Introduction Handover is a process of transferring information, responsibility and authority for providing care of critically ill patients from a departing intensivist to an oncoming intensivist. The effect of i admission during a medical handover on clinical outcomes is unknown. Objectives Our purpose was to evaluate the impact of ICU admission during a medical handover on clinical outcomes. Methods Post hoc analysis of a cohort study addressing the effect of ICU admissions during the handover on outcomes. This retrospective, single center, propensity matched cohort study was conducted in a 41-bed open general ICU located in a private tertiary care hospital in São Paulo, Brazil. Based on time of ICU admission, patients were categorized into two cohorts: handover group (ICU admission between 6:30 am to 7:30 or 6:30 pm to 7:30 pm) or control group (admission between 7:31 am to 6:29 pm or 7:31 pm to 6:29 am). Patients in the handover group were propensity matched to patients in the control group at 1:2 ratio. Our primary outcome was hospital mortality. Results Between June 1, 2013 and May 31, 2015, 6,650 adult patients were admitted to the ICU. Following exclusion of ineligible participants, 5,779 patients [389 (6.7%) in handover group and 5390 (93.3%) in control group] were eligible for propensity score matching, of whom 1,166 were successfully matched [389 (33.4%) handover group and 777 (66.6%) in control group]. Before matching, hospital mortality was 14.1% (55/389 patients) in handover group compared to 11.7% (628/5,390) in control group (p=0.142). After propensity-score matching, ICU admission during handover was not associated with increased risk of ICU (OR, 1.40; 95% CI, 0.92 to 2.11; p=0.11) and hospital (OR, 1.23; 95%CI, 0.85 to 1.75; p=0.26) mortality. ICU and hospital length of stay did not differ between the groups. Conclusion In this propensity-matched single center cohort study, ICU admission during medical handover did not affect clinical outcomes.

A major challenge for hospitals in low-income and middle-income countries is to improve management of patients diagnosed with sepsis. The objective of the present study was to evaluate the Institute for Healthcare Improvement (IHI) Model as a strategy to implement a managed sepsis protocol aimed at reducing sepsis mortality. We performed a longitudinal, prospective, non-randomised study using PDSA cycles for translating and implementing improvement actions and tools. Baseline case mortality/case fatality data were collected, and compliance rates were evaluated according to the Surviving Sepsis Campaign guidelines (3-hour care-bundle). Sepsis multidisciplinary work teams were designated and were responsible to develop Driver Diagrams and implement process changes in the intensive care unit, wards and emergency department. Satisfaction levels of healthcare professionals were assessed (balance variables). The study was carried out in a public quaternary hospital, in São Paulo city, Brazil (Hospital Municipal da Vila Santa Catarina). The number of patients with sepsis studied was 416 who were followed over a 15-month period. The data analyses were carried out by statistical process control. Case fatality rates were kept below a prespecified target of 25% (15.9%) during the period. Satisfaction level of the participating staff was high (95.2%) and 71% of participants reported no work overload. The IHI model was found to be a feasible and useful strategy for implementing a sepsis management clinical protocol.

Background: Although 13 years have passed since the first publication of the international treatment guidelines, sepsis continues to be the leading cause of death in Brazilian Intensive Care Units (ICU), with lethality rates of 55%. The main causes of such high rates are poor adherence to the Surviving Sepsis Campaign (SSC) guidelines and insufficient implementation of the measures indicated in the care package. The present study reports our experience in implementing a Managed Sepsis Protocol (MSP) in a public hospital. Methods: In order to improve the care for septic patients, we based our actions on the Quality Improvement Model (QIM), the methodology widespread by the Institute for Healthcare Improvement (IHI-USA), using the Plan-Do-Study- Act (PDSA) cycle to deploy and standardize processes. Results: Main obstacles during in the implementation of a Managed Sepsis Protocol (MSP) were: low levels of staff engagement with setting of poor priorities; inadequate notification of new sepsis cases and data collection; lack of automatic alarms system for sepsis detection and of a reference multidisciplinary team, unclear patient flow and definition of team member roles. After a series of interventions focused on the standardization of sepsis management processes, we observed 70% compliance with the SSC care-bundle and that the reporting of suspected cases increased by 60%. In addition, the time interval between the opening of the MSP for a given patient and the arrival of the initial standard sepsis-evaluating lab tests was shortened to 30 min. Conclusion: We conclude that the IHI quality-improvement model seems to be a suitable tool to implement sepsis management protocols.

