Adverse events associated with long-term ketamine use in pediatric septic shock

Objective: Ketamine hydrochloride is a noncompetitive antagonist of the NMDA receptors and produce a dissociative state described a “functional and neurophysiological dissociation between the neocortical and limbic systems” 1,2 . Methods: We describe long-term use of ketamine in pediatric intensive care unit (PICU) inducing pyramidal liberation in a septic shock patient. Case: A 15 months years old boy with congenital cardiopathy and developmental delay without previous chronic encephalopathy history. He was admitted with septic shock and during PICU stay received association of multiples analgesic-sedatives agents and high doses of ketamine IV infusion (table 1) Table 1Daily total doses of analgesic-sedatives agents

Introduction Septic patients frequently develop critical illness myopathies (CIMs) that may represent a crucial factor for prolonged intensive care unit treatment and for ventilator weaning delay. Experimental fi ndings have identifi ed that oxidative stress plays a role in causing muscle depletion in chronic pathological states like sepsis. It is well documented that regular moderate physical exercise can decreased oxidative stress and enhance antioxidant functions. Objective To investigate whether exercise training reduces oxidative damage in septic rats induced by cecal ligation and perforation (CLP). Methods Wistar rats were randomly assigned to three groups: Sham (submitted to a fake surgery), CLP, and CLP that was previously trained (CLPT). The exercise training protocol consisted of 8 weeks of running on a treadmill, 5 days/week, for 60 minutes at 60% of the maximal running speed obtained on the graded treadmill test. Rats were subjected to CLP surgery; after 120 hours of surgical procedure they were killed by decapitation. Oxidative damage of lipids (thiobarbituric acid reactive species (TBARS)) and proteins (carbonyl groups) were analyzed in Soleus (type I fi ber) and plantaris (type II fi ber) muscles. Results See Table 1.
Introduction Tissue hypoxia and infl ammation are the pillars of multiple organ dysfunction. Current therapeutic interventions aimed to improve systemic oxygen delivery are mediated by increases in cardiac output, but myocardium energetic demand increases in conditions of limited supply. Only scarce data are available on heart oxygen utilization during hypoxic injuries. Objective To understand the heart metabolism, challenged by diff erent tissue hypoxia models, by examining oxygen, lactate, and glucose in vascular compartments, including coronary sinus. Methods Thirty-seven pigs, fully monitored, were challenged with diff er ent injuries, including normovolemic anemia (n = 8), cardiac tamponade (n = 8), hypoxic hypoxia (n = 8), peritonitis-induced sepsis (n = 8) while fi ve served as controls. In addition to global hemodynamics and oxygen transport, we measured oxygen saturation, lactate and glucose concentrations in arterial, pulmonary artery and coronary sinus vascular compartments. Cardiac power output was calculated as a surrogate marker of cardiac demand. Results No signifi cant alterations were found in the energetic profi le in the stagnant group. There was both a decrease in lactate consumption and an increase in glucose consumption in anemia (ΔLAC changed from -0.7 to +0.5 mmol/l, P = 0.018; ΔGLU changed from -0.1 to -0.4 mmol/l, P = 0.118) and in hypoxic hypoxia (ΔLAC from -0.4 to -0.2 mmol/l, P = 0.361; ΔGLU from -0.25 to -0.5 mmol/l, P = 0.096) groups. In sepsis, we observed a progressive increase in glucose (ΔGLU from -0.1 to -0.25 mmol/l, P = 0.618) and lactate (ΔLAC from -0.26 to -0.53 mmol/l, P = 0.105) consumption by the heart. The highest lactate production was observed in late phases of anemia (+0.5 mmol/l) and the highest glucose consumption (-0.5 mmol/l) in late phases of hypoxic hypoxia. A similar and low CPO (between 3.31 and 4.4 W) was achieved in diff erent time points according to the hypoxia model, such as a FiO 2 about 10%, a Htc about 7%, a 30% reduction of cardiac output in tamponade, or 4 hours after fecal peritonitis induction, suggesting that the heart better tolerates hypoxia and anemia than sepsis and tamponade. See Figures 1 and 2 overleaf. Conclusion Energetic substrate selection seems to be an important adaptive mechanism in response to diff erent types of tissue oxygen delivery impairment, which may have implications on inotropic agent choice. Background Intensive care unit (ICU) admission of critically ill cancer patients was controversial until recently. In the last years, advances in the management of malignancies and organ failures have improved outcomes of patients, resulting in higher rates of survival in the ICU. The aim of this study is to prospectively evaluate the characteristics, short and midterm outcomes of cancer patients requiring intensive care. Methods During 2 years, we evaluated prospectively patients with cancer admitted to the Instituto do Cancer do Estado de São Paulo.
A total of 3,400 patients were included in the study; and collected data were baseline data, risk scores, clinical status, co-morbidities, admission diagnosis, ICU interventions, ICU and hospital outcomes and 90-day outcomes. Results From 3,400 patients, 52.8% had solid tumors and 47.2% had hematologic malignancies. The most frequent reasons for ICU admission were: sepsis (32%), postoperative care (27%) and respiratory failure (21%). The mean APACHE II score value 24 hours after admission was 23.1 ± 7.8 (8 to 45). ICU mortality was 22%, hospital mortality was 31% and 3-month mortality was 44%. Logistic regression analysis showed that need for mechanical ventilation (odds ratio = 7.76; 95% CI = 4.56 to 12.85), presence of metastasis (odds ratio = 2.87; 95% CI = 2.06 to 5.28), occurrence of acute renal failure (odds ratio = 2.92; 95% CI = 1.67 to 9.46) and higher SOFA scores 72 hours after admission (odds ratio = 6.76; 95% CI = 5.56 to 13.85) were independently associated with increased hospital mortality. The 3-month quality of life of patients who survived was considered unchanged in 51% patients, worse in 25% and better in 24%. Conclusion This prospective analysis of 3,400 patients with cancer needing intensive care shows high survival rates and good quality of life after ICU admission. These data encourage intensive care treatment in oncologic patients to prevent, detect and cure organ dysfunction.
The aim of this study was to determine if RBC transfusion after cardiac surgery results in improvement of tissue perfusion. Methods From February 2009 to February 2010, a total of 502 patients underwent cardiac surgery with cardiopulmonary bypass at InCor -University of São Paulo. Arterial lactate, standard base defi cit (SBD), arterial bicarbonate and oxygen central venous saturation (ScVO 2 ) were collected immediately at the beginning and end of the procedure, immediately postoperative (POI), after 24 hours (1PO), 48 hours (2PO), 72 hours (3PO) and at ICU discharge. Mean values of these abovementioned parameters were compared in patients exposed to RBC transfusions and patients not exposed through repeated-measures variance analysis.
Results Hemoglobin values were diff erent between groups since before surgery until just before ICU discharge and in all periods, the group not exposed to RBC transfusions presented higher values compared with the exposed group (see Figure 1 overleaf ). Conclusion In this prospective study, red blood transfusion did not result in improvement of tissue perfusion parameters. This fi nding brings to discussion the real role of blood transfusion in cardiac patients. Background Patients exposed to long-term infusion or high-dose of opioids may develop physiological dependence and withdrawal symptoms during discontinuation. In mechanically ventilated adult patients, the occurrence of fentanyl withdrawal syndrome has been associated with diffi culties in discontinuing ventilatory support and with increased length of stay (LOS). Objective We tested the hypothesis that replacement of fentanyl infusion by enteral methadone decreases weaning time from mechanical ventilation. Methods A prospective, randomized and double-blind study involving patients fulfi lling criteria to weaning from mechanical ventilation but under high risk for fentanyl abstinence syndrome (defi ned as continuous fentanyl for more than 5 days or more than 5 μg/kg/hour during 12 hours). Patients were randomized into two groups, methadone (MET) group and control (CT) group, as follows: at fi rst 24 hours both groups were given 80% of the original dose of fentanyl and received, additionally, in the MET group enteral methadone (10 mg each 6 hours) or enteral placebo in the CT group. After the fi rst 24 hours, the MET group received enteral methadone and intravenous placebo while the CT group received enteral placebo and intravenous fentanyl. In both groups, the blinded intravenous solutions were reduced by 20% of the original dose, every 24 hours. Any abstinence symptoms were treated with a bolus of fentanyl. A Kaplan-Meyer curve was constructed and the Student t test was used to compare groups in following criteria: (1) weaning time from MV, (2) days under MV and (3) ICU LOS. Results Of 75 randomized patients, seven were excluded and 68 were analyzed: 37 at MET and 31 in CT. Between the beginning of weaning and extubation, there was a greater probability of anticipation of extubation in the methadone group, but the diff erence was not signifi cant (hazard ratio = 1.44; 95% CI = 0.81 to 2.56; P = 0.21). The eff ects of treatment on weaning time were time dependent, and we observed that on the fi fth day the probability of successful weaning was 2.27 times greater in the MET (P vs. 13.28 ± 12.85 days, P < 0.004). There was no diff erence between the two groups with respect to the duration of mechanical ventilation and ICU LOS. Conclusion These data show that replacement of fentanyl infusion by enteral methadone reduces the weaning time from mechanical ventilation. Introduction Use of ultrasound introduced as part of intensive care therapy makes viable bedside invasive procedures and diagnosis. Due to portability, combined with team training, its use guarantees less complications related to insertion, as well as patients' safety. It also reduces severe conditions related to the catheter, such as pneumothorax among others. The aim of this study was to evaluate the accuracy related to ultrasound-guided venous catheter insertion in a low-cost famtoma among medical students of third-year graduation compared with experienced doctors and medical residents. We evaluated the success rate of insertion, the number of puncture attempts and the time related to the insertion of the needle from Figure 1 (abstract P6). Comparison between groups exposed or not to red blood cell transfusions considering hemoglobin (Hb) values and perfusion tissue parameters (lactate, oxygen venous central saturation, standard base excess and bicarbonate). *P <0.005.
contact with the surface of the phantom and its correct placement in the vein. Methods Study participants were 25 undergraduate students of medicine (third year) participating in the curriculum of emergency medicine and intensive care, nine medical residents (internal medicine) and nine critical care physicians. All participants had no previous experience with ultrasound-guided procedures, and medical students had no previous experience with central venous access puncture. There was a lecture prior to the study of 2 hours in ultrasound-guided venous cannulation. Evaluation of the average time between groups was performed by ANOVA using data processing in rank due to lack of homogeneity and the Tukey test for multiple comparisons. A possible relationship between the time needed until the puncture is performed and length of experience was assessed by Spearman correlation, due to lack of normality in the data. Results We found a success rate of 100% in the insertion of a catheter in phantom among all participants, a longer time in the group of graduate students (Table 1), as well as the number of punctures (mean of 2). Objective Ketamine hydrochloride is a noncompetitive antagonist of the NMDA receptors and produces a dissociative state described as a 'functional and neuro-physiological dissociation between the neocortical and limbic systems' [1,2]. Methods We describe long-term use of ketamine in the pediatric intensive care unit (PICU) inducing pyramidal liberation in a septic shock patient. Case A 15-month-old boy with congenital cardiopathy and developmental delay without previous chronic encephalopathy history. He was admitted with septic shock and during the PICU stay received association of multiple analgesic-sedative agents and high doses of ketamine intravenous infusion ( Figure 1). The patient presented after 10 days of PICU stay symptoms associated with pyramidal liberation: deep hyperrefl exia with sinrefl exia, Babinski sign on both sides, opisthotonus, trismus. The clinical signs were not associated with new metabolic or structural intracranial lesion. The patient was discharged from hospital after 36 days receiving pericyazine that was interrupted 1 week after hospital discharge. Conclusion The ketamine side eff ects after short-term use include [1,2]: hypertension, apnoea, laryngospasm, emergence phenomena, vomiting, nystagmus, ataxia, myoclonus, random limb movements, opistho tonus, transient facial rash or fl ushing, intracranial hypertension. The long-term-use side eff ects are unknown. This is the fi rst report of pyramidal liberation-associated intravenous ketamine for a prolonged period.

