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Leung LY, Huang HL, Hung KK, Leung CY, Lam CC, Lo RS, Yeung CY, Tsoi PJ, Lai M, Brabrand M, Walline JH, Graham CA. Door-to-antibiotic time and mortality in patients with sepsis: Systematic review and meta-analysis. Eur J Intern Med 2024:S0953-6205(24)00262-0. [PMID: 39034174 DOI: 10.1016/j.ejim.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 06/02/2024] [Accepted: 06/12/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVES To evaluate whether the timing of initial antibiotic administration in patients with sepsis in hospital affects mortality. METHODS This systematic review and meta-analysis included studies from inception up to 19 May 2022. Interventional and observational studies including adult human patients with suspected or confirmed sepsis and reported time of antibiotic administration with mortality were included. Data were extracted by two independent reviewers. Summary estimates were calculated by using random-effects model. The primary outcome was mortality. RESULTS We included 42 studies comprising 190,896 patients with sepsis. Pooled data showed that the OR for patient mortality who received antibiotics ≤1 hr was 0.83 (95 %CI: 0.67 to 1.04) when compared with patients who received antibiotics >1hr. Significant reductions in the risk of death in patients with earlier antibiotic administration were observed in patients ≤3 hrs versus >3 hrs (OR: 0.80, 95 %CI: 0.68 to 0.94) and ≤6 hrs vs 6 hrs (OR: 0.57, 95 %CI: 0.39 to 0.82). CONCLUSIONS Our findings show an improvement in mortality in sepsis patients with early administration of antibiotics at <3 and <6 hrs. Thus, these results suggest that antibiotics should be administered within 3 hrs of sepsis recognition or ED arrival regardless of the presence or absence of shock.
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Affiliation(s)
- Ling Yan Leung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China
| | - Hsi-Lan Huang
- Department of Global Health Policy, The University of Tokyo, Japan
| | - Kevin Kc Hung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China
| | - Chi Yan Leung
- Department of Global Health Policy, The University of Tokyo, Japan
| | - Cherry Cy Lam
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China
| | - Ronson Sl Lo
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China
| | - Chun Yu Yeung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China
| | - Peter Joseph Tsoi
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China; James Cook University, Townsville, Australia
| | - Michael Lai
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China; Department of Emergency Medicine, University of British Columbia, Canada
| | - Mikkel Brabrand
- Department of Emergency Medicine, University of Southern Denmark, Denmark
| | - Joseph H Walline
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China
| | - Colin A Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China.
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Gomes CLR, Cleto-Yamane TL, Ruzani F, Suassuna JHR. Socioeconomic Influences on the Outcomes of Dialysis-Requiring Acute Kidney Injury in Brazil. Kidney Int Rep 2023; 8:1772-1783. [PMID: 37705894 PMCID: PMC10496017 DOI: 10.1016/j.ekir.2023.06.003] [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: 12/16/2022] [Revised: 05/03/2023] [Accepted: 06/05/2023] [Indexed: 09/15/2023] Open
Abstract
Introduction Although research suggests that socioeconomic deprivation is linked to a higher incidence of acute kidney injury (AKI) and worse outcomes in high-income countries, there is limited knowledge about these epidemiologic factors in developing countries. In addition, the impact of medical institution administration (private versus public) on AKI outcomes remains to be determined. Methods We studied 15,186 pediatric and adult patients with dialysis-requiring AKI (AKI-D) admitted to private and public hospitals in Rio de Janeiro, Brazil. According to Brazil's demographic census, socioeconomic indicators were derived from patient zip codes. Propensity score matching analysis and a mixed-effect Cox regression were used to assess the impact of socioeconomic indicators and hospital governance on patient survival. Results Crude mortality rates were higher in private hospitals than in public hospitals (71.8% vs. 59.5%, P < 0.001) and were associated with significant differences in age (75 years, interquartile range [IQR]: 61-83 vs. 53 years, IQR: 31-66), baseline renal function (prevalence of chronic kidney disease [CKD]: 33.2% vs. 23%, P < 0.001), comorbidities (Charlson score: 2.03 ± 0.87 vs. 1.72 ± 0.75, P < 0.001), and severity of presentation (mechanical ventilation: 76.5% vs. 58% and vasopressors: 72.8% vs. 50.5%, P < 0.001). After adjustments and propensity score matching, we found no effect of different hospital administrations or socioeconomic factors on mortality. Baseline characteristics and the severity of presentation primarily influenced AKI-D prognosis. Conclusions Despite significant racial and socioeconomic differences in hospital governance, these indicators had no independent influence on mortality. Future epidemiologic studies should investigate these relevant assumptions to allow healthcare systems to manage this severe syndrome promptly.
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Affiliation(s)
- Conrado Lysandro Rodrigues Gomes
- Clinical and Academic Unit of Nephrology, Hospital Universitário Pedro Ernesto, Faculty of Medical Sciences, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
- Kidney Assistance Ltd., Rio de Janeiro, Brazil
| | - Thais Lyra Cleto-Yamane
- Clinical and Academic Unit of Nephrology, Hospital Universitário Pedro Ernesto, Faculty of Medical Sciences, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Frederico Ruzani
- Clinical and Academic Unit of Nephrology, Hospital Universitário Pedro Ernesto, Faculty of Medical Sciences, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
- Kidney Assistance Ltd., Rio de Janeiro, Brazil
| | - José Hermógenes Rocco Suassuna
- Clinical and Academic Unit of Nephrology, Hospital Universitário Pedro Ernesto, Faculty of Medical Sciences, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
- Kidney Assistance Ltd., Rio de Janeiro, Brazil
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Moraes RB, Haas JS, Vidart J, Nicolaidis R, Deutschendorf C, Moretti MMS, Friedman G, Silva D. A Coordinated and Multidisciplinary Strategy can Reduce the Time for Antibiotics in Septic Patients at a University Hospital. Indian J Crit Care Med 2023; 27:465-469. [PMID: 37502294 PMCID: PMC10369314 DOI: 10.5005/jp-journals-10071-24483] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 06/06/2023] [Indexed: 07/29/2023] Open
Abstract
Objectives We carried out this work with the aim of assessing the effectiveness of a set of interventions over time for the administration of antibiotics. Design Prospective observational study. Setting Patients admitted to the emergency room and ICU of the hospital where the study was conducted are evaluated daily for some sociodemographic and clinical variables. Among them are some quality indicators, such as the time between the diagnosis of sepsis or septic shock until the start of the infusion of antibiotics. This indicator reflects several aspects related to a set of assistance measures (adequacy of antibiotic dispensation, rapid response team (RRT), sepsis care quality improvement program, antimicrobial management program, improvements in emergency department assistance). Patients or participants Patients with sepsis or septic shock were admitted to the ICU of a university and public hospital in southern Brazil. Main variables of interest The time between the diagnosis of sepsis or septic shock and the beginning of the infusion of antibiotics. Results Between 2013 and 2018, 1676 patients were evaluated. The mean time for antibiotic infusion decreased from 6.1 ± 8.6 hours to 1.7 ± 2.9 hours (p < 0.001). The percentage of patients who received antibiotics in the first hour increased from 20.7 to 59.0% (p < 0.001). Conclusion In this study, we demonstrated that a set of actions adopted in a large tertiary hospital was associated with decreased time to start antibiotic therapy in septic patients. How to cite this article Moraes RB, Haas JS, Vidart J, Nicolaidis R, Deutschendorf C, Moretti MMS, et al. A Coordinated and Multidisciplinary Strategy can Reduce the Time for Antibiotics in Septic Patients at a University Hospital. Indian J Crit Care Med 2023;27(7):465-469.
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Affiliation(s)
| | | | - Josi Vidart
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Rafael Nicolaidis
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Gilberto Friedman
- Programa de Pos-graduacao em Ciencias Pneumologicas, Universidade Federal do Rio Grande do Sul – School of Medicine, Porto Alegre, Rio Grande do Sul, Brazil
| | - Daiandy Silva
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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Qin Y, Caldino Bohn RI, Sriram A, Kernan KF, Carcillo JA, Kim S, Park HJ. Refining empiric subgroups of pediatric sepsis using machine-learning techniques on observational data. Front Pediatr 2023; 11:1035576. [PMID: 36793336 PMCID: PMC9923004 DOI: 10.3389/fped.2023.1035576] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/05/2023] [Indexed: 01/31/2023] Open
Abstract
Sepsis contributes to 1 of every 5 deaths globally with 3 million per year occurring in children. To improve clinical outcomes in pediatric sepsis, it is critical to avoid "one-size-fits-all" approaches and to employ a precision medicine approach. To advance a precision medicine approach to pediatric sepsis treatments, this review provides a summary of two phenotyping strategies, empiric and machine-learning-based phenotyping based on multifaceted data underlying the complex pediatric sepsis pathobiology. Although empiric and machine-learning-based phenotypes help clinicians accelerate the diagnosis and treatments, neither empiric nor machine-learning-based phenotypes fully encapsulate all aspects of pediatric sepsis heterogeneity. To facilitate accurate delineations of pediatric sepsis phenotypes for precision medicine approach, methodological steps and challenges are further highlighted.
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Affiliation(s)
- Yidi Qin
- Department of Human Genetics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Rebecca I. Caldino Bohn
- Department of Human Genetics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Aditya Sriram
- Department of Human Genetics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Soyeon Kim
- Division of Pediatric Pulmonary Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Hyun Jung Park
- Department of Human Genetics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
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Chronic hemodialysis patients with COVID-19 cared for by the public health system have higher mortality than those treated in private facilities: analysis of the Brazilian dialysis registry. Int Urol Nephrol 2023; 55:449-458. [PMID: 35994131 PMCID: PMC9395793 DOI: 10.1007/s11255-022-03289-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 06/26/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Brazil is the third country globally in dialysis patients. Little is known about the impact of the type of health insurance on the outcome of these patients after COVID-19. METHODS We analyzed comorbidities, sociodemographic factors, and dialysis-related parameters from a retrospective cohort study of 1866 Brazilian chronic hemodialysis patients with COVID-19 from Feb 2020-July 2021. We evaluated the influence of health insurance (private vs. public) on the intensive care unit admission and 90 day fatality risk. RESULTS From 1866 hemodialysis patients, 455 (24%) were admitted to the intensive care unit, and 350 (19%) died. The mean age was 57.5 years, 88% had public health insurance. Crude case-fatality rate was not different between groups (private vs. public risk ratio 1.11; 95% CI 0.82-1.52, p = 0.498). In fully adjusted multivariate models, patients with private health insurance did not have a higher chance to be admitted to an intensive care unit (odds ratio 0.97; 95% CI 0.63-1.50, p = 0.888), but they presented a lower death risk (hazard ratio 0.56; 95% CI 0.37-0.85, p = 0.006). CONCLUSION The type of health insurance did not influence the access of hemodialysis patients with COVID-19 to an intensive care unit, but patients with private health insurance had a lower mortality risk.
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Disparities in adult critical care resources across Pakistan: findings from a national survey and assessment using a novel scoring system. Crit Care 2022; 26:209. [PMID: 35818054 PMCID: PMC9272593 DOI: 10.1186/s13054-022-04046-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/26/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
In response to the COVID-19 pandemic, concerted efforts were made by provincial and federal governments to invest in critical care infrastructure and medical equipment to bridge the gap of resource-limitation in intensive care units (ICUs) across Pakistan. An initial step in creating a plan toward strengthening Pakistan’s baseline critical care capacity was to carry out a needs-assessment within the country to assess gaps and devise strategies for improving the quality of critical care facilities.
