Chronic critical illness: reason for concern during and after ICU admission!

Evolution of healthcare assistance in the ICU, due to its technological apparatus, has increased survival of critically ill patients substantially. In this ballast, patients who require prolonged length of stay, as well as demand continued intensive care support (particularly mechanical ventilation (MV)), are increasingly identified. These patients suffer from chronic critical illness (CCI), a rapidly growing syndrome which has immune, neuroendocrine and metabolic particularities-today, they represent 5-15% of all patients admitted to the ICU.

Introduction: Brazilian registries [1] have shown that there is a gap between evidence-based therapies and the real treatment provided to patients with myocardial infarction. A chest pain protocol was implemented in a private hospital group in 2012 aiming at standardized optimal care for these patients. Objective: To evaluate the hypothesis of improving the use of reperfusion therapy and benefit in clinical outcomes in patients with STEMI after 2 years of implementation of the protocol in a large chest pain network. Methods: In 2012, physicians and nurses from 22 emergencies were trained to comply with a chest pain protocol and were provided access to telemedicine with a reference cardiologist available 24 hours a day, 7 days a week, for clinical discussion. All cases of ST segment elevation myocardial infarction (STEMI) were transferred to a reference hospital and the use of fibrinolytics before transfer (pharmacoinvasive strategy) was recommended. Data of STEMI patients transferred in 2011 (before protocol and telemedicine) were compared with the patients treated in 2013/14 (after implementation). A maximum limit of significance of 5% was defined for the chance of type I error (p < 0.05 was considered statistically significant). , two patients treated with fibrinolytics died during the hospital stay (1.05%), whereas hospital mortality was 8.06% among those not treated with thrombolysis (p < 0.001). The patients that received reperfusion therapy in the first hospital used telemedicine more frequently (63.3% versus 42.2%; p = 0.001). See Table 1. Conclusion: Two years after implementation of a chest pain protocol in a private emergency network, there was significant increase in the use of reperfusion therapy probably explained by a more frequent use of telemedicine in the group treated with reperfusion therapy.  Introduction: Clinical care programs (CCP) that monitor and optimize care have the potential to improve outcomes; however, their real benefits are still controversial.
Objective: This study aims to evaluate the hypothesis of benefits in clinical outcomes after 2 years of a CCP.
Methods: Prospective study of consecutive patients hospitalized with HF in a Brazilian private cardiovascular center. Two groups were compared based on the time to CCP initiation: the historical group, compounded by patients from the 6 months prior to CCP (group 1); and the intervention group, compounded by patients admitted with diagnosis of HF from July 2012 until June 2014, the period when patients and staff were monitored on a daily basis by a case manager nurse and a medical leader which provided educational interventions. The CCP was certified by an international society in October 2012.
Results: In a total of 2188 patients, the mean age was 69.3 years and 55.8% were male (Table 1). Evidence-based therapies at hospital discharge (ACEI/ARB and beta-blocker in eligible patients) showed no significant change (95.8% pre-CCP and 97.5% post-CCP; p = 0.12). The outcomes analyzed in groups 1 and 2, were, respectively: hospital readmissions due to HF within 30 days (13.9% vs. 9.1%; p = 0.008); length of stay (8.9 ± 7.9 days vs. 7.9 ± 5.6 days, p = 0.01); decompensation of HF by poor adherence (16.8% vs. 10.5%; p = 0.001); and in-hospital mortality (9% vs. 6.9%; p = 0.24). Conclusion: During the 2 years of the CCP there was a reduction of 1 day in the length of stay, and a lower frequency of hospitalizations by poor treatment adherence, and in readmissions in 30 days. Introduction: Heart failure (HF) is responsible for the majority of hospitalizations due to cardiovascular disease, and different clinical triggers are related to the cardiac decompensation.
