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Orsatti VN, Ribeiro VST, de Oliveira Montenegro C, Costa CJ, Raboni EA, Sampaio ER, Michielin F, Gasparetto J, Telles JP, Tuon FF. Sepsis death risk factor score based on systemic inflammatory response syndrome, quick sequential organ failure assessment, and comorbidities. Med Intensiva 2024; 48:263-271. [PMID: 38575400 DOI: 10.1016/j.medine.2024.03.005] [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: 04/06/2024]
Abstract
OBJECTIVE In this study, we aimed to evaluate the death risk factors of patients included in the sepsis protocol bundle, using clinical data from qSOFA, SIRS, and comorbidities, as well as development of a mortality risk score. DESIGN This retrospective cohort study was conducted between 2016 and 2021. SETTING Two university hospitals in Brazil. PARTICIPANTS Patients with sepsis. INTERVENTIONS Several clinical and laboratory data were collected focused on SIRS, qSOFA, and comorbidities. MAIN VARIABLE OF INTEREST In-hospital mortality was the primary outcome variable. A mortality risk score was developed after logistic regression analysis. RESULTS A total of 1,808 patients were included with a death rate of 36%. Ten variables remained independent factors related to death in multivariate analysis: temperature ≥38 °C (odds ratio [OR] = 0.65), previous sepsis (OR = 1.42), qSOFA ≥ 2 (OR = 1.43), leukocytes >12,000 or <4,000 cells/mm3 (OR = 1.61), encephalic vascular accident (OR = 1.88), age >60 years (OR = 1.93), cancer (OR = 2.2), length of hospital stay before sepsis >7 days (OR = 2.22,), dialysis (OR = 2.51), and cirrhosis (OR = 3.97). Considering the equation of the binary regression logistic analysis, the score presented an area under curve of 0.668, is not a potential model for death prediction. CONCLUSIONS Several risk factors are independently associated with mortality, allowing the development of a prediction score based on qSOFA, SIRS, and comorbidities data, however, the performance of this score is low.
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Affiliation(s)
- Vinicius Nakad Orsatti
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Victoria Stadler Tasca Ribeiro
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Carolina de Oliveira Montenegro
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Clarice Juski Costa
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Eduardo Albanske Raboni
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Eduardo Ramos Sampaio
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Fernando Michielin
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Juliano Gasparetto
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - João Paulo Telles
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Felipe Francisco Tuon
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil.
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Salluh JIF, Lisboa T, Bozza FA. Challenges for the care delivery for critically ill COVID-19 patients in developing countries: the Brazilian perspective. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:593. [PMID: 32998757 PMCID: PMC7526707 DOI: 10.1186/s13054-020-03278-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 09/04/2020] [Indexed: 01/20/2023]
Affiliation(s)
- Jorge I F Salluh
- Department of Critical Care and Postgraduate Program in Translational Medicine, D'Or Institute for Research and Education (IDOR), Rua Diniz Cordeiro, 30 - 3º andar, Rio de Janeiro, 22281-100, Brazil. .,Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Thiago Lisboa
- Critical Care Department and Programa de Pós-Graduação em Ciencias Pneumologicas, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Instituto de Pesquisa Hospital do Coração - HCor, São Paulo, Brazil
| | - Fernando A Bozza
- Department of Critical Care and Postgraduate Program in Translational Medicine, D'Or Institute for Research and Education (IDOR), Rua Diniz Cordeiro, 30 - 3º andar, Rio de Janeiro, 22281-100, Brazil.,Critical Care Lab, National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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Bastos LSL, Hamacher S, Zampieri FG, Cavalcanti AB, Salluh JIF, Bozza FA. Structure and process associated with the efficiency of intensive care units in low-resource settings: An analysis of the CHECKLIST-ICU trial database. J Crit Care 2020; 59:118-123. [PMID: 32610246 DOI: 10.1016/j.jcrc.2020.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Characteristics of structure and process impact ICU performance and the outcomes of critically ill patients. We sought to identify organizational characteristics associated with efficient ICUs in low-resource settings. MATERIALS AND METHODS This is a secondary analysis of a multicenter cluster-randomized clinical trial in Brazil (CHECKLIST-ICU). Efficient units were defined by standardized mortality ratio (SMR) and standardized resource use (SRU) lower than the overall medians and non-efficient otherwise. We used a regularized logistic regression model to evaluate associations between organizational factors and efficiency. RESULTS From 118 ICUs (13,635 patients), 47 units were considered efficient and 71 non-efficient. Efficient units presented lower incidence rates (median[IQR]) of central line-associated bloodstream infections (4.95[0.00-22.0] vs 6.29[0.00-25.6], p = .04), utilization rates of mechanical ventilation (0.41[0.07-0.73] vs 0.58[0.19-0.82], p < .001), central venous catheter (0.67[0.15-0.98] vs 0.78[0.33-0.98], p = .04), and indwelling urinary catheter (0.62[0.22-0.95] vs 0.76[0.32-0.98], p < .01) than non-efficient units. The reported active surveillance of ventilator-associated pneumonia (OR = 1.72; 95%CI, 1.16-2.57) and utilization of central venous catheters (OR = 1.94; 95%CI, 1.32-2.94) were associated with efficient ICUs. CONCLUSIONS In low-resource settings, active surveillance of nosocomial infections and the utilization of invasive devices were associated with efficiency, supporting the management and evaluation of performance indicators as a starting point for improvement in ICU.
