Echocardiography in critically ill patients has become essential in the evaluation of patients in different settings, such as the hospital. However, unlike for other matters related to the care of these patients, there are still no recommendations from national medical societies on the subject. The objective of this document was to organize and make available expert consensus opinions that may help to better incorporate echocardiography in the evaluation of critically ill patients. Thus, the Associação de Medicina Intensiva Brasileira, the Associação Brasileira de Medicina de Emergência, and the Sociedade Brasileira de Medicina Hospitalar formed a group of 17 physicians to formulate questions relevant to the topic and discuss the possibility of consensus for each of them. All questions were prepared using a five-point Likert scale. Consensus was defined a priori as at least 80% of the responses between one and two or between four and five. The consideration of the issues involved two rounds of voting and debate among all participants. The 27 questions prepared make up the present document and are divided into 4 major assessment areas: left ventricular function, right ventricular function, diagnosis of shock, and hemodynamics. At the end of the process, there were 17 positive (agreement) and 3 negative (disagreement) consensuses; another 7 questions remained without consensus. Although areas of uncertainty persist, this document brings together consensus opinions on several issues related to echocardiography in critically ill patients and may enhance its development in the national scenario.

Echocardiography in critically ill patients has become essential in the evaluation of patients in different settings, such as the hospital. However, unlike for other matters related to the care of these patients, there are still no recommendations from national medical societies on the subject. The objective of this document was to organize and make available expert consensus opinions that may help to better incorporate echocardiography in the evaluation of critically ill patients. Thus, the Associação de Medicina Intensiva Brasileira, the Associação Brasileira de Medicina de Emergência, and the Sociedade Brasileira de Medicina Hospitalar formed a group of 17 physicians to formulate questions relevant to the topic and discuss the possibility of consensus for each of them. All questions were prepared using a five-point Likert scale. Consensus was defined a priori as at least 80% of the responses between one and two or between four and five. The consideration of the issues involved two rounds of voting and debate among all participants. The 27 questions prepared make up the present document and are divided into 4 major assessment areas: left ventricular function, right ventricular function, diagnosis of shock, and hemodynamics. At the end of the process, there were 17 positive (agreement) and 3 negative (disagreement) consensuses; another 7 questions remained without consensus. Although areas of uncertainty persist, this document brings together consensus opinions on several issues related to echocardiography in critically ill patients and may enhance its development in the national scenario.

The use of echocardiography by physicians who are not echocardiographers has become common throughout the world across highly diverse settings where the care of acutely ill patients is provided. Echocardiographic evaluation performed in a point-of-care manner can provide relevant information regarding the mechanism of causes of shock, for example, increasing the rates of correct diagnosis and allowing for faster informed decision-making than through evaluation methods. Considering that the accurate diagnosis of life-threatening situations is essential for professionals working with acutely ill patients, several international associations recommend that physicians responsible for critically ill patients acquire and develop the ability to perform bedside ultrasound examinations, including echocardiographic examinations. However, there is no consensus in the literature regarding which specific applications should be included in the list of skills for nonechocardiographer physicians. Taking into account the multiplicity of applications of echocardiography in different scenarios related to acutely ill patients; the differences in the published protocols, with regard to both the teaching methodology and competence verification; and the heterogeneity of training among highly diverse specialties responsible for their care at different levels, this consensus document aimed to reflect the position of representatives of related Brazilian medical societies on the subject and may thus serve as a starting point both for standardization among different specialties and for the transmission of knowledge and verification of the corresponding competencies.

