10 results on '"Thiago Lisboa"'
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2. Do we need new trials of procalcitonin-guided antibiotic therapy?
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Thiago Lisboa, Jorge Salluh, and Pedro Povoa
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Medical emergencies. Critical care. Intensive care. First aid ,RC86-88.9 - Abstract
Abstract Using biomarkers as a guide to tailor the duration of antibiotic treatment in respiratory infections is an attractive hypothesis assessed in several studies. Recent work aiming to summarize the evidence assessed the effect of a procalcitonin (PCT)-guided antibiotic treatment on outcomes in acute lower respiratory tract infections (LRTI), suggesting that significant reductions in antibiotic duration occur when using a PCT-guided algorithm. However, controversial evidence also suggested PCT-guided algorithms were associated with increased antibiotic duration and increased incidence of Clostridium difficile, without any impact on mortality, in real-world settings. So, although using PCT-guided antibiotic stewardship is promising, after more than a decade of randomized controlled trials on this topic the evidence in its favor is still less than compelling due to limitations in trial design, not taking into consideration fundamental aspects of PCT biology, and the absence of evidence-based antimicrobial duration in intervention and control groups. In this commentary we highlight some questions and limitations of primary PCT study data that might impact interpretation and clinical use of PCT at the bedside.
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- 2018
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3. Challenges for the care delivery for critically ill COVID-19 patients in developing countries: the Brazilian perspective
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Fernando A. Bozza, Jorge I. F. Salluh, and Thiago Lisboa
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medicine.medical_specialty ,Latin Americans ,Coronavirus disease 2019 (COVID-19) ,Critical Illness ,media_common.quotation_subject ,Pneumonia, Viral ,MEDLINE ,Developing country ,Critical Care and Intensive Care Medicine ,Betacoronavirus ,03 medical and health sciences ,0302 clinical medicine ,Denial ,Pandemic ,medicine ,Humans ,Intensive care medicine ,Developing Countries ,Pandemics ,media_common ,SARS-CoV-2 ,business.industry ,Social distance ,lcsh:Medical emergencies. Critical care. Intensive care. First aid ,COVID-19 ,030208 emergency & critical care medicine ,lcsh:RC86-88.9 ,Triage ,Intensive Care Units ,Commentary ,Coronavirus Infections ,business ,Delivery of Health Care ,Brazil - Abstract
The delivery of critical care is a major challenge for developing countries [1]. The inequity of access to an ICU bed, heterogeneous triage policies, a low staff/patient ratio and suboptimal adherence to evidence-based practices contribute to disproportionally high mortality of sepsis and acute respiratory distress syndrome in these countries [2,3,4,5]. In addition, limited step-down and specialized ward beds’ availability further widens the gap between critical and non-critical care inside hospitals. As the COVID-19 pandemic spreads through the world, developing countries are challenged with the surge of pneumonia cases where up to 30% of all hospitalized cases will require ICU admission [6]. In August 2020, Brazil is a hotspot of COVID-19 with more than 100,000 deaths. Other Latin American countries such as Mexico, Peru, Colombia, and Chile are also among the 10 countries with most cases worldwide. Several factors seem to have contributed to the dramatic progress of the epidemic in the country. Initial measures of social distancing were adopted at the beginning of the epidemic in several states. However, the lack of central coordination and, at a certain point, the denial of the pandemic by a populist government meant that more effective measures such as lockdown were not adopted whereas use of unproven therapies such as hydroxychloroquine was encouraged. Also, the low availability of tests and progression towards the interior and peripheries of large cities made the epidemic hard to control causing overwhelming hospitals and ICUs.
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- 2020
4. Organizational factors and patient outcomes in Brazilian ICUs: the ORCHESTRA study
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W Viana, Leonardo Brauer, Thiago Lisboa, M Soares, Derek C. Angus, J Salluh, LP Azevedo, Fernando A. Bozza, Pedro Emmanuel Alvarenga Americano do Brasil, and Jeremy M. Kahn
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medicine.medical_specialty ,business.industry ,health care facilities, manpower, and services ,Alternative medicine ,Critical Care and Intensive Care Medicine ,Data science ,Large sample ,health services administration ,Family medicine ,parasitic diseases ,Poster Presentation ,medicine ,business ,geographic locations - Abstract
The aim was to investigate the impact of organizational factors on patient outcomes in a large sample of Brazilian ICUs.
