Spontaneous Breathing Trials With T-Piece or Pressure Support Ventilation.

Spontaneous breathing trials (SBTs) are among the most commonly employed techniques to facilitate weaning from mechanical ventilation. The preferred SBT technique, however, is still unclear. To clarify the preferable SBT (T-piece or pressure support ventilation [PSV]), we conducted this systematic review. We then searched the MEDLINE, EMBASE, SciELO, Google Scholar, CINAHL, ClinicalTrials.gov, and Cochrane CENTRAL databases through June 2015, without language restrictions. We included randomized controlled trials involving adult subjects being weaned from mechanical ventilation comparing T-piece with PSV and reporting (1) weaning failure, (2) re-intubation rate, (3) ICU mortality, or (4) weaning duration. Anticipating clinical heterogeneity among the included studies, we compared prespecified subgroups: (1) simple, difficult, or prolonged weaning and (2) subjects with COPD. We summarized the quality of evidence for intervention effects using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology. We identified 3,674 potentially relevant studies and reviewed 23 papers in full. Twelve studies (2,161 subjects) met our inclusion criteria. Overall, the evidence was of very low to low quality. SBT technique did not influence weaning success (risk ratio 1.23 [0.94-1.61]), ICU mortality (risk ratio 1.11 [0.80-1.54]), or re-intubation rate (risk ratio 1.21 [0.90-1.63]). Prespecified subgroup analysis suggested that PSV might be superior to T-piece with regard to weaning success for simple-to-wean subjects (risk ratio 1.44 [1.11-1.86]). For the prolonged-weaning subgroup, however, T-piece was associated with a shorter weaning duration (weighted mean difference -3.08 [-5.24 to -0.92] d). In conclusion, low-quality evidence is available concerning this topic. PSV may be associated with lower weaning failure rates in the simple-to-wean subgroup. In contrast, in prolonged-weaning subjects, T-piece may be related to a shorter weaning duration, although this is at high risk of bias. Further study of the difficult-to-wean and COPD subgroups is required.

Diazepam or midazolam for orotracheal intubation in the ICU?

OBJECTIVE: to compare clinical and cost effectiveness of midazolam and diazepam for urgent intubation. METHODS: patients admitted to the Central ICU of the Santa Casa Hospital Complex in Porto Alegre, over the age of 18 years, undergoing urgent intubation during 6 months were eligible. Patients were randomized in a single-blinded manner to either intravenous diazepam or midazolam. Diazepam was given as a 5 mg intravenous bolus followed by aliquots of 5 mg each minute. Midazolam was given as an intravenous bolus of 5 mg with further aliquots of 2.5 mg each minute. Ramsay sedation scale 5-6 was considered adequate sedation. We recorded time and required doses to reach adequate sedation and duration of sedation. RESULTS: thirty four patients were randomized, but one patient in the diazepam group was excluded because data were lost. Both groups were similar in terms of illness severity and demographics. Time for adequate sedation was shorter (132 ± 87 sec vs. 224 ± 117 sec, p = 0.016) but duration of sedation was similar (86 ± 67 min vs. 88 ± 50 min, p = 0.936) for diazepam in comparison to midazolam. Total drug dose to reach adequate sedation after either drugs was similar (10.0 [10.0-12.5] mg vs. 15.0 [10.0-17.5] mg, p = 0.248). Arterial pressure and sedation intensity reduced similarly overtime with both drugs. Cost of sedation was lower for diazepam than for midazolam (1.4[1.4-1.8] vs. 13.9[9.4-16.2] reais, p <0.001). CONCLUSIONS: intubation using intravenous diazepam and midazolam is effective and well tolerated. Sedation with diazepam is associated to a quicker sedation time and to lower costs.

Blood markers of oxidative stress predict weaning failure from mechanical ventilation.

