Severe imported malaria: a case report

BACKGROUND AND OBJECTIVES
Malaria is still considered a major global health problem. The severity form of the disease is caused, mainly by P. falciparum and may occur together with cerebral, kidney, pulmonary, hematologic, circulatory and hepatic complications. This report is about a patient with a case of severe imported malaria.


CASE REPORT
A 30-years-old man, mulatto, Philippine, sailor, coming from a ship arriving from Nigeria, with a history of abdominal pain on the right hypochondrium, jaundice, fever, decreased in the consciousness. Lab tests made upon his admission showed hyperbilirubinemia at a level of 50 mg/dL, severe metabolic acidosis, thrombocytopenia, creatinine levels of 5.6 mg/dL and leukocytosis with deviation through metamyelocytes. The APACHE II score was 37, with death estimated risk of 88%. During his stay at the hospital, P. Falciparum Malaria was diagnosed through the thick drop test. And, even with the adequate anti-malaria therapy, the patients condition evolved to an acute renal failure requiring hemodialis; acute respiratory distress syndrome (ARDS); septic shock, and hematological disorders, forming a multiple organ dysfunction syndrome (MODS). After being discharged from the hospital, the patient did not present any cerebral, pulmonary or kidney sequel.


CONCLUSIONS
From the criteria described in medical literature to define critical malaria, the patient fulfilled the following: acute renal failure, ARDS, metabolic acidosis, altered level of consciousness, macroscopic hemoglobinuria, hyperparasitism and hyperbilirubinemia, related to a lethality rate of over 10%, depending on early treatment and available resources. Severe malaria requires fast diagnosis allied to a quick access to an intensive care treatment, since any delay increases the morbid-mortality of the disease.

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.
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'. 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.
Background Pulse pressure respiratory variation (PPV), which is the difference between the maximal and minimal arterial pulse pressure values after each positive-pressure breath, is largely used for early identification of hypovolemic status. Increased PPV observed in hypovolemia results from exaggerated respiratory variation in transpulmonary blood flow that results in corresponding left ventricular preload variations during respiratory cycles. Hence, any modulations that affect the left ventricular preload would influence PPV.
Objective To test the hypothesis that PPV amplification observed in hypovolemia can also be detected after pulmonary thromboembolism obtained with central venous injection of blood cloth.
Methods PPV was studied in five anesthetized and mechanically ventilated male rabbits weighing 1.6 ± 0.3 kg. The heart rate (HR) and mean arterial pressure (MAP) were monitored after central venous (jugular) and arterial (carotid) catheterization, and 1.5 ml/kg autologous blood cloth were injected slowly through the jugular catheter into the central circulation. The HR, MAP and PPV were registered before and after blood cloth injection and compared using the Student t test.

Results
The HR did not change, but the MAP was significantly lowered as much as PPV significantly increased after cloth injection. See Table 1. Conclusion PPV amplification observed in hypovolemia can be also detected after pulmonary thromboembolism obtained with central venous injection of blood cloth. It is possible to conclude that pulmonary hypertension should be assumed as a limitation for cardiovascular fluid responsiveness determination by PPV.

P9
Pharmacological vasodilatation increased pulse pressure variation mimicking hypovolemic status in rabbits Introduction Volume replacement is one of the cornerstones in the management of sepsis. The type and amount of fluid are still controversial. Hypothesis A hypertonic isoncotic solution could promote superior hemodynamic benefits as the initial fluid regimen than standard crystalloid resuscitation, and mixed venous oxygen saturation could be useful to guide fluid administration in experimental sepsis. Methods Anesthetized mongrel dogs received an intravenous infusion of 1.2 x 10 10 cfu/kg live E. coli in 30 minutes (T0-T30).
After 60 minutes (T90), the dogs were randomized to receive isotonic saline solution, 32 ml/kg over 20 minutes (NS, n = 7) or 7.5% hypertonic isoncotic solution (Hyper-Haes) 4 ml/kg over 5 minutes (HH, n = 7). After 30 and 60 minutes (T120 and T150), additional isotonic saline solution 32 ml/kg was administered if mixed venous oxygen saturation was below 70% in both groups. the mean arterial pressure (MAP), cardiac output (CO) and portal blood flow (PVBF) were monitored; blood gases and lactate levels were analyzed at each timepoint. Results See Table 1. Data are expressed as the mean ± SEM. Conclusion Both solutions promoted similar and partial benefits at systemic and regional levels in this hypodynamic sepsis model. Although initial fluid requirement after HH was lower than NS, overall fluid infused was not statistically different between groups (HH 31.4 ± 10.9 ml/kg vs NS 50.3 ± 6.5 ml/kg). Acknowledgement Supported by FAPESP 05/51176-5. 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.
Available online http://ccforum.com/supplements/11/S3 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. 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. References 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.  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. Materials and methods Ten anesthetized and ventilated mongrel dogs (17-25 kg) were subjected to BD, by brainstem herniation, induced through an intracerebral balloon filled to maintain intra-Available online http://ccforum.com/supplements/11/S3  S8 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.
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. 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). 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. 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.
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. Introduction 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.

