Functional independence and spirometry in adult post-intensive care unit patients. / Independência funcional e espirometria em pacientes adultos pós-unidade de terapia intensiva.

OBJECTIVE: To relate functional independence to the degree of pulmonary impairment in adult patients 3 months after discharge from the intensive care unit. METHODS: This was a retrospective cohort study conducted in one adult intensive care unit and a multi-professional post-intensive care unit outpatient clinic of a single center. Patients admitted to the intensive care unit from January 2012 to December 2013 who underwent (3 months later) spirometry and answered the Functional Independence Measure Questionnaire were included. RESULTS: Patients were divided into groups according to the classification of functional independence and spirometry. The study included 197 patients who were divided into greater dependence (n = 4), lower dependence (n = 12) and independent (n = 181) groups. Comparing the three groups, regarding the classification of the Functional Independence Measure, patients with greater dependence had higher Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment values at intensive care unit admission with more advanced age, more days on mechanical ventilation, and longer stay in the intensive care unit and hospital. The majority of patients presented with pulmonary impairment, which was the obstructive pattern observed most frequently. When comparing functional independence with pulmonary function, it was observed that the lower the functional status, the worse the pulmonary function, with a significant difference being observed in peak expiratory flow (p = 0.030). CONCLUSION: The majority of patients who returned to the outpatient clinic 3 months after discharge had good functional status but did present with pulmonary impairment, which is related to the degree of functional dependence.

OBJETIVO: Relatar a independência funcional e o grau de comprometimento pulmonar em pacientes adultos 3 meses após a alta da unidade de terapia intensiva. MÉTODOS: Este foi um estudo de coorte retrospectiva conduzido em uma unidade de terapia intensiva multiprofissional para pacientes adultos em um único centro. Incluíram-se pacientes admitidos à unidade de terapia intensiva entre janeiro de 2012 e dezembro de 2013 que, 3 meses mais tarde, foram submetidos à espirometria e responderam ao questionário Medida de Independência Funcional. RESULTADOS: Os pacientes foram divididos em grupos segundo sua classificação de independência funcional e espirometria. O estudo incluiu 197 pacientes, que foram divididos entre os grupos maior dependência (n = 4), menor dependência (n = 12) e independente (n = 181). Na comparação dos três grupos com relação à classificação pela Medida de Independência Funcional, pacientes com maior dependência tinham escores Acute Physiology and Chronic Health Evaluation II e Sequential Organ Failure Assessment mais altos quando da admissão à unidade de terapia intensiva, idade mais avançada, mais dias sob ventilação mecânica e tempo mais longo de permanência na unidade de terapia intensiva e no hospital. A maioria dos pacientes apresentava comprometimento pulmonar, sendo o padrão obstrutivo o mais frequentemente observado. Na comparação da independência funcional com a função pulmonar, observou-se que, quanto pior a condição funcional, pior a função pulmonar, observando-se diferenças significantes em relação ao pico de fluxo expiratório (p = 0,030). CONCLUSÃO: Em sua maioria, os pacientes que retornaram ao ambulatório 3 meses após a alta tinham boa condição funcional, porém apresentavam comprometimento pulmonar relacionado com o grau de dependência funcional.

Corrigendum to "Factors Associated with the Incidence and Severity of New-Onset Atrial Fibrillation in Adult Critically Ill Patients".

[This corrects the article DOI: 10.1155/2017/8046240.].

End-of-life management in intensive care units: a multicentre observational prospective cohort study.

BACKGROUNDS: The study was conducted to evaluate intensive care unit (ICU) patients that ultimately died but could have met criteria for end-of-life management/palliative care (ELM-PC), and to analyse the application of components of palliative care, either "unperformed procedures" or elements of "futile/unnecessary treatment". METHODS: An observational prospective cohort in five ICUs in Southern Brazil. Adult patients who died were evaluated, searching for criteria for ELM-PC. The correct application of nine preselected items by the ICU team was studied. RESULTS: Among 253 admissions, 52 patients died; among these, 38.5% met criteria for ELM-PC. Among ELM-PC candidates (n = 20), the ELM-PC was started later (after day 3) in 60%, and only three patients received adequate palliative care. "Analgesia" and "daily family interviews" were the most correctly applied ELM-PC elements. "Terminal extubation/weaning" was not performed in any of the patients. A reduction in the lifespan from the onset of ELM-PC to death was observed in patients who underwent "correct" interventions - 66.6% died on the first day of ELM-PC. CONCLUSIONS: In a patient cohort from a low-medium-income country, one-third of patients who died in the ICU had criteria (indications) for ELM-PC; however, the palliative care was adequately performed for only 15% of patients, with great heterogeneity and delays regarding its initiation.

