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Dadam MM, Pereira AB, Cardoso MR, Carnin TC, Westphal GA. Effect of Reintubation Within 48 Hours on Mortality in Critically Ill Patients After Planned Extubation. Respir Care 2024; 69:829-838. [PMID: 38772683 DOI: 10.4187/respcare.11077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
BACKGROUND Re-intubation is necessary in 2% to 30% of cases of patients receiving a planned extubation. This procedure is associated with prolonged mechanical ventilation, a greater need for tracheostomy, a higher incidence of ventilator-associated pneumonia, and higher mortality. The aim of this study was to evaluate the effect of re-intubation within 48 h on mortality after planned extubation by using a randomized controlled trial database. METHODS Secondary analysis of a multi-center randomized trial, which evaluated the effect of reconnection to mechanical ventilation for 1 h after a successful spontaneous breathing trial, followed by extubation. The study included adult subjects who received invasive mechanical ventilation for > 12 h. The subjects were divided into an extubation failure group and an extubation success group. The outcome was in-hospital mortality. Two multivariate logistic regression models were constructed to identify independent factors associated with mortality. RESULTS Among the 336 subjects studied, extubation failed in 52 (15.4%) and they were re-intubated within 48 h. Most re-intubations occurred between 12 and 24 h after planned extubation (median [interquartile range] 16 [6-36] h). Mortality of the extubation failure group was higher both in the ICU (32.6% vs 6.6%; odds ratio [OR] 6.77, 95% CI 3.22-14.24; P < .001) and in-hospital (42.3% vs 14.0%; OR 4.47, 95% CI 2.34-8.51; P < .001) versus the extubation success group. Multivariate logistic regression analyses showed that re-intubation within 48 h was independently associated with both ICU mortality (OR 6.10, 95% CI 2.84-13.07; P < .001) and in-hospital mortality (OR 3.36, 95% CI 1.67-6.73; P = .001). In-hospital mortality was also associated with rescue noninvasive ventilation after extubation (OR 2.44, 95% CI 1.25-4.75; P = .009). CONCLUSIONS Re-intubation within 48 h after planned extubation was associated with mortality in subjects who were critically ill.
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Reggio E, Westphal GA, Zahdi NS, Bessa JD, Gomes CM, Mazzucchi E, Nahas WC. Obstructive urosepsis - is it possible to personalize the ureteral endoscopic treatment? Urol Int 2024:000539890. [PMID: 38889697 DOI: 10.1159/000539890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 06/15/2024] [Indexed: 06/20/2024]
Abstract
INTRODUCTION Urinary tract infection involves mortality rate when combined to ureteral obstruction. Lithotripsy has been contraindicated, however it has been shown to be safe in selected situations. No specific criteria has been widely accepted to indicate which patients are suitable for definitive treatment. The cbjective of this study is to identify prognostic factors associated with poor outcome but also those patients whose definitive treatment can be performed. METHODS observational cohort study from a prospectively maintained database of septic patients defined by the Sequential Organ Failure Assessment (SOFA). Univariate analysis was used to compare prognostic factors with Δ-SOFA score < 2 (group 1) and those with a Δ-SOFA≥2 (group 2) obtained on day 3 and on admission. Different combinations of neutrophils, lymphocytes and platelets were tested as prognostic factors. Time to decompression calculated from the CT scan report to end of surgery. RESULTS 229 patients were enrolled during 11 years. Two patients died. Time from CTscan to urinary tract decompression was higher in the Δ-SOFA≥2 (p=0.04). Thrombocytopenia and the platelet to lymphocyte ratio were associated with Δ-SOFA≥2. Stones were disintegrated in 33.48% in group 1 and 48.84% in group 2. Platelets count and time to decompression were associated with worse prognosis (p = 0.0008 and 0.0017). On ROC curve analysis, platelets count < 105,056 and time to decompression > 4.72hours linked to poorer outcome. CONCLUSIONS Personalized treatment, based on accessible biomarkers can be achieved in most patients. Early surgical decompression was associated with better prognosis and definitive treatment can be performed in selected patients.
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Maia IS, Medrado FA, Tramujas L, Tomazini BM, Oliveira JS, Sady ERR, Barbante LG, Nicola ML, Gurgel RM, Damiani LP, Negrelli KL, Miranda TA, Santucci E, Valeis N, Laranjeira LN, Westphal GA, Fernandes RP, Zandonai CL, Pincelli MP, Figueiredo RC, Bustamante CLS, Norbin LF, Boschi E, Lessa R, Romano MP, Miura MC, de Alencar MS, Dantas VCDS, Barreto PA, Hernandes ME, Grion CMC, Laranjeira AS, Mezzaroba AL, Bahl M, Starke AC, Biondi RS, Dal-Pizzol F, Caser EB, Thompson MM, Padial AA, Veiga VC, Leite RT, Araújo G, Guimarães M, Martins PDA, Lacerda FH, Hoffmann CR, Melro L, Pacheco E, Ospina-Táscon GA, Ferreira JC, Freires FJC, Machado FR, Cavalcanti AB, Zampieri FG. Prospective, randomized, controlled trial assessing the effects of a driving pressure-limiting strategy for patients with acute respiratory distress syndrome due to community-acquired pneumonia (STAMINA trial): protocol and statistical analysis plan. CRITICAL CARE SCIENCE 2024; 36:e20240210en. [PMID: 38775567 PMCID: PMC11098077 DOI: 10.62675/2965-2774.20240210-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 01/12/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Driving pressure has been suggested to be the main driver of ventilator-induced lung injury and mortality in observational studies of acute respiratory distress syndrome. Whether a driving pressure-limiting strategy can improve clinical outcomes is unclear. OBJECTIVE To describe the protocol and statistical analysis plan that will be used to test whether a driving pressure-limiting strategy including positive end-expiratory pressure titration according to the best respiratory compliance and reduction in tidal volume is superior to a standard strategy involving the use of the ARDSNet low-positive end-expiratory pressure table in terms of increasing the number of ventilator-free days in patients with acute respiratory distress syndrome due to community-acquired pneumonia. METHODS The ventilator STrAtegy for coMmunIty acquired pNeumoniA (STAMINA) study is a randomized, multicenter, open-label trial that compares a driving pressure-limiting strategy to the ARDSnet low-positive end-expiratory pressure table in patients with moderate-to-severe acute respiratory distress syndrome due to community-acquired pneumonia admitted to intensive care units. We expect to recruit 500 patients from 20 Brazilian and 2 Colombian intensive care units. They will be randomized to a driving pressure-limiting strategy group or to a standard strategy using the ARDSNet low-positive end-expiratory pressure table. In the driving pressure-limiting strategy group, positive end-expiratory pressure will be titrated according to the best respiratory system compliance. OUTCOMES The primary outcome is the number of ventilator-free days within 28 days. The secondary outcomes are in-hospital and intensive care unit mortality and the need for rescue therapies such as extracorporeal life support, recruitment maneuvers and inhaled nitric oxide. CONCLUSION STAMINA is designed to provide evidence on whether a driving pressure-limiting strategy is superior to the ARDSNet low-positive end-expiratory pressure table strategy for increasing the number of ventilator-free days within 28 days in patients with moderate-to-severe acute respiratory distress syndrome. Here, we describe the rationale, design and status of the trial.