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Affiliation(s)
- Leonardo S L Bastos
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Silvio Hamacher
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Fernando G Zampieri
- Research Institute, Hospital do Coração (HCor), São Paulo, Brazil; D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil; Brazilian Research in Intensive Care Network (BRICNet), Brazil
| | - Alexandre B Cavalcanti
- Research Institute, Hospital do Coração (HCor), São Paulo, Brazil; Brazilian Research in Intensive Care Network (BRICNet), Brazil
| | - Jorge I F Salluh
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil; Brazilian Research in Intensive Care Network (BRICNet), Brazil
| | - Fernando A Bozza
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil; Brazilian Research in Intensive Care Network (BRICNet), Brazil; Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, RJ, Brazil.
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Bahlis LF, Diogo LP, Kuchenbecker RDS, Fuchs SC. Clinical, epidemiological, and etiological profile of inpatients with community-acquired pneumonia in a public hospital in the interior of Brazil. ACTA ACUST UNITED AC 2019; 44:261-266. [PMID: 30328925 PMCID: PMC6326715 DOI: 10.1590/s1806-37562017000000434] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/18/2018] [Indexed: 02/05/2023]
Abstract
Objective: To describe the patient profile, mortality rates, the accuracy of prognostic scores, and mortality-associated factors in patients with community-acquired pneumonia (CAP) in a general hospital in Brazil. Methods: This was a cohort study involving patients with a clinical and laboratory diagnosis of CAP and requiring admission to a public hospital in the interior of Brazil between March 2014 and April 2015. We performed multivariate analysis using a Poisson regression model with robust variance to identify factors associated with in-hospital mortality. Results: We included 304 patients. Approximately 70% of the patients were classified as severely ill on the basis of the severity criteria used. The mortality rate was 15.5%, and the ICU admission rate was 29.3%. After multivariate analysis, the factors associated with in-hospital mortality were need for mechanical ventilation (OR: 3.60; 95% CI: 1.85-7.47); a Charlson Comorbidity Index score > 3 (OR: 1.30; 95% CI: 1.18-1.43); and a mental Confusion, Urea, Respiratory rate, Blood pressure, and age > 65 years (CURB-65) score > 2 (OR: 1.46; 95% CI: 1.09-1.98). The mean time from patient arrival at the emergency room to initiation of antibiotic therapy was 10 h. Conclusions: The in-hospital mortality rate of 15.5% and the need for ICU admission in almost one third of the patients reflect the major impact of CAP on patients and the health care system. Individuals with a high burden of comorbidities, a high CURB-65 score, and a need for mechanical ventilation had a worse prognosis. Measures to reduce the time to initiation of antibiotic therapy may result in better outcomes in this group of patients.
