Reversible contrast-induced encephalopathy after coil embolization of epistaxis. / Encefalopatia reversível induzida por contraste após embolização com espiras por epistaxe.

A 37-year-old woman (35 weeks pregnant) was admitted to a local hospital due to severe epistaxis resulting in shock and the need for emergency cesarean section. After failure to tamponade the bleeding, angiographic treatment was provided. After the procedure, she was admitted to the neurocritical intensive care unit and was confused and agitated, requiring sedation and endotracheal intubation. In the intensive care unit, diagnostic investigations included brain magnetic resonance imaging, lumbar puncture with viral panel, electroencephalogram, tests for autoimmunity, and hydroelectrolytic and metabolic evaluations. Magnetic resonance imaging showed a puntiform restricted diffusion area on the left corona radiata on diffusion weighted imaging and mild cortical posterior edema (without restricted diffusion), and an electroencephalogram showed moderate diffuse slow activity and fronto-temporal slow activity of the left hemisphere with associated scarce paroxysmal components. The other exams did not show any relevant alterations. Due to the temporal relationship, the clinical history and the magnetic resonance imaging results, a diagnosis of contrast-induced encephalopathy was made. After 2 days in the intensive care unit, sedation was withdrawn, the patient was extubated, and total neurological recovery was verified within the next 24 hours.

Uma mulher com 37 anos de idade, gestante de 35 semanas, foi admitida em um hospital local em razão de epistaxe grave, que resultou em choque e em necessidade de realização de cesárea emergencial. Após falha do tamponamento para controlar a hemorragia, decidiu-se por tratamento angiográfico. Após o procedimento, ela foi admitida à unidade de terapia intensiva neurocrítica, encontrando-se confusa e agitada, com necessidade de sedação e intubação orotraqueal. Na unidade de terapia intensiva, as investigações incluíram exames de ressonância magnética, punção lombar com painel viral, eletroencefalograma, testes para autoimunidade e avaliações hidroeletrolítica e metabólica. O exame de ressonância magnética mostrou área puntiforme restrita na corona radiata esquerda nas sequências de imagens pesadas em difusão, além de leve edema cortical posterior (sem restrição à difusão), e o eletroencefalograma mostrou atividade lenta difusa moderada, atividade frontoparietal lenta e escassos componentes paroxísticos associados no hemisfério esquerdo. Outros exames não mostraram alterações relevantes. Por causa da relação temporal e da história clínica, assim como imagens de ressonância magnética, formulou-se o diagnóstico de encefalopatia induzida por contraste. A sedação foi retirada após 2 dias na unidade de terapia intensiva, e a paciente foi extubada, verificando-se completa recuperação neurológica dentro das 24 horas seguintes.

Transcutaneous electrical diaphragmatic stimulation reduces the duration of invasive mechanical ventilation in patients with cervical spinal cord injury: retrospective case series.

STUDY DESIGN: Retrospective case series. OBJECTIVES: To compare individuals with cervical spinal cord injury (SCI) submitted to transcutaneous electrical diaphragmatic stimulation (TEDS) or a standard weaning protocol (SWP) according to the following variables: invasive mechanical ventilation (IMV) time, ventilator weaning time, intensive care unit (ICU) length of stay, and overall hospital length of stay. SETTINGS: Tertiary university hospital. Clinical Hospital of Campinas State University-UNICAMP-Campinas (SP), Brazil. METHODS: Retrospective case study investigating ICU patients submitted to tracheostomy due to cervical SCI at a tertiary university hospital (Clinical Hospital of Campinas State University, Brazil). Data were extracted from medical records of patients seen between January 2007 and December 2016. According to medical records, four patients were submitted to TEDS and six to a SWP. Provision of training to patients in the TEDS group was based on consensus medical decision, preference of the physical therapy team and availability of electrostimulation equipment in the ICU. RESULTS: Total IMV time in the TEDS and the SWP group was 33 ± 15 and 60 ± 22 days, respectively. Length of stay in ICU in the TEDS and the SWP group was 31 ± 18 and 63 ± 45 days, respectively. CONCLUSION: TEDS appears to influence the duration of IMV as well as the length of stay in ICU. This physiotherapeutic intervention may be a potentially promising tool for treatment of patients with SCI. However, randomized clinical trials are warranted to support this assumption.

