Sepsis, cardiovascular events and short-term mortality risk in critically ill patients

INTRODUCTION@#There is paucity of data on the occurrence of cardiovascular events (CVEs) in critically ill patients with sepsis. We aimed to describe the incidence, risk factors and impact on mortality of CVEs in these patients.@*METHODS@#This was a retrospective cohort study of critically ill patients admitted to the medical intensive care unit (ICU) between July 2015 and October 2016. The primary outcome was intra-hospital CVEs, while the secondary outcomes were in-hospital mortality, ICU and hospital length of stay.@*RESULTS@#Patients with sepsis (n=662) had significantly more CVEs compared to those without (52.9% versus 23.0%, P<0.001). Among sepsis patients, 350 (52.9%) had 1 or more CVEs: 59 (8.9%) acute coronary syndrome; 198 (29.9%) type 2 myocardial infarction; 124 (18.7%) incident atrial fibrillation; 76 (11.5%) new or worsening heart failure; 32 (4.8%) cerebrovascular accident; and 33 (5.0%) cardiovascular death. Factors associated with an increased risk of CVEs (adjusted relative risk [95% confidence interval]) included age (1.013 [1.007-1.019]); ethnicity-Malay (1.214 [1.005-1.465]) and Indian (1.240 [1.030-1.494]) when compared to Chinese; and comorbidity of ischaemic heart disease (1.317 [1.137-1.527]). There were 278 patients (79.4%) who developed CVEs within the first week of hospitalisation. Sepsis patients with CVEs had a longer median (interquartile range [IQR]) length of stay in the ICU (6 [3-12] vs 4 [2-9] days, P<0.001), and hospital (21 [10-42] vs 15 [7-30] days, P<0.001) compared to sepsis patients without CVEs. There was no difference in in-hospital mortality between the 2 groups (46.9% vs 45.8%, P=0.792).@*CONCLUSION@#CVEs complicate half of the critically ill patients with sepsis, with 79.4% of patients developing CVEs within the first week of hospitalisation, resulting in longer ICU and hospital length of stay.

Características epidemiológicas de los pacientes atendidos en el sector de reanimación de un servicio de emergencia en un hospital de tercer nivel de Argentina / Epidemiological features of patients admitted to the resuscitation unit at an emergency department of a third level hospital in Argentina

Introducción. Conocer las características epidemiológicas (CE) de una población resulta primordial para la definición de estrategias sanitarias. Nuestro objetivo es describir las características de pacientes críticos ingresados al sector reanimación (SR). Materiales y métodos. Estudio descriptivo y retrospectivo realizado en un servicio de urgencias de un hospital de tercer nivel entre 2/7/2018 y 1/7/2019. Se incluyeron todos los pacientes ingresados a SR. Se registró edad, sexo, motivo de ingreso, condición crónica, procedimientos diagnósticos y terapéuticos efectuados. Los datos fueron obtenidos del libro de registro y la historia clínica informatizada, y analizados con software Redcap Versión 8.9.2. Las variables categóricas se expresaron como frecuencias y porcentajes y las continuas con mediana y rango intercuartílico. Resultados. Ingresaron 2292 pacientes. El 94% fueron menores de 16 años. El 56,5% presentaba condiciones crónicas (CC), siendo más frecuentes las enfermedades neurológicas (29%), endocrino/metabólicas (15,5%) y cardiovasculares (11%). Los motivos de ingreso más habituales: enfermedad respiratoria aguda baja (31%), estado epiléptico (13%), sepsis (13%) y deshidratación grave (7%). Estudios complementarios más utilizados: laboratorio (54%), radiografía (28%), hemocultivos (23%). Los procedimientos realizados con más frecuencia fueron la colocación de acceso venoso periférico (67%), cánula nasal de alto flujo (6%) y ventilación mecánica (5%). Las drogas más indicadas: oxígeno (42%), fluidos (34%), antibióticos (22%). El 14% ingresó a cuidados intensivos. Hubo 11 paros cardiorrespiratorios y 6 óbitos. Conclusiones. En el SR se asisten pacientes críticos con patologías de alta prevalencia como también pacientes con enfermedades crónicas complejas. La evaluación periódica de CE resulta una herramienta fundamental para detectar dificultades y elaborar estrategias de mejora (AU)