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Tavares CDAM, de Azevedo LCP, Rea-Neto Á, Campos NS, Amendola CP, Bergo RR, Kozesinski-Nakatani AC, David-João PG, Westphal GA, Guimarães Júnior MRR, Lobo SMA, Tavares MS, Dracoulakis MDA, de Souza GM, de Almeida GMB, Gebara OCE, Tomba PO, Albuquerque CSN, Silva MCR, Pereira AJ, Damiani LP, Corrêa TD, Serpa-Neto A, Berwanger O, Zampieri FG. Dapagliflozin in patients with critical illness: rationale and design of the DEFENDER study. CRITICAL CARE SCIENCE 2023; 35:256-265. [PMID: 38133155 PMCID: PMC10734800 DOI: 10.5935/2965-2774.20230129-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/09/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Critical illness is a major ongoing health care burden worldwide and is associated with high mortality rates. Sodium-glucose cotransporter-2 inhibitors have consistently shown benefits in cardiovascular and renal outcomes. The effects of sodium-glucose cotransporter-2 inhibitors in acute illness have not been properly investigated. METHODS DEFENDER is an investigator-initiated, multicenter, randomized, open-label trial designed to evaluate the efficacy and safety of dapagliflozin in 500 adult participants with acute organ dysfunction who are hospitalized in the intensive care unit. Eligible participants will be randomized 1:1 to receive dapagliflozin 10mg plus standard of care for up to 14 days or standard of care alone. The primary outcome is a hierarchical composite of hospital mortality, initiation of kidney replacement therapy, and intensive care unit length of stay, up to 28 days. Safety will be strictly monitored throughout the study. CONCLUSION DEFENDER is the first study designed to investigate the use of a sodium-glucose cotransporter-2 inhibitor in general intensive care unit patients with acute organ dysfunction. It will provide relevant information on the use of drugs of this promising class in critically ill patients. CLINICALTRIALS.GOV REGISTRY NCT05558098.
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Westphal GA, Besen BAMP, de Andrade J, Sardinha LA, Franke CA. Brazilian Contributions on Standardized Education for Brain Death Determination. Neurocrit Care 2023; 39:740-741. [PMID: 37752296 DOI: 10.1007/s12028-023-01850-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 09/28/2023]
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Westphal GA, Fernandes RP, Pereira AB, Moerschberger MS, Pereira MR, Gonçalves ARR. Incidence of Delirium in Critically Ill Patients With and Without COVID-19. J Intensive Care Med 2023; 38:751-759. [PMID: 36939479 PMCID: PMC10030890 DOI: 10.1177/08850666231162805] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
BACKGROUND It is known that patients with COVID-19 are at high risk of developing delirium. The aim of the study was to compare the incidence of delirium between critically ill patients with and without a diagnosis of COVID-19. METHODS This is a retrospective study conducted in a southern Brazilian hospital from March 2020 to January 2021. Patients were divided into two groups: the COVID-19 group consisted of patients with a diagnosis of COVID-19 confirmed by reverse transcription-polymerase chain reaction (RT-PCR) or serological tests who were admitted to specific ICUs. The non-COVID-19 group consisted of patients with other surgical and medical diagnoses who were admitted to non-COVID ICUs. All patients were evaluated daily using the Intensive Care Delirium Screening Checklist (ICDSC). The two cohorts were compared in terms of the diagnosis of delirium. RESULTS Of the 649 patients who remained more than 48 h in the ICU, 523 were eligible for the study (COVID-19 group: 292, non-COVID-19 group: 231). There were 119 (22.7%) patients who had at least one episode of delirium, including 96 (32.9%) in the COVID-19 group and 23 (10.0%) in the non-COVID-19 group (odds ratio [OR] 4.42; 95% confidence interval [CI], 2.69 to 7.26; p < 0.001). Among patients mechanically ventilated for two days or more, the incidence of delirium did not differ between groups (COVID-19: 89/211, 42.1% vs non-COVID-19: 19/47, 40.4%; p = 0.82). Logistic regression showed that the duration of mechanical ventilation was the only independent factor associated with delirium (p = 0.001). CONCLUSION COVID-19 can be associated with a higher incidence of delirium among critically ill patients, but there was no difference in this incidence between groups when mechanical ventilation lasted two days or more.