Results
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. Methods A before-after study design with prospective consecutive data collection in a 124-bed private medical center. 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).

P22
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 Components of SBE on the first day.
was examined at the mesenteric lymph nodes (MLN), liver and spleen by culture in MacConkey medium. Control groups were the sham group (Sham-G, saline injection) (n = 18) and the naïve group (N-G, without any procedure) (n = 6).
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 Increasing evidence suggests that bacterial translocation (BT) has been implicated in the pathogenesis of sepsis and multiple organ failure. In this study we examined the role of the mesenteric lymph during the BT process on the intestinal and systemic tissue perfusion in association with nonlethal sepsis. Materials and methods Adult Wistar rats (±200 g) were submitted to the induction of BT (E. coli R6 10 ml of 10 10 CFU/ml), sepsis (E. cloacae 89 2 ml of 10 7 CFU/ml, i.v.) and sepsis plus BT, with or without interruption of the mesenteric lymph flow by mesenteric lymph node resection and lymph duct ligature 5 days prior to the experiments. The tissue perfusion (jejunum, ileum, liver and kidneys) was monitored (laser Doppler) before and 2 hours after the inoculation. Groups (n = 16/group): BT group (BT-G); BT with lymphadenectomy group (BTL-G); sepsis group (S-G); sepsis with lymphadenectomy group (SL-G); combination of sepsis plus BT group (C-G); combination with lymphadenectomy group (CL-G); sham BT group (SBT-G); sham sepsis group (SS-G); and sham combination group (SC-G).

Results
Following BT induction, with or without sepsis or lymphadenectomy, the bacterial recovery was 100% in all groups. A significant and similar reduction of the tissue perfusion was observed in all organs in BT-G (P < 0.0001) and C-G (P < 0.0001). However, with lymph interruption (BTL-G and CL-G), the tissue perfusion drop was completely abrogated and was as similar as the respective sham groups ( Figure 1). Mortality of 50% (LD 50 ) was observed only in C-G.

Conclusion
The components of the mesenteric lymph during the BT process were a determinant factor related to the impairment of the splachnic and systemic tissue perfusion index possibly by gutassociated tissue activation, suggesting a possible participation of BT in the genesis of the hypodynamic state of 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. nmol/ml. No significant difference was found related to retinol levels, TBARS and APACHE II 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.

Evaluation of the source of infection in patients with severe sepsis
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.  Mean tissue perfusion units (∆%) of sham and BT groups. S13 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).

Methods and results
Balb/c mice were pretreated with vehicle or with specific HO-1 inhibitor (ZnPPIX, 30 mg/kg, s.c.) and subjected to S-CLP. Mice were killed 6 hours after CLP, and HO-1 expression in the mesentery and in circulating neutrophils were determined. In another set of experiments, mice were sacrificed 6 and 12 hours after sepsis induction, and intraperitoneal neutrophil migration, bacteremia, lung neutrophil sequestration, cytokines and mean arterial pressure were evaluated. A significant increase in HO-1 expression was observed in the mesentery and in circulating neutrophils of mice pretreated with vehicle and subjected to S-CLP. The inhibition of HO-1 prevents the failure of neutrophil endothelium rolling, adhesion and migration observed in animals pretreated with vehicle and submitted to S-CLP. As consequence, the HO-1 inhibition promoted a reduction of bacteremia, low levels of circulating cytokine and lung neutrophil sequestration, and improves the mean arterial pressure, resulting in an increase of the survival rate.
Conclusion These data suggest that during an infectious process HO-1 displays a crucial role in the failure of neutrophil migration to the infectious focus, and consequently in the susceptibility in severe sepsis. Acknowledgements Supported by FAPESP/CAPES/FAEPA.