Patients undergoing mechanical ventilation (MV) often experience respiratory muscle dysfunction, which complicates the weaning process. There is no simple means to predict or diagnose respiratory muscle dysfunction because diagnosis depends on measurements in muscle diaphragmatic fibre. As oxidative stress is a key mechanism contributing to MV-induced respiratory muscle dysfunction, the aim of this study was to determine if differences in blood measures of oxidative stress in patients who had success and failure in a spontaneous breathing trial (SBT) could be used to predict the outcome of MV. This was a prospective analysis of MV-dependent patients (≥72 hrs; n = 34) undergoing a standard weaning protocol. Clinical, laboratory and oxidative stress analyses were performed. Measurements were made on blood samples taken at three time-points: immediately before the trial, 30 min. into the trial in weaning success (WS) patients, or immediately before return to MV in weaning failure (WF) patients, and 6 hrs after the trial. We found that blood measures of oxidative stress distinguished patients who would experience WF from patients who would experience WS. Before SBT, WF patients presented higher oxidative damage in lipids and higher antioxidant levels and decreased nitric oxide concentrations. The observed differences in measures between WF and WS patients persisted throughout and after the weaning trial. In conclusion, WF may be predicted based on higher malondialdehyde, higher vitamin C and lower nitric oxide concentration in plasma.

Diazepam or midazolam for orotracheal intubation in the ICU? / Diazepam ou midazolam para entubação orotraqueal na UTI?

Objective: to compare clinical and cost effectiveness of midazolam and diazepam for urgent intubation. Methods: patients admitted to the Central ICU of the Santa Casa Hospital Complex in Porto Alegre, over the age of 18 years, undergoing urgent intubation during 6 months were eligible. Patients were randomized in a single-blinded manner to either intravenous diazepam or midazolam. Diazepam was given as a 5 mg intravenous bolus followed by aliquots of 5 mg each minute. Midazolam was given as an intravenous bolus of 5 mg with further aliquots of 2.5 mg each minute. Ramsay sedation scale 5-6 was considered adequate sedation. We recorded time and required doses to reach adequate sedation and duration of sedation. Results: thirty four patients were randomized, but one patient in the diazepam group was excluded because data were lost. Both groups were similar in terms of illness severity and demographics. Time for adequate sedation was shorter (132 ± 87 sec vs. 224 ± 117 sec, p = 0.016) but duration of sedation was similar (86 ± 67 min vs. 88 ± 50 min, p = 0.936) for diazepam in comparison to midazolam. Total drug dose to reach adequate sedation after either drugs was similar (10.0 [10.0-12.5] mg vs. 15.0 [10.0-17.5] mg, p = 0.248). Arterial pressure and sedation intensity reduced similarly overtime with both drugs. Cost of sedation was lower for diazepam than for midazolam (1.4[1.4-1.8] vs. 13.9[9.4-16.2] reais, p <0.001). Conclusions: intubation using intravenous diazepam and midazolam is effective and well tolerated. Sedation with diazepam is associated to a quicker sedation time and to lower costs. .

Objetivo: comparar eficácia clínica e custo de midazolam e diazepam para intubação urgente. Métodos: pacientes internados na UTI Central do Complexo Hospitalar Santa Casa de Porto Alegre, >18 anos de idade e submetidos a entubação urgente durante seis meses eram elegíveis. Pacientes foram randomizados para receber diazepam ou midazolam intravenoso. Diazepam foi dado como bolus IV de 5 mg seguido por alíquotas de 5 mg a cada minuto. Midazolam foi dado como um bolus IV de 5 mg, com alíquotas adicionais de 2,5 mg a cada minuto. Escala de sedação de Ramsay 5-6 foi considerada sedação adequada. Registramos tempo e doses necessárias para atingir sedação adequada e sua duração. Resultados: trinta e quatro pacientes foram randomizados; um paciente no grupo diazepam foi excluído por perda dos dados. Grupos foram semelhantes para gravidade da doença e demografia. Tempo de sedação adequada foi mais curto (132 ± 87 vs. 224 ± 117 segundos, p = 0,016), mas a duração da sedação foi similar (86 ± 67 vs. 88 ± 50 min., p = 0,936) para o diazepam em comparação com o midazolam. Dose total da droga para atingir a sedação adequada foi semelhante para ambas as drogas (10,0 [10,0-12,5] vs. 15,0 [10,0-17,5] mg, p = 0,248). Pressão arterial e intensidade da sedação reduziram da mesma forma para ambas as drogas ao longo do tempo. O custo da sedação foi menor para diazepam do que para midazolam (1,4[1,4-1,8] vs. 13,9[9,4-16,2] reais, p < 0,001). Conclusões: entubação usando diazepam e midazolam intravenosos é eficaz e bem tolerada. Sedação com diazepam está associada a sedação mais rápida e menores custos. .

