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Azevedo LCP, Park M, Salluh JIF, Rea-Neto A, Souza-Dantas VC, Varaschin P, Oliveira MC, Tierno PFGMM, dal-Pizzol F, Silva UVA, Knibel M, Nassar AP, Alves RA, Ferreira JC, Teixeira C, Rezende V, Martinez A, Luciano PM, Schettino G, Soares M. Clinical outcomes of patients requiring ventilatory support in Brazilian intensive care units: a multicenter, prospective, cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R63. [PMID: 23557378 PMCID: PMC3672504 DOI: 10.1186/cc12594] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 03/26/2013] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Contemporary information on mechanical ventilation (MV) use in emerging countries is limited. Moreover, most epidemiological studies on ventilatory support were carried out before significant developments, such as lung protective ventilation or broader application of non-invasive ventilation (NIV). We aimed to evaluate the clinical characteristics, outcomes and risk factors for hospital mortality and failure of NIV in patients requiring ventilatory support in Brazilian intensive care units (ICU). METHODS In a multicenter, prospective, cohort study, a total of 773 adult patients admitted to 45 ICUs over a two-month period requiring invasive ventilation or NIV for more than 24 hours were evaluated. Causes of ventilatory support, prior chronic health status and physiological data were assessed. Multivariate analysis was used to identifiy variables associated with hospital mortality and NIV failure. RESULTS Invasive MV and NIV were used as initial ventilatory support in 622 (80%) and 151 (20%) patients. Failure with subsequent intubation occurred in 54% of NIV patients. The main reasons for ventilatory support were pneumonia (27%), neurologic disorders (19%) and non-pulmonary sepsis (12%). ICU and hospital mortality rates were 34% and 42%. Using the Berlin definition, acute respiratory distress syndrome (ARDS) was diagnosed in 31% of the patients with a hospital mortality of 52%. In the multivariate analysis, age (odds ratio (OR), 1.03; 95% confidence interval (CI), 1.01 to 1.03), comorbidities (OR, 2.30; 95% CI, 1.28 to 3.17), associated organ failures (OR, 1.12; 95% CI, 1.05 to 1.20), moderate (OR, 1.92; 95% CI, 1.10 to 3.35) to severe ARDS (OR, 2.12; 95% CI, 1.01 to 4.41), cumulative fluid balance over the first 72 h of ICU (OR, 2.44; 95% CI, 1.39 to 4.28), higher lactate (OR, 1.78; 95% CI, 1.27 to 2.50), invasive MV (OR, 2.67; 95% CI, 1.32 to 5.39) and NIV failure (OR, 3.95; 95% CI, 1.74 to 8.99) were independently associated with hospital mortality. The predictors of NIV failure were the severity of associated organ dysfunctions (OR, 1.20; 95% CI, 1.05 to 1.34), ARDS (OR, 2.31; 95% CI, 1.10 to 4.82) and positive fluid balance (OR, 2.09; 95% CI, 1.02 to 4.30). CONCLUSIONS Current mortality of ventilated patients in Brazil is elevated. Implementation of judicious fluid therapy and a watchful use and monitoring of NIV patients are potential targets to improve outcomes in this setting. TRIAL REGISTRATION ClinicalTrials.gov NCT01268410.
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Ríos FG, Estenssoro E, Villarejo F, Valentini R, Aguilar L, Pezzola D, Valdez P, Blasco M, Orlandi C, Alvarez J, Saldarini F, Gómez A, Gómez PE, Deheza M, Zazu A, Quinteros M, Chena A, Osatnik J, Violi D, Gonzalez ME, Chiappero G. Lung function and organ dysfunctions in 178 patients requiring mechanical ventilation during the 2009 influenza A (H1N1) pandemic. Crit Care 2011; 15:R201. [PMID: 21849039 PMCID: PMC3387643 DOI: 10.1186/cc10369] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 07/11/2011] [Accepted: 08/17/2011] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Most cases of the 2009 influenza A (H1N1) infection are self-limited, but occasionally the disease evolves to a severe condition needing hospitalization. Here we describe the evolution of the respiratory compromise, ventilatory management and laboratory variables of patients with diffuse viral pneumonitis caused by pandemic 2009 influenza A (H1N1) admitted to the ICU. METHOD This was a multicenter, prospective inception cohort study including adult patients with acute respiratory failure requiring mechanical ventilation (MV) admitted to 20 ICUs in Argentina between June and September of 2009 during the influenza A (H1N1) pandemic. In a standard case-report form, we collected epidemiological characteristics, results of real-time reverse-transcriptase--polymerase-chain-reaction viral diagnostic tests, oxygenation variables, acid-base status, respiratory mechanics, ventilation management and laboratory tests. Variables were recorded on ICU admission and at days 3, 7 and 10. RESULTS During the study period 178 patients with diffuse viral pneumonitis requiring MV were admitted. They were 44 ± 15 years of age, with Acute Physiology And Chronic Health Evaluation II (APACHE II) scores of 18 ± 7, and most frequent comorbidities were obesity (26%), previous respiratory disease (24%) and immunosuppression (16%). Non-invasive ventilation (NIV) was applied in 49 (28%) patients on admission, but 94% were later intubated.Acute respiratory distress syndrome (ARDS) was present throughout the entire ICU stay in the whole group (mean PaO2/FIO2 170 ± 25). Tidal-volumes used were 7.8 to 8.1 ml/kg (ideal body weight), plateau pressures always remained < 30 cmH2O, without differences between survivors and non-survivors; and mean positive end-expiratory pressure (PEEP) levels used were between 8 to 12 cm H2O. Rescue therapies, like recruitment maneuvers (8 to 35%), prone positioning (12 to 24%) and tracheal gas insufflation (3%) were frequently applied. At all time points, pH, platelet count, lactate dehydrogenase assay (LDH) and Sequential Organ Failure Assessment (SOFA) differed significantly between survivors and non-survivors. Lack of recovery of platelet count and persistence of leukocytosis were characteristic of non-survivors. Mortality was high (46%); and length of MV was 10 (6 to 17) days. CONCLUSIONS These patients had severe, hypoxemic respiratory failure compatible with ARDS that persisted over time, frequently requiring rescue therapies to support oxygenation. NIV use is not warranted, given its high failure rate. Death and evolution to prolonged mechanical ventilation were common outcomes. Persistence of thrombocytopenia, acidosis and leukocytosis, and high LDH levels found in non-survivors during the course of the disease might be novel prognostic findings.