Objective: To evaluate the prognosis of patients hospitalized due to acute HF, according to the cause of decompensation. Methods: We retrospectively evaluated data from 731 patients consecutively admitted to a private cardiovascular center due to acute HF during 2013. We analyzed the frequency of each factor assigned as the trigger for the decompensation of HF among these patients, and also the length of stay and the number of deaths in each group. The infection group was compared with the other two groups separately, using Fisher's exact test for categorical variables and Student's t test for continuous variables.
Results: The factor "infection" was associated with more days of hospitalization (Table 1), above the average of other triggers (10 × 6.95 days; p <0.01). The number of days in ICU in the cases of decompensation due to infection was also higher than the average from other causes (5.8 × 3.35 days; p <0.01). In addition, of the 48 deaths in 2013, 58% (n = 28) were in patients with decompensated HF due to infection, and among these 28 deaths 15 were secondary to evolution of sepsis, in 6 there were predominance of the cardiac condition while the remaining 7 deaths showed mixed shock (cardiac and septic) or other complications related to both conditions leading to death. Conclusion: Infection was the main factor of decompensation, requiring a longer hospital stays, more days in the ICU and being responsible for most of the deaths occurred in patients hospitalized for acute HF. Studies of specific approaches in acute HF triggered by infection are warranted. Conclusion: Infection was the main factor of decompensation, requiring a longer hospital stay, more days in the ICU and being responsible for most of the deaths occurring in patients hospitalized for acute HF. Studies of specific approaches in acute HF triggered by infection are warranted. Introduction: Hemolysis is a frequent complication of different extracorporeal circulation and membrane oxygenation (ECMO) support systems. Usually it is assessed by measuring the levels of haptoglobin or the concentrations of free hemoglobin in the plasma, but automated biochemical laboratory analyzers now detect the hemolysis index (HI) of all blood samples as a measure of sample quality. We studied whether this simple index could detect populations at high risk of active hemolysis and whether it is correlated with outcome. Methods: We evaluated all admissions to our department of intensive care during 2013 and collected relevant demographic and organ dysfunction data during the first 24 hours as required for the SOFA score (not the neurological component). We also collected data on whether or not the patients needed renal replacement therapy during the ICU stay. Patients were classified into three groups: those who needed ECMO support during the ICU stay, those who were admitted after cardiac surgery and had cardiopulmonary bypass (CPB), and other patients. We compared the initial and median (throughout the ICU stay) HI values in the different groups and the survivors with the nonsurvivors. We used SPSS 22.0 (IBM, USA) for all analyses and a p value < 0.05 was considered as significant. Results: We studied 2021 patients with the characteristics presented in Table 1. Patients treated with ECMO and cardiac surgery patients had higher initial and median HI values than the other patients. The nonsurvivors in the ECMO group had higher median HI values than survivors (4 (2-21) vs. 2 (1-3), p < 0.01). There were no differences in the initial or median HI values between patients treated or not with renal replacement therapy. Introduction: Quality improvement is an important activity for all members of an interdisciplinary cardiology critical care team.
Objective: To evaluate whether multidisciplinary quality improvement in cardiac critical care, focused on a daily routine of rounds, protocol standardizations, and under the leadership of the same attending cardiologist in charge of coordinating a team, could produce better outcomes and resource utilization. Methods: Prospectively collected data for consecutive patients who were admitted to a nine-bed cardiac intensive care unit (CICU) in two periods: January-June 2013 and January-June 2014. In the first period (control group) the patients were evaluated by common CICU routine, each day attended by a different intensivist physician, with no standardization of the multidisciplinary approach. Between the two periods there was a 6-month multidisciplinary training. In the second period (intervention group) the same cardiologist and multidisciplinary team made the daily routine rounds, with standardizations of managements and evidence-based care. Introduction: Cardiovascular diseases are the leading cause of death in the world, and sudden cardiac arrest is a major contributor to this index. Training reduces ignorance and fear, increasing safety to recognize that the victim is not breathing properly, so as to trigger help and start CPR as soon as possible.