Methods
To assess the baseline critical care capacity of Pakistan, we conducted a series of cross-sectional surveys of hospitals providing COVID-19 care across the country. These hospitals were pre-identified by the Health Services Academy (HSA), Pakistan. Surveys were administered via telephonic and on-site interviews and based on a unique checklist for assessing critical care units which was created from the Partners in Health 4S Framework, which is: Space, Staff, Stuff, and Systems. These components were scored, weighted equally, and then ranked into quartiles.
Results
A total of 106 hospitals were surveyed, with the majority being in the public sector (71.7%) and in the metropolitan setting (56.6%). We found infrastructure, staffing, and systems lacking as only 19.8% of hospitals had negative pressure rooms and 44.4% had quarantine facilities for staff. Merely 36.8% of hospitals employed accredited intensivists and 54.8% of hospitals maintained an ideal nurse-to-patient ratio. 31.1% of hospitals did not have a staffing model, while 37.7% of hospitals did not have surge policies. On Chi-square analysis, statistically significant differences (p < 0.05) were noted between public and private sectors along with metropolitan versus rural settings in various elements. Almost all ranks showed significant disparity between public–private and metropolitan–rural settings, with private and metropolitan hospitals having a greater proportion in the 1st rank, while public and rural hospitals had a greater proportion in the lower ranks.
Conclusion
Pakistan has an underdeveloped critical care network with significant inequity between public–private and metropolitan–rural strata. We hope for future resource allocation and capacity development projects for critical care in order to reduce these disparities.
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Souza-Silva MVR, Ziegelmann PK, Nobre V, Gomes VMR, Etges APBDS, Schwarzbold AV, Nunes AGS, Maurílio ADO, Scotton ALBA, Costa ASDM, Glaeser AB, Farace BL, Ribeiro BN, Ramos CM, Cimini CCR, de Carvalho CA, Rempel C, Silveira DV, Carazai DDR, Ponce D, Pereira EC, Kroger EMS, Manenti ERF, Cenci EPDA, Lucas FB, dos Santos FC, Anschau F, Botoni FA, Aranha FG, de Aguiar FC, Bartolazzi F, Crestani GP, Vietta GG, Nascimento GF, Noal HC, Duani H, Vianna HR, Guimarães HC, de Alvarenga JC, Chatkin JM, de Morais JDP, Carvalho JDSN, Rugolo JM, Ruschel KB, Gomes LDBW, de Oliveira LS, Zandoná LB, Pinheiro LS, Pacheco LS, Menezes LDSM, Sousa LDD, de Moura LCS, Santos LEA, Nasi LA, Cabral MADS, Floriani MA, Souza MD, Carneiro M, de Godoy MF, Cardoso MMDA, Nogueira MCA, Lima MOSDS, de Figueiredo MP, Guimarães-Júnior MH, Sampaio NDCS, de Oliveira NR, Andrade PGS, Assaf PL, Martelli PJDL, Martins RC, Valacio RA, Pozza R, Menezes RM, Mourato RLS, de Abreu RM, Silva RDF, Francisco SC, Guimarães SMM, Araújo SF, Oliveira TF, Kurtz T, Fereguetti TO, de Oliveira TC, Ribeiro YCNMB, Ramires YC, Polanczyk CA, Marcolino MS. Hospital characteristics associated with COVID-19 mortality: data from the multicenter cohort Brazilian Registry. Intern Emerg Med 2022; 17:2299-2313. [PMID: 36153772 PMCID: PMC9510333 DOI: 10.1007/s11739-022-03092-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/30/2022] [Indexed: 11/27/2022]
Abstract
The COVID-19 pandemic caused unprecedented pressure over health care systems worldwide. Hospital-level data that may influence the prognosis in COVID-19 patients still needs to be better investigated. Therefore, this study analyzed regional socioeconomic, hospital, and intensive care units (ICU) characteristics associated with in-hospital mortality in COVID-19 patients admitted to Brazilian institutions. This multicenter retrospective cohort study is part of the Brazilian COVID-19 Registry. We enrolled patients ≥ 18 years old with laboratory-confirmed COVID-19 admitted to the participating hospitals from March to September 2020. Patients' data were obtained through hospital records. Hospitals' data were collected through forms filled in loco and through open national databases. Generalized linear mixed models with logit link function were used for pooling mortality and to assess the association between hospital characteristics and mortality estimates. We built two models, one tested general hospital characteristics while the other tested ICU characteristics. All analyses were adjusted for the proportion of high-risk patients at admission. Thirty-one hospitals were included. The mean number of beds was 320.4 ± 186.6. These hospitals had eligible 6556 COVID-19 admissions during the study period. Estimated in-hospital mortality ranged from 9.0 to 48.0%. The first model included all 31 hospitals and showed that a private source of funding (β = - 0.37; 95% CI - 0.71 to - 0.04; p = 0.029) and location in areas with a high gross domestic product (GDP) per capita (β = - 0.40; 95% CI - 0.72 to - 0.08; p = 0.014) were independently associated with a lower mortality. The second model included 23 hospitals and showed that hospitals with an ICU work shift composed of more than 50% of intensivists (β = - 0.59; 95% CI - 0.98 to - 0.20; p = 0.003) had lower mortality while hospitals with a higher proportion of less experienced medical professionals had higher mortality (β = 0.40; 95% CI 0.11-0.68; p = 0.006). The impact of those association increased according to the proportion of high-risk patients at admission. In-hospital mortality varied significantly among Brazilian hospitals. Private-funded hospitals and those located in municipalities with a high GDP had a lower mortality. When analyzing ICU-specific characteristics, hospitals with more experienced ICU teams had a reduced mortality.
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Affiliation(s)
- Maira Viana Rego Souza-Silva
- grid.8430.f0000 0001 2181 4888Medical School and University Hospital, Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190, sala 246, Belo Horizonte, Minas Gerais Brazil
| | - Patricia Klarmann Ziegelmann
- grid.8532.c0000 0001 2200 7498Departament of Statistics, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Rio Grande do Sul Brazil
| | - Vandack Nobre
- grid.8430.f0000 0001 2181 4888Medical School and University Hospital, Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190, sala 246, Belo Horizonte, Minas Gerais Brazil
| | - Virginia Mara Reis Gomes
- grid.411452.70000 0000 9898 6728Centro Universitário de Belo Horizonte (UniBH), Belo Horizonte, Minas Gerais Brazil
| | | | | | | | | | | | | | - Andressa Barreto Glaeser
- grid.414856.a0000 0004 0398 2134Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul Brazil
| | - Bárbara Lopes Farace
- grid.490178.3Hospital Risoleta Tolentino Neves, Belo Horizonte, Minas Gerais Brazil
| | | | | | | | | | - Claudete Rempel
- grid.441846.b0000 0000 9020 9633Universidade Do Vale Do Taquari, Lajeado, Rio Grande do Sul Brazil
| | | | | | - Daniela Ponce
- grid.410543.70000 0001 2188 478XMedical School, Universidade Estadual Paulista “Júlio de Mesquita Filho”, Botucatu, São Paulo Brazil
| | | | | | | | | | | | | | - Fernando Anschau
- grid.414914.dHospital Nossa Senhora da Conceição, Porto Alegre, Rio Grande do Sul Brazil
| | | | | | - Filipe Carrilho de Aguiar
- grid.411227.30000 0001 0670 7996University Hospital, Universidade Federal de Pernambuco, Recife, Pernambuco Brazil
| | | | - Gabriela Petry Crestani
- grid.414871.f0000 0004 0491 7596Hospital Mãe de Deus, Porto Alegre, Rio Grande do Sul Brazil
| | | | | | - Helena Carolina Noal
- grid.488599.10000 0004 0481 6891Hospital Universitário de Santa Maria, Santa Maria, Rio Grande do Sul Brazil
| | - Helena Duani
- grid.8430.f0000 0001 2181 4888Medical School and University Hospital, Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190, sala 246, Belo Horizonte, Minas Gerais Brazil
| | - Heloisa Reniers Vianna
- grid.419130.e0000 0004 0413 0953Faculdade de Ciências Médicas de Minas Gerais, University Hospital, Belo Horizonte, Minas Gerais Brazil
| | | | | | - José Miguel Chatkin
- grid.411379.90000 0001 2198 7041Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, Rio Grande do Sul Brazil
| | - Júlia Drumond Parreiras de Morais
- grid.419130.e0000 0004 0413 0953Faculdade de Ciências Médicas de Minas Gerais, University Hospital, Belo Horizonte, Minas Gerais Brazil
| | | | - Juliana Machado Rugolo
- grid.410543.70000 0001 2188 478XHospital das Clínicas da Faculdade de Medicina de Botucatu, Botucatu, São Paulo Brazil
| | - Karen Brasil Ruschel
- grid.414871.f0000 0004 0491 7596Hospital Mãe de Deus, Porto Alegre, Rio Grande do Sul Brazil
| | | | | | - Liege Barella Zandoná
- grid.441846.b0000 0000 9020 9633Universidade Do Vale Do Taquari, Lajeado, Rio Grande do Sul Brazil
| | - Lílian Santos Pinheiro
- grid.411287.90000 0004 0643 9823Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Teófilo Otoni, Minas Gerais Brazil
| | - Liliane Souto Pacheco
- grid.488599.10000 0004 0481 6891Hospital Universitário de Santa Maria, Santa Maria, Rio Grande do Sul Brazil
| | - Luanna da Silva Monteiro Menezes
- grid.8430.f0000 0001 2181 4888Medical School and University Hospital, Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190, sala 246, Belo Horizonte, Minas Gerais Brazil
| | | | | | - Luisa Elem Almeida Santos
- grid.441942.e0000 0004 0490 8155Centro Universitário de Patos de Minas, Patos de Minas, Minas Gerais Brazil
| | - Luiz Antonio Nasi
- grid.414856.a0000 0004 0398 2134Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul Brazil
| | - Máderson Alvares de Souza Cabral
- grid.8430.f0000 0001 2181 4888Medical School and University Hospital, Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190, sala 246, Belo Horizonte, Minas Gerais Brazil
| | - Maiara Anschau Floriani
- grid.414856.a0000 0004 0398 2134Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul Brazil
| | - Maíra Dias Souza
- Hospital Metropolitano Odilon Behrens, Belo Horizonte, Minas Gerais Brazil
| | - Marcelo Carneiro
- Hospital Santa Cruz, Santa Cruz do Sul, Rio Grande do Sul Brazil
| | - Mariana Frizzo de Godoy
- grid.411379.90000 0001 2198 7041Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, Rio Grande do Sul Brazil
| | | | | | | | | | | | | | - Neimy Ramos de Oliveira
- grid.452464.50000 0000 9270 1314Hospital Eduardo de Menezes, Belo Horizonte, Minas Gerais Brazil
| | | | - Pedro Ledic Assaf
- Hospital Metropolitano Doutor Célio de Castro, Belo Horizonte, Minas Gerais Brazil
| | | | | | | | - Roberta Pozza
- Hospital Tacchini, Bento Gonçalves, Rio Grande do Sul Brazil
| | | | | | | | | | | | | | | | | | - Tatiana Kurtz
- Hospital Santa Cruz, Santa Cruz do Sul, Rio Grande do Sul Brazil
| | | | | | | | | | - Carísi Anne Polanczyk
- Institute for Health Technology Assessment (IATS/ CNPq), Porto Alegre, Rio Grande do Sul Brazil
- grid.8532.c0000 0001 2200 7498Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul Brazil
| | - Milena Soriano Marcolino
- grid.8430.f0000 0001 2181 4888Medical School and University Hospital, Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190, sala 246, Belo Horizonte, Minas Gerais Brazil
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Silva LMFD, Diogo LP, Vieira LB, Michielin FDC, Santarem MD, Machado MLP. Performance of scores in the prediction of clinical outcomes in patients admitted from the emergency service. Rev Lat Am Enfermagem 2021; 29:e3479. [PMID: 34495190 PMCID: PMC8432508 DOI: 10.1590/1518-8345.4722.3479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 04/17/2021] [Indexed: 11/24/2022] Open
Abstract
Objective: to evaluate the performance of the quickSOFA scores and Systemic Inflammatory Response Syndrome as predictors of clinical outcomes in patients admitted to an emergency service. Method: a retrospective cohort study, involving adult clinical patients admitted to the emergency service. Analysis of the ROC curve was performed to assess the prognostic indexes between scores and outcomes of interest. Multivariate analysis used Poisson regression with robust variance, evaluating the relationship between variables with biological plausibility and outcomes. Results: 122 patients were selected, 58.2% developed sepsis. Of these, 44.3% had quickSOFA ≥2 points, 87% developed sepsis, 55.6% septic shock and 38.9% died. In the evaluation of Systemic Inflammatory Response Syndrome, 78.5% obtained results >2 points; of these, 66.3% developed sepsis, 40% septic shock and 29.5% died. quickSOFA ≥2 showed greater specificity for diagnosis of sepsis in 86% of the cases, for septic shock 70% and for mortality 64%, whereas the second score showed better results for sensitivity with diagnosis of sepsis in 87.5%, septic shock in 92.7% and death in 90.3%. Conclusion: quickSOFA showed by its practicality that it can be used clinically within the emergency services, bringing clinical applicability from the risk classification of patients for the early recognition of unfavorable outcomes.