References
Introduction Sepsis is a frequent complication in patients with cancer associated with adverse outcomes. The aim of this study was to evaluate the clinical course and to identify independent predictors of mortality in these patients.

Methods
We performed a secondary analysis of a prospective cohort study conducted at an oncological medical-surgical ICU. Logistic regression was used to identify predictors of hospital mortality. Background Sepsis is an infl ammatory response secondary to an infectious process with presumed or known [1] focus that can lead to involvement of multiple organs and death. The incidence of severe sepsis and septic shock among patients admitted to intensive care units (ICUs) in Brazil was 36 and 30 per 1,000 patient-days, respectively [2]. ICUs in other countries reported an incidence of severe sepsis of 21  According to the results, we can observe that the better performance was seen in the emergency care units and intensive care. This does not exclude such units from a proposal for continuing education, since the primary concern relates to the retention of clinical symptoms.

References
Introduction Sepsis is an important cause of death at Diadema State Hospital, therefore a sepsis protocol was designed.
Objective To reduce sepsis prevalence, morbidity, the mortality rate and its high cost. Methods An audit was conducted in the period of April to September 2010 with data collected through hospital records. Results Sixty-three patients were enrolled. Analyzed was each item of the package of 6 hours according to the designed protocol, including total adherence to the package of 6 hours, mortality of eligible patients and mortality of patients who adhered to the package of 6 hours. Of 63 patients, 28 patients were discharged and 35 evolved to death, only one case not correlated with death from septic shock. Mortality due to sepsis at our service was 56%, which is consistent with the mortality rate in Brazil (57.3%, according to ILAS) and in public hospitals (63.9%).
Adherence to the package of 6 hours recommended by the SSC was only 21 of the 63 cases. Of these 21 cases, 11 patients survived and 10 died. Thirty cases of all had some compliance with the protocol of 6 hours, and of these 17 were discharged and 13 died. Disrupting the total mortality (35 cases, 56%), it was found that mortality among patients who adhered to the package of 6 hours was lower (48%) when compared with those who did not join (60%).

