Search

Background: Critically ill patients with COVID-19 may develop multiple organ dysfunction syndrome, including acute kidney injury (AKI). We report the incidence, risk factors, associations, and outcomes of AKI and renal replacement therapy (RRT) in critically ill COVID-19 patients. Methods: We performed a retrospective cohort study of adult patients with COVID-19 diagnosis admitted to the intensive care unit (ICU) between March 2020 and May 2020. Multivariable logistic regression analysis was applied to identify risk factors for the development of AKI and use of RRT. The primary outcome was 60-day mortality after ICU admission. Results: 101 (50.2%) patients developed AKI (72% on the first day of invasive mechanical ventilation [IMV]), and thirty-four (17%) required RRT. Risk factors for AKI included higher baseline Cr (OR 2.50 [1.33–4.69], p = 0.005), diuretic use (OR 4.14 [1.27–13.49], p = 0.019), and IMV (OR 7.60 [1.37–42.05], p = 0.020). A higher C-reactive protein level was an additional risk factor for RRT (OR 2.12 [1.16–4.33], p = 0.023). Overall 60-day mortality was 14.4% {23.8% (n = 24) in the AKI group versus 5% (n = 5) in the non-AKI group (HR 2.79 [1.04–7.49], p = 0.040); and 35.3% (n = 12) in the RRT group versus 10.2% (n = 17) in the non-RRT group, respectively (HR 2.21 [1.01–4.85], p = 0.047)}. Conclusions: AKI was common among critically ill COVID-19 patients and occurred early in association with IMV. One in 6 AKI patients received RRT and 1 in 3 patients treated with RRT died in hospital. These findings provide important prognostic information for clinicians caring for these patients.

RESUMO Objetivo: Avaliar a frequência de síndrome de burnout grave em profissionais de terapia intensiva e correlacioná-la com o engajamento com o trabalho. Métodos: Foi distribuído um questionário autoaplicável que incluía o Inventário de Burnout de Maslach, a Escala de Depressão Ansiedade e Estresse e o questionário Gallup. Todas as análises foram estratificadas por local de trabalho (unidade de terapia intensiva ou unidade semi-intensiva) e por grupo profissional (enfermeiros versus médicos versus fisioterapeutas). Resultados: Entre fevereiro de 2017 e junho de 2017, 206 dos 325 profissionais convidados (63,4%) responderam aos questionários. Destes, 55 eram médicos (26,7%), 88 eram fisioterapeutas (42,7%) e 63 eram enfermeiros (30,6%). A frequência de burnout grave foi de 34,3% (27,9 - 41,4%), e não se identificaram diferenças entre os grupos profissionais ou locais de trabalho. A frequência de casos graves ou muito graves de depressão, ansiedade ou estresse foi de 12,9%, 11,4% e 10,5%, respectivamente. O escore mediano (intervalo interquartil) observado pelo questionário Gallup foi 41 (34 - 48), e não se observaram diferenças entre os grupos profissionais ou locais de trabalho. Houve correlação negativa entre burnout e engajamento com o trabalho (r = -0,148; p = 0,035). Conclusão: A frequência de burnout grave foi elevada entre os profissionais de saúde que trabalham na unidade de terapia intensiva e na unidade semi-intensiva. Existe uma correlação negativa entre burnout e engajamento com o trabalho. ABSTRACT Objective: To evaluate the frequency of severe burnout syndrome among critical care providers and to correlate it with work engagement. Methods: A self-administered survey including the Maslach Burnout Inventory, Depression Anxiety and Stress Scales, and Gallup questionnaire was distributed. All analyses were stratified by setting (intensive care unit or step-down unit) and by professional group (nurses versus physicians versus physiotherapists). Results: Between February 2017 and June 2017, 206 out of 325 invited professionals (63.4%) answered the questionnaires. Of these, 55 were physicians (26.7%), 88 were physiotherapists (42.7%) and 63 were nurses (30.6%). The frequency of severe burnout was 34.3% (27.9 - 41.4%), and no difference was found between professional groups or settings. The frequency of severe or very severe cases of depression, anxiety or stress was 12.9%, 11.4% and 10.5%, respectively. The median (interquartile range) score observed on the Gallup questionnaire was 41 (34 - 48), and no differences were found between professional groups or settings. There was a negative correlation between burnout and work engagement (r = -0.148; p = 0.035). Conclusion: There is a high frequency of severe burnout among critical care providers working in the intensive care unit and step-down unit. There was a negative correlation between burnout and work engagement.