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Nedel WL, Kopczynski A, Rodolphi MS, Strogulski NR, De Bastiani M, Montes THM, Abruzzi J, Galina A, Horvath TL, Portela LV. Mortality of septic shock patients is associated with impaired mitochondrial oxidative coupling efficiency in lymphocytes: a prospective cohort study. Intensive Care Med Exp 2021; 9:39. [PMID: 34304333 PMCID: PMC8310546 DOI: 10.1186/s40635-021-00404-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/10/2021] [Indexed: 12/16/2022] Open
Abstract
Background Septic shock is a life-threatening condition that challenges immune cells to reprogram their mitochondrial metabolism towards to increase ATP synthesis for building an appropriate immunity. This could print metabolic signatures in mitochondria whose association with disease progression and clinical outcomes remain elusive. Method This is a single-center prospective cohort study performed in the ICU of one tertiary referral hospital in Brazil. Between November 2017 and July 2018, 90 consecutive patients, aged 18 years or older, admitted to the ICU with septic shock were enrolled. Seventy-five patients had Simplified Acute Physiology Score (SAPS 3) assessed at admission, and Sequential Organ Failure Assessment (SOFA) assessed on the first (D1) and third (D3) days after admission. Mitochondrial respiration linked to complexes I, II, V, and biochemical coupling efficiency (BCE) were assessed at D1 and D3 and Δ (D3–D1) in isolated lymphocytes. Clinical and mitochondrial endpoints were used to dichotomize the survival and death outcomes. Our primary outcome was 6-month mortality, and secondary outcomes were ICU and hospital ward mortality. Results The mean SAPS 3 and SOFA scores at septic shock diagnosis were 75.8 (± 12.9) and 8 (± 3) points, respectively. The cumulative ICU, hospital ward, and 6-month mortality were 32 (45%), 43 (57%), and 50 (66%), respectively. At the ICU, non-surviving patients presented elevated arterial lactate (2.8 mmol/L, IQR, 2–4), C-reactive protein (220 mg/L, IQR, 119–284), and capillary refill time (5.5 s, IQR, 3–8). Respiratory rates linked to CII at D1 and D3, and ΔCII were decreased in non-surviving patients. Also, the BCE at D1 and D3 and the ΔBCE discriminated patients who would evolve to death in the ICU, hospital ward, and 6 months after admission. After adjusting for possible confounders, the ΔBCE value but not SOFA scores was independently associated with 6-month mortality (RR 0.38, CI 95% 0.18–0.78; P = 0.009). At a cut-off of − 0.002, ΔBCE displayed 100% sensitivity and 73% specificity for predicting 6-month mortality Conclusions The ΔBCE signature in lymphocytes provided an earlier recognition of septic shock patients in the ICU at risk of long-term deterioration of health status. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-021-00404-9.
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Affiliation(s)
- Wagner Luis Nedel
- Laboratory of Neurotrauma and Biomarkers, Departamento de Bioquímica, Programa de Pós-Graduação em Bioquímica, ICBS, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600, anexo, Porto Alegre, RS, Brazil.,Intensive Care Unit, Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
| | - Afonso Kopczynski
- Laboratory of Neurotrauma and Biomarkers, Departamento de Bioquímica, Programa de Pós-Graduação em Bioquímica, ICBS, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600, anexo, Porto Alegre, RS, Brazil
| | - Marcelo Salimen Rodolphi
- Laboratory of Neurotrauma and Biomarkers, Departamento de Bioquímica, Programa de Pós-Graduação em Bioquímica, ICBS, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600, anexo, Porto Alegre, RS, Brazil
| | - Nathan Ryzewski Strogulski
- Laboratory of Neurotrauma and Biomarkers, Departamento de Bioquímica, Programa de Pós-Graduação em Bioquímica, ICBS, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600, anexo, Porto Alegre, RS, Brazil
| | - Marco De Bastiani
- Zimmer Lab, Departamento de Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Tiago Hermes Maeso Montes
- Intensive Care Unit, Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
| | - Jose Abruzzi
- Intensive Care Unit, Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
| | - Antonio Galina
- Laboratory of Bioenergetics and Mitochondrial Physiology, Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Tamas L Horvath
- Program in Integrative Cell Signaling and Neurobiology of Metabolism, Department of Comparative Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Luis Valmor Portela
- Laboratory of Neurotrauma and Biomarkers, Departamento de Bioquímica, Programa de Pós-Graduação em Bioquímica, ICBS, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600, anexo, Porto Alegre, RS, Brazil.
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10
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Souza DC, Barreira ER, Shieh HH, Ventura AMC, Bousso A, Troster EJ. Prevalence and outcomes of sepsis in children admitted to public and private hospitals in Latin America: a multicenter observational study. Rev Bras Ter Intensiva 2021; 33:231-242. [PMID: 34231803 PMCID: PMC8275081 DOI: 10.5935/0103-507x.20210030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 06/25/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To report the prevalence and outcomes of sepsis in children admitted to public and private hospitals. METHODS Post hoc analysis of the Latin American Pediatric Sepsis Study (LAPSES) data, a cohort study that analyzed the prevalence and outcomes of sepsis in critically ill children with sepsis on admission at 21 pediatric intensive care units in five Latin American countries. RESULTS Of the 464 sepsis patients, 369 (79.5%) were admitted to public hospitals and 95 (20.5%) to private hospitals. Compared to those admitted to private hospitals, sepsis patients admitted to public hospitals did not differ in age, sex, immunization status, hospital length of stay or type of admission but had higher rates of septic shock, higher Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality 2 (PIM 2), and Pediatric Logistic Organ Dysfunction (PELOD) scores, and higher rates of underlying diseases and maternal illiteracy. The proportion of patients admitted from pediatric wards and sepsis-related mortality were higher in public hospitals. Multivariate analysis did not show any correlation between mortality and the type of hospital, but mortality was associated with greater severity on pediatric intensive care unit admission in patients from public hospitals. CONCLUSION In this sample of critically ill children from five countries in Latin America, the prevalence of septic shock within the first 24 hours at admission and sepsis-related mortality were higher in public hospitals than in private hospitals. Higher sepsis-related mortality in children admitted to public pediatric intensive care units was associated with greater severity on pediatric intensive care unit admission but not with the type of hospital. New studies will be necessary to elucidate the causes of the higher prevalence and mortality of pediatric sepsis in public hospitals.
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Affiliation(s)
- Daniela Carla Souza
- Unidade de Terapia Intensiva Pediátrica, Hospital Universitário, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Pediátrica, Hospital Sírio-Libanês - São Paulo (SP), Brasil
| | - Eliane Roseli Barreira
- Unidade de Terapia Intensiva Pediátrica, Hospital Universitário, Universidade de São Paulo - São Paulo (SP), Brasil.,Departamento de Emergência, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Huei Hsin Shieh
- Unidade de Terapia Intensiva Pediátrica, Hospital Universitário, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - Albert Bousso
- Departamento de Pediatria, Escola Médica, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Hospital Municipal Vila Santa Catarina - São Paulo (SP), Brasil
| | - Eduardo Juan Troster
- Departamento de Medicina, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Pediátrica, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
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11
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Provenzano BC, Bartholo T, Ribeiro-Alves M, Santos APGD, Mafort TT, Castro MCSD, Oliveira JGPD, Bruno LP, Lopes AJ, Costa CHD, Rufino R. The impact of healthcare-associated infections on COVID-19 mortality: a cohort study from a Brazilian public hospital. Rev Assoc Med Bras (1992) 2021; 67:997-1002. [DOI: 10.1590/1806-9282.20210433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/30/2021] [Indexed: 11/21/2022] Open
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12
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Gritte RB, Souza-Siqueira T, Curi R, Machado MCC, Soriano FG. Why Septic Patients Remain Sick After Hospital Discharge? Front Immunol 2021; 11:605666. [PMID: 33658992 PMCID: PMC7917203 DOI: 10.3389/fimmu.2020.605666] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/29/2020] [Indexed: 12/29/2022] Open
Abstract
Sepsis is well known to cause a high patient death rate (up to 50%) during the intensive care unit (ICU) stay. In addition, sepsis survival patients also exhibit a very high death rate after hospital discharge compared to patients with any other disease. The addressed question is then: why septic patients remain ill after hospital discharge? The cellular and molecular mechanisms involved in the high rate of septic patient deaths are still unknown. We described herein the studies that investigated the percentage of septic patients that died after hospital discharge ranging from 90 days up to 5 years. We also reported the symptoms of septic patients after hospital discharge and the development of the recently called post-sepsis syndrome (PSS). The most common symptoms of the PSS are cognitive disabilities, physical functioning decline, difficulties in performing routine daily activities, and poor life quality. The PSS also associates with quite often reinfection and re-hospitalization. This condition is the cause of the high rate of death mentioned above. We reported the proportion of patients dying after hospital discharge up to 5 years of followed up and the PSS symptoms associated. The authors also discuss the possible cellular and metabolic reprogramming mechanisms related with the low survival of septic patients and the occurrence of PSS.