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Tannous LA, Westphal GA, Ioshii SO, de Lima Alves GN, Pigatto RN, Pinto RL, de Carvalho KAT, Francisco JC, Guarita-Souza LC. Histological, Laboratorial, and Clinical Benefits of an Optimized Maintenance Strategy of a Potential Organ Donor-A Rabbit Experimental Model. Life (Basel) 2023; 13:1439. [PMID: 37511814 PMCID: PMC10381703 DOI: 10.3390/life13071439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION Most transplanted organs are obtained from brain-dead donors. Inflammation results in a higher rate of rejection. Objectives: The objective of this animal model of brain death (BD) was to evaluate the effect of the progressive institution of volume expansion, norepinephrine, and combined hormone therapy on clinical, laboratory, and histological aspects. Methods: Twenty rabbits were divided: A (control), B (induction of BD + infusion of crystalloid), C (BD + infusion of crystalloid and noradrenaline (NA)), and D (BD + infusion of crystalloid + vasopressin + levothyroxine + methylprednisolone + NA). The animals were monitored for four hours with consecutives analysis of vital signs and blood samples. The organs were evaluated by a pathologist. Results: In Group D, we observed fewer number and lesser volume of infusions (p = 0.032/0.014) when compared with groups B and C. Mean arterial pressure levels were higher in group D when compared with group B (p = 0.008). Group D had better glycemic control when compared with group C (p = 0.016). Sodium values were elevated in group B in relation to groups C and D (p = 0.021). In Group D, the organ perfusion was better. Conclusion: The optimized strategy of management of BD animals is associated with better hemodynamic, glycemic, and natremia control, besides reducing early signs of ischemia.
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Ramos J, Westphal C, Fezer AP, Moerschberger MS, Westphal GA. Effect of virtual information on the satisfaction for decision-making among family members of critically ill COVID-19 patients. Intensive Care Med 2022; 48:488-490. [PMID: 35089411 PMCID: PMC8795945 DOI: 10.1007/s00134-021-06616-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2021] [Indexed: 11/28/2022]
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Maia IS, Marcadenti A, Zampieri FG, Damiani LP, Santos RHN, Negrelli KL, Gomes SPDC, Gomes JO, Carollo MBDS, Miranda TA, Santucci E, Valeis N, Laranjeira LN, Westphal GA, Horta JGA, Flato UAP, Fernandes C, Barros WC, Bolan RS, Gebara OCE, de Alencar Filho MS, Hamamoto VA, Hernandes ME, Golin NA, de Olinda RT, Machado FR, Rosa RG, Veiga VC, de Azevedo LCP, Avezum A, Lopes RD, Souza TML, Berwanger O, Cavalcanti AB. Antivirals for adult patients hospitalized with SARS-CoV-2 infection: A randomized, Phase II/III, multicenter, placebo-controlled, adaptive study, with multiple arms and stages. COALITION COVID-19 BRAZIL IX - REVOLUTIOn: protocol and statistical analysis plan. Rev Bras Ter Intensiva 2022. [PMID: 35766657 PMCID: PMC9345580 DOI: 10.5935/0103-507x.20220002-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Maia IS, Marcadenti A, Zampieri FG, Damiani LP, Santos RHN, Negrelli KL, Gomes SPDC, Gomes JO, Carollo MBDS, Miranda TA, Santucci E, Valeis N, Laranjeira LN, Westphal GA, Horta JGA, Flato UAP, Fernandes C, Barros WC, Bolan RS, Gebara OCE, Alencar Filho MSD, Hamamoto VA, Hernandes ME, Golin NA, Olinda RTD, Machado FR, Rosa RG, Veiga VC, Azevedo LCPD, Avezum A, Lopes RD, Souza TML, Berwanger O, Cavalcanti AB. Antivirals for adult patients hospitalized with SARS-CoV-2 infection: A randomized, Phase II/III, multicenter, placebo-controlled, adaptive study, with multiple arms and stages. COALITION COVID-19 BRAZIL IX - REVOLUTIOn: protocol and statistical analysis plan. Rev Bras Ter Intensiva 2022; 34:44-55. [PMID: 35766657 DOI: 10.5935/0103-507x.20220002-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/31/2021] [Indexed: 11/20/2022] Open
Abstract
Repurposed drugs are important in resource-limited settings because the interventions are more rapidly available, have already been tested safely in other populations and are inexpensive. Repurposed drugs are an effective solution, especially for emerging diseases such as COVID-19. The REVOLUTIOn trial has the objective of evaluating three repurposed antiviral drugs, atazanavir, daclatasvir and sofosbuvir, already used for HIV- and hepatitis C virus-infected patients in a randomized, placebo-controlled, adaptive, multiarm, multistage study. The drugs will be tested simultaneously in a Phase II trial to first identify whether any of these drugs alone or in combination reduce the viral load. If they do, a Phase III trial will be initiated to investigate if these medications are capable of increasing the number of days free respiratory support. Participants must be hospitalized adults aged ≥ 18 years with initiation of symptoms ≤ 9 days and SpO2 ≤ 94% in room air or a need for supplemental oxygen to maintain an SpO2 > 94%. The expected total sample size ranges from 252 to 1,005 participants, depending on the number of stages that will be completed in the study. Hence, the protocol is described here in detail together with the statistical analysis plan. In conclusion, the REVOLUTIOn trial is designed to provide evidence on whether atazanavir, daclatasvir or sofosbuvir decrease the SARS-CoV-2 load in patients with COVID-19 and increase the number of days patients are free of respiratory support. In this protocol paper, we describe the rationale, design, and status of the trial. ClinicalTrials.gov identifier: NCT04468087.
