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Fanelli C, Pistidda L, Terragni P, Pasero D. Infection Prevention and Control Strategies According to the Type of Multidrug-Resistant Bacteria and Candida auris in Intensive Care Units: A Pragmatic Resume including Pathogens R 0 and a Cost-Effectiveness Analysis. Antibiotics (Basel) 2024; 13:789. [PMID: 39200090 PMCID: PMC11351734 DOI: 10.3390/antibiotics13080789] [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: 07/02/2024] [Revised: 07/29/2024] [Accepted: 08/02/2024] [Indexed: 09/01/2024] Open
Abstract
Multidrug-resistant organism (MDRO) outbreaks have been steadily increasing in intensive care units (ICUs). Still, healthcare institutions and workers (HCWs) have not reached unanimity on how and when to implement infection prevention and control (IPC) strategies. We aimed to provide a pragmatic physician practice-oriented resume of strategies towards different MDRO outbreaks in ICUs. We performed a narrative review on IPC in ICUs, investigating patient-to-staff ratios; education, isolation, decolonization, screening, and hygiene practices; outbreak reporting; cost-effectiveness; reproduction numbers (R0); and future perspectives. The most effective IPC strategy remains unknown. Most studies focus on a specific pathogen or disease, making the clinician lose sight of the big picture. IPC strategies have proven their cost-effectiveness regardless of typology, country, and pathogen. A standardized, universal, pragmatic protocol for HCW education should be elaborated. Likewise, the elaboration of a rapid outbreak recognition tool (i.e., an easy-to-use mathematical model) would improve early diagnosis and prevent spreading. Further studies are needed to express views in favor or against MDRO decolonization. New promising strategies are emerging and need to be tested in the field. The lack of IPC strategy application has made and still makes ICUs major MDRO reservoirs in the community. In a not-too-distant future, genetic engineering and phage therapies could represent a plot twist in MDRO IPC strategies.
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Affiliation(s)
- Chiara Fanelli
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy (L.P.); (P.T.)
| | - Laura Pistidda
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy (L.P.); (P.T.)
| | - Pierpaolo Terragni
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy (L.P.); (P.T.)
- Head of Intensive Care Unit, University Hospital of Sassari, 07100 Sassari, Italy
| | - Daniela Pasero
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy (L.P.); (P.T.)
- Head of Intensive Care Unit, Civil Hospital of Alghero, 07041 Alghero, Italy
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Santa Cruz R, Matesa A, Gómez A, Nadur J, Pagano F, Prieto D, Bolaños O, Solis B, Yusta S, González-Velásquez E, Estenssoro E, Cavalcanti A. Mortality Due to Acute Respiratory Distress Syndrome in Latin America. Crit Care Med 2024; 52:1275-1284. [PMID: 38635486 DOI: 10.1097/ccm.0000000000006312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
OBJECTIVES Mortality due to acute respiratory distress syndrome (ARDS) is a major global health problem. Knowledge of epidemiological data on ARDS is crucial to design management, treatment strategies, and optimize resources. There is ample data regarding mortality of ARDS from high-income countries; in this review, we evaluated mortality due to ARDS in Latin America. DATA SOURCES We searched in PubMed, Cochrane Central Register of Controlled Trials, Web of Science, and Latin American and Caribbean Health Science Literature databases from 1967 to March 2023. STUDY SELECTION We searched prospective or retrospective observational studies and randomized controlled trials conducted in Latin American countries reporting ARDS mortality. DATA EXTRACTION Three pairs of independent reviewers checked all studies for eligibility based on their titles and abstracts. We performed meta-analysis of proportions using a random-effects model. We performed sensitivity analyses including studies with low risk of bias and with diagnosis using the Berlin definition. Subgroup analysis comparing different study designs, time of publication (up to 2000 and from 2001 to present), and studies in which the diagnosis of ARDS was made using Pa o2 /F io2 less than or equal to 200 and regional variations. Subsequently, we performed meta-regression analyses. Finally, we graded the certainty of the evidence (Grading of Recommendations Assessment, Development, and Evaluation). DATA SYNTHESIS Of 3315 articles identified, 32 were included (3627 patients). Mortality was 52% in the pooled group (low certainty of evidence). In the sensitivity analysis (according to the Berlin definition), mortality was 46% (moderate certainty of evidence). In the subgroup analysis mortality was 53% (randomized controlled trials), 51% (observational studies), 66% (studies published up to 2000), 50% (studies after 2000), 44% (studies with Pa o2 /F io2 ≤ 200), 56% (studies from Argentina/Brazil), and 40% (others countries). No variables were associated with mortality in the meta-regression. CONCLUSIONS ARDS mortality in Latin America remains high, as in other regions. These results should constitute the basis for action planning to improve the prognosis of patients with ARDS (PROSPERO [CRD42022354035]).
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Affiliation(s)
- Roberto Santa Cruz
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
- Universidad de Magallanes, Escuela de Medicina, Punta Arenas, Chile
- Instituto Universitario Ciencias de la Salud, Fundación Barceló, Argentina
| | - Amelia Matesa
- Clínica Basilea, Ciudad Autónoma de Buenos Aires, Argentina
| | - Antonella Gómez
- Hospital de Clínicas, Montevideo, Uruguay
- UDELAR, Universidad de la República, Montevideo, Uruguay
| | - Juan Nadur
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
- Clínica CIAREC (Clínica de Internación Aguda en Rehabilitación y Cirugía), Buenos Aires, Argentina
| | - Fernando Pagano
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
| | - Daniel Prieto
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
| | | | - Beatriz Solis
- Universidad de Magallanes, Escuela de Medicina, Punta Arenas, Chile
| | - Sara Yusta
- Universidad de Magallanes, Escuela de Medicina, Punta Arenas, Chile
| | | | - Elisa Estenssoro
- Dirección de Investigación, Escuela de Gobierno, Ministerio de Salud de la Provincia de Buenos Aires, Argentina
- Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Buenos Aires, Argentina
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Bruna M, Alfaro S, Muñoz F, Cisternas L, Gonzalez C, Conlledo R, Ulloa-Morrison R, Huilcaman M, Retamal J, Castro R, Rola P, Wong A, Argaiz ER, Contreras R, Hernandez G, Kattan E. Dynamic changes of hepatic vein Doppler velocities predict preload responsiveness in mechanically ventilated critically ill patients. Intensive Care Med Exp 2024; 12:46. [PMID: 38717558 PMCID: PMC11078902 DOI: 10.1186/s40635-024-00631-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/04/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Assessment of dynamic parameters to guide fluid administration is one of the mainstays of current resuscitation strategies. Each test has its own limitations, but passive leg raising (PLR) has emerged as one of the most versatile preload responsiveness tests. However, it requires real-time cardiac output (CO) measurement either through advanced monitoring devices, which are not routinely available, or echocardiography, which is not always feasible. Analysis of the hepatic vein Doppler waveform change, a simpler ultrasound-based assessment, during a dynamic test such as PLR could be useful in predicting preload responsiveness. The objective of this study was to assess the diagnostic accuracy of hepatic vein Doppler S and D-wave velocities during PLR as a predictor of preload responsiveness. METHODS Prospective observational study conducted in two medical-surgical ICUs in Chile. Patients in circulatory failure and connected to controlled mechanical ventilation were included from August to December 2023. A baseline ultrasound assessment of cardiac function was performed. Then, simultaneously, ultrasound measurements of hepatic vein Doppler S and D waves and cardiac output by continuous pulse contour analysis device were performed during a PLR maneuver. RESULTS Thirty-seven patients were analyzed. 63% of the patients were preload responsive defined by a 10% increase in CO after passive leg raising. A 20% increase in the maximum S wave velocity after PLR showed the best diagnostic accuracy with a sensitivity of 69.6% (49.1-84.4) and specificity of 92.8 (68.5-99.6) to detect preload responsiveness, with an area under curve of receiving operator characteristic (AUC-ROC) of 0.82 ± 0.07 (p = 0.001 vs. AUC-ROC of 0.5). D-wave velocities showed worse diagnostic accuracy. CONCLUSIONS Hepatic vein Doppler assessment emerges as a novel complementary technique with adequate predictive capacity to identify preload responsiveness in patients in mechanical ventilation and circulatory failure. This technique could become valuable in scenarios of basic hemodynamic monitoring and when echocardiography is not feasible. Future studies should confirm these results.
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Affiliation(s)
- Mario Bruna
- Unidad de Cuidados Intensivos, Hospital de Quilpué, Quilpué, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Andrés Bello, Viña del Mar, Chile
| | - Sebastian Alfaro
- Unidad de Cuidados Intensivos, Hospital de Quilpué, Quilpué, Chile
| | - Felipe Muñoz
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Liliana Cisternas
- Unidad de Cuidados Intensivos, Hospital de Quilpué, Quilpué, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Andrés Bello, Viña del Mar, Chile
| | - Cecilia Gonzalez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Rodrigo Conlledo
- Unidad de Cuidados Intensivos, Hospital de Quilpué, Quilpué, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Andrés Bello, Viña del Mar, Chile
| | | | - Marcos Huilcaman
- Unidad de Cuidados Intensivos, Hospital Gustavo Fricke, Viña del Mar, Chile
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Philippe Rola
- Intensive Care Unit, Hopital Santa Cabrini, CIUSSS EMTL, Montreal, Canada
| | - Adrian Wong
- Department of Critical Care, King's College Hospital, London, UK
| | - Eduardo R Argaiz
- Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City, Mexico
| | - Roberto Contreras
- Unidad de Cuidados Intensivos, Hospital Biprovincial Quillota-Petorca, Quillota, Chile
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile.
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Rivera-Lara L, Videtta W, Calvillo E, Mejia-Mantilla J, March K, Ortega-Gutierrez S, Obrego GC, Paranhos JE, Suarez JI. Reducing the incidence and mortality of traumatic brain injury in Latin America. Eur J Trauma Emerg Surg 2023; 49:2381-2388. [PMID: 36637481 DOI: 10.1007/s00068-022-02214-4] [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] [Received: 03/25/2021] [Accepted: 12/26/2022] [Indexed: 01/14/2023]
Abstract
Traumatic brain injury (TBI) represents a considerable portion of the global injury burden. The incidence of TBI will continue to increase in view of an increase in population density, an aging population, and the increased use of motor vehicles, motorcycles, and bicycles. The most common causes of TBI are falls and road traffic injuries. Deaths related to road traffic injury are three times higher in low-and middle-income countries (LMIC) than in high-income countries (HIC). The Latin American Caribbean region has the highest incidence of TBI worldwide, primarily caused by road traffic injuries. Data from HIC indicates that road traffic injuries can be successfully prevented through concerted efforts at the national level, with coordinated and multisector responses to the problem. Such actions require implementation of proven measures to address the safety of road users and the vehicles themselves, road infrastructure, and post-crash care. In this review, we focus on the epidemiology of TBI in Latin America and the implementation of solutions and preventive measures to decrease mortality and long-term disability.