Encefalopatia reversível induzida por contraste após embolização com espiras por epistaxe / Reversible contrast-induced encephalopathy after coil embolization of epistaxis

RESUMO Uma mulher com 37 anos de idade, gestante de 35 semanas, foi admitida em um hospital local em razão de epistaxe grave, que resultou em choque e em necessidade de realização de cesárea emergencial. Após falha do tamponamento para controlar a hemorragia, decidiu-se por tratamento angiográfico. Após o procedimento, ela foi admitida à unidade de terapia intensiva neurocrítica, encontrando-se confusa e agitada, com necessidade de sedação e intubação orotraqueal. Na unidade de terapia intensiva, as investigações incluíram exames de ressonância magnética, punção lombar com painel viral, eletroencefalograma, testes para autoimunidade e avaliações hidroeletrolítica e metabólica. O exame de ressonância magnética mostrou área puntiforme restrita na corona radiata esquerda nas sequências de imagens pesadas em difusão, além de leve edema cortical posterior (sem restrição à difusão), e o eletroencefalograma mostrou atividade lenta difusa moderada, atividade frontoparietal lenta e escassos componentes paroxísticos associados no hemisfério esquerdo. Outros exames não mostraram alterações relevantes. Por causa da relação temporal e da história clínica, assim como imagens de ressonância magnética, formulou-se o diagnóstico de encefalopatia induzida por contraste. A sedação foi retirada após 2 dias na unidade de terapia intensiva, e a paciente foi extubada, verificando-se completa recuperação neurológica dentro das 24 horas seguintes.

ABSTRACT A 37-year-old woman (35 weeks pregnant) was admitted to a local hospital due to severe epistaxis resulting in shock and the need for emergency cesarean section. After failure to tamponade the bleeding, angiographic treatment was provided. After the procedure, she was admitted to the neurocritical intensive care unit and was confused and agitated, requiring sedation and endotracheal intubation. In the intensive care unit, diagnostic investigations included brain magnetic resonance imaging, lumbar puncture with viral panel, electroencephalogram, tests for autoimmunity, and hydroelectrolytic and metabolic evaluations. Magnetic resonance imaging showed a puntiform restricted diffusion area on the left corona radiata on diffusion weighted imaging and mild cortical posterior edema (without restricted diffusion), and an electroencephalogram showed moderate diffuse slow activity and fronto-temporal slow activity of the left hemisphere with associated scarce paroxysmal components. The other exams did not show any relevant alterations. Due to the temporal relationship, the clinical history and the magnetic resonance imaging results, a diagnosis of contrast-induced encephalopathy was made. After 2 days in the intensive care unit, sedation was withdrawn, the patient was extubated, and total neurological recovery was verified within the next 24 hours.

The prognostic accuracy evaluation of SAPS 3, SOFA and APACHE II scores for mortality prediction in the surgical ICU: an external validation study and decision-making analysis.

BACKGROUND: The early postoperative period is critical for surgical patients. SOFA, SAPS 3 and APACHE II are prognostic scores widely used to predict mortality in ICU patients. This study aimed to evaluate these index tests for their prognostic accuracy for intra-ICU and in-hospital mortalities as target conditions in patients admitted to ICU after urgent or elective surgeries and to test whether they aid in decision-making. The process comprised the assessment of discrimination through analysis of the areas under the receiver operating characteristic curves and calibration of the prognostic models for the target conditions. After, the clinical relevance of applying them was evaluated through the measurement of the net benefit of their use in the clinical decision. RESULTS: Index tests were found to discriminate regular for both target conditions with a poor calibration (C statistics-intra-ICU mortality AUROCs: APACHE II 0.808, SAPS 3 0.821 and SOFA 0.797/in-hospital mortality AUROCs: APACHE II 0.772, SAPS 3 0.790 and SOFA 0.742). Calibration assessment revealed a weak correlation between the observed and expected number of cases in several thresholds of risk, calculated by each model, for both tested outcomes. The net benefit analysis showed that all score's aggregate value in the clinical decision when the calculated probabilities of death ranged between 10 and 40%. CONCLUSIONS: In this study, we observed that the tested ICU prognostic scores are fair tools for intra-ICU and in-hospital mortality prediction in a cohort of postoperative surgical patients. Also, they may have some potential to be used as ancillary data to support decision-making by physicians and families regarding the level of therapeutic investment and palliative care.

