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IMPORTANCE: Intravenous fluids are used for almost all intensive care unit (ICU) patients. Clinical and laboratory studies have questioned whether specific fluid types result in improved outcomes, including mortality and acute kidney injury. OBJECTIVE: To determine the effect of a balanced solution vs saline solution (0.9% sodium chloride) on 90-day survival in critically ill patients. DESIGN, SETTING, AND PARTICIPANTS: Double-blind, factorial, randomized clinical trial conducted at 75 ICUs in Brazil. Patients who were admitted to the ICU with at least 1 risk factor for worse outcomes, who required at least 1 fluid expansion, and who were expected to remain in the ICU for more than 24 hours were randomized between May 29, 2017, and March 2, 2020; follow-up concluded on October 29, 2020. Patients were randomized to 2 different fluid types (a balanced solution vs saline solution reported in this article) and 2 different infusion rates (reported separately). INTERVENTIONS: Patients were randomly assigned 1:1 to receive either a balanced solution (n = 5522) or 0.9% saline solution (n = 5530) for all intravenous fluids. MAIN OUTCOMES AND MEASURES: The primary outcome was 90-day survival. RESULTS: Among 11 052 patients who were randomized, 10 520 (95.2%) were available for the analysis (mean age, 61.1 [SD, 17] years; 44.2% were women). There was no significant interaction between the 2 interventions (fluid type and infusion speed; P = .98). Planned surgical admissions represented 48.4% of all patients. Of all the patients, 60.6% had hypotension or vasopressor use and 44.3% required mechanical ventilation at enrollment. Patients in both groups received a median of 1.5 L of fluid during the first day after enrollment. By day 90, 1381 of 5230 patients (26.4%) assigned to a balanced solution died vs 1439 of 5290 patients (27.2%) assigned to saline solution (adjusted hazard ratio, 0.97 [95% CI, 0.90-1.05]; P = .47). There were no unexpected treatment-related severe adverse events in either group. CONCLUSION AND RELEVANCE: Among critically ill patients requiring fluid challenges, use of a balanced solution compared with 0.9% saline solution did not significantly reduce 90-day mortality. The findings do not support the use of this balanced solution. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02875873.

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OBJECTIVE: To relate functional independence to the degree of pulmonary impairment in adult patients 3 months after discharge from the intensive care unit. METHODS: This was a retrospective cohort study conducted in one adult intensive care unit and a multi-professional post-intensive care unit outpatient clinic of a single center. Patients admitted to the intensive care unit from January 2012 to December 2013 who underwent (3 months later) spirometry and answered the Functional Independence Measure Questionnaire were included. RESULTS: Patients were divided into groups according to the classification of functional independence and spirometry. The study included 197 patients who were divided into greater dependence (n = 4), lower dependence (n = 12) and independent (n = 181) groups. Comparing the three groups, regarding the classification of the Functional Independence Measure, patients with greater dependence had higher Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment values at intensive care unit admission with more advanced age, more days on mechanical ventilation, and longer stay in the intensive care unit and hospital. The majority of patients presented with pulmonary impairment, which was the obstructive pattern observed most frequently. When comparing functional independence with pulmonary function, it was observed that the lower the functional status, the worse the pulmonary function, with a significant difference being observed in peak expiratory flow (p = 0.030). CONCLUSION: The majority of patients who returned to the outpatient clinic 3 months after discharge had good functional status but did present with pulmonary impairment, which is related to the degree of functional dependence.

OBJETIVO: Relatar a independência funcional e o grau de comprometimento pulmonar em pacientes adultos 3 meses após a alta da unidade de terapia intensiva. MÉTODOS: Este foi um estudo de coorte retrospectiva conduzido em uma unidade de terapia intensiva multiprofissional para pacientes adultos em um único centro. Incluíram-se pacientes admitidos à unidade de terapia intensiva entre janeiro de 2012 e dezembro de 2013 que, 3 meses mais tarde, foram submetidos à espirometria e responderam ao questionário Medida de Independência Funcional. RESULTADOS: Os pacientes foram divididos em grupos segundo sua classificação de independência funcional e espirometria. O estudo incluiu 197 pacientes, que foram divididos entre os grupos maior dependência (n = 4), menor dependência (n = 12) e independente (n = 181). Na comparação dos três grupos com relação à classificação pela Medida de Independência Funcional, pacientes com maior dependência tinham escores Acute Physiology and Chronic Health Evaluation II e Sequential Organ Failure Assessment mais altos quando da admissão à unidade de terapia intensiva, idade mais avançada, mais dias sob ventilação mecânica e tempo mais longo de permanência na unidade de terapia intensiva e no hospital. A maioria dos pacientes apresentava comprometimento pulmonar, sendo o padrão obstrutivo o mais frequentemente observado. Na comparação da independência funcional com a função pulmonar, observou-se que, quanto pior a condição funcional, pior a função pulmonar, observando-se diferenças significantes em relação ao pico de fluxo expiratório (p = 0,030). CONCLUSÃO: Em sua maioria, os pacientes que retornaram ao ambulatório 3 meses após a alta tinham boa condição funcional, porém apresentavam comprometimento pulmonar relacionado com o grau de dependência funcional.

