Influence of sedation on morbidity and mortality in the intensive care unit

CONTEXTO: Embora cerca de 30% a 50% dos pacientes hospitalizados em unidades de terapia intensiva (UTI) recebam algum tipo de sedativo, existe escassez de informações sobre efeitos adversos desta prática, especialmente no Brasil. Estes efeitos podem ser significantes e o uso de sedativos é associado a elevação de infecção e mortalidade, mesmo sendo difícil avaliar o impacto clínico deste procedimento. OBJETIVO: Avaliar o impacto da sedação sobre incidência de complicações e mortalidade em doentes graves durante internação em unidade de terapia intensiva. TIPO DE ESTUDO: Estudo prospectivo. LOCAL: Unidade de Terapia Intensiva Cirúrgica da Universidade Federal de São Paulo (UNIFESP) - Escola Paulista de Medicina. PARTICIPANTES: Após excluídos pacientes que permaneceram menos de 24 horas ou sem exames indispensáveis para o cálculo do índice de gravidade (APACHE II), restaram 307 pacientes. Estes foram divididos em dois grupos: Grupo Sedado e Grupo Não Sedado. Constatada heterogeneidade com relação ao APACHE II, foram pareados 97 sedados e 97 não sedados com idênticos índices de gravidade. VARIÁVEIS ESTUDADAS: Impacto da sedação e das técnicas sobre a mortalidade, tempo de internação, além da incidência de escara de decúbito ou pressão, trombose venosa profunda e infecção. RESULTADOS: Não houve diferença na incidência de trombose venosa profunda, entre os grupos Sedado e Não Sedado, enquanto que escara de decúbito foi significativamente maior nos sedados (p = 0,03). Infecção foi detectada em 45,4% dos pacientes com sedação e em 21,6% dos pacientes sem sedação (p = 0,006). A mortalidade para os pacientes que não receberam qualquer tipo de sedativo foi de 20,6% e, para aqueles que foram sedados durante a internação, foi de 52,6% (p < 0,0001). CONCLUSÕES: Conclui-se que a sedação está associada a maior duração da internação, morbidade e mortalidade significativas. Apesar da intensidade das associações encontradas, não é possível estabelecer relação causal entre sedação e mortalidade.

Hospital-dia: para quem e para quê?

OBJETIVO: Estudar prospectivamente a população internada em um hospital-dia (HD) em relação a fatores que poderiam influenciar na melhora e na duração da internação. MÉTODOS: Foram entrevistados, para obtenção de dados sociodemográficos e avaliação da evolução, 34 pacientes internados no Hospital-Dia da Faculdade de Medicina de Botucatu, Unesp, durante um ano. O diagnóstico psiquiátrico foi avaliado pela CIDI (Composite International Diagnostic Interview), a sintomatologia psiquiátrica pela BPRS (Brief Psychiatric Rating Scale) e a incapacitação psicossocial pela DAS (Psychiatric Disability Assessment Schedule). Todos os pacientes foram acompanhados, e seus familiares, entrevistados. RESULTADOS: Predominaram mulheres (76%), jovens (61,8%), sem vínculo conjugal (71%), sem trabalho (82,4%), com diagnóstico de transtornos afetivos (44,1%) e com internações psiquiátricas prévias (44%). Apenas quatro (12%) pacientes apresentavam uma síndrome maior segundo BPRS. Houve considerável incapacitação psicossocial dos pacientes em alguns papéis sociais. Maior renda per capita foi um fator associado à melhor evolução. As internações duraram em média 74 dias. Pacientes com internações prévias tenderam a permanecer menos tempo no HD. CONCLUSÕES: Portadores de transtornos afetivos e quadros não-psicóticos geralmente não necessitam de internação por período integral em hospital psiquiátrico. Contudo, os pacientes deste estudo tiveram um elevado número de internações psiquiátricas prévias, provavelmente por necessitarem de um nível de atendimento além das possibilidades dos ambulatórios. Entretanto, pacientes com maior número de internações -- em tese mais graves -- tenderam a permanecer menos tempo no HD, o que suscita dúvidas quanto à sua adesão a serviços abertos, bem como aos possíveis fatores facilitadores dessa adesão. em um momento de crescimento expressivo no número de serviços de internação parcial no Brasil, como nos últimos anos, mais estudos são necessários a fim de esclarecer para quem e para quê são destinados esses serviços.