Effects of Neuromuscular Electrical Stimulation of the Quadriceps and Diaphragm in Critically Ill Patients: A Pilot Study.

BACKGROUND: Deep and respiratory muscle disorders are commonly observed in critically ill patients. Neuromuscular electrical stimulation (NMES) is an alternative to mobilize and to exercise that does not require active patient participation and can be used on bedridden patients. OBJECTIVE: Evaluate the effectiveness of the NMES therapy in quadriceps versus diaphragm subjects in mechanical ventilation (MV). METHODS: Sixty-seven subjects in MV were included, divided into 3 groups: (a) control group (CG, n=26), (b) stimulation of quadriceps (quadriceps group-QG, n=24), and (c) stimulation of diaphragm (diaphragm group-DG, n=17). The QG and DG patients received consecutive daily electrical stimulation sessions at specific points from the first day of randomization until ICU discharge. Respiratory and peripheral muscle strength, MV time, length of hospitalization, and functional independence score (the Functional Status Score-ICU) were recorded. RESULTS: There were studied n=24 (QG), n=17 (DG), and n=26 (CG) patients. Peripheral muscle strength improved significantly in the QG (p=0.030). Functional independence at ICU discharge was significantly better in QG (p=0.013), and the QG presented a better Barthel Index compared to DG and CG (p=0.0049) and also presented better FSS compared to CG (p=0.001). CONCLUSIONS: Electrical stimulation of quadriceps had best outcomes for peripheral muscle strength compared with controls or electrical stimulation of diaphragm among mechanically ventilated critically ill subjects and promoted functional independence and decreased length of hospitalization.

Epidemiology, prognostic factors, and outcome of trauma patients admitted in a Brazilian intensive care unit.

BACKGROUND: Trauma is a major cause of hospital admissions and is associated with manifold complications and high mortality rates. However, data on intensive care unit (ICU) admissions are scarce in developing and low-income countries, where its incidence has been increasing. OBJECTIVES: To analyze epidemiological and clinical factors and outcomes in adult trauma patients admitted to the ICU of a public teaching hospital in a developing country as well as to identify risk factors for complications in the ICU. PATIENTS AND METHODS: Retrospective cohort of adult trauma patients admitted to the general ICU of a public teaching hospital in southern Brazil in the year 2012. Demographic, clinical, and outcome data from the ICU were analyzed. RESULTS: During the study period, 144 trauma patients were admitted (83% male, Acute Physiology and Chronic Health Evaluation Score II =18.6±7.2, age =33.3 years, 93% required mechanical ventilation). Of these, 60.4% suffered a traffic accident (52% motorcycle), and 31.2% were victims of violence (aggressions, gunshot wounds, or stabbing); 71% had brain trauma, 37% had chest trauma, and 21% had abdominal trauma. Patients with trauma presented a high incidence of complications, such as infections, acute renal failure, acute respiratory distress syndrome, and thrombocytopenia. The ICU mortality rate was 22.9%. CONCLUSION: In a Brazilian public teaching ICU, there was a great variability of trauma etiologies (mainly traffic accidents with motorcycles and victims of violence); patients with trauma had a high incidence of complications and mortality in the ICU.

A influência do delirium no tempo de ventilação mecânica em pacientes críticos: uma revisão sistemática / The influence of delirium in the time of mechanical ventilation in critical patients: a systematic review

O delirium consiste em um estado confusional agudo e de curso flutuante representando uma manifestação da disfunção cerebral que pode estar associado com diferentes manifestações clínicas. Os pacientes com delirium têm sido estudados, pois tem apresentado maior tempo de ventilação mecânica e de internação em unidade de terapia intensiva. O objetivo do estudo foi realizar uma revisão de literatura acerca da influência do delirium no tempo de ventilação mecânica, sedação e na mortalidade de pacientes internados em unidade de terapia intensiva. Foi realizada uma busca por estudos nas bases de dados PubMed e Embase, com os descritores delirium, intensive care unit and mechanical ventilation. Nos resultados foram incluídos oito artigos, um recebeu graduação A e sete receberam graduação B na escala de Oxford. Os principais resultados foram: Os pacientes com delirium apresentaram maior gravidade, maior tempo de ventilação mecânica, maior tempo de sedação e maior mortalidade. Conclui-se que o delirium parece estar associado ao maior tempo da ventilação mecânica, maior dosagem de sedação e de mortalidade nestes pacientes.