Introduction. Knowledge on the epidemiological characteristics (EC) of a population is essential to define healthcare strategies. Our aim was to describe the characteristics of critical patients admitted to the resuscitation unit (RU). Materials and methods. A descriptive and retrospective study was conducted at an emergency department of a third-level hospital between 2/7/2018 and 1/7/2019. All patients admitted to the RU were included. Age, sex, reason for admission, underlying disease, and diagnostic and therapeutic procedures performed were recorded. The data were obtained from the logbook and electronic records, and analyzed using Redcap software Version 8.9.2. Categorical variables were expressed as frequencies and percentages and continuous variables as median and interquartile range. Results. 2292 patients were admitted; 94% were younger than 16 years of age. Overall, 56.5% had underlying diseases (UD), the most common of which were neurological (29%), endocrine/metabolic (15.5%), and cardiovascular (11%) disorders. The most common reasons for admission were acute lower respiratory tract disease (31%), status epilepticus (13%), sepsis (13%), and severe dehydration (7%). The most frequently used complementary studies were laboratory tests (54%), x-rays (28%), and hemocultures (23%). The most frequently performed procedures were peripheral venous line (67%), high-flow nasal cannula (6%), and mechanical ventilation (5%) placement. The most frequently indicated medications were oxygen (42%), fluids (34%), and antibiotics (22%). Overall, 14% required admission to the intensive care unit. There were 11 cardiorespiratory arrests and six deaths. Conclusions. Critical patients with highly prevalent diseases as well as patients with complex underlying diseases are seen at the RU. Periodic EC evaluation is a key tool for detecting difficulties and developing improvement strategies (AU)

Características e preditores de doença crítica crônica na unidade de terapia intensiva / Characteristics and predictors of chronic critical illness in the intensive care unit

RESUMO Objetivo: Caracterizar os pacientes com doença crítica crônica e identificar os preditores relacionados à evolução para doença crítica crônica. Métodos: Coleta prospectiva de dados por 1 ano realizada na unidade de terapia intensiva de um hospital geral localizado na Região Sul do país. Construíram-se três modelos de regressão logística para identificar os fatores associados com doença crítica crônica. Resultados: Dentre os 574 pacientes admitidos à unidade de terapia intensiva durante o período do estudo, 200 foram submetidos à ventilação mecânica. Destes, 85 (43,5%) pacientes desenvolveram doença crítica crônica, totalizando 14,8% de todos os pacientes admitidos à unidade de terapia intensiva. O modelo de regressão que avaliou os fatores prévios à admissão à unidade de terapia intensiva associados com doença crítica crônica identificou insuficiência renal crônica submetida à diálise (OR 3,57; p = 0,04) e diagnóstico neurológico quando da admissão ao hospital (OR 2,25; p = 0,008) como fatores independentes. No modelo que avaliou a associação de doença crítica crônica com situações ocorridas durante a permanência na unidade de terapia intensiva, destacaram-se fraqueza muscular (OR 2,86; p = 0,01) e úlceras por pressão (OR 9,54; p < 0,001). Na análise multivariada global (fatores prévios e situações ocorridas durante a permanência na unidade de terapia intensiva), destacaram-se admissão ao hospital por doenças neurológicas (OR 2,61; p = 0,03) e desenvolvimento de úlceras por pressão (OR 9,08; p < 0,001). Conclusão: A incidência de doença crítica crônica foi similar à observada em outros estudos e teve associação mais forte com o diagnóstico de doenças neurológicas quando da admissão ao hospital e insuficiência renal crônica submetida à hemodiálise, assim como com complicações desenvolvidas durante a hospitalização, como úlceras por pressão e fraqueza muscular.

ABSTRACT Objective: To characterize patients with chronic critical illness and identify predictors of development of chronic critical illness. Methods: Prospective data was collected for 1 year in the intensive care unit of a general hospital in Southern Brazil. Three logistic regression models were constructed to identify factors associated with chronic critical illness. Results: Among the 574 subjects admitted to the intensive care unit, 200 were submitted to mechanical ventilation. Of these patients, 85 (43.5%) developed chronic critical illness, composing 14.8% of all the patients admitted to the intensive care unit. The regression model that evaluated the association of chronic critical illness with conditions present prior to intensive care unit admission identified chronic renal failure in patients undergoing hemodialysis (OR 3.57; p = 0.04) and a neurological diagnosis at hospital admission (OR 2.25; p = 0.008) as independent factors. In the model that evaluated the association of chronic critical illness with situations that occurred during intensive care unit stay, muscle weakness (OR 2.86; p = 0.01) and pressure ulcers (OR 9.54; p < 0.001) had the strongest associations. In the global multivariate analysis (that assessed previous factors and situations that occurred in the intensive care unit), hospital admission due to neurological diseases (OR 2.61; p = 0.03) and the development of pressure ulcers (OR 9.08; p < 0.001) had the strongest associations. Conclusion: The incidence of chronic critical illness in this study was similar to that observed in other studies and had a strong association with the diagnosis of neurological diseases at hospital admission and chronic renal failure in patients undergoing hemodialysis, as well as complications developed during hospitalization, such as pressure ulcers and muscle weakness.

Tracheostomy in the ICU: hope or delusion?

