Vancomycin-resistant enterococci outbreak in an intensive care unit: prevention and control

Infection caused by vancomycin-resistant enterococci (VRE) is associated with high morbidity and mortality rates; it poses a serious threat, in particular, to critically ill patients. It generates high costs and challenges infection control programs. An important component of VRE control is the identification of colonized patients. Since December 2001 we have monitored patients in high-risk units, who would be most susceptible for acquiring VRE. Contact precautions are implemented for VRE-colonized or VRE-infected patients.


Introduction
The intestinal hypothesis of sepsis has been attributed to bacterial translocation (BT), and the aggravation of sepsis is related to the increased vascular permeability state that potentates the BT index.In this study we examined the BT index during sepsis with or without mesenteric lymph exclusion.Materials and methods Wistar rats (±200 g) were submitted to the BT process (E. coli R6 10 ml of 10 10 CFU/ml) and nonlethal sepsis (E.cloacae 89 2 ml of 10 7 CFU/ml) plus BT, with or without mesenteric lymph interruption by mesenteric lymph node resection and lymph duct ligature 5 days prior to the experiments.Samples (blood, spleen and liver) were collected 2 hours after the innoculation and cultured to recover bacteria of intestinal origin.One-half of the animals per group was observed to mortality.Groups (n = 20/group): BT group (BT-G), BT with lymphadenectomy group (BTL-G), combination group (C-G) and combination with lymphadenectomy group (CL-G).Results BT was 100% positive in all groups.The BT index was similar between the BT-G, the BTL-G and the CL-G (P = 0.6), and mortality was not observed in these groups although a considerable amount of translocated bacteria could be recovered, Critical Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America particularly at the liver and spleen (Figure 1).When BT was added to the sepsis without lymph exclusion (C-G), the BT index was statistically lower (P = 0.04); however, 50% (LD 50 ) of mortality occurred within 30 hours (Figure 1).Conclusion These results show that, more than the amount of translocated bacteria, the gut-associated lymphoid system activation by the BT process played a pivotal role in the worsening of sepsis.Besides, BT occurred independently of mesenteric lymph interruption, showing that the hematological route of BT might be the principal route for bacterial dissemination into the bloodstream.There is a marked defect in neutrophil migration into the infectious focus during severe sepsis, which is associated with the severity of disease.Recently, we demonstrated that this phenomenon is a consequence of downregulation of the chemokine receptor CXCR2 on the surface of circulating neutrophils.Toll-like receptors are pattern-recognition receptors that are important in innate immune responses to bacterial infection.Toll-like receptor activation in phagocytes produces proinflammatory cytokines and chemokines that contribute directly to elimination of infectious agents.A sustained inflammatory response, however, can result in tissue damage and sepsis.Here, we address the role of Toll-like receptor 2 (TLR2) in the downregulation of CXCR2 and the establishment of neutrophil migration impairment in severe sepsis.TLR2-deficient (TLR2 -/-) and C57BL/6 (WT) mice were subjected to severe polymicrobial sepsis by the cecal ligation and puncture model, and neutrophil migration, bacteremia, CXCR2 expression and cytokine levels were evaluated.It was observed that TLR2 is critical for downregulation of CXCR2 expression on circulating neutrophils during severe sepsis, since this event was prevented in TLR2 -/-mice.In accordance, TLR2 -/-mice did not present failure of neutrophil migration into the infectious focus and, consequently, they presented lower bacteremia and did not display systemic inflammation determined by reduced levels of circulating cytokines, showing an improve of survival rate.Furthermore, in vitro, TLR2 agonist (lipoteichoic acid) was able to downregulate CXCR2 expression and markedly to inhibit neutrophil chemotaxis induced by CXCR2 ligand.The downregulation of CXCR2 was associated with enhanced expression of G-protein-coupled receptor kinases-2 (GRK-2), which is known to play an important role in desensitization and internalization of this chemokine receptor.Finally, we showed that in-vitro lipoteichoic acid-stimulated neutrophils adoptively transferred into naïve WT mice display a significantly reduced competence to migrate into peritoneal cavity in response to thioglycolate.Altogether, these findings suggest that TLR2, through GRK2 signaling, downregulates CXCR2 expression on the surface of circulating neutrophils, which is a critical determinant of impairment of neutrophil migration into the infection focus during severe sepsis.

P3
Introduction Clinical evidence suggests that bacterial translocation (BT) may not be the primary cause in the development of sepsis and multiple organ dysfunction.However, BT has an important role in the activation of the immune system.Therapies have been extensively investigated to improve tissue perfusion and reduce intestinal ischemia.The aim of this study is to evaluate the effects of hypertonic saline (HSS) 7.5% and lactated Ringer's (LR) solutions on intestinal BT in rats that underwent intestinal obstruction and ischaemia (IO).Methods Wistar rats (300 ± 50 g) underwent anesthesia with sodium pentobarbital (50 mg/kg, i.p.) and were submitted to IO: (i) cecum exposure, (ii) ileum ligation at 1.5 cm proximal to the ileocecal valve, and (iii) ligation of the mesenteric vessels that supply a 7-10 cm length of the ileal loop.Two hours after surgical procedures, 4 ml/kg of 7.5% HSS or LR were administered intravenously, during 5 minutes.Animals were killed 24 hours after IO, and microbiological assays were performed in mesenteric lymph nodes, liver, spleen, and blood.Results See Table 1.Conclusion HSS reduced the number of CFU/g in the liver, spleen, and blood after IO, resulting in improvement of the 'gut barrier function'.Background Variations in intrathoracic pressure interfere with venous return and cardiac output (CO).Inspiratory fall in central venous pressure (CVP) traces (ifCVP) during spontaneous breathing have been recommended for cardiovascular fluid responsiveness (CFR) evaluation.We recently described the usefulness of CVP wave amplitude variation (pressoric vena cava collapsibility index, Cvc i ) during mechanical ventilation for CFR estimation in critically ill patients.There are no data about the Cvc i evaluation during spontaneous breathing.Objective To test the hypothesis that Cvc i can be used for CFR evaluation during spontaneous ventilation.Methods In six male, anesthetized, intubated and spontaneous breathing dogs, CO measurements and CVP waves were registered through a Swan-Ganz catheter while the mean arterial pressure (MAP) was measured through an intraarterial catheter.
After baseline measurements a graded hemorrhage was performed in 10% quota until 50% of the estimated volemia.The total shed blood volume was then re-infused in the same quota.Measurements of the heart rate (HR), CO, MAP, CVP, ifCVP, and Cvc i are performed in every bleeding and re-infusion step.Results Of the 110 patients, there was a predominance of women and mean age 54.2 ± 18.7 years.The length of stay in the ICU was 6.5 ± 7.4 days and the mean APACHE II index, at the first 24 hours of admission, was 21.0 ± 8.1 points.Most patients survived (71.9%), 9.3% died during the first 48 hours in the ICU and 18.6% after 48 hours from admission to this unit.The standardized mortality ratio was 0.715.Patients with early mortality, during the first 48 hours in the ICU, had lower base excess (-7.75 ± 8.33 vs -3.17 ± 5.43) and serum bicarbonate (16.7 ± 6.2 vs 20.9 ± 5.6) than survivors (P < 0.05).Patients with permanence in the ICU up to 7 days and patients that stayed in this unit for more than 7 days had similar base excess and serum bicarbonate (-3.24 ± 5.37 vs -2.98 ± 5.72 and 20.9 ± 5.3 vs 20.9 ± 6.3) (P > 0.05).Conclusion Serum bicarbonate and base excess were associated with early mortality during the ICU stay.However, these parameters did not correlate with ICU length of stay.Objective To evaluate the utility of the pulmonary artery catheter (PAC) to classify the type of shock in hemodynamic instability patients with no known reason.

Materials and methods Nineteen patients from Grajau State
Hospital ICU who had shock diagnosis and those who needed a PAC to diagnose were evaluated.

Results
The average age was 49 years and the APACHE II average score was 17.The average catheter length of stay was 3.68 days.The most common reason for inpatient admission was cardiovascular (42.1%), followed by respiratory (26.3%); 52.6% of clinical diagnoses were of distributive shock, only 42.1% were confirmed by catheter.Cardiogenic shock was diagnosed in 42.1% before the catheter, and after the PAC it was 26.3%.Hypovolemic shock had the same rate of 5.2% before and after catheter insertion.Conclusion Even with a clinical body being well trained to classify shock and the low number of patients in this study, the PAC is certainly useful to predict the type of shock.References Introduction Despite the evolution of transplant techniques, the great number of donated organs continues to proceed from donors in brain death (BD).The need for stabilization in patients with BD, in the view of the triggered autonomic storm, is basic in such a way that knowledge of the physiopathologic, hemodynamic and metabolic disturbances becomes essential.
Objective We evaluated hemodynamic and metabolic changes induced by experimental BD in dogs.cranial pressure (ICP) > systolic arterial pressure for 30 minutes (baseline-T30).The animals were observed for 30 minutes thereafter (T60).Systemic hemodynamics was evaluated by arterial and pulmonary artery catheters, while regional perfusion was assessed by portal vein blood flow (PVBF) and hepatic artery blood flow (HABF) with ultrasonic flow probes.

Materials and methods
Results See Table 1.The data are expressed as the mean ± SEM.Conclusion BD promoted an initial hyperkinetic state followed by marked hypotension without systemic and regional lactic acidosis.
In spite of the severe hypotension, the hepatosplachnic blood flow was preserved.Objective To study whether cardiodepression found in septic patients is associated with plasma markers of myocardial necrosis and with myocardial polyADP(ribose)polymerase (PARP) activation.Sepsis is associated with increased production of superoxide and nitric oxide with consequent peroxynitrite (ONOO -) generation.Cardiodepression is induced in the heart during oxidative stress associated with septic shock.Oxidative and nitrosative stress can lead to activation of the nuclear enzyme PARP, with subsequent loss of myocardial contractile function.

Sepsis
Design A prospective and observational study.Setting A university hospital ICU for clinical and surgical patients.Participants We assigned 25 patients presenting severe sepsis or septic shock.Interventions Patients were followed for 28 days, and data were collected and analyzed a posteriori, separating into two groups: survivors and nonsurvivors.

Measurements and main results
Function of the heart in septic patients correlates to PARP activation in dead patients.The study population included 25 individuals, of whom 12 died during the follow-up period of 6 days.The initial data of inflammation marker C-reactive protein and APACHE severity were similar in both groups.Overall, an increase in the plasma troponin level was related to increased mortality risk.Patients that died presented heart dysfunction, and histological analysis of the heart showed inflammatory infiltration, increased collagen in the interstitium, and derangement of mitochondrial cryptae.Immunohistochemical staining for poly(ADP-ribose) (PAR), the product of activated PARP, was demonstrated in septic hearts.There was a positive correlation between PAR staining score and troponin I (r 2 = 0.81); and a correlation of PAR staining score and LVSSW (r 2 = 0.61).Results Sixty patients were included in the study.At admission to the ICU, septic patients presented a severe metabolic acidosis with an average pH of 7.29; PCO 2 = 36 mmHg and SBE = -8.0. Figure 1 presents the several components of the metabolic acidbase disturbances found on the first day in the ICU.We found that the magnitude of metabolic acidosis, measured by the SBE, was greater among the nonsurvivors than the survivors.However, the components of acid-base disturbances are kept proportionally constant among different clinical outcome subgroups.
During the study period, the survivor group presented an increased SBE from -6.4 to -1.5 due to a significant decrease in serum lactate level and SIG.No change occurred in the albumin serum level, which persisted as an alkalinizing force.In contrast, the nonsurvivor group became even more acidemic due to an increase in the PCO 2 and persistence of a highly negative SBE.From the metabolic point of view, no significant change occurred in this group from the first to the last day of the study, except for a small increase in the phosphate serum level.

Conclusion
Severe septic patients present, on the first day in the ICU, a complex metabolic acid-base disturbance marked by a mixed high-degree acidosis partially attenuated by a hypoalbuminemic alkalosis.Over the study period, the survivor group partially corrected its acidosis mainly through the disappearance of unmeasured anions and lactate.Nonsurvivors did not change significantly their metabolic acidosis over time.Twelve months after the institutional Surviving Sepsis Campaign implementation and current use of the respective treatment bundles, this medical center adopted a standardized hospital maneuver to anticipate the identification of two or more suggestive infection signs.Demographic data, the time interval for recognition of two or more infection risk signs, and the mortality rate are evaluated during the next 5 months (phase II) and compared with the same data obtained during the initial 12 months (phase I).
Results A total of 85 patients with two or more suggestive infection signs were enrolled.Thirty-two patients were recognized with severe sepsis during phase I and 22 patients in phase II.Demographic variables and severity of illness measured by the APACHE II score (P = 0.12) were similar for both groups.The phase I severe sepsis patients were identified after 29 ± 32 hours from the initial presentation of two or more infections signs.On the other hand, during phase II this time was lower: 14.5 ± 16 hours (P < 0.07).The hospital mortality was greater in the phase I group (50%) when compared with the phase II group (27.3%) (P < 0.08).

Conclusion
These preliminary data suggest that the implementation of the proposed methodology for early sepsis risk identification in hospitalized patients was associated with early severe sepsis recognition and reduced mortality.

Introduction
The literature has shown the participation of intestinal microbiota in the genesis of primary infections as well as of sepsis.
In this study we examine the role of sepsis on the microbiota by examining the most frequently recovered Gram-negative bacteria (G-).

Materials and methods
Adult Wistar rats (±200 g) were submitted to the induction of semi-lethal sepsis (S-G) (E. coli R6 1 ml of 10 8 CFU/ml/100 g body weight, i.v.).Firstly, fecal Gkinetic following sepsis induction was examined (6, 12, 24, 48, 72, 120 and 216 hours) (n = 6).After sepsis induction, in other groups (n = 18), samples were harvested from the small bowel (duodenum, jejunum, ileum) and large bowel (cecum and feces before and after sepsis) at 6, 12 and 24 hours, and the BT index  Results Overall data showed that, after sepsis induction, fecal Gmicrobiota increased progressively up to 24 hours (P < 0.05) returning to control level after 72 hours (data not shown).Gut segment overgrowth was also found until 24 hours and BT occurred during this period (Figure 1).Conclusion Sepsis provoked G-overgrowth and this was able to induce the BT process.Other factors, such as splanchnic hypoperfusion, decreased peristalsis and gut immunity by sepsis, might have also contributed to this event.

Influence of bacterial translocation in the genesis of the microcirculation: hypoperfusion in sepsis
Introduction The pathogenesis of sepsis and multiple organ failure has been associated with bacterial translocation (BT).In a previous study we observed intestinal and systemic tissue hypoperfusion 2 hours after a BT process.In this study we examined the perfusion kinetics a longer period after one unique challenge of BT.

Materials and methods
Adult female Wistar rats (±200 g) were submitted to the induction of 2 hours of BT (E. coli R6 10 10 CFU/ml, 5 ml/100 g weight by oroduodenal catheterization).Sham groups received saline.The tissue perfusion (jejunum, ileum, liver and right and left kidneys) was monitored before BT and 2, 6, 24 and 72 hours, 7 and 14 days after BT (n = 6/group).

