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People living with HIV (PLWH) are more prone to severe respiratory infections. We used the severe acute respiratory infection (SARI) definition to describe the etiology, clinical, and epidemiological characteristics in this population. This was a prospective observational study including PLWH hospitalized with fever and cough. Those with symptom onset up to 10 days were classified as severe acute respiratory infection and 11–30 days as non-severe acute respiratory infection. Blood, urine samples and nasopharyngeal swabs were collected. Data were extracted from patient charts during their hospital stay. Forty-nine patients were included, median CD4 cell count: 80 cells/mm3, median time since HIV diagnosis and hospital admission: 84 months and 80% were antiretroviral therapy exposed. Twenty-seven patients were classified as SARI. Etiology was identified in 69%, 47% were polymicrobial. Respiratory virus (9 SARI vs. 13 non-SARI), bacteria (5 SARI vs. 4 non-SARI), Mycobacterium tuberculosis (6 SARI group vs. 7 non-SARI group), Pneumocystis jirovecii (4 SARI vs. 1 non-SARI), Cryptococcus neoformans (1 SARI vs. 3 non-SARI), and influenza A (1 SARI vs. 2 non-SARI). Dyspnea was statistically more prevalent in SARI (78% vs. 36%, p = 0.011) but the risk of death was higher in the non-SARI (4% vs. 36%, p = 0.0067). In the severely immunocompromised PLWH, severe acute respiratory infection can be caused by multiple pathogens and codetection is a common feature.

Purpose: To examine quality indicators of end-of-life (EOL) care among privately insured people with cancer in Brazil. Methods: We evaluated medical records linked to health insurance databank to study consecutive patients who died of cancer. We collected information about demographics, cancer type, and quality indicators of EOL care including emergency department (ED) visits, intensive care unit (ICU) admissions, chemotherapy use, medical imaging utilization, blood transfusions, home care support, days of inpatient care, and hospital deaths. Results: We included 865 patients in the study. In the last 30 days of life, 62% visited the ED, 33% were admitted to the ICU, 24% received blood transfusions, and 51% underwent medical imaging. Only 1% had home care support in the last 60 days of life, and 29% used chemotherapy in the last 14 days of life. Patients had an average of 8 days of inpatient care and 52% died in the hospital. Patients with advanced cancer who used chemotherapy were more likely to visit the ED (78% vs 59%; P < .001), undergo medical imaging (67% vs 51%; P < .001), and die in the hospital (73% vs 50%; P = .03) than patients who did not use chemotherapy. In the multivariate analysis, chemotherapy use near death and advanced cancer were associated with ED visits and ICU admissions, respectively (odds ratio >1). Conclusion: Our study suggests that privately insured people with cancer receive poor quality EOL care in Brazil. Further research is needed to assess the impact of improvements in palliative care provision in this population.

Background Central nervous system infections (CNSI) are diseases with high morbidity and mortality, and their diagnosis in the intensive care environment can be challenging. Objective: To develop and validate a diagnostic model to quickly screen intensive care patients with suspected CNSI using readily available clinical data. Methods Derivation cohort: 783 patients admitted to an infectious diseases intensive care unit (ICU) in Oswaldo Cruz Foundation, Rio de Janeiro RJ, Brazil, for any reason, between 01/01/2012 and 06/30/2019, with a prevalence of 97 (12.4%) CNSI cases. Validation cohort 1: 163 patients prospectively collected, between 07/01/2019 and 07/01/2020, from the same ICU, with 15 (9.2%) CNSI cases. Validation cohort 2: 7,270 patients with 88 CNSI (1.21%) admitted to a neuro ICU in Chicago, IL, USA between 01/01/2014 and 06/30/2019. Prediction model: Multivariate logistic regression analysis was performed to construct the model, and Receiver Operating Characteristic (ROC) curve analysis was used for model validation. Eight predictors—age 2 cells/mm3, fever (≥38°C/100.4°F), focal neurologic deficit, Glasgow Coma Scale Results The pool data’s model had an Area Under the Receiver Operating Characteristics (AUC) curve of 0.892 (95% confidence interval 0.864–0.921, P Conclusions A promising and straightforward screening tool for central nervous system infections, with few and readily available clinical variables, was developed and had good accuracy, with internal and external validity.

Background: The 30-day readmission rate is an indicator of the quality of hospital care and transition to the outpatient setting. Recent studies suggest HIV infection might increase the risk of readmission although estimates of 30-day readmission rates are unavailable among HIV-infected individuals living in middle/lowincome settings. Additionally, factors that may increase readmission risk in HIV-infected populations are poorly understood. Methods: Thirty-day readmission rates were estimated for HIVinfected adults from the Instituto Nacional de Infectologia Evandro Chagas/Fiocruz cohort in Rio de Janeiro, Brazil, from January 2007 to December 2013. Cox regression models were used to evaluate factors associated with the risk of 30-day readmission. Results: Between January 2007 and December 2013, 3991 patients were followed and 1861 hospitalizations were observed. The estimated 30-day readmission rate was 14% (95% confidence interval: 12.3 to 15.9). Attending a medical visit within 30 days after discharge (adjusted hazard ratio [aHR] = 0.73, P = 0.048) and being hospitalized in more recent calendar years (aHR = 0.89, P = 0.002) reduced the risk of 30 day readmission. In contrast, low CD4 counts (51–200 cells/mm³: aHR = 1.70, P = 0.024 and # 50 cells/mm³: aHR = 2.05, P = 0.003), time since HIV infection diagnosis $10 years (aHR = 1.58, P = 0.058), and leaving hospital against medical advice (aHR = 2.67, P = 0.004) increased the risk of 30-day readmission. Conclusions: Patients with advanced HIV/AIDS are most at risk of readmission and should be targeted with prevention strategies to reduce this risk. Efforts to reduce discharge against medical advice and to promote early postdischarge medical visit would likely reduce 30-day readmission rates in our population.