Introduction: Current literature suggests that tracheostomy has no impact on survival in unselected intensive care unit (ICU) patients, and that it actually transfers mortality from ICU to the ward. Methods: Data from 71 adult subjects who underwent tracheostomy as part of their ICU management and were subsequently transferred to the ward were obtained retrospectively. Results: During 2015, 104 subjects received tracheostomy. Thirty-two died during their initial ICU admission (30.4%) and were excluded from analysis. Of the remaining 73 individuals, 28 died (38.3%) in hospital. Most common diagnoses were sepsis (33.8%) and neurological emergencies (23.9%). Life-sustaining treatments were withheld or withdrawn in 25 decedents. Seven subjects died in later hospitalizations at our institution over the period recorded. Conclusions: Tracheostomy may represent a burden after ICU discharge, involving high resource use and low survival rate. Efforts should be made to recognize patients who might clearly benefit from this technique to avoid unwanted prolonged mechanical ventilation. (AU)

Predictores de éxito después de la decanulación en pacientes adultos críticamente enfermos: un estudio de cohorte retrospectivo / Success predictors after decannulation in critically ill adult patients: a retrospective cohort study

Introducción: la traqueostomía es una práctica frecuente dentro de las unidades de cuidados intensivos (UCI). El proceso de decanulación y el tiempo utilizado en ella resultan de interés clínico, mientras que los factores asociados al proceso y la dificultad en dicho proceso han sido poco estudiados. Objetivos: describir características clínicas y epidemiológicas de la población en estudio y su evolución desde el momento del ingreso en la UCI hasta el alta hospitalaria. Informar la incidencia de fallo de decanulación y analizar los factores de riesgo independientes asociados a la imposibilidad de esta. Materiales y métodos: estudio observacional de cohorte retrospectivo de pacientes internados en la UCI del Hospital Italiano de San Justo Agustín Rocca que requirieron traqueostomía durante su estadía. Utilizando la historia clínica informatizada se registraron variables epidemiológicas previas al ingreso en la UCI y datos evolutivos durante la internación. El período analizado fue desde el 5 de enero de 2016 hasta el 17 de diciembre de 2017. Se utilizaron modelos de regresión logística para la evaluación de potenciales predictores. Resultados: se reclutaron 50 pacientes, y todos fueron incluidos en el presente análisis. La edad promedio fue de 66 años (desvío estándar [DE] ± 15,5) y el 66% fueron hombres. El 42% fue decanulado durante el seguimiento. La incidencia en el fallo de decanulación fue del 4,77% (intervalo de confianza [IC] 95% 0,85-22,67). La mediana de tiempo hasta la decanulación desde la desvinculación de la asistencia ventilatoria fue de 17 días. En el análisis univariado hubo diferencias estadísticamente significativas en tipo de diagnóstico de ingreso en UCI y en el alta vivo hospitalaria al comparar pacientes decanulados versus no decanulados. En el análisis multivariado de regresión logística se halló el tipo de diagnóstico de ingreso en UCI como predictor independiente de imposibilidad de decanulación. Conclusiones: el motivo de ingreso clínico en UCI fue un factor predictor independiente asociado al fracaso de la decanulación y esto, posiblemente, está relacionado con la condición clínica y el estado general al ingreso, en comparación con los pacientes que ingresaron por causas quirúrgicas. No se hallaron comorbilidades ni antecedentes que se relacionen con el fracaso de la decanulación. (AU)

Introduction: the tracheostomy remains a very common surgical procedure done in the intensive care unit (ICU). The process of decannulation is of scientific interest with its associated factors not being sufficiently studied. Objectives: to describe the clinical and epidemiological characteristics of the population and their relationship to effective decanulation. To report the cumulative incidence of decannulation failure and success. To analyze independent risk factors associated with decannulation failure. Materials and methods: the present was a retrospective cohort of adult patients in the ICU at Hospital Italiano de San Justo who required tracheostomy during their in-hospital stay. Epidemiological variables were recorded before ICU admission and during their hospital stay using data from the electronic medical record. The inclusion period was 2 years long. We used descriptive statistics and logistic regression models to compare the proportion of patients who could be decannulated versus those who could not. Results: 50 patients were enrolled in the present study. Their mean age was 66 (±15.5) years and 66% of patients were male. 21 patients (42%) achieved to be decannulated. The cumulative incidence of decannulation failure was 4.77% (95% CI: 0.85-22.87). Median time from weaning to decannulation was 17 days. In univariate analysis, statistically significant differences were found in ICU admission diagnosis (p<0.001) and hospital discharge alive (p<0.001) when comparing decannulated versus not decannulated patients. In multivariate logistic regression analysis, ICU admission diagnosis was found to be an independent predictor of decannulation failure (p<0.01). Conclusions: clinical ICU admission diagnosis was an independent predictor associated with decannulation failure. This could be related to differences in baseline morbidity and clinical condition of these patients compared with surgical patients. However, no individual morbidities or clinical conditions were found to be associated in decannulation failure. (AU)

Preventable adverse drug events in critically ill HIV patients: Is the detection of potential drug-drug interactions a useful tool?

