Challenges and perspectives in porcine model of acute lung injury using oleic acid.

The oleic acid (OA) models of lung injury try to simulate the findings of human Acute Respiratory Distress Syndrome (ARDS). However, these models are difficult to replicate because they vary in terms of animals species, OA doses, time for establishment of lung injury, different observation periods and settings of mechanical ventilation. The objective of this study was to evaluate a protocol of administration of OA in lung injury model, challenges in its development and its effects on respiratory mechanics, hemodynamic changes, histology, gas exchange and mortality. We then submitted ten Large White pigs to acute lung injury through intravenous infusion of acid oleic in the pulmonary artery. The mortality of the model was 50%, due to an intense hemodynamic instability during OA administration, even with early use of vasoactive drugs. Three animals required additional doses of OA to achieve criteria for acute lung injury. Histology showed findings consistent with acute lung injury. However, more pulmonary edema was observed in lower segments than in upper segments of both lungs (p = 0.01). IL-6 and IL-8 were significantly increased compared to normal lungs (p < 0.05), and IL-6 showed higher levels in upper segments compared to lower segments (p = 0.03). Positive cells for Caspase 3 were present in all samples, localized mainly in respiratory epithelial cells and macrophages. In conclusion, this model shows histological findings of acute lung injury and inflammatory response similar to those of clinical ARDS, it presents high mortality, inconsistent reproducibility and hardly controlled hemodynamic instability.

Proposition of a Shared and Value-Oriented Work Structure for Hospital-Based Health Technology Assessment and Enterprise Risk Management Processes.

BACKGROUND: Healthcare organizations have invested efforts on hospital-based health technology assessment (HB-HTA) and enterprise risk management (ERM) processes for novel systems to obtain more accurate data on which to base strategic decisions. This study proposes to analyze how HB-HTA and ERM processes can share personal resources and skills to achieve principles with value-oriented results. METHODS: Literature on ERM and HB-HTA and data from interviews with healthcare managers compose the research data sources, which were submitted to a qualitative data analysis. It was oriented to identify the association between ERM and HB-HTA application in hospitals and the common principles between both processes, in addition to proposing the capability to share personal resources between both teams in a matrix. RESULTS: The common principles and personal background suggested for HB-HTA and ERM teams allowed the build of a matrix identifying how both teams can work in an integrated manner being more effective and value-oriented. The shared resource matrix reports how each professional (with a specific background) may interact with each activity associated to HB-HTA or ERM implementation guidelines. CONCLUSIONS: The identification of common principles and capabilities between ERM and HB-HTA suggested advances with the literature from both research areas. The opportunity to share personal resources also contributes to the implementation of those processes in hospitals with less financial resources, approaching its own management to be more efficient with the care chain.

Predictors of in-hospital mortality in patients undergoing elective surgery in a university hospital: a prospective cohort / Preditores de mortalidade intra-hospitalar em pacientes submetidos a cirurgias não eletivas em um hospital universitário: uma coorte prospectiva

Abstract Introduction Morbidity and mortality associated with urgent or emergency surgeries are high compared to elective procedures. Perioperative risk scores identify the non-elective character as an independent factor of complications and death. The present study aims to characterize the population undergoing non-elective surgeries at the Hospital de Clínicas de Porto Alegre and identify the clinical and surgical factors associated with death within 30 days postoperatively. Methodology A prospective cohort study of 187 patients undergoing elective surgeries between April and May 2014 at the Hospital de Clínicas, Porto Alegre. Patient-related data, pre-operative risk situations, and surgical information were evaluated. Death in 30 days was the primary outcome measured. Results The mean age of the sample was 48.5 years, and 84.4% of the subjects had comorbidities. The primary endpoint was observed in 14.4% of the cases, with exploratory laparotomy being the procedure with the highest mortality (47.7%). After multivariate logistic regression, age (odds ratio [OR] 1.0360, p < 0.05), anemia (OR 3.961, p < 0.05), acute or chronic renal insufficiency (OR 6.075, p < 0.05), sepsis (OR 7.027, p < 0.05), and patient-related risk factors for mortality, in addition to the large surgery category (OR 7.502, p < 0.05) were identified. Conclusion The high mortality rate found may reflect the high complexity of the institution's patients. Knowing the profile of the patients assisted helps in the definition of management priorities, suggesting the need to create specific care lines for groups identified as high risk in order to reduce perioperative complications and deaths.