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Affiliation(s)
- Lucia Rivera-Lara
- Department of Neurology, School of Medicine, Center for Academic Medicine, Stanford University, 453 Quarry Road, Palo Alto, CA, 94304, USA.
| | - Walter Videtta
- Department of National Hospital, Alejandro Posadas, Buenos Aires, Argentina
| | - Eusebia Calvillo
- Departments of Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA
| | | | - Karen March
- Clinical Development at Integra Life Sciences, Seattle, WA, USA
| | | | | | - Jorge E Paranhos
- Santa Casa da Misericordia de São João del Rey, Minas Gerais, Brazil
| | - Jose I Suarez
- Departments of Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA
- Departments of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA
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Rubatto Birri PN, Giannoni R, Furche M, Nahra M, Arce Gallardo M, Segui G, Ilutovich S, Olmos M, Birri P, Romano M, Ayala P, Petrochelli V, Huespe L, Banegas D, Gomez A, Zakalik G, Lipovestky F, Montefiore JP, Galletti C, Pendino C, Vera M, Mare S, Bergallo L, Fernandez G, Campassi ML, Ríos F, Saul P, Bonsignore P, Gallardo B, Gimenez M, Estenssoro E. Epidemiology, patterns of care and prognosis of acute kidney injury in critically ill patients: A multicenter study in Argentina (The EPIRA study). J Crit Care 2023; 78:154382. [PMID: 37516091 DOI: 10.1016/j.jcrc.2023.154382] [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] [Received: 06/07/2023] [Revised: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is associated with high morbidity and mortality rates in the intensive care unit (ICU). In low- and middle-income countries (LMICs), epidemiological information about this condition is still scarce. Our main objective was to characterize its epidemiology, prognosis, and its treatment. METHODS This multicenter prospective cohort study included 1466 patients from 35 ICUs during 6 months in Argentina in 2018. Risk factors and outcomes in patients with and without AKI, and between AKI on admission (AKIadm) and that developed during hospitalization (AKIhosp) were analyzed. RESULTS AKI occurred in 61.3% of patients (900/1466); 72.6% were AKIadm and 27.3% AKIhosp. Risk factors were age, BMI, arterial hypertension, cardiovascular diseases, diabetes, SOFA, APACHE II, dehydration, sepsis, vasopressor use, radiocontrast, diuresis/h and mechanical ventilation. Independent predictors for AKI were sepsis, diabetes, dehydration, vasopressors on admission, APACHE II and radiocontrast use. Renal replacement therapies (RRT) requirement in AKI patients was 14.8%. Hospital mortality in AKI vs. non-AKI was 38.7% and 23.3% (p < 0.001); and in AKIadm vs. AKIhosp, 41.2% and 37.8% (p = 0.53). CONCLUSIONS ICU-acquired AKI has high incidence, complications and mortality. Risk factors for AKI and RRT utilization were similar to those described in other epidemiological studies. AKIadm was more frequent than AKIhosp, but had equal prognosis.
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Affiliation(s)
| | - Roberto Giannoni
- Hospital Regional Ramon Carrillo, Santiago del Estero, Santiago del Estero, Argentina; Centro Integral de Salud, La Banda, Santiago del Estero, Argentina.
| | - Mariano Furche
- Sanatorio De los Arcos, Ciudad Autónoma de Buenos Aires, Argentina.
| | - M Nahra
- Hospital Español, Ciudad Autónoma de Buenos Aires, Argentina
| | - M Arce Gallardo
- Hospital Regional Ramon Carrillo, Santiago del Estero, Santiago del Estero, Argentina
| | - Gabriela Segui
- Hospital Dr. Luis Güemes, Haedo, Buenos Aires, Argentina
| | | | - Matias Olmos
- Hospital Universitario Fundación Favaloro, Ciudad Autónoma de Buenos Aires, Argentina
| | | | | | | | | | - Luis Huespe
- Hospital Escuela General San Martin, Corrientes, Argentina
| | - David Banegas
- Sanatorio Otamendi, Ciudad Autónoma de Buenos Aires, Argentina
| | - Alejandro Gomez
- Sanatorio De los Arcos, Ciudad Autónoma de Buenos Aires, Argentina
| | | | | | | | | | | | | | | | | | | | | | | | - Pablo Saul
- Policlínico UOM, Ciudad Autónoma Buenos Aires, Argentina
| | | | | | - Mirta Gimenez
- Hospital Centenario, Gualeguaychú, Entre Ríos, Argentina
| | - Elisa Estenssoro
- Escuela de Gobierno en Salud, Ministerio de Salud de la Provincia de Buenos Aires, Buenos Aires, Argentina.
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Mwangi W, Kaddu R, Njoki Muiru C, Simiyu N, Patel V, Sulemanji D, Otieno D, Okelo S, Chikophe I, Pisani L, Dona DPG, Beane A, Haniffa R, Misango D, Waweru-Siika W. Organisation, staffing and resources of critical care units in Kenya. PLoS One 2023; 18:e0284245. [PMID: 37498872 PMCID: PMC10374136 DOI: 10.1371/journal.pone.0284245] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 03/27/2023] [Indexed: 07/29/2023] Open
Abstract
OBJECTIVE To describe the organisation, staffing patterns and resources available in critical care units in Kenya. The secondary objective was to explore variations between units in the public and private sectors. MATERIALS AND METHODS An online cross-sectional survey was used to collect data on organisational characteristics (model of care, type of unit, quality- related activities, use of electronic medical records and participation in the national ICU registry), staffing and available resources for monitoring, ventilation and general critical care. RESULTS The survey included 60 of 75 identified units (80% response rate), with 43% (n = 23) located in government facilities. A total of 598 critical care beds were reported with a median of 6 beds (interquartile range [IQR] 5-11) per unit, with 26% beds (n = 157) being non functional. The proportion of ICU beds to total hospital beds was 3.8% (IQR 1.9-10.4). Most of the units (80%, n = 48) were mixed/general units with an open model of care (60%, n = 36). Consultants-in-charge were mainly anesthesiologists (69%, n = 37). The nurse-to-bed ratio was predominantly 1:2 with half of the nurses formally trained in critical care. Most units (83%, n = 47) had a dedicated ventilator for each bed, however 63% (n = 39) lacked high flow nasal therapy. While basic multiparametric monitoring was ubiquitous, invasive blood pressure measurement capacity was low (3% of beds, IQR 0-81%), and capnography moderate (31% of beds, IQR 0-77%). Blood gas analysers were widely available (93%, n = 56), with 80% reported as functional. Differences between the public and private sector were narrow. CONCLUSION This study shows an established critical care network in Kenya, in terms of staffing density, availability of basic monitoring and ventilation resources. The public and private sector are equally represented albeit with modest differences. Potential areas for improvement include training, use of invasive blood pressure and functionality of blood gas analysers.
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Affiliation(s)
- Wambui Mwangi
- Department of Anesthesia and Intensive Care, Nyeri County Referral Hospital, Nyeri, Kenya
- Kenya Critical Care Registry, Critical Care Society of Kenya, Nairobi, Kenya
| | - Ronnie Kaddu
- Kenya Critical Care Registry, Critical Care Society of Kenya, Nairobi, Kenya
- Intensive Care Unit, Aga Khan Mombasa Hospital, Mombasa, Kenya
| | - Carolyne Njoki Muiru
- Kenya Critical Care Registry, Critical Care Society of Kenya, Nairobi, Kenya
- Egerton University Surgery Department, Nakuru Level V ICU, Nakuru, Kenya
- Department of Anesthesia and Critical Care, AAR Hospital, Nairobi, Kenya
| | - Nabukwangwa Simiyu
- Kenya Critical Care Registry, Critical Care Society of Kenya, Nairobi, Kenya
- Department of Anesthesia and Intensive Care, Kisii County Referral Hospital, Kisii, Kenya
| | - Vishal Patel
- Department of Anesthesia and Intensive Care, MP Shah Hospital, Nairobi, Kenya
| | - Demet Sulemanji
- Kenya Critical Care Registry, Critical Care Society of Kenya, Nairobi, Kenya
- Department of Anesthesia and Critical Care, AAR Hospital, Nairobi, Kenya
| | - Dorothy Otieno
- Kenya Critical Care Registry, Critical Care Society of Kenya, Nairobi, Kenya
| | - Stephen Okelo
- Kenya Critical Care Registry, Critical Care Society of Kenya, Nairobi, Kenya
- Department of Anesthesia and Critical Care, Maseno University, Maseno, Kenya
| | - Idris Chikophe
- Kenya Critical Care Registry, Critical Care Society of Kenya, Nairobi, Kenya
- Department of Anesthesia and Critical Care, Kenyatta National Hospital, Nairobi, Kenya
| | - Luigi Pisani
- Mahidol Oxford Tropical Research Unit, Bangkok, Thailand
| | | | - Abi Beane
- Mahidol Oxford Tropical Research Unit, Bangkok, Thailand
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, Scotland
| | - Rashan Haniffa
- Mahidol Oxford Tropical Research Unit, Bangkok, Thailand
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, Scotland
| | - David Misango
- Kenya Critical Care Registry, Critical Care Society of Kenya, Nairobi, Kenya
- Department of Anesthesia, Aga Khan University, Nairobi, Kenya
| | - Wangari Waweru-Siika
- Kenya Critical Care Registry, Critical Care Society of Kenya, Nairobi, Kenya
- Department of Anesthesia, Aga Khan University, Nairobi, Kenya
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The decision-making process of transferring patients home to die from an intensive care unit in mainland China: A qualitative study of family members' experiences. Intensive Crit Care Nurs 2023; 76:103399. [PMID: 36731266 DOI: 10.1016/j.iccn.2023.103399] [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: 10/12/2021] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To map the decision-making process of family members involved in transferring a critically ill patient home to die from an intensive care unit in mainland China and to explore the experiences of those family members. DESIGN A constructivist qualitative study. SETTING One hospitals intensive care unit in Southeast China. METHODS Thirteen adult family members (of ten patients) who participated in decision-making related to transferring a relative home to die from the intensive care unit were purposively selected. Data were collected via interviews and analysed applying thematic analysis. FINDINGS A two-stage decision-making process was identified. Family decision-making was mediated by factors including: accepting the impending death and hope that the patient would not die; time pressures in which decisions had to be made, and the challenges of meeting cultural expectations of a home death. Transfer home was a family-centred decision constrained by a gender-based hierarchy restricting the involvement of different family members. CONCLUSION The stages and key factors in the decision-making process of family members when involved in transferring a patient home to die from an intensive care unit in China are rooted and informed by cultural expectations and limits in the current healthcare system regarding end-of-life care options. Understanding the climate in which family members must make decisions will facilitate supportive interventions to be implemented by healthcare professionals. Further empirical research is needed to explore family members' needs when the patient has been transferred and dies at home in mainland China. IMPLICATIONS FOR CLINICAL PRACTICE Healthcare professionals need to understand the challenges family members face when deciding to transfer a relative home to die from an intensive care unit. For example time pressures can limit the choices of family members so that to provide them with timely, ongoing, realistic updates for a greater involvement of family members in generating end of life care plans could be beneficial.1.
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Ponce-Blandón JA, Romero-Castillo R, Rodríguez-Leal L, González-Hervías R, Velarde-García JF, Álvarez-Embarba B. A Multicenter Study about the Population Treated in the Respiratory Triage Stations Deployed by the Red Cross during the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:313. [PMID: 36612635 PMCID: PMC9819537 DOI: 10.3390/ijerph20010313] [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: 11/23/2022] [Revised: 12/18/2022] [Accepted: 12/22/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Care demand exceeded the availability of human and material resources during the COVID-19 pandemic, which is the reason why triage was fundamental. The objective is to know the clinical and sociodemographic factors of confirmed or suspected COVID-19 cases in triage stations from different Ecuadorian provinces. METHOD A multicenter study with a retrospective and descriptive design. The patients included were those who accessed the Respiratory Triage stations deployed by the Ecuadorian Red Cross in eight Ecuadorian provinces during March and April 2021. Triage allows for selecting patients that need urgent treatment and favors efficacy of health resources. RESULTS The study population consisted of a total of 21,120 patients, of which 43.1% were men and 56.9% were women, with an age range between 0 and 98 years old. Severity of COVID-19 behaved differently according to gender, with mild symptoms predominating in women and severe or critical symptoms in men. Higher incidence of critical cases was observed in patients over 65 years old. It was observed that overweight predominated in critical, severe, and moderate cases, while the body mass index of patients with mild symptoms was within the normal range. CONCLUSIONS The Ecuadorian Red Cross units identified some suspected COVID-19 cases, facilitating their follow-up and isolation. Fever was the most significant early finding.