Objective: To apply theoretical-practical training to a vocational public high school, so as to work correctly, quickly and safely before cardiopulmonary arrest, resuscitation maneuvers running efficiently, in order to save lives.  Results: These study results evidenced a statistically significant increase in correct answers on the theoretical knowledge and psychomotor skill assessment tools after the training in relation to the areas. Exact and agricultural sciences were the areas that most evolved in terms of the number of correct psychomotor skills. Agricultural and biological sciences were the areas that most evolved regarding theoretical knowledge about cardiopulmonary resuscitation. Before the training, the mean number of correct skills was an average 1.79 points higher for each additional year of age and the men's score was 6.6 points lower than the women's score. After the course, only the relation between age and number of correct skills continued significant and gained strength. For each additional year of age, the number of correct skills increased by an average 8.21 points. As regards the theoretical knowledge score on CPR, before the course, a significant relation existed between age and having taken the first aid course. The score increased by 0.22 points for each additional year of age and was 0.63 points higher among participants who had taken the course earlier. After the training, sex and having taken the course earlier remained significantly related with the theoretical knowledge score on CPR.
Conclusion: These study results indicate that the participants have presented improvements in their performances. After the training, the increase in the number of correct answers on the psychomotor skill tool was directly proportional to the age. Concerning the theoretical knowledge on CPR after the course, age and having taken the first aid course contributed to increasing the number of correct answers.

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Caring for critically ill patients outside ICUs due to a full unit Introduction: The risk factors described associated with urinary tract infection (UTI) during urethral catheterization are the colonization of the urinary tissue during evaluation. The incidence of UTI is directly related to the duration of the catheterization, and, after considering this everpresent factor in multivariate analysis, it is the main and most important risk factor for UTI. Thus, a simple noninvasive method for determining the volume of urine in the bladder would be very well received. As such, it is possible for properly trained nursing staff to use ultrasound as a vehicle for the evaluation of residual urinary volume, and Brazilian institutions have the potential to gain much based on surveys already conducted.
Objective: To analyze the duration of time Foley catheters are used and then replace with use of ultrasound scanning to evaluate residual urine volume.
Methods: This is a quantitative study, assessed by the ethics committee of Albert Einstein Israelita Hospital, protocol number 2267601380000071. In the first phase, 20 nurses were allowed to evaluate the residual urine volume with ultrasound and create proper care guidelines. After being taught these guidelines, nurses were allowed to remove Foley catheters from patients showing no signs of diuresis for at least 4 hours. The resulting identification of urinary volume was communicated to the attending physician and subsequent actions were determined by him. The information was recorded in a manner established in advance with volume data, volume drained, medical procedure, gender, age, reason for admission, and duration of time with indwelling bladder catheter all evaluated.
Results: An ultrasound evaluation of residual urine volume after catheterization was performed on 94 patients in the ICU. Thirty-one of these were surgical patients and 63 were clinical patients. Thirty-six were female and 58 were male. The Foley catheter was used for an average period of 3 days (DP 1.2). The average time for the nursing team to evaluate residual urine volume was 6 hours (DP 2.3). Fifty-eight out of the 94 patients studied exhibited spontaneous diuresis after mechanical stimulation such as a change in position on the bed, use of cold or warm bags, and stimuli from the ultrasound transducer during examination and abdominal massage. Foley catheters were used in 12 patients who had more than 1000 ml urine retention 4 hours after removal of the catheter. It was recommended to use the Nelaton catheter in 28 patients with an average urinary volume of 300 ml. Of the 94 patients studied, none exhibited signs of UTI during their hospital stay.