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Maia IS, Marcadenti A, Zampieri FG, Damiani LP, Santos RHN, Negrelli KL, Gomes SPDC, Gomes JO, Carollo MBDS, Miranda TA, Santucci E, Valeis N, Laranjeira LN, Westphal GA, Horta JGA, Flato UAP, Fernandes C, Barros WC, Bolan RS, Gebara OCE, Alencar Filho MSD, Hamamoto VA, Hernandes ME, Golin NA, Olinda RTD, Machado FR, Rosa RG, Veiga VC, Azevedo LCPD, Avezum A, Lopes RD, Souza TML, Berwanger O, Cavalcanti AB, BRICNet CIXIAT. Antivirals for adult patients hospitalized with SARS-CoV-2 infection: A randomized, Phase II/III, multicenter, placebo-controlled, adaptive study, with multiple arms and stages. COALITION COVID-19 BRAZIL IX - REVOLUTIOn: protocol and statistical analysis plan. Rev Bras Ter Intensiva 2022. [DOI: 10.5935/0103-507x.20220002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Freitas FGRD, Hammond N, Li Y, Azevedo LCPD, Cavalcanti AB, Taniguchi L, Gobatto A, Japiassú AM, Bafi AT, Mazza BF, Noritomi DT, Dal-Pizzol F, Bozza F, Salluh JIF, Westphal GA, Soares M, Assunção MSCD, Lisboa T, Lobo SMA, Barbosa AR, Ventura AF, Souza AFD, Silva AF, Toledo A, Reis A, Cembranel A, Rea Neto A, Gut AL, Justo APP, Santos AP, Albuquerque ACDD, Scazufka A, Rodrigues AB, Fernandino BB, Silva BG, Vidal BS, Pinheiro BV, Pinto BVC, Feijo CAR, Abreu Filho CD, Bosso CEDCN, Moreira CEN, Ramos CHF, Tavares C, Arantes C, Grion C, Mendes CL, Kmohan C, Piras C, Castro CPP, Lins C, Beraldo D, Fontes D, Boni D, Castiglioni D, Paisani DDM, Pedroso DFF, Mattos ER, Brito Sobrinho ED, Troncoso EMV, Rodrigues Filho EM, Nogueira EEF, Ferreira EL, Pacheco ES, Jodar E, Ferreira ELA, Araujo FFD, Trevisol FS, Amorim FF, Giannini FP, Santos FPM, Buarque F, Lima FG, Costa FAAD, Sad FCDA, Aranha FG, Ganem F, Callil F, Costa Filho FF, Dall Arto FTC, Moreno G, Friedman G, Moralez GM, Silva GAD, Costa G, Cavalcanti GS, Cavalcanti GS, Betônico GN, Betônico GN, Reis H, Araujo HBN, Hortiz Júnior HA, Guimaraes HP, Urbano H, Maia I, Santiago Filho IL, Farhat Júnior J, Alvarez JR, Passos JT, Paranhos JEDR, Marques JA, Moreira Filho JG, Andrade JN, Sobrinho JODC, Bezerra JTDP, Alves JA, Ferreira J, Gomes J, Sato KM, Gerent K, Teixeira KMC, Conde KAP, Martins LF, Figueirêdo L, Rezegue L, Tcherniacovsk L, Ferraz LO, Cavalcante L, Rabelo L, Miilher L, Garcia L, Tannous L, Hajjar LA, Paciência LEM, Cruz Neto LMD, Bley MV, Sousa MF, Puga ML, Romano MLP, Nobrega M, Arbex M, Rodrigues ML, Guerreiro MO, Rocha M, Alves MAP, Alves MAP, Rosa MD, Dias MD, Martins M, Oliveira MD, Moretti MMS, Matsui M, Messender O, Santarém OLDA, Silveira PJHD, Vassallo PF, Antoniazzi P, Gottardo PC, Correia P, Ferreira P, Torres P, Silva PGMDBE, Foernges R, Gomes R, Moraes R, Nonato Filho R, Borba RL, Gomes RV, Cordioli R, Lima R, López RP, Gargioni RRDO, Rosenblat R, Souza RMD, Almeida R, Narciso RC, Marco R, Waltrick R, Biondi R, Figueiredo R, Dutra RS, Batista R, Felipe R, Franco RSDS, Houly S, Faria SS, Pinto SF, Luzzi S, Sant'ana S, Fernandes SS, Yamada S, Zajac S, Vaz SM, Bezerra SAB, Farhat TBT, Santos TM, Smith T, Silva UVA, Damasceno VB, Nobre V, Dantas VCDS, Irineu VM, Bogado V, Nedel W, Campos Filho W, Dantas W, Viana W, Oliveira Filho WD, Delgadinho WM, Finfer S, Machado FR. Resuscitation fluid practices in Brazilian intensive care units: a secondary analysis of Fluid-TRIPS. Rev Bras Ter Intensiva 2021; 33:206-218. [PMID: 34231801 PMCID: PMC8275089 DOI: 10.5935/0103-507x.20210028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 12/08/2020] [Indexed: 12/16/2022] Open
Abstract
Objective To describe fluid resuscitation practices in Brazilian intensive care units and to compare them with those of other countries participating in the Fluid-TRIPS. Methods This was a prospective, international, cross-sectional, observational study in a convenience sample of intensive care units in 27 countries (including Brazil) using the Fluid-TRIPS database compiled in 2014. We described the patterns of fluid resuscitation use in Brazil compared with those in other countries and identified the factors associated with fluid choice. Results On the study day, 3,214 patients in Brazil and 3,493 patients in other countries were included, of whom 16.1% and 26.8% (p < 0.001) received fluids, respectively. The main indication for fluid resuscitation was impaired perfusion and/or low cardiac output (Brazil: 71.7% versus other countries: 56.4%, p < 0.001). In Brazil, the percentage of patients receiving crystalloid solutions was higher (97.7% versus 76.8%, p < 0.001), and 0.9% sodium chloride was the most commonly used crystalloid (62.5% versus 27.1%, p < 0.001). The multivariable analysis suggested that the albumin levels were associated with the use of both crystalloids and colloids, whereas the type of fluid prescriber was associated with crystalloid use only. Conclusion Our results suggest that crystalloids are more frequently used than colloids for fluid resuscitation in Brazil, and this discrepancy in frequencies is higher than that in other countries. Sodium chloride (0.9%) was the crystalloid most commonly prescribed. Serum albumin levels and the type of fluid prescriber were the factors associated with the choice of crystalloids or colloids for fluid resuscitation.
