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Introduction: In Brazil, data show an important decrease in morbi-mortality of high-risk surgical patients over a 10-year high. The objective of this post-hoc study was to evaluate the mechanism explaining this trend in high-risk surgical patients admitted to Brazilian ICUs in two large Brazilian multicenter cohort studies performed 10 years apart. Methods: The patients included in the 2 cohorts studies published in 2008 and 2018 were compared after a (1:1) propensity score matching. Patients included were adults who underwent surgeries and admitted to the ICU afterwards. Results: After matching, 704 patients were analyzed. Compared to the 2018 cohort, 2008 cohort had more postoperative infections (OR 13.4; 95%CI 6.1–29.3) and cardiovascular complications (OR 1.5; 95%CI 1.0–2.2), as well as a lower survival ICU stay (HR = 2.39, 95% CI: 1.36–4.20) and hospital stay (HR = 1.64, 95% CI: 1.03–2.62). In addition, by verifying factors strongly associated with hospital mortality, it was found that the risk of death correlated with higher intraoperative fluid balance (OR = 1.03, 95% CI 1.01–1.06), higher creatinine (OR = 1.31, 95% CI 1.1–1.56), and intraoperative blood transfusion (OR = 2.32, 95% CI 1.35–4.0). By increasing the mean arterial pressure, according to the limits of sample values from 43 mmHg to 118 mmHg, the risk of death decreased (OR = 0.97, 95% CI 0.95–0.98). The 2008 cohort had higher fluid balance, postoperative creatinine, and volume of intraoperative blood transfused and lower mean blood pressure at ICU admission and temperature at the end of surgery. Conclusion: In this sample of ICUs in Brazil, high-risk surgical patients still have a high rate of complications, but with improvement over a period of 10 years. There were changes in the management of these patients over time. [ABSTRACT FROM AUTHOR]

Ketamine is unique among anesthetics and analgesics. The drug is a rapid-acting general anesthetic that produces an anesthetic state characterized by profound analgesia, preserved pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression. Research has demonstrated the efficacy of its use on anesthesia, pain, palliative care, and intensive care. Recently, it has been used for postoperative and chronic pain, as an adjunct in psychotherapy, as a treatment for depression and posttraumatic stress disorder, as a procedural sedative, and as a treatment for respiratory and/or neurologic clinical conditions. Despite being a safe and widely used drug, many physicians, such as intensivists and those practicing in emergency care, are not aware of the current clinical applications of ketamine. The objective of this narrative literature review is to present the theoretical and practical aspects of clinical applications of ketamine in intensive care unit and emergency department settings. [ABSTRACT FROM AUTHOR]

Background and objectives: Hypothermia occurs commonly during surgery and can cause postoperative complications. We aimed to describe the characteristics and outcomes of hypothermia in patients undergoing major surgeries. Methods: This prospective, observational, multicenter study of a nationally representative sample included all patients over 18 years of age admitted to an intensive care unit (ICU). Thirty ICUs were selected randomly at national level. The main outcome measure was the proportion of patients who developed postoperative hypothermia in the first 24 hours of ICU admission. Patients were divided into three groups based on temperature: <35°C, <36°C, and ≥36°C (no hypothermia). Patients' characteristics, postoperative complications, and risk factors were evaluated in all groups. To verify whether hypothermia was a strong risk factor for postoperative complications, a Kaplan–Meier curve was generated and adjusted using a Cox regression model. Results: In total, 738 patients had their temperatures measured. The percentage of patients with temperature <35°C (median [Q1-Q3], 34.7°C [34.3–34.9°C]) was 19.1% (95% confidence interval [CI] = 16.1–22.5) and that of patients with temperature <36°C (median [Q1-Q3], 35.4°C [35.0–35.8°C]) was 64% (95% CI = 58.3–70.0). The percentage of surgical complications was 38.9%. Patients with hypothermia were older, had undergone abdominal surgeries, had undergone procedures of longer duration, and had more comorbidities. A postoperative temperature ≤35°C was an independent risk for composite postoperative complications (hazard ratio = 1.523, 95% CI = 1.15–2.0), especially coagulation and infection. Conclusions: Inadvertent hypothermia was frequent among patients admitted to the ICU and occurred more likely after abdominal surgery, after a long procedure, in elderly patients, and in patients with a higher number of comorbidities. Low postoperative temperature was associated with postoperative complications. [ABSTRACT FROM AUTHOR]

