DACIE - Departamento de Anestesiologia, Cuidados Intensivos e Emergência
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- Acute Kidney Injury in the Critically Ill PatientPublication . Herrera-Gutiérrez, M.; Seller-Pérez, G.; Maynar-Moliner, J.; Sánchez-Izquierdo-Riera, J.; Marinho, A.; Do pico, J.
- Additional Risk factors for infection by multidrug-resistant pathogens in healthcare associated infection: a large cohort studyPublication . Cardoso, T.; Ribeiro, O.; Aragão, I.; Costa-Pereira, A.; Sarmento, A.BACKGROUND: There is a lack of consensus regarding the definition of risk factors for healthcare-associated infection (HCAI). The purpose of this study was to identify additional risk factors for HCAI, which are not included in the current definition of HCAI, associated with infection by multidrug-resistant (MDR) pathogens, in all hospitalized infected patients from the community. METHODS: This 1-year prospective cohort study included all patients with infection admitted to a large, tertiary care, university hospital. Risk factors not included in the HCAI definition, and independently associated with MDR pathogen infection, namely MDR Gram-negative (MDR-GN) and ESKAPE microorganisms (vancomycin-resistant Enterococcus faecium, methicillin-resistant Staphylococcus aureus, extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella species, carbapenem-hydrolyzing Klebsiella pneumonia and MDR Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter species), were identified by logistic regression among patients admitted from the community (either with community-acquired or HCAI). RESULTS: There were 1035 patients with infection, 718 from the community. Of these, 439 (61%) had microbiologic documentation; 123 were MDR (28%). Among MDR: 104 (85%) had MDR-GN and 41 (33%) had an ESKAPE infection. Independent risk factors associated with MDR and MDR-GN infection were: age (adjusted odds ratio (OR) = 1.7 and 1.5, p = 0.001 and p = 0.009, respectively), and hospitalization in the previous year (between 4 and 12 months previously) (adjusted OR = 2.0 and 1,7, p = 0.008 and p = 0.048, respectively). Infection by pathogens from the ESKAPE group was independently associated with previous antibiotic therapy (adjusted OR = 7.2, p < 0.001) and a Karnofsky index <70 (adjusted OR = 3.7, p = 0.003). Patients with infection by MDR, MDR-GN and pathogens from the ESKAPE group had significantly higher rates of inadequate antibiotic therapy than those without (46% vs 7%, 44% vs 10%, 61% vs 15%, respectively, p < 0.001). CONCLUSIONS: This study suggests that the inclusion of additional risk factors in the current definition of HCAI for MDR pathogen infection, namely age >60 years, Karnofsky index <70, hospitalization in the previous year, and previous antibiotic therapy, may be clinically beneficial for early diagnosis, which may decrease the rate of inadequate antibiotic therapy among these patients.
- Adrenal Crisis During Cesarean Section in a Patient With Primary Adrenal InsufficiencyPublication . Pestana, Inês; Guimarães, Henrique; Saraiva, Alexandra; Veiga, Dalila; Machado, HumbertoCongenital adrenal hyperplasia (CAH) is a type of primary adrenal insufficiency (AI) that predisposes to adrenal crisis (AC) during stress. We describe a case of a primipara with CAH who was admitted in labor. To prevent AC, glucocorticoid replacement was given according to guidelines. Due to fetal decelerations, an emergency C-section was performed under general anesthesia following which refractory hypotension emerged. The diagnosis of AC was considered, and hydrocortisone was given with sustained hemodynamic improvement. AC is a life-threatening emergency whose diagnosis requires a high index of suspicion. Despite adequate steroid coverage, additional stressors may precipitate AC, so it is of paramount importance that anesthesiologists consider this emergency
- [Adverse postoperative cognitive disorders: a national survey of portuguese anesthesiologists]Publication . Susano, M.; Vasconcelos, L.; Lemos, T.; Amorim, P.; Abelha, F.Background and objectives: Postoperative delirium and postoperative cognitive dysfunction are some of the most common complications in older surgical patients and are associated with adverse outcomes. The aim of this study was to evaluate portuguese anesthesiologists' perspectives and knowledge about adverse postoperative cognitive disorders, and routine clinical practice when caring for older surgical patients. Methods: We used a prospective online survey with questions using a Likert scale from 1 to 5 (completely disagree to completely agree), or yes/no/don't know answer types. Potential participants were portuguese anesthesiologists working in hospitals affiliated with the portuguese national health system and private hospitals. Results: We analyzed 234 surveys (17.7% of total potential respondents). The majority believed that the risk of cognitive side effects should be considered when choosing the type of anesthesia (87.6%) and that preoperative cognitive function should be routinely assessed (78.6%). When caring for an agitated and confused patient postoperatively, 62.4% would first administer an analgesic and 11.1% an anxiolytic. Protocols to screen and manage postoperative cognitive disorders are rarely used. Nearly all respondents believe that postoperative delirium and postoperative cognitive dysfunction are neglected areas in anesthesiology. Conclusions: Overall, participants perceive postoperative cognitive disorders as important adverse outcomes following surgery and anesthesia are aware of the main risk factors for their development but may lack information on prevention and management of postoperative delirium. The majority of hospitals do not have protocols regarding preoperative cognitive assessment, diagnosis, management or follow-up of patients with delirium and postoperative cognitive dysfunction.
