Mortalidade e o tempo de internação em uma unidade de terapia intensiva cirúrgica / Mortality and length of stay in a surgical intensive care unit

JUSTIFICATIVA E OBJETIVOS: Em cuidados intensivos os resultados podem ser relacionados aos índices de mortalidade ou morbidade. Quando avaliada de forma isolada, a mortalidade é uma medida insuficiente do resultado na Unidade de Terapia Intensiva (UTI); o tempo de internação pode ser uma medida indireta do resultado relacionado com a morbidade. O objetivo do presente estudo foi avaliar a incidência e os fatores preditivos para mortalidade e tempo de internação dos pacientes admitidos numa UTI cirúrgica. MÉTODO: Participaram deste estudo prospectivo, realizado, entre abril e julho de 2004, todos os 185 pacientes submetidos a procedimentos programados ou de emergência, admitidos numa UTI cirúrgica. Foram registrados os seguintes parâmetros: idade, sexo, altura e peso, temperatura central estado físico segundo a ASA, tipo de intervenção cirúrgica, porte cirúrgico, técnica anestésica, quantidade e qualidade de fluídos administrados durante a anestesia, monitorização da temperatura ou de técnica de aquecimento corporal peri-operatório, duração da anestesia, tempo de permanência na UTI e no hospital e escore SAPS II. RESULTADOS: O tempo médio de internação na UTI foi de 4,09 ± 10,23 dias. Fatores de risco significativos para permanências mais prolongadas na UTI foram o valor do escore SAPS II, estado físico ASA, quantidade administrada, durante a intervenção cirúrgica, de colóides, unidades de plasma fresco e unidades de concentrados de hemáceas. Quatorze pacientes (7,60 por cento) morreram durante a internação na UTI e 29 (15,70 por cento) morreram durante a internação hospitalar. Fatores de risco independentes de mortalidade com diferença estatística significativa foram intervenções cirúrgicas de emergência, de grande porte, escores altos SAPS II, permanência prolongada na UTI e no hospital. Fatores protetores com diferença estatística significativa para risco de morte hospitalar foram baixo peso corporal e baixo índice de massa corporal (IMC). CONCLUSÕES: As internações prolongadas em UTI são mais freqüentes nos pacientes mais graves à admissão e estão associadas às maiores mortalidades hospitalares. A mortalidade hospitalar é também mais freqüente em pacientes submetidos a intervenções cirúrgicas de emergência ou de grande porte.

[Mortality and length of stay in a surgical intensive care unit.]. / Mortalidade e o tempo de internação em uma unidade de terapia intensiva cirúrgica.

BACKGROUND AND OBJECTIVES: Outcome in intensive care can be categorized as mortality related or morbidity related. Mortality is an insufficient measure of ICU outcome when measured alone and length of stay may be seen as an indirect measure of morbidity related outcome. The aim of the present study was to estimate the incidence and predictive factors for intrahospitalar outcome measured by mortality and LOS in patients admitted to a surgical ICU. METHODS: In this prospective study all 185 patients, who underwent scheduled or emergency surgery admitted to a surgical ICU in a large tertiary university medical center performed during April and July 2004, were eligible to the study. The following variables were recorded: age, sex, body weight and height, core temperature (Tc), ASA physical status, emergency or scheduled surgery, magnitude of surgical procedure, anesthesia technique, amount of fluids during anesthesia, use of temperature monitoring and warming techniques, duration of the anesthesia, length of stay in ICU and in the hospital and SAPS II score. RESULTS: The mean length of stay in the ICU was 4.09 +/- 10.23 days. Significant risk factors for staying longer in ICU were SAPS II, ASA physical status, amount of colloids, fresh frozen plasma units and packed erythrocytes units used during surgery. Fourteen (7.60%) patients died in ICU and 29 (15.70%) died during their hospitalization. Statistically significant independent risk factors for mortality were emergency surgery, major surgery, high SAPS II scores, longer stay in ICU and in the hospital. Statistically significant protective factors against the probability of dying in the hospital were low body weight and low BMI. CONCLUSIONS: In conclusion, prolonged ICU stay is more frequent in more severely ill patients at admission and it is associated with higher hospital mortality. Hospital mortality is also more frequent in patients submitted to emergent and major surgery.

