Assessment of the components of fluid balance in patients with septic shock: a prospective observational study.

BACKGROUND: The optimal amount for initial fluid resuscitation is still controversial in sepsis and the contribution of non-resuscitation fluids in fluid balance is unclear. We aimed to investigate the main components of fluid intake and fluid balance in both survivors and non-survivor patients with septic shock within the first 72 hours. METHODS: In this prospective observational study in two intensive care units, we recorded all fluids administered intravenously, orally, or enterally, and losses during specific time intervals from vasopressor initiation: T1 (up to 24 hours), T2 (24 to 48 hours) and T3 (48 to 72 hours). Logistic regression and a mathematical model assessed the association with mortality and the influence of severity of illness. RESULTS: We included 139 patients. The main components of fluid intake varied across different time intervals, with resuscitation and non-resuscitation fluids such as antimicrobials and maintenance fluids being significant contributors in T1 and nutritional therapy in T2/T3. A positive fluid balance both in T1 and T2 was associated with mortality (p = 0.049; p = 0.003), while nutritional support in T2 was associated with lower mortality (p = 0.040). The association with mortality was not explained by severity of illness scores. CONCLUSIONS: Non-resuscitation fluids are major contributors to a positive fluid balance within the first 48 hours of resuscitation. A positive fluid balance in the first 24 and 48 hours seems to independently increase the risk of death, while higher amount of nutrition seems protective. This data might inform fluid stewardship strategies aiming to improve outcomes and minimize complications in sepsis.

Assessment of the components of fluid balance in patients with septic shock: a prospective observational study

Abstract Background: The optimal amount for initial fluid resuscitation is still controversial in sepsis and the contribution of non-resuscitation fluids in fluid balance is unclear. We aimed to investigate the main components of fluid intake and fluid balance in both survivors and non-survivor patients with septic shock within the first 72 hours. Methods: In this prospective observational study in two intensive care units, we recorded all fluids administered intravenously, orally, or enterally, and losses during specific time intervals from vasopressor initiation: T1 (up to 24 hours), T2 (24 to 48 hours) and T3 (48 to 72 hours). Logistic regression and a mathematical model assessed the association with mortality and the influence of severity of illness. Results: We included 139 patients. The main components of fluid intake varied across different time intervals, with resuscitation and non-resuscitation fluids such as antimicrobials and maintenance fluids being significant contributors in T1 and nutritional therapy in T2/T3. A positive fluid balance both in T1 and T2 was associated with mortality (p = 0.049; p = 0.003), while nutritional support in T2 was associated with lower mortality (p = 0.040). The association with mortality was not explained by severity of illness scores. Conclusions: Non-resuscitation fluids are major contributors to a positive fluid balance within the first 48 hours of resuscitation. A positive fluid balance in the first 24 and 48 hours seems to independently increase the risk of death, while higher amount of nutrition seems protective. This data might inform fluid stewardship strategies aiming to improve outcomes and minimize complications in sepsis.

Fibrinolytic therapy in patients with COVID-19 and ARDS: protocol for a systematic review and meta-analysis.

INTRODUCTION: In COVID-19-related acute respiratory distress syndrome (ARDS), the clot play a role in gas exchange abnormalities. Fibrinolytic therapy can improve alveolar ventilation by restoring blood flow. In this systematic review and meta-analysis protocol, we aim to assess the safety and efficacy of fibrinolytic therapy in such a population. METHODS: We will perform a systematic search in MEDLINE, EMBASE, Cochrane CENTRAL and LILACS databases without language restrictions for relevant randomised controlled trials (RCTs) and quasi-RCTs. Two review authors will independently perform data extraction and quality assessments of data from included studies. In case of divergence, a third author will be contacted. The Cochrane handbook will be used for guidance. If the results are not appropriate for a meta-analysis, a descriptive analysis will be performed. DISCUSSION: This systematic review and meta-analysis protocol will provide current evidence about the safety and efficacy of fibrinolytic therapy in patients with COVID-19 and ARDS. These findings will provide if fibrinolytic therapy might be an option for a desperate clinical setting, where all medical efforts have been used. PROSPERO REGISTRATION NUMBER: PROSPERO CRD42020187482. ETHICS AND DISSEMINATION: Ethics committee approval is not necessary. We intend to update the public registry, report any protocol amendments and publish the results in a widely accessible journal.

