Serviço de Medicina Intensiva e Intermédia
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- International EMS systems: PortugalPublication . Gomes, E.; Araújo, R.; Soares-Oliveira, M.; Pereira, N.
- Efeito da exposição prolongada a ruído ocupacional na função respiratória de trabalhadores da indústria têxtilPublication . Cardoso, A.; Oliveira, M.; Silva, A.; Águas, A.; Sousa-Pereira, A.Vibroacoustic disease is a pathology caused by long occupational exposure to large pressure amplitude and low frequency noise. It is a systemic disease, with evolvement of respiratory structures. The exposure workers to this noise of textile industry may favour alterations in lung function. We studied 28 women working more than ten years in cotton-mill rooms to evaluate their lung function, including Spirometry, forced oscillation technique (I.O.S.) and Diffusion capacity. These results were compared with those of 30 women of similar ages not exposed to similar noise and not presenting respiratory disease. Statistical significance (P<0.05) was found with FEV25, R5 and Delta Rs5-Rs20. There was a resistance frequency dependence in 36% of the population exposed to noise, not statistically confirmed. Neither restriction nor changes in diffusing capacity where detected. CONCLUSION: The analysis of global alterations of lung function parameters suggests small airways aggression by noise. However we cannot definitively exclude the influence of cotton dust inhalation in itself which effects could be increased by the loss of ciliated cells and impairment of airways clearance caused by noise.
- A case-control study on risk factors for early-onset respiratory tract infection in patients admitted in ICUPublication . Cardoso, T.; Lopes, M.; Carneiro, A.BACKGROUND: Respiratory tract infections are common in intensive care units (ICU), with incidences reported from 10 to 65%, and case fatality rates over 20% in pneumonia. This study was designed to identify risk factors for the development of an early onset respiratory tract infection (ERI) and to review the microbiological profile and the effectiveness of first intention antibiotic therapy. METHODS: Case-control, retrospective clinical study of the patients admitted to the Intensive Care Unit (ICU) of our hospital, a teaching and tertiary care facility, from January to September 2000 who had a respiratory tract infection diagnosed in the first 5 days of hospital stay. RESULTS: Of the 385 patients admitted to our unit: 129 (33,5%) had a diagnosis of ERI and 86 patients were admitted to the control group. Documented aspiration (adjusted OR = 5,265; 95% CI = 1,155 - 24,007) and fractured ribs (adjusted OR = 12,150; 95% CI = 1,571 - 93,941) were found to be independent risk factors for the development of ERI (multiple logistic regression model performed with the diagnostic group as dependent variable and adjusted for age, sex, SAPS II, documented aspiration, non-elective oro-tracheal intubation (OTI), fractured ribs, pneumothorax and pleural effusion).A total of 78 organisms were isolated in 61 patients (47%). The normal flora of the upper airway (Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenza and Moraxella catharralis) accounted for 72% of all isolations achieved, polimicrobian infections were responsible for 25% of all microbiological documented infections. First intention treatment was, in 62% of the patients, the association amoxacillin+clavulanate, being effective in 75% of the patients to whom it was administered. The patients with ERI needed more days of OTI (6 vs 2, p < 0,001) and mechanical ventilation (6 vs 2, p < 0,001) and had a longer ICU (7 vs 2, p < 0,001) and hospital length of stay (17 vs 11, p = 0,018), when compared with controls. CONCLUSION: In this study documented tracheobronchial aspiration and fractured ribs were identified as independent risk factors for ERI. Microbiological profile was dominated by sensitive micro-organisms. The choice amoxacilin+clavulanate revealed to be a good option with an effectiveness rate of 77% in the patients in whom it was used.