Resumo Introdução Quando comparada a procedimentos eletivos, a morbimortalidade associada às cirurgias de urgência ou emergência é alta. Escores de risco perioperatório identificam o caráter não eletivo como fator independente de complicações e morte. O presente estudo objetiva caracterizar a população submetida a cirurgias não eletivas no Hospital de Clínicas de Porto Alegre e identificar fatores clínicos e cirúrgicos associados à morte em 30 dias no pós-operatório. Metodologia Coorte prospectiva de 187 pacientes submetidos a cirurgias não eletivas entre abril e maio de 2014 no Hospital de Clínicas de Porto Alegre. Avaliaram-se dados relacionados ao paciente, situações de risco pré-operatórias e informações do âmbito cirúrgico. Mensurou-se óbito em 30 dias como desfecho primário. Resultados A média de idade da amostra foi 48,5 anos; 84,4% dos indivíduos apresentavam comorbidades. O desfecho primário foi observado em 14,4% dos casos, laparotomia exploradora foi o procedimento com maior mortalidade (47,7%). Após regressão logística multivariada, identificaram-se idade (odds ratio [OR] 1.0360, p < 0,05), anemia (OR 3.961, p < 0,05), insuficiência renal aguda ou crônica agudizada (OR 6.075, p < 0,05) e sepse (OR 7.027, p < 0,05) como os fatores de risco relacionados ao paciente significativos para mortalidade, além da categoria cirurgia de grande porte (OR 7.502, p < 0,05). Conclusão A elevada taxa de mortalidade encontrada pode refletir a alta complexidade dos pacientes da instituição. O conhecimento do perfil dos pacientes atendidos auxilia na definição de prioridades de gerenciamento, sugere a necessidade de criação de linhas de cuidado específicas para grupos identificados como de alto risco, a fim de reduzir complicações e óbitos no perioperatório.

Development of an enterprise risk inventory for healthcare.

BACKGROUND: The first phase of an enterprise risk management (ERM) program is the identification of risks. Accurate identification is essential to a proactive and effective ERM function. The authors identified a lack of such risk identification in the literature and in practical cases when interviewing the chief risk officers from healthcare organizations. A risk inventory specific to healthcare organizations that includes detailed risk scenarios and risk impacts currently does not exist. Thus, the objective of this research is to develop an enterprise risk inventory for healthcare organizations to create a common understanding of how each type of risk impacts a healthcare organization. METHOD: ERM guidelines and data from 15 interviews with chief risk officers were analyzed to create the risk inventory. The identified risks were confirmed through a survey of risk managers from a range of global healthcare organizations during the ASHRM conference in 2017. Descriptive statistics were developed and cluster analysis was performed using the survey results. RESULTS: The risk inventory includes 28 risks and their specific risk scenarios. Cyberattack was ranked as the principal risk by the participants, followed by sentinel events and risks associated with human capital management (organizational culture, use of electronic medical records and physician wellness). The data analysis showed that the specific characteristics of the survey participants, such as the length of time working in risk management, the size of the organization, and the presence of a school of medicine, do not impact an individual's opinion of the importance of the risks identified. A personal background in risk management (clinical or enterprise) was a characteristic that showed a small difference in the perceived importance of the risks from the proposed risk inventory. CONCLUSIONS: In addition to defining specific risk scenarios, the enterprise risk inventory presented in this research can contribute to guiding the risk identification phase of an ERM program and thereby support the development of a risk culture. Patient data security in hospitals that operate with high levels of technology is fundamental to delivering high quality and safe care to patients. At the top of the risk ranking, the identification of cyberattacks reflects the importance that healthcare risk managers place on this risk by allocating time and other resources. Exploring opportunities to improve cyber risk management and evaluating the benefits of using the risk inventory at the beginning of the risk identification phase in an ERM program are suggestions for future studies.

Evaluation of systemic inflammation in patients being weaned from mechanical ventilation.