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Affiliation(s)
- Raquel Bragante Gritte
- Interdisciplinary Post-Graduate Program in Health Sciences, Cruzeiro do Sul University, Sao Paulo, Brazil
| | - Talita Souza-Siqueira
- Interdisciplinary Post-Graduate Program in Health Sciences, Cruzeiro do Sul University, Sao Paulo, Brazil
| | - Rui Curi
- Interdisciplinary Post-Graduate Program in Health Sciences, Cruzeiro do Sul University, Sao Paulo, Brazil.,Immunobiological Production Section, Bioindustrial Center, Butantan Institute, São Paulo, Brazil
| | | | - Francisco Garcia Soriano
- University Hospital, University of São Paulo, São Paulo, Brazil.,Internal Medicine Department, School of Medicine, University of São Paulo, São Paulo, Brazil
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13
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Rudd KE, Hantrakun V, Somayaji R, Booraphun S, Boonsri C, Fitzpatrick AL, Day NPJ, Teparrukkul P, Limmathurotsakul D, West TE. Early management of sepsis in medical patients in rural Thailand: a single-center prospective observational study. J Intensive Care 2019; 7:55. [PMID: 31827803 PMCID: PMC6886203 DOI: 10.1186/s40560-019-0407-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/14/2019] [Indexed: 02/07/2023] Open
Abstract
Background The burden of sepsis is highest in low- and middle-income countries, though the management of sepsis in these settings is poorly characterized. Therefore, the objective of this study was to assess the early management of sepsis in Thailand. Methods Pre-planned analysis of the Ubon-sepsis study, a single-center prospective cohort study of Thai adults admitted to the general medical wards and medical intensive care units (ICUs) of a regional referral hospital with community-acquired sepsis. Results Between March 2013 and January 2017, 3,716 patients with sepsis were enrolled. The median age was 59 years (IQR 44-72, range 18-101), 58% were male, and 88% were transferred from other hospitals. Eighty-six percent of patients (N = 3,206) were evaluated in the Emergency Department (ED), where median length of stay was less than 1 hour. Within the first day of admission, most patients (83%, N = 3,089) were admitted to the general medical wards, while 17% were admitted to the ICUs. Patients admitted to the ICUs had similar age, gender, and comorbidities, but had more organ dysfunction and were more likely to receive measured sepsis management interventions. Overall, 84% (N = 3,136) had blood cultures ordered and 89% (N = 3,308) received antibiotics within the first day of hospital admission. Among the 3,089 patients admitted to the general medical wards, 38% (N = 1,165) received an adrenergic agent, and 21% (N = 650) received invasive mechanical ventilation. Overall mortality at 28 days was 21% (765/3,716), and 28-day mortality in patients admitted to the ICUs was higher than that in patients admitted to the general medical wards within the first day (42% [263/627] vs. 16% [502/3,089], p < 0.001). Conclusions Sepsis in a regional referral hospital in rural Thailand, where some critical care resources are limited, is commonly managed on general medical wards despite high rates of respiratory failure and shock. Enhancing sepsis care in the ED and general wards, as well as improving access to ICUs, may be beneficial in reducing mortality. Trial registration The Ubon-sepsis study was registered on clinicaltrials.gov (NCT02217592).
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Affiliation(s)
- Kristina E Rudd
- 1International Respiratory and Severe Illness Center, University of Washington, Seattle, WA USA.,2Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA USA.,3Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Viriya Hantrakun
- 4Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand
| | - Ranjani Somayaji
- 2Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA USA.,5Department of Medicine, The University of Calgary, Calgary, Alberta Canada
| | | | | | - Annette L Fitzpatrick
- 7Departments of Family Medicine, Epidemiology, and Global Health, University of Washington, Seattle, WA USA
| | - Nicholas P J Day
- 4Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand.,8Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Direk Limmathurotsakul
- 4Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand.,8Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - T Eoin West
- 1International Respiratory and Severe Illness Center, University of Washington, Seattle, WA USA.,2Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA USA
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14
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Chen K, Shi X, Jin Y, Wang F, Shen Q, Xu W. High lncRNA MEG3 expression is associated with high mortality rates in patients with sepsis and increased lipopolysaccharide-induced renal epithelial cell and cardiomyocyte apoptosis. Exp Ther Med 2019; 18:3943-3947. [PMID: 31641380 PMCID: PMC6796421 DOI: 10.3892/etm.2019.8049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 06/13/2019] [Indexed: 12/29/2022] Open
Abstract
Long non-coding RNA (lncRNA) maternally expressed 3 (MEG3) has been reported to be a key component in cancer biology. Preliminary microarray data from a previous study indicated that lncRNA MEG3 expression was altered in plasma of patients with sepsis. The present study found that the plasma levels of lncRNA MEG3 were significantly higher in sepsis patients compared with healthy controls. Patients were subsequently divided into high and low lncRNA MEG3 expression groups according to the Youden's index. Patients from the high lncRNA MEG3 expression group exhibited a significantly higher mortality rate compared with those from the low lncRNA MEG3 expression group. According to treatment outcomes, patients were divided into survival and mortality groups. It was observed that the pre-therapy expression levels of lncRNA MEG3 were significantly higher in mortality group compared with the survival group. Cell experiments in vitro revealed that lncRNA MEG3 overexpression and silencing using siRNA promoted and inhibited renal epithelial cell and cardiomyocyte apoptosis induced by lipopolysaccharide, respectively. In conclusion, these data suggest that lncRNA MEG3 overexpression may be involved in sepsis, and the downregulation of lncRNA MEG3 may serve as a potential therapeutic target for sepsis.
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Affiliation(s)
- Kang Chen
- Department of Emergency Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 201400, P.R. China
| | - Xiaojun Shi
- Department of Emergency Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 201400, P.R. China
| | - Ye Jin
- Department of Emergency Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 201400, P.R. China
| | - Feng Wang
- Department of Emergency Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 201400, P.R. China
| | - Qing Shen
- Department of Emergency Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 201400, P.R. China
| | - Weiming Xu
- Department of Emergency Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 201400, P.R. China
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15
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Leoncio JM, Almeida VFD, Ferrari RAP, Capobiango JD, Kerbauy G, Tacla MTGM. Impact of healthcare-associated infections on the hospitalization costs of children. Rev Esc Enferm USP 2019; 53:e03486. [PMID: 31433016 DOI: 10.1590/s1980-220x2018016303486] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 10/26/2018] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To evaluate the impact of Healthcare-Associated Infections on the hospitalization cost of children. METHOD A prospective, quantitative cohort study involving children admitted to the Inpatient and Pediatric Intensive Care Units of a public university hospital. The data were analyzed through SPSS software by frequency distribution, central tendency measures and dispersion. The level of statistical significance was set at p<0.05 for all analyzes. RESULTS The sample consisted of 173 children, of whom 18.5% developed Healthcare-Associated Infections, which increased the hospitalization costs 4.2 times (p<0.001). A greater cost impact was observed among patients with two or more infectious sites (R$81,037.57; p=0.010) and sepsis (R$46,315.63; p<0.001). Children colonized by multiresistant microorganisms with a prevalence of E. coli and A. baumannii ESBL also generated higher costs of R$35,206.15 and R$30,692.52, respectively. CONCLUSION Healthcare-Associated Infections significantly increased the hospitalization costs for children, especially among those with more than two infectious sites, who developed sepsis or were colonized by multiresistant microorganisms.
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Affiliation(s)
| | - Vanessa Fraga de Almeida
- Universidade Estadual de Londrina, Residência em Enfermagem em Infectologia, Londrina PR, Brasil
| | | | | | - Gilselena Kerbauy
- Universidade Estadual de Londrina, Departamento de Enfermagem, Londrina, PR, Brasil
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16
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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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17
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Morello LG, Dalla-Costa LM, Fontana RM, Netto ACSDO, Petterle RR, Conte D, Pereira LA, Krieger MA, Raboni SM. Assessment of clinical and epidemiological characteristics of patients with and without sepsis in intensive care units of a tertiary hospital. EINSTEIN-SAO PAULO 2019; 17:eAO4476. [PMID: 30994701 PMCID: PMC6459321 DOI: 10.31744/einstein_journal/2019ao4476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 11/12/2018] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To describe the clinical and epidemiological features of patients with and without sepsis at critical care units of a public hospital. METHODS A cross-sectional study was carried out from May 2012 to April 2013. Clinical and laboratory data of patients with and without sepsis in the intensive care units were reviewed of medical records. RESULTS We evaluated 466 patients, 58% were men, median age was 40 years, and 146 (31%) of them were diagnosed with sepsis. The overall mortality was 20% being significantly higher for patients with sepsis (39%). The factors associated with intensive care unit mortality were the presence of sepsis (OR: 6.1, 95%CI: 3.7-10.5), age (OR: 3.6, 95%CI: 1.4-7.2), and length of hospital stay (OR: 0.96, 95%CI: 0.94-0.98). Pulmonary (49%) and intra-abdominal (20%) infections were most commonly identified sites, and coagulase-negative staphylococci and enteric Gram negative bacilli the most frequent (66%) pathogens isolated. CONCLUSION Although the impact of sepsis on mortality is related to patients' clinical and epidemiological characteristics, a critical evaluation of these data is important since they will allow the direct implementation of local policies for managing this serious public health problem.
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Affiliation(s)
| | | | | | | | | | - Danieli Conte
- Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | | | | | - Sonia Mara Raboni
- Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
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18
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Bahlis LF, Diogo LP, Kuchenbecker RDS, Fuchs SC. Clinical, epidemiological, and etiological profile of inpatients with community-acquired pneumonia in a public hospital in the interior of Brazil. ACTA ACUST UNITED AC 2019; 44:261-266. [PMID: 30328925 PMCID: PMC6326715 DOI: 10.1590/s1806-37562017000000434] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/18/2018] [Indexed: 02/05/2023]
Abstract
Objective: To describe the patient profile, mortality rates, the accuracy of prognostic scores, and mortality-associated factors in patients with community-acquired pneumonia (CAP) in a general hospital in Brazil. Methods: This was a cohort study involving patients with a clinical and laboratory diagnosis of CAP and requiring admission to a public hospital in the interior of Brazil between March 2014 and April 2015. We performed multivariate analysis using a Poisson regression model with robust variance to identify factors associated with in-hospital mortality. Results: We included 304 patients. Approximately 70% of the patients were classified as severely ill on the basis of the severity criteria used. The mortality rate was 15.5%, and the ICU admission rate was 29.3%. After multivariate analysis, the factors associated with in-hospital mortality were need for mechanical ventilation (OR: 3.60; 95% CI: 1.85-7.47); a Charlson Comorbidity Index score > 3 (OR: 1.30; 95% CI: 1.18-1.43); and a mental Confusion, Urea, Respiratory rate, Blood pressure, and age > 65 years (CURB-65) score > 2 (OR: 1.46; 95% CI: 1.09-1.98). The mean time from patient arrival at the emergency room to initiation of antibiotic therapy was 10 h. Conclusions: The in-hospital mortality rate of 15.5% and the need for ICU admission in almost one third of the patients reflect the major impact of CAP on patients and the health care system. Individuals with a high burden of comorbidities, a high CURB-65 score, and a need for mechanical ventilation had a worse prognosis. Measures to reduce the time to initiation of antibiotic therapy may result in better outcomes in this group of patients.
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Affiliation(s)
- Laura Fuchs Bahlis
- . Faculdade de Medicina, Universidade do Vale do Rio dos Sinos, Campus São Leopoldo, São Leopoldo (RS) Brasil.,. Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil.,. Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil
| | | | | | - Sandra Costa Fuchs
- . Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
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Zampieri FG, Araújo F, Santos RHN, Cavalcanti AB. Existing capacity for renal replacement therapy and site-specific practices for managing acute kidney injury at centers participating in the BaSICS trial. Rev Bras Ter Intensiva 2018; 30:264-285. [PMID: 30328984 PMCID: PMC6180470 DOI: 10.5935/0103-507x.20180058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/25/2018] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To investigate the existing capacity for renal replacement therapy and site-specific practices for managing acute kidney injury at centers participating in the BaSICS trial. METHODS A questionnaire was provided to the chairs of 61 intensive care units enrolled in a randomized clinical trial in Brazil. A total of 124 physicians completed the questionnaire. RESULTS Approximately 15% of the patients admitted to the analyzed intensive care units received renal replacement therapy at the time of data collection. At least one renal replacement method was available in all of the analyzed units. Continuous methods were available more frequently at the private units than at the public units. The time from indication to onset of treatment was longer at the public units than at private units. The main obstacles to treatment initiation at public intensive care units were related to the availability of equipment and personnel, while the main bottleneck at private units was the nephrologist assessment. A considerable proportion of the participants stated that they would change their approach to renal replacement therapy if there were no limitations on the availability of methods in their units. CONCLUSION There was wide variation in the availability of resources for renal replacement therapy and in the management of acute kidney injury in Brazilian intensive care units. This information should be taken into account when planning clinical trials focused on this topic in Brazil.