Summary Background The efficacy and safety of azithromycin in the treatment of COVID-19 remain uncertain. We assessed whether adding azithromycin to standard of care, which included hydroxychloroquine, would improve clinical outcomes of patients admitted to the hospital with severe COVID-19. Methods We did an open-label, randomised clinical trial at 57 centres in Brazil. We enrolled patients admitted to hospital with suspected or confirmed COVID-19 and at least one additional severity criteria as follows: use of oxygen supplementation of more than 4 L/min flow; use of high-flow nasal cannula; use of non-invasive mechanical ventilation; or use of invasive mechanical ventilation. Patients were randomly assigned (1:1) to azithromycin (500 mg via oral, nasogastric, or intravenous administration once daily for 10 days) plus standard of care or to standard of care without macrolides. All patients received hydroxychloroquine (400 mg twice daily for 10 days) because that was part of standard of care treatment in Brazil for patients with severe COVID-19. The primary outcome, assessed by an independent adjudication committee masked to treatment allocation, was clinical status at day 15 after randomisation, assessed by a six-point ordinal scale, with levels ranging from 1 to 6 and higher scores indicating a worse condition (with odds ratio [OR] greater than 1·00 favouring the control group). The primary outcome was assessed in all patients in the intention-to-treat (ITT) population who had severe acute respiratory syndrome coronavirus 2 infection confirmed by molecular or serological testing before randomisation (ie, modified ITT [mITT] population). Safety was assessed in all patients according to which treatment they received, regardless of original group assignment. This trial was registered at ClinicalTrials.gov, NCT04321278. Findings 447 patients were enrolled from March 28 to May 19, 2020. COVID-19 was confirmed in 397 patients who constituted the mITT population, of whom 214 were assigned to the azithromycin group and 183 to the control group. In the mITT population, the primary endpoint was not significantly different between the azithromycin and control groups (OR 1·36 [95% CI 0·94–1·97], p=0·11). Rates of adverse events, including clinically relevant ventricular arrhythmias, resuscitated cardiac arrest, acute kidney failure, and corrected QT interval prolongation, were not significantly different between groups. Interpretation In patients with severe COVID-19, adding azithromycin to standard of care treatment (which included hydroxychloroquine) did not improve clinical outcomes. Our findings do not support the routine use of azithromycin in combination with hydroxychloroquine in patients with severe COVID-19. Funding COALITION COVID-19 Brazil and EMS.

