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Pressure ulcer (PU) can be classified according to tissue impairment, etiology, healing time and tissue characteristics. Currently, it is the third type of adverse event most reported by the patient safety centers of health services in the country, according to the National Report of Incidents Related to Health Care. The classification and the identification of risk factors are essential for implementation of preventive and therapeutic actions in susceptible patients. Nutritional status is a fundamental piece for the prevention and development of PU, making it essential to integrate the interdisciplinary team in the prevention and treatment of PU, with a focus on quality, safety and patient experience. In this sense, the objective of this campaign is to disseminate knowledge, providing technical support for patient care and reducing PU rates. A mnemonic was developed with the word “CICATRIZATION”, in which each letter proposes steps that help in the identification of risk, assessment, treatment and monitoring of PU. Thus, the sequence of 12 steps established in this campaign is suggested as a measure to assist health professionals in this management

Background: nutrition therapy is a complex area of healthcare systems that encompasses patient characteristics, medical decision making, nutritional formula characteristics, and costs, composing a complex ecosystem. The integration of these different domains is actualized in medical prescription in a heuristic and iterative way, taking into account patient characteristics and formulas, with a limited capacity for in-scale calculations and inclusion of factors involved in the prescription of nutritional formulas and other ecosystem elements. From a practical standpoint, depicting the four areas as equalities could provide the necessary equivalence to study dependence and consequence from left- and right-side terms. Objectives: the objective of this theoretical study is to provide a mathematical model that describes and integrates different aspects of nutrition therapy. Methods: in this theoretical study, we deducted a mathematical representation for nutrition therapy using first-grade equations and simple calculus techniques. Results: a formula that coordinates four elements of the nutrition therapy ecosystem was found: cashflow, compliance adherence, patient, and macronutrient mass, formula density and unitary cost. Conclusion: factors involving decision-making in nutrition therapy can be unified in a mathematical model.Antecedentes: la terapia nutricional es un área compleja de los sistemas de salud que abarca las características del paciente, la toma de decisiones médicas, las características de la fórmula nutricional y los costos, componiendo un ecosistema complejo. La integración de estos diferentes dominios se actualiza en la prescripción médica de forma heurística e iterativa, teniendo en cuenta las características y fórmulas del paciente, con una capacidad limitada para cálculos a escala e inclusión de otros factores relacionados con la prescripción de la terapia nutricional y los elementos del ecosistema. Desde un punto de vista práctico, describir las cuatro áreas como igualdades podría proporcionar la equivalencia necesaria para estudiar la dependencia y la consecuencia de los términos del lado izquierdo y derecho. Objetivos: el objetivo de este estudio teórico es brindar un modelo matemático que describa e integre diferentes aspectos de la terapia nutricional. Métodos: en este estudio teórico se dedujo una representación matemática para la terapia nutricional utilizando ecuaciones de primer grado y técnicas de cálculo simple. Resultados: se encontró una fórmula que coordina cuatro elementos del ecosistema de la terapia nutricional: flujo de caja, adherencia al cumplimiento, masa del paciente y macronutrientes, densidad de la fórmula y costo unitario. Conclusión: los factores que involucran la toma de decisiones en la terapia nutricional se pueden unificar en un modelo matemático.