Conclusion
The results show a lower mortality rate in cases where there was total adherence to the package of interventions in the fi rst 6 hours, but we still have low level of adherence to this package (33%). The average length of stay decreased dramatically from 2008 to 2010 (73% vs. 62%) when we compared the patients who died with those who survived, which is still high but has fallen over time, surpassing the survival rates measured in other public hospitals in Brazil (data from ILAS). After these fi rst results, improvements were made to be implemented in 2011 such as review and redrafting of the protocol fl ow; training diff erent categories of professionals (technicians, nurses, physiotherapists, doctors, pharmacists); realignment with ILAS, including manager selection protocol with capacity-building and training for use of the international database for comparative analysis; review the recommendation of antimicrobials for the second focus of infection with sepsis; and regular monitoring of results, including average length of stay and mortality. The challenge now is to decrease deaths, aiming to achieve levels comparable with the best institutions in the world. In partnership with ILAS, the project SPDM against Sepsis, our team has strived to achieve this goal.
Introduction Sepsis is a worldwide disease with heterogeneous outcome. The main factors related to prognosis are age, associated comorbidities, invader virulence, and time to therapeutic initiation. Data related to social-economical attributes have been scarcely investigated.
Objective To evaluate the distribution of sepsis-associated deaths in São Paulo city using a geographic information system (GIS); to verify whether there is any correlation between socioeconomic status and number of deaths. Methods GIS is a system for input, storage, manipulation, and output of geographic information. GIS allows one to know the socioeconomic conditions of the region studied, including provision of health services, spatial data (rivers, parks, and so on), population data (age and sex), and estimated demand for health services. Thus, GIS could support health managers for planning, monitoring, priority setting and decision-making. Sepsis was identifi ed through death certifi cates using several International Disease Codes including, but not restricted to, sepsis, septicemia, pneumonia, urinary tract infection, wound surgical infection, bloodstream infection, meningitis, and multiple organ failure among others. Results Figure 1 (overleaf ) depicts every death according to the location of residence. Conclusion Death secondary to sepsis is widely distributed throughout the regions of São Paulo, and further analysis needs to be done in diff erent subgroups for better characterization and contrast of this syndrome in distinct regions and socioeconomic strata of the city.   Analyzing the HbA1c as a continuous variable, we found only a statistically signifi cant correlation with blood glucose levels at inclusion (P = 0.04), serum insulin at inclusion (P = 0.02) and insulin resistance at inclusion (P = 0.02). Studying the population characteristics, an association between HbA1c change and presence of comorbidities was observed (P = 0.004). Furthermore, patients with HbA1c changes were older (P = 0.02), had higher blood glucose at inclusion (P = 0.03) and higher lactate after 24 hours of inclusion (P = 0.03). See Figure 1. Conclusion In this sample of patients with sepsis without previous history of DM a high incidence of patients with diabetes and glucose intolerance undiagnosed was found. Therefore, HbA1c measurement in the ICU may be useful in the investigation of patients with hyperglycemia.  Methods We evaluated 1,129 patients with severe sepsis, septic shock, or postoperative after high-risk surgery. Lactate and SBD collected at admission and after 24 hours were compared between survivors and nonsurvivors. We evaluated whether arterial lactate and SBD are independent predictors of ICU and hospital mortality. Results There were 854 hospital survivors (76.5%). Twenty-four-hour lactate >1.9 mmol/l (OR = 4.02, CI = 2.7 to 5.97) and SBD <-2.3 (OR = 2.4, CI = 1.64 to 3.52) were independent predictors of ICU mortality. Twenty-four-hour lactate >1.9 mmol/l (HR = 2.63, CI = 1.99 to 3.47) and 24-hour SBD <-2.3 mmol/l (HR = 1.74, CI = 1.33 to 2.27) were independent predictors of hospital death. Conclusion Our fi ndings suggest that lactate and SBD measurement should be included in the routine assessment of patients with cancer admitted to the ICU. These markers may be useful in the adequate allocation of resources in this population.

P16
Introduction Sepsis is a systemic infl ammatory syndrome triggered by infection. It has been recognized that a dynamic interaction between proinfl ammatory and anti-infl ammatory response is present in this syndrome, which is balanced by as yet unknown mechanisms. We and others showed that infl ammatory cytokines are upregulated in the early phase and downregulated in the late phases of sepsis, while antiinfl ammatory cytokines are preserved. However, there are few data about the dynamics of these cytokines during follow-up of patients and their relation with clinical outcome. The aim of this study was to evaluate the plasma levels of a proinfl ammatory, IL-6, and an antiinfl ammatory, IL-10, cytokine in septic patients. Methods This prospective study included 53 septic patients (SP) and 29 healthy volunteers (HV) as a control group. Patients were admitted to the intensive care units of São Paulo, Sirio-Libanes and Israelita Albert Einstein hospitals. Samples were collected during the fi rst 48 hours of organ dysfunction or sepsis (D0). A second sample was collected after 7 days from 35 SP (D7). The plasma levels of cytokines were measured using the cytometric bead array method (limit detection 2.0 pg/ml) by fl ow cytometry. Results IL-6 and IL-10 plasma levels were higher in SP (median 170.8 pg/ ml, range 3.53 to 16,028.52 pg/ml; and median 6.6 pg/ml, range 0.0 to 1,698.92 pg/ml, respectively) than HV (median 2.3 pg/ml, range 0.0 to 19.92 pg/ml for IL-6; and median 2.4 pg/ml, range 0.0 to 12.7 pg/ml for IL-10) (P = 0.0001 and P = 0.007, respectively). Plasma levels of IL-6 and IL-10 at D7 were not signifi cant diff erent from those at D0 (P = 0.85 and P = 0.59, respectively). IL-6 and IL-10 admission plasma levels were higher in nonsurvivors (median 284.76 pg/ml, range 9.16 to 16,028.52 pg/ml; and median 17.6 pg/ml, range 0.0 to 1,698.92 pg/ml, respectively) than in survivors (median 103.57, range 3.53 to 9,745.43 pg/ml; and median 9.91 pg/ml, range 0.0 to 313 pg/ml; P = 0.02 and P = 0.003, respectively). Conclusion Our results show that both proinfl ammatory and antiinfl ammatory cytokines are detected during sepsis and a higher level of both cytokines at admission is associated with worst outcomes. Patients who died or were discharged within 24 hours after admission, with previous hematological disease and those whose data were incomplete were excluded from the study. We compared the eosinophil cell count (hematology analyzer ABX Pentra DF 120; Horiba Medical, Montpellier, France) on the day of admission to the ICU between the non-infected group (negative and SIRS) and the infected group (sepsis, severe sepsis and septic shock). The normality of the distribution was tested by the Kolmogorov-Smirnov test and the comparisons were made utilizing the Mann-Whitney test. Statistical analyses were done utilizing SPSS 19 version. Results Three hundred patients were admitted to the ICU in the period, mean age 58.6 ± 20 years. The mean length of stay was 9.2 ± 15.7 days, the mean APACHE II score was 9.4 ± 6.5. Eighteen patients were excluded (one because of discharge within 24 hours; 11 patients because of previous hematological disease; six because of incomplete data). The remaining 282 patients were enrolled into the study, classifi ed as follows: negative (158 patients -56%), SIRS (25 -8.8%), sepsis (44 -15.6%), severe sepsis (23 -8.2%) and septic shock (32 -11.4%). At the time of admission, 99 (35.1%) patients had an infection. The mean ± SD eosinophil count was 167.6 ± 131.5, 153.6 ± 129 and 153.7 ± 135.6 cells/mm 3 in the total, non-infected and infected groups, respectively (P = 0.46; Figure 1). At a cut-off value of 100 cells/mm 3 , the eosinophil count yielded a sensitivity of 35%, a specifi city of 71%, a PPV of 40% and a NPV of 66%.