To evaluate the frequency of severe burnout syndrome among critical care providers and to correlate it with work engagement.A self-administered survey including the Maslach Burnout Inventory, Depression Anxiety and Stress Scales, and Gallup questionnaire was distributed. All analyses were stratified by setting (intensive care unit or step-down unit) and by professional group (nurses versus physicians versus physiotherapists).Between February 2017 and June 2017, 206 out of 325 invited professionals (63.4%) answered the questionnaires. Of these, 55 were physicians (26.7%), 88 were physiotherapists (42.7%) and 63 were nurses (30.6%). The frequency of severe burnout was 34.3% (27.9 - 41.4%), and no difference was found between professional groups or settings. The frequency of severe or very severe cases of depression, anxiety or stress was 12.9%, 11.4% and 10.5%, respectively. The median (interquartile range) score observed on the Gallup questionnaire was 41 (34 - 48), and no differences were found between professional groups or settings. There was a negative correlation between burnout and work engagement (r = -0.148; p = 0.035).There is a high frequency of severe burnout among critical care providers working in the intensive care unit and step-down unit. There was a negative correlation between burnout and work engagement.Avaliar a frequência de síndrome de burnout grave em profissionais de terapia intensiva e correlacioná-la com o engajamento com o trabalho.Foi distribuído um questionário autoaplicável que incluía o Inventário de Burnout de Maslach, a Escala de Depressão Ansiedade e Estresse e o questionário Gallup. Todas as análises foram estratificadas por local de trabalho (unidade de terapia intensiva ou unidade semi-intensiva) e por grupo profissional (enfermeiros versus médicos versus fisioterapeutas).Entre fevereiro de 2017 e junho de 2017, 206 dos 325 profissionais convidados (63,4%) responderam aos questionários. Destes, 55 eram médicos (26,7%), 88 eram fisioterapeutas (42,7%) e 63 eram enfermeiros (30,6%). A frequência de burnout grave foi de 34,3% (27,9 - 41,4%), e não se identificaram diferenças entre os grupos profissionais ou locais de trabalho. A frequência de casos graves ou muito graves de depressão, ansiedade ou estresse foi de 12,9%, 11,4% e 10,5%, respectivamente. O escore mediano (intervalo interquartil) observado pelo questionário Gallup foi 41 (34 - 48), e não se observaram diferenças entre os grupos profissionais ou locais de trabalho. Houve correlação negativa entre burnout e engajamento com o trabalho (r = -0,148; p = 0,035).A frequência de burnout grave foi elevada entre os profissionais de saúde que trabalham na unidade de terapia intensiva e na unidade semi-intensiva. Existe uma correlação negativa entre burnout e engajamento com o trabalho.

A retrospective cohort study was conducted to evaluate the bundle of techniques developed by the multidisciplinary team to minimize infections in an adult intensive care unit over a 22-year span. Two periods were analyzed: 1996-2006 and 2007-2017. Bloodstream infections, urinary tract infections, and ventilator-associated pneumonia declined 58.6%, 56.7%, and 82.6%, respectively (P.05) from 2007 to 2017 compared with these same infections during 1996-2006.

Objective The objective of the present study is to evaluate the association of red blood cell distribution width with acute kidney injury in sepsis. Methods This is a retrospective study of 849 critically ill patients with sepsis in intensive care unit. Demographic data, renal function, inflammation, complete blood count, and acid-base parameters were compared between acute kidney injury and non-acute kidney injury groups. Therefore, a multivariate analysis was performed to observe independent predictive factors. Results Comparatively, higher levels of C-reactive protein, lactate, red blood cell distribution width, and Simplified Acute Physiology Score 3 were found in the acute kidney injury group. The study showed a higher frequency of women, hemoglobin (Hgb) concentration, platelets, bicarbonate and PaO2/FiO2 ratio in the non-acute kidney injury group. In addition, there was an independent association of comorbidity-chronic kidney disease [OR 3.549, 95%CI: 1.627-7.743; p