OBJECTIVES: The aim of this study was to develop a strategy to identify adverse drug events associated with drug-drug interactions by analyzing the prescriptions of critically ill patients. METHODS: This retrospective study included HIV/AIDS patients who were admitted to an intensive care unit between November 2006 and September 2008. Data were collected in two stages. In the first stage, three prescriptions administered throughout the entire duration of these patients' hospitalization were reviewed, with the Micromedex database used to search for potential drug-drug interactions. In the second stage, a search for adverse drug events in all available medical, nursing and laboratory records was performed. The probability that a drug-drug interaction caused each adverse drug events was assessed using the Naranjo algorithm. RESULTS: A total of 186 drug prescriptions of 62 HIV/AIDS patients were analyzed. There were 331 potential drug-drug interactions, and 9% of these potential interactions resulted in adverse drug events in 16 patients; these adverse drug events included treatment failure (16.7%) and adverse reactions (83.3%). Most of the adverse drug reactions were classified as possible based on the Naranjo algorithm. CONCLUSIONS: The approach used in this study allowed for the detection of adverse drug events related to 9% of the potential drug-drug interactions that were identified; these adverse drug events affected 26% of the study population. With the monitoring of adverse drug events based on prescriptions, a combination of the evaluation of potential drug-drug interactions by clinical pharmacy services and the monitoring of critically ill patients is an effective strategy that can be used as a complementary tool for safety assessments and the prevention of adverse drug events.

Severity and workload related to adverse events in the ICU / Gravedad y carga de trabajo relacionadas a eventos adversos en UTI / Gravidade e carga de trabalho relacionadas a eventos adversos em UTI

ABSTRACT Objective: To analyze whether an increase in patient severity and nursing workload are correlated to a greater incidence of adverse events (AEs) in critical patients. Method: A prospective single cohort study was performed on a sample of 138 patients hospitalized in an intensive care unit (ICU). Results: A total of 166 AEs, occurred, affecting 50.7% of the patients. Increased patient severity presented a direct relationship to the probability of AEs occurring. However, nursing workload did not present a statistically significant relationship with the occurrence of AEs. Conclusion: The results cast light on the importance of using evaluation tools by the nursing personnel in order to optimize their daily activities and focus on patient safety.

RESUMEN Objetivo: Analizar si el aumento de la gravedad del paciente y la carga de trabajo de enfermería está relacionada con mayor incidencia de Eventos Adversos (EAs) en pacientes críticos. Método: Estudio de cohorte única, prospectivo, con muestra de 138 pacientes internados en una Unidad de Terapia Intensiva (UTI). Resultados: En total, fueron evidenciados 166 EAs, incidiendo sobre 50,7% de los pacientes. El aumento de la gravedad del paciente mostró relación directa con la posibilidad de ocurrencia de EAs. Sin embargo, la carga de trabajo de enfermería no demostró relación estadísticamente significativa en la ocurrencia de EAs. Conclusión: Los resultados permiten reflexionar sobre la importancia del equipo de enfermería, en utilizar instrumentos de evaluación, con el objeto de mejorar y planificar sus acciones diarias, enfocándose en la seguridad del paciente.

RESUMO Objetivo: Analisar se o aumento da gravidade do paciente e a carga de trabalho de enfermagem está relacionado à maior incidência de Eventos Adversos (EAs) em pacientes críticos. Método: Estudo de coorte única, prospectivo, com amostra de 138 pacientes internados em uma Unidade de Terapia Intensiva (UTI). Resultados: Ao todo, foram evidenciados 166 EAs, que acometeram 50,7% dos pacientes. O aumento da gravidade do paciente apresentou relação direta com a chance de ocorrência de EAs. Entretanto, a carga de trabalho de enfermagem não apresentou relação estatisticamente significativa, na ocorrência de EAs. Conclusão: Os resultados permitem refletir acerca da importância da equipe de enfermagem, em utilizar instrumentos de avaliação, com o objetivo de melhorar e planejar suas ações diárias, com foco na segurança do paciente.

Doença crítica crônica: estamos salvando ou criando vítimas? / Chronic critical illness: are we saving patients or creating victims?

RESUMO Os avanços tecnológicos que permitem dar suporte às disfunções de órgãos levaram a um aumento nas taxas de sobrevivência para a maioria dos pacientes críticos. Alguns destes pacientes sobrevivem à condição crítica inicial, porém continuam a sofrer com disfunções de órgãos e permanecem em estado inflamatório por longos períodos. Este grupo de pacientes críticos foi descrito desde os anos 1980 e teve diferentes critérios diagnósticos ao longo dos anos. Sabe-se que estes pacientes têm longas permanências no hospital, sofrem importantes alterações do metabolismo muscular e ósseo, apresentam imunodeficiência, consomem quantias substanciais de recursos de saúde, têm reduzida capacidade funcional e cognitiva após a alta, demandam uma considerável carga de trabalho para seus cuidadores, e apresentam elevadas taxas de mortalidade em longo prazo. O objetivo desta revisão foi apresentar as evidências atuais, em termos de definição, fisiopatologia, manifestações clínicas, tratamento e prognóstico da doença crítica persistente.

ABSTRACT The technological advancements that allow support for organ dysfunction have led to an increase in survival rates for the most critically ill patients. Some of these patients survive the initial acute critical condition but continue to suffer from organ dysfunction and remain in an inflammatory state for long periods of time. This group of critically ill patients has been described since the 1980s and has had different diagnostic criteria over the years. These patients are known to have lengthy hospital stays, undergo significant alterations in muscle and bone metabolism, show immunodeficiency, consume substantial health resources, have reduced functional and cognitive capacity after discharge, create a sizable workload for caregivers, and present high long-term mortality rates. The aim of this review is to report on the most current evidence in terms of the definition, pathophysiology, clinical manifestations, treatment, and prognosis of persistent critical illness.