Delirium consists of an acute, fluctuating, confusional state, representing a manifestation of cerebral dysfunction that can occur with different clinical manifestations. Patients with delirium have been studied because they have had longer time of mechanical ventilation and hospitalization in the intensive care unit. The objective of the study was to perform a literature review about the influence of delirium on the time of mechanical ventilation, sedation and on the mortality of patients admitted in intensive care units. A search for studies with the keywords delirium, intensive care unit and mechanical ventilation was performed in PubMed and Embase databases. As result eight articles were included, one received level A and seven received level B on the Oxford scale. The main results were: Patients with delirium presented greater severity, longer time of mechanical ventilation, longer sedation time and higher mortality. It is concluded that delirium appears to be associated with longer mechanical ventilation, greater sedation and mortality rates in these patients.

Characteristics and Outcomes of Intensive Care Unit Survivors: Experience of a Multidisciplinary Outpatient Clinic in a Teaching Hospital

OBJECTIVES: To describe the experience of an outpatient clinic with the multidisciplinary evaluation of intensive care unit survivors and to analyze their social, psychological, and physical characteristics in a low-income population and a developing country. METHODS: Retrospective cohort study. Adult survivors from a general intensive care unit were evaluated three months after discharge in a post-intensive care unit outpatient multidisciplinary clinic over a period of 6 years (2008-2014) in a University Hospital in southern Brazil. RESULTS: A total of 688 out of 1945 intensive care unit survivors received care at the clinic. Of these, 45.2% had psychological disorders (particularly depression), 49.0% had respiratory impairments (abnormal spirometry), and 24.6% had moderate to intense dyspnea during daily life activities. Patients experienced weight loss during hospitalization (mean=11.7%) but good recovery after discharge (mean gain=9.1%), and 94.6% were receiving nutrition orally. One-third of patients showed a reduction of peripheral muscular strength, and 5.7% had moderate to severe tetraparesis or tetraplegia. There was a significant impairment in quality of life (SF-36), particularly in the physical and emotional aspects and in functional capacity. The economic impacts on the affected families, which were mostly low-income families, were considerable. Most patients did not have full access to rehabilitation services, even though half of the families were receiving financial support from the government. CONCLUSIONS: A significant number of intensive care unit survivors evaluated 3 months after discharge had psychological, respiratory, motor, and socioeconomic problems; these findings highlight that strategies aimed to assist critically ill patients should be extended to the post-hospitalization period and that this problem is particularly important in low-income populations.

Factors Associated with the Incidence and Severity of New-Onset Atrial Fibrillation in Adult Critically Ill Patients.

BACKGROUND: Acute Atrial Fibrillation (AF) is common in critically ill patients, with significant morbidity and mortality; however, its incidence and severity in Intensive Care Units (ICUs) from low-income countries are poorly studied. Additionally, impact of vasoactive drugs on its incidence and severity is still not understood. This study aimed to assess epidemiology and risk factors for acute new-onset AF in critically ill adult patients and the role of vasoactive drugs. METHOD: Cohort performed in seven general ICUs (including cardiac surgery) in three cities in Paraná State (southern Brazil) for 45 days. Patients were followed until hospital discharge. RESULTS: Among 430 patients evaluated, the incidence of acute new-onset AF was 11.2%. Patients with AF had higher ICU and hospital mortality. Vasoactive drugs use (norepinephrine and dobutamine) was correlated with higher incidence of AF and higher mortality in patients with AF; vasopressin (though used in few patients) had no effect on development of AF. CONCLUSIONS: In general ICU patients, incidence of new-onset AF was 11.2% with a high impact on morbidity and mortality, particularly associated with the presence of Acute Renal Failure. The use of vasoactive drugs (norepinephrine and dobutamine) could lead to a higher incidence of new-onset AF-associated morbidity and mortality.

Characteristics and Outcomes of Intensive Care Unit Survivors: Experience of a Multidisciplinary Outpatient Clinic in a Teaching Hospital.

