LUCIANO CESAR PONTES DE AZEVEDO
Projetos de Pesquisa
Unidades Organizacionais
LIM/51 - Laboratório de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina
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- Clinical outcomes of patients requiring ventilatory support in Brazilian intensive care units: a multicenter, prospective, cohort study(2013) AZEVEDO, Luciano C. P.; PARK, Marcelo; SALLUH, Jorge I. F.; REA-NETO, Alvaro; SOUZA-DANTAS, Vicente C.; VARASCHIN, Pedro; OLIVEIRA, Mirella C.; TIERNO, Paulo Fernando G. M. M.; DAL-PIZZOL, Felipe; SILVA, Ulysses V. A.; KNIBEL, Marcos; NASSAR JR., Antonio P.; ALVES, Rossine A.; FERREIRA, Juliana C.; TEIXEIRA, Cassiano; REZENDE, Valeria; MARTINEZ, Amadeu; LUCIANO, Paula M.; SCHETTINO, Guilherme; SOARES, MarcioIntroduction: Contemporary information on mechanical ventilation (MV) use in emerging countries is limited. Moreover, most epidemiological studies on ventilatory support were carried out before significant developments, such as lung protective ventilation or broader application of non-invasive ventilation (NIV). We aimed to evaluate the clinical characteristics, outcomes and risk factors for hospital mortality and failure of NIV in patients requiring ventilatory support in Brazilian intensive care units (ICU). Methods: In a multicenter, prospective, cohort study, a total of 773 adult patients admitted to 45 ICUs over a two-month period requiring invasive ventilation or NIV for more than 24 hours were evaluated. Causes of ventilatory support, prior chronic health status and physiological data were assessed. Multivariate analysis was used to identifiy variables associated with hospital mortality and NIV failure. Results: Invasive MV and NIV were used as initial ventilatory support in 622 (80%) and 151 (20%) patients. Failure with subsequent intubation occurred in 54% of NIV patients. The main reasons for ventilatory support were pneumonia (27%), neurologic disorders (19%) and non-pulmonary sepsis (12%). ICU and hospital mortality rates were 34% and 42%. Using the Berlin definition, acute respiratory distress syndrome (ARDS) was diagnosed in 31% of the patients with a hospital mortality of 52%. In the multivariate analysis, age (odds ratio (OR), 1.03; 95% confidence interval (CI), 1.01 to 1.03), comorbidities (OR, 2.30; 95% CI, 1.28 to 3.17), associated organ failures (OR, 1.12; 95% CI, 1.05 to 1.20), moderate (OR, 1.92; 95% CI, 1.10 to 3.35) to severe ARDS (OR, 2.12; 95% CI, 1.01 to 4.41), cumulative fluid balance over the first 72 h of ICU (OR, 2.44; 95% CI, 1.39 to 4.28), higher lactate (OR, 1.78; 95% CI, 1.27 to 2.50), invasive MV (OR, 2.67; 95% CI, 1.32 to 5.39) and NIV failure (OR, 3.95; 95% CI, 1.74 to 8.99) were independently associated with hospital mortality. The predictors of NIV failure were the severity of associated organ dysfunctions (OR, 1.20; 95% CI, 1.05 to 1.34), ARDS (OR, 2.31; 95% CI, 1.10 to 4.82) and positive fluid balance (OR, 2.09; 95% CI, 1.02 to 4.30). Conclusions: Current mortality of ventilated patients in Brazil is elevated. Implementation of judicious fluid therapy and a watchful use and monitoring of NIV patients are potential targets to improve outcomes in this setting.
