ANTONIO PAULO NASSAR JUNIOR
Projetos de Pesquisa
Unidades Organizacionais
LIM/51 - Laboratório de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina
8 resultados
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- Sepsis-3 definitions predict ICU mortality in a low-middle-income country(2016) BESEN, Bruno Adler Maccagnan Pinheiro; ROMANO, Thiago Gomes; NASSAR JR., Antonio Paulo; TANIGUCHI, Leandro Utino; AZEVEDO, Luciano Cesar Pontes; MENDES, Pedro Vitale; ZAMPIERI, Fernando Godinho; PARK, MarceloBackground: Sepsis-3 definitions were published recently and validated only in high-income countries. The aim of this study was to assess the new criteria's accuracy in stratifying mortality as compared to its predecessor (Sepsis-2) in a Brazilian public intensive care unit (ICU) and to investigate whether the addition of lactate values would improve stratification. Methods: Retrospective cohort study conducted between 2010 and 2015 in a public university's 19-bed ICU. Data from patients admitted to the ICU with sepsis were retrieved from a prospectively collected database. ICU mortality was compared across categories of both Sepsis-2 definitions (sepsis, severe sepsis and septic shock) and Sepsis-3 definitions (infection, sepsis and septic shock). Area under the receiving operator characteristic curves were constructed, and the net reclassification index and integrated discrimination index for the addition of lactate as a categorical variable to each stratum of definition were evaluated. Results: The medical records of 957 patients were retrieved from a prospectively collected database. Mean age was 52 +/- 19 years, median SAPS 3 was 65 [50,79], respiratory tract infection was the most common cause (42%, 402 patients), and 311 (32%) patients died in ICU. The ICU mortality rate was progressively higher across categories of sepsis as defined by the Sepsis-3 consensus: infection with no organ dysfunction-7 /103 (7%); sepsis-106/419 (25%); and septic shock-198/435 (46%) (P < 0.001). For Sepsis-2 definitions, ICU mortality was different only across the categories of severe sepsis [43/252-(17%)] and septic shock [250/572-(44%)] (P < 0.001); sepsis had a mortality of 18/135(13%) (P = 0.430 vs. severe sepsis). When combined with lactate, the definitions' accuracy in stratifying ICU mortality only improved with lactate levels above 4 mmol/L. This improvement occurred in the severe sepsis and septic shock groups (Sepsis-2) and the no-dysfunction and septic shock groups (Sepsis-3). Multivariate analysis demonstrated similar findings. Conclusions: In a Brazilian ICU, the new Sepsis-3 definitions were accurate in stratifying mortality and were superior to the previous definitions. We also observed that the new definitions' accuracy improved progressively with severity. Serum lactate improved accuracy for values higher than 4 mmol/L in the no-dysfunction and septic shock groups.
- Early Versus Late Initiation of Renal Replacement Therapy in Critically Ill Patients: Systematic Review and Meta-Analysis(2019) BESEN, Bruno Adler Maccagnan Pinheiro; ROMANO, Thiago Gomes; MENDES, Pedro Vitale; GALLO, Cesar Albuquerque; ZAMPIERI, Fernando Godinho; NASSAR JR., Antonio Paulo; PARK, MarceloObjective: Early initiation of renal replacement therapy (RRT) effect on survival and renal recovery of critically ill patients is still uncertain. We aimed to systematically review current evidence comparing outcomes of early versus late initiation of RRT in critically ill patients. Methods: We searched the Medline (via Pubmed), LILACS, Science Direct, and CENTRAL databases from inception until November 2016 for randomized clinical trials (RCTs) or observational studies comparing early versus late initiation of RRT in critically ill patients. The primary outcome was mortality. Duration of mechanical ventilation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and renal function recovery were secondary outcomes. Meta-analysis and trial sequential analysis (TSA) were used for the primary outcome. Results: Sixty-two studies were retrieved and analyzed, including 11 RCTs. There was no difference in mortality between early and late initiation of RRT among RCTs (odds ratio [OR] = 0.78; 95% confidence interval [CI]: 0.52-1.19; I-2 = 63.1%). Trial sequential analysis of mortality across all RCTs achieved futility boundaries at both 1% and 5% type I error rates, although a subgroup analysis of studies including only acute kidney injury patients was not conclusive. There was also no difference in time on mechanical ventilation, ICU and hospital LOS, or renal recovery among studies. Early initiation of RRT was associated with reduced mortality among prospective (OR = 0.69; 95% CI: 0.49-0.96; I-2 = 85.9%) and retrospective (OR = 0.61; 95% CI: 0.41-0.92; I-2 = 90.9%) observational studies, both with substantial heterogeneity. However, subgroup analysis excluding low-quality observational studies did not achieve statistical significance. Conclusion: Pooled analysis of randomized trials indicates early initiation of RRT is not associated with lower mortality rates. The potential benefit of reduced mortality associated with early initiation of RRT was limited to low-quality observational studies.