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Affiliation(s)
- José Antonio Ponce-Blandón
- Red Cross Nursing University Centre, University of Seville, 41009 Seville, Spain
- International Federation of the Red Cross, Ecuador Headquarters, Quito 170403, Ecuador
| | | | - Leyre Rodríguez-Leal
- Red Cross Nursing University College, Autonomous University of Madrid, 28003 Madrid, Spain
| | | | - Juan Francisco Velarde-García
- Red Cross Nursing University College, Autonomous University of Madrid, 28003 Madrid, Spain
- Research Group of Humanities and Qualitative Research in Health Science (Hum&QRinHS), Universidad Rey Juan Carlos, Avenida Atenas s/n, 28922 Alcorcon, Spain
- Nursing Research Support Unit, Hospital General Universitario Gregorio Maranon, Calle Dr. Esquerdo 46, 28007 Madrid, Spain
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Antonio ACP, Jesus-Silva SGD. The challenges of low and middle-income countries in healthcare management after COVID-19. REVISTA CIÊNCIAS EM SAÚDE 2022. [DOI: 10.21876/rcshci.v12i4.1363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
More than two years after WHO declared the novel coronavirus (COVID-19) outbreak a pandemic, a year after deploying the first COVID vaccine, and as we approach nearly 6.5 million infection-related deaths1, we wonder, as Brazilian front-line physicians, what are the lessons we should have learned. Accordingly, healthcare was the first of all systems affected by COVID-19, particularly in developing nations. Despite the additional costs of unemployment, supply chain disturbances, finance expenses to support businesses, and millions of children deprived of education, we still witness the abundance of daily clinical practices of low-value care, failed public health policies, and scientific researches of controversial relevance and not centered in the patient.
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Barros-Poblete M, Bernardes Neto SC, Benavides-Cordoba V, Vieira RP, Baz M, Martí JD, Spruit MA, Torres-Castro R. Early mobilization in intensive care unit in Latin America: A survey based on clinical practice. Front Med (Lausanne) 2022; 9:1005732. [PMID: 36479097 PMCID: PMC9720404 DOI: 10.3389/fmed.2022.1005732] [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: 07/28/2022] [Accepted: 10/28/2022] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND The application of early mobilization (EM) in intensive care units (ICUs) has shown to improve the physical and ventilatory status of critically ill patients, even after ICU stay. This study aimed to describe the practices regarding EM in ICUs in Latin America. METHODS We conducted an observational, cross-sectional study of professionals from all countries in Latin America. Over 3 months, professionals working in ICU units in Latin America were invited to answer the survey, which was designed by an expert committee and incorporated preliminary questions based on studies about EM recommendations. RESULTS As many as 174 health professionals from 17 countries completed the survey. The interventions carried out within each ICU were active mobilization (90.5%), passive mobilization (85.0%), manual and instrumental techniques for drainage of mucus secretion (81.8%), and positioning techniques (81%). The professionals who most participated in the rehabilitation process in ICUs were physiotherapists (98.7%), intensive care physicians (61.6%), nurses (56.1%), and respiratory therapists (43.8%). In only 36.1% of the ICUs, protocols were established to determine when a patient should begin EM. In 38.1% of the cases, the onset of EM was established by individual evaluation, and in 25.0% of the cases, it was the medical indication to start rehabilitation and EM. CONCLUSION This report shows us that EM of critically ill patients is an established practice in our ICUs like in other developed countries.
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Affiliation(s)
- Marisol Barros-Poblete
- Programa de Doctorado en Ciencias Médicas, Escuela de Graduados Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile
| | - Saint-Clair Bernardes Neto
- FACISA—Faculdade de Ciências de Saúde do Trairi, Federal University of Rio Grande do Norte, Natal, Brazil
| | | | - Rodolfo P. Vieira
- Evangelical University of Goias (Unievangélica), Goiás, Brazil
- Brazil University, São Paulo, Brazil
- Brazilian Institute of Teaching and Research in Pulmonary and Exercise Immunology (IBEPIPE), São Paulo, Brazil
- Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Manuel Baz
- Área de Cuidados Intermedios, Departamento Clínico de Medicina, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Joan-Daniel Martí
- Cardiovascular Surgery Intensive Care Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Martijn A. Spruit
- Department of Research and Development, CIRO, Horn, Netherlands
- Department of Respiratory Medicine, Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Centre, NUTRIM School, Maastricht University, Maastricht, Netherlands
| | - Rodrigo Torres-Castro
- Departamento de Kinesiología, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- International Physiotherapy Research Network (PhysioEvidence), Barcelona, Spain
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11
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Providing Neurocritical Care in Resource-Limited Settings: Challenges and Opportunities. Neurocrit Care 2022; 37:583-592. [PMID: 35840824 DOI: 10.1007/s12028-022-01568-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/23/2022] [Indexed: 10/17/2022]
Abstract
Acute neurologic illnesses (ANI) contribute significantly to the global burden of disease and cause disproportionate death and disability in low-income and middle-income countries (LMICs) where neurocritical care resources and expertise are limited. Shifting epidemiologic trends in recent decades have increased the worldwide burden of noncommunicable diseases, including cerebrovascular disease and traumatic brain injury, which coexist in many LMICs with a persistently high burden of central nervous system infections such as tuberculosis, neurocysticercosis, and HIV-related opportunistic infections and complications. In the face of this heavy disease burden, many resource-limited countries lack the infrastructure to provide adequate care for patients with ANI. Major gaps exist between wealthy and poor countries in access to essential resources such as intensive care unit beds, neuroimaging, clinical laboratories, neurosurgical capacity, and medications for managing complex neurologic emergencies. Moreover, many resource-limited countries face critical shortages in health care workers trained to manage neurologic emergencies, with subspecialized neurocritical care expertise largely absent outside of high-income countries. Numerous opportunities exist to overcome these challenges through capacity-building efforts that improve outcomes for patients with ANI in resource-limited countries. These include research on needs and best practices for ANI management in LMICs, developing systems for effective triage, education and training to expand the neurology workforce, and supporting increased collaboration and data sharing among LMIC health care workers and systems. The success of these efforts in curbing the disproportionate and rising impact of ANI in LMICs will depend on the coordinated engagement of the global neurocritical care community.
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12
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Plotnikow GA, Gogniat E, Accoce M, Navarro E, Dorado JH. Epidemiology of mechanical ventilation in Argentina. The EpVAr multicenter observational study. Med Intensiva 2022; 46:372-382. [PMID: 35660286 DOI: 10.1016/j.medine.2022.05.002] [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] [Received: 08/25/2021] [Revised: 09/22/2021] [Accepted: 10/04/2021] [Indexed: 06/15/2023]
Abstract
OBJETIVE To describe mechanical ventilation (MV) practices in Argentina, and to explore factors associated with ICU mortality in this population. DESIGN A prospective, multicenter, observational study was carried out. SETTING Intensive Care. PATIENTS We enrolled patients above 18 years old admitted to any of the participating ICUs requiring invasive MV for at least 12 h since the admission to the healthcare institution, including MV initiation in emergency department, operating room or other hospitals. INTERVENTIONS None. VARIABLES All variables were classified into three categories: variables related to demographic and clinical factors before the MV, factors related to the first day on MV, and factors related to events happening during the MV (complications and weaning from MV). Mechanical ventilation weaning and mortality were classified according to WIND. RESULTS The primary analysis included 950 patients. The main indication for MV was acute respiratory failure (58% of patients). Initial ventilation mode was volume control-continuous mandatory ventilation in 75% of cases. ICU and hospital mortality were 44.6% and 47.9% respectively. The variables identified as independent predictors of mortality in ICU were age (OR 3.48 IC 95% 1.22-11.66; p = 0.028), failure to implement NIV before MV (OR 2.76 IC 95% 1.02-7.10; p = 0.038), diagnosis of sepsis (OR 2.46 IC 95% 1.09-5.47; p = 0.027) and extubation failure (OR 4.50 IC 95% 2.05-9.90; p < 0.001). CONCLUSIONS The present study allowed us to describe the characteristics and clinical course of the patients who received mechanical ventilation in Argentina, finding as the main result that mortality was higher than that reported in international studies.
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Affiliation(s)
- G A Plotnikow
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina; Hospital Británico de Buenos Aires, CABA, Argentina; Docente Adjunto de Cátedra de Kinesfisiatría Cardiorrespiratoria de la Carrera de Kinesiología y Fisiatría, Universidad Abierta Interamericana, CABA, Argentina; Director del Grupo de Estudios Especializados en VM, Universidad Abierta Interamericana, CABA, Argentina.
| | - E Gogniat
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina
| | - M Accoce
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina; Docente Adjunto de Cátedra de Kinesfisiatría Cardiorrespiratoria de la Carrera de Kinesiología y Fisiatría, Universidad Abierta Interamericana, CABA, Argentina; Sanatorio Anchorena San Martín, Buenos Aires, Argentina
| | - E Navarro
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina; Sanatorio Anchorena San Martín, Buenos Aires, Argentina; Centro del Parque, CABA, Argentina
| | - J H Dorado
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina; Sanatorio Anchorena San Martín, Buenos Aires, Argentina
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13
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Reyes LF, Bastidas A, Narváez PO, Parra-Tanoux D, Fuentes YV, Serrano-Mayorga CC, Ortíz V, Caceres EL, Ospina-Tascon G, Díaz AM, Jibaja M, Vera M, Silva E, Gorordo-Delsol LA, Maraschin F, Varón-Vega F, Buitrago R, Poveda M, Saucedo LM, Estenssoro E, Ortíz G, Nin N, Calderón LE, Montaño GS, Chaar AJ, García F, Ramírez V, Picoita F, Peláez C, Unigarro L, Friedman G, Cucunubo L, Bruhn A, Hernández G, Martin-Loeches I. Clinical characteristics, systemic complications, and in-hospital outcomes for patients with COVID-19 in Latin America. LIVEN-Covid-19 study: A prospective, multicenter, multinational, cohort study. PLoS One 2022; 17:e0265529. [PMID: 35358238 PMCID: PMC8970353 DOI: 10.1371/journal.pone.0265529] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/03/2022] [Indexed: 01/28/2023] Open
Abstract
Purpose The COVID-19 pandemic has spread worldwide, and almost 396 million people have been infected around the globe. Latin American countries have been deeply affected, and there is a lack of data in this regard. This study aims to identify the clinical characteristics, in-hospital outcomes, and factors associated with ICU admission due to COVID-19. Furthermore, to describe the functional status of patients at hospital discharge after the acute episode of COVID-19. Material and methods This was a prospective, multicenter, multinational observational cohort study of subjects admitted to 22 hospitals within Latin America. Data were collected prospectively. Descriptive statistics were used to characterize patients, and multivariate regression was carried out to identify factors associated with severe COVID-19. Results A total of 3008 patients were included in the study. A total of 64.3% of patients had severe COVID-19 and were admitted to the ICU. Patients admitted to the ICU had a higher mean (SD) 4C score (10 [3] vs. 7 [3)], p<0.001). The risk factors independently associated with progression to ICU admission were age, shortness of breath, and obesity. In-hospital mortality was 24.1%, whereas the ICU mortality rate was 35.1%. Most patients had equal self-care ability at discharge 43.8%; however, ICU patients had worse self-care ability at hospital discharge (25.7% [497/1934] vs. 3.7% [40/1074], p<0.001). Conclusions This study confirms that patients with SARS CoV-2 in the Latin American population had a lower mortality rate than previously reported. Systemic complications are frequent in patients admitted to the ICU due to COVID-19, as previously described in high-income countries.