O emprego da ecocardiografia por médicos não ecocardiografistas tem se tornado comum em todo o mundo nos mais diversos ambientes em que se dá o cuidado do paciente agudamente doente. A avaliação ecocardiográfica realizada de forma point-of-care pode fornecer informações pertinentes em relação ao mecanismo das causas de choque, por exemplo, incrementando as taxas de diagnóstico correto e possibilitando a tomada de decisão fundamentada de forma mais rápida do que por meio dos métodos tradicionais de avaliação. Considerando que o diagnóstico preciso de situações ameaçadoras à vida é indispensável a profissionais atuando junto a pacientes agudamente enfermos, diversas entidades associativas internacionais recomendam que médicos responsáveis por pacientes gravemente doentes devam adquirir e desenvolver a habilidade para realizar exames ultrassonográficos à beira do leito, inclusive ecocardiográficos. Entretanto, não há consenso na literatura acerca de quais aplicações específicas devam compor o rol de habilidades do médico não ecocardiografista. Levando-se em consideração a multiplicidade de aplicações da ecocardiografia em diversos cenários relativos ao paciente agudamente enfermo; as diferenças nos protocolos publicados, tanto no que diz respeito à metodologia de ensino como de verificação de competências, bem como a heterogeneidade da formação entre as mais diversas especialidades responsáveis pelo seu cuidado em diferentes níveis, este documento de consenso teve o objetivo de refletir o posicionamento de representantes de sociedades médicas brasileiras afins acerca do tema, podendo, assim, servir de ponto de partida para a uniformização entre diferentes especialidades, bem como para a transmissão de conhecimento e a verificação das competências correspondentes.

Echocardiography in critically ill patients has become essential in the evaluation of patients in different settings, such as the hospital. However, unlike for other matters related to the care of these patients, there are still no recommendations from national medical societies on the subject. The objective of this document was to organize and make available expert consensus opinions that may help to better incorporate echocardiography in the evaluation of critically ill patients. Thus, the Associação de Medicina Intensiva Brasileira, the Associação Brasileira de Medicina de Emergência, and the Sociedade Brasileira de Medicina Hospitalar formed a group of 17 physicians to formulate questions relevant to the topic and discuss the possibility of consensus for each of them. All questions were prepared using a five-point Likert scale. Consensus was defined a priori as at least 80% of the responses between one and two or between four and five. The consideration of the issues involved two rounds of voting and debate among all participants. The 27 questions prepared make up the present document and are divided into 4 major assessment areas: left ventricular function, right ventricular function, diagnosis of shock, and hemodynamics. At the end of the process, there were 17 positive (agreement) and 3 negative (disagreement) consensuses; another 7 questions remained without consensus. Although areas of uncertainty persist, this document brings together consensus opinions on several issues related to echocardiography in critically ill patients and may enhance its development in the national scenario.

The use of echocardiography by physicians who are not echocardiographers has become common throughout the world across highly diverse settings where the care of acutely ill patients is provided. Echocardiographic evaluation performed in a point-of-care manner can provide relevant information regarding the mechanism of causes of shock, for example, increasing the rates of correct diagnosis and allowing for faster informed decision-making than through evaluation methods. Considering that the accurate diagnosis of life-threatening situations is essential for professionals working with acutely ill patients, several international associations recommend that physicians responsible for critically ill patients acquire and develop the ability to perform bedside ultrasound examinations, including echocardiographic examinations. However, there is no consensus in the literature regarding which specific applications should be included in the list of skills for nonechocardiographer physicians. Taking into account the multiplicity of applications of echocardiography in different scenarios related to acutely ill patients; the differences in the published protocols, with regard to both the teaching methodology and competence verification; and the heterogeneity of training among highly diverse specialties responsible for their care at different levels, this consensus document aimed to reflect the position of representatives of related Brazilian medical societies on the subject and may thus serve as a starting point both for standardization among different specialties and for the transmission of knowledge and verification of the corresponding competencies.

The first coronavirus disease 2019 (COVID-19) report in Brazil occurs by the end of February, and 4 months later, there was more than 1 million infected patients and 54,971 deaths. The health-care system in Brazil is universal, meaning that all inhabitants are covered by the Unified Health Care System, and 20% of Brazilian citizens are covered by private health-care insurances. In this scenario, the government adopted some actions to combat the pandemics, including guidelines for COVID-19 prevention and management, allocation of funds to support primary care, extension of medical services in primary health units, increase in the number of health-care professionals, distribution of COVID-19 tests, use of telemedicine to monitor patients with flu-like symptoms, and teleconsulting with psychiatrist and psychologists. Since the pandemic offers a unique opportunity for research and management in Brazil, a coalition initiative conducted several therapeutic trials in search of safe treatments for patients with COVID-19. Other issue in this field was the organization of health system, both in private and public organizations.