Inspiratory Muscle Training in the Intensive Care Unit: A New Perspective.

BACKGROUND: Prolonged use of mechanical ventilation (MV) leads to weakening of the respiratory muscles, especially in patients subjected to sedation, but this effect seems to be preventable or more quickly reversible using respiratory muscle training. The aims of the study were to assess variations in respiratory and hemodinamic parameters with electronic inspiratory muscle training (EIMT) in tracheostomized patients requiring MV and to compare these variations with those in a group of patients subjected to an intermittent nebulization program (INP). METHODS: This was a pilot, prospective, randomized study of tracheostomized patients requiring MV in one intensive care unit (ICU). Twenty-one patients were randomized: 11 into the INP group and 10 into the EIMT group. Two patients were excluded in experimental group because of hemodynamic instability. RESULTS: In the EIMT group, maximal inspiratory pressure (MIP) after training was significantly higher than that before (P = 0.017), there were no hemodynamic changes, and the total weaning time was shorter than in the INP group (P = 0.0192). CONCLUSION: The EIMT device is safe, promotes an increase in MIP, and leads to a shorter ventilator weaning time than that seen in patients treated using INP.

American Society of Anesthesiologists Score: still useful after 60 years? Results of the EuSOS Study.

OBJECTIVE: The European Surgical Outcomes Study described mortality following in-patient surgery. Several factors were identified that were able to predict poor outcomes in a multivariate analysis. These included age, procedure urgency, severity and type and the American Association of Anaesthesia score. This study describes in greater detail the relationship between the American Association of Anaesthesia score and postoperative mortality. METHODS: Patients in this 7-day cohort study were enrolled in April 2011. Consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery with a recorded American Association of Anaesthesia score in 498 hospitals across 28 European nations were included and followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Decision tree analysis with the CHAID (SPSS) system was used to delineate nodes associated with mortality. RESULTS: The study enrolled 46,539 patients. Due to missing values, 873 patients were excluded, resulting in the analysis of 45,666 patients. Increasing American Association of Anaesthesia scores were associated with increased admission rates to intensive care and higher mortality rates. Despite a progressive relationship with mortality, discrimination was poor, with an area under the ROC curve of 0.658 (95% CI 0.642 - 0.6775). Using regression trees (CHAID), we identified four discrete American Association of Anaesthesia nodes associated with mortality, with American Association of Anaesthesia 1 and American Association of Anaesthesia 2 compressed into the same node. CONCLUSION: The American Association of Anaesthesia score can be used to determine higher risk groups of surgical patients, but clinicians cannot use the score to discriminate between grades 1 and 2. Overall, the discriminatory power of the model was less than acceptable for widespread use.

O escore da American Society of Anesthesiologists: ainda útil após 60 anos? Resultados do estudo EuSOS / American Society of Anesthesiologists Score: still useful after 60 years? Results of the EuSOS Study

