Nursing Activities Score: an updated guideline for its application in the Intensive Care Unit

ABSTRACT Objective To describe nursing workload in Intensive Care Units (ICU) in different countries according to the scores obtained with Nursing Activities Score (NAS) and to verify the agreement among countries on the NAS guideline interpretation. Method This cross-sectional study considered 1-day measure of NAS (November 2012) obtained from 758 patients in 19 ICUs of seven countries (Norway, the Netherlands, Spain, Poland, Egypt, Greece and Brazil). The Delphi technique was used in expertise meetings and consensus. Results The NAS score was 72.8% in average, ranging from 44.5% (Spain) to 101.8% (Norway). The mean NAS score from Poland, Greece and Egypt was 83.0%, 64.6% and 57.1%, respectively. The NAS score was similar in Brazil (54.0%) and in the Netherlands (51.0%). There were doubts in the understanding of five out 23 items of the NAS (21.7%) which were discussed until researchers’ consensus. Conclusion NAS score were different in the seven countries. Future studies must verify if the fine standardization of the guideline can have a impact on differences in the NAS results.

Uso do cilindro infiltrômetro único em diferentes solos

O infiltrômetro de anéis concêntricos (IAC) tem sido empregado para a determinação da velocidade de infiltração básica de água no solo (VIB), porém, para sistemas de irrigação por aspersão, a melhor técnica é a que apresenta carga hidráulica zero, como nos simuladores de chuva. O presente trabalho teve o objetivo de avaliar o uso de infiltrômetro de cilindro único (ICU), comparando-o com o IAC e com um simulador de chuva. O experimento foi realizado em dois tipos de solo classificados como Latossolo Vermelho distroférrico e Cambissolo, onde se utilizou um ICU com 0,20 m de diâmetro e 0,50 m de altura. As cargas hidráulicas utilizadas variaram de 0,03 m a 0,30 m com intervalos crescentes de 0,03 m, com três repetições. Utilizou-se de um IAC de 0,30 e 0,90 m de diâmetro, com três repetições, nas cargas hidráulicas mais utilizadas no campo, 0,05 m e 0,10 m. O simulador de chuva utilizado teve área útil de 1,0 m² com dois difusores. Com o aumento da carga hidráulica para o ICU, o fluxo de entrada de água no solo aumentou de forma polinomial para os dois solos. Para o IAC, a VIB pode ser subestimada ou superestimada, dependendo do solo e da carga hidráulica. Pode-se estimar a VIB, para uma carga hidráulica zero, utilizando-se de um ICU na carga desejada, desde que se aplique o fator de correção inerente de cada tipo de solo.

Síndrome da alça aferente com necrose simulando pseudocisto de pâncreas

Afferent loop obstruction after gastrectomy and Billroth II reconstruction is an uncommon problem. Complete acute obstruction requires emergent laparotomy. We describe a patient who developed acute abdominal pain, hyperamylasemia, and palpable abdominal mass, five years after Billroth II gastrectomy. At laparotomy the patient was found to have a complete stricture of the afferent limb with evidence of strangulation and necrosis. There was no evidence of pancreatitis or pancreatic pseudocyst. The patient underwent pancreaticoduodenectomy plus degastrectomy and died 18 hours after the procedure in the ICU. The mass was initially inte1preted as pancreatic pseudocyst. Ultrasonography may provide enough evidence to differentiate a pancreatic pseudocyst. from an obstructed afferent loop, by the presence of a peripancreatic cystic mass or debris within the mass or the absence of the keyboard sign, suggesting effacement of the valvulae conniventes of the small bowel. Howewer, CT scan of the abdomen has been suggested to be highly characteristic, if not pathognomonic, for an obstructed afferent loop and should be considered first in patients with pancreatitis after Billroth II gastrectomy. A history of previous gastrectomy, recurrent or severe abdominal pain, hyperamylasemia with characteristic tomography, and endoscopic findings will establish the diagnosis and necessitate surgical evaluation and intervention.

Amputação interescapulotorácica sob anestesia locorregional

Forequarter amputations are an uncommon option for the treatment of upper limb and shoulder girdle tumors nowadays. This procedure can be done by different approaches and general anesthesia is commonly used. The authors report a case of forequarter amputation by the posterior approach performed for treatment of a soft-tissue sarcoma under a brachial plexus block associated with venous sedation and local anesthesia.