OBJECTIVES: The aim of this study was to evaluate systemic inflammatory factors and their relation to success or failure in a spontaneous ventilation test. METHODS: This cross-sectional study included a sample of 54 adult patients. Demographic data and clinical parameters were collected, and blood samples were collected in the first minute of the spontaneous ventilation test to evaluate interleukin (IL)-1ß, IL-6, IL-8, and IL-10, tumour necrosis factor alpha (TNFα) and C-reactive protein. RESULTS: Patients who experienced extubation failure presented a lower rapid shallow breathing index than those who passed, and these patients also showed a significant increase in C-reactive protein 48 hours after extubation. We observed, moreover, that each unit increase in inflammatory factors led to a higher risk of spontaneous ventilation test failure, with a risk of 2.27 (1.001 - 4.60, p=0.049) for TNFα, 2.23 (1.06 - 6.54, p=0.037) for IL-6, 2.66 (1.06 - 6.70, p=0.037) for IL-8 and 2.08 (1.01 - 4.31, p=0.04) for IL-10, and the rapid shallow breathing index was correlated with IL-1 (r=-0.51, p=0.04). CONCLUSIONS: C-reactive protein is increased in patients who fail the spontaneous ventilation test, and increased ILs are associated with a greater prevalence of failure in this process; the rapid shallow breathing index may not be effective in patients who present systemic inflammation.

[Predictors of in-hospital mortality in patients undergoing elective surgery in a university hospital: a prospective cohort]. / Preditores de mortalidade intra­hospitalar em pacientes submetidos a cirurgias não eletivas em um hospital universitário: uma coorte prospectiva.

INTRODUCTION: Morbidity and mortality associated with urgent or emergency surgeries are high compared to elective procedures. Perioperative risk scores identify the non-elective character as an independent factor of complications and death. The present study aims to characterize the population undergoing non-elective surgeries at the Hospital de Clínicas de Porto Alegre and identify the clinical and surgical factors associated with death within 30 days postoperatively. METHODOLOGY: A prospective cohort study of 187 patients undergoing elective surgeries between April and May 2014 at the Hospital de Clínicas, Porto Alegre. Patient-related data, pre-operative risk situations, and surgical information were evaluated. Death in 30 days was the primary outcome measured. RESULTS: The mean age of the sample was 48.5 years, and 84.4% of the subjects had comorbidities. The primary endpoint was observed in 14.4% of the cases, with exploratory laparotomy being the procedure with the highest mortality (47.7%). After multivariate logistic regression, age (odds ratio [OR] 1.0360, p <0.05), anemia (OR 3.961, p <0.05), acute or chronic renal insufficiency (OR 6.075, p <0.05), sepsis (OR 7.027, p <0.05), and patient-related risk factors for mortality, in addition to the large surgery category (OR 7.502, p <0.05) were identified. CONCLUSION: The high mortality rate found may reflect the high complexity of the institution's patients. Knowing the profile of the patients assisted helps in the definition of management priorities, suggesting the need to create specific care lines for groups identified as high risk in order to reduce perioperative complications and deaths.

ERM for Health Care Organizations: An Economic Enterprise Risk Management Innovation Program (E2RMhealth care).

BACKGROUND: In recent years, health care organizations have looked to enterprise risk management (ERM) for novel systems to obtain more accurate data on which to base risk strategies. OBJECTIVE: This study proposes a conceptual ERM framework specifically designed for health care organizations. METHODS: We explore how hospitals in the United States and Brazil are structuring and implementing ERM processes within their management structure. This study incorporates interviews with 15 chief risk officers (8 from the United States and 7 from Brazil) with qualitative data analysis using NVivo (QSR International software). RESULTS: The interviews confirm that adopting ERM for health care organizations has gained momentum and become a priority, and that the demand for risk economic assessment orientation is common among health care risk managers. CONCLUSION: We propose an ERM model for health care (Economic Enterprise Risk Management in Health Care) divided into four maturity levels and complemented by an implementation timeline. The model is accompanied by guidelines to orient the gradual implementation of ERM, including orientation to perform risk economic assessment.

