Clinimetric properties of the Perme Intensive Care Unit Mobility Score -a multicenter study for minimum important difference and responsiveness analysis.

Background: The use of instruments in clinical practice with measurement properties tested is highly recommended, in order to provide adequate assessment and measurement of outcomes. Objective: To calculate the minimum clinically important difference (MCID) and responsiveness of the Perme Intensive Care Unit Mobility Score (Perme Score). Methods: This retrospective, multicentric study investigated the clinimetric properties of MCID, estimated by constructing the Receiver Operating Characteristic (ROC). Maximizing sensitivity and specificity by Youden's, the ROC curve calibration was performed by the Hosmer and Lemeshow goodness-of-fit test. Additionally, we established the responsiveness, floor and ceiling effects, internal consistency, and predictive validity of the Perme Score. Results: A total of 1.200 adult patients records from four mixed general intensive care units (ICUs) were included. To analyze which difference clinically reflects a relevant evolution we calculated the area under the curve (AUC) of 0.96 (95% CI: 0.95-0.98), and the optimal cut-off value of 7.0 points was established. No substantial floor (8.8%) or ceiling effects (4.9%) were observed at ICU discharge. However, a moderate floor effect was observed at ICU admission (19.3%), in contrast to a very low incidence of ceiling effect (0.6%). The Perme Score at ICU admission was associated with hospital mortality, OR 0.86 (95% CI: 0.82-0.91), and the predictive validity for ICU stay presented a mean ratio of 0.97 (95% CI: 0.96-0.98). Conclusion: Our findings support the establishment of the minimum clinically important difference and responsiveness of the Perme Score as a measure of mobility status in the ICU.

Antecedentes: Se recomienda encarecidamente el uso de instrumentos en la práctica clínica con propiedades de medición probadas, con el fin de proporcionar una evaluación y medición adecuada de los resultados. Objetivo: Calcular la diferencia mínima clínicamente importante (MCID) y la capacidad de respuesta de la puntuación de movilidad de la unidad de cuidados intensivos de Perme (Perme Score). Métodos: Este estudio multicéntrico retrospectivo investigó las propiedades clinimétricas de MCID, estimadas mediante la construcción de la característica operativa del receptor (ROC). Maximizando la sensibilidad y especificidad mediante la prueba de Youden, la calibración de la curva ROC se realizó mediante la prueba de bondad de ajuste de Hosmer y Lemeshow. Además, establecimos la capacidad de respuesta, los efectos suelo y techo, la consistencia interna y la validez predictiva del Perme Score. Resultados: Se incluyeron un total de 1,200 registros de pacientes adultos de cuatro unidades de cuidados intensivos (UCI) generales mixtas. Para analizar qué diferencia refleja clínicamente una evolución relevante calculamos el área bajo la curva (AUC) de 0.96 (95% CI: 0.95-0.98); y se estableció el valor de corte óptimo de 7.0 puntos. No se observaron efectos suelo (8.8%) o techo (4.9%) sustanciales al alta de la UCI. Sin embargo, se observó un efecto suelo moderado al ingreso en la UCI (19.3%), en contraste con una incidencia muy baja del efecto techo (0.6%). El Perme Score al ingreso en UCI se asoció con la mortalidad hospitalaria, OR 0.86 (95% CI: 0.82-0.91), y la validez predictiva de estancia en UCI presentó una relación media de 0.97 (95% CI: 0.96-0.98). Conclusiones: Nuestros hallazgos respaldan el establecimiento de la diferencia mínima clínicamente importante y la capacidad de respuesta de el Perme Score como medida del estado de movilidad en la UCI.

Clinimetric properties of the Perme Intensive Care Unit Mobility Score -a multicenter study for minimum important difference and responsiveness analysis

Background: The use of instruments in clinical practice with measurement properties tested is highly recommended, in order to provide adequate assessment and measurement of outcomes. Objective: To calculate the minimum clinically important difference (MCID) and responsiveness of the Perme Intensive Care Unit Mobility Score (Perme Score). Methods: This retrospective, multicentric study investigated the clinimetric properties of MCID, estimated by constructing the Receiver Operating Characteristic (ROC). Maximizing sensitivity and specificity by Youden's, the ROC curve calibration was performed by the Hosmer and Lemeshow goodness-of-fit test. Additionally, we established the responsiveness, floor and ceiling effects, internal consistency, and predictive validity of the Perme Score. Results: A total of 1.200 adult patients records from four mixed general intensive care units (ICUs) were included. To analyze which difference clinically reflects a relevant evolution we calculated the area under the curve (AUC) of 0.96 (95% CI: 0.95-0.98), and the optimal cut-off value of 7.0 points was established. No substantial floor (8.8%) or ceiling effects (4.9%) were observed at ICU discharge. However, a moderate floor effect was observed at ICU admission (19.3%), in contrast to a very low incidence of ceiling effect (0.6%). The Perme Score at ICU admission was associated with hospital mortality, OR 0.86 (95% CI: 0.82-0.91), and the predictive validity for ICU stay presented a mean ratio of 0.97 (95% CI: 0.96-0.98). Conclusion: Our findings support the establishment of the minimum clinically important difference and responsiveness of the Perme Score as a measure of mobility status in the ICU.