- Accounting for single center effects in systematic reviews cannot be overlooked(2017) BESEN, Bruno Adler Maccagnan Pinheiro; PARK, Marcelo; NASSAR JR., Antonio Paulo
- Daily sedative interruption versus intermittent sedation in mechanically ventilated critically ill patients: a randomized trial(2014) NASSAR JUNIOR, Antonio Paulo; PARK, MarceloBackground: Daily sedative interruption and intermittent sedation are effective in abbreviating the time on mechanical ventilation. Whether one is superior to the other has not yet been determined. Our aim was to compare daily interruption and intermittent sedation during the mechanical ventilation period in a low nurse staffing ICU. Methods: Adult patients expected to need mechanical ventilation for more than 24 hours were randomly assigned, in a single center, either to daily interruption of continuous sedative and opioid infusion or to intermittent sedation. In both cases, our goal was to maintain a Sedation Agitation Scale (SAS) level of 3 or 4; that is patients should be calm, easily arousable or awakened with verbal stimuli or gentle shaking. Primary outcome was ventilator-free days in 28 days. Secondary outcomes were ICU and hospital mortality, incidence of delirium, nurse workload, self-extubation and psychological distress six months after ICU discharge. Results: A total of 60 patients were included. There were no differences in the ventilator-free days in 28 days between daily interruption and intermittent sedation (median: 24 versus 25 days, P = 0.160). There were also no differences in ICU mortality (40 versus 23.3%, P = 0.165), hospital mortality (43.3 versus 30%, P = 0.284), incidence of delirium (30 versus 40%, P = 0.472), self-extubation (3.3 versus 6.7%, P = 0.514), and psychological stress six months after ICU discharge. Also, the nurse workload was not different between groups, but it was reduced on day 5 compared to day 1 in both groups (Nurse Activity Score (NAS) in the intermittent sedation group was 54 on day 1 versus 39 on day 5, P<0.001; NAS in daily interruption group was 53 on day 1 versus 38 on day 5, P<0.001). Fentanyl and midazolam total dosages per patient were higher in the daily interruption group. The tidal volume was higher in the intermittent sedation group during the first five days of ICU stay. Conclusions: There was no difference in the number of ventilator-free days in 28 days between both groups. Intermittent sedation was associated with lower sedative and opioid doses.
- Despertar, exercitar, sentar-se, deambular e extubar: uma mudança nos paradigmas para pacientes mecanicamente ventilados(2014) PARK, Marcelo; PIRES-NETO, Ruy Camargo; NASSAR JUNIOR, Antonio Paulo
- Protocolos de sedação versus interrupção diária de sedação: uma revisão sistemática e metanálise(2016) NASSAR JUNIOR, Antonio Paulo; PARK, MarceloABSTRACT Objective: The aim of this study was to systematically review studies that compared a mild target sedation protocol with daily sedation interruption and to perform a meta-analysis with the data presented in these studies. Methods: We searched Medline, Scopus and Web of Science databases to identify randomized clinical trials comparing sedation protocols with daily sedation interruption in critically ill patients requiring mechanical ventilation. The primary outcome was mortality in the intensive care unit. Results: Seven studies were included, with a total of 892 patients. Mortality in the intensive care unit did not differ between the sedation protocol and daily sedation interruption groups (odds ratio [OR] = 0.81; 95% confidence interval [CI] 0.60 - 1.10; I2 = 0%). Hospital mortality, duration of mechanical ventilation, intensive care unit and hospital length of stay did not differ between the groups either. Sedation protocols were associated with an increase in the number of days free of mechanical ventilation (mean difference = 6.70 days; 95%CI 1.09 - 12.31 days; I2 = 87.2%) and a shorter duration of hospital length of stay (mean difference = -5.05 days, 95%CI -9.98 - -0.11 days; I2 = 69%). There were no differences in regard to accidental extubation, extubation failure and the occurrence of delirium. Conclusion: Sedation protocols and daily sedation interruption do not appear to differ in regard to the majority of analyzed outcomes. The only differences found were small and had a high degree of heterogeneity.
bookPart Manejo da COVID-19 na unidade de terapia intensiva(2023) BESEN, Bruno Adler Maccagnan Pinheiro; MENDES, Pedro Vitale; NASSAR JUNIOR, Antonio Paulo; PARK, Marcelo; TANIGUCHI, Leandro Utino- Protocolized sedation effect on post-ICU posttraumatic stress disorder prevalence: A systematic review and network meta-analysis(2015) NASSAR JR., Antonio Paulo; ZAMPIERI, Fernando G.; RANZANI, Otavio T.; PARK, MarceloPurpose: Strategies aiming light sedation are associated with decreased length on mechanical ventilation. However, awake or easily arousable patients may be prone to greater prevalence of posttraumatic stress disorder (PTSD). These systematic review and meta-analysis aimed to evaluate the safety of light sedation strategies regarding the prevalence of PTSD. Methods: We searched MEDLINE, Scopus, and Web of Science from inception to November 2014 for randomized controlled trials that evaluated light sedation strategies and addressed PTSD prevalence in the follow-up as a specific outcome. Because not all trials performed the same comparisons, we performed a network-meta-analysis to evaluate indirect comparisons. Results: Five studies fulfilled our inclusion criteria and were included in the meta-analysis. Two studies compared daily sedation interruption with usual care (92 patients), 2 studies compared a light sedation protocol with daily sedation interruption (47 patients), and 1 study compared light and deep sedation (102 patients). Compared with usual sedation care/deep sedation, neither daily interruption of sedation (odds ratio = 0.66; 95% confidence interval, 0.22-1.98) nor a light sedation protocol (odds ratio = 0.90, 95% confidence interval, 0.27-3.05) was associated with increased risks on long-term PTSD prevalence. Conclusion: Light sedation strategies seem to be safe in terms of PTSD prevalence. However, the small number of included trials and patients may not be sufficient to drive strong statements.