Results and discussion
The tissue perfusions in BT groups were statistically decreased at 2 and 24 hours in all organs, returning to normal levels after 72 hours up to 14 days compared with sham groups, except the ileum that remained with a high perfusion index after 72 hours onward.Interestingly, in the 6 hours BT group a transitory increased perfusion occurred in all organs, being significant at gut tissues, denoting that at this time point transient inflammatory-response-dependent vasodilatation might have occurred (Figure 1).The BT-related hypoperfusion effect seems to be related to a BT-induced host inflammatory response.

Conclusion
Single BT challenge provoked significant and enduring local and systemic tissue hypoperfusion.These findings can support the hypothesis of BT-related sepsis aggravation.

Figure 1 (abstract P24)
Mean tissue perfusion units (∆%) and mortality in all groups.*P < 0.05.Sepsis, which may be considered systemic inflammatory response syndrome facing an infectious stimulus, is the main cause of mortality in patients in ICUs.As a result of the systemic inflammatory response and of the decrease of the aerobic metabolism in sepsis, oxidative stress occurs.Vitamin A is recognized by the favorable effect that it exerts on the immune response to infections and antioxidant action.

P26
The aim of the present study was to assess the association between serum concentrations of retinol, carotenoids and oxidative stress in septic patients in the ICU.score between the groups (P = 0.33/P = 0.24/P = 0.43).This was found between CRP levels and carotenoids (P = 0.001/P = 0.047).The results bring subsidies for the establishment/revision of the nutritional protocol directed to the group, particularly as regards the intake of vitamin A, aiming at improvement of the prognosis, evolution and survival of these patients.

Introduction
The growing frequency of patients with severe infection in the ICU, resulting in persistent high mortality associated with high costs, is a concern that calls for attention in critical care medicine.It is important to amplify knowledge about severe sepsis and septic shock, in an attempt to prevent it, to identify it early and to reduce mortality.The objective of this study is to evaluate the source of infection and the evolution of patients with severe infection in the ICU.Methods All patients admitted to the ICU of a public university hospital in the period January-June 2004 were included.The variables collected were demographic data, admission diagnostic, SOFA and APACHE II scores, definition of sepsis and sepsisrelated conditions were in accordance with the ACCP/SCCM definitions, and the source and site of infection were recorded for each of first sepsis event.The length of stay and mortality were also recorded.For statistical analysis, the program Epi Info version 3.3.2was used.
Results During the study period 316 patients were admitted to the ICU, the male sex was more frequent (65.8%), and the mean age was 56.5 ± 20.4 years.At admission 141 patients (44.6%) had a diagnostic of severe infection, 86 (28.5%) being severe sepsis and 55 (18.2%) septic shock.The most frequent admission diagnoses of these patients were sepsis, gastrointestinal surgery and intracranial hemorrhage.When comparing the group of patients with severe infection with the other patients we found a higher APACHE II score (25.09 ± 8.7 and 17.93 ± 6.7, respectively; P <0.0001), and a higher SOFA score (9.4 ± 4.3 and 5.5 ± 3.3, respectively; P < 0.0001).The sites of infection more frequently observed were pulmonary (63.8%), abdominal (11.3%) and urinary (7.8%).The source of infection was in the community in 46.1% of the cases of severe infection and nosocomial in 53.2% (P = 0.23).
The mortality stratified by the source of infection did not differ among patients (60% community and 62.6% in the nosocomial infection group, P = 0.52).

Conclusion
Severe infection was a common cause of admission to the ICU in this study.The patients with severe infection had a higher severity of disease and more organ failure when compared with the other patients admitted to the ICU.The frequency of community and nosocomial infection was similar in the group of patients with severe infection, as was the associated mortality.

P28
The critical role of heme oxygenase in neutrophil migration impairment in polymicrobial sepsis
adhesion in a noninfectious inflammatory model.This study aimed to investigate a possible role of the HO-1 pathway on the failure of neutrophil recruitment in mice subjected to severe (S-CLP) polymicrobial sepsis induced by cecal ligation and puncture (CLP).

Conclusion
The SOFA score, APACHE II score, number of organic failures and the need for mechanical ventilation were associated with mortality from the beginning admission to the ICU, while the metabolic and inflammatory parameters were associated with late mortality.These variables should be studied as potential candidates for the models of prediction of death in the aged.with an interval of 1 week or when they had been discharged.At the same time, revision of the basic procedure such as dealing with materials and equipments, training, an informative leaflet though the web, and visits in the unit were performed in order to provide education and orientation to the staff.There was a reduction in the number of new cases of VRE after all measures, and the outbreak was considered controlled in December 2005.

Results
The VAP incidence rate reduced from 21.15/1,000 to 6.72/1,000 mechanical ventilation days (P < 0.01) -an incidence rate ratio of 3.15 (95% CI 1.2-9.5).After 5 months, the rate of VAP was zero.This period was the lowest incidence of VAP ever registered in the ICU.The incidence of multiresistant Gramnegative bacteria infections was also lower than before bundle implementation.

Conclusion
After 5 months of VAP bundle implementation with the aid of homemade software to help clinicians follow the results in daily basis, results have demonstrated an important reduction in the incidence of VAP in our ICU.The impact of this system implementation for a longer period should be followed with the aid of homemade software.

P36
Severe imported malaria: a case report  Objective To study the alterations on the correlation among QTc, troponin and the echocardiogram with sepsis mortality.Methods Holter and echocardiogram were performed, where we were able to analyze the QTc space and the chamber's size.We checked the troponin, CPK and CKMB levels on the 1st, 6th and 12th day after admission.Magnesium and potassium levels were also checked.

Results
Nineteen patients were studied.Ten of them died (52%).
The APACHE score (29.8 ± 8.4 and 26.8 ± 6.5) and age (48 ± 6.4 and 58 ± 6.4 years) were similar in survivor and nonsurvivor groups, respectively.There was no meaningful difference in the daily dosage of vocative drips.Troponin was significantly elevated among those who died during the first 12 days (day 1: 0.5 ± 0.3 and 1.4 ± 1.1; day 6: 0.4 ± 0.1 and 1.4 ± 1.2; day 12: 0.3 ± 0.1 and 1.0 ± 0.8; P < 0.05).The QTc was elevated in the nonsurvivor group (day 1: 0.44 ± 0.05 and 0.46 ± 0.04; day 6: 0.45 ± 0.05 and 0.46 ± 0.08; day 12: 0.41 ± 0.02 and 0.45 ± 0.09; P < 0.05 -survivors and nonsurvivors, respectively).There was an increase in acute events in the nonsurvivor group (40 ± 6 mm) on the 12-day trial.Conclusion QTc, troponin and acute event data were elevated among the nonsurvivor patients.There is therefore an evident correlation of these parameters and their clinical evolution.Objective To determine the association between the high risk to embolic events and the application of guidelines for their prevention in ICU patients.Methods A retrospective study evaluating the medical files of 200 ICU patients.Inclusion criteria: patients ≥18 years old that did not have diagnosis of deep-vein thromboembolism (DVP) and pulmonary embolism (PE) at internment.Exclusion criteria: use of previous or present anticoagulant, counterindication for use of heparin in prophylactic doses.The patients were classified according to risk stratification to thromboembolism of low, moderate and high risk.

Conclusion
This study showed a nonsignificant association (P = 0.269) between high risk for thromboembolism and the performance of thromboprophylaxis, which is a potential risk factor for mortality in the ICU.

Introduction and objective
The door-to-electrocardiogram (ECG) time is recommended to be 10 minutes or less in patients with chest pain presenting to the emergency department (ED).The aim of this study was to identify factors associated with delays in the door-to-ECG time in patients admitted to the ED with acute myocardial infarction (AMI).Patients and methods A total of 186 patients (70% male, mean age: 65.0 ± 14.0 years) hospitalized for AMI were evaluated.The door-to-ECG time was prospectively measured from the time of patient arrival in the ED to the time of initial ECG acquisition (minutes).Statistical analysis was performed using ANOVA and multiple comparison tests (Bonferroni, Scheffé, Tukey, Duncan).P < 0.05 was considered statistically significant.

Results
The results are presented in Table 1.Conclusion A significant increase in the rate of ACEi/ARB prescription was observed both in the first and the second years after AMI protocol implementation.A trend toward an increase was also observed when the first and second years post-protocol are compared.These data suggest that managed protocols that include continuous monitoring of quality indicators are useful tools for implementing scientific evidence into clinical practice.

Introduction and objective
Inhospital treatment delays experienced by women may limit their potential to achieve the maximum benefits of acute myocardial infarction (AMI) therapies.The door-to-electrocardiogram (ECG) time is recommended to be 10 minutes or less in patients with chest pain presenting to the emergency department (ED).The aim of this study was to examine gender differences in the door-to-ECG time for patients admitted to the ED with AMI.Patients and methods A total of 384 patients hospitalized for AMI were evaluated.Of those, 107 were female (27%) and the mean age was 67.1 ± 14.2 years.The door-to-ECG time was prospectively measured from the time of patient arrival in the ED to the time of initial ECG acquisition (minutes).Statistical analysis was performed using the chi-square test and the Fisher exact test.P < 0.05 was considered statistically significant.

Conclusion
Women with AMI had a door-to-ECG time twice as high compared with male patients.Factors such as older age, lower prevalence of STEMI and atypical clinical presentation, more common among women in this cohort, may have contributed to the longest delay in the door-to-ECG time.Background Hypothermia is defined as a core temperature less than 35°C.Critical trauma patients usually are hypothermic.A reversible coma simulating cerebral death could be one of the clinical manifestations of hypothermia.Life-threatening ventricular arrhythmias could be evident when moving the patient and during the rewarming process.Electrocardiographic manifestations of hypothermia are: bradycardia, absence of atrial activity, narrow QRS complexes and a prolonged QT interval.The presence of the 'J (Osborn) wave', a second upward wave immediately following S waves, is pathognomonic.The 'J (Osborn) wave' is the result of the difference of potential action between the epicarde and endocarde during phases 1 and 2 of the ventricular repolarisation and is related to increase in mortality.

P45
Objective To report a case of penetrating thoracic gunshot wound with electrocardiographic manifestations of hypothermia, including a 'J (Osborn) wave', who died.Methods Case report and literature review.
Results A 30-year-old male injured in the left hemithorax was transferred to our emergency department 8 hours after aggressive initial resuscitative thoracotomy, total left pneumectomy and cardiopulmonary maneuvers.He was admitted in shock, midriasis and with core temperature of 32°C, after 1.5 hours of interhospital transportation.A ventricular fibrillation occurred and was treated with two biphasic shocks.An electrocardiogram showed: an absence of P waves, a ventricular rate of 78 beats, narrow QRS complexes, a prolonged QT interval and a 'J (Osborn) wave' (Figure 1).The patient was resuscitated by the principles of early goal direct therapy and was submitted to external and internal rewarming processes.Although there was an effective and clear

Results
The comparison between groups found a significant decrease in the door-to-ECG time in the post-implementation period (P = 0.00002) (Table 1).

Figure 1 (abstract P45)
Electrocardiographic manifestations of Hypothermia: absence of P waves, ventricular rate of 78 beats, narrow QRS complexes, a prolonged QT interval and the 'J (Osborn) wave' (white arrows).

Conclusion
The implementation of this new triage tool had a significant impact on reducing the door-to-ECG time and it may become a useful tool for identifying atypical AMI patients.

Conclusion
The present findings showed that the RMSSD index associated positively with pulmonary function and that cardiac autonomic regulation is impaired after CABG.Additionally, the PI can be a potential therapeutic to reestablish the parasympathetic activity in these patients.) of the surgical patients and the mortality in this group was greater than in the group of patients that did not develop this complication, respectively 63.2% and 15.1% (P < 0.001).The patients with ARF were older than the patients without this complication (64.9 ± 7.9 years vs 50.6 ± 21.14 years, P < 0.007) and the APACHE II score was higher (20.3 ± 4.9) in the ARF patients when compared with patients without ARF (16.5 ± 7.4, P < 0.06).The median length of stay was higher in the patients with ARF, being 6 days, varying from 3 to 65 days, while in the patients without ARF the median was 2 days, varying from 1 to 33 days (P < 0.001).

Conclusion
The high frequency of ARF found in this study was probably due to the definition criteria adopted, including transient oliguria and pre-renal ARF.The occurrence of renal dysfunction resulted in higher morbidity and mortality in this group of patients.
Several studies have been carried out to determine the patients at high risk of developing ARF in the postoperative period, and protective strategies have been developed, but the results are as yet inconclusive.Method Initially a pilot study was performed with the aim of estimating the failure rate of MV weaning of patients hospitalized in the CUC.The results confirmed the necessity of improving the method then employed by the multidisciplinary team.Hence, 36 patients, who utilized MV for a period greater than 24 hours and were ready for weaning, were prospectively included in the study.

P58
The average age of the patients was 59.5 ± 16.4 years.The number of patients needed to include in the study was determined by calculating the sample size.The patients were then randomly placed into two groups: the experimental group (EG) and the control group (CG).In the EG, extubation was standardized according to the spontaneous respiratory test (SRT) of the American guidelines for weaning and was conducted by investigator in the study.For the CG, the SRT was also performed by the same investigator but without altering the extubation procedure employed, which was determined by the multidisciplinary team.

Results
The groups were matched so there were no statistically significant differences in respect to gender, age, diagnoses at admission, ventilation parameters, physiological variables and APACHE II score.The time necessary for weaning was significantly shorter in the EG (2 hours and 24 minutes vs 70 hours; P = 0.0009).
Sixteen patients in the CG were extubated, of which 11 (69%) did not fulfill the clinical criteria of the SRT.Of these 16 cases, 12 (75%) were reintubated and four (25%) were successfully weaned with all the successful cases among patients who passed the SRT.Of the 18 patients in the EG, 11 fulfilled the criteria for SRT and were extubated.Of these, eight (73%) cases were successful and three (27%) required reintubation.The reintubation rate was significantly higher in the CG (75% vs 25%; P = 0.0001).

Conclusion
The application of the weaning MV guidelines in heart disease patients hospitalized in the CUC reduces the time necessary to complete weaning, increases the success rate and reduces the reintubation rates.
Lung morphometric analysis showed some edema at the perivascular tissue with no neutrophil infiltration in the parenchyma of the PEEP10 group compared with the other groups (P < 0.05).There were no changes in mean arterial blood pressure in all groups along the study period.Objective Current evidence suggests that patients spend about 41% of their time in mechanical ventilation (MV) with weaning.The application of weaning protocols brings better results over the treatment based upon simple observation of the patient, reducing the time of MV and its associated complications.The goal of this study was to evaluate the results from the application of a weaning protocol executed by the Physical Therapy team, aiming to reduce the weaning length and the MV length.Methods Fifty-eight inpatients were prospectively studied at the Clinica São Vicente ICU, from June 2005 to February 2007.These patients were ventilated through an endotracheal tube and were in MV ≥48 hours.The ventilatory status of these patients was evaluated daily and after they fitted the protocol we started the weaning program, using pressure support ventilation (PSV).Patients that tolerated one spontaneous ventilation attempt were considered eligible for extubation, considering PSV of 7 cmH 2 O and PEEP of 4 cmH 2 O for 30 minutes.Higher levels of PSV and PEEP were accepted for patients with chronic obstructive pulmonary disease (COPD).