Antecedentes: Se recomienda encarecidamente el uso de instrumentos en la práctica clínica con propiedades de medición probadas, con el fin de proporcionar una evaluación y medición adecuada de los resultados. Objetivo: Calcular la diferencia mínima clínicamente importante (MCID) y la capacidad de respuesta de la puntuación de movilidad de la unidad de cuidados intensivos de Perme (Perme Score). Métodos: Este estudio multicéntrico retrospectivo investigó las propiedades clinimétricas de MCID, estimadas mediante la construcción de la característica operativa del receptor (ROC). Maximizando la sensibilidad y especificidad mediante la prueba de Youden, la calibración de la curva ROC se realizó mediante la prueba de bondad de ajuste de Hosmer y Lemeshow. Además, establecimos la capacidad de respuesta, los efectos suelo y techo, la consistencia interna y la validez predictiva del Perme Score. Resultados: Se incluyeron un total de 1,200 registros de pacientes adultos de cuatro unidades de cuidados intensivos (UCI) generales mixtas. Para analizar qué diferencia refleja clínicamente una evolución relevante calculamos el área bajo la curva (AUC) de 0.96 (95% CI: 0.95-0.98); y se estableció el valor de corte óptimo de 7.0 puntos. No se observaron efectos suelo (8.8%) o techo (4.9%) sustanciales al alta de la UCI. Sin embargo, se observó un efecto suelo moderado al ingreso en la UCI (19.3%), en contraste con una incidencia muy baja del efecto techo (0.6%). El Perme Score al ingreso en UCI se asoció con la mortalidad hospitalaria, OR 0.86 (95% CI: 0.82-0.91), y la validez predictiva de estancia en UCI presentó una relación media de 0.97 (95% CI: 0.96-0.98). Conclusiones: Nuestros hallazgos respaldan el establecimiento de la diferencia mínima clínicamente importante y la capacidad de respuesta de el Perme Score como medida del estado de movilidad en la UCI.

Analysis of mobility level of COVID-19 patients undergoing mechanical ventilation support: A single center, retrospective cohort study.

BACKGROUND: Severe coronavirus disease 2019 (COVID-19) patients frequently require mechanical ventilation (MV) and undergo prolonged periods of bed rest with restriction of activities during the intensive care unit (ICU) stay. Our aim was to address the degree of mobilization in critically ill patients with COVID-19 undergoing to MV support. METHODS: Retrospective single-center cohort study. We analyzed patients' mobility level, through the Perme ICU Mobility Score (Perme Score) of COVID-19 patients admitted to the ICU. The Perme Mobility Index (PMI) was calculated [PMI = ΔPerme Score (ICU discharge-ICU admission)/ICU length of stay], and patients were categorized as "improved" (PMI > 0) or "not improved" (PMI ≤ 0). Comparisons were performed with stratification according to the use of MV support. RESULTS: From February 2020, to February 2021, 1,297 patients with COVID-19 were admitted to the ICU and assessed for eligibility. Out of those, 949 patients were included in the study [524 (55.2%) were classified as "improved" and 425 (44.8%) as "not improved"], and 396 (41.7%) received MV during ICU stay. The overall rate of patients out of bed and able to walk ≥ 30 meters at ICU discharge were, respectively, 526 (63.3%) and 170 (20.5%). After adjusting for confounders, independent predictors of improvement of mobility level were frailty (OR: 0.52; 95% CI: 0.29-0.94; p = 0.03); SAPS III Score (OR: 0.75; 95% CI: 0.57-0.99; p = 0.04); SOFA Score (OR: 0.58; 95% CI: 0.43-0.78; p < 0.001); use of MV after the first hour of ICU admission (OR: 0.41; 95% CI: 0.17-0.99; p = 0.04); tracheostomy (OR: 0.54; 95% CI: 0.30-0.95; p = 0.03); use of extracorporeal membrane oxygenation (OR: 0.21; 95% CI: 0.05-0.8; p = 0.03); neuromuscular blockade (OR: 0.53; 95% CI: 0.3-0.95; p = 0.03); a higher Perme Score at admission (OR: 0.35; 95% CI: 0.28-0.43; p < 0.001); palliative care (OR: 0.05; 95% CI: 0.01-0.16; p < 0.001); and a longer ICU stay (OR: 0.79; 95% CI: 0.61-0.97; p = 0.04) were associated with a lower chance of mobility improvement, while non-invasive ventilation within the first hour of ICU admission and after the first hour of ICU admission (OR: 2.45; 95% CI: 1.59-3.81; p < 0.001) and (OR: 2.25; 95% CI: 1.56-3.26; p < 0.001), respectively; and vasopressor use (OR: 2.39; 95% CI: 1.07-5.5; p = 0.03) were associated with a higher chance of mobility improvement. CONCLUSION: The use of MV reduced mobility status in less than half of critically ill COVID-19 patients.