- Determinants of Oxygen and Carbon Dioxide Transfer during Extracorporeal Membrane Oxygenation in an Experimental Model of Multiple Organ Dysfunction Syndrome(2013) PARK, Marcelo; COSTA, Eduardo Leite Vieira; MACIEL, Alexandre Toledo; SILVA, Debora Prudencio e; FRIEDRICH, Natalia; BARBOSA, Edzangela Vasconcelos Santos; HIROTA, Adriana Sayuri; SCHETTINO, Guilherme; AZEVEDO, Luciano Cesar PontesExtracorporeal membrane oxygenation (ECMO) has gained renewed interest in the treatment of respiratory failure since the advent of the modern polymethylpentene membranes. Limited information exists, however, on the performance of these membranes in terms of gas transfers during multiple organ failure (MOF). We investigated determinants of oxygen and carbon dioxide transfer as well as biochemical alterations after the circulation of blood through the circuit in a pig model under ECMO support before and after induction of MOF. A predefined sequence of blood and sweep flows was tested before and after the induction of MOF with fecal peritonitis and saline lavage lung injury. In the multivariate analysis, oxygen transfer had a positive association with blood flow (slope = 66, p<0.001) and a negative association with premembrane PaCO2 (slope = -0.96, P = 0.001) and SatO(2) (slope = 21.7, p<0.001). Carbon dioxide transfer had a positive association with blood flow (slope = 17, p<0.001), gas flow (slope = 33, p<0.001), pre-membrane PaCO2 (slope = 1.2, p<0.001) and a negative association with the hemoglobin (slope = -3.478, P = 0.042). We found an increase in pH in the baseline from 7.50[7.46,7.54] to 7.60[7.55,7.65] (p<0.001), and during the MOF from 7.19[6.92,7.32] to 7.41[7.13,7.5] (p<0.001). Likewise, the PCO2 fell in the baseline from 35 [32,39] to 25 [22,27] mmHg (p<0.001), and during the MOF from 59 [47,91] to 34 [28,45] mmHg (p<0.001). In conclusion, both oxygen and carbon dioxide transfers were significantly determined by blood flow. Oxygen transfer was modulated by the pre-membrane SatO(2) and CO2, while carbon dioxide transfer was affected by the gas flow, pre-membrane CO2 and hemoglobin.
- Short-term effects of stored homologous red blood cell transfusion on cardiorespiratory function and inflammation: an experimental study in a hypovolemia model(2018) BIAGINI, S.; DALE, C. S.; REAL, J. M.; MOREIRA, E. S.; CARVALHO, C. R. R.; SCHETTINO, G. P. P.; WENDEL, S.; AZEVEDO, L. C. P.The pathophysiological mechanisms associated with the effects of red blood cell (RBC) transfusion on cardiopulmonary function and inflammation are unclear. We developed an experimental model of homologous 14-days stored RBC transfusion in hypovolemic swine to evaluate the short-term effects of transfusion on cardiopulmonary system and inflammation. Sixteen healthy male anesthetized swine (68 +/- 3.3 kg) were submitted to controlled hemorrhage (25% of blood volume). Two units of non-filtered RBC from each animal were stored under blood bank conditions for 14 days. After 30 min of hypovolemia, the control group (n=8) received an infusion of lactated Ringer's solution (three times the removed volume). The transfusion group (n=8) received two units of homologous 14-days stored RBC and lactated Ringer's solution in a volume that was three times the difference between blood removed and blood transfusion infused. Both groups were followed up for 6 h after resuscitation with collection of hemodynamic and respiratory data. Cytokines and RNA expression were measured in plasma and lung tissue. Stored RBC transfusion significantly increased mixed oxygen venous saturation and arterial oxygen content. Transfusion was not associated with alterations on pulmonary function. Pulmonary concentrations of cytokines were not different between groups. Gene expression for lung cytokines demonstrated a 2-fold increase in mRNA level for inducible nitric oxide synthase and a 0.5-fold decrease in mRNA content for IL-21 in the transfused group. Thus, stored homologous RBC transfusion in a hypovolemia model improved cardiovascular parameters but did not induce significant effects on microcirculation, pulmonary inflammation and respiratory function up to 6 h after transfusion.
- Extracorporeal membrane oxygenation for severe respiratory failure in adult patients: A systematic review and meta-analysis of current evidence(2013) ZAMPIERI, Fernando Godinho; MENDES, Pedro Vitale; RANZANI, Otavio T.; TANIGUCHI, Leandro Utino; AZEVEDO, Luciano Cesar Pontes; COSTA, Eduardo Leite Vieira; PARK, MarceloBackground: Extracorporeal membrane oxygenation (ECMO) for acute respiratory failure is still a matter of debate. Methods: We performed a structured search on Pubmed, EMBASE, Lilacs, and the Cochrane Library for randomized controlled trials and observational case-control studies with severity-paired patients, evaluating the use of ECMO on severe acute respiratory failure in adult patients. A random-effect model using DerSimonian and Laird method for variance estimator was performed to evaluate the effect of ECMO use on hospital mortality. Heterogeneity between studies was assessed with Cochran's Q statistic and Higgin's I-2. Results: Three studies were included on the metanalysis, comprising 353 patients in the main analysis, in which 179 patients were ECMO supported. One study was a randomized controlled trial and two were observational studies with a propensity score matching. The most common reason for acute respiratory failure was influenza H1N1 pneumonia (45%) and pneumonia (33%). ECMO was not associated with a reduction in hospital mortality (OR = 0.71; CI 95% = 0.34-1.47; P = 0.358). If alternative severity-pairing method presented by the two observational studies was included, a total of 478 cases were included, in which 228 received ECMO support. In the former analysis, ECMO had a benefit on hospital mortality (OR = 0.52; CI 95% = 0.35-0.76; P < 0.001). Conclusion: Extracorporeal membrane oxygenation benefit on hospital mortality is unclear. Results were sensitive to statistical analysis, and no definitive conclusion can be drawn from the available data. More studies are needed before the widespread use of ECMO can be recommended.