Relevance of eosinopenia as an early sepsis marker
Conclusion Eosinopenia was not a good early diagnostic marker for sepsis in this population.  upregulation and downregulation of cellular activity is observed, depending on the cells and functions evaluated. Nevertheless, the interaction of innate and adaptative immune responses has been little studied in clinical sepsis.
Objective The aims of this study were to evaluate the presence of TCD4 lymphocytes Th1, Th17, regulatory (Treg) and alternatively activated monocytes in septic patients and their association with prognosis. Methods Septic patients were enrolled at admission (D0, n = 67) and after 7 days of therapy (D7, n = 33). Thirty-two healthy volunteers matched for age and gender were included as controls. PBMC were obtained by the Ficoll gradient method. Th1 and Th17 lymphocytes were identifi ed by the intracellular detection of IFNγ and IL-17, respectively, and Treg cells were identifi ed by Foxp3 + CD127or CD25 + CD127expression. Monocytes were evaluated for CD206 and CD163 expression.
Results Spontaneous production of IFNγ and IL-17A was increased in TCD4 cells of septic patients when compared with healthy volunteers. After PMA/Io stimulation, the percentage of TCD4 lymphocytes producing IFNγ was lower and IL-17 was higher in septic patients than in healthy volunteers. The results based on absolute TCD4 + lymphocyte counting showed a lower proportion of Th1 cells and double the proportion of Th17 cells in septic patients compared with healthy volunteers while the proportion of Treg remained unchanged. In follow-up samples, a higher percentage of IFNγ and a lower percentage of IL-17 producing cells were observed compared with D0 samples. A higher percentage of spontaneously producing IFNγ was found in D7 compared with D0 samples from patients who died and a decreased percentage of PMA/Io-induced IL-17 producing cells between patients' samples of follow-up (D7) compared with admission samples was found in survivors. Septic patients showed a markedly increased proportion of alternatively activated monocytes, which was sustained in both patients' samples. Conclusion Sepsis remains an important health problem in children in Brazil. The institution of universal primary care programs has been associated with substantially reduced sepsis incidence and therefore deaths; however, hospital mortality rates in children with sepsis remain unchanged. Implementation of additional health initiatives to reduce sepsis mortality in hospitalized patients could have great impact on childhood mortality rates in Brazil. Introduction Sepsis is considered one of the most challenging diseases of all time [1]. During many years the concept of sepsis was not the same inside the medical court, which resulted in a heterogeneous population [2]. Its incidence has been growing dramatically over the past decades, having advanced age of patients, increase of invasive procedures, frequent use of immunosuppressive drugs and the increase of infections caused by multiresistant bacteria as the main contributors [3]. Nurses have an important role in early recognition of sepsis.

Role of nurses in the early recognition of sepsis
Objective We investigated whether nurses are able to early recognize signals and symptoms of sepsis. Objective To evaluate maximum inspiratory pressure and the prevalence of respiratory muscle weakness in hospitalized patients with acute heart failure. Methods A cohort study, performed at Hospital Israelita Albert Einstein in acute heart failure patients admitted to our hospital. We excluded patients with chronic pulmonary disease, neurological and neuromuscular disorders, postoperative period and those that needed an orotracheal tube. Patients after respiratory and hemodynamic stability were submitted to a maximum inspiratory pressure (MIP) measurement by a manuvacuometer. Measurement was performed using a facial mask and unidirectional valve with the patient positioned at 45°. We also collected demographic data, brain natriuretic peptide hormone (BNP), ejection fraction estimated by echocardiogram and use of non-invasive ventilation. MIP was measured at two moments, the fi rst measurement as soon as patients were clinically stable and the second measurement before hospital discharge. Introduction Altered pharmacokinetics in patients with major burns may result in anti-infective plasma concentrations below those required to be eff ective against the common pathogens encountered in burn patients. Altered fl uid volumes and increased renal blood fl ow in these patients are the main factors responsible for pharmacokinetic Objective Anti-infective plasma measurements in one burn patient with sepsis to determine whether drug effi cacy was achieved, thereby improving the likelihood of infection control. Methods A male burn child, 8 years old, 40 kg with severe thermal plus inhalation injuries (petrol), 45% total burn surface area, was investigated. He has received six anti-infective agents during the 88-day period in the ICU. Drug plasma monitoring, pharmacokinetics and the PK-PD correlation were done by blood sample collection, and drug plasma measurements were performed by high-performance liquid chromatography.

Results
Results Since in burns pharmacokinetics is unpredictable for all agents investigated, drug effi cacy was based on PK-PD correlation ( Table 1). Dose adjustment was performed for vancomycin (from 0.5 g 6-hourly to 1 g 8-hourly), meropenem (from 0.75 to 1 g 8-hourly) and linezolid (from 0.3 to 0.6 g 12-hourly).
Conclusion PK-PD correlation was applied to investigate changes on dose regimen to reach the effi cacy for all anti-infective agents. Dose adjustments were required only for vancomycin, linezolid, and meropenem to guarantee drug effi cacy. Acknowledgements The authors are grateful to the Brazilian Foundation CAPES, CNPq and FAPESP for fi nancial support. Background Among the measures for preventing ventilator-associated pneumonia (VAP) in patients at risk, strict control of the bed head above 30° stands as the single one with better cost benefi t [1]. While the semi-recumbent position is intended to be an inexpensive and easily performed action by the intensive care unit team, the smart beds currently available are not the reality for the vast majority of hospitals around the world because of the high cost. Therefore, the simple theoretical principles for its execution are contradicted by its diffi cult practical application.
Objective We propose a new methodology for continuous control of the bed head, thus making possible the appropriate compliance to the semi-recumbent position, seeking a reduction in the VAP rates. Methods A retrospective observational study with 41 mechanically ventilated patients over a 7-month period starting in May 2010, in a neurointensive critical care unit of a private tertiary hospital. There was a historical control as reference during 3 months before the intervention made in August, and measurements for the same time after it as a means to confi rm its appropriate implementation, based on the National Nosocomial Infections Surveillance System (NNISS) as a parameter. Applied was a technique for an hourly basis positioning of the head of bed angle in such a manner that it never remained below 30º for over 1 hour in the 24 hours daily. It was turned into a mandatory item in the prescription and its execution was performed by the nursing staff , through reading of a specifi c angulation marking adhesive in the side head rail, and annotation in the usual sheet for recording the vital signs, followed by the prompt adjustment to the right position. Other items of the institutional bundle of VAP were not modifi ed. Results There was a trend towards reduction in the ventilatorassociated respiratory infection rate ( Figure 1) after the implementation of the methodology, bringing it to zero despite the elevation in device utilization ( Figure 2). Conclusion This unsophisticated and low-cost method for controlling heads of beds in an intensive care unit allowed its adequate employment, thus seeming to cause an impact in the incidence of VAP when comparing respiratory infection rate and device utilization, despite limitations about the small case series and the short following period. Reference