Clinical characteristics and outcomes of COVID-19 patients admitted to the intensive care unit during the first year of the pandemic in Brazil: a single center retrospective cohort study.

OBJECTIVE: To describe clinical characteristics, resource use, outcomes, and to identify predictors of in-hospital mortality of patients with COVID-19 admitted to the intensive care unit. METHODS: Retrospective single-center cohort study conducted at a private hospital in São Paulo (SP), Brazil. All consecutive adult (≥18 years) patients admitted to the intensive care unit, between March 4, 2020 and February 28, 2021 were included in this study. Patients were categorized between survivors and non-survivors according to hospital discharge. RESULTS: During the study period, 1,296 patients [median (interquartile range) age: 66 (53-77) years] with COVID-19 were admitted to the intensive care unit. Out of those, 170 (13.6%) died at hospital (non-survivors) and 1,078 (86.4%) were discharged (survivors). Compared to survivors, non-survivors were older [80 (70-88) versus 63 (50-74) years; p<0.001], had a higher Simplified Acute Physiology Score 3 [59 (54-66) versus 47 (42-53) points; p<0.001], and presented comorbidities more frequently. During the intensive care unit stay, 56.6% of patients received noninvasive ventilation, 32.9% received mechanical ventilation, 31.3% used high flow nasal cannula, 11.7% received renal replacement therapy, and 1.5% used extracorporeal membrane oxygenation. Independent predictors of in-hospital mortality included age, Sequential Organ Failure Assessment score, Charlson Comorbidity Index, need for mechanical ventilation, high flow nasal cannula, renal replacement therapy, and extracorporeal membrane oxygenation support. CONCLUSION: Patients with severe COVID-19 admitted to the intensive care unit exhibited a considerable morbidity and mortality, demanding substantial organ support, and prolonged intensive care unit and hospital stay.

The Perme Mobility Index: A new concept to assess mobility level in patients with coronavirus (COVID-19) infection.

INTRODUCTION: The Coronavirus Disease 2019 (COVID-19) outbreak is evolving rapidly worldwide. Data on the mobility level of patients with COVID-19 in the intensive care unit (ICU) are needed. OBJECTIVE: To describe the mobility level of patients with COVID-19 admitted to the ICU and to address factors associated with mobility level at the time of ICU discharge. METHODS: Single center, retrospective cohort study. Consecutive patients admitted to the ICU with confirmed COVID-19 infection were analyzed. The mobility status was assessed by the Perme Score at admission and discharge from ICU with higher scores indicating higher mobility level. The Perme Mobility Index (PMI) was calculated [PMI = ΔPerme Score (ICU discharge-ICU admission)/ICU length of stay]. Based on the PMI, patients were divided into two groups: "Improved" (PMI > 0) and "Not improved" (PMI ≤ 0). RESULTS: A total of 136 patients were included in this analysis. The hospital mortality rate was 16.2%. The Perme Score improved significantly when comparing ICU discharge with ICU admission [20.0 (7-28) points versus 7.0 (0-16) points; P < 0.001]. A total of 88 patients (64.7%) improved their mobility level during ICU stay, and the median PMI of these patients was 1.5 (0.6-3.4). Patients in the improved group had a lower duration of mechanical ventilation [10 (5-14) days versus 15 (8-24) days; P = 0.021], lower hospital length of stay [25 (12-37) days versus 30 (11-48) days; P < 0.001], and lower ICU and hospital mortality rate. Independent predictors for mobility level were lower age, lower Charlson Comorbidity Index, and not having received renal replacement therapy. CONCLUSION: Patients' mobility level was low at ICU admission; however, most patients improved their mobility level during ICU stay. Risk factors associated with the mobility level were age, comorbidities, and use of renal replacement therapy.