Objectives: The characteristics of critically ill HIV-positive patients and the causes of their admission to intensive care units (ICUs) are only known through retrospective and unicentric studies. This study aims to fill this knowledge gap. Methods: This is a prospective, multicentre cohort study of short- and medium-term prognostic factors. The setting consisted of ICUs of three tertiary referral hospitals from the three largest metropolitan areas in Brazil in the period January 2014 to November 2015. In all, 161 HIV patients over 18 years old were included. Results: The clinical data of the outcomes (ICU mortality, hospital mortality and 90-day survival) were extracted from medical records using the REDCap® web-based form and analysed with the MedCalc® application. Median age was 41.7 [interquartile range (IQR): 34-50] years, the Simplified Acute Physiologic Score 3 (SAPS 3) was 64 (IQR: 56-74), and the Sequential Organ Failure Assessment Score (SOFA) was 6 (IQR: 4-9) points. The main causes of admission were sepsis (54.5%) and acute respiratory failure (13.7%). ICU and hospital mortality rates were 32.3% and 40.4%, respectively. In a multivariate analysis, time until ICU admission ≥ 3 days (P = 0.0013), performance status (Eastern Cooperative Oncology Group score, P = 0.0344), coma (Glasgow Coma Scale ≤ 8 points, P = 0.0213) and sepsis (P = 0.0003) were associated with increased hospital mortality. Coma (P = 0.0002) and sepsis (P = 0.0008) were independently associated with 90-day survival. Conclusions: Delayed ICU admission and the severity of critical illness determine the short- and medium-term mortality rates of HIV-infected patients admitted to the ICU, rather than factors associated with HIV infection. These results suggest that prognostic factors of HIV-infected patients in the ICU are similar to those of non-HIV-infected populations.

Patients with complex palliative care needs can experience delayed discharge, which causes an inappropriate occupancy of hospital beds. Post-acute care facilities (PACFs) have emerged as an alternative discharge destination for some of these patients. The aim of this study was to investigate the frequency of admissions and characteristics of palliative care patients discharged from hospitals to a PACF. We conducted a retrospective analysis of PACF admissions between 2014 and 2016 that were linked to hospital discharge reports and electronic health records, to gather information about hospital-to-PACF transitions. In total, 205 consecutive patients were discharged from 6 different hospitals to our PACF. Palliative care patients were involved in 32% (n = 67) of these discharges. The most common conditions were terminal cancer (n = 42, 63%), advanced dementia (n = 17, 25%), and stroke (n = 5, 8%). During acute hospital stays, patients with cancer had significant shorter lengths of stay (13 vs 99 days, P = .004), a lower use of intensive care services (2% vs 64%, P < .001) and mechanical ventilation (2% vs 40%, P < .001), when compared to noncancer patients. Approximately one-third of discharges from hospitals to a PACF involved a heterogeneous group of patients in need of palliative care. Further studies are necessary to understand the trajectory of posthospitalized patients with life-limiting illnesses and what factors influence their decision to choose a PACF as a discharge destination and place of death. We advocate that palliative care should be integrated into the portfolio of post-acute services.

Patients with hematologic malignancies (HMs) often receive poor-quality end-of-life care. This study aimed to identify trends in end-of-life care among patients with HM in Brazil. We conducted a retrospective cohort study (2015-2018) of patients who died with HM, using electronic medical records linked to health insurance databank, to evaluate outcomes consistent with health-care resource utilization at the end of life. Among 111 patients with HM, in the last 30 days of life, we found high rates of emergency department visits (67%, n = 75), intensive care unit admissions (56%, n = 62), acute renal replacement therapy (10%, n = 11), blood transfusions (45%, n = 50), and medical imaging utilization (59%, n = 66). Patients received an average of 13 days of inpatient care and the majority of them died in the hospital (53%, n = 58). We also found that almost 40% of patients (38%, n = 42) used chemotherapy in the last 14 days of life. These patients were more likely to be male (64% vs 22%; P < .001), to receive blood transfusions (57% vs 38%; P = .05), and to die in the hospital (76% vs 39%; P = .009) than patients who did not use chemotherapy in the last 14 days of life. This study suggests that patients with HM have high rates of health-care utilization at the end of life in Brazil. Patients who used chemotherapy in the last 14 days of life were more likely to receive blood transfusions and to die in the hospital.

Objectives : To compare the discriminatory capacity of the quick sequential organ failure assessment (qSOFA) vs. the systemic inflammatory response syndrome (SIRS) score for predicting 30-day mortality and intensive care unit (ICU) admission in patients with suspicion of infection at an HIV reference centre. Methods We performed a prospective cohort study including consecutive adult patients who had suspected infection and who were subsequently admitted to the medical ward. Variables related to qSOFA and SIRS were measured at admission. The performance (area under the receiver operating curve, AUROC) of qSOFA (score ≥2) and SIRS (≥2 criteria) as a predictor of 30-day mortality and ICU admission was evaluated. Results One hundred seventy-three patients (mean ± standard deviation age, 42.6 ± 12.4 years) were included in the analysis; 107 (61.8%) were male, and 111 (64.2%) were HIV positive. Respiratory and gastrointestinal infections occurred in 49 (28.3%) and 23 (13.3%), respectively. The 30-day mortality rate was 9 (5.2%) of 173. The prognostic performance of qSOFA was similar compared to SIRS, with an AUROC of 0.68 (95% confidence interval, 0.55–0.81) and 0.69 (95% confidence interval, 0.53–0.86) (p 0.96). Twenty patients (11%) were admitted to the ICU; qSOFA and SIRS had a similar discriminatory capacity for ICU admission (AUROC 0.63 (95% confidence interval, 0.51–0.75) and 0.63 (95% confidence interval, 0.50–0.76)), respectively). Conclusions We found a poor prognostic accuracy of the qSOFA to predict 30-day mortality in hospitalized patients suspected of infection in a setting with a high burden of HIV infection.

Andre Miguel Japiassu. Fundacao Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Documento produzido em parceria ou por autor vinculado a Fiocruz, mas nao consta a informacao no documento.

Detailed information on organization and process of care in intensive care units (ICU) in emerging countries is scarce. Here, we investigated the impact of organizational factors on the outcomes and resource use in a large sample of Brazilian ICUs. Retrospective cohort study of 59,693 patients (medical admissions, 67 %) admitted to 78 ICUs during 2013. We retrieved patients’ data from an ICU quality registry and surveyed ICUs regarding structure, organization, staffing patterns, and process of care. We used multilevel logistic regression analysis to identify factors associated with hospital mortality. Efficient resource use was assessed by estimating standardized resource use and mortality rates adjusted for the SAPS 3 score. ICUs were mostly medical-surgical (79 %) and located at private hospitals (86 %). Median nurse to bed ratio was 0.20 (IQR, 0.15–0.28) and board-certified intensivists were present 24/7 in 16 (21 %) of ICUs. Multidisciplinary rounds occurred in 67 (86 %) and daily checklists were used in 36 (46 %) ICUs. Most frequent protocols focused on sepsis management and prevention of healthcare-associated infections. Hospital mortality was 14.4 %. In multivariable analysis, the number of protocols was the only organizational characteristic associated with mortality [odds ratio = 0.944 (95 % CI 0.904–0.987)]. The effects of protocols were consistent across subgroups including surgical and medical patients as well as the SAPS 3 tertiles. We also observed a significant trend toward efficient resource use as the number of protocols increased. In emerging countries such as Brazil, organizational factors, including the implementation of protocols, are potential targets to improve patient outcomes and resource use in ICUs.