Factors influencing physical functional status in intensive care unit survivors two years after discharge.

BACKGROUND: Studies suggest that in patients admitted to intensive care units (ICU), physical functional status (PFS) improves over time, but does not return to the same level as before ICU admission. The goal of this study was to assess physical functional status two years after discharge from an ICU and to determine factors influencing physical status in this population. METHODS: The study reviewed all patients admitted to two non-trauma ICUs during a one-year period and included patients with age ≥ 18 yrs, ICU stay ≥ 24 h, and who were alive 24 months after ICU discharge. To assess PFS, Karnofsky Performance Status Scale scores and Lawton-Instrumental Activities of Daily Living (IADL) scores at ICU admission (K-ICU and L-ICU) were compared to the scores at the end of 24 months (K-24mo and L-24mo). Data at 24 months were obtained through telephone interviews. RESULTS: A total of 1,216 patients were eligible for the study. Twenty-four months after ICU discharge, 499 (41.6%) were alive, agreed to answer the interview, and had all hospital data available. PFS (K-ICU: 86.6 ± 13.8 vs. K-24mo: 77.1 ± 19.6, p < 0.001) and IADL (L-ICU: 27.0 ± 11.7 vs. L-24mo: 22.5 ± 11.5, p < 0.001) declined in patients with medical and unplanned surgical admissions. Most strikingly, the level of dependency increased in neurological patients (K-ICU: 86 ± 12 vs. K-24mo: 64 ± 21, relative risk [RR] 2.6, 95% CI, 1.8-3.6, p < 0.001) and trauma patients (K-ICU: 99 ± 2 vs. K-24mo: 83 ± 21, RR 2.7, 95% CI, 1.6-4.6, p < 0.001). The largest reduction in the ability to perform ADL occurred in neurological patients (L-ICU: 27 ± 7 vs. L-24mo: 15 ± 12, RR 3.3, 95% CI, 2.3-4.6 p < 0.001), trauma patients (L-ICU: 32 ± 0 vs. L-24mo: 25 ± 11, RR 2.8, 95% CI, 1.5-5.1, p < 0.001), patients aged ≥ 65 years (RR 1.4, 95% CI, 1.07-1.86, p = 0.01) and those who received mechanical ventilation for ≥ 8 days (RR 1.48, 95% CI, 1.02-2.15, p = 0.03). CONCLUSIONS: Twenty-four months after ICU discharge, PFS was significantly poorer in patients with neurological injury, trauma, age ≥ 65 tears, and mechanical ventilation ≥ 8 days. Future studies should focus on the relationship between PFS and health-related quality of life in this population.

Prediction of chronic critical illness in a general intensive care unit / Predição de doença crítica crônica em uma unidade geral de cuidados intensivos resumo

OBJECTIVE: To assess the incidence, costs, and mortality associated with chronic critical illness (CCI), and to identify clinical predictors of CCI in a general intensive care unit. METHODS: This was a prospective observational cohort study. All patients receiving supportive treatment for over 20 days were considered chronically critically ill and eligible for the study. After applying the exclusion criteria, 453 patients were analyzed. RESULTS: There was an 11% incidence of CCI. Total length of hospital stay, costs, and mortality were significantly higher among patients with CCI. Mechanical ventilation, sepsis, Glasgow score < 15, inadequate calorie intake, and higher body mass index were independent predictors for cci in the multivariate logistic regression model. CONCLUSIONS: CCI affects a distinctive population in intensive care units with higher mortality, costs, and prolonged hospitalization. Factors identifiable at the time of admission or during the first week in the intensive care unit can be used to predict CCI.

OBJETIVO: Avaliar a incidência, custos e mortalidade relacionados a doença crítica crônica (DCC) e identificar seus preditores clínicos em uma unidade de terapia intensiva geral. MÉTODOS: Trata-se de uma coorte observacional prospectiva. Todos pacientes que recebiam tratamento de suporte por mais de 20 dias eram considerados doentes críticos crônicos. Permaneceram 453 pacientes após a aplicação dos critérios de exclusão. RESULTADOS: A incidência de DCC foi de 11%. Permanência hospitalar, custos e mortalidade foram significativamente maiores na população com DCC. Ventilação mecânica, sepse, Glasgow escore < 15, inadequada ingestão calórica e elevado índice de massa corporal foram preditores independentes para dcc em um modelo multivariado de regressão logística. CONCLUSÃO: DCC abrangeumadistintapopulaçãonasunidadesde terapiaintensiva apresentando maiores mortalidade, custos e permanência hospitalar. Alguns fatores presentes na admissão ou durante a primeira semana na unidade de terapia intensiva podem ser usados como preditores de DCC.