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Westphal GA, Robinson CC, Cavalcanti AB, Gonçalves ARR, Guterres CM, Teixeira C, Stein C, Franke CA, da Silva DB, Pontes DFS, Nunes DSL, Abdala E, Dal-Pizzol F, Bozza FA, Machado FR, de Andrade J, Cruz LN, de Azevedo LCP, Machado MCV, Rosa RG, Manfro RC, Nothen RR, Lobo SM, Rech TH, Lisboa T, Colpani V, Falavigna M. Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the AMIB, ABTO, BRICNet, and the General Coordination of the National Transplant System. Ann Intensive Care 2020; 10:169. [PMID: 33315161 PMCID: PMC7736434 DOI: 10.1186/s13613-020-00787-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To contribute to updating the recommendations for brain-dead potential organ donor management. METHOD A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, joined a task force formed by the General Coordination Office of the National Transplant System/Brazilian Ministry of Health (CGSNT-MS), the Brazilian Association of Intensive Care Medicine (AMIB), the Brazilian Association of Organ Transplantation (ABTO), and the Brazilian Research in Intensive Care Network (BRICNet). The questions were developed within the scope of the 2011 Brazilian Guidelines for Management of Adult Potential Multiple-Organ Deceased Donors. The topics were divided into mechanical ventilation, hemodynamic support, endocrine-metabolic management, infection, body temperature, blood transfusion, and use of checklists. The outcomes considered for decision-making were cardiac arrest, number of organs recovered or transplanted per donor, and graft function/survival. Rapid systematic reviews were conducted, and the quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Two expert panels were held in November 2016 and February 2017 to classify the recommendations. A systematic review update was performed in June 2020, and the recommendations were reviewed through a Delphi process with the panelists between June and July 2020. RESULTS A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong (lung-protective ventilation strategy, vasopressors and combining arginine vasopressin to control blood pressure, antidiuretic hormones to control polyuria, serum potassium and magnesium control, and antibiotic use), 11 as weak (alveolar recruitment maneuvers, low-dose dopamine, low-dose corticosteroids, thyroid hormones, glycemic and serum sodium control, nutritional support, body temperature control or hypothermia, red blood cell transfusion, and goal-directed protocols), and 1 was considered a good clinical practice (volemic expansion). CONCLUSION Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak. The observed lack of robust evidence on the topic highlights the importance of the present guideline to improve the management of brain-dead potential organ donors.
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Cherem S, Fernandes V, Zambonato KD, Westphal GA. Can the behavior of blood pressure after elevation of the positive end-expiratory pressure help to determine the fluid responsiveness status in patients with septic shock? Rev Bras Ter Intensiva 2020; 32:374-380. [PMID: 33053026 PMCID: PMC7595715 DOI: 10.5935/0103-507x.20200065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 02/12/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To evaluate whether the decrease in blood pressure caused by the increase in the positive end-expiratory pressure corresponds to the pulse pressure variation as an indicator of fluid responsiveness. METHODS This exploratory study prospectively included 24 patients with septic shock who were mechanically ventilated and subjected to three stages of elevation of the positive end-expiratory pressure: from 5 to 10cmH2O (positive end-expiratory pressure level 1), from 10 to 15cmH2O (positive end-expiratory pressure level 2), and from 15 to 20cmH2O (positive end-expiratory pressure level 3). Changes in systolic blood pressure, mean arterial pressure, and pulse pressure variation were evaluated during the three maneuvers. The patients were classified as responsive (pulse pressure variation ≥ 12%) or unresponsive to volume replacement (pulse pressure variation < 12%). RESULTS The best performance at identifying patients with pulse pressure variation ≥ 12% was observed at the positive end-expiratory pressure level 2: -9% systolic blood pressure variation (area under the curve 0.73; 95%CI: 0.49 - 0.79; p = 0.04), with a sensitivity of 63% and specificity of 80%. Concordance was low between the variable with the best performance (variation in systolic blood pressure) and pulse pressure variation ≥ 12% (kappa = 0.42; 95%CI: 0.19 - 0.56). The systolic blood pressure was < 90mmHg at positive end-expiratory pressure level 2 in 29.2% of cases and at positive end-expiratory pressure level 3 in 41.63% of cases. CONCLUSION Variations in blood pressure in response to the increase in positive end-expiratory pressure do not reliably reflect the behavior of the pulse pressure as a measure to identify the fluid responsiveness status.
