LUCIANO CESAR PONTES DE AZEVEDO
Projetos de Pesquisa
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LIM/51 - Laboratório de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina
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- Severe hypoxemia during veno-venous extracorporeal membrane oxygenation: exploring the limits of extracorporeal respiratory support(2014) NUNES, Liane Brescovici; MENDES, Pedro Vitale; HIROTA, Adriana Sayuri; BARBOSA, Edzangela Vasconcelos; MACIEL, Alexandre Toledo; SCHETTINO, Guilherme Pinto Paula; COSTA, Eduardo Leite Vieira; AZEVEDO, Luciano Cesar Pontes; PARK, MarceloOBJECTIVE: Veno-venous extracorporeal oxygenation for respiratory support has emerged as a rescue alternative for patients with hypoxemia. However, in some patients with more severe lung injury, extracorporeal support fails to restore arterial oxygenation. Based on four clinical vignettes, the aims of this article were to describe the pathophysiology of this concerning problem and to discuss possibilities for hypoxemia resolution. METHODS: Considering the main reasons and rationale for hypoxemia during veno-venous extracorporeal membrane oxygenation, some possible bedside solutions must be considered: 1) optimization of extracorporeal membrane oxygenation blood flow; 2) identification of recirculation and cannula repositioning if necessary; 3) optimization of residual lung function and consideration of blood transfusion; 4) diagnosis of oxygenator dysfunction and consideration of its replacement; and finally 5) optimization of the ratio of extracorporeal membrane oxygenation blood flow to cardiac output, based on the reduction of cardiac output. CONCLUSION: Therefore, based on the pathophysiology of hypoxemia during veno-venous extracorporeal oxygenation support, we propose a stepwise approach to help guide specific interventions.
- Characterization of critically ill adult burn patients admitted to a Brazilian intensive care unit(2014) CAMPOS, Edvaldo Vieira de; PARK, Marcelo; GOMEZ, David Souza; FERREIRA, Marcus Castro; AZEVEDO, Luciano Cesar PontesIntroduction: To characterize the evolution of clinical and physiological variables in severe adult burn patients admitted to a Brazilian burn ICU, we hypothesized that characteristics of survivors are different from non-survivors after ICU admission. Methods: A five-year observational study was carried out. The clinical characteristics, physiological variables, and outcomes were collected during this period. Results: A total of 163 patients required ICU support and were analyzed. Median age was 34 [25,47] years. Total burn surface area (TBSA) was 29 [18,43]%, and hospital mortality rate was 42%. Lethal burn area at which fifty percent of patients died (LA50%) was 36.5%. Median SAPS3 was 41 [34,54]. Factors associated with hospital mortality were analyzed in three steps, the first incorporated ICU admission data, the second incorporated first day ICU data, and the third incorporated data from the first week of an ICU stay. We found a significant association between hospital mortality and SAPS3 [OR(95%CI) = 1.114(1.062-1.168)], TBSA [OR(95%CI) = 1.043(1.010-1.076)], suicide attempts [OR(95%CI) = 8.126(2.284-28.907)], and cumulative fluid balance per liter within the first week [OR(95%CI) = 1.090(1.030-1.154)]. Inhalation injury was present in 45% of patients, and it was not significantly associated with hospital mortality. Conclusions: In this study of an ICU in a developing country, the mortality rate of critically ill burn patients was high and the TBSA was an independent risk factor for death. SAPS3 at admission and cumulative fluid balance in the first seven days, were also associated with unfavorable outcomes. The implementation of judicious fluid management after an acute resuscitation phase may help to improve outcomes in this scenario.
- The effects of discharge to an intermediate care unit after a critical illness: A 5-year cohort study(2014) RANZANI, Otavio T.; ZAMPIERI, Fernando Godinho; TANIGUCHI, Leandro Utino; FORTE, Daniel Neves; AZEVEDO, Luciano Cesar Pontes; PARK, MarceloPurpose: The impact of the intermediate care unit (IMCU) on post-intensive care unit (ICU) outcomes is controversial. Materials and Methods: We analyzed admissions from January 2003 to December 2008 from a mixed ICU in a teaching hospital in Brazil with a high patient-to-nurse ratio (3.5:1 on the ICU, 11:1 on the IMCU, 20-25:1 on the ward). A retrospective propensity-matched analysis was performed with data from 690 patients who were discharged after at least 3 days of ICU stay. Results: Of the 690 patients, 160 (23%) were discharged to the IMCU. A total of 399 propensity-matched patients were compared: 298 were discharged to the ward and 101 were discharged to the IMCU. Ninety-day mortality rate was similar between the IMCU and ward patients (22% vs 18%, respectively, P =. 37), as was the unplanned ICU readmission rate (P =. 63). In a multivariate logistic regression, discharge to the IMCU had no effect on the 90-day mortality rate (P = .27). Conclusions: In a resource-limited setting with a high patient-to-nurse ratio, discharge to IMCU had no impact on 90-day mortality rate and on unplanned readmission rate. The impact of discharge to the IMCU on the outcome for critically ill patients should be evaluated in further studies.
- Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study(2014) TANAKA, Lilian Maria Sobreira; AZEVEDO, Luciano Cesar Pontes; PARK, Marcelo; SCHETTINO, Guilherme; NASSAR JR., Antonio Paulo; REA-NETO, Alvaro; TANNOUS, Luana; SOUZA-DANTAS, Vicente Ces de; TORELLY, Andre; LISBOA, Thiago; PIRAS, Claudio; CARVALHO, Frederico Bruzzi; MAIA, Marcelo de Oliveira; GIANNINI, Fabio Poianas; MACHADO, Flavia Ribeiro; DAL-PIZZOL, Felipe; CARVALHO, Alexandre Guilherme Ribeiro de; SANTOS, Ronaldo Batista dos; TIERNO, Paulo Fernando Guimaraes Morando Marzocchi; SOARES, Marcio; SALLUH, Jorge Ibrain FigueiraIntroduction: Sedation overuse is frequent and possibly associated with poor outcomes in the intensive care unit (ICU) patients. However, the association of early oversedation with clinical outcomes has not been thoroughly evaluated. The aim of this study was to assess the association of early sedation strategies with outcomes of critically ill adult patients under mechanical ventilation (MV). Methods: A secondary analysis of a multicenter prospective cohort conducted in 45 Brazilian ICUs, including adult patients requiring ventilatory support and sedation in the first 48 hours of ICU admissions, was performed. Sedation depth was evaluated after 48 hours of MV. Multivariate analysis was used to identify variables associated with hospital mortality. Results: A total of 322 patients were evaluated. Overall, ICU and hospital mortality rates were 30.4% and 38.8%, respectively. Deep sedation was observed in 113 patients (35.1%). Longer duration of ventilatory support was observed (7 (4 to 10) versus 5 (3 to 9) days, P = 0.041) and more tracheostomies were performed in the deep sedation group (38.9% versus 22%, P=0.001) despite similar PaO2/FiO(2) ratios and acute respiratory distress syndrome (ARDS) severity. In a multivariate analysis, age (Odds Ratio (OR) 1.02; 95% confidence interval (CI) 1.00 to 1.03), Charlson Comorbidity Index >2 (OR 2.06; 95% Cl, 1.44 to 2.94), Simplified Acute Physiology Score 3 (SAPS 3) score (OR 1.02; Cl 95%, 1.00 to 1.04), severe ARDS (OR 1.44; Cl 95%, 1.09 to 1.91) and deep sedation (OR 2.36; Cl 9596, 1.31 to 4.25) were independently associated with increased hospital mortality. Conclusions: Early deep sedation is associated with adverse outcomes and constitutes an independent predictor of hospital mortality in mechanically ventilated patients.
- Sepsis-related deaths in Brazil: an analysis of the national mortality registry from 2002 to 2010(2014) TANIGUCHI, Leandro U.; BIERRENBACH, Ana Luiza; TOSCANO, Cristiana M.; SCHETTINO, Guilherme P. P.; AZEVEDO, Luciano C. P.Introduction: Limited population-based epidemiologic information about sepsis' demography, including its mortality and temporal changes is available from developing countries. We investigated the epidemiology of sepsis deaths in Brazil using secondary data from the Brazilian Mortality Information System. Methods: Retrospective descriptive analysis of Brazilian multiple-cause-of-death data between 2002 and 2010, with sepsis-associated International Classification of Diseases, 10th Revision (ICD-10) code indicated as the cause of death. Population-based sepsis associated mortality rates and trends were estimated. Annual population-based mortality rates were calculated using age-stratified population estimates from the 2010 census provided by the Brazilian Institute of Geography and Statistics as denominators. Results: The total number of annual deaths recorded in Brazil increased over the decade, from 982,294 deaths reported in 2002 to 1,133,761 deaths reported in 2010. The number of sepsis associated deaths also increased both in absolute numbers and proportions from 95,972 (9.77% of total deaths) in 2002 to 186,712 deaths (16.46%) in 2010. The age-adjusted rate of sepsis-associated mortality increased from 69.5 deaths per 100,000 to 97.8 deaths per 100,000 population from 2002 to 2010 (P < 0.001). Sepsis-associated mortality was higher in individuals older than 60 years of age as compared to subjects aged 0 to 20 years (adjusted rate ratio 15.7 (95% confidence interval (CI) 15.6 to 15.8)) and in male subjects (1.15 (95% CI 1.15 to 1.16)). Conclusions: Between 2002 and 2010 the contribution of sepsis to all cause mortality as reported in multiple-cause-of-death forms increased significantly in Brazil. Age-adjusted mortality rates by sepsis also increased in the last decade. Our results confirm the importance of sepsis as a significant healthcare issue in Brazil.