Clinical characteristics and outcomes of COVID-19 patients admitted to the intensive care unit during the first year of the pandemic in Brazil: a single center retrospective cohort study / Características clínicas e desfechos de pacientes com COVID-19 admitidos em unidade de terapia intensiva durante o primeiro ano de pandemia no Brasil: um estudo de coorte retrospectivo em centro único

ABSTRACT Objective: To describe clinical characteristics, resource use, outcomes, and to identify predictors of in-hospital mortality of patients with COVID-19 admitted to the intensive care unit. Methods: Retrospective single-center cohort study conducted at a private hospital in São Paulo (SP), Brazil. All consecutive adult (≥18 years) patients admitted to the intensive care unit, between March 4, 2020 and February 28, 2021 were included in this study. Patients were categorized between survivors and non-survivors according to hospital discharge. Results: During the study period, 1,296 patients [median (interquartile range) age: 66 (53-77) years] with COVID-19 were admitted to the intensive care unit. Out of those, 170 (13.6%) died at hospital (non-survivors) and 1,078 (86.4%) were discharged (survivors). Compared to survivors, non-survivors were older [80 (70-88) versus 63 (50-74) years; p<0.001], had a higher Simplified Acute Physiology Score 3 [59 (54-66) versus 47 (42-53) points; p<0.001], and presented comorbidities more frequently. During the intensive care unit stay, 56.6% of patients received noninvasive ventilation, 32.9% received mechanical ventilation, 31.3% used high flow nasal cannula, 11.7% received renal replacement therapy, and 1.5% used extracorporeal membrane oxygenation. Independent predictors of in-hospital mortality included age, Sequential Organ Failure Assessment score, Charlson Comorbidity Index, need for mechanical ventilation, high flow nasal cannula, renal replacement therapy, and extracorporeal membrane oxygenation support. Conclusion: Patients with severe COVID-19 admitted to the intensive care unit exhibited a considerable morbidity and mortality, demanding substantial organ support, and prolonged intensive care unit and hospital stay.

RESUMO Objetivo: Descrever características clínicas, uso de recursos e desfechos e identificar preditores de mortalidade intra-hospitalar de pacientes com COVID-19 admitidos na unidade de terapia intensiva. Métodos: Estudo de coorte retrospectivo, em centro único, realizado em um hospital privado localizado em São Paulo (SP). Pacientes adultos (≥18 anos) admitidos consecutivamente na unidade de terapia intensiva, entre 4 de março de 2020 a 28 de fevereiro de 2021, foram incluídos neste estudo. Os pacientes foram classificados como sobreviventes e não sobreviventes, de acordo com a alta hospitalar. Resultados: Durante o período do estudo, 1.296 pacientes [mediana (intervalo interquartil) de idade: 66 (53-77) anos] com COVID-19 foram admitidos na unidade de terapia intensiva. Destes, 170 (13,6%) pacientes morreram no hospital (não sobreviventes), e 1.078 (86,4%) receberam alta hospitalar (sobreviventes). Comparados aos sobreviventes, os não sobreviventes eram mais idosos [80 (70-88) versus 63 (50-74) anos; p<0,001], apresentavam pontuação mais alta no sistema prognóstico Simplified Acute Physiology Score 3 [59 (54-66) versus 47 (42-53); pontos p<0,001] e tinham mais comorbidades. Durante a internação na unidade de terapia intensiva, 56,6% dos pacientes usaram ventilação não invasiva, 32,9% usaram ventilação mecânica invasiva, 31,3% usaram cateter nasal de alto fluxo, 11,7% foram submetidos à terapia renal substitutiva, e 1,5% usou oxigenação por membrana extracorpórea. Os preditores independentes de mortalidade intra-hospitalar foram idade, Sequential Organ Failure Assessment, Índice de Comorbidade de Charlson, necessidade de ventilação mecânica, uso de cateter nasal de alto fluxo, uso de terapia renal substitutiva e suporte por oxigenação por membrana extracorpórea. Conclusão: Pacientes com quadros graves da COVID-19 admitidos na unidade de terapia intensiva apresentaram considerável mortalidade e morbidade, com alta demanda de terapia de suporte e internação prolongada em unidade de terapia intensiva e hospitalar.

Burnout syndrome and engagement among critical care providers: a cross-sectional study. / Síndrome de burnout e engajamento em profissionais de saúde: um estudo transversal.