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Affiliation(s)
- Laura Fuchs Bahlis
- . Faculdade de Medicina, Universidade do Vale do Rio dos Sinos, Campus São Leopoldo, São Leopoldo (RS) Brasil.,. Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil.,. Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil
| | | | | | - Sandra Costa Fuchs
- . Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
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Salluh JIF, Soares M, Singer M. Spreading the knowledge on the epidemiology of sepsis. THE LANCET. INFECTIOUS DISEASES 2017; 17:1104-1106. [PMID: 28826589 DOI: 10.1016/s1473-3099(17)30480-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 01/16/2023]
Affiliation(s)
- Jorge I F Salluh
- Department of Critical Care, D'Or Institute for Research and Education, Rio de Janeiro CEP 22281-100, Brazil; Internal Medicine Department, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Marcio Soares
- Department of Critical Care, D'Or Institute for Research and Education, Rio de Janeiro CEP 22281-100, Brazil; Internal Medicine Department, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
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Soares M, Bozza FA, Angus DC, Japiassú AM, Viana WN, Costa R, Brauer L, Mazza BF, Corrêa TD, Nunes ALB, Lisboa T, Colombari F, Maciel AT, Azevedo LCP, Damasceno M, Fernandes HS, Cavalcanti AB, do Brasil PEAA, Kahn JM, Salluh JIF. Organizational characteristics, outcomes, and resource use in 78 Brazilian intensive care units: the ORCHESTRA study. Intensive Care Med 2016; 41:2149-60. [PMID: 26499477 DOI: 10.1007/s00134-015-4076-7] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 09/15/2015] [Indexed: 01/09/2023]
Abstract
PURPOSE Detailed information on organization and process of care in intensive care units (ICU) in emerging countries is scarce. Here, we investigated the impact of organizational factors on the outcomes and resource use in a large sample of Brazilian ICUs. METHODS Retrospective cohort study of 59,693 patients (medical admissions, 67 %) admitted to 78 ICUs during 2013. We retrieved patients' data from an ICU quality registry and surveyed ICUs regarding structure, organization, staffing patterns, and process of care. We used multilevel logistic regression analysis to identify factors associated with hospital mortality. Efficient resource use was assessed by estimating standardized resource use and mortality rates adjusted for the SAPS 3 score. RESULTS ICUs were mostly medical-surgical (79 %) and located at private hospitals (86 %). Median nurse to bed ratio was 0.20 (IQR, 0.15-0.28) and board-certified intensivists were present 24/7 in 16 (21 %) of ICUs. Multidisciplinary rounds occurred in 67 (86 %) and daily checklists were used in 36 (46 %) ICUs. Most frequent protocols focused on sepsis management and prevention of healthcare-associated infections. Hospital mortality was 14.4 %. In multivariable analysis, the number of protocols was the only organizational characteristic associated with mortality [odds ratio = 0.944 (95 % CI 0.904-0.987)]. The effects of protocols were consistent across subgroups including surgical and medical patients as well as the SAPS 3 tertiles. We also observed a significant trend toward efficient resource use as the number of protocols increased. CONCLUSIONS In emerging countries such as Brazil, organizational factors, including the implementation of protocols, are potential targets to improve patient outcomes and resource use in ICUs.
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Rabello L, Conceição C, Ebecken K, Lisboa T, Bozza FA, Soares M, Póvoa P, Salluh JIF. Management of severe community-acquired pneumonia in Brazil: a secondary analysis of an international survey. Rev Bras Ter Intensiva 2015; 27:57-63. [PMID: 25909314 PMCID: PMC4396898 DOI: 10.5935/0103-507x.20150010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 02/22/2015] [Indexed: 12/03/2022] Open
Abstract
Objective This study aimed to evaluate Brazilian physicians’ perceptions regarding the
diagnosis, severity assessment, treatment and risk stratification of severe
community-acquired pneumonia patients and to compare those perceptions to current
guidelines. Methods We conducted a cross-sectional international anonymous survey among a convenience
sample of critical care, pulmonary, emergency and internal medicine physicians
from Brazil between October and December 2008. The electronic survey evaluated
physicians’ attitudes towards the diagnosis, risk assessment and therapeutic
interventions for patients with severe community-acquired pneumonia. Results A total of 253 physicians responded to the survey, with 66% from Southeast Brazil.
The majority (60%) of the responding physicians had > 10 years of medical
experience. The risk assessment of severe community-acquired pneumonia was very
heterogeneous, with clinical evaluation as the most frequent approach. Although
blood cultures were recognized as exhibiting a poor diagnostic performance, these
cultures were performed by 75% of respondents. In contrast, the presence of
urinary pneumococcal and Legionella antigens was evaluated by
less than 1/3 of physicians. The vast majority of physicians (95%) prescribe
antibiotics according to a guideline, with the combination of a
3rd/4th generation cephalosporin plus a macrolide as the
most frequent choice. Conclusion This Brazilian survey identified an important gap between guidelines and clinical
practice and recommends the institution of educational programs that implement
evidence-based strategies for the management of severe community-acquired
pneumonia.