Objective: To define the epidemiological profile and the main determinants of morbidity and mortality in noncardiac high surgical risk patients in Brazil. Methods: This was a prospective, observational and multicenter study. All noncardiac surgical patients admitted to intensive care units, i.e., those considered high risk, within a 1-month period were evaluated and monitored daily for a maximum of 7 days in the intensive care unit to determine complications. The 28- day postoperative, intensive care unit and hospital mortality rates were evaluated. Results: Twenty-nine intensive care units participated in the study. Surgeries were performed in 25,500 patients, of whom 904 (3.5%) were high-risk (95% confidence interval - 95%CI 3.3% - 3.8%) and were included in the study. Of the participating patients, 48.3% were from private intensive care units, and 51.7% were from public intensive care units. The length of stay in the intensive care unit was 2.0 (1.0 - 4.0) days, and the length of hospital stay was 9.5 (5.4 - 18.6) days. The complication rate was 29.9% (95%CI 26.4 - 33.7), and the 28-day postoperative mortality rate was 9.6% (95%CI 7.4 - 12.1). The independent risk factors for complications were the Simplified Acute Physiology Score 3 (SAPS 3; odds ratio - OR = 1.02; 95%CI 1.01 - 1.03) and Sequential Organ Failure Assessment Score (SOFA) on admission to the intensive care unit (OR = 1.17; 95%CI 1.09 - 1.25), surgical time (OR = 1.001, 95%CI 1.000 - 1.002) and emergency surgeries (OR = 1.93, 95%CI, 1.10 - 3.38). In addition, there were associations with 28-day mortality (OR = 1.032; 95%CI 1.011 - 1.052), SAPS 3 (OR = 1.041; 95%CI 1.107 - 1.279), SOFA (OR = 1.175, 95%CI 1.069 - 1.292) and emergency surgeries (OR = 2.509; 95%CI 1.040 - 6.051). Conclusion: Higher prognostic scores, elderly patients, longer surgical times and emergency surgeries were strongly associated with higher 28-day mortality and more complications during the intensive care unit stay. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation is a modality of extracorporeal life support that allows for temporary support in pulmonary and/or cardiac failure refractory to conventional therapy. Since the first descriptions of extracorporeal membrane oxygenation, significant improvements have occurred in the device and the management of patients and, consequently, in the outcomes of critically ill patients during extracorporeal membrane oxygenation. Many important studies about the use of extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome refractory to conventional clinical support, under in-hospital cardiac arrest and with cardiogenic refractory shock have been published in recent years. The objective of this literature review is to present the theoretical and practical aspects of extracorporeal membrane oxygenation support for respiratory and/or cardiac functions in critically ill patients. [ABSTRACT FROM AUTHOR]

Objective: To investigate the impacts of continuous venovenous hemodiafiltration on the microcirculation in patients with acute kidney injury. Methods: A prospective observational pilot study conducted in a 40-bed, open clinical-surgical intensive care unit of a private tertiary care hospital located in the city of São Paulo (SP), Brazil. Microcirculation was assessed using nearinfrared spectroscopy by means of a 15mm probe placed over the thenar eminence. Vascular occlusion test was performed on the forearm to be submitted to near-infrared spectroscopy by inflation of a sphygmomanometer cuff to 30mmHg higher than the systolic arterial pressure. The primary endpoint was the assessment of near-infrared spectroscopyderived parameters immediately before, 1, 4 and 24 hours after the initiation of continuous venovenous hemodiafiltration. Results: Nine patients were included in this pilot study over a period of 2 months. Minimum tissue oxygen saturation measured during the vascular occlusion test was the only near-infrared spectroscopy-derived parameter to differed over the time (decrease compared to baseline values up to 24 hours after initiation of continuous venovenous hemodiafiltration). Conclusion: The impacts of microcirculatory dysfunction on clinical outcomes of patients undergoing to continuous venovenous hemodiafiltration need to be further investigated. [ABSTRACT FROM AUTHOR]

Copyright of Revista Brasileira de Terapia Intensiva is the property of Associacao de Medicina Intensiva Brasileira and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Revista Brasileira de Terapia Intensiva is the property of Associacao de Medicina Intensiva Brasileira and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: The health environment is an important reservoir for a multitude of microorganisms. Contact with environment surfaces contaminated with multidrugresistant organisms (MDROs) may be associated with healthcare-associated infections and higher hospital costs, morbidity, and mortality.(1) Objective: To perform a systematic review of clinical and microbiological outcomes associated with interventions based on use of sanitizers in hospital environment surfaces or medical devices. Methods: Published studies were identified through electronic literature search of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and SCOPUS by three independent reviewers. All interventions based on use of sanitizers (in isolation or combined with other methods) and targeting the hospital environment or medical devices were included. No restrictions regarding patients and microorganisms were imposed. Bench studies, studies involving surface contamination with MDROs and animal studies were excluded. The quality of randomized controlled trials (RCTs) and non-randomized trials was assessed using the Cochrane Collaboration's tool and the Newcastle-Ottawa scale, respectively. Results: A total of 8,984 studies involving sanitizer interventions targeting the healthcare environment or medical devices were found. Of these, 26 were included in this review (Figure 1). Intervention effectiveness varied between studies. The five randomized studies which met the inclusion criteria involved the use of different sanitizers in disinfection: isopropyl alcohol swab, sodium hypochlorite (bleach), benzalkonium chloride swabs, quaternary ammonium disinfectant and UV-C light, bleach, and UV-C light, organosilane, hydrogen peroxide and silver vapor, and 65% ethyl alcohol. Environmental studies comprised two multicenter randomized trials and one single center randomized trial. All these studies assessed microbiological outcomes and only 6 included clinical outcomes. Studies focusing on medical device disinfection consisted of single center randomized trials and assessed microbiological outcomes. Selected studies involved the use of different chemical or physical-chemical cleaning and disinfection methods. Significant variation in cleaning and disinfection strategies in these settings reflect of lack of consensus on management of hospital rooms, medical devices and patients infected with MDROs. Conclusion: The efficacy of sanitizers was consistent across studies included in this systematic review. However, few RCTs were found, and most were limited to microbiological outcomes. More studies are urgently needed to evaluate the impact of environmental interventions on clinical outcomes. [ABSTRACT FROM AUTHOR]