OBJECTIVE: To evaluate the frequency of severe burnout syndrome among critical care providers and to correlate it with work engagement. METHODS: A self-administered survey including the Maslach Burnout Inventory, Depression Anxiety and Stress Scales, and Gallup questionnaire was distributed. All analyses were stratified by setting (intensive care unit or step-down unit) and by professional group (nurses versus physicians versus physiotherapists). RESULTS: Between February 2017 and June 2017, 206 out of 325 invited professionals (63.4%) answered the questionnaires. Of these, 55 were physicians (26.7%), 88 were physiotherapists (42.7%) and 63 were nurses (30.6%). The frequency of severe burnout was 34.3% (27.9 - 41.4%), and no difference was found between professional groups or settings. The frequency of severe or very severe cases of depression, anxiety or stress was 12.9%, 11.4% and 10.5%, respectively. The median (interquartile range) score observed on the Gallup questionnaire was 41 (34 - 48), and no differences were found between professional groups or settings. There was a negative correlation between burnout and work engagement (r = -0.148; p = 0.035). CONCLUSION: There is a high frequency of severe burnout among critical care providers working in the intensive care unit and step-down unit. There was a negative correlation between burnout and work engagement.

OBJETIVO: Avaliar a frequência de síndrome de burnout grave em profissionais de terapia intensiva e correlacioná-la com o engajamento com o trabalho. MÉTODOS: Foi distribuído um questionário autoaplicável que incluía o Inventário de Burnout de Maslach, a Escala de Depressão Ansiedade e Estresse e o questionário Gallup. Todas as análises foram estratificadas por local de trabalho (unidade de terapia intensiva ou unidade semi-intensiva) e por grupo profissional (enfermeiros versus médicos versus fisioterapeutas). RESULTADOS: Entre fevereiro de 2017 e junho de 2017, 206 dos 325 profissionais convidados (63,4%) responderam aos questionários. Destes, 55 eram médicos (26,7%), 88 eram fisioterapeutas (42,7%) e 63 eram enfermeiros (30,6%). A frequência de burnout grave foi de 34,3% (27,9 - 41,4%), e não se identificaram diferenças entre os grupos profissionais ou locais de trabalho. A frequência de casos graves ou muito graves de depressão, ansiedade ou estresse foi de 12,9%, 11,4% e 10,5%, respectivamente. O escore mediano (intervalo interquartil) observado pelo questionário Gallup foi 41 (34 - 48), e não se observaram diferenças entre os grupos profissionais ou locais de trabalho. Houve correlação negativa entre burnout e engajamento com o trabalho (r = -0,148; p = 0,035). CONCLUSÃO: A frequência de burnout grave foi elevada entre os profissionais de saúde que trabalham na unidade de terapia intensiva e na unidade semi-intensiva. Existe uma correlação negativa entre burnout e engajamento com o trabalho.

Síndrome de burnout e engajamento em profissionais de saúde: um estudo transversal / Burnout syndrome and engagement among critical care providers: a cross-sectional study

RESUMO Objetivo: Avaliar a frequência de síndrome de burnout grave em profissionais de terapia intensiva e correlacioná-la com o engajamento com o trabalho. Métodos: Foi distribuído um questionário autoaplicável que incluía o Inventário de Burnout de Maslach, a Escala de Depressão Ansiedade e Estresse e o questionário Gallup. Todas as análises foram estratificadas por local de trabalho (unidade de terapia intensiva ou unidade semi-intensiva) e por grupo profissional (enfermeiros versus médicos versus fisioterapeutas). Resultados: Entre fevereiro de 2017 e junho de 2017, 206 dos 325 profissionais convidados (63,4%) responderam aos questionários. Destes, 55 eram médicos (26,7%), 88 eram fisioterapeutas (42,7%) e 63 eram enfermeiros (30,6%). A frequência de burnout grave foi de 34,3% (27,9 - 41,4%), e não se identificaram diferenças entre os grupos profissionais ou locais de trabalho. A frequência de casos graves ou muito graves de depressão, ansiedade ou estresse foi de 12,9%, 11,4% e 10,5%, respectivamente. O escore mediano (intervalo interquartil) observado pelo questionário Gallup foi 41 (34 - 48), e não se observaram diferenças entre os grupos profissionais ou locais de trabalho. Houve correlação negativa entre burnout e engajamento com o trabalho (r = -0,148; p = 0,035). Conclusão: A frequência de burnout grave foi elevada entre os profissionais de saúde que trabalham na unidade de terapia intensiva e na unidade semi-intensiva. Existe uma correlação negativa entre burnout e engajamento com o trabalho.

