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Rationale: The effects of balanced crystalloid versus saline on clinical outcomes for ICU patients may be modified by the type of fluid that patients received for initial resuscitation and by the type of admission. Objectives: To assess whether the results of a randomized controlled trial could be affected by fluid use before enrollment and admission type. Methods: Secondary post hoc analysis of the BaSICS (Balanced Solution in Intensive Care Study) trial, which compared a balanced solution (Plasma-Lyte 148) with 0.9% saline in the ICU. Patients were categorized according to fluid use in the 24 hours before enrollment in four groups (balanced solutions only, 0.9% saline only, a mix of both, and no fluid before enrollment) and according to admission type (planned, unplanned with sepsis, and unplanned without sepsis). The association between 90-day mortality and the randomization group was assessed using a hierarchical logistic Bayesian model. Measurements and Main Results: A total of 10,520 patients were included. There was a low probability that the balanced solution was associated with improved 90-day mortality in the whole trial population (odds ratio [OR], 0.95; 89% credible interval [CrI], 0.66-10.51; probability of benefit, 0.58); however, probability of benefit was high for patients who received only balanced solutions before enrollment (regardless of admission type, OR, 0.78; 89% CrI, 0.56-1.03; probability of benefit, 0.92), mostly because of a benefit in unplanned admissions due to sepsis (OR, 0.70; 89% CrI, 0.50-0.97; probability of benefit, 0.96) and planned admissions (OR, 0.79; 89% CrI, 0.65-0.97; probability of benefit, 0.97). Conclusions: There is a high probability that balanced solution use in the ICU reduces 90-day mortality in patients who exclusively received balanced fluids before trial enrollment. Clinical trial registered with www.clinicaltrials.gov (NCT02875873). [ABSTRACT FROM AUTHOR]

Importance: Intravenous fluids are used for almost all intensive care unit (ICU) patients. Clinical and laboratory studies have questioned whether specific fluid types result in improved outcomes, including mortality and acute kidney injury.Objective: To determine the effect of a balanced solution vs saline solution (0.9% sodium chloride) on 90-day survival in critically ill patients.Design, Setting, and Participants: Double-blind, factorial, randomized clinical trial conducted at 75 ICUs in Brazil. Patients who were admitted to the ICU with at least 1 risk factor for worse outcomes, who required at least 1 fluid expansion, and who were expected to remain in the ICU for more than 24 hours were randomized between May 29, 2017, and March 2, 2020; follow-up concluded on October 29, 2020. Patients were randomized to 2 different fluid types (a balanced solution vs saline solution reported in this article) and 2 different infusion rates (reported separately).Interventions: Patients were randomly assigned 1:1 to receive either a balanced solution (n = 5522) or 0.9% saline solution (n = 5530) for all intravenous fluids.Main Outcomes and Measures: The primary outcome was 90-day survival.Results: Among 11 052 patients who were randomized, 10 520 (95.2%) were available for the analysis (mean age, 61.1 [SD, 17] years; 44.2% were women). There was no significant interaction between the 2 interventions (fluid type and infusion speed; P = .98). Planned surgical admissions represented 48.4% of all patients. Of all the patients, 60.6% had hypotension or vasopressor use and 44.3% required mechanical ventilation at enrollment. Patients in both groups received a median of 1.5 L of fluid during the first day after enrollment. By day 90, 1381 of 5230 patients (26.4%) assigned to a balanced solution died vs 1439 of 5290 patients (27.2%) assigned to saline solution (adjusted hazard ratio, 0.97 [95% CI, 0.90-1.05]; P = .47). There were no unexpected treatment-related severe adverse events in either group.Conclusion and Relevance: Among critically ill patients requiring fluid challenges, use of a balanced solution compared with 0.9% saline solution did not significantly reduce 90-day mortality. The findings do not support the use of this balanced solution.Trial Registration: ClinicalTrials.gov Identifier: NCT02875873. [ABSTRACT FROM AUTHOR]