Determinants of death in critically ill COVID-19 patients during the first wave of COVID-19: a multicenter study in Brazil.

OBJECTIVE: To evaluate clinical outcomes and factors associated with mortality, focusing on secondary infections, in critically ill patients with COVID-19 in three Brazilian hospitals during the first pandemic wave. METHODS: This was a retrospective observational study involving adult patients with COVID-19 admitted to one of the participating ICUs between March and August of 2020. We analyzed clinical features, comorbidities, source of SARS-CoV-2 infection, laboratory data, microbiology data, complications, and causes of death. We assessed factors associated with in-hospital mortality using logistic regression models. RESULTS: We included 645 patients with a mean age of 61.4 years. Of those, 387 (60.0%) were male, 12.9% (83/643) had undergone solid organ transplant, and almost 10% (59/641) had nosocomial COVID-19 infection. During ICU stay, 359/644 patients (55.7%) required invasive mechanical ventilation, 225 (34.9%) needed renal replacement therapy, 337 (52.2%) received vasopressors, and 216 (33.5%) had hospital-acquired infections (HAIs), mainly caused by multidrug-resistant gram-negative bacteria. HAIs were independently associated with a higher risk of death. The major causes of death were refractory shock and multiple organ dysfunction syndrome but not ARDS, as previously reported in the literature. CONCLUSIONS: In this study, most of our cohort required invasive mechanical ventilation and almost one third had HAIs, which were independently associated with a higher risk of death. Other factors related to death were Charlson Comorbidity Index, SOFA score at admission, and clinical complications during ICU stay. Nosocomial COVID-19 infection was not associated with death. The main immediate causes of death were refractory shock and multiple organ dysfunction syndrome.

Determinants of death in critically ill COVID-19 patients during the first wave of COVID-19: a multicenter study in Brazil / Determinantes de mortalidade em pacientes com COVID-19 em estado crítico durante a primeira onda da doença: estudo multicêntrico no Brasil

ABSTRACT Objective: To evaluate clinical outcomes and factors associated with mortality, focusing on secondary infections, in critically ill patients with COVID-19 in three Brazilian hospitals during the first pandemic wave. Methods: This was a retrospective observational study involving adult patients with COVID-19 admitted to one of the participating ICUs between March and August of 2020. We analyzed clinical features, comorbidities, source of SARS-CoV-2 infection, laboratory data, microbiology data, complications, and causes of death. We assessed factors associated with in-hospital mortality using logistic regression models. Results: We included 645 patients with a mean age of 61.4 years. Of those, 387 (60.0%) were male, 12.9% (83/643) had undergone solid organ transplant, and almost 10% (59/641) had nosocomial COVID-19 infection. During ICU stay, 359/644 patients (55.7%) required invasive mechanical ventilation, 225 (34.9%) needed renal replacement therapy, 337 (52.2%) received vasopressors, and 216 (33.5%) had hospital-acquired infections (HAIs), mainly caused by multidrug-resistant gram-negative bacteria. HAIs were independently associated with a higher risk of death. The major causes of death were refractory shock and multiple organ dysfunction syndrome but not ARDS, as previously reported in the literature. Conclusions: In this study, most of our cohort required invasive mechanical ventilation and almost one third had HAIs, which were independently associated with a higher risk of death. Other factors related to death were Charlson Comorbidity Index, SOFA score at admission, and clinical complications during ICU stay. Nosocomial COVID-19 infection was not associated with death. The main immediate causes of death were refractory shock and multiple organ dysfunction syndrome.