Evaluation of systemic inflammation in patients being weaned from mechanical ventilation

OBJECTIVES: The aim of this study was to evaluate systemic inflammatory factors and their relation to success or failure in a spontaneous ventilation test. METHODS: This cross-sectional study included a sample of 54 adult patients. Demographic data and clinical parameters were collected, and blood samples were collected in the first minute of the spontaneous ventilation test to evaluate interleukin (IL)-1β, IL-6, IL-8, and IL-10, tumour necrosis factor alpha (TNFα) and C-reactive protein. RESULTS: Patients who experienced extubation failure presented a lower rapid shallow breathing index than those who passed, and these patients also showed a significant increase in C-reactive protein 48 hours after extubation. We observed, moreover, that each unit increase in inflammatory factors led to a higher risk of spontaneous ventilation test failure, with a risk of 2.27 (1.001 - 4.60, p=0.049) for TNFα, 2.23 (1.06 - 6.54, p=0.037) for IL-6, 2.66 (1.06 - 6.70, p=0.037) for IL-8 and 2.08 (1.01 - 4.31, p=0.04) for IL-10, and the rapid shallow breathing index was correlated with IL-1 (r=-0.51, p=0.04). CONCLUSIONS: C-reactive protein is increased in patients who fail the spontaneous ventilation test, and increased ILs are associated with a greater prevalence of failure in this process; the rapid shallow breathing index may not be effective in patients who present systemic inflammation.

Effectiveness of diaphragmatic stimulation with single-channel electrodes in rabbits.

Every year, a large number of individuals become dependent on mechanical ventilation because of a loss of diaphragm function. The most common causes are cervical spinal trauma and neuromuscular diseases. We have developed an experimental model to evaluate the performance of electrical stimulation of the diaphragm in rabbits using single-channel electrodes implanted directly into the muscle. Various current intensities (10, 16, 20, and 26 mA) produced tidal volumes above the baseline value, showing that this model is effective for the study of diaphragm performance at different levels of electrical stimulation.

Effectiveness of diaphragmatic stimulation with single-channel electrodes in rabbits / Efetividade da estimulacao diafragmatica com eletrodos monocanais em coelhos

Every year, a large number of individuals become dependent on mechanical ventilation because of a loss of diaphragm function. The most common causes are cervical spinal trauma and neuromuscular diseases. We have developed an experimental model to evaluate the performance of electrical stimulation of the diaphragm in rabbits using single-channel electrodes implanted directly into the muscle. Various current intensities (10, 16, 20, and 26 mA) produced tidal volumes above the baseline value, showing that this model is effective for the study of diaphragm performance at different levels of electrical stimulation.

A cada ano um grande número de pessoas perde a função do diafragma tornando-se dependentes de ventilação mecânica. As principais causas são o trauma raquimedular da região cervical e as doenças neuromusculares. Desenvolvemos um modelo experimental para avaliar o desempenho da estimulação elétrica do diafragma em coelhos com eletrodos monocanais implantados diretamente neste músculo. Foram aplicadas diferentes intensidades de correntes (10, 16, 20 e 26 mA), as quais geraram volumes correntes acima dos valores basais, mostrando que este modelo é eficaz para estudar o desempenho do diafragma sob diferentes tipos de estimulação elétrica.

Effect of positive end-expiratory pressure after porcine unilateral left lung transplant.

OBJECTIVES: To evaluate the effects of 2 different levels of positive end-expiratory pressure on pigs who had unilateral lung transplants. MATERIALS AND METHODS: A left lung transplant was performed in 12 pigs. The animals were randomized into 2 groups based on positive end-expiratory pressure: group 1 (5 cm H(2)O) and group 2 (10 cm H(2)O). Hemodynamics, gas exchange, and respiratory mechanics were measured before and after surgery. Cytokines, oxidative stress, and histologic scores were assessed in the lung tissue of each pig. RESULTS: Pigs in group 2 exhibited a significantly higher mean heart rate (P = .006), static compliance (P = .001), lower mean arterial pressure (P = .003), and airway resistance (P = .001) than did pigs in group 1. There were no postoperative differences between the groups in concentrations of thiobarbituric acid reactive substances, superoxide dismutase, and interleukin 8. At the end of the observation period, pigs in group 2 had higher levels of thiobarbituric acid reactive substances (P = .001) and interleukin 8 (P = .05), and pigs in group 1 had higher levels of superoxide dismutase (P = .05) than they did at baseline. CONCLUSIONS: After unilateral lung transplant, higher positive end-expiratory pressure was associated with improved respiratory mechanics, a negative effect on hemodynamics, a stronger inflammatory response, and increased production of reactive oxygen species, but no effect on gas exchange.