Results
The average age was 83 ± 8 years (minimum = 60, maximum = 99) and 65% were female. Septic shock represented 71% of cases and the mortality was 44%. The average length of ICU stay was 16 ± 9 days (minimum = 1, maximum = 28). The average APACHE II score was 19 ± 6 (minimum = 6, maximum = 44) and the average SOFA scores on days 1, 3, 5, 7, 14, 28 were 8 ± 3, 8 ± 4, 7 ± 4, 7 ± 3, 8 ± 3, respectively. The variables associated with mortality were: SOFA score on days 1, 3, 5, 7, 14 and 28 (P = 0.00010), CRP on days 5, 14 and 28 (P = 0.03, P = 0.005 and P = 0.02, respectively), lactate on days 14 and 28 (P = 0.023 and P = 0.005), albumin on days 14 and 28 (P = 0.00010), APACHE II score (P = 0.44), presence of two or more organic failures (P = 0.0001), need for mechanical ventilation (P = 0.001) and length of ICU stay (P = 0.002). 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.

Introduction
The Surviving Sepsis Campaign is an international effort to reduce severe-sepsis-associated mortality. We have decided to implement the recommendations proposed by the Campaign through a management protocol in our institution.
Objective To describe the impact of the Surviving Sepsis Campaign recommendations on mortality in severe sepsis patients admitted to the ICU.

Methods
The study was conducted within the emergency department and ICU of a tertiary hospital in Brazil. A management protocol for the care of severe sepsis and septic shock based on the Surviving Sepsis Campaign guidelines was implemented by a 'sepsis' team comprising emergency department physicians, pharmacists, and critical care physicians, chaired by a coordinator. Also, we have used the individual collected data proposed by the Surviving Sepsis Campaign to obtain information about quality indicators. Results A total of 160 patients with septic shock were identified. Ninety-four patients were managed before the implementation of the standardized protocol, constituting the Control group, and 66 patients were evaluated after the implementation of the standardized protocol (Intervention group). Demographic variables and severity of illness scores (APACHE II and SOFA) were similar for both groups. Patients in the Intervention group showed statistically significant larger numbers of cultures obtained, earlier antibiotics and a more rigorous glucose control. In addition, those patients received more corticoids and activated protein C. The ICU and hospital lengths of stay were similar in both groups. The hospital mortality rate was significantly lower in the after group (56.4% vs 37.9%, P < 0.05). Conclusion The implementation of the Surviving Sepsis Campaign guidelines through a standardized protocol was associated with improved patient care and a reduction in severe-sepsis-related mortality.   S15 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. Conclusion The active surveillance program among high-risk patients resulted in the complete control of the VRE outbreak at our institution.  [1], patients with at least two positive sites and sepsis or with total parenteral nutrition or a recent surgical intervention received antifungal treatment (fluconazole or Caspofungin)preemptive treatment. The incidence after the Candida score implementation was reduced from 1.91 (2/1,049 patient-days) to 0.92 (1/1,081 patient-days) with no statistical significance (P = 0.3). Conclusion In this preliminary report, the Candida score seems to be a helpful tool to reduce the incidence of Candida infections in a general critical care unit. In a large population, the use of the Candida score system may assist in identifying candidates for preemptive antifungal treatment among the critical care population. Background Ventilator-associated pneumonia (VAP) is an airways infection that must have developed more than 48 hours after the patient was intubated. VAP is the leading cause of death among hospital-acquired infections, exceeding the rate of death due to central line infections, severe sepsis, and respiratory tract infections in the nonintubated patient. The hospital mortality of ventilated patients who develop VAP is 46%, compared with 32% for ventilated patients who do not develop VAP. Reducing mortality due to VAP requires an organized process that guarantees early recognition of pneumonia and consistent application of the best evidence-based practices. The Ventilator Bundle is a series of interventions related to ventilator care that, when implemented together, will achieve significantly better outcomes than when implemented individually. Objective To evaluate the implementation effect of a VAP bundle in a general ICU, with the utilization of homemade software designed for this purpose (http://www.bundle.com.br).

