Incidence and risk factors for major infections in hospitalized children with nephrotic syndrome / Incidência e fatores de risco para infecções graves em crianças hospitalizadas com síndrome nefróticas

ABSTRACT Introduction: Children with nephrotic syndrome are at increased risk of infections because of disease status itself and use of various immunosuppressive agents. In majority, infections trigger relapses requiring hospitalization with increased risk of morbidity and mortality. This study aimed to determine the incidence, spectrum, and risk factors for major infections in hospitalized children with nephrotic syndrome. Methods: All consecutive hospitalized children between 1-12 years of age with nephrotic syndrome were enrolled in the study. Children with acute nephritis, secondary nephrotic syndrome as well as those admitted for diagnostic renal biopsy and intravenous cyclophosphamide or rituximab infusion were excluded. Results: A total of 148 children with 162 admissions were enrolled. Incidence of major infections in hospitalized children with nephrotic syndrome was 43.8%. Peritonitis was the commonest infection (24%), followed by pneumonia (18%), urinary tract infection (15%), and cellulitis (14%), contributing with two thirds of major infections. Streptococcus pneumoniae (n = 9) was the predominant organism isolated in children with peritonitis and pneumonia. On logistic regression analysis, serum albumin < 1.5gm/dL was the only independent risk factor for all infections (OR 2.6; 95% CI, 1.2-6; p = 0.01), especially for peritonitis (OR 29; 95% CI, 3-270; p = 0.003). There were four deaths (2.5%) in our study, all due to sepsis and multiorgan failure. Conclusions: Infection remains an important cause of morbidity and mortality in children with nephrotic syndrome. As Pneumococcus was the most prevalent cause of infection in those children, attention should be paid to the pneumococcal immunization in children with nephrotic syndrome.

RESUMO Introdução: Crianças com síndrome nefrótica apresentam maior risco de infecções devido ao próprio status da doença e ao uso de vários agentes imunossupressores. Em grande parte, as infecções desencadeiam recidivas que exigem hospitalização, com risco aumentado de morbidade e mortalidade. Este estudo teve como objetivo determinar a incidência, o espectro e os fatores de risco para infecções graves em crianças hospitalizadas com síndrome nefrótica. Métodos: Todas as crianças hospitalizadas consecutivamente entre 1 e 12 anos de idade com síndrome nefrótica foram incluídas no estudo. Crianças com nefrite aguda, síndrome nefrótica secundária, bem como aquelas admitidas para biópsia renal diagnóstica e infusão intravenosa de ciclofosfamida ou rituximabe foram excluídas. Resultados: Foram cadastradas 148 crianças com 162 internações. A incidência de infecções graves em crianças hospitalizadas com síndrome nefrótica foi de 43,8%. A peritonite foi a infecção mais comum (24%), seguida por pneumonia (18%), infecção do trato urinário (15%) e celulite (14%), contribuindo com dois terços das principais infecções. Streptococcus pneumoniae (n = 9) foi o organismo predominantemente isolado em crianças com peritonite e pneumonia. Na análise de regressão logística, a albumina sérica < 1,5gm / dL foi o único fator de risco independente para todas as infecções (OR 2,6; 95% CI, 1,2-6; p = 0,01), especialmente para peritonite (OR 29; IC95% 3 -270, p = 0,003). Houve quatro mortes (2,5%) em nosso estudo, todas devido a sepse e falência de múltiplos órgãos. Conclusões: A infecção continua sendo uma importante causa de morbimortalidade em crianças com síndrome nefrótica. Como o Pneumococo foi a causa mais prevalente de infecção nessas crianças, deve-se atentar para a imunização pneumocócica em crianças com síndrome nefrótica.

Etiologia da hiperglicemia em crianças críticas e o impacto da disfunção de órgãos / Etiology of hyperglycemia in critically ill children and the impact of organ dysfunction

RESUMO Objetivo: Verificar a incidência da hiperglicemia de estresse em crianças em condição grave e investigar a etiologia da hiperglicemia com base em um modelo de avaliação da homeostasia. Métodos: Estudo prospectivo de coorte, conduzido em uma unidade de terapia intensiva pediátrica da Cairo University, que incluiu 60 crianças com doença grave e 21 controles saudáveis. Utilizaram-se os níveis séricos de glicose, insulina e peptídeo C, avaliados em até 24 horas após a admissão. O modelo de avaliação da homeostasia foi utilizado para analisar a função das células beta e a sensibilidade à insulina. Resultados: A hiperglicemia foi estimada em 70% dos pacientes. Valores de glicemia ≥ 180mg/dL se associaram com desfechos piores. Os níveis de glicemia se correlacionaram de forma positiva com o Pediatric Risk for Mortality (PRISM III) e o número de órgãos com disfunção (p = 0,019 e p = 0,022, respectivamente), enquanto os níveis de insulina se correlacionaram de forma negativa com o número de órgãos com disfunção (r = -0,33; p = 0,01). O modelo de avaliação da homeostasia revelou que 26 (43,3%) das crianças em condições graves tinham baixa função de células beta e 18 (30%) baixa sensibilidade à insulina. Detectou-se patologia combinada em apenas dois (3,3%) pacientes. Baixa função de células beta se associou de forma significante com a presença de disfunção de múltiplos órgãos, disfunção respiratória, cardiovascular e hematológica, e presença de sepse. Conclusões: A disfunção de células beta pareceu ser prevalente em nossa coorte e se associou com disfunção de múltiplos órgãos.