ABSTRACT Objective: To evaluate the frequency of severe burnout syndrome among critical care providers and to correlate it with work engagement. Methods: A self-administered survey including the Maslach Burnout Inventory, Depression Anxiety and Stress Scales, and Gallup questionnaire was distributed. All analyses were stratified by setting (intensive care unit or step-down unit) and by professional group (nurses versus physicians versus physiotherapists). Results: Between February 2017 and June 2017, 206 out of 325 invited professionals (63.4%) answered the questionnaires. Of these, 55 were physicians (26.7%), 88 were physiotherapists (42.7%) and 63 were nurses (30.6%). The frequency of severe burnout was 34.3% (27.9 - 41.4%), and no difference was found between professional groups or settings. The frequency of severe or very severe cases of depression, anxiety or stress was 12.9%, 11.4% and 10.5%, respectively. The median (interquartile range) score observed on the Gallup questionnaire was 41 (34 - 48), and no differences were found between professional groups or settings. There was a negative correlation between burnout and work engagement (r = -0.148; p = 0.035). Conclusion: There is a high frequency of severe burnout among critical care providers working in the intensive care unit and step-down unit. There was a negative correlation between burnout and work engagement.

Intensive support recommendations for critically-ill patients with suspected or confirmed COVID-19 infection.

In December 2019, a series of patients with severe pneumonia were identified in Wuhan, Hubei province, China, who progressed to severe acute respiratory syndrome and acute respiratory distress syndrome. Subsequently, COVID-19 was attributed to a new betacoronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Approximately 20% of patients diagnosed as COVID-19 develop severe forms of the disease, including acute hypoxemic respiratory failure, severe acute respiratory syndrome, acute respiratory distress syndrome and acute renal failure and require intensive care. There is no randomized controlled clinical trial addressing potential therapies for patients with confirmed COVID-19 infection at the time of publishing these treatment recommendations. Therefore, these recommendations are based predominantly on the opinion of experts (level C of recommendation).

Mobilization practices in the ICU: A nationwide 1-day point- prevalence study in Brazil.

BACKGROUND: Mobilization of critically ill patients is safe and may improve functional outcomes. However, the prevalence of mobilization activities of ICU patients in Brazil is unknown. METHODS: A one-day point prevalence prospective study with a 24-hour follow-up period was conducted in Brazil. Demographic data, ICU characteristics, prevalence of mobilization activities, level of patients' mobilization, and main reasons for not mobilizing patients were collected for all adult patients with more than 24hs of ICU stay in the 26 participating ICUs. Mobilization activity was defined as any exercise performed during ICU stay. RESULTS: In total, 358 patients were included in this study. Mobilization activities were performed in 87.4% of patients. Patients received mobilization activities while under invasive mechanical ventilation (44.1%), noninvasive ventilation (11.7%), or without any ventilatory support (44.2%). Passive exercises were more frequently performed [46.5% in all patients; 82.3% in mechanically ventilated patients]. Mobilization activities included in-bed exercise regimen (72.2%). Out-of-bed mobility was reported in 39.9% of mobilized patients, and in 16.3% of patients under invasive mechanical ventilation. The presence of an institutional early mobility protocol was associated with early mobilization (OR, 3.19; 95% CI, 1.23 to 8.22; p = 0.016), and with out-of-bed exercise (OR, 5.80; 95% CI, 1.33 to 25.30; p = 0.02). CONCLUSION: Mobilization activities in critically ill patients in Brazil was highly prevalent, although there was almost no active mobilization in the mechanically ventilated patients. Moreover, the presence of an institutional early mobility protocol was associated with a threefold higher chance of ICU mobilization during that day.

Intensive support recommendations for critically-ill patients with suspected or confirmed COVID-19 infection / Recomendações de suporte intensivo para pacientes graves com infecção suspeita ou confirmada pela COVID-19

ABSTRACT In December 2019, a series of patients with severe pneumonia were identified in Wuhan, Hubei province, China, who progressed to severe acute respiratory syndrome and acute respiratory distress syndrome. Subsequently, COVID-19 was attributed to a new betacoronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Approximately 20% of patients diagnosed as COVID-19 develop severe forms of the disease, including acute hypoxemic respiratory failure, severe acute respiratory syndrome, acute respiratory distress syndrome and acute renal failure and require intensive care. There is no randomized controlled clinical trial addressing potential therapies for patients with confirmed COVID-19 infection at the time of publishing these treatment recommendations. Therefore, these recommendations are based predominantly on the opinion of experts (level C of recommendation).

RESUMO Em dezembro de 2019, uma série de pacientes com pneumonia grave foi identificada em Wuhan, província de Hubei, na China. Esses pacientes evoluíram para síndrome respiratória aguda grave e síndrome do desconforto respiratório agudo. Posteriormente, a COVID-19 foi atribuída a um novo betacoronavírus, o coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2). Cerca de 20% dos pacientes com diagnóstico de COVID-19 desenvolvem formas graves da doença, incluindo insuficiência respiratória aguda hipoxêmica, síndrome respiratória aguda grave, síndrome do desconforto respiratório agudo e insuficiência renal aguda e requerem admissão em unidade de terapia intensiva. Não há nenhum ensaio clínico randomizado controlado que avalie potenciais tratamentos para pacientes com infecção confirmada pela COVID-19 no momento da publicação destas recomendações de tratamento. Dessa forma, essas recomendações são baseadas predominantemente na opinião de especialistas (grau de recomendação de nível C).