Introduction Higher mortality for patients admitted to intensive care units (ICUs) during the weekends has been occasionally reported with conflicting results that could be related to organisational factors. We investigated the effects of ICU organisational and staffing patterns on the potential association between weekend admission and outcomes in critically ill patients. Methods We included 59 614 patients admitted to 78 ICUs participating during 2013. We defined ‘weekend admission’ as any ICU admission from Friday 19:00 until Monday 07:00. We assessed the association between weekend admission with hospital mortality using a mixed logistic regression model controlling for both patient-level (illness severity, age, comorbidities, performance status and admission type) and ICU-level (decrease in nurse/bed ratio on weekend, full-time intensivist coverage, use of checklists on weekends and number of institutional protocols) confounders. We performed secondary analyses in the subgroup of scheduled surgical admissions. Results A total of 41 894 patients (70.3%) were admitted on weekdays and 17 720 patients (29.7%) on weekends. In univariable analysis, weekend admitted patients had higher ICU (10.9% vs 9.0%, P

OBJECTIVES: The aim of this study was to develop a strategy to identify adverse drug events associated with drug-drug interactions by analyzing the prescriptions of critically ill patients. METHODS: This retrospective study included HIV/AIDS patients who were admitted to an intensive care unit between November 2006 and September 2008. Data were collected in two stages. In the first stage, three prescriptions administered throughout the entire duration of these patients’ hospitalization were reviewed, with the Micromedex database used to search for potential drug-drug interactions. In the second stage, a search for adverse drug events in all available medical, nursing and laboratory records was performed. The probability that a drug-drug interaction caused each adverse drug events was assessed using the Naranjo algorithm. RESULTS: A total of 186 drug prescriptions of 62 HIV/AIDS patients were analyzed. There were 331 potential drug-drug interactions, and 9% of these potential interactions resulted in adverse drug events in 16 patients; these adverse drug events included treatment failure (16.7%) and adverse reactions (83.3%). Most of the adverse drug reactions were classified as possible based on the Naranjo algorithm. CONCLUSIONS: The approach used in this study allowed for the detection of adverse drug events related to 9% of the potential drug-drug interactions that were identified; these adverse drug events affected 26% of the study population. With the monitoring of adverse drug events based on prescriptions, a combination of the evaluation of potential drug-drug interactions by clinical pharmacy services and the monitoring of critically ill patients is an effective strategy that can be used as a complementary tool for safety assessments and the prevention of adverse drug events.

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 Unico de Saude) 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.

Objectives To evaluate the correlation of the total distance walked during the six-minute walk test (6MWT) with left ventricular function and quality of life in patients with Chagas Disease (ChD) complicated by heart failure. Methods This is a cross-sectional study of adult patients with ChD and heart failure diagnosed based on Framingham criteria. 6MWT was performed following international guidelines. New York Heart Association functional class, brain natriuretic peptide (BNP) serum levels, echocardiographic parameters and quality of life (SF-36 and MLHFQ questionnaires) were determined and their correlation with the distance covered at the 6MWT was tested. Results Forty adult patients (19 male; 60 ± 12 years old) with ChD and heart failure were included in this study. The mean left ventricular ejection fraction was 35 ± 12%. Only two patients (5%) ceased walking before 6 min had elapsed. There were no cardiac events during the test. The average distance covered was 337 ± 105 metres. The distance covered presented a negative correlation with BNP (r = −0.37; P = 0.02), MLHFQ quality-of-life score (r = −0.54; P = 0.002), pulmonary artery systolic pressure (r = −0.42; P = 0.02) and the degree of diastolic dysfunction (r = −0.36; P = 0.03) and mitral regurgitation (r = −0.53; P = 0.0006) and positive correlation with several domains of the SF-36 questionnaire. Conclusions The distance walked during the 6MWT correlates with BNP, quality of life and parameters of left ventricular diastolic function in ChD patients with heart failure. We propose this test to be adopted in endemic areas with limited resources to aid in the identification of patients who need referral for tertiary centres for further evaluation and treatment.

The goal of this study was to explore possible microcirculatory alterations by changing sedative infusion from propofol to midazolam in patients with septic shock.Patients (n=16) were sedated with propofol during the first 24 hours after intubation, then with midazolam, following a predefined algorithm. Systemic hemodynamics, perfusion parameters, and microcirculation were assessed at 2 time points: just before stopping propofol and 30 minutes after the start of midazolam infusion. Sublingual microcirculation was evaluated by sidestream dark-field imaging.The microvascular flow index and the proportion of perfused small vessels were greater when patients were on midazolam than when on propofol infusion (2.8 [2.4-2.9] vs 2.3 [1.9-2.6] and 96.4% [93.7%-97.6%] vs 92.7% [88.3%-94.7%], respectively; P.005), and the flow heterogeneity index was greater with propofol than with midazolam use (0.49 [0.2-0.8] vs 0.19 [0.1-0.4], P.05). There were no significant changes in systemic hemodynamics and perfusion parameters either during propofol use or during midazolam infusions. Data are presented as median (25th-75th percentiles).In this study, sublingual microcirculatory perfusion improved when the infusion was changed from propofol to midazolam in patients with septic shock. This observation could not be explained by changes in systemic hemodynamics.

Background Reliable information on severe morbidity is essential for identifying priorities for case management and to guide resource allocation within the health sector. Methods This study describes overall, AIDS- and non-AIDS-related severe morbidity as well as mortality and its determinants in an urban cohort of HIV-infected individuals from a public healthcare institution, the Evandro Chagas Research Institute (IPEC) of the Oswaldo Cruz Foundation, Rio de Janeiro, Brazil. Severe morbid events were defined as all clinical diagnoses listed in hospitalization discharge records; all diagnoses were checked and validated. Generalized estimating equation models were used to estimate incidence rates while adjusting for within-subject correlation. Results Between 2000 and 2010, 3,537 patients were followed for a total of 16,960 person-years (PY) of follow-up. Over the years, annual incidence rate of severe morbid events, AIDS-related events, non-AIDS-related events, and deaths significantly decreased from, respectively, 36.6, 12.9, 23.7 and 3.2 per 100 PY in 2000 to 25.3, 7.9, 17.4 and 1.9 per 100 PY in 2010. Patients’ immunological profiles significantly improved with time; 84% of the patients used combination antiretroviral therapy (cART) per year. Immunodeficiency was associated with a higher incidence rate of AIDS- and non-AIDS-related events as well as with the incidence rate of specific non-AIDS events (bacterial infections, toxicities, cardiovascular, renal and respiratory diseases). Conclusions Our results show that in a middle income country with access to cART, non-AIDS-related events represent an important cause of severe morbidity alongside a still high incidence rate of AIDS-related events.