ABSTRACT Objective: This study aimed to study the incidence of stress hyperglycemia in critically ill children and to investigate the etiological basis of the hyperglycemia based on homeostasis model assessment. Methods: This was a prospective cohort study in one of the pediatric intensive care units of Cairo University, including 60 critically ill children and 21 healthy controls. Serum blood glucose, insulin, and C-peptide levels were measured within 24 hours of admission. Homeostasis model assessment was used to assess β-cell function and insulin sensitivity. Results: Hyperglycemia was estimated in 70% of patients. Blood glucose values ≥ 180mg/dL were associated with a poor outcome. Blood glucose levels were positively correlated with Pediatric Risk for Mortality (PRISM III) score and number of organ dysfunctions (p = 0.019 and p = 0.022, respectively), while insulin levels were negatively correlated with number of organ dysfunctions (r = −0.33, p = 0.01). Homeostasis model assessment revealed that 26 (43.3%) of the critically ill patients had low β-cell function, and 18 (30%) had low insulin sensitivity. Combined pathology was detected in 2 (3.3%) patients only. Low β-cell function was significantly associated with the presence of multi-organ dysfunction; respiratory, cardiovascular, and hematological dysfunctions; and the presence of sepsis. Conclusions: β-Cell dysfunction appeared to be prevalent in our cohort and was associated with multi-organ dysfunction.

Prevalência da falência de múltiplos órgãos na unidade de terapia intensiva pediátrica: comparação dos escores Pediatric Risk of Mortality III e Pediatric Logistic Organ Dysfunction para predição de mortalidade / Prevalence of multiple organ dysfunction in the pediatric intensive care unit: Pediatric Risk of Mortality III versus Pediatric Logistic Organ Dysfunction scores for mortality prediction

RESUMO Objetivo: Avaliar a frequência de falência de múltiplos órgãos primária e o papel da sepse como agente causal em pacientes pediátricos críticos; e calcular e avaliar a precisão dos escores Pediatric Risk of Mortality III (PRISM III) e Pediatric Logistic Organ Dysfunction (PELOD) para predizer os desfechos de crianças em estado crítico. Métodos: Estudo retrospectivo, que avaliou dados de pacientes admitidos entre janeiro a dezembro de 2011 na unidade de terapia intensiva pediátrica do Children's Hospital da Cairo University. Resultados: Dentre os 237 pacientes estudo, 72% tiveram falência de múltiplos órgãos e 45% sepse com falência de múltiplos órgãos. A taxa de mortalidade em pacientes com falência de múltiplos órgãos foi de 73%. Os fatores independentes de risco para óbito foram ventilação mecânica e falência neurológica (OR: 36 e 3,3, respectivamente). O PRISM III foi mais preciso para prever óbito, com qui quadrado no teste de Hosmer-Lemeshow de 7,3 (df = 8; p = 0,5). A área sob a curva foi de 0,723 para o PRISM III e de 0,78 para o PELOD. Conclusão: A falência de múltiplos órgãos esteve associada à elevada mortalidade. A sepse foi sua principal causa. Pneumonia, diarreia e infecções do sistema nervoso central foram as principais causas de sepse. O PRISM III teve melhor calibração do que o PELOD para prognóstico dos pacientes, apesar da elevada frequência da síndrome de falência de múltiplos órgãos.

ABSTRACT Objectives: To assess the frequency of primary multiple organ failure and the role of sepsis as a causative agent in critically ill pediatric patients; and calculate and evaluate the accuracy of the Pediatric Risk of Mortality III (PRISM III) and Pediatric Logistic Organ Dysfunction (PELOD) scores to predict the outcomes of critically ill children. Methods: Retrospective study, which evaluated data from patients admitted from January to December 2011 in the pediatric intensive care unit of the Children's Hospital of the University of Cairo. Results: Out of 237 patients in the study, 72% had multiple organ dysfunctions, and 45% had sepsis with multiple organ dysfunctions. The mortality rate in patients with multiple organ dysfunction was 73%. Independent risk factors for death were mechanical ventilation and neurological failure [OR: 36 and 3.3, respectively]. The PRISM III score was more accurate than the PELOD score in predicting death, with a Hosmer-Lemeshow X2 (Chi-square value) of 7.3 (df = 8, p = 0.5). The area under the curve was 0.723 for PRISM III and 0.78 for PELOD. Conclusion: A multiple organ dysfunctions was associated with high mortality. Sepsis was the major cause. Pneumonia, diarrhea and central nervous system infections were the major causes of sepsis. PRISM III had a better calibration than the PELOD for prognosis of the patients, despite the high frequency of the multiple organ dysfunction syndrome.