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Affiliation(s)
| | - Flavio Araújo
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
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Maekawa H, Negishi K. Extended Sessions of Polymyxin-B Immobilized Fiber Column Hemoperfusion Ameliorate Renal Outcome and Mortality in Septic Shock with Acute Kidney Injury. Blood Purif 2018; 46:81-89. [DOI: 10.1159/000488639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 03/19/2018] [Indexed: 12/21/2022]
Abstract
Background/Aims: Polymyxin-B (PMX) treatment has been reported to decrease mortality in patients with septic shock and acute kidney injury (AKI). In this study, we aimed to evaluate whether extended sessions of PMX (Ext-PMX) immobilized fiber column hemoperfusion ameliorate clinical outcomes in patients complicated with septic shock and AKI without surgical control. Methods: Twenty-two patients with nonsurgical septic shock and AKI who received PMX were included. They were divided according to the duration of PMX treatment: Ext-PMX and standard PMX (Std-PMX). Results: The mean blood pressure increased and inotrope requirement decreased within 24 h after PMX initiation. The median value of predicted mortality was 52.5%, and the 28-day mortalities in the Ext-PMX and Std-PMX groups were 44.4 and 75% respectively. Renal replacement therapy (RRT) was also initiated in 17 patients, and renal insufficiency was recovered. Conclusion: Ext-PMX combined with RRT improved clinical outcomes in patients with nonsurgical septic shock and AKI.
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Epidemiology of sepsis in Brazil: Incidence, lethality, costs, and other indicators for Brazilian Unified Health System hospitalizations from 2006 to 2015. PLoS One 2018; 13:e0195873. [PMID: 29652944 PMCID: PMC5898754 DOI: 10.1371/journal.pone.0195873] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/30/2018] [Indexed: 12/20/2022] Open
Abstract
Background Sepsis is considered a major worldwide health burden, with high mortality and associated costs. Health indicators are essential to define strategies to improve the treatment of diseases, and the epidemiology information of sepsis in developing countries is scarce. Thus, the aim of this work is to assess trends in the incidence, lethality, costs, and other indicators of sepsis for Brazilian Unified Health System (SUS—Sistema Único de Saúde) hospitalizations for the period from January 2006 to December 2015. Materials and methods We conducted this study using data from the SUS hospital information system. We selected registries of SUS hospitalizations of patients diagnosed with sepsis (total of 724,458 cases from 4,271 public and private Brazilian hospitals). Results From 2006 to 2015, the annual sepsis incidence increased 50.5% from 31.5/100,000 to 47.4/100,000 persons. The mean hospital length of stay (LOS) was 9.0 days. A total of 29.1% of the hospitalizations had admission to the intensive care unit (ICU) with a mean ICU LOS of 8.0 days. The mean cost per hospitalization was US$624.0 and for hospitalizations requiring intensive care was U$1,708.1. The overall sepsis lethality rate was 46.3%, and for hospitalizations with admission to the ICU, it was 64.5%. During the study period, the lethality rate for children/teenagers decreased 40.1%, but for all other age groups it increased 11.4%. The sepsis lethality rate in public hospitals (55.5%) was higher than private hospitals (37.0%) (p < 0.001). The mean hospitalization LOS for public hospitals (10.3 days) was higher than private hospitals (7.6 days) (p < 0.001). Conclusions The incidence and lethality rate of sepsis increased in SUS hospitalizations during the study period. The SUS’s low reimbursement to hospitals for treating sepsis may be one of the reasons for the high lethality rate.
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Real JM, Ferreira LRP, Esteves GH, Koyama FC, Dias MVS, Bezerra-Neto JE, Cunha-Neto E, Machado FR, Salomão R, Azevedo LCP. Exosomes from patients with septic shock convey miRNAs related to inflammation and cell cycle regulation: new signaling pathways in sepsis? Crit Care 2018. [PMID: 29540208 PMCID: PMC5852953 DOI: 10.1186/s13054-018-2003-3] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Exosomes isolated from plasma of patients with sepsis may induce vascular apoptosis and myocardial dysfunction by mechanisms related to inflammation and oxidative stress. Despite previous studies demonstrating that these vesicles contain genetic material related to cellular communication, their molecular cargo during sepsis is relatively unknown. In this study, we evaluated the presence of microRNAs (miRNAs) and messenger RNAs (mRNAs) related to inflammatory response and redox metabolism in exosomes of patients with septic shock. Methods Blood samples were collected from 24 patients with septic shock at ICU admission and after 7 days of treatment. Twelve healthy volunteers were used as control subjects. Exosomes were isolated by ultracentrifugation, and their miRNA and mRNA content was evaluated by qRT-PCR array. Results As compared with healthy volunteers, exosomes from patients with sepsis had significant changes in 65 exosomal miRNAs. Twenty-eight miRNAs were differentially expressed, both at enrollment and after 7 days, with similar kinetics (18 miRNAs upregulated and 10 downregulated). At enrollment, 35 differentially expressed miRNAs clustered patients with sepsis according to survival. The pathways enriched by the miRNAs of patients with sepsis compared with control subjects were related mostly to inflammatory response. The comparison of miRNAs from patients with sepsis according to hospital survival demonstrated pathways related mostly to cell cycle regulation. At enrollment, sepsis was associated with significant increases in the expression of mRNAs related to redox metabolism (myeloperoxidase, 64-fold; PRDX3, 2.6-fold; SOD2, 2.2-fold) and redox-responsive genes (FOXM1, 21-fold; SELS, 16-fold; GLRX2, 3.4-fold). The expression of myeloperoxidase mRNA remained elevated after 7 days (65-fold). Conclusions Exosomes from patients with septic shock convey miRNAs and mRNAs related to pathogenic pathways, including inflammatory response, oxidative stress, and cell cycle regulation. Exosomes may represent a novel mechanism for intercellular communication during sepsis. Electronic supplementary material The online version of this article (10.1186/s13054-018-2003-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Juliana Monte Real
- Research and Education Institute, Hospital Sirio-Libanes, Rua Professor Daher Cutait 69, São Paulo, SP, 01539-001, Brazil.,Sao Paulo State Cancer Institute, University of São Paulo, São Paulo, Brazil.,Hospital do Servidor Publico Estadual de São Paulo, São Paulo, Brazil
| | - Ludmila Rodrigues Pinto Ferreira
- Morphology Department, Instituto de Ciencias Biologicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Laboratory of Immunology, Heart Institute, University of São Paulo, School of Medicine, São Paulo, Brazil
| | | | - Fernanda Christtanini Koyama
- Research and Education Institute, Hospital Sirio-Libanes, Rua Professor Daher Cutait 69, São Paulo, SP, 01539-001, Brazil.,Ludwig Institute for Cancer Research, São Paulo, Brazil
| | | | | | - Edécio Cunha-Neto
- Laboratory of Immunology, Heart Institute, University of São Paulo, School of Medicine, São Paulo, Brazil.,Division of Clinical Immunology and Allergy, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | | | - Luciano Cesar Pontes Azevedo
- Research and Education Institute, Hospital Sirio-Libanes, Rua Professor Daher Cutait 69, São Paulo, SP, 01539-001, Brazil. .,Emergency Medicine, University of São Paulo, São Paulo, Brazil.
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Freitas FGR, Lombardi F, Pacheco ES, Sandes-Freitas TVD, Viana LA, Junior HTS, Medina-Pestana JO, Bafi AT, Machado FR. Clinical Features of Kidney Transplant Recipients Admitted to the Intensive Care Unit. Prog Transplant 2017; 28:56-62. [PMID: 29258377 DOI: 10.1177/1526924817746685] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION There is a paucity of data regarding the complications in kidney transplant patients who may require intensive care unit (ICU) management, despite being the most common solid organ transplant worldwide. OBJECTIVE To identify the main reasons for ICU admission and to determine the factors associated with hospital mortality in kidney transplant recipients. DESIGN This single-center retrospective cohort study was conducted between September 2013 and June 2014, including all consecutive kidney transplant patients requiring ICU admission. We collected data on patient demographics, transplant characteristics, clinical data, and prognostic scores. The independent determinants of hospital mortality were identified by multiple logistic regression analysis. We also assessed the performance of Simplified Acute Physiology Score 3 (SAPS 3) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. RESULTS We analyzed data from 413 patients, the majority of whom were admitted late after renal transplantation (1169 days; 63-3003 days). The main reason for admission was sepsis (33.2%), followed by cardiovascular disease (16%). Age (odds ratio [OR] 1.05, confidence interval [CI], 1.01-1.09), SAPS 3 score (OR 1.04, CI, 1.01-1.08), the need for mechanical ventilation (OR 26.47, CI, 10.30-68.08), and vasopressor use (OR 3.34, CI, 1.37-8.13) were independently associated with hospital mortality. The performance of SAPS 3 and APACHE II scores was poor in this population and overestimated the mortality rates. CONCLUSION Sepsis was the main reason for ICU admission in kidney transplant recipients, followed by cardiovascular disease. Age and disease severity were associated with hospital mortality.
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Affiliation(s)
- Flávio Geraldo Rezende Freitas
- 1 Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, São Paulo, Brazil.,2 Unidade de Transplante, Disciplina de Nefrologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Fábio Lombardi
- 1 Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Eduardo Souza Pacheco
- 1 Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Laila Almeida Viana
- 2 Unidade de Transplante, Disciplina de Nefrologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Hélio Tedesco-Silva Junior
- 2 Unidade de Transplante, Disciplina de Nefrologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - José Osmar Medina-Pestana
- 2 Unidade de Transplante, Disciplina de Nefrologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Antônio Tonete Bafi
- 1 Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, São Paulo, Brazil.,2 Unidade de Transplante, Disciplina de Nefrologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Flavia Ribeiro Machado
- 1 Disciplina de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, São Paulo, Brazil
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Health Care Disparities Among English-Speaking and Spanish-Speaking Women With Pelvic Organ Prolapse at Public and Private Hospitals: What Are the Barriers? Female Pelvic Med Reconstr Surg 2017; 22:460-466. [PMID: 27636216 DOI: 10.1097/spv.0000000000000315] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study was to compare perceptions and barriers between Spanish-speaking and English-speaking women in public and private hospitals being treated for pelvic organ prolapse (POP). METHODS Eight focus groups, 4 in English and 4 in Spanish, were conducted at 3 institutions with care in female pelvic medicine and reconstructive surgery. Standardized questions were asked regarding patients' emotions to when they initially noticed the POP, if they sought family support, and their response to the diagnosis and treatment. Transcripts were analyzed using grounded theory qualitative methods. RESULTS Thirty-three women were Spanish-speaking and 25 were English-speaking. Spanish speakers were younger (P = 0.0469) and less likely to have a high school diploma (P < 0.0001) than English speakers. Spanish-speaking women had more concerns that the bulge or treatments could lead to cancer, were more resistant to treatment options, and were less likely to be offered surgery. Women in the private hospital desired more information, were less embarrassed, and were more likely to be offered surgery as first-line treatment. The concept emerged that patient care for POP varied based on socioeconomic status and language and suggested the presence of disparities in care for underserved women with POP. CONCLUSIONS The discrepancies in care for Spanish-speaking women and women being treated at public hospitals suggest that there are disparities in care for POP treatment for underserved women. These differences may be secondary to profit-driven pressures from private hospitals or language barriers, low socioeconomic status, low health literacy, and barriers to health care.