Implementation of a perioperative management protocol for patients undergoing orthopedic surgery

OBJECTIVE: To evaluate the initial results after the implementation of perioperative protocol in patients over 60 years of age undergoing surgical treatment for femur fractures.METHODS: We conducted a prospective study of patients older than 60 years who were hospitalized with femur fracture. They were operated under spinal anesthesia and analgesia by lumbar plexus blockade. Data evaluation was performed before arrival in the operating room during surgery, in the post-anesthesia recovery room and in the ward the next morning of the operation.RESULTS: 105 patients underwent various types of surgical corrections of the femur. The hospital stay ranged from three to 86 days. Fasting ranged from 9h15min to 19h30mn. Hypotension occurred in 5.7%. The duration of motor blockade ranged from 1h45min to 5h30imn. Maltodextrin feeding ranged from 50min to 3h45min and the time spent in the post-anesthetic care unit ranged from 50 minutes to 4 hours. Onset of oral intake in the ward ranged from 4hto 8h15min. The duration of anesthesia ranged from 14 to 33 hours. No patient required a urinary catheter, nor was transferred to the ICU. All patients were able to be discharged on the first postoperative day.CONCLUSION: The use of a protocol to accelerate the postoperative period may reduce the fasting time, length of hospital stay and provide faster i discharge n elderly patients with femur fractures.

Normal values of b-wave responses of full-field electroretinogram in Lhasa Apso dogs with cataracts according to age

Lhasa Apso dogs with immature, mature or hypermature cataracts were divided into four groups according to their age (G1: 1 to 3 years old, G2: 4 to 7 years old, G3: 8 to 11 years old, G4: more than 12 years old). All animals were evaluated under the same sedation protocol to allow the performance of the electroretinogram (ERG) exam to determine normal value of b-wave response of the full-field ERG according to age. Three ERG responses were recorded: rod, maximal and cone responses. The amplitude values and b-wave implicit time of the responses of all groups were compared and analyzed by Kruskal-Wallis test (variance analysis for non-repeated measures), followed by the Dunn post-test (when p<0,05). A significant decrease was observed in maximal responses' amplitude, when comparing the G4 group with G1 and G2. No statistically relevant differences were observed in the b-wave implicit time values between groups. The ERG values are directly influenced by the animal's age. Older patients presented a decrease in the amplitude of the maximal response. The study determined the normal parameters of ERG b-waves for Lhasa Apso dogs with cataract according to their age group.

Evaluation of cardiopulmonary parameters and recovery from anesthesia in cougars (Puma concolor) anesthetized with detomidine/ketamine and isoflurane or sevoflurane

Abstract: The aim of this study was to assess the cardiopulmonary effects, the onset time after the administration of a detomidine/ketamine combination, and the recovery from anesthesia of cougars (Puma concolor) anesthetized with detomidine/ketamine and isoflurane or sevoflurane for abdominal ultrasound imaging. Fourteen animals were randomly allocated into two experimental groups: GISO (n=7) and GSEVO (n=7). Chemical restraint was performed using 0.15mg/kg detomidine combined with 5mg/kg ketamine intramuscularly; anesthesia induction was achieved using 2mg/kg propofol intravenously and maintenance with isoflurane (GISO) or sevoflurane (GSEVO). The following parameters were assessed: heart rate, respiratory rate, systolic and diastolic arterial blood pressure, mean arterial blood pressure, oxyhemoglobin saturation, rectal temperature, central venous pressure, and end-tidal carbon dioxide. The time to sternal recumbency (TSR) and time to standing position (TSP) were also determined. There was not statistically significant difference for the cardiopulmonary variables or TSP whereas TSR was significantly shorter in GSEVO. The time to onset of anesthesia was 11.1±1.2 minutes and 11.3±1.8 minutes for GISO and GSEVO, respectively. The anesthesia of cougars with detomidine/ketamine and isoflurane or sevoflurane was conducted with safety, cardiopulmonary stability, and increased time to sternal recumbency in the GISO group.