Síndrome do desconforto respiratório agudo relacionada à sepse em crianças com câncer: dinâmica respiratória de uma condição devastadora / Sepsis-related acute respiratory distress syndrome in children with cancer: the respiratory dynamics of a devastating condition

RESUMO Objetivo: Avaliar a evolução clínica e os parâmetros respiratórios de crianças com câncer submetidas à ventilação mecânica que apresentavam síndrome do desconforto respiratório agudo relacionada à sepse. Métodos: Este estudo longitudinal, prospectivo e observacional de coorte com duração de 2 anos incluiu 29 crianças e adolescentes. Dados clínicos, avaliações de gasometria sanguínea e parâmetros ventilatórios foram coletados em quatro momentos diferentes. As flutuações entre as avaliações e as diferenças entre as médias estimadas foram analisadas por meio de modelos lineares mistos, tendo como parâmetro primário (endpoint) a ocorrência de óbito dentro de 28 dias após o início da síndrome do desconforto respiratório agudo. Resultados: Ocorreram 17 óbitos dentro de 28 dias após o início da síndrome do desconforto respiratório agudo, e outros 7 entre 29 e 60 dias. Apenas cinco pacientes sobreviveram por mais de 60 dias. Nove (31%) pacientes faleceram como consequência direta de hipoxemia refratária, e os demais em razão de falência de múltiplos órgãos e choque refratário a catecolaminas. Em 66% das avaliações, o volume corrente demandado para obter saturação de oxigênio igual ou acima de 90% foi superior a 7mL/kg. As médias estimadas de complacência dinâmica foram baixas e similares para sobreviventes e não sobreviventes, porém com inclinação negativa da reta entre a primeira e última avaliações, acompanhada por uma inclinação negativa da reta para volume corrente nos não sobreviventes. Os não sobreviventes tiveram significantemente mais hipoxemia, com relações PaO2/FiO2 que demonstravam médias mais baixas e inclinação negativa da reta nas quatro avaliações. As pressões pico, expiratória e média das vias aéreas demonstraram inclinações positivas na reta para os não sobreviventes, que também apresentaram mais acidose metabólica. Conclusões: Na maioria de nossas crianças com câncer, a sepse e a síndrome do desconforto respiratório agudo evoluíram com deterioração dos índices ventilatórios e progressiva disfunção de órgãos, o que tornou esta tríade praticamente fatal em crianças.

ABSTRACT Objective: To evaluate the clinical course and respiratory parameters of mechanically ventilated children with cancer suffering from sepsis-related acute respiratory distress syndrome. Methods: This 2-year prospective, longitudinal, observational cohort study enrolled 29 children and adolescents. Clinical data, measurements of blood gases and ventilation parameters were collected at four different time points. Fluctuations between measurements as well as differences in estimated means were analyzed by linear mixed models in which death within 28 days from the onset of acute respiratory distress syndrome was the primary endpoint. Results: There were 17 deaths within 28 days of acute respiratory distress syndrome onset and another 7 between 29 - 60 days. Only 5 patients survived for more than 60 days. Nine (31%) patients died as a direct consequence of refractory hypoxemia, and the others died of multiple organ failure and catecholamine-refractory shock. In 66% of the measurements, the tidal volume required to obtain oxygen saturation equal to or above 90% was greater than 7mL/kg. The estimated means of dynamic compliance were low and were similar for survivors and non-survivors but with a negative slope between the first and final measurements, accompanied by a negative slope of the tidal volume for non-survivors. Non-survivors were significantly more hypoxemic, with PaO2/FiO2 ratios showing lower estimated means and a negative slope along the four measurements. Peak, expiratory and mean airway pressures showed positive slopes in the non-survivors, who also had more metabolic acidosis. Conclusions: In most of our children with cancer, sepsis and acute respiratory distress syndrome progressed with deteriorating ventilation indexes and escalating organic dysfunction, making this triad nearly fatal in children.