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- 2015
5. Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study
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Felipe Dal-Pizzol, Luciano Cesar Pontes Azevedo, Marcelo de Oliveira Maia, Fabio Poianas Giannini, Ronaldo Batista Dos Santos, Frederico Bruzzi de Carvalho, Thiago Lisboa, Lilian Maria Sobreira Tanaka, Paulo Fernando Guimarães Morando Marzocchi Tierno, André Peretti Torelly, Jorge I. F. Salluh, Alexandre Guilherme Ribeiro de Carvalho, Antonio Paulo Nassar, Guilherme Schettino, Marcelo Park, Flávia Ribeiro Machado, Claudio Piras, Marcio Soares, Luana Alves Tannous, Vicente Ces de Souza-Dantas, and Álvaro Réa-Neto
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Male ,medicine.medical_specialty ,Sedation ,Critical Care and Intensive Care Medicine ,law.invention ,law ,medicine ,Humans ,Hospital Mortality ,Simplified Acute Physiology Score ,Dexmedetomidine ,Prospective cohort study ,business.industry ,Research ,Glasgow Coma Scale ,Odds ratio ,Intensive care unit ,Respiration, Artificial ,Intensive Care Units ,Emergency medicine ,Female ,medicine.symptom ,Deep Sedation ,business ,Cohort study ,medicine.drug - Abstract
Introduction Sedation overuse is frequent and possibly associated with poor outcomes in the intensive care unit (ICU) patients. However, the association of early oversedation with clinical outcomes has not been thoroughly evaluated. The aim of this study was to assess the association of early sedation strategies with outcomes of critically ill adult patients under mechanical ventilation (MV). Methods A secondary analysis of a multicenter prospective cohort conducted in 45 Brazilian ICUs, including adult patients requiring ventilatory support and sedation in the first 48 hours of ICU admissions, was performed. Sedation depth was evaluated after 48 hours of MV. Multivariate analysis was used to identify variables associated with hospital mortality. Results A total of 322 patients were evaluated. Overall, ICU and hospital mortality rates were 30.4% and 38.8%, respectively. Deep sedation was observed in 113 patients (35.1%). Longer duration of ventilatory support was observed (7 (4 to 10) versus 5 (3 to 9) days, P = 0.041) and more tracheostomies were performed in the deep sedation group (38.9% versus 22%, P = 0.001) despite similar PaO2/FiO2 ratios and acute respiratory distress syndrome (ARDS) severity. In a multivariate analysis, age (Odds Ratio (OR) 1.02; 95% confidence interval (CI) 1.00 to 1.03), Charlson Comorbidity Index >2 (OR 2.06; 95% CI, 1.44 to 2.94), Simplified Acute Physiology Score 3 (SAPS 3) score (OR 1.02; CI 95%, 1.00 to 1.04), severe ARDS (OR 1.44; CI 95%, 1.09 to 1.91) and deep sedation (OR 2.36; CI 95%, 1.31 to 4.25) were independently associated with increased hospital mortality. Conclusions Early deep sedation is associated with adverse outcomes and constitutes an independent predictor of hospital mortality in mechanically ventilated patients.
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- 2014
6. Towards zero rate in healthcare-associated infections: one size shall not fit all
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Jordi Rello and Thiago Lisboa
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Healthcare associated infections ,Male ,medicine.medical_specialty ,Catheterization, Central Venous ,Quality management ,Psychological intervention ,MEDLINE ,Critical Care and Intensive Care Medicine ,Cohort Studies ,Patient safety ,Critical care nursing ,Health care ,medicine ,Humans ,Intensive care medicine ,Cross Infection ,Critically ill ,business.industry ,Tertiary Healthcare ,medicine.disease ,Intensive Care Units ,Catheter-Related Infections ,Commentary ,Female ,Medical emergency ,business - Abstract
We set a goal to reduce the incidence rate of catheter-related bloodstream infections to rate of1 per 1,000 central line days in a two-year period.This is an observational cohort study with historical controls in a 25-bed intensive care unit at a tertiary academic hospital. All patients admitted to the unit from January 2008 to December 2011 (31,931 patient days) were included. A multidisciplinary team consisting of hospital epidemiologist/infectious diseases physician, infection preventionist, unit physician and nursing leadership was convened. Interventions included: central line insertion checklist, demonstration of competencies for line maintenance and access, daily line necessity checklist, and quality rounds by nursing leadership, heightened staff accountability, follow-up surveillance by epidemiology with timely unit feedback and case reviews, and identification of noncompliance with evidence-based guidelines. Molecular epidemiologic investigation of a cluster of vancomycin-resistant Enterococcus faecium (VRE) was undertaken resulting in staff education for proper acquisition of blood cultures, environmental decontamination and daily chlorhexidine gluconate (CHG) bathing for patients.Center for Disease Control/National Health Safety Network (CDC/NHSN) definition was used to measure central line-associated bloodstream infection (CLA-BSI) rates during the following time periods: baseline (January 2008 to December 2009), intervention year (IY) 1 (January to December 2010), and IY 2 (January to December 2011). Infection rates were as follows: baseline: 2.65 infections per 1,000 catheter days; IY1: 1.97 per 1,000 catheter days; the incidence rate ratio (IRR) was 0.74 (95% CI=0.37 to 1.65, P=0.398); residual seven CLA-BSIs during IY1 were VRE faecium blood cultures positive from central line alone in the setting of findings explicable by noninfectious conditions. Following staff education, environmental decontamination and CHG bathing (IY2): 0.53 per 1,000 catheter days; the IRR was 0.20 (95% CI=0.06 to 0.65, P=0.008) with 80% reduction compared to the baseline. Over the two-year intervention period, the overall rate decreased by 53% to 1.24 per 1,000 catheter-days (IRR of 0.47 (95% CI=0.25 to 0.88, P=0.019) with zero CLA-BSI for a total of 15 months.Residual CLA-BSIs, despite strict adherence to central line bundle, may be related to blood culture contamination categorized as CLA-BSIs per CDC/NHSN definition. Efforts to reduce residual CLA-BSIs require a strategic multidisciplinary team approach focused on epidemiologic investigations of practitioner- or unit-specific etiologies.