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Aguiar FP, Westphal GA, Dadam MM, Mota ECC, Pfutzenreuter F, França PHC. Characteristics and predictors of chronic critical illness in the intensive care unit. Rev Bras Ter Intensiva 2020; 31:511-520. [PMID: 31967226 PMCID: PMC7009003 DOI: 10.5935/0103-507x.20190088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 07/11/2019] [Indexed: 12/17/2022] Open
Abstract
Objective To characterize patients with chronic critical illness and identify predictors of development of chronic critical illness. Methods Prospective data was collected for 1 year in the intensive care unit of a general hospital in Southern Brazil. Three logistic regression models were constructed to identify factors associated with chronic critical illness. Results Among the 574 subjects admitted to the intensive care unit, 200 were submitted to mechanical ventilation. Of these patients, 85 (43.5%) developed chronic critical illness, composing 14.8% of all the patients admitted to the intensive care unit. The regression model that evaluated the association of chronic critical illness with conditions present prior to intensive care unit admission identified chronic renal failure in patients undergoing hemodialysis (OR 3.57; p = 0.04) and a neurological diagnosis at hospital admission (OR 2.25; p = 0.008) as independent factors. In the model that evaluated the association of chronic critical illness with situations that occurred during intensive care unit stay, muscle weakness (OR 2.86; p = 0.01) and pressure ulcers (OR 9.54; p < 0.001) had the strongest associations. In the global multivariate analysis (that assessed previous factors and situations that occurred in the intensive care unit), hospital admission due to neurological diseases (OR 2.61; p = 0.03) and the development of pressure ulcers (OR 9.08; p < 0.001) had the strongest associations. Conclusion The incidence of chronic critical illness in this study was similar to that observed in other studies and had a strong association with the diagnosis of neurological diseases at hospital admission and chronic renal failure in patients undergoing hemodialysis, as well as complications developed during hospitalization, such as pressure ulcers and muscle weakness.
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Westphal GA, Fernandes V, Westphal V, Fonseca JC, Silva LRD, Valiatti JLDS. Use of CPAP as an alternative to the apnea test during the determination of brain death in hypoxemic patients. Report of two cases. Rev Bras Ter Intensiva 2020; 32:319-325. [PMID: 32667440 PMCID: PMC7405752 DOI: 10.5935/0103-507x.20200032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 12/02/2019] [Indexed: 11/20/2022] Open
Abstract
The apnea test, which involves disconnection from the mechanical ventilator, presents risks during the determination of brain death, especially in hypoxemic patients. We describe the performance of the apnea test without disconnection from the mechanical ventilator in two patients. The first case involved an 8-year-old boy admitted with severe hypoxemia due to pneumonia. He presented with cardiorespiratory arrest, followed by unresponsive coma due to hypoxic-ischemic encephalopathy. Two clinical exams revealed the absence of brainstem reflexes, and transcranial Doppler ultrasound revealed brain circulatory arrest. Three attempts were made to perform the apnea test, which were interrupted by hypoxemia; therefore, the apnea test was performed without disconnection from the mechanical ventilator, adjusting the continuous airway pressure to 10cmH2O and the inspired fraction of oxygen to 100%. The oxygen saturation was maintained at 100% for 10 minutes. Posttest blood gas analysis results were as follows: pH, 6.90; partial pressure of oxygen, 284.0mmHg; partial pressure of carbon dioxide, 94.0mmHg; and oxygen saturation, 100%. The second case involved a 43-year-old woman admitted with subarachnoid hemorrhage (Hunt-Hess V and Fisher IV). Two clinical exams revealed unresponsive coma and absence of all brainstem reflexes. Brain scintigraphy showed no radioisotope uptake into the brain parenchyma. The first attempt at the apnea test was stopped after 5 minutes due to hypothermia (34.9°C). After rewarming, the apnea test was repeated without disconnection from the mechanical ventilator, showing maintenance of the functional residual volume with electrical bioimpedance. Posttest blood gas analysis results were as follows: pH, 7.01; partial pressure of oxygen, 232.0mmHg; partial pressure of carbon dioxide, 66.9mmHg; and oxygen saturation, 99.0%. The apnea test without disconnection from the mechanical ventilator allowed the preservation of oxygenation in both cases. The use of continuous airway pressure during the apnea test seems to be a safe alternative in order to maintain alveolar recruitment and oxygenation during brain death determination.
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Giordani NE, Robinson CC, Westphal GA, Rosa RG, Sganzerla D, Cavalcanti AB, Machado FR, Azevedo LCP, Bozza FA, Teixeira C, de Andrade J, Franke CA, Guterres CM, Madalena IC, Rohden AI, da Silva SS, Andrighetto LV, Rech GS, Gimenes BDP, Hammes LS, Pontes DFS, Meade MO, Falavigna M. Statistical analysis plan for a cluster-randomised trial assessing the effectiveness of implementation of a bedside evidence-based checklist for clinical management of brain-dead potential organ donors in intensive care units: DONORS (Donation Network to Optimise Organ Recovery Study). Trials 2020; 21:540. [PMID: 32552839 PMCID: PMC7298918 DOI: 10.1186/s13063-020-04457-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 05/25/2020] [Indexed: 11/28/2022] Open
Abstract
Background The quality of clinical care of brain-dead potential organ donors may help reduce donor losses caused by irreversible or unreversed cardiac arrest and increase the number of organs donated. We sought to determine whether an evidence-based, goal-directed checklist for donor management in intensive care units (ICUs) can reduce donor losses to cardiac arrest. Methods/design The DONORS study is a multicentre, cluster-randomised controlled trial with a 1:1 allocation ratio designed to compare an intervention group (goal-directed checklist for brain-dead potential organ donor management) with a control group (standard ICU care). The primary outcome is loss of potential donors due to cardiac arrest. Secondary outcomes are the number of actual organ donors and the number of solid organs recovered per actual donor. Exploratory outcomes include the achievement of relevant clinical goals during the management of brain-dead potential organ donors. The present statistical analysis plan (SAP) describes all primary statistical procedures that will be used to evaluate the results and perform exploratory and sensitivity analyses of the trial. Discussion The SAP of the DONORS study aims to describe its analytic procedures, enhancing the transparency of the study. At the moment of SAP subsmission, 63 institutions have been randomised and were enrolling study participants. Thus, the analyses reported herein have been defined before the end of the study recruitment and database locking. Trial registration ClinicalTrials.gov, NCT03179020. Registered on 7 June 2017.