- Efeito econômico do uso da oxigenação extracorpórea para suporte de pacientes adultos com insuficiência respiratória grave no Brasil: uma análise hipotética(2014) PARK, Marcelo; MENDES, Pedro Vitale; ZAMPIERI, Fernando Godinho; AZEVEDO, Luciano Cesar Pontes; COSTA, Eduardo Leite Vieira; ANTONIALI, Fernando; RIBEIRO, Gustavo Calado de Aguiar; CANEO, Luiz Fernando; CRUZ NETO, Luiz Monteiro da; CARVALHO, Carlos Roberto Ribeiro; TRINDADE, Evelinda MarramonObjetivo: Analisar o custo-utilidade do uso da oxigenação extracorpórea para pacientes com síndrome da angústia respiratória aguda grave no Brasil. Métodos: Com bancos de dados de estudos previamente publicados, foi construída uma árvore encadeada de decisões. Os custos foram extraídos da média de 3 meses do preço pago pelo Sistema Único de Saúde em 2011. Com 10 milhões de pacientes simulados com desfechos e custos predeterminados, uma análise da relação de incremento de custo e de anos de vida ganhos ajustados pela qualidade (custo-utilidade) foi realizada com sobrevida de 40 e 60% dos pacientes que usaram oxigenação extracorpórea. Resultados: A árvore de decisões resultou em 16 desfechos com técnicas diferentes de suporte à vida. Com a sobrevida de 40/60%, respectivamente, o incremento de custos foi de R$ -301,00/-14,00, com o preço pago de R$ -30.913,00/-1.752,00 por ano de vida ganho ajustado pela qualidade para 6 meses e de R$ -2.386,00/-90,00 por ano de vida ganho ajustado pela qualidade até o fim de vida, quando se analisaram todos os pacientes com síndrome da angústia respiratória aguda grave. Analisando somente os pacientes com hipoxemia grave (relação da pressão parcial de oxigênio no sangue sobre a fração inspirada de oxigênio <100mmHg), o incremento de custos foi de R$ -5.714,00/272,00, com preço por ano de vida ganho ajustado pela qualidade em 6 meses de R$ -9.521,00/293,00, e com o custo de R$ -280,00/7,00 por ano de vida ganho ajustado pela qualidade. Conclusão: A relação de custo-utilidade do uso da oxigenação extracorpórea no Brasil foi potencialmente aceitável neste estudo hipotético.
- Validação in vitro e in vivo da viabilidade de eritrócitos suínos estocados para estabelecer um modelo experimental de transfusão homóloga de hemácias: estudo piloto(2014) BIAGINI, Silvana; COSTA, Paulo Aguirre; WENDEL, Silvano; SCHETTINO, Guilherme; AZEVEDO, Luciano Cesar PontesObjetivo: Para desenvolver modelos experimentais de transfusão de hemácias, o primeiro passo é assegurar a viabilidade dos eritrócitos transfundidos. Avaliamos a viabilidade de eritrócitos transfundidos com validação in vitro e in vivo de eritrócitos suínos homólogos armazenados por 14 dias. Métodos: Neste estudo piloto, o sangue coletado de um suíno Agroceres® foi estocado em duas unidades de hemácias. A validação in vivo foi realizada pela marcação dos eritrócitos com Na2 51CrO4 e recuperação dos eritrócitos viáveis após 24 horas da infusão em um animal autólogo e quatro homólogos. A validação in vitro foi realizada na avaliação basal e após 14 dias, pela mensuração da hemoglobina, hematócrito, índice de hemólise e hemoglobina livre em seis unidades de hemácias. Foi realizada uma esplenectomia post-mortem para avaliar o sequestro esplênico de eritrócitos, e a radioatividade das amostras de sobrenadante foi contada para avaliar a hemólise intravascular. Resultados: Após 14 dias de estocagem, as unidades de hemácias tinham volumes menores e concentração total de hemoglobina equivalente em comparação aos padrões humanos. A concentração de hemoglobina livre aumentou de 31,0±9,3 para 112,4±31,4mg/dL (p<0,001) e o índice de hemólise aumentou de 0,1±0,1 para 0,5±0,1% (p<0,001). Entretanto, esses testes se encontravam dentro da faixa aceitável para os padrões humanos. A percentagem de radioatividade nas amostras de sobrenadante foi similar na avaliação basal e após 24 horas, afastando, assim, a presença de hemólise significante. Não se encontraram evidências de sequestro esplênico de eritrócitos radioativos. Conclusão: Hemácias suínas estocadas por 14 dias são viáveis e podem ser utilizadas em estudos experimentais de transfusão. Esses experimentos de validação são importantes para ajudar os investigadores a estabelecerem modelos experimentais de transfusão.
