9th International Symposium on Intensive Care and Emergency Medicine for Latin America

P01 Complications associated with the use of temporary pacemakers in hospitalized patients awaiting definitive implant procedure in a public hospital in Sao Paulo Andres Eduardo Larrovere Vasquez, Aymée Lustosa Nogueira Torres, Paulo Vinicius Prates Silva, Ana Helena Vicente Andrade, Luciana Gioli-Pereira HMBM Hospital Municipal Dr Moyses Deutsch, São Paulo, SP, Brasil Critical Care 2017, 21(Suppl 2):P01

Introduction: Weekend admission is considered a risk factor for worse outcomes in critically ill patients, but more robust information on the underlying mechanisms related to intensive care unit (ICU) organization is still lacking. Objective: To assess whether ICU organizational and staffing patterns could explain the association between weekend admission and outcomes in critically ill patients. Methods: Retrospective cohort study using the ORCHESTRA study database [1] comprising 59,614 patients admitted to the participant ICUs during 2013. The association between weekend admission and hospital mortality was assessed using mixed logistic regression adjusting for clinically relevant patient-level (age, severity of organ dysfunctions, comorbidities, performance status; admission type and length of hospital stay before ICU admission) and ICU-level (use of checklists on weekend; 24/7 full-time intensivists; nurse/bed ratio; unit type and number of protocols) characteristics. Results: 41,894 patients (70.3%) were admitted on weekdays and 17,720 patients (29.7%) were admitted on weekends. In univariate analysis, weekend admitted patients had higher ICU (10.9% vs. 9.0%, p < 0.001) and hospital (16.5% vs. 13.5%, p < 0.001) mortality rates. After regression, weekend admission was not associated with higher hospital mortality (OR 1.05, 95% CI 0.99-1.12, p = 0.095). However, a "weekend effect" was still observed in scheduled surgical patients, as well as in ICUs not holding checklists and with a decrease in nurse/bed ratio during the weekends. In addition, units with a lower number of implemented protocols had also higher mortality for patients admitted during the weekends. For unscheduled admissions, no "weekend effect" was observed regardless of ICU´s characteristics. Conclusions: Weekend admissions were associated with higher mortality in certain situations related to potentially modifiable patients' and centers' features, representing an opportunity to improve ICU performance and patients' outcomes.

P05
Outcome of oncological patients admitted to ICU for full treatment who were discharged on exclusive palliative care with consensus to no readmission to ICU Ana Paula Agnolon Praça, Pedro Caruso, Antônio Paulo Nassar Junior AC Camargo -AC Camargo Cancer Center, São Paulo, SP, Brasil Critical Care 2017, 21(Suppl 2):P05 Introduction: The number of oncological patients admitted to intensive care unit (ICU) is increasing worldwide [1]. However, there have always been discussions about the benefit of ICU for certain groups of patients [2] and concerns with end of life care, because it is usually in the ICU that the transition from full treatment to exclusive palliative care occurs. The decision making process involves patients, relatives, the attending team and is usually a shared and consensual decision [3]. Our hypotheses are that the patients discharged from the ICU on exclusive palliate care would have a high hospital and long-term mortality, would have a small but not neglecting ICU readmission rate despite the consensus to no ICU readmission, and finally some would resume their cancer treatment. Experimental and observational studies were eligible for inclusion if: 1) enrolled adult critically ill patients, 2) ICUAW was evaluated using clinical (MRC: Medical Research Council score), electrophysiological tests or a combination of both and, 3) reported at least one comparison between participants with and without ICUAW. A data collection form was developed and used to extract data from the included studies by one reviewer and cross-checked by a second reviewer. Studies using MRC score at awakening were included in a meta-analysis.
Results: Thirty-seven articles on 29 patient groups (n = 4011 patients) were included. Eighteen studies were conducted in Europe, 6 in the USA and 1 in each of the following countries: Australia, Brazil, Egypt, India and Vietnam. Twenty-two studies were cohorts, 6 randomized controlled trials (RCTs) and 1 cross-sectional study. Nine observational studies (9/23) and 2 RCTs (2/6) had low risk of bias. Fifteen studies used the MRC score to diagnose ICUAW and 14 used electrophysiological tests. Twenty-seven studies excluded patients with a previous history of neuromuscular disease. The pooled ICUAW prevalence (95% CI) was 40.1% (32.5, 47.7%) regardless of the diagnostic test used and time of first assessment. Eight studies evaluating 1488 patients were included in the meta-analysis. Risk factors for ICUAW measured with MRC score at awakening included older age, female gender, high SOFA score, sepsis on ICU admission and any use of corticosteroids during ICU stay (Table 1). In addition, ICUAW was associated with poor outcomes including longer ICU and hospital length of stay (Table 1). Conclusions: Intensive care acquired weakness occurs in approximately 40% of general critically ill patients. The current meta-analysis provides evidence of risk factors for MRC diagnosed ICUAW. Further research should consider including these risk factors when building multivariable models to investigate the contributors to the development of ICUAW.
Introduction: The use of antibiotics (ATB) are becoming quite common in intensive care units (ICUs) throughout the world, being present in prescriptions of the vast majority of patients.
Objective: To seek for substrates capable to contribute in future optimization of use of antibiotics, due to the emergence of resistant microorganisms.
Methods: Retrospective study performed through database analysis of patients admitted to three ICUs of the Hospital Geral de Fortaleza, from October 2016 to January 2017. Results: Our sample included 134 patients, mostly male (54.5%), age average of 53.5 ± 19 years (median: 55.5 years), average SOFA at admission was 5.6 ± 4.6 points (median: 5 points), length of stay average of 17.8 ± 17.5 days (median: 12 days), ATB use average, per patient, was 4.4 ± 3.8 (median: 4) and mortality reached 26.1%. In this group of patients, 119 (88.8%) used ATB at any moment during hospitalization time and 15 (11.2%) did not use it at all. Comparing the two groups, we noticed a higher SOFA score average among those ar used ATB (6.2 x 1.1, p < 0.05), and higher mortality rates (29.4% x 0%, p < 0,05). The most commonly used ATBs were meropenem (55.4%), piperacillin-tazobactam (50.4%) and polymyxin B (44.5%). SOFA score average and mortality were particularly higher considering patients in whom polymyxin B was used, than in non-users. Still regarding polymyxin B usage, the drug was prescribed to 6 (4.5%) patients immediately upon ICU admission.
Conclusions: The use of ATB remains very prevalent among patients admitted to ICUs. In addition, we were surprised by the amount of polymyxin B usage, reaching almost half of the studied population, and even prescribed to some patients right on ICU arrival. This leads us to imagine that an expressive part of our ICU patients are infected by resistant microorganisms, increasing the chance of treatment failure. Introduction: Advances in oncology have lead to reduction in mortality rates nowadays. The cancer patients are usually admitted to the ICU due to postoperative high-risk surgeries, clinical complications due to acute process, especially infection/sepsis and complications due to chemotherapy [1,2]. Objective: To evaluate the hospital mortality and morbidities outcomes in medical and surgical cancer patients requiring ICU admission Methods: Retrospective study conducted in 11-bed ICU of a public cancer hospital in São Luis-Maranhão, northeast of Brazil. All patients with a definitive cancer diagnosis requiring ICU from January to December 2016 were classified based on the reason of ICU´s medical and surgical admissions. We evaluate demographic and clinical variables at ICU admission, ICU support and outcomes: ICU and hospital length of stay (LOS), ICU readmission, nosocomial ICU infection, and ICU and hospital mortality, respectively. The statistical difference was tested using Pearson´s chisquare or Mann-Whitney tests. The significance level adopted was 0,05. Results: 495 patients fulfilled the study criteria, 239 (48%) were admitted due to medical reasons and 256 (52%) due to surgical reasons. The main reasons for intensive care admission were postoperative care after elective surgery (47%), infection/sepsis (15%) and respiratory failure (10%). Medical and surgical admission did not differ in sex, age, MD mean difference, OR odds ratio, LOS length of stay nosocomial ICU infection and hospital LOS. Medical admission of cancer patients had higher SAPS 3 and SOFA scores, higher need for mechanical ventilation and vasopressors, higher length in ICU (p < 0,001 for all). The overall ICU and hospital mortality were 32% and 50% respectively; 55% and 80% for medical ICU admission and 10% and 25% for surgical ICU admission (p < 0,001) ( Table 2).
Conclusions: Cancer patients that required ICU admission due to medical reasons were sicker at ICU admission and had worse outcomes compared to those admitted due to surgical reasons. The results corroborate the importance of early diagnosis, access to medical attendance and prompt reference. The possibility to early ICU admission may offer opportunities to prevent and better manage life-threatening complication.
