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Organizational aspects, namely the implementation of protocols and presence of clinical pharmacists in the ICU, and close collaboration between oncologists and ICU teams are targets to improve mortality and resource use in critically ill patients with cancer.

In this narrative review, we discuss the relevant issues of therapeutic plasma exchange (TPE) in critically ill patients. For many conditions, the optimal indication, device type, frequency, duration, type of replacement fluid and criteria for stopping TPE are uncertain. TPE is a potentially lifesaving but also invasive procedure with risk of adverse events and complications and requires close monitoring by experienced teams. In the intensive care unit (ICU), the indications for TPE can be divided into (1) absolute, well-established, and evidence-based, for which TPE is recognized as first-line therapy, (2) relative, for which TPE is a recognized second-line treatment (alone or combined) and (3) rescue therapy, where TPE is used with a limited or theoretical evidence base. New indications are emerging and ongoing knowledge gaps, notably regarding the use of TPE during critical illness, support the establishment of a TPE registry dedicated to intensive care medicine.

BackgroundMaternal mortality and morbidity are among the top public health priorities in Brazil, being quite high, especially among the most disadvantage women. A case control study was developed to identify risk factors for severe maternal morbidity in Sao Luis, one of the poorest Brazilian State Capitals.MethodsThe case–control study was carried out between 01/03/2009 and 28/02/2010 in two public high-risk maternities facilities and in two intensive care units (ICUs) for referral of obstetric cases. All cases hospitalized due to complications during gestation period, childbirth or up to 42 days of puerperium and who fulfilled any of Mantel's and/or Waterstone's criteria were identified. Two controls per case were randomly selected among patients of the same clinics discharged for other reasons. Data were obtained through a structured interview as well as from medical charts and prenatal cards and included sociodemographic variables, clinical and obstetric histories, behavioral factors and exposure to stress factors during pregnancy, pre-natal assistance and obstetric complication and childbirth care.ResultsIn the final model of the unconditional logistic regression analysis, being older than 35 years (OR=3.11; 95% CI:1.53-6.31), previous hypertension (OR=2.52; 95% CI:1.09-5.80), history of abortion (OR=1.61; 95% CI:0.97-2.68), 4–5 pre-natal consultations (OR=1.78; 95% CI:1.05-3.01) and 1–3 pre-natal consultations (OR=1.89; 95% CI:1.03-3.49) were independently associated with severe maternal morbidity.ConclusionsThe results corroborate the importance of reproductive healthcare, of identifying a high-risk pregnancy and of a qualified and complete prenatal care to prevent severe morbid events.ResumoIntroduçãoA mortalidade e morbidade maternas estão entre os tópicos prioritários da Saúde Pública brasileira, especialmente na população de menor nível socioeconômico. Um estudo caso-controle foi desenvolvido para identificar os fatores de risco para morbidade materna grave em São Luís, capital de um dos estados mais pobres do Brasil.MétodoEstudo caso-controle realizado em duas maternidades públicas de alto risco e duas UTIs de referência aos casos obstétricos entre 01/03/2009 e 28/02/2010. Foram incluídas todas as pacientes internadas por complicação do período grávido-puerperal e que preenchiam os critérios de Waterstone e/ou Mantel para morbidade materna grave. Foram selecionados para cada caso, dois controles por sorteio aleatório dentre as pacientes internadas no mesmo período e mesma maternidade que o caso. As informações de domínio sociodemográfico, clínico, obstétrico, comportamental, exposição a eventos estressores na gestação, assistência ao pré-natal, intercorrências obstétricas e atenção ao parto, foram obtidas por meio de entrevista estruturada. As variáveis foram analisadas por modelo de regressão logística múltipla não condicional, baseado em modelo hierarquizado a priori.ResultadosForam identificados como fatores de risco para morbidade materna grave: idade >35 anos (OR=3,11; IC 95%:1,53-6,31), hipertens...

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BackgroundThere is an increasing need for standardized instruments for quality assessment that are able to reflect the actual conditions of the intensive care practices, especially in low and middle-income countries. The aim of this article is to describe the preparation of an instrument for quality assessment of adult intensive care services adapted to the actual conditions of intensive care in a middle-income country and comprising indicators validated in the literature.MethodsThe study consisted of five steps: (1) a literature survey; (2) a discussion with specialists by consensus method; (3) a pilot field test; (4) a description of indicators; and (5) an elaboration of the final version of the instrument. Each generated indicator was attributed a score (“out of standard” = 0; “below standard” = 1; “standard” = 2) that allowed calculation of the total score for each service assessed.ResultsA total of 62 indicators were constructed, distributed as follows: 38 structure indicators (physical structure: 4; human resources: 14; continued education and training: 2; protocols and routines: 12; material resources: 6); 17 process indicators (safety: 7; work: 10); and seven outcome indicators. The maximum possible total score was 124.ConclusionsPossible future applications of the instrument for the assessment of intensive care units that was constructed in the present study include benchmarking, multicenter studies, self-assessment of intensive care units, and evaluation of changes resulting from interventions.Electronic supplementary materialThe online version of this article (doi:10.1186/s13104-017-2563-3) contains supplementary material, which is available to authorized users.

Objective To depict the clinical presentation and outcomes of a cohort of critically ill patients with esophageal cancer. Methods We carried out a multicenter retrospective study that included patients with esophageal cancer admitted to intensive care units with acute illness between September 2009 and December 2017. We collected the demographic and clinical characteristics of all included patients, as well as organ-support measures and hospital outcomes. We performed logistic regression analysis to identify independent factors associated with in-hospital mortality. Results Of 226 patients included in the study, 131 (58.0%) patients died before hospital discharge. Squamous cell carcinoma was more frequent than adenocarcinoma, and 124 (54.9%) patients had metastatic cancer. The main reasons for admission were sepsis/septic shock and acute respiratory failure. Mechanical ventilation (OR = 6.18; 95%CI 2.86 - 13.35) and metastatic disease (OR = 7.10; 95%CI 3.35 - 15.05) were independently associated with in-hospital mortality. Conclusion In this cohort of patients with esophageal cancer admitted to intensive care units with acute illness, the in-hospital mortality rate was very high. The requirement for invasive mechanical ventilation and metastatic disease were independent prognostic factors and should be considered in discussions about the short-term outcomes of these patients.