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Therapeutic plasmapheresis is a therapeutic procedure in which the patient's blood is passed through a medical device which separates out plasma from other components of blood. The plasma is removed and replaced with a replacement solution. Studies on the use of plasmapheresis in critically ill patients are scarce. The aim of this study was to review all therapeutic plasmapheresis sessions carried out in the Hospital Beatriz Ângelo intensive care unit.An observational retrospective study was conducted between April 2012 and March 2019. All patients who underwent therapeutic plasmapheresis in the intensive care unit were included, and plasmapheresis sessions held outside the intensive care unit were excluded.Of 46 patients, 63% were men (n = 29), with a median age of 53 years. The most frequent diagnoses were hypertriglyceridemia-induced pancreatitis, vasculitis, autoimmune haemolytic anaemia, and atypical haemolytic-uremic syndrome. A total of 198 plasmapheresis sessions were carried out in the intensive care unit. Most of the used replacement solutions were fresh frozen plasma (34.4%), albumin/crystalloid (24.2%), and albumin/fresh frozen plasma (19.2%). The most common complications were hydroelectrolytic changes (84; 42.4%) and coagulation disorders/thrombocytopenia (65; 32.8%). There was no need to interrupt any plasmapheresis session due to complications related to the patient.Therapeutic plasmapheresis is an urgent procedure that can reduce morbidity and mortality in critically ill patients. This justifies that 37% of patients started the technique before the diagnostic confirmation. The indications for plasmapheresis and the choice of replacement solution were in agreement with the guidelines. Despite the risk of bleeding, no haemorrhagic complications were recorded.Therapeutic plasmapheresis is a complex technique that requires specific training. The indications are diverse, and some are not consensual. Complications were frequent, but they did not increase morbidity.Introdução: A plasmaferese terapêutica é um procedimento em que o sangue passa por um circuito extracorpóreo que separa o plasma dos outros componentes do sangue. O plasma removido é substituído por soluções de reposição. Os estudos sobre a utilização de plasmaferese terapêutica no doente crítico são escassos. O objetivo do estudo foi rever todas as sessões de plasmaferese realizadas no serviço de Medicina Intensiva do Hospital Beatriz Ângelo. Material e Métodos: Estudo observacional retrospetivo de todos os doentes admitidos no serviço de Medicina Intensiva entre abril de 2012 e março de 2019. Foram selecionados os doentes submetidos a plasmaferese e excluídas as sessões realizadas fora do serviço de Medicina Intensiva. Resultados: No período de estudo foram incluídos 46 doentes. A maioria eram homens (n = 29; 63%) com uma idade mediana de 53 anos. Os diagnósticos mais frequentes foram pancreatite secundária a hipertrigliceridemia, vasculite, anemia hemolítica autoimune e síndrome hemolítica urémica atípica. Foram realizadas 198 sessões de plasmaferese no serviço de Medicina Intensiva. As soluções de substituição mais utilizadas foram plasma fresco congelado (34,4%), albumina/cristalóide (24,2%) e albumina/plasma (19,2%). As complicações mais comuns foram alterações hidroeletrolíticas (84; 42,4%), e distúrbios da coagulação/plaquetas (65; 32,8%). Em nenhum dos casos a técnica teve que ser interrompida por complicações relacionadas com o doente. Discussão: A plasmaferese terapêutica é um procedimento urgente capaz de reduzir a morbilidade e mortalidade no doente crítico. Isto justifica que 37% dos doentes tenham iniciado a técnica antes da confirmação diagnóstica. As indicações e soluto de reposição escolhido foram de acordo com as recomendações. Apesar do risco hemorrágico, nenhuma complicação desta natureza foi reportada. Conclusão: A plasmafere terapêutica é uma técnica complexa que requer treino específico. As indicações são diversas e algumas não consensuais. As complicações foram frequentes, mas não condicionaram morbilidade associada.