Conclusion:
The results of this study show that the use of ultrasound as a tool for nurses to reduce Foley catheters in critically ill patients is an effective strategy to avoid ICU. Ultrasound is an effective nursing tool that safely and efficiently assesses urine volume within the bladder without the need for catheter insertion. Introduction: ICU patients are exposed to adverse events, which are defined as unintended complications but are preventable. Objective: To identify the adverse effects on the application of the Prófisio Functional Physical Therapy Protocol in critical patients. Methods: Experimental study, longitudinal and contemporary, taking place between January and October 2014 with patients admitted to the ICUs of the Trabalhador, Vita Curitiba, Vita Batel, Marcelino Champagnat Hospital and the Neurology Institute of Cutitiba (INC) in the city of Curitiba, PR. The sample was composed of 375 patients, being 57% male and 42.6% female, with an age average of 58 ± 20.9, medium Glasgow and Ramsey 5. The Prófisio Functional Physical Therapy Protocol (Table 1) was applied once a day to patients who were age 18 or older, hemodynamically stable with PAM between 60 and 110 mmHg, whose responsible agreed to sign the TCLE. The hemodynamic variables (heart rate, blood pressure, breathing rate and oxygen saturation) were evaluated before and after the application of the protocol. The adverse effects were defined as loss of central or peripheral venous access, electrodes for cardiac monitoring, intracranial pressure monitoring, external ventricular derivation, removal of urinary catheter, removal of gavage, orthotracheal or tracheostomy tubes, surgical drains, bleedings, and decrease and opening of sutures, and were observed during all application of the protocol.
Results: A total of 1144 interventions were observed, where only seven (0.61%) showed adverse events. Of the seven only adverse effects, three were classified as light-loss of electrodes of cardiac monitoring-and four were classified as moderate-the unscheduled removal of the gavage, hypotension, drop and loss of surgical drain. The hemodynamic variables did not suffer significant alterations. Conclusion: The application of the Prófisio Functional Physical Therapy Protocol showed itself to be safe and with a low risk of adverse effects, when applied to critical patients. Introduction: Aging is a fact that occurs today, and is associated with increased prevalence of chronic diseases and functional impairment. This leads to an increase in hospitalization, especially in ICUs. A better understanding of the characteristics of these patients is essential to provide the best assistance we can and to have the best of the resources needed for the proper treatment of these patients [1].
Objective: The aim of this study is to compare the epidemiological characteristics of older patients (>70 years) with those with lower age (<70 years), admitted to a general ICU. Methods: A retrospective analysis was performed from June to December 2014, using the database EPIMED®. We evaluated 758 patients who were hospitalized in two ICUs, corresponding to 37 beds. Statistical analysis was performed using SPSS 22, using the Student t test for numerical variables     Introduction: One of the main challenges in critical patient management is to assess the blood volume and determine which patients will benefit from volume expansion and which patients will benefit from support with vasopressor and/or inotropic drugs. It is known that 40-72 % of critical patients respond to volume expansion with increased stroke volume or cardiac index. Objective: To search the literature for methods assessing fluid responsiveness in spontaneously breathing critically ill patients. Methods: The present study is a systematic literature review. We searched randomized clinical trials through a blind search performed by two independent authors in any language in the National Library of Medicine from 2009 to 2014. Results: We selected three articles for full review and analysis, totaling 116 patients. The results are shown in Table 1. Conclusion: This systematic review supports the beneficial effects of adopting maneuvers that amplify the hemodynamic changes, increasing the accuracy of methods to predict fluid responsiveness in spontaneously breathing critically ill patients.  Introduction: A biofilm is found on the inner side of endotracheal tubes (ETT) in mechanically ventilated patients. Saline instillation inside the ETT during the suctioning procedure is very common. This procedure could displace bacteria to the lower airways, increasing the risk of ventilatorassociated pneumonia (VAP).
Objective: Evaluation of the bacteriological cultures of the ETT lavage with saline after extubation of mechanically ventilated patients to verify dislocation of bacteria through this procedure. Methods: The ETT was removed using an aseptic technique during extubation. Saline (10 ml) was instilled into the tube, and the drainage fluid was collected on the other side. This material was sent to microbiological cultures in two different culture mediums (chocolate blood agar and MacConkey). We considered the quantitative culture of more than 100,000 UFC/ml as positive. The characteristics of the patients with and without positive cultures were compared. Results: Forty endotracheal tubes were analyzed (n = 40). Positive culture was observed in eight tubes (20 %). The bacteria observed were: five Gram-positive (Staphylococcus aureus in three, Streptococcus pneumoniae in one and Staphylococcus haemolytics in one) and three Gram-negative (Acinetobacter baumani, Klebsiella pneumoniae, Enterobacter cloacae). We did not observe differences between the group with positive and negative cultures in relation to demographic and clinical characteristics, intubation time and tube diameter (p >0.05).