Introduction: Pregnancy-related acute kidney injury (AKI) can be defined as the abrupt decline of renal function during pregnancy or postpartum period [1]. It's important cause of maternal and fetal morbidity and mortality. Objective: We attempted to classify the renal function of patients admitted to a maternal intensive care unit by KDIGO Criteria [2] and to evaluate the impact of each category on mortality in a maternal ICU.  Fig. 2). None of patients with conservative renal treatment classified as KDIGO stage 3 evolved to death. These aspects reinforces the importance of indication of renal replacement therapy at the appropriate time, as well as to classify AKI, especially in critical ill patients, since this makes it possible for predict prognosis.
Conclusions: KDIGO Criteria [2] was directly related to mortality in the pregnancy-related AKI, notably those who needed renal replacement therapy. Introduction: Intravascular volume expansion is a common intervention in critically ill patients. Assessment of fluid responsiveness prior to volume expansion is critical to avoid fluid overload, which has been associated with poor outcomes. Maneuvers to assess fluid responsiveness are well established in mechanically ventilated patients [1]; however, few studies evaluated maneuvers to predict fluid responsiveness in spontaneously breathing patients. Objective: Our objective was to perform a systematic review of literature addressing the available methods to assess fluid responsiveness in spontaneously breathing patients. Results: Our search strategy identified 6,156 studies, and three studies were added through manual search. Of these, seven studies (5 ICU patients, 1 OR and 1 ED patients) were retrieved and included in this analysis. In total, 329 spontaneously breathing patients were assessed for fluid responsiveness. Of these, 171 (52%) were deemed fluid responsive. Eighteen maneuvers to assess fluid responsiveness in spontaneous breathing in patients were found (Fig. 6). Deep inspiration maneuver-induced change in pulse pressure and deep inspiration maneuver-induced change in velocity peak of femoral artery flow showed the highest accuracy to predict fluid responsiveness in this population of patients (Fig. 7). Conclusions: Our systematic review indicates that spontaneous breathing is not a limitation to accurately assess fluid responsiveness in critically ill patients. Further well-designed studies, with adequate simple size and power, are necessary to confirm the real accuracy of the different methods used to assess fluid responsiveness in this population of patients. Introduction: Plants produce many metabolites and some are used to defend themselves from predators; consequently, some species are toxic to humans. There are three main plant poisoning causes: unintentional intoxication, intentional intoxication (homicides and suicides) and poisoning due to abuse of plant material (medicinal use) [1]. Children are the population at risk to suffer unintentional intoxication from poisonous plants, especially in schools with ornamental plants [2]. Objective: Facilitate the clinical approach to poisonous plants intoxication, separating the clinical features into syndromes, with the perspective treatment to each. Methods: This paper is a literature review discussing different mechanisms of action, etiology, clinical features and treatment of the most common ornamental poisonous plants in Brazil (Fig. 9).
Results: The symptoms of plant intoxication were divided into five syndromes ( Table 3). The first is the skin irritation [3] and the second is the eye irritation [4]. The treatment of both syndromes is hygiene and symptomatic drugs. The third is the gastrointestinal irritation (GII) without systemic manifestations (SM), that causes abdominal cramps, vomiting, diarrhea, and dehydration and hepatotoxicity in severe cases. The treatment consists in avoiding gastric lavage or emesis, stimulating demulcent liquids and using symptomatic drugs [3]. The fourth is the syndrome of GII with SM, that has the same GI symptoms, with addition to fever, dyspnea, arrhythmia, cardiac arrest and kidney failure. The treatment is similar to the GII without SM, but with an early correction to the hydroelectrolytic disorders [1,6]. The last is the cardioneurotoxicity, that simulates intoxication to atropine or digitalis, or causes cellular anoxia by cyanuric acid. Cardiovascular symptoms are tachycardia or  . Agreement and correlation between tissue hemoglobin index determined with near-infrared spectroscopy (THI) and blood hemoglobin levels measured at central lab (HbLab) in critically ill patients bradycardia, hypotension, arrhythmias and the neurological symptoms are headache, seizures, coma. Respiratory disorders and renal failure can be associated [5,6]. See the treatment on (Table 3).
Conclusions: Symptoms of plants intoxication vary from a simple pruritus to coma and death; consequently, physicians must be aware of the different clinical features from the big variety of poisonous plants, and know how to manage each situation.

Mamona
Datura suaveolens L. Objective: The objective of this study was to analyze the incidence of hospital acquired infections in burn patients, and to determine the principal infection sites and the sensitivity profile of the microorganisms to antimicrobials.

Saia-branca
Methods: This is a retrospective cohort study in a specialized center for the treatment of burns from January 2009 to December 2013. The sample consisted of 404 patients, divided into two groups: the first group of 142 patients without infection and the second group of 262 patients who acquired healthcare-associated infections.
Results: There was a predominance of males in both groups, and the mean age of the patients without infection was 37 years (standard deviation SD 14.89) and of the patients with healthcare-associated infections 38 years (SD 15.78). Of the 523 infections observed in this study, the most frequent sites were pneumonia with 216 (41%) cases and urinary tract infections with 137 (26%) episodes. The pathogens identified were Acinetobacter baumannii 93 (40%), Pseudomonas aeruginosa 50 (21%) and Klebsiella (pneumoniae/ oxytoca) 23 (10%) and were resistant to most common antimicrobials.
In the study population, no pathogens resistant to vancomycin were found. Conclusions: The present study describes high rates of infection in burn victims. The most frequent infections were pneumonia, followed by urinary tract infections caused respectively by non-fermenting bacteria with a high frequency of antimicrobial resistance. Introduction: Bacteremia, also called bloodstream infection (BSI), refers to the presence of bacteria in the bloodstream and it is conceptually classified into primary and secondary bacteremia. In the hospital environment, the BSI represents a very significant number and it is usually indicative of severe events, with lethality attributed around 30-50% [1,2]. Included in the scope of hospital infections, we can also highlight the Health Care-Associated Infection (HCAI), which are among the five leading causes of death in the world.

P21
Objective: The objectives of this study were to evaluate the occurrence of bacteremia, classify it as primary or secondary, evaluate the associated factors with it and their respective clinical manifestations, in addition to characterize the clinical profile of patients hospitalized in a tertiary care hospital.
Methods: Descriptive, quantitative, retrospective study; It was carried out in the department of critical care of a large private hospital in the state of São Paulo -between July 2016 and January 2017. The Chi-square test and the Fisher's exact test were used to perform the clinical correlations. The T-Student test (for the independent groups) and the Mann-Whitney test were also used.
Results: The total sample size was 392. The female patients were the majority (77,5%). In the studied groups, the Simplified Acute Physiology Score (SAPS 3) and high mortality risk were observed. These results were higher in the group that did not present bacteremia (mean: 54,5); 25,0% of the infections presented in patients with bacteremia were associated with medical devices. The frequency of primary bacteremia was higher (85,0%) than secondary bacteremia. There was an association between the occurrence of BSI and infections related to the use of devices (p = 0,000), with a very high prevalence ratio (34,4%). It was demonstrated by logistic regression, that "BSI", "infectious diagnoses" and "endocrine comorbidities" have a significant influence on the occurrence of bacteremia, according to the Wald test, with values of 0,033, 0,039 and 0,045, respectively. Conclusions: Our study showed high severity (SAPS 3 ranged from 96% to 80%) in the study population. Most of the bacteremia detected was related to medical devices, and the frequency of the primary bacteremia was greater than the secondary ones.

Nephrology P22
Early versus delayed initiation of renal replacement therapy for acute kidney injury-an updated systematic review, meta-analysis, meta-regression and trial sequential analysis of randomized controlled trials Introduction: Acute kidney injury (AKI) is a common condition in critically ill patients, associated with higher mortality, particularly if renal replacement therapy (RRT) is required. While life-threatening AKI related symptoms of fluid overload, or metabolic disorders are clear indications for RRT, it is uncertain when to initiate RRT in absence of these conditions. Objective: The aim of the present study was to evaluate whether early initiation of RRT is associate with lower mortality in patients with AKI compared to delayed initiation. Methods: We performed a systematic review and meta-analysis of randomized controlled trials (RCT) comparing early versus delayed initiation of RRT in patients with AKI without life-threatening AKI related symptoms of fluid overload or metabolic disorders. The primary outcome was mortality at the longest follow-up. Results: Six RCTs (1,292 patients) were included (Fig. 10). There was no statistically significant difference between early and delayed initiation of RRT regarding the primary outcome (OR 0.82; 95% CI, 0.48 -1.42; p = 0.488); there was an increased risk of catheter-related bloodstream infection when RRT was initiated early (OR 1.77; 95% CI, 1.01 -3.11; p = 0.047) (Fig. 11). The quality of evidence generated by our meta-analysis for the primary outcome was considered low due to the risk of bias of the included studies and the heterogeneity among them.
Conclusions: Early initiation of RRT is not associated with improved survival. However, the quality of the current evidence is low and the criteria used for 'early' and 'delayed' initiation of RRT are too heterogenous among studies.