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Affiliation(s)
- Luis F. Reyes
- Universidad de La Sabana, Chía, Colombiaa
- Department of Intensive Care, Clínica Universidad de La Sabana, Chía, Colombia
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | | | | | | | - Yuli V. Fuentes
- Universidad de La Sabana, Chía, Colombiaa
- Department of Intensive Care, Clínica Universidad de La Sabana, Chía, Colombia
| | - Cristian C. Serrano-Mayorga
- Universidad de La Sabana, Chía, Colombiaa
- Department of Intensive Care, Clínica Universidad de La Sabana, Chía, Colombia
| | | | - Eder L. Caceres
- Universidad de La Sabana, Chía, Colombiaa
- Department of Intensive Care, Clínica Universidad de La Sabana, Chía, Colombia
| | - Gustavo Ospina-Tascon
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- TransLab- CCM, Universidad Icesi, Cali, Colombia
| | - Ana M. Díaz
- Critical Care Unit, Hospital Eugenio Espejo-Escuela de Medicina de la Universidad International, Quito, Ecuador
| | - Manuel Jibaja
- Critical Care Unit, Hospital Eugenio Espejo-Escuela de Medicina de la Universidad International, Quito, Ecuador
| | - Magdalena Vera
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Edwin Silva
- Universidad de La Sabana, Chía, Colombiaa
- Fundación Clínica Shaio, Bogota, Colombia
| | | | - Francesca Maraschin
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Fabio Varón-Vega
- Department of Intensive Care, Fundación Neumológica Colombiana-Fundación Cardioinfantil, Bogotá, Colombia
| | - Ricardo Buitrago
- Universidad de La Sabana, Chía, Colombiaa
- Fundación Clínica Shaio, Bogota, Colombia
| | - Marcela Poveda
- Universidad de La Sabana, Chía, Colombiaa
- Fundación Clínica Shaio, Bogota, Colombia
| | | | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martín de La Plata, La Plata, Argentina
| | | | - Nicolás Nin
- Intensive Care Unit, Hospital Español, Montevideo, Uruguay
| | - Luis E. Calderón
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
| | | | | | - Fernanda García
- Critical Care Unit, Hospital Eugenio Espejo-Escuela de Medicina de la Universidad International, Quito, Ecuador
| | - Vanessa Ramírez
- Critical Care Unit, Hospital Eugenio Espejo-Escuela de Medicina de la Universidad International, Quito, Ecuador
| | - Fabricio Picoita
- Critical Care Unit, Hospital Eugenio Espejo-Escuela de Medicina de la Universidad International, Quito, Ecuador
| | - Cristian Peláez
- Critical Care Unit, Hospital Eugenio Espejo-Escuela de Medicina de la Universidad International, Quito, Ecuador
| | - Luis Unigarro
- Critical Care Unit, Hospital Eugenio Espejo-Escuela de Medicina de la Universidad International, Quito, Ecuador
| | - Gilberto Friedman
- School of Medicine, Universidad de Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Laura Cucunubo
- Department of Intensive Care, Fundación Neumológica Colombiana-Fundación Cardioinfantil, Bogotá, Colombia
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ignacio Martin-Loeches
- Department of Clinical Medicine, St James’s Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Dublin, Ireland
- Hospital Clinic, IDIBAPS, Universidad de Barcelona, CIBERes, Barcelona, Spain
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14
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Gilardino R, Gallesio A, Arias-López MP, Boada N, Mandich V, Sagardia J, Ratto ME, Fernández A. Current stage of the intensive care unit structure in Argentina: results from the Sociedad Argentina de Terapia Intensiva self-assessment survey of intensive care units. Rev Bras Ter Intensiva 2022; 34:237-246. [PMID: 35946654 DOI: 10.5935/0103-507x.20220021-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 03/12/2022] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To describe and compare the structure of Argentinean intensive care units that completed the "self-assessment survey of intensive care units" developed by the Sociedad Argentina de Terapia Intensiva. METHODS An observational crosssectional study was conducted using an online voluntary survey through the Sociedad Argentina de Terapia Intensiva member database and other social media postings. Answers received between December 2018 and July 2020 were analyzed. Descriptive statistics and nonparametric tests were used. RESULTS A total of 392 surveys were received, and 244 were considered for the analysis. Seventy-seven percent (187/244) belonged to adult intensive care units, and 23% (57/244) belonged to pediatric intensive care units. The overall completion rate was 76%. The sample included 2,567 ICU beds (adult: 1,981; pediatric: 586). We observed a clear concentration of intensive care units in the Central and Buenos Aires regions of Argentina. The median number of beds was 10 (interquartile range 7 - 15).The median numbers of multiparameter monitors, mechanical ventilators, and pulse oximeters were 1 per bed with no regional or intensive care unit type differences (adult versus pediatric). Although our sample showed that the pediatric intensive care units had a higher mechanical ventilation/bed ratio than the adult intensive care units, this finding was not linearly correlated. CONCLUSION Argentina has a notable concentration of critical care beds and better structural complexity in the Buenos Aires and Centro regions for both adult and pediatric intensive care units. In addition, a lack of accurate data reported from the intensive care unit structure and resources was observed. Further improvement opportunities are required to allocate intensive care unit resources at the institutional and regional levels.
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Affiliation(s)
- Ramiro Gilardino
- Comité de Gestión, Calidad y Datos, Sociedad Argentina de Terapia Intensiva - Buenos Aires, Argentina
| | - Antonio Gallesio
- Comité de Gestión, Calidad y Datos, Sociedad Argentina de Terapia Intensiva - Buenos Aires, Argentina
| | - María Pilar Arias-López
- Comité de Gestión, Calidad y Datos, Sociedad Argentina de Terapia Intensiva - Buenos Aires, Argentina
| | - Nancy Boada
- Comité de Gestión, Calidad y Datos, Sociedad Argentina de Terapia Intensiva - Buenos Aires, Argentina
| | - Verónica Mandich
- Comité de Gestión, Calidad y Datos, Sociedad Argentina de Terapia Intensiva - Buenos Aires, Argentina
| | - Judith Sagardia
- Comité de Gestión, Calidad y Datos, Sociedad Argentina de Terapia Intensiva - Buenos Aires, Argentina
| | - Maria Elena Ratto
- Comité de Gestión, Calidad y Datos, Sociedad Argentina de Terapia Intensiva - Buenos Aires, Argentina
| | - Ariel Fernández
- Comité de Gestión, Calidad y Datos, Sociedad Argentina de Terapia Intensiva - Buenos Aires, Argentina
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15
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Pisani L, Algera AG, Neto AS, Azevedo L, Pham T, Paulus F, de Abreu MG, Pelosi P, Dondorp AM, Bellani G, Laffey JG, Schultz MJ. Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies. Lancet Glob Health 2022; 10:e227-e235. [PMID: 34914899 PMCID: PMC8766316 DOI: 10.1016/s2214-109x(21)00485-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/05/2021] [Accepted: 10/01/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. METHODS In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. FINDINGS Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p<0·0001). INTERPRETATION Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. FUNDING No funding.
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Affiliation(s)
- Luigi Pisani
- Department of Intensive Care, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, Netherlands; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Section of Operative Research, Doctors with Africa, CUAMM, Padova, Italy; Department of Intensive Care, Miulli Regional General Hospital, Acquaviva delle Fonti, Bari, Italy.
| | - Anna Geke Algera
- Department of Intensive Care, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, Netherlands
| | - Ary Serpa Neto
- School of Public Health and Preventive Medicine, Monash University, Australian; New Zealand Intensive Care Research Centre, Melbourne, VIC, Australia; Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia; Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, VIC, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Luciano Azevedo
- Department of Critical Care Medicine, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Tài Pham
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, Netherlands
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus and Technical University Dresden, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Giacomo Bellani
- Department of Intensive Care, University of Milan Bicocca, Monza, Italy; Department of Medicine and Surgery, University of Milan Bicocca, Monza, Italy; Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland, and Galway University Hospitals Ireland, Galway, Ireland; Regenerative Medicine Institute at CÚRAM Centre for Research in Medical Devices, National University of Ireland, and Galway University Hospitals Ireland, Galway, Ireland
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, Netherlands; Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, Netherlands; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
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16
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Greco M, De Corte T, Ercole A, Antonelli M, Azoulay E, Citerio G, Morris AC, De Pascale G, Duska F, Elbers P, Einav S, Forni L, Galarza L, Girbes ARJ, Grasselli G, Gusarov V, Jubb A, Kesecioglu J, Lavinio A, Delgado MCM, Mellinghoff J, Myatra SN, Ostermann M, Pellegrini M, Povoa P, Schaller SJ, Teboul JL, Wong A, De Waele JJ, Cecconi M. Clinical and organizational factors associated with mortality during the peak of first COVID-19 wave: the global UNITE-COVID study. Intensive Care Med 2022; 48:690-705. [PMID: 35596752 PMCID: PMC9123859 DOI: 10.1007/s00134-022-06705-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/13/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To accommodate the unprecedented number of critically ill patients with pneumonia caused by coronavirus disease 2019 (COVID-19) expansion of the capacity of intensive care unit (ICU) to clinical areas not previously used for critical care was necessary. We describe the global burden of COVID-19 admissions and the clinical and organizational characteristics associated with outcomes in critically ill COVID-19 patients. METHODS Multicenter, international, point prevalence study, including adult patients with SARS-CoV-2 infection confirmed by polymerase chain reaction (PCR) and a diagnosis of COVID-19 admitted to ICU between February 15th and May 15th, 2020. RESULTS 4994 patients from 280 ICUs in 46 countries were included. Included ICUs increased their total capacity from 4931 to 7630 beds, deploying personnel from other areas. Overall, 1986 (39.8%) patients were admitted to surge capacity beds. Invasive ventilation at admission was present in 2325 (46.5%) patients and was required during ICU stay in 85.8% of patients. 60-day mortality was 33.9% (IQR across units: 20%-50%) and ICU mortality 32.7%. Older age, invasive mechanical ventilation, and acute kidney injury (AKI) were associated with increased mortality. These associations were also confirmed specifically in mechanically ventilated patients. Admission to surge capacity beds was not associated with mortality, even after controlling for other factors. CONCLUSIONS ICUs responded to the increase in COVID-19 patients by increasing bed availability and staff, admitting up to 40% of patients in surge capacity beds. Although mortality in this population was high, admission to a surge capacity bed was not associated with increased mortality. Older age, invasive mechanical ventilation, and AKI were identified as the strongest predictors of mortality.