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Machado FR, Cavalcanti AB, Bozza FA, Ferreira EM, Angotti Carrara FS, Sousa JL, Caixeta N, Salomao R, Angus DC, Pontes Azevedo LC. The epidemiology of sepsis in Brazilian intensive care units (the Sepsis PREvalence Assessment Database, SPREAD): an observational study. THE LANCET. INFECTIOUS DISEASES 2017; 17:1180-1189. [PMID: 28826588 DOI: 10.1016/s1473-3099(17)30322-5] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/24/2017] [Accepted: 04/19/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND The sepsis burden on acute care services in middle-income countries is a cause for concern. We estimated incidence, prevalence, and mortality of sepsis in adult Brazilian intensive care units (ICUs) and association of ICU organisational factors with outcome. METHODS We did a 1-day point prevalence study with follow-up of patients in ICU with sepsis in a nationally representative pseudo-random sample. We produced a sampling frame initially stratified by geographical region. Each stratum was then stratified by hospitals' main source of income (serving general public vs privately insured individuals) and ICU size (ten or fewer beds vs more than ten beds), finally generating 40 strata. In each stratum we selected a random sample of ICUs so as to enrol the total required beds in 1690 Brazilian adult ICUs. We followed up patients until hospital discharge censored at 60 days, estimated incidence from prevalence and length of stay, and generated national estimates. We assessed mortality prognostic factors using random-effects logistic regression models. FINDINGS On Feb 27, 2014, 227 (72%) of 317 ICUs that were randomly selected provided data on 2632 patients, of whom 794 had sepsis (30·2 septic patients per 100 ICU beds, 95% CI 28·4-31·9). The ICU sepsis incidence was 36·3 per 1000 patient-days (95% CI 29·8-44·0) and mortality was observed in 439 (55·7%) of 788 patients (95% CI 52·2-59·2). Low availability of resources (odds ratio [OR] 1·67, 95% CI 1·02-2·75, p=0·045) and adequacy of treatment (OR 0·56, 0·37-0·84, p=0·006) were independently associated with mortality. The projected incidence rate is 290 per 100 000 population (95% CI 237·9-351·2) of adult cases of ICU-treated sepsis per year, which yields about 420 000 cases annually, of whom 230 000 die in hospital. INTERPRETATION The incidence, prevalence, and mortality of ICU-treated sepsis is high in Brazil. Outcome varies considerably, and is associated with access to adequate resources and treatment. Our results show the burden of sepsis in resource-limited settings, highlighting the need to establish programmes aiming for sepsis prevention, early diagnosis, and adequate treatment. FUNDING Fundação de Apoio a Pesquisa do Estado de São Paulo (FAPESP).
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Affiliation(s)
- Flavia R Machado
- Anesthesiology, Pain, and Intensive Care Department, Universidade Federal de São Paulo, São Paulo, Brazil; Latin America Sepsis Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil.
| | - Alexandre Biasi Cavalcanti
- Latin America Sepsis Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; Research Institute, Hospital do Coração (HCor), São Paulo, Brazil
| | - Fernando Augusto Bozza
- Latin America Sepsis Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil
| | | | | | | | | | - Reinaldo Salomao
- Infectious Disease Department, Universidade Federal de São Paulo, São Paulo, Brazil; Latin America Sepsis Institute, São Paulo, Brazil
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Luciano Cesar Pontes Azevedo
- Latin America Sepsis Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; Hospital Sírio Libanes, São Paulo, Brazil
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Machado FR, Ferreira EM, Schippers P, de Paula IC, Saes LSV, de Oliveira FI, Tuma P, Nogueira Filho W, Piza F, Guare S, Mangini C, Guth GZ, Azevedo LCP, Freitas FGR, do Amaral JLG, Mansur NS, Salomão R. Implementation of sepsis bundles in public hospitals in Brazil: a prospective study with heterogeneous results. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:268. [PMID: 29089025 PMCID: PMC5664817 DOI: 10.1186/s13054-017-1858-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 10/05/2017] [Indexed: 01/21/2023]
Abstract
Background Public hospitals in emerging countries pose a challenge to quality improvement initiatives in sepsis. Our objective was to evaluate the results of a quality improvement initiative in sepsis in a network of public institutions and to assess potential differences between institutions that did or did not achieve a reduction in mortality. Methods We conducted a prospective study of patients with sepsis or septic shock. We collected baseline data on compliance with the Surviving Sepsis Campaign 6-h bundles and mortality. Afterward, we initiated a multifaceted quality improvement initiative for patients with sepsis or septic shock in all hospital sectors. The primary outcome was hospital mortality over time. The secondary outcomes were the time to sepsis diagnosis and compliance with the entire 6-h bundles throughout the intervention. We defined successful institutions as those where the mortality rates decreased significantly over time, using a logistic regression model. We analyzed differences over time in the secondary outcomes by comparing the successful institutions with the nonsuccessful ones. We assessed the predictors of in-hospital mortality using logistic regression models. All tests were two-sided, and a p value less than 0.05 indicated statistical significance. Results We included 3435 patients from the emergency departments (50.7%), wards (34.1%), and intensive care units (15.2%) of 9 institutions. Throughout the intervention, there was an overall reduction in the risk of death, in the proportion of septic shock, and the time to sepsis diagnosis, as well as an improvement in compliance with the 6-h bundle. The time to sepsis diagnosis, but not the compliance with bundles, was associated with a reduction in the risk of death. However, there was a significant reduction in mortality in only two institutions. The reduction in the time to sepsis diagnosis was greater in the successful institutions. By contrast, the nonsuccessful sites had a greater increase in compliance with the 6-h bundle. Conclusions Quality improvement initiatives reduced sepsis mortality in public Brazilian institutions, although not in all of them. Early recognition seems to be a more relevant factor than compliance with the 6-h bundle. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1858-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Flavia Ribeiro Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil. .,Latin American Sepsis Institute, São Paulo, SP, Brazil. .,Latin American Sepsis Institute, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 6° andar, Vila Clementino, 04024-002, São Paulo, SP, Brazil.
| | | | | | | | | | | | - Paula Tuma
- Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | | | - Felipe Piza
- Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | - Sandra Guare
- Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | - Cláudia Mangini
- Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | | | | | - Flavio Geraldo Resende Freitas
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil.,Latin American Sepsis Institute, São Paulo, SP, Brazil
| | - Jose Luiz Gomes do Amaral
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil.,Latin American Sepsis Institute, São Paulo, SP, Brazil.,Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | | | - Reinaldo Salomão
- Latin American Sepsis Institute, São Paulo, SP, Brazil.,Infectious Disease Department, Federal University of São Paulo, São Paulo, SP, Brazil
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Faiotto VB, Franci D, Enz Hubert RM, de Souza GR, Fiusa MML, Hounkpe BW, Santos TM, Carvalho-Filho MA, De Paula EV. Circulating levels of the angiogenesis mediators endoglin, HB-EGF, BMP-9 and FGF-2 in patients with severe sepsis and septic shock. J Crit Care 2017; 42:162-167. [PMID: 28746898 DOI: 10.1016/j.jcrc.2017.07.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 06/18/2017] [Accepted: 07/16/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE Endothelial barrier dysfunction is a hallmark of sepsis, and is at least partially mediated by pathways that regulate endothelial barrier assembly during angiogenesis. Not surprisingly, increased levels of key angiogenic proteins such as VEGF-A and Angiopoietin-2 have been described in sepsis. The purpose of this study was to investigate if additional pathways that regulate endothelial barrier integrity during angiogenesis could also be involved in the host response of sepsis. MATERIAL AND METHODS We evaluated circulating levels of four proteins involved in angiogenesis, not previously studied in sepsis, in a cohort of 50 patients with severe sepsis and septic shock. RESULTS Circulating levels of BMP-9 and FGF-2 were similar in patients and healthy volunteers. In contrast, patients with septic shock presented 1.5-fold higher levels of endoglin (P=0.004), and 2-fold lower levels of Heparin-Binding EGF-like growth factor (HB-EGF) (P=0.002) when compared to healthy individuals. Of note, HB-EGF deficiency has been recently demonstrated to be detrimental to survival in a murine model of sepsis. CONCLUSIONS Endoglin and HB-EGF could be involved in the host response of sepsis. Additional studies are warrant to investigate their role as biomarker or therapeutic targets in sepsis.
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Affiliation(s)
| | - Daniel Franci
- School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | | | | | | | | | | | | | - Erich Vinicius De Paula
- School of Medical Sciences, University of Campinas, Campinas, SP, Brazil; Hematology and Hemotherapy Center, University of Campinas, Campinas, SP, Brazil.
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Tale of 2 Health-care Systems: Disparities in Demographic and Clinical Characteristics between 2 Ischemic Stroke Populations in Los Angeles County. J Stroke Cerebrovasc Dis 2017; 26:1357-1362. [PMID: 28279550 DOI: 10.1016/j.jstrokecerebrovasdis.2017.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 01/24/2017] [Accepted: 02/03/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Individuals who present to the emergency departments of safety-net systems often have poorly controlled risk factors due to lack of primary care. Little is known about potential differences in presenting characteristics, discharge medications, and discharge destinations of patients with acute ischemic stroke (AIS) who present to safety-net settings versus university medical centers (UMCs). METHODS Demographic characteristics, medical history, premorbid medication use, stroke severity, discharge medications, and discharge destination were assessed among consecutive admissions for AIS over a 2-year period at a UMC (n = 385) versus 2 university-affiliated safety-net hospitals (SNHs) (n = 346) in Los Angeles County. RESULTS Compared with patients presenting to the UMC, individuals admitted to the SNHs were younger, more frequently male, nonwhite, current smokers, hypertensive, and diabetic; they were less likely to take antithrombotics and statins before admission, and had worse serum lipid and glycemic markers (all P < .05). Patients admitted to the UMC trended toward more cardioembolic strokes and had higher stroke severity scores (P < .0001). At discharge, patients admitted to the SNHs were more likely to receive antihypertensive medications than do patients admitted to the UMC (P < .001), but there were no differences in prescription of antiplatelet medications or statins. CONCLUSIONS Individuals with AIS admitted to SNHs in Los Angeles County are younger and have poorer vascular risk factor control than their counterparts at a UMC. Discharge treatment does not vary considerably between systems. Early and more vigorous efforts at primary vascular risk reduction among patients seen at SNHs may be warranted to reduce disparities.
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Arabi YM, Schultz MJ, Salluh JIF. Intensive Care Medicine in 2050: global perspectives. Intensive Care Med 2016; 43:1695-1699. [PMID: 27900405 DOI: 10.1007/s00134-016-4631-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 11/18/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Yaseen M Arabi
- Department of Intensive Care, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), PO Box 22490, Riyadh, 11426, Saudi Arabia. .,King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia.