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- 2013
7. C-reactive protein in community-acquired sepsis: you can teach new tricks to an old dog
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Jorge I. F. Salluh and Thiago Lisboa
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Male ,medicine.medical_specialty ,macromolecular substances ,Critical Care and Intensive Care Medicine ,Sepsis ,Outcome Assessment, Health Care ,Medicine ,Humans ,In patient ,Hospital Mortality ,Prospective Studies ,Intensive care medicine ,Severe sepsis ,Aged ,biology ,Portugal ,business.industry ,C-reactive protein ,Middle Aged ,medicine.disease ,Response to treatment ,Anti-Bacterial Agents ,Community-Acquired Infections ,Intensive Care Units ,C-Reactive Protein ,biology.protein ,Commentary ,Biomarker (medicine) ,Female ,business ,Biomarkers - Abstract
C-reactive protein (CRP) has been shown to be a valuable marker in the diagnosis of infection and in monitoring its response to antibiotics. Our objective was to evaluate serial CRP measurements after prescription of antibiotics to describe the clinical course of Community-Acquired Sepsis admitted to intensive care units (ICU).During a 12-month period a multi-center, prospective, observational study was conducted, segregating adults with Community-Acquired Sepsis. Patients were followed-up during the first five ICU days, day of ICU discharge or death and hospital outcome. CRP-ratio was calculated in relation to Day 1 CRP concentration. Patients were classified according to the pattern of CRP-ratio response to antibiotics: fast response if Day 5 CRP-ratio was0.4, slow response if Day 5 CRP-ratio was between 0.4 and 0.8, and no response if Day 5 CRP-ratio was0.8. Comparison between survivors and non-survivors was performed.A total of 891 patients (age 60 ± 17 yrs, hospital mortality 38%) were studied. There were no significant differences between the CRP of survivors and non-survivors until Day 2 of antibiotic therapy. On the following three days, CRP of survivors was significantly lower (P0.001). After adjusting for the Simplified Acute Physiology Score II and severity of sepsis, the CRP course was significantly associated with mortality (ORCRP-ratio = 1.03, confidence interval 95%= (1.02, 1.04), P0.001). The hospital mortality of patients with fast response, slow response and no response patterns was 23%, 30% and 41%, respectively (P = 0.001). No responders had a significant increase on the odds of death (OR = 2.5, CI95% = (1.6, 4.0), P0.001) when compared with fast responders.Daily CRP measurements after antibiotic prescription were useful as early as Day 3 in identification of Community-Acquired Sepsis patients with poor outcome. The rate of CRP decline during the first five ICU days was markedly associated with prognosis. The identification of the pattern of CRP-ratio response was useful in the recognition of the individual clinical course.
