Background: Higher intraoperative driving pressures (DP) are associated with increased postoperative pulmonary complications (PPC). We hypothesised that dynamic adjustment of PEEP throughout abdominal surgery reduces DP, maintains positive end-expiratory transpulmonary pressures (P tp_ee ) and increases respiratory system static compliance (C rs ) with PEEP levels that are variable between and within patients. Methods: In a prospective multicentre pilot study, adults at moderate/high risk for PPC undergoing elective abdominal surgery were randomised to one of three ventilation protocols: (1) PEEP 2 cm H 2 O, compared with periodic recruitment manoeuvres followed by individualised PEEP to either optimise respiratory system compliance (PEEP maxCrs ) or maintain positive end-expiratory transpulmonary pressure (PEEP Ptp_ee ). The composite primary outcome included intraoperative DP, P tp_ee , C rs , and PEEP values (median (interquartile range) and coefficients of variation [CV PEEP ]). Results: Thirty-seven patients (48.6% female; age range: 47e73 yr) were assigned to control (PEEP 2 cm H 2 O; n¼13), PEEP maxCrs (n¼16), or PEEP Ptp_ee (n¼8) groups. The PEEP Ptp_ee intervention could not be delivered in two patients. Subjects assigned to PEEP maxCrs had lower DP (median8 cm H 2 O [7e10]), compared with the control group (12 cm H 2 O [10e15]; P¼0.006). PEEP maxCrs was also associated with higher P tp_ee (2.0 cm H 2 O [-0.7 to 4.5] vs controls: -8.3 cm H 2 O [-13.0 to -4.0]; P 0.001) and higher C rs (47.7 ml cm H 2 O [43.2e68.8] vs controls: 39.0 ml cm H 2 O [32.9e43.4]; P¼0.009). Individualised PEEP (PEEP maxCrs and PEEP Ptp_ee combined) varied widely (median: 10 cm H 2 O [8-15]; CV PEEP ¼0.24 [0.14e0.35]), both between, and within, subjects throughout surgery. Conclusions: This pilot study suggests that individualised PEEP management strategies applied during abdominal surgery reduce driving pressure, maintain positive P tp_ee and increase static compliance. The wide range of PEEP observed suggests that an individualised approach is required to optimise respiratory mechanics during abdominal surgery. Clinical trial registration: NCT02671721.
The effects of orthostatism in adult intensive care unit patients Efeito imediato do ortostatismo em pacientes internados na unidade de terapia intensiva de adultos
OBJECTIVE: Evaluate the Glasgow outcome scale (GOS) at discharge (GOS-HD) as a prognostic indicator in patients with traumatic brain injury (TBI). METHOD: Retrospective data were collected of 45 patients, with Glasgow coma scale <8, age 25±10 years, 36 men, from medical records. Later, at home visit, two measures were scored: GOS-HD (according to information from family members) and GOS LATE (12 months after TBI). RESULTS: At discharge, the ERG showed: vegetative state (VS) in 2 (4%), severe disability (SD) in 27 (60%), moderate disability (MD) in 15 (33%) and good recovery (GR) in 1 (2%). After 12 months: death in 5 (11%), VS in 1 (2%), SD in 7 (16%), MD in 9 (20%) and GR in 23 (51%). Variables associated with poor outcome were: worse GOS-HD (p=0.03), neurosurgical procedures (p=0.008) and the kind of brain injury (p=0.009). CONCLUSION: The GOS-HD was indicator of prognosis in patients with severe TBI.
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