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Aspergillus terreus, a fungus commonly used in pharmaceutical industry to produce lovastatin and other secondary metabolites, has been reported to have beneficial biological properties. In this study the exopolysaccharides (AT-EPS) produced by A. terreus were evaluated as potential modulators of certain functions of macrophages. The production parameters for EPS obtained from the liquid culture broth of the studied fungus were optimized using response surface methodology (RSM) and indicated good correlation between the experimental and predicted values. The optimum conditions for AT-EPS extraction included fermentation at 28 °C, pH 8.79, under 98 rpm of agitation, using 2.39% glucose (carbon source) and 0.957% ammonium nitrate (nitrogen source). Under these optimized conditions, AT-EPS production was 1.34 g/L medium. The chemical analyses showed that AT-EPS was composed by mannose (Man; 40.5 mol%), galactose (Gal; 35.2 mol%), and glucose (Glc; 24.3 mol%), and the spectroscopic (FTIR; NMR) and methylation analyses indicated the presence of galactomannans, ß-1,3-glucans, and glycogen-like glucans. AT-EPS was tested on murine macrophages to verify its immunoactivity and the treated cells were able to produce nitric oxide, superoxide anion, TNF-α and interleukin 6 similarly to the positive control cells. Furthermore, the macrophages treated with AT-EPS showed activated-like morphological alterations.

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Importance: The effects of intensive care unit (ICU) visiting hours remain uncertain. Objective: To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium. Design, Setting and Participants: Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018. Interventions: Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation. Main Outcomes and Measures: Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory). Results: Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation. Conclusions and Relevance: Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium. Trial Registration: ClinicalTrials.gov Identifier: NCT02932358.

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Among onco-hematological patients with acute respiratory failure (ARpF), surgical lung biopsy (SLB) could contribute to the medical management, by guiding initiation, maintenance or discontinuation of diagnostic and therapeutic interventions. The aim of the present study was to evaluate the results of SLB in these patients in an oncological center from a medium-income country, as well as analyze if this procedure is clinically useful in this context, and its impact on complications and mortality. This observational retrospective study analyzed onco-hematological patients with ARpF in the Intensive Care Unit (ICU) of a cancer center in southern Brazil between 2010-2016, who required mechanical ventilation and were submitted to open SLB. Among the studied population (n=17), the most commonly found etiology was infectious, present in ~50% of the biopsies, followed by unspecific inflammatory infiltrate acute respiratory distress syndrome and interstitial fibrosis, alveolar hemorrhage, neoplastic infiltrate and pulmonary embolism. Biopsy has led to a change of management in 63.3% of patients that were alive when results were available; however, 35% of patients succumbed prior to the pathological result. There was no requirement for re-operation or mortality attributable to the procedure. However, ICU mortality was elevated (88%). SLB in onco-hematological patients mechanically ventilated in the ICU is a safe procedure with few severe complications and that contributes for diagnosis and management in the majority of cases. Due to the high mortality of this population, controlled trials may be required to establish its benefit in mortality and ICU outcomes.

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[This corrects the article DOI: 10.1155/2017/8046240.].

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BACKGROUNDS: The study was conducted to evaluate intensive care unit (ICU) patients that ultimately died but could have met criteria for end-of-life management/palliative care (ELM-PC), and to analyse the application of components of palliative care, either "unperformed procedures" or elements of "futile/unnecessary treatment". METHODS: An observational prospective cohort in five ICUs in Southern Brazil. Adult patients who died were evaluated, searching for criteria for ELM-PC. The correct application of nine preselected items by the ICU team was studied. RESULTS: Among 253 admissions, 52 patients died; among these, 38.5% met criteria for ELM-PC. Among ELM-PC candidates (n = 20), the ELM-PC was started later (after day 3) in 60%, and only three patients received adequate palliative care. "Analgesia" and "daily family interviews" were the most correctly applied ELM-PC elements. "Terminal extubation/weaning" was not performed in any of the patients. A reduction in the lifespan from the onset of ELM-PC to death was observed in patients who underwent "correct" interventions - 66.6% died on the first day of ELM-PC. CONCLUSIONS: In a patient cohort from a low-medium-income country, one-third of patients who died in the ICU had criteria (indications) for ELM-PC; however, the palliative care was adequately performed for only 15% of patients, with great heterogeneity and delays regarding its initiation.

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BACKGROUND: Deep and respiratory muscle disorders are commonly observed in critically ill patients. Neuromuscular electrical stimulation (NMES) is an alternative to mobilize and to exercise that does not require active patient participation and can be used on bedridden patients. OBJECTIVE: Evaluate the effectiveness of the NMES therapy in quadriceps versus diaphragm subjects in mechanical ventilation (MV). METHODS: Sixty-seven subjects in MV were included, divided into 3 groups: (a) control group (CG, n=26), (b) stimulation of quadriceps (quadriceps group-QG, n=24), and (c) stimulation of diaphragm (diaphragm group-DG, n=17). The QG and DG patients received consecutive daily electrical stimulation sessions at specific points from the first day of randomization until ICU discharge. Respiratory and peripheral muscle strength, MV time, length of hospitalization, and functional independence score (the Functional Status Score-ICU) were recorded. RESULTS: There were studied n=24 (QG), n=17 (DG), and n=26 (CG) patients. Peripheral muscle strength improved significantly in the QG (p=0.030). Functional independence at ICU discharge was significantly better in QG (p=0.013), and the QG presented a better Barthel Index compared to DG and CG (p=0.0049) and also presented better FSS compared to CG (p=0.001). CONCLUSIONS: Electrical stimulation of quadriceps had best outcomes for peripheral muscle strength compared with controls or electrical stimulation of diaphragm among mechanically ventilated critically ill subjects and promoted functional independence and decreased length of hospitalization.

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BACKGROUND: Trauma is a major cause of hospital admissions and is associated with manifold complications and high mortality rates. However, data on intensive care unit (ICU) admissions are scarce in developing and low-income countries, where its incidence has been increasing. OBJECTIVES: To analyze epidemiological and clinical factors and outcomes in adult trauma patients admitted to the ICU of a public teaching hospital in a developing country as well as to identify risk factors for complications in the ICU. PATIENTS AND METHODS: Retrospective cohort of adult trauma patients admitted to the general ICU of a public teaching hospital in southern Brazil in the year 2012. Demographic, clinical, and outcome data from the ICU were analyzed. RESULTS: During the study period, 144 trauma patients were admitted (83% male, Acute Physiology and Chronic Health Evaluation Score II =18.6±7.2, age =33.3 years, 93% required mechanical ventilation). Of these, 60.4% suffered a traffic accident (52% motorcycle), and 31.2% were victims of violence (aggressions, gunshot wounds, or stabbing); 71% had brain trauma, 37% had chest trauma, and 21% had abdominal trauma. Patients with trauma presented a high incidence of complications, such as infections, acute renal failure, acute respiratory distress syndrome, and thrombocytopenia. The ICU mortality rate was 22.9%. CONCLUSION: In a Brazilian public teaching ICU, there was a great variability of trauma etiologies (mainly traffic accidents with motorcycles and victims of violence); patients with trauma had a high incidence of complications and mortality in the ICU.

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O delirium consiste em um estado confusional agudo e de curso flutuante representando uma manifestação da disfunção cerebral que pode estar associado com diferentes manifestações clínicas. Os pacientes com delirium têm sido estudados, pois tem apresentado maior tempo de ventilação mecânica e de internação em unidade de terapia intensiva. O objetivo do estudo foi realizar uma revisão de literatura acerca da influência do delirium no tempo de ventilação mecânica, sedação e na mortalidade de pacientes internados em unidade de terapia intensiva. Foi realizada uma busca por estudos nas bases de dados PubMed e Embase, com os descritores delirium, intensive care unit and mechanical ventilation. Nos resultados foram incluídos oito artigos, um recebeu graduação A e sete receberam graduação B na escala de Oxford. Os principais resultados foram: Os pacientes com delirium apresentaram maior gravidade, maior tempo de ventilação mecânica, maior tempo de sedação e maior mortalidade. Conclui-se que o delirium parece estar associado ao maior tempo da ventilação mecânica, maior dosagem de sedação e de mortalidade nestes pacientes.

Delirium consists of an acute, fluctuating, confusional state, representing a manifestation of cerebral dysfunction that can occur with different clinical manifestations. Patients with delirium have been studied because they have had longer time of mechanical ventilation and hospitalization in the intensive care unit. The objective of the study was to perform a literature review about the influence of delirium on the time of mechanical ventilation, sedation and on the mortality of patients admitted in intensive care units. A search for studies with the keywords delirium, intensive care unit and mechanical ventilation was performed in PubMed and Embase databases. As result eight articles were included, one received level A and seven received level B on the Oxford scale. The main results were: Patients with delirium presented greater severity, longer time of mechanical ventilation, longer sedation time and higher mortality. It is concluded that delirium appears to be associated with longer mechanical ventilation, greater sedation and mortality rates in these patients.

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