Background: To describe the clinical and microbiological data of carbapenem-resistant Enterobacteriaceae (CRE) infections, the treatment used, hospital- and infection-related mortality, and risk factors for death. Methods: A prospective cohort conducted from March 2011 to December 2012. Clinical, demographic, and microbiological data such as in vitro sensitivity, clonality, carbapenemase gene mortality related to infection, and overall mortality were evaluated. Data were analyzed using Epi Info version 7.0 (CDC, Atlanta, GA, USA) and SPSS (Chicago, IL, USA). Results: One hundred and twenty-seven patients were evaluated. Pneumonia, 52 (42 %), and urinary tract infections (UTI), 51 (40.2 %), were the most frequent sites of infection. The isolates were polyclonal; the BlaKPC gene was found in 75.6 % of isolates, and 27 % of isolates were resistant to colistin. Mortality related to infection was 34.6 %, and was higher among patients with pneumonia (61.4 %). Combination therapy was used in 98 (77.2 %), and monotherapy in 22.8 %; 96.5 % of them were UTI patients. Shock, age, and dialysis were independent risk factors for death. There was no difference in infection-related death comparing colistin-susceptible and colistin-resistant infections (p = 0.46); neither in survival rate comparing the use of combination therapy with two drugs or more than two drugs (p = 0.32). Conclusions: CRE infection mortality was higher among patients with pneumonia. Infections caused by colistin-resistant isolates did not increase mortality. The use of more than two drugs on combination therapy did not show a protective effect on outcome. The isolates were polyclonal, and the blaKPC gene was the only carbapenemase found. Shock, dialysis, and age over 60 years were independent risk factors for death. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the loss of lean mass in patients with burns using ultrasonography of the quadriceps muscle of the thigh., Methods: A prospective longitudinal study was conducted using ultrasound of the quadriceps muscle of the thigh to assess the change in thickness in millimeters on days 1, 3 and 7 after study enrollment in 45 patients with burns who were admitted to a burn center (BTC) of a university hospital between April 2020 and September 2021. Patients burns on the thighs, which made it difficult to undertake examinations, were excluded. Depending on where they were admitted, patients were divided into ward and intensive care unit (ICU) patients. ICU patients were considered to have more severe injuries. The general data collected included age, sex, weight, height, area of body surface burn, burn degree and etiology, and airway injury. The data collected for all patients during hospitalization at the BTC were as follows: existence of chronic illness, requirement for mechanical ventilation, Simplified Acute Physiology Score 3 (SAPS 3) and Sequential Organ Failure Assessment (SOFA) on the first day of hospitalization in an intensive care bed in the burn treatment unit (BTU), health-related infection, feeding route, length of hospital stay, and time spent in the BTU., Results: Loss of muscle thickness was observed in all patients between days 1 and 7. The median thickness for all patients on day 1 was 24.50 mm (ITQ 21.22-30.85) and on day 7 it was 18.80 (ITQ 16.07-23.62), with P = 0.0001. The variation in thigh quadricep muscle thickness between day 1 and day 3, a median of - 2.80 mm (ITQ - 3.52-2.02) was obtained for patients on the ward and - 2.50 mm (ITQ - 3.92 to - 1.47) for ICU patients. Between day 3 and day 7, the variation was - 2.55 mm (ITQ - 4.55 to - 1.25) for ward patients and - 2.10 mm (ITQ - 3.12 to - 1.15) for ICU patients. The median thickness variation assessed between day 1 and day 7 was - 4.95 mm (ITQ - 8.25 to - 3.70) for patients on the ward and - 4.40 mm (ITQ - 7, 35 to - 2.90) for ICU patients. A correlation was observed between the variation in muscle thickness in the interval between day 1 to day 3 and age (P = 0.035)., Conclusions: Muscle loss occurred early and rapidly within the first seven days of hospitalization, reflecting the impact of burn injury on nutritional risk. An association was observed between muscle thickness loss and age, but no association was observed with the extent of burn, length of hospital stay, occurrence of health-related infections or mortality. These findings suggest the importance of monitoring muscle loss in these patients in planning nutritional therapy, early mobilization, and prevention of complications., (Copyright © 2023 Elsevier Ltd and ISBI. All rights reserved.)

