UCI - Artigos
Permanent URI for this collection
Browse
Recent Submissions
- Association of Noradrenaline Dose With Mortality in Critically Ill Patients: a Systematic Review and Dose-Response Meta-Analysis.Publication . Reinikainen, Matti; Delamarre, Louis; Blaser, Annika Reintam; Hollenberg, Steven M; Lobo, Suzana M; Rezende, Ederlon; Moreno, Rui; Rhodes, Andrew; Ranzani, Otavio T; Singer, Mervyn; Lakbar, Inès; Moreno, RuiBackground: Noradrenaline is currently the first-line vasopressor in treatment of circulatory failure. Its dose reflects illness severity, and together with dopamine, dobutamine and adrenaline, it is used in the Sequential Organ Failure Assessment (SOFA) score to grade cardiovascular dysfunction. Over the years, noradrenaline use has increased and it has largely replaced dopamine. As part of the SOFA-2 update, we conducted a systematic review and dose-response meta-analysis to assess the association between noradrenaline dose and mortality. Methods: We searched MEDLINE, Embase, and Web of Science from 1 January 2013 to 30 October 2024 for studies reporting mortality by noradrenaline dose in critically ill adults. The primary outcome was mortality. We generated pooled relative risks (RR) and assessed linear and non-linear dose-response relationships. Mortality was also analysed by SOFA-2 noradrenaline categories. The study followed PRISMA guidelines and was registered with PROSPERO (CRD42024501533). Results: Nineteen studies, including totally 29,935 patients, were included in the systematic review, and six in the meta-analysis. We observed a consistent increase in mortality: the relative risk escalated by a factor of 1.5 for every 0.1 µg/kg/min increase in peak noradrenaline dose. We did not find inflection points in the dose-mortality curve. In SOFA-2 categories, hospital mortality was 16.5% in the dose category ≤ 0.2 µg/kg/min, 31.9% in the category > 0.2 to 0.4 µg/kg/min, and 40.3% in the category > 0.4 µg/kg/min (p < 0.001). Conclusions: In critically ill patients, escalating doses of noradrenaline correlate with an exponentially rising relative risk of mortality. This dose-dependent pattern reinforces the role of noradrenaline dose as a marker of cardiovascular failure severity.
- An Interactive Dashboard for Statistical Analysis of Intensive Care Unit COVID-19 DataPublication . Dias, Rúben; Ferreira, Artur; Pinto, Iola; Geraldes, Carlos; Von Rekowski, Cristiana; Bento, LuísBackground: COVID-19 caused a pandemic, due to its ease of transmission and high number of infections. The evolution of the pandemic and its consequences for the mortality and morbidity of populations, especially the elderly, generated several scientific studies and many research projects. Among them, we have the Predictive Models of COVID-19 Outcomes for Higher Risk Patients Towards a Precision Medicine (PREMO) research project. For such a project with many data records, it is necessary to provide a smooth graphical analysis to extract value from it. Methods: In this paper, we present the development of a full-stack Web application for the PREMO project, consisting of a dashboard providing statistical analysis, data visualization, data import, and data export. The main aspects of the application are described, as well as the diverse types of graphical representations and the possibility to use filters to extract relevant information for clinical practice. Results: The application, accessible through a browser, provides an interactive visualization of data from patients admitted to the intensive care unit (ICU), throughout the six waves of COVID-19 in two hospitals in Lisbon, Portugal. The analysis can be isolated per wave or can be seen in an aggregated view, allowing clinicians to create many views of the data and to study the behavior and consequences of different waves. For instance, the experimental results show clearly the effect of vaccination as well as the changes on the most relevant clinical parameters on each wave. Conclusions: The dashboard allows clinicians to analyze many variables of each of the six waves as well as aggregated data for all the waves. The application allows the user to extract information and scientific knowledge about COVID-19’s evolution, yielding insights for this pandemic and for future pandemics.
- Organ Crosstalk and Dysfunction in Sepsis.Publication . Borges, André; Bento, LuísSepsis is a dysregulated immune response to an infection that leads to organ dysfunction. Sepsis-associated organ dysfunction involves multiple inflammatory mechanisms and complex metabolic reprogramming of cellular function. These mechanisms cooperate through multiple organs and systems according to a complex set of long-distance communications mediated by cellular pathways, solutes, and neurohormonal actions. In sepsis, the concept of organ crosstalk involves the dysregulation of one system, which triggers compensatory mechanisms in other systems that can induce further damage. Despite the abundance of studies published on organ crosstalk in the last decade, there is a need to formulate a more comprehensive framework involving all organs to create a more detailed picture of sepsis. In this paper, we review the literature published on organ crosstalk in the last 10 years and explore how these relationships affect the progression of organ failure in patients with septic shock. We explored these relationships in terms of the heart-kidney-lung, gut-microbiome-liver-brain, and adipose tissue-muscle-bone crosstalk in sepsis patients. A deep connection exists among these organs based on crosstalk. We also review how multiple therapeutic interventions administered in intensive care units, such as mechanical ventilation, antibiotics, anesthesia, nutrition, and proton pump inhibitors, affect these systems and must be carefully considered when managing septic patients. The progression to multiple organ dysfunction syndrome in sepsis patients is still one of the most frequent causes of death in critically ill patients. A better understanding and monitoring of the mechanics of organ crosstalk will enable the anticipation of organ damage and the development of individualized therapeutic strategies.