Background: the planning of nutritional therapy depends restrictions defined by the prescriber, in a way that nutrients and calories levels are placed at appropriate intervals. Since industrialized formulas (IF) have fixed compositions of macro and micronutrients, there is a high risk of not meeting the set of restrictions in a given clinical scenario, i.e., attendance of the caloric, but not of the protein target. Objective: the objective of this study is to identify under what conditions it is possible an industrialized formula to meet the clinical restrictions of calories, macro and micronutrients. Methods: we deduced a mathematical relationship that must be met in order to satisfy such constraints. Using as variables: a) the necessary volume of an FI to meet the energy goal; b) the energy density of the FI; c) upper limit of calorie or nutrient; and d) the lower limit of calorie or nutrient. Results: a first degree inequality was developed that if attended allows to discriminate if a prescribed volume v of an IF meets the set of restrictions placed by the prescriber, in order to previously select viable formulas among a portfolio. Clinical vignettes are presented. Conclusion: the viability condition of an industrialized formula for the attendance of a system of constraints can be identified with the aid of a mathematical formula of the first-degree inequality type.Introducción: la planificación de la terapia nutricional depende de las restricciones definidas por el prescriptor, de manera que los niveles de nutrientes y calorías se coloquen a intervalos apropiados. Como las fórmulas industrializadas (IF) tienen composiciones fijas tanto de macronutrientes como de micronutrientes, existe un alto riesgo de no cumplir con el conjunto de restricciones en un escenario clínico dado; es decir, la consecución del objetivo calórico, pero no del objetivo proteico. Objetivo: el objetivo de este estudio es identificar bajo qué condiciones una fórmula industrializada puede cumplir con las restricciones clínicas de calorías, macronutrientes y micronutrientes. Métodos: dedujimos una relación matemática que debe cumplirse para satisfacer tales restricciones. Usando como variables: a) el volumen necesario de un FI para alcanzar la meta energetic; b) la densidad de energía del FI; c) el límite superior de calorías o nutrientes; y d) el límite inferior de calorías o nutrientes. Resultados: se desarrolló una desigualdad de primer grado que, si se atiende, permite discriminar si un volumen prescrito v de un IF cumple con el conjunto de restricciones impuestas por el prescriptor para seleccionar previamente fórmulas viables entre una cartera. Se presentan viñetas clínicas. Conclusión: la condición de viabilidad de una fórmula industrializada para el cumplimiento de un sistema de restricciones puede identificarse con la ayuda de una fórmula matemática del tipo de desigualdad de primer grado.

Background: the planning of nutritional therapy depends on restrictions defined by the prescriber, in a way that nutrients and calories levels are placed at appropriate intervals. Since industrialized formulas (IF) have fixed compositions of macro and micronutrients, there is a high risk of not meeting the set of restrictions in a given clinical scenario, i.e., attendance of the caloric, but not of the protein target. Objective: the objective of this study is to identify under what conditions it is possible an industrialized formula to meet the clinical restrictions of calories, macro and micronutrients. Methods: we deduced a mathematical relationship that must be met in order to satisfy such constraints. Using as variables: a) the necessary volume of an FI to meet the energy goal; b) the energy density of the FI; c) upper limit of calorie or nutrient; and d) the lower limit of calorie or nutrient. Results: a first degree inequality was developed that if attended allows to discriminate if a prescribed volume v of an IF meets the set of restrictions placed by the prescriber, in order to previously select viable formulas among a portfolio. Clinical vignettes are presented. Conclusion: the viability condition of an industrialized formula for the attendance of a system of constraints can be identified with the aid of a mathematical formula of the first-degree inequality type.

We investigated the role of Fas ligand in murine silicosis. Wild-type mice instilled with silica developed severe pulmonary inflammation, with local production of tumor necrosis factor (TNF)-α, and interstitial neutrophil and macrophage infiltration in the lungs. Strikingly, Fas ligand–deficient generalized lymphoproliferative disease mutant (gld) mice did not develop silicosis. The gld mice had markedly reduced neutrophil extravasation into bronchoalveolar space, and did not show increased TNF-α production, nor pulmonary inflammation. Bone marrow chimeras and local adoptive transfer demonstrated that wild-type, but not Fas ligand–deficient lung macrophages recruit neutrophils and initiate silicosis. Silica induced Fas ligand expression in lung macrophages in vitro and in vivo, and promoted Fas ligand–dependent macrophage apoptosis. Administration of neutralizing anti-Fas ligand antibody in vivo blocked induction of silicosis. Thus, Fas ligand plays a central role in induction of pulmonary silicosis.

Evidências recentes sugerem que o balanço proteico negativo secundário à doença grave se associa ao aumento de morbidade. A perda da proteína corporal total é inevitável nesse cenário, mesmo com uma abordagem nutricional agressiva, e resulta, principalmente, do catabolismo da fibra muscular esquelética. O principal mecanismo bioquímico e metabólico envolvido nesse processo é o sistema ubiquitina-proteassoma, que, paradoxalmente, consome a adenosina trifosfatocomo fonte energética e motriz. É possível que a neutralidade do balanço proteico nessas instâncias clínicas, seja tão importante na melhora dos desfechos quanto atingir a meta calórica estimada ou medida pela calorimetria indireta. Estudos recentes apontam a utilização de concentrações mais elevadas de proteínas na terapia nutricional do paciente grave como importante para um impacto positivo na mortalidade. A proposta deste trabalho foi revisar alguns princípios da terapia nutricional relativos ao metabolismo proteico, sinalizar para as principais assertivas das diretrizes das sociedades especializadas e comentar estudos recentes, que abordam a questão em tela, sob a visão crítica da experiência clínica dos autores. Recent evidence suggests that a negative protein balance secondary to severe disease is associated with increased morbidity. A loss of total body protein is inevitable in this scenario, even with an aggressive nutritional approach, primarily due to the catabolism of skeletal muscle fibers. The ubiquitin-proteasome system is the primary metabolic and biochemical mechanism involved in this process; paradoxically, this system consumes adenosine triphosphate as its energy source. It is possible that a neutral protein balance in these clinical situations is important for improving outcomes and achieving the caloric goals estimated or measured by indirect calorimetry. Recent studies have suggested that the use of higher protein concentrations in nutritional therapy for critically ill patients may help to reduce mortality. The purpose of this study was to review some of the nutrition therapy principles related to protein metabolism, evaluate the main assertions of the guidelines of specialty societies and review the recent studies that address these issues using critical insights from the authors' clinical experience.