Objective: To investigate the impact of intensive care unit admission during medical handover on mortality. Methods: Post-hoc analysis of data extracted from a prior study aimed at addressing the impacts of intensive care unit readmission on clinical outcomes. This retrospective, single-center, propensity-matched cohort study was conducted in a 41-bed general open-model intensive care unit. Patients were assigned to one of two cohorts according to time of intensive care unit admission: Handover Group (intensive care unit admission between 6:30 am and 7:30 am or 6:30 pm and 7:30 pm) or Control Group (intensive care unit admission between 7:31 am and 6:29 pm or 7:31 pm and 6:29 am). Patients in the Handover Group were propensity-matched to patients in the Control Group at a 1:2 ratio. Results: A total of 6,650 adult patients were admitted to the intensive care unit between June 1st 2013 and May 31st 2015. Following exclusion of non-eligible participants, 5,779 patients (389; 6.7% and 5,390; 93.3%, Handover and Control Group) were deemed eligible for propensity score matching. Of these, 1,166 were successfully matched (389; 33.4% and 777; 66.6%, Handover and Control Group). Following propensity-score matching, intensive care unit admission during handover was not associated with increased risk of intensive care unit (OR: 1.40; 95%CI: 0.92-2.11; p=0.113) or in-hospital (OR: 1.23; 95%CI: 0.85-1.75; p=0.265) mortality. Conclusion: Intensive care unit admission during medical handover did not affect in-hospital mortality in this propensity-matched, single-center cohort study. RESUMO Objetivo: Avaliar o impacto na mortalidade da admissão em unidade de terapia intensiva durante passagem de plantão médico. Métodos: Análise post-hoc de estudo original publicado previamente, com o objetivo de avaliar os impactos da readmissão em unidade de terapia intensiva nos desfechos clínicos. Este estudo de coorte retrospectivo, em centro único, com pareamento por escore de propensão, foi conduzido em uma unidade de terapia intensiva geral, aberta, com 41 leitos. Com base no tempo de internação na unidade de terapia intensiva, os pacientes foram categorizados em duas coortes: Grupo Passagem de Plantão (admissão entre 6h30 e 7h30 ou 18h30 e 19h30) ou Grupo Controle (internação entre 7h31 e 18h29 ou 19h31 e 6h29). Pacientes no Grupo Passagem de Plantão foram pareados com Grupo Controle na proporção de 1:2. Resultados: Entre 1° de junho de 2013 e 31 de maio de 2015, 6.650 pacientes adultos foram admitidos na unidade de terapia intensiva. Após a exclusão de participantes inelegíveis, 5.779 pacientes (389; 6,7% no Grupo de Admissão na Passagem de Plantão e 5.390; 93,3% no Grupo de Controle) foram elegíveis para pareamento por escore de propensão, dos quais 1.166 foram pareados com sucesso (389; 33,4% no Grupo Passagem de Plantão e 777; 66,6% no Grupo Controle). Após pareamento, admissão na unidade de terapia intensiva durante a passagem plantão não foi associada ao aumento da chance de óbito na unidade de terapia intensiva (RC: 1,40; IC95%: 0,92-2,11; p=0,113) ou no hospital (RC: 1,23; IC95%: 0,85-1,75; p=0,265). Conclusão: Internação em unidade de terapia intensiva durante passagem de plantão médico não impactou na mortalidade hospitalar.

Objective: To describe clinical characteristics, resource use, outcomes, and to identify predictors of in-hospital mortality of patients with COVID-19 admitted to the intensive care unit. Methods: Retrospective single-center cohort study conducted at a private hospital in São Paulo (SP), Brazil. All consecutive adult (≥18 years) patients admitted to the intensive care unit, between March 4, 2020 and February 28, 2021 were included in this study. Patients were categorized between survivors and non-survivors according to hospital discharge. Results: During the study period, 1,296 patients [median (interquartile range) age: 66 (53-77) years] with COVID-19 were admitted to the intensive care unit. Out of those, 170 (13.6%) died at hospital (non-survivors) and 1,078 (86.4%) were discharged (survivors). Compared to survivors, non-survivors were older [80 (70-88) versus 63 (50-74) years; p

No Brasil, o primeiro paciente com a doenca do coronavirus 2019 (COVID-19) foi diagnosticado em 26 de fevereiro de 2020. Morava em Sao Paulo (SP) e retornara recentemente de uma viagem da Europa. Ao longo das semanas seguintes, a maioria dos novos casos de COVID-19 tinha um fator de risco epidemiologico identificavel – ter viajado ao exterior ou tido contato com um paciente que sabidamente estava com o coronavirus da sindrome respiratoria aguda grave 2 (SARS-CoV-2). No entanto, como as [...]