Conclusion: The use of saline during an endotracheal suctioning procedure can dislocate pathogenic bacteria from the endotracheal tube biofilm to the lower airways, and could increase the risk of VAP. The use of saline should be minimized during patient care. Introduction: About 8-21 % of hospital infections in ICUs are urinary [1,2], 80 % of them being associated with the use of urinary catheters [3]. Several studies show that the early removal of urinary catheters reduces the rate of urinary tract infection. However, critically ill patients who require this device do not have the option to remove. For this group, the best preventive measure seems to be educative activity for the nursing staff responsible for the insertion and manipulation of this device. Objective: To create a team of professionals trained in the insertion of urinary catheters and to organize actions aimed at reducing the rate of urinary tract infection associated with urinary catheters in the ICU. Methods: Prospective study conducted for 12 months in the ICU. Started in July 2013, the intervention program involved the creation of a qualified team for the insertion of urinary catheter and the creation of audits to stimulate the removal of inappropriate urinary catheters and assess the process of inserting these devices. The obtained results were compared with the 12 months preceding the beginning of the interventions.

Success of a urinary catheter insertion team in reducing urinary infections in the ICU
Results: Comparison between August 2012-July 2013 and August 2013-July 2014 (Table 1, Figures 1 and 2) shows that there was a fall of 57.2 % (2.4-1.0, p = 0.040) in the rate of urinary tract infection associated with a urinary catheter and a reduction of 13.4 % (from 0.24 to 0.21, p = 0.001) in the utilization rate of urinary catheters. In the 12 months after intervention (August 2013-July 2014) the percentage of compliance of technical insertion of urinary catheter was 97 % and the inappropriate removal rate of urinary catheters was 85 % ( Table 2).

Conclusion:
The results show that low-cost educational interventions can reduce urinary infections and provide more security for patients in ICUs.   Introduction: Previous studies have suggested that female sex hormones have a protective action, because they contribute to reduce the inflammatory degree in females after trauma.

Figure 1(abstract cc14690) Incidence density ratio of urinary tract infections before and after interventions
Objective: This study aimed to investigate sex differences in the course of the inflammatory process in rats subjected to brain death (BD). Methods: Wistar rats were randomized into three groups (male rats, n = 5; female rats, n = 10; and ovariectomized rats, n = 5) and subjected to BD by rapid inflation of a catheter Fogarty® 4F. The liver, kidneys, lungs and the heart were collected after 6 hours and samples (4 µm) were stained with H&E for histological analyses. Leukocyte infiltration, edema and hemorrhage were measured and data were compared using GraphPad Prism v.6.10, and p values lower than 0.05 were considered significant.