Recent evidence suggests that a negative protein balance secondary to severe disease is associated with increased morbidity. A loss of total body protein is inevitable in this scenario, even with an aggressive nutritional approach, primarily due to the catabolism of skeletal muscle fibers. The ubiquitin-proteasome system is the primary metabolic and biochemical mechanism involved in this process; paradoxically, this system consumes adenosine triphosphate as its energy source. It is possible that a neutral protein balance in these clinical situations is important for improving outcomes and achieving the caloric goals estimated or measured by indirect calorimetry. Recent studies have suggested that the use of higher protein concentrations in nutritional therapy for critically ill patients may help to reduce mortality. The purpose of this study was to review some of the nutrition therapy principles related to protein metabolism, evaluate the main assertions of the guidelines of specialty societies and review the recent studies that address these issues using critical insights from the authors' clinical experience.

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 Agência Nacional de Vigilância Sanitária (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.

OBJETIVO: Terapia nutricional é elemento importante no cuidado ao paciente grave. Mesmo reconhecida enquanto especialidade, a existência de equipes multidisciplinares ainda é escassa nas unidades terapia intensiva. Possivelmente a aplicação de cuidados em terapia nutricional seja variada entre intensivistas. O objetivo do estudo foi descrever percepções destes especialistas sobre atitudes e práticas em terapia nutricional enteral. MÉTODOS: Elaboramos questionário em plataforma on-line. Após fase de pré-validação, o instrumento foi distribuído via eletrônica. Após 30 dias as respostas foram computadas, considerando-se apenas os formulários completos. RESULTADOS: Cento e quatorze formulários foram devolvidos, 112 foram analisados. Os respondedores concentraram-se predominantemente na região sudeste do país. Sobre a instituição do suporte enteral, a maioria das respostas reflete percepções coadunadas às orientações de sociedades de especialistas. Os respondedores percebem frequentemente a aplicação de protocolos assistenciais relativos aos cuidados nutricionais. Após o início dos cuidados nutricionais, a percepção dos respondedores sobre a participação em modificações no plano terapêutico nutricional aparenta ser menor. O auto-conhecimento sobre o tema "terapia enteral" entre os respondedores foi quantificado em 6,0 (média aritmética), em escala de 1 a 10. CONCLUSÕES: Mais estudos para avaliação de práticas nutricionais entre médicos intensivistas são necessários. Alternativas à distribuição via plataforma on-line devem ser consideradas. Possivelmente intensivistas lidam melhor com as fases iniciais de instituição dos cuidados com nutrição enteral do que em relação à continuidade dos cuidados ou mudança na programação nutricional. Médicos intensivistas percebem em geral conhecimento sub-ótimo sobre o tema terapia nutricional enteral. OBJECTIVE: Nutritional therapy is an important element in critical ill patient care. Although recognized as specialty, multidisciplinary teams in nutrition support are scarce in our country. Possibly, nutrition support therapy is applied by intensive care physicians and this may vary. The aim of the study is describe these specialists perceptions about theirs attitudes in enteral nutrition support. METHODS: A questionnaire was elaborated in an on-line platform. After pre-validation, it was sent by electronic mail to intensivists. In 30 days answers were collected, considering only the full-filled questionnaires. RESULTS: One hundred an fourteen forms were returned, 112 were analyzed. The responders were localized at majority in southeastern region. About beggining of nutritional support, the majority of answers reflect perceptions in accord to specialists societies recommendations. The responders' perception the frequent utilization of assistentials protocols in nutrition care. After support beginning, the responders perceptions about theirs participation in changes in therapeutic plan seems to be lower. The self-knowledge about the theme among the responders was 6.0 (arithmetic media) in a 1 to 10 scale. CONCLUSIONS: More studies are necessary to evaluate nutritional support practices among intensive care physicians. Alternatives to on-line platform should be considered. Possibly, intensive care physicians do better in the initial phases of enteral support than in continuity of care. Intensive care physicians knowledge about the issue is suboptimal.

