Participação do Rio de Janeiro no 28th ISICEM 2008

O  Rio de Janeiro esteve presente em Bruxelas com trabalhos científicos:

1- Validation of procalcitonin measurement to the side of the stream bed as marking infection in intensive therapy patients

M Vaisman, R Lima, C Filho, M Dourado, A Castro, H Torres, I Barbosa, D Castro and J Machado
Samaritano Hospital, Rio de Janeiro, Brazil.
from 28th International Symposium on Intensive Care and Emergency Medicine
Brussels, Belgium. 18–21 March 2008
Critical Care 2008, 12(Suppl 2):P183doi:10.1186/cc6404

Elevation of the serum concentration of procalcitonin (PCT) has been proposed as a marker of disease severity and is associated with systemic infection. This association has led to the proposed use of PCT as a novel biomarker for bacterial sepsis. We sought to evaluate the PCT measurement with culture samples to quickly ratify the sepsis and rapidly begin the use of antibiotics.

Between September 2006 and March 2007 we evaluated 82 blood samples from 82 patients – 48 males (80.33 ± 10.55 years old) and 34 females (81.17 ± 13.83 years old) – with sepsis or SIRS in the adult ICU of a tertiary hospital. The PCT levels were measured by a quantitative imunoturbidimetry method (PCTL) in ng/ml (Lumitest PCT; Brahms, Germany) and the results compared with a sample culture (blood, urine, tracheal secretion and others).

With the cutoff of PCT levels at 2 ng/ml and positive or negative sample cultures, the analysis found that sensitivity is 37%, specificity is 92%, positive predictive value is 0.84, negative predictive value is 0.40, positive likelihood ratio is 4.62 and negative likelihood ratio is 0.68. With the cutoff of PCT levels at 0.5 ng/ml and positive or negative sample cultures, the analysis found that sensitivity is 72%, specificity is 33%, positive predictive value is 0.54, negative predictive value is 0.48, positive likelihood ratio is 1.07 and negative likelihood ratio is 0.84.

This preliminary analysis suggests that PCT can be used to accurately early identify sepsis only at levels above 2 ng/ml and then decide to rapidly begin the use of antibiotics. In patients with PCT < 2 ng/ml we cannot use PCT to exclude the diagnosis of sepsis. With the cutoff of 0.5 ng/ml we found the same result. Other studies with more samples are necessary to confirm this conclusion.

1. Giamarellos-Bourboulis EJ, Mega A, Grecka P, et al.: Procalcitonin: a marker to clearly differentiate systemic inflammatory response syndrome and sepsis in the critically ill patient?

Intensive Care Med 2002, 28:1351-1356. PubMed Abstract | Publisher Full Text

2- Effects of an open lung approach following the ARDS Network ventilatory strategy in patients with early acute lung injury/acute respiratory distress syndrome

V Rotman1, F Bozza2, A Carvalho3, R Rodrigues4, J Castro1, J Pantoja1, F Saddy1, D Medeiros1, W Viana1,
E Salgueiro1 and CRR de Carvalho5
   1Copa Dor Hospital, Rio de Janeiro, Brazil.
   2Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.
   3University Clinic Carl Gustav Carus, Dresden, Germany.
   4Federal University of Rio de Janeiro, Brazil.
   5São Paulo University, São Paulo, Brazil.
from 28th International Symposium on Intensive Care and Emergency Medicine
Brussels, Belgium. 18–21 March 2008
Critical Care 2008, 12(Suppl 2):P295doi:10.1186/cc6516

The beneficial effects of the institution of high levels of positive end-expiratory pressure (PEEP) after recruitment maneuvers are controversial. We aim to compare the effects of the ARDS Network (ARDSNet) ventilatory strategy and open lung approach (OLA) applied in a sequential way, in patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS).

Ten patients fulfilling criteria for early ALI/ARDS were recruited. For definitive selection, blood gas collected after 30 minutes application of 5 cmH2O PEEP and tidal volume (VT) = 10 ml/kg had to demonstrate PaO2/FIO2 < 300 mmHg. The patients were initially ventilated for 24 hours according to the ARDSNet protocol. After this period, if the PaO2/FIO2 was ≤ 350 mmHg, a recruitment maneuver was performed (sequential 5 cmH2O increments in PEEP starting from 20 cmH2O, until PaO2/FIO2 > 350 mmHg) and an additional 24 hours of ventilation according to the OLA (VT = 6 ml/kg and PEEP to achieve a PaO2/FIO2 > 350 mmHg) was applied. Whole lung computed tomography images (1.0 mm thickness with 10 mm gap) were acquired after 24 hours of each strategy.