Epidemiological profile of ICU patients at Faculdade de Medicina de Marília / Perfil epidemiológico dos pacientes da UTI da Faculdade de Medicina de Marília

SUMMARY Objective: To characterize the epidemiological profile of the hospitalized population in the ICU of Hospital das Clínicas de Marília (Famema). Method: A retrospective, descriptive and quantitative study. Data regarding patients admitted to the ICU Famema was obtained from the Technical Information Center (Núcleo Técnico de Informações, NTI, Famema). For data analysis, we used the distribution of absolute and relative frequencies with simple statistical treatment. Results: 2,022 ICU admissions were recorded from June 2010 to July 2012 with 1,936 being coded according to the ICD-10. The epidemiological profile comprised mostly males (57.91%), predominantly seniors ≥ 60 years (48.89%), at an average age of 56.64 years (±19.18), with limited formal education (63.3% complete primary school), mostly white (77.10%), Catholic (75.12%), from the city of Marília, state of São Paulo, Brazil (53.81%). The average occupancy rate was 94.42%. The predominant cause of morbidity was diseases of the circulatory system with 494 admissions (25.5%), followed by traumas and external causes with 446 admissions (23.03%) and neoplasms with 213 admissions (11.00%). The average stay was 8.09 days (±10.73). The longest average stay was due to skin and subcutaneous tissue diseases, with average stay of 12.77 days (±17.07). There were 471 deaths (24.32%), mainly caused by diseases of the circulatory system (30.99%). The age group with the highest mortality was the range from 70 to 79 years with 102 deaths (21.65%). Conclusion: The ICU Famema presents an epidemiological profile similar to other intensive care units in Brazil and worldwide, despite the few studies available in the literature. Thus, we feel in tune with the treatment of critical care patients.

RESUMO Objetivo: caracterizar o perfil epidemiológico da população internada na UTI do Hospital das Clínicas da Faculdade de Medicina de Marília (Famema). Método: estudo retrospectivo, descritivo, quantitativo. Os dados foram obtidos do Núcleo Técnico de Informações (NTI) da Famema dos pacientes internados na UTI Famema. Para a análise dos dados, utilizou-se distribuição de frequências absoluta e relativa com tratamento de estatística simples. Resultados: foram registradas 2.022 internações no período de junho de 2010 a julho de 2012 na UTI Famema, sendo 1.936 codificadas de acordo com a CID-10. O perfil epidemiológico mostrou predominância do sexo masculino (57,91%), população idosa ≥ 60 anos (48,89%), média de idade de 56,64 anos (±19,18) e baixa escolaridade com até 1º grau completo (63,30%), cristão católico (75,12%), brancos (77,10%), procedentes de Marília, SP (53,81%). A taxa média de ocupação foi de 94,42%. A morbidade predominante foram as doenças do aparelho circulatório com 494 internações (25,5%), seguida dos traumas e causas externas com 446 admissões (23,03%) e neoplasias com 213 admissões (11,00%). A média de permanência foi 8,09 dias (±10,73), sendo as doenças de pele e tecido subcutâneo as com maior tempo (12,77 dias; ±17,07). Ocorreram 471 óbitos (24,32%), cuja causa mais prevalente foram as doenças do aparelho circulatório (30,99%). A faixa etária de maior mortalidade foi 70 a 79 anos com 102 óbitos (21,65%). Conclusão: a UTI Famema apresentou um perfil epidemiológico semelhante ao de outras unidades no Brasil e no mundo, apesar dos poucos estudos na literatura. Com isso, nos sentimos em sintonia no atendimento ao paciente crítico.

Acute kidney injury in a tropical country: a cohort study of 253 patients in an infectious diseases intensive care unit

Introduction: Acute kidney injury (AKI) is a frequent and potentially fatal complication in infectious diseases. The aim of this study was to investigate the clinical aspects of AKI associated with infectious diseases and the factors associated with mortality. Methods: This retrospective study was conducted in patients with AKI who were admitted to the intensive care unit (ICU) of a tertiary infectious diseases hospital from January 2003 to January 2012. The major underlying diseases and clinical and laboratory findings were evaluated. Results: A total of 253 cases were included. The mean age was 46±16 years, and 72% of the patients were male. The main diseases were human immunodeficiency virus (HIV) infection, HIV/acquired immunodeficiency syndrome (AIDS) (30%), tuberculosis (12%), leptospirosis (11%) and dengue (4%). Dialysis was performed in 70 cases (27.6%). The patients were classified as risk (4.4%), injury (63.6%) or failure (32%). The time between AKI diagnosis and dialysis was 3.6±4.7 days. Oliguria was observed in 112 cases (45.7%). The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were higher in patients with HIV/AIDS (57±20, p-value=0.01) and dengue (68±11, p-value=0.01). Death occurred in 159 cases (62.8%). Mortality was higher in patients with HIV/AIDS (76.6%, p-value=0.02). A multivariate analysis identified the following independent risk factors for death: oliguria, metabolic acidosis, sepsis, hypovolemia, the need for vasoactive drugs, the need for mechanical ventilation and the APACHE II score. Conclusions: AKI is a common complication in infectious diseases, with high mortality. Mortality was higher in patients with HIV/AIDS, most likely due to the severity of immunosuppression and opportunistic diseases. .