Application of a new
Methods In a 15-bed general ICU, implementation of the bundle was done over 3 months beginning in January 2006. The key components of the VAP bundle are: elevation of the head of the bed; daily sedation interruptions; a ventilation tube with a subglotic aspiration system; peptic ulcer disease prophylaxis; deep venous thrombosis prophylaxis; an oral feeding tube instead of a nasal feeding tube; and oral hygiene with chlorexidine twice a day. We compared the incidence density rate from April to December 2005 with the same period in 2006 (Software Stata 8.0).

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.

Introduction
The widening of the QTc is a mortality predictor in acute coronary syndromes and cerebral vascular accident.
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. 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. 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.

Implementation of evidence in clinical practice for prevention of thromboembolic events in intensive medicine
Conclusion The 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.

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.
Results The mean door-to-ECG time was 6.7 ± 12.6 minutes for men and 12.7 ± 21.8 minutes for women (P = 0.007). Women were older (72.3 ± 13.6 years vs 65.2 ± 13.9 years, P < 0.0001), had a lower prevalence of ST-elevation myocardial infarction (STEMI) (20.5% vs 79.5%, P < 0.0001) and tended to present less often chest pain on admission (47.1% vs 58.2%, P = 0.05) in comparison with men. 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.
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  Background Emergencies in cardiology are 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 procedures until proficiency is achieved.
Objectives (1) To address the use of medical simulation as a way for medical learners to acquire and maintain skills needed to manage emergencies in cardiology. (2)  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).

S20
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.

P48
Relationship between B-type natriuretic peptide plasma levels and echocardiography parameters in compensated chronic heart failure patients treated with levosimendan 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. Results We retrospectively analyzed 37 consecutive CHF patients to whom levosimendan was prescribed by the attending physician besides standard measures. BNP levels were significantly lower within 72 hours of levosimendan treatment (P < 0.01). A significant reduction of PAP (P < 0.05) was also found during the same period. A good correlation between the levosimendan-induced changes in LVEF and the respective reduction of BNP levels (P < 0.01) was observed.

Conclusion
Our results indicate that changes in BNP levels may be useful as biochemical markers of levosimendan-induced improvement in echocardiographic and clinical parameters. Background Thrombocytopenia is a common problem in the ICU and in cardiovascular patients. It has been considered to play a role in 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. 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. and the 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). Table 1 presents the comparisons among conditions.

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. Acknowledgements This work was supported by grants from FAPESP and CNPq. Background During continuous renal replacement therapy (CRRT), anticoagulation of the extracorporeal circuit is generally required to prevent clotting of the circuit, preserve filter performance, 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.

Nephrology
Objective To asses the safety and efficacy of the use of an enoxaparin dose protocol based on anti-Xa activity in CRRT. 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.