Nephrology
Introduction Renal replacement therapy is frequently required in critically ill patients with acute kidney injury. With intermittent hemodialysis, large volumes of fl uid need to be removed over a relatively short period of time, jeopardizing hemodynamic stability in already hemodynamically compromised patients. Established methods of dry weight estimation are not practical in critical care and the estimation of excess body fl uid removable by hemodialysis constitutes a particular change in these patients. Dynamic parameters of fl uid responsiveness are increasingly being used to guide fl uid therapy in critical care, but their suitability to monitor fl uid removal with hemodialysis is not known.
Objective The aim of our study was to analyze changes in a dynamic parameter of fl uid responsiveness (pulse pressure variation) in critically ill patients submitted to intermittent hemodialysis. Methods Changes in pulse pressure variation, central venous pressure, median arterial pressure, and cardiac index were analyzed every hour over intermittent hemodynamics using a minimally hemodynamic monitoring device (LIDCO plus) in 28 mechanically ventilated patients. Additional measurements of lactate and central venous saturation were measured at the same time.
Results Median dialysis duration was 4.5 hours, and a median of 2,900 ml fl uid was removed. There were 102 hypotensive episodes. The median arterial blood pressure was 72 mmHg. Median CVP was 16 ± 6 and pulse pressure variation was 9 ± 6 just before hemodialysis. There was a signifi cant increase in the pulse pressure variation over the dialysis treatment (15 ± 4) and a decrease in the CVP value (13 ± 6).
Comparing the group of patients already fl uid responsive (ΔPp >13%) just before the start of hemodialysis with the group nonfl uid reponsive (ΔPp <13%), the median values of lactate (2.1 x 1.9, P = 0.78) and central venous saturation (0.74 x 0.72, P = 0.94) were not signifi cantly diff erent, but at the end of the procedure a signifi cant diff erence in lactate was observed (4.2 x 2.5, P <0.2). Conclusion In our study the rate of ultrafi ltration during hemodialysis was refl ected by the changes in the pulse pressure variation. In patients already fl uid responsive (ΔPp >13%) just before hemodialysis, the impact of fl uid removal at the end of the procedure in perfusion parameters was signifi cantly higher. Dynamic parameters of volemia could be useful to guide fl uid removal and avoid hypoperfusion in acute renal failure patients mechanically ventilated during hemodialysis treatment.    relationships between Hgb and serum levels of sFas, Epo, TNFα, IL-6, IL-10 and iron status.
In multivariate analysis, after adjusting for markers of iron store and infl ammation, levels of IL-6 (P <0.001), sFas (P <0.001) and TNFα (P = 0.01) correlated negatively with Hgb in critically ill patients. Conclusion Our fi ndings demonstrate that sFas is associated with anemia in ARF and critically ill patients. Serum sFas and Epo levels were higher and Hgb levels were lower in critically ill patients with ARF, suggesting that sFas may be associated with Epo hyporesponsiveness in ARF and critical illness. There was no diff erence in mortality of older and nonolder patients (P = 0.16), in the days of mechanical ventilation (P = 0.22) and days of weaning (P = 0.55). In older patients, the IWI was the only variable associated with respiratory weaning in this population (P <0.0001). See Tables 1 to 5.     CI, confi dence interval: lower limit (%) to upper limit (%).

Conclusion
The IWI was the main independent variable in weaning of the older patient population, and it can contribute to this critical moment. and asked the patients to give a note from 0 to 10 on a visual comfort scale. Then, we changed the patients to PAV-plus ventilation with 65% support and after 20 minutes we measured the same mentioned parameters plus the respiratory system compliance, resistance and the patients work of breathing. The same procedure was made after changing the patients to PAV-plus ventilation of 50% support. We established the association between the estimated work of breathing by the ventilator and the measured respiratory parameters (P <0.05).

NS
Conclusion ICU patients recovering from acute respiratory failure could be maintained comfortably in PAV-plus ventilation of 65% and 50% compared with PSV of 15 cmH 2 O and their estimated work of breathing correlated negatively with patient's compliance and positively with patient's resistance. Data are mean ± SD.

Results
The variability indices for all variables analyzed during the 10-minute ventilation are shown in Table 1.
Conclusion The authors conclude that the use of a T-piece device allows lower variability during manual ventilation, with the exception of respiratory rate and expiratory time. We speculate that this lower variability could result in lower lung injury during manual ventilation.       Introduction Many interventions are known to decrease the incidence of ventilator-associated pneumonia, which has great impact on mortality, length of stay and costs in intensive care units. One of them is the aspiration of the secretions that pool above the cuff of the endotracheal tube [1]. It is a simple device but its use is not free from complications [2], being, most of them, bleedings and obstructions due to lesions of tracheal mucosa. The maintenance of a constant suction, without wide pressure variation, is an important point to minimize these complications. The common manometers do not have enough precision to set an adequate aspiration pressure, because of its broad scale, and are not able to avoid or to limit pressure variations in case of partial occlusions, by secretion, for example, facilitating lesions occurrence. Pressure transmitting devices (Figure 1), usually used for continuous aspiration of pleural drainage, have those helpful characteristics. It can be set in an adequate aspiration pressure (20 mmHg ~ 27 cmH 2 O) by setting the water column height. It avoids suction pressure variations since the air bubbles up on the water, balancing pressure inside the system.