Introduction It is unclear whether the treatment of an HIV infection with highly active antiretroviral therapy (HAART) affects intensive care unit (ICU) outcomes. In this paper, we report the results of a systematic review and meta-analysis performed to summarize the effects of HAART on the prognosis of critically ill HIV positive patients. Materials and methods A bibliographic search was performed in 3 databases (PubMed, Web of Science and Scopus) to identify articles that investigated the use of HAART during ICU admissions for short- and long-term mortality or survival. Eligible articles were selected in a staged process and were independently assessed by two investigators. The methodological quality of the selected articles was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) tool. Results Twelve articles met the systematic review inclusion criteria and examined short-term mortality. Six of them also examined long-term mortality (≥90 days) after ICU discharge. The short-term mortality meta-analysis showed a significant beneficial effect of initiating or maintaining HAART during the ICU stay (random effects odds ratio 0.53, p = 0.02). The data analysis of long-term outcomes also suggested a reduced mortality when HAART was used, but the effect of HAART on long-term mortality of HIV positive critically ill patients remains uncertain. Conclusions This meta-analysis suggests improved survival rates for HIV positive patients who were treated with HAART during their ICU admission.

The presentation of study results is a key step in scientific research, and submitting an abstract to a meeting is often the first form of public communication. Meeting abstracts have a defined structure that is similar to abstracts for scientific articles, with an introduction, the objective, methods, results and conclusions. However, abstracts for meetings are not presented as part of a full article and, therefore, must contain the necessary and most relevant data. In this article, we detail their structure and include tips to make them technically correct.

Pressure ulcers are preventable events. Critically ill patients are particularly vulnerable. The Braden scale has been used to identify hospitalized patients at high risk for the development of pressure ulcers; however, this predictive tool has not been adequately validated for critically ill patients.We aimed to validate and improve the Braden scale for critically ill patients by adding clinical variables to the original scale.We conducted a cohort study in 12 intensive care units (ICUs) within a network of hospitals in Brazil during 2013. We excluded patients who stayed less than 48 hours, patients with one or more pressure ulcers at admission, and those who developed a pressure ulcer within the first 48 hours. We evaluated the Braden scale and clinical variables through a competing risk analysis. Discrimination and calibration were evaluated using the Concordance index (C-index) and a calibration plot, respectively. We used bootstrapping to assess internal validation.Our primary outcome was incident pressure ulcer within 30 days of ICU admission. We analyzed 9,605 patients and observed 157 pressure ulcers (rate of 3.33 pressure ulcers/1,000 patient-days). The majority of pressure ulcers were detected at stage I or II (28.7 and 66.2%, respectively). The Braden scale had good discrimination (C-index, 0.753; 95% confidence interval, 0.712-0.795), although its performance decreased for the most severely ill patients. We derived a modified predictive tool by adding eight clinical variables to the Braden scale: age, sex, diabetes mellitus, hematological malignancy, peripheral artery disease, hypotension at ICU admission, and need for mechanical ventilation or renal replacement therapy in the first 24 hours after ICU admission. The derived score had better discrimination and calibration than the original Braden scale. The best score cutoff was at least 6 points, with a sensitivity of 87% and a specificity of 71%.The original Braden scale measured at ICU admission is a valuable tool for pressure ulcer prediction, although it is not accurate for severely ill patients. To overcome the limitations of the original scale, we derived a modified score with better performance, which may identify high-risk ICU patients and support target interventions. External validation of the proposed clinical prediction score is needed.

Background Tuberculosis is one of the leading causes of death from infectious diseases worldwide, mainly after the human immunodeficiency virus (HIV) epidemics. Patient with HIV-related illness are more likely to present with severe TB due to immunosuppression. Very few studies have explored HIV/TB co-infection in critically ill patients. The goal of this study was to analyze factors associated with long-term mortality in critically ill patient with HIV-related disease coinfected with TB. Methods We conducted a retrospective study in an infectious disease reference center in Brazil that included all patient with HIV-related illness admitted to the ICU with laboratory-confirmed tuberculosis from March 2007 until June 2012. Clinical and laboratory variables were analyzed based on six-month survival. Results Forty-four patients with HIV-related illness with a confirmed diagnosis of tuberculosis were analyzed. The six-month mortality was 52 % (23 patients). The main causes of admission were respiratory failure (41 %), severe sepsis/septic shock (32 %) and coma/torpor (14 %). The median time between HIV diagnosis and ICU admission was 5 (1–60) months, and 41 % of patients received their HIV infection diagnosis ≤ 30 days before admission. The median CD4 count was 72 (IQR: 23–136) cells/mm3. The clinical presentation was pulmonary tuberculosis in 22 patients (50 %) and disseminated TB in 20 patients (45.5 %). No aspect of TB diagnosis or treatment was different between survivors and nonsurvivors. Neurological dysfunction was more prevalent among nonsurvivors (43 % vs. 14 %, p = 0.04). The nadir CD4 cell count lower than 50 cells/mm3 was independently associated with Six-month mortality (hazard ratio 4.58 [1.64–12.74], p

A evolução para disfunção de múltiplos órgãos ainda é comum na sepse e está relacionada diretamente com a disfunção microcirculatória. Através de pesquisa nas bases de dados PubMed, empregando-se os unitermos microcirculação e sepse, vinte e seis artigos foram selecionados para esta revisão, bem como citações consideradas relevantes extraídas de artigos de revisão. Com o advento da técnica de imagem obtida através de polarização ortogonal, que permite a observação à beira do leito da microcirculação em pacientes críticos, é possível estabelecer uma relação entre disfunção microvascular e prognóstico, além de observar diretamente o efeito de diferentes intervenções terapêuticas. No entanto, a relação causal entre disfunção microcirculatória e prognóstico adverso na sepse, bem como os efeitos de terapias dirigidas para correção destas anormalidades microcirculatórias ainda precisam ser melhor definidos.

