Point-of-care ultrasonography in Brazilian intensive care units: a national survey

The use of bedside echocardiography in the care of critically ill patients - a joint consensus document of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Medicina de Emergência and Sociedade Brasileira de Medicina Hospitalar. Part 2 - Technical aspects

Echocardiography in critically ill patients has become essential in the evaluation of patients in different settings, such as the hospital. However, unlike for other matters related to the care of these patients, there are still no recommendations from national medical societies on the subject. The objective of this document was to organize and make available expert consensus opinions that may help to better incorporate echocardiography in the evaluation of critically ill patients. Thus, the Associação de Medicina Intensiva Brasileira, the Associação Brasileira de Medicina de Emergência, and the Sociedade Brasileira de Medicina Hospitalar formed a group of 17 physicians to formulate questions relevant to the topic and discuss the possibility of consensus for each of them. All questions were prepared using a five-point Likert scale. Consensus was defined a priori as at least 80% of the responses between one and two or between four and five. The consideration of the issues involved two rounds of voting and debate among all participants. The 27 questions prepared make up the present document and are divided into 4 major assessment areas: left ventricular function, right ventricular function, diagnosis of shock, and hemodynamics. At the end of the process, there were 17 positive (agreement) and 3 negative (disagreement) consensuses; another 7 questions remained without consensus. Although areas of uncertainty persist, this document brings together consensus opinions on several issues related to echocardiography in critically ill patients and may enhance its development in the national scenario.

Use of bedside echocardiography in the care of critically ill patients - a joint consensus document of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Medicina de Emergência, and Sociedade Brasileira de Medicina Hospitalar. Part 1 - Competence in bedside echocardiography

The use of echocardiography by physicians who are not echocardiographers has become common throughout the world across highly diverse settings where the care of acutely ill patients is provided. Echocardiographic evaluation performed in a point-of-care manner can provide relevant information regarding the mechanism of causes of shock, for example, increasing the rates of correct diagnosis and allowing for faster informed decision-making than through evaluation methods. Considering that the accurate diagnosis of life-threatening situations is essential for professionals working with acutely ill patients, several international associations recommend that physicians responsible for critically ill patients acquire and develop the ability to perform bedside ultrasound examinations, including echocardiographic examinations. However, there is no consensus in the literature regarding which specific applications should be included in the list of skills for nonechocardiographer physicians. Taking into account the multiplicity of applications of echocardiography in different scenarios related to acutely ill patients; the differences in the published protocols, with regard to both the teaching methodology and competence verification; and the heterogeneity of training among highly diverse specialties responsible for their care at different levels, this consensus document aimed to reflect the position of representatives of related Brazilian medical societies on the subject and may thus serve as a starting point both for standardization among different specialties and for the transmission of knowledge and verification of the corresponding competencies.

Refusal of beds and triage of patients admitted to intensive care units in Brazil: a cross-sectional national survey

OBJECTIVE

To obtain data on bed refusal in intensive care units in Brazil and to evaluate the use of triage systems by professionals.

METHODS

A cross-sectional survey. Using the Delphi methodology, a questionnaire was created contemplating the objectives of the study. Physicians and nurses enrolled in the research network of the Associação de Medicina Intensiva Brasileira (AMIBnet) were invited to participate. A web platform (SurveyMonkey®) was used to distribute the questionnaire. The variables in this study were measured in categories and expressed as proportions. The chi-square test or Fisher's exact test was used to verify associations. The significance level was set at 5%.

RESULTS

In total, 231 professionals answered the questionnaire, representing all regions of the country. The national intensive care units had an occupancy rate of more than 90% always or frequently for 90.8% of the participants. Among the participants, 84.4% had already refused admitting patients to the intensive care unit due to the capacity of the unit. Half of the Brazilian institutions (49.7%) did not have triage protocols for admission to intensive beds.

CONCLUSIONS

Bed refusal due to high occupancy rates is common in Brazilian intensive care units. Even so, half of the services in Brazil do not adopt protocols for triage of beds.

Comparison of the proximal and distal approaches for axillary vein catheterization under ultrasound guidance (PANDA) in cardiac surgery patients susceptible to bleeding: a randomized controlled trial

BACKGROUND

The present study aimed at comparing the success rate and safety of proximal versus distal approach for ultrasound (US)-guided axillary vein catheterization (AVC) in cardiac surgery patients susceptible to bleeding.

METHODS

In this single-center randomized controlled trial, cardiac surgery patients susceptible to bleeding and requiring AVC were randomized to either the proximal or distal approach group for US-guided AVC. Patients susceptible to bleeding were defined as those who received oral antiplatelet drugs or anticoagulants for at least 3 days. Success rate, catheterization time, number of attempts, and mechanical complications within 24 h were recorded for each procedure.

RESULTS

A total of 198 patients underwent randomization: 99 patients each to the proximal and distal groups. The proximal group had the higher first puncture success rate (75.8% vs. 51.5%, p < 0.001) and site success rate (93.9% vs. 83.8%, p = 0.04) than the distal group. However, the overall success rates between the two groups were similar (99.0% vs. 99.0%; p = 1.00). Moreover, the proximal group had fewer average number of attempts (p < 0.01), less access time (p < 0.001), and less successful cannulation time (p < 0.001). There was no significant difference in complications between the two groups, such as major bleeding, minor bleeding, arterial puncture, pneumothorax, nerve injuries, and catheter misplacements.

CONCLUSIONS

For cardiac surgery patients susceptible to bleeding, both proximal and distal approaches for US-guided AVC can be considered as feasible and safe methods of central venous cannulation. In terms of the first puncture success rate and cannulation time, the proximal approach is superior to the distal approach. Trial registration Clinicaltrials.gov, NCT03395691. Registered January 10, 2018, https://clinicaltrials.gov/ct2/show/NCT03395691?cond=NCT03395691&draw=1&rank=1 .

The Value of Focused Echocardiography During Cardiac Arrest

Cardiac arrest is the absence of a centrally palpable pulse and no respiratory effort in an unresponsive patient. This often-lethal medical condition affects hundreds of thousands of people in the United States alone every year. Immediate intervention is crucial to provide the patient with any chance of survival. Advanced cardiac life support (ACLS) is the cornerstone therapy for cardiac arrest. Increased awareness and proper identification of life-threatening arrhythmias is critical, as it may lead to prompt medical treatment and improved mortality. The use of focused echocardiography, during a cardiac arrest, has been a developing area of interest over the past several years. The specific aim of this literature review was to emphasize the role of a focused echocardiogram and the valuable information that can be provided during a cardiac arrest.