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Affiliation(s)
- Massimiliano Greco
- grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy ,grid.417728.f0000 0004 1756 8807IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Thomas De Corte
- grid.5342.00000 0001 2069 7798Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium ,grid.410566.00000 0004 0626 3303Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Ari Ercole
- grid.5335.00000000121885934Cambridge Centre for Artificial Intelligence in Medicine, University of Cambridge, Cambridge, UK ,grid.120073.70000 0004 0622 5016University of Cambridge Division of Anaesthesia, Addenbrooke’s Hospital, Hills Road, Cambridge, UK
| | - Massimo Antonelli
- grid.8142.f0000 0001 0941 3192Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy ,grid.8142.f0000 0001 0941 3192Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Elie Azoulay
- grid.508487.60000 0004 7885 7602Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital, Paris University, Paris, France ,grid.508487.60000 0004 7885 7602Université de Paris, Paris, France
| | - Giuseppe Citerio
- grid.7563.70000 0001 2174 1754School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy ,Department Neuroscience, Neurointensive Care, ASST-Monza, Monza, Italy
| | - Andy Conway Morris
- grid.5335.00000000121885934Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Division of Immunology, Department of Pathology, University of Cambridge, Cambridge, UK ,grid.120073.70000 0004 0622 5016JVF Intensive Care Unit, Addenbrookes Hospital, Cambridge, UK
| | - Gennaro De Pascale
- grid.8142.f0000 0001 0941 3192Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy ,grid.8142.f0000 0001 0941 3192Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Frantisek Duska
- grid.4491.80000 0004 1937 116XDepartment of Anaesthesia and Intensive Care, Third Faculty of Medicine, Charles University, Prague, Czech Republic ,grid.412819.70000 0004 0611 1895FNKV University Hospital in Prague, Prague, Czech Republic
| | - Paul Elbers
- grid.12380.380000 0004 1754 9227Department of Intensive Care Medicine, Laboratory of Critical Care Computational Intelligence, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sharon Einav
- grid.414505.10000 0004 0631 3825General Intensive Care Unit of the Shaare Zedek Medical Center, Jerusalem, Israel ,grid.9619.70000 0004 1937 0538Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Lui Forni
- grid.5475.30000 0004 0407 4824Department of Critical Care, Royal Surrey Hospital and Faculty of Experimental Medicine, University of Surrey, Guildford, UK
| | - Laura Galarza
- grid.470634.2Intensive Care Unit, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - Armand R. J. Girbes
- grid.12380.380000 0004 1754 9227Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), UMC, Location VUmc, VU Amsterdam, Amsterdam, The Netherlands
| | - Giacomo Grasselli
- grid.414818.00000 0004 1757 8749Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy ,grid.4708.b0000 0004 1757 2822Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Vitaly Gusarov
- grid.510503.2Pirogov National Medical and Surgical Center, Moscow, 105203 Russian Federation
| | - Alasdair Jubb
- grid.5335.00000000121885934Division of Anaesthesia, University of Cambridge Department of Medicine, Cambridge, UK ,grid.24029.3d0000 0004 0383 8386Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals, Cambridge, UK ,grid.498239.dCancer Research UK-Cambridge Institute, Cambridge, UK
| | - Jozef Kesecioglu
- grid.5477.10000000120346234Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Andrea Lavinio
- grid.24029.3d0000 0004 0383 8386Neurosciences and Trauma Critical Care Unit (NCCU), Anaesthesia Medical Examiner and Clinical Lead Organ Donation-Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Maria Cruz Martin Delgado
- grid.488600.20000 0004 1777 7270Intensive Care Unit, Hospital Universitario de Torrejón, Madrid, Spain ,grid.449795.20000 0001 2193 453XUniversidad Francisco de Vitoria, Madrid, Spain
| | - Johannes Mellinghoff
- grid.12477.370000000121073784School of Sports and Health Sciences, University of Brighton, Brighton, UK
| | - Sheila Nainan Myatra
- grid.450257.10000 0004 1775 9822Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marlies Ostermann
- grid.420545.20000 0004 0489 3985Department of Critical Care, King’s College London, Guy’s & St Thomas’ Hospital, London, UK
| | - Mariangela Pellegrini
- Intensive Care Unit, AnOpIVA, Akademiska sjukhuset, Uppsala, Sweden ,grid.8993.b0000 0004 1936 9457Hedenstierna Laboratory, Department of Surgical Science, Uppsala University, Uppsala, Sweden
| | - Pedro Povoa
- grid.10772.330000000121511713CHRC, CEDOC, NOVA Medical School, New University of Lisbon, Lisbon, Portugal ,grid.414462.10000 0001 1009 677XPolyvalent Intensive Care Unit, Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal ,grid.7143.10000 0004 0512 5013Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Stefan J. Schaller
- grid.7468.d0000 0001 2248 7639Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany ,grid.6936.a0000000123222966School of Medicine, Klinikum rechts der Isar, Department of Anesthesiology and Intensive Care, Technical University of Munich, Munich, Germany
| | - Jean-Louis Teboul
- grid.413784.d0000 0001 2181 7253Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP Université Paris-Saclay, Inserm UMR S_999, Le Kremlin-Bicêtre, France
| | - Adrian Wong
- grid.46699.340000 0004 0391 9020Department of Critical Care, King’s College Hospital, London, UK
| | - Jan J. De Waele
- grid.5342.00000 0001 2069 7798Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium ,grid.410566.00000 0004 0626 3303Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Maurizio Cecconi
- grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy ,grid.417728.f0000 0004 1756 8807IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
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Legrand M, Aldrich M. Further evidence in support of closed ICUs. Anaesth Crit Care Pain Med 2021; 40:100978. [PMID: 34748939 DOI: 10.1016/j.accpm.2021.100978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, UCSF, San Francisco, USA.
| | - Matthew Aldrich
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, UCSF, San Francisco, USA
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Plotnikow G, Gogniat E, Accoce M, Navarro E, Dorado J. Epidemiología de la ventilación mecánica en Argentina. Estudio observacional multicéntrico EpVAr. Med Intensiva 2021. [DOI: 10.1016/j.medin.2021.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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19
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Estenssoro E, Loudet CI, Ríos FG, Kanoore Edul VS, Plotnikow G, Andrian M, Romero I, Piezny D, Bezzi M, Mandich V, Groer C, Torres S, Orlandi C, Rubatto Birri PN, Valenti MF, Cunto E, Sáenz MG, Tiribelli N, Aphalo V, Reina R, Dubin A. Clinical characteristics and outcomes of invasively ventilated patients with COVID-19 in Argentina (SATICOVID): a prospective, multicentre cohort study. THE LANCET RESPIRATORY MEDICINE 2021; 9:989-998. [PMID: 34224674 PMCID: PMC8253540 DOI: 10.1016/s2213-2600(21)00229-0] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/01/2021] [Accepted: 05/06/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although COVID-19 has greatly affected many low-income and middle-income countries, detailed information about patients admitted to the intensive care unit (ICU) is still scarce. Our aim was to examine ventilation characteristics and outcomes in invasively ventilated patients with COVID-19 in Argentina, an upper middle-income country. METHODS In this prospective, multicentre cohort study (SATICOVID), we enrolled patients aged 18 years or older with RT-PCR-confirmed COVID-19 who were on invasive mechanical ventilation and admitted to one of 63 ICUs in Argentina. Patient demographics and clinical, laboratory, and general management variables were collected on day 1 (ICU admission); physiological respiratory and ventilation variables were collected on days 1, 3, and 7. The primary outcome was all-cause in-hospital mortality. All patients were followed until death in hospital or hospital discharge, whichever occurred first. Secondary outcomes were ICU mortality, identification of independent predictors of mortality, duration of invasive mechanical ventilation, and patterns of change in physiological respiratory and mechanical ventilation variables. The study is registered with ClinicalTrials.gov, NCT04611269, and is complete. FINDINGS Between March 20, 2020, and Oct 31, 2020, we enrolled 1909 invasively ventilated patients with COVID-19, with a median age of 62 years [IQR 52-70]. 1294 (67·8%) were men, hypertension and obesity were the main comorbidities, and 939 (49·2%) patients required vasopressors. Lung-protective ventilation was widely used and median duration of ventilation was 13 days (IQR 7-22). Median tidal volume was 6·1 mL/kg predicted bodyweight (IQR 6·0-7·0) on day 1, and the value increased significantly up to day 7; positive end-expiratory pressure was 10 cm H2O (8-12) on day 1, with a slight but significant decrease to day 7. Ratio of partial pressure of arterial oxygen (PaO2) to fractional inspired oxygen (FiO2) was 160 (IQR 111-218), respiratory system compliance 36 mL/cm H2O (29-44), driving pressure 12 cm H2O (10-14), and FiO2 0·60 (0·45-0·80) on day 1. Acute respiratory distress syndrome developed in 1672 (87·6%) of patients; 1176 (61·6%) received prone positioning. In-hospital mortality was 57·7% (1101/1909 patients) and ICU mortality was 57·0% (1088/1909 patients); 462 (43·8%) patients died of refractory hypoxaemia, frequently overlapping with septic shock (n=174). Cox regression identified age (hazard ratio 1·02 [95% CI 1·01-1·03]), Charlson score (1·16 [1·11-1·23]), endotracheal intubation outside of the ICU (ie, before ICU admission; 1·37 [1·10-1·71]), vasopressor use on day 1 (1·29 [1·07-1·55]), D-dimer concentration (1·02 [1·01-1·03]), PaO2/FiO2 on day 1 (0·998 [0·997-0·999]), arterial pH on day 1 (1·01 [1·00-1·01]), driving pressure on day 1 (1·05 [1·03-1·08]), acute kidney injury (1·66 [1·36-2·03]), and month of admission (1·10 [1·03-1·18]) as independent predictors of mortality. INTERPRETATION In patients with COVID-19 who required invasive mechanical ventilation, lung-protective ventilation was widely used but mortality was high. Predictors of mortality in our study broadly agreed with those identified in studies of invasively ventilated patients in high-income countries. The sustained burden of COVID-19 on scarce health-care personnel might have contributed to high mortality over the course of our study in Argentina. These data might help to identify points for improvement in the management of patients in middle-income countries and elsewhere. FUNDING None. TRANSLATION For the Spanish translation of the Summary see Supplementary Materials section.
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Affiliation(s)
- Elisa Estenssoro
- Hospital Interzonal de Agudos General San Martín, Buenos Aires, Argentina.
| | - Cecilia I Loudet
- Hospital Interzonal de Agudos General San Martín, Buenos Aires, Argentina
| | | | | | | | | | | | | | - Marco Bezzi
- Hospital Santojanni, Buenos Aires, Argentina
| | | | - Carla Groer
- Hospital Juan A Fernández, Buenos Aires, Argentina
| | | | | | | | | | | | - María G Sáenz
- Hospital Interzonal de Agudos General San Martín, Buenos Aires, Argentina
| | - Norberto Tiribelli
- Complejo Médico de la Policía Federal Argentina Churruca Visca, Buenos Aires, Argentina
| | | | - Rosa Reina
- Sociedad Argentina de Terapia Intensiva, Buenos Aires, Argentina
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20
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Midega TD, Leite Filho NCV, Nassar AP, Alencar RM, Capone Neto A, Ferraz LJR, Corrêa TD. Impact of intensive care unit admission during handover on mortality: propensity matched cohort study. EINSTEIN-SAO PAULO 2021; 19:eAO5748. [PMID: 34161436 PMCID: PMC8225264 DOI: 10.31744/einstein_journal/2021ao5748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 12/06/2020] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To investigate the impact of intensive care unit admission during medical handover on mortality. METHODS Post-hoc analysis of data extracted from a prior study aimed at addressing the impacts of intensive care unit readmission on clinical outcomes. This retrospective, single-center, propensity-matched cohort study was conducted in a 41-bed general open-model intensive care unit. Patients were assigned to one of two cohorts according to time of intensive care unit admission: Handover Group (intensive care unit admission between 6:30 am and 7:30 am or 6:30 pm and 7:30 pm) or Control Group (intensive care unit admission between 7:31 am and 6:29 pm or 7:31 pm and 6:29 am). Patients in the Handover Group were propensity-matched to patients in the Control Group at a 1:2 ratio. RESULTS A total of 6,650 adult patients were admitted to the intensive care unit between June 1st 2013 and May 31st 2015. Following exclusion of non-eligible participants, 5,779 patients (389; 6.7% and 5,390; 93.3%, Handover and Control Group) were deemed eligible for propensity score matching. Of these, 1,166 were successfully matched (389; 33.4% and 777; 66.6%, Handover and Control Group). Following propensity-score matching, intensive care unit admission during handover was not associated with increased risk of intensive care unit (OR: 1.40; 95%CI: 0.92-2.11; p=0.113) or in-hospital (OR: 1.23; 95%CI: 0.85-1.75; p=0.265) mortality. CONCLUSION Intensive care unit admission during medical handover did not affect in-hospital mortality in this propensity-matched, single-center cohort study.
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Affiliation(s)
| | | | | | - Roger Monteiro Alencar
- Hospital Municipal Dr. Moysés Deutsch; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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21
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Arabi YM, Azoulay E, Al-Dorzi HM, Phua J, Salluh J, Binnie A, Hodgson C, Angus DC, Cecconi M, Du B, Fowler R, Gomersall CD, Horby P, Juffermans NP, Kesecioglu J, Kleinpell RM, Machado FR, Martin GS, Meyfroidt G, Rhodes A, Rowan K, Timsit JF, Vincent JL, Citerio G. How the COVID-19 pandemic will change the future of critical care. Intensive Care Med 2021; 47:282-291. [PMID: 33616696 PMCID: PMC7898492 DOI: 10.1007/s00134-021-06352-y] [Citation(s) in RCA: 119] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 01/11/2021] [Indexed: 01/28/2023]
Abstract
Coronavirus disease 19 (COVID-19) has posed unprecedented healthcare system challenges, some of which will lead to transformative change. It is obvious to healthcare workers and policymakers alike that an effective critical care surge response must be nested within the overall care delivery model. The COVID-19 pandemic has highlighted key elements of emergency preparedness. These include having national or regional strategic reserves of personal protective equipment, intensive care unit (ICU) devices, consumables and pharmaceuticals, as well as effective supply chains and efficient utilization protocols. ICUs must also be prepared to accommodate surges of patients and ICU staffing models should allow for fluctuations in demand. Pre-existing ICU triage and end-of-life care principles should be established, implemented and updated. Daily workflow processes should be restructured to include remote connection with multidisciplinary healthcare workers and frequent communication with relatives. The pandemic has also demonstrated the benefits of digital transformation and the value of remote monitoring technologies, such as wireless monitoring. Finally, the pandemic has highlighted the value of pre-existing epidemiological registries and agile randomized controlled platform trials in generating fast, reliable data. The COVID-19 pandemic is a reminder that besides our duty to care, we are committed to improve. By meeting these challenges today, we will be able to provide better care to future patients.