Development of a new experimental model of intramuscular electrical stimulation of the diaphragm in rabbits.

PURPOSE: To develop an animal model of diaphragmatic electrical stimulation able to generate an appropriate ventilatory support through the direct implantation of electrodes in the diaphragm (electroventilation). METHODS: Six New Zealand female rabbits (2-3 kg) were placed on mechanical ventilation. Then, a laparotomy was performed in order to identify the motor points in each hemidiaphragm, followed by the implantation of the electrodes for diaphragmatic stimulation. We tested two types of electrodes according to the conduction of electrical stimulation: unipolar and bipolar. The electrodes were placed on different occasions in the same animals and tested with current intensities of 20, 26 and 32 mA. Each current intensity was repeated three times for 10 respiratory cycles with 1 minute interval between each cycle, and 5 minutes for new current intensity. We recorded the relationship between current intensity and inspiratory volume. RESULTS: The electrodes adequately stimulate the diaphragm and obtain inspired volumes using different intensity currents. The bipolar electrode generated inspiratory volumes as high as 4.5 times of baseline while the unipolar electrode reached up to 3.5 times of baseline. CONCLUSION: This model has proved to be effective for studying the performance of the diaphragm under different electrical stimulations using different set of electrodes.

Development of a new experimental model of intramuscular electrical stimulation of the diaphragm in rabbits / Desenvolvimento de um novo modelo experimental de estimulação elétrica intramuscular do diafragma em coelhos

PURPOSE: To develop an animal model of diaphragmatic electrical stimulation able to generate an appropriate ventilatory support through the direct implantation of electrodes in the diaphragm (electroventilation). METHODS: Six New Zealand female rabbits (2-3 kg) were placed on mechanical ventilation. Then, a laparotomy was performed in order to identify the motor points in each hemidiaphragm, followed by the implantation of the electrodes for diaphragmatic stimulation. We tested two types of electrodes according to the conduction of electrical stimulation: unipolar and bipolar. The electrodes were placed on different occasions in the same animals and tested with current intensities of 20, 26 and 32 mA. Each current intensity was repeated three times for 10 respiratory cycles with 1 minute interval between each cycle, and 5 minutes for new current intensity. We recorded the relationship between current intensity and inspiratory volume. RESULTS: The electrodes adequately stimulate the diaphragm and obtain inspired volumes using different intensity currents. The bipolar electrode generated inspiratory volumes as high as 4.5 times of baseline while the unipolar electrode reached up to 3.5 times of baseline. CONCLUSION: This model has proved to be effective for studying the performance of the diaphragm under different electrical stimulations using different set of electrodes.

OBJETIVO: Desenvolver um modelo animal de estimulação elétrica diafragmática capaz de gerar um suporte ventilatório adequado através da implantação direta de eletrodos no diafragma (eletroventilação). MÉTODOS: Seis coelhas da raça Nova Zelândia (2-3 kg) foram colocadas em ventilação mecânica. Através de uma laparotomia foram identificados os pontos motores em ambas as cúpulas diafragmáticas, seguido pela implantação dos eletrodos para estimulação diafragmática. Foram testados dois tipos de eletrodos de acordo com a condução do estímulo elétrico: unipolar e bipolar. Os eletrodos foram posicionados em diferentes ocasiões nos mesmos animais e testados com intensidades de corrente de 20, 26 e 32 mA, sendo cada uma delas repetidas três vezes durante 10 ciclos respiratórios com intervalo de 1 minuto entre cada ciclo e repouso de 5 minutos para nova intensidade de corrente. Foram registradas a relação entre a intensidade de corrente e o volume de ar inspirado. RESULTADOS: Os eletrodos estimularam adequadamente o diafragma com um volume de ar inspirado até 4,5 vezes maior no modo bipolar e de 3,5 vezes no modo unipolar em relação à linha de base. CONCLUSÃO: Este modelo demonstrou ser efetivo para o estudo do desempenho do diafragma sob diferentes estimulações elétricas e diferentes tipos de eletrodos.

Ventilation strategy and its influence on the functional performance of lung grafts in an experimental model of single lung transplantation using non-heart-beating donors.