Background: Coagulation abnormalities in severe COVID-19 patients have not been addressed in depth. Methods: Prospective longitudinal single-center study involving COVID-19 patients admitted to the ICU. Conventional coagulation tests (prothrombin time, international normalized ratio and activated partial thromboplastin time), rotational thromboelastometry (ROTEM), platelet function, plasma fibrinolysis markers, antithrombin, protein C and S were measured at the time of study inclusion (baseline), and at days 1, 3, 7 and 14 after enrollment. Based on median total maximum SOFA score, patients were divided in two groups: SOFA ≤ 10 and SOFA > 10.Results: From March, 2020 through May, 2020, 30 patients [median (IQR) age: 61 (52-83) yrs; SAPS III score: 49 (41-61) points] were included in this study. Conventional coagulation tests remained unchanged during the study period, while the majority of patients exhibited a hypercoagulability state based on ROTEM. Fibrinogen levels were increased in both groups. ROTEM (INTEM and EXTEM) maximum clot firmness increased in both study groups from day 0 to day 14. ROTEM – FIBTEM maximum clot firmness was high in both groups during the study period, with a slight decrease from day 0 to day 14 in group SOFA ≤ 10 and a slight increase during the same period in group SOFA > 10. Fibrinolysis (INTEM and EXTEM maximum lysis) was low and decreased over time in all groups, with the most pronounced decrease observed in INTEM maximum lysis in group SOFA > 10. Antithrombin slightly increased over time in group SOFA ≤ 10 while it remained stable in group SOFA > 10. Protein C plasma levels increased over time in both groups, although patients in group SOFA > 10 exhibited lower values in comparison to patients in group SOFA ≤ 10. Protein S plasma levels were low in both groups at baseline and increased over time with no between-group differences.Conclusion: COVID-19 patients have a pronounced hypercoagulability state, characterized by impaired endogenous anticoagulation and decreased fibrinolysis. The magnitude of coagulation abnormalities seems to correlate with the severity of organ dysfunction. The hypercoagulability state of COVID-19 patients was detected by ROTEM, but not with conventional coagulation tests.

Summary: COVID-19 is a recently identified illness that is associated with thromboembolic events. We report a case of pulmonary embolism in a patient with COVID-19, treated by catheter directed thrombectomy. A 57 year old patient presented to the emergency center with severe COVID-19 symptoms and developed massive pulmonary embolism. The patient was treated with catheter directed thrombolysis (CDT) and recovered completely. Coagulopathy associated with COVID-19 is present in all severe cases and is a dynamic process. We describe a case of massive/high risk pulmonary embolism, in a patient with COVID-19 receiving full anticoagulation, who was treated by percutaneous intervention. CDT can be an additional therapeutic option in patients with COVID-19 and pulmonary embolism that present with rapid clinical collapse.

INTRODUCTION Many are the uncertainties generated by the potential healthcare resource scarcity in the face of a relevant increase in the number of cases of coronavirus disease 2019 (COVID-19), an infectious disease caused by the novel coronavirus (SARS-CoV-2) of the Coronaviridae family. The virus emerged in China, in December 2019, spreading rapidly to other regions of the world, including Brazil. Since March 11, 2020, COVID-19 has been considered a pandemic by the World Health Organization (WHO). Viral pandemics tend to [...]

