UCI - Artigos
Permanent URI for this collection
Browse
Recent Submissions
- Anaphylaxis in an emergency department: a retrospective 10-year study in a tertiary hospitalPublication . Alen Coutinho, I.; Ferreira, D; Regateiro, FS; Pita, J; Ferreira, M; Martins, JF; Fonseca, IA; Loureiro, C; Todo-Bom, ABackground. Anaphylaxis is a potentially fatal medical emergency. The frequency of hospital admissions for anaphylaxis seems to be increasing in the recent decades. Objective. Characterize the patients admitted for anaphylaxis to the adult emergency department (ED) of a tertiary care hospital over a 10-year period, discriminating aetiologies, clinical features and therapy administered. Methods. Retrospective, descriptive and inferential study, evaluating age, sex, Manchester triage system, suspected allergen, site of allergen exposure, comorbidities, cofactors, clinical findings and symptoms, treatment and management. Patients admitted between January 2007 and December 2016 were included. Results. Forty-three patients were enrolled: 23 males, mean age 54.3 ± 16.2 years, n = 22 had history of allergic disease. Two patients were triaged as non-urgent. The most frequently suspected causes of anaphylaxis were: drugs (33%, n = 14), Hymenoptera venoms (23%, n = 10), foods (21%, n = 9) and iodinated contrast products (12%, n = 5). Adrenaline was used in 88% of the episodes (n = 38), 55% of which (n = 21) intramuscularly. Mortality was registered in one case. At discharge, adrenaline auto-injector was prescribed in 7% (n = 3) of the patients, and Allergy and Clinical Immunology consultation (ACIC) was requested in 65% of the episodes (n = 28). Statistically significant associations (p minor 0.05) were established: a, anaphylaxis to drugs associated with a low intramuscular adrenaline use and with frequent oxygen therapy; b, anaphylaxis to food associated with intramuscular adrenaline administration; c, anaphylaxis to Hymenoptera venom associated with male sex; and d, anaphylaxis to iodinated contrasts associated with referral to ACIC and with shock. All obese patients developed shock. Conclusions. Anaphylaxis is a life-threatening condition that requires early recognition. Although most patients received adrenaline, administration was not always performed by the recommended route and only a few patients were prescribed adrenaline auto-injector.
- Intoxicações Agudas num Serviço de Medicina Intensiva: Anos 2002 a 2014Publication . Ferreira, R; Cunha, B; Ferreira, DM; Devesa, N; Pimentel, J
- Decreasing the time to achieve therapeutic vancomycin concentrations in critically ill patients: developing and testing of a dosing nomogramPublication . Baptista, JP; Roberts, JA; Sousa, E; Freitas, R; Deveza, N; Pimentel, JINTRODUCTION: Achievement of optimal vancomycin exposure is crucial to improve the management of patients with life-threatening infections caused by susceptible Gram-positive bacteria and is of particular concern in patients with augmented renal clearance (ARC). The aim of this study was to develop a dosing nomogram for the administration of vancomycin by continuous infusion for the first 24 hours of therapy based on the measured urinary creatinine clearance (8 h CLCR). METHODS: This single-center study included all critically ill patients treated with vancomycin over a 13-month period (group 1), in which we retrospectively assessed the correlation between vancomycin clearance and 8 h CLCR. This data was used to develop a formula for optimised drug dosing. The efficiency of this formula was prospectively evaluated in a second cohort of 25 consecutive critically ill patients (group 2). Vancomycin serum concentrations between 20 to 30 mg/L were considered adequate. ARC was defined as 8 h CLCR more than 130 ml/min/1.73 m(2). RESULTS: The incidence of ARC was 36% (n = 29/79) and 40% (10/25) in group 1 (n = 79) and 2 (n = 25), respectively. The mean serum vancomycin concentration on day 1 was 21.5 (6.4) and 24.5 (5.2) mg/L, for both groups respectively. On the treatment day, vancomycin plasma clearance was 5.12 (1.9) L/h in group 1 and correlated significantly with the 8 h CLCR (r(2) = 0.66; P < 0.001). The achievement of adequate vancomycin serum concentrations in group 2 was 84% (n = 21/25) versus 51% (n = 40/79) - P < 0.005. CONCLUSIONS: This new vancomycin nomogram enabled the achievement of adequate serum concentrations in 84% of the patients on the first day of treatment.