Elevated catecholamine levels might be associated with unfavorable outcome after traumatic brain injury (TBI). We investigated the association between catecholamine levels in the first 24 h post-trauma and functional outcome in patients with isolated moderate-to-severe TBI.

Background Traumatic brain injury (TBI) elicits intense sympathetic nervous system (SNS) activation with profuse catecholamine secretion. The resultant hyperadrenergic state is linked to immunomodulation both within the brain and systemically. Dysregulated inflammation post-TBI exacerbates secondary brain injury and contributes to unfavorable patient outcomes including death. The aim of this study was to characterize the early dynamic profile of circulating inflammatory cytokines/chemokines in patients admitted for moderate-to-severe TBI, to examine interrelationships between these mediators and catecholamines, as well as clinical indices of injury severity and neurological outcome. Methods Blood was sampled from 166 isolated TBI patients (aged 45 ± 20.3 years; 74.7 % male) on admission, 6-, 12-, and 24-h post-injury and from healthy controls ( N = 21). Plasma cytokine [interleukin (IL)-1β, -2, -4, -5, -10, -12p70, -13, tumor necrosis factor (TNF)-α, interferon (IFN)-γ] and chemokine [IL-8, eotaxin, eotaxin-3, IFN-γ-induced protein (IP)-10, monocyte chemoattractant protein (MCP)-1, -4, macrophage-derived chemokine (MDC), macrophage inflammatory protein (MIP)-1β, thymus activation regulated chemokine (TARC)] concentrations were analyzed using high-sensitivity electrochemiluminescence multiplex immunoassays. Plasma catecholamines [epinephrine (Epi), norepinephrine (NE)] were measured by immunoassay. Neurological outcome at 6 months was assessed using the extended Glasgow outcome scale (GOSE) dichotomized as good (>4) or poor (≤4) outcomes. Results Patients showed altered levels of IL-10 and all chemokines assayed relative to controls. Significant differences in a number of markers were evident between moderate and severe TBI cohorts. Elevated IL-8, IL-10, and TNF-α, as well as alterations in 8 of 9 chemokines, were associated with poor outcome at 6 months. Notably, a positive association was found between Epi and IL-1β, IL-10, Eotaxin, IL-8, and MCP-1. NE was positively associated with IL-1β, IL-10, TNF-α, eotaxin, IL-8, IP-10, and MCP-1. Conclusions Our results provide further evidence that exaggerated SNS activation acutely after isolated TBI in humans may contribute to harmful peripheral inflammatory cytokine/chemokine dysregulation. These findings are consistent with a potentially beneficial role for therapies aimed at modulating the inflammatory response and hyperadrenergic state acutely post-injury.

Traumatic brain injury (TBI) is the main cause of trauma-related deaths. Systemic hypotension and intracranial hypertension causes cerebral ischemia by altering metabolism of prostanoids. We describe prostanoid, pupilar and pathological response during resuscitation with hypertonic saline solution (HSS) in TBI.Method Fifteen dogs were randomized in three groups according to resuscitation after TBI (control group; lactated Ringer’s (LR) group and HSS group), with measurement of thromboxane, prostaglandin, macroscopic and microscopic pathological evaluation and pupil evaluation.Result Concentration of prostaglandin is greater in the cerebral venous blood than in plasma and the opposite happens with concentration of thromboxane. Pathology revealed edema in groups with the exception of group treated with HSS.Discussion and conclusion There is a balance between the concentrations of prostaglandin and thromboxane. HSS prevented the formation of cerebral edema macroscopically detectable. Pupillary reversal occurred earlier in HSS group than in LR group.