Atuação do time de resposta rápida em hospital universitário no atendimento de código amarelo / The performance of a rapid response team in the management of code yellow events at a university hospital

OBJETIVO: Descrever dados epidemiológicos de eventos de instabilidade clínica em pacientes atendidos pelo time de resposta rápida e identificar fatores prognósticos. MÉTODOS: Estudo longitudinal, realizado de janeiro a junho de 2010, com população adulta internada em ambiente hospitalar. Os dados coletados sobre o atendimento do código amarelo foram critérios de instabilidade clínica, terapia medicamentosa e não medicamentosa, orientações e procedimentos. Os desfechos avaliados foram necessidade de admissão em unidade de terapia intensiva e mortalidade hospitalar. O nível de significância utilizado foi de p=0,05. RESULTADOS: Foram avaliados 150 códigos amarelos que ocorreram com 104 pacientes. Os motivos mais frequentes estiveram relacionados à insuficiência respiratória aguda, apresentando hipóxia ou alteração da frequência respiratória, e preocupação da equipe com o estado clínico do paciente. Houve necessidade de solicitação de transferência para unidade de terapia intensiva em 80/150 (53,3%) ocasiões. Foi necessária a realização de 42 procedimentos, sendo os mais frequentes a intubação orotraqueal e a inserção de cateter venoso central. Os pacientes graves que aguardavam leito de unidade de terapia intensiva apresentaram maior chance de morte, comparados aos demais pacientes (hazard ratio: 3,12; IC95%: 1,80-5,40; p<0,001). CONCLUSÃO: Existem pacientes graves que necessitam de tratamento intensivo especializado nos leitos comuns de enfermarias dos hospitais. Os eventos que mais levaram ao acionamento do código amarelo estiveram relacionados a suporte respiratório e hemodinâmico. As intervenções realizadas caracterizam a necessidade do médico na equipe. A situação de demanda reprimida está associada à maior mortalidade.

OBJECTIVE: To describe the epidemiological data of the clinical instability events in patients attended to by the rapid response team and to identify prognostic factors. METHODS: This was a longitudinal study, performed from January to July 2010, with an adult inpatient population in a hospital environment. The data collected regarding the code yellow service included the criteria of the clinical instability, the drug and non-drug therapies administered and the activities and procedures performed. The outcomes evaluated were the need for intensive care unit admission and the hospital mortality rates. A level of p=0.05 was considered to be significant. RESULTS: A total of 150 code yellow events that occurred in 104 patients were evaluated. The most common causes were related to acute respiratory insufficiency with hypoxia or a change in the respiratory rate and a concern of the team about the patient's clinical condition. It was necessary to request a transfer to the intensive care unit in 80 of the 150 cases (53.3%). It was necessary to perform 42 procedures. The most frequent procedures were orotracheal intubation and the insertion of a central venous catheter. The patients who were in critical condition and had to wait for an intensive care unit bed had a higher risk of death compared to the other patients (hazard ratio: 3.12; 95% CI: 1.80-5.40; p<0.001). CONCLUSIONS: There are patients in critical condition that require expert intensive care in the regular ward unit hospital beds. The events that most frequently led to the code yellow activation were related to hemodynamic and respiratory support. The interventions performed indicate the need for a physician on the team. The situation of pent-up demand is associated with a higher mortality rate.

Estimación de prevalencia de niños con enfermedades limitantes de la vida en un hospital pediátrico de alta complejidad / Prevalence of patients with life-limiting conditions in a high complexity pediatric hospital

En Chile fallecen aproximadamente 800 niños menores de 15 años por diversas causas, entre ellas, por enfermedades sin tratamiento curativo. La Sociedad Chilena de Pediatría creó el Comité de Niños y Adolescentes con Necesidades Especiales en Atención de Salud (NANEAS), que entregó las pautas para una atención integral de estos pacientes, incluyendo los cuidados paliativos (CP). Resulta indispensable conocer el número y características de los pacientes que padecen enfermedades limitantes de la vida (ELV) para elaborar programas de atención que prioricen por un cuidado ambulatorio bajo la supervisión de equipos multidisciplinarios. Objetivo: Estimar la prevalencia de pacientes con ELV en un hospital pediátrico de alta complejidad. Pacientes y método: Se revisaron los egresos de las Unidades de Pediatría General y Unidad de Paciente Crítico del Hospital Roberto del Río, durante el 2009 y 2010. Se seleccionaron los casos con diagnósticos de ELV según CIE-10, registrando datos demográficos y clasificándolos según los grupos de la ACT para ELV. Se excluyeron pacientes con cáncer avanzado. Resultados: De 6585 pacientes egresados, 190 tenían diagnóstico ELV (2.89 por ciento). Los lactantes fueron el grupo más numeroso (33 por ciento). El 51,6 por ciento de los pacientes pertenecían al grupo 4 (parálisis cerebral severa, genopatías complejas, TEC con secuelas graves) y todos fueron atendidos por 3 o más especialistas. Conclusión: Los niños con ELV constituyen un grupo emergente entre los pacientes pediátricos hospitalizados, demandando una atención de alta complejidad. Es un desafío implementar políticas públicas que optimicen su manejo y permitan planificar unidades especializadas para su atención, incluyendo los CP.