- COLLOIDS IN SEPSIS: EVENLY DISTRIBUTED MOLECULES SURROUNDED BY UNEVEN QUESTIONS(2013) ZAMPIERI, Fernando Godinho; PARK, Marcelo; AZEVEDO, Luciano Cesar PontesColloids are frequently used for fluid expansion in the intensive care unit, although its use on several clinical scenarios remains unproven of any relevant clinical benefit. The purpose of this article was to carry out a narrative review regarding the safety and efficacy of colloids in patients with sepsis and septic shock, with emphasis on the most commonly used colloids, albumin and starches. Colloids are effective fluid expanders and are able to restore the hemodynamic profile with less total volume than crystalloids. These properties appear to be preserved even in patients with sepsis with increased capillary permeability. However, some colloids are associated with renal impairment and coagulation abnormalities. Starch use was associated with increased mortality in two large clinical trials. Also, starches probably have significant renal adverse effects and may be related to more need for renal replacement therapy in severe sepsis. Albumin is the only colloid that has been shown safe in patients with sepsis and that may be associated with improved outcomes on specific subpopulations. No trial so far found any robust clinical end point favoring colloid use in patients with sepsis. Because there is no proven benefit of the use of most colloids in patients with sepsis, its use should not be encouraged outside clinical trials. Albumin is the only colloid solution that has proven to be safe, and its use may be considered on hypoalbuminemic patients with sepsis. Nevertheless, there are no robust data to recommend routine albumin administration in sepsis. Starch use should be avoided in patients with sepsis because of the recent findings of a multicenter randomized study until further evidence is available.
- Increased risk of death and readmission after hospital discharge of critically ill patients in a developing country: a retrospective multicenter cohort study(2018) LIMA, Vanessa Chaves Barreto Ferreira de; BIERRENBACH, Ana Luiza; ALENCAR, Gizelton Pereira; ANDRADE, Ana Lucia; AZEVEDO, Luciano Cesar PontesTo describe long-term mortality and hospital readmissions of patients admitted to Brazilian intensive care units (ICU). Retrospective cohort study of adult patients admitted to Brazilian hospitals affiliated to the Public Healthcare System from 10 state capitals. ICU patients were paired to non-ICU patients by frequency matching (ratio 1:2), according to postal code and admission semester. Hospitalization records were linked through deterministic linkage to national mortality data. Primary outcome was mortality up to 1 year. Other outcomes were mortality and readmissions at 30 and 90 days and 3 years. Multiple Cox regressions were used adjusting for age, sex, cancer diagnosis, type of hospital, and surgical status. We included 324,594 patients (108,302 ICU and 216,292 non-ICU). ICU patients had increased hospital length of stay [9 (5-17) vs. 3 (1-6) days, p < 0.001] and mortality (18.5 vs. 3.6%, p < 0.001) versus non-ICU patients. One year after discharge, ICU patients were more frequently readmitted to hospital (25.4 vs. 17.4%, p < 0.001) and to ICU (31.4 vs. 7.3%, p < 0.001) than controls. Mortality up to 1 year was also higher for ICU patients (14.3 vs. 3.9%, p < 0.001). A significant interaction between surgical status and mortality was found, with adjusted hazard ratios (HRs) up to 1 year of 2.7 [95% confidence interval (CI) 2.5-2.9] for surgical patients, and 3.4 (95%CI 3.3-3.5) for medical patients. The risk for death and readmission diminished over time up to 3 years. In a public healthcare system of a developing country, ICU patients have excessive long-term mortality and frequent readmissions. The ICU burden tended to reduce over time after hospital discharge.