Introduction: The environment is an important reservoir of microorganisms, especially multidrug-resistant (MR) organisms, which often tend to survive on surfaces (bed rails, door handles, computer keyboards) for extended periods of time. Evidence regarding the relationship between inadequate environmental hygiene practices and/or infrastructure and increased risk of healthcareassociated infections (HAIs) is unclear.(1,2) Objective: To identify hospital infrastructure patterns potentially associated with intensive care unit-acquired infections (ICU-AIs) using unsupervised machine learning techniques. Methods: Thirty-eight Brazilian hospitals located in different regions of the country were visited by healthcare professionals trained by the Research Group between November and December 2020. An instrument comprising 99 specifically designed questions and K-means clustering were used to examine potential relationships between items and presence of infection upon patient admission to respective intensive care units. The number of clusters was chosen according to the silhouette metric, as can be seen in figure 1. Results: Two groups (Group 0 and Group 1) were created after application of the K-means clustering algorithm. Findings revealed differences between hospital clusters, which may be related to the number of infections diagnosed upon admission. Intensive care unit-acquired infection rates were 28% higher in Group 0 relative to Group 1 hospitals (preliminary results; table 1). The three most distinguishing characteristics were: percentage of properly functioning liquid soap dispenser (58% and 100%, Group 0 and Group 1 respectively); percentage of alcohol solution dispensers in the unit (8% and 22%, Group 0 and Group 1 respectively); percentage of alcoholic solution availability in visible and readily accessible areas close to the point of care (10% and 60%, Group 0 and Group 1 respectively). Conclusion: Unsupervised machine learning methods (such as K-means) can be used to distinguish between hospitals according to infrastructure characteristics. Preliminary results suggest a relation between infrastructure and infection at admission. [ABSTRACT FROM AUTHOR]

Pulmonary aspiration of gastric residues during anesthesia is a potentially fatal complication for which no specific treatment is available. The primary way to prevent its occurrence in the context of elective surgeries is adherence to fasting protocols. However, some clinical conditions can prolong the gastric emptying time, and the risk of aspiration may exist despite adequate fasting. Recognizing the risk factors for gastroparesis allows the adoption of preventive methods and is the primary way to reduce morbidity and mortality from pulmonary aspiration. In this scenario, the anesthesiologist can investigate the gastric content by using ultrasound, adjust the anesthetic technique, and even postpone elective surgeries. Here, we describe incidental computed tomography finding of solid contents in the stomach of a patient without prior identification of the risk factors for gastroparesis. The patient underwent elective renal nodule ablation under general anesthesia after fasting for 9 hours. During the procedure, solid contents in the stomach were noted on computed tomography. Subsequently, it was discovered that the patient had been using semaglutide for 6 days and had not disclosed this information. Semaglutide use may represent a new and significant risk factor for anesthesia-related pulmonary aspiration. Until studies provide information on the appropriate perioperative management of patients using semaglutide, anesthesiologists need to adopt preventive measures to avoid aspiration. Awareness of this potential association and open communication among patients, physicians, and anesthesia teams are essential for enhancing patient safety. [ABSTRACT FROM AUTHOR]

