BRUNO ADLER MACCAGNAN PINHEIRO BESEN
Projetos de Pesquisa
Unidades Organizacionais
Instituto Central, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/51 - Laboratório de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina
LIM/51 - Laboratório de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina
14 resultados
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- Calcium use during cardiac arrest: A systematic review(2022) PADRAO, Eduardo Messias Hirano; BUSTOS, Brian; MAHESH, Ashwin; RANDHAWA, Ravneet; DIPOLLINA, Christopher John; CARDOSO, Rhanderson; GROVER, Prashant; BESEN, Bruno Adler Maccagnan Pinheiro; CASTRO, Monaliza de AlmeidaIntroduction: Calcium use during cardiac arrest has conflicting results in terms of efficacy. Therefore, we performed a systematic review evaluating the role of calcium administration in cardiac arrest. Methods: We searched PubMed, Cochrane, and EMBASE for studies comparing calcium administration versus no calcium administration during cardiac arrest. The study was prospectively registered in PROSPERO (CRD42022316641) adhering to PRISMA guideline recommendations. The primary outcome was return of spontaneous circulation (ROSC) or survival at one hour. The secondary outcomes included survival to discharge or at 30 days, and favorable neurologic outcomes at 30 and 90 days. We planned to perform a random-effects meta-analysis of low risk of bias studies. We evaluated risk of bias with RoB-2 and ROBINS-I.Results: We identified 1,921 articles and included ten studies with 2509 patients. We were not able to perform a meta-analysis with low-risk of bias studies as only one study was found to be at low-risk of bias. However, for the primary outcome, the three RCTs included showed no benefit with calcium administration during cardiac arrest for ROSC. For the secondary outcomes, based on the most recent study and lower risk of bias, there was a neutral effect for survival to discharge or at 30 days and neurologic outcomes at 30 days. However, there was unfavorable neurologic out-comes at 90 days. Conclusion: Based on our results, calcium administration in cardiac arrests shows no benefit and can cause harm. Further studies on this matter are likely not advisable.
- Validation of a low-cost continuous renal replacement therapy dialysate fluid controller for experimental purposes(2024) SANTOS, Yuri de Albuquerque Pessoa dos; PARK, Viviane Flor; CARDOZO JUNIOR, Luis Carlos Maia; BESEN, Bruno Adler Maccagnan Pinheiro; MENDES, Pedro Vitale; PARK, MarceloBackgroundContinuous renal replacement therapy (CRRT) support is crucial for critically ill patients and it is underexplored in specific situations. Experimental CRRT offers a means to gain insights into these scenarios, but the prohibitive cost of CRRT machines limits their accessibility. This study aimed to develop and validate a low-cost and precise dialysate controller for experimental CRRT.ResultsOur results demonstrate a commendable level of precision in affluent flow control, with a robust correlation (R2 = 0.99) for continuous flow and a strong correlation (R2 = 0.95) for intermittent flow. Additionally, we observed acceptable agreement with a bias = 3.4 mL (upper limit 95% = 43.9 mL and lower limit 95% = - 37 mL) for continuous flow and bias = - 20.9 mL (upper limit 95% = 54 mL and lower limit 95% = - 95.7 mL) for intermittent flow, in this way, offering a precise CRRT dose for the subjects. Furthermore, we achieved excellent precision in the cumulative ultrafiltration net (UFnet), with a bias = - 2.8 mL (upper limit 95% = 6.5 mL and lower limit 95% = - 12 mL). These results remained consistent even at low affluent flow rates of 8, 12, and 20 mL/min, which are compatible with CRRT doses of 25-30 mL/kg for medium-sized animals. Moreover, the acceptable precision of our findings persisted when the dialysate controller was subjected to high filter dialysate chamber pressure for an extended duration, up to 797 min.ConclusionsThe low-cost dialysate controller developed and tested in this study offers a precise means of regulating CRRT in experimental settings. Its affordability and accuracy render it a valuable instrument for studying CRRT support in unconventional clinical scenarios, particularly in middle-income countries' experimental ICU laboratories.