Methodology
Introduction Cocaine is a social and medical problem. In the United States, 14.6% of a trialed population has already used cocaine. The physiopathology of the renal injury is multifactorial and largely remains unknown, and rhabdomyolysis is most frequently responsible for the renal injury.
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.
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. Background Pulse pressure variation (PPV) has been recommended to evaluate the cardiac responsiveness to fluid infusion in mechanically ventilated patients with sepsis shock or following cardiac surgery. The recommendation is that PPV measurements must be performed during the volume-controlled ventilatory mode (VC) and not with the pressure control mode (PC).
Objective To test the hypothesis that the PC should not cause an important change on PPV when compared with the VC during mechanical ventilation. 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 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. 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. 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. Results After 2 hours of MV, there were no differences between PEEP0 and PEEP5 in the number of rolling leukocytes/10 minutes (127 ± 16 and 147 ± 26, respectively), adherent leukocytes/ 100 µm (3 ± 1 and 4 ± 2, respectively), migrated leukocytes into the perivascular tissue/5,000 µm 2 (2 ± 1 and 2 ± 1, respectively) and total white blood cells/mm 3 (11,730 ± 2,856 and 10,200 ± 2,222, respectively). However, the PEEP10 group presented an increased number of rolling leukocytes (188 ± 15 cells/ 10 min, P < 0.05), adherent leukocytes (8 ± 1 cells/100 µm, P < 0.05), migrated leukocytes (12 ± 1 cells/5,000 µm 2 , P < 0.05) at the mesentery, and an increased number of total white blood cells (18,786 ± 4,207 cells/mm 3 , P < 0.05), basically neutrophils. 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. Conclusion After 2 hours of MV, PEEP = 10 cmH 2 O induced an inflammatory response in rat mesenteric microcirculation. 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).
Available online http://ccforum.com/supplements/11/S3 Objective We tested the hypothesis that enteral methadone can reduce fentanyl requirements and, thereby, decrease mechanical ventilation duration and ICU LOS. Methods A prospective, randomized and double-blind study involving patients fulfilling criteria for weaning from mechanical ventilation but under high risk for fentanyl abstinence syndrome (defined as continuous fentanyl for more than 5 days or more than 5 µg/kg/hour during 12 hours). Patients were randomized into two groups, methadone (MET) group and control (CT) group, as follows: for the first 24 hours both groups were given 80% of the original dose of fentanyl and received, additionally, in the MET group enteral methadone (10 mg each 6 hours) or in the CT group enteral placebo. After the first 24 hours, the MET group received enteral methadone and intravenous placebo while the CT group received enteral placebo and intravenous fentanyl. In both groups, the blinded intravenous solutions were reduced by 20% of the original dose, every 24 hours. Any abstinence symptoms were treated with a bolus of fentanyl. The Student t test was used to compare groups in the following criteria: (1) days under mechanical ventilation and (2) ICU LOS. 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. The protective ventilatory strategy provided by usual ventilatory modes is a cornerstone factor to determine prognosis in acute respiratory distress syndrome (ARDS). However, there are situations where alternative strategies must be used. We describe three patients, all females with a mean age of 76 ± 6 years, admitted to the ICU presenting ARDS related to communityacquired pneumonia (two patients) and pneumonia secondary to gastric aspiration (one patient). The mean APACHE II score was 25 ± 2. The ventilator used was the Puritan-Bennet 840. The mean static compliance (Cst), paCO 2 and PaO 2 /FiO 2 ratio after orotracheal intubation in the VCV mode and a PEEP level of 10 cmH 2 O were 24.3 ± 3.1, 48 ± 4 mmHg and 120.6 ± 46, respectively. All patients presented septic shock and were monitored with a Swan-Ganz catheter. The initial mean pulmonary 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 inspiratory pressure level of 30 ± 2 cmH 2 O and I:E ratio of 1:1. The mean PaO 2 /FiO 2 ratio was raised to 153 ± 25 (26.8%). Nitric oxide (NO) was started and the mean concentration used was 37 ± 3 ppm. After 4 hours, the mean pulmonary artery pressure and PaCO 2 decreased to 40 ± 4 mmHg (28.6%) and 42 ± 2 mmHg (12.5%), respectively, and the PaO 2 /FiO 2 ratio increased to 268 ± 22 (122.2%). After 24 hours NO was decreased to 18 ± 4 ppm, and was discontinued 12 hours after. Two patients were successfully weaned from mechanical ventilation after 8 and 10 days, respectively, and discharged home afterwards. One patient died. This series of cases was the first that depicted the Bilevel plus PSV mode wholly with NO to control pulmonary hypertension and ARDS. These interventions seems to be beneficial and feasible to support critically ill patients, mainly those who failed to respond to recruitment maneuver and conventional ventilatory modality.  Conclusion MRS and PEEP at 25 cmH 2 O were able to minimize collapse and TR, while ventilation with PEEP 10 cmH 2 O did not prevent TR. This finding suggests that low PEEP, even associated with low volumes and pressures, is a suboptimal protective strategy.

Maximal recruitment strategy guided by thoracic computed tomography scan in acute respiratory distress syndrome patients: preliminary results of a clinical study
Introduction There is great controversy concerning protective ventilatory strategy in ARDS. Recruitment maneuvers and PEEP Available online http://ccforum.com/supplements/11/S3   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. Objective To evaluate healthy young men's heart rate variability with and without noninvasive positive pressure ventilation (NPPV). 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%.
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 ± 0.2 vs 0.8 ± 0.2) and HF bands lower values (0.4 ± 0.2 vs 0.2 ± 0.2) during NPPV compared with spontaneous breathing. Conclusion The NPPV application produced autonomic modulation adjustments, with a parasympathetic cardiac activity reduction and a sympathetic increase in healthy male youngsters. 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. Reference 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.