Background Coagulation abnormalities in COVID-19 patients have not been addressed in depth. Objective To perform a longitudinal evaluation of coagulation profile of patients admitted to the ICU with COVID-19. Methods Conventional coagulation tests, rotational thromboelastometry (ROTEM), platelet function, fibrinolysis, antithrombin, protein C and S were measured at days 0, 1, 3, 7 and 14. Based on median total maximum SOFA score, patients were divided in two groups: SOFA ≤ 10 and SOFA > 10. Results Thirty patients were studied. Some conventional coagulation tests, as aPTT, PT and INR remained unchanged during the study period, while alterations on others coagulation laboratory tests were detected. Fibrinogen levels were increased in both groups. ROTEM maximum clot firmness increased in both groups from Day 0 to Day 14. Moreover, ROTEM–FIBTEM maximum clot firmness was high in both groups, with a slight decrease from day 0 to day 14 in group SOFA ≤ 10 and a slight increase during the same period in group SOFA > 10. Fibrinolysis was low and decreased over time in all groups, with the most pronounced decrease observed in INTEM maximum lysis in group SOFA > 10. Also, D-dimer plasma levels were higher than normal reference range in both groups and free protein S plasma levels were low in both groups at baseline and increased over time, Finally, patients in group SOFA > 10 had lower plasminogen levels and Protein C ​​than patients with SOFA Conclusion COVID-19 patients have a pronounced hypercoagulability state, characterized by impaired endogenous anticoagulation and decreased fibrinolysis. The magnitude of coagulation abnormalities seems to correlate with the severity of organ dysfunction. The hypercoagulability state of COVID-19 patients was not only detected by ROTEM but it much more complex, where changes were observed on the fibrinolytic and endogenous anticoagulation system.

In December 2019, a series of patients with severe pneumonia were identified in Wuhan, Hubei province, China, who progressed to severe acute respiratory syndrome and acute respiratory distress syndrome. Subsequently, COVID-19 was attributed to a new betacoronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Approximately 20% of patients diagnosed as COVID-19 develop severe forms of the disease, including acute hypoxemic respiratory failure, severe acute respiratory syndrome, acute respiratory distress syndrome and acute renal failure and require intensive care. There is no randomized controlled clinical trial addressing potential therapies for patients with confirmed COVID-19 infection at the time of publishing these treatment recommendations. Therefore, these recommendations are based predominantly on the opinion of experts (level C of recommendation).

IntroductionHandover is a process of transferring information, responsibility and authority for providing care of critically ill patients from a departing intensivist to an oncoming intensivist. The effect of i admission during a medical handover on clinical outcomes is unknown.ObjectivesOur purpose was to evaluate the impact of ICU admission during a medical handover on clinical outcomes.MethodsPost hoc analysis of a cohort study addressing the effect of ICU admissions during the handover on outcomes. This retrospective, single center, propensity matched cohort study was conducted in a 41-bed open general ICU located in a private tertiary care hospital in São Paulo, Brazil. Based on time of ICU admission, patients were categorized into two cohorts: handover group (ICU admission between 6:30 am to 7:30 or 6:30 pm to 7:30 pm) or control group (admission between 7:31 am to 6:29 pm or 7:31 pm to 6:29 am). Patients in the handover group were propensity matched to patients in the control group at 1:2 ratio. Our primary outcome was hospital mortality.ResultsBetween June 1, 2013 and May 31, 2015, 6,650 adult patients were admitted to the ICU. Following exclusion of ineligible participants, 5,779 patients [389 (6.7%) in handover group and 5390 (93.3%) in control group] were eligible for propensity score matching, of whom 1,166 were successfully matched [389 (33.4%) handover group and 777 (66.6%) in control group]. Before matching, hospital mortality was 14.1% (55/389 patients) in handover group compared to 11.7% (628/5,390) in control group (p=0.142). After propensity-score matching, ICU admission during handover was not associated with increased risk of ICU (OR, 1.40; 95% CI, 0.92 to 2.11; p=0.11) and hospital (OR, 1.23; 95%CI, 0.85 to 1.75; p=0.26) mortality. ICU and hospital length of stay did not differ between the groups.ConclusionIn this propensity-matched single center cohort study, ICU admission during medical handover did not affect clinical outcomes.