Objective: Increasing evidence points to the role of mitochondrial dysfunction in the pathogenesis of sepsis. Previous data indicate that mitochondrial function is affected in monocytes from septic patients, but the underlying mechanisms and the impact of these changes on the patients’ outcome are unknown. We aimed to determine the mechanisms involved in mitochondrial dysfunction in peripheral blood mononuclear cells from patients with septic shock. Design: A cohort of patients with septic shock to study peripheral blood mononuclear cell mitochondrial respiration by high-resolution respirometry analyses and to compare with cells from control subjects. Setting: Three intensive care units and an academic research laboratory. Subjects: Twenty patients with septic shock and a control group composed of 18 postoperative patients without sepsis or shock. Interventions: Ex vivo measurements of mitochondrial oxygen consumption were carried out in digitonin-permeabilized peripheral blood mononuclear cells from 20 patients with septic shock taken during the first 48 hrs after intensive care unit admission as well as in peripheral blood mononuclear cells from control subjects. Clinical parameters such as hospital outcome and sepsis severity were also analyzed and the relationship between these parameters and the oxygen consumption pattern was investigated. Measurements and Main Results: We observed a significant reduction in the respiration specifically associated with adenosine-5-triphosphate synthesis (state 3) compared with the control group (5.60 vs. 9.89 nmol O2/min/10 7 cells, respectively, p < .01). Reduction of state 3 respiration in patients with septic shock was seen with increased prevalence of organ failure (r 0.46, p .005). Nonsurviving patients with septic shock presented significantly lower adenosine diphosphate-stimulated respiration when compared with the control group (4.56 vs. 10.27 nmol O2/min/10 7 cells, respectively; p .004). Finally, the presence of the functional F1Fo adenosine-5’-triphosphate synthase complex (0.51 vs. 1.00 ng oligo/mL/10 6 cells, p .02), but not the adenine nucleotide translocator, was significantly lower in patients with septic shock compared with control cells. Conclusion: Mitochondrial dysfunction is present in immune cells from patients with septic shock and is characterized as a reduced respiration associated to adenosine-5-triphosphate synthesis. The molecular basis of this phenotype involve a reduction of F1Fo adenosine-5-triphosphate synthase activity, which may contribute to the energetic failure found in sepsis. (Crit Care Med 2011; 39:1056 –1063)

Human albumin has been used as a therapeutic agent in intensive care units for more than 50 years. However, clinical studies from the late 1990s described possible harmful effects in critically ill patients. These studies' controversial results followed other randomized controlled studies and meta-analyses that showed no harmful effects of this colloid solution. In Brazil, several public and private hospitals comply with the Agencia Nacional de Vigilância Sanitaria (the Brazilian Health Surveillance Agency) recommendations for appropriate administration of intravenous albumin. This review discusses indications for albumin administration in critically ill patients and analyzes the evidence for metabolic and immunomodulatory effects of this colloid solution. We also describe the most significant studies from 1998 to the present time; these reveal an absence of incremental mortality from intravenous albumin administration as compared to crystalloid solutions. The National Health Surveillance Agency indications are discussed relative to the current body of evidence for albumin use in critically ill patients.

Hemodynamic instability plays a major role in the pathogenesis of systemic inflammation, tissue hypoxia, and multiple organ dysfunction in sepsis. Aggressive fluid replacement is one of the key interventions for the hemodynamic support in severe sepsis. In this scenario, the ability to restore the imbalance between tissue oxygen demand and supply, the heterogeneity in microcirculation, and endothelial dysfunction in the early stages of sepsis are associated with reduced mortality. In 2001, a single-center randomized controlled trial showed impressive reductions in hospital mortality when patients presenting to the emergency department with severe sepsis were treated with an aggressive protocol of fluids, blood transfusion, and inotropes aiming to improve tissue perfusion. However, external validation of this trial remains to be carried out. To date, there is no unequivocal evidence that such strategy is both universally feasible and effective. In the present article, we review the current evidence and comment on the future perspectives on early fluid resuscitation in severe sepsis.

OBJETIVOS: A variação respiratória da pressão arterial é um bom preditor da resposta a fluidos em pacientes ventilados. Foi recentemente demonstrado que a variação respiratória na pressão arterial de pulso se correlaciona com a variação da amplitude da onda pletismográfica da oximetria de pulso. Nossa intenção foi avaliar a correlação entre a variação respiratória da pressão arterial de pulso e a variação respiratória na amplitude da onda pletismográfica da oximetria de pulso, e determinar se esta correlação foi influenciada pela administração de norepinefrina. MÉTODOS: Estudo prospectivo de sessenta pacientes com ritmo sinusal normal sob ventilação mecânica, profundamente sedados e hemodinamicamente estáveis. Foram monitorados o índice de oxigenação e pressão arterial invasiva. A variação respiratória da pressão do pulso e a variação respiratória da amplitude da onda pletismográfica na oximetria de pulso foram registradas simultaneamente batimento a batimento, e foram comparadas utilizando o coeficiente de concordância de Pearson e regressão linear. RESULTADOS: Trinta pacientes (50%) necessitaram de norepinefrina. Ocorreu uma correlação significante (K=0,66; p

OBJETIVOS: Devido ao aumento de longevidade da população e a alta prevalência de doença coronariana em idosos, o procedimento de revascularização miocárdica se tornou mais freqüente nesta faixa etária. O objetivo deste estudo foi avaliar as características operatórias, tempo de internação, complicações e desfechos de curto prazo, observada nas cirurgias de revascularização miocárdica em idosos. MÉTODOS: Entre fevereiro de 2005 e outubro de 2007, 269 pacientes foram submetidos à revascularização miocárdica . Foram identificados dados demográficos, comorbidades, escores prognósticos (Euroscore, Ontário e APACHE II), caráter eletivo versus urgente da cirurgia, dados do intra-operatório, complicações no período pós-operatório e tempo de permanência e letalidade na unidade de terapia intensiva. Os pacientes foram divididos em 4 grupos de acordo com a faixa etária: grupo I (até 60 anos, n = 68), II (60-69, n = 86), III (70-79, n = 93) e IV (acima de 80, n = 22). RESULTADOS: Quando comparados a outros grupos etários, o grupo IV foi submetido a maior número de cirurgias combinadas com troca valvar e de caráter urgente, com maior tempo de Unidade de Terapia Intensiva (p < 0,01). A incidência de pelo menos uma complicação pósoperatória foi significativamente maior no grupo com mais de 80 anos (p < 0.001). A análise multivariada demonstrou que idade e tempo de circulação extracorpórea foram fatores associados independentemente com a ocorrência de complicações. A letalidade foi maior em pacientes com mais de 70 anos (p = 0,03). CONCLUSÕES: Pacientes com mais de 80 anos submetidos à cirurgia de revascularização miocárdica apresentaram maior tempo de permanência na unidade de terapia intensiva, número de complicações e letalidade. Idade e tempo de circulação extracorpórea foram fatores de risco, independentemente associados com a incidência de complicações pós-operatórias.

Macrophage migration inhibitory factor (MIF) is a cytokine playing a critical role in the pathophysiology of experimental sepsis. The purpose of this study was to determine the levels of MIF and to compare those to interleukin-6 (IL-6) levels in predicting mortality among critically ill patients with sepsis. The levels of MIF and IL-6 were measured in 25 patients with septic shock, 17 patients with sepsis, and 11 healthy volunteers. The median plasma concentrations of MIF and IL-6 were significantly higher in patients with septic shock and in patients with sepsis than in healthy controls. MIF levels were significantly different between survivors and nonsurvivors, as were IL-6 levels. Discriminatory power in predicting mortality, as assessed by the areas under receiver operating characteristic curves (AUROC), was 0.793 for MIF and 0.680 for IL-6. Finally, high plasma levels of MIF (> 1100 pg/mL) had a sensitivity of 100% and a specificity of 64% to identify the patients who eventually would evolve to a fatal outcome. Thus, our data suggest that an elevated MIF level in recently diagnosed septic patients appears to be an early indicator of poor outcome and a potential entry criterion for future studies with therapeutic intervention aiming at MIF neutralization.