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands
| | - Jorge I F Salluh
- Critical Care department, D'OR Institute for Research and Education, Rio De Janeiro, Brazil.,Post-Graduate Program Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
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Besen BAMP, Romano TG, Nassar AP, Taniguchi LU, Azevedo LCP, Mendes PV, Zampieri FG, Park M. Sepsis-3 definitions predict ICU mortality in a low-middle-income country. Ann Intensive Care 2016; 6:107. [PMID: 27807819 PMCID: PMC5093106 DOI: 10.1186/s13613-016-0204-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 10/17/2016] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis-3 definitions were published recently and validated only in high-income countries. The aim of this study was to assess the new criteria’s accuracy in stratifying mortality as compared to its predecessor (Sepsis-2) in a Brazilian public intensive care unit (ICU) and to investigate whether the addition of lactate values would improve stratification. Methods Retrospective cohort study conducted between 2010 and 2015 in a public university’s 19-bed ICU. Data from patients admitted to the ICU with sepsis were retrieved from a prospectively collected database. ICU mortality was compared across categories of both Sepsis-2 definitions (sepsis, severe sepsis and septic shock) and Sepsis-3 definitions (infection, sepsis and septic shock). Area under the receiving operator characteristic curves were constructed, and the net reclassification index and integrated discrimination index for the addition of lactate as a categorical variable to each stratum of definition were evaluated. Results The medical records of 957 patients were retrieved from a prospectively collected database. Mean age was 52 ± 19 years, median SAPS 3 was 65 [50,79], respiratory tract infection was the most common cause (42%, 402 patients), and 311 (32%) patients died in ICU. The ICU mortality rate was progressively higher across categories of sepsis as defined by the Sepsis-3 consensus: infection with no organ dysfunction—7/103 (7%); sepsis—106/419 (25%); and septic shock—198/435 (46%) (P < 0.001). For Sepsis-2 definitions, ICU mortality was different only across the categories of severe sepsis [43/252-(17%)] and septic shock [250/572-(44%)] (P < 0.001); sepsis had a mortality of 18/135-(13%) (P = 0.430 vs. severe sepsis). When combined with lactate, the definitions’ accuracy in stratifying ICU mortality only improved with lactate levels above 4 mmol/L. This improvement occurred in the severe sepsis and septic shock groups (Sepsis-2) and the no-dysfunction and septic shock groups (Sepsis-3). Multivariate analysis demonstrated similar findings. Conclusions In a Brazilian ICU, the new Sepsis-3 definitions were accurate in stratifying mortality and were superior to the previous definitions. We also observed that the new definitions’ accuracy improved progressively with severity. Serum lactate improved accuracy for values higher than 4 mmol/L in the no-dysfunction and septic shock groups. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0204-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bruno Adler Maccagnan Pinheiro Besen
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil. .,Hospital da Luz, Amil, São Paulo, Brazil.
| | - Thiago Gomes Romano
- Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil.,Nephrology Department, ABC Medical School, Santo Andre, Brazil
| | - Antonio Paulo Nassar
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil.,A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Leandro Utino Taniguchi
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil.,Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Luciano Cesar Pontes Azevedo
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil.,Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Pedro Vitale Mendes
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil.,Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Fernando Godinho Zampieri
- Research Institute, HCor-Hospital do Coração, São Paulo, Brazil.,Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Marcelo Park
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar, 255, Room 6040, São Paulo, ZIP 05403-000, Brazil
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Research in Latin America: opportunities and challenges. Intensive Care Med 2016; 42:1045-7. [PMID: 27043235 DOI: 10.1007/s00134-016-4342-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 03/22/2016] [Indexed: 12/21/2022]
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Azevedo LCP, Toscano C, Andrade AL, Bierrenbach AL. Long-term outcomes of adult patients admitted with sepsis to brazilian public hospitals: a national retrospective matched cohort study. Intensive Care Med Exp 2015; 3:A86. [PMID: 27290453 PMCID: PMC4797912 DOI: 10.1186/2197-425x-3-s1-a86] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Research networks and clinical trials in critical care in Brazil: current status and future perspectives. Rev Bras Ter Intensiva 2015; 26:79-80. [PMID: 25028940 PMCID: PMC4103932 DOI: 10.5935/0103-507x.20140013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Giacomini MG, Lopes MVCA, Gandolfi JV, Lobo SMA. Septic shock: a major cause of hospital death after intensive care unit discharge. Rev Bras Ter Intensiva 2015; 27:51-6. [PMID: 25909313 PMCID: PMC4396897 DOI: 10.5935/0103-507x.20150009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 02/19/2015] [Indexed: 11/28/2022] Open
Abstract
Objective To assess the causes and factors associated with the death of patients between
intensive care unit discharge and hospital discharge. Methods The present is a pilot, retrospective, observational cohort study. The records of
all patients admitted to two units of a public/private university hospital from
February 1, 2013 to April 30, 2013 were assessed. Demographic and clinical data,
risk scores and outcomes were obtained from the Epimed monitoring system and
confirmed in the electronic record system of the hospital. The relative risk and
respective confidence intervals were calculated. Results A total of 581 patients were evaluated. The mortality rate in the intensive care
unit was 20.8% and in the hospital was 24.9%. Septic shock was the cause of death
in 58.3% of patients who died after being discharged from the intensive care unit.
Of the patients from the public health system, 73 (77.6%) died in the intensive
care unit and 21 (22.4%) died in the hospital after being discharged from the
unit. Of the patients from the Supplementary Health System, 48 (94.1%) died in the
intensive care unit and 3 (5.9%) died in the hospital after being discharged from
the unit (relative risk, 3.87%; 95% confidence interval, 1.21 - 12.36; p <
0.05). The post-discharge mortality rate was significantly higher in patients with
intensive care unit hospitalization time longer than 6 days. Conclusion The main cause of death of patients who were discharged from the intensive care
unit and died in the ward before hospital discharge was septic shock. Coverage by
the public healthcare system and longer hospitalization time in the intensive care
unit were factors associated with death after discharge from the intensive care
unit.
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Affiliation(s)
| | | | - Joelma Villafanha Gandolfi
- Serviço de Terapia Intensiva, Hospital de Base de São José do Rio Preto, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brasil
| | - Suzana Margareth Ajeje Lobo
- Serviço de Terapia Intensiva, Hospital de Base de São José do Rio Preto, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brasil
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Rabello L, Conceição C, Ebecken K, Lisboa T, Bozza FA, Soares M, Póvoa P, Salluh JIF. Management of severe community-acquired pneumonia in Brazil: a secondary analysis of an international survey. Rev Bras Ter Intensiva 2015; 27:57-63. [PMID: 25909314 PMCID: PMC4396898 DOI: 10.5935/0103-507x.20150010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 02/22/2015] [Indexed: 12/03/2022] Open
Abstract
Objective This study aimed to evaluate Brazilian physicians’ perceptions regarding the
diagnosis, severity assessment, treatment and risk stratification of severe
community-acquired pneumonia patients and to compare those perceptions to current
guidelines. Methods We conducted a cross-sectional international anonymous survey among a convenience
sample of critical care, pulmonary, emergency and internal medicine physicians
from Brazil between October and December 2008. The electronic survey evaluated
physicians’ attitudes towards the diagnosis, risk assessment and therapeutic
interventions for patients with severe community-acquired pneumonia. Results A total of 253 physicians responded to the survey, with 66% from Southeast Brazil.
The majority (60%) of the responding physicians had > 10 years of medical
experience. The risk assessment of severe community-acquired pneumonia was very
heterogeneous, with clinical evaluation as the most frequent approach. Although
blood cultures were recognized as exhibiting a poor diagnostic performance, these
cultures were performed by 75% of respondents. In contrast, the presence of
urinary pneumococcal and Legionella antigens was evaluated by
less than 1/3 of physicians. The vast majority of physicians (95%) prescribe
antibiotics according to a guideline, with the combination of a
3rd/4th generation cephalosporin plus a macrolide as the
most frequent choice. Conclusion This Brazilian survey identified an important gap between guidelines and clinical
practice and recommends the institution of educational programs that implement
evidence-based strategies for the management of severe community-acquired
pneumonia.
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Affiliation(s)
- Lígia Rabello
- Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, RJ, Brasil
| | - Catarina Conceição
- Unidade Polivalente de Terapia Intensiva, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, CEDOC, Faculdade Médica NOVA, Nova Universidade de Lisboa, Lisboa, Portugal
| | - Katia Ebecken
- Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, RJ, Brasil
| | - Thiago Lisboa
- Unidade de Terapia Intensiva e Comitê de Controle de Infecção, Hospital das Clínicas, Programa de Pós-Graduação em Pneumologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | | | - Márcio Soares
- Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, RJ, Brasil
| | - Pedro Póvoa
- Unidade Polivalente de Terapia Intensiva, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, CEDOC, Faculdade Médica NOVA, Nova Universidade de Lisboa, Lisboa, Portugal
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Cavalcanti AB, Machado F, Bozza F, Ibrain J, Salluh F, Campagnucci VP, Guimarães HP, Normilio-Silva K, Chiattone VC, Vendramim P, Carrara F, Lubarino J, da Silva AR, Viana G, Damiani LP, Romano E, Teixeira C, da Silva NB, Chang CCH, Angus DC, Berwanger O. A cluster randomized trial of a multifaceted quality improvement intervention in Brazilian intensive care units: study protocol. Implement Sci 2015; 10:8. [PMID: 25928627 PMCID: PMC4342101 DOI: 10.1186/s13012-014-0190-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 12/09/2014] [Indexed: 01/01/2023] Open
Abstract
Background The uptake of evidence-based therapies in the intensive care environment is suboptimal, particularly in limited-resource countries. Checklists, daily goal assessments, and clinician prompts may improve compliance with best practice processes of care and, in turn, improve clinical outcomes. However, the available evidence on the effectiveness of checklists is unreliable and inconclusive, and the mechanisms are poorly understood. We aim to evaluate whether the use of a multifaceted quality improvement intervention, including the use of a checklist and the definition of daily care goals during multidisciplinary daily rounds and clinician prompts, can improve the in-hospital mortality of patients admitted to intensive care units (ICUs). Our secondary objectives are to assess the effects of the study intervention on specific processes of care, clinical outcomes, and the safety culture and to determine which factors (the processes of care and/or safety culture) mediate the effect of the study intervention on mortality. Methods/design This is a cluster randomized trial involving 118 ICUs in Brazil conducted in two phases. In the observational preparatory phase, we collect baseline data on processes of care and clinical outcomes from 60 consecutive patients with lengths of ICU stay longer than 48 h and apply the Safety Attitudes Questionnaire (SAQ) to 75% or more of the health care staff in each ICU. In the randomized phase, we assign ICUs to the experimental or control arm and repeat data collection. Experimental arm ICUs receive the multifaceted quality improvement intervention, including a checklist and definition of daily care goals during daily multidisciplinary rounds, clinician prompting, and feedback on rates of adherence to selected care processes. Control arm ICUs maintain usual care. The primary outcome is in-hospital mortality, truncated at 60 days. Secondary outcomes include the rates of adherence to appropriate care processes, rates of other clinical outcomes, and scores on the SAQ domains. Analysis follows the intention-to-treat principle, and the primary outcome is analyzed using mixed effects logistic regression. Discussion This is a large scale, pragmatic cluster-randomized trial evaluating whether a multifaceted quality improvement intervention, including checklists applied during the multidisciplinary daily rounds and clinician prompting, can improve the adoption of proven therapies and decrease the mortality of critically ill patients. If this study finds that the intervention reduces mortality, it may be widely adopted in intensive care units, even those in limited-resource settings. Trial registration ClinicalTrials.gov NCT01785966 Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0190-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexandre Biasi Cavalcanti
- Research Institute - Hospital do Coração (IEP- HCor), Rua Abílio Soares 250, 12th floor, CEP: 04005-000 - São Paulo, SP, Brazil.