Background: Improving adherence to hand hygiene (HH) of healthcare workers (HCWs) is a challenge for health institutions, and the use of technologies has been considered an important strategy within this process. Methods: To evaluate the impact of the use of alcohol-based hand rub gel (ABHR) dispensers with light sensors on the adherence to HH by HCWs. This is a prospective quasi-experimental study with comparative analysis between two 4-bed adult intensive care units at a private, tertiary-care hospital conducted over 22 weeks. An approach detection module with an LED lamp was attached to the ABHR dispenser. As a healthcare personnel approached it, the sensor was activated, and a red light turned on as a visual stimulus for HH. The color of the light changed to blue when HH was performed. All ABHR dispensers had electronic counters, but light sensors were installed only in the 4-bed dispensers of the intervention unit. Throughout the period, direct observation of adherence to HH was performed by 4 nurses who had previously been rated with an excellent coefficient of agreement (κ test = 0.951 and 0.902). At the end of the study, a perception survey was performed with the HCWs. Results: The median activation of ABHR dispensers per week was higher in the intervention unit with 1,004 (IQR, 706–1,455) versus 432 (IQR, 350–587) in the control group (P < .001). The same occurred when compared to the median activation per 1,000 patient days, with 53,069 (IQR, 47,575–67,275) versus 19,602 (IQR, 15,909–24,500) in the control group (P < .001). However, there was no evidence of difference in adherence to HH during direct observation between the 2 groups: 51.0% HH compliance (359 of 704) in the control group and 53.8% HH compliance (292 of 543) in the intervention group (P = .330). The same result emerged when we evaluated the “My Five Moments for HH” and by professional category. HCWs (N=66) answered the perception survey: 66.6% stated that lighting devices caught their attention regularly or most of the time and 59% agreed that the devices motivated HH. Conclusions: Using light sensors in ABHR dispensers can be an effective technology for improving HH. This finding was evident in the evaluation of the number of uses of the ABHR dispensers and in the HCW perceptions. Although direct observation did not show statistical evidence of difference between the groups, adherence was higher in the intervention group.Funding: NoneDisclosures: None

Positive deviance (PD) can be a strategy for the improvement of hand hygiene (HH) compliance.This study was conducted in 8 intensive care units and 1 ward at 7 tertiary care, private, and public hospitals. Phase 1 was a 3-month baseline period (from August to October 2011) in which HH counts were performed by observers using iPods (iScrub program). From November 2011 to July 2012, phase 2, a PD intervention was performed in all the participating centers. We evaluated the consumption of HH products (alcohol gel and chlorhexidine) and the incidence density of health care-associated infections.There was a total of 5,791 HH observations in the preintervention phase and 11,724 HH observations in the intervention phase (PD). A statistically significant difference was found in overall HH compliance with 46.5% in the preintervention phase and 62.0% in the PD phase (P.001). There was a statistically significant reduction in the incidence of density of device-associated infections per 1,000 patient-days and also in the median of length of stay between the preintervention phase and the PD phase (13.2 vs 7.5 per 1,000 patient-days, respectively, P = .039; and 11.0 vs 6.8 days, respectively, P.001, respectively).PD demonstrated great promise for improving HH in multiple inpatient settings and was associated with a decrease in the median length of stay and the incidence of device-associated HAIs.

Healthcare associated costs are growing. For instance, in developed countries as in United States, they may reach sums that encompass 17% of the GDP. In Brazil, total healthcare costs comprise 9% of the GDP, with around half of that related to the public system

Severe hemorrhage with necessity of allogeneic blood transfusion is common complication in intensive care unit and is associated with increased morbidity and mortality. Prompt recognition and treatment of bleeding causes becomes essential for the effective control of hemorrhage, rationalizing the use of allogeneic blood components, and in this way, preventing an occurrence of their potential adverse effects. Conventional coagulation tests such as prothrombin time and activated partial thromboplastin time present limitations in predicting bleeding and guiding transfusion therapy in critically ill patients. Viscoelastic tests such as thromboelastography and rotational thromboelastometry allow rapid detection of coagulopathy and goal-directed therapy with specific hemostatic drugs. The new era of thromboelastometry relies on its efficacy, practicality, reproducibility and cost-effectiveness to establish itself as the main diagnostic tool and transfusion guide in patients with severe active bleeding.