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Affiliation(s)
- Lígia Rabello
- Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, RJ, Brasil
| | - Catarina Conceição
- Unidade Polivalente de Terapia Intensiva, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, CEDOC, Faculdade Médica NOVA, Nova Universidade de Lisboa, Lisboa, Portugal
| | - Katia Ebecken
- Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, RJ, Brasil
| | - Thiago Lisboa
- Unidade de Terapia Intensiva e Comitê de Controle de Infecção, Hospital das Clínicas, Programa de Pós-Graduação em Pneumologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | | | - Márcio Soares
- Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, RJ, Brasil
| | - Pedro Póvoa
- Unidade Polivalente de Terapia Intensiva, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, CEDOC, Faculdade Médica NOVA, Nova Universidade de Lisboa, Lisboa, Portugal
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Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study. Intensive Care Med 2013; 40:182-191. [PMID: 24146003 DOI: 10.1007/s00134-013-3131-5] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/04/2013] [Indexed: 01/28/2023]
Abstract
PURPOSE To evaluate whether a multifaceted, centrally coordinated quality improvement program in a network of hospitals can increase compliance with the resuscitation bundle and improve clinical and economic outcomes in an emerging country setting. METHODS This was a pre- and post-intervention study in ten private hospitals (1,650 beds) in Brazil (from May 2010 to January 2012), enrolling 2,120 patients with severe sepsis or septic shock. The program used a multifaceted approach: screening strategies, multidisciplinary educational sessions, case management, and continuous performance assessment. The network administration and an external consultant provided performance feedback and benchmarking within the network. The primary outcome was compliance with the resuscitation bundle. The secondary outcomes were hospital mortality, hospital and ICU length of stay, quality-adjusted life year (QALY) gain, and cost-effectiveness. RESULTS The proportion of patients who received all the required items for the resuscitation bundle improved from 13% [95% confidence interval (CI) 8-18%] at baseline to 62% (95% CI 54-69%) in the last trimester (p < 0.001). Hospital mortality decreased from 55% (95% CI 48-62%) to 26% (95% CI 19-32%, p < 0.001). Full compliance with the resuscitation bundle was associated with lower risk of hospital mortality (propensity weighted corrected risk ratio 0.74; 95% CI 0.56-0.94, p = 0.02). There was a reduction in the total cost per patient from 29.3 (95% CI 23.9-35.4) to 17.5 (95% CI 14.3-21.1) thousand US dollars from baseline to the last 3 months (mean difference -11,815; 95% CI -18,604 to -5,338). The mean QALY increased from 2.63 (95% CI 2.15-3.14) to 4.06 (95% CI 3.58-4.57). For each QALY, the full compliance saves US$5,383. CONCLUSIONS A multifaceted approach to severe sepsis and septic shock patients in an emerging country setting led to high compliance with the resuscitation bundle. The intervention was cost-effective and associated with a reduction in mortality.
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Abstract
PURPOSE OF REVIEW Despite global progress towards reducing maternal mortality, sepsis remains a leading cause of preventable maternal death. This review focuses on current measurement challenges, trends, causes and efforts to curb maternal death from sepsis in high and low-income countries. RECENT FINDINGS Under-reporting using routine registration data, compounded by misclassification and unreported deaths, results in significant underestimation of the burden of maternal death from sepsis. In the UK and the Netherlands the recent increase in maternal death from sepsis is mainly attributed to an increase in invasive group A streptococcal infections. Susceptibility to infection may be complicated by modulation of maternal immune response and increasing rates of risk factors such as caesarean section and obesity. Failure to recognize severity of infection is a major universal risk factor. Standardized Surviving Sepsis Campaign (SSC) recommendations for management of severe maternal sepsis are continuing to be implemented worldwide; however, outcomes differ according to models of intensive care resourcing and use. SUMMARY The need for robust data with subsequent analyses is apparent. This will significantly increase our understanding of risk factors and their causal pathways, which are critical to informing effective treatment strategies in consideration of resource availability.