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- 2011
8. The simple and the simpler in pneumonia diagnosis
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Thiago Lisboa and Jordi Rello
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medicine.medical_specialty ,business.industry ,Research ,Colony Count, Microbial ,Diagnostic accuracy ,Gold standard (test) ,Critical Care and Intensive Care Medicine ,medicine.disease ,Nursing Homes ,Specimen Handling ,Trachea ,Clinical Practice ,Endotracheal aspirate ,Pneumonia ,Predictive Value of Tests ,Predictive value of tests ,Pneumonia, Bacterial ,medicine ,Homes for the Aged ,Humans ,Nursing homes ,Intensive care medicine ,business - Abstract
Introduction Diagnostic strategies based on tracheal aspirates in patients with severe nursing home-acquired pneumonia have not previously been evaluated. The objectives of the study were to investigate, in patients with severe nursing home-acquired pneumonia, the diagnostic value of quantitative endotracheal aspirate (QEA) cultures using increasing interpretative cutoff points, as compared with bronchoalveolar lavage (BAL) and protected specimen brush (PSB) quantitative cultures. Methods Seventy-five nursing home patients requiring mechanical ventilation for suspected pneumonia were studied. Endotracheal aspirate, PSB, and BAL samples were obtained consecutively. The diagnostic yield of QEA at thresholds raging from 103 to 107 colony-forming units (cfu)/ml was assessed by calculating sensitivities, specificities, and accuracy rates. A receiver operator characteristic curve for the series of cutoff points was constructed. Results Forty-nine patients were diagnosed with pneumonia either by BAL (≤ 104 cfu/ml) or PSB (≤ 103 cfu/ml). Diagnostic accuracy of QEA was most favorable at 104 cfu/ml. At this threshold, endotracheal aspirates coincided with both BAL and PSB in 30 cases, whereas partial agreement was observed in 14 cases. This resulted in sensitivity and specificity of 90% (95% confidence interval 78% to 97%) and 77% (95% confidence interval 56% to 91%), respectively. QEA findings correlated significantly with both PSB and BAL quantitative cultures (r = 0.71 [P < 0.001] and r = 0.77 [P < 0.001], respectively). Conclusion QEA may be used as a diagnostic tool to determine the presence of pneumonia in ventilated patients admitted from nursing homes when bronchoscopic procedures are not feasible or available.
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- 2007
9. [Untitled]
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Jandyra Maria Guimarães Fachel, Renato Seligman, Paulo José Zimermann Teixeira, Tania B. Filippin, Michael Meisner, Thiago Lisboa, and Felipe Teixeira Hertz
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medicine.medical_specialty ,business.industry ,Ventilator-associated pneumonia ,Odds ratio ,Critical Care and Intensive Care Medicine ,medicine.disease ,Intensive care unit ,Procalcitonin ,Surgery ,law.invention ,law ,Internal medicine ,medicine ,SOFA score ,business ,Prospective cohort study ,Survival rate ,Cohort study - Abstract
This study sought to assess the prognostic value of the kinetics of procalcitonin (PCT), C-reactive protein (CRP) and clinical scores (clinical pulmonary infection score (CPIS), Sequential Organ Failure Assessment (SOFA)) in the outcome of ventilator-associated pneumonia (VAP) at an early time point, when adequacy of antimicrobial treatment is evaluated. This prospective observational cohort study was conducted in a teaching hospital. The subjects were 75 patients consecutively admitted to the intensive care unit from October 2003 to August 2005 who developed VAP. Patients were followed for 28 days after the diagnosis, when they were considered survivors. Patients who died before the 28th day were non-survivors. There were no interventions. PCT, CRP and SOFA score were determined on day 0 and day 4. Variables included in the univariable logistic regression model for survival were age, Acute Physiology and Chronic Health Evaluation (APACHE) II score, decreasing ΔSOFA, decreasing ΔPCT and decreasing ΔCRP. Survival was directly related to decreasing ΔPCT with odds ratio (OR) = 5.67 (95% confidence interval 1.78 to 18.03), decreasing ΔCRP with OR = 3.78 (1.24 to 11.50), decreasing ΔSOFA with OR = 3.08 (1.02 to 9.26) and APACHE II score with OR = 0.92 (0.86 to 0.99). In a multivariable logistic regression model for survival, only decreasing ΔPCT with OR = 4.43 (1.08 to 18.18) and decreasing ΔCRP with OR = 7.40 (1.58 to 34.73) remained significant. Decreasing ΔCPIS was not related to survival (p = 0.59). There was a trend to correlate adequacy to survival. Fifty percent of the 20 patients treated with inadequate antibiotics and 65.5% of the 55 patients on adequate antibiotics survived (p = 0.29). Measurement of PCT and CRP at onset and on the fourth day of treatment can predict survival of VAP patients. A decrease in either one of these marker values predicts survival.
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- 2006
10. [Untitled]
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L Mallmann, E Parolo, Rafael Barberena Moraes, Gilberto Friedman, and Thiago Lisboa
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medicine.medical_specialty ,business.industry ,Critically ill ,medicine.drug_class ,Antibiotics ,Critical Care and Intensive Care Medicine ,Intensive care unit ,law.invention ,Empirical antibiotic therapy ,Empirical treatment ,law ,Antibiotic therapy ,Emergency medicine ,medicine ,Initial treatment ,Intensive care medicine ,business - Abstract
Infectious pathologies are among the most prevalent in the ICU and significantly influence the outcome of critically ill patients. However, the emergency of resistant pathogens to different antibiotics makes the choice of the initial treatment more complex. In addition, inadequate empirical antibiotic therapy is associated with a poorer outcome.
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- 2005
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