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint Louis University Hospital and Paris 7 University, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - Hasan M Al-Dorzi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Jason Phua
- FAST and Chronic Programmes, Alexandra Hospital, Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
| | - Jorge Salluh
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Alexandra Binnie
- Critical Care Department, William Osler Health System, Etobicoke, ON, Canada
- Faculty of Medicine and Biomedical Sciences, University of Algarve, Faro, Portugal
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- Monash University, Melbourne, Australia
- Monash Partners Academic Health Science Centre, Prahran, Australia
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Maurizio Cecconi
- Deparment of Anaesthesia and Intensive Care, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
| | - Bin Du
- State Key Laboratory of Complex, Severe and Rare Diseases, and Medical ICU, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rob Fowler
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Hospital, Toronto, Canada
- Department of Medicine, Sunnybrook Hospital, Toronto, Canada
| | - Charles D Gomersall
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Peter Horby
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital and Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ruth M Kleinpell
- Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN, 37203, USA
| | - Flavia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, Brazil
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Emory Critical Care Center and Grady Memorial Hospital, Atlanta, GA, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust and St George's University of London, London, UK
| | - Kathryn Rowan
- Intensive Care National Audit and Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Jean-François Timsit
- AP-HP, Bichat Hospital, Medical and Infectious Diseases ICU (MI2), University of Paris, IAME, INSERM, 75018, Paris, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Monza, Italy
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22
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Hashmi M, Taqi A, Memon MI, Ali SM, Khaskheli S, Sheharyar M, Hayat M, Shiekh M, Kodippily C, Gamage D, Dondorp AM, Haniffa R, Beane A. A national survey of critical care services in hospitals accredited for training in a lower-middle income country: Pakistan. J Crit Care 2020; 60:273-278. [PMID: 32942162 PMCID: PMC7441021 DOI: 10.1016/j.jcrc.2020.08.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE To describe the extent and variation of critical care services in Pakistan. MATERIALS AND METHODS A cross-sectional survey was conducted in all intensive care units (ICUs) recognised for postgraduate training to determine administration, infrastructure, equipment, staffing, and training. RESULTS There were 151 hospitals recognised for training, providing 2166 ICU beds and 1473 ventilators. Regional distribution of ICU beds per 100,000 population ranged from 1.0 in Sindh to none in Gilgit Baltistan (median 0.7). A senior clinician trained in critical care was available in 19 (12.1%) of units. One-to-one nurse-to-bed ratio during the day was available in 84 (53.5%) of units, dropping to 75 (47.8%) at night. Availability of 1:1 nursing also varied between provinces, ranging from 56.5% in Punjab compared to 0% in Azad Jamu Kashmir. Similarly, there was disparity in the availability of ventilators between provinces. All ICUs had basic infrastructure (electricity, running water, piped oxygen) and basic equipment (electronic monitoring and infusion pumps). CONCLUSION Pakistan, a lower middle-income country, has an established network of critical care facilities with access to basic equipment, but inequalities in its distribution. Investment in critical care training for doctors and nurses is needed.
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Affiliation(s)
- Madiha Hashmi
- Ziauddin University, 4/B, Saharah-e-Ghalib, Block 6, Clifton Karachi, 7500, Sindh, Pakistan
| | - Arshad Taqi
- Kaul Associates, 14 AbuBaker Block, New Garden Town, Lahore, Punjab, Pakistan
| | - Muhammad I Memon
- Pakistan Institute of Medical Sciences, Ibn-e-Sina Road, G-8/3, Islamabad, Islamabad Capital Territory, Pakistan
| | - Syed Muneeb Ali
- Pakistan Institute of Medical Sciences, Ibn-e-Sina Road, G-8/3, Islamabad, Islamabad Capital Territory, Pakistan
| | - Saleh Khaskheli
- People's University of Medical & Health Sciences for Women, Nawabshah, Shaheed Benazirabad, 67480, Sindh, Pakistan
| | - Muhammad Sheharyar
- Lady Reading Hospital, Soekarno Road, Peshawar, Khyber Pakhtunkhwa 25000, Pakistan
| | - Muhammad Hayat
- North West General Hospital, Sector A-3, Phase 5, Hayatabad, Peshawar, Khyber Pakhtunkhwa 25100, Pakistan
| | - Mohiuddin Shiekh
- South East Asian Research in Criticalcare and Health, Remedial Centre Hospital, D-9, Block-I, North Nazimabad, Karachi 74700, Pakistan
| | - Chamira Kodippily
- Network for Improving Critical Care Systems and Training, 2nd floor, YMBA Building, Colombo 08, Sri Lanka
| | - Dilanthi Gamage
- Network for Improving Critical Care Systems and Training, 2nd floor, YMBA Building, Colombo 08, Sri Lanka
| | - Arjen M Dondorp
- Department of Malaria and Critical Illness, Mahidol Oxford Tropical Medicine Research Unit, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, 2nd floor, YMBA Building, Colombo 08, Sri Lanka; Department of Malaria and Critical Illness, Mahidol Oxford Tropical Medicine Research Unit, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok 10400, Thailand; Bloomsbury Institute for Intensive Care Medicine, Division of Medicine, University College London, Gower Street, London WC1E 6BT, United Kingdom
| | - Abi Beane
- Network for Improving Critical Care Systems and Training, 2nd floor, YMBA Building, Colombo 08, Sri Lanka; Department of Malaria and Critical Illness, Mahidol Oxford Tropical Medicine Research Unit, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok 10400, Thailand; Amsterdam Institute for Global Health and Development, University of Amsterdam, Paasheuvelweg 25, 1105, BP, Amsterdam, Netherlands.
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23
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Vargas MADO, Peter E, Luz KRD, Barlem ELD, Ventura CAA, Nascimento ERPD. Management of bed availability in intensive care in the context of hospitalization by court order. Rev Lat Am Enfermagem 2020; 28:e3271. [PMID: 32401898 PMCID: PMC7217627 DOI: 10.1590/1518-8345.3420.3271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 02/13/2020] [Indexed: 12/03/2022] Open
Abstract
Objective: to identify, from the nurse perspective, situations that interfere with the
availability of beds in the intensive care unit in the context of
hospitalization by court order. Method: qualitative exploratory, analytical research carried out with 42 nurses
working in adult intensive care. The selection took place by
non-probabilistic snowball sampling. Data collected by interview and
analyzed using the Discursive Textual Analysis technique. Results: three categories were analyzed, entitled deficiency of physical structure and
human resources; Lack of clear policies and criteria for patient admission
and inadequate discharge from the intensive care unit. In situations of
hospitalization by court order, there is a change in the criteria for the
allocation of intensive care beds, due to the credibility of professionals,
threats of medico-legal processes by family members and judicial imposition
on institutions and health professionals. Conclusion: nurses defend the needs of the patients, too, with actions that can
positively impact the availability of intensive care beds and adequate care
infrastructure.
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Affiliation(s)
| | - Elizabeth Peter
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Kely Regina da Luz
- Departamento de Enfermagem, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | | | - Carla Aparecida Arena Ventura
- Collaborating Centre OPS/OMS for Nursing Development Research, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
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24
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He H, Ma X, Su L, Wang L, Guo Y, Shan G, He HJ, Zhou X, Liu D, Long Y, Zhao Y, Zhang S. Effects of a national quality improvement program on ICUs in China: a controlled pre-post cohort study in 586 hospitals. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:73. [PMID: 32131872 PMCID: PMC7057512 DOI: 10.1186/s13054-020-2790-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 02/14/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Patient safety and critical care quality remain a challenging issue in the ICU. However, the effects of the national quality improvement (QI) program remain unknown in China. METHODS A national ICU QI program was implemented in a controlled cohort of 586 hospitals from 2016 to 2018. The effects of the QI program on critical care quality were comprehensively investigated. MAIN RESULTS A total of 81,461,554 patients were enrolled in 586 hospitals, and 1,587,724 patients were admitted to the ICU over 3 years. In 2018, there was a significantly higher number of ICU beds (2016 vs. 2018: 10668 vs. 13,661, P = 0.0132) but a lower doctor-to-bed ratio (2016 vs. 2018: 0.64 (0.50, 0.83) vs. 0.60 (0.45, 0.75), P = 0.0016) and nurse-to-bed ratio (2016 vs. 2018: 2.00 (1.64, 2.50) vs. 2.00 (1.50, 2.40), P = 0.031) than in 2016. Continuous and significant improvements in the ventilator-associated pneumonia (VAP) incidence rate, microbiology detection rate before antibiotic use and deep vein thrombosis (DVT) prophylaxis rate were associated with the implementation of the QI program (VAP incidence rate (per 1000 ventilator-days), 2016 vs. 2017 vs. 2018: 11.06 (4.23, 22.70) vs. 10.20 (4.25, 23.94) vs. 8.05 (3.13, 17.37), P = 0.0002; microbiology detection rate before antibiotic use (%), 2016 vs. 2017 vs. 2018: 83.91 (49.75, 97.87) vs. 84.14 (60.46, 97.24) vs. 90.00 (69.62, 100), P < 0.0001; DVT prophylaxis rate, 2016 vs. 2017 vs. 2018: 74.19 (33.47, 96.16) vs. 71.70 (38.05, 96.28) vs. 83.27 (47.36, 97.77), P = 0.0093). Moreover, the 6-h SSC bundle compliance rates in 2018 were significantly higher than those in 2016 (6-h SSC bundle compliance rate, 2016 vs. 2018: 64.93 (33.55, 93.06) vs. 76.19 (46.88, 96.67)). A significant change trend was not found in the ICU mortality rate from 2016 to 2018 (ICU mortality rate (%), 2016 vs. 2017 vs. 2018: 8.49 (4.42, 14.82) vs. 8.95 (4.89, 15.70) vs. 9.05 (5.12, 15.80), P = 0.1075). CONCLUSIONS The relationship between medical human resources and ICU overexpansion was mismatched during the past 3 years. The implementation of a national QI program improved ICU performance but did not reduce ICU mortality.
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Affiliation(s)
- Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xudong Ma
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing, 100044, China
| | - Longxiang Su
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Lu Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yanhong Guo
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing, 100044, China
| | - Guangliang Shan
- Department of Epidemiology and Biostatistics, Institute of Basic Medicine Sciences, Chinese Academy of Medical Sciences (CAMS) & School of Basic Medicine, Peking Union Medical College, Beijing, 100730, China
| | - Hui Jing He
- Department of Epidemiology and Biostatistics, Institute of Basic Medicine Sciences, Chinese Academy of Medical Sciences (CAMS) & School of Basic Medicine, Peking Union Medical College, Beijing, 100730, China
| | - Xiang Zhou
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Shuyang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
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Predictive Validity of Sepsis-3 Definitions and Sepsis Outcomes in Critically Ill Patients: A Cohort Study in 49 ICUs in Argentina. Crit Care Med 2019; 46:1276-1283. [PMID: 29742584 DOI: 10.1097/ccm.0000000000003208] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The new Sepsis-3 definitions have been scarcely assessed in low- and middle-income countries; besides, regional information of sepsis outcomes is sparse. Our objective was to evaluate Sepsis-3 definition performance in Argentina. DESIGN Cohort study of 3-month duration beginning on July 1, 2016. SETTINGS Forty-nine ICUs. PATIENTS Consecutive patients admitted to the ICU with suspected infection that triggered blood cultures and antibiotic administration. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were classified as having infection, sepsis (infection + change in Sequential Organ Failure Assessment ≥ 2 points), and septic shock (vasopressors + lactate > 2 mmol/L). Patients on vasopressors and lactate less than or equal to 2 mmol/L (cardiovascular dysfunction) were analyzed separately, as those on vasopressors without serum lactate measurement. Systemic inflammatory response syndrome was also recorded. Main outcome was hospital mortality. Of 809 patients, 6% had infection, 29% sepsis, 20% cardiovascular dysfunction, 40% septic shock, and 3% received vasopressors with lactate unmeasured. Hospital mortality was 13%, 20%, 39%, 51%, and 41%, respectively (p = 0.000). Independent predictors of outcome were lactate, Sequential Organ Failure Assessment score, comorbidities, prior duration of symptoms (hr), mechanical ventilation requirement, and infection by highly resistant microorganisms. Area under the receiver operating characteristic curves for mortality for systemic inflammatory response syndrome and Sequential Organ Failure Assessment were 0.53 (0.48-0.55) and 0.74 (0.69-0.77), respectively (p = 0.000). CONCLUSIONS Increasing severity of Sepsis-3 categories adequately tracks mortality; cardiovascular dysfunction subgroup, not included in Sepsis-3, has distinct characteristics. Sequential Organ Failure Assessment score shows adequate prognosis accuracy-contrary to systemic inflammatory response syndrome. This study supports the predictive validity of Sepsis-3 definitions.