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Conde KAP, Silva E, Silva CO, Ferreira E, Freitas FGR, Castro I, Rea-Neto A, Grion CMC, Moura AD, Lobo SM, Azevedo LCP, Machado FR. Differences in sepsis treatment and outcomes between public and private hospitals in Brazil: a multicenter observational study. PLoS One 2013; 8:e64790. [PMID: 23762255 PMCID: PMC3675193 DOI: 10.1371/journal.pone.0064790] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 04/18/2013] [Indexed: 11/18/2022] Open
Abstract
Background Previous studies showed higher sepsis mortality rates in Brazil compared to other developed or developing countries. Moreover, another trial demonstrated an increased mortality rate in public hospitals compared to private hospitals in Brazil. The reasons for these findings may include delayed recognition and inadequate treatment of sepsis in public facilities. We designed this study to evaluate the factors associated with mortality in septic patients admitted to intensive care units in a network of public and private institutions. Materials and Methods This study is a retrospective analysis of a prospective cohort of sepsis patients in 19 private and public institutions in Brazil. We analyzed data from the original database and collected additional data to assess compliance to the treatment guidelines and to determine the time from the onset of organ dysfunction and the sepsis diagnosis by the healthcare team. Results A total of 396 patients were analyzed. Patients in public hospitals were younger, had a greater number of dysfunctional organs at baseline and a lower chance to have sepsis diagnosed within two hours of the onset of organ dysfunction. Private hospitals had a better compliance to lactate and blood culture sampling and maintenance of glycemic control. The multivariate analysis showed that age, disease severity at baseline and being treated at a public hospital were independent risk factors for mortality. A delay in the sepsis diagnosis of longer than two hours was associated with mortality only in the public setting. Conclusions We confirmed a lower sepsis mortality rate in the private hospitals of this network. Being treated in a public hospital was an independent factor for mortality. Delayed recognition of sepsis was more frequent in public institutions and this might have been associated with a higher mortality. Improving sepsis recognition and early diagnosis may be important targets in public institutions.
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Affiliation(s)
- Katia Aparecida Pessoa Conde
- Departamento de Anestesiologia, Dor e Terapia Intensiva. Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Eliezer Silva
- Latin-America Sepsis Institute, São Paulo, SP, Brazil
| | | | | | | | - Isac Castro
- Latin-America Sepsis Institute, São Paulo, SP, Brazil
| | - Alvaro Rea-Neto
- Centro de Estudos e Pesquisas em Terapia Intensiva (CEPETI), Curitiba, PR, Brazil
| | | | | | - Suzana Margareth Lobo
- Serviço de Terapia Intensiva, Faculdade de Medicina de São José do Rio Preto, Hospital de Base, São Jose do Rio Preto, SP, Brazil
| | - Luciano Cesar Pontes Azevedo
- Departamento de Anestesiologia, Dor e Terapia Intensiva. Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Latin-America Sepsis Institute, São Paulo, SP, Brazil
| | - Flavia Ribeiro Machado
- Departamento de Anestesiologia, Dor e Terapia Intensiva. Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Latin-America Sepsis Institute, São Paulo, SP, Brazil
- * E-mail:
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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: 105] [Impact Index Per Article: 9.5] [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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Maude RJ, Hoque G, Hasan MU, Sayeed A, Akter S, Samad R, Alam B, Yunus EB, Rahman R, Rahman W, Chowdhury R, Seal T, Charunwatthana P, Chang CC, White NJ, Faiz MA, Day NPJ, Dondorp AM, Hossain A. Timing of enteral feeding in cerebral malaria in resource-poor settings: a randomized trial. PLoS One 2011; 6:e27273. [PMID: 22110624 PMCID: PMC3217943 DOI: 10.1371/journal.pone.0027273] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 10/12/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Early start of enteral feeding is an established treatment strategy in intubated patients in intensive care since it reduces invasive bacterial infections and length of hospital stay. There is equipoise whether early enteral feeding is also beneficial in non-intubated patients with cerebral malaria in resource poor settings. We hypothesized that the risk of aspiration pneumonia might outweigh the potential benefits of earlier recovery and prevention of hypoglycaemia. METHOD AND FINDINGS A randomized trial of early (day of admission) versus late (after 60 hours in adults or 36 hours in children) start of enteral feeding was undertaken in patients with cerebral malaria in Chittagong, Bangladesh from May 2008 to August 2009. The primary outcome measures were incidence of aspiration pneumonia, hypoglycaemia and coma recovery time. The trial was terminated after inclusion of 56 patients because of a high incidence of aspiration pneumonia in the early feeding group (9/27 (33%)), compared to the late feeding group (0/29 (0%)), p = 0.001). One patient in the late feeding group, and none in the early group, had hypoglycaemia during admission. There was no significant difference in overall mortality (9/27 (33%) vs 6/29 (21%), p = 0.370), but mortality was 5/9 (56%) in patients with aspiration pneumonia. CONCLUSIONS In conclusion, early start of enteral feeding is detrimental in non-intubated patients with cerebral malaria in many resource-poor settings. Evidence gathered in resource rich settings is not necessarily transferable to resource-poor settings. TRIAL REGISTRATION Controlled-Trials.com ISRCTN57488577.