OBJECTIVE: Although intra-abdominal hypertension (IAH) can cause dysfunction of several organs and raise mortality, little information is available on the incidence and risk factors for IAH in critically ill patients. This study assessed the prevalence of IAH and its risk factors in a mixed population of intensive care patients. DESIGN: A multicentre, prospective 1-day point-prevalence epidemiological study conducted in 13 ICUs of six countries. INTERVENTIONS: None. PATIENTS: Ninety-seven patients admitted for more than 24 h to one of the ICUs during the 1-day study period. METHODS: Intra-abdominal pressure (IAP) was measured four times (every 6 h) by the bladder pressure method. Data included the demographics, medical or surgical type of admission, SOFA score, etiological factors such as abdominal surgery, haemoperitoneum, abdominal infection, massive fluid resuscitation, and ileus and predisposing conditions such as hypothermia, acidosis, polytransfusion, coagulopathy, sepsis, liver dysfunction, pneumonia and bacteraemia. RESULTS: We enrolled 97 patients, mean age 64+/-15 years, 57 (59%) medical and 40 (41%) surgical admission, SOFA score of 6.5+/-4.0. Mean IAP was 9.8+/-4.7 mmHg. The prevalence of IAH (defined as IAP 12 mmHg or more) was 50.5 and 8.2% had abdominal compartment syndrome (defined as IAP 20 mmHg or more). The only risk factor significantly associated with IAH was the body mass index, while massive fluid resuscitation, renal and coagulation impairment were at limit of significance. CONCLUSION: Although we found a quite high prevalence of IAH, no risk factors were reliably associated with IAH; consequently, to get valid information about IAH, IAP needs to be measured.

Evidence exists that during pressure support ventilation (PSV), the addition of an extrinsic (ie, ventilator-generated) breath-to-breath variability (BBV) of breathing pattern improves respiratory function. If BBV is beneficial per se, choosing the PS level that maximizes it could be considered a valid strategy for conventional PSV. In this study, we evaluated the effect of different PS levels on intrinsic BBV in acutely ill, mechanically ventilated subjects to determine whether a significant relationship exists between PS level and BBV magnitude.Fourteen invasively mechanically ventilated subjects were prospectively studied. PS was adjusted at 20 cm H2O and sequentially reduced to 15, 10, and 5 cm H2O. Arterial blood gas analysis and pressure at 0.1 s after the onset of inspiration (P0.1) were measured at each PS level. Airway and esophageal pressure and air flow were continuously recorded. Peak inspiratory flow, tidal volume (VT), breathing frequency, and pressure-time product (PTP) were calculated on a breath-by-breath basis. The breathing pattern variability was assessed by the coefficient of variation of the time series of VT, peak inspiratory flow, and breathing frequency from ∼ 60 consecutive breath cycles at each PS level. A general linear model for repeated measures was applied, with PS as an independent factor. A significance level of .05 was considered.Despite a large inter-individual difference in all measured variables (P.001), the coefficient of variation was as low as 30%, and no significant differences in the coefficient of variation of peak inspiratory flow, breathing frequency, and VT between PS levels were observed (P.15). Additionally, a significant increase in P0.1, PTP, and breathing frequency (P.01) and a reduction in VT (P.001) were observed with PS reduction.Despite a significant increase in spontaneous activity with PS reduction, BBV was not influenced by the PS level and was as low as 30% for all evaluated parameters.

INTRODUCTION: In recent years, the incidence of sepsis has increased in critically ill HIV/AIDS patients, and the presence of severe sepsis emerged as a major determinant of outcomes in this population. The inflammatory response and deregulated cytokine production play key roles in the pathophysiology of sepsis; however, these mechanisms have not been fully characterized in HIV/AIDS septic patients. METHODS: We conducted a prospective cohort study that included HIV/AIDS and non-HIV patients with septic shock. We measured clinical parameters and biomarkers (C-reactive protein and cytokine levels) on the first day of septic shock and compared these parameters between HIV/AIDS and non-HIV patients. RESULTS: We included 30 HIV/AIDS septic shock patients and 30 non-HIV septic shock patients. The HIV/AIDS patients presented low CD4 cell counts (72 [7-268] cells/mm(3)), and 17 (57%) patients were on HAART before hospital admission. Both groups were similar according to the acute severity scores and hospital mortality. The IL-6, IL-10 and G-CSF levels were associated with hospital mortality in the HIV/AIDS septic group; however, the CRP levels and the surrogates of innate immune activation (cytokines) were similar among HIV/AIDS and non-HIV septic patients. Age (odds ratio 1.05, CI 95% 1.02-1.09, p=0.002) and the IL-6 levels (odds ratio 1.00, CI 95% 1.00-1.01, p=0.05) were independent risk factors for hospital mortality. CONCLUSIONS: IL-6, IL-10 and G-CSF are biomarkers that can be used to predict prognosis and outcomes in HIV/AIDS septic patients. Although HIV/AIDS patients are immunocompromised, an innate immune response can be activated in these patients, which is similar to that in the non-HIV septic population. In addition, age and the IL-6 levels are independent risk factors for hospital mortality irrespective of HIV/AIDS disease.

OBJETIVO: Avaliar as repercussões gasométricas de dois métodos de ventilação (ventilador de transporte e ressuscitador manual autoinflável) durante o transporte intra-hospitalar de pacientes submetidos à cirurgia cardíaca. MÉTODOS: Estudo observacional, longitudinal, prospectivo e randomizado. Foram coletadas gasometrias arteriais ao final da cirurgia e ao final do transporte do paciente. RESULTADOS: Foram incluídos 23 pacientes: 13 no Grupo ventilador de transporte e 10 no ressuscitador manual autoinflável. As características dos pacientes entre os grupos foram semelhantes, exceto pela maior gravidade no Grupo ventilador de transporte. Observaram-se diferenças significativas nas comparações das variações percentuais dos dados gasométricos: pH (VT: + 4% vs RMA: - 5%, p=0,007), PaCO2 (VT: - 8% vs RMA: + 13%, p=0,006), PaO2 (VT: + 47% vs RMA: - 34%, p=0,01) e SatO2 (VT: + 0,6% vs RMA: - 1,7%, p=0,001). CONCLUSÃO: O uso de ventilador mecânico causa menor repercussão nos gases sanguíneos no transporte intra-hospitalar de pacientes após de cirurgia cardíaca. OBJECTIVE: To evaluate the effects on blood gases by two methods of ventilation (with transport ventilation or self-inflating manual resuscitator) during intra-hospital transport of patients after cardiac surgery. METHODS: Observational, longitudinal, prospective, randomized study. Two samples of arterial blood were collected at the end of the surgery and another at the end of patient transport. RESULTS: We included 23 patients: 13 in the Group with transport ventilation and 10 in the Group with self-inflating manual resuscitator. Baseline characteristics were similar between both groups, except for higher acute severity of illness in the Group with transport ventilation. We observed significant differences in comparisons of percentage variations of gasometric data: pH (transport ventilation + 4% x MR -5%, p=0.007), PaCO2 (-8% x +13%, p=0.006), PaO2 (+47% x -34%, p=0.01) and SatO2 (+0.6% x -1.7%, p=0.001). CONCLUSION: The use of mechanical ventilation results in fewer repercussions for blood gas analysis in the intra-hospital transport of cardiac surgery patients.