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Affiliation(s)
- Fernando G Ríos
- Sociedad Argentina de Terapia Intensiva (SATI), The Registry of the Argentinian Society of Intensive Care, Niceto Vega 4617, (C1414BEA) Ciudad de Buenos Aires, Argentina
- Department of Adult Intensive Care, Hospital Nacional Alejandro Posadas, Marconi e Illia s/n, (B1706), El Palomar, Buenos Aires, Argentina
- Department Intensive Care, Hospital Interzonal General San Martin, Calle 1 n 1791, (B1900) La Plata, Buenos Aires, Argentina
| | - Elisa Estenssoro
- Sociedad Argentina de Terapia Intensiva (SATI), The Registry of the Argentinian Society of Intensive Care, Niceto Vega 4617, (C1414BEA) Ciudad de Buenos Aires, Argentina
- Department Intensive Care, Clínica Olivos, Maipú 1660, (B1602ABQ), Vicente López, Buenos Aires, Argentina
- Department Intensive Care, CEMIC, Av. Las Heras 2900, (C1425AUM), Ciudad de Buenos Aires, Argentina
- Department of Adult Intensive Care, Hospital Nacional Alejandro Posadas, Marconi e Illia s/n, (B1706), El Palomar, Buenos Aires, Argentina
- Department Intensive Care, Hospital General de Agudos Velez Sarsfield, Calderón de la Barca 1550, (C1407AHH), Ciudad de Buenos Aires, Argentina
- Department Critical Care, Hospital Britanico, Perdriel 74, (C1280AEB) Ciudad de Buenos Aires, Argentina
- Department Intensive care, Hospital Lopez Lima, Gelonch 721, (R8332HLH) Gral. Roca, Río Negro, Argentina
- Department Critical care, Hospital Universitario Austral, Juan D. Perón 1500, (B1629ODT), Pilar, Buenos Aires, Argentina
- Department Intensive Care, Hospital General de Agudos "Donación Francisco Santojanni", Pilar 950, (C1408INH), Ciudad de Buenos Aires, Argentina
- Intensive Care Unit, Sanatorio de Los Arcos, Av. Juan B Justo 909, (C1425FSD), Ciudad de Buenos Aires, Argentina
- Critical Care Unit, Sanatorio Juncal, Av Almirante Brown 2779, (B1832) Temperley, Buenos Aires, Argentina
- Department Intensive Care, Hospital Bernardino Rivadavia, Av Las Heras 267, (C1425ASQ) Ciudad de Buenos Aires, Argentina
- Intensive Care Unit, Clínica de Especialidades, Corrientes 733, (X5901ACG), Villa María, Córdoba, Argentina
- Department Critical Care, Hospital General de Agudos, Juan A Fernández, Av Cervino 3356, (C1425AGP), Ciudad de Buenos Aires, Argentina
- Department Intensive Care, Hospital Lagomaggiore, Gordillo s/n, (5500), Mendoza, Argentina
- Department Intensive Care, Hospital Aleman, Av. Pueyrredón 1640, (C1118AAT), Ciudad de Buenos Aires, Argentina
- Department Intensive Care, Hospital Interzonal Guemes, Av. 2° Rivadavia 15.000, (B1404), Haedo, Buenos Aires, Argentina
- Department Intensive Care, Hospital Privado de la Comunidad, Córdoba 4545, (B7602CBM) Mar del Plata, Argentina
- Intensive Care Unit, Hospital Universidad Abierta Interamericana, Portela 2975, (C1069AAB), Ciudad de Buenos Aires, Argentina
- Intensive Care Unit, Sanatorio San Lucas, Belgrano 363, (B1642), San Isidro, Buenos Aires, Argentina
| | - Fernando Villarejo
- Department Intensive Care, Clínica Olivos, Maipú 1660, (B1602ABQ), Vicente López, Buenos Aires, Argentina
| | - Ricardo Valentini
- Department Intensive Care, CEMIC, Av. Las Heras 2900, (C1425AUM), Ciudad de Buenos Aires, Argentina
| | - Liliana Aguilar
- Department of Adult Intensive Care, Hospital Nacional Alejandro Posadas, Marconi e Illia s/n, (B1706), El Palomar, Buenos Aires, Argentina
| | - Daniel Pezzola
- Department of Adult Intensive Care, Hospital Nacional Alejandro Posadas, Marconi e Illia s/n, (B1706), El Palomar, Buenos Aires, Argentina
