Clinical outcomes of patients requiring ventilatory support in Brazilian intensive care units: a multicenter, prospective, cohort study.

INTRODUCTION: Contemporary information on mechanical ventilation (MV) use in emerging countries is limited. Moreover, most epidemiological studies on ventilatory support were carried out before significant developments, such as lung protective ventilation or broader application of non-invasive ventilation (NIV). We aimed to evaluate the clinical characteristics, outcomes and risk factors for hospital mortality and failure of NIV in patients requiring ventilatory support in Brazilian intensive care units (ICU). METHODS: In a multicenter, prospective, cohort study, a total of 773 adult patients admitted to 45 ICUs over a two-month period requiring invasive ventilation or NIV for more than 24 hours were evaluated. Causes of ventilatory support, prior chronic health status and physiological data were assessed. Multivariate analysis was used to identifiy variables associated with hospital mortality and NIV failure. RESULTS: Invasive MV and NIV were used as initial ventilatory support in 622 (80%) and 151 (20%) patients. Failure with subsequent intubation occurred in 54% of NIV patients. The main reasons for ventilatory support were pneumonia (27%), neurologic disorders (19%) and non-pulmonary sepsis (12%). ICU and hospital mortality rates were 34% and 42%. Using the Berlin definition, acute respiratory distress syndrome (ARDS) was diagnosed in 31% of the patients with a hospital mortality of 52%. In the multivariate analysis, age (odds ratio (OR), 1.03; 95% confidence interval (CI), 1.01 to 1.03), comorbidities (OR, 2.30; 95% CI, 1.28 to 3.17), associated organ failures (OR, 1.12; 95% CI, 1.05 to 1.20), moderate (OR, 1.92; 95% CI, 1.10 to 3.35) to severe ARDS (OR, 2.12; 95% CI, 1.01 to 4.41), cumulative fluid balance over the first 72 h of ICU (OR, 2.44; 95% CI, 1.39 to 4.28), higher lactate (OR, 1.78; 95% CI, 1.27 to 2.50), invasive MV (OR, 2.67; 95% CI, 1.32 to 5.39) and NIV failure (OR, 3.95; 95% CI, 1.74 to 8.99) were independently associated with hospital mortality. The predictors of NIV failure were the severity of associated organ dysfunctions (OR, 1.20; 95% CI, 1.05 to 1.34), ARDS (OR, 2.31; 95% CI, 1.10 to 4.82) and positive fluid balance (OR, 2.09; 95% CI, 1.02 to 4.30). CONCLUSIONS: Current mortality of ventilated patients in Brazil is elevated. Implementation of judicious fluid therapy and a watchful use and monitoring of NIV patients are potential targets to improve outcomes in this setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT01268410.

Alterações eletrocardiográficas na intoxicação aguda por antidepressivotricíclico e suas implicações clínicas: [revisão] / Electrocardiographic alterations in acute tricyclic antidepressant intoxication and its clinical implications: [review]

Introdução: A intoxicação aguda por antidepressivos tricíclicos é comum nas salas de emergência. Anormalidades no eletrocardiograma de 12 derivações (ECG) são associadas a este tipo de intoxicação, com implicações diagnósticas e prognósticas. O ECG pode ter valor incremental principalmente em situações de alteração de consciência, convulsões ou distúrbios do ritmo cardíaco associado. Objetivo: Revisar as principais alterações eletrocardiográficas descritas na intoxicação por antidepressivos tricíclicos e estabelecer suas implicações prognósticas no manejo desta condição clínica. Metodologia: Pesquisa bibliográfica no MEDLINE (PubMEd) limitada aos artigos publicados entre 1980 e 2010 em língua inglesa, utilizando-se unitermos (tricyclic antidepressant overdose OR tricyclic antidepressant intoxication OR tricyclic antidepressant poisoning OR tricyclic antidepressant ingestionAND electrocardiography). Dos 133 artigos identificados, foram selecionados 44 para a revisão...