Measurements and results
The mean age of the patients was 66.25 years (SD ± 20.21), with 52.6% males and 47.4% females.The average time of MV was 6.44 days (SD ± 3.17) and weaning length was 1.52 days (SD ± 1.09).The indication for an artificial airway and MV was 15 postoperative patients (26.3%), 33 patients with acute respiratory distress (57.9%) and nine neurology affected patents (15.8%).At the extubation time the average PSV was 7.81 (SD ± 1.30) and the average PEEP was 4.54 (SD ± 1.00).Forty-seven patients were successful (82.5%), while 10 needed reintubation (17.5%).There was no correlation between nonsuccess and age, COPD, MV causes or the Tobin index, considered a predictive index of success in the literature.
Regarding the maximal inspiratory pressure, there was a statistically significant correlation (P = 0.01).

Conclusion
The time spent to weaning in our study was shorter than the literature description, and the reintubation rate was compatible with anterior publishing.The study showed that the institution of protocols can minimize the weaning length and the MV length in ICUs.Results Clinical and laboratory data are presented in Table 1.There were no complications due to transportation to the CT room, and no barotrauma was detected.Methods Eleven healthy men (22 ± 2.2 years) were evaluated.The heart rate and R-R intervals (R-Ri) were recorded in a sitting position during spontaneous breathing and NPPV application (600 min each).The NPPV was delivered using a bi-level positive airway pressure (BiPAP) applied via a nasal mask with inspiratory and expiratory levels of 20 and 13 cmH 2 O, respectively.The heart rate and its variability were analyzed in the time domain by the RMSSD (root mean square of the squares of the differences between successive R-Ri) and SDNN (standard deviation of all R-Ri) indexes of R-Ri (ms); and in the frequency domain by the low-frequency (LF) and high-frequency (HF), in normalized units (nu), and the LF/HF ratio.For statistical analysis, the paired t test was used with a level of significance of 5%.

Critical
Results No significant differences were observed in the time domain between two conditions.In the frequency domain, however, the LF bands presented significant higher values (0.6 ± 0.

Conclusion
We observed that the major amount of patients requesting speech therapist evaluation in the ICU had neurologic or pneumologic origin diseases or were post-liver transplants patients (65% male patients and 80.8% with alternative feeding methods).In 68 (76.4%) of 89 cases, some degree of dysphagia was detected.
We would like to emphasize that speech deglutition evaluation contributed to identifying dysphagia and consequently was indicated to begin the rehabilitation process or to reintroduce oral feeding with safety.More findings of this analysis will be discussed further.Objective To analyze the cases from the first 12 months after implementation of the protocol for early treatment of AIS at a large public hospital in Rio de Janeiro.Methods An observational series study was conducted including cases of all patients admitted to an ICU with signs of stroke in an interval of up to 3 hours after the start of the symptoms, with a multidisciplinary team specially trained at Albert Einstein Hospital and Mãe de Deus Hospital.

Results
During the period of study, 24 patients were admitted with signs of stroke inside the 3-hour period.Amongst them, four presented with signs of hemorrhagic stroke at computerized tomography, while the remaining 17 did not possess evidence of bleeding, suggesting AIS.Thrombolytic therapy, in accordance with the protocol, was implemented in 17 of the cases, leaving three excluded from the thrombolytic protocol -one of these three due to the family's refusal to go through with the protocol, another one for possessing a history of AIS in less than 3 months and the last one due to reversion of the symptoms.Amongst the patients that underwent thrombolysis, the mean Glasgow Coma Scale was 10.4 ± 1.5 and mean National Institute of Health Stroke Scale (NIHSS) was 12.6 ± 5.There were two casualties, including a patient that presented with hemorrhagic transformation.Three did not show significant clinical improvement; however, 12 presented with important improvement, with force restoration and aphasia involution according to the NIHSS, modified Ranking, and Barthel's Index.Conclusion Implementation of the protocol for early treatment of the AIS in a large public emergency hospital assumes a series of challenges, but constitutes the main entrance to patient who are victims of acute stroke.During implementation and training there was a need for greater consciousness and involvement of all sectors in order to make the process effective: starting at prehospital until ICU admittance, with an exclusive bed reserved for AIS.Facing the impressive number of stroke victims, there are few patients who could benefit from treatment.In spite of this small sample size, among the deceased patients one presented with an AIS located in the brainstem and the other suffered nonsurgical bleeding with complications due to severe prior coronary artery disease.With the consolidation and divulging of the protocol, the number of beneficiaries might be greater.Hyponatremia is an electrolyte disturbance presenting the potential for morbidity and mortality in patients with neurological complications secondary to brain injury, trauma-related or not.In such patients, hyponatremia is frequently accompanied by the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).However, in rare cases, hyponatremia can be accompanied by a controversial pathology known as cerebral salt-wasting syndrome (CSWS), which is generally associated with subarachnoid hemorrhage in adults.In this report, we describe the clinical evolution and treatment of a 47-month-old male patient with ventriculo-peritoneal shunt resulting from congenital hydrocephalus.The patient had developed severe hyponatremia (121 mEq/l) accompanied by signs of dehydration, intracranial hypertension and hypouricemia, as well as elevated urinary sodium and osmolality.In addition to intravenous fluid replacement and infusion of 3% saline, high levels of sodium replacement (up to 25 mEq/kg/day), together with fluorocortisone administration, were required in order to maintain appropriate serum levels of sodium.The diagnosis of CSWS was confirmed on the basis of the high serum level of atrial natriuretic peptide.The patient showed progressive improvement and resolution of the condition after confirmation of intracranial hypertension and clearance of the ventriculo-peritoneal shunt obstruction.We emphasize the importance of recognizing CSWS in patients with hyponatremia accompanied by central nervous system disturbances, as well as the differential diagnosis with SSIADH.

Results
The mean age was 83 ± 8.2 years, the APACHE score was 19.4 ± 6.2, the SOFA score was 9.31 ± 2.9 and the period of time to initiate EF (tEF) was 0.97 ± 1.1 days.The seriousness of clinical conditions was demonstrated by a death rate of 50.7% and this was not reduced either by tEF nor the use of EF itself.However, it was related to the APACHE II score (P = 0.17), the SOFA score over the first day (P = 0.04), the length of stay in the ICU (5.1 ± 8.9 days) (P = 0.002), the initial diagnosis of septic shock (P = 0.01) and number of organ failures.The difficulty of initiating EF was not associated with the APACHE or SOFA scores over the first day, blood lactate levels, CRP, albumin or number of organ failures.However, hyperglycemia was a factor that retarded the initiation of EF (P = 0.02).It was not possible to initiate EF in 46.1% of patients due to several factors.Pulmonary sepsis was associated with the number of organ failures.Urinary sepsis was not associated with such failures.Conclusion Septic shock has a high mortality associated with multiple organ failure.EF, even when early tolerated in patients with severe sepsis or septic shock, was not able to reduce mortality or the number of organ failures.Hyperglycemia was a retarding factor in the initiation of enteral nutrition.

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Impact of early enteral nutrition on the morbi-mortality of patients with severe acute pancreatitis JR Azevedo 1,2 , LSS Passos 1,2 , PCO Moreira 1,2 , RP Azevedo Background and objective For many years total parenteral nutrition was considered the mainstay of nutritional support in patients with severe acute pancreatitis [1].Recent studies with a limited number of cases have shown that early enteral nutrition is feasible and associated with a reduction of morbidity in these patients [2,3].The objective of this study was to evaluate the Available online http://ccforum.com/supplements/11/S3impact of early enteral nutrition on the morbi-mortality of patients with severe acute pancreatitis.Methods We compared two groups of patients with acute severe pancreatitis admitted to a general ICU in the period from 1994 to 2004.Patients admitted between 1994 and August 1999 systematically received total parenteral nutrition (TPN), while those admitted from September 1999 to December 2004 received enteral nutrition through a nasojejunal tube.All other aspects of treatment were similar between the two groups.Results Forty-four patients were included in the study.Eighteen of them, admitted between 1994 and 1999, received parenteral nutrition (TPN group), and 26 patients admitted between 1999 and 2004 received enteral nutrition (EN group).The two groups were comparable regarding age, gender, etiology of pancreatitis and APACHE III score.Thirteen patients were qualified as 'C' of Balthazar (seven in the TPN group and six in the EN group).Twenty-seven patients were qualified as 'D' or 'E' (eight in the TPN group and 19 in the EN group).Severe pancreatic necrosis was seen in 14 patients (three in the TPN group and 11 in the EN group).Morbidity and mortality data are presented in Table 1.Background and objective Intensive insulin therapy significantly reduced morbi-mortality in a population of critically ill surgical patients [1].The results in medical ICU patients were less clear [2].The objective of this study was to determine whether intensive insulin therapy is more safe and efficient than a glycemic control strategy without the use of high doses of insulin in a heterogeneous population of critically ill adult patients.Methods Included in the study were all adult patients admitted from 1 July 2004 to 31 December 2006 to a 20-bed multidisciplinary ICU of a general hospital and to an 11-bed trauma center ICU that had at least two blood glucose levels above 150 mg/dl from three measurements obtained in the first 12 hours after admission.Patients were randomly assigned to strict normalization of blood glucose levels (80-120 mg/dl) with the use of insulin infusion or to glycemic control through glucose-free venous hydration, hypoglycidic nutritional formula and subcutaneous insulin if the blood glucose level was higher than 180 mg/dl in the measurements taken every 6 hours.
Results Three hundred and thirty-seven patients were enrolled in the study.At admission the two groups were comparable regarding age, sex, APACHE III score, prevalence of diabetes mellitus and nosologies.Patients in group 1 (n = 168) received 52 (35-74.5)units regular insulin per day, while group 2 (n = 169) received 2 (0-6.5)units insulin/day (P < 0.001).The median glucose level during treatment was 133.6 (119.7-153.3)mg/dl in group 1 and was 144 (123-174.2) mg/dl in group 2 (P = 0.003).ICU mortality was 22.6% in group 1 and 25.0% in group 2 (P = 0.6).There was no difference between the two groups regarding length of ICU stay, infectious complications and organ dysfunctions.Hypoglycemia occurred in 27 patients (16%) in group 1 and six patients (3.5%) in group 2 (P < 0.001).No permanent cognitive defects were recorded in patients with hypoglycemia.When a subgroup of patients who stayed in the ICU for more than 5 days was analyzed, although a small trend toward mortality reduction was noted (25.5% in group 1 and 30.3% in group 2; relative reduction of 16%), this difference did not reach statistical significance.

Conclusion
This study demonstrates the need to use protocols to control hyperglycemia that allows a less strict blood glucose control.With this approach it is possible to limit the hazards of hypoglycemia and, at the same time, to maintain the benefits of glycemic control.With such an approach it would be possible to extend the benefits of blood glucose control to ward patients.References Objective To compare intensive insulin therapy with conventional glycemic control in patients with acute neurological injury, evaluating neurological outcome and morbi-mortality.Methods Patients with two glycemias above 150 mg/dl 12 hours after admission were randomized to receive intensive insulin therapy (G1) or conventional treatment (G2).We evaluated a subgroup of patients with acute brain injury from July 2004 to June 2006.Results G1 patients (n = 31) received 70.5 (45.1-87.5)units insulin/ day while G2 patients (n = 19) received 2 (0.6-14.1) units/day (P < 0.0001).The median glycemia was comparable in both groups (P = 0.16).Hypoglycemia occurred in two patients (6.4%) in G1 and in one patient (5.8%) in G2 (P = 1.0).Mortality in G1 was 25.8%, and it was 35.2% in G2 (relative reduction of 27%).Neurological outcome was similar in both groups.Conclusion A less strict intensive insulin therapy can reduce hypoglycemia and still maintain its benefits.

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A computer-guided insulin protocol causes less hypoglycemia than a strict glycemic control protocol: a randomized controlled trial AB Cavalcanti 1 , J Eluf-Neto 2 , AJ Pereira Objective We report the results of a randomized controlled trial to evaluate the efficacy and safety of three insulin algorithms in medical ICU (MICU) patients.Methods MICU patients with at least one blood glucose ≥150 mg/dl and who were on mechanical ventilation, or had SIRS, or were admitted because of trauma or burn were randomized to one of the following treatments: algorithm A -continuous insulin infusion with adjustments guided by a handheld device or desktop software targeting glucose levels between 100 and 130 mg/dl; algorithm B -continuous insulin aiming at glucose levels between 80 and 110 mg/dl; algorithm C -conventional treatment of intermittent subcutaneous administration of insulin if blood glucose levels exceeded 150 mg/dl.Efficacy was measured by the mean of patients' median blood glucose and safety was measured by the incidence of hypoglycemia (≤40 mg/dl).
Results One hundred and nine patients were included.The APACHE II score was similar in the groups (20.5 ± 7.9).The efficacy and safety of the algorithms to attain glucose control are presented in Table 1.Conclusion A computer-guided insulin infusion protocol causes less episodes of hypoglycemia than, and is as efficacious as, the standard strict glycemic control protocol for controlling glucose at normal nonfasting levels (80-140 mg/dl) in MICU patients.

Conclusion
The two glucose meters evaluated might not be sufficiently reliable to be used in the ICU setting, especially for patients under strict blood glucose control.Moreover, there are marked differences between equipments and a decrease in precision if capillary or venous samples are used.Introduction Administration of drugs by an enteral feeding tube is a common practice in critically ill patients, since it provides an easy access for those unable to swallow.

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Available online http://ccforum.com/supplements/11/S3Enteral nutritional therapy (ENT) has a solid and important role in the treatment of severely ill patients in ICUs.The multidisciplinary team therefore has to assure a safe nutritional therapy free from failures.The objectives of this study were to compare the prescribed and administrated volume of enteral diet; to compare daily caloric needs (DCN) with the prescribed calories (PC) and the administrated calories (AC); and to identify the factors associated with failures in the administration of enteral therapy.This is a descriptive, comparative and prospective study carried out in two general ICUs of a private hospital in the city of São Paulo, Brazil, in 2005.The data were collected daily based on information from medical records.Descriptive statistics as well as the Student t test, kappa rate and logistic regression model (stepwise forward) were used to analyze the data.P < 0.05 was considered statistically significant.The sample was composed of 61 patients (636 enteral diet daily administration).The time between the admission to the ICU and ENT was, on average, 2.5 days; most diets (57.6%) were special and were administered through an enteral catheter placed into the stomach (56.9%).The volume of diet administered was usually smaller than the prescribed one, respectively 1,111.8 ± 400.4 ml and 1,257.2± 306.9 ml (P = 0.000).Concerning calories, PC (1,302.6 ± 481.9) as well as AC (1,164.8± 508.2) were statistically smaller than the DCN (1,797.1 ± 292.7).The comparison between volume and calories according to the intervals showed a moderate concordance between the prescribed and administered volumes (kappa = 0.614) and low concordance between the DCN and PC (kappa = 0.191) and between the DCN and AC (kappa = 0.100).From a total of 308 reasons for failure while administering the prescribed volume, the wrong calculus of the infusion speed by the nursing team was predominant (20.8%) followed by diagnostic or therapeutic examinations and surgical procedures (14.9%); 70.6% of the reasons were avoidable.The factors associated with failure in volume administration were age, infusion speed and DCN.The results indicate the importance of further studies that look into adverse events related to the administration of enteral therapy aiming to guarantee the actual nutritional needs of severely ill patients in ICUs.
Epidemiology/quality of life/administration Objectives To characterize the severity of patients, comparing the observed versus expected mortality, and to evaluate the ICU performance regarding assistance.Method A prospective study in which the APII was calculated and the outcome of the patients admitted to our ICU from 24 June 2006 to 19 October 2006 was studied.For such calculation, the largest discrepancy from the reference values was considered in the first 24 hours in the ICU.The study included 202 patients, 116 men (57.4%) and 86 women (42.6%), with age varying between 22 and 94 years (mean age: 63.9 years).The most prevalent diseases were: postoperative cardiac care (14.8%), congestive heart failure (13.4%), acute arterial insufficiency (11.9%) and pneumonia (9.4%).The length of stay in the ICU varied from 0 to 63 days (average = 5.7 days).The cutoff value of the APII was 25 and the results of RO were 36.8%.

Results
According to the ROC curve, a sensitivity of 87.5% and a specificity of 77% was observed for an APII cutoff value of 25; thus, 87% of the patients who died had APII ≥25 and 77% of the patients classified as high severity presented APII <25.The curve also showed that 88% of the patients who died presented RO ≥36.8% and 74% of patients classified as high severity had a RO <36.8%.When correlating the cutoff value of 25 from the APII with 36.8% for the RO, it was noticed that 96.9% of patients with APII ≥25 and RO ≥36.8% evolved to death and that 93.7% of patients with APII <25 and RO <36.8% were classified as high severity; there was only 4.95% of inconsistency.The global expected mortality was 44% while the observed mortality was 37%.APII <12 excluded death, and APII ≥45 confirmed death.

Conclusion
The population studied included patients of higher severity when compared with those described in the general literature.The observed mortality was less than the expected mortality, suggesting adequate assistance.The APII is a good prognostic index, and when used in the first 24 hours of internment presents high specificity and sensitivity to calculate the death risk.the ER in 62.5% of the requests.There was no difference between mortality of requests from the ER and from the ward (P = 0.17).

Conclusion
In this population, 57.6% of the demand for ICU beds was not admitted immediately.The waiting time for clinical admissions was very high, suggesting that time-sensitive diseases like sepsis had a worst prognosis.The mortality among ER patients waiting for ICU beds was no higher then ward patients.We suggest a study to evaluate the impact of delay on the prognosis of admitted patients.

P95
Burnout syndrome and quality of life in intensivists D de Souza Barros Introduction Burnout is a prolonged response to chronic emotional and interpersonal stressors on the job, and is defined by three dimensions: exhaustion, cynism (depersonalization), and inefficacy [1].ICU physicians are exposed to several stress factors and are particularly predisposed to this syndrome [2].Objective To describe the prevalence of burnout syndrome among intensivists and its relation to their quality of life.Methods An epidemiological cross-sectional survey conducted to evaluate all adult ICU physicians in Salvador, BA (Brazil), from October to December 2006.The quality of life and burnout syndrome were evaluated respectively by the WHOQOL-Bref instrument [3] and the Maslach Burnout Inventory (MBI) [1].Burnout was classified into low, moderate and high levels for the three studied dimensions, according the MBI classification, and it was defined by the presence of a high level in at least one dimension.The quality of life was evaluated in four domains: physical, psychological, social relationships and environment, graduated from 0 to 100, with higher scores denoting higher quality-of-life.
Results A total of 297 intensivists were enrolled (88.4% of the eligible population).The mean age was 34.2 ± 6.9 years and 71.7% were male.The mean time since graduation was 10.0 ± 6.7 years.According to the literature, placement of a speaking valve provides many benefits to the patient: facilitation of voicing, even in ventilator-dependent patients, facilitation of deglutition, use of the upper airway, which improves the ability to cough and manage secretions, improvement of olfaction and taste, and others.
Objective To verify patient perception of the speaking-valve benefits and compare it with available literature data.Methods A questionnaire was given to a group of 20 inpatients at the Intensive Therapy Unit of Hospital Albert Einstein who had been using the speaking valve for at least 2 weeks, introduced by the speech and language pathologist.A list of possible benefits described in the literature was presented and patients could fill a column choosing one of three possibilities: better/worse/same after the introduction of the speaking valve.

Results
The primary results show that the restoration of oral communication is the primary benefit of the one-way valve for these patients (70%), followed by improvement of deglutition (60%) and even anxiety control (60%).Better quality of life was reported by 90% of the patients.The other findings are being collected and will be discussed further.

Conclusion
The speaking valve was shown to be a wellacceptable device for patients in the ITU who used it, and assisted in improving patient quality of life, according to the patient perspective.A 52-year-old black woman presented to the emergency department with a complaint of worsening lumbar pain during the last month.A report of untreated severe arterial hypertension was provided.She had been suffering from chronic lumbar pain for the previous 2 years.During the investigation of lumbar pain she had been diagnosed as having an abdominal aortic aneurism, but she declined treatment and follow-up.At presentation she was hemodynamically stable and had no signs of peritoneal irritation on physical examination.An abdominal computed tomography was performed and revealed a ruptured posteriorly blocked aortic aneurism, which caused severe erosions on the anterior vertebral bodies of L3 and L4.The patient was operated on the next day after admission, and an aneurysmal repair was performed.She was admitted to the ICU and evolved with shock, acute renal failure, mesenteric ischemia and multiple organ dysfunction.She died on the third day after hospital admission.).An X-ray scan did not show pneumothorax, pneumomediastinum or subcutaneous enphysema.An abdominal CT showed a huge pneumoperitoneum.As it was impossible to rule out perforation of a viscus she underwent a laparotomy, which was 'white'.After a while, in the critical care unit, the patient started again to present AD and HI.A tiny abdominal tube drainage system was placed to try to control the progressive AD and HI.

P104
After that procedure the patient's HI got better but she developed a sudden cardiac arrest and died.Discussion Lone tension pneumoperitoneum is extremely rare.Macklin and Macklin [1] related the possibility of perivascular sheath air dissection from the mediastinum to the abdominal cavity when someone is under mechanical ventilation.Needless to say, exploratory laparotomy is very common in these cases [2].Some tests could have been done to rule out a perforation of a viscus [3].
The patient probably died from a pulmonary air embolism.References epidural effects on tonometric indicators in pigs submitted to exploratory laparotomy and to compare the effects of analgesic and anesthetic solutions.Methods Twenty-seven pigs (weight: 26 ± 2.33 kg) were anesthetized and monitored.The epidural catheter positioning was confirmed by radioscopy (T10-T11).The animals were randomized into a control group (saline solution), a 0.5 group (levobupivicaine S75-R25 0.5%, n = 9), and a 0.05 group (levobupivicaine S75-R25 0.05% + 4 µg/ml fentanyl, n = 9).Fifteen minutes after epidural injection, the animals were submitted to exploratory laparotomy and intestinal manipulation during 45 minutes.The tonometric, hemodynamic and laboratory parameters were collected before the epidural injection (T0), and 60 and 120 minutes after the injection (T1 and T2 hematemesis, gastric contents >50 ml or hemoglobin decrease >2 g/dl in 24 hours) were identified.UGIB prophylaxis prescription was also recorded and, when it occurred, the medication(s) used and the UGIB risk factors associated.
In multivariable evaluation, previous bleeding, coagulation problems and hepatopathy were risk factors for UGIB (P = 0.01, P = 0.03 and P = 0.11, respectively), while prophylaxis gives protection (P = 0.034).The univariable analysis identifies heparin as a potential risk factor for bleeding (+4.9 and P = 0.026), which was not confirmed in multivariable analysis.

Conclusion
Although UGIB had high prevalence and potential severe prognosis, about 12% of all patients with a strong indication for prophylaxis do not take it in a suitable way, showing the gap between guidelines and clinical practice.Background The conservative approach of blunt hepatic trauma and low-energy (stab) penetrating injuries is well established.Routine surgical exploration remains the standard practice for all penetrating solid organ injuries.Nonoperative treatment of patients who suffered civilian (medium-energy) gunshot wound (GSW) of the torso, including the liver, although controversial, could be conducted without surgery in selected patients presenting to the emergency room hemodynamically stable and without evidence of peritonism.The physical examination and abdominal computed tomography (CT) are essential to guide the initial therapy.The nonoperative management is attractive once it avoids the morbidity of a nontherapeutic laparotomy, reported to be as high as 41.3%.Objective To analyse the feasibility, safety and acute complications of nonoperative, protocol-driven treatment of GSW of the liver.

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Methods A prospective, observational, protocol-driven study with patients who suffered civilian GSW of the liver, admitted to the emergency room between 1998 and 2006.All patients had a single, right thoracoabdominal GSW.All patients had one initial abdominal CT scan and were observed in a semi-ICU (emergency room), with noninvasive monitoring and serial physical examination, for at least 24 hours.Results Twenty-four consecutive patients (mean age 24.3 (range 16-47) years) were enrolled and treated initially without surgery, and 22 were hemodynamically stable (Table 1).Twenty patients were maintained with conservative treatment.Sixteen of these patients (78.94%), had minor liver injuries (grade I/II/III -American Association for the Surgery of Trauma (AAST)), whereas four patients sustained major grade IV/V injuries.Two patients with major liver injuries were hemodynamically unstable with rapid response to saline infusion and were maintained in the protocol (Tables 2 and 3).The aspartate aminotransferase (AST) and alanine aminotransferase (ALT) mean values were proportionally higher according to the grade of the liver injury (Table 4).Chest injuries were noted in 10 patients (47.36%) and pleural drainage under water seal was necessary in nine of them.Two patients sustained an associated renal injury with microscopic hematuria.Laparotomy was performed in four patients because of two main indications: persistent right hippocondrius pain (n = 2) and a projectile inside the pelvis on CT (n = 2).In this group, two laparotomies were nontherapeutic and two revealed small diaphragmatic injuries.All four liver injuries were minor and without active bleeding.

Conclusion
Civilian GSW of the liver can be treated without surgery in selected adult patients presenting to the emergency room as hemodynamically stable, with Glasgow Coma Scale score of 15, without evidence of peritonism, and in trauma centers with a defined protocol based on findings from an abdominal CT scan.
Treatment could be done in a semi-ICU, with noninvasive monitoring and serial physical examination.The grade of liver injury and the presence of perihepatic fluid (hemoperitoneum) does not contraindicate the conservative approach.Pulmonary trauma was the most commonly associated injury and was treated with pleural drainage under water seal.Renal-associated injury could be treated without surgery.The values of AST and ALT could be correlated with the grade of liver injury.More large prospective series are warranted.
Critical Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America All patients were attended by an urban advanced life support unit.Results Ninety-seven patients received dissociative anesthesia in the period.In nine patients ketamine was administered for rapid sequence intubation, and these were excluded.Eighty-eight met the criteria for sedation and analgesia.Collision was the leading trauma kinematics in 50%.The main indication for dissociative anesthesia was vehicle-entrapped patients in 26.5%.The most important traumatic lesion was inferior extremity fractures in 49.25%.The complications reported in this series were four orotracheal intubations secondary to: seizure (one patient), lowered level of consciousness (two patients), and protection of the airway from orofacial hemorrhage after reduction of a mandibular fracture and dislocation (one patient).One respiratory depression was treated by bag-valve-mask-assisted ventilatory support.Neither cardiorespiratory arrest nor deaths occurred.The mean administered doses were 118.5 mg for ketamine and 4.84 mg for midazolan.The percentages of orotracheal intubations were greater in group 1 of 19 patients with Glasgow Coma Scale (GCS) less than or equal to 13 corresponding to 10.52%, versus 2.89% in group 2 of 69 patients with GCS of 14 and 15.Table 1 presents the data variable comparison between groups 1 and 2. Background The conservative approach of blunt hepatic trauma and low-energy (stab) penetrating injuries is well established.Nonoperative treatment of patients who suffered civilian (mediumenergy) gunshot wound (GSW) of the torso, including the liver, although controversial, could be conducted without surgery in selected patients presenting to the emergency room hemodynamically stable and without evidence of peritonism.Physical examination and abdominal computed tomography (CT) are essential to guide the initial therapy.The nonoperative management is attractive once it avoids the morbidity of a nontherapeutic laparotomy, reported to be as high as 41.3%.In a hemo-Available online http://ccforum.com/supplements/11/S3

1 .
Yu DT, Platt R, Lanken PN, et al.: Relationship of pulmonary artery catheter use to mortality and resource utilization in patients with severe sepsis.Crit Care Med 2003, 31:2734-2741.2. Rapoport J, Teres D, Steingrub J, et al.: Patient characteristics and ICU organizational factors that influence frequency of pulmonary artery catheterization.JAMA 2000, 283:2559-2567.3. American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization: Practice guidelines for pulmonary artery catheterization: an update report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization.Anesthesiology 2003, 99:988-1014.P15 Systemic and regional hemodynamic and metabolic changes in an experimental model of brain death FA De Luca, RJ Cruz Jr, AG Garrido, R Prist, F Scuotto, M Rocha e Silva Heart Institute -InCor, University of São Paulo -SP, Brazil Critical Care 2007, 11(Suppl 3):P15 (doi: 10.1186/cc5802)

Women with acute myocardial infarction are more likely than men to have a delayed
door-to-electrocardiogram time MRP Makdisse, AG Correa, A Pfeferman, LMA Forlenza, M Knobel, AP Mello, T Tavares, V Oliveira, S Ellovitch, COB Filho, A Pieri, E Knobel Hospital Israelita Albert Einstein, São Paulo -SP, Brazil Critical Care 2007, 11(Suppl 3):P44 (doi: 10.1186/cc5831) da Paixão, TR Diniz, T Duarte, BCV Lemos, AP Antunes, I Dellandrea, AM Neiva, LT Carvalhido, MAB Cristino, CL Menezes, IFM Pereira Department of General Surgery, Division of Emergency and Trauma, Hospital Municipal Odilon Behrens, Belo Horizonte -MG, Brazil Critical Care 2007, 11(Suppl 3):P45 (doi: 10.1186/cc5832) Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America diuresis, an improvement in lactic acidosis and central venous saturation, and a body temperature of 36°C, the patient had cerebral death declared on the second day and died on the third day.Conclusion The search for electrocardiographic manifestations of hypothermia should be part of the routine for critical trauma patients and, when reported, should alert the surgical team about the possibility of supporting a bad prognosis.Berkeley, Rio de Janeiro -RJ, Brazil Critical Care 2007, 11(Suppl 3):P46 (doi: 10.1186/cc5833)

Table 1 (abstract P4) Microbiological assays
Sham group, false operated; +/n, number of animals with positive cultures for E. coli/total number of animals; CFU/g, colony formation units/g tissue (mean value ± SEM, n = 7 animals in each group); NG, no growth.

Table 1 (abstract P11)
The Cvc i was calculated with the following formula: Cvc i (%) = [(CVPP exp -CVPP ins ) / CVPP exp ] x 100, using the inspiratory (CVPP ins ) and expiratory central venous pulse pressure (CVPP exp ).ifCVP = CVP measured in the 'a' wave base at expiration minus CVP measured Introduction Echocardiography in critically ill patients enables diagnosis of a large number of cardiac conditions, including lifethreatening ones.Intensivists can use it as a powerful diagnostic tool.Objective A comparison of intravascular volume and tissue perfusion parameters in critically ill patients to enhance beneficial conduct in treatment and outcome using the inferior vena cava diameter as guidance.Conclusion Cases reported in this study demonstrate how the IVC helped monitor hemodynamics in critically ill patients and led to further decisions in treatment.Other studies also recommend the incorporation of this technology as a routine in ICUs due to its noninvasivity, feasibility, accessibility and lower risks.Introduction Base excess is considered an indicator of injury, shock and adequate resuscitation.We looked to establish a relation between base excess and serum bicarbonate obtained on admission to the ICU and the prognostics of patients.Methods A retrospective study with analysis of 110 patients admitted consecutively to the ICU, during the period June-December 2006.Critical Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America >90 mmHg); central venous pressure (CVP: 8-12 mmHg); serum lactate (Lac: < 1 mmol/l); arterial oxygen saturation (SaO 2 : >90%); central venous oxygen saturation (ScvO 2 : >75%); ∆PCO 2 (<4 mmHg indicates a cardiac index >2.5 l/min/m 2 ); inferior vena cava diameter (IVC: >15 mm) and its variation with inspiration (∆IVC: <50%).Results A total of 32 patients were investigated -of which five presented with the following apparent divergences: 2 : 95.9%; SvcO 2 : 74.3%; ∆PCO 2 : 3.4 mmHg; IVC: 12 mm; ∆IVC: 60%.Procedure: patient with subarachnoid hemorrhage.Normal IVC diameter and collapsibility helped to maintain MBP > 100 mmHg and prevent vasospasm.5. CR: 128 bpm; MBP: 90 mmHg; CVP: 18.5 mmHg; Lac: 1.4 mmol/l; SaO 2 : 80%; SvcO 2 : 71.2%; ∆PCO 2 : 3.2 mmHg; IVC: 25 mm; ∆IVC: 5%.Procedure: hypervolemic patient with ARDS, in mechanical ventilation (APRV-Bilevel).Increased IVC resulted in volume restriction and use of diuretics to improve P/F.

cardiovas- cular variables in survivors and nonsurvivors of human septic shock: heart rate as an early predictor of prognosis
Background Sepsis-induced multiple organ failure is the major cause of mortality and morbidity in critically ill patients.However, the precise mechanisms by which this dysfunction is caused remain to be elucidated.It seems that, in sepsis, mitochondria dysfunction results in raised tissue oxygen tensions and organ failure.Possibly due to oxide nitric, that is produced in excess in sepsis, and is known to inhibit mitochondrial respiration in vitro.Critical Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America Introduction Septic shock (SS) is a disease associated with high mortality worldwide.In Brazil, mortality in SS reaches 60%.The aim of our study was to identify clinical variables easily accessed in the presentation of SS and their correlation with mortality.Methods Between January 2003 and December 2004, all patients with SS criteria according to the ACCP/SCCM were included in this observational study.At the time of SS diagnosis the following variables were collected: age, gender, heart rate (HR) and mean arterial pressure (MAP).On the ICU admission day the APACHE II and SOFA scores were calculated.Data were retrieved from the patient chart by one of the investigators, then transferred to STATA version 9.0 software, where all analyses were run.All patients were followed until ICU discharge or death.
Conclusion Septic patients with impaired cardiac function demonstrate inflammatory alterations and PARP activation.We suggest that PARP activation may be, in part, responsible for the cardiac function depression observed in patients with severe sepsis.Objective To analyze cellular damage to electronic microscopy and evaluated its possible relation with serum cardiac markers (troponin, MB-creatin phosphate kinase), and homodynamic data.Methods We selected all consecutive patients who met the criteria for septic shock, and we collected blood samples from the first through the 12th day, or until death.We also analyzed homodynamic parameters by pulmonary catheter.From the patients that died, a fragment of the left ventricle was sent for electronic microscopy.The exclusion criteria were previous coronary artery disease or dilated miocardiopathy.ResultsWe studied 22 patients, age 53 ± 4 years, APACHE scores 22 ± 2; mortality was 45%.The patients who died showed data of cardiac damage from the first day.This was shown by troponin (0.54 ± 0.08 U/Ml vs 1.7 ± 0.3 U/Ml) and the left ventricular systolic worth index (64.2±3.7 vs 37.6 ± 1.3), respectively, in survivor and nonsurvivor groups.The electronic microscopy from the myocardial of the nonsurvivor group showed a significant injury in the mitochondria, represented by an increase in its numbers.There was an alteration on organelle organization and mitochondria crest lesions.The histology of the heart demonstrated inflammatory infiltration and increases of collagen fibers.Conclusion Septic patients with impaired cardiac function demonstrate inflammatory alterations and mitochondrial damage.We hypothesize that mitochondrial damage may, in part, be responsible for the cardiac depression seen in severe septic patients.ContextAlthough observational studies have demonstrated an alteration of heart rate variability (HRV) in septic patients, no single study has systematically addressed the relationship of heart damage by systemic inflammation and metabolic alterations.Objective To determine whether heart damage from sepsis is caused by free fatty acids (FFA) and may be detected with HRV analysis.Design A prospective and observational study of patients presenting with severe sepsis or septic shock.Results During the period of study, there were 794 admissions to the ICU, of whom 239 (30%) presented SS.Sixty-seven percent were male, mean age was 57.0 (SD = 17.7) years, mean HR was 108 (SD = 26.3)bpm, and mean MAP was 64.5 (SD = 21.2) mmHg.The mean APACHE II score was 23.3 (SD = 8.6) and the mean SOFA score was 9.7 (SD = 3.2).The ICU mortality rate was 66.5%.In the analysis of the prevalence of mortality and its crude association with independent variables, age and gender show no association.Patients with HR above 108 bpm presented a mortality OR of 1.78 (0.98-3.24) compared with those patients with HR equal to or less than 108 bpm (P < 0.05).An APACHE II score greater than 24 points was associated with a mortality OR of 2.91 (1.52-5.78)compared with those patients with a score equal to or less than 24 (P < 0.001).A SOFA score greater than 8 points was associated with a mortality OR of 1.89 (1.04-3.42),compared with patients with values equal to or less than 8.The analysis of MAP demonstrated a trend to a lower mortality, in association with a higher level.Conclusion Our study confirmed, as previously demonstrated, that a HR less than 110 bpm at SS presentation is associated with low mortality, as well a higher level of MAP.The severity of illness (APACHE II score > 24 points) is indicative of high-risk mortality; multiple organ dysfunction (SOFA score > 8 points), and a worse outcome.References 1. Parker MM, Shelhamer JH, Natanson C, et al.: Serial .Crit Care Med 1987, 15:923-929.2. Bernard GR, Vincent JL, Laterre PF, et al.: Efficacy

and safety of recombinant human activated protein C for severe sepsis.
N Engl J Med 2001, 344:699-709.Available online http://ccforum.com/supplements/11/S3Introduction Applying a quantitative methodology, we described the acid-base status of severe septic patients in the first 5 days after admission to the ICU.Patients and methods Patients were studied if they had a diagnosis of severe sepsis with less than 24 hours of organ dysfunction.Data were prospectively collected daily until the fifth day after inclusion.

P22 Institutional evaluation of a new methodology for early sepsis risk identification in hospitalized patients GA Westphal, KFP Fujiwara, AA Kawate, AO Monteiro, MM Schroeder, N Ferrari, RR da Silva, IV Scremin, R Beims Centro
Hospitalar Unimed, Joinville -SC, Brazil Critical Care 2007, 11(Suppl 3):P22 (doi: 10.1186/cc5809) Background The effectiveness of sepsis, severe sepsis and septic shock management on prognosis depends strongly on early clinical suspicion and rigorous diagnosis methods.Early clinical suggestive infection sign recognition is therefore also a cornerstone of successful treatment.Objective To evaluate a new institutional methodology for early sepsis risk identification in hospitalized patients.Methods A before-after study design with prospective consecutive data collection in a 124-bed private medical center.
Critical Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America

Implementation strategy of a severe sepsis management protocol in a tertiary hospital AG de Sousa, CJ Fernandes Jr, G de Paula Dias Santos, E Silva, N Akamine, LF Lisboa
Objective To describe the methodology of sepsis protocol implementation in a tertiary hospital.Methods A team composed of a case manager, physicians, nurses, a clinical pharmacist and a respiratory therapist was created to organize the flow of septic patients in our institution.Every severe septic patient recognized by a physician was followed by the case manager and every member of the team was alerted.The ICU, ER, central lab and imaging service receive simultaneously a message about this patient.Several tools were created in order to facilitate the implementation process, such as patient flow (Figures1 and 2), continuous education by the web, multidepartmental training and sepsis kit (normal saline bags, arterial and central venous catheter Presep).Also, we have used the individual collect data

P33 Vancomycin-resistant enterococci outbreak in an intensive care unit: prevention and control FP Almeida, MDV Martino, M Silva Jr, LC Lamblet, L Corrêa, S Silbert, C Vallone
Critical Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America

The clinical spectrum of severe imported falciparum malaria in the ICU: report of 188 cases in adults
. Am J Respir Crit Care Med 2003, 167:684-689.P37 Catheter-related bloodstream infections in the intensive care unit TPB Silva, RN Parrode, JPM Bittar, PM Tedeschi, HP Guimarães, LS Vendrame, AC Lopes Disciplina de Clínica Médica, Universidade Federal de São Paulo (UNIFESP/EPM), São Paulo -SP, Brazil Critical Care 2007, 11(Suppl 3):P37 (doi: 10.1186/cc5824)BackgroundIn ICUs, physicians insert many central venous catheters every year.Central venous catheters allow measurement of hemodynamic variables, delivery medications, hemodialysis and nutritional support.Unfortunately, catheter-related bloodstream infections are common, costly, and potentially lethal.Infection complication is reported to occur in 5-26% of patients.Objectives To identify rates of catheter-related infection in ICU patients.To identify whether catheter-related infection prolongs the time of hospitalization in the ICU.Methods A retrospective analysis of patients with catheter-related infection was performed, including 132 patients admitted to the ICU.All patients with catheter-related infection were identified regardless of the diagnosis at ICU admission.Results The average age was 58.27 years, 58% were male.Thirtytwo patients (24.24%) had catheter-related bloodstream infection.The medium time of ICU stay in the infection group was 23.96 days against 12.18 days in the control group.Conclusion The use of central venous catheters was associated with bloodstream infection and was hazardous to patients.In these patients, catheter-related infection prolongs hospitalization in the ICU.

P40 Critically ill patients with Takotsubo cardiomyopathy JO Oishi, LC Thome, A Rea-Neto, MC Oliveira, JL Rocha, VG
Critical Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America Background A cardiac syndrome of 'apical ballooning', also named Takotsubo cardiomyopathy, consists of an acute onset of transient akinesia of apical and mid portions of the left ventricle, without significant coronary stenosis.It is considered to be trigged by emotional stress.Recently, it has also been described in critically ill patients.Cardiogenic shock can occur but is not usual.Objective To describe one HIV patient with Takotsubo cardiomyopathy in an ICU admission.
Lemke CEPETI, Curitiba -PR, Brazil Critical Care 2007, 11(Suppl 3):P40 (doi: 10.1186/cc5827) Methods and results NSB, a Caucasian 54-year-old female, with previous history of anemia and depression, was admitted to the ICU due to altered mental status.Her family reported mood changes and lethargy.Her physical examination showed oral candidiasis and loss of consciousness.After ventilatory support, an MRI image was obtained showing ring-enhancing mass lesions suggesting intracerebral toxoplasmosis.Folinic acid, pyrimethamine and sulfadizine were initiated.Screening and confirmatory tests were positive for HIV.Over the following days the patient developed haemodynamic instability requiring intravenous vasopressors.Troponin, CKMB and CK were normal and the ECG showed an inverted T wave in leads V2-V5.An echocardiography showed anteroapical akinesia.The cardiac catheterization did not reveal any obstructive coronary lesion; however, ventriculography demonstrated an abnormal left ventricle with anterioapical akinesia.After 3 days, the patient was stable and without inotropic support.In a second echocardiography, the left ventricular wall motion was normal.Conclusion Critically ill patients can present a cardiomyopathy with reversible anteroapical akinesia without coronary stenosis.This diagnosis should be considered among ICU patients.References 1. Akashi YJ, Nakazawa K, Sakakibara M, et al.: The clinical features of takotsubo cardiomyopathy.Q J Med 2003, 96:563-573.2. Park JH, Kang SJ, Ong JK, et al.:

Left ventricular apical balloon- ing due to severe physical stress in patients admitted to the medical ICU. Chest 2005, 128:296-302. P41 Cardiovascular complications related to cocaine use: a case report
The echocardiogram demonstrated left ventricular hypocinesia, a 17 mm ventricular thrombus and a 12% ejection fraction.Bleeding from the left upper lobe was identified during a pulmonary bronchoscopy, which was treated with arterial embolization.After 48 hours of the procedure, the patient was asymptomatic and antithrombotic treatment with warfarin and enoxaparin was started.No obstruction was found at the cineangiography and the patient was discharged after clinical improvement.The patient was admitted again to the ICU in July with intensive chest pain and dyspnea at rest.A new cineangiography was performed and occlusion in the anterior descendent coronary artery was observed.ConclusionThe acute effects of cocaine are commonly seen in the Emergency Department but the chronic effects, such as the cardiovascular manifestations, can take longer to be correlated as a side effect of cocaine use.Its prolonged use is related to left ventricular systolic dysfunction due to hypertrophy or myocardial dilation, atherosclerosis, arrhythmias, myocyte apoptosis and sympathetic damage.
F Gazoni, A Truffa, C Kawamura, H Guimarães, R Lopes, L Vendrame, A Lopes Universidade Federal de São Paulo -SP, Brazil Critical Care 2007, 11(Suppl 3):P41 (doi: 10.1186/cc5828)Background and objective Cocaine is the most commonly used illicit drug and its acute and chronic effects are related to a variety of physiological changes, mainly in the cardiovascular system.This study is a case report of a patient with cardiomyopathy related to cocaine use.Case report A 19-year-old man, who has been using cocaine and crack since he was 15 years old, was admitted to the Emergency Department in February 2006 with progressive dyspnea during minimal efforts and bloody expectoration.During the physical examination, leg edema, jugular stasis and dyspnea at rest were observed.P42Factors associated with the door-to-electrocardiogram time in patients with acute myocardial infarction AG Correa, T Tavares, M Vaidotas, V Oliveira, AP Mello, RG Souza, LMA Forlenza, MRP Makdisse, RB Magaldi, LF Lisboa, ME Knobel, E Knobel Hospital Israelita Albert Einstein, São Paulo -SP, Brazil Critical Care 2007, 11(Suppl 3):P42 (doi: 10.1186/cc5829)

Table 1 (abstract P42)
ConclusionOur data show that among the analyzed factors only the absence of chest pain on admission was significantly associated with a prolonged door-to-ECG time.This finding suggests that early identification of AMI patients with atypical presentation should facilitate appropriate and timely management.Available online http://ccforum.com/supplements/11/S3

P43 Increase in prescription rate of angiotensin-converting enzyme inhibitors or angiotensin receptor blocker for hospitalized patients with acute myocardial infarction and left ventricular systolic dysfunction MRP
Introduction and objectiveThe rate of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ACEi/ARB) at discharge is a quality indicator for acute myocardial infarction (AMI) care.The aim of the study was to evaluate changes in drug prescription before and after the implementation of a managed AMI protocol in patients hospitalized for AMI with moderate to severe left ventricular systolic dysfunction (LVSD).
Makdisse, AG Correa, M Knobel, S Lagudis, F Bacal, SS Morhy, CH Fischer, MLC Vieira, EBL Filho, PKO Yokota, E Knobel Hospital Israelita Albert Einstein, São Paulo -SP, Brazil Critical Care 2007, 11(Suppl 3):P43 (doi: 10.1186/cc5830) Patients and methods A total of 578 consecutive AMI patients (mean age: 68.0 ± 14.4 years) were evaluated.Of these, 92 were eligible for ACEi/ARB therapy at discharge (had LVEF <40% and/or narrative of LVSD and/or did not have a contraindication to ACEi/ARB and had survived their hospital stay without transfer to another facility).The managed AMI protocol was implemented in a tertiary hospital on 1 March 2005.Quality indicators were prospectively followed by a nurse case-manager, and periodic performance feedback (reports) were given to local hospital managers and clinical staff.Patients were divided into three groups: G1, pre-protocol (March 2004-February 2005); G2, first year post-protocol (March 2005-February 2006); and G3, second year post-protocol (March 2006-February 2007).Statistical analysis was performed using the chi-square test and Fisher's exact test.P < 0.05 was considered statistically significant.

Relationship between B-type natriuretic peptide plasma levels and echocardiography parameters in compensated chronic heart failure patients treated with levosimendan EJ de Almeida Figueiredo
worsening the prognosis of ICU patients.Especially, patients submitted to cardiac surgery may be exposed to prolonged heparin infusions.After open-heart surgery, as opposed to other surgical procedures, the platelet count falls, primarily due to platelet damage and destruction in the bypass circuit and hemodilution.Heparin is the most common drug to be implicated in thrombocytopenia in ICU patients.Determining the etiology for the low platelet count is important for the implementation of appropriate management.The use of a direct thrombin inhibitor in treatment should be considered early if a diagnosis of heparin-induced thrombocytopenia is possible.Objective The aim of the study is to present one case of heparininduced thrombocytopenia after a mitral valve replacement surgery and to compare the rotational thromboelastography (roTEG) and coagulation tests before and after argatroban use.Case report An 83-year-old female patient was hospitalized because of acute mitral regurgitation secondary to chordal rupture and was submitted to a mitral valve replacement.Past medical history included hypertension, diabetes, chronic atrial fibrillation and mild renal failure.Before the surgery, a coronary angiography was performed and revealed normal coronary arteries and a normal left function.After 4 days using unfractionated heparin, the platelet count dropped 30% and the anticoagulation was changed from unfractionated heparin to fractionated heparin.
, A Perez, E Knobel, JMA Souza, MB Ferri, M Knobel, M Nigri, P Silveira, RD Morsch, RH Passos Hospital Israelita Albert Einstein, São Paulo -SP, Brazil Critical Care 2007, 11(Suppl 3):P48 (doi: 10.1186/cc5835) Background B-type natriuretic peptide (BNP) plasma levels have recently been demonstrated as significant neurohormonal markers of chronic heart failure (CHF) progression and prognosis.Additionally, clinical studies have shown that the calcium sensitizer levosimendan beneficially affects the central hemodynamics of CHF patients and improves their long-term prognosis.Objective To investigate whether levosimendan-induced hemodynamic improvement, as confirmed by echocardiogram of CHF patients, is related to respective changes in BNP levels.Methods Circulating levels of BNP were measured by ELISA in 37 patients with decompensated advanced CHF at baseline and 72 hours after the initiation of levosimendan treatment.Echocardiographic parameters -pulmonary artery pressure (PAP), enddiastolic volume, end-systolic volume and left ventricular ejection fraction (LVEF) -were also measured at baseline and 72 hours after infusion initiation.We used the threshold of 500 pg/ml for BNP, 30 mmHg for PAP and 50% for LVEF to define patients as having altered results.EA Silva, ET Leite, C Teles, T Crochemore, S Machareth, F Gutierrez, RC Costa-FilhoHospital Pró-Cardíaco, Rio de Janeiro -RJ, Brazil Critical Care 2007, 11(Suppl 3):P49 (doi: 10.1186/cc5836) Background Thrombocytopenia is a common problem in the ICU and in cardiovascular patients.It has been considered to play a role in Postoperatively, the patient presented shock, acute renal failure and signs of peripheral hypoperfusion and increased abdominal pressure.Seven days after the surgery, the suspicion of heparin-induced thrombocytopenia was confirmed by ELISA test for PF4-heparin antibodies.Heparin was stopped and argatroban was initiated.The patient died from multiple organ failure 1 week later.Methods We evaluated the roTEG and coagulation tests (platelets; PTT; TAT; PAI; PTN-C; fibrinogen; D-dimer and antithrombin III) before and after argatroban use.Comments In this case the roTEG was as good as a wide coagulation profile test to evaluate the effects of anticoagulation using argatroban in a heparin-induced thrombocytopenia patient.

P50 Analysis of the TIMI score in patients admitted with ST-segment elevation myocardial infarction in an intensive care unit SLM Arruda, HJP Branisso, EC Figueiredo, VA Pereira, JA Luna
Critical Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America classified by TIMI score.Statistical analysis was performed with one-way ANOVA with the Tukey post test and Pearson correlation.ResultsThe TIMI score was between 0 and 12; 76.9% of patients were men.Details are presented in Table1.ConclusionThe patient age was significantly lower in TIMI scores 0-3.The mortality increased proportionally with TIMI score.Nevertheless, there was no mortality in the higher TIMI scores, probably because of the small number of patients.

Unstable angina and non-ST-segment elevation myocardial infarction: an analysis by TIMI score SLM Arruda, HJP Branisso, EC Figueiredo, C Gangoni, D Ferreira, LR Del Sarto
myocardial infarction (NSTEMI) and were classified by the TIMI score.Statistical analysis was performed with one-way ANOVA with the Tukey post test and Pearson correlation.Results Of the 203 patients, 92 had unstable angina and 111 had NSTEMI.The mean age was 66.3 years, and 65.5% were men.The details of each group of TIMI score are shown in Table1.The groups that were submitted to angioplasty and myocardial revascularization surgery (MRS) had no mortality.ConclusionThe mortality was higher in the group with clinical treatment.The age was a determinant of higher mortality when compared with the TIMI score.There was no correlation of the TIMI score and mortality.

P52 Influence of obesity in patients admitted with acute coronary syndrome to the intensive care unit SLM Arruda, EC Figueiredo, HJP Branisso, M Amorim
collection was made prospectively.The follow-up was made 6 months after initial hospitalization for evaluation of later death, new cardiac hospital admission and persistence of symptoms after the coronary event.Statistic analysis was performed with Fisher's exact test and the Mann-Whitney test.Results Ninety-six patients with obesity (BMI ≥ 30 kg/m 2 ) were analyzed.The mean age was 61.8 years old (43-90 years), being significantly lower in obese patients than in nonobese patients Available online http://ccforum.com/supplements/11/S3

Table 1 (abstract P51)
Conclusion Obesity predisposes to a higher risk of cardiovascular disease in the young population.Nevertheless, mortality was lower, probably because of the lower mean age of this obese group with ACS.

P53 Evaluation of the percutaneous coronary intervention as a diagnostic or therapeutic tool in 501 consecutive cases of acute coronary syndrome SLM
Introduction Cardiac arrest is the sudden interruption of ventricular and respiratory activities, sufficient equipment for the maintenance of life.Atherosclerosis is the most frequent cause, although in Brazil there is Chagas disease and its arrhythmias.
Arruda, EC Figueiredo, HJP Branisso, P Rodrigues, V Amorim Hospital Santa Lúcia, Brasília -DF, Brazil Critical Care 2007, 11(Suppl 3):P53 (doi: 10.1186/cc5840) Objective The evaluation of the percutaneous coronary intervention (PCI) as a diagnostic or therapeutic tool in patients with acute coronary syndrome (ACS) admitted to an ICU.4%) received a pharmacological stent.The most affected arteries were the anterior descending (58.2%), right coronary (44.8%), and circumflex (24.8%).Seventy-six patients were submitted to coronary artery bypass graft after PCI.Hospital mortality was 6.2%, corresponding to 5.5% of diagnostic PCI and 7.0% of the angioplasty group (P = 0.54).Follow-up was made with 304 or 86.6% of the patients at least 6 months after the initial hospitalization.The mean time of follow-up was 12.68 months Methods A retrospective analysis of 66 adults admitted to our emergency room in cardiac arrest in 2004.A series of clinical and epidemiologic variables was evaluated.They included: sex, age, causes, electrocardiographic rate, comorbidity, and time between the arrest and the beginning of cardiopulmonary resuscitation.Comparison was made between the findings of the retrospective analysis and the literature.The literature search was carried out through the electronic databases Medline and LILACS in January 2007.ConclusionThe average age, the causes and the electrocardiographic rate are concordant with the studied literature.We could not correlate the time between the arrest and the beginning of cardiopulmonary resuscitation with the prognosis.We demonstrated a high rate of mortality, 83%, as in the literature.The unsuitable filling in of the hospital cards did contribute to the small number of analysed cases.However, the results demonstrate the urgency of accurate filling of the hospital charts and also for the publication of this type of research, due to the lack of this information in the literature.

P55 Heart rate variability and pulmonary function behavior in patients undergoing coronary artery bypass grafting and physiotherapy intervention RG Mendes, RP Simões, FSM Costa, CBF Pantoni, S Luzzi, AM Catai, A Borghi-Silva
maximal voluntary ventilation (MVV) were obtained.RMS was measured by maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) obtained by an aneroid manovacuometer (Ger-Ar).All patients had initiated PI after 24 hours of the extubation, following a program of steps previously established.The Friedman test followed by the Dunn post-hoc test was utilized to compare the variables among conditions before and after surgery, and Spearman correlation analysis to verify relationship among RMSSD and pulmonary parameters.The significance level was set at 5% for all analyses.Results Significant correlations were observed between the RMSSD and FVC, FEV 1 , MMV and MIP (r = 0.6) and the RMSSD and MEP (r = 0.7).Table1presents the comparisons among conditions.
Methods Fourteen patients undergoing CABG and PI underwent a prospective study consisting of HRV analysis, spirometry and respiratory muscle strength (RMS) evaluation before and after (1 and 4 days) surgery.The heart rate (HR) and R-R intervals were recorded by the cardiofrequencimeter (Polar S810i), beat-to-beat, in the resting condition and 10 minutes in a supine position.HRV was evaluated in the time domain by the RMSSD index.The spirometry (Vitalograph 2120) was evaluated and the forced vital capacity (FVC), the forced expiratory volume in 1 second (FEV 1 ) and the

Table 1 (abstract P55) Results of heart rate variability and pulmonary function on the preoperative, first postoperative and fourth postoperative days of CABG
†Values as median.*P < 0.05 preoperative vs 1st day postoperative, † P < 0.05 preoperative vs 4th day postoperative.

P56 Preliminary report of an enoxaparin dose protocol based on anti-Xa activity in continuous renal replacement therapy
Acknowledgements This work was supported by grants from FAPESP and CNPq.MethodologyFrom September 2005 to December 2006, 26 patients were submitted to 55 CRRT sessions.All sessions used an enoxparin dose protocol based on anti-Xa activity (target 0.25-0.4U/ml).The endpoints analyzed were the circuit time (hours) to judge efficacy, and death (30-day mortality) and serious bleeding (red cell transfusion) to judge safety.Conclusion In this series, the use of an enoxaparin dose protocol based on anti-Xa activity in CRRT was considered relatively safe and effective.The circuit time of 41 hours was acceptable in effectiveness and efficiency.
mance, optimize circuit survival, and prevent blood loss due to circuit clotting.Unfractionated heparin and low-molecular-weight heparin are generally used to perform this strategy.This anticoagulation may cause dangerous bleeding, however, especially in acute renal critical patients.In these patients, it is very difficult to predict bleeding or thrombosis correctly during CRRT.Objective To asses the safety and efficacy of the use of an enoxaparin dose protocol based on anti-Xa activity in CRRT.

P57 Evaluation of acute renal failure in surgical patients in the intensive care unit EHT Anami, T Matsuo, CMC Grion, TF Perazolo, LTQ Cardoso Hospital
Methods A retrospective observational study conducted in the ICU of a public university hospital during the period January 2004-December 2004.The research was realized in an electronic database and included demographic data, diagnostic, SOFA and APACHE II scores, length of stay in the ICU and mortality.The renal dysfunction was defined as a SOFA score ≥2 (creatinine ≥2 mg/dl or oliguria <500 ml/day).Patients with chronic renal failure were excluded.For statistical analysis, the Epi Info program version 3.3.2was used.Results One hundred and five surgical patients were admitted to the ICU in the study period, male sex was more frequent (55.2%), with a mean age of 53.2 years, mean APACHE II score of 17 ± 7, and length of stay varying from 1 to 65 days (median 3 days).
Universitário, Universidade Estadual de Londrina, Londrina -PR, Brazil Critical Care 2007, 11(Suppl 3):P57 (doi: 10.1186/cc5844) Background Acute renal failure (ARF) is a common and serious complication in the postoperative period of critically ill patients.It occurs, depending on specific definition, in up to 30% of patients submitted to cardiac surgery.Recent evidence suggests that even small oscillations in serum creatinine are associated with significant effects on mortality.The objective of this study is to evaluate the impact of ARF on the morbidity and mortality of surgical patients in the ICU.

Acute renal failure patients submitted to conservative and dialytic treatment in an intensive care unit
Twenty to 25% of ICU patients have acute renal failure (ARF).Dialytic treatment in ARF patients reduces mortality and is well used worldwide.The objective of this study was to analyze ICU patients with a creatinine rate above 1.3 ng/dl who were treated and nontreated with dialysis.The epidemiologic study was of 392 inpatients from the ICU of the HEG where 42% had ARF diagnosed.Only 29.1% were submitted to hemodialysis as inpatients.We can realize the high creatinine rate before dialysis treatment and the lower ICU stay of patients that did not need this treatment.The ARF incidence in the ICU of the HEG was higher than that in the literature, but dialysis was less used.This can be easily explained by the low availability of necessary equipment.Sepsis is the first cause of ARF, but in this study it is the number two cause, especially in dialytic patients.Mortality was similar to other studies.In conclusion, the ARF mortality rate is still high, even with new dialytic treatments.Dialysis is therefore associated with better life quality and less time in hospital.Results GC, male, 29 years old, a cocaine and marihuana user, presented a sudden condition of irritability, aggressiveness and delirious after consuming the drugs.In the subsequent days he presented hyperthermia, jaundice, oliguria, and respiratory insufficiency.He was admitted to the ICU in a severe condition with hypertension, hyperthermia and P/F = 128.Due to anuric ARF, the patient went to daily hemodialysis.Discussion Physiopathologic effects include hemodynamic alterations, failure in the synthesis of glomerular matrix, degradation and oxidative stress and induced renal atherogenesis.Rhabdomyolysis is the main cause responsible for renal injury.It has a high index of mortality and its mechanisms remain unknown.There is evidence that it is intimately related to vasoconstriction due to ischemia, direct toxicity, hyperpyrexia and increased muscular activity.A quick implementation of treatment for convulsions, hyperpyrexia and agitation improves prognosis and decreases complications.The therapeutic goals are removal of precipitating factors, handling of complications and early dialysis.The treatment of rhabdomyolysis is based on hydration, induced osmotic diuresis and urine alkalinization.Conclusion There are few renal injury cases reported in the literature.These generally describe renal infarction after having inhaled the drug, acute interstitial nephritis and cocaine-induced ARF with or without rhabdomyolysis.However, it is imperative that well-designed epidemiologic studies are designed to better elucidate the physiopathology of cocaine-induced renal injuries.
Objectives To describe and analyze the case of a patient with anuric acute renal failure (ARF) due to cocaine overdose.To compare and identify more recent scientific evidence for the treatment.Materials and methods A search and analysis of the case of a patient with anuric ARF treated in the ICU of a public emergency hospital.References 1. Jaffe JA, Kimmel PL: Chronic nephropathies of cocaine and heroin abuse: a critical review.American Society of Nephrology.Clin J Am Soc Nephrol 2006, 1:655-667.2. Bemanian S, Motallebiand M, Nosrati SM: Cocaine-induced renal infarction: report of a case and review of the literature.BMC Nephrol 2005, 6:10.3. Cami J, Farré M: Drug addiction.N Engl J Med 2003,

349:975- 986. Pneumology P60 The influence of different ventilatory modes on the intensity of pulse pressure variation PS Andrade, GA Westphal, M Caldeira Filho
Critical Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America determined with the Vt set at 10 ml/kg.All settings included PEEP of 5 cmH 2 O and a respiratory rate of 15 rpm.The mean arterial pressure and PPV obtained in each ventilatory set are compared with each other using the paired Student t test.Conclusion The pressure-controlled mode should not cause important changes or significant clinical misinterpretation on PPV when compared with the volume-controlled mode during mechanical ventilation.These findings are especially evident when the pressure-controlled mode with the Vt limited at 10 ml/kg (S4 set) is used, demonstrated by the best accuracy on reproducing the PPV obtained during the volume-controlled mode.
Methods A prospective, nonrandomized, observational and comparative study that compares effects on PPV of the VC with another three PC ventilatory settings applied in sedated and mechanically ventilated critically ill patients with an arterial catheter in place.Initial/control setting (S1): VC with tidal volume (Vt) = 10 ml/kg; setting 2 (S2): PC with the peak pressure (Pp) obtained in S1; setting 3 (S3): PC with the Pp set in the plateau pressure level obtained in S1; setting 4 (S4): PC with pressure values P61 Application of a mechanical ventilation weaning protocol in a coronary unit RF Piotto, LN Maia, M de Nassau Machado, SP Orrico Unidade Coronariana do Hospital de Base/Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto -SP, Brazil Critical Care 2007, 11(Suppl 3):P61 (doi: 10.1186/cc5848)Introduction Weaning is the transitional period when a patient under mechanical ventilation (MV) transfers to unassisted spontaneous breathing.Failure in the discontinuation of ventilatory support is associated with an increase in the number of complications.The use of standardized guidelines to carry out weaning is already well established in general ICUs.The conditions most commonly seen in the coronary unit of care (CUC), such as acute myocardial ischemia, left ventricular dysfunction and after coronary artery bypass grafting surgery, however, cause completely different hemodynamic and circulatory alterations to those observed in other types of severely ill patients.The effects of mechanical ventilation and of weaning should therefore be tested specifically for these patients.Objective To compare MV weaning performed according to the application of a series of guidelines versus nonstandardized weaning in patients hospitalized in a CUC.

Table 1 (abstract P63) Respiratory and hemodynamic variables measured with two cycling-off criteria (25% and 40%)
Introduction The possibility of changing the pressure slope during pressure support ventilation is a characteristic of the new generation of ICU ventilators.However, the influence of the slope changes on the respiratory parameters in ICU patients is still under investigation.Objective To analyze the effects of two different pressure slopes (150 or 300 ms) of pressure support ventilation on the respiratory parameters of ICU mechanically ventilated patients.Methods We prospectively evaluated ICU patients recovering from acute respiratory failure that could be comfortably ventilated with pressure support of 15 cmH 2 O, PEEP of 5 cmH 2 O and FIO 2 Critical Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America Conclusion After 2 hours of MV, PEEP = 10 cmH 2 O induced an inflammatory response in rat mesenteric microcirculation. of 40%.The patients were submitted to two different pressure slopes of pressure support with 150 and 300 ms delays.The respiratory rate (RR), expiratory tidal volume (V Te ), minute ventilation (MV), VCO 2 , VTCO 2 , ETCO 2 , SpO 2 , mean arterial pressure (MAP) and heart rate (HR) were measured in these different conditions.Results Comparisons between different pressure slopes did not result in any statistically significant changes for the evaluated variables.There were no significant changes in blood pressure or HR under any experimental conditions (Table1).

Table 1 (abstract P64) Respiratory and hemodynamic variables measured with two pressure slopes
Purpose Unplanned extubation occurs in approximately 1-14% of patients receiving mechanical ventilation.These extubations have widely varying effects on morbidity and mortality.Patients who experience an unplanned extubation in the ICU may experience a survival benefit, provided that they do not require reintubation.Our objective was to document the incidence of unplanned extubations, to discern possible variables predictive of occurrence and outcome, and to formulate preventive measures.These data were compared with the medical literature.Results Of 203 adults intubated in the 24-month period, four (2%) unplanned extubations occurred.Only one was reintubated, and a few hours later the endotracheal tube was removed safely.Three patients were male.Two patients were admitted for trauma.The mean APACHE II score was 17.75 ± 10.47.The patients studied have a RAMSAY scale of 3 (two patients) or 2 (two patients).Unplanned extubation patients were ventilated for 4 ± 0.5 days (range, 4-5 days) before their episode of unplanned extubation.Pressure support (PSV) was the main ventilatory mode in this group.All patients received sedation propofol (two patients) or dexmetedomidine (two patients) during the self-extubation day.All patients were discharged from the ICU.ConclusionOur data suggest that self-extubation is relatively rare in our institution compared with the literature.Trauma patients and the presence of pain should alarm the ICU team for this complication.Staff vigilance and a proper weaning period were some of the factors to which we attributed this low occurrence rate.References 1. Krinsley JS, Barone JE: The

Characteristics and outcomes of patients who self-extubate from ventilatory support
: a case-control study.Chest 1997, 112:

1317-1323. P67 Less fentanyl requirement by enteral methadone decreases mechanical ventilation duration and intensive care unit length of stay R Wanzuita 1 , GA Westphal 1 , ARR Gonçalves 1 , F Pfuetzenreiter 1 , AV Ribeiro 1 , SA Ayres 1 , LF Poli de Figueiredo 2
BrazilCritical Care 2007, 11(Suppl 3):P67 (doi: 10.1186/cc5854) Background Patients exposed to long-term infusion or a high dose of opioids may develop physiological dependence and withdrawal symptoms during its discontinuation.In mechanically ventilated adult patients, the occurrence of fentanyl withdrawal syndrome has been associated with difficulties in discontinuing ventilatory support and with increased length of stay (LOS).

Table 1 (abstract P65) Respiratory and hemodynamic variables measured with two different trigger systems
Results Sixteen patients were included, seven in the MET group and nine in the CT group.The LOS was significantly lower in the MET group (13 ± 3 vs 27 ± 13 days, P < 0.02).Days under mechanical ventilation were also significantly decreased in patients from the MET group (4 ± 0.8 vs 20 ± 21 days, P < 0.05).Conclusion These preliminary data show that, by replacing fentanyl infusion with methadone through the enteral route, it is possible to decrease mechanical ventilation duration as well as the ICU length of stay.

P68 Bilevel plus PSV and nitric oxide as an alternative ventilatory strategy in acute respiratory distress syndrome patients F Saddy, TMF Castelões, HM Mesquita, JLF Costa, JRB Martins, PN Gomes, R Costa-Filho
artery pressure was 56 ± 4 mmHg on vasopressors to maintain a mean systemic arterial pressure above 65 mmHg.The patients were submitted to a recruitment maneuver using a pressure gradient between the PEEP and inspiratory pressure of 15 cmH 2 O during 2 minutes each step to a limit of 60 cmH 2 O, and after that the mean level of PEEP used was 20 ± 3 cmH 2 O and the ventilatory mode was switched to Bilevel plus PSV (derived mode from APRV).The mean Vt/kg used was 5.6 ± 0.8 ml/kg, with an P69 Evaluation of a weaning protocol in an intensive care unit RB Pivoto, M Weiss, F Cabral, T Ojopi, C Faccin, R Affonso, AC Maia, IC Neves, I Small, A Aguiar, A Vianna Clínica São Vicente, Rio de Janeiro, RJ, Brazil Critical Care 2007, 11(Suppl 3):P69 (doi: 10.1186/cc5856)

Table 1 (abstract P71) Clinical and laboratory data
*Data expressed as the mean ± SD. # P < 0.0001.Objective To evaluate healthy young men's heart rate variability with and without noninvasive positive pressure ventilation (NPPV).

Table 1 .
June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America In this retrospective study we evaluated each patient's admission form during the period between January 2006 and February 2007 in a seven-bed chronic ventilatory care unit.The collected data consist of: sex, age, APACHE II score, diagnosis, frequency and type of infection, antibiotic utilization, frequency of hemodialysis, ventilatory parameters, length of stay (LOS), frequency of transference to the ICU and mortality.Results are presented as the mean ± SD and percentage.Conclusion All scales had a substantial agreement, but the RASS and SAS had the best agreement.We believe that the Portuguese version of these two scales can be used in the ICU to evaluate patients' sedation and agitation.
Reference 1. O'Neil KH, Purdy M, Falk J, Gallo L: The dysphagia outcome and severity scale.Dysphagia 1999, 14:139-145.Critical Care Results Sixty-eight patients were enrolled in the study.There were 35 females and 33 males.The mean age and APACHE II score were 74.99 ± 13.97 years and 14.46 ± 5.16, respectively.The main diagnosis was chronic obstructive pulmonary disease (COPD) (42.64%).Pneumonia associated with mechanical ventilation (PAV) was the main source of infection (38.2%), followed by urinary

on stroke prevention, diagnosis, and therapy. Stroke 1989, 20:1407-1431. P78 Delirium impact in a chronic ventilatory care unit
Critical Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America References 1. Brazilian consensus for the thrombolysis in acute ischemic stroke.Arq Neuropsiquiatr 2002, 60:675-680.2.National Institute of Neurological Disorders and Stroke (NINDS): rt-PA Stroke Study Group.Tissue plasminogen activator for acute ischemic stroke.N Engl J Med 1995, 333:1581-1587.3.WHO Task Force on Stroke and Other Cerebrovascular Disorders: Recommendations ObjectivesTo compare the usual clinical assessment for delirium and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), to describe its characteristics in chronically ventilated patients and to evaluate the incidence, associated clinical conditions, length of stay and late mortality.Patients and methods A prospective observational study.Delirium was evaluated on a daily basis and followed by a group of previously trained nurses.Twenty-one tracheotomized, mechanically ventilated, awake and cooperative subjects admitted to the

Table 1 (abstract P76)
ConclusionThe incidence of delirium in this study was less than expected.The CAM-ICU demonstrated inferior sensibility to that described in the literature.The presence of delirium was related to early onset of new infection despite normal inflammatory markers.The main limitation of this study was the low number of patients enrolled.P79Cerebral salt-wasting syndrome in children: a case report OVB Andrade, JLD Gherpelli, MLM Andrea, A Stape, EJ Troster Pediatric Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo -SP, Brazil Critical Care 2007, 11(Suppl 3):P79 (doi: 10.1186/cc5866) Background Some beneficial effects of early enteral feeding (EF) have been reported for the immune response, the infectious complications rate, multiple organ failure and antibiotic usage and the length of hospital stay.Objective To determine the relationship among early feeding practice, mortality and multiple organ failure, considering the prognostic indices such as APACHE II score, SOFA score, and plasma concentration of albumin, CRP, glucose and lactate.Design A cohort study in a general ICU using 65 medical patients requiring intensive care after diagnosis of septic shock or severe sepsis were studied during 18 consecutive months.Methods Enteral tube feeding was initiated as soon as possible, considering the absence of abdominal distention, gastric stasis, hyperglycemia >300 mg or clinical signs of severe hypoxia.Over the first day in the ICU, blood levels of albumin, CRP, glucose and lactate were evaluated and the APACHE and SOFA scores were performed.

Reliability of arterial, capillary and venous point-of-care glucose measurements in the intensive care unit setting: evaluation of two glucometers
Introduction Increased risk of hypoglycemia is the major drawback of strict glycemic control, which has been extensively used in critically ill patients.Fast and precise glucose measurements are therefore mandatory.Our aim was to evaluate the accuracy of two methods of bedside point-of-care testing for glucose measurements using arterial, capillary and venous blood samples in ICU patients.Methods A cross-sectional study with prospective data collection, including 86 patients admitted to a 40-bed clinical-surgical ICU of a tertiary care hospital.Results from two different methods of glucose measurement were compared with central laboratory arterial blood measurements: (1) AccuChek Advantage ® (Roche), arterial, venous and capillary samples; (2) Precision PCx ® (Abbott), arterial sample.All samples were collected simultaneously.Agreement between measurements was tested with the Bland-Altman method.Results Comparisons between pairs of measurements are presented in Table1.

Table 1 (abstract P84)
By monitoring the administration of drugs by an enteral feeding tube in the adult and pediatric ICUs, we have found several factors that could lead to an unsuccessful practice.Since most patients are given continuous enteral feeding, problems such as drugnutrient interactions, tube obstruction, changes in drug bioavailability, and biological risk for the nursing team may occur.In a survey conducted from April to June 2006 in the ICU, 83 pharmacist interventions relating to problems with drugs administered by feeding tube were found.Of these 83 interventions, 23 were associated with absorption problems, 44 with obstruction problems, 15 with drug-nutrient interactions, and one with a biological risk for the nursing team.Objective To implement a procedure to increase clinical pharmacist interventions for drug administration by feeding tube in order to avoid problems with this mode of administration.Materials and methods A patient follow-up form was prepared in June 2006.As of this date, all medical prescriptions containing drugs to be administered by feeding tube were reviewed.A new survey from July to September was carried out to assess the results of the new procedure.Results After the implementation of the follow-up procedure, clinical pharmacist interventions were increased by 100%.Conclusion Complete follow-up of prescriptions containing drugs to be administered by feeding tube by the clinical pharmacist reduces the possible risks related to this practice.