RESUMO Objetivo: O European Surgical Outcomes Study foi um estudo que descreveu a mortalidade após a cirurgia de pacientes internados. Em uma análise multivariada, foram identificados diversos fatores capazes de prever maus resultados, os quais incluem idade, urgência do procedimento, gravidade e porte, assim como o escore da American Association of Anaesthesia. Este estudo descreveu, com mais detalhes, o relacionamento entre o escore da American Association of Anaesthesia e a mortalidade pós-operatória. Métodos: Os pacientes neste estudo de coorte com duração de sete dias foram inscritos em abril de 2011. Foram incluídos e seguidos, por no máximo 60 dias, pacientes consecutivos com idade de 16 anos ou mais, internados e submetidos à cirurgia não cardíaca e com registro do escore da American Association of Anaesthesia em 498 hospitais, localizados em 28 países europeus. O parâmetro primário foi mortalidade hospitalar. Foi utilizada uma árvore decisória, com base no sistema CHAID (SPSS), para delinear os nós associados à mortalidade. Resultados: O estudo inscreveu um total de 46.539 pacientes. Em função de valores faltantes, foram excluídos 873 pacientes, resultando na análise 45.666. Aumentos no escore da American Association of Anaesthesia se associaram com o acréscimo das taxas de admissão à terapia intensiva e de mortalidade. Apesar do relacionamento progressivo com mortalidade, a discriminação foi fraca, com uma área sob a curva ROC de 0,658 (IC 95% 0,642 - 0,6775). Com o uso das árvores de regressão (CHAID), foram identificadas quatro discretas associações dos nós da American Association of Anaesthesia com mortalidade, estando o escore American Association of Anaesthesia 1 e o escore da American Association of Anaesthesia 2 comprimidos em um mesmo nó. Conclusão: O escore da American Association of Anaesthesia pode ser utilizado para determinar grupos de pacientes cirúrgicos de alto risco, porém os médicos não podem utilizá-lo para ...

ABSTRACT Objective: The European Surgical Outcomes Study described mortality following in-patient surgery. Several factors were identified that were able to predict poor outcomes in a multivariate analysis. These included age, procedure urgency, severity and type and the American Association of Anaesthesia score. This study describes in greater detail the relationship between the American Association of Anaesthesia score and postoperative mortality. Methods: Patients in this 7-day cohort study were enrolled in April 2011. Consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery with a recorded American Association of Anaesthesia score in 498 hospitals across 28 European nations were included and followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Decision tree analysis with the CHAID (SPSS) system was used to delineate nodes associated with mortality. Results: The study enrolled 46,539 patients. Due to missing values, 873 patients were excluded, resulting in the analysis of 45,666 patients. Increasing American Association of Anaesthesia scores were associated with increased admission rates to intensive care and higher mortality rates. Despite a progressive relationship with mortality, discrimination was poor, with an area under the ROC curve of 0.658 (95% CI 0.642 - 0.6775). Using regression trees (CHAID), we identified four discrete American Association of Anaesthesia nodes associated with mortality, with American Association of Anaesthesia 1 and American Association of Anaesthesia 2 compressed into the same node. Conclusion: The American Association of Anaesthesia score can be used to determine higher risk groups of surgical patients, but clinicians cannot use the score to discriminate between grades 1 and 2. Overall, the discriminatory power of the model was less than acceptable for widespread use. .

Delirium in intensive care: an under-diagnosed reality.

Delirium occurs in up to 80% of patients admitted to intensive care units. Although under-diagnosed, delirium is associated with a significant increase in morbidity and mortality in critical patients. Here, we review the main risk factors, clinical manifestations and preventative and therapeutic approaches (pharmacological and non-pharmacological) for this illness.

Delirium na unidade de cuidados intensivos: uma realidade subdiagnosticada / Delirium in intensive care: an under-diagnosed reality

Entidade frequente em medicina intensiva, ocorrendo em até 80% dos doentes internados na unidade de cuidados intensivos, embora muito subdiagnosticado, o delirium está associado a aumento significativo da morbilidade e da mortalidade no doente crítico. No presente artigo, foram revistos os principais fatores de risco, manifestações clínicas e abordagens preventivas e terapêuticas (farmacológicas e não farmacológicas) nessa doença.

Delirium occurs in up to 80% of patients admitted to intensive care units. Although under-diagnosed, delirium is associated with a significant increase in morbidity and mortality in critical patients. Here, we review the main risk factors, clinical manifestations and preventative and therapeutic approaches (pharmacological and non-pharmacological) for this illness.