Hypomagnesemia in critically ill cancer patients: a prospective study of predictive factors

Hypomagnesemia is the most common electrolyte disturbance seen upon admission to the intensive care unit (ICU). Reliable predictors of its occurrence are not described. The objective of this prospective study was to determine factors predictive of hypomagnesemia upon admission to the ICU. In a single tertiary cancer center, 226 patients with different diagnoses upon entering were studied. Hypomagnesemia was defined by serum levels <1.5 mg/dl. Demographic data, type of cancer, cause of admission, previous history of arrhythmia, cardiovascular disease, renal failure, drug administration (particularly diuretics, antiarrhythmics, chemotherapy and platinum compounds), previous nutrition intake and presence of hypovolemia were recorded for each patient. Blood was collected for determination of serum magnesium, potassium, sodium, calcium, phosphorus, blood urea nitrogen and creatinine levels. Upon admission, 103 (45.6%) patients had hypomagnesemia and 123 (54.4%) had normomagnesemia. A normal dietary habit prior to ICU admission was associated with normal Mg levels (P = 0.007) and higher average levels of serum Mg (P = 0.002). Postoperative patients (N = 182) had lower levels of serum Mg (0.60 ± 0.14 mmol/l compared with 0.66 ± 0.17 mmol/l, P = 0.006). A stepwise multiple linear regression disclosed that only normal dietary habits (OR = 0.45; CI = 0.26-0.79) and the fact of being a postoperative patient (OR = 2.42; CI = 1.17-4.98) were significantly correlated with serum Mg levels (overall model probability = 0.001). These findings should be used to identify patients at risk for such disturbance, even in other critically ill populations.

Hypomagnesemia is a risk factor for nonrecovery of renal function and mortality in AIDS patients with acute kidney injury

The objective of the present study was to determine the prevalence of electrolyte disturbances in AIDS patients developing acute kidney injury in the hospital setting, as well as to determine whether such disturbances constitute a risk factor for nephrotoxic and ischemic injury. A prospective, observational cohort study was carried out. Hospitalized AIDS patients were evaluated for age; gender; coinfection with hepatitis; diabetes mellitus; hypertension; time since HIV seroconversion; CD4 count; HIV viral load; proteinuria; serum levels of creatinine, urea, sodium, potassium and magnesium; antiretroviral use; nephrotoxic drug use; sepsis; intensive care unit (ICU) admission, and the need for dialysis. Each of these characteristics was correlated with the development of acute kidney injury, with recovery of renal function and with survival. Fifty-four patients developed acute kidney injury: 72% were males, 59% had been HIV-infected for >5 years, 72% had CD4 counts <200 cells/mm³, 87% developed electrolyte disturbances, 33% recovered renal function, and 56% survived. ICU admission, dialysis, sepsis and hypomagnesemia were all significantly associated with nonrecovery of renal function and with mortality. Nonrecovery of renal function was significantly associated with hypomagnesemia, as was mortality in the multivariate analysis. The risks for nonrecovery of renal function and for death were 6.94 and 6.92 times greater, respectively, for patients with hypomagnesemia. In hospitalized AIDS patients, hypomagnesemia is a risk factor for nonrecovery of renal function and for in-hospital mortality. To determine whether hypomagnesemia is a determinant or simply a marker of critical illness, further studies involving magnesium supplementation in AIDS patients are warranted.

Outcomes and organ dysfunctions of critically ill patients with systemic lupus erythematosus and other systemic rheumatic diseases

Our objective was to compare the pattern of organ dysfunctions and outcomes of critically ill patients with systemic lupus erythematosus (SLE) with patients with other systemic rheumatic diseases (SRD). We studied 116 critically ill SRD patients, 59 SLE and 57 other-SRD patients. The SLE group was younger and included more women. Respiratory failure (61%) and shock (39%) were the most common causes of ICU admission for other-SRD and SLE groups, respectively. ICU length-of-stay was similar for the two groups. The 60-day survival adjusted for the groups’ baseline imbalances was not different (P = 0.792). Total SOFA scores were equal for the two groups at admission and during ICU stay, although respiratory function was worse in the other-SRD group at admission and renal and hematological functions were worse in the SLE group at admission. The incidence of severe respiratory dysfunction (respiratory SOFA >2) at admission was higher in the other-SRD group, whereas severe hematological dysfunction (hematological SOFA >2) during ICU stay was higher in the SLE group. SLE patients were younger and displayed a decreased incidence of respiratory failure compared to patients with other-SRDs. However, the incidences of renal and hematological failure and the presence of shock at admission were higher in the SLE group. The 60-day survival rates were similar.