Mechanical ventilation profi le in an adult ICU in Brazil
Methods Pressure transmitting devices were tested in 12 patients with subglottic aspiration on their orotracheal tubes. They were watched for complications and the fi ndings are reported. The aspiration pressure used was set at 20 cmH 2 O. Results The proposed system was used for periods that lasted from 3 to 14 days in each patient. It was able to remove the subglottic secretions in all tested cases. There were two episodes of system obstruction due to thick secretions, one of them was a blood clot (the patient had an abundant oral bleeding), easily treated with gentle suction using a 5-ml syringe. There was one case of obstruction resolved with air injection through the subglottic suction lumen. There was no bleeding related to subglottic suction. There was no ventilator-associated pneumonia. Conclusion In those reported cases, the subglottic suction system using a pressure transmitting device seemed to be eff ective, without serious complications. This study of cases is not able to affi rm these conclusions. It is just an initial test of a new method. For better evidence, this system has to be compared with other devices, like manometers, that are usually used for aspiration pressure control.
Introduction Acute respiratory distress syndrome is characterized by acute-onset, refractory hypoxemia, bilateral infi ltrates on chest radiographs and PAOP <18 mmHg or absence of clinical signs of left atrial hypertension. The protective ventilatory strategy limiting plateau pressure to lower than 28 cmH 2 O, driving pressure below 15 cmH 2 O and tidal volume between 4 and 6 ml/kg using a PEEP level to sustain the open lung approach usually results in hypercapnia. However, it is the mainstream supportive therapy that can modulate survival in this syndrome.
Methods We describe a case report where a 31-year-old woman who was admitted to the intensive care unit with fatigue, shortness of breath and hypoxemia. She was 24 weeks pregnant and acute myeloid leukemia, subtype M3 was diagnosed 5 days before admission. Noninvasive ventilatory support, chemotherapy (doxirubicin and all-trans retinoic acid) and blood components (red blood cells, fresh frozen plasma, cryoprecipitate and platelets) were implemented. After 4 days the clinical scenario was out of control and she was intubated. Renal function deteriorated and hemodialysis was required. Results Controlled mechanical ventilation using neuromuscular blocking (NMB) agents was set to limit plateau pressure, driving pressure, tidal volume and high level of PEEP (15 cmH 2 O). However, oxygenation progressively deteriorated despite the instituted therapy and on the eighth day on mechanical ventilation the intraabdominal pressure (IAP) was 20 mmHg, the driving pressure was 20 cmH 2 O and Vt was 5 ml/kg, which resulted in PaO 2 /FiO 2 of 90, pH 7.15, PaCO 2 of 115 mmHg. Interventional lung assist (iLA; Novalung, GmbH, Talheim, Germany), a pumpless arterio-venous extracorporeal membrane for CO 2 removal, was connected without systemic anticoagulation. After 20 minutes using iLA with 9 l/minute O 2 , a PEEP level of 20 cmH 2 O, Vt of 4 ml/kg, driving pressure of 20 cmH 2 O, I:E of 1:1 resulted in a PaO 2 / FiO 2 of 175, PaCO 2 of 57 mmHg and pH 7.35. Hemodynamics were stable and vasopressor agents were not needed. The blood fl ow in the circuit was 1.4 l/minute. After 14 hours on iLA the NMB agent was interrupted and assisted ventilatory support with Bivent + PSV (Servo i Maquet, Solna, Sweden) was started, sustaining a driving pressure of 15 cmH 2 O. After 48 hours on iLA the baby was born naturally and the IAP decreased to 7 mmHg. Respiratory system mechanics and the PaO 2 / FiO 2 ratio improved: 56% and 64%, respectively. CPAP + PSV was started on day 8 after iLA implementation and it was surgically removed on the day after when the PaCO 2 was sustained below 40 mmHg. Conclusion We present the fi rst case so far where iLA was safely used during 9 days in a pregnant woman with severe ARDS and multiple organ dysfunction syndrome under continuous hemodialytic support that allowed us to set a protective ventilatory strategy using an assisted ventilation mode.     Figure 1.
Conclusion Implementation of a daily bundle with SBTs is associated with reduction of mechanical ventilation time, and it is the determinant factor to have lower indexes of VAP.

Introduction
The use of lung ultrasound in the detection of pneumothorax is becoming routine in emergency departments and intensive care units in the United States and Europe [1]. The interposition of the visceral and parietal pleura (pleural-lung interface) produces pulmonary artifacts easily visualized by ultrasound and described initially by Lichtenstein and Meziere [2]. In evaluating the lung for pneumothorax, the most important fi nding is the presence or absence of lung sliding. The presence of pleural sliding essentially rules out a pneumothorax in the analyzed region and the absence of lung sliding indicates a high suspicion of disease. Organizations such as the American College of Emergency Physicians (ACEP) have demonstrated the short learning curve and prompt application to clinical practice of this use of lung ultrasound. There is already evidence, both in Brazil and beyond, that knowledge retention based on an educational model using computer simulation would be particularly useful in training Brazilian physicians in lung ultrasound if it was proven to be eff ective.
Objective To evaluate the sensitivity and specifi city of diagnosis of medical students compared with emergency physicians (experts) in identifying pneumothorax by lung ultrasound. Methods Students of 3 years of medical graduation participating in the module Radiology Emergency Medicine (n = 40) and emergency physicians (n = 11) with training in emergency medicine and intensive care, called experts, were invited to participate. The study subjects were assessed for the correct diagnosis of 20 cases of pneumothorax after training through classroom teaching of lung ultrasound lasting 2 hours addressing the recognition of artifacts in the lung and identifi cation of pneumothorax Lung Sliding Lines B. Prior to training, medical students and emergency physicians had no prior knowledge or practice in emergency ultrasonography. We used video-clips of 10 positive and 10 negative real cases of pneumothorax obtained by an experienced examiner in lung ultrasound. The comparison between the two groups was described by the mean and standard deviation of hits in each group and tested by the nonparametric Mann-Whitney test. The agreement between raters overall and in each group was estimated by the kappa correlation coeffi cient. The diff erence between the agreement observers in each group was tested by Z test for proportions. Results Students and experts did not have statistically diff erent test scores as shown in Table 1. There was a high degree of agreement between raters both overall and in each isolated group. Conclusion Medical students and medical experts are able to accurately identify pneumothorax, despite an abbreviated training time with no previous knowledge of ultrasound lung. Therefore the use of a simulation model based on lung ultrasound videos can be implemented in a systematic way to help health professionals and medical students in their training.
Introduction Mental healthcare in hospital wards for critical patients is necessary both for individuals with psychological or psychiatric disorders that require intensive medical care and for those individuals who develop these disorders during hospitalization, often in the same function, illness or treatment. These disorders may cause negative impact on adherence to clinical care, well-being, psychosocial rehabilitation and patient safety during hospitalization. In our department there is a psychologist working in conjunction as part of the healthcare team, aiming to identify psychological risk factors that may impact on treatment and help the team in handling diffi cult situations psychologically. To identify patients with psychiatric risk, we developed a protocol for Psychiatric Risk Assessment, whereby the presence of 11 items identifi ed by the nurse initiates the discussion of a case with a psychiatrist at the Center for Psychosomatic Medicine of Hospital Israelita Albert Einstein, which directs care and/or suggests mental health interventions. Driving this protocol is the need to ask the nurse to discuss with the mental health professional based on the identifi cation and recovery of behavioral changes that may be missed and/or be identifi ed only when there is already an exacerbation of psychiatric conditions or occurrences related to them. Aiming to assist the nursing staff on early identifi cation of these risks and organize actions during the stay in the ward and at discharge, a multidisciplinary meeting weekly was implemented to discuss cases and situations related to them. Methods Implementation of a multidisciplinary meeting consisting of nurses, psychologists, psychiatrists, medical and nursing coordinators in November 2010. Conducting a weekly meeting with the purpose of discussing situations related to behavioral changes in patients hospitalized in the unit, planning, multidisciplinary care and management of cases. After the meeting, the nurse forwarded to the treatment team a summary that included a description of what qualifi es as a psychological or psychiatric risk factor for each case, the guidelines for the team for management of the situation and suggestions for the doctor when involving medical management. Results There were 68 psychiatric risks in the semi-intensive unit in the second half of 2010. Of these, 31 cases were reported in December, the month following the beginning of the multidisciplinary meeting. Whereas 12 cases were reported in October and 12 cases in November, there was an increase of 158% in the number of cases reported in December. Regarding reports of psychological risk, we observed that the multidisciplinary meeting to discuss the risks promotes to the nurse the understanding of all aspects involved, allowing the discrimination of the psychological aspects and relevance to specialist interventions as well as instrumentalizing the team to handle the patient and family. Discussion The discussion of disciplinary cases seems to have enabled an understanding, appreciation and discrimination of which behaviors observed by the nurse should be accompanied by the psychology team as the protocol of psychiatric risk. The discussion of mental health with professionals may have aff orded the team a better idea of how these professionals can help provide routine care, promoting the early identifi cation of psychological and psychiatric risks. Other studies should be performed to confi rm the eff ectiveness of this intervention. Conclusion A multidisciplinary meeting was eff ective to assist the team in early detection and recovery of his observations of psychiatric disorders in hospitalized patients in a semi-intensive unit.