OBJETIVO: Terapia nutricional é elemento importante no cuidado ao paciente grave. Mesmo reconhecida enquanto especialidade, a existência de equipes multidisciplinares ainda é escassa nas unidades terapia intensiva. Possivelmente a aplicação de cuidados em terapia nutricional seja variada entre intensivistas. O objetivo do estudo foi descrever percepções destes especialistas sobre atitudes e práticas em terapia nutricional enteral. MÉTODOS: Elaboramos questionário em plataforma on-line. Após fase de pré-validação, o instrumento foi distribuído via eletrônica. Após 30 dias as respostas foram computadas, considerando-se apenas os formulários completos. RESULTADOS: Cento e quatorze formulários foram devolvidos, 112 foram analisados. Os respondedores concentraram-se predominantemente na região sudeste do país. Sobre a instituição do suporte enteral, a maioria das respostas reflete percepções coadunadas às orientações de sociedades de especialistas. Os respondedores percebem frequentemente a aplicação de protocolos assistenciais relativos aos cuidados nutricionais. Após o início dos cuidados nutricionais, a percepção dos respondedores sobre a participação em modificações no plano terapêutico nutricional aparenta ser menor. O auto-conhecimento sobre o tema "terapia enteral" entre os respondedores foi quantificado em 6,0 (média aritmética), em escala de 1 a 10. CONCLUSÕES: Mais estudos para avaliação de práticas nutricionais entre médicos intensivistas são necessários. Alternativas à distribuição via plataforma on-line devem ser consideradas. Possivelmente intensivistas lidam melhor com as fases iniciais de instituição dos cuidados com nutrição enteral do que em relação à continuidade dos cuidados ou mudança na programação nutricional. Médicos intensivistas percebem em geral conhecimento sub-ótimo sobre o tema terapia nutricional enteral.

Nutritional therapy is an important element in critical ill patient care. Although recognized as specialty, multidisciplinary teams in nutrition support are scarce in our country. Possibly, nutrition support therapy is applied by intensive care physicians and this may vary. The aim of the study is describe these specialists perceptions about theirs attitudes in enteral nutrition support.A questionnaire was elaborated in an on-line platform. After pre-validation, it was sent by electronic mail to intensivists. In 30 days answers were collected, considering only the full-filled questionnaires.One hundred an fourteen forms were returned, 112 were analyzed. The responders were localized at majority in southeastern region. About beggining of nutritional support, the majority of answers reflect perceptions in accord to specialists societies recommendations. The responders' perception the frequent utilization of assistentials protocols in nutrition care. After support beginning, the responders perceptions about theirs participation in changes in therapeutic plan seems to be lower. The self-knowledge about the theme among the responders was 6.0 (arithmetic media) in a 1 to 10 scale.More studies are necessary to evaluate nutritional support practices among intensive care physicians. Alternatives to on-line platform should be considered. Possibly, intensive care physicians do better in the initial phases of enteral support than in continuity of care. Intensive care physicians knowledge about the issue is suboptimal.

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.

Respiratory system, lung, and chest wall mechanical properties were subdivided into their resistive, elastic, and viscoelastic/inhomogeneous components in normal rats, to define the sites of action of sevoflurane. In addition, we aimed to determine the extent to which pretreatment with atropine modified these parameters. Twenty-four rats were divided into four groups of six animals each: in the P group, rats were sedated (diazepam) and anesthetized with pentobarbital sodium; in the S group, sevoflurane was administered; in the AP and AS groups, atropine was injected 20 min before sedation/anesthesia with pentobarbital and sevoflurane, respectively. Sevoflurane increased lung viscoelastic/inhomogeneous pressures and static elastance compared with rats belonging to the P group. In AS rats, lung static elastance increased in relation to the AP group. In conclusion, sevoflurane anesthesia acted not at the airway level but at the lung periphery, stiffening lung tissues and increasing mechanical inhomogeneities. These findings were supported by the histological demonstration of increased areas of alveolar collapse and hyperinflation. The pretreatment with atropine reduced central and peripheral airway secretion, thus lessening lung inhomogeneities.