Avaliação da mortalidade na pancreatite aguda grave: estudo comparativo entre índices de gravidade específicos e gerais / Mortality assessment in patients with severe acute pancreatitis: a comparative study of specific and general severity indices

OBJETIVO: Comparar os índices de gravidade gerais e os específicos de pancreatite aguda grave na avaliação do prognóstico numa unidade de terapia intensiva polivalente. MÉTODOS: Estudo retrospectivo de 108 pacientes com diagnóstico de saída de pancreatite aguda grave, no período de 1º de julho de 1991 a 31 de março de 2010. Foram colhidos dados demográficos, clínicos e calculados os seguintes índices de gravidade: Ranson, Osborn, Blamey e Imrie, Balthasar, POP, APACHE II, SAPS II e SOFA. O poder discriminativo dos diferentes índices foi avaliado com base na área sob a curva ROC (aROC), em relação à mortalidade, na unidade de terapia intensiva e no hospital. RESULTADOS: Não existiram diferenças significativas entre os dados demográficos basais dos doentes sobreviventes e dos falecidos. A mortalidade na unidade de terapia intensiva foi de 27%, com uma mortalidade hospitalar de 39%. Os índices de gravidade com maior capacidade discriminativa para a mortalidade na unidade de terapia intensiva e hospitalar foram o POP 0, POP 24, o SOFA (na admissão, 24, 48 horas e máximo), o SAPS II e o APACHE II. CONCLUSÃO: O índice POP mostrou ser superior a todos os outros índices (aROC>0,8), quer às 24 horas (como foi originalmente descrito), quer à admissão. Os índices de disfunção fisiológica gerais apresentaram também uma capacidade discriminativa razoável (aROC na ordem dos 0,75-0,8) por oposição aos outros índices específicos de pancreatite, cujo valor discriminativo foi francamente mais baixo.

OBJECTIVE: This study compared the general and specific severity indices to assess the prognosis of severe acute pancreatitis at a polyvalent intensive care unit. METHODS: This retrospective study included 108 patients who were diagnosed with severe acute pancreatitis from July 1, 1999 to March 31, 2012. Their demographic and clinical data were collected, and the following severity indices were calculated: Ranson, Osborne, Blamey and Imrie, Balthazar, POP, APACHE II, SAPS II, and SOFA. The discriminative power of these indices with regard to mortality at the intensive care unit and hospital was assessed using the area under the ROC curve. RESULTS: The demographic data of the surviving and deceased patients did not significantly differ at baseline. The mortality rates were 27% and 39% at the intensive care unit and hospital, respectively. The severity indices that exhibited the greatest discriminative power with regard to mortality at the intensive care unit and hospital were the POP 0, POP 24, SOFA (at admission, 24 hours, 48 hours, and discharge), SAPS II, and APACHE II. CONCLUSION: The POP performed better than the other indices (aROC>0.8) at admission and 24 hours later (as originally described). The general physiological dysfunction indices also exhibited reasonable discriminative power (aROC=0.75-0.8), which was unlike the remaining pancreatitis specific indices, whose discriminative power was lower.

Prevalência e desfechos clínicos de infecções em UTIs brasileiras: subanálise do estudo EPIC II / Prevalence and outcomes of infections in Brazilian ICUs: a subanalysis of EPIC II study