- Association between piperacillin/tazobactam use and acute kidney injury in critically ill patients: a retrospective multicentre cohort study(2024) TOMAZINI, Bruno Martins; BESEN, Bruno Adler Maccagnan Pinheiro; TANIGUCHI, Leandro Utino; ZAMPIERI, Fernando Godinho; CAVALCANTI, Alexandre BiasiBackground: Piperacillin/tazobactam is one of the most common antibiotics prescribed in the ICU and the combination of piperacillin/tazobactam with vancomycin has been associated with acute kidney injury (AKI) in critically ill patients. However, data on the risk of AKI with piperacillin/tazobactam, despite vancomycin co-exposure, are lacking. Objectives: To investigate the association of piperacillin/tazobactam with AKI and renal replacement therapy (RRT) among adult ICU patients. Methods: We analysed data from patients included in two open access databases (MIMIC-IV and eICU). Critically ill patients who received piperacillin/tazobactam or cefepime (a cephalosporin with similar broad-spectrum activity to piperacillin/tazobactam) during their first ICU stay were eligible for the study. Marginal structural Cox models, accounting for time-fixed covariates and time-dependent covariates were performed. The primary outcomes were AKI and need of RRT. Results: A total of 20 107 patients were included, with 11 213 in the piperacillin/tazobactam group and 8894 in the cefepime group. Exposure to piperacillin/tazobactam was associated with AKI (HR 1.77; 95% CI 1.51-2.07; P < 0.001) and with need of RRT (HR 1.31; 95% CI 1.08-1.57; P = 0.005). Tests for interaction were not statistically significant for occurrence of AKI and RRT in the subgroup of patients exposed to vancomycin or not (P = 0.26 and P = 0.6, respectively). Conclusions: In critically ill patients, exposure to piperacillin/tazobactam was associated with increased risk of AKI and with increased risk of RRT, regardless of combination therapy with vancomycin.
- Adverse events leading to intensive care unit admission in a low-and-middle-income-country: A prospective cohort study and a systematic review(2024) PEDRO, Rodolpho Augusto de Moura; BESEN, Bruno Adler Maccagnan Pinheiro; MENDES, Pedro Vitale; GOMES, Augusto Cezar Marins; CARVALHO, Marcelo Ticianelli de; MALBOUISSON, Luiz Marcelo Sa; PARK, Marcelo; TANIGUCHI, Leandro UtinoIntroduction: Adverse events (AE) are frequent in critical care and could be even more prevalent in LMIC due to a shortage of ICU beds and Human resources. There is limited data on how relevant AE are among the reasons for ICU admission, being all of which published by High-Income-Countries services. Our main goal is to describe the rate of adverse events-related ICU admissions and their preventability in a LMIC scenario, comparing our results with previous data.Methods: This was a prospective cohort study, during a one-year period, in two general ICUs from a tertiary public academic hospital. Our exposure of interest was ICU admission related to an AE in adult patients, we further characterized their preventability and clinical outcomes. We also performed a systematic review to identify and compare previous published data on ICU admissions due to AE.Results: Among all ICU admissions, 12.1% were related to an AE (9.8% caused by an AE, 2.3% related but not directly caused by an AE). These ICU admissions were not associated with a higher risk of death, but most of them were potentially preventable (70.9% of preventability rate, representing 8.6% of all ICU admissions). The meta-analysis resulted in a proportion of ICU admissions due to AE of 11% (95% CI 6%-16%), with a pre-ventability rate of 54% (95% CI 42%-66%).Conclusions: In this prospective cohort, adverse events were a relevant reason for ICU admission. This result is consistent with data retrieved from non-LMIC as shown in our meta-analysis. The high preventability rate described reinforces that quality and safety programs could work as a tool to optimize scarce resources.
- Fluid responsiveness assessment using inferior vena cava collapsibility among spontaneously breathing patients: Systematic review and meta-analysis(2023) CARDOZO, L. C. M.; LEMOS, G. S. D.; BESEN, B. A. M. P.Objective: To synthesize the evidence about diagnostic accuracy of inferior vena cava collapsi-bility (IVCc) in prediction of fluid responsiveness among spontaneously breathing patients. Design: Systematic review of diagnostic accuracy studies. Setting: Intensive care units or emergency departments. Patients and participants: spontaneously breathing patients with indication for fluid bolus administration. Interventions: A search was conducted in MEDLINE and EMBASE. We included studies assessing IVCc accuracy for fluid responsiveness assessment with a standard method for cardiac output measure as index test. Main variables of interest: General information (year, setting, cutoffs, standard method), sen-sitivity, specificity, and area under the receiving operator characteristics curve (AUROC). Risk of bias was assessed with QUADAS 2 tool. We obtained the pooled sensitivity, specificity and sum-mary ROC curve, with estimated confidence intervals from a bivariate model. We also calculated positive and negative likelihood ratios and developed a Fagon nomogram. Results: Eight studies were included with 497 patients. Overall, the studies presented a high risk of bias. IVCc sensitivity was 63% (95% CI --46-78%) and specificity 83% (95% CI --76-87%). Despite moderate accuracy of IVCc (SROC 0.83, 95% CI --0.80-0.86), post-test probability of being fluid responsive based on a 50% pre-test probability led to considerable misclassification. Conclusions: IVCc had moderate accuracy for fluid responsiveness assessment in spontaneously breathing patients and should not be used in isolation for this purpose. & COPY; 2022 Elsevier Espan & SIM;a, S.L.U. y SEMICYUC. All rights reserved.