Background: Among nonsurvivors admitted to the intensive care unit (ICU), some present early mortality while other patients, despite having a favorable evolution regarding the initial disease, die later due to complications related to hospitalization. This study aims to identify factors associated with the time until death after admission to an ICU of a university hospital., Methods: Retrospective longitudinal study that included adult patients admitted to the ICU between January 1, 2008, and December 31, 2017. Nonsurviving patients were divided into groups according to the length of time from admission to the ICU until death: Early (0-5 days), intermediate (6-28 days), and late (>28 days). Patients were considered septic if they had this diagnosis on admission to the ICU. Simple linear regression analysis was performed to evaluate the association between time to death over the years of the study. Multivariate cox regression was used to assess risk factors for the outcome in the ICU., Results: In total, 6596 patients were analyzed. Mortality rate was 32.9% in the ICU. Most deaths occurred in the early (42.8%) and intermediate periods (47.9%). Patients with three or more dysfunctions on admission were more likely to die early ( P < 0.001). The diagnosis of sepsis was associated with a higher mortality rate. The multivariate analysis identified age >60 years (hazard ratio [HR] 1.009), male (HR 1.192), mechanical ventilation (HR 1.476), dialysis (HR 2.297), and sequential organ failure assessment >6 (HR 1.319) as risk factors for mortality., Conclusion: We found a higher proportion of early and intermediate deaths in the study period. The presence of three or more organ dysfunctions at ICU admission was associated with early death. The diagnosis of sepsis evident on ICU admission was associated with higher mortality., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 International Journal of Critical Illness and Injury Science.)

Introduction: Treatment for Helicobacter pylori (H. pylori) infection is recommended in transplant candidates due to the association between this infection and gastrointestinal disorders, which could significantly increase morbidity after renal transplantation with the use of immunosuppression. The objective of this study was to analyze the rate of eradication of H. pylori after antimicrobial treatment in chronic kidney disease patients who are candidates for kidney transplantation., Methods: A multicenter prospective cohort study was conducted. All adult chronic kidney disease patients seen at our institution were included. In the pre-transplantation evaluation, 83 patients underwent an upper gastrointestinal endoscopy with 2 diagnostic methods to detect H. pylori: histology and the rapid urease test. In total, 33 patients with H. pylori infection received treatment with 20 mg omeprazole, 500 mg amoxicillin, and 500 mg clarithromycin once daily for 14 days. Another upper gastrointestinal endoscopy was performed 8 to 12 weeks after the end of treatment to check for healing., Results: The study showed a prevalence of H. pylori in 51 (61.4%) patients. Histology was positive in 50 (98%) patients and the rapid urease test was positive in 31 (60.8%). The infection eradication rate was 48.5% (16 patients)., Conclusions: There was a high prevalence rate of H. pylori and a low eradication rate after the long-term antimicrobial triple scheme used. The association of the rapid urease test with gastric mucosa histology did not increase the detection rate of H. pylori.

Background: It is unknown whether lung-protective ventilation is applied in burn patients and whether they benefit from it. This study aimed to determine ventilation practices in burn intensive care units (ICUs) and investigate the association between lung-protective ventilation and the number of ventilator-free days and alive at day 28 (VFD-28)., Methods: This is an international prospective observational cohort study including adult burn patients requiring mechanical ventilation. Low tidal volume ( V T ) was defined as V T  ≤ 8 mL/kg predicted body weight (PBW). Levels of positive end-expiratory pressure (PEEP) and maximum airway pressures were collected. The association between V T and VFD-28 was analyzed using a competing risk model. Ventilation settings were presented for all patients, focusing on the first day of ventilation. We also compared ventilation settings between patients with and without inhalation trauma., Results: A total of 160 patients from 28 ICUs in 16 countries were included. Low V T was used in 74% of patients, median V T size was 7.3 [interquartile range (IQR) 6.2-8.3] mL/kg PBW and did not differ between patients with and without inhalation trauma ( p  = 0.58). Median VFD-28 was 17 (IQR 0-26), without a difference between ventilation with low or high V T ( p  = 0.98). All patients were ventilated with PEEP levels ≥5 cmH 2 O; 80% of patients had maximum airway pressures <30 cmH 2 O., Conclusion: In this international cohort study we found that lung-protective ventilation is used in the majority of burn patients, irrespective of the presence of inhalation trauma. Use of low V T was not associated with a reduction in VFD-28., Trial Registration: Clinicaltrials.gov NCT02312869. Date of registration: 9 December 2014., (© The Author(s) 2021. Published by Oxford University Press.)