RESUMO Objetivo: Avaliar desfechos clínicos e fatores associados à mortalidade, com foco em infecções secundárias, em pacientes com COVID-19 em estado crítico em três hospitais brasileiros durante a primeira onda da pandemia. Métodos: Estudo observacional retrospectivo envolvendo pacientes adultos com COVID-19 internados nas UTIs participantes entre março e agosto de 2020. Analisaram-se características clínicas, comorbidades, fonte de infecção por SARS-CoV-2, dados laboratoriais, dados microbiológicos, complicações e causas de óbito. Os fatores associados à mortalidade hospitalar foram avaliados por meio de modelos de regressão logística. Resultados: Foram incluídos 645 pacientes com média de idade de 61,4 anos. Desses, 387 (60,0%) eram do sexo masculino, 12,9% (83/643) haviam sido submetidos a transplante de órgão sólido, e quase 10% (59/641) apresentaram infecção nosocomial por COVID-19. Durante a internação na UTI, 359/644 pacientes (55,7%) necessitaram de ventilação mecânica invasiva, 225 (34,9%) necessitaram de terapia renal substitutiva, 337 (52,2%) receberam vasopressores, e 216 (33,5%) apresentaram infecções hospitalares (IHs), causadas principalmente por bactérias Gram-negativas multirresistentes. As IHs associaram-se de forma independente a maior risco de óbito. As principais causas de óbito foram choque refratário e síndrome de disfunção de múltiplos órgãos, mas não SDRA, como relatado anteriormente na literatura. Conclusões: Neste estudo, a maior parte de nossa coorte necessitou de ventilação mecânica invasiva, e quase um terço apresentou IHs, que se associaram de forma independente a maior risco de óbito. Outros fatores relacionados à mortalidade foram Índice de Comorbidade de Charlson, SOFA na admissão e complicações clínicas durante a internação na UTI. A infecção nosocomial por COVID-19 não se associou à mortalidade. As principais causas imediatas de óbito foram choque refratário e síndrome de disfunção de múltiplos órgãos.

Sepsis in patients hospitalized with coronavirus disease 2019: how often and how severe?

PURPOSE OF REVIEW: To discuss why severe COVID-19 should be considered sepsis and how co-infection and secondary infection can aggravate this condition and perpetuate organ dysfunction leading to high mortality rates. RECENT FINDINGS: In severe COVID-19, there is both direct viral toxicity and dysregulated host response to infection. Although both coinfection and/or secondary infection are present, the latest is of greater concern mainly in resource-poor settings. Patients with severe COVID-19 present a phenotype of multiorgan dysfunction that leads to death in an unacceptable high percentage of the patients, with wide variability around the world. Similarly to endemic sepsis, the mortality of COVID-19 critically ill patients is higher in low-income and middle-income countries as compared with high-income countries. Disparities, including hospital strain, resources limitations, higher incidence of healthcare-associated infections (HAI), and staffing issues could in part explain this variability. SUMMARY: The high mortality rates of critically ill patients with severe COVID-19 disease are not only related to the severity of patient disease but also to modifiable factors, such as the ICU strain, HAI incidence, and organizational aspects. Therefore, HAI prevention and the delivery of best evidence-based care for these patients to avoid additional damage is important. Quality improvement interventions might help in improving outcomes mainly in resource-limited settings.

Data-driven ICU management: Using Big Data and algorithms to improve outcomes.

The digitalization of the Intensive Care Unit (ICU) led to an increasing amount of clinical data being collected at the bedside. The term "Big Data" can be used to refer to the analysis of these datasets that collect enormous amount of data of different origin and format. Complexity and variety define the value of Big Data. In fact, the retrospective analysis of these datasets allows to generate new knowledge, with consequent potential improvements in the clinical practice. Despite the promising start of Big Data analysis in medical research, which has seen a rising number of peer-reviewed articles, very limited applications have been used in ICU clinical practice. A close future effort should be done to validate the knowledge extracted from clinical Big Data and implement it in the clinic. In this article, we provide an introduction to Big Data in the ICU, from data collection and data analysis, to the main successful examples of prognostic, predictive and classification models based on ICU data. In addition, we focus on the main challenges that these models face to reach the bedside and effectively improve ICU care.

Practices for promoting sleep in intensive care units in Brazil: a national survey. / Práticas de promoção de sono em unidades de terapia intensiva no Brasil: um inquérito nacional.

OBJECTIVE: To conduct a national survey of intensive care professionals to identify the practices for promoting sleep in adult intensive care units in Brazil and describe the professionals' perceptions of the importance of sleep for patients. METHODS: An electronic questionnaire was distributed by the clinical research cooperation network of the Associação de Medicina Intensiva Brasileira and by the Brazilian Research in Intensive Care Network to physicians and nurses registered with the association. The questionnaire evaluated the profile of the respondents, the profile of their intensive care units, whether protocols for promoting sleep were present, the pharmacological and nonpharmacological measures typically employed in the unit, and the professionals' perceptions regarding sleep in critically ill patients. RESULTS: A total of 118 questionnaires were evaluated. The Southeast region of the country was the most represented (50 questionnaires, 42.4%). The majority of units had a clinical-surgical profile (93 questionnaires; 78.8%), and 26 had a continuous visitation policy (22.0%). Only 18 intensive care units (15.3%) reported having protocols for promoting sleep. The most cited measure for sleep promotion was reducing light during the night (95 questionnaires; 80.5%), which was more often performed in private intensive care units. Almost all of the responders (99%) believed that poor-quality sleep has a negative impact on patient recovery. CONCLUSION: The responses to this Brazilian survey revealed that few intensive care units had a program for promoting sleep, although almost all participants recognized the importance of sleep in patient recovery.

Práticas de promoção de sono em unidades de terapia intensiva no Brasil: um inquérito nacional / Practices for promoting sleep in intensive care units in Brazil: a national survey

RESUMO Objetivo: Realizar um inquérito nacional com profissionais de terapia intensiva para determinar as práticas de promoção do sono em unidades de terapia intensiva para adultos no Brasil, e descrever suas percepções sobre a importância do sono para os pacientes. Métodos: Um questionário eletrônico foi distribuído pela rede de cooperação em pesquisa clínica da Associação de Medicina Intensiva Brasileira aos médicos e enfermeiros registrados na associação e pela Brazilian Research in Intensive Care Network. O questionário avaliou o perfil dos respondedores, de suas unidades de terapia intensiva, se estavam presentes protocolos de promoção do sono, quais as medidas farmacológicas e não farmacológicas usualmente empregadas na unidade e a percepção dos profissionais em relação ao sono nos pacientes críticos. Resultados: Foram avaliados 118 questionários. A Região Sudeste foi a mais representada (50 questionários; 42,4%). A maioria apresentava perfil clínico-cirúrgico (93 questionários; 78,8%) e 26 possuíam política de visita contínua (22,0%). Apenas 18 unidades de terapia intensiva (15,3%) referiram apresentar protocolos de promoção do sono. A medida mais citada para promoção de sono foi a redução da luminosidade no período noturno (95 questionários; 80,5%), sendo mais executada em unidades de terapia intensiva privadas. Quase a totalidade dos respondedores (99%) acreditou que o sono com qualidade ruim tinha impacto negativo na recuperação do paciente. Conclusão: Nas respostas deste inquérito brasileiro, poucas unidades apresentaram um programa de promoção de sono na unidade de terapia intensiva, embora a quase totalidade dos participantes reconhecesse a importância do sono na recuperação do paciente.