- Comportamentos dos Enfermeiros Perante os Alarmes Clínicos em Unidades de Cuidados Intensivos: uma Revisão IntegrativaPublication . Galo, AR; Diogo, C; Cipriano, D; Araújo, I; Martins, J; Cunha, LO presente estudo tem como propósito refletir sobre a prática de enfermagem no que concerne à temática da monitorização hemodinâmica. Pretendemos identificar a evidência empírica produzida sobre o comportamento dos enfermeiros perante os alarmes clínicos e, consequentemente, incentivar a adoção de estratégias que promovam um ambiente de cuidados intensivos menos ruidoso. Perspetivou-se um estudo de revisão sistemática da literatura. Selecionámos um conjunto de dezoito bases de dados eletrónicas, tendo recorrido a três idiomas. A colheita de informação decorreu entre dezembro de 2011 e janeiro de 2012 e, através de uma estratégia de cruzamento dos descritores selecionados, foram incluídos 5 artigos. Face a todo o corpo de discussão salientamos três categorias essenciais: opinião dos profissionais de saúde acerca dos alarmes clínicos; comportamento dos profissionais; estratégias promotoras de um ambiente menos ruidoso. Constatamos que os profissionais de saúde têm presente a bipolaridade dos alarmes clínicos e identificam limitações na sua gestão. Verificamos ainda que o comportamento dos profissionais nos estudos analisados não é linear, variando entre alterar os parâmetros no início de cada turno até ignorar uma grande maioria deles. Cientes desta realidade, os profissionais sugerem diversas estratégias passíveis de implementar, com vista a alarmes e comportamentos mais eficazes.
- Continuous infusion of piperacillin/tazobactam in septic critically ill patients--a multicenter propensity matched analysisPublication . Gonçalves-Pereira, J; Oliveira, BS; Janeiro, S; Estilita, J; Monteiro, C; Salgueiro, A; Vieira, A; Gouveia, J; Paulino, C; Bento, L; Póvoa, PThe clinical efficacy of continuous infusion of piperacillin/tazobactam in critically ill patients with microbiologically documented infections is currently unknown. We conducted a retrospective multicenter cohort study in 7 Portuguese intensive care units (ICU). We included 569 critically ill adult patients with a documented infection and treated with piperacillin/tazobactam admitted to one of the participating ICU between 2006 and 2010. We successfully matched 173 pairs of patients according to whether they received continuous or conventional intermittent dosing of piperacillin/tazobactam, using a propensity score to adjust for confounding variables. The majority of patients received 16g/day of piperacillin plus 2g/day of tazobactam. The 28-day mortality rate was 28.3% in both groups (p = 1.0). The ICU and in-hospital mortality were also similar either in those receiving continuous infusion or intermittent dosing (23.7% vs. 20.2%, p = 0.512 and 41.6% vs. 40.5%, p = 0.913, respectively). In the subgroup of patients with a Simplified Acute Physiology Score (SAPS) II>42, the 28-day mortality rate was lower in the continuous infusion group (31.4% vs. 35.2%) although not reaching significance (p = 0.66). We concluded that the clinical efficacy of piperacillin/tazobactam in this heterogeneous group of critically ill patients infected with susceptible bacteria was independent of its mode of administration, either continuous infusion or intermittent dosing.
- Polineuropatia desmielinizante inflamatória como primeira manisfestação de infecção VIH-1Publication . Speidel, A; Shamasna, M; Velho, P; Coelho, R; Oliveira, F; Faria, MJ; Barros, MS
- Augmented renal clearance in septic patients and implications for vancomycin optimisationPublication . Baptista, JP; Sousa, E; Martins, PJ; Pimentel, JMThe aim of this study was to evaluate the effect of augmented renal clearance (ARC) on vancomycin serum concentrations in critically ill patients. This prospective, single-centre, observational, cohort study included 93 consecutive, critically ill septic patients who started treatment that included vancomycin by continuous infusion, admitted over a 2-year period (March 2006 to February 2008). ARC was defined as 24-h creatinine clearance (CL(Cr))>130mL/min/1.73m(2). Two groups were analysed: Group A, 56 patients with a CL(Cr)≤130mL/min/1.73m(2); and Group B, 37 patients with a CL(Cr)>130mL/min/1.73m(2). Vancomycin therapeutic levels were assessed on the first 3 days of treatment (D(1), D(2) and D(3)). Serum vancomycin levels on D(1), D(2) and D(3), respectively, were 13.1, 16.6 and 18.6μmol/L for Group A and 9.7, 11.7 and 13.8μmol/L for Group B (P<0.05 per day). The correlation between CL(Cr) and serum vancomycin on D(1) was -0.57 (P<0.001). ARC was strongly associated with subtherapeutic vancomycin serum concentrations on the first 3 days of treatment.