P88 Prognostic evaluation of critically ill patients from the intensive care unit of the Hospital Beneficence Portuguese of Ribeirão Preto MA Martins, EB Massa
Introduction A prognostic evaluation system was developed to measure the clinical severity of patients and to evaluate assistance quality, among other objectives.The APACHE II score (APII) analyses 12 clinical, physiological and laboratorial variables, through which the risk of death can be obtained, translating the patient severity into numerical values.The evaluation of the patient prognosis and the prediction of the risk of death for seriously ill patients are of great importance, requiring adequate intensive assistance.

Evaluation of the nurse care given to critically ill patients through quality indicators
Critical Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America Introduction Patient safety is one of the major concerns of healthcare professionals, especially in an intensive care setting.For identifying risk factors for adverse events and drug-related problems (DRPs), a clinical pharmacy (CP) service in the adult and pediatric ICUs of the Albert Einstein Jewish Hospital (HIAE) was created to work directly with medical prescriptions.This service, started in 2001, assesses factors such as: the route and frequency of administration, dose, compatibility, dilution, drug interaction, adverse drug reactions, allergy, infusion time, and indication.After the acceptance of a pharmacist in this team, in 2005, the clinical pharmacy has been expanded, with one pharmacist in each ICU, and in 2006 the clinical pharmacist has also started to act in procedures managed by the institution.Objective To show progressively the role of a clinical pharmacist in the hospital ICU, and to identify and classify DRPs in these units.Materials and methods A prospective study from 2004 to 2006 of the daily follow-up of patient prescriptions and medical charts at ICUs, identifying and intervening with DRPs.Results According to the goal established by the institution, some indicators such as phlebitis and fall out of the bed were found within the expected rates.The accidental extubation and development of pressure ulcers were very close to the expected numbers.According to Souza and colleagues[1]the daily evaluation and systematic intervention in order to prevent and treat pressure ulcers is a nurse's task.There is a proven relation between assistance quality and pressure ulcer care.The drug-related complications and nasoenteral catheter displacement were above the established limits, requiring specific actions from the ICU team to reduce these problems.As the population ages, the number of diseases related to the elderly increases, having as a consequence an acute complication status that requires ICU admission.Considering that these units are complex and costly, admission of the elderly to ICUs is controversial and is presumed to have a high nursing workload.Based on that, the aims of this study were to compare the nursing workload (Nursing Activities Score (NAS)) and the severity of illness (SAPS II) among elderly patients and to identify predictors of the nursing workload in ICUs.In a prospective study, data were collected from 71 elderly patients (≥60 years) admitted to ICUs in three hospitals in the city of São Paulo, Brazil, in 2004.Objective Specific features of different populations may influence prognostic index results.The literature shows differences in the Available online http://ccforum.com/supplements/11/S3standardized mortality rate (SMR), calibration, and discrimination of such indexes.This study intends to evaluate the capacity of SAPS 3 on predicting ICU patient outcome, using two of its equations -global and Central/South American -and to compare it with the APACHE II score in a general ICU in Brazil.

Table 1 .
ConclusionThe accuracy of the APACHE II score to predict ICU and inhospital mortality in critically ill cancer patients was modest and similar to the described in the literature.The severity of multiple organ failure evaluated through the SOFA score on day 1 and the maximum SOFA score reached a better accuracy to predict both ICU and hospital mortality in an oncologic population.

Is a specific oncological scoring system better at predicting the prognosis of cancer patients admitted for an acute medical complication in an intensive care unit than general gravity scores?
Support Care Cancer 2004, 12

:234-239. P94 Intensive care unit bed shortage leading to a delay in patient admission to public intensive care units LTQ Cardoso, CMC Grion, AM Bonametti, LMD Seko, HB Zampa, GL Ferreira
Their mean age was no different from those who died before admission (57.8 ± 18.33 years).The origin sector was Critical Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America

evolution and prognosis of elderly patients admitted to a medical intensive care unit LS
Introduction Organ dysfunction is a major determinant of morbidity and mortality in the critically ill septic patient.We tried to establish the mortality prediction accuracy of SOFA-derived variables (maximum SOFA, 48-hour ∆SOFA and highest SOFA) in a Brazilian sample of ICU patients.Methods Patients with severe sepsis or septic shock admitted for at least 5 days to a seven-bed medicosurgical ICU from a Brazilian university hospital were studied.The daily SOFA score for each patient was calculated during the first 5 days of admission.Relevant data were prospectively acquired from March 2003 to May 2006, the latter retrieved from an electronic database.Medians and interquartile ranges (IQR) were used to describe the sample.The accuracy of each SOFA-derived variable to predict ICU mortality was calculated as the area under the receiver operator characteristics curve (AUROC).

Morbidity and mortality of the old and oldest-old patients in the intensive care unit FA de Meneses, MM de Alemida, RQ de Souza, AA Peixoto Junior
ResultsThe mean age was 54.0 ± 19.8 years, 52.3% were female and most of patients originated from hospital (51.8%).The APACHE II score was 18.3 ± 8.3 points.The length of stay in the ICU was 6.6 ± 7.4 days and mortality was 34.9%, 3.9% before 48 hours.The SMR was 1.04.In the group of old patients (≥65 years old, n = 416), the mean APACHE II score was 19.5 ± 7.6 points.Respiratory insufficiency, sepsis and acute coronary syndrome were the most frequent reasons for admission

Study of critically ill patients with systemic lupus erythematosus in a Brazilian university hospital intensive care unit FA de Meneses, CAR Feijó, DO Couto, SM Aguiar Hospital
Critical Care June 2007 Vol 11 Suppl 3 Fourth International Symposium on Intensive Care and Emergency Medicine for Latin America Universitário Walter Cantídio, Fortaleza -CE, Brazil Critical Care 2007, 11(Suppl 3):P99 (doi: 10.1186/cc5886) Objective To describe the features and outcome of patients with systemic lupus erythematosus (SLE) admitted to the ICU in a teaching hospital.The SMR was 0.78.Between the patients who were discharged from the ICU, 30.3% were readmitted, with 3% before 48 hours.The patients with an APACHE II score >18, more than three acute organ involvements, leucopenia (<4,000 cells/mm 3 ) and gastrointestinal or metabolic involvement had higher mortality in the ICU.Conclusion Despite the severity of patients with SLE at admission to the ICU (demonstrated by APACHE II score and the acute dysfunctions), they had benefit, as expressed by the SMR.fine membrane opens during inspiration, allowing air to enter the tracheotomy tube, and closes during expiration, so that air is directed to trachea and vocal folds producing a voice.

Table 1 (abstract P107) Variable comparison from RSI in trauma versus nontrauma patients (n = 691)
Background Rapid sequence intubation (RSI) is the gold standard procedure for performing orotracheal intubation in emergency situations.Trying to intubate without RSI can be deleterious because of the hemodynamic and central nervous system reflexes that it causes.RSI may facilitate the establishment of a definitive airway and increase the success rate.Hypoxemia is a major contributor to poor outcomes in head-injury patients, and prehospital intubation can improve survival.Trauma patients who are managed using early intubation have been shown to have improved outcome.RSI in a prehospital environment is still little reported and used because of concern for respiratory paralysis and the possibility of nonintubation situations with a nonanesthetist and paramedics.Objective To analyze the efficiency, safety and complications of RSI, in a protocol-driven study, in a prehospital environment.Methods A retrospective, observational, protocol-driven study, which included all RSIs from 1998 to 2003.RSI was defined when at least one sedative followed by a neuromuscular blocking agent were administered together before orotracheal intubation.Intubations with sedative or neuromuscular blocking agents alone were excluded.ResultsA total of 696 patients were enrolled.Five patients were excluded because of incomplete data.In 621 patients, trauma was Available online http://ccforum.com/supplements/11/S3leadingindicationfortheprocedure, with a success rate of 99.1%.In 0.9% (six patients) orotracheal intubation was not possible: two cases were treated by bag-valve-mask-assisted ventilatory support and four with surgical cricotiroidostomy (all of them with facial trauma; one dead).In the remaining 70 patients with nontraumatic indications, the success rate was 100%.In 364 patients from 1998 to 2001 the RSI was performed by nonanaesthetist doctors in 95.9%.In 588 patients (except 2002), the leading sedative used was ethomidate in 68.7% whereas the neuromuscular blocking agent was succinilcholine in 74.5%.Table1presents a data variable comparison from RSI in trauma versus nontrauma patients.Table2presents a data variable comparison from RSI in successful intubation versus failed intubation groups.Conclusion RSI is efficient, safe and with lower incidence of complications in achieving orotracheal intubation during the prehospital environment, in a protocol-driven series, and could be performed by nonanaesthetist doctors.In cases of trauma, mainly facial, and failure of orotracheal intubation, a surgical airway should be promptly available as a rescue technique. the

11(Suppl 3):P109
(doi: 10.1186/cc5896) Background Dissociative anesthesia is usually performed in a hospital setting.The advantages of ketamine are respiratory and hemodynamic stability, low price and worldwide availability.Its use in the emergency room is safe, but use in a prehospital environment is less known and less reported.Objective To analyze the safety and complications of dissociative anesthesia guided by an institutional protocol in a prehospital environment.Methods A retrospective, observational series, protocol-driven study with dissociative anesthesia with ketamine plus midazolan from 1998 to 2004 (excluding 2000, because no available data).

Table 1 (abstract P109) Variable comparison between groups 1 and 2
ConclusionDissociative anesthesia is a safe procedure even in a prehospital environment when performed in a group of patients with GCS 14 or 15 after implementation of an institutional protocol.Proficiency in definitive airway techniques is necessary.Improvement in the quality of attendance and humanization of the EMS are best performed by introducing analgesia protocols into the prehospital environment.

Table 4 (abstract P108) AST and ALT mean admission values in surgical and nonsurgical patients
with GSW of the liver, nonoperative treatment carries great controversy.Objective To report two cases of nonoperative treatment of GSW of the liver with hemodynamic instability guided by an institutional protocol in the emergency department.Methods Case reports.Results Case 1 A 37-year-old male patient became hemodynamically unstable and had systolic blood pressure of 90 mmHg 12 hours after admission on an institutional protocol to the emergency department.After infusion of 1,500 ml saline solution the patient rapidly became stable and 2 units red blood packed cells were administered.The abdominal CT scan showed injuries in segments 5, 6, 7 and 8.The control abdominal CT showed good evolution.Case 2 An 18-year-old female patient suffered an isolated GSW in the right hippocondrius.The patient was admitted to the emergency room with hemodynamic instability, systolic blood pressure of 80 mmHg, cardiac frequency of 128, agitated and without verbal response.After infusion of saline solution the patient rapidly became stable and 2 units red blood packed cells were administered.The abdominal CT showed injuries in segments 7 and 8.A control abdominal CT was not necessary.Conclusion Nonoperative treatment of GSW of the liver with hemodynamic instability is possible in selected young patients, who rapidly became stable after initial fluid reanimation, in the emergency room and guided by an institutional protocol.

P111 Emergency department decompressive laparostomy secondary to abdominal compartment syndrome BF Belezia, RG Freitas, AM Neiva, MMA Andrade, T Duarte, AP Antunes, TR Diniz, I Dellandrea, LT Carvalhido, MAB Cristino, BCV Lemos, CL Menezes, IFM Pereira
Background Abdominal compartment syndrome (ACS) is a multietiology disease secondary to traumatic and clinical conditions.It is defined by elevated intra-abdominal pressure, usually above 25 cmH 2 O (Grades 3 and 4 intra-abdominal hypertension) associated with clinical signs of organ failure (respiratory, circulatory and renal).The measurement of intra-abdominal pressure is done through an intravesical catheter.The typical patient candidate for ACS usually has emergency abdominal surgery, shock and has received a massive amount of fluids and transfusion during initial resuscitation.Objective To report two cases of nontraumatic ACS in the surgical emergency department.Methods Case reports and literature review.Results Case 1 A 49-year-old female with an acute abdomen and chronic use of warfarin for a deep venous thrombosis of a lower extremity.The abdominal computed tomography (CT) scan showed a large pelvic hematoma with displacement of the bladder.The patient was treated initially with a conservative approach, but 12 hours after admission developed respiratory failure, shock, oliguria and abdominal distension.She was submitted to an endotracheal intubation and mechanical ventilatory support.The intra-abdominal pressure was 50 cmH 2 O and a laparotomy was indicated.The hematoma was stable and was not explored.A laparostomy with two layers of a plastic bag was fixed according to an institutional protocol.In the postoperative period she was shifted to the ICU for 12 days, with gradual improvement of the condition and progressive laparostomy closure.Case 2 A 70-year-old female was admitted to the emergency room 'in extremis', with abdominal distension, and developed cardiopulmonary arrest with important ventilatory restriction.An emergency department laparostomy with two layers of a plastic bag was fixed according to an institutional protocol.Following abdominal opening, immediate relief in restrictive ventilatory insufficiency was noted on a bag-valve-mask.A diagnosis of mesenteric ischemia was made and the patient died 24 hours later.Conclusion Emergency department laparostomy can be a primary lifesaving procedure in patients with ACS and could be carried out, even in the emergency room, together with cardiorespiratory resuscitation.Background Because ventilation and endotracheal intubation can be life saving for a patient in respiratory distress, airway management is among the key requirements of appropriate therapy in emergency and critically ill patients.Medical simulation used in combination with traditional training methods can provide a comprehensive learning opportunity that allows the clinician to safely learn, practice, and repeat the procedure until proficiency is achieved.Objectives To address the use of medical simulation as a way for medical learners to acquire and maintain the skills needed to manage difficult airways.To evaluate the students' satisfaction with the course.Methods The study was performed at Berkeley Training Center -Brazil, between August 2005 and February 2007, with a total number of 311 trainees.Trainees received a baseline evaluation followed by an 8-hour training session that involved an introductory lecture, a computer-enhanced mannequin simulator, clinical scenarios for training procedural skills in a difficult airway algorithm, and instructor-facilitated debriefings.After finishing the course, the trainees were retested and completed a numerical scale survey of their perceptions about our course (1 = poor, 2 = fair, 3 = good, and 4 = excellent).Results Performance improved significantly after simulator training (48.5% vs 72.7%, P < 0.001).Seventy-five percent of participants scored less than 60% in the baseline evaluation, while only 25% scored less than 65% in the retest.The course was considered excellent by 70% of the participants and good by 29%.Conclusion The extremely positive response to simulation-based training on airway management found in this pilot study suggests that this training modality may be valuable in the training of medical students and physicians.Simulation-based training is expected to become routine in many healthcare settings in the coming decade.