- Non-invasive ventilation in cardiogenic pulmonary edema in the emergency department.Publication . Carvalho, L.; Carneiro, R.; Freire, E.; Pinheiro, P.; Aragão, I.; Martins, A.Abstract Bilevel positive pressure (BiPAP) non-invasive ventilation (NIV) is frequently used in our emergency department (ED), as an adjuvant in the treatment of acute cardiogenic pulmonary edema (ACPE) to reduce the need for tracheal intubation (TI) in these patients. The purpose of our study was to evaluate the safety of NIV in patients with ACPE in our ED, used by a group of physicians outside the intensive care unit (ICU), by comparing our results with previously published results. We also wanted to identify possible additional advantages of NIV in the treatment of acpe. We recorded clinical and physiological data before and after NIV of all patients with diagnosis and treatment of ACPE in our ED and for whom NIV was ordered as adjuvant treatment, between July 2004 and February 28 2005. During this period, NIV was ordered in 17 patients with ACPE. The mean ventilation pressures used were p(INSP) 16.5 +/- 5 cm H2O and p(exp) 8.8 +/- 4 cm H2O. none of the patients refused NIV. In six patients NIV was not initiated immediately together with medical therapeutics. one patient required Ti and the other 16 (94%) improved after NIV. After the acpe episode had resolved, fourteen patients (82%) were eventually discharged from hospital whereas 3 (18%) died during hospitalization. We observed a statistically significant improvement after one hour of NIV in respiratory and pulse rate, arterial pH, PaCO2 and peripheral blood O2 saturation. Despite the small sample size, these results suggest that it is possible to use NIV in the treatment of ACPE outside the ICU, without increasing the risks of TI or decreasing efficacy. In these cases NIV probably accelerates clinical resolution and relieves symptoms.
- Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injuryPublication . Vesconi, S.; Cruz, D.; Fumagalli, R.; Kindgen-Milles, D.; Monti, G.; Marinho, A.; Mariano, F.; Formica, M.; Marchesi, M.; René, R.; Livigni, S.; Ronco, C.Introduction The optimal dialysis dose for the treatment of acute kidney injury (AKI) is controversial. We sought to evaluate the relationship between renal replacement therapy (RRT) dose and outcome. Methods We performed a prospective multicentre observational study in 30 intensive care units (ICUs) in eight countries from June 2005 to December 2007. Delivered RRT dose was calculated in patients treated exclusively with either continuous RRT (CRRT) or intermittent RRT (IRRT) during their ICU stay. Dose was categorised into more-intensive (CRRT ≥ 35 ml/kg/hour, IRRT ≥ 6 sessions/week) or less-intensive (CRRT < 35 ml/kg/hour, IRRT < 6 sessions/week). The main outcome measures were ICU mortality, ICU length of stay and duration of mechanical ventilation. Results Of 15,200 critically ill patients admitted during the study period, 553 AKI patients were treated with RRT, including 338 who received CRRT only and 87 who received IRRT only. For CRRT, the median delivered dose was 27.1 ml/kg/hour (interquartile range (IQR) = 22.1 to 33.9). For IRRT, the median dose was 7 sessions/week (IQR = 5 to 7). Only 22% of CRRT patients and 64% of IRRT patients received a more-intensive dose. Crude ICU mortality among CRRT patients were 60.8% vs. 52.5% (more-intensive vs. less-intensive groups, respectively). In IRRT, this was 23.6 vs. 19.4%, respectively. On multivariable analysis, there was no significant association between RRT dose and ICU mortality (Odds ratio (OR) moreintensive vs. less-intensive: CRRT OR = 1.21, 95% confidence interval (CI) = 0.66 to 2.21; IRRT OR = 1.50, 95% CI = 0.48 to 4.67). Among survivors, shorter ICU stay and duration of mechanical ventilation were observed in the more-intensive RRT groups (more-intensive vs. less-intensive for all: CRRT (median): 15 (IQR = 8 to 26) vs. 19.5 (IQR = 12 to 33.5) ICU days, P = 0.063; 7 (IQR = 4 to 17) vs. 14 (IQR = 5 to 24) ventilation days, P = 0.031; IRRT: 8 (IQR = 5.5 to 14) vs. 18 (IQR = 13 to 35) ICU days, P = 0.008; 2.5 (IQR = 0 to 10) vs. 12 (IQR = 3 to 24) ventilation days, P = 0.026). Conclusions After adjustment for multiple variables, these data provide no evidence for a survival benefit afforded by higher dose RRT. However, more-intensive RRT was associated with a favourable effect on ICU stay and duration of mechanical ventilation among survivors. This result warrants further exploration. Trial Registration Cochrane Renal Group (CRG110600093).