OBJECTIVES:. Data on cardiac arrest survivors from developing countries are scarce. This study investigated clinical characteristics associated with in-hospital mortality in resuscitated patients following cardiac arrest in Brazil. DESIGN:. Retrospective analysis of prospectively collected data. SETTING:. Ninety-two general ICUs from 55 hospitals in Brazil between 2014 and 2015. PATIENTS:. Adult patients with cardiac arrest admitted to the ICU. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. We analyzed 2,296 patients (53% men; median 67 yr (interquartile range, 54–79 yr]). Eight-hundred patients (35%) had a primary admission diagnosis of cardiac arrest suggesting an out-of-hospital cardiac arrest; the remainder occurred after admission, comprising an in-hospital cardiac arrest cohort. Overall, in-hospital mortality was 83%, with only 6% undergoing withholding/withdrawal-of-life support. Random-effects multivariable Cox regression was used to assess associations with survival. After adjusting for age, sex, and severity scores, mortality was associated with shock (adjusted odds ratio, 1.25 [95% CI, 1.11–1.39]; p < 0.001), temperature dysregulation (adjusted odds ratio for normothermia, 0.85 [95% CI, 0.76–0.95]; p = 0.007), increased lactate levels above 4 mmol/L (adjusted odds ratio, 1.33 [95% CI, 1.1–1.6; p = 0.009), and surgical or cardiac cases (adjusted odds ratio, 0.72 [95% CI, 0.6–0.86]; p = 0.002). In addition, survival was better in patients with probable out-of-hospital cardiac arrest, unless ICU admission was delayed (adjusted odds ratio for interaction, 1.63 [95% CI, 1.21–2.21]; p = 004). CONCLUSIONS:. In a large multicenter cardiac arrest cohort from Brazil, we found a high mortality rate and infrequent withholding/withdrawal of life support. We also identified patient profiles associated with worse survival, such as those with shock/hypoperfusion and arrest secondary to nonsurgical admission diagnoses. Our findings unveil opportunities to improve postarrest care in developing countries, such as prompt ICU admission, expansion of the use of targeted temperature management, and implementation of shock reversal strategies (i.e., early coronary angiography), according to modern guidelines recommendations.

OBJECTIVE:To describe fluid resuscitation practices in Brazilian intensive care units and to compare them with those of other countries participating in the Fluid-TRIPS.METHODS:This was a prospective, international, cross-sectional, observational study in a convenience sample of intensive care units in 27 countries (including Brazil) using the Fluid-TRIPS database compiled in 2014. We described the patterns of fluid resuscitation use in Brazil compared with those in other countries and identified the factors associated with fluid choice.RESULTS:On the study day, 3,214 patients in Brazil and 3,493 patients in other countries were included, of whom 16.1% and 26.8% (p < 0.001) received fluids, respectively. The main indication for fluid resuscitation was impaired perfusion and/or low cardiac output (Brazil: 71.7% versus other countries: 56.4%, p < 0.001). In Brazil, the percentage of patients receiving crystalloid solutions was higher (97.7% versus 76.8%, p < 0.001), and 0.9% sodium chloride was the most commonly used crystalloid (62.5% versus 27.1%, p < 0.001). The multivariable analysis suggested that the albumin levels were associated with the use of both crystalloids and colloids, whereas the type of fluid prescriber was associated with crystalloid use only.CONCLUSION:Our results suggest that crystalloids are more frequently used than colloids for fluid resuscitation in Brazil, and this discrepancy in frequencies is higher than that in other countries. Sodium chloride (0.9%) was the crystalloid most commonly prescribed. Serum albumin levels and the type of fluid prescriber were the factors associated with the choice of crystalloids or colloids for fluid resuscitation.