Results: Female rats exhibited increased leukocyte infiltration into the lungs and the heart when compared with male rats (p = 0.009 in the lungs and p = 0.022 in the heart) and presented also a sudden decrease in estradiol levels 6 hours after BD (p = 0.01). The intensity of hemorrhage was greater in ovariectomized rats compared with the other groups (p = 0.001) in the lungs. All groups presented slight to moderate leukocyte infiltration and absence to slight hemorrhage in the liver. Leukocyte infiltration had a wide distribution in female rat kidneys, and in male and ovariectomized rat kidneys infiltration varied from absent to slight. Conclusion: The increased inflammation in the lungs and heart of female rats might be a result of the lack of female sex hormones. Therefore, the idea of introducing a therapeutic use of female sex hormones on female BD donors could be considered. Each year, about 700,000 people suffer a new or recurrent stroke. It is the major cause of serious, long-term disability, with more than 1,100,000 American adults reporting functional limitations resulting from stroke. Review of the evidence on how acute variation in blood pressure (BP) during the first 24 hours of acute ischemic stroke can influence outcome, considering interesting preliminary evidence that without intervening medications may be superior to some use of drugs in modifying an acute rise in BP, and suggesting that the blood pressure decline spontaneously without administration of medication may also have an influence on the acquired disabilities.  Review authors will work independently to assess risk of bias using criteria described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) to assess trial quality. This set of criteria is based on evidence of associations between overestimate of effect and high risk of bias of the article such as sequence generation, allocation concealment, blinding, incomplete outcome data and selective reporting. If the raters disagreed, the final rating was made by consensus, with the involvement of another member of the review group. Where inadequate details of randomization and other characteristics of trials were provided, authors of the studies were contacted in order to obtain further information. Nonconcurrence in quality assessment was reported, but if disputes arose as to in which category a trial was to be allocated, again, resolution was made by discussion. The level of risk of bias was noted in both the text of the review and in the "Summary of findings tables". Primary outcomes: death or dependency at the end of scheduled follow-up. Dependency is defined as being severely dependent on others in activities of daily living, or being significantly disabled; this corresponds to a Barthel Index score or a modified Rankin Scale grade 3-6 at 3-month follow-up. Introduction: There is a big divergence regarding the indexes that show whether an extubation process is successful or not. Regardless of this, the spontaneous breathing trial is the most recommended for that aim.   Introduction: Unplanned extubation (UE) is usually associated with a longer duration of mechanical ventilation (MV), ICU stay and hospitalization. In the Albert Einstein Hospital, it was noticed that there had been an increase in the number of UEs at the beginning of 2014, when protocols such as the daily sedation interruptions were established. UE is more common in patients who are agitated, when they have low levels of sedation or when the endotracheal tube is not well secured.
Objective: To evaluate an UE prevention program based on five actions. Methods: The UE ratio from April to August 2014 was compared with that of the same period from the previous year, comparing the UE index before and after the adoption of a prevention program for patients with a high risk of UE. The prevention of UE was based on five elements: the risk patients were identified during the patient's daily discussion; the endotracheal tube being secured by two different means; arm restraints; the sedation protocol being properly applied; and a sign indicating the potential risk was placed beside the bed. were aware of the intubation and their surroundings (n = 8). Within 12 patients, four had UEs owing to poor tube security. Five of those 12 patients were sedated, only one was agitated and two were in the process of spontaneous trials. In point of fact, these two patients did not need any ventilatory assistance after extubation; six of the patients were reintubated and five had to use NIV. In 2014 the majority of the UEs also occurred in patients who were aware of the intubation and their surroundings (n = 7) and only one patient had improper tube security. They were all identified as being at a high risk of UE, all restrained, and with double tube security. Three of them were sedated, and were being ventilated in controlled mode. The other five patients were breathing spontaneously (PSV). As the necessity for ventilator intervention after extubation, four of the eight were reintubated; three needed NIV and one needed no support. Conclusion: Although this analysis was carried out over a short period of time, the program and the effort of the staff was invaluable in order to diminish and control the number of UEs in our ICU, resulting in a level lower than 3 %. Acknowledgements: The authors thank all ICU staff for their efforts and for engaging in this project with their ideas and actions Introduction: Heat-and-moisture exchangers (HMEs) have been increasingly used to heat and humidify the inspired gases in patients undergoing mechanical ventilation. However, little is known about its interference during measurement of the rapid shallow breathing index (RSBI).
