ORCID Profile
0000-0002-9752-5625
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Publisher: Springer Science and Business Media LLC
Date: 06-2020
DOI: 10.1186/S13613-020-00687-3
Abstract: Survival benefit from low tidal volume ( V T ) ventilation (LTVV) has been demonstrated for patients with acute respiratory distress syndrome (ARDS), and patients not having ARDS could also benefit from this strategy. Organizational factors may play a role on adherence to LTVV. The present study aimed to identify organizational factors with an independent association with adherence to LTVV. Secondary analysis of the database of a multicenter two-phase study (prospective cohort followed by a cluster-randomized trial) performed in 118 Brazilian intensive care units. Patients under mechanical ventilation at day 2 were included. LTVV was defined as a V T ≤ 8 ml/kg PBW on the second day of ventilation. Data on the type and number of beds of the hospital, teaching status, nursing, respiratory therapists and physician staffing, use of structured checklist, and presence of protocols were tested. A multivariable mixed-effect model was used to assess the association between organizational factors and adherence to LTVV. The study included 5719 patients 3340 (58%) patients received LTVV. A greater number of hospital beds (absolute difference 7.43% [95% confidence interval 0.61–14.24%] p = 0.038), use of structured checklist during multidisciplinary rounds (5.10% [0.55–9.81%] p = 0.030), and presence of at least one nurse per 10 patients during all shifts (17.24% [0.85–33.60%] p = 0.045) were the only three factors that had an independent association with adherence to LTVV. Number of hospital beds, use of a structured checklist during multidisciplinary rounds, and nurse staffing are organizational factors associated with adherence to LTVV. These findings shed light on organizational factors that may improve ventilation in critically ill patients.
Publisher: Mary Ann Liebert Inc
Date: 08-2014
DOI: 10.1089/SUR.2012.228
Abstract: Infectious complications are frequent in severe acute pancreatitis (SAP) but multinational epidemiologic data are lacking. The aim of the study was to analyze the characteristics of the infectious complications and antimicrobial use in this setting. One-day point prevalence study of infection in critically ill patients (Extended Prevalence of Infection in the ICU-II study), performed in 1,265 ICUs in 75 countries. Of the 13,796 patients in the study, 159 were admitted with SAP. One-hundred sixteen (73%) had infections: 31% intra-abdominal, 16% extra-abdominal, and 26% both. Gram-negative bacteria were more prevalent than gram-positive organisms, anaerobes, or fungi. Therapeutically, penicillins and other beta-lactams were used most frequently. Prophylactic antibiotics were administered to 24% of the patients with SAP. Infections are frequent in patients admitted with SAP most are intra-abdominal infections. Microbiology is erse with gram-negative micro-organisms most frequently isolated. Most patients admitted to the ICU for SAP receive antibiotics at some point.