OBJETIVO: Demonstrar as taxas de prevalência de infecção em unidades de terapia intensiva brasileiras e mortalidade atribuída pela análise dos dados ­obtidos pelo estudo Extended Prevalence of Infection in Intensive Care (EPIC II). MÉTODOS: O EPIC II é um estudo multicêntrico, internacional, prospectivo, de prevalência de infecção em UTIs, realizado em apenas um dia. Ele descreve as características demográficas, fisiológicas, bacteriológicas, terapêuticas, acompanhamento até o 60º dia, a prevalência de infecção, a taxa de mortalidade de todos os pacientes internados nas unidades de terapia intensiva participantes entre zero hora e meia noite do dia 8 de maio de 2007. Um total de 14.414 pacientes foram inlcuídos no estudo original, sendo que destes, 1.235 eram brasileiros provenientes de 90 unidades de terapia intensiva do país, que representaram o foco do estudo. RESULTADOS: Dos 1.235 pacientes, 61,6% apresentavam infecção no dia do estudo, sendo que o pulmão era o principal sítio de infecção (71,2%). Metade dos pacientes apresentava cultura positiva, sendo que o predomínio foi de bacilos Gram-negativos (72%). No dia do estudo, o Sequential Organ Failure Assessment (SOFA) mediano foi 5 (3-8) e o Simplified Acute Physiology Score II (SAPS II) mediano 36 (26-47). Os doentes infectados apresentaram escore SOFA significativamente maior do que os não infectados, 6 (4-9) e 3 (2-6), respectivamente. A taxa de mortalidade global na unidade de terapia intensiva foi 28,4%, sendo de 37,6% em infectados e 13,2% em não infectados (p<0,001). Da mesma forma, a taxa de mortalidade hospitalar foi maior em pacientes infectados (44,2% versus 17,7%), tendo como taxa global 34,2% (p<0,001). Na análise multivariada, os principais fatores relacioanados ao desenvolvimento de infecção foram cirurgia de emergência (OR: 2,89, IC95%=1,72-4,86; p<0,001), ventilação mecânica (OR=2,06, IC95%=1,5-2,82; p<0,001), SAPS II - por ponto obtido (OR=1,04, IC95%=1,03-1,06; p<0,001) e para mortalidade foram insuficiência cardíaca congestiva (ICC) Classe Funcional III/IV (OR=3,0, IC95%=1,51-5,98; p<0,01), diabetes mellitus (OR=0,48, IC95%=0,25-0,95; p<0,03), cirrose (OR=4,62, IC95%=1,47-14,5; p<0,01), gênero masculino (OR=0,68, IC95%=0,46-1,0; p<0,05), ventilação mecânica (OR=1,87, IC95%=1,19-2,95; p<0,01), hemodiálise (OR 1,98, IC95%=1,05-3,75; p<0,03), SAPS II - por ponto obtido (OR=1,08, IC95%=1,06-1,10; p<0,001). CONCLUSÃO: Taxas de prevalência de infecção e de mortalidade mais elevadas que outros relatos foram observadas na presente amostra. Há clara relação entre infecção e mortalidade.

OBJECTIVE: To determine the prevalence of infections in Brazilian intensive care units and the associated mortality by analyzing the data obtained in the Extended Prevalence of Infection in Intensive Care (EPIC II) study. METHODS: EPIC II was a multicenter, international, cross-sectional prospective study of infection prevalence. It described the demographic, physiological, bacteriological, and therapeutic characteristics, outcome up to the 60th day, prevalence of infection, and mortality of all the patients admitted to the participating ICUs between zero hour and midnight on May 8, 2007. A total of 14,414 patients were included in the original study. Of these 14,414 patients, 1,235 were Brazilian and were hospitalized in 90 Brazilian ICUs. They represent the focus of this study. RESULTS: Among these 1,235 Brazilian patients, 61,6% had an infection on the day of the trial, and the lungs were the main site of infection (71.2%). Half of the patients had positive cultures, predominantly gram-negative bacilli (72%). On the day of the study, the median SOFA score was 5 (3-8) and the median SAPS II score was 36 (26-47). The infected patients had SOFA scores significantly higher than those of the non-infected patients 6 (4-9) and 3 (2-6), respectively). The overall ICU mortality rate was 28.4%: 37.6% in the infected patients, and 13.2% in the non-infected patients (p<0.001). Similarly, the in-hospital mortality rate was 34.2%, with a higher rate in the infected than in the non-infected patients (44.2% vs. 17.7%) (p<0.001). In the multivariate analysis, the main factors associated with infection incidence were emergency surgery (OR 2.89, 95%CI [1.72-4.86], p<0.001), mechanical ventilation (OR 2.06, 95% CI [1.5-2.82], p<0.001), and the SAPS II score (OR 1.04, 95% CI [1.03-1.06], p<0.001). The main factors related to mortality were ICC functional class III/ IV (OR 3.0, 95% CI [1.51-5.98], p<0.01), diabetes mellitus (OR 0.48, 95% CI [0.25-0.95], p<0.03), cirrhosis (OR 4.62, 95% CI [1.47-14,5], p<0.01), male gender (OR 0.68, 95% CI [0.46-1.0], p<0.05), mechanical ventilation (OR 1.87, 95% CI [1.19-2.95], p<0.01), hemodialysis (OR 1.98, 95% CI [1.05-3.75], p<0.03), and the SAPS II score (OR 1.08, 95% CI [1.06-1.10], p<0.001). CONCLUSION: The present study revealed a higher prevalence of infections in Brazilian ICUs than has been previously reported. There was a clear association between infection and mortality.