OBJECTIVE: To compare the influence of two different ventilation strategies-volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV)-on the functional performance of lung grafts in a canine model of unilateral left lung transplantation using donor lungs harvested after three hours of normothermic cardiocirculatory arrest under mechanical ventilation. METHODS: The study comprised 40 mongrel dogs, randomized into two groups: VCV and PCV. Of the 20 recipients, 5 did not survive the transplant, and 5 died before the end of the post-transplant assessment period. The remaining 10 survivors (5 in each group) were evaluated for 360 min after lung transplantation. The functional performance of the grafts was evaluated regarding respiratory mechanics, gas exchange, and lung graft histology. RESULTS: There were no significant differences between the groups regarding respiratory mechanics (peak inspiratory pressure, plateau pressure, mean airway pressure, dynamic compliance, and static compliance) or gas exchange variables (PaO2, venous oxygen tension, PaCO2, venous carbon dioxide tension, and the arterial-venous oxygen content difference). The histopathological findings were consistent with nonspecific acute lung injury and did not differ between the groups. CONCLUSIONS: This model of lung transplantation showed that the functional performance of lung grafts was not influenced by the ventilation strategy employed during the first six hours after reperfusion.

Influência da estratégia ventilatória no desempenho funcional de enxertos pulmonares em um modelo experimental de transplante pulmonar unilateral de doadores após parada cardiocirculatória / Ventilation strategy and its influence on the functional performance of lung grafts in an experimental model of single lung transplantation using non-heart-beating donors

OBJETIVO: Comparar a influência de duas estratégias ventilatórias - ventilação controlada a volume (VCV) e ventilação controlada a pressão (VCP) - no desempenho funcional de enxertos pulmonares em um modelo canino de transplante pulmonar unilateral esquerdo, utilizando-se doadores cujos pulmões foram captados após três horas de parada cardiocirculatória em temperatura ambiente e sob ventilação mecânica. MÉTODOS: O estudo incluiu 40 cães mestiços randomizados nos grupos VCV e VCP. Dos 20 receptores, 5 não sobreviveram ao transplante, e 5 não sobreviveram ao período de avaliação pós-transplante. Os 10 receptores sobreviventes (5 em cada grupo) foram avaliados durante 360 min após o término do transplante pulmonar. O desempenho funcional dos enxertos foi estudado através da avaliação da mecânica respiratória, trocas gasosas e histologia do enxerto. RESULTADOS: Não houve diferenças significativas entre os grupos quanto às variáveis de mecânica respiratória (pressão de pico inspiratória, pressão de platô, pressão média de vias aéreas, complacência dinâmica e complacência estática) e de trocas gasosas (PaO2, pressão venosa mista de oxigênio, PaCO2, pressão venosa mista de CO2 e diferença arteriovenosa de oxigênio). As alterações histopatológicas foram compatíveis com o padrão de lesão pulmonar aguda não específica e não diferiram entre os grupos. CONCLUSÕES: Este modelo de transplante pulmonar mostrou que o desempenho funcional do enxerto não foi influenciado pela estratégia ventilatória utilizada até seis horas após a reperfusão.

OBJECTIVE: To compare the influence of two different ventilation strategies-volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV)-on the functional performance of lung grafts in a canine model of unilateral left lung transplantation using donor lungs harvested after three hours of normothermic cardiocirculatory arrest under mechanical ventilation. METHODS: The study comprised 40 mongrel dogs, randomized into two groups: VCV and PCV. Of the 20 recipients, 5 did not survive the transplant, and 5 died before the end of the post-transplant assessment period. The remaining 10 survivors (5 in each group) were evaluated for 360 min after lung transplantation. The functional performance of the grafts was evaluated regarding respiratory mechanics, gas exchange, and lung graft histology. RESULTS: There were no significant differences between the groups regarding respiratory mechanics (peak inspiratory pressure, plateau pressure, mean airway pressure, dynamic compliance, and static compliance) or gas exchange variables (PaO2, venous oxygen tension, PaCO2, venous carbon dioxide tension, and the arterial-venous oxygen content difference). The histopathological findings were consistent with nonspecific acute lung injury and did not differ between the groups. CONCLUSIONS: This model of lung transplantation showed that the functional performance of lung grafts was not influenced by the ventilation strategy employed during the first six hours after reperfusion.