Náuseas e vômitos no pós-operatório: uma revisão do "pequeno-grande" problema / Postoperative nausea and vomiting: a review of the minor-major problem

JUSTIFICATIVA E OBJETIVOS: Apesar da investigação contínua e do desenvolvimento de novos fármacos e técnicas, as náuseas e vômitos no pós-operatório (NVPO) são freqüentes e podem contribuir para o desenvolvimento de complicações com conseqüente aumento dos custos hospitalares e dos recursos humanos. Os objetivos deste artigo são a revisão dos mecanismos fisiológicos, dos fatores de risco e das medidas terapêuticas disponíveis para o manuseio de NVPO. CONTEUDO: Várias são as estratégias de manuseio de NVPO sugeridas neste artigo, destacando-se, no entanto, as linhas de orientação emitidas por Gan em 2003. Estas constituem a contribuição mais recente para a estratificação de risco, prevenção e tratamento dos pacientes com NVPO. CONCLUSÕES: Embora o manuseio de NVPO tenha melhorado nos últimos anos, estes ainda ocorrem freqüentemente em grupos de risco elevado. A estratégia atual para a prevenção e manuseio de NVPO permanece por estabelecer e as linhas de orientação de Gan deverão ser adaptadas a cada população de pacientes e à instituição hospitalar.

Hypothermia in a surgical intensive care unit.

BACKGROUND: Inadvertent hypothermia is not uncommon in the immediate postoperative period and it is associated with impairment and abnormalities in various organs and systems that can lead to adverse outcomes. The aim of this study was to estimate the prevalence, the predictive factors and outcome of core hypothermia on admission to a surgical ICU. METHODS: All consecutive 185 adult patients who underwent scheduled or emergency noncardiac surgery admitted to a surgical ICU between April and July 2004 were admitted to the study. Tympanic membrane core temperature (Tc) was measured before surgery, on arrival at ICU and every two hours until 6 hours after admission. The following variables were also recorded: age, sex, body weight and height, ASA physical status, type of surgery, magnitude of surgical procedure, anesthesia technique, amount of intravenous fluids administered during anesthesia, use of temperature monitoring and warming techniques, duration of the anesthesia, ICU length of stay, hospital length of stay and SAPS II score. Patients were classified as either hypothermic (Tc < or = 35 degrees C) or normothermic (Tc> 35 degrees C). Univariate analysis and multiple regression binary logistic with an odds ratio (OR) and its 95% Confidence Interval (95%CI) were used to compare the two groups of patients and assess the relationship between each clinical predictor and hypothermia. Outcome measured as ICU length of stay and mortality was also assessed. RESULTS: Prevalence of hypothermia on ICU admission was 57.8%. In univariate analysis temperature monitoring, use of warming techniques and higher previous body temperature were significant protective factors against core hypothermia. In this analysis independent predictors of hypothermia on admission to ICU were: magnitude of surgery, use of general anesthesia or combined epidural and general anesthesia, total intravenous crystalloids administrated and total packed erythrocytes administrated, anesthesia longer than 3 hours and SAPS II scores. In multiple logistic regression analysis significant predictors of hypothermia on admission to the ICU were magnitude of surgery (OR 3.9, 95% CI, 1.4-10.6, p = 0.008 for major surgery; OR 3.6, 95% CI, 1.5-9.0, p = 0.005 for medium surgery), intravenous administration of crystalloids (in litres) (OR 1.4, 95% CI, 1.1-1.7, p = 0.012) and SAPS score (OR 1.0, 95% CI 1.0-1.7, p = 0.014); higher previous temperature in ward was a significant protective factor (OR 0.3, 95% CI 0.1-0.7, p = 0.003). Hypothermia was neither a risk factor for hospital mortality nor a predictive factor for staying longer in ICU. CONCLUSION: The prevalence of patient hypothermia on ICU arrival was high. Hypothermia at time of admission to the ICU was not an independent factor for mortality or for staying longer in ICU.

[Postoperative nausea and vomiting: a review of the 'minor-major' problem.]. / Náuseas e vômitos no pós-operatório: uma revisão do 'pequeno-grande' problema.

BACKGROUND AND OBJECTIVES: Notwithstanding continuous investigations and the development of new drugs and techniques, postoperative nausea and vomiting (PONV) are frequent and may contribute to the development of complications, thus increasing hospital and human costs. This article aimed at reviewing physiological mechanisms, risk factors and therapeutic approaches available to manage PONV. CONTENTS: Several strategies to manage PONV are suggested in this article, but stress is given to guidelines published by Gan in 2003. They are the most recent contribution for risk stratification, prevention and treatment of PONV patients. CONCLUSIONS: Although the management of PONV has improved in recent years, it is still common among high-risk patients. Current strategy to prevent and treat PONV is not yet established and Gan guidelines should be adapted to each population and institution.