P48
Tissue plasminogen activator-treated patients with acute ischemic stroke in the pioneer public service of Rio

Conclusions
The study reported an early presentation of AIS, which may be associated with diffi cult access to primary care in this city. The entry NIHSS was similar in both studies. In the NINDS, 50% of the patients received t-PA within 1.5 hours, and only 16% in the HMSA at this time.
Pre-hospital quick reference and rapid diagnosis in the emergency room could diminish the Dt. Symptomatic hemorrhage (13% HMSA) was similar if we take into account only deaths from the use of t-PA therapy. Finally, we demonstrated benefi ts with t-PA treatment in AIS in Rio de Janeiro and recognized limitations that, when overcome, will allow improving the treatment of such severe disorder.
variables were reported as the mean and standard deviation. Interobserver agreement was assessed using Cohen's kappa statistic (κ). All statistics and their 95% confi dence intervals were computed using SPSS software and Medcalc software.

Results
In the period of 39 days, 106 patients were screened, and 42 patients fulfi lled inclusion criteria and were enrolled in the study. The incidence of delirium was 21.4% (nine patients). The average time to development of delirium was 62.67 hours (± 33.76), and 88.9% of patients developed delirium in the fi rst 5 days in the ICU. The agreement of clinical diagnoses in relation to the CAM-ICU method was moderate, with the best agreement assigned to nurses. A trend for increased length of ICU and hospital stay was found between patients who developed delirium. The average time in the ICU for patients with delirium was 12.11 days (± 15.44) and patients without delirium was 5.75 days (± 7.13), P = 0.0821. The average time of hospitalization for patients with delirium was 29 days (± 28.99) and without delirium was 21.69 days (± 22.83), P = 0.428. See Table 1.

Introduction
The present study aimed to analyze the adverse eff ects of the therapy using the passive bicycle in the intensive care unit (ICU). Methods This was a longitudinal, experimental, non-randomized controlled trial study. Performed with patients hospitalized in the ICU from Vita Curitiba and Batel Hospitals, and the Institute of Neurology from Curitiba, between 10 March and 30 June 2010. The total sample was 41 patients, with a total of 215 events, of both genders, being 23 men and 18 women, with an average age of 64 years, Glasgow average 11 ± 3 and APACHE II average score was 19 ± 6. Of the total sample, only two patients were evaluated according to the Ramsay scale, with an average of 4 ± 0.7. The passive bicycle activity was performed while the patient was in a bed or chair. The hemodynamic variables (heart rate, respiratory rate, mean arterial pressure and oxygen saturation) were collected at the beginning (before start of activity), 3 minutes after the start, and at the very end of the activity, and there was no preestablished activity time. The adverse eff ects accidental extubation; monitoring loss, like electrode, pulse oximetry and non-invasive blood pressure measures; change of balance, as lack of trunk control; fall; probe removal (nasogastric, nasoenteral and/or bladder); peripheral venous/arterial access were observed during the whole therapy time. The passive bicycle activity was performed 113 times in a chair (53%), and 102 times in bed (47%), having an average of 7.8 ± 2.29 minutes.
Results For the 215 events, were observed seven monitoring loss (3.27%) and one for skin lesion (0.467%), and there was no statistic signifi cant from the proportion test. The adverse eff ects fall, probe removal, change of balance and extubation did not occur during the activity application. For the hemodynamic variables, using the Student t test (P <0.05), mean arterial pressure, heart rate and respiratory rate, did not have signifi cant change, without any hemodynamic instability during the activity (see Figure 1).

Conclusion
The results show that using the passive bicycle in the ICU as a physiotherapy feature is secure and has a low risk of adverse eff ects related to ICU conduct. Introduction There are classical predictors of death after ICU discharge, such as age, severity of disease and level of nursing care. CRP concentrations at discharge have also been reported as a predictor of in-hospital outcome, but with controversial results. Considering that albumin is a negative acute-phase protein and its decrease may be an indicator of disease severity, we hypothesized that the CRP/albumin ratio could be a marker of unfavorable outcomes in the post-ICU period.
Objective This study aimed to investigate whether the CRP/albumin ratio at ICU discharge may be a predictor of post-ICU death. We also evaluated which is the best cut-off value of the CRP/albumin ratio to predict mortality. Methods Patients discharged from the ICU after at least 72 hours of stay were retrieved from our prospective collected database. A multivariate analysis was performed using a backward-LR binary logistic model taking in-hospital death as a dependent variable and age, APACHE II at admission, comorbidities, ICU length of stay (LOS), support during ICU, SOFA at ICU discharge, admission characteristics and CRP/albumin ratio as independent variables. ROC curves and the Youden index were used to calculate the best cut-off value of the CRP/albumin ratio.

Results
We retrieved 548 patients. Mean age was 49 ± 19 years, median APACHE II score at admission was 16 (10 to 21) and median SOFA score at discharge was 2 (1 to 3). The main causes of admission were septic syndromes and respiratory failure. The in-hospital mortality after ICU discharge was 18.6%. The ICU length of stay was 7 (4 to 11) days. At the moment of ICU discharge the median CRP was 47 (22 to 109) mg/l, albumin 27 (23 to 31) g/l and the mean of CRP/albumin ratio was 3. The multivariate analysis resulted in the following independent in-hospital death predictors: age (OR = 1.028, 95% CI = 1.014 to 1.043, P <0.001).
Conclusion We demonstrated that the CRP/albumin ratio, a possible marker of residual infl ammation, in addition to classical variables, could be a useful and objective tool to support the clinical judgment on the ICU discharge decision process. The best value of the CRP/albumin ratio to predict death after ICU discharge is 2. Further prospective investigations are necessary to confi rm these fi ndings. Reference