- Anaesthesiology trainees and their needs: a Romanian perspective. Results from a European surveyPublication . Valeanu, L.; Stefan, M.; Fernandes, D.; Rauseo, M.; Matias, B.; Predoi, C.; Bubenek, S.; Filipescu, D.Anaesthesiology training is going through continuous transformations worldwide. Recent data from a European Survey on anaesthesiology postgraduate trainees and their concerns have been published for the first time, following an initiative by the European Society of Anaesthesiology. Among the responders of this survey, 10.8% were represented by Romanian trainees. The main needs of the Romanian anaesthesiology trainees who completed the questionnaire were, in descending order educational contents/EDAIC, technical skills, exchange programmes, residency workload, residency costs and autonomy transition. Another observation coming from the analysed data is that Romanian anaesthesiologists in training are highly concerned and interested in the field of intensive care medicine. The results also pinpoint to the high costs associated with continuous medical education, leading to a high incentive for workforce migration.
- Analysis of electroencephalogram-derived indexes for anesthetic depth monitoring in pediatric patients with intellectual disability undergoing dental surgeryPublication . Silva, A.; Amorim, P.; Felix, L.; Abelha, F.; Mourão, J.Background: Patients with intellectual disability (ID) often require general anesthesia during oral procedures. Anesthetic depth monitoring in these patients can be difficult due to their already altered mental state prior to anesthesia. In this study, the utility of electroencephalographic indexes to reflect anesthetic depth was evaluated in pediatric patients with ID. Methods: Seventeen patients (mean age, 9.6 ± 2.9 years) scheduled for dental procedures were enrolled in this study. After anesthesia induction with propofol or sevoflurane, a bilateral sensor was placed on the patient's forehead and the bispectral index (BIS) was recorded. Anesthesia was maintained with sevoflurane, which was adjusted according to the clinical signs by an anesthesiologist blinded to the BIS value. The index performance was accessed by correlation (with the end-tidal sevoflurane [EtSevo] concentration) and prediction probability (with a clinical scale of anesthesia). The asymmetry of the electroencephalogram between the left and right sides was also analyzed. Results: The BIS had good correlation and prediction probabilities (above 0.5) in the majority of patients; however, BIS was not correlated with EtSevo or the clinical scale of anesthesia in patients with Lennox-Gastaut, West syndrome, cerebral palsy, and epilepsy. BIS showed better correlations than SEF95 and TP. No significant differences were observed between the left- and right-side indexes. Conclusion: BIS may be able to reflect sevoflurane anesthetic depth in patients with some types of ID; however, more research is required to better define the neurological conditions and/or degrees of disability that may allow anesthesiologists to use the BIS.
- ANESTÉSICOS: NEUROTOXICIDADEPublication . Correia, F.
- Anesthesia for craniotomy with intraoperative awakening: how to avoid respiratory depression and hypertension?Publication . LOBO, F.; AMORIM, P.Anesthesia for craniotomy with intraoperative awakening: how to avoid respiratory depression and hypertension? Lobo FA, Amorim P. Comment on Anesth Analg. 2005 Aug;101(2):502-8, table of contents. PMID: 16632860 [PubMed - indexed for MEDLINE]
- Auditoria à prática profilática e incidência de náuseas e vómitos pós-operatórios (NVPO)Publication . Mota, A.; Saraiva, A.; Duarte, S.; Pereira, F.; Araújo, M.; Amadeu, E.Introdução: As NVPO são uma das principais queixas dos doentes do pós-operatório. Este trabalho teve como objetivo registar a prática farmacológica para profilaxia de NVPO em cirurgia programada e avaliar a sua eficácia. Metodologia: Incluídos todos os doentes submetidos a cirurgia programada das especialidades de Cirurgia Geral, Urologia e Cirurgia Vascular entre 3 e 21 de Dezembro de 2012. Excluídos se alta<24horas(h), pós-operatório no Serviço Cuidados Intensivos/ Intermédios ou impossível acesso aos registos. Tendo como modelos o Score Apfel Simplificado e as recomendações para cirurgia de ambulatório(1) (Tabela 1), a profilaxia instituída foi dividida em adequada, a mais ou a menos; avaliação da ocorrência de NVPO na Unidade Cuidados Pós-Anestésicos e às 24h (registos anestésicos e entrevista). Resultados apresentados em percentagem. Aplicação teste qui quadrado com p<0,05 para significância. Resultados: Avaliados 255 doentes (excluídos 68, incluídos 187). Com 0-1 fator risco (FR) 34%, 2 FR 45%, 3-4 FR 21%. A profilaxia foi adequada em 53% dos doentes, a mais em 16% e a menos em 31%. Incidência total de NVPO - 22% (24% no grupo de doentes que fez profilaxia adequada e 20% no grupo de profilaxia inadequada (p=0.35012)). Neste último grupo 13% realizaram profilaxia a mais e 24% a menos. Resultados da incidência de NVPO por fator de risco na tabela 2. A incidência de NVPO por FR nos doentes com profilaxia adequada foi menor ou igual em todos os grupos em relação ao previsto no Score Apfel simplicado(1,2). No grupo que fez profilaxia inadequada, esta foi a menos principalmente no grupo de 2 FR, com 71% de NVPO; e foi a mais essencialmente no grupo com 1 FR (4 doentes, todos com NVPO). Incidência menor com anestesia locoregional (ALR) vs anestesia geral (AG) (13% vs 27%) (p<0.001). Discussão e Conclusões: A profilaxia foi adequada, segundo as recomendações para cirurgia de ambulatório, em cerca de metade dos doentes. Apesar da profilaxia adequada, nos grupos de FR 1 e 2 não houve redução da incidência de NVPO comparando com a prevista pelo score de Apfel, alertando para a importância de outros fatores de risco não previstos neste score e que estas recomendações poderão ser insuficientes para a profilaxia de NVPO em cirurgia em regime de internamento. A incidência de NVPO foi menor com ALR vs AG, corroborando a ALR como melhor opção em doentes de risco de NVPO (1,2). Estes resultados salientam a importância da adoção de estratégias para redução do risco basal.
- Automatic real-time analysis and interpretation of arterial blood gas sample for Point-of-care testing: Clinical validationPublication . Rodríguez-Villar, Sancho; Poza-Hernández, Paloma; Freigang, Sascha; Zubizarreta-Ormazabal, Idoia; Paz-Martín, Daniel; Holl, Etienne; Pérez-Pardo, Osvaldo Ceferino; Tovar-Doncel, María Sherezade; Wissa, Sonja Maria; Cimadevilla-Calvo, Bonifacio; Tejón-Pérez, Guillermo; Moreno-Fernández, Ismael; Escario-Méndez, Alejandro; Arévalo-Serrano, Juan; Valentín, Antonio; Vale, Bruno; Fletcher, Helen Marie; Lorenzo- Fernández, Jesús MedardoBackground: Point-of-care arterial blood gas (ABG) is a blood measurement test and a useful diagnostic tool that assists with treatment and therefore improves clinical outcomes. However, numerically reported test results make rapid interpretation difficult or open to interpretation. The arterial blood gas algorithm (ABG-a) is a new digital diagnostics solution that can provide clinicians with real-time interpretation of preliminary data on safety features, oxygenation, acid-base disturbances and renal profile. The main aim of this study was to clinically validate the algorithm against senior experienced clinicians, for acid-base interpretation, in a clinical context. Methods: We conducted a prospective international multicentre observational cross-sectional study. 346 sample sets and 64 inpatients eligible for ABG met strict sampling criteria. Agreement was evaluated using Cohen's kappa index, diagnostic accuracy was evaluated with sensitivity, specificity, efficiency or global accuracy and positive predictive values (PPV) and negative predictive values (NPV) for the prevalence in the study population. Results: The concordance rates between the interpretations of the clinicians and the ABG-a for acid-base disorders were an observed global agreement of 84,3% with a Cohen's kappa coefficient 0.81; 95% CI 0.77 to 0.86; p < 0.001. For detecting accuracy normal acid-base status the algorithm has a sensitivity of 90.0% (95% CI 79.9 to 95.3), a specificity 97.2% (95% CI 94.5 to 98.6) and a global accuracy of 95.9% (95% CI 93.3 to 97.6). For the four simple acid-base disorders, respiratory alkalosis: sensitivity of 91.2 (77.0 to 97.0), a specificity 100.0 (98.8 to 100.0) and global accuracy of 99.1 (97.5 to 99.7); respiratory acidosis: sensitivity of 61.1 (38.6 to 79.7), a specificity of 100.0 (98.8 to 100.0) and global accuracy of 98.0 (95.9 to 99.0); metabolic acidosis: sensitivity of 75.8 (59.0 to 87.2), a specificity of 99.7 (98.2 to 99.9) and a global accuracy of 97.4 (95.1 to 98.6); metabolic alkalosis sensitivity of 72.2 (56.0 to 84.2), a specificity of 95.5 (92.5 to 97.3) and a global accuracy of 93.0 (88.8 to 95.3); the four complex acid-base disorders, respiratory and metabolic alkalosis, respiratory and metabolic acidosis, respiratory alkalosis and metabolic acidosis, respiratory acidosis and metabolic alkalosis, the sensitivity, specificity and global accuracy was also high. For normal acid-base status the algorithm has PPV 87.1 (95% CI 76.6 to 93.3) %, and NPV 97.9 (95% CI 95.4 to 99.0) for a prevalence of 17.4 (95% CI 13.8 to 21.8). For the four-simple acid-base disorders and the four complex acid-base disorders the PPV and NPV were also statistically significant. Conclusions: The ABG-a showed very high agreement and diagnostic accuracy with experienced senior clinicians in the acid-base disorders in a clinical context. The method also provides refinement and deep complex analysis at the point-of-care that a clinician could have at the bedside on a day-to-day basis. The ABG-a method could also have the potential to reduce human errors by checking for imminent life-threatening situations, analysing the internal consistency of the results, the oxygenation and renal status of the patient.