Introduction: Age and inhalation injury are important risk factors for acute respiratory distress syndrome (ARDS) in the burned patient; however, the impact of interventions such as mechanical ventilation, fluid balance (FB), and packed red blood cell transfusion remains unclear. The purpose of this study was to determine the incidence of moderate and severe ARDS and its risk factors among burn-related demographic variables and clinical interventions in mechanically ventilated burn patients. Risk factors for death within 28 days were also evaluated., Method: A prospective longitudinal study was carried out over a period of 30 months between July 2015 and December 2017. Patients older than 18 years, with a burn injury and under mechanical ventilation were included. The outcomes of interest were diagnosis of ARDS up to seven days after admission and death within 28 days. The proportional Cox regression risk model was used to obtain the hazard ratio for each independent variable., Results: The cases of 61 patients were analyzed. Thirty-seven (60.66%) of the patients developed ARDS. The groups of patients with or without ARDS did not present differences regarding age, sex, burned body surface, or prognostic scores. Factors independently related to the occurrence of ARDS were age (hazard ratio [HR] = 1.04; 95% confidence interval [CI] 1.02-1.06; P < 0.001), inhalation injury (HR = 2.50; 95% CI 1.25-5.02; P = 0.01), and static compliance (HR = 0.97; 95% CI 0.94-0.99; P = 0.03). Tidal volume, driving pressure, acute renal injury, and FB between days 1 and 7 were similar in both groups. Accumulated FBs of 48, 72, 96, and 168 hours were also similar. Mortality at 28 days was 40.98% (25 patients). ARDS (HR = 3.63, 95% CI 1.36 to 9.68; P = 0.01) and burned body surface area (HR = 1.03, 95% CI 1.02 to 1.05; P < 0.001) were associated with death in 28 days., Conclusion: ARDS was a frequent complication and a risk factor for death in patients under mechanical ventilation, with large burned areas. Age and inhalation injury were independent factors for ARDS. Current tidal volume, driving pressure, red blood cell transfusion, acute renal injury, and FB were not predictors of ARDS., Competing Interests: None., (IJBT Copyright © 2020.)

Objectives: This study sought to analyze the clinical and epidemiologic characteristics of critically ill patients who were denied intensive care unit admission due to the unavailability of beds and to estimate the direct costs of treatment., Methods: A prospective cohort study was performed with critically ill patients treated in a university hospital. All consecutive patients denied intensive care unit beds due to a full unit from February 2012 to February 2013 were included. The data collected included clinical data, calculation of costs, prognostic scores, and outcomes. The patients were followed for data collection until intensive care unit admission or cancellation of the request for the intensive care unit bed. Vital status at hospital discharge was noted, and patients were classified as survivors or non-survivors considering this endpoint., Results: Four hundred and fifty-four patients were analyzed. Patients were predominantly male (54.6%), and the median age was 62 (interquartile range (ITQ): 47 - 73) years. The median APACHE II score was 22.5 (ITQ: 16 - 29). Invasive mechanical ventilation was used in 298 patients (65.6%), and vasoactive drugs were used in 44.9% of patients. The median time of follow-up was 3 days (ITQ: 2 - 6); after this time, 204 patients were admitted to the intensive care unit and 250 had the intensive care unit bed request canceled. The median total cost per patient was US$ 5,945.98., Conclusions: Patients presented a high severity in terms of disease scores, had multiple organ dysfunction and needed multiple invasive therapeutic interventions. The study patients received intensive care with specialized consultation during their stay in the hospital wards and presented high costs of treatment.