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Structural features shared by ICUs belonging to research networks an international survey. "Critical care research network survey". J Crit Care 2019; 54:99-104. [PMID: 31404722 DOI: 10.1016/j.jcrc.2019.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 05/21/2019] [Accepted: 05/27/2019] [Indexed: 11/21/2022]
Abstract
PURPOSE Major acute care research is conducted within critical care research networks (CCRN). Our aims were to describe CCRN and participating ICUs. METHODS A cross-sectional survey was conducted among all CCRNs belonging to the International Forum of Acute Care Trialists. A network questionnaire was sent to CCRN directors and an ICU e-questionnaire was sent to participating ICUS. RESULTS Survey was answered by 366 ICUs from 17 CCRNs (median response rate 21% [12-38]). CCRNs have different organizations (ownership, memberships, funding). The number of studies conducted, patients included and publications varied a lot across CCRNs. The collaboration with other research networks or health authorities was very frequent (n = 13, 76%). Most ICUs (n = 315; 86%) are located in large teaching hospitals in high income countries with a mean volume of 968 (842-1102 (95% CI)) annual admissions. The recognition at the academic level (n = 133; 70%), the collaboration with experts (n = 284; 85%), and improving practices (n = 286; 86%) are incentives reported to belong to a CCRN. CONCLUSIONS Despite different organizations, CCRN share similar ventures including the value of improving quality of critical care delivery. Participating ICUs share several structural and managerial patterns. These observations enlighten the importance of CCRN to enhance quality of critical care delivery.
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Estenssoro E, Loudet CI, Edul VSK, Osatnik J, Ríos FG, Vásquez DN, Pozo MO, Lattanzio B, Pálizas F, Klein F, Piezny D, Rubatto Birri PN, Tuhay G, Díaz A, Santamaría A, Zakalik G, Dubin A. Health inequities in the diagnosis and outcome of sepsis in Argentina: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:250. [PMID: 31288865 PMCID: PMC6615149 DOI: 10.1186/s13054-019-2522-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/19/2019] [Indexed: 12/19/2022]
Abstract
Background Socioeconomic variables impact health outcomes but have rarely been evaluated in critical illness. Low- and middle-income countries bear the highest burden of sepsis and also have significant health inequities. In Argentina, public hospitals serve the poorest segment of the population, while private institutions serve patients with health coverage. Our objective was to analyze differences in mortality between public and private hospitals, using Sepsis-3 definitions. Methods This is a multicenter, prospective cohort study including patients with sepsis admitted to 49 Argentine ICUs lasting 3 months, beginning on July 1, 2016. Epidemiological, clinical, and socioeconomic status variables and hospital characteristics were compared between patients admitted to both types of institutions. Results Of the 809 patients included, 367 (45%) and 442 (55%) were admitted to public and private hospitals, respectively. Those in public institutions were younger (56 ± 18 vs. 64 ± 18; p < 0.01), with more comorbidities (Charlson score 2 [0–4] vs. 1 [0–3]; p < 0.01), fewer education years (7 [7–12] vs. 12 [10–16]; p < 0.01), more frequently unemployed/informally employed (30% vs. 7%; p < 0.01), had similar previous self-rated health status (70 [50–90] vs. 70 [50–90] points; p = 0.30), longer pre-admission symptoms (48 [24–96] vs. 24 [12–48] h; p < 0.01), had been previously evaluated more frequently in any healthcare venue (28 vs. 20%; p < 0.01), and had higher APACHE II, SOFA, lactate levels, and mechanical ventilation utilization. ICU admission as septic shock was more frequent in patients admitted to public hospitals (47 vs. 35%; p < 0.01), as were infections caused by multiresistant microorganisms. Sepsis management in the ICU showed no differences. Twenty-eight-day mortality was higher in public hospitals (42% vs. 24%; p < 0.01) as was hospital mortality (47% vs. 30%; p < 0.01). Admission to a public hospital was an independent predictor of mortality together with comorbidities, lactate, SOFA, and mechanical ventilation; in an alternative prediction model, it acted as a correlate of pre-hospital symptom duration and infections caused by multiresistant microorganisms. Conclusions Patients in public hospitals belonged to a socially disadvantaged group and were sicker at admission, had septic shock more frequently, and had higher mortality. Unawareness of disease severity and delays in the health system might be associated with late admission. This marked difference in outcome between patients served by public and private institutions constitutes a state of health inequity. Electronic supplementary material The online version of this article (10.1186/s13054-019-2522-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elisa Estenssoro
- Servicio de Terapia Intensiva, Hospital Interzonal de Agudos San Martin de La Plata, Calle 42 No.577, 1900, La Plata, Buenos Aires, Argentina.
| | - Cecilia I Loudet
- Servicio de Terapia Intensiva, Hospital Interzonal de Agudos San Martin de La Plata, Calle 42 No.577, 1900, La Plata, Buenos Aires, Argentina
| | | | | | - Fernando G Ríos
- Hospital Alejandro Posadas, El Palomar, Buenos Aires, Argentina
| | | | | | | | | | - Francisco Klein
- Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Damián Piezny
- Hospital Alejandro Posadas, El Palomar, Buenos Aires, Argentina
| | | | - Graciela Tuhay
- Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | | | | | | | - Arnaldo Dubin
- Sanatorio Otamendi y Miroli, Buenos Aires, Argentina
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Nassar AP, Zampieri FG, Salluh JI, Bozza FA, Machado FR, Guimarães HP, Damiani LP, Cavalcanti AB. Organizational factors associated with target sedation on the first 48 h of mechanical ventilation: an analysis of checklist-ICU database. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:34. [PMID: 30696474 PMCID: PMC6352335 DOI: 10.1186/s13054-019-2323-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/11/2019] [Indexed: 12/24/2022]
Abstract
Background Although light sedation levels are associated with several beneficial outcomes for critically ill patients on mechanical ventilation, the majority of patients are still deeply sedated. Organizational factors may play a role on adherence to light sedation levels. We aimed to identify organizational factors associated with a moderate to light sedation target on the first 48 h of mechanical ventilation, as well as the association between early achievement of within-target sedation and mortality. Methods This study is a secondary analysis of a multicenter two-phase study (prospective cohort followed by a cluster-randomized controlled trial) performed in 118 Brazilian ICUs. We included all critically ill patients who were on mechanical ventilation 48 h after ICU admission. A moderate to light level of sedation or being alert and calm (i.e., the Richmond Agitation-Sedation Scale of − 3 to 0) was the target for all patients on mechanical ventilation during the study period. We collected data on the type of hospital (public, private, profit and private, nonprofit), hospital teaching status, nursing and physician staffing, and presence of sedation, analgesia, and weaning protocols. We used multivariate random-effects regression with ICU and study phase as random-effects and correction for patients’ Simplified Acute Physiology Score 3 and Sequential Organ Failure Assessment. We also performed a mediation analysis to explore whether sedation level was just a mediator of the association between organizational factors and mortality. Results We included 5719 patients. Only 1710 (29.9%) were on target sedation levels on day 2. Board-certified intensivists on the morning and afternoon shifts were associated with an adequate sedation level on day 2 (OR = 2.43; CI 95%, 1.09–5.38). Target sedation levels were associated with reduced hospital mortality (OR = 0.63; CI 95%, 0.55–0.72). Mediation analysis also suggested such an association, but did not suggest a relationship between the physician staffing model and hospital mortality. Conclusions Board-certified intensivists on morning and afternoon shifts were associated with an increased number of patients achieving lighter sedation goals. These findings reinforce the importance of organizational factors, such as intensivists’ presence, as a modifiable quality improvement target. Electronic supplementary material The online version of this article (10.1186/s13054-019-2323-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antonio Paulo Nassar
- Intensive Care Unit and Postgraduate Program, A.C. Camargo Cancer Center, São Paulo, Brazil.
| | - Fernando G Zampieri
- Research Institute, HCor-Hospital do Coração, São Paulo, Brazil.,Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Jorge I Salluh
- Graduate Program in Translational Medicine and Department of Critical Care, D'Or Institute for Research and Education, Rio De Janeiro, Brazil.,Programa de Pós-Graduação em Clinica médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fernando A Bozza
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil
| | - Flávia Ribeiro Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, Brazil
| | - Helio Penna Guimarães
- Research Institute, HCor-Hospital do Coração, São Paulo, Brazil.,Federal univeristy of São Paulo, São Paulo, Brazil
| | - Lucas P Damiani
- Research Institute, HCor-Hospital do Coração, São Paulo, Brazil
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Raimondi N, Quintero Villareal A, Valdivia Nuñez A, Martín Delgado MC. The Pan American and Iberian Federation of Critical Medicine and Intensive Therapy develops its Strategic Plan. Med Intensiva 2018; 43:176-179. [PMID: 30482556 DOI: 10.1016/j.medin.2018.08.010] [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: 07/31/2018] [Revised: 08/13/2018] [Accepted: 08/28/2018] [Indexed: 10/28/2022]
Abstract
The Pan-American and Iberian Federation of Critical Medicine and Intensive Therapy, A.C. (FEPIMCTI), has prepared its Strategic Plan for the next 5 years. In this Plan, it defines its course towards the future, establishes its long-term objectives and works to achieve success. Its strategic objectives are framed in consolidating the legal, fiscal and administrative structure, the updating of its statutes, the implementation of a process management system encompassed in a quality culture, the implementation of committees of experts, achieving academic excellence by developing training programs and giving visibility to the Federation. Their main values refer to equity, professionalism, respect and social solidarity. The implementation of the Strategic Plan in a collaborative manner must serve as a driving force for change to position FEPIMCTI as a relevant Scientific Society in the Critical Medicine of its member countries.
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Affiliation(s)
- N Raimondi
- División de Terapia intensiva, Hospital Juan A. Fernández, Buenos Aires, Argentina
| | | | - A Valdivia Nuñez
- Consultor independiente en Gestión Estratégica y Administración, Estado de México, México
| | - M C Martín Delgado
- Servicio Medicina Intensiva, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, España.