The frequency of immunocompromised patients has increased dramatically over the last decades. Frequently, combined mechanisms of immunosuppression coexist, and patients are at increased risk for sepsis and for infections due to opportunistic pathogens. Despite the recent evidence demonstrating improved outcomes when they become critically ill, care for these patients remains a major challenge for intensivists and infectious diseases consultants. In this sense, immunosuppressed patients, such as those with malignancies and HIV/AIDS, provide a good opportunity to validate the PIRO concept. The predisposing factors (i.e., specific immune defects, previous antimicrobial or immunosuppressive exposure), infection (i.e., microbiologic data or clinical features related to specific pathogens), response (i.e., biomarkers, imaging findings,) and organ failure (i.e., main site of clinical expression of disease and/or associated organ dysfunction) constitute the framework to refine the information about the epidemiology, outcomes, risk stratification and response to therapeutic strategies in these patients, which are essential for future research, to assist clinicians in decision-making, therapeutic tailoring, and patient and family counseling.

The aim of this study was to investigate Clostridium difficile-associated diarrhea (CDAD) in an intensive care unit (ICU) of a tertiary hospital in Rio de Janeiro, Brazil, and to characterize epidemiologically C. difficile strains obtained from an outbreak of CDAD. Within almost a 4-year surveillance period, CDAD incidence was determined for the first time in Brazil, and a 3-fold increase was observed in the average rate of CDAD, featuring an outbreak. About 80% of the patients were over 65 years. The main antibiotic that could be probably associated to CDAD was piperacillin/tazobactam. Four toxigenic strains were isolated, 3 from stools and 1 from environmental samples. They were all resistant to clindamycin and fluoroquinolones. Fingerprinting analysis revealed their distribution between 2 different polymerase chain reaction ribotypes, with one of them being exclusively found in Brazil. It was possible to detect cross-infection and environmental contamination in the ICU. Our results highlight the importance of a continuous CDAD surveillance in the hospitals, especially when a risk group is exposed.

Corticosteroids have been proposed for decades as adjunctive therapy of severe infections. These drugs have complex mechanisms of action involving anti-inflammatory and vasoactive properties. However, due to discordant results from clinical studies, the use of corticosteroids to treat patients with severe infections is still a matter of intense debate in the scientific and medical community. In the present article, we review the underlying mechanisms related to the potential benefits of corticosteroids and their impact on clinical management of severe sepsis.

Low-grade polymicrobial infection induced by cecal ligation and puncture is lethal in heme oxygenase-1-deficient mice (Hmox1(-/-)), but not in wild-type (Hmox1(+/+)) mice. Here we demonstrate that the protective effect of this heme-catabolizing enzyme relies on its ability to prevent tissue damage caused by the circulating free heme released from hemoglobin during infection. Heme administration after low-grade infection in mice promoted tissue damage and severe sepsis. Free heme contributed to the pathogenesis of severe sepsis irrespective of pathogen load, revealing that it compromised host tolerance to infection. Development of lethal forms of severe sepsis after high-grade infection was associated with reduced serum concentrations of the heme sequestering protein hemopexin (HPX), whereas HPX administration after high-grade infection prevented tissue damage and lethality. Finally, the lethal outcome of septic shock in patients was also associated with reduced HPX serum concentrations. We propose that targeting free heme by HPX might be used therapeutically to treat severe sepsis.

OBJETIVOS: Prever reinternação na unidade de terapia intensiva, analisando as primeiras 24 horas de pacientes após admissão em unidade de terapia intensiva. MÉTODOS: A primeira internação de pacientes de janeiro a maio de 2009 em UTI geral foi estudada. Considerou-se reinternação em unidade de terapia intensiva na mesma permanência hospitalar ou retorno em até 3 meses após alta da unidade. Pacientes que faleceram na 1ª admissão foram excluídos. Fatores demográficos, uso de assistência ventilatória e permanência na unidade de terapia intensiva por mais de 3 dias foram analisadas de forma uni e multivariada de acordo com desfecho reinternação. RESULTADOS: Quinhentos e setenta e sete pacientes foram incluídos (33 óbitos excluídos). O grupo de reinternação foi 59 pacientes, e 518 não reinternados. O tempo entre admissão índice e reinternação foi 9 (3-28) dias (18 foram readmitidos com menos de 3 dias) e 10 faleceram. Os pacientes reinternados pelo menos 1 vez na unidade de terapia intensiva apresentaram as seguintes diferenças em relação ao grupo controle: maior idade: 75 (67-81) versus 67 (56-78) anos, p

Corticosteroids are widely used to treat a diversity of pathological conditions including allergic, autoimmune and some infectious diseases. These drugs have complex mechanisms of action involving both genomic and non-genomic mechanisms and interfere with different signal transduction pathways in the cell. The use of corticosteroids to treat critically ill patients with acute respiratory distress syndrome and severe infections, such as sepsis and pneumonia, is still a matter of intense debate in the scientific and medical community with evidence both for and against its use in these patients. Here, we review the basic molecular mechanisms important for corticosteroid action as well as current evidence for their use, or not, in septic patients. We also present an analysis of the reasons why this is still such a controversial point in the literature.