Introduction: When the number of patients who require intensive care is greater than the number of beds available, intensive care unit (ICU) entry flow is obstructed. This phenomenon has been associated with higher mortality rates in patients that are not admitted despite their need, and in patients that are admitted but are waiting for a bed. The purpose of this study is to evaluate if a delay in ICU admission affects mortality for critically ill patients., Methods: A prospective cohort of adult patients admitted to the ICU of our institution between January and December 2005 were analyzed. Patients for whom a bed was available were immediately admitted; when no bed was available, patients waited for ICU admission. ICU admission was classified as either delayed or immediate. Confounding variables examined were: age, sex, originating hospital ward, ICU diagnosis, co-morbidity, Acute Physiology and Chronic Health Evaluation (APACHE) II score, therapeutic intervention, and Sequential Organ Failure Assessment (SOFA) score. All patients were followed until hospital discharge., Results: A total of 401 patients were evaluated; 125 (31.2%) patients were immediately admitted and 276 (68.8%) patients had delayed admission. There was a significant increase in ICU mortality rates with a delay in ICU admission (P = 0.002). The fraction of mortality risk attributable to ICU delay was 30% (95% confidence interval (CI): 11.2% to 44.8%). Each hour of waiting was independently associated with a 1.5% increased risk of ICU death (hazard ratio (HR): 1.015; 95% CI 1.006 to 1.023; P = 0.001)., Conclusions: There is a significant association between time to admission and survival rates. Early admission to the ICU is more likely to produce positive outcomes.

Objectives: The objective of this study was to estimate disease incidence and mortality rate of sepsis in a tertiary public hospital., Methods: Patients admitted to the Intensive Care Unit (ICU) in 2004 and 2005 were monitored for sepsis using an observational longitudinal study design. Patients were monitored daily for diagnostic criteria of sepsis, according to ACCP/SCCM Consensus Conference criteria, until either death or hospital discharge., Results: During the study, we analyzed 1,179 patients. Systemic Inflammatory Response Syndrome (SIRS) was present in 1,048 (88.9%) patients on admission, and was associated with infection in 554 (47.0%) patients. Of these, sepsis was diagnosed in 30 (2.5%) patients, while severe sepsis was diagnosed in 269 (22.8%) patients, and septic shock was diagnosed in 255 (21.6%) patients. APACHE II and SOFA scores were higher in septic patients (p < 0.001), and the ensuing mortality rates were 32.8% (IC 95%: 21.6-45.7%) for patients with sepsis, 49.9% (IC 95%: 44.5-55.2%) for severe sepsis, and 72.7% (IC 95%: 68.1-76.9%) for septic shock., Conclusions: The data from our study revealed a high incidence of sepsis among hospitalized patients. Moreover, sepsis patients had a high rate of mortality.

Objectives: To evaluate the application of the Sequential Organ Failure Assessment (SOFA) in describing the severity of organ dysfunctions and the associated mortality rates in critically ill patients at a teaching hospital., Research Methodology: Prospective longitudinal study performed in 1164 adult, critically ill patients who were admitted consecutively into intensive care units between January 2004 and December 2005. We analysed static evaluation of SOFA and dynamic changes in the SOFA scores. The discriminative power of SOFA was evaluated using ROC curves., Results: There was an increase in the mortality rate when the SOFA scores increased (chi2(trend)=272.08, p<0.001, increase rate=0.13). The SOFA score on the third day in the ICU had the highest area under the curve for hospital mortality (AUC: 0.817+/-0.0133, CI 95%: 0.792-0.840). We analysed SOFA score changes with time and observed that patients with low scores (0-5) upon admission and who increased to the medium or high SOFA groups had a significantly higher mortality rate (51.7 and 100%, respectively, p<0.001)., Conclusions: Applying SOFA to critically ill patients effectively described the severity of organ dysfunctions, and higher SOFA scores had a positive association with mortality., (Copyright 2009 Elsevier Ltd. All rights reserved.)