- Reducing mortality in severe sepsis with the implementation of a core 6-hour bundle: results from the Portuguese community-acquired sepsis study (SACiUCI study)Publication . Cardoso, T.; Carneiro, A.; Ribeiro, O.; Teixeira-Pinto, A.; Costa-Pereira, A.Abstract INTRODUCTION: To evaluate the impact of compliance with a core version of the Surviving Sepsis Campaign 6-hour bundle on 28 days mortality. METHODS: Cohort, multi-centre, prospective study on community-acquired sepsis (CAS). RESULTS: Seventeen intensive care units (ICU) entered the study. Over a one year period, 4,142 patients were enrolled in the study. Of the 897 (24%) admitted with CAS, 778 (87%) had severe sepsis or septic shock on ICU admission. In the first six hours of hospital admission: (1) 62% had serum lactate measured; (2) 69% fluids administered; (3) 77% specimens collected for microbiology before antibiotic administration; (4) 48% blood cultures obtained; (5) 52% antibiotics administered within the first hour of the diagnosis; (6) vasopressors were given in 78%; (7) 56% had central venous measurement (CVP) measurement; (8) 17% had a central venous oxygen saturation (ScvO2) measurement; (9) dobutamine was administered in 52%. Compliance with all actions 1 to 6 (core bundle) was associated with an odds ratio (OR) of 0.44 [95% confidence interval (CI) = 0.24-0.80] in severe sepsis and 0.49 (95% CI = 0.25-0.95) in septic shock, for 28 days mortality. This corresponded to a number needed to treat of 6 patients to save one life. CONCLUSIONS: Compliance with this core bundle was associated with a significant reduction in the 28 days mortality. Urgent action should be taken in order to ensure that early sepsis diagnosis is followed by full completion of this "core bundle" followed by activation of expertise help in severe sepsis.
- DISTÚRBIOS PSÍQUICOS: BURNOUTPublication . Teixeira, C.
- Nutritional requirements of the critically ill patientPublication . Costa, N.; Marinho, A.; Cançado, L.Objective: Given the inaccessibility of indirect calorimetry, intensive care units generally use predictive equations or recommendations that are established by international societies to determine energy expenditure. The aim of the present study was to compare the energy expenditure of critically ill patients, as determined using indirect calorimetry, to the values obtained using the Harris-Benedict equation. Methods: A retrospective observational study was conducted at the Intensive Care Unit 1 of the Centro Hospitalar do Porto. The energy requirements of hospitalized critically ill patients as determined using indirect calorimetry were assessed between January 2003 and April 2012. The accuracy (± 10% difference between the measured and estimated values), the mean differences and the limits of agreement were determined for the studied equations. Results: Eighty-five patients were assessed using 288 indirect calorimetry measurements. The following energy requirement values were obtained for the different methods: 1,753.98±391.13 kcal/ day (24.48 ± 5.95 kcal/kg/day) for indirect calorimetry and 1,504.11 ± 266.99 kcal/day (20.72±2.43 kcal/kg/day) for the HarrisBenedict equation. The equation had a precision of 31.76% with a mean difference of -259.86 kcal/day and limits of agreement between -858.84 and 339.12 kcal/day. Sex (p=0.023), temperature (p=0.009) and body mass index (p< 0.001) were found to significantly affect energy expenditure Conclusion: The Harris-Benedict equation is inaccurate and tends to underestimate energy expenditure. In addition, the Harris-Benedict equation is associated with significant differences between the predicted and true energy expenditure at an individual level