- Ultrasound Monitoring of Skeletal Muscle Wasting and Relation to Nutritional Intervention in Critically Ill Patients: MUScleNut Study.Publication . Rosa Domingues, Catarina; Rodeia, Simão; Francisco, Ana Rita; Santos, Laura; Cerca, Carolina; Costa, Madalena; Pinto, Vera; Fortuna, Philip; Brito-Costa, Ana; Bento, LuísBackground: Critically ill patients frequently experience profound skeletal muscle (SM) wasting, to which early detection and effective clinical management remain significant challenges. Ultrasonography (US) provides early objective information about SM compared with usual functional tests. The characteristics of the optimal nutritional support are controversial. This observational study aimed to characterize the SM changes through US in the first week after Intensive Care Unit (ICU) admission and to evaluate the potential interference factors with a focus on nutritional support. Results: A total of 95 patients (age 55.7 ± 16.01 years, 70.5% male) were included. All the ultrasound SM measures tendentially reduced after admission: quadriceps muscle layer thickness (QMLT) 10.03% (0.38 ± 0.73 cm), rectus femoris cross-sectional area (RF-CSA) 10.48% (0.50 ± 1.38 cm2), RF pennation angle (RF-PA) 0.94 ± 4.14 º, RF echogenicity (RF-EG) 1.05 ± 22.33 in echo-intensity gray scale and RF shear wave elastography (RF-SWE) 0.13 ± 1.25 m/s and 3.96 ± 28.10 kPa. A significant association between nutritional risk at baseline and SM changes (QMLT 0.194, p = 0.079 and RF-CSA 0.25, p = 0.027) was observed and confirmed in a linear regression model (1.257 and p = 0.011). No significant associations were found between SM changes and nutritional support. Conclusion: Present findings demonstrate a marked reduction in the SM ultrasound measures evaluated in the first week after ICU admission, mainly in patients at nutritional risk. More evidence on optimal nutritional strategies to attenuate SM wasting is warranted.
- Reconciliação Medicamentosa num Serviço de Urgência: um Processo de Melhoria ContínuaPublication . de Almeida Marinho Diniz, Ana Cristina; Pereira Borges Sousa, Anabela; Tartaglia Reis, Cláudia; Sardinha Vieira Ramos, Susana Maria; Máximo Barreiros, Paulo Mnuel; dos Santos Sousa, Paulo JorgeObjetivos: estruturar o plano de melhoria para a reconciliação da medicação num serviço de urgência português. Método: elaborou-se o projeto de melhoria com a metodologia Plan, Do, Act, Plan (PDSA), em um estudo observacional, descritivo, quantitativo. Na etapa Plan, participaram 282 pacientes admitidos em serviço de urgência, cujo familiar teve teleconsulta de Enfermagem; e 447 na etapa Study. Realizada a estruturação da teleconsulta com a técnica Identify, Situation, Background, Assessment e Recommendation (ISBAR); formação da equipe. Resultados: na prática habitual dos enfermeiros, identificaram-se 4,6% (n=13) discrepâncias não intencionais entre a prescrição e a medicação em uso no domicílio. Observou-se o aumento para 9,4% (n=42) de discrepâncias após a estruturação da teleconsulta, que passou a incluir as questões sobre a medicação habitual. A interrupção, sobretudo de medicamentos que atuam no sistema nervoso central, dose/frequência incorreta, foi a discrepância mais frequente, posteriormente corrigida. Conclusão: o estudo contribuiu para identificar/corrigir as falhas na reconciliação de medicação, a fim de evidenciar a importância da participação da Enfermagem e da família
- Abdominal Hypoperfusion and Acute Kidney Injury in the Critically Ill Patient with Liver Cirrhosis: A Prospective Cohort Study.Publication . Pereira, Rui; Lopes, Diogo; Brandão Machado, Sara; Val-Flores, Luís; Caeiro, Fernando; Perdigoto, Rui; Marcelino, Paulo; Saliba, FaouziReduced abdominal perfusion pressure (APP) is an underdiagnosed potential pathophysiological mechanism for acute kidney injury (AKI) in the patient with liver cirrhosis and ascites. This study aimed to analyze the prevalence of abdominal hypoperfusion (AhP) (APP <60 mm Hg) and the impact of APP on AKI in critically ill patients with liver cirrhosis. This was a post hoc analysis from a prospective cohort study set in a general ICU at a tertiary university hospital. Patients were recruited between October 2016 and December 2021. Acute renal failure (ARF) was defined by stage 3 AKI according to the International Club of Ascites. Fifty-eight patients where included, with a mean age of 57 (±8.4) years, 79% were male, and 93% had acute-on-chronic liver failure at admission. The prevalence of AhP reached 75%, and 29% of cases had persisting AhP during the first week of ICU stay. Patients with baseline AhP had a higher 28-day mortality compared to those without AhP (respectively, 76% vs. 49%, = 0.03). Acute renal failure developed in 48% of patients. Higher serum urea (aOR: 1.01, 95% CI: 1.00-1.02, = 0.04) and white blood cell count (aOR: 1.1, 95% CI: 1.01-1.2, = 0.02) at ICU admission, as well as low persisting APP (aOR: 0.9, 95% CI: 0.86-0.98, = 0.02) were independent risk factors for ARF. Critically ill patients with liver cirrhosis presented a high prevalence of ARF, independently associated with higher baseline serum urea and WBC, and lower persisting APP. A structured clinical approach to optimize APP may reduce renal dysfunction in high-risk patients with cirrhosis.
- What Every Intensivist Should Know About ... Ammonia in Liver Failure.Publication . Duarte, Tiago; Fidalgo, Pedro; Karvellas, Constantine J; Cardoso, Filipe S; ElsevierPurpose: Acute liver failure (ALF) or acute-on-chronic liver failure (ACLF) patients have high short-term mortality and morbidity. In the context of liver failure, increased serum ammonia is associated with worse neurological outcomes, including high-grade hepatic encephalopathy (HE), cerebral edema, and intracranial hypertension. Besides its neurotoxicity, hyperammonemia may contribute to immune dysfunction and the risk of infection, a frequent trigger for multi-organ failure in these patients. Material and methods: We performed a literature-based narrative review. Publications available in PubMed® up to June 2023 were considered. Results: In the ICU management of liver failure patients, serum ammonia may play an important role. Accordingly, in this review, we focus on recent insights about ammonia metabolism, serum ammonia measurement strategies, hyperammonemia prognostic value, and ammonia-targeted therapeutic strategies. Conclusions: Serum ammonia may have prognostic value in liver failure. Effective ammonia targeted therapeutic strategies are available, such as laxatives, rifaximin, L-ornithine-l-aspartate, and continuous renal replacement therapy.
- Time of Day and its Association with Risk of Death and Chance of Discharge in Critically Ill Patients: a Retrospective StudyPublication . Zajic, P; Bauer, P; Rhodes, A; Moreno, R; Fellinger, T; Metnitz, B; Posch, M; Metnitz, POutcomes following admission to intensive care units (ICU) may vary with time and day. This study investigated associations between time of day and risk of ICU mortality and chance of ICU discharge in acute ICU admissions. Adult patients (age ≥ 18 years) who were admitted to ICUs participating in the Austrian intensive care database due to medical or surgical urgencies and emergencies between January 2012 and December 2016 were included in this retrospective study. Readmissions were excluded. Statistical analysis was conducted using the Fine-and-Gray proportional subdistribution hazards model concerning ICU mortality and ICU discharge within 30 days adjusted for SAPS 3 score. 110,628 admissions were analysed. ICU admission during late night and early morning was associated with increased hazards for ICU mortality; HR: 1.17; 95% CI: 1.08-1.28 for 00:00-03:59, HR: 1.16; 95% CI: 1.05-1.29 for 04:00-07:59. Risk of death in the ICU decreased over the day; lowest HR: 0.475, 95% CI: 0.432-0.522 for 00:00-03:59. Hazards for discharge from the ICU dropped sharply after 16:00; lowest HR: 0.024; 95% CI: 0.019-0.029 for 00:00-03:59. We conclude that there are "time effects" in ICUs. These findings may spark further quality improvement efforts.
- Why the Sequential Organ Failure Assessment Score Needs Updating?Publication . Moreno, R; Singer, M; Rhodes, A
- Pancreatic Stone Protein As a Biomarker of SepsisPublication . Lopes, D; Chumbinho, B; Bandovas, JP; Faria, P; Espírito Santo, C; Ferreira, B; Val-Flores, L; Pereira, R; Germano, N; Bento, L