P23
Early The primary outcome was the last described mortality. Duration of mechanical ventilation, intensive care unit (ICU) length-of-stay (LOS), hospital LOS and renal function recovery were secondary outcomes. Random-effects meta-analysis and trial sequential analysis (TSA) was used for the primary outcome; and meta-analysis for secondary outcomes.
Results: 62 studies were retrieved, including 11 RCTs. There was no difference in mortality between early and late initiation of RRT among RCTs (OR = 0.78; CI 95%, 0.52-1.19; I2 = 63.1% - Fig. 12). TSA of mortality across all RCTs achieved futility boundaries at both 1% (Fig. 13) and 5% type I error rates, although a subgroup analysis of studies including only AKI patients was not conclusive. There was also no difference in time on mechanical ventilation, ICU and hospital LOS, or renal recovery among studies. Early initiation of RRT was associated with reduced mortality among prospective (OR = 0.69; CI 95%, 0.49-0.96; I2 = 85.9%) and retrospective (OR = 0.61; CI 95%, 0.41-0.92; I2 = 90.9%) observational studies, both with substantial heterogeneity. However, subgroup analysis excluding low quality observational studies did not achieve statistical significance.
Conclusions: The potential benefit of reduced mortality associated with early initiation of RRT was limited to low quality observational studies, which indicates potential selection bias and confounding by indication. Pooled analysis of randomized trials indicates early initiation of RRT is not associated with lower mortality rates. Furthermore, TSA suggests futility boundaries have been achieved, although the level of confidence in this conclusion is not high, given that this finding did not hold true when considering only patients with AKI.  Introduction: Renal Doppler resistive index (RI) is a rapid and noninvasive investigative tool used to predict acute kidney injury (AKI) reversibility at ICU setting. However, despite recent meta-analysis had showed a good RI ability to predict persistent AKI, a marked heterogeneity among the studies included was observed. Therefore, it's imperative to discern factors that could influence the RI performance in critically ill patients. Objective: Evaluate the variables that could impact RI in critically ill patients.
Methods: Prospective observational study performed at medical-surgical ICU from November 2013 to October 2014. Doppler RI was performed daily until third day after ICU admission, death or RRT requirement. Clinical and blood data were also collected throughout this period. AKI was defined according KDIGO criteria. AKI's reversibility was categorized on transient (normalization of renal function within 48 hours of AKI onset) and persistent (non-resolution of AKI within 48 hours of onset or need for RRT). Linear mixed model was performed between the interested variables (presence of circulatory shock, sepsis, AKI categories, SAPS 3, age, serum chloride, serum lactate and pulse pressure) to evaluate the factors that could influence RI analysis. Results: Eighty-three consecutive patients were included. 65% were male and 50.6% was medical admissions. SAPS 3 were 47 ± 16. No differences were observed in age, gender and vasopressor therapy requirement between AKI groups. Sepsis was more common in patients with persistent AKI (14.7%) when compared to other groups (p = 0.01). Serum lactate, pulse pressure and serum chloride was not different between groups. Doppler RI was statistically different between no-AKI (0.64 ± 0.06), transient AKI (0.64 ± 0.07) and persistent AKI patients (0.70 ± 0.08, p < 0.01). RI also showed a good accuracy to predict persistent AKI on patients with AKI at ICU admission (AUC = 0.78, 95% IC 0.65-0.91 - Fig. 14). Variables associated with RI variations were pulse pressure, lactate, age and AKI category (p < 0.05). Conclusions: We observed a goof ability of RI to predict AKI reversibility in critically ill patients. However, some relevant factors might influence RI on this setting.   Introduction: Pregnancy-related acute kidney injury (AKI) is an important cause of maternal morbidity and mortality with rates greater than 30%1. Determining the right moment to start hemodialysis can minimize mortality1. Objective: We attempt to identify the prognostic factors for need for hemodialysis (HD) in pregnancy-related AKI patients admitted to ICU/HMIB. Methods: This was a retrospective analysis of observational data prospectively collected from January 2014 to April 2016 in the maternal ICU/HMIB, Brasilia, Federal District, Brazil. All consecutive patients diagnosed with AKI were included. Patients with a previous diagnosis of renal failure prior to pregnancy were excluded. Results: From a total of 619 patients admitted in the ICU during the study period, pregnancy related AKI was present in 172 cases (27,8%). From the 172 patients with pregnancy related AKI, average age was 29 ± 7 years, gestational age was 32.5 ± 5.7 weeks, APACHE II was 12 ± 7, SOFA score was 3 ± 3, ICU length of stay was 7.6 ± 10.2 days and mortality rate was 8.7% (N = 15). One hundred ten patients were classified as KDIGO 1 (64.0%), 43 as KDIGO 2 (20.9%), and 22 patients as KDIGO 3 (15.1%). Thirteen patients needed HD (7.6%). These patients showed greater APACHE II (26 ± 8 vs. 11 ± 6, P = 0.00), need for invasive mechanical ventilation (IMV 92.3% vs. 24.1%, P = 0.00), use of vasopressors (92.3% vs. 11.9%, P = 0.00) and use of blood products transfusion (53.8% vs. 6.9%). Furthermore, patients required HD had lower mean artery pressure at admission (66 ± 25 vs. 93 ± 21 mmHg, P = 0.00) and use of magnesium sulfate therapy (7.7% vs. 74.2%, P = 0.00) (Fig. 15). Conclusions: In pregnancy related AKI, higher APACHE II, higher SOFA score, lower mean artery pressure, need for IMV, use of vasopressors and use of blood products transfusion were associated with need for HD. Besides, patients that used magnesium sulfate therapy had lower need for HD. Introduction: Hospital Moyses Deutsch, in the southern city of São Paulo, is indicated for the use of rtPA intravenously in patients with ischemic stroke frame according to the protocol established by the service since 2011. It is necessary to ask neurological evaluation the distance trough of the Hospital Israelita Albert Einstein Telemedicine. Objective: Demonstrate experience the use of intravenous alteplase clinical practice with Neurologist Telemedicine support, checking the efficiencies and procedure safety. Methods: Retrospective study, in all cases of ischemic stroke who received intravenous alteplase, from December 2011 to December 2016. The protocol indicates the use of alteplase for patients with inclusion criteria, the period between the onset of symptoms and hospital admission up to 4.5 hours and no contraindication to the use of thrombolytics, NIHSS (National Institutes of Health Scale course) calculated on admission and 24 hours after thrombolysis. Computed tomography (CT) on admission and after 24 hours. Solicitation evaluation required by neurological Telemedicine Hospital Israelita Albert Einstein shortly after the conclusion of the TC Cranio. The rt-PA dose of 0.9 mg / kg, 10% of the remaining bolus dose continuous infusion over 1 hour to a maximum dose of 90 mg. Results: Alteplase was used in 104 patients with diagnosis of ischemic stroke. Evaluation Neurology Telemedicine trough has been triggered in 89 cases. Time between onset of symptoms and drug administration, 49 patients less than 90 minutes between 38 90 and 180 minutes, 17 patients between 180-360 minutes The average NIHSS at admission was 18, with 66 patients showed a reduction of 5 or more the points NIHSS score within the first 24 hours. 11 patient non-symptomatic intracranial hemorrhage and 9 symptomatic intracranial hemorrhage and 12 deaths during the period. Results: Alteplase was used in 104 patients with diagnosis of stroke ischemic. Evaluation Neurology Telemedicine trough has been triggered in 89 (86%) cases as shown in Fig. 16. Time between onset of symptoms and drug administration, 49 (37%) patients less than 90 minutes between 38 (47%) 90 and 180 minutes and 17 (16%) patients between 180-360 minutes as shown in Fig. 17. The average NIHSS at admission was 18, with 66 patients showed a reduction of 5 or more the points NIHSS score within the first 24 hours as shown in Fig. 18. 11 (8%) patient nonsymptomatic intracranial hemorrhage and 9 (6%) symptomatic intracranial hemorrhage and 12 deaths during the period as shown in Fig. 19. Conclusions: All patients receiving alteplase in the recommended time interval and underwent CT Cranio control. Some cases were not triggered by the evaluation of Neurology Telemedicine. There was improvement in NIHSS score similar percentage observed in reference studies. The protocol implementation has been adequate excellent support of Telemedicine Neurology team. Good profitability of time and therapeutic efficacy. The mortality that correlated with the severity of patients and the NIHSS admission. This data ratifies the safety of intravenous alteplase use in the treatment of ischaemic stroke.    Introduction: The presence of the dysphagia symptom is relevant in patients who had a stroke episode. This symptom can cause numerous changes in the patient's clinical condition, so there is a need to obtain data that allow the profile of the patients affected by this swallowing disorder to be pointed out [1] Objective: Check the rate and degree of dysphagia in patients after stroke-I evaluated by the speech therapy team. Methods: It is a longitudinal quantitative qualitative study of retrospective methodology of records from the Hospital da Cidade de Passo Fundo -Rio Grande do Sul. The 152 patient records were analyzed, 89 men and 63 women, in the years 2014 and 2015 with stroke-I. It was included in the study patients with stroke-I diagnosis, of both genders, without age restriction. Did not enter in the search stroke-I patients who developed to stroke-H and other diseases such as Parkinson's, Alzheimer's and cancer patients. The evaluation found demographic and clinical data of the previous patients' history medical records. Results: It was found a higher incidence of dysphagia in older adults with a mean of 70 years old for males. Prevailed mild dysphagia in both genders and oral dietary. From 152 patients, 6 died. In patients post-stroke with dysphagia, there are symptoms such as: absence or delay of the swallowing reflex, increasing the risk of aspiration; Pharyngeal transit levied by absence of intra-oral pressure, alteration of vocal behavior after oral diet suggesting laryngeal penetration, decrease in larynx elevation; Alteration of the labial sphincter, making it difficult to start the swallowing process, reducing tongue control during the oral phase dynamics [1]. Individuals with neurological oropharyngeal dysphagia had a higher frequency of severe grade (46%), followed by mild and moderate degrees (27%, respectively) [2]. The data are in contrast to the study which indicated that, in patients who had neurological oropharyngeal dysphagia, the most present degree was mild, followed by severe and moderate. Conclusions: It was identified a high incidence of patients experiencing dysphagia symptom. Strengthening thus the importance of clinical assessment in patients after stroke-I episode to detect possible swallowing disorder. Introduction: Guillan Barré Syndrome is caracterized by muscular weakness. The intensity may vary from mild weakness to complete tetraplegia with indication to mechanical ventilation which requires hospitalization in an Intensive Care Unit (ICU). Quadriceps muscle ultrasonography represents one of the strategies to evaluate the linear development of muscular mass in acute patients, as it is a noninvasive procedure and highly applicable to bedridden patient1.