Introduction: Failure to accurately estimate energy requirements may result in an impaired recovery.Overfeeding has been associated with increased carbon dioxide production, respiratory failure, hyperglycemia and fat deposits in the liver, while underfeeding can lead to malnutrition, muscle weakness and impaired immunity.Objective: This study aimed to determine the metabolic profile of infant and preschool children submitted to mechanical ventilation in the ICU.Methods: A prospective study was carried out in a pediatric ICU in Rio de Janeiro that included children aged from 1 month to 6 years submitted to mechanical ventilation from June 2013 to May 2015.Indirect calorimetry was used to obtain resting energy expenditure (REE) and oxygen consumption (VO 2 ) in the first 48 hours of admission.The predicted basal metabolic rate (PBMR) was calculated using the Schofield equation.The metabolic state of each patient was assigned as hypermetabolic (REE/PBMR >110%), hypometabolic (REE/PBMR <90%) or normal (REE/PBMR 90-110%).The ratio of caloric intake to REE was also calculated and ratios of >1.5 and <0.5 were classified as overfeeding and underfeeding respectively.Results: A total of 35 infants and 17 preschool children were included.The male/female ratio was 34/18.In respect of severity of sepsis, 19 patients had septic shock, 24 had sepsis, five had severe sepsis and four had systemic inflammatory response syndrome.We observed a high incidence of hypometabolism (88.5%) and a low incidence of normal metabolism (7.7%) and hypermetabolism (3.8%).A low value of VO 2 was observed in 46.1% of the patients (VO 2 ≤120 ml/minute/m 2 ), a normal value in 40.4% (VO 2 >120 to ≤160 ml/minute/m 2 ) and a high value in only 13.5% of the patients (VO 2 > 160 ml/minute/m 2 ).Among the 52 included patients, 18 were fasting at the moment of the examination.The ratio of caloric intake to REE for the remaining 34 patients showed 38.2% overfeeding, 11.8% underfeeding and 50.0%normal feeding.Conclusion: Predictive equations do not accurately predict REE in critically ill infants and preschool children, resulting in inadequate feeding.Although hypermetabolism and enhanced energy expenditure are the main clinical features of critical illness in adults, the majority of our patients were found to be hypometabolic which reinforces the need for a different approach between adult and pediatric critically ill patients.

# Outcomes and opportunities for improvement in self-inflicted blunt and penetrating trauma {#article-title-2} Self-inflicted trauma (SIT) is a public health issue ranking 4th as leading cause of death and disability in young adults. Retrospective descriptive analysis of patients admitted to a

The presence of coagulopathy is common after severe trauma. The aim of this study was to identify whether isolated severe traumatic brain injury (TBI) is an independent risk factor for coagulopathy.

Sandra Christina Pereira Lima Shiramizo,Murillo Santucci Cesar Assuncao, AndreiaPardini, Antonio Capone Neto, and EliezerSilva work in the critical care unit andAna Maria Santos works in the emergencydepartment at Hospital Israelita AlbertEinstein, Sao Paulo, Brazil.For questions related to this article, contactSandra Shiramizo at sandralima@einstein.br.

Background: Calcium is one of the triggers involved in ischemic neuronal death. Because hypotension is a strong predictor of outcome in traumatic brain injury (TBI), we tested the hypothesis that early fluid resuscitation blunts calcium influx in hemorrhagic shock associated to TBI.Methods: Fifteen ketamine-halothane anesthetized mongrel dogs (18.7 kg +/- 1.4 kg) underwent unilateral cryogenic brain injury. Blood was shed in 5 minutes to a target mean arterial pressure of 40 mm Hg to 45 mm Hg and maintained at these levels for 20 minutes (shed blood volume = 26 mL/kg +/- 7 mL/kg). Animals were then randomized into three groups: CT (controls, no fluid resuscitation), HS (7.5% NaCl, 4 mL/kg, in 5 minutes), and LR (lactate Ringer's, 33 mL/kg, in 15 minutes). Twenty minutes later, a craniotomy was performed and cerebral biopsies were obtained next to the lesion ("clinical penumbra") and from the corresponding contralateral side ("lesion's mirror") to determine intracellular calcium by fluorescence signals of Fura-2-loaded cells.Results: Controls remained hypotensive and in a low-flow state, whereas fluid resuscitation improved hemodynamic profile. There was a significant increase in intracellular calcium in the injured hemisphere in CT (1035 nM +/- 782 nM), compared with both HS (457 nM +/- 149 nM, p = 0.028) and LR (392 nM +/- 178 nM, p = 0.017), with no differences between HS and LR (p = 0.38). Intracellular calcium at the contralateral, uninjured hemisphere was 438 nM +/- 192 nM in CT, 510 nM +/- 196 nM in HS, and 311 nM +/- 51 nM in LR, with no significant differences between them.Conclusion: Both small volume hypertonic saline and large volume lactated Ringer's blunts calcium influx in early stages of TBI associated to hemorrhagic shock. No fluid resuscitation strategy promotes calcium influx and further neural damage.

