OTAVIO TAVARES RANZANI
Projetos de Pesquisa
Unidades Organizacionais
LIM/09 - Laboratório de Pneumologia, Hospital das Clínicas, Faculdade de Medicina
9 resultados
Resultados de Busca
Agora exibindo 1 - 9 de 9
- Recalibrating our prediction models in the ICU: time to move from the abacus to the computer(2014) PIRRACCHIO, Romain; RANZANI, Otavio T.
- Evaluation of a minimal sedation protocol using ICU sedative consumption as a monitoring tool: a quality improvement multicenter project(2014) RANZANI, Otavio T.; SIMPSON, Evelyn Senna; AUGUSTO, Talita Barbosa; CAPPI, Sylas Bezerra; NORITOMI, Danilo TeixeiraIntroduction: Oversedation frequently occurs in ICUs. We aimed to evaluate a minimal sedation policy, using sedative consumption as a monitoring tool, in a network of ICUs targeting decrement of oversedation and mechanical ventilation (MV) duration. Methods: A prospective quality improvement project was conducted in ten ICUs within a network of nonteaching hospitals in Brazil during a 2-year period (2010 to 2012). In the first 12 months (the preintervention period), we conducted an audit to identify sedation practice and barriers to current guideline-based practice regarding sedation. In the postintervention period, we implemented a multifaceted program, including multidisciplinary daily rounds, and monthly audits focusing on sedative consumption, feedback and benchmarking purposes. To analyze the effect of the campaign, we fit an interrupted time series (ITS). To account for variability among the network ICUs, we fit a hierarchical model. Results: During the study period, 21% of patients received MV (4,851/22,963). In the postintervention period, the length of MV was lower (3.91 +/- 6.2 days versus 3.15 +/- 4.6 days; mean difference, -0.76 (95% CI, -1.10; -0.43), P < 0.001) and 28 ventilator-free days were higher (16.07 +/- 12.2 days versus 18.33 +/- 11.6 days; mean difference, 2.30 (95% CI, 1.57; 3.00), P < 0.001) than in the preintervention period. Midazolam consumption (in milligrams per day of MV) decreased from 329 +/- 70 mg/day to 163 +/- 115 mg/day (mean difference, -167 (95% CI, -246; -87), P < 0.001). In contrast, consumption of propofol (P = 0.007), dexmedetomidine (P = 0.017) and haloperidol (P = 0.002) increased in the postintervention period, without changes in the consumption of fentanyl. Through ITS, age (P = 0.574) and Simplified Acute Physiology Score III (P = 0.176) remained stable. The length of MV showed a secular effect (secular trend beta(1) = -0.055, P = 0.012) and a strong decrease immediately after the intervention (intervention beta(2) = -0.976, P < 0.001). The impact was maintained over the course of one year, despite the waning trend for the intervention's effect (postintervention trend beta(3) = 0.039, P = 0.095). Conclusions: By using a light sedation policy in a group of nonteaching hospitals, we reproduced the benefits that have previously been demonstrated in controlled settings. Furthermore, systematic monitoring of sedative consumption should be a feasible instrument for supporting the implementation of a protocol on a large scale.
- Pneumonia nosocomial na unidade de terapia intensiva: é possível prever a falha do tratamento?(2014) RANZANI, Otavio T.; PRINA, Elena; TORRES, Antoni
- 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.
- An increase in mean platelet volume after admission is associated with higher mortality in critically ill patients(2014) ZAMPIERI, Fernando G.; RANZANI, Otavio T.; SABATOSKI, Viviane; SOUZA, Heraldo Possolo de; BARBEIRO, Hermes; DA NETO, Luiz Monteiro Cruz; PARK, Marcelo; SILVA, Fabiano Pinheiro daBackground: Platelet activation and consumption are common in critically ill patients and are associated with poorer prognosis. Mean platelet volume is a simple surrogate for platelet activation, with higher MPV being associated with worse clinical condition on a large array of clinical diagnoses. We therefore aimed to investigate associations between changes in platelet count and mean platelet volume (MPV) with prognosis and inflammatory cytokine values in critically ill patients. Methods: This study prospectively included 84 critically ill patients. Patients were stratified into four groups according to proportional changes in MPV (Delta MPV24h) and platelet count (Delta Plat(24h)) in the first 24 hours after admission. Mortality between groups was compared using the chi(2) test. Logistic regression was performed using hospital mortality as outcome and Simplified Acute Physiology Score (SAPS 3), Delta Plat(24h) and Delta MPV24h as covariates. Concentrations of the following inflammatory mediators were measured using Miliplex (R) technology: IL1 beta, IL6, IL8, IL10, epidermal growth factor, vascular endothelial growth factor, TNF alpha and IFN alpha. Cytokine concentrations were compared between groups using the Kruskal-Wallis test with Bonferroni correction. Results: Patients in whom MPV increased and platelet count decreased had higher mortality rates (46%). According to logistic regression, Delta MPV24h was independently associated with increased mortality (OR 1.28 per 1% increase; 95% CI 1.08 to 1.48). No strong associations between inflammatory mediators and changes in MPV and platelet count were found. Conclusion: An increase in MPV after admission to an ICU is independently associated with higher hospital mortality.
- Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study(2014) NORITOMI, Danilo Teixeira; RANZANI, Otavio T.; MONTEIRO, Mariana Barbosa; FERREIRA, Elaine Maria; SANTOS, Sergio Ricardo; LEIBEL, Fernando; MACHADO, Flavia RibeiroPurpose: To evaluate whether a multifaceted, centrally coordinated quality improvement program in a network of hospitals can increase compliance with the resuscitation bundle and improve clinical and economic outcomes in an emerging country setting. Methods: This was a pre- and post-intervention study in ten private hospitals (1,650 beds) in Brazil (from May 2010 to January 2012), enrolling 2,120 patients with severe sepsis or septic shock. The program used a multifaceted approach: screening strategies, multidisciplinary educational sessions, case management, and continuous performance assessment. The network administration and an external consultant provided performance feedback and benchmarking within the network. The primary outcome was compliance with the resuscitation bundle. The secondary outcomes were hospital mortality, hospital and ICU length of stay, quality-adjusted life year (QALY) gain, and cost-effectiveness. Results: The proportion of patients who received all the required items for the resuscitation bundle improved from 13 % [95 % confidence interval (CI) 8-18 %] at baseline to 62 % (95 % CI 54-69 %) in the last trimester (p < 0.001). Hospital mortality decreased from 55 % (95 % CI 48-62 %) to 26 % (95 % CI 19-32 %, p < 0.001). Full compliance with the resuscitation bundle was associated with lower risk of hospital mortality (propensity weighted corrected risk ratio 0.74; 95 % CI 0.56-0.94, p = 0.02). There was a reduction in the total cost per patient from 29.3 (95 % CI 23.9-35.4) to 17.5 (95 % CI 14.3-21.1) thousand US dollars from baseline to the last 3 months (mean difference -11,815; 95 % CI -18,604 to -5,338). The mean QALY increased from 2.63 (95 % CI 2.15-3.14) to 4.06 (95 % CI 3.58-4.57). For each QALY, the full compliance saves US$5,383. Conclusions: A multifaceted approach to severe sepsis and septic shock patients in an emerging country setting led to high compliance with the resuscitation bundle. The intervention was cost-effective and associated with a reduction in mortality.