ABSTRACT Objective: To conduct a national survey of intensive care professionals to identify the practices for promoting sleep in adult intensive care units in Brazil and describe the professionals' perceptions of the importance of sleep for patients. Methods: An electronic questionnaire was distributed by the clinical research cooperation network of the Associação de Medicina Intensiva Brasileira and by the Brazilian Research in Intensive Care Network to physicians and nurses registered with the association. The questionnaire evaluated the profile of the respondents, the profile of their intensive care units, whether protocols for promoting sleep were present, the pharmacological and nonpharmacological measures typically employed in the unit, and the professionals' perceptions regarding sleep in critically ill patients. Results: A total of 118 questionnaires were evaluated. The Southeast region of the country was the most represented (50 questionnaires, 42.4%). The majority of units had a clinical-surgical profile (93 questionnaires; 78.8%), and 26 had a continuous visitation policy (22.0%). Only 18 intensive care units (15.3%) reported having protocols for promoting sleep. The most cited measure for sleep promotion was reducing light during the night (95 questionnaires; 80.5%), which was more often performed in private intensive care units. Almost all of the responders (99%) believed that poor-quality sleep has a negative impact on patient recovery. Conclusion: The responses to this Brazilian survey revealed that few intensive care units had a program for promoting sleep, although almost all participants recognized the importance of sleep in patient recovery.

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.

Estimation of Stroke Volume and Stroke Volume Changes by Electrical Impedance Tomography.

BACKGROUND: Electrical impedance tomography (EIT) is a noninvasive imaging method that identifies changes in air and blood volume based on thoracic impedance changes. Recently, there has been growing interest in EIT to measure stroke volume (SV). The objectives of this study are as follows: (1) to evaluate the ability of systolic impedance variations (ΔZsys) to track changes in SV in relation to a baseline condition; (2) to assess the relationship of ΔZsys and SV in experimental subjects; and (3) to identify the influence of body dimensions on the relationship between ΔZsys and SV. METHODS: Twelve Agroceres pigs were instrumented with transpulmonary thermodilution catheter and EIT and were mechanically ventilated in a random order using different settings of tidal volume (VT) and positive end-expiratory pressure (PEEP): VT 10 mL·kg and PEEP 10 cm H2O, VT 10 mL·kg and PEEP 5 cm H2O, VT 6 mL·kg and PEEP 10 cm H2O, and VT 6 mL·kg and PEEP 5 cm H2O. After baseline data collection, subjects were submitted to hemorrhagic shock and successive fluid challenges. RESULTS: A total of 204 paired measurements of SV and ΔZsys were obtained. The 4-quadrant plot showed acceptable trending ability with a concordance rate of 91.2%. Changes in ΔZsys after fluid challenges presented an area under the curve of 0.83 (95% confidence interval, 0.74-0.92) to evaluate SV changes. Conversely, the linear association between ΔZsys and SV was poor, with R from linear mixed model of 0.35. Adding information on body dimensions improved the linear association between ΔZsys and SV up to R from linear mixed model of 0.85. CONCLUSIONS: EIT showed good trending ability and is a promising hemodynamic monitoring tool. Measurements of absolute SV require that body dimensions be taken into account.

Patterns of C-reactive protein ratio predicts outcomes in healthcare-associated pneumonia in critically ill patients with cancer.

PURPOSE: Describe the patterns of C-reactive protein relative changes in response to antibiotic therapy in critically ill cancer patients with healthcare-associated pneumonia (HCAP) and its ability to predict outcome. METHODS: Secondary analysis of a prospective cohort of critically ill cancer patients with HCAP. CRP was sampled every other day from D0 to D6 of antibiotic therapy. Patients were classified according to an individual pattern of CRP-ratio response: fast - CRP at D4 of therapy was <0.4 of D0 CRP; slow - a continuous but slow decrease of CRP; non - CRP remained ≥0.8 of D0 CRP; biphasic - initial CRP decrease to levels <0.8 of the D0 CRP followed by a secondary rise ≥0.8. RESULTS: 129 patients were included and septic shock was present in 74% and invasive mechanical ventilation was used in 73%. Intensive care unit (ICU) and hospital mortality rates were 47% and 64%, respectively. By D4, both CRP and CRP-ratio of survivors were significantly lower than in nonsurvivors (p<0.001 and p=0.004, respectively). Both time-dependent analysis of CRP-ratio of the four previously defined patterns (p<0.001) as ICU mortality were consistently different [fast 12.9%, slow 43.2%, biphasic 66.7% and non 71.8% (p<0.001)]. CONCLUSION: CRP-ratio was useful in the early prediction of poor outcomes in cancer patients with HCAP.