- Association of fasting in the first 72 h of intensive care unit stay with outcomes of critically ill patients(2023) CARDOZO JUNIOR, Luis Carlos Maia; BESEN, Bruno Adler Maccagnan Pinheiro; SANTOS, Yuri de Albuquerque Pessoa dos; MENDES, Pedro Vitale; PARK, MarceloBackground Whether fasting early in critical illness course is acceptable is not clear and high-quality data on this topic are lacking. To generate equipoise for future clinical trials and bring additional data to current literature, we compared outcomes of patients fasted during the first 72 h of intensive care unit (ICU) stay to patients receiving any nutrition support during this period. Methods Retrospective cohort study of a medical ICU from a tertiary academic center in Brazil. Adult patients treated between November 2017 and February 2022 with an ICU length of stay of >= 5 days were included. Baseline and daily data were retrieved from the prospectively collected administrative database. We did 1:1 propensity score matching to compare patients fasting for at least 72 h with controls. Primary outcome was hospital mortality and secondary outcomes were other resources' use. Results During the study period, 1591 patients were cared for in this ICU, of which 998 stayed >= 5 days. After excluding readmissions and propensity score matching, 93 patients in the fasting group were matched to 93 controls. Hospital mortality was similar between fasting and matched control groups (odds ratio = 1.04; 95% CI = 0.56-1.94; P > 0.99). Secondary outcomes were not different between groups, including length of stay, days on mechanical ventilation, and incidence of new infections. Conclusion Withholding nutrition support in the first 72 h of ICU stay was not associated with worse outcomes in this cohort of severe critically ill patients.
- Immunothrombosis and COVID-19-a nested post-hoc analysis from a 3186 patient cohort in a Latin American public reference hospital(2023) LIMA, Clarice Antunes de; GONCALVES, Fabio Augusto Rodrigues; BESEN, Bruno Adler Maccagnan Pinheiro; PEREIRA, Antonio Jose Rodrigues; PERAZZIO, Sandro Felix; TRINDADE, Evelinda Marramon; FONSECA, Luiz Augusto Marcondes; SUMITA, Nairo Massakazu; PINTO, Vanusa Barbosa; DUARTE, Alberto Jose da Silva; MANIN, Carolina Broco; LICHTENSTEIN, ArnaldoObjective: COVID-19 is associated with an elevated risk of thromboembolism and excess mortality. Difficulties with best anticoagulation practices and their implementation motivated the current analysis of COVID-19 patients who developed Venous Thromboembolism (VTE). Method: This is a post-hoc analysis of a COVID-19 cohort, described in an economic study already published. The authors analyzed a subset of patients with confirmed VTE. We described the characteristics of the cohort, such as demographics, clinical status, and laboratory results. We tested differences amid two subgroups of patients, those with VTE or not, with the competitive risk Fine and Gray model. Results: Out of 3186 adult patients with COVID-19, 245 (7.7%) were diagnosed with VTE, 174 (5.4%) of them dur-ing admission to the hospital. Four (2.3% of these 174) did not receive prophylactic anticoagulation and 19 (11%) discontinued anticoagulation for at least 3 days, resulting in 170 analyzed. During the first week of hospitaliza-tion, the laboratory most altered results were C-reactive protein and D-dimer. Patients with VTE were more criti-cal, had a higher mortality rate, worse SOFA score, and, on average, 50% longer hospital stay. Conclusion: Proven VTE incidence in this severe COVID-19 cohort was 7.7%, despite 87% of them complying completely with VTE prophylaxis. The clinician must be aware of the diagnosis of VTE in COVID-19, even in patients receiving proper prophylaxis.