| | - Pascual Valdez
- Department Intensive Care, Hospital General de Agudos Velez Sarsfield, Calderón de la Barca 1550, (C1407AHH), Ciudad de Buenos Aires, Argentina
| | - Miguel Blasco
- Department Critical Care, Hospital Britanico, Perdriel 74, (C1280AEB) Ciudad de Buenos Aires, Argentina
| | - Cristina Orlandi
- Department Intensive care, Hospital Lopez Lima, Gelonch 721, (R8332HLH) Gral. Roca, Río Negro, Argentina
| | - Javier Alvarez
- Department Critical care, Hospital Universitario Austral, Juan D. Perón 1500, (B1629ODT), Pilar, Buenos Aires, Argentina
| | - Fernando Saldarini
- Department Intensive Care, Hospital General de Agudos "Donación Francisco Santojanni", Pilar 950, (C1408INH), Ciudad de Buenos Aires, Argentina
| | - Alejandro Gómez
- Intensive Care Unit, Sanatorio de Los Arcos, Av. Juan B Justo 909, (C1425FSD), Ciudad de Buenos Aires, Argentina
| | - Pablo E Gómez
- Critical Care Unit, Sanatorio Juncal, Av Almirante Brown 2779, (B1832) Temperley, Buenos Aires, Argentina
| | - Martin Deheza
- Department Intensive Care, Hospital Bernardino Rivadavia, Av Las Heras 267, (C1425ASQ) Ciudad de Buenos Aires, Argentina
| | - Alan Zazu
- Intensive Care Unit, Clínica de Especialidades, Corrientes 733, (X5901ACG), Villa María, Córdoba, Argentina
| | - Mónica Quinteros
- Department Critical Care, Hospital General de Agudos, Juan A Fernández, Av Cervino 3356, (C1425AGP), Ciudad de Buenos Aires, Argentina
- Department Intensive Care, Hospital Lagomaggiore, Gordillo s/n, (5500), Mendoza, Argentina
- Department Intensive Care, Hospital Aleman, Av. Pueyrredón 1640, (C1118AAT), Ciudad de Buenos Aires, Argentina
- Department Intensive Care, Hospital Interzonal Guemes, Av. 2° Rivadavia 15.000, (B1404), Haedo, Buenos Aires, Argentina
- Department Intensive Care, Hospital Privado de la Comunidad, Córdoba 4545, (B7602CBM) Mar del Plata, Argentina
- Intensive Care Unit, Hospital Universidad Abierta Interamericana, Portela 2975, (C1069AAB), Ciudad de Buenos Aires, Argentina
- Intensive Care Unit, Sanatorio San Lucas, Belgrano 363, (B1642), San Isidro, Buenos Aires, Argentina
| | - Ariel Chena
- Department Intensive Care, Hospital Lagomaggiore, Gordillo s/n, (5500), Mendoza, Argentina
| | - Javier Osatnik
- Department Intensive Care, Hospital Aleman, Av. Pueyrredón 1640, (C1118AAT), Ciudad de Buenos Aires, Argentina
| | - Damian Violi
- Department Intensive Care, Hospital Interzonal Guemes, Av. 2° Rivadavia 15.000, (B1404), Haedo, Buenos Aires, Argentina
| | - Maria Eugenia Gonzalez
- Department Intensive Care, Hospital Privado de la Comunidad, Córdoba 4545, (B7602CBM) Mar del Plata, Argentina
| | - Guillermo Chiappero
- Department Critical Care, Hospital General de Agudos, Juan A Fernández, Av Cervino 3356, (C1425AGP), Ciudad de Buenos Aires, Argentina
- Department Intensive Care, Hospital Lagomaggiore, Gordillo s/n, (5500), Mendoza, Argentina
- Department Intensive Care, Hospital Aleman, Av. Pueyrredón 1640, (C1118AAT), Ciudad de Buenos Aires, Argentina
- Department Intensive Care, Hospital Interzonal Guemes, Av. 2° Rivadavia 15.000, (B1404), Haedo, Buenos Aires, Argentina
- Department Intensive Care, Hospital Privado de la Comunidad, Córdoba 4545, (B7602CBM) Mar del Plata, Argentina
- Intensive Care Unit, Hospital Universidad Abierta Interamericana, Portela 2975, (C1069AAB), Ciudad de Buenos Aires, Argentina
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