na revista THORAX desse mês...Survival of HIV-infected patients in the intensive care unit in the era of highly active antiretroviral therapy

Thorax 2007;62:964-968

Survival of HIV-infected patients in the intensive care unit in the era of highly active antiretroviral therapy
S J Dickson1, S Batson2, A J Copas3, S G Edwards4, M Singer2, R F Miller3

Background: Several studies have described improved outcomes for HIV-infected patients admitted to the intensive care unit (ICU) since the introduction of highly active antiretroviral therapy (HAART). A study was undertaken to examine the outcome from the ICU for HIV-infected patients and to identify prognostic factors.

Methods: A retrospective study of HIV-infected adults admitted to a university affiliated hospital ICU between January 1999 and December 2005 was performed. Information was collected on patient demographics, receipt of HAART (no patient began HAART on the ICU), reason for ICU admission and hospital course. Outcomes were survival to ICU discharge and to hospital discharge.

Results: 102 patients had 113 admissions to the ICU; HIV infection was newly diagnosed in 31 patients. Survival (first episode ICU discharge and hospital discharge) was 77% and 68%, respectively, compared with 74% and 65% for general medical patients. ICU and hospital survival was 78% and 67% in those receiving HAART, and 75% and 66% in those who were not. In univariate analysis, factors associated with survival were: haemoglobin (OR = 1.25, 95% CI 1.03 to 1.51, for an increase of 1 g/dl), CD4 count (OR = 1.59, 95% CI 0.98 to 2.58, for a 10-fold increase in cells/µl), APACHE II score (OR = 0.51, 95% CI 0.29 to 0.90, for a 10 unit increase) and mechanical ventilation (OR = 0.29, 95% CI 0.10 to 0.83).

Conclusions: The outcome for HIV-infected patients admitted to the ICU was good and was comparable to that in general medical patients. More than a quarter of patients had newly diagnosed HIV infection. Patients receiving HAART did not have a better outcome.

Clinical practice guidelines for support of the family in the patient-centered intensive care unit

Novas diretrizes da Society of critical care medicine aboradm uma questão fundamental , mas frequentemente subestimada: a familia dos pacientes críticos

clique no título desse post e abra o arquivo em pdf!



Clinical practice guidelines for support of the family in the patient-centered intensive care unit: 2004-2005
Crit Care Med 2007 Feb 35(2):605-622

RBTI no Scielo: Boa notícia para os intensivistas brasileiros

Amigos,

a revista brasileira de terapia intensiva foi indexada na base do SCIELO.
A sua inclusão na mais expressiva base de dados científicos latino-americana é prova de sua evolução qualitativa e também uma grande oportunidade (com maior visibilidade) para as publicações nacionais.

um portal prórpio está sendo construido em www.rbti.org.br

boas novas

visitem no link http://www.scielo.br/scielo.php?script=sci_serial&pid=0103-507X&nrm=iso&lng=en

Economic Implications of An Evidence-Based Sepsis Protocol

Mais uma idéia sobre o uso de protocolos em medicina intensiva.

Economic Implications of An Evidence-Based Sepsis Protocol: Can We Improve Outcomes and Lower Costs?

Shorr AF, Micek ST, Jackson WL, Kollef MH
Crit Care Med. 2007;35:1257-1262
Summary

Severe sepsis and septic shock together comprise a common and lethal disease, occurring in 10% to 25% of all patients in intensive care units, with approximate mortality rates of 40% and 60%, respectively.[1,2] With the recent development of various potential therapies for severe sepsis and septic shock (eg, early goal-directed therapy, recombinant human activated protein C, corticosteroids, glycemic control), a new era has emerged for managing these complex patients. Clinical care is moving toward evidence-based protocols that apply the evidence from these studies[1,2] to optimal patient management. Although prior studies have shown that these protocols, such as those advocated by the Surviving Sepsis Campaign,[3] have salutary effects on survival and organ dysfunction,[4,5] they have not been tested economically. The authors of this study sought to determine whether the application of a severe sepsis management protocol was cost-effective in their institution, a tertiary-care academic hospital. Data were collected before and after implementation of a severe sepsis protocol; outcomes were assessed and hospital costs were estimated. Survival increased after implementation of the protocol (from 52% to 70%) and hospital length of stay was reduced by an average of 5 days. Median total hospital costs per patient were less after the implementation of the sepsis protocol ($16,103 vs $21,985), and remained less even when considering only the survivors.
Viewpoint