Extracorporeal membrane oxygenation: a literature review. / Oxigenação por membrana extracorpórea: revisão da literatura.

Extracorporeal membrane oxygenation is a modality of extracorporeal life support that allows for temporary support in pulmonary and/or cardiac failure refractory to conventional therapy. Since the first descriptions of extracorporeal membrane oxygenation, significant improvements have occurred in the device and the management of patients and, consequently, in the outcomes of critically ill patients during extracorporeal membrane oxygenation. Many important studies about the use of extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome refractory to conventional clinical support, under in-hospital cardiac arrest and with cardiogenic refractory shock have been published in recent years. The objective of this literature review is to present the theoretical and practical aspects of extracorporeal membrane oxygenation support for respiratory and/or cardiac functions in critically ill patients.

A oxigenação por membrana extracorpórea é uma modalidade de suporte de vida extracorpóreo que possibilita suporte temporário à falência da função pulmonar e/ou cardíaca, refratária ao tratamento clínico convencional. Desde as primeiras descrições da oxigenação por membrana extracorpórea, melhorias significativas ocorreram no dispositivo, no manejo do paciente e, consequentemente, nos desfechos dos pacientes em oxigenação por membrana extracorpórea. Diversos estudos importantes sobre a utilização de oxigenação por membrana extracorpórea em pacientes com síndrome do desconforto respiratório agudo refratária ao suporte clínico convencional, em parada cardíaca intra-hospitalar e choque cardiogênico refratário foram publicados nos últimos anos. Dessa forma, o objetivo desta revisão é apresentar conceitos teóricos e práticos sobre a utilização da oxigenação por membrana extracorpórea em situações de falência pulmonar e/ou cardíaca refratária ao manejo clínico convencional em pacientes críticos.

Oxigenação por membrana extracorpórea: revisão da literatura / Extracorporeal membrane oxygenation: a literature review

RESUMO A oxigenação por membrana extracorpórea é uma modalidade de suporte de vida extracorpóreo que possibilita suporte temporário à falência da função pulmonar e/ou cardíaca, refratária ao tratamento clínico convencional. Desde as primeiras descrições da oxigenação por membrana extracorpórea, melhorias significativas ocorreram no dispositivo, no manejo do paciente e, consequentemente, nos desfechos dos pacientes em oxigenação por membrana extracorpórea. Diversos estudos importantes sobre a utilização de oxigenação por membrana extracorpórea em pacientes com síndrome do desconforto respiratório agudo refratária ao suporte clínico convencional, em parada cardíaca intra-hospitalar e choque cardiogênico refratário foram publicados nos últimos anos. Dessa forma, o objetivo desta revisão é apresentar conceitos teóricos e práticos sobre a utilização da oxigenação por membrana extracorpórea em situações de falência pulmonar e/ou cardíaca refratária ao manejo clínico convencional em pacientes críticos.

ABSTRACT Extracorporeal membrane oxygenation is a modality of extracorporeal life support that allows for temporary support in pulmonary and/or cardiac failure refractory to conventional therapy. Since the first descriptions of extracorporeal membrane oxygenation, significant improvements have occurred in the device and the management of patients and, consequently, in the outcomes of critically ill patients during extracorporeal membrane oxygenation. Many important studies about the use of extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome refractory to conventional clinical support, under in-hospital cardiac arrest and with cardiogenic refractory shock have been published in recent years. The objective of this literature review is to present the theoretical and practical aspects of extracorporeal membrane oxygenation support for respiratory and/or cardiac functions in critically ill patients.

Efeitos do uso de cateter nasal de alto fluxo na intubação e na reintubação de pacientes críticos: revisão sistemática, metanálise e análise de sequência de ensaios / The effects of high-flow nasal cannula on intubation and re-intubation in critically ill patients: a systematic review, meta-analysis and trial sequential analysis

RESUMO Objetivo: Avaliar a eficácia do cateter nasal de alto fluxo na prevenção de intubação e reintubação de pacientes críticos em comparação com oxigenoterapia convencional ou ventilação não invasiva. Métodos: Esta revisão sistemática foi realizada por meio de busca eletrônica em bancos de dados incluindo trabalhos publicados entre 1966 e abril de 2018. O desfecho primário foi a necessidade de intubação ou reintubação. Os desfechos secundários foram escalonamento de terapia, mortalidade no seguimento mais longo, mortalidade hospitalar e necessidade de ventilação não invasiva. Resultados: Dezessete estudos com 3.978 pacientes foram incluídos. Não houve redução na necessidade de intubação ou reintubação (OR 0,72; IC95% 0,52 - 1,01; p = 0,056). Não houve diferença no escalonamento de terapia (OR 0,80; IC95% 0,59 - 1,08; p = 0,144), na mortalidade no seguimento mais longo (OR 0,94; IC95% 0,70 - 1,25; p = 0,667), na mortalidade hospitalar (OR 0,84; IC95% 0,56 - 1,26; p = 0,391) ou na necessidade de ventilação não invasiva (OR 0,64; IC95% 0,39 - 1,05, p = 0,075). Na análise sequencial de ensaios, o número de eventos incluídos foi menor que o tamanho ótimo de informação, com erro tipo I global > 0,05. Conclusão: No presente estudo e no cenário avaliado, o cateter nasal de alto fluxo não foi associado com redução na necessidade de intubação ou reintubação em pacientes críticos.

ABSTRACT Objective: To evaluate the efficacy of high-flow nasal cannula in the prevention of intubation and re-intubation in critically ill patients compared to conventional oxygen therapy or noninvasive ventilation. Methods: This systematic review was performed through an electronic database search of articles published from 1966 to April 2018. The primary outcome was the need for intubation or re-intubation. The secondary outcomes were therapy escalation, mortality at the longest follow-up, hospital mortality and the need for noninvasive ventilation. Results: Seventeen studies involving 3,978 patients were included. There was no reduction in the need for intubation or re-intubation with high-flow nasal cannula (OR 0.72; 95%CI 0.52 - 1.01; p = 0.056). There was no difference in the need for therapy escalation (OR 0.80, 95% CI 0.59 - 1.08, p = 0.144), mortality at the longest follow-up (OR 0.94; 95%CI 0.70 - 1.25; p = 0.667), hospital mortality (OR 0.84; 95%CI 0.56 - 1.26; p = 0.391) or noninvasive ventilation (OR 0.64, 95%CI 0.39 - 1.05, p = 0.075). In the trial sequential analysis, the number of events included was lower than the optimal information size with a global type I error > 0.05. Conclusion: In the present study and setting, high-flow nasal cannula was not associated with a reduction of the need for intubation or re-intubation in critically ill patients.

Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts.

PURPOSE: Mechanical power (MP) may unify variables known to be related to development of ventilator-induced lung injury. The aim of this study is to examine the association between MP and mortality in critically ill patients receiving invasive ventilation for at least 48 h. METHODS: This is an analysis of data stored in the databases of the MIMIC-III and eICU. Critically ill patients receiving invasive ventilation for at least 48 h were included. The exposure of interest was MP. The primary outcome was in-hospital mortality. RESULTS: Data from 8207 patients were analyzed. Median MP during the second 24 h was 21.4 (16.2-28.1) J/min in MIMIC-III and 16.0 (11.7-22.1) J/min in eICU. MP was independently associated with in-hospital mortality [odds ratio per 5 J/min increase (OR) 1.06 (95% confidence interval (CI) 1.01-1.11); p = 0.021 in MIMIC-III, and 1.10 (1.02-1.18); p = 0.010 in eICU]. MP was also associated with ICU mortality, 30-day mortality, and with ventilator-free days, ICU and hospital length of stay. Even at low tidal volume, high MP was associated with in-hospital mortality [OR 1.70 (1.32-2.18); p < 0.001] and other secondary outcomes. Finally, there is a consistent increase in the risk of death with MP higher than 17.0 J/min. CONCLUSION: High MP of ventilation is independently associated with higher in-hospital mortality and several other outcomes in ICU patients receiving invasive ventilation for at least 48 h.

Bronchial hygiene techniques in patients on mechanical ventilation: what are used and why?

Objective To analyze and describe the maneuvers most commonly used in clinical practice by physical therapists and the reasons for choosing them. Methods A prospective multicenter study using a questionnaire. The sample consisted of physical therapists from five hospitals (three private hospitals, a teaching hospital and a public hospital). Results A total of 185 questionnaires were filled in. Most professionals had graduated 6 to 10 years before and over had over 10 years of intensive care unit experience. The most often used maneuvers were vibrocompression, hyperinflation, postural drainage, tracheal suction and motor mobilization. The most frequent reason for choosing these maneuvers was "I notice they are more efficient in clinical practice." Conclusion Physical therapy is mostly based on individual experience acquired in the clinical practice, and not on the scientific literature.