Background Respiratory virome is an integral part of the human microbiome and its characterization may contribute to a better understanding of the changes that arise in the disease and, consequently, influence the approach and treatment of patients with acute lower respiratory infections. The aim of this study was to evaluate the presence of respiratory viruses in the lower airways of individuals undergoing invasive mechanical ventilation, with and without acute lower respiratory infection (respectively WRI and WORI groups). Methods We studied 44 mini-bronchoalveolar lavage samples (collected with a double catheter, Combicath® kit) from patients with mean age in the seventh decade, 20 from WORI group and 24 from WRI group, who were hospitalized for acute respiratory failure in Intensive Care Units of two hospitals in the Lisbon area. Real-time PCR was applied to verify analyse the presence of 15 common respiratory viruses (adenovirus, human bocavirus, influenza virus A and B, repiratory syncytial virus, human parainfluenza virus types 1, 2, 3 and 4, human enterovirus, human rhinovirus, human metapneumovirus, human coronavirus group 1 (229E, NL63) and 2 (OC43, HKU1). Results Respiratory viruses were detected in six of the 20 patients in the WORI group: influenza AH3 (n = 2), parainfluenza virus 1/3 (n = 2), human rhinovirus (n = 2), respiratory syncytial virus (n = 1) and human metapneumovirus (n = 1). In the WRI group, respiratory viruses were detected in 12 of the 24 patients: influenza AH3 (n = 3), human rhinovirus (n = 3), respiratory syncytial virus (n = 3), human metapneumovirus (n = 3), human bocavirus (n = 2) and human enterovirus (n = 1). Simultaneous detection of two viruses was recorded in two samples in both groups. Conclusions The results of this study suggest the presence of common respiratory viruses in the lower respiratory tract without causing symptomatic infection, even in carefully collected lower samples. This may have important implications on the interpretation of the results on the diagnostic setting.

To double the percentage of time within the 100 - 180mg/dL blood glucose range in the first three months following a phased implementation of a formal education program, and then, of an insulin therapy protocol, without entailing an increased incidence of hypoglycemia.The pre-intervention glycemic control was assessed retrospectively. Next, were carried out the implementation of a formal education program, distribution of manual algorithms for intravenous insulin therapy - optimized by the users, based on the modified Yale protocol - and informal training of the nursing staff. The use of electronic blood glucose control systems was supported, and the results were recorded prospectively.The first phase of the program (formal education) lead to improvement of the time within the euglycemic interval (28% to 37%). In the second phase, euglycemia was achieved 66% of the time, and the incidence of hypoglycemia was decreased. The percentage of patients on intravenous insulin infusion at 48 hours from admission increased from 6% to 35%.The phased implementation of a formal education program, fostering the use of electronic insulin therapy protocols and dynamic manuals, received good adherence and has shown to be safe and effective for blood glucose control in critically ill patients, with a concomitant decrease in hypoglycemia.Duplicar a percentagem de tempo no intervalo glicêmico 100 - 180mg/dL nos primeiros 3 meses após implementação faseada de um programa de educação formal e, posteriormente, de um protocolo de insulinoterapia, sem condicionar um aumento da frequência de hipoglicemia.Foi feita a avaliação retrospetiva do controle glicêmico pré-intervenção. Foram realizados: implementação de um programa formal de educação; distribuição de algoritmos manuais de insulinoterapia endovenosa - otimizados pelos utilizadores, a partir do protocolo de Yale modificado - e formação informal da equipe de enfermagem. Foi dado apoio à utilização dos sistemas eletrônicos de controle glicêmico e do registo prospetivo dos resultados.A primeira fase do programa (educação formal) melhorou o tempo no intervalo euglicêmico (28% para 37%). A segunda fase permitiu atingir 66% do tempo de euglicemia, com diminuição das hipoglicemias. A percentagem de doentes sob perfusão endovenosa de insulina às 48 horas de internamento aumentou (6% para 35%).A implementação faseada de um programa formal de educação que favoreceu a aplicação de protocolos de insulinoterapia eletrônicos e manuais dinâmicos demonstrou ter aderência e ser segura e eficaz no controle glicêmico no doente crítico, com diminuição concomitante das hipoglicemias.

Spindle coma is an electroclinical entity that has been used to describe an EEG pattern of “sleep-like” activity in comatose patients. Although it has been associated with favourable prognosis, its aetiology is one of the key factors for patient outcome. The authors present three cases of spindle coma with different aetiologies (amitriptyline overdose, pontine myelinolysis and hypoxic-ischaemic encephalopathy) that culminated in different outcomes. LEARNING POINTS Spindle coma (SC) is an electroclinical “sleep-like” pattern that appears in comatose patients. It implies the functional preservation of the cerebral hemispheres which can be associated with a good prognosis. The aetiology of SC is a key factor for outcome. Keywords: Spindle coma, coma, EEG, physiopathology INTRODUCTION The reversed halo sign (RHS) was initially considered to be a specific sign of organising pneumonia (OP). However, it has been described in a variety of pulmonary diseases. We report a case of an unexpected diagnosis of pulmonary tuberculosis (PT) that was initially thought to be OP due to the presence of this sign, reinforcing the importance of excluding other possible aetiologies when the RHS is present.