Náuseas e vômitos pós-operatórios são comuns e podem ser evitados. Complicações provenientes deste problema acarretam aumento de morbi-mortalidade. Foi realizada revisão de literatura no MEDLINE, com foco em estudos clínicos controlados. A fisiopatologia é complexa, com várias vias centrais aferentes e eferentes, e seu entendimento ajuda na escolha das medicações. Fatores de risco são apresentados, com escala de estratificação de chance para desenvolvimento de náuseas e vômitos pósoperatórios. Algoritmo para abordagem de pacientes com maior risco foi elaborado e estratifica nível de prevenção/tratamento a ser recebido, de modo a evitar uso excessivo de drogas e seus paraefeitos. Náuseas e vômitos pós-operatórios devem ser prevenidos, pois acarretam complicações e desconforto nos pacientes. Abordagem sistemática com análise de fatores de risco per-operatórios e prescrição de medicações podem ser eficazes para sua prevenção. Postoperative nausea and vomiting are common and can be prevented. Complications of this condition cause higher rates of morbidity and mortality. A review of literature was carried out on MEDLINE, with focus on controlled clinical trials. Pathophysiology is complex, with many afferent and efferent pathways, and its comprehension facilitate the choice of medication. Risk factors are presented, with a stratified score of chance to develop postoperative nausea and vomiting. An algorithm for identification of higher risk patients was elaborated and classified the level of prevention/treatment recommended to avoid excessive use of drugs and their side effects. Postoperative nausea and vomiting must be prevented, because of the involved complications and discomfort for patients. A systematic approach with analysis of preoperative risk factors and prescription of medication can be effective for prevention.

1-9 Physicians from the Intensive Care Unit of Casa de Saude Sao Jose, Rio de Janeiro (RJ), Brazil. 10 – Physician from the Intensive Care Unit of Casa de Saude Sao Jose, Rio de Janeiro (RJ), Brazil and Institute for Clinical Research Evandro Chagas FIOCRUZ, Rio de Janeiro (RJ), Brazil. We wish to thank Dr. Helcio Griffhorn for his interest in our work. We have shown that octogenarians present a longer stay, higher incidence of complications and higher mortality, with worse peri-operative severity of illness. However, nonelderly and sexagenarian patients had similar performance, disclosing increased life expectancy and quality in Brazilian population.(1) Septuagenarian were characterized by hybrid results, showing increased severity of disease, higher incidence of postoperative atrial fibrillation and reoperation, however ICU length of stay and mortality were similar to those of younger groups. Worse performance of elderly can result from need for urgent surgery, efforts to prolong treatment with drugs and coronary angioplasty procedures. Blood transfusion was more often used at preoperative of septuagenarians and octogenarians (critical levels of anemia with advanced age or greater use of blood products may significantly influence outcomes).(2,3) The study included only patients submitted to coronary artery bypass graft (CABG) as the main surgery although a significant number also had an indication for valve replacement, secondarily. As commented, mortality of CABG patients who needed valve replacement is higher (15.5%). There were 61 orovalvular surgeries during the study’s period, with 6 deaths, but they were excluded because we wanted to specifically analyze a homogeneous group of CABG. Presence of aortic valve disease may increase surgical and extracorporeal circulation (ECC) duration, however there was no impact on the incidence of complications, perhaps due to exclusion of most orovalvular surgeries. Of the 343 cardiac surgeries in this time period, 11(3%) were performed without ECC. Duration of surgery and morbidity may be less frequent with this approach,(4) but could increase heterogeneity of the study group. Decision of the operation technique always rested upon the surgical team before admission. If the complications most often found in elderly (atrial fibrillation, left ventricle failure, significant thoracic bleeding, acute renal dysfunction and nosocomial sepsis) were added to high frequency of urgent surgeries and longer time of ECC, there are reasons for higher morbidity and mortality of elderly patients. Finally, postoperative transient inflammatory reaction that comes together with ECC was analyzed in some studies. Cytokines, as macrophage migration inhibitor factor, interleukin 6 and monocyte chemoattractant protein, undergo a significant early increase after induction of anesthesia and return to baseline levels after 24 hours, and(5) correlate with levels of organ dysfunctions. Researchers are looking for predictive biomarkers of postoperative morbidity, mainly in the elderly. Received from the Intensive Care Unit of the Casa de Saude Sao Jose, Rio de Janeiro (RJ), Brazil. Submitted on January 16, 2009 Accepted on January 31, 2009

JUSTIFICATIVA E OBJETIVOS: Os efeitos adversos da hipertensao intra-abdominal (PIA) sao conhecidos ha muitos anos, mas apenas recentemente deu-se importância a sua monitorizacao. Ha evidencias que cerca de um quarto dos centros de tratamento intensivo (CTI) nao medem a PIA por falta de conhecimento da sua importância ou dificuldade na interpretacao dos resultados. O objetivo deste estudo foi avaliar o conhecimento dos medicos sobre a sindrome de compartimento abdominal (SCA) e as caracteristicas do seu manuseio. METODO: Para a realizacao deste estudo foi enviado um questionario, contendo 12 perguntas sobre o assunto, para medicos que trabalham em CTI. RESULTADOS: O conhecimento das definicoes internacionais de SCA nao parece estar influenciado pelo tempo de exercicio da Medicina, mas sim pelo tempo de atividade dedicada a Medicina Intensiva. Embora a maioria esteja ciente da existencia da SCA, menos da metade dos medicos que responderam ao questionario conhece as definicoes internacionais de 2004. A medida da PIA e realizada em pacientes com predisposicao para SCA, por via intravesical, com injecao de 25 a 100 mL de liquido, com intervalos de 4 a 8 horas. Nao parece existir valor de PIA (associado ou nao a disfuncoes orgânicas) de consenso entre medicos desta pesquisa em relacao ao tratamento clinico ou cirurgico. CONCLUSOES: O conhecimento sobre SCA e satisfatorio quando considerados apenas os medicos que atuam majoritariamente em Medicina Intensiva. Contudo, e necessaria a educacao acerca da presenca e gravidade da hipertensao intra-abdominal para grande parte dos medicos atuantes na Medicina Intensiva na regiao metropolitana do Rio de Janeiro.

The adverse effects of intra-abdominal hypertension are known for many years. Only recently proper attention has been given to routine intra-abdominal pressure (IAP) monitoring. There is evidence that a quarter of intensive care units (ICU) do not measure IAP, due to a lack of knowledge of its importance or difficulty in results interpretation. The aim of this study is investigate the knowledge of ICU physicians about abdominal compartimental syndrome and its management.A questionnaire with 12 questions about this issue was mailed to ICU physicians.The current knowledge of the international definitions of ACS does not seem to be linked to the number of years of medical practice, but was associated with the time spent working on intensive care. Although most physicians are aware of the existence of ACS, less than half know the present international definitions. The IAP monitoring is performed in patients at risk for ACS, by means of the intravesical filling with 25 to 100 mL of liquids, in intervals varying from of 4 to 8 hours. There was no consensus on the value of IAP values (with or without organ dysfunctions) for the clinical or surgical treatments of ACS in this survey.The knowledge of ACS is satisfactory when we consider only physicians that devote most of their time to ICU work. However, it is necessary to improve education and knowledge of most intensive care physicians regarding the presence and severity of intra-abdominal hypertension in Rio de Janeiro.