Organ Correlation in IgG4-Related Diseases

IgG4-related disease (IgG4-RD) is a potentially multiorgan disorder. In this study, clinical and serological features from 132 IgG4-RD patients were compared about organ correlations. Underlying pathologies comprised autoimmune pancreatitis (AIP) in 85 cases, IgG4-related sclerosing cholangitis (IgG4-SC) in 12, IgG4-related sialadenitis (IgG4-SIA) in 56, IgG4-related dacryoadenitis (IgG4-DAC) in 38, IgG4-related lymphadenopathy (IgG4-LYM) in 20, IgG4-related retroperitoneal fibrosis (IgG4-RF) in 19, IgG4-related kidney disease (IgG4-KD) in 6, IgG4-related pseudotumor (IgG4-PT) in 3. Sixty-five patients (49%) had multiple IgG4-RD (two affected organs in 36 patients, three in 19, four in 8, five in 1, and six in 1). Serum IgG4 levels were significantly higher with multiple lesions than with a single lesion (P<0.001). The proportion of association with other IgG4-RD was 42% in AIP, the lowest of all IgG4-RDs. Serum IgG4 level was lower in AIP than in other IgG4-RDs. Frequently associated IgG4-RDs were SIA (25%) and DAC (12%) for AIP; AIP (75%) for IgG4-SC; DAC (57%), AIP (38%) and LYM (27%) for IgG4-SIA; AIP (26%) and LYM (26%) for IgG4-DAC; SIA (75%), DAC (50%) and AIP (45%) for IgG4-LYM; SIA (58%), AIP (42%) and LYM (32%) for IgG4-RF; AIP (100%) and SIA (67%) for IgG4-KID; and DAC (67%) and SIA (67%) for IgG4-PT. Most associated IgG4-RD lesions were diagnosed simultaneously, but IgG4-SIA and IgG4-DAC were sometimes identified before other lesions. About half of IgG4-RD patients had multiple IgG4-RD lesions, and some associations were seen between specific organs.

Red blood cell transfusions worsen the outcomes even in critically ill patients undergoing a restrictive transfusion strategy / Transfusões de concentrados de hemácias pioram os resultados mesmo em pacientes graves, submetidos a estratégia restritiva de transfusão

CONTEXT AND OBJECTIVE: Anemia and blood transfusions are common in intensive care. This study aimed to evaluate epidemiology and outcomes among critically ill patients under a restrictive transfusion strategy. DESIGN AND SETTING: Prospective observational cohort study in an intensive care unit (ICU) at a tertiary hospital. METHODS: All adults admitted to the ICU over a one-year period who remained there for more than 72 hours were included, except those with acute coronary syndrome, ischemic stroke, acute hemorrhage, prior transfusion, pregnant women and Jehovah's Witnesses. The restrictive strategy consisted of transfusion indicated when hemoglobin levels were less than or equal to 7.0 g/dl. RESULTS: The study enrolled 167 patients; the acute physiology and chronic health evaluation II (APACHE II) score was 28.9 ± 6.5. The baseline hemoglobin level was 10.6 ± 2.2 g/dl and on day 28, it was 8.2 ± 1.3 g/dl (P < 0.001). Transfusions were administered to 35% of the patients. In the transfusion group, 61.1% did not survive, versus 48.6% in the non-transfusion group (P = 0.03). Transfusion was an independent risk factor for mortality (P = 0.011; odds ratio, OR = 2.67; 95% confidence interval, CI = 1.25 to 5.69). ICU stay and hospital stay were longer in the transfusion group: 20.0 (3.0-83.0) versus 8.0 (3.0-63.0) days (P < 0,001); and 24.0 (3.0-140.0) versus 14.0 (3.0-80.0) days (P = 0.002), respectively. CONCLUSIONS: In critically ill patients, there was a reduction in hemoglobin with increasing length of ICU stay. Moreover, transfusion was associated with worse prognoses.

CONTEXTO E OBJETIVO: Anemia e transfusões sanguíneas são comuns em terapia intensiva. O objetivo deste estudo foi investigar a epidemiologia e resultados em pacientes críticos sob o regime de transfusão restritiva. TIPO DE ESTUDO E LOCAL: Estudo de coorte, prospectivo e observacional em unidade de terapia intensiva de um hospital terciário. MÉTODOS: Foram incluídos todos adultos admitidos na unidade durante um ano e que permaneceram internados por mais de 72 horas, exceto pacientes com lesão coronariana aguda, isquemia cerebral aguda, hemorragia aguda, transfusão anterior, mulheres grávidas e testemunhas de Jeová. A estratégia restritiva consiste na transfusão indicada com a hemoglobina inferior ou igual a 7.0 g/dl. RESULTADOS: Totalizando 167 pacientes incluídos, APACHE II (Acute Physiology and Chronic Health disease II) foi de 28,9 ± 6,5. O valor da hemoglobina basal foi de 10,6 ± 2.2 g/dl e no 28º dia foi de 8,2 ± 1.3 g/dl (P < 0,001). 35% dos pacientes receberam transfusões. No grupo de transfusão 61,1% não sobreviveram versus 48,6% do grupo não transfusão (P = 0,03). A transfusão foi fator de risco independente de mortalidade (P = 0,011; odds ratio, OR = 2,67; intervalo de confiança, IC 95% = 1,25-5,69). A internação na unidade de terapia intensiva e hospitalar foi maior no grupo de transfusão: 20,0 (3,0-83,0) versus 8,0 (3,0-63,0) dias (P < 0,001); e 24,0 (3,0-140,0) versus 14,0 (3,0-80,0) dias (P = 0,002). CONCLUSÕES: Em pacientes graves, observou-se redução da hemoglobina com a progressão da permanência na UTI. Além disso, a transfusão foi associada com piores prognósticos.

