Tuberculose grave com necessidade de internação em UTI

Abstract

Tuberculosis is a curable disease that can evolve to severe forms, requiring the treatment of the patients in an ICU, especially if there is a delay in the diagnosis or if it affects elderly patients, those on dialysis, or those with HIV infection or other states of immunosuppression, as well as in cases of multidrug resistant disease. Knowledge of the radiological presentation of the cases can help diagnose these severe forms, as can the introduction of new tests, such as the early detection of the etiological agent by PCR and chest CT, which favors the early initiation of treatment. In addition, the use of regimens without isoniazid and rifampin, as well as uncertain enteral absorption and low serum concentrations of antituberculosis drugs, can reduce the efficacy of treatment. For such patients, the prognosis is generally poor and mortality rates are high.Keywords: Tuberculosis; Respiratory insufficiency; Respiration, artificial; Hospitalization. ResumoA tuberculose é uma doença curável que pode evoluir para formas graves com necessidade de tratamento dos pacientes em UTI, especialmente se essa não for diagnosticada em tempo ou se afetar pacientes idosos, aqueles em diálise e aqueles com infecção pelo HIV ou outros estados de imunossupressão, assim como nos casos de doença multirresistente. O conhecimento da apresentação radiológica dos casos pode auxiliar no diagnóstico dessas formas graves, assim como a introdução de novos testes, como a detecção rápida do agente por PCR e a TC de tórax, favorecendo o início precoce do tratamento. Além disso, o uso de esquemas sem isoniazida e rifampicina, a absorção entérica incerta e as baixas concentrações séricas das drogas antituberculose podem contribuir para a diminuição da eficácia do tratamento. O prognóstico desses pacientes geralmente é ruim, com elevadas taxas de mortalidade.

Factors associated with mortality among patients with active pulmonary tuberculosis requiring intensive care

“…Although HIV infection itself is a risk factor for mortality in the ICU, (28) our study concurred with others (4,13,29) in finding that HIV infection was not an independent risk factor for mortality among patients with TB in the ICU. Some authors have postulated that the short duration before death was insufficient time for HIV itself to cause mortality in patients with TB requiring ICU care, and that when TB was very severe, HIV infection was not likely to influence patient outcome any further.…”

“…These were comparable to the mortality rates (range 47%-65.7%) reported from China, (9) Taiwan, (8) Korea (5) and Brazil. (13) Other centres have reported lower mortality rates in the range of 20%-30%. (3,4) A retrospective study by Erbes et al in Germany reported ICU mortality rates of 22.4% and in-hospital mortality of 25.9%, (4) which were significantly lower than the rates observed in our study.…”

“…(3,5) Although ICU scoring systems of APACHE and SOFA scores have been validated for use for predicting individual patient outcomes during ICU admissions, (26) both of these scoring systems have only been shown to be associated with mortality in patients with PTB requiring ICU care in a few studies, (6,14) with many others not reporting such an association. (4,5,13,15) APACHE II scores may severely underestimate the mortality risk of patients with TB who have septic shock. (27) In our study, the mean APACHE II score was 22.6 with predicted in-hospital mortality of 46% instead of the observed 62.7%.…”

“…(3)(4)(5)(6)(7)(8)(9)(10)(11)(12) Identified risk factors for mortality include acute respiratory distress syndrome, (4,5) need for mechanical ventilation, (4) HIV infection, (7) multiple organ failure, (3,5) consolidation on chest radiograph, (3,5) acute renal failure, (4) early ICU admission, (13) Acute Physiology and Chronic Health Evaluation (APACHE) II score, (6) Sequential Organ Failure Assessment (SOFA) score, (14) sepsis, (4,6) low albumin, (7) age (15) and nosocomial-or ventilator-associated pneumonia. (4,8,13) Besides these factors, treating PTB in the ICU is challenging because of poor absorption of antituberculous treatment among the critically ill and the paradoxical deterioration of TB during treatment. (12) The most common reasons for ICU admission were acute respiratory failure and multiorgan failure.…”

Caracterização de infecções pulmonares no pós-operatório tardio de transplante renal: uma revisão integrativa

“…Os pacientes com tuberculose internados em UTIs podem desenvolver outras complicações, tais como pneumonia associada à VM, falência de múltiplos órgãos, choque séptico, insuficiência renal aguda, coagulação intravascular disseminada e sangramento digestivo. A insuficiência respiratória aguda causada por tuberculose e com necessidade de VM tem sido associada com taxas de mortalidade, entre 17,5% e 81,0% (69) .…”