Eustachian valve endocarditis is rare. A literature review revealed that only 29 cases have been reported and, among them, there is only one mention of an intensive care unit (ICU) admission. We present an 82-year-old man without previous medical records who presented with septic shock with multiple organ dysfunction. The patient was admitted to the ICU and deteriorated with combined shock (septic + cardiogenic). A second ultrasound screen detected a prominent Eustachian valve with mobile multilobulated vegetation attached. Transesophageal echocardiography confirmed a 12 mm oscillating mass attached to a visible Eustachian valve.

Delirium is the more common form of acute cerebral dysfunction in Intensive Care Unit (ICU), characterized by transitory and alternate changes in conscience and cognitive impairment that occur with physical disease. The incidence in ICU is high, reaching 89% of the patients. The diagnosis is exclusively clinic and could be used any one of the validated scales: Confusion Assessment Method for the ICU (CAM-ICU) or Intensive Care Delirium Screening Check-list (ICDSC), which should be applied, at least, once per shift by trained professionals. Its treatment and, more important, its prevention are known for several years. Currently there are new, safer and more effective therapeutic strategies for Haloperidol, such as Dexmedetomidine. Two new definitions of Delirium exist, besides the usual (hiperactive, hipoactive, mixed), which are: Subsyndromal Delirium and Delirium Superimposed on Dementia. Although they don't have all the same risks, the occurrence of Delirium in general leads to a decrease in cognitive function at long term and to a higher mortality. In spite of that, only 33% of the intensivists actively seek diagnoses of Delirium.O Delirium é a forma mais comum de disfunção cerebral aguda na Unidade de Cuidados Intensivos (UCI), caracterizada por alterações da consciência transitórias e flutuantes e compromisso cognitivo que ocorrem com a doença física. Tem elevada incidência na UCI, atingindo 89% dos doentes. O seu diagnóstico é exclusivamente clínico, podendo usar-se qualquer uma das escalas validadas para este meio: Confusion Assessment Method for the ICU (CAM-ICU) ou Intensive Care Delirium Screening Check-list (ICDSC), as quais devem ser aplicadas, pelo menos, uma vez por turno, por uma equipa treinada. O seu tratamento e, principalmente, a sua prevenção, são conhecidos há vários anos. Actualmente existem novas estratégias terapêuticas mais seguras e eficazes em relação ao Haloperidol como a Dexmedetomidina. Existem duas novas definições de Delirium além das habituais (hiperativo, hipoativo, misto): o Delirium subsindromático e o Delirium sobreposto à Demência. Embora não tenham todas os mesmos riscos, a ocorrência de Delirium no geral associa-se a diminuição da função cognitiva a longo-prazo e a maior mortalidade. Apesar disso, apenas 33% dos intensivistas procura ativamente diagnosticar o Delirium.

© All rights are reserved by Carlota Saldanha, Sepsis characteristics were highlight in this mini review in order to call attention for a complex, age- independent, acute disease faced suddenly by the human body under infection or traumatic stimuli. It may follow surgical intervention, traumatic accident or exposure to an infectious agent. Timely diagnosis and accurate stratification of the severity of sepsis are needed to understand the molecular mechanisms involved in this pathophysiology and reduce mortality. In order to obtain these achievements follow-up studies need to be conducted in intensive care units under translational research.

© 2016 – IOS Press and the authors. All rights reserved, AIM: Soluble CD40 ligand (sCD40L) has been considered as a marker of thrombosis and inflammation in several diseases, including sepsis. Recent studies challenge this view and point to a role of sCD40L in vascular and endothelial function. An indication of that association in sepsis has not been obtained so far. Therefore, herein we evaluated association between sCD40L and markers of hemorheology and inflammation on context of septic shock. METHODS: Time-changes of sCD40L levels over 72 hours of Intensive Care Unit (ICU) internment were assessed in 22 patients with septic shock and compared with 36 healthy volunteers. Association of sCD40L levels with erythrocyte deformability and aggregation (as markers of hemorheology), plasma concentrations of haemoglobin (Hb, as markers of endothelial function) and white blood cells (WBC) count (as marker of low-grade inflammation) were assessed in patients with septic shock. RESULTS: At ICU admission, sCD40L concentrations in patients with septic shock were lower (p = 0.024) than levels of healthy volunteers. However, sCD40L did not change over 72 hours of internment (F = 2.1, p = 0.137). Soluble CD40L levels in patients with septic shock at ICU admission correlate with concentrations of Hb (r = 0.61, p = 0.00) and WBC count (r = 0.63, p = 0.00), but not to erythrocyte deformability (r≥0.157, p≤0.235) and aggregation (r≥–0.109, p≤0.192). CONCLUSIONS: These results seem to highlight a possible association of sCD40L to endothelial function and inflammation in septic shock context., Work was financially supported by Fundação para a Ciência e Tecnologia (SFRM/BPD/6308/2009)

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