Morbilidad de la insuficiencia multiorgánica en áreas de atención al grave / Morbidity of multiorgan insufficiency in grave patients attention areas

Se realizó un estudio sobre la Disfunción Múltiple de Órganos (DMO) en la Unidad de Cuidados Intensivos del Hospital Militar Mario Muñoz Monroy de Matanzas, durante el período comprendido desde enero del 2002 a diciembre del 2006, mediante la revisión de historias clínicas de los pacientes egresados del servicio. El universo de nuestro estudio estuvo constituido por 82 pacientes que al ingreso en la unidad o durante su evolución se les diagnosticó DMO representando el 9.7 por ciento de los pacientes atendidos en la unidad. El estudio se realizó para conocer la magnitud del problema en la unidad, así como identificar su comportamiento. Hubo mayor incidencia en el sexo masculino, encontrándose como antecedente patológico más frecuente la Diabetes Mellitus, aunque se vio gran relación con el postoperatorio. La elevada letalidad de este proceso y el número de órganos afectados fue directamente proporcional.

We carried out a study about the Multiple Dysfunction of Organs in the Intensive Care Unit of the Military Hospital Mario Muñoz Monroy of Matanzas, from January 2002 to December 2006, reviewing the Medical Records of the patients entering the service. The universe of our study was formed by 82 patients diagnosed with multiple dysfunctions of the organs when entered the unit or during their evolution, representing 97 percent of the patients attended in the unit. The study was made to determine the magnitude of the problem in the unit, and also to identify its behavior. There was a higher evidence in male sex, finding the Diabetes Mellitus as the most frequent pathologic antecedent though there was seen a great relation with post surgery period. The high lethality of this process and the number of affected organs were proportional.

La sepsis, la campaña de "Sobrevivir a la sepsis" y la medicina basada en la evidencia (1a parte) / Sepsis, Surviving sepsis campaign and medicine based on evidence (part 1)

Objetivos: El objetivo central de esta serie de trabajos es presentar los conocimientos más actuales sobre el problema complejo de la sepsis. Fuentes de consulta: Como método de estudio utilizaremos la bibliografía proveniente de reuniones de consenso de expertos en el tema y las publicaciones periódicas que tratan sobre el problema, utilizando como motor de búsqueda los métodos electrónicos, en especial las publicaciones indexadas en Pubmed, la Cochrane Data Base of Systematic Reviews, revistas nacionales, la Revista Argentina de Anestesiología y las revisiones sobre la sepsis efectuadas por la Revista Electrónica de Medicina Intensiva (REMI), cuya página web es http://remi.uninet.edu. Resultados: La sepsis severa es una importante causa de muerte tanto en las unidades de cuidados intensivos (UTI) como en otros medios asistenciales, incluyendo la sala de operaciones. Aun cuando nuestra comprensión de la fisiopatología, del grave proceso mejoró notablemente, han quedado todavía muchos aspectos que permanecen sin recibir un consenso unánime. En muchos países se carece de estadísticas sobre incidencia y mortalidad asociadas a la sepsis, ya que al no ser diagnosticada tampoco es informada en las estadísticas hospitalarias ni en los certificados de defunción. Por este motivo, es frecuente que debamos recurrir a estudios epidemiológicos a veces referidos a años muy anteriores al inicio de la campaña de "Sobrevivir a la sepsis". La sepsis puede ser definida como una respuesta inflamatoria sistémica a la infección. En las conferencias de consenso se definieron lo que es infección, sepsis, sepsis severa, shock séptico y síndrome de la disfunción orgánica múltiple, que acompaña habitualmente al síndrome séptico, en especial a la sepsis severa y al shock séptico. También en esas conferencias se definió la respuesta inflamatoria sistémica (SIRS), que es una consecuencia de la sepsis o guarda mucha similitud con sus manifestaciones y fisiopatología. En un terreno de evol...

Prevalencia de sepsis grave en las Unidades de Cuidado Intensivo: Primer estudio nacional multicéntrico / Prevalence of severe sepsis in Intensive Care Units: A national multicentric study

Background: Severe sepsis (SS) is the leading cause of death in the Intensive Care Units (ICU). Aim: To study the prevalence of SS in Chilean ICUs. Material and methods: An observational, cross-sectional study using a predesigned written survey was done in all ICUs of Chile on April 21st, 2004. General hospital and ICU data and the number of hospitalized patients in the hospital and in the ICU at the survey day, were recorded. Patients were followed for 28 days. Results: Ninety four percent of ICUs participated in the survey. The ICU occupation index was 66 percent. Mean age of patients was 57.7+18 years and 59 percent were male, APACHE II score was 15+7.5 and SOFA score was 6+4. SS was the admission diagnosis of 94 of the 283 patients (33 percent) and 38 patients presented SS after admission. On the survey day, 112 patients fulfilled SS criteria (40 percent). APACHE II and SOFA scores were significantly higher in SS patients than in non SS patients. Global case-fatality ratio at 28 days was 15.9 percent (45/283). Case-fatality ratio in patients with or without SS at the moment of the survey was 26.7 percent (30/112) and 8.7 percent (17/171), respectively p <0.05. Thirteen percent of patients who developed SS after admission, died. Case-fatality ratios for patients with SS from Santiago and the other cities were similar, but APACHE II score was significantly higher in patients from Santiago. In SS patients, the independent predictors of mortality were SS as cause of hospital admission, APACHE II and SOFA scores. Ninety nine percent of SS patients had a known sepsis focus (48 percent respiratory and 30 percent abdominal). Eighty five patients that presented SS after admission, had a respiratory focus. Conclusions: SS is highly prevalent in Chilean ICUs and represents the leading diagnosis at admission. SS as cause of hospitalization, APA CHE II and SOFA scores were independent predictors of mortality.

Incidence of ventilator-associated pneumonia (VAP) after the institution of an educational program on VAP prevention.

OBJECTIVE: Demonstrate if the institution of an educational program on VAP and its prevention is effective in helping reduce the incidence of VAP in a surgical ICU. MATERIAL AND METHOD: An educational program on VAP and its prevention, which consisted of a 1-hour formal lecture, an educational handout, and a pre-and post-test exam was given to the nursing staff beginning in April 1st, 2003. Reminding posters were posted throughout the ICU. The pre-and post-intervention clinical data that included age, sex, diagnosis, APACHE II, ventilator days, and incidence of VAP were collected. VAP was considered to have occurred only after the patient had been on mechanical ventilation for greater than 48 hours. The primary outcome measure was the incidence of VAP The secondary outcome measures were duration of the ICU and hospital stay, and the ICU and hospital mortality. Values were expressed as mean +/- standard deviation, and median (range). Multiple logistic regression analysis of various variables was used to identify risk factors for the occurrence of the VAP. RESULTS: Eight-five patients in Pre- (July 1st, 2002 to June 30th, 2003) and 89 patients in post- (July 1st, 2003 to June 30th, 2004) intervention met the inclusion criteria. The incidence of VAP decreased from 39.7 per 1000 ventilator-day to 10.5 per 1000 ventilator-day (p-value < 0.001) after the institution of an educational program. The ICU, hospital length of stay, and the mortality rate remained unchanged. Age and the interventional program were found to correlate with the occurrence of VAP. CONCLUSION: An institution of an educational program on VAP and its prevention helps reduce the incidence of the VAP at the study institution but does not affect the ICU, hospital length of stay, and the mortality rate.

Admission hypomagnesemia - impact on mortality or morbidity in critically ill patients

No previous study exists to evaluate admission serum magnesium level as a predictor of morbidity or mortality. The aim of this study was to define the prevalence of admission hypomagnesemia in critically ill patients and to evaluate its relationship with organ dysfunction, length of stay, and mortality. A retrospective study was done on 100 patients >/= 16 years old, admitted to the medical-surgical intensive care unit [ICU] at the University Hospital over 2 years period. Observations were made on admission total serum magnesium level, a variety of lab tests related to magnesium, need for ventilator, duration of mechanical ventilation, hospital/ICU lengths of stay, and general patient demographics. The serum magnesium level [normal value, 1.3-2.1 mEq/L] was measured at admission. At admission, 51% of patients had hypomagnesemia, 49% had normal magnesium levels. There was significant difference in mortality rate [55% vs 35%], the length of hospital [15.29 +/- 0.66 vs 12.81 +/- 0.91], or ICU [9.16 +/- 0.53 vs 5.71 +/- 0.55] stay between these two groups of patients [p < 0.05 for all]. Hypomagnesemic patients more frequently had total hypocalcemia, hypokalemia, and hyponatremia. A total of 51 patients developed hypomagnesemia during their ICU stay; these patients had higher Acute Physiology And Chronic Health Evaluation II [APACHE II] [14.16 +/- 1.03 vs 10.80 +/- 0.94] and Sequential Organ Failure Assessment [SOFA; 10.89 +/- 0.90 vs 7.58 +/- 5.01] scores at admission [p < 0.01 for both], a higher maximum SOFA score during their ICU stay [14.75 +/- 0.73 vs 8.08 +/- 0.52, p < 0.01], a more need to ventilator [58.6% vs 41.4%, p < 0.05], and longer duration of mechanical ventilation [7.2 vs 4.7 day, p < 0.01] than the other patients. The ROC curve of SOFA score in the hypomagnesemia yields significantly better results than APACHE II. An increase of 5 units in the APACHE II or SOFA measured on admission increase relative probability of hypomagnesemia by a factor of 0.12 and 0.16 respectively. Development of hypomagnesemia during an ICU stay is associated with guarded prognosis. Monitoring of serum magnesium levels may have prognostic, and perhaps therapeutic, implications