Purpose of review Trauma systems are central in the care of trauma patients and the concept of 'Critical Care Cascade' matches the concept of the 'Trauma Systems'. Both concepts aim to offer a model of continuum care from prehospital assistance to ICU discharge that can have a significant impact on outcome. In spite of the trauma system concept maturity, many controversies still remain unresolved. This text will review some of the relevant literature related to prehospital and early hospital care of trauma patients. Recent findings Effectiveness of trauma systems and outcome studies on prehospital and early hospital care have been published recently. Limitations, controversies and important points of those studies will be highlighted in this text. Summary Although there is a lack of definitive evidence to support many of the current recommendations for the acute care of trauma patients, the historical development of trauma systems, their long experience and even the existing controversies, can help to establish other critical pathways and can guide performance evaluations so necessary to improve outcomes.

Myocardial contusion is often associated with blunt chest trauma. Its diagnosis is challenging to the professionals who work in emergency department due to nonspecific symptoms and the lack of auxiliary exams with enough accuracy to diagnose. Among the available diagnostic tools, the biomarkers of myocardial injury troponin I and troponin T have stood out. Troponins are proteins of the citocellular apparatus, released into the bloodstream only after the disruption of myocytes cellular membrane. Therefore they are highly specific to detect myocardial injuries.We performed a clinical review using the electronic databases MedLine and LILACS from January 1980 to November 2006 about the importance of a serial measurement of troponin I and T as a diagnostic tool as well as predictor of unfavorable clinical outcome in patients with myocardial contusion after a blunt chest trauma.Although troponins I and T are more specific than usual biomarkers CKMB and CK, these two first biomarkers show a low sensitivity and positive predictive value to diagnosis myocardial contusion. Patients with ECG abnormalities, troponins elevations or both should remain in an intensive care unit (ICU) for at least 24 hours, period in which they cam develop most of the complications related to myocardial contusion.

BACKGROUND AND OBJECTIVES:Myocardial contusion is often associated with blunt chest trauma. Its diagnosis is challenging to the professionals who work in emergency department due to nonspecific symptoms and the lack of auxiliary exams with enough accuracy to diagnose. Among the available diagnostic tools, the biomarkers of myocardial injury troponin I and troponin T have stood out. Troponins are proteins of the citocellular apparatus, released into the bloodstream only after the disruption of myocytes cellular membrane. Therefore they are highly specific to detect myocardial injuries.CONTENTS:We performed a clinical review using the electronic databases MedLine and LILACS from January 1980 to November 2006 about the importance of a serial measurement of troponin I and T as a diagnostic tool as well as predictor of unfavorable clinical outcome in patients with myocardial contusion after a blunt chest trauma.CONCLUSIONS:Although troponins I and T are more specific than usual biomarkers CKMB and CK, these two first biomarkers show a low sensitivity and positive predictive value to diagnosis myocardial contusion. Patients with ECG abnormalities, troponins elevations or both should remain in an intensive care unit (ICU) for at least 24 hours, period in which they cam develop most of the complications related to myocardial contusion.