OBJECTIVES: To describe the experience of an outpatient clinic with the multidisciplinary evaluation of intensive care unit survivors and to analyze their social, psychological, and physical characteristics in a low-income population and a developing country. METHODS: Retrospective cohort study. Adult survivors from a general intensive care unit were evaluated three months after discharge in a post-intensive care unit outpatient multidisciplinary clinic over a period of 6 years (2008-2014) in a University Hospital in southern Brazil. RESULTS: A total of 688 out of 1945 intensive care unit survivors received care at the clinic. Of these, 45.2% had psychological disorders (particularly depression), 49.0% had respiratory impairments (abnormal spirometry), and 24.6% had moderate to intense dyspnea during daily life activities. Patients experienced weight loss during hospitalization (mean=11.7%) but good recovery after discharge (mean gain=9.1%), and 94.6% were receiving nutrition orally. One-third of patients showed a reduction of peripheral muscular strength, and 5.7% had moderate to severe tetraparesis or tetraplegia. There was a significant impairment in quality of life (SF-36), particularly in the physical and emotional aspects and in functional capacity. The economic impacts on the affected families, which were mostly low-income families, were considerable. Most patients did not have full access to rehabilitation services, even though half of the families were receiving financial support from the government. CONCLUSIONS: A significant number of intensive care unit survivors evaluated 3 months after discharge had psychological, respiratory, motor, and socioeconomic problems; these findings highlight that strategies aimed to assist critically ill patients should be extended to the post-hospitalization period and that this problem is particularly important in low-income populations.

Comparison of Proportional Assist Ventilation Plus, T-Tube Ventilation, and Pressure Support Ventilation as Spontaneous Breathing Trials for Extubation: A Randomized Study.

BACKGROUND: Failure to wean can prolong ICU stay, increase complications associated with mechanical ventilation, and increase morbidity and mortality. The spontaneous breathing trial (SBT) is one method used to assess weaning. The aim of this study was to assess proportional assist ventilation plus (PAV+) as an SBT by comparing its applicability, safety, and efficacy with T-tube and pressure support ventilation (PSV). METHODS: A randomized study was performed involving 160 adult subjects who remained on mechanical ventilation for > 24 h. Subjects were randomly assigned to the PAV+, PSV, or T-tube group. When subjects were ready to perform the SBT, subjects in the PAV+ group were ventilated in PAV+ mode (receiving support of up to 40%), the pressure support was reduced to 7 cm H2O in the PSV group, and subjects in the T-tube group were connected to one T-piece with supplemental oxygen. Subjects were observed for signs of intolerance, whereupon the trial was interrupted. When the trial succeeded, the subjects were extubated and assessed until discharge. RESULTS: The subjects were predominantly male (66.5%), and the leading cause of admission was traumatic brain injury. The groups were similar with respect to baseline characteristics, and no significant difference was observed among the groups regarding extubation success or failure. Analysis of the specificity and sensitivity revealed good sensitivity for all groups; however, the PAV+ group had higher specificity (66.6%) and higher sensitivity (97.6%), with prediction of ∼ 92.1% of the success and failure events. CONCLUSIONS: No significant differences in the groups was observed regarding the rate of extubation failure, duration of mechanical ventilation, and ICU and hospital stay, indicating that PAV+ is an alternative for use as an SBT.

Passive orthostatism (tilt table) in critical patients: Clinicophysiologic evaluation.

PURPOSE: To assess the effects of passive orthostatism on various clinicophysiologic parameters of adult intensive care unit (ICU) patients, by daily placement on a tilt table. MATERIALS AND METHODS: This prospective cohort study was performed in a general ICU. Twenty-three patients 18 years or older, intubated or tracheostomized, without sedation and under weaning from mechanical ventilation, were analyzed. All variables were evaluated at tilting of 30°, 45°, 60°, 75°, and 90°. RESULTS: Glasgow Coma Scale increased during tilt in the first and second day, as well as Richmond Agitation-Sedation Scale. No significant differences were detected in the physiological parameters; however, there was a nonsignificant decrease on the mean arterial pressure at angles of 75° and 90°. The maximum inspiratory pressure significantly increased at 60° compared with 30° on day 1 of the intervention. No significant differences were observed for maximum expiratory pressure, rapid shallow breathing index, and the tidal volume. CONCLUSION: A protocol with daily use of a tilt table for ICU patients is safe and improves the level of consciousness and inspiratory maximum pressure, without causing deleterious acute physiological effects.

Sedation and memories of patients subjected to mechanical ventilation in an intensive care unit.