Prevalence and outcomes of infections in Brazilian ICUs: a subanalysis of EPIC II study. / Prevalência e desfechos clínicos de infecções em UTIs brasileiras: subanálise do estudo EPIC II.

OBJECTIVE: To determine the prevalence of infections in Brazilian intensive care units and the associated mortality by analyzing the data obtained in the Extended Prevalence of Infection in Intensive Care (EPIC II) study. METHODS: EPIC II was a multicenter, international, cross-sectional prospective study of infection prevalence. It described the demographic, physiological, bacteriological, and therapeutic characteristics, outcome up to the 60th day, prevalence of infection, and mortality of all the patients admitted to the participating ICUs between zero hour and midnight on May 8, 2007. A total of 14,414 patients were included in the original study. Of these 14,414 patients, 1,235 were Brazilian and were hospitalized in 90 Brazilian ICUs. They represent the focus of this study. RESULTS: Among these 1,235 Brazilian patients, 61,6% had an infection on the day of the trial, and the lungs were the main site of infection (71.2%). Half of the patients had positive cultures, predominantly gram-negative bacilli (72%). On the day of the study, the median SOFA score was 5 (3-8) and the median SAPS II score was 36 (26-47). The infected patients had SOFA scores significantly higher than those of the non-infected patients 6 (4-9) and 3 (2-6), respectively). The overall ICU mortality rate was 28.4%: 37.6% in the infected patients, and 13.2% in the non-infected patients (p<0.001). Similarly, the in-hospital mortality rate was 34.2%, with a higher rate in the infected than in the non-infected patients (44.2% vs. 17.7%) (p<0.001). In the multivariate analysis, the main factors associated with infection incidence were emergency surgery (OR 2.89, 95%CI [1.72-4.86], p<0.001), mechanical ventilation (OR 2.06, 95% CI [1.5-2.82], p<0.001), and the SAPS II score (OR 1.04, 95% CI [1.03-1.06], p<0.001). The main factors related to mortality were ICC functional class III/ IV (OR 3.0, 95% CI [1.51-5.98], p<0.01), diabetes mellitus (OR 0.48, 95% CI [0.25-0.95], p<0.03), cirrhosis (OR 4.62, 95% CI [1.47-14,5], p<0.01), male gender (OR 0.68, 95% CI [0.46-1.0], p<0.05), mechanical ventilation (OR 1.87, 95% CI [1.19-2.95], p<0.01), hemodialysis (OR 1.98, 95% CI [1.05-3.75], p<0.03), and the SAPS II score (OR 1.08, 95% CI [1.06-1.10], p<0.001). CONCLUSION: The present study revealed a higher prevalence of infections in Brazilian ICUs than has been previously reported. There was a clear association between infection and mortality.

Mortality assessment in patients with severe acute pancreatitis: a comparative study of specific and general severity indices. / Avaliação da mortalidade na pancreatite aguda grave: estudo comparativo entre índices de gravidade específicos e gerais.

OBJECTIVE: This study compared the general and specific severity indices to assess the prognosis of severe acute pancreatitis at a polyvalent intensive care unit. METHODS: This retrospective study included 108 patients who were diagnosed with severe acute pancreatitis from July 1, 1999 to March 31, 2012. Their demographic and clinical data were collected, and the following severity indices were calculated: Ranson, Osborne, Blamey and Imrie, Balthazar, POP, APACHE II, SAPS II, and SOFA. The discriminative power of these indices with regard to mortality at the intensive care unit and hospital was assessed using the area under the ROC curve. RESULTS: The demographic data of the surviving and deceased patients did not significantly differ at baseline. The mortality rates were 27% and 39% at the intensive care unit and hospital, respectively. The severity indices that exhibited the greatest discriminative power with regard to mortality at the intensive care unit and hospital were the POP 0, POP 24, SOFA (at admission, 24 hours, 48 hours, and discharge), SAPS II, and APACHE II. CONCLUSION: The POP performed better than the other indices (aROC>0.8) at admission and 24 hours later (as originally described). The general physiological dysfunction indices also exhibited reasonable discriminative power (aROC=0.75-0.8), which was unlike the remaining pancreatitis specific indices, whose discriminative power was lower.