JUSTIFICATIVA E OBJETIVOS: A contusão miocárdica está freqüentemente associada ao trauma torácico fechado. Seu correto diagnóstico é um constante desafio aos profissionais que trabalham em unidades de emergência, devido aos seus sintomas inespecíficos e a ausência de exames subsidiários com precisão para fazer o diagnóstico. Dentre os diversos métodos diagnósticos estudados, tem-se destacado nos últimos anos o papel dos indicadores de necrose miocárdica troponina I e troponina T. Por serem proteí­nas constituintes do aparelho de regulação contrátil celular, são liberadas na corrente sanguínea somente após a perda da integridade de membrana dos miócitos e, portanto, são altamente específicas para detectar lesão miocárdica. CONTEUDO: Foi realizada uma revisão de estudos clínicos nas bases eletrônicas de dados MedLine e LILACS, no período de janeiro de 1980 a novembro de 2006, sobre a importância da dosagem seriada de troponina como instrumento diagnóstico e preditor de evolução clínica desfavorável nos pacientes com contusão miocárdica. CONCLUSÕES: Embora exista maior especificidade das troponinas I e T quando comparadas aos indicadores tradicionais, CKMB massa e CPK total, esses dois indicadores apresentarem sensibilidade e valor preditivo positivo baixos para diagnosticar contusão miocárdica. Pacientes que apresentam alterações eletrocardiográficas, elevação de troponinas, ou ambas, devem permanecer em observação em unidade de terapia intensiva (UTI), por no mínimo 24 horas, período em que se desenvolve a maioria das complicações decorrentes da contusão miocárdica.BACKGROUND AND OBJECTIVES: Myocardial contusion is often associated with blunt chest trauma. Its diagnosis is challenging to the professionals who work in emergency department due to nonspecific symptoms and the lack of auxiliary exams with enough accuracy to diagnose. Among the available diagnostic tools, the biomarkers of myocardial injury troponin I and troponin T have stood out. Troponins are proteins of the citocellular apparatus, released into the bloodstream only after the disruption of myocytes cellular membrane. Therefore they are highly specific to detect myocardial injuries. CONTENTS: We performed a clinical review using the electronic databases MedLine and LILACS from January 1980 to November 2006 about the importance of a serial measurement of troponin I and T as a diagnostic tool as well as predictor of unfavorable clinical outcome in patients with myocardial contusion after a blunt chest trauma. CONCLUSIONS: Although troponins I and T are more specific than usual biomarkers CKMB and CK, these two first biomarkers show a low sensitivity and positive predictive value to diagnosis myocardial contusion. Patients with ECG abnormalities, troponins elevations or both should remain in an intensive care unit (ICU) for at least 24 hours, period in which they cam develop most of the complications related to myocardial contusion.

therapy in juvenile systemic lupus erythematosus: prospective vali-dation of the disease activity core set. Arthritis Rheum 2005;52:2854–64.3. Bombardier C, Gladman DD, Urowitz MB, Caron D, Chang CH,and the Committee on Prognosis Studies in SLE. Derivation of theSLEDAI: a disease activity index for lupus patients. ArthritisRheum 1992;35:630–40.4. Liang MH, Socher SA, Larson MG, Schur PH. Reliability andvalidity of six systems for the clinical assessment of disease activityin systemic lupus erythematosus. Arthritis Rheum 1989;32:1107–18.5. Vitali C, Bencivelli W, Isenberg DA, Smolen JS, Snaith ML, SciutoM, et al, and The European Consensus Study Group for DiseaseActivity in SLE. Disease activity in systemic lupus erythematosus:report of the Consensus Study Group of the European Workshopfor Rheumatology Research. II. Identification of the variablesindicative of disease activity and their use in the development of anactivity score. Clin Exp Rheumatol 1992;10:541–7.6. Ruperto N, Ravelli A, Murray KJ, Lovell DJ, Andersson-Gare B,Feldman BM, et al, for the Paediatric Rheumatology InternationalTrials Organisation (PRINTO) and the Pediatric RheumatologyCollaborative Study Group (PRCSG). Preliminary core sets ofmeasures for disease activity and damage assessment in juvenilesystemic lupus erythematosus and juvenile dermatomyositis. Rheu-matology (Oxford) 2003;42:1452–9.7. Ruperto N, Ravelli A, Oliveira S, Alessio M, Mihaylova D, Pasic S,et al, for the Pediatric Rheumatology International Trials Or-ganization (PRINTO) and the Pediatric Rheumatology Collabora-tive Study Group (PRCSG). The Pediatric Rheumatology Inter-national Trials Organization/American College of Rheumatologyprovisional criteria for the evaluation of response to therapy injuvenile systemic lupus erythematosus: prospective validationof the definition of improvement. Arthritis Rheum2006;55:355–63.

Departments: Abstracts of Papers to Be Presented at the Sixty-Third Annual Meeting of the American Association for the Surgery of Trauma Grand Wailea Resort & Spa, Maui, Hawaii September, 29-October 2, 2004: PDF Only