Postweaning multisystemic wasting syndrome in farmed wild boars (Sus scrofa) in Rio Grande do Sul

This report concerns an outbreak of postweaning multisystemic wasting syndrome in wild boars from commercial herds in Rio Grande do Sul, Brazil. The main clinical signs were progressive wasting, respiratory distress, diarrhea, and ocular discharges. Enhanced lymph nodes and spleens, ascites, hydrothorax, and non collapsed lungs were the principal gross lesions. Varying degrees of lymphohistiocytic infiltrates in lymph nodes, spleen, and intestines were the most significant microscopic changes. Although a total of 26 animals had showed clinical and pathological findings consistent with the disease, only in 11 of them it was possible to confirm a PMWS diagnosis through the association of specific lesions in lymphoid tissues with the presence of the viral antigen detected by immunohistochemistry. These findings were similar to those reported in the swine disease.

Descreve-se a ocorrência da síndrome multissistêmica do definhamento suíno em javalis de dois rebanhos comerciais no estado do Rio Grande do Sul. Os principais sinais observados foram definhamento progressivo, tosse, espirros, diarréia e descarga ocular. Linfonodos e baços aumentados, ascite, hidrotórax e pulmões não colapsados foram os principais achados macroscópicos. Infiltrados linfo-histiocitários de graus variáveis em linfonodos, baços e intestinos foram as lesões microscópicas mais relevantes. Embora 26 animais tenham apresentado achados clínicos e patológicos compatíveis com a enfermidade, apenas em 11 desses foi possível confirmar o diagnóstico através da associação de lesões histológicas específicas nos tecidos linfóides com a presença do antígeno viral, detectado pela técnica de imunoistoquímica. Tanto os achados clínicos como patológicos foram semelhantes aos descritos na doença suína.

Frecuencia de falla orgánica en la pancreatitis aguda necrótica / Frecuency of organic failure in acute necrosis pancreatitis

Introducción: La pancreatitis aguda se clasifica como severa por la presencia de necrosis glandular o falla orgánica. Sin embargo, ambas condiciones no son simultáneas. En este estudio determinamos la frecuencia de falla orgánica en pacientes con necrosis pancreática por pancreatitis aguda. Material y Métodos: Se realizó un estudio retrospectivo, transversal, descriptivo y observacional. Se incluyeron los casos de necrosis pancreática por pancreatitis aguda presentados del 1 de enero de 1996 al 31 de diciembre de 2000. Se determinó la presencia de falla orgánica, así como edades, sexo, etiología, estado nutricional, criterios de Ranson, cirugías realizadas y mortalidad. Resultados: De los pacientes con necrosis pancreática, 45% desarrolló falla orgánica. En ellos predominó el sexo masculino y la realización de alguna cirugía. De los pacientes con falla orgánica, 92% la presentó al ingreso; el sistema afectado más frecuente fue el circulatorio, seguido por el pulmonar y el renal. Los pacientes con falla orgánica tuvieron mortalidad de 88%. Las causas de muerte fueron SIRPA y choque irreversible. Discusión: La relación entre necrosis y falla orgánica no es clara. Existen factores a considerar tales como la muerte de tejido pancreático por apoptosis, que limita el daño y la necrosis que lo favorece. La hipoperfusión tisular puede ser determinante entre estas dos formas de lesión.