Nitrogen balance is a non-invasive and accessible technic to evaluate metabolic stress which consists of comparing the difference between ingestion and excretion of nitrogen. The higher the losses the higher the catabolism degree. Objective: Our objective was to evaluate the efficacy of quadriceps muscle ultrasound serial in the patient with GBS in the ICU, to optimize to protein intake and minimize muscle mass loss.
Methods: This study obtained written informed consent from participant. Male adult patient, 39 years of age, with GBS, in the ICU from 8/18/2016 to 11/22/2016. Quadriceps muscle ultrasound, nitrogen balance and weight check were performed weekly to adjust protein intake during nutritional therapy. The thickness of the quadriceps musculature was quantified with a portable B-mode ultrasound device.
With the patient lying supine, knees extended and relaxed, 2 landmarks on each quadriceps were identified and marked. The muscle thickness was quantified by the use of onscreen calipers and taken as the distance between the upper margin of the femoral bone and the lower boundary of the deep fascia of the rectus femoris. Each landmark was imaged twice and averaged across each leg and then between legs.
Results: In the first month at ICU the average protein intake was between 1,6 g to 1,8 g/Kg/day, having an average weight loss of 6,2 kg and nitrogen balance of -14. In the second month the average protein intake was between 2,0 g to 2,5 g/Kg/day, having an average weight loss of 10,3 kg, a decrease of 0,36 mm of quadriceps muscle and nitrogen balance of -7,3. In the third month the average protein intake was 3,5 g/Kg/day, having a stabilized weight, increase of 0,16 mm of quadriceps muscle and nitrogen balance of +3,0. During data collection the motor rehabilitation protocol was kept.
Conclusions: Quadriceps Ultrasonography serial measures were efficient and useful to optimize protein intake. This case showed a correlation between negative nitrogen balance and muscle mass loss and between positive nitrogen balance and muscle mass gain assessment by US. Introduction: Bedside ultrasound measurement has previously been used to quantify muscle layer thickness at the quadriceps muscle and some studies about nutritional assessment have showed excellent inter-rater and intra-rater reliability of the technique.
Objective: The objectives of this study were to evaluate the intra, inter-reliability and facility of measuring quadriceps muscle layer thickness (QMLT) using bedside ultrasound. Methods: The study was approved by the ethics committee of Hospital Israelita Albert Einstein. A prospective study was carried out for measuring QMLT in two healthy volunteers. The thickness of the quadriceps musculature was quantified with a portable B-mode ultrasound device in volunteers the lying supine, knees extended and relaxed, beside 2 landmarks on each quadriceps were identified. QMLT was calculated by measuring at the border between the lower third and upper two-thirds between the anterior superior iliac spine (ASIS) and the upper pole of the patella, as well as the measurement of the midpoint between the ASIS and the upper pole of the patella. The muscle thickness was quantified using onscreen calipers and taken as the distance between the upper margin of the femoral bone and the lower boundary of the deep fascia of the rectus femoris (Fig. 20).
To standardize measurements, an accompanying training with practical lessons and 6 hours' load time were held for team training. Trainer was 1 physician with advanced training in bedside ultrasound (expert). Trainees were comprised of 3 dietitians, 2 physicians, 1 physiotherapist with no prior ultrasound experience. To validate the image collection by ultrasound measurements were performed comparing between expert and all of trainees in different gender volunteers.
Results: Overall, 112 images were examined by expert and compared to trainees. The correlation of Person found excellent relation between expert and all of trainees R2 > 0.90 (Fig. 21). The best association was between the expert and dietitians R2 0.99, P < 0.001 and the worst between expert and physicians R2 0.92, P < 0.001. Regarding Bland Altman comparison, the highest percentage of error found between expert and trainees was 5.12% (CI 95% 3.64-12.37) and the lowest was 1.01% (CI 95% 0.72-2.58), in addition the highest bias of the values described was -0,12 ± 0,19 and lowest was -0,01 ± 0,04.

Conclusions:
The data analyzed showed an excellent correlation of the measures between expert and trainees. Therefore, this exam as a new nutritional assessment tool is feasible and easily applicable for all health professionals.  2). Objective: The objective of this study was to evaluate the measuring quadriceps muscle layer thickness using bedside ultrasound in critically ill patient during 7 days follow up.
Methods: This was a prospective, single-center study, conducted in a tertiary care hospital. The study was approved by the ethics committee of Hospital Israelita Albert Einstein and written informed consent obtained from each study participant. Patients aged 18 years or older who during their ICU stay required mechanical ventilation were included. Demographic data, anthropometric data, prognostic index (SAPS 3), nutrition risk screening (NRS) and image of US QMLT were collected for analysis. The thickness of the quadriceps musculature was quantified with a portable B-mode ultrasound device. With the patient lying supine, knees extended and relaxed, 2 landmarks on each quadriceps were identified. The underlying tissues were then maximally compressed by the ultrasound probe, and the screen image was frozen. The muscle thickness was quantified using onscreen calipers and taken as the distance between the upper margin of the femoral bone and the lower boundary of the deep fascia of the rectus femoral. Each landmark was imaged and averaged across each leg. Measurements of the first (D1), third (D3) and seventh (D7) days were performed and the percentage of QMLT was displayed for left and right legs.  Fig. 26).
Conclusions: The measuring quadriceps muscle layer thickness using ultrasound demonstrated that critical ill patients present muscle wasting daily, and this procedure can be a great differential to identify patients most likely to benefit from enhanced nutritional and rehabilitation support.  Introduction: Intensive care unit acquired weakness (ICU-AW) is diagnosed in up to 67% among long-term ventilated patients and is associated with a high morbidity and mortality [1]. Testosterone has been shown to ameliorate the catabolism and increase net protein synthesis in severe burn injury [2], chronic obstructive pulmonary disease (COPD) [3] and acquired immunodeficiency syndrome (AIDS) [4]. Objective: To assess the potential role of testosterone on ICU-AW recovery and reduction in duration of mechanical ventilation (MV).

Methods:
A pilot open-label, randomized, controlled trial of testosterone therapy on chronic critically ill adult patients requiring prolonged ventilatory support, defined as endotracheal intubation and MV for more than 14 days, or need for tracheostomy and MV for more than 8 days. Exclusion criteria: arterial or venous thromboembolism in the last 6 months; prior or current history of prostate cancer; refractory shock; severe thrombocytopenia (less than 20,000 platelets per microliter); acute liver failure or decompensate chronic liver disease; overt congestive heart failure; end-of-life care; and patient or surrogate's refusal to participate. Subjects are randomly assigned to receive standard nutritional support and physical therapy, or an additional bi-weekly dose of 200 mg intramuscular testosterone cypionate up to ICU discharge. We use a computergenerated, randomization scheme with varying block sizes ranging from 4 to 8, stratified by gender and coexistence of COPD and/or AIDS; allocation is concealed. Diaphragm ultrasound and Medical Research Council (MRC) score assessment are performed to evaluate muscular weakness. Patients are monitored through complete blood count, lipid panel, renal and hepatic function tests, blood gas analysis, serum free testosterone levels, and caloric and protein intake. Minimum sample foreseen is 15 individuals in each arm. Primary outcome is ventilator-free days. Results: The present research is in initial phase of recruitment, and it will be finished by January 2018. Eleven individuals have been enrolled so far -7 men and 4 women. In this sample, 7 patients were discharged from the ICU and four died. Currently, only one patient has completed three doses of testosterone, and duration of MV was 90 days. Eight participants have been randomized to intervention with anabolic steroids. Conclusions: High mortality showed by chronic critically ill population is the main obstacle for conduction of present study. Firstly, we aim to better define which type of patient most derives benefit, if any, from anabolic steroids administration. Data obtained from this clinical research may provide great contribution to fill the gap in knowledge of best management of prolonged MV and ICU-AW. Introduction: The PESI is a score for risk stratification after acute pulmonary embolism. It was inserted in the 2014 ESC guidelines for guiding the management of these patients. Objective: The objective of this study was validated the PESI score in a Brazilian cohort. Methods: This investigation was a retrospective cohort that included patients hospitalized at the emergency department of our hospital with the diagnosis of acute pulmonary embolism from the period of January 2009 until December 2015. The PESI score (original and simplified version) was applied in all patients with the admission data. The mortality rate in 30 days was the outcome observed. Results: One hundred twenty-three (123) patients were included (57 ± 17 years, 60%female). The mortality rate according to the PESI class (original version) was: Class I (0.80%), Class II (1.62%), Class III (4.87%), Class IV (3.25%), Class V (12.20%); p < 0,0001. Dichotomized analysis showed: Class I-II (5,8%) vs. Class III-IV-V (34,7%), relative risk (RR): 5.9; 95% confidence interval (CI): 1.88-18.51; p = 0.0002 and simplified version was 0 points (3,25%) vs. 1 points (19,51%); RR: 2.38; 95%CI: 0.89-6.38; p = 0.06. The survival analysis through the Kaplan-Meier curve showed that the Class I and II had similar curves (p = 0.59) and Class III-IV-V had similar curves too (p = 0.25) and the comparison of curves of the Class III-IV-V vs. Class I-II showed significantly higher mortality rate at the first group, RR: 7.63; 95%CI: 2.29-25.21; p = 0.0001(log-ranktest) justifying this dichotomized analysis (Fig. 27). The simplified version higher or equal 1 points was associated with higher   Introduction: Troponin and N-terminal (NT)-pro natriuretic peptide of type B (BNP) can be used for prognostic stratification after acute pulmonary embolism (APE), mainly in haemodynamically stable patients. Despite this, the appropriate cutoff values of these biomarkers are not clear. Usually, the troponin cut-off value used is the 99th percentile of the curve of normal individuals, which is the same value used for myocardial infarction definition. The NT-proBNP cut-off value used is 600 pg/ml. Objective: The objective was to evaluate the performance of this cut-off value for these biomarkers in patients with APE in a Brazilian cohort.
Methods: This is a retrospective cohort that included patients hospitalized at the emergency department of our hospital with APE diagnosis from the period of January 2009 until December 2015. We analyzed only the haemodynamically stable patients in which these biomarkers was quantified through Vidas® Troponin I Ultra and Vidas® NT-proBNP (bioMérieux, France). The 99th percentile for this troponin assay is 0.01 mcg/L. The mortality rate in 30 days was the outcome observed. The levels of biomarkers were expressed in median and interquartile range (75th percentile -25th percentile). Results: Troponin levels were quantified in 75 patients (55 ± 11 years, 40%male), this biomarker was positive in 36 patients (48%), comparing its levels between survivors vs. non-survivors was not observed difference: 0.01(0.08) mcg/L vs. 0.19 (0.34) mcg/L; p = 0.19 and in survival analysis positive troponin was not a predictor of mortality (RR: 1.38; 95%CI: 0.42-4.54; p = 0.58). This troponin cut-off value showed low sensibility 55%; 95%CI: 23-83 e low specificity 53%, 95%CI: 40-66 and low accuracy (curve-ROC area: 0.53; 95%CI: 0.37-0.70) for mortality prediction. NT-proBNP levels were quantified in 64 patients (57 ± 17 years, 34% male), this biomarker was positive in 45 patients (70%), comparing its levels between survivors vs. non-survivors was observed a tendency of higher value in the second group: 1484 (3498) pg/ml vs. 3953 (8418) pg/ml; p = 0.09 and in survival analysis there was a tendency of higher mortality at the group with values higher than 600 pg/ml (RR: 5.12; 95%CI: 0.66-39.7); p = 0.08. This cut-off value of NT-proBNP levels showed adequate sensibility 92%; 95%CI: 62-100, but low specificity 35%; 95%CI: 54-74 and regular accuracy (curve-ROC area: 0.63; 95%CI: 0.52-0.73) for mortality prediction. Conclusions: Despite the underpowered sample, the cut-off value usually used for troponin showed inadequate performance and the cut-off value used for NT-proBNP showed high sensibility however low specificity for mortality prediction in this setting. Introduction: Mechanical ventilation is increasingly recognized as potentially harmful intervention in patients without the acute respiratory distress syndrome (ARDS), and tidal volume size and airway pressures have been associated with worse outcomes in these patients. Objective: To improve the outcome of invasively ventilated patients without the acute respiratory distress syndrome (ARDS), potentially modifiable factors associated with mortality need to be identified. Methods: The observational 'PRactice of VENTilation in patients without ARDS' (PRoVENT) study was an international, multi-center, prospective cohort study of consecutive ventilated patients in a convenience sample of 119 ICUs from 16 countries across four continents. A pre-specified secondary aim was to examine which factors are associated with outcome. The Lung Injury Prediction Score (LIPS) was used to stratify risk of ARDS. The primary outcome measure was mortality, defined as mortality at hospital discharge or at 90 days after start of mechanical ventilation, whichever occurred first. Results: Nine hundred thirty-five patients were included in the analysis. Patients at risk of ARDS and ventilated with higher maximum airway pressure (Pmax), higher driving pressure levels, higher levels of positive end-expiratory pressure (PEEP), and larger tidal volumes had a higher mortality compared to those receiving ventilation with lower parameters and not at risk of ARDS (Fig. 28). Potentially modifiable factors associated with increased mortality in multivariable analyses included Pmax and pHa (Fig. 29). Non-modifiable factors associated with worsened outcome included older age, presence of COPD, use of immunosuppression and a more dependent condition. Conclusions: Lower maximum airway pressure is associated with improved survival in invasively ventilated patients without ARDS. Results: A 30-year-old male patient was hospitalized for H1N1 Acute Respiratory Insufficiency. ICU care was required after worsening of the respiratory condition, with signs of severe ARDS. The patient did not respond to non-invasive measures, he was placed in in Mechanical Ventilation (MV) with FiO2 100%. Measures for protective ventilation were initiated, and even with alveolar recruitment, use of electrical impedance tomography and neuroblockers still maintained a gasometric ratio of 70, without improvement of peripheral oxygen saturation (SpO2) 90%, then placed the Patient in Prone position. However, there was no improvement and the ECMO Venovenous was indicated. Additionally, ECMO specialists had recently been trained, this was one of the first cases that occurred after this training. The ECMO being passed to bedside and guided by Transoesophageal Echocardiography. Cannulas of size 18-F were used in Right Jugular Vein and 25-F in Right Femoral Vein without difficulties. After ECMO application, there was improvement in SpO2 to 96%, decrease of FiO2 to 40%, and improvement of gasometric hypoxia. The nursing team was responsible for monitoring all support in the search for clots system, as well as observing the pressures of the oxygenator membrane, and with the medical and physiotherapy team to discuss the gasometric values and possible adjustment of the gas pressures and equipment flow. On the fifth day of ECMO, the patient remained stable. Due to this, with acceptable values of gasometry and radiographic findings, it was decided to withdraw the support temporarily to evaluate if the patient presented some decompensation.There was no diference in respiratory condition, the patient was decannulated with no complication and extubation was performed after 12 hours of turn off ECMO. Patient was discharged to intermediate unit after ninth day of ICU. Finally, there were 21 days of hospitalization,     [1]. Nowadays, patients on prolonged ventilation are among the major challenges of intensive care [2,3]. In this regard, specific exercises for respiratory muscles can result in better functional performance in critically ill patients during weaning process [1].
Objective: To evaluate the effects of inspiratory muscle training (IMT) program on patients in prolonged weaning. Methods: Prospective randomized controlled trial. By the time participants were judged as apt for ventilator weaning, they underwent IMT with a new device called POWERbreathe K-5 (UK), Intervention group, or were managed in a conventional way with a tracheal collar, Control group. The primary endpoint was successful weaning. Muscle strength, and 30 days after intervention survival in the ICU were also analysed. Inspiratory strength was measured by the timed inspiratory effort index (TIE) employing a digital vacuometer MVD300 (Globalmed, Brazil) [4].
