Epidemiologia e desfecho dos pacientes de alto risco cirúrgico admitidos em unidades de terapia intensiva no Brasil / Epidemiology and outcome of high-surgical-risk patients admitted to an intensive care unit in Brazil

RESUMO Objetivo: Definir o perfil epidemiológico e os principais determinantes de morbimortalidade dos pacientes cirúrgicos não cardíacos de alto risco no Brasil. Métodos: Estudo prospectivo, observacional e multicêntrico. Todos os pacientes cirúrgicos não cardíacos admitidos nas unidades de terapia intensiva, ou seja, considerados de alto risco, no período de 1 mês, foram avaliados e acompanhados diariamente por, no máximo, 7 dias na unidade de terapia intensiva, para determinação de complicações. As taxas de mortalidade em 28 dias de pós-operatório, na unidade de terapia intensiva e hospitalar foram avaliadas. Resultados: Participaram 29 unidades de terapia intensiva onde foram realizadas cirurgias em 25.500 pacientes, dos quais 904 (3,5%) de alto risco (intervalo de confiança de 95% - IC95% 3,3% - 3,8%), tendo sido incluídos no estudo. Dos pacientes envolvidos, 48,3% eram de unidades de terapia intensiva privadas e 51,7% de públicas. O tempo de internação na unidade de terapia intensiva foi de 2,0 (1,0 - 4,0) dias e hospitalar de 9,5 (5,4 - 18,6) dias. As taxas de complicações foram 29,9% (IC95% 26,4 - 33,7) e mortalidade em 28 dias pós-cirurgia 9,6% (IC95% 7,4 - 12,1). Os fatores independentes de risco para complicações foram Simplified Acute Physiology Score 3 (SAPS 3; razão de chance − RC = 1,02; IC95% 1,01 - 1,03) e Sequential Organ Failure Assessment Score (SOFA) da admissão na unidade de terapia intensiva (RC =1,17; IC95% 1,09 - 1,25), tempo de cirurgia (RC = 1,001; IC95% 1,000 - 1,002) e cirurgias de emergências (RC = 1,93; IC95% 1,10 - 3,38). Em adição, foram associados com mortalidade em 28 dias idade (RC = 1,032; IC95% 1,011 - 1,052) SAPS 3 (RC = 1,041; IC95% 1,107 - 1,279), SOFA (RC = 1,175; IC95% 1,069 - 1,292) e cirurgias emergenciais (RC = 2,509; IC95% 1,040 - 6,051). Conclusão: Pacientes com escores prognósticos mais elevados, idosos, tempo cirúrgico e cirurgias emergenciais estiveram fortemente associados a maior mortalidade em 28 dias e mais complicações durante permanência em unidade de terapia intensiva.

ABSTRACT Objective: To define the epidemiological profile and the main determinants of morbidity and mortality in noncardiac high surgical risk patients in Brazil. Methods: This was a prospective, observational and multicenter study. All noncardiac surgical patients admitted to intensive care units, i.e., those considered high risk, within a 1-month period were evaluated and monitored daily for a maximum of 7 days in the intensive care unit to determine complications. The 28-day postoperative, intensive care unit and hospital mortality rates were evaluated. Results: Twenty-nine intensive care units participated in the study. Surgeries were performed in 25,500 patients, of whom 904 (3.5%) were high-risk (95% confidence interval - 95%CI 3.3% - 3.8%) and were included in the study. Of the participating patients, 48.3% were from private intensive care units, and 51.7% were from public intensive care units. The length of stay in the intensive care unit was 2.0 (1.0 - 4.0) days, and the length of hospital stay was 9.5 (5.4 - 18.6) days. The complication rate was 29.9% (95%CI 26.4 - 33.7), and the 28-day postoperative mortality rate was 9.6% (95%CI 7.4 - 12.1). The independent risk factors for complications were the Simplified Acute Physiology Score 3 (SAPS 3; odds ratio - OR = 1.02; 95%CI 1.01 - 1.03) and Sequential Organ Failure Assessment Score (SOFA) on admission to the intensive care unit (OR = 1.17; 95%CI 1.09 - 1.25), surgical time (OR = 1.001, 95%CI 1.000 - 1.002) and emergency surgeries (OR = 1.93, 95%CI, 1.10 - 3.38). In addition, there were associations with 28-day mortality (OR = 1.032; 95%CI 1.011 - 1.052), SAPS 3 (OR = 1.041; 95%CI 1.107 - 1.279), SOFA (OR = 1.175, 95%CI 1.069 - 1.292) and emergency surgeries (OR = 2.509; 95%CI 1.040 - 6.051). Conclusion: Higher prognostic scores, elderly patients, longer surgical times and emergency surgeries were strongly associated with higher 28-day mortality and more complications during the intensive care unit stay.