Introduction: The acute pancreatitis is classified as severe by the presence of glandular necrosis or organic failure. However both conditions are not simultaneous. We determine the frequency of organic failure in patients with pancreatic necrosis for acute pancreatitis. Material and Methods: A study retrospective, transverse, descriptive and observational is carried. Were included the cases of pancreatic necrosis by acute pancreatitis presented of January 1 from 1996 to December 31 2000. The presence of organic failure was determined, as well as ages, sex, etiology, nutritional state, Ranson's criteria, surgeries carried and mortality. Results: 45% of the patients with necrosis pancreatic development organic failure. The masculine sex and the realization of some surgery predominated in them. 92% of the patients with organic failure presents it to the admission, the system circulatory was the more frequently affected, continued by the respiratory and the renal. The patients with organic failure had a mortality of 88% against 0% of those that didn 't present it. The SIRPA and irreversible shock were the causes of death. Discussion: Not is clear the relationship between necrosis and organic failure. The death of pancreatic tissue for apoptosis, that limits the damage and the necrosis, that it favors, is factors to consider. The hypoperfusion tissular can be the determinant among these two lesion forms.

Insuficiência de múltiplos órgäos e sistemas: epidemiologia e prognóstico na unidade de terapia intensiva do Hospital Universitário da Universidade Federal de Juiz de Fora / Multiple organ failure syndrome: epidemiology and prognosis in the intensive care unity (Hospital Universitario - Universidade Federal de Juiz de Fora)

A insuficiência de múltiplos órgäos e sistemas (IMOS) representa a disfunçäo de órgäos e sistemas a partir de uma resposta inflamatória sistêmica, comum em doentes críticos. Sua incidência varia de 2,1 a 49 por cento, em funçäo dos critérios de definiçäo de falência de cada órgäo e das diferenças das populaçöes atendidas em cada unidade. A IMOS é importante causa de óbitos nas UTIs, estando relacionada com o número de órgäos envolvidos e o tempo de disfunçäo de cada órgäo. Nesse estudo prospectivo, aberto, realizado na Unidade de Terapia Intensiva do Hospital Universitário da Universidade Federal de Juiz de Fora (HU-UFJF) os autores avaliaram a incidência de IMOS, verificaram quais os sistemas mais frequentemente envolvidos, correlacionaram a presença de IMOS com a evoluçäo do paciente. Os pacientes foram avaliados diariamente, verificando-se a presença de falência respiratória, cardiovascular, renal, hepática, hematológica e neurológica, segundo os critérios descritos por Knaus em 1991. Correlacionou-se a presença das mesmas com a evoluçäo do paciente. A IMOS ocorreu em 22,2 por cento dos 248 pacientes estudados. A mortalidade dos paccientes com IMOS foi maior do que daqueles sem a síndrome (78,2 por cento versus 15 por cento, p<0,001). O aumento no número de sistemas acometidos correlacionou-se com o aumento na mortalidade. A falência mais comumente encontrada foi a respiratória. Concluímos que na UTI do HU a IMOS ocorre em incidência semelhante à da literatura. Sua presença está associada a uma maior mortalidade, principalmente quando se aumenta o número de órgäos envolvidos.

Síndrome de disfunción multiorgánica (SDMO): variación temporal de su intensidad en un área de cuidados intensivos a través de 11 años de monitoreo / Multiple organ failure syndrome: temporal evolution in an area of intensive care through 11 years of monitoring

El desarrollo del sídrome de disfunción multiorgánica (SDMO) se relaciona estrechamente con la mortalidad y los costos en UTI. El estudio del SDMO mediante su intensidad (peso) posibilita una valoración objetiva del mismo. Objetivo: Analizar la intensidad (peso) del SDMO durante 11 años de asistencia en UTI. Material y método: En el presente estudio se compara la intensidad del SDMO precoz (en las primeras 48 horas) considerándose 2 etapas: Histórica (1985-1990 -: 782) y Actual (1991-1996- n: 1063). En cada una de ellas se diferenció un set Desarrollo y otro de Validación y mediante regresión logística múltiple se obtuvieron los coeficientes ß a fin de calcular los "pesos" de cada disfunción para su posterior comparación. Según los "pesos" obtenidos para cada período (H y A) se diferenciaron diferentes niveles de intensidad (NI) y se trazaron las curvas ROC correspondientes. Resultados: En la Etapa Histórica, el SNC surgió como el de mayor intensidad (6,5), seguido por el Respiratorio (R) (4,5), Renal (Re) (3,0); Cardiovascular (CV) y Hematológico (H) (1,5) y Digestivo (D) (1,0). El área bajo la ROC fue de 0,79. En la Etapa Actual: El SNC continuó siendo el de mayor intensidad pero ésta fue substancialmente inferior a la de H (3,0), seguido por la R (2,5); CV (2,0); Re (2,0); D (1,5) y H (1,0). El área bajo la ROC fue 0,80. Conclusiones: La intensidad del SDMO valorado mediante los "pesos" resultó ser substancialmente inferior en la etapa Actual. La disfunción del SNC fue la de mayor "peso" en ambas etapas. Se reafirma la importancia del monitoreo del SDMO en la evolución temporal