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Westphal GA, Ramos J. Shared decision-making in the context of COVID-19. Rev Bras Ter Intensiva 2020; 32:200-202. [PMID: 32667450 PMCID: PMC7405738 DOI: 10.5935/0103-507x.20200034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 05/17/2020] [Indexed: 01/15/2023] Open
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Westphal GA, Veiga VC, Franke CA. Diagnosis of brain death in Brazil. Rev Bras Ter Intensiva 2019; 31:403-409. [PMID: 31618361 PMCID: PMC7005965 DOI: 10.5935/0103-507x.20190050] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/04/2019] [Indexed: 11/25/2022] Open
Abstract
Brain death, defined as the complete and irreversible loss of brain functions, has a history that is linked to the emergence of intensive care units and the advancement of artificial ventilatory support. In Brazil, by federal law, the criteria for the diagnosis of brain death have been defined by the Federal Council of Medicine since 1997 and apply to the entire Brazilian territory. Resolution 2,173/2017 of the Federal Council of Medicine updated the criteria for diagnosing brain death. These changes include the following: the requirement for the patient to meet specific physiological prerequisites and for the physician to provide optimized care to the patient before starting the procedures for diagnosing brain death and to perform complementary tests, as well as the need for specific training for physicians who make this diagnosis. Other changes include the reduction of the time interval between the two clinical examinations, the possibility of continuing procedures in the presence of unilateral ear or eye injury, the performance of a single apnea test and the creation of a statement of brain death determination that includes the recording of all procedures in a single document. This document, despite the controversy surrounding it, increases the safety necessary when establishing a diagnosis of such importance and has positive implications that extend beyond the patient and the physician to reach the entire health system.
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Westphal GA, Pereira AB, Fachin SM, Barreto ACC, Bornschein ACGJ, Caldeira Filho M, Koenig Á. Characteristics and outcomes of patients with community-acquired and hospital-acquired sepsis. Rev Bras Ter Intensiva 2019; 31:71-78. [PMID: 30970093 PMCID: PMC6443308 DOI: 10.5935/0103-507x.20190013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 12/04/2018] [Indexed: 12/29/2022] Open
Abstract
Objective To compare the clinical characteristics and outcomes of patients with
community-acquired and hospital-acquired sepsis. Methods This is a retrospective cohort study that included all patients with a
diagnosis of sepsis detected between January 2010 and December 2015 at a
private hospital in southern Brazil. Outcomes (mortality, intensive care
unit and hospital lengths of stay) were measured by analyzing electronic
records. Results There were 543 hospitalized patients with a diagnosis of sepsis, with a
frequency of 90.5 (85 to 105) cases/year. Of these, 319 (58%) cases were
classified as hospital-acquired sepsis. This group exhibited more severe
disease and had a larger number of organ dysfunctions, with higher hospital
[8 (8 - 10) versus 23 (20 - 27) days; p <
0.001] and intensive care unit [5 (4 - 7)
versus 8.5 (7 - 10); p < 0.001] lengths of
stay and higher in-hospital mortality (30.7% versus 15.6%;
p < 0.001) than those with community-acquired sepsis. After adjusting for
age, APACHE II scores, and hemodynamic and respiratory dysfunction,
hospital-acquired sepsis remained associated with increased mortality (OR
1.96; 95%CI 1.15 - 3.32, p = 0.013). Conclusion The present results contribute to the definition of the epidemiological
profile of sepsis in the sample studied, in which hospital-acquired sepsis
was more severe and was associated with higher mortality.
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Westphal GA, Robinson CC, Biasi A, Machado FR, Rosa RG, Teixeira C, de Andrade J, Franke CA, Azevedo LCP, Bozza F, Guterres CM, da Silva DB, Sganzerla D, do Prado DZ, Madalena IC, Rohden AI, da Silva SS, Giordani NE, Andrighetto LV, Benck PS, Roman FR, de Melo MDFRB, Pereira TB, Grion CMC, Diniz PC, Oliveira JFP, Mecatti GC, Alves FAC, Moraes RB, Nobre V, Hammes LS, Meade MO, Nothen RR, Falavigna M. DONORS (Donation Network to Optimise Organ Recovery Study): Study protocol to evaluate the implementation of an evidence-based checklist for brain-dead potential organ donor management in intensive care units, a cluster randomised trial. BMJ Open 2019; 9:e028570. [PMID: 31243035 PMCID: PMC6597655 DOI: 10.1136/bmjopen-2018-028570] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION There is an increasing demand for multi-organ donors for organ transplantation programmes. This study protocol describes the Donation Network to Optimise Organ Recovery Study, a planned cluster randomised controlled trial that aims to evaluate the effectiveness of the implementation of an evidence-based, goal-directed checklist for brain-dead potential organ donor management in intensive care units (ICUs) in reducing the loss of potential donors due to cardiac arrest. METHODS AND ANALYSIS The study will include ICUs of at least 60 Brazilian sites with an average of ≥10 annual notifications of valid potential organ donors. Hospitals will be randomly assigned (with a 1:1 allocation ratio) to the intervention group, which will involve the implementation of an evidence-based, goal-directed checklist for potential organ donor maintenance, or the control group, which will maintain the usual care practices of the ICU. Team members from all participating ICUs will receive training on how to conduct family interviews for organ donation. The primary outcome will be loss of potential donors due to cardiac arrest. Secondary outcomes will include the number of actual organ donors and the number of organs recovered per actual donor. ETHICS AND DISSEMINATION The institutional review board (IRB) of the coordinating centre and of each participating site individually approved the study. We requested a waiver of informed consent for the IRB of each site. Study results will be disseminated to the general medical community through publications in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER NCT03179020; Pre-results.