In Chile, approximately 800 children under the age of 15 years die from a variety of causes, including life-limiting conditions (LLC). The Chilean Society of Pediatrics established a Committee on Children and Adolescents with Special Health Care Needs (NANEAS), which established guidelines for comprehensive care of these patients, including palliative care (PC). It is essential to know the number and characteristics of patients with LLC, in order to develop programs for outpatient care under the supervision of multidisciplinary teams. Objective: To estimate the prevalence of patients with LLC in a high complexity pediatric hospital. Patients and methods: We reviewed the discharges from General Pediatric Units and the Critical Patient Unit at the Roberto del Rio Hospital during 2009 and 2010. We selected patients with LLC according to ICD-10. Their demographic characteristics were registered and classified into the four ACT groups. Patients with advanced cancer were excluded. Results: Of 6585 patients discharged, 190 were diagnosed as LLC (2.89 percent). Infants were the largest group (33 percent). 51.6 percent of patients belonged to group 4 (severe cerebral palsy, genopathies, serious sequelae of traumatic brain injury) and all were attended by at least three specialists. Conclusion: Children with LLC are an emerging group among hospitalized pediatric patients and they are demanding attention of high complexity. It is a challenge to design and implement public policies that can optimize health care for these patients, and facilitate the establishement of specialized units for this purpose, including PC.

Epidemiological Study of Morbidity Pattern of Critically Ill Children Admitted in Child Intensive Therapy Unit.

Background : In India 34.3% of the total population is constituted by the most vulnerable segment of our society i.e. infants and children. Malnutrition, respiratory and diarrhoeal diseases are three main scourges of the children but the great devils hovering upon them are lack of proper treatment and management. The present study was conducted to find out the morbidity pattern of our vulnerable children. Aims and Objectives : 1. To find out the prevalence of critically ill children admitted in the hospital. 2. To find out the morbidity pattern of critically ill children admitted in the child intensive therapy unit, in a hospital. Research Question : What is the epidemiological pattern of morbidity in critically ill children of age 1 month to 12 years? Study Design : Cross-sectional Study. Study Participants : All critically ill children coming to the emergency unit of the hospital during study period. Statistical Analysis : Simple percent and proportions, Chi square test.

Causas atribuidas a eventos de aparente amenaza a la vida del lactante / Causes attributed to apparent life-threatening event: 3 years of experience

Background: An Apparent Life-Threatening Event (ALTE) is an important challenge for the pediatrician, which requires guidelines for finding the etiology and making appropriate clinical decisions. Objective: To describe etiologies and clinical features of ALTE in infants, as determined by a standarized protocol. Methods: A prospective study including infants admitted to the Emergency Room and hospitalized due to an ALTE between May 2002 and May 2005. They were evaluated with an established protocol that considers the episode description, clinical history, and complementary laboratory studies. Results: 109 patients with ALTE and a mean age of 11 weeks had the following symptoms: apnea (100 percent), skin color changes (97 percent), and muscle tone changes (83 percent). 96 percent received CPR maneuvers or strong stimulation maneuvers for ending the episode. Fourteen percent of the cases were idiopathic, while other etiologies included respiratory infections (46 percent), gastroesophageal reflux (16 percent), seizures (6 percent), and urinary tract infections (6 percent). 3 patients expired. Conclusions: With this protocol, based on tools available in most public tertiary hospitals in Chile, we can identify the causes of ALTE similar to those reported in other studies, howeber with a lesser percentage of idiopathic episodes.

Introducción: Un Evento de Aparente Amenaza a la Vida (ALTE) plantea un importante desafío al pediatra, quién debe investigar la etiología para orientar su conducta. Esta labor se facilita con la aplicación de una guía. Objetivo: Describir la presentación clínica y determinar posibles causas de ALTE mediante un protocolo especifico. Pacientes y Método: Estudio prospectivo en lactantes que consultaron en un Servicio de Urgencia y se hospitalizaron por ALTE entre Mayo 2002 a Mayo 2005. Se evaluaron con un protocolo preestablecido considerando la descripción del episodio, antecedentes y estudios complementarios por pasos. Resultados: En 109 pacientes con ALTE, edad promedio 11 semanas, se observó apnea en 100 por ciento y cambio de color en 97 por ciento. El 83 por ciento presentó cambio de tono y en el 96 por ciento se utilizaron maniobras para abortar el episodio. Se consideró idiopático el 14 por ciento de los casos. Las principales causas atribuidas fueron: infecciones respiratorias (46 por ciento), reflujo gastroesofágico (16 por ciento), convulsiones (6 por ciento) e infecciones urinarias (6 por ciento). Fallecieron 3 pacientes. Conclusiones: Mediante este protocolo, que utiliza herramientas disponibles en la mayoría de los hospitales públicos terciarios de nuestro país, se atribuyeron causas similares a las reportadas en otros estudios prospectivos, donde destaca un menor porcentaje de episodios idiopáticos.