Introduction: The acute poisoning by tricyclic antidepressants is common in emergency rooms. Abnormalities in 12-lead electrocardiogram (ECG) are associated with this type of poisoning, with diagnostic and prognostic implications. The ECG may have incremental value especially in situations of altered consciousness, seizures or heart rhythm disturbances associated. Objective: To review the electrocardiographic changes described in tricyclic antidepressant poisoning and to establish their prognostic implications in the management of this condition. Methods: Bibliographic search in MEDLINE (PubMed) limited to articles published between 1980 and 2010 in English, using key words (tricyclic antidepressant overdose OR tricyclic antidepressant intoxicationOR tricyclic antidepressant poisoning OR tricyclic antidepressant ingestion AND electrocardiography). Of the 133 articles identified, 44 were selected for review...

Bloqueio atrioventricular e endocardite infecciosa em prótese valvar / Atrioventricular block and infectious endocarditis in valve prosthesis

A endocarditre infecciosa é uma infecção grave, rara e pouco diagnosticada. O presente relato de caso visa chamar a atenção para o diagnóstico de endocardite infecciosa complicada, na presença de distúrbios de condução atrioventricular. Trata-se de um paciente do sexo masculino, 68 anos, portador de prótese valvar aórtica biológica, há 5 anos, atendido na sala de emergência de hospital terciário, com quadro de tosse com expectoração clara, dispnéia em repouso (há 3 meses) e febre (há 01 dia). Eletrocardiograma com bloqueio atrioventricular total e ecocardiograma transesofágico, com vegetações nos folhetos da prótese biológica aórtica, abscesso e insuficiência perivalvares.

Acidente botrópico fatal / Death caused by bothrops poisoning

Os acidentes ofídicos causados pelo gênero Bothrops ocasionam manifestações locais secundárias à ação inflamatória aguda do veneno. A ocorrência de óbito (em torno de 0,6% do total de casos atendidos anualmente no Brasil) é rara, mas certamente, traumática. O relato deste caso visa chamar a atenção para possíveis complicações locais e sistêmicas (insuficiência renal e sepsis) neste tipo de envenenamento e enfatizar as medidas terapêuticas e de suporte que devem ser realizadas em tempo hábil.

The Snakebite caused by Bothrops gender cause local events secondary to acute inflammatory action of the poison. The occurrence of death (about 0.6% of all cases occurred each year in Brazil) is rare, but certainly traumatic. The report of this case aims to draw attention to possible local and systemic complications (sepsis and renal failure) in this type of poisoning and emphasize the therapeutic and supportive measures that should be carried out in a timely fashion.

Efficacy and safety of aprotinin use for reoperative valvular surgery.

BACKGROUND: Preservation of the hemostatic system during cardiac surgery is a main concern, primarily after repeated cardiac operations. METHODS: We compared the outcomes of adult patients undergoing isolated reoperative valvular surgery receiving full-dose of aprotinin (redo group, n = 70) with patients experiencing primary isolated valvular surgery not receiving aprotinin (primary group, n = 135). RESULTS: The mean age was lower in the redo group (45 +/- 14 years vs 50 +/- 17 years, p = 0.036). The redo group had more female patients (73% vs 51%, p = 0.003), patients in functional class IV (15% vs 4% p = 0.009), and patients with chronic atrial fibrillation (48% vs 24%, p = 0.001). The cardiopulmonary bypass duration was longer in the redo group (119 +/- 50 minutes vs 103 +/- 41 minutes, p = 0.014). However, the blood loss was significantly lower (300 +/- 279 mL vs 776 +/- 584 mL, p = 0.001) and fewer patients needed transfusions (3.0% vs 13%, p = 0.023) in the redo group. The postoperative morbidity was similar in both groups. The postoperative in-hospital mortality was 7% in the primary group and 10% in the redo group (p = 0.419). Factors associated with postoperative in-hospital mortality were the following: age greater than 60 years (p = 0.040, odds ratio [OR] 3.0), New York Heart Association class IV (p = 0.022, OR 5.0), preoperative critical state (p < 0.001, OR 12), emergent operation (p = 0.012, OR 7.0), endocarditis (p = 0.004, OR 10.0), and reoperation due to mechanical mitral prosthesis dysfunction (p = 0.009, OR 7). CONCLUSIONS: The mortality and morbidity in redo valve surgery with aprotinin administration was comparable with primary valve surgery without aprotinin. Bleeding and transfusion requirements were significantly lower in redo patients receiving aprotinin.