Results: Sixty-five tracheostomized patients were selected. Thirty-four patients comprised the Intervention group (20 male, mean age 65 ± 17 years, mean APACHE II score 28.9 ± 4.8). The weaning process duration was 13.7 ± 8.8 days, and the initial and final TIE indexes were 0.8 ± 0.3 and 1.7 ± 0.9, respectively (P = 0.0001). Thirty patients (88%) were successfully weaned, and 11 (31%) had a fatal course. The control group encompassed 31 patients (14 male, mean age 68 ± 16 years, mean APACHE II score 26.1 ± 5.5). The weaning process duration was 21.7 ± 16.4 days, and the initial and final TIE indexes were 0.8 ± 0.6 and 1.0 ± 0.8 respectively (P = 0,053). Thirteen cases (42%) were successfully weaned, and 22 (63%) had a fatal course. The 30 days after intervention survival rates for the intervention and control groups were 79% and 44%, respectively (P = 0.025), Fig. 30. Conclusions: In support to our working hypothesis, the rate of weaning success and the survival rate 30 days after intervention were higher for patients undergoing inspiratory muscle training. Introduction: Nowadays, patients on prolonged ventilation are among the major challenges of intensive care [1]. The recent timed inspiratory effort index (TIE) has been shown to be a clinically valuable tool to predict the success of ventilatory weaning, especially for patients with difficult weaning [2]. Objective: To validate the accuracy of the TIE index in patients in prolonged weaning.
Methods: This prospective observational study was approved by the hospital research ethics committee under the number CAAE: 50264415.2.000.5256. The exams were performed, evaluated and classified at the beginning and after weaning outcome. The area under the ROC curves was used to validate the accuracy of the TIE index, and the Youden method for calculating the cut-off point. The Med Calc version 12.1 program was used for statistical analysis. Results: Sixty-five patients were selected, 33 men (51%), mean age 67 ± 16 years. All were tracheostomized, mean duration of mechanical ventilation was 22.7 ± 14.1 days, and APACHE II was 27.6 ± 5.4, 41 (63%) were successfully weaned, but 31 (47.7%) had a fatal course. One hundred and thirty examinations were performed during the prolonged weaning process. The sensitivity was 87.8 and the specificity was 88.8. The cut-off point > 0.99 was established to predict success at weaning. More relevant to the purpose of the study was the area under the ROC curve of 0.93 ± 0.02 (Fig. 31).

Conclusions:
The performance of the TIE index as a predictor in prolonged weaning was consistent with previous publications reinforcing that it can be a precious tool in this setting.
Introduction: Cancer patients represent an important proportion of intensive care unit admissions [1]. Oncologists and intensivists have distinct knowledge backgrounds, and conflicts about the appropriate management of these patients may emerge. Objective: To compare the proportion of oncologists and intensivists who favored withdrawal of life support measures for two critically ill cancer patients. Methods: We surveyed oncologists and intensivists at two academic cancer centers regarding their management of two hypothetical patients with different cancer types (metastatic pancreatic cancer and metastatic breast cancer with positive receptors for estrogen, progesterone and HER-2) who develop septic shock and multiple organ failure. We asked two questions in each case vignette: 1. What would    (Fig. 32a). More intensivists than oncologists favored an ICU admission with restrictions of life support measures [46/59 (78%) vs. 27/46 (59%), p = 0.055] (Fig. 32b).
Oncologists and intensivists similarly favored withdrawal of life support measures for the pancreatic cancer patient [33/46 (72%) vs. 48/ 60 (80%), p = 0.45] (Fig. 32c)  Introduction: Some critically ill patients receive urgent chemotherapy that is nowadays considered feasible [1][2][3]. Urgent chemotherapy has the potential to decrease or increase the mortality in critically ill patients, but its effect on mortality was only evaluated in descriptive studies and not in studies comparing similar patients that received or not urgent chemotherapy. Objective: The primary objective of the present study was to compare the ICU mortality, hospital mortality and the long-term survival between critically ill patients that received or not urgent chemotherapy during the ICU stay. The secondary objective was to compare the effect of urgent chemotherapy on mortality and survival of patients with hematological malignancies or solid tumors. Methods: We designed a retrospective observational study including adult patients that received at least one day of urgent intravenous chemotherapy for a cancer-related life-threatening complication. Using the propensity score method and adjusting for ten different variables, we elected a population of critically ill patients that not received urgent chemotherapy but was similar to the one that received. We compared the intensive care unit mortality, hospital mortality and long-term survival between patients that received nor not urgent chemotherapy. As a subgroup analysis, we compared the mortality of patients with solid tumors or hematological malignancies. Results: We included 47 patients that received urgent chemotherapy and 94 matched patients that did not receive it. At intensive care unit admission, the groups were similar except that patients that received urgent chemotherapy less frequently had received chemotherapy before the intensive care unit. The intensive care unit (48.9% vs 23.4%; P < 0.01) and hospital (76.6% vs 46.8%; P < 0.01) mortality of the patients that received urgent chemotherapy was higher than the patients that did not. Likewise, the long-term survival of patients that received urgent chemotherapy was lower (P < 0.01). The subgroup analysis showed that the higher mortality was limited to the patients with solid tumors, while the urgent chemotherapy did not change the mortality of the patients with hematological malignancies (Fig. 33). Conclusions: The use of urgent chemotherapy in unselected critically ill patients increases the ICU mortality, hospital mortality and decrease the long-term mortality in patients with solid tumors but not in patients with hematological malignancies.  Introduction: Introduction: The evidence of association between nursing care time spent with patients and healthcare quality indicators may be an important management tool, supporting the decision-making process on issues related to quantitative and qualitative adequacy of nursing professionals when handling the care quality and safety standards needed by health services. Objective: Objective: To investigate the correlation between average times of nursing care spent with adult patients in intensive care units (ICU) in São Paulo and care quality indicators: Non Planned Incidence of Loss of Oro / Nasogastric tube (NGT) for Nutritional Intake; Non Planned Extubating (NPE) incidence of Endotracheal Cannula; Incidence of Loss of Central Venous Catheter (CVC). Methods: Method: this is a quantitative observational, correlational study carried out in 11 adult ICU patients in two public and one private hospital, located in the city of São Paulo. The population understood quantity and quality records of nursing professionals, the number of patients with at least one of therapeutic devices (NGT, NPE, CVC) and occurrences relating to device losses. Hospitals were nominated by HA, HB and HC initials. Data collection in HA and HB, occurred in the period from 17 July to 17 November 2015. In HC data were collected from August 12 to December 12, 2015. The analysis was based on descriptive and inferential statistics, with 5% significance. Results: Results: 2,569 patients were assisted in the four months of the study. The average time of nursing care spent with patients accounted for 18, 86 hours at HA, HB and 21 hours at HB and 19, 50 at the HC. The average percentage of time dedicated by the nurses was 37.75% in HA, 35.00% in HB and 41.36% in HC. The indicator Non Planned Loss of NGT for Nutritional Intake averaged 2.19 / 100 patient-days (SD = 10.93). The average indicator incidence of NPE of Endotracheal Cannula corresponded to 0.42 / 100 patient-days (SD = 4.51) and the average indicator Incidence loss of CVC was 0.22 / 100 patient-days (SD = 2, 04). There was no statistically significant correlation between the average time of nursing care spent by the team, average time spent by professional category and the mentioned quality indicators. Conclusions: Conclusions: Though the study hypothesis was disproved, this research moves towards elucidating other variables that may affect the correlation between adverse events related to the analyzed therapeutic artifacts and the nursing professionals. The results of this study may support methodological decisions for the verticalization of the technical / scientific knowledge in nursing and the management of future researches aiming to demonstrate the impact of nursing human resources in the quality and safety of patients, health professionals and institutions. Introduction: Intra-hospital transport is defined as the temporary or definitive referral of patients within the hospital environment and may have a diagnostic and/or therapeutic purpose. It is a complex activity and must ensure the preservation of clinical conditions to those who are transported, throughout the course of the procedure.