Hospital malnutrition and inflammatory response in critically ill children and adolescents admitted to a tertiary intensive care unit

Critical illness has a major impact on the nutritional status of both children and adults. A retrospective study was conducted to evaluate the incidence of hospital malnutrition at a pediatric tertiary intensive care unit (PICU). Serum concentrations of IL-6 in subgroups of well-nourished and malnourished patients were also evaluated in an attempt to identify those with a potential nutritional risk. METHODS: A total of 1077 patients were enrolled. Nutritional status was evaluated by Z-score (weight for age). We compared mortality, sepsis incidence, and length of hospital stay for nourished and malnourished patients. We had a subgroup of 15 patients with severe malnutrition (MN) and another with 14 well-nourished patients (WN). Cytokine IL-6 determinations were performed by enzyme-linked immunosorbent assay. RESULTS: 53 percent of patients were classified with moderate or severe malnutrition. Similar amounts of C- reactive protein (CRP) were observed in WN and MN patients. Both groups were able to increase IL-6 concentrations in response to inflammatory systemic response and the levels followed a similar evolution during the study. However, the mean values of serum IL-6 were significantly different between WN and MN patients across time, throughout the study (p = 0.043). DISCUSSION: a considerable proportion of malnourished patients need specialized nutritional therapy during an intensive care unit (ICU) stay. Malnutrition in children remains largely unrecognized by healthcare workers on admission. CONCLUSIONS: The incidence of malnutrition was very high. Malnourished patients maintain the capacity to release inflammatory markers such as CRP and IL-6, which can be considered favorable for combating infections On the other hand, this capacity might also have a significant impact on nutritional status during hospitalization.

Prediction of mortality and morbidity by simplified acute physiology score II in obstetric intensive care unit admissions.

BACKGROUND: Critical care in obstetrics has received much attention in recent times. Despite progress in medical field and improvement in health facilities provided, maternal mortality is still very high in most of the developing countries. AIM: To study and analyze records of patients requiring intensive care in obstetrics and to assess utility of simplified acute physiology score (SAPS II) for predicting maternal mortality. SETTING: A multidisciplinary intensive care unit (ICU) at a tertiary care center. DESIGN: Retrospective review. MATERIALS AND METHODS: Fifty-seven consecutive obstetric patients' records requiring ICU admissions were studied for clinical picture, diagnosis, complications, morbidity and mortality over a period of 21/2 years - from 1st May 2002 to 31st Oct. 2004. SAPS II score was calculated according to the different variables for predicting mortality. STATISTICAL ANALYSIS: SAPS II scores were regressed on mortality status using logistic regression analysis. The predictability was assessed by goodness-of-fit test and receiver operated characteristic curve. RESULTS: Maternal mortality in obstetric ICU admissions was 1.15/1,000 deliveries, amounting to 40.35% of obstetric ICU admissions. The mean SAP II score was significantly higher (40.04 +/- 12.97 vs. 22.6 +/- 7.31) in those patients who died compared to survivors (P < 0.001%). CONCLUSIONS: The SAPS II accurately predicted mortality in obstetric patients admitted to ICU. Computation of the score as a routine in ICU may help in identifying those at high risk of mortality and then to reduce this risk.

El gasto energético en reposo, medido contra estimado, en pacientes críticamente enfermos / Energy consumed vs estimated energy expenditure at rest in critically ill patients

Se determinaron las diferencias entre el método de calorimetría indirecta (Ci) y el método de Harris-Benedict, para la evaluación de los requerimientos calóricos en pacientes críticamente enfermos, utilizándose un procedimiento manual en la Ci. Se evaluaron 40 pacientes por ambos métodos. En el método de Harris-Benedict, se añadieron factores de actividad y lesión de acuerdo a cada caso. La Ci se basó en el análisis de gases (O2 y CO2) de una muestra de aire inspirado y expirado por el paciente, mediante las ecuacions de Weir y las tablas de Lusk. El análisis de calorimetría indirecta contra Harris-Benedict solo, es decir, sin factor de actividad o lesión, no presentó diferencias estadísticamente significativas. Los resultados mostraron diferencias estadísticamente significativas cuando se compararon calorimetría indirecta (p>0.05 y p>0.001, respectivamente). Harris-Benedict no mostró una correlación apropiada en estos pacientes, concordando con lo reportado en la literatura. El procedimiento de medición calorimétrica empleada, tiene validez, y puede ser utilizado en todo hospital de segundo nivel de atención