Fungemia by yeasts in Brazil: occurrence and phenotypic study of strains isolated at the Public Hospital, Botucatu, São Paulo

Objective. - In this study strains of yeasts isolated from the blood of human patients were analyzed taxonomically, their virulence factors were determined and compared, and phenotypic markers were used to compare the samples with respect to phenotypic differences across the range of patients as well as between samples isotated from the same patient.Methods. - the study involved a total of 75 strains of yeast isolated from the blood of in-patients of the Public Hospital, Botucatu, S (a) over tildeo Paulo, Brazil, with a clinical profile of fungemia. The hospital wards with the largest number of fungemias were neonatal intensive care units (ICUs) (32%) followed by gastric surgery (13.4%) and pediatric wards (10.7%). After identification, the samples were analyzed for the production of phospholipase and proteinase enzymes, and biotyped according to their susceptibility to killer toxins.Results. - the most frequent species found was Candida albicans (38.7%) followed by C. parapsilosis (30.7%). In terms of enzyme production, 98.7% of the 75 samples of yeast presented a strongly positive activity for proteinase; however, 78.7% did not present any phospholipasic activity. Six different biotypes were identified, the most frequent being 511 and 888.Conclusion. In association with phenotypic methods, genetic analyses should also be made of the samples under study to help in the rational development of a wider range of preventive measures and better control of hospital-contracted infections. (c) 2005 Published by Elsevier SAS.

Predictors of incorrectness in antimicrobial prescription in the Bauru State Hospital (Bauru city, São Paulo State, Brazil)

The inappropriate use of antimicrobials in hospitals presents a negative impact on patient outcome and is associated with the emergence and spread of multidrug-resistant microorganisms. Antimicrobial stewardship programs (ASPs) have been instituted in order to improve the quality of prescriptions in hospitals. In this setting, the identification of patterns of inappropriate antimicrobial prescription is a valuable tool that allows ASPs to identify priorities for directing educative/restrictive policies. With this purpose, a study was conducted in the Bauru State Hospital, a teaching hospital with 285 beds affiliated to the Botucatu Medical School, São Paulo State University. The hospital maintains an active ASP since it was opened, in 2002. We selected 25% of the requests for parenteral antimicrobials (RPAs) from 2005 for analysis. Prescriptions for prophylactic purposes were excluded. All other RPAs were classified according to a modified Kunin and Jones categories. Univariate and multivariable analyses were performed to identify predictors of general inappropriateness and of specific prescription errors. Prescriptions classified as "appropriate'' or "probably appropriate" were selected as controls in all stages of the study. Among 963 RPAs included in our study, 34.6% were inappropriate. General predictors of inappropriateness were: prescription on weekends/holidays (OR = 1.67, 95% CI = 1.20-2.28, p = 0.002), patient from intensive care unit (OR = 1.57, 95% CI = 1.11-2.23, p = 0.01), peritoneal (OR = 2.15, 95% CI = 1.27-3.65, p = 0.004) or urinary tract infection (OR = 1.89, 95% CI = 1.25-2.87, p = 0.002), combined therapy with two or more antimicrobials (OR = 1.72, 95% CI = 1.15-2.57, p = 0.008) and prescriptions including penicillin (OR = 2.12, 95% CI = 1.39-3.25, p = 0.001) or first-generation cephalosporins (OR = 1.74, 95% CI = 1.01-3.00, p = 0.048). Previous consultation with an infectious diseases (ID) specialist had a protective effect against inappropriate prescription (OR = 0.34, 95% CI = 0.24-0.50, p < 0.001). Factors independently associated with specific prescription errors varied. However, consultation with an ID specialist was protective against both unnecessary antimicrobial use (OR = 0.04, 95% CI = 0.01-0.26, p = 0.001) and requests for agents with insufficient spectrum (OR = 0.14, 95% CI = 0.03-0.30, p = 0.01). In conclusion, the analysis of factors predictive of inappropriateness in antimicrobial prescription allowed us to identify issues requiring intervention. Also, it provided a positive feedback of the ASP efficacy, demonstrating the importance of previous consultation with an ID specialist to assure the quality of antimicrobial prescriptions.

Variability on red blood cell transfusion practices among Brazilian neonatal intensive care units

BACKGROUND:Guidelines for red blood cell (RBC) transfusions exist; however, transfusion practices vary among centers. This study aimed to analyze transfusion practices and the impact of patients and institutional characteristics on the indications of RBC transfusions in preterm infants.STUDY DESIGN and METHODS:RBC transfusion practices were investigated in a multicenter prospective cohort of preterm infants with a birth weight of less than 1500 g born at eight public university neonatal intensive care units of the Brazilian Network on Neonatal Research. Variables associated with any RBC transfusions were analyzed by logistic regression analysis.RESULTS:Of 952 very-low-birth-weight infants, 532 (55.9%) received at least one RBC transfusion. The percentages of transfused neonates were 48.9, 54.5, 56.0, 61.2, 56.3, 47.8, 75.4, and 44.7%, respectively, for Centers 1 through 8. The number of transfusions during the first 28 days of life was higher in Center 4 and 7 than in other centers. After 28 days, the number of transfusions decreased, except for Center 7. Multivariate logistic regression analysis showed higher likelihood of transfusion in infants with late onset sepsis (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.8-4.4), intraventricular hemorrhage (OR, 9.4; 95% CI, 3.3-26.8), intubation at birth (OR, 1.7; 95% CI, 1.0-2.8), need for umbilical catheter (OR, 2.4; 95% CI, 1.3-4.4), days on mechanical ventilation (OR, 1.1; 95% CI, 1.0-1.2), oxygen therapy (OR, 1.1; 95% CI, 1.0-1.1), parenteral nutrition (OR, 1.1; 95% CI, 1.0-1.1), and birth center (p < 0.001).CONCLUSIONS:The need of RBC transfusions in very-low-birth-weight preterm infants was associated with clinical conditions and birth center. The distribution of the number of transfusions during hospital stay may be used as a measure of neonatal care quality.