The institution of OLA was necessary in nine of the 10 studied patients. The PEEP was significantly higher during OLA (17 cmH2O (17–19) vs 8 cmH2O (8–11); P = 0.007) and resulted in a significant improvement of oxygenation sustained for 24 hours of follow-up, with no significant differences in plateau pressure, static compliance, minute ventilation, PaCO2 and pH (P > 0.1). OLA resulted in a significant reduction of the fraction of nonaerated regions as compared with the ARDSNet protocol (13% (10–23) vs 37% (33–42); P = 0.018) without a significant increase in the percentage of hyperinsufflation (5% (1–13) vs 2% (0–7); P = 0.149). No significant differences were observed in the infused doses of vasopressors, fluid balance and arterial blood pressure.

When compared with the ARDSNet protocol OLA improved oxygenation, reducing the fraction of nonaerated regions without significant increase in hyperinflated areas with comparable levels of hemodynamics and fluid balance.

1. Grasso S, et al.:

Anesthesiology. 2002, 96:795-802. PubMed Abstract | Publisher Full Text

3-Decisions to limit care: evaluation of newly graduated physicians during a selection process for medical residency in Brazil

R Goldwasser1, C David1, A Coelho1, E Muxfeldt1, E Santos1, V Fonseca1, M Lobo1, K Bloch1, S Zaidhaft1,
S Porto2, S Saintive2 and M Amaral3
   1Hospital Universitario-Universidade Federal do Rio de Janeiro, Brazil.
   2Instituto de Pediatria Martagão Gesteira, Rio de Janeiro, Brazil.
   3Instituto de Psiquiatria da Universidade do Brasil, Rio de Janeiro, Brazil.
from 28th International Symposium on Intensive Care and Emergency Medicine
Brussels, Belgium. 18–21 March 2008
Critical Care 2008, 12(Suppl 2):P522doi:10.1186/cc6743

'Doctor. Do whatever necessary to save her life'. This is a challenge for doctors in daily practice, mainly when it deals with attempts to prolong life and admission to the ICU should be denied. The objective of the present study is to determine attitudes and practices of newly graduated physicians in Brazil about end of life care and to evaluate the new set of skills they have to be prepared to deal with.

A multiple-choice cognitive test was applied to physicians as part of a selection process for a residency program. The question was about a 77-year-old woman, with dementia, who has lived in long-term geriatric care for the past 5 years. She was transferred to the hospital with acute respiratory failure and pneumonia. The lung image showed disseminated malignancy. The granddaughter (GD), although unaware of the prognosis, asked the doctor to do 'everything to save the life'. The candidates were asked for the appropriate behavior. Option (A) to treat, including performing advanced life support at the ICU, independent of a previous quarrel with the GD; Option (B) to not perform any diagnostic or therapeutically measure and inform the GD that this will no longer bring benefit to her grandmother; Option (C) to define, together with the GD, possible palliative interventions; or Option (D) to apply protocols based on evidence related to palliative care, independently of the GD's opinion. The correct answer was based on two skills: the concern about futile treatment and ethical issues – Option (C).

A total of 1,133 physicians participated in the selection process for medical residency and answered the questionnaire. Of the respondents, 698 (61.61%) would rather define with the family possible palliative interventions (correct option – (C)); 312 respondents (27.54%) would treat the patient even without the family's opinion (option (A)); 122 respondents (10.77%) would apply protocols, again independent of the GD's opinion (option (D)); and one candidate (0.08%) chose option (B).

Although the concept of palliative care and the importance to share decisions with the family has been chosen by the majority of the newly graduating physicians, 38.31% would still make decisions independently of the family's opinion. Medical students have to be prepared for a new set of skills.

1. Kasper DL, Braunwald E, Fauci AS, et al.: Harrison's Principle of Internal Medicine. 16th edition. McGraw-Hill; 2005.
2. Tinker J, Browne DRG, Sibbald WJ: Critical Care. Standards, Audit and Ethics. London: Arnold; 1996.