Prediction of chronic critical illness in a general intensive care unit.

OBJECTIVE: To assess the incidence, costs, and mortality associated with chronic critical illness (CCI), and to identify clinical predictors of CCI in a general intensive care unit. METHODS: This was a prospective observational cohort study. All patients receiving supportive treatment for over 20 days were considered chronically critically ill and eligible for the study. After applying the exclusion criteria, 453 patients were analyzed. RESULTS: There was an 11% incidence of CCI. Total length of hospital stay, costs, and mortality were significantly higher among patients with CCI. Mechanical ventilation, sepsis, Glasgow score <15, inadequate calorie intake, and higher body mass index were independent predictors for CCI in the multivariate logistic regression model. CONCLUSIONS: CCI affects a distinctive population in intensive care units with higher mortality, costs, and prolonged hospitalization. Factors identifiable at the time of admission or during the first week in the intensive care unit can be used to predict CCI.

Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients.

BACKGROUND: Our aim was to examine whether serial blood lactate levels could be used as predictors of outcome. METHODS: We prospectively studied 44 high-risk, hemodynamically stable, surgical patients. Blood lactate values, mean arterial pressure, heart rate and urine output were obtained at patient admission to the study, at 12, 24 and 48 hours. RESULTS: The nonsurvivors (n = 7) had similar blood lactate levels initially (3.1 +/- 2.3 mmol/l versus 2.2 +/- 1.0 mmol/l, P = not significant [NS]), but had higher levels after 12 hours (2.9 +/- 1.7 mmol/l versus 1.6 +/- 0.9 mmol/l, P = 0.012), after 24 hours (2.1 +/- 0.6 mmol/l versus 1.5 +/- 0.7 mmol/l, P = NS) and after 48 hours (2.7 +/- 1.8 mmol/l versus 1.9 +/- 1.4 mmol/l, P = NS) as compared with the survivors (n = 37). Arterial bicarbonate concentrations increased significantly in survivors and were higher than in nonsurvivors after 24 hours (22.9 +/- 5.2 mEq/l versus 16.7 +/- 3.9 mEq/l, P = 0.01) and after 48 hours (23.1 +/- 4.1 mEq/l versus 17.6 +/- 7.1 mEq/l, P = NS). The PaO2/FiO2 ratio was higher in survivors initially (334 +/- 121 mmHg versus 241 +/- 133 mmHg, P = 0.03) and remained elevated for 48 hours. There were no significant differences in mean arterial pressure, heart rate, and arterial blood oxygenation at any time between survivors and nonsurvivors. The intensive care unit stay (40 +/- 42 hours versus 142 +/- 143 hours, P < 0.001) and the hospital stay (12 +/- 11 days versus 24 +/- 17 days, P = 0.022) were longer for nonsurvivors than for survivors. The Simplified Acute Physiology Score II score was higher for nonsurvivors than for survivors (34 +/- 9 versus 25 +/- 14, P = NS). The urine output was slightly lower in the nonsurvivor group (P = NS). The areas under the receiving operating characteristic curves were larger for initial values of Simplified Acute Physiology Score II and blood lactate for predicting death. CONCLUSION: Elevated blood lactate levels are associated with a higher mortality rate and postoperative complications in hemodynamically stable surgical patients.

Clinical review: Hypertonic saline resuscitation in sepsis.

The present review discusses the hemodynamic effects of hypertonic saline in experimental shock and in patients with sepsis. We comment on the mechanisms of action of hypertonic saline, calling upon data in hemorrhagic and septic shock. Specific actions of hypertonic saline in severe sepsis and septic shock are highlighted. Data are available that support potential benefits of hypertonic saline infusion in various aspects of the pathophysiology of sepsis, including tissue hypoperfusion, decreased oxygen consumption, endothelial dysfunction, cardiac depression, and the presence of a broad array of proinflammatory cytokines and various oxidant species. The goal of research in this field is to identify reliable therapies to prevent ischemia and inflammation, and to reduce mortality.