Objetivo: Este estudo definiu o perfil epidemiológico e principais determinantes de morbimortalidade dos pacientes cirúrgicos não cardíacos de alto risco do Brasil. Métodos: Estudo prospectivo, observacional, multicêntrico, que consiste na identificação de pacientes cirúrgicos de alto risco em amostra representativa do Brasil. Todos os pacientes cirúrgicos não cardíacos que foram admitidos nas unidades de terapia intensiva (UTI) foram avaliados no período de 1 mês e acompanhados diariamente por no máximo 07 dias durante a UTI para determinação de complicações. No 28° dia de pós-operatório foi verificado mortalidade. Resultados: Foram selecionadas aleatoriamente 30 UTIs que forneceram dados de 25500 pacientes cirúrgicos, dos quais 904 de alto risco (70 pacientes por cada 100 camas de UTI, IC 95% 65,4-74,6). A distribuição dos pacientes recrutados no estudo apresentou 48,2% de UTIs privadas e 51,7% publicas, 59,6% da região Sudeste, 26,6% Sul, 9,3% Centro oeste e 4,4% norte e nordeste. A taxa de complicações foi 22,4% (95% IC 19,4-25,8) e mortalidade em 28 dias pós-cirurgia 11,6% (IC 95% 9,0-14,5). Públicas UTIs (OR=1,56, IC 95%=1,07-2,29), SAPS 3 (OR=1,04, IC 95%=1,02-1,06), SOFA da admissão na UTI (OR=1,13, IC 95%=1,04-1,23), ASA (OR=1,52, IC 95%=1,11-2,11), cirurgias de emergências (OR=3,17, IC 95%=1,47-6,86) ou cirurgias oncológicas (OR=2,34, IC 95%=1,21-4,55) foram independentemente associados à mortalidade de 28 dias. Conclusão: Nossos resultados apontam para o ônus do tratamento nos pacientes que apresentam maiores escores prognósticos, de cirurgias oncológicas ou emergenciais, em UTIs públicas do Brasil, pois são fatores fortemente associados a mortalidade após 28 dias de acompanhamento. [ABSTRACT FROM AUTHOR]

Objective: To address the impact of continuous venovenous hemodiafiltration (CVVHDF) on microcirculation of patients with acute kidney injury. Methods: Prospective observational pilot study was conducted in a forty bed, open clinical-surgical, ICU of a private, tertiary care, hospital in São Paulo, Brazil. Microcirculation was assessed using near-infrared spectroscopy (NIRS) (InSpectra StO2 Tissue Oxygenation Monitor model 650, Hutchinson, MN, USA) with a 15-mm probe over the thenar eminence. Vascular occlusion test (VOT) were performed by inflation of a sphygmomanometer cuff to 30 mmHg above the systolic arterial pressure on the forearm of the NIRS during 3 minutes. Primary endpoint was the assessment of NIRSderived parameters, immediately before, one, four, and 24 hours after the initiation of CVVHDF. Results: Nine patients were included in this study over a period of two months. Median (IQR) age was 66 (61 - 76) years and SAPS III score was 60 (51-63). Baseline median (IQR) tissue oxygen saturation (StO2), maximum StO2, descending slope, ascending slope and recovery time were, respectively, 83 (81-89) %, 94 (87-95) %, 8.3 (4.4-10.4) %/min, 1.6 (1.2-3.1) %/sec and 31.0 (29.5-48.5) sec. Only minimum StO2 during VOT was different over the time, with a decrease from 64 (49-67) % at baseline to 52 (43-59) % after 24 hours of CVVHDF initiation (p=0.023). Conclusion: Minimum StO2 measured during the VOT was the only NIRS-derived parameter affected during the first 24 hours of CVVHDF. [ABSTRACT FROM AUTHOR]

Objective: To evaluate sublingual microcirculation in adult critically ill patients and in health volunteers using a thirdgeneration handheld microscope. Methods: Patients with and without shock admitted to the ICU within 24h and healthy volunteers were studied (n=20, each). Sublingual microcirculation was assessed with Cytocam-IDF imaging (Braedius Medical, Huizen, The Netherlands). Total vessel density (TVD) and perfused vessel density (PVD) for small vessels were performed automatically (CytoCamTools 1.7.12 software, Braedius Medical, The Netherlands). Microvascular flow index (MFI) was calculated by real-time visual evaluation. Results: Shock patients had a higher SAPS III score [53 (45-65) vs. 30 (22-46), p<0.001] and higher 28-day mortality [5 (25.0%) vs. 0 (0.0%); p=0.047) than non-shock patients. Median (IQR) TVD [16.5 (12.4-21.6), 16.6 (14.4-19.4), 19.0 (16.8-20.7) mm/mm2, respectively for shock, nonshock and health volunteers; p=0.37)] and PVD [10.0 (8.2-13.6), 8.8 (7.5-12.2), 8.9 (7.9-11.2) mm/mm2, respectively; p=0.40] did not differ between the groups. Shock patients had a lower MFI compared to health volunteers [2.0 (1.8-2.5) vs. 2.6 (2.3-2.7), respectively; p=0.013] but not compared to non-shock [2.3 (2.1-2.7)] patients. Conclusion: Microvascular blood flow assessed with a third-generation microscope poorly discriminate between shock and non-shock critically ill patients. [ABSTRACT FROM AUTHOR]