Caring for organ donors: The intensive care unit nurses' view

The nursing care for patients who are pronounced brain-dead but kept alive to serve as organ donors demands technical-scientific skills and the ability to handle situations that are often in conflict with the traditional concepts of nursing care. Based on the phenomenological approach in this article, essential themes of the lived experience of caring for these patients, including the technical and specific nursing care, the relationship with organ donors and their families, and the nurses' perception of themselves in this professional situation are described. The results point to the contradictions and ambiguities of this type of nursing, especially in regards to the affective and philosophical aspects.

Psychiatric disorders and psychiatric consultation in a general hospital: A case- control study

Introduction: Psychiatric consultation (PC) has been considered an efficient tool to develop research, to track and to give assistance benefiting patients, health professionals and the institution. However, it has not been much used in Brazil. Although 30 to 50% of general hospital (GH) inpatients may present a psychiatric disorder, only 1 to 12% of them are referred to assessment. The aims of this study were: to assess mental disorders in a GH; to identify which of these patients are sent to psychiatric care; to verify alleged reasons for referral to psychiatric consultation, and to examine the relationship between PC and psychiatric learning (during medical school and residence). Methods: A case-control patient study was conducted (47 cases and 94 controls) to analyze in detail the following variables: socio-demographic; clinical; degree of information (about the disease and diagnostic/therapeutic procedures), and relationship between patient and health team. Psychiatric diagnoses were made according to the ICD- 10 criteria. The Self Report Questionnaire (SRQ), the CAGE and Brief Psychiatric Rating Scale (BPRS) were used as well as a specifically designed questionnaire to collect clinical and demographic data. Results: Behavioral alterations, either of elation or of depression, were the main for requesting a PC; 95.8% of the cases and 27.7% of the controls had a mental disorder. Organic mental disorders and alcohol-related disorders were the most frequent diagnoses in group I (cases), while anxiety, depressive and alcohol-related disorders were predominant in group II (controls). Control group patients were better informed and more able to establish an appropriate relationship with the health team than case patients. The logistic regression showed CAGE-positive patients having 12.85 times greater risk of being referred to PC, followed by unemployed patients (2.44 times more PC referrals). Discussion: The SRQ and CAGE were quite useful in the screening of possible patients and might be important for medical students to learn and use as generalists. Further research is needed to verify if and how the newly-established service will improve the diagnostic and treatment skills of our students.

The frequency of pharmacological pain relief in university neonatal intensive care units

Objective: To evaluate the use of drugs to relieve the pain of invasive procedures newborn infants cared for at a university hospital NICU. Methods: A prospective cohort study of all newborn infants hospitalized in four NICU during October 2001. The following data were collected: demographic data of the hospitalized newborn infants; clinical morbidity; number of potentially painful procedures and frequency of analgesic administration. Factors associated with the use of analgesia in this cohort of patients were studied by multiple linear regression using SPSS 8.0. Results: Ninety-one newborn infants were admitted to the NICU during the study period (1,025 patient-days). Only 25% of the 1,025 patient-days received systemic analgesia. No specific drugs were administered to relieve acute pain during any of the following painful events: arterial punctures, venous, capillary and lumbar punctures or intubations. For chest tube insertion, 100% of newborn infants received specific analgesia. For the insertion of central catheters 8% of the newborn infants received painkillers. Only nine of the 17 newborn infants that underwent surgical procedures received any analgesic dosage during the postoperative period. For 93% of patients under analgesia the drug of choice was fentanyl. The presence of mechanical ventilation increased the chance of newborn infants receiving painkillers by 6.9 times and the presence of chest tube increased this chance by five times. Conclusion: It is necessary to train health professionals in order to bridge the gap between scientific knowledge regarding newborn infant pain and clinical practice. Copyright © 2005 by Sociedade Brasileira de Pediatria.