Introduction
The increasing costs of treatment in intensive care units (ICUs) and the need to use resources effi ciently require adequacy between nursing staff and nursing workload, as a high cost is attributed to the nurse staff of ICUs. The intensity of the nursing work eff ort should be considered because staffi ng needs vary according to the amount of patients being cared for, as well as the type of care provided for each of those patients. As the intensity of the nursing work eff ort increases, the amount of nursing staff required to properly care for patients also increases.
Objective To analyze the adequacy of nursing staff according to NAS, and compare the time of care according to NAS and time of care according to Nurse Call. Methods An exploratory, descriptive prospective study was performed in an adult 32-bed ICU of a private general hospital in São Paulo, Brazil. In our study we included 18 beds for which the Nurse Call System by Austco was available. The Nurse Call System by Austco enables nurses to provide prompt and eff ective responses to patients' calls at all times. For the analysis of the adequacy of the nursing staff , the mean NAS expressed as percentage time was initially converted into hours considering a 6-hour shift (6 hours equivalent to an NAS of 100%). Results Follow-up of 1,710 patients who were admitted to the ICU between July and December 2009 resulted in 4,592 NAS assessments. Analysis of the nursing workload showed a mean NAS of 90.1 ± 4.4% (ranging between 82.9 and 93.7%). The number of patients ranged from 26.5 to 34.7 in the ICU. The ICU occupation rate fl uctuated between 82.8 and 113.9%, during the study, suggesting that managing of the unit was suboptimal. The hours available for nursing care in the 6-hour shift remained constant throughout the studied period and represented a total of 156 hours per shift-day. This number was the same for the entire study period, as the number professionals was fi xed. According to the NAS, during half of the studied period (July to September) there was a need for an increased number of nursing professionals, as there was an average defi cit of 30 hours (range 4.4 and 48.9 hours). In the second half of the study (October to December) the number of nurses available exceeded that considered necessary by NAS. This surplus was of 14.2 hours on average (range 9.0 and 22.5). The time required for nurse care per patient per day was very similar between the two assessment tools (NAS and Nurse Call). While for NAS the mean time required by patient was 5.4 hours per day (ranging between 5.0 and 5.6), for the Nurse Call this time was 5.3 hours per day (ranging between 4.9 and 5.5). Introduction There is growing interest in quality-of-care indicators in the ICU. Readmission is one of the proposed indicators to be measured. Objective To investigate the incidence of, outcomes and possible risk factors for readmission in a large cohort of patients in a medicalsurgical ICU and to evaluate the accuracy of Simplifi ed Acute Physiology Score III (SAPS III) and Acute Physiologic and Chronic Health Evaluation IV (APACHE IV) to predict readmissions.

Methods
We conducted an analysis of prospectively collected data from all patients admitted between January 2009 and December 2010 who survived their fi rst ICU stay. Patients aged <18 years, patients transferred to another hospital and those who were not yet discharged until 1 February 2011 were excluded from the analysis. The following variables were evaluated as possible risk factors for readmission: sex, age, type of admission (medical vs. surgical), SAPS III, APACHE III score, APACHE IV mortality predicted risk, ICU length of stay (LOS), ICU discharge at night and on weekends. Accuracies of SAPS III and APACHE IV mortality predicted risk were assessed by calculating the area under the receiver operating characteristic curve. Categorical variables are presented as absolute numbers and percentages. Continuous variables are presented as medians and interquartile ranges. Results A total of 3,993 patients were admitted during the study period and 3,637 fulfi lled study inclusion criteria. Two hundred and eightythree (7.8%) had at least one readmission. Patients' characteristics are displayed in Table 1. In the multivariate analysis, SAPS III (OR = 1.020; P = 0.008), APACHE III score (OR = 1.015; P <0.001).
Conclusion Readmitted patients were older, had longer ICU LOS and higher severity scores at admission. Readmission was an independent factor associated with in-hospital mortality. SAPS III and APACHE IV at fi rst admission had only moderate ability to predict readmissions. Introduction Previous studies have indicated risk factors for ICU readmission; sepsis, respiratory insuffi ciency, medical admission, organ dysfunctions and age are associated with this outcome. Specifi c physiological and laboratory data were explored in some studies, but no association was shown with readmission. Our hypothesis is that infl ammation and organ dysfunctions are more important for this outcome than demographic data or type of admission. Methods We selected all consecutive patients admitted to the fi ve ICUs of a tertiary hospital. All patients discharged from the ICU at least once were included. Demographic, physiological and laboratory data were collected on the fi rst day after the fi rst admission and organ support resources (mechanical ventilation, use of vasopressors and renal dialysis) were researched throughout the ICU stay. Organ dysfunctions were defi ned as they are in the SOFA score. A logistic regression was made with all of the parameters with P <0.2 in the univariate analysis. Objective To report a case of severe symptomatic hyponatremia secondary to previously undiagnosed congenital adrenal hyperplasia. Case A 37-day-old infant, born at 38 weeks gestation, presented with hypoactivity, weight loss, poor feeding and vomiting in the hospital. The main clinical features were irritability, dehydration, hyponatremia, hyperkalemia and ambiguous genitalia. The biochemical data are presented in Table 1. The patient received isotonic fl uids (fi rst day) and treatment for severe chronic hyponatremia (developing over more than 48 hours) calculated to 125 mEq/l under slow correction in 96 hours. The sodium levels did not exceed 0.5 mEq/l/hour or 12 mEq/l/day. On the fi rst day was initiated hydrocortisone (100 mg/m 2 ) and afterwards 50 mg/m 2 . There were no complications of treatment and the child was discharged 2 weeks later without sequels. The karyotype was 46,XX. Conclusion Hyponatremia is a frequent electrolyte disorder. It is considered severe (<115 mEq/l) and chronic when the duration is >48 hours or the installation time is unknown. Irreparable harm can happen when abnormal serum sodium levels are corrected too quickly or too slowly. The correct diagnosis and understanding of the pathophysiology and mechanisms associated with hyponatremia allows establishing safe treatment criteria and consequently avoiding the sequels.

Reference
Introduction Delivering early nutrition support therapy, primarily using the enteral route, is seen as a strategy that may reduce disease severity, diminish complications, decrease length of stay in the ICU, and favorably impact patient outcome. SCCM and ASPEN guidelines support that after the initiation of enteral feeding we have 10 days to meet 100% of predicted energy requirements before we consider supplementation with parenteral nutrition (PN). There are scarce data about the clinical eff ects of using a more accelerated approach to reach full caloric adequacy with enteral nutrition (EN).
Objective The aim of this observational study is to evaluate whether a diminished time to target caloric goal is associated with more patient intolerance and clinical benefi ts in ICU patients receiving EN. Methods From January 2010 to June 2010 we prospectively followed all consecutive ICU patients receiving EN. We collected epidemiological data, APACHE II score, LOS (ICU and hospital), need for mechanical ventilation, incidence of nosocomial infection and hospital mortality. We also collected data on nutrition therapy as the time to target caloric goal (120 hours), total time on nutrition therapy, incidence of diarrhea and other signs of EN intolerance (vomits, abdominal pain and distension). For statistical analysis we used the Kolmogorov-Smirnov test, Student's t test and Pearson's correlation coeffi cient. Results We enrolled 32 patients (17 male/15 female) in the study. The mean age was 66 ± 18 years, mean APACHE II score 21 ± 9, mean ICU and hospital LOS were 21.3 and 35 days respectively, incidence of nosocomial infection was 21.8%, mean total time in nutrition therapy was 18.3 ± 14 days and hospital mortality was 28%. There was need for mechanical ventilation in 56%. There was need for PN supplementation in 9.4% (n = 3) of patients. Comparing the diff erent groups (120 hours, n = 16) we were unable to detect any diff erence with statistical signifi cance regarding incidence of diarrhea, EN intolerance, need for MV, total time on nutrition therapy, incidence of nosocomial infection, ICU and hospital LOS and hospital mortality. Conclusion These preliminary data have shown no correlation of a diminished time to meet energy requirements in EN with patient tolerance to nutrition therapy and clinical benefi ts.