifentanil na prática clínica das UTI. CONTEÚDO: O remifentanil é um opióide de curta duração, relativamente novo e ainda pouco utilizado em Medicina intensiva. Com o surgimento de novos fármacos anestésicos outros esquemas terapêuticos têm sido considerados. Vários estudos já demonstraram benefícios e segurança do remifentanil em relação ao seu uso em Medicina Intensiva, mas ainda se faz necessário maior número de estudos, particularmente em relação aos pacientes sépticos. CONCLUSÕES: Por se tratar de um fármaco relativamente novo, ele ainda não faz parte da rotina de fármacos mais utilizados para sedação em Medicina Intensiva, apesar de evidências sólidas que suportam a segurança e a eficácia de seu uso em UTI.

BACKGROUND AND OBJECTIVES: Critically ill patients frequently need to use sedative and analgesic drugs, as part of their treatment or during several procedures. It is a challenge for all intensive care providers to determine the best drug to be used for each patient, with less collateral effects. The objective of this study is to describe the background to give the use of remifentanil in intensive care clinical practice. CONTENTS: Remifentanil is a short acting opioid agonist little used in intensive care medicine. Several studies have been published, showing that remifentanil is a safe drug to be used for the sedation and analgesia for intensive care patients, still needing more information regardless to septic shock patients. CONCLUSIONS: Because remifentanil is a relatively new drug, it is not yet part of the routine drugs used for intensive care providers, although solid evidences of its safety and efficiency for critically ill patients.