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Westphal GA, Pereira AB, Fachin SM, Sperotto G, Gonçalves M, Albino L, Bittencourt R, Franzini VDR, Koenig Á. An electronic warning system helps reduce the time to diagnosis of sepsis. Rev Bras Ter Intensiva 2018; 30:414-422. [PMID: 30570029 PMCID: PMC6334482 DOI: 10.5935/0103-507x.20180059] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/30/2018] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To describe the improvements of an early warning system for the identification of septic patients on the time to diagnosis, antibiotic delivery, and mortality. METHODS This was an observational cohort study that describes the successive improvements made over a period of 10 years using an early warning system to detect sepsis, including systematic active manual surveillance, electronic alerts via a telephonist, and alerts sent directly to the mobile devices of nurses. For all periods, after an alert was triggered, early treatment was instituted according to the institutional sepsis guidelines. RESULTS In total, 637 patients with sepsis were detected over the study period. The median triage-to-diagnosis time was reduced from 19:20 (9:10 - 38:15) hours to 12:40 (2:50 - 23:45) hours when the manual surveillance method was used (p = 0.14), to 2:10 (1:25 - 2:20) hours when the alert was sent automatically to the hospital telephone service (p = 0.014), and to 1:00 (0:30 - 1:10) hour when the alert was sent directly to the nurse's mobile phone (p = 0.016). The diagnosis-to-antibiotic time was reduced to 1:00 (0:55 - 1:30) hours when the alert was sent to the telephonist and to 0:45 (0:30 - 1:00) minutes when the alert was sent directly to the nurse's mobile phone (p = 0.02), with the maintenance of similar values over the following years. There was no difference in the time of treatment between survivors and non-survivors. CONCLUSION Electronic systems help reduce the triage-to-diagnosis time and diagnosis-to-antibiotic time in patients with sepsis.
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Westphal GA, Moerschberger MS, Vollmann DD, Inácio AC, Machado MC, Sperotto G, Cavalcanti AB, Koenig Á. Effect of a 24-h extended visiting policy on delirium in critically ill patients. Intensive Care Med 2018; 44:968-970. [PMID: 29605880 DOI: 10.1007/s00134-018-5153-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2018] [Indexed: 10/17/2022]
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Westphal GA, Garcia VD, de Souza RL, Franke CA, Vieira KD, Birckholz VRZ, Machado MC, de Almeida ERB, Machado FO, Sardinha LADC, Wanzuita R, Silvado CES, Costa G, Braatz V, Caldeira Filho M, Furtado R, Tannous LA, de Albuquerque AGN, Abdala E, Gonçalves ARR, Pacheco-Moreira LF, Dias FS, Fernandes R, Giovanni FD, de Carvalho FB, Fiorelli A, Teixeira C, Feijó C, Camargo SM, de Oliveira NE, David AI, Prinz RAD, Herranz LB, de Andrade J. Guidelines for the assessment and acceptance of potential brain-dead organ donors. Rev Bras Ter Intensiva 2017; 28:220-255. [PMID: 27737418 PMCID: PMC5051181 DOI: 10.5935/0103-507x.20160049] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Organ transplantation is the only alternative for many patients with terminal diseases. The increasing disproportion between the high demand for organ transplants and the low rate of transplants actually performed is worrisome. Some of the causes of this disproportion are errors in the identification of potential organ donors and in the determination of contraindications by the attending staff. Therefore, the aim of the present document is to provide guidelines for intensive care multi-professional staffs for the recognition, assessment and acceptance of potential organ donors.
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Kobs VC, Ferreira JA, Bobrowicz TA, Ferreira LE, Deglmann RC, Westphal GA, França PHCD. The role of the genetic elements bla oxa and IS Aba 1 in the Acinetobacter calcoaceticus-Acinetobacter baumannii complex in carbapenem resistance in the hospital setting. Rev Soc Bras Med Trop 2017; 49:433-40. [PMID: 27598629 DOI: 10.1590/0037-8682-0002-2016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 07/12/2016] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Members of the Acinetobacter genus are key pathogens that cause healthcare-associated infections, and they tend to spread and develop new antibiotic resistance mechanisms. Oxacillinases are primarily responsible for resistance to carbapenem antibiotics. Higher rates of carbapenem hydrolysis might be ascribed to insertion sequences, such as the ISAba1 sequence, near bla OXA genes. The present study examined the occurrence of the genetic elements bla OXA and ISAba1 and their relationship with susceptibility to carbapenems in clinical isolates of the Acinetobacter calcoaceticus-Acinetobacter baumannii complex. METHODS Isolates identified over 6 consecutive years in a general hospital in Joinville, Southern Brazil, were evaluated. The investigation of 5 families of genes encoding oxacillinases and the ISAba1 sequence location relative to bla OXA genes was conducted using polymerase chain reaction. RESULTS All isolates presented the bla OXA-51-like gene (n = 78), and 91% tested positive for the bla OXA-23-like gene (n = 71). The presence of ISAba1 was exclusively detected in isolates carrying the bla OXA-23-like gene. All isolates in which ISAba1 was found upstream of the bla OXA-23-like gene (n = 69) showed resistance to carbapenems, whereas the only isolate in which ISAba1 was not located near the bla OXA-23-like gene was susceptible to carbapenems. The ISAba1 sequence position of another bla OXA-23-like-positive isolate was inconclusive. The isolates exclusively carrying the bla OXA-51-like gene (n = 7) showed susceptibility to carbapenems. CONCLUSIONS The presence of the ISAba1 sequence upstream of the bla OXA-23-like gene was strongly associated with carbapenem resistance in isolates of the A. calcoaceticus-A. baumannii complex in the hospital center studied.
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