- NUTRIÇÃO ARTIFICIAL NO DOENTE CRÍTICOPublication . Marinho, A.; Cançado, L.; Castelões, P.; Castro, H.; Lafuente, E.; Afonso, O.; Camara, M.; Marinho, R.Introdução: O suporte nutricional tem papel importan- te no tratamento dos doentes internados em Unidades de Cuidados Intensivos (UCI). O objetivo deste trabalho foi avaliar a carga calórica fornecida aos doentes críticos, con- siderando o impacto da carga calórica “secundária” (não nutricional) e a teoria da “Subnutrição permissiva”. Obje- tivos: Avaliar a carga calórica fornecida aos doentes inter- nados em Unidades de Cuidados Intensivos. Material e métodos: Estudo transversal analítico realizado em 6 dife- rentes Unidades de Cuidados Intensivos em doentes inter- nados mais de 5 dias. Resultados: 153 doentes, idade 58,18 ± 18,47 anos, sendo do foro médico (22,88%), cirúrgico (21,56%), neurocirúrgico (28,76%) e trauma (26,80%). Internados durante 14,54 ± 9,05 dias, com SOFA de 6,95 ± 3.23 e IMC de 24,57 ± 3,84. A mortalidade foi de 32,03%. Foram fornecidos 12,3 ± 8,4 kcal/kg/dia, com evolução gradativa nos 10 primeiros dias. A carga calórica secundária decresceu, apresentando impacto no valor calórico global somente até ao 2o dia de internamento. Os doentes do foro médico atingiram mais precocemente os objetivos nutricio- nais. A carga calórica secundária teve maior impacto nos pacientes cirúrgicos. Numa fase imediata e intermediária os doentes receberam um aporte calórico significativamente superior ao modelo de Wilmore, enquanto que na fase final o aporte foi significativamente inferior. Discussão: A sub- nutrição encontrada revelou-se diferente do conceito de subnutrição permissiva de Wilmore, provavelmente devido à desvalorização do peso, do bom estado nutricional na admissão, ou à própria gravidade desses doentes, colocan- do a terapia nutricional em segundo plano. Conclusão: Este estudo vem realçar a dificuldade que existe em fornecer um suporte nutricional adequado aos doentes internados em Unidades de Cuidados Intensivos.
- Avaliação das necessidades energéticas no doente críticoPublication . Marinho, A.; Pinho, J.; Cançado, L.; Oliveira, M.; Marinho, R.; Martins, F.Introdução: Os doentes críticos são um grupo de do- entes francamente hipermetabólicos que necessitam de um suporte nutricional adequado às suas necessidades. Objectivos: Verificar o melhor método para determinar as neces- sidades energéticas de doentes críticos. Material e métodos: Estudo transversal analítico no qual foram recolhidos dados demográficos, determinado o consumo energético quer por calorimetria indirecta, quer pela fórmula de Harris-Benedict e além disso calculado o fator de stress de pacientes internados entre 2004 e 2009. Resultados: Incluíram- se neste estudo 139 doentes (33% feminino, 67% masculino). Foram efetuadas 298 medidas pela calorimetria indireta, com tempo útil médio de 9 horas, que foram compa- radas às necessidades energéticas calculadas a partir da equação de Harris-Benedict. Encontraram-se diferenças significativas entre os resultados obtidos. O consumo energético mensurado foi 27,9 Kcal/kg (mediana), e quando comparado à equação de Harris-Benedict, evidenciou-se um valor subestimado em 25% (7 Kcal/kg). A mediana do fator de stress encontrado para a correção da fórmula de Harris- Benedict foi de 1,31. Discussão e conclusão: Embora exista uma variabilidade do consumo energético nesses doentes, a fórmula de Harris-Benedict, quando associada a um fator stress entre 1,25 – 1,35, poderá ser um método eficaz na avaliação das necessidades nutricionais. Por outro lado, pode-se optar também por uma abordagem mais simplificada, utilizando valores energéticos entre 25 a 30 Kcal por quilograma de peso. Obviamente, a calorimetria indireta continua a ser o “gold standard’’ da avaliação do consumo energético, já que nos permite adequar as necessidades energéticas em função do consumo energético in- dividual de acordo com o gasto real de cada doente.