Objective: To describe the adverse events occurring during the intrahospital transportation of adult patients hospitalized in an Intensive Care Unit (ICU) and to evaluate the association with morbidity and mortality. Methods: A prospective cohort study conducted from July 2014 to July 2015. Data collection comprised demographic data and clinical data, such as medical diagnosis, prognostic scores of the Sequential Organ Failure Assessment (SOFA) and Simplified Acute Physiology Score (SAPS 3), the presence of comorbidities, length of stay, and outcome at discharge from the ICU and hospital. Data was also collected on transport and adverse events. Adverse events were classified according to the World Health Organization following the degree of damage into: None, Mild, Moderate, Severe, and Death. The level of significance was set at 5%. Results: A total of 293 patients were analyzed during the study period, with follow-up of 143 patient transportations and records of 86 adverse events. Of these events, 44.1% were related to physiological alterations, 23.5% occurred due to equipment failure, 19.7% due to team failure, and 12.7% due to delays. Half of the events were classified as moderate degree. The mean time spent in the ICU of the group that presented adverse events during transportation was higher when compared to patients transported without the occurrence of adverse events (21.7 versus 9.2 days respectively, p < 0.001), as was the mean time of hospital stay (31.4 versus 16.6 days, respectively, p < 0.001). No difference in mortality was found between these two groups of patients. Conclusions: Adverse events were frequent during intra-hospital transportation of critically ill patients. Physiological alterations were the most frequently encountered events, followed by equipment and team failures. The degree of damage associated with the adverse events was classified as moderate in most cases and associated with an increase in the length of ICU and hospital stay.
Introduction: Customer satisfaction is an essential issue for companies to stay on the market. In the hospital environment, the dissatisfied customer spreads negative information and thus the image of the organization is impaired, therefore, customer satisfaction is an important marketing tool that can be used to retain customer loyalty, avoid complaints and make the company more competitive in the Marketplace. Objective: The objective of this study is to evaluate in real time the satisfaction of the client regarding the assistance offered during the hospitalization in the Intensive and Semi-Intensive Therapy and consequently reduce the number of complaints in the SAC. Methods: Used the Ishikawa diagram, brainstorming and 5W2H tools. The Care Team defines as action strategy for the year, chooses customer satisfaction as a value proposition, bother with high number of complaints, performs mapping before implementation of the customer satisfaction index project: Client / family / medical team, performs first draft of the project and presents for nursing leadership, defines vision of the unit -"to be a reference in patient satisfaction, Coordination of the area meets with team -strengthens the project, Establishment of the first channel Communication with client -Visit the seniors in the first 48 hours of hospitalization (routines / glossary items / team presentation), Defines metrics: no complaints X no exits, Elaborates and implants satisfaction flag -"Lighthouse of satisfaction", Elaborates an active search Complaint: "Near complaint", Identifies patients at risk for complaint and visits the bedside (active unstructured search), Project structure -triggering Stakeholders Results: There were 97 patient visits to the ICU during the data collection period, with 64% visits by senior nurses to guide the filling of the satisfaction lighthouse, of these 52% were in the first 48 hours of hospitalization, 8% reported dissatisfaction. 2% related to the courtesy of the multiprofessional team, 2% hygiene of the apartment, 3% furniture, 1% nursing practice. All non-formalized complaints were resolved in a timely manner, even during ICU patient admission, thereby avoiding 8 formal complaints to the critical care sector. Conclusions: Future actions will be necessary to disseminate and expand this method of work for every institution. As well as creating a dynamic framework to assist the quantification of data and to spread new collaborators with the Patient Satisfaction Week Introduction: Although 13 years have passed since the first publication of the international treatment guidelines, sepsis continues to be the leading cause of death in Brazilian Intensive Care Units (ICU), with lethality rates of 50% [1]. Objective: The present study reports our experience at implementing a Managed Sepsis Protocol (MSP) in a public hospital. This action was based on the Quality Improvement Model (QIM), a methodology proposed by the Institute for Healthcare Improvement (IHI -USA). Methods: The study is a longitudinal, prospective, nonrandomized one, lasting 18 months (Jan-16 to Jun-17), and took place in a high complexity municipal hospital of the city of São Paulo. Applying the IHI methodology required establishing Multidisciplinary Work Teams (MWT), in 3 phases (ICU, ward and emergency department -ED). Area-specific driver diagrams were developed as well as "Plan-Do-Study-Act"-PDSA cycles in order to test the proposed changes and improvements. Semistructured interviews were performed with members of MWT and hospital staff. Results: The main challenges identified by the research team were: need of adaptation the new local MSP, poor clinical staff engagement, problems with case notifications and data collection, lack of alarm systems to identify, absence of a reference multidisciplinary team, inadequate settings of priorities, unclear patient flows and team member roles. The interviewed MWT members (8 in total) agreed to the need of improving the procedures regarding the care for septic patients and that the use of the QIM in MSP implementation improved their work performance by making it more synchronized, faster, on time and more standardized. Furthermore, they did not perceive workload increases and reported satisfaction with the used methodology, as they became participants in the decision making processes. In addition, specific management changes were introduced and sustainable long lasting improvements are expected to improve recognition, diagnosis and treatment of sepsis, and reduce lethality. Conclusions: The IHI quality-improvement model seems to be a suitable tool to implement sepsis management protocols and should be further tested. Full results of this study will be available by the end of 2017, as quantitative analysis about its impacts on outcomes (lethality rates), processes (compliance 3-hour care bundles) and staff opinions about workload. Introduction: Cancer is the third major cause of death in Brazil. The students of medical schools should know how to deal with patients diagnosed with oncological final stages very carefully. The care of the patient in these oncological final stages must be holistic and consider his biosocial environment. Nowadays, procedements and therapeutic diagnosis try to improve the patient´s quality of life. It also gives to the patient palliative cares. In this bibliographic review, we found articles with strong evidences about the professional's difficulties on how to deal with oncological final stages patients. Those healthcare professionals try to preserve life and see the death of a patient as a loss.
Objective: This study intends to verify how the formation of the new medical professionals is in front of the terminal oncologic phase; Analyze how the contact with the patient in this period affects the professional future; As well as discussing the importance of the multiprofessional team against these patients. Methods: For the construction of the article, the bibliographic review was also used, where references were made available in the Scielo and PubMed database. We selected articles published between 2006 and 2016, the research being carried out through four basic descriptors, the terminal patient, Cancer institutes, Humanization of care and Oncology. Thus articles were used as inclusion criteria in Portuguese, and exclusion of re-readings of works and articles with an exclusive view of nursing. Results: Humanized care has increasingly been pointed out as the ideal way of taking care of health, considering an integrated vision and an adoption of an ethics of care, leading to a quality of care, but many patients are still not followed up in this way. It is indisputable that the institutions that involve the medical areas need to focus on this pillar of the training of future professionals always showing the importance of this concept in the improvement of the patient, since these professionals are finding difficulties in dealing with this type of situation. Conclusions: It is important that the health professional understands the death process since graduation, in order to prepare it that can reduce stress and anxiety. In this way, he will be able to maintain an interpersonal relationship of help, which is the essence of the act of caring humanized. Introduction: Ultrasonography (US) has been increasingly used in intensive care units due to its easy access, low cost and also ability to guide the diagnosis of many clinical conditions, assist in procedures and punctures and also evaluate the response to specific therapies. However, ultrasound transducers and associated materials have been an increasingly important source of cross-infection and nosocomial infections. Objective: To evaluate the knowledge about adequate hygiene and the profile of the users of ultrasound devices and probes in the emergency and intensive care units (ICU) of the Ernesto Dorneles Hospital during the 12-month period. Methods: A prospective, cross-sectional study at a single medical center (Ernesto Dornelles Hospital), with a questionnaire analyzing the profile and knowledge about the ultrasonography of the physicians working in the emergency and ICU sections of the hospital. We interviewed with structured questionnaire all physicians contracted active of the respective sectors in the period of February 3, 2016 until February 3, 2017. For analysis were described categorical variables by frequencies and percentages Results: The responses of 52 physicians (n = 52) were analyzed. It was seen that 31 (60%) of the participants were female. The predominant age group of the studied population was 20 to 40 years old (88%). 49 (95%) had already performed some type of specific training with the ultrasound device. The main reason for using the device was to guide procedures -51 (98%). Finally, 43 (83%) participants concluded that they had never received any guidance and / or training on proper hygiene of the ultrasound device Conclusions: Most physicians, with a labor relationship with the institution, who use ultrasound in their work routine, have never received guidelines and or formal instructions on proper hygiene techniques of the device. The numbers reached by this study are in agreement with the results found in research carried out in other institutions, which reinforces the need for more investments and studies in this area and the creation of a protocol to be followed by the institution. Introduction: Ventilator-associated pneumonia (VAP) is a major complication of patients admitted to intensive care and follow-up is necessary to implement preventive actions, as well as analyze the results and train as teams. VAP rates in Brazil are higher than those related in Europe and USA. Objective: was to examine the effect of the Institute for Healthcare Improvement's ventilator bundle plus oral decontamination with chlorhexidine (ODC) in the incidence of VAP in an intensive care unit. Methods: The study was conducted in a 20-bed, medical-surgical ICU. Criteria for nosocomial pneumonia are those from the CDC. Strategy was to implement the IHI's ventilator bundle plus ODC. The goals were the ICU team adhesion of 80% achieved in ninth month after bundle implementation and 100% after one year of follow up. These measures included five strategies to prevent ventilator-associated pneumonia: 30°-45°elevation of the head of the bed, adequate sedation level (RASS 1 or 2), DVT/PE prevention, peptic ulcer prophylaxis and oral decontamination with chlorhexidine 0.12%. From February 2012 on, the ICU nursing staff and ICT performed a daily checklist in order to observe the five issues accomplishment. If any item was found to be inadequate it was promptly corrected. Results: February 2012 and December 2016, adherence to the whole package was gradually increased up to 100%, respectively (p < 0.001). VAP density was proportionately smaller to group membership in the same period, 20 per 1000 ventilation / day and 4.5, respectively. In 2015 -2016 zero density VAP. Conclusions: Initial VAP rates were extremely high even for Brazilian benchmarks. Although we could not implement expensive technologies like continuous aspiration of subglottic secretions, ICU team and ICT efforts were crucial for satisfactory results, as well the administrative board support, which turned this issue an institutional priority. Our goals are to reduce even more, implementing ''ventilator bundle-getting to zero'' program, maintaining a continuum effort to sustain these results. Introduction: Fentanyl is a commonly prescribed opioid for the treatment of pain in patients undergoing mechanical ventilation. In Brazil, a 50 mcg/mL solution is commonly used in clinical practice, although doses of 10 mcg/h may be enough to achieve pain resolution.