OBJECTIVE: To investigate the relationship between sedation and the memories reported by patients subjected to mechanical ventilation following discharge from the intensive care unit. METHODS: This prospective, observational, cohort study was conducted with individuals subjected to mechanical ventilation who remained in the intensive care unit for more than 24 hours. Clinical statistics and sedation records were extracted from the participants' clinical records; the data relative to the participants' memories were collected using a specific validated instrument. Assessment was performed three months after discharge from the intensive care unit. RESULTS: A total of 128 individuals were assessed, most of whom (84.4%) reported recollections from their stay in the intensive care unit as predominantly a combination of real and illusory events. The participants subjected to sedation (67.2%) at deep levels (Richmond Agitation-Sedation Scale [RASS] -4 and -5) for more than two days and those with psychomotor agitation (33.6%) exhibited greater susceptibility to occurrence of illusory memories (p>0.001). CONCLUSION: The probability of the occurrence of illusory memories was greater among the participants who were subjected to deep sedation. Sedation seems to be an additional factor that contributed to the occurrence of illusory memories in severely ill individuals subjected to mechanical ventilation.

Delirium during Weaning from Mechanical Ventilation.

Background. We compare the incidence of delirium before and after extubation and identify the risk factors and possible predictors for the occurrence of delirium in this group of patients. Methods. Patients weaned from mechanical ventilation (MV) and extubated were included. The assessment of delirium was conducted using the confusion assessment method for the ICU and completed twice per day until discharge from the intensive care unit. Results. Sixty-four patients were included in the study, 53.1% of whom presented with delirium. The risk factors of delirium were age (P = 0.01), SOFA score (P = 0.03), APACHE score (P = 0.01), and a neurological cause of admission (P = 0.01). The majority of the patients began with delirium before or on the day of extubation. Hypoactive delirium was the most common form. Conclusion. Acute (traumatic or medical) neurological injuries were important risk factors in the development of delirium. During the weaning process, delirium developed predominantly before or on the same day of extubation and was generally hypoactive (more difficult to detect). Therefore, while planning early prevention strategies, attention must be focused on neurological patients who are receiving MV and possibly even on patients who are still under sedation.

Sedação e memórias de pacientes submetidos à ventilação mecânica em unidade de terapia intensiva / Sedation and memories of patients subjected to mechanical ventilation in an intensive care unit

Objetivo: Investigar a relação entre sedação e as memórias relatadas por pacientes submetidos à ventilação mecânica após a alta da unidade de terapia intensiva. Métodos: Estudo de coorte prospectivo, observacional, realizado com pacientes submetidos à ventilação mecânica e que permaneceram por mais de 24 horas na unidade de terapia intensiva. Dados clínicos e de sedação foram pesquisados em prontuários, e os dados referentes às memórias do paciente foram coletados por meio de um instrumento validado para esse fim. As avaliações foram realizadas 3 meses após a alta da unidade de terapia intensiva. Resultados: Dos 128 pacientes avaliados, a maioria (84,4%) relatou lembranças do período de internação na unidade de terapia intensiva, prevalecendo uma combinação de eventos reais e ilusórios. Pacientes que permaneceram sedados (67,2%), com sedação profunda (RASS -4 e -5) durante um período maior do que 2 dias e que apresentaram agitação psicomotora (33,6%) foram mais suscetíveis a apresentarem memórias ilusórias (p>0,001). Conclusão: A probabilidade de os pacientes apresentarem memórias de ilusão foi maior naqueles com sedação profunda. A sedação, portanto, parece ser um fator adicional que contribuiu para o desenvolvimento de memórias ilusórias em pacientes gravemente enfermos e submetidos à ventilação mecânica. .

Objective: To investigate the relationship between sedation and the memories reported by patients subjected to mechanical ventilation following discharge from the intensive care unit. Methods: This prospective, observational, cohort study was conducted with individuals subjected to mechanical ventilation who remained in the intensive care unit for more than 24 hours. Clinical statistics and sedation records were extracted from the participants' clinical records; the data relative to the participants' memories were collected using a specific validated instrument. Assessment was performed three months after discharge from the intensive care unit. Results: A total of 128 individuals were assessed, most of whom (84.4%) reported recollections from their stay in the intensive care unit as predominantly a combination of real and illusory events. The participants subjected to sedation (67.2%) at deep levels (Richmond Agitation-Sedation Scale [RASS] -4 and -5) for more than two days and those with psychomotor agitation (33.6%) exhibited greater susceptibility to occurrence of illusory memories (p>0.001). Conclusion: The probability of the occurrence of illusory memories was greater among the participants who were subjected to deep sedation. Sedation seems to be an additional factor that contributed to the occurrence of illusory memories in severely ill individuals subjected to mechanical ventilation. .