Implications of extubation failure and prolonged mechanical ventilation in the postoperative period following elective intracranial surgery

Patients undergoing neurosurgery are predisposed to a variety of complications related to mechanical ventilation (MV). There is an increased incidence of extubation failure, pneumonia, and prolonged MV among such patients. The aim of the present study was to assess the influence of extubation failure and prolonged MV on the following variables: postoperative pulmonary complications (PPC), mortality, reoperation, tracheostomy, and duration of postoperative hospitalization following elective intra-cranial surgery. The study involved a prospective observational cohort of 317 patients submitted to elective intracranial surgery for tumors, aneurysms and arteriovenous malformation. Preoperative assessment was performed and patients were followed up for the determination of extubation failure and prolonged MV (>48 h) until discharge from the hospital or death. The occurrence of PPC, incidence of death, the need for reoperation and tracheostomy, and the length of hospitalization were assessed during the postoperative period. Twenty-six patients (8.2%) experienced extubation failure and 30 (9.5%) needed prolonged MV after surgery. Multivariate analysis showed that extubation failure was significant for the occurrence of death (OR = 8.05 [1.88; 34.36]), PPC (OR = 11.18 [2.27; 55.02]) and tracheostomy (OR = 7.8 [1.12; 55.07]). Prolonged MV was significant only for the occurrence of PPC (OR = 4.87 [1.3; 18.18]). Elective intracranial surgery patients who experienced extubation failure or required prolonged MV had a higher incidence of PPC, reoperation and tracheostomy and required a longer period of time in the ICU. Level of consciousness and extubation failure were associated with death and PPC. Patients who required prolonged MV had a higher incidence of extubation failure.

Furosemide is associated with acute kidney injury in critically ill patients

Acute kidney injury (AKI) is common in critically ill patients. Diuretics are used without any evidence demonstrating a beneficial effect on renal function. The objective of the present study is to determine the incidence of AKI in an intensive care unit (ICU) and if there is an association between the use of furosemide and the development of AKI. The study involved a hospital cohort in which 344 patients were consecutively enrolled from January 2010 to January 2011. A total of 132 patients (75 females and 57 males, average age 64 years) remained for analysis. Most exclusions were related to ICU discharge in the first 24 h. Laboratory, sociodemographic and clinical data were collected until the development of AKI, medical discharge or patient death. The incidence of AKI was 55% (95%CI = 46-64). The predictors of AKI found by univariate analysis were septic shock: OR = 3.12, 95%CI = 1.36-7.14; use of furosemide: OR = 3.27, 95%CI = 1.57-6.80, and age: OR = 1.02 (95%CI = 1.00-1.04). Analysis of the subgroup of patients with septic shock showed that the odds ratio of furosemide was 5.5 (95%CI = 1.16-26.02) for development of AKI. Age, use of furosemide, and septic shock were predictors of AKI in critically ill patients. Use of furosemide in the subgroup of patients with sepsis/septic shock increased (68.4%) the chance of development of AKI when compared to the sample as a whole (43.9%).

Effect of heat and moisture exchangers on the prevention of ventilator-associated pneumonia in critically ill patients

Ventilator-associated pneumonia (VAP) remains one of the major causes of infection in the intensive care unit (ICU) and is associated with the length of hospital stay, duration of mechanical ventilation, and use of broad-spectrum antibiotics. We compared the frequency of VAP 10 months prior to (pre-intervention group) and 13 months after (post-intervention group) initiation of the use of a heat and moisture exchanger (HME) filter. This is a study with prospective before-and-after design performed in the ICU in a tertiary university hospital. Three hundred and fourteen patients were admitted to the ICU under mechanical ventilation, 168 of whom were included in group HH (heated humidifier) and 146 in group HME. The frequency of VAP per 1000 ventilator-days was similar for both the HH and HME groups (18.7 vs 17.4, respectively; P = 0.97). Duration of mechanical ventilation (11 vs 12 days, respectively; P = 0.48) and length of ICU stay (11 vs 12 days, respectively; P = 0.39) did not differ between the HH and HME groups. The chance of developing VAP was higher in patients with a longer ICU stay and longer duration of mechanical ventilation. This finding was similar when adjusted for the use of HME. The use of HME in intensive care did not reduce the incidence of VAP, the duration of mechanical ventilation, or the length of stay in the ICU in the study population.