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Mancini N, Burioni R, Clementi M. Microbiological diagnosis of sepsis: the confounding effects of a "gold standard". Methods Mol Biol 2015; 1237:1-4. [PMID: 25319774 DOI: 10.1007/978-1-4939-1776-1_1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The need of rapid and sensitive diagnostic techniques for sepsis is every day more compelling. Its morbidity and mortality loads are dramatically high, with one quarter of patients eventually dying. Several diagnostic progresses have been made in the last years using both molecular- and nonmolecular-based approaches, and they have to be broadly shared in the scientific community also under the technical point of view. The initial chapters of this book give a thorough overlook of the state of the art in the actual diagnosis of sepsis. The other chapters provide a broad range of protocols describing both already used and futuristic tools, covering both microbiological and nonmicrobiological aspects. The potential role of each described protocol is evidenced by a brief introduction on the specific topic of each chapter. A final chapter describing algorithms potentially useful in stratifying the risk of sepsis in each single patient and suggesting the future perspectives in the diagnosis of sepsis closes the book.
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Affiliation(s)
- Nicasio Mancini
- Laboratory of Microbiology and Virology, University Vita-Salute San Raffaele, Via Olgettina 58, 20132, Milan, Italy,
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de Carvalho MA, Freitas FGR, Silva Junior HT, Bafi AT, Machado FR, Pestana JOM. Mortality predictors in renal transplant recipients with severe sepsis and septic shock. PLoS One 2014; 9:e111610. [PMID: 25369197 PMCID: PMC4219732 DOI: 10.1371/journal.pone.0111610] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Accepted: 10/02/2014] [Indexed: 12/29/2022] Open
Abstract
Introduction The growing number of renal transplant recipients in a sustained immunosuppressive state is a factor that can contribute to increased incidence of sepsis. However, relatively little is known about sepsis in this population. The aim of this single-center study was to evaluate the factors associated with hospital mortality in renal transplant patients admitted to the intensive care unit (ICU) with severe sepsis and septic shock. Methods Patient demographics and transplant-related and ICU stay data were retrospectively collected. Multiple logistic regression was conducted to identify the independent risk factors associated with hospital mortality. Results A total of 190 patients were enrolled, 64.2% of whom received kidneys from deceased donors. The mean patient age was 51±13 years (males, 115 [60.5%]), and the median APACHE II was 20 (16–23). The majority of patients developed sepsis late after the renal transplantation (2.1 [0.6–2.3] years). The lung was the most common infection site (59.5%). Upon ICU admission, 16.4% of the patients had ≤1 systemic inflammatory response syndrome criteria. Among the patients, 61.5% presented with ≥2 organ failures at admission, and 27.9% experienced septic shock within the first 24 hours of ICU admission. The overall hospital mortality rate was 38.4%. In the multivariate analysis, the independent determinants of hospital mortality were male gender (OR = 5.9; 95% CI, 1.7–19.6; p = 0.004), delta SOFA 24 h (OR = 1.7; 95% CI, 1.2–2.3; p = 0.001), mechanical ventilation (OR = 30; 95% CI, 8.8–102.2; p<0.0001), hematologic dysfunction (OR = 6.8; 95% CI, 2.0–22.6; p = 0.002), admission from the ward (OR = 3.4; 95% CI, 1.2–9.7; p = 0.02) and acute kidney injury stage 3 (OR = 5.7; 95% CI,1.9–16.6; p = 0.002). Conclusions Hospital mortality in renal transplant patients with severe sepsis and septic shock was associated with male gender, admission from the wards, worse SOFA scores on the first day and the presence of hematologic dysfunction, mechanical ventilation or advanced graft dysfunction.
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Affiliation(s)
- Mônica Andrade de Carvalho
- Unidade de Transplante, Disciplina de Nefrologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- * E-mail:
| | - Flávio Geraldo Rezende Freitas
- Unidade de Transplante, Disciplina de Nefrologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Disciplina de Anestesiologia, Dor e Terapia Intensiva. Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Hélio Tedesco Silva Junior
- Unidade de Transplante, Disciplina de Nefrologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Antônio Toneti Bafi
- Unidade de Transplante, Disciplina de Nefrologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Disciplina de Anestesiologia, Dor e Terapia Intensiva. Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Flávia Ribeiro Machado
- Disciplina de Anestesiologia, Dor e Terapia Intensiva. Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - José Osmar Medina Pestana
- Unidade de Transplante, Disciplina de Nefrologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Positive fluid balance as a prognostic factor for mortality and acute kidney injury in severe sepsis and septic shock. J Crit Care 2014; 30:97-101. [PMID: 25269788 DOI: 10.1016/j.jcrc.2014.09.002] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 07/22/2014] [Accepted: 09/01/2014] [Indexed: 01/07/2023]
Abstract
PURPOSE The purpose of this study is to assess whether late positive fluid balances are associated with acute kidney injury and mortality in severe sepsis and septic shock. METHODS In this retrospective study, fluid balances were calculated at 3 different time points: the onset of organ dysfunction attributed to sepsis, sepsis diagnosis, and vasopressors initiation. Data were analyzed in logistic regression models for mortality and acute kidney injury as outcomes. RESULTS We included 116 patients. A RIFLE score F, diuresis less than 0.9 L from the second day after the first organ dysfunction, and fluid balance more than 3 L between the 24th and the 48th hour after diagnosis were independently associated with higher mortality, whereas in the subgroup with shock, only the latter parameter and diuresis less than 0.85 L on the first day of shock were independent risk factors. After adjusting for age, creatinine more than 1.2 mg/dL, a nonrenal Sequential Organ Failure Assessment greater than or equal to 7.5 on the first day and urine output less than 1.3 L on the first day after organ dysfunction were independent risk factors for RIFLE F. No relationship was found between fluid balance and acute kidney injury. CONCLUSION Late positive fluid balance is an independent risk factor for mortality in severe sepsis. Positive fluid balances are not associated with either protection against or risk for acute kidney injury.
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Mancini N, Sambri V, Corti C, Ghidoli N, Tolomelli G, Paolucci M, Clerici D, Carletti S, Greco R, Tassara M, Pizzorno B, Zaniolo O, Povero M, Pradelli L, Burioni R, Stanzani M, Landini MP, Ciceri F, Clementi M. Cost-effectiveness of blood culture and a multiplex real-time PCR in hematological patients with suspected sepsis: an observational propensity score-matched study. Expert Rev Mol Diagn 2014; 14:623-32. [DOI: 10.1586/14737159.2014.916212] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Potential impact of a microarray-based nucleic acid assay for rapid detection of Gram-negative bacteria and resistance markers in positive blood cultures. J Clin Microbiol 2014; 52:1242-5. [PMID: 24478405 DOI: 10.1128/jcm.00142-14] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
We evaluated the Verigene Gram-negative blood culture (BC-GN) test, a microarray that detects Gram-negative bacteria and several resistance genes. A total of 102 positive blood cultures were tested, and the BC-GN test correctly identified 97.9% of the isolates within its panel. Resistance genes (CTX-M, KPC, VIM, and OXA genes) were detected in 29.8% of the isolates, with positive predictive values of 95.8% (95% confidence interval [CI], 87.7% to 98.9%) in Enterobacteriaceae and 100% (95% CI, 75.9% to 100%) in Pseudomonas aeruginosa and negative predictive values of 100% (95% CI, 93.9% to 100%) and 78.6% (95% CI, 51.0% to 93.6%), respectively.
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Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study. Intensive Care Med 2013; 40:182-191. [PMID: 24146003 DOI: 10.1007/s00134-013-3131-5] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/04/2013] [Indexed: 01/28/2023]
Abstract
PURPOSE To evaluate whether a multifaceted, centrally coordinated quality improvement program in a network of hospitals can increase compliance with the resuscitation bundle and improve clinical and economic outcomes in an emerging country setting. METHODS This was a pre- and post-intervention study in ten private hospitals (1,650 beds) in Brazil (from May 2010 to January 2012), enrolling 2,120 patients with severe sepsis or septic shock. The program used a multifaceted approach: screening strategies, multidisciplinary educational sessions, case management, and continuous performance assessment. The network administration and an external consultant provided performance feedback and benchmarking within the network. The primary outcome was compliance with the resuscitation bundle. The secondary outcomes were hospital mortality, hospital and ICU length of stay, quality-adjusted life year (QALY) gain, and cost-effectiveness. RESULTS The proportion of patients who received all the required items for the resuscitation bundle improved from 13% [95% confidence interval (CI) 8-18%] at baseline to 62% (95% CI 54-69%) in the last trimester (p < 0.001). Hospital mortality decreased from 55% (95% CI 48-62%) to 26% (95% CI 19-32%, p < 0.001). Full compliance with the resuscitation bundle was associated with lower risk of hospital mortality (propensity weighted corrected risk ratio 0.74; 95% CI 0.56-0.94, p = 0.02). There was a reduction in the total cost per patient from 29.3 (95% CI 23.9-35.4) to 17.5 (95% CI 14.3-21.1) thousand US dollars from baseline to the last 3 months (mean difference -11,815; 95% CI -18,604 to -5,338). The mean QALY increased from 2.63 (95% CI 2.15-3.14) to 4.06 (95% CI 3.58-4.57). For each QALY, the full compliance saves US$5,383. CONCLUSIONS A multifaceted approach to severe sepsis and septic shock patients in an emerging country setting led to high compliance with the resuscitation bundle. The intervention was cost-effective and associated with a reduction in mortality.
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Theobaldo MC, Llimona F, Petroni RC, Rios ECS, Velasco IT, Soriano FG. Hypertonic saline solution drives neutrophil from bystander organ to infectious site in polymicrobial sepsis: a cecal ligation and puncture model. PLoS One 2013; 8:e74369. [PMID: 24069301 PMCID: PMC3775765 DOI: 10.1371/journal.pone.0074369] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 08/04/2013] [Indexed: 12/18/2022] Open
Abstract
The effects of hypertonic saline solution (HSS) have been shown in several animal models of ischemia and shock. Literature has shown potential benefits of HSS modulating inflammatory response after sepsis in an animal model. We studied the HSS effects in sepsis through cecal ligation and puncture (CLP) in Balb-C mice. Groups studied: 1- CLP without treatment (CLP-C); 2- CLP treated with normal saline solution NaCl 0.9% – 34 ml/Kg (CLP-S); 3- CLP treated with HSS NaCl 7.5% – 4 ml/Kg (CLP-H); and 4- group (Basal) without no CLP or treatment. Volume infusion was always applied 30 min after CLP. Lung and peritoneal lavage were harvested after 6h and 24h of CLP to analyze cytokines amount, oxide nitric, lipid peroxidation and neutrophil infiltration. Neutrophil infiltration, ICAM-1, CXCR-2, and CXCL-1 in lung were reduced by HSS (CLP-H) compared to CLP-C or CLP-S. Neutrophil in peritoneal lavage was increased in 24h with HSS (CLP-H) compared to CLP and CLP-S. Peritoneal CXCR-2 was increased in CLP-C and CLP-S but presented a lower increase with HSS (CLP-H) after 6 hours. GRK-2 presented difference among the groups at 24 h, showing a profile similar to neutrophil infiltration. Pro-inflammatory cytokines (TNF-α and IL-6) were reduced by HSS treatment; CLP-S increased TNF-α. IL-10 was increased in lung tissue by the HSS treatment. The oxidative stress (TBARS and nitric oxide biochemistry markers) was reduced with HSS. Animal survival was 33.3% in CLP-C group, 46.6% in CLP-S group and 60% in the CLP-H group after the sixth day. The HSS protects the animal against sepsis. Our results suggest that the volume replacement modulate pro and anti-inflammatory mediators of an inflammatory response, but HSS presented a more effective and potent effect.
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Affiliation(s)
| | - Flavia Llimona
- Emergency of Medicine Division-Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ricardo Costa Petroni
- Emergency of Medicine Division-Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Irineu Tadeu Velasco
- Emergency of Medicine Division-Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Francisco Garcia Soriano
- Emergency of Medicine Division-Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- * E-mail:
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