objectIve. The aim of this study was to evaluate the criteria used in clinical practice to triage patients who are candidates for ICU admission. Methods. This was a prospective cohort study conducted at a tertiary hospital. Patients were assessed for their need for ICU admission and ranked by priority into groups 1, 2, 3 and 4 (highest priority 1, lowest priority 4) and these groups were compared. results. The sample comprised 359 patients with a median age of 66 years (53.2-75.0). Median APACHE II score was 23 (18-30). The ICU granted 70.4% of requests for ICU beds. Patients who were refused admission to the ICU were older, 66.2±16.1 vs. 61.9±15.2 years (p= 0.02), and fewer priority 1 patients were refused ICU beds; 23.8% vs. 39.1% of requests refused (p=0.01). The opposite was observed with priorities 3 and 4. Priority 3 and 4 patients were older, scored higher on the prognostic scale and the organ dysfunction scale and had a higher bed refusal rate. Patients in priority groups 3 and 4 had higher in-ICU mortality rates when compared to priority 1 and 2 patients: 86.7% vs. 31.3% (p<0.001). conclusIon. Age, prognostic scores and organ dysfunction scores were all greater among priority 3 and 4 patients and were related to refusal of ICU admission. Patients refused admission to the ICU had higher mortality rates and mortality remained higher among priority 3 and 4 patients even when they were admitted to the ICU.
Ventilator-associated pneumonia (VAP) is the most commonly-acquired infection in patients in intensive care units. We analyzed epidemiological and microbiological characteristics and the outcome, in a cohort of criticallyill patients with confirmed diagnosis of VAP. All patients who had been on mechanical ventilation (MV) for more than 48 hours were included in our study; material collection for microbiological analysis was done within the first 24 hours after beginning treatment or after changing antibiotics. There were 55/265 (20.7%) VAP cases diagnosed, at a rate of 21.6 episodes per 1,000 days of mechanical ventilation. Mean age of the patients was 66 years, with a mean APACHE II score of 26.7 + 7.0; male patients were more prevalent. The mortality rates in the intensive care unit (ICU) and during the hospital stay were 71% and 80%, respectively. MV duration in patients with VAP was 17 (range 3-43) days and among patients who had not developed VAP, 6 (2-32) days (p < 0.0001). 98.2% of the samples were positive, with a high prevalence of Gram-negative bacteria, mainly Acinetobacter calcoaceticus. Risk factors for death included age, MV duration and surgery. VAP incidence in this sample of critically-ill patients was high, with a high mortality rate. Control and prevention strategies based on continuing education of healthcare workers, developed by a multidisciplinary team, should be encouraged to minimize morbimortality of this infection.
Background: Acute kidney injury (AKI) is a common complication in critical care patients. The presence of AKI is a marker for poor outcomes such as longer hospitalization durations, more hospital readmissions, and especially, higher mortality rates. Sepsis is one of the major causes of AKI within the intensive care unit (ICU) population. Sepsis-related AKI occurs in approximately 20% of patients, reaching more than 50% in patients with septic shock. The diagnosis of AKI depends on urine output and/or serum creatinine measurements. Unfortunately, serum creatinine is a late and unreliable (insensitive and nonspecific) indicator of AKI. However, biomarkers of renal damage have great potential in facilitating early diagnosis of AKI. Several biomarkers, including urinary neutrophil gelatinase-associated lipocalin (uNGAL), have been used in the early detection of AKI. Objectives: The aim of this study was to evaluate uNGAL for the diagnosis and prognosis of AKI in critical ill patients with infections. Design: Original study (Cohort Prospective Observational). Setting: Study in 2 ICUs of different Brazilian hospitals, in the city of Curitiba: Hospital de Clínicas da Universidade Federal do Paraná and Hospital da Polícia Militar do Paraná, from November 12, 2016 to May 15, 2018. Participants: Critically ill patients with infections, sepsis, or septic shock were selected. The inclusion criteria were patients older than 18 years with infection. They were followed up for 30 days in the analysis of outcomes. We requested that consent forms be signed by all eligible patients or their caregivers. Measurements: The urinary neutrophil gelatinase-associated lipocalin (uNGAL) levels of the patients were measured on 4 consecutive days and was assayed using a chemiluminescent microparticle immunoassay system. The screening time occurred within 72 hours of admission to the ICU. The first urine sample was collected within the first 24 hours of the screening hours. Mortality and AKI were assessed during first 30 days. Methods: clinical and laboratory data, including daily uNGAL levels, were assessed. The AKI stage using the KDIGO criteria was evaluated. Sensitivity, specificity, and the area under the curve-receiver operating characteristic (AUC-ROC) values were calculated to determine the optimal uNGAL level for predicting AKI. Results: We had 38 patients who completed the study during the screening period. The incidence of AKI was 76.3%. The hospitalization period was longer in the group that developed AKI, with 21 days of median (interquartile range [IQR]: 13.5-25); non-AKI group had a median of 13 days (IQR 7-18; P = .019). We found a direct relationship between uNGAL levels and the progression to AKI. Increased values of the biomarker were associated with the worsening of AKI ( P < .05). The cutoff levels of uNGAL that identified patients who would progress to AKI were the following: (d1) >116 ng/mL, (d2) >100 ng/mL, and (d3) 284 ng/mL. The value of the fourth and last measurement was not predictive of patients who would progress to AKI. The median urinary uNGAL was also associated with mortality on Days 1, 3, and 4: d1, P = .039; d3, P = .005; d4, P = .005. The performance of uNGAL in detecting AKI patients (AUC-ROC = 0.881). There were no risk factors other than AKI that could be correlated with increased uNGAL levels on Day 1. Limitations: The study was carried out in 2 centers, having used only 1 biomarker, and our small number of patients were limitations. Conclusion: the uNGAL had an association in its values with the diagnosis and prognosis of patients with severe infections and AKI. We suggest that studies with a greater number of patients could better establish the cutoff values of uNGAL and/or serum NGAL in the identification of infected patients who are at a high risk of developing AKI.
RESUMO JUSTIFICATIVA E OBJETIVOS: Um dos maiores desafios dos médicos intensivistas é o controle da hipoperfusão tecidual, sendo o lactato sérico classicamente aceito como indicador de hipóxia tecidual. Deste modo, estudos demonstraram boa correlação entre o lactato e o prognóstico no choque e durante a reanimação. O objetivo deste estudo foi avaliar a utilidade clínica do lactato arterial à admissão na UTI como indicador de morbimortalidade em pacientes críticos no pós-operatório de intervenções cirúrgicas não cardíacas de alto risco. MÉTODO: Estudo de coorte prospectivo observacional, realizado em UTI de hospital terciário no período
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