- Effect of flow rate and temperature on transmembrane blood pressure drop in an extracorporeal artificial lung(2014) PARK, M.; COSTA, E. L. V.; MACIEL, A. T.; BARBOSA, E. V. S.; HIROTA, A. S.; SCHETTINO, G. de P.; AZEVEDO, L. C. P.Introduction: Transmembrane pressure drop reflects the resistance of an artificial lung system to blood transit. Decreased resistance (low transmembrane pressure drop) enhances blood flow through the oxygenator, thereby, enhancing gas exchange efficiency. This study is part of a previous one where we observed the behaviour and the modulation of blood pressure drop during the passage of blood through artificial lung membranes. Methods: Before and after the induction of multi-organ dysfunction, the animals were instrumented and analysed for venous-venous extracorporeal membrane oxygenation, using a pre-defined sequence of blood flows. Results: Blood flow and revolutions per minute (RPM) of the centrifugal pump varied in a linear fashion. At a blood flow of 5.5 L/min, pre- and post-pump blood pressures reached -120 and 450 mmHg, respectively. Transmembrane pressures showed a significant spread, particularly at blood flows above 2 L/min; over the entire range of blood flow rates, there was a positive association of pressure drop with blood flow (0.005 mmHg/mL/minute of blood flow ) and a negative association of pressure drop with temperature (-4.828 mmHg/(o)Celsius). These associations were similar when blood flows of below and above 2000 mL/minute were examined. Conclusions: During its passage through the extracorporeal system, blood is exposed to pressure variations from -120 to 450 mmHg. At high blood flows (above 2 L/min), the drop in transmembrane pressure becomes unpredictable and highly variable. Over the entire range of blood flows investigated (0 - 5500 mL/min), the drop in transmembrane pressure was positively associated with blood flow and negatively associated with body temperature.
- Incidence and long-term outcomes of critically ill adult patients with moderate-to-severe diabetic ketoacidosis: Retrospective matched cohort study(2014) AZEVEDO, Luciano C. P.; CHOI, Heidi; SIMMONDS, Kim; DAVIDOW, Jon; BAGSHAW, Sean M.Objective: The objective of this study was to describe the clinical outcomes and treatment intensity of adult intensive care unit (ICU) patients with moderate-to-severe diabetic ketoacidosis (DKA). We aimed also to compare their clinical course with matched non-DKA ICU controls and to identify prognostic factors for mortality and hospital readmission within 1 year. Design: This is a retrospective matched cohort study. Setting: The settings are 2 tertiary teaching hospitals in Edmonton, Canada. Patients: Patients were adults with moderate-to-severe DKA admitted from January 2002 to December 2009. Control patients were defined as randomly selected age, sex, and Acute Physiology and Chronic Health Evaluation II score-matched nondiabetic ICU patients (1: 4.5 matching ratio). Diabetic patients were stratified according to severity of exacerbation. Interventions: None. Measurements and main results: From 2002 to 2009, the incidence of DKA per 1000 admissions was 4.59 (95% confidence interval [ CI], 3.64-5.71). Severe DKA was associated with higher Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores in the first 3 days of ICU stay as compared with moderate DKA. Mechanical ventilation was received in 39%, vasopressors in 17%, and renal replacement therapy in 12% of DKA patients, respectively. One-year mortality and readmission rates were 9% and 36%. By logistic regression, death and/or readmission occurring in 1 year was independently associated with insulin use (odds ratio, 4.79; 95% CI, 1.14-20.05) and treatment noncompliance (odds ratio, 3.33; 95% CI, 1.04-10.64). Compared with matched non-DKA patients, those with DKA had lower mortality and were more likely to be discharged home. Conclusions: Diabetic ketoacidosis necessitating ICU admission is associated with considerable resource utilization and long-term risk for death. Interventions aimed to improve compliance with therapy may prevent readmissions and improve the long-term outcome. (C) 2014 Elsevier Inc. All rights reseved.