conferenceObject PEEP titration with lung ultrasound and electrical impedance tomography in an ARDS animal model(2014) PRINA, Elena; COSTA, Eduardo Leite Vieira; RANZANI, Otavio Tavares; GOMES, Susimeire; SANTIAGO, Roberta Ribeiro De Santis; NAKAMURA, Myiuki; AMATO, Marcelo Britto Passos; TORRES, Antoni; CARVALHO, Carlos Roberto Ribeiro De- Gravity Predominates Over Ventilatory Pattern in the Prevention of Ventilator-Associated Pneumonia(2014) BASSI, Gianluigi Li; MARTI, Joan Daniel; SAUCEDO, Lina; RIGOL, Montserrat; ROCA, Ignasi; CABANAS, Maria; MUNOZ, Laura; RANZANI, Otavio Tavares; GIUNTA, Valeria; LUQUE, Nestor; ESPERATTI, Mariano; GABARRUS, Albert; FERNANDEZ, Laia; RINAUDO, Mariano; FERRER, Miguel; RAMIREZ, Jose; VILA, Jordi; TORRES, AntoniObjective: In the semirecumbent position, gravity-dependent dissemination of pathogens has been implicated in the pathogenesis of ventilator-associated pneumonia. We compared the preventive effects of a ventilatory strategy, aimed at decreasing pulmonary aspiration and enhancing mucus clearance versus the Trendelenburg position. Design: Prospective randomized animal study. Setting: Animal research facility, University of Barcelona, Spain. Subjects: Twenty-four Large White-Landrace pigs. Interventions: Pigs were intubated and on mechanical ventilation for 72 hours. Following surgical preparation, pigs were randomized to be positioned: 1) in semirecumbent/prone position, ventilated with a duty cycle (TITTOT) of 0.33 and without positive end-expiratory pressure (control); 2) as in the control group, positive end-expiratory pressure of 5 cm H2O and TITTOT to achieve a mean expiratory-inspiratory flow bias of 10 L/min (treatment); 3) in Trendelenburg/prone position and ventilated as in the control group (Trendelenburg). Following randomization, Pseudomonas aeruginosa was instilled into the oropharynx. Measurements and Main Results: Mucus clearance rate was measured through fluoroscopic tracking of tracheal markers. Microspheres were instilled into the subglottic trachea to assess pulmonary aspiration. Ventilator-associated pneumonia was confirmed by histological/microbiological studies. The mean expiratory-inspiratory flow in the treatment, control, and Trendelenburg groups were 10.7 +/- 1.7, 1.8 +/- 3.7 and 4.3 +/- 2.8 L/min, respectively (p < 0.001). Mucus clearance rate was 11.3 +/- 9.9 mm/min in the Trendelenburg group versus 0.1 +/- 1.0 in the control and 0.2 +/- 1.0 in the treatment groups (p = 0.002). In the control group, we recovered 1.35% +/- 1.24% of the instilled microspheres per gram of tracheal secretions, whereas 0.22% +/- 0.25% and 0.97% +/- 1.44% were recovered in the treatment and Trendelenburg groups, respectively (p = 0.031). Ventilator-associated pneumonia developed in 66.67%, 85.71%, and 0% of the animals in the control, treatment, and Trendelenburg groups (p < 0.001). Conclusions: The Trendelenburg position predominates over expiratory flow bias and positive end-expiratory pressure in the prevention of gravity-dependent translocation of oropharyngeal pathogens and development of ventilator-associated pneumonia. These findings further substantiate the primary role of gravity in the pathogenesis of ventilator-associated pneumonia.
- Relationship between acid-base status and inflammation in the critically ill(2014) ZAMPIERI, Fernando G.; KELLUM, John A.; PARK, Marcelo; RANZANI, Otavio T.; BARBEIRO, Hermes V.; SOUZA, Heraldo P. de; CRUZ NETO, Luiz Monteiro da; SILVA, Fabiano Pinheiro daIntroduction: There is a complex interplay between changes in acid base components and inflammation. This manuscript aims to explore associations between plasma cytokines and chemokines and acid base status on admission to intensive care. Methods: We conducted a prospective cohort study in a 13-bed ICU in a tertiary-care center in Brazil. 87 unselected patients admitted to the ICU during a 2-year period were included. We measured multiple inflammatory mediators in plasma using multiplex assays and evaluated the association between mediator concentrations and acid base variables using a variety of statistical modeling approaches, including generalized linear models, multiadaptive regression splines and principal component analysis. Results: We found a positive association between strong ion gap (SIG) and plasma concentrations of interleukin (IL)6, 8, 10 and tumor necrosis factor (TNF); whereas albumin was negatively associated with IL6, IL7, IL8, IL10, TNF and interferon (IFN)alpha. Apparent strong ion difference (SIDa) was negatively associated with IL10 and IL17. A principal component analysis including SAPS 3 indicated that the association between acid base components and inflammatory status was largely independent of illness severity, with both increased SIG and decreased SIDa (both drivers of acidosis) associated with increased inflammation. Conclusion: Acid base variables (especially increased SIG, decreased albumin and decreased SIDa) on admission to ICU are associated with immunological activation. These findings should encourage new research into the effects of acid base status on inflammation.