- Brazilian Contributions on Standardized Education for Brain Death Determination(2023) WESTPHAL, Glauco Adrieno; BESEN, Bruno Adler Maccagnan Pinheiro; ANDRADE, Joel de; SARDINHA, Luiz Antonio; FRANKE, Cristiano Augusto
- Predictive Performance for Hospital Mortality of SAPS 3, SOFA, ISS, and New ISS in Critically Ill Trauma Patients: A Validation Cohort Study(2024) ROEPKE, Roberta Muriel Longo; BESEN, Bruno Adler Maccagnan Pinheiro; DALTRO-OLIVEIRA, Renato; GUAZZELLI, Renata Mello; BASSI, Estevao; SALLUH, Jorge Ibrain Figueira; DAMOUS, Sergio Henrique Bastos; UTIYAMA, Edivaldo Massazo; MALBOUISSON, Luiz Marcelo SaBackground: It is not known whether anatomical scores perform better than general critical care scores for trauma patients admitted to the intensive care unit (ICU). We compare the predictive performance for hospital mortality of general critical care scores (SAPS 3 and SOFA) with anatomical injury-based scores (Injury Severity Score [ISS] and New ISS [NISS]). Methods: Retrospective cohort study of patients admitted to a specialized trauma ICU from a tertiary hospital in Sao Paulo, Brazil between May, 2012 and January, 2016. We retrieved data from the ICU database for critical care scores and calculated ISS and NISS from chart data and whole body computed tomography results. We compared the predictive performance for hospital mortality of each model through discrimination, calibration, and decision-curve analysis. Results: The sample comprised 1053 victims of trauma admitted to the ICU, with 84.2% male patients and mean age of 40 (& PLUSMN;18) years. Main injury mechanism was blunt trauma (90.7%). Traumatic brain injury was present in 67.8% of patients; 43.3% with severe TBI. At the time of ICU admission, 846 patients (80.3%) were on mechanical ventilation and 644 (64.3%) on vasoactive drugs. Hospital mortality was 23.8% (251). Median SAPS 3 was 41; median maximum SOFA within 24 h of admission, 7; ISS, 29; and NISS, 41. AUROCs (95% CI) were: SAPS 3 = 0.786 (0.756-0.817), SOFA = 0.807 (0.778-0.837), ISS = 0.616 (0.577-0.656), and NISS = 0.689 (0.649-0.729). In pairwise comparisons, SAPS 3 and SOFA did not differ, while both outperformed the anatomical scores (p < .001). Maximum SOFA within 24 h of admission presented the best calibration and net benefit in decision-curve analysis. Conclusions: Trauma-specific anatomical scores have fair performance in critically ill trauma patients and are outperformed by SAPS 3 and SOFA. Illness severity is best characterized by organ dysfunction and physiological variables than anatomical injuries.
- Delirium During Critical Illness and Subsequent Change of Treatment in Patients With Cancer: A Mediation Analysis(2024) VIZZACCHI, Barbara A.; DETTINO, Aldo L. A.; BESEN, Bruno A. M. P.; CARUSO, Pedro; JR, Antonio P. NassarOBJECTIVES: To assess whether delirium during ICU stay is associated with subsequent change in treatment of cancer after discharge.DESIGN: Retrospective cohort study.SETTING: A 50-bed ICU in a dedicated cancer center.PATIENTS: Patients greater than or equal to 18 years old with a previous proposal of cancer treatment (chemotherapy, target therapy, hormone therapy, immunotherapy, radiotherapy, oncologic surgery, and bone marrow transplantation).INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: We considered delirium present if Confusion Assessment Method for the ICU was positive. We assessed the association between delirium and modification of the treatment after discharge. We also performed a mediation analysis to assess both the direct and indirect (i.e., mediated by the development of functional dependence after discharge) of delirium on modification of cancer treatment and whether the modification of cancer treatment was associated with mortality at 1 year. We included 1,134 patients, of whom, 189 (16.7%) had delirium. Delirium was associated with the change in cancer treatment (adjusted odds ratio [OR], 3.80; 95% CI, 2.72-5.35). The association between delirium in ICU and change of treatment was both direct and mediated by the development of functional dependence after discharge. The proportion of the total effect of delirium on change of treatment mediated by the development of functional dependence after discharge was 33.0% (95% CI, 21.7-46.0%). Change in treatment was associated with increased mortality at 1 year (adjusted OR, 2.68; 95% CI, 2.01-3.60).CONCLUSIONS: Patients who had delirium during ICU stay had a higher rate of modification of cancer treatment after discharge. The effect of delirium on change in cancer treatment was only partially mediated by the development of functional dependence after discharge. Change in cancer treatment was associated with increased 1-year mortality.