Síndrome hepatopulmonar / Hepatopulomonar syndrome

Introdução: a síndrome hepatopulmonar (SHP), caracterizada pela tríade de doença hepática, hipoxemia e comunicações arteriovenosas intrapulmonares (CAVI), é considerada uma indicação para o transplante hepático. Nosso objetivo é avaliar a prevalência da SHP no nosso meio. Métodos: avaliamos 40 pacientes com cirrose, sem doença cardiopulmonar, nos quais realizamos gasometria arterial com o paciente em repouso e respirando em ar ambiente e a pesquisa de CAVI pela ecocardiografia com contraste (ECC). Resultados: a SHP foi encontrada em 9/40 (22,5%) e em 10/40 (25,0%), e embora houvesse a presença de CAVI, os mesmos não apresentavam hipoxemia, assim como em 4/40 (10,0%) observamos hipoxemia sem a presença de CAVI. Os pacientes foram divididos em: grupo A, com 9 (22,5%) pacientes portadores da SHP, sendo 5 (55,6%) masculinos com a média de 48,2 ± 8,5 anos; e grupo B, 31 (77,5%) pacientes sem SHP, 18 (58,1%) masculinos com média 48,7 ± 12,6 anos (p>0,05). Os pacientes do grupo A apresentavam maior hipoxemia (PaO2 = 73,3 ± 7,3mmHg e gradiente alvéolo-arterial de oxigênio de 34,5 ± 11,9mmHg) quando comparados com os do grupo B (91,8 ± 8,6mmHg e 10,1 ± 8,8mmHg) (p<0,0001). Conclusão: nossos achados sugerem que a SHP é comum nos cirróticos (22,5%). E que nessa população a hipoxemia é multifatorial.

Introduction: the hepatopulmonary syndrome (HPS), characterized by the triad of liver disease, hypoxemia and intrapulmonary arteriovenous communications (IAVC), is considered a guidemark for liver transplantation. Our goal is to assess the prevalence of HPS in our midst. Methods: we evaluated 40 patients with cirrhosis without cardiopulmonary disease, in which we performed arterial blood gases analysis with the patient at rest breathing room air and researched IAVC submitting them to contrast echocardiography (CEC). Results: the HPS was found in 9/40 (22.5%) and in 10/40 (25.0%), although there was the presence of IAVC, they did not have hypoxemia. Just as in 4/40 (10.0%) we observed the presence of hypoxemia without IAVC. Patients were divided into Group A, represented by 9 (22.5%) patients with HPS, in which 5 (55.6%) were male with an average of age of 48.2 ± 8.5 years old. Group B was composed by 31 (77.5%) patients without HPS, in which 18 (58.1%) of them were male with an average of age of 48.7 ± 12.6 years old (p>0.05). Patients in group A had greater hypoxemia (PaO2 = 73.3 ± 7.3mmHg and alveolar-arterial gradient of oxygen = 34.5 ± 11.9mmHg) compared with group B (91.8 ± 8, 6mmHg and 10.1 ± 8.8mmHg) (p<0.0001). Conclusion: our fi ndings suggest that HPS is common in cirrhotic patients (22.5%). And that hypoxemia in this population is multifactorial.