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Shrestha GS, Kwizera A, Lundeg G, Baelani JI, Azevedo LCP, Pattnaik R, Haniffa R, Gavrilovic S, Mai NTH, Kissoon N, Lodha R, Misango D, Neto AS, Schultz MJ, Dondorp AM, Thevanayagam J, Dünser MW, Alam AKMS, Mukhtar AM, Hashmi M, Ranjit S, Otu A, Gomersall C, Amito J, Vaeza NN, Nakibuuka J, Mujyarugamba P, Estenssoro E, Ospina-Tascón GA, Mohanty S, Mer M. International Surviving Sepsis Campaign guidelines 2016: the perspective from low-income and middle-income countries. THE LANCET. INFECTIOUS DISEASES 2018; 17:893-895. [PMID: 28845789 DOI: 10.1016/s1473-3099(17)30453-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/30/2017] [Accepted: 07/26/2017] [Indexed: 01/26/2023]
Affiliation(s)
- Gentle S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu 44600, Nepal.
| | - Arthur Kwizera
- Department of Anaesthesia, Anaesthesia and General Intensive Care, Mulago National Referral Hospital, Makerere University, Kampala, Uganda
| | - Ganbold Lundeg
- Department of Critical Care and Anesthesia, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - John I Baelani
- Department of Anesthesia and Emergency, Doctors on Call for Service Education Hospital, Goma, Democratic Republic of the Congo
| | - Luciano C P Azevedo
- Emergency Department, University of São Paulo, São Paulo, Brazil; Hospital Sírio-Libanes, São Paulo, Brazil
| | | | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
| | - Srdjan Gavrilovic
- Institute for Pulmonary Diseases of Vojvodina, The Clinic for Urgent Pulmonology, Sremska Kamenica, Serbia; Department of Emergency Medicine, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Nguyen Thi Hoang Mai
- Hospital For Tropical Diseases, Oxford University Clinical Research Unit Vietnam, Ho Chi Minh City, Vietnam
| | - Niranjan Kissoon
- Department of Paediatrics and Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - David Misango
- Department of Critical Care Medicine, Aga Khan University Hospital, Nairobi, Kenya
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcus J Schultz
- Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Department of Intensive Care, Amsterdam Medical Center and University of Amsterdam, Amsterdam, Netherlands
| | - Arjen M Dondorp
- Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Department of Intensive Care, Amsterdam Medical Center and University of Amsterdam, Amsterdam, Netherlands
| | | | - Martin W Dünser
- Department of Critical Care Medicine, University College of London Hospitals, London, UK
| | - A K M Shamsul Alam
- Department of Anaesthesia and Intensive Care, Chittagong Medical College, Chittagong, Bangladesh
| | - Ahmed M Mukhtar
- Department of Anesthesia and Intensive Care, Cairo University, Cairo, Egypt
| | - Madiha Hashmi
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | - Suchitra Ranjit
- Pediatric Intensive Care and Emergency Services, Apollo Children's Hospital, Chennai, Tamil Nadu, India
| | - Akaninyene Otu
- Department of Internal Medicine, University of Calabar, Calabar, Nigeria
| | - Charles Gomersall
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jacinta Amito
- Department of Anaesthetics and Intensive Care, St Mary's Hospital Lacor, Gulu, Uganda
| | | | - Jane Nakibuuka
- Department of Medicine, General Intensive Care Unit, Mulago National Referral Hospital, Kampala, Uganda
| | - Pierre Mujyarugamba
- Medical Laboratory Technology Department, University of Gitwe, Gitwe, Rwanda
| | - Elisa Estenssoro
- Servicio de Terapia Intensiva, Hospital Interzonal de Agudos San Martín de La Plata, Buenos Aires, Argentina
| | - Gustavo A Ospina-Tascón
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Cali, Colombia
| | | | - Mervyn Mer
- Divisions of Critical Care and Pulmonology, Department of Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Pellegrini JAS, Cordioli RL, Grumann ACB, Ziegelmann PK, Taniguchi LU. Point-of-care ultrasonography in Brazilian intensive care units: a national survey. Ann Intensive Care 2018; 8:50. [PMID: 29808412 PMCID: PMC5972134 DOI: 10.1186/s13613-018-0397-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/12/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Point-of-care ultrasonography (POCUS) has recently become a useful tool that intensivists are incorporating into clinical practice. However, the incorporation of ultrasonography in critical care in developing countries is not straightforward. METHODS Our objective was to investigate current practice and education regarding POCUS among Brazilian intensivists. A national survey was administered to Brazilian intensivists using an electronic questionnaire. Questions were selected by the Delphi method and assessed topics included organizational issues, POCUS technique and training patterns, machine availability, and main applications of POCUS in daily practice. RESULTS Of 1533 intensivists who received the questionnaire, 322 responded from all of Brazil's regions. Two hundred and five (63.8%) reported having access to an ultrasound machine dedicated to the intensive care unit (ICU); however, this was more likely in university hospitals than in non-university hospitals (80.6 vs. 59.6%; risk ratio [RR] = 1.35 [1.16-1.58], p = 0.002). The main applications of POCUS were ultrasound-guided central vein catheterization (49.4%) and bedside echocardiographic assessment (33.9%). Two hundred and fifty-eight (80.0%) reported having at least one POCUS-trained intensivist in their staff (trained units). Trained units were more likely to perform routine ultrasound-guided jugular vein catheterization than non-trained units (38.6 vs. 16.4%; RR = 2.35 [1.31-4.23], p = 0.001). The proportion of POCUS-trained intensivists and availability of a dedicated ultrasound machine were both independently associated with performing ultrasound-guided jugular vein catheterization (RR = 1.91 [1.32-2.77], p = 0.001) and (RR = 2.20 [1.26-3.29], p = 0.005), respectively. CONCLUSIONS A significant proportion of Brazilian ICUs had at least one intensivist with POCUS capability in their staff. Although ultrasound-guided central vein catheterization constitutes the main application of POCUS, adherence to guideline recommendations is still suboptimal.
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Affiliation(s)
- José Augusto Santos Pellegrini
- Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ricardo Luiz Cordioli
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil. .,Department of Critical Care Medicine, Alemão Oswaldo Cruz Hospital, São Paulo, Brazil. .,Department of Intensive Care Unit, Hospital Israelita Albert Einstein, 627, Albert Einstein St., São Paulo, 05652-900, Brazil.
| | | | - Patrícia Klarmann Ziegelmann
- Statistics Department and Post-Graduation Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Leandro Utino Taniguchi
- Department of Critical Care Medicine, Hospital das Clínicas de São Paulo, FMUSP, São Paulo, Brazil
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Castro R, Nin N, Ríos F, Alegría L, Estenssoro E, Murias G, Friedman G, Jibaja M, Ospina-Tascon G, Hurtado J, Marín MDC, Machado FR, Cavalcanti AB, Dubin A, Azevedo L, Cecconi M, Bakker J, Hernandez G. The practice of intensive care in Latin America: a survey of academic intensivists. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:39. [PMID: 29463310 PMCID: PMC5820791 DOI: 10.1186/s13054-018-1956-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 01/16/2018] [Indexed: 12/29/2022]
Abstract
Background Intensive care medicine is a relatively young discipline that has rapidly grown into a full-fledged medical subspecialty. Intensivists are responsible for managing an ever-increasing number of patients with complex, life-threatening diseases. Several factors may influence their performance, including age, training, experience, workload, and socioeconomic context. The aim of this study was to examine individual- and work-related aspects of the Latin American intensivist workforce, mainly with academic appointments, which might influence the quality of care provided. In consequence, we conducted a cross-sectional study of intensivists at public and private academic and nonacademic Latin American intensive care units (ICUs) through a web-based electronic survey submitted by email. Questions about personal aspects, work-related topics, and general clinical workflow were incorporated. Results Our study comprised 735 survey respondents (53% return rate) with the following country-specific breakdown: Brazil (29%); Argentina (19%); Chile (17%); Uruguay (12%); Ecuador (9%); Mexico (7%); Colombia (5%); and Bolivia, Peru, Guatemala, and Paraguay combined (2%). Latin American intensivists were predominantly male (68%) young adults (median age, 40 [IQR, 35–48] years) with a median clinical ICU experience of 10 (IQR, 5–20) years. The median weekly workload was 60 (IQR, 47–70) h. ICU formal training was between 2 and 4 years. Only 63% of academic ICUs performed multidisciplinary rounds. Most intensivists (85%) reported adequate conditions to manage patients with septic shock in their units. Unsatisfactory conditions were attributed to insufficient technology (11%), laboratory support (5%), imaging resources (5%), and drug shortages (5%). Seventy percent of intensivists participated in research, and 54% read scientific studies regularly, whereas 32% read no more than one scientific study per month. Research grants and pharmaceutical sponsorship are unusual funding sources in Latin America. Although Latin American intensivists are mostly unsatisfied with their income (81%), only a minority (27%) considered changing to another specialty before retirement. Conclusions Latin American intensivists constitute a predominantly young adult workforce, mostly formally trained, have a high workload, and most are interested in research. They are under important limitations owing to resource constraints and overt dissatisfaction. Latin America may be representative of other world areas with similar challenges for intensivists. Specific initiatives aimed at addressing these situations need to be devised to improve the quality of critical care delivery in Latin America. Electronic supplementary material The online version of this article (10.1186/s13054-018-1956-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Diagonal Paraguay #362, Santiago Centro, RM, 8330077, Chile. .,Unidad de Paciente Critico Adultos, Hospital Clinico UC-CHRISTUS, Marcoleta #367, Santiago Centro, RM, 8330077, Chile.
| | - Nicolas Nin
- Hospital Español, Avenida General Garibaldi, 1729 esq., Rocha, Montevideo, Uruguay.,Agencia Nacional de Investigación e Innovación (ANII), Montevideo, Uruguay
| | - Fernando Ríos
- Servicio de Terapia Intensiva. Hospital Alejandro Posadas, Avenida Presidente Arturo U. Illia, El Palomar, Buenos Aires, Argentina
| | - Leyla Alegría
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Diagonal Paraguay #362, Santiago Centro, RM, 8330077, Chile
| | - Elisa Estenssoro
- Servicio de Terapia Intensiva, Hospital Interzonal de Agudos General San Martin de La Plata, Avenida 1 1794, Casco Urbano, La Plata, Buenos Aires, B1904CFU, Argentina
| | - Gastón Murias
- Clinica Bazterrica and Clinica Santa Isabel, Billinghurst 2072 (esquina Juncal), Ciudad Autónoma de Buenos Aires, Argentina
| | - Gilberto Friedman
- Departamento de Medicina Interna - Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350 - Santa Cecilia, Porto Alegre, RS, 90035-903, Brasil
| | - Manuel Jibaja
- Escuela de Medicina, Universidad Internacional del Ecuador, Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Avenida Gran Colombia, Quito, 170136, Ecuador
| | - Gustavo Ospina-Tascon
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Cali, Carrera 98 No. 18-49, Cali, Valle del Cauca, Colombia
| | - Javier Hurtado
- Hospital Español, Avenida General Garibaldi, 1729 esq., Rocha, Montevideo, Uruguay.,Agencia Nacional de Investigación e Innovación (ANII), Montevideo, Uruguay
| | - María Del Carmen Marín
- Unidad de Cuidados Intensivos, Hospital Regional 1 Octubre, ISSSTE, Avenida Instituto Politécnico Nacional 1669. Colonia Lindavista, c.p., Delegación Gustavo A. Madero, Ciudad de México, 07300, México
| | - Flavia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of Sao Paulo, Rua Sena Madureira, 1500 - Clementino, São Paulo, SP, 04021-001, Brasil
| | - Alexandre Biasi Cavalcanti
- Research Institute HCor, Hospital do Coração, Rua. Desembargador Eliseu Guilherme, 147 - Paraíso, São Paulo, SP, 04004-030, Brasil
| | - Arnaldo Dubin
- Catedra de Farmacología, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Buenos Aires, Argentina.,Servicio de Terapia Intensiva, Sanatorio Otamendi y Miroli, Azcuénaga 894, CABA, C1115AAB, Argentina
| | - Luciano Azevedo
- Anesthesiology, Pain and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, Brazil.,Emergency Medicine Department, University of Sao Paulo, Hospital Sirio-Libanes, Rua Dona Adma Jafet, 91 - Vista, Sao Paulo, SP, 01308-050, Brasil
| | - Maurizio Cecconi
- St. George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - Jan Bakker
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Diagonal Paraguay #362, Santiago Centro, RM, 8330077, Chile.,Unidad de Paciente Critico Adultos, Hospital Clinico UC-CHRISTUS, Marcoleta #367, Santiago Centro, RM, 8330077, Chile
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