Pró-calcitonina como biomarcador inflamatório e prognóstico de mortalidade à admissão na unidade de terapia intensiva: experiência de um hospital universitário / Procalcitonin as an inflammatory and prognostic biomarker of mortality at intensive care unit admission: experience at an university hospital

Introdução: A Pró-calcitonina (PCT) é um dos principais biomarcadores inflamatórios a ser avaliado no paciente critico. Seu papel discriminatório entre etiologias bacterianas e virais, bem como no acompanhamento do tratamento anti-infeccioso é bem estabelecido. O objetivo deste estudo foi avaliar se os níveis séricos de PCT na admissão em UTI eram preditores de mortalidade em pacientes adultos. Métodos: Estudo de coorte histórica. Foram avaliados os prontuários de pacientes consecutivos admitidos na UTI Geral de adultos de um Hospital Universitário, com diferentes diagnósticos etiológicos. Foi acompanhado o desfecho de saída (mortalidade), e comparado com outros marcadores inflamatórios e de prognóstico. Resultados: Incluídos 108 pacientes. Nos pacientes com sepse na admissão, os níveis de PCT foram significativamente maiores. Em todos os grupos, houve tendência a valores maiores dos níveis de PCT entre os pacientes que evoluíram para o óbito na UTI. Valores acima de 3,0 ng/ml foram preditores de mortalidade. Conclusões: Níveis séricos elevados de PCT na admissão em UTI, além de auxílio discriminatório de infecção e sepse, podem ser preditivos de mortalidade (AU)

Introduction: Procalcitonin (PCT) is one of the main inflammatory biomarkers to be evaluated in critically ill patients. Its discriminatory role among bacterial and viral etiologies, as well as in the monitoring of anti-infective treatment, is well established. The aim of this study was to evaluate whether serum PCT levels at admission to ICU were predictors of mortality in adult patients. Methods: A historical cohort study. The medical records of consecutive patients with different etiological diagnoses admitted to the General ICU of a University Hospital were assessed. The outcome (mortality) was accompanied and compared with other inflammatory and prognostic markers. Results: The study comprised 108 patients. In patients with sepsis on admission , PCT levels were signifi cantly higher. In all groups, there was a trend to higher levels of PCT in patients who eventually died in ICU. Values above 3.0 ng/ml were predictors of mortality. Conclusions: Elevated serum PCT levels on ICU admission, besides the discriminatory aid of infection and sepsis, may be predictive of mortality (AU)

Marchiafava-Bignami disease: a rare entity with a poor outcome.

Marchiafava-Bignami disease is a rare affliction characterized by primary degeneration of the corpus callosum associated with chronic consumption of ethanol. The disease may occasionally occur in patients who are not alcoholics but are chronically malnourished. A complex deficiency of group B vitamins is the main etiopathogenic hypothesis, and many patients improve after the administration of these compounds. However, a good response is not always observed. The definitive diagnosis of Marchiafava-Bignami disease can be problematic and is based on features of neuroimaging studies, especially magnetic resonance imaging. Its treatment is still controversial and shows variable results. Because nutritional factors are implicated, as in Wernicke's encephalopathy, some authors claim that replacement of B vitamins is beneficial. The present article is a case report of a severe acute form of Marchiafava-Bignami disease in an alcohol-dependent male patient who improved after the administration of parenteral B vitamins. As a consequence of his neurological and immunologic conditions, he developed multiple pulmonary infections and had a protracted course in the intensive care unit. He eventually died of sepsis associated with an uncommon fungus, Rhodotorula mucilaginosa. The present article reports the clinical and neuroimaging data from this patient and contains a review of Marchiafava-Bignami disease and Rhodotorula infections in the intensive care unit.

Doença de Marchiafava-Bignami: uma rara entidade com prognóstico sombrio / Marchiafava-Bignami disease: a rare entity with a poor outcome

A doença de Marchiafava-Bignami é uma entidade rara, caracterizada por uma degeneração primária do corpo caloso, associada com o consumo crônico do etanol. A doença pode, ocasionalmente, ocorrer em pacientes não etilistas cronicamente desnutridos. Uma deficiência de vitaminas do complexo B é considerada como a hipótese etiopatogênica principal, uma vez que muitos pacientes obtiveram uma melhora após a administração desses compostos. Algumas vezes, entretanto, tal resposta terapêutica não foi observada. O diagnóstico definitivo da doença de Marchiafava-Bignami pode ser problemático e depende das características de estudos de neuroimagem, especialmente a ressonância magnética. Seu tratamento, dessa forma, é ainda controverso, com resultados variáveis. Como estão implicados fatores nutricionais, analogamente à encefalopatia de Wernicke, alguns autores recomendam a reposição de vitaminas do complexo B, particularmente da B1. O presente artigo relata a forma aguda da doença de Marchiafava-Bignami em um paciente masculino dependente do álcool, que apresentou discreta melhora após a administração parenteral das vitaminas do complexo B. Como consequência de suas más condições neurológicas e imunológicas, ele desenvolveu infecções pulmonares múltiplas e permaneceu, por longo tempo, na unidade de terapia intensiva. Seu óbito ocorreu por sepse causada por um fungo raro, o Rhodotorula mucilaginosa. O artigo é um relato clínico da evolução desse paciente, com a apresentação de seus dados de neuroimagem, acompanhada por uma revisão sobre doença de Marchiafava-Bignami e sobre as infecções por Rhodotorula dentro da perspectiva da unidade de cuidado intensivo.