This study provides an important piece of information for both physicians and institutions to determine how best to optimize the care of patients with severe sepsis. While the true costs of caring for patients with sepsis may vary across institutions, these data suggest that institutions may actually reduce expenditures while saving lives. Many physicians and institutions are already in the process of implementing protocols for the management of these patients, and with the data from this study, even more should be willing to do so. These data may be of most importance for indigent care hospitals where containment of costs is often paramount in order to ensure care for all. At this point, it seems prudent for each hospital to proactively consider how best to manage their sepsis patients, and to strongly consider both the healthcare and financial advantages of protocolized sepsis care.

Noninvasive Ventilation in Acute Respiratory Failure- Standard of care, mas para quem ?

Mais um artigo que reforça que temos grandes evidencias para uso mais disseminado em DPOC e IVE , mas que os critérios de seleção dos pacientes nas demais situações (ALI, pneumonia, imunocomprometidos, desmame...) é a chave do sucesso.

From Critical Care Medicine

Noninvasive Ventilation in Acute Respiratory Failure



Nicholas S. Hill, MD; John Brennan, MD; Erik Garpestad, MD; Stefano Nava, MD


Background: Noninvasive ventilation has assumed an important role in the management of respiratory failure in critical care units, but it must be used selectively depending on the patient's diagnosis and clinical characteristics.
Data: We review the strong evidence supporting the use of noninvasive ventilation for acute respiratory failure to prevent intubation in patients with chronic obstructive pulmonary disease exacerbations or acute cardiogenic pulmonary edema, and in immunocompromised patients, as well as to facilitate extubation in patients with chronic obstructive pulmonary disease who require initial intubation. Weaker evidence supports consideration of noninvasive ventilation for chronic obstructive pulmonary disease patients with postoperative or postextubation respiratory failure; patients with acute respiratory failure due to asthma exacerbations, pneumonia, acute lung injury, or acute respiratory distress syndrome; during bronchoscopy; or as a means of preoxygenation before intubation in critically ill patients with severe hypoxemia.
Conclusion: Noninvasive ventilation has assumed an important role in managing patients with acute respiratory failure. Patients should be monitored closely for signs of noninvasive ventilation failure and promptly intubated before a crisis develops. The application of noninvasive ventilation by a trained and experienced intensive care unit team, with careful patient selection, should optimize patient outcomes.

Livro artigos comentados

Terapia combinada reduz mortalidade em pneumonia adquirida na comunidade

Combination Antibiotic Therapy Improves Survival in Patients With Community-Acquired Pneumonia and Shock

Rodriquez A, Mendia A, Sirvent J-M, et al
Crit Care Med. 2007;35:1493-1498

Community-acquired pneumonia (CAP) remains one of the most common infectious diseases requiring hospitalization, and severe cases continue to carry a high mortality rate.[1] Early institution of antibiotics has been shown to improve survival in this condition[2] as well as in septic shock.[3] The authors of the current study sought to confirm the findings of previous studies[4-6] that suggested that additional (eg, "dual" or "combination") antibiotic coverage may also improve outcomes for patients with severe CAP. This study examined data from a prior observational cohort study of 529 critically ill patients with CAP in Spain. There was no difference in mortality rate between single and combination antibiotic therapy overall, but for patients with shock, combination therapy was associated with a survival advantage (hazard ratio [HR] 1.69 for single antibiotic therapy). Because it was possible that this finding was due to inappropriate antibiotic coverage for pneumonia pathogens, the authors repeated the analysis in patients with appropriate antibiotic therapy and found a persistent increase in mortality for patients treated with single antibiotic therapy (HR 1.64).