Objective: The objective of this study was to evaluate the effect of the use of a hygroscopic HME during the measurement of RSBI in patients under mechanical ventilation (MV). Methods: Randomized and controlled clinical study in patients admitted to the ICU. Inclusion criteria were patients of age ≥18 years, with MV for at least 24 hours through an orotracheal tube (OTT) with an internal diameter of 7.5-9.0 mm, who were in the process of MV weaning. Patients were randomly allocated into the HME group or the non-HME group by a nonrelated investigator. Before the RSBI, subjects received respiratory physical therapy (bronchial hygiene therapy and tracheal suctioning) and were ventilated at pressure support ventilation with PEEP = 5-8 cmH 2  Introduction: Recent large multicenter studies on early resuscitation protocols for sepsis in the emergency room (ER) have shown a mortality rate of 19 % in the control groups [1,2]. These results suggest that the strategies used to include patients in these studies (high lactate or use of norepinephrine) did not identify a population at high risk of mortality. We explored the prognostic values of these criteria in an ICU population. Methods: All admissions to our department of intensive care in 2013 were retrospectively screened to identify patients who had an initial elevated lactate (≥2 mEq/l) or needed norepinephrine infusion (group OR) vs. those who had an initial elevated lactate and needed norepinephrine infusion (group AND) during the first 24 hours. We then classified the groups by the presence of sepsis at admission or not. The analysis was repeated using a lactate threshold of ≥4 mEq/l. We collected relevant demographic and clinical data including the type of admission, data  0.14 (0.03-0.44) μg/kg/minute), and ≥4 mEq/l yielded similar results. The mortality rates are shown in Figure 1. Patients in the group AND had higher mortality rates than the group OR, but there was a much smaller number of patients. Patients admitted with an infection but not fulfilling the criteria for the group AND or group OR had a lower mortality rate. Conclusion: Mortality in our septic population was higher than that reported in recent randomized controlled trials for early sepsis resuscitation in the ER [1,2], limiting the external validity of these trial results to other ICU populations. Mortality was higher when hyperlactatemia and need for norepinephrine were present simultaneously compared with the presence of only one of these two criteria. Methods: Cross-sectional observational study. All adult patients admitted to a 41-bed medical-surgical ICU of a tertiary care private hospital in São Paulo, Brazil from 12 June to 13 July 2013 (control period) and from 12 June to 13 July 2014 (FIFA World Cup period) were included in this study. Demographic data, SAPS 3 score, clinical and outcome data were retrieved from an electronic ICU quality registry (Epimed Monitor System). Comparisons were performed between the World Cup and the control periods.
Results: Two hundred and sixty-seven patients were admitted to the ICU during the control period and 251 patients during the World Cup period. The proportion of male patients did not differ between the two periods (58 % vs. 54 %, respectively for control and World Cup periods, p = 0.37), as well as the proportion of clinical, elective and emergency surgery admissions (p = 0.18). Patients admitted to the ICU during the World Cup period were slightly younger (mean (SD)) than patients admitted during the control period (63 years (±18) vs. 67 years (±18), p = 0.031) and had lower SAPS 3 score (45.3 (±15.9) vs. 49.5 (±18.5), p = 0.006). The ICU mortality rate was 6.8 % (17/251) for the World Cup period and 6.7 % (18/267) for the control period (adjusted OR, 1.90; 95 % CI, 0.84-4.30; p = 0.13). While the median (IQR) length of ICU stay did not differ between the World Cup and control periods (2 (1 to 4) days vs. 2 (1 to 4), respectively, p = 0.75), the length of hospital stay was significantly lower during the World Cup period (11 (5 to 28) days vs. 14 (7 to 32) days, p = 0.01). Conclusion: Although patients admitted to the ICU of a private hospital during the World Cup were slightly younger and less sick compared with patients admitted during the same period in the previous year, the pattern of ICU admissions and the outcomes were not affected. Our results should be compared with those obtained in the other 11 cities selected for the tournament, including private and public hospitals. Introduction: The fluid balance of critically ill patients has emerged as a potential marker of disease severity. This is associated with worse outcome and prolonged time of use of intensive care support in the ICU. Introduction: Mortality rates for severe sepsis and septic shock are decreasing through the years worldwide. Most of this improvement in mortality is associated with protocols for early recognition, resuscitation and adequate initial antibiotic choice in patients presenting with sepsis to the emergency department. Objective: To assess the pattern of organic dysfunction as described by the Sequential Organ Failure Assessment (SOFA) score in a 4-year period.