- A comparison of estimates of glomerular filtration in critically ill patients with augmented renal clearancePublication . Baptista, JP; Udy, AA; Sousa, E; Pimentel, J; Wang, L; Roberts, JA; Lipman, JINTRODUCTION: Increasingly, derived estimates of glomerular filtration, such as the modification of diet in renal disease (MDRD) equation and Cockcroft-Gault (CG) formula are being employed in the intensive care unit (ICU). To date, these estimates have not been rigorously validated in those with augmented clearances, resulting in potentially inaccurate drug prescription. METHODS: Post-hoc analysis of prospectively collected data in two tertiary level ICU's in Australia and Portugal. Patients with normal serum creatinine concentrations manifesting augmented renal clearance (ARC) (measured creatinine clearance (CLCR) > 130 ml/min/1.73 m2) were identified by chart review. Comparison between measured values and MDRD and CG estimates were then undertaken. Spearman correlation coefficients (rs) were calculated to determine goodness of fit, and precision and bias were assessed using Bland-Altman plots. RESULTS: Eighty-six patients were included in analysis. The median [IQR] measured CLCR was 162 [145-190] ml/min/1.73 m2, as compared to 135 [116-171], 93 [83-110], 124[102-154], and 108 [87-135] ml/min/1.73 m2 estimated by CG, modified CG, 4-variable MDRD and 6-variable MDRD formulae. All of the equations significantly under-estimated the measured value, with CG displaying the smallest bias (39 ml/min/1.73 m2). Although a moderate correlation was noted between CLCR and CG (rs = 0.26, P = 0.017) and 4-variable MDRD (rs = 0.22, P = 0.047), neither had acceptable precision for clinical application in this setting. CG estimates had the highest sensitivity for correctly identifying patients with ARC (62%). CONCLUSIONS: Derived estimates of GFR are inaccurate in the setting of ARC, and should be interpreted with caution by the physician. A measured CLCR should be performed to accurately guide drug dosing.
- Pneumonia eosinofílica aguda com evolução para síndroma de dificuldade respiratória aguda: caso clínicoPublication . Baptista, JP; Casanova, PC; Almeida e Sousa, JP; Martins, JP; Simões, A; Fernandes, V; Souto, J; Costa, JJ; Carvalho, L; Pimentel, JThe Authors present a case of acute eosinophilic pneumonia (AEP) associated with severe acute respiratory distress syndrome in a previously healthy young adult, medicated with nitrofurantoin. AEP must be included in the differential diagnosis of community adquired pneumonia, as well as a cause of acute respiratory distress syndrome; its diagnosis is suggested by the presence of eosinophilic alveolitis in bronchoalveolar lavage fluid. The early diagnosis of AEP and corticosteroid therapy may be lifesaving.
- Hérnias diafragmáticas traumáticas: revisão casuísticaPublication . Almeida e Sousa, JP; Baptista, JP; Martins, L; Pimentel, JAIMS: This study classifies cases of traumatic diaphragmatic hernias (TDH) in patients admitted to the Intensive Care Unit (ICU) of the Coimbra University Hospitals (HUC) from 1990 to 2004. METHODS: Retrospective analysis of 34 cases of TDH, studying anatomical location, place and time of diagnosis, complementary tests aiding diagnosis, herniated organs, associated traumatism, morbidity and mortality. RESULTS: Twenty-eight male and six female patients with an average age of 40.5 years +/- 20.5, average SAPS score 38.8. Average length of stay was 19.1 +/- 13.6 days, all suffered from closed traumatism and were put on artificial ventilation. The left-side diaphragm was more frequently affected (94.1%) then the right. Diagnosis in 19 cases was made up in the first six hours following the diagnosis of traumatism, in four cases within 12 hours and in the remaining cases between 48 hours and 16 years after traumatism. In 13 patients the diagnosis was established intra-operatively. The stomach was typically one of the herniated organs. The most frequently associated lesions at the thoracic level were pulmonary contusion, haemothorax and pneumothorax, and at the abdominal level, haemoperitoneum and splenic lesion. The rates for complications and mortality were 55.8% and 11.7% respectively. CONCLUSIONS: TDH mainly occurs on the left side through closed thoraco-abdominal trauma following road traffic accidents. This group of patients, on average younger than others admitted to ICU, presents a longer average hospitalisation period, but has lower rates of mortality and lower SAPS severity scores. The most commonly herniated organ was the stomach and the most frequently encountered lesions were cranial-encephalic, splenic and pleural traumatisms. Pre-operative diagnosis of diaphragmatic injuries is difficult and a high index of clinical suspicion is needed after thoraco-abdominal trauma. This diagnosis should always be considered a possibility in cases of closed thoraco-abdominal traumas.