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Affiliation(s)
- Richard J. Maude
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Gofranul Hoque
- Chittagong Medical College Hospital, Chittagong, Bangladesh
| | | | - Abu Sayeed
- Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Shahena Akter
- Fatik Chari Thana Health Complex, Chittagong, Bangladesh
| | - Rasheda Samad
- Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Badrul Alam
- Chittagong Medical College Hospital, Chittagong, Bangladesh
| | | | - Ridwanur Rahman
- Hossain Shahid Sohrawardy Medical College, Dhaka, Bangladesh
| | - Waliur Rahman
- Chittagong Medical College Hospital, Chittagong, Bangladesh
| | | | - Tapan Seal
- Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Prakaykaew Charunwatthana
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Christina C. Chang
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - M. Abul Faiz
- Sir Salimullah Medical College, Dhaka, Bangladesh
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Amir Hossain
- Chittagong Medical College Hospital, Chittagong, Bangladesh
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Japiassú AM, Amâncio RT, Mesquita EC, Medeiros DM, Bernal HB, Nunes EP, Luz PM, Grinsztejn B, Bozza FA. Sepsis is a major determinant of outcome in critically ill HIV/AIDS patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R152. [PMID: 20698966 PMCID: PMC2945136 DOI: 10.1186/cc9221] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Revised: 04/09/2010] [Accepted: 08/10/2010] [Indexed: 01/20/2023]
Abstract
Introduction New challenges have arisen for the management of critically ill HIV/AIDS patients. Severe sepsis has emerged as a common cause of intensive care unit (ICU) admission for those living with HIV/AIDS. Contrastingly, HIV/AIDS patients have been systematically excluded from sepsis studies, limiting the understanding of the impact of sepsis in this population. We prospectively followed up critically ill HIV/AIDS patients to evaluate the main risk factors for hospital mortality and the impact of severe sepsis on the short- and long-term survival. Methods All consecutive HIV-infected patients admitted to the ICU of an infectious diseases research center, from June 2006 to May 2008, were included. Severity of illness, time since AIDS diagnosis, CD4 cell count, antiretroviral treatment, incidence of severe sepsis, and organ dysfunctions were registered. The 28-day, hospital, and 6-month outcomes were obtained for all patients. Cox proportional hazards regression analysis measured the effect of potential factors on 28-day and 6-month mortality. Results During the 2-year study period, 88 HIV/AIDS critically ill patients were admitted to the ICU. Seventy percent of patients had opportunist infections, median CD4 count was 75 cells/mm3, and 45% were receiving antiretroviral therapy. Location on a ward before ICU admission, cardiovascular and respiratory dysfunctions on the first day after admission, and the presence of severe sepsis/septic shock were associated with reduced 28-day and 6-month survival on a univariate analysis. After a multivariate analysis, severe sepsis determined the highest hazard ratio (HR) for 28-day (adjusted HR, 3.13; 95% CI, 1.21-8.07) and 6-month (adjusted HR, 3.35; 95% CI, 1.42-7.86) mortality. Severe sepsis occurred in 44 (50%) patients, mainly because of lower respiratory tract infections. The survival of septic and nonseptic patients was significantly different at 28-day and 6-month follow-up times (log-rank and Peto test, P < 0.001). Conclusions Severe sepsis has emerged as a major cause of admission and mortality for hospitalized HIV/AIDS patients, significantly affecting short- and longer-term survival of critically ill HIV/AIDS patients.
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Affiliation(s)
- André M Japiassú
- Intensive Care Unit, Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Av Brasil 4365, Rio de Janeiro, Brazil.
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