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Methods: Retrospective cohort study that included all clinical patients admitted to the ICU from the emergency department with diagnosis of severe sepsis or septic shock. Surgical patients and patients admitted from the ward or referrals were excluded. Demographic data and SOFA score (including individual organic dysfunctions and the general score, which is the sum of organ-specific scores) were collected from January 2008 to December 2012 at admission, 48 hours and 7 days. Results: We included a total of 472 patients. The median age was 70 (IQR 55-82) and most patients were male (61.2 %). Respiratory tract infection was the most common infection site (52.7 %). The median APACHE II score was 19 (IQR 17-24) and the median SOFA score at admission was 4 (IQR 3-7). A total of 58.5 % of the patients presented with severe sepsis. The SOFA score at admission was statistically significant throughout the years (P = 0.004). This was mainly due to circulatory and respiratory dysfunctions at admission, which significantly reduced throughout the years (P <0.001 and 0.045, respectively). The SOFA score significantly decreased along the days (from admission to 7 days) (P <0.0001) and this was consistent throughout the years. Conclusion: Higher severity SOFA scores are decreasing through the years probably due to the increase in early recognition and resuscitation of severe sepsis and septic shock patients admitted from the emergency department. Introduction: Sepsis is a clinical problem of great relevance within the ICU because survivors can suffer from severe dysfunction and symptoms, such as fatigue, dyspnea, muscle weakness and a decrease in the healthrelated quality of life; however, the effects of this disease on physical activity in daily life in the short and medium term are not known.
Objective: The objective of the study was to quantify the physical activity in daily life, muscle strength and exercise capacity in the short and medium term in survivors from severe sepsis and septic shock. Furthermore, we investigated clinical and laboratory factors that determine muscle strength, exercise capacity and physical activity in daily life. Methods: Prospective cohort study with a follow-up from hospital admission to 3 months after hospital discharge. Seventy-two patients admitted to the ICU due to severe sepsis or septic shock and a control group of healthy sedentary subjects (n = 50) were enrolled. All patients had their physical activity in daily life quantified by an accelerometer during their hospital stay and 3 months after hospital discharge. Exercise capacity (6-minute walking distance) and respiratory, handgrip and quadriceps muscle strength were also evaluated during hospitalization and 3 months after. Results: During hospitalization, patients spent the majority of their time inactive in a lying or sitting position (90 ± 34 % of daily time). Physical inactivity was partially reduced 3 months after hospital discharge (58 ± 20 % of daily time). However, the time patients spent walking was only 63 % of the time reported for healthy subjects. Patients also showed a reduction in walking intensity. At hospital discharge, muscle strength and exercise capacity were approximately 54 % of the predicted value, and these parameters showed a small but significant increase in patients 3 months after hospital discharge (70 % of predicted value). A multivariate regression analysis demonstrated that the use of systemic corticosteroids and hospitalization time negatively influenced quadriceps strength and exercise capacity at the time of hospital discharge. Conclusion: Our results strongly suggest that survivors of sepsis admitted to the ICU have a substantial reduction in physical activity, exercise capacity and muscle strength compared with healthy subjects that remains even 3 months after hospital discharge.
Introduction: Traumatic brain injury (TBI) is considered a public health problem by the World Health Organization because it is the major cause of sequelae among people younger than 44 years, affecting all races and ages [1]. The TBI patients are at risk for development of pressure ulcer (PU) due to the therapeutic used; hemodynamic and metabolic changes, immobility, loss of bladder and bowel control, changes in the ability of adequate nutritional intake and dependence on self-care are considered risk factors for development of PU [2,3]. Objective: To evaluate the incidence of PU in patients with TBI and its relation to the level of consciousness and risk of PU development.  (Table 1).
Conclusion: There was a high incidence of PU, and patients with GCS and BE of low scores were more likely to develop the complication. Several factors increase the likelihood of PU in this population, so assessment and prevention measures must be strict at hospitalization.