Background: Patients undergoing orthotropic liver transplant (LTx) often present with chronic kidney disease (CKD). Identification of patients who will progress to end-stage renal disease (ESRD) might allow not only the implementation of kidney protective measures but also simultaneous kidney transplant.Study Design: Retrospective cohort study in adults who underwent LTx at a single center. ESRD, death, and composite of ESRD or death were studied outcomes.Results: 331 patients, who underwent LTx, were followed up for 2.6 +/- 1.4 years; 31(10%) developed ESRD, 6 (2%) underwent kidney transplant after LTx and 25 (8%) remained on chronic hemodialysis. Patients with preoperative eGFR lesser than 60 ml/min per 1.73 m(2) had a 4-fold increased risk of developing ESRD after adjustment for sex, diabetes mellitus, APACHE II score, use of nephrotoxic drugs, and severe liver graft failure (HR = 3.95, 95% CI 1,73, 9.01; p = 0.001). Other independent risk factors for ESRD were preoperative diabetes mellitus and post-operative severe liver graft dysfunction.Conclusion: These findings emphasize low eGFR prior to LTx as a predictor for ESRD or death. the consideration for kidney after liver transplant as a treatment modality should be taken into account for those who develop chronic kidney failure after LTx. Albert Einstein Israelita Hosp HIAE, Learning & Res Inst, Transplantat Program, São Paulo, Brazil Universidade Federal de São Paulo, Div Nephrol, São Paulo, Brazil Euryclides Jesus Zerbini Transplant Hosp Sao Paul, Liver Unit, São Paulo, Brazil Tufts Univ, Sch Med, St Elizabeths Med Ctr, Brighton, MA USA Universidade Federal de São Paulo, Div Nephrol, São Paulo, Brazil Web of Science

This paper summarizes the 20 years of liver transplantation in Brazil, in the context of the Western world scenario. More than 5000 liver transplantations have been performed in the country since September 1, 1985. The living-donor liver transplantation, one of the landmarks in liver transplantation, was first described by our team in 1989. Brazil is the seventh country in number of liver transplants in the Western world and the first in Latin America. Almost 1000 procedures were performed in 2004, 19% of them involving living donors.

Background Acute kidney injury is a common complication of liver transplantation. In this single-centre retrospective observational study, we investigated the impact of acute kidney disease on liver recipient survival. Methods The study population consisted of patients who underwent a liver engraftment between January 2002 and November 2006, at a single transplantation centre in São Paulo, Brazil. Acute kidney injury diagnosis and staging were according to the recommendations of the Acute Kidney Injury Network and consisted of scanning the daily serum creatinine levels throughout the hospital stay. Patients requiring renal replacement therapy prior to transplantation, those who developed acute kidney injury before the procedure or those receiving their second liver graft were excluded from the study. Results A total of 444 liver transplantations were performed during the study period, and 129 procedures (29%) were excluded. The remaining 315 patients constituted the study population. In 207 procedures, the recipient was male (65%). The mean age of the population was 51 years. Cumulative incidence of acute kidney injury within 48 h, during the first week after transplantation, and throughout the hospital stay was 32, 81 and 93%, respectively. Renal replacement therapy was required within a week after the transplantation in 31 procedures (10%), and another 17 (5%) required replacement therapy after that period. Mean follow-up period was 2.3 years. Time in days from acute kidney injury diagnosis to initiation of replacement therapy or reaching serum creatinine peak was associated with lower overall survival even when adjusted for significant potential confounders (HR 1.03; 95% CI 1.01, 1.05; p=0.002). Overall, patients experiencing acute kidney injury lasting for a week or more before initiation of replacement therapy experienced a threefold increase in risk of death (HR 3.02; 95% CI 2.04, 4.46; p Conclusions Acute kidney injury after liver transplantation is remarkably frequent and has a substantial impact on patient survival. Delaying the initiation of renal replacement therapy in such population may increase mortality by more than 20% per day.