Publisher: Springer Science and Business Media LLC
Date: 28-08-2012
Abstract: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH 2 O and peak pressure of 60 cmH 2 O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure ≤30 cmH 2 O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay length of hospital stay pneumothorax requiring chest tube during first 7 days barotrauma during first 7 days mechanical ventilation-free days from days 1 to 28 ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method. ClinicalTrials.gov Identifier: NCT01374022
Publisher: Springer Science and Business Media LLC
Date: 09-03-2016
DOI: 10.1186/S13054-016-1229-1
Abstract: To characterize and identify prognostic factors for 28-day mortality among patients with hospital-acquired fungemia (HAF) in the Intensive Care Unit (ICU). A sub-analysis of a prospective, multicenter non-representative cohort study conducted in 162 ICUs in 24 countries. Of the 1156 patients with hospital-acquired bloodstream infections (HA-BSI) included in the EUROBACT study, 96 patients had a HAF. Median time to its diagnosis was 20 days (IQR 10.5–30.5) and 9 days (IQR 3–15.5) after hospital and ICU admission, respectively. Median time to positivity of blood culture was longer in fungemia than in bacteremia (48.7 h vs. 38.1 h p = 0.0004). Candida albicans was the most frequent fungus isolated (57.1 %), followed by Candida glabrata (15.3 %) and Candida parapsilosis (10.2 %). No clear source of HAF was detected in 33.3 % of the episodes and it was catheter-related in 21.9 % of them. Compared to patients with bacteremia, HAF patients had a higher rate of septic shock (39.6 % vs. 21.6 % p = 0.0003) and renal dysfunction (25 % vs. 12.4 % p = 0.0023) on admission and a higher rate of renal failure (26 % vs. 16.2 % p = 0.0273) at diagnosis. Adequate treatment started within 24 h after blood culture collection was less frequent in HAF patients (22.9 % vs. 55.3 % p 0.001). The 28-day all cause fatality was 40.6 %. According to multivariate analysis, only liver failure (OR 14.35 95 % CI 1.17–175.6 p = 0.037), need for mechanical ventilation (OR 8.86 95 % CI 1.2–65.24 p = 0.032) and ICU admission for medical reason (OR 3.87 95 % CI 1.25–11.99 p = 0.020) were independent predictors of 28-day mortality in HAF patients. Fungi are an important cause of hospital-acquired BSI in the ICU. Patients with HAF present more frequently with septic shock and renal dysfunction on ICU admission and have a higher rate of renal failure at diagnosis. HAF are associated with a significant 28-day mortality rate (40 %), but delayed adequate antifungal therapy was not an independent risk factor for death. Liver failure, need for mechanical ventilation and ICU admission for medical reason were the only independent predictors of 28-day mortality.
Publisher: Springer Science and Business Media LLC
Date: 26-09-2012
DOI: 10.1007/S00134-012-2695-9
Abstract: The recent increase in drug-resistant micro-organisms complicates the management of hospital-acquired bloodstream infections (HA-BSIs). We investigated the epidemiology of HA-BSI and evaluated the impact of drug resistance on outcomes of critically ill patients, controlling for patient characteristics and infection management. A prospective, multicentre non-representative cohort study was conducted in 162 intensive care units (ICUs) in 24 countries. We included 1,156 patients [mean ± standard deviation (SD) age, 59.5 ± 17.7 years 65 % males mean ± SD Simplified Acute Physiology Score (SAPS) II score, 50 ± 17] with HA-BSIs, of which 76 % were ICU-acquired. Median time to diagnosis was 14 [interquartile range (IQR), 7-26] days after hospital admission. Polymicrobial infections accounted for 12 % of cases. Among monomicrobial infections, 58.3 % were gram-negative, 32.8 % gram-positive, 7.8 % fungal and 1.2 % due to strict anaerobes. Overall, 629 (47.8 %) isolates were multidrug-resistant (MDR), including 270 (20.5 %) extensively resistant (XDR), and 5 (0.4 %) pan-drug-resistant (PDR). Micro-organism distribution and MDR occurrence varied significantly (p < 0.001) by country. The 28-day all-cause fatality rate was 36 %. In the multivariable model including micro-organism, patient and centre variables, independent predictors of 28-day mortality included MDR isolate [odds ratio (OR), 1.49 95 % confidence interval (95 %CI), 1.07-2.06], uncontrolled infection source (OR, 5.86 95 %CI, 2.5-13.9) and timing to adequate treatment (before day 6 since blood culture collection versus never, OR, 0.38 95 %CI, 0.23-0.63 since day 6 versus never, OR, 0.20 95 %CI, 0.08-0.47). MDR and XDR bacteria (especially gram-negative) are common in HA-BSIs in critically ill patients and are associated with increased 28-day mortality. Intensified efforts to prevent HA-BSIs and to optimize their management through adequate source control and antibiotic therapy are needed to improve outcomes.
Publisher: Massachusetts Medical Society
Date: 31-05-2012
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2014
No related grants have been discovered for Frederico Carvalho.