Objective: We aimed to compare fentanyl consumption between a "before" period of concentrated solution and an "after" period of diluted solution use and pain assessment and treatment training.
Methods: This is a retrospective cohort study with a historical control including all mechanically ventilated patients. A quality intervention program was implemented on October, 2014, in which a diluted solution of fentanyl (10 mcg/mL) was defined as the standard of care of the unit, which started on October, 2014, with the infusion starting at 1-2 mL/h and titrated according to patients' pain (either through a numerical rating scale or behavioral pain scale as assessed by nurses or physicians). We compared fentanyl consumption (ampules per month) between the first period (January, 2014 through September, 2014) and the second period (November, 2014 through December, 2015). Results: There were 306 patients (Period 1, Before) and 515 patients (Period 2, After) in each period. Baseline characteristics were comparable between groups (Fig. 35). Fentanyl consumption (ampules/ month) substantially reduced from 843.33 in Period 1 to 339.07 in Period 2 (Fig. 36). Median mechanical ventilation duration reduced from 2 days to 1 day (p = 0.0001) and median intensive care unit length-of-stay reduced from 5 days to 4 days (p = 0.0371). ICU and hospital mortality were unchanged between groups. Conclusions: The use of a dilute fentanyl infusion and basic nurse and physician training resulted in lower opioid consumption, a shorter mechanical ventilation duration and shorter ICU length-ofstay. These results should be interpreted with caution, given that this is not a time-series analysis and we did not control for confounding factors.     (Fig. 37). Imipenem PK showed to be altered by comparison of data obtained in septic burn patients with previously reported data in healthy adult volunteers3. Biological half-life was prolonged and the volume of distribution was increased by trice compared to adult healthy volunteers; a strong correlation between these parameters was obtained, (Fig. 38). Eradication of nosocomial pathogens occurred in 29/34 by the initial dose regimen, and daily dose was adjusted against MIC 4 mg/L strains in five of them for target attainment.
Conclusions: Imipenem PK is altered in burns with consequences in drug effectiveness. Desired outcome in general is reached based on TDM emphasizing the recommendation of PK/PD approach once a week during the antimicrobial therapy. Introduction: Metabolic and changes in pharmacokineticspharmacodynamics (PK/PD) changes are expected in burn patients (ICU). In general, renal insufficiency occurs during septic shock; then, the control of infection is a challenge, once drug effectiveness depends on drug plasma levels during the antimicrobial therapy.
Objective: The aim was to investigate drug effectiveness in septic burn patients receiving vancomycin-piperacillin combined at the dose regimen recommended to renal dysfunction based on drug plasma monitoring and PK/PD approach. Conclusions: Drug plasma monitoring and PK/PD approach are today considered clinically relevant tools for target attainment; cure of nosocomial infections and also to avoid microbial resistance in critically ill burn patients (ICU).  Introduction: Metabolic changes occur in critically ill patients, and pharmacokinetics-pharmacodynamics (PK/PD) altered for antimicrobial agents is expected. Consequently, the control of severe infections in burn patients is a challenge, once drug effectiveness depends on antimicrobial plasma levels during the therapy. Objective: To evaluate drug effectiveness for target attainment by PK/PD approach in burn patients receiving piperacillin-tazobactam 4.5 g tid by comparison of two empirical dose regimens. Methods: 35 adult patients of both genders (6 F/29 M) and Clcr > 50 ml/min were included: 39+/-16 yrs (mean +/-SD), 70+/-12 kg, total burn surface area 33+/-20%. Thermal/electrical injuries occurred in 32/3 patients and inhalation injury in 21/35 of them. Tracheal intubation and vasoactive drugs were necessary in 30/35 patients. Length of stay in the Intensive Care Burn Unit was 21-37 days (95% CI). Empirical dose regimen recommended was prescribed to burn patients in septic shock caused by piperacillin susceptible nosocomial strains and daily dose 12 g versus 16 g were compared. Patients presented Clcr 115 (100 -130) ml/min, white blood cells 11,601 (9,923 -13,280) cells/mm3, Creactive protein 202 (187-255) mg/L, means (95% CI). Blood sampling was done for cultures, pathogens isolation and susceptibility testing done in the central laboratory. A series of 3-4 blood samples (2 mL/ each) were done at time dose interval for drug plasma measurement done by liquid chromatography. Pharmacokinetics-pharmacodynamics (PK/PD) approach was performed by Prism 5.0, based on the predictive index of drug effectiveness (100%fT > MIC), and MIC is the minimum inhibitory concentration.
Conclusions: Drug plasma monitoring done in real time based on PK/PD approach is quite useful permitting an earlier clinical intervention to treat the nosocomial infection in burn patients. Finally, these tools can impact the drug effectiveness related to avoid the bacterial resistance for more aggressive gram-positive and gram-negative piperacillin susceptible strains.    Introduction: In 2016, a new consensus on the definitions of sepsis (SEPSIS-III) was released amid major controversy. The new criteria endorse the SOFA score (Sequential Organ Failure Assessment) as the main diagnostic tool [1]. In Brazil, the main criticism for the application of these new criteria is the expected difficulty in obtaining, in a timely manner, the results of complementary exams that are components of the SOFA, which could delay the diagnosis and treatment of sepsis, worsening the patient's prognosis. Thus, based on data collected only in developed countries, the new approach seems to be a setback for countries where the health system is precarious and there is a clear need for studies that assess its real applicability in such scenarios.
Objective: Verify if the proposed new approach delays the diagnosis of septic patients and, thus, worsens their prognosis.
Methods: This research is a prospective observational study. A questionnaire was applied to 21 patients in the emergency room of a hospital in Rio de Janeiro, which allows to compare the "door-to-diagnostic" time, according to the usual approach versus that obtained through the approach proposed by SEPSIS-III. The ΔDoor (Systemic inflammatory response syndrome) and ΔDoor times were defined as the time elapsed from entry into the unit to the diagnosis of sepsis by the SIRS and SOFA criteria, respectively. These times were considered similar when the difference between them was less than 30 minutes. Results: Among the analyzed cases, 95% had two or more SIRS criteria at the time of the initial evaluation, thus being diagnosed as septic, while only 71% had a SOFA greater than or equal to two. In patients diagnosed as septic, both by SIRS and SOFA criteria, it was observed that, in five cases, ΔDoor was equal to ΔDoor. In four cases, ΔDoor was higher, whereas in other four cases ΔDoor was lower (Fig. 45). As a whole, there were no significant differences in the time elapsed since the patient entered the unit until the diagnosis of sepsis was established based on SIRS or SOFA criteria. It is important to note that in 80% of patients with altered SOFA, the diagnosis was established based only on the clinical parameters belonging to the score and the arterial blood gas analysis as shown in Fig. 46. Conclusions: It is clear that more advanced methods for the identification of sepsis in the emergency room are not needed. Instead, it is necessary to do a work of awareness, among the population and health professionals, so that we can start the treatment as soon as possible and, thus, guarantee a better prognosis for the septic patient.  by difference of bounded from total propofol. Free propofol plasma levels were monitored during CABG, and data obtained at the post CPB-H were compared to the period before starts the CPB-H. Total drug binding to plasma proteins was reduced; then, increases in propofol free plasma levels occurred, Fig. 48. It was shown a strong correlation between BIS values and free drug levels by the chosen Emax model sigmoid shape-variable slope analyzed by Prism v.5, Fig. 48.
Conclusions: It was demonstrated that free fraction of propofol was increased by CPB-H during CABG intervention. A high correlation of BIS versus free drug plasma levels was obtained. PK/PD approach indicated that the free propofol plasma levels increased and the prolonged period of orotracheal-intubation could justify the residual hypnosis that occurs in these patients.