Application of a modified sequential organ failure assessment score to critically ill patients

The purpose of the present study was to explore the usefulness of the Mexican sequential organ failure assessment (MEXSOFA) score for assessing the risk of mortality for critically ill patients in the ICU. A total of 232 consecutive patients admitted to an ICU were included in the study. The MEXSOFA was calculated using the original SOFA scoring system with two modifications: the PaO2/FiO2 ratio was replaced with the SpO2/FiO2 ratio, and the evaluation of neurologic dysfunction was excluded. The ICU mortality rate was 20.2%. Patients with an initial MEXSOFA score of 9 points or less calculated during the first 24 h after admission to the ICU had a mortality rate of 14.8%, while those with an initial MEXSOFA score of 10 points or more had a mortality rate of 40%. The MEXSOFA score at 48 h was also associated with mortality: patients with a score of 9 points or less had a mortality rate of 14.1%, while those with a score of 10 points or more had a mortality rate of 50%. In a multivariate analysis, only the MEXSOFA score at 48 h was an independent predictor for in-ICU death with an OR = 1.35 (95%CI = 1.14-1.59, P < 0.001). The SOFA and MEXSOFA scores calculated 24 h after admission to the ICU demonstrated a good level of discrimination for predicting the in-ICU mortality risk in critically ill patients. The MEXSOFA score at 48 h was an independent predictor of death; with each 1-point increase, the odds of death increased by 35%.

Impairment of locomotor activity induced by the novelN-acylhydrazone derivatives LASSBio-785 and LASSBio-786 in mice

The N-acylhydrazone (NAH) analogues N-methyl 2-thienylidene 3,4-benzoylhydrazine (LASSBio-785) and N-benzyl 2-thienylidene 3,4-benzoylhydrazine (LASSBio-786) were prepared from 2-thienylidene 3,4-methylenedioxybenzoylhydrazine (LASSBio-294). The ability of LASSBio-785 and LASSBio-786 to decrease central nervous system activity was investigated in male Swiss mice. LASSBio-785 or LASSBio-786 (30 mg/kg, ip) reduced locomotor activity from 209 ± 26 (control) to 140 ± 18 (P < 0.05) or 146 ± 15 crossings/min (P < 0.05), respectively. LASSBio-785 (15 or 30 mg/kg, iv) also reduced locomotor activity from 200 ± 15 to 116 ± 29 (P < 0.05) or 60 ± 16 crossings/min (P < 0.01), respectively. Likewise, LASSBio-786 (15 or 30 mg/kg, iv) reduced locomotor activity from 200 ± 15 to 127 ± 10 (P < 0.01) or 96 ± 14 crossings/min (P < 0.01), respectively. Pretreatment with flumazenil (20 mg/kg,ip) prevented the locomotor impairment induced by NAH analogues (15 mg/kg, iv), providing evidence that the benzodiazepine (BDZ) receptor is involved. This finding was supported by the structural similarity of NAH analogues to midazolam. However, LASSBio-785 showed weak binding to the BDZ receptor. LASSBio-785 or LASSBio-786 (30 mg/kg,ip, n = 10) increased pentobarbital-induced sleeping time from 42 ± 5 (DMSO) to 66 ± 6 (P < 0.05) or 75 ± 4 min (P < 0.05), respectively. The dose required to achieve 50% hypnosis (HD50) following iv injection of LASSBio-785 or LASSBio-786 was 15.8 or 9.5 mg/kg, respectively. These data suggest that both NAH analogues might be useful for the development of new neuroactive drugs for the treatment of insomnia or for use in conjunction with general anesthesia.