Marchiafava-Bignami disease is a rare affliction characterized by primary degeneration of the corpus callosum associated with chronic consumption of ethanol. The disease may occasionally occur in patients who are not alcoholics but are chronically malnourished. A complex deficiency of group B vitamins is the main etiopathogenic hypothesis, and many patients improve after the administration of these compounds. However, a good response is not always observed. The definitive diagnosis of Marchiafava-Bignami disease can be problematic and is based on features of neuroimaging studies, especially magnetic resonance imaging. Its treatment is still controversial and shows variable results. Because nutritional factors are implicated, as in Wernicke's encephalopathy, some authors claim that replacement of B vitamins is beneficial. The present article is a case report of a severe acute form of Marchiafava-Bignami disease in an alcohol-dependent male patient who improved after the administration of parenteral B vitamins. As a consequence of his neurological and immunologic conditions, he developed multiple pulmonary infections and had a protracted course in the intensive care unit. He eventually died of sepsis associated with an uncommon fungus, Rhodotorula mucilaginosa. The present article reports the clinical and neuroimaging data from this patient and contains a review of Marchiafava-Bignami disease and Rhodotorula infections in the intensive care unit.

Epidemiologia, estratégias e evolução de pacientes submetidos à ventilação mecânica / Epidemiology, strategies and outcome of patients submitted to mechanical ventilation

JUSTIFICATIVA E OBJETIVOS: A epidemiologia e uso de estratégias ventilatórias variam amplamente entre pacientes submetidos à ventilação mecânica (VM). O objetivo deste estudo foi avaliar o perfil dos pacientes submetidos à VM em diferentes instituições, bem como as estratégias ventilatórias e complicações.MÉTODO: Estudo de coorte prospectivo de pacientes submetidos à VM por período maior de 24h em cinco unidades de terapia intensiva (UTI) de três cidades da região Oeste do estado do Paraná. Foram analisados dados clínico-demográficos,complicações durante o período de VM e desfechos clínicos. As estratégias ventilatórias, de desmame e tratamento clínico geral ficaram a critério de cada UTI. RESULTADOS: Foram avaliados 242 pacientes (idade mediana de 49 anos; 65,7% do sexo masculino), que ficaram em VM por um período mediano de 8 dias. A etiologia mais frequente foi trauma e clínico/cardiológico. O modo ventilatório mais utilizado foi assistido-controlado ciclado a volume. Traqueostomia foi realizada em 36,8%, no 8º dia de VM. Pneumonia associada à VM ocorreu em 35,1% dos pacientes. A mortalidade na UTI foi de 45,0%, sendo de 47,5% nos pacientes com síndrome do desconforto respiratório agudo. Houve grande variabilidade na utilização de estratégias e nos resultados entre as instituições e de acordo com a etiologia. CONCLUSÃO: As características clínicas e utilização de estratégias ventilatórias variam amplamente entre os pacientes com insuficiência respiratória e VM. O conhecimento da epidemiologia e das condutas clínicas utilizadas pode contribuir para redução de complicações e melhor evolução entre estes pacientes.