- Challenges in patients supported with extracorporeal membrane oxygenation in Brazil(2012) MENDES, Pedro Vitale; MOURA, Ewandro; BARBOSA, Edzangela Vasconcelos Santos; HIROTA, Adriana Sayuri; SCORDAMAGLIO, Paulo Rogerio; AJJAR, Fabiana Maria; COSTA, Eduardo Leite Vieira; AZEVEDO, Luciano Cesar Pontes; PARK, Marcelo
- Association of Sepsis Diagnosis at Daytime and on Weekdays with Compliance with the 3-Hour Sepsis Treatment Bundles A Multicenter Cohort Study(2020) RANZANI, Otavio T.; MONTEIRO, Mariana Barbosa; BESEN, Bruno Adler Maccagnan Pinheiro; AZEVEDO, Luciano Cesar PontesRationale: Compliance with sepsis bundles is associated with better outcomes, but information to support structural actions that might improve compliance is scarce. Few studies have evaluated bundle compliance in different time periods, with conflicting results. Objectives: To evaluate the association of sepsis identification during the daytime versus during the nighttime and on weekdays versus weekends with 3-hour sepsis treatment bundle compliance. Methods: This was an observational, multicenter study including patients with sepsis admitted between 2010 and 2017 to 10 hospitals in Brazil. Our exposures of interest were daytime (7:00 A.M.-6:59 P.M.) versus nighttime (7:00 P.M.-6:59 A.M.) and weekdays (Monday 7:00 A.M.-Friday 6:59 P.M.) versus weekends (Friday 7:00 P.M.-Monday 659 A.M.). Our primary outcome was full compliance with the 3-hour sepsis treatment bundles. We adjusted by potential confounding factors with multivariable logistic regression models. Results: Of 11,737 patients (8,733 sepsis and 3,004 septic shock), 3-hour bundle compliance was 79.1% and hospital mortality was 24.7%. The adjusted odds ratio (adjOR) for 3-hour full bundle compliance for patients diagnosed during the daytime versus during the nighttime was 1.35 (95% confidence interval [CI), 1.23-1.49; P < 0.001) and was more pronounced in the emergency department (adjOR, 1.55; 95% CI, 1.35 1.77; P < 0.001) than in nonemergency areas (adjOR, 1.19; 95% CI, 1.04-1.37; P = 0.014). Overall, there was no association between diagnosis on the weekends versus on weekdays and 3-hour full bundle compliance (adjOR, 1.08; 95% CI, 0.98-1.19; P = 0.115), although there was an association among those diagnosed in nonemergency areas (adjOR, 1.15; 95% CI, 1.00-1.32; P = 0.047). The lower compliance observed for sepsis diagnosed during the nighttime was more evident 2 years after implementation of the quality improvement initiative. Conclusions: Compliance with sepsis bundles was associated with the moment of sepsis diagnosis. The place of diagnosis and the time from campaign implementation were factors modifying this association. Our results support areas for better design of quality improvement initiatives to mitigate the influence of the period of sepsis diagnosis on treatment compliance.
- Sepsis: A Threat That Needs a Global Solution(2018) MACHADO, Flavia Ribeiro; AZEVEDO, Luciano Cesar Pontes
- Outcomes and organ dysfunctions of critically ill patients with systemic lupus erythematosus and other systemic rheumatic diseases(2011) RANZANI, O. T.; BATTAINI, L. C.; MORAES, C. E.; PRADA, L. F. L.; PINAFFI, J. V.; GIANNINI, F. P.; SHINJO, S. K.; AZEVEDO, L. C. P.; PARK, M.Our objective was to compare the pattern of organ dysfunctions and outcomes of critically ill patients with systemic lupus erythematosus (SLE) with patients with other systemic rheumatic diseases (SRD). We studied 116 critically ill SRD patients, 59 SLE and 57 other-SRD patients. The SLE group was younger and included more women. Respiratory failure (61%) and shock (39%) were the most common causes of ICU admission for other-SRD and SLE groups, respectively. ICU length-of-stay was similar for the two groups. The 60-day survival adjusted for the groups' baseline imbalances was not different (P = 0.792). Total SOFA scores were equal for the two groups at admission and during ICU stay, although respiratory function was worse in the other-SRD group at admission and renal and hematological functions were worse in the SLE group at admission. The incidence of severe respiratory dysfunction (respiratory SOFA > 2) at admission was higher in the other-SRD group, whereas severe hematological dysfunction (hematological SOFA > 2) during ICU stay was higher in the SLE group. SLE patients were younger and displayed a decreased incidence of respiratory failure compared to patients with other-SRDs. However, the incidences of renal and hematological failure and the presence of shock at admission were higher in the SLE group. The 60-day survival rates were similar.