Profile of deglutition speech evaluation in an intensive
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. References 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. 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.

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. 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 S34 impact 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. Conclusion This study contributes to reinforcing the conclusions from other authors that have shown a trend towards the reduction of morbi-mortality of patients with acute pancreatitis that received early enteral nutrition. 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.
Introduction Strict glycemic control has been recommended for critically ill patients. However, its implementation may face difficulties with increased nursing workload, inadequate glucose control and higher risk of hypoglycemia.
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. 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 Table 1.

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.

S36
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. Enteral 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. 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.

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. Objective To improve nurse care given to patients in the ICU through the systematic collection of data from six previously defined quality indicators. Methods Retrospective analysis of six quality indicators (phlebitis, falls out of the bed, accidental extubation, drug-related complications, pressure ulcer and accidental nasoenteral catheter displacement) from a 10-bed medical ICU in a private hospital, which were collected daily by nurses from the data found in the patient's medical register. A monthly critical and statistic evaluation of these data was accomplished in order to develop an action plan. 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. Conclusion The rates presented through the analyses of the quality indicators shows specific failures in nurse care. The action plan to correct these failures consists of continued education with close monitoring of the quality indicators to assure better results, regarding increased patient safety. Reference

Introduction
The number of acute organ failures has been shown to be an important determinant of prognosis in critically ill cancer patients admitted to an ICU [1]. Although the SOFA score is useful in analyzing the number and the severity of acute organ failures related to ICU mortality, it is not validated to predict outcomes in the ICU. On the other hand, general prognostic models have failed to accurately predict outcomes in the oncologic population [2,3]. Given this, we propose to analyze the ability of the SOFA score compared with the APACHE II score in predicting ICU and inhospital mortality in oncologic patients. Methods ICU data from a tertiary university hospital were prospectively collected from March 2003 to November 2005. Oncologic patients with an ICU admission longer than 24 hours were selected. The SOFA and APACHE II scores were retrieved from our prospectively acquired database. The accuracy of the APACHE II, first-day SOFA (SOFA1) and maximum SOFA during the entire ICU admission (mSOFA) scores were analyzed through the area under the ROC curve (AUC). Results Seventy out of 793 patients had an oncologic diagnosis. Eleven patients were excluded due to an ICU length of stay less than 24 hours. One patient had missing SOFA data. Of the 58 analyzed patients, the mean age was 52 ± 18 years, male gender 53%, medical admission 74%, hematological malignancies 50% and mean APACHE II score 20 ± 8. The ICU mortality was 43% and the inhospital mortality was 65%. The accuracy of the scores for mortality prediction is presented in Table 1.
Conclusion The 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.
Introduction ICU bed shortage is a daily problem that leads to delayed ICU treatment for those with an extended waiting time. This population is thought to have a bad prognosis, mainly those from wards. The objective of this study is to identify whether the delay between reference and ICU admissions caused by an ICU bed shortage could lead to a higher mortality rate in ER patients. 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]. The length of stay was 6.5 ± 3.9 days (P > 0.05). Conclusion Old age was not associated with a high fatal outcome or length of stay in ICU. However, mortality in patients aged 85 years or more was higher than expected. The APACHE II score could allow an early identification of patients at high risk of death, even in old and oldest-old patients. A prospective assessment is mandatory to confirm these preliminary data. Objective To verify patient perception of the speaking-valve benefits and compare it with available literature data.

P99
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. . 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. 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.

P105
The  S43 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).

Results
The 0.5 group demonstrated a tendency to improve tonometric indicators: increased the pHi and decreased the gap CO 2 , but reached no statistically significance. The IRVS decreased in T1 in the 0.5 and 0.05 groups (P < 0.05), remaining reduced at T2 in the 0.5 group (P < 0.05).

Conclusion
The epidural with levobupivicaine 0.5 or 0.05 in pigs submitted to intestinal manipulation had no statistically significant alterations in the tonometric indicators compared with the control group. The pHi and gap CO 2 had a tendency to a better performance in the 0.5 group associated with better hemodynamic parameters. References 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. 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.  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.

P107
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). 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.  Conclusion Dissociative 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. 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 Contrast blush within liver parenchyma None 0 Segments according to Couinaud's anatomy.  S46 dynamically unstable patient 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.

AST and ALT mean admission values in surgical and nonsurgical patients
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. 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.