BACKGROUND AND OBJECTIVES: Epidemiology and ventilatory strategies vary widely among patients undergoin gmechanical ventilation (MV). The objective of this study was to evaluate the profile of patients submitted to MV in different institutions, as well as ventilation strategies and complications. METHOD: Prospective cohort study of patients undergoing MV for longer than 24 hours in five intensive care units (ICU) of three cities in Paraná state, southern Brazil. We analyzed clinical and demographic data, complications during mechanical ventilation and clinical outcomes. Ventilatory strategies, weaning and clinical management were kept according of each ICU. RESULTS: It was evaluated 242 patients (median age 49 years; 65.7% male) who remained on MV for a median of 8 days.The most frequent etiologies were trauma and clinical/cardiology. Most used ventilatory mode was assisted controlled cycled volume. Tracheostomy was performed in 36.8%, at 8th day of MV. Ventilator-associated pneumonia occurred in 35.1% of patients.The ICU mortality was 45.0% (being 47.5% in patients with acute respiratory distress syndrome. There was great variability in the use of strategies and outcomes between institutions as well as according to the etiology. CONCLUSION: Clinical features and use of ventilatory strategies varies widely among patients with respiratory failure and MV. Knowledge of the epidemiology and clinical procedures used may contribute to reducing complications and better outcomes among these patients.

Procalcitonin in patients with influenza A (H1N1) infection and acute respiratory failure / Pró-calcitonina em pacientes com infecção por influenza A (H1N1) e insuficiência respiratória aguda

ABSTRACT Objective: To verify serum procalcitonin levels of patients with acute respiratory failure secondary to influenza A (H1N1) upon their admission to the Intensive Care Unit and to compare these results to values found in patients with sepsis and trauma admitted to the same unit. Methods: Analysis of records of patients infected with influenza A (H1N1) and respiratory failure admitted to the General Intensive Care Unit during in a period of 60 days. The values of serum procalcitonin and clinical and laboratory data were compared to those of all patients admitted with sepsis or trauma in the previous year. Results: Among patients with influenza A (H1N1) (n = 16), the median serum procalcitonin level upon admission was 0.11 ng/mL, lower than in the sepsis group (p < 0.001) and slightly lower than in trauma patients. Although the mean values were low, serum procalcitonin was a strong predictor of hospital mortality in patients with influenza A (H1N1). Conclusion: Patients with influenza A (H1N1) with severe acute respiratory failure presented with low serum procalcitonin values upon admission, although their serum levels are predictors of hospital mortality. The kinetics study of this biomarker may be a useful tool in the management of this group of patients.

RESUMO Objetivo: Verificar os níveis de pró-calcitonina sérica em pacientes com insuficiência respiratória aguda secundária à influenza A (H1N1) admitidos à Unidade de Terapia Intensiva, e comparar esses resultados com valores encontrados em pacientes com sepse e trauma admitidos na mesma unidade. Métodos: Análise de prontuários de pacientes infectados com influenza A (H1N1) e insuficiência respiratória aguda admitidos na Unidade de Terapia Intensiva Geral em um período de 60 dias. Os valores de pró-calcitonina sérica e os dados clínicos e laboratoriais foram comparados com todos pacientes admitidos com sepse ou trauma no ano anterior. Resultados: Entre os pacientes com influenza A (H1N1) (n = 16), a mediana de pró-calcitonina sérica na admissão foi 0,11 ng/mL, menor do que o grupo de sepse (p < 0,01) e levemente menor do que os com trauma. Embora os valores médios tenham sido baixos, o nível sérico de pró-calcitonina foi um poderoso preditor de mortalidade hospitalar em pacientes com influenza A (H1N1). Conclusão: Pacientes com influenza A (H1N1) com insuficiência respiratória aguda grave tiveram baixos níveis de pró-calcitonina à admissão, embora seu nível sérico seja preditor de mortalidade hospitalar. A cinética desse biomarcador poderia ser uma ferramenta útil para o manejo desses pacientes.

Procalcitonin in patients with influenza A (H1N1) infection and acute respiratory failure.

OBJECTIVE: To verify serum procalcitonin levels of patients with acute respiratory failure secondary to influenza A (H1N1) upon their admission to the Intensive Care Unit and to compare these results to values found in patients with sepsis and trauma admitted to the same unit. METHODS: Analysis of records of patients infected with influenza A (H1N1) and respiratory failure admitted to the General Intensive Care Unit during in a period of 60 days. The values of serum procalcitonin and clinical and laboratory data were compared to those of all patients admitted with sepsis or trauma in the previous year. RESULTS: Among patients with influenza A (H1N1) (n = 16), the median serum procalcitonin level upon admission was 0.11 ng/mL, lower than in the sepsis group (p < 0.001) and slightly lower than in trauma patients. Although the mean values were low, serum procalcitonin was a strong predictor of hospital mortality in patients with influenza A (H1N1). CONCLUSION: Patients with influenza A (H1N1) with severe acute respiratory failure presented with low serum procalcitonin values upon admission, although their serum levels are predictors of hospital mortality. The kinetics study of this biomarker may be a useful tool in the management of this group of patients.