A família do paciente em situação crônica de vida: a visão de enfermeiros de um hospital de ensino

This exploratory descriptive study, of qualitative nature had the purpose to study how the nurses from a hospital school see the family as care participants. Six nurses from clinics of chronically ill patients were interviewed. The data analysis allowed to infer that the nurses had only little knowledge of the family's thematic during graduation, making the relationship with the accompanying families very difficult. Daily care during hospitalization period is marked by easy moments when members are willing to participate in the process, and by difficulties when they attempt to break institutional rules. It was suggested that new nurses have theoretical foundation to attend the family in several scenarios of care. It was considered the need of investments in professional training, and that the advance of humanization of services implies in exchange and integration of knowledge among patients, family members, health professionals, support staff and managers beyond the science field.

Evaluation of children's behavior aged 0-3 years during dental care: A longitudinal analysis

Child temperament has been studied in various researches and may be useful to predict how a child responds to dental treatment, especially very young children. The purpose of the present longitudinal study was to evaluate the behavioral manifestation of children aged 0 to 3 years, considering different types of dental situation. A total of 169 children were selected and the following data were collected: the age of the child, gender, age of the mother, number of dental visits and their respective dates, stimuli offered to the child, and behavioral response to these stimuli. The children and their respective behaviors were divided into five groups according to the dental situation offered: control, missed visits, fluoride varnish, restoration, and dental trauma. The data were submitted to descriptive and inferential analysis using the chi-square test, with the level of significance set at 5%. Analysis of the different situation offered to infants during routine dental care revealed a predominance of collaborating and partially collaborating behavior, and age at the time of dental care influenced the behavior of the infants, irrespective of the stimulus group. The different types of dental situation provoked changes in the behavioral response of the children of certain age groups, especially in the dental trauma group.

Detection of SPM and IMP metallo-β-lactamases in clinical specimens of Pseudomonas aeruginosa from a Brazilian public tertiary hospital

Phenotypic and genotypic SPM and IMP metallo-β-lactamases (MBL) detection and also the determination of minimal inhibitory concentrations (MIC) to imipenem, meropenem and ceftazidime were evaluated in 47 multidrug-resistant Pseudomonas aeruginosa isolates from clinical specimens. Polymerase chain reaction detected 14 positive samples to either blaSPM or blaIMP genes, while the best phenotypic assay (ceftazidime substrate and mercaptopropionic acid inhibitor) detected 13 of these samples. Imipenem, meropenem and ceftazidime MICs were higher for MBL positive compared to MBL negative isolates. We describe here the SPM and IMP MBL findings in clinical specimens of P. aeruginosa from the University Hospital of Botucatu Medical School, São Paulo, Brazil, that reinforce local studies showing the high spreading of blaSPM and blaIMP genes among Brazilian clinical isolates. © 2011 Elsevier Editora Ltda.

Cuidado em saúde mental: a escuta de pacientes egressos de um Hospital Dia.

This is a qualitative study aiming at understanding how patients discharged from a Mental Health Day Hospital view the service, at learning whether such service contributed to changes in their lives and at whether those individuals continued treatment. Semi-structured interviews and documental research were used for nine patients who had completed treatment at the service in 2008. Thematic analysis was adopted for organization of the data obtained, which were analyzed according to the Psychosocial Rehabilitation framework. It emphasizes the importance of looking for the various subjective aspects of human existence, requiring from services and professionals the establishment of a caring relationship that enables the reconstruction of trajectories interrupted by the onset of the disease, through actions that consider the integrality and intersectionality.

Avaliação de custos das internações de gestantes diabéticas de um Hospital Universitário do interior de São Paulo

This study aimed at identifying the hospitalization costs of pregnant women with Diabetes Mellitus (DM) at a University Hospital. It is an observational, quantitative study with descriptive data analysis. The direct and indirect costs available in the institution were identified in order to determine the hospitalization costs for patients diagnosed with DM during pregnancy and childbirth. By means of descriptive statistics, it was observed that 63.46% of the patients had caesarean delivery; the mean total cost was R$ 362.93 (U$ 218.10)/hospitalization during pregnancy, R$ 2,642.65 (U$ 1,588.13)/hospitalization for caesarean delivery, and R$ 2.319.77 (U$ 1,394.09)/hospitalization for vaginal delivery. It was concluded that the analysis of hospitalization costs for patients with DM is of utmost importance, since they are highcomplexity hospitalizations that require a large number of interventions, increasing thus the service costs.

Reforming health-care management in Latin America

Includes bibliography

Colonization pressure and risk factors for acquisition of imipenem-resistant Acinetobacter baumannii in a medical surgical intensive care unit in Brazil

We studied a nonconcurrent cohort of 582 patients admitted to a medical-surgical intensive care unit. Use of antimicrobials (imipenem and metronidazole) was a risk factor for acquisition of imipenem-resistant Acinetobacter baumannii only for the subcohort of patients admitted in months in which colonization pressure was lower than the median value. © 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.