RESUMO Objetivo: Descrever as práticas de ressuscitação volêmica em unidades de terapia intensiva brasileiras e compará-las com as de outros países participantes do estudo Fluid-TRIPS. Métodos: Este foi um estudo observacional transversal, prospectivo e internacional, de uma amostra de conveniência de unidades de terapia intensiva de 27 países (inclusive o Brasil), com utilização da base de dados Fluid-TRIPS compilada em 2014. Descrevemos os padrões de ressuscitação volêmica utilizados no Brasil em comparação com os de outros países e identificamos os fatores associados com a escolha dos fluidos. Resultados: No dia do estudo, foram incluídos 3.214 pacientes do Brasil e 3.493 pacientes de outros países, dos quais, respectivamente, 16,1% e 26,8% (p < 0,001) receberam fluidos. A principal indicação para ressuscitação volêmica foi comprometimento da perfusão e/ou baixo débito cardíaco (Brasil 71,7% versus outros países 56,4%; p < 0,001). No Brasil, a percentagem de pacientes que receberam soluções cristaloides foi mais elevada (97,7% versus 76,8%; p < 0,001), e solução de cloreto de sódio a 0,9% foi o cristaloide mais comumente utilizado (62,5% versus 27,1%; p < 0,001). A análise multivariada sugeriu que os níveis de albumina se associaram com o uso tanto de cristaloides quanto de coloides, enquanto o tipo de prescritor dos fluidos se associou apenas com o uso de cristaloides. Conclusão: Nossos resultados sugerem que cristaloides são usados mais frequentemente do que coloides para ressuscitação no Brasil, e essa discrepância, em termos de frequências, é mais elevada do que em outros países. A solução de cloreto de sódio 0,9% foi o cristaloide mais frequentemente prescrito. Os níveis de albumina sérica e o tipo de prescritor de fluidos foram os fatores associados com a escolha de cristaloides ou coloides para a prescrição de fluidos.

Intensive care medicine is a specialty in which the results are closely related to the ability to organize and work as a team. While technological advancements offer a wide variety of tests and a myriad of possible treatments and procedures for critically ill patients, this large arsenal of options is often misused, which in addition to not providing significant benefits to patients can cause unnecessary risk and harm. Based on these principles, the American Board of Internal Medicine Foundation (ABIM) began a campaign in 2012 to identify clinical practices that should be questioned to make physicians aware of the importance of using only interventions and procedures that are indicated for the patient and that do not put him or her at risk. For this purpose, a list of items considered most relevant to conscious decision-making was developed and was named Choosing Wisely.(1) Since then, numerous medical societies around the world have started to make their lists to prompt discussions of and providing warnings about the main practices to be questioned and the importance of always using the utmost discernment. The following are considered basic principles of the campaign: it must be led by physicians, the choices should be patient-centered, there must be multi-professional participation, the campaign should be evidence-based, and the selection process must be transparent.(2) The Associação de Medicina Intensiva Brasileira (AMIB) appointed a group of experts to prepare the recommendations. Initially, the experts elaborated 28 recommendations and, by using the modified Delphi method, those that reached more than 80% consensus among them were excluded. In the end, there were ten recommendations, which the members voted on electronically through the association’s website (https://amorintensopelavida.com.br/choosing/). Members received an invitation to vote by email and were identified by their Natural Person Registration (CPF Cadastro de Pessoa Física) number at the time of voting to avoid duplication. A total of 1,754 members from all regions of the country participated, which represented approximately 30% of AMIB members. The five recommendations that received the most votes were chosen by more than 50% of the participants, as shown in figure 1.

Introduction: The cuff pressure is measured in industrial equipment, however, be valid in the craft equipment is still questioned. Objective: To evaluate the reliability of the measurement methods of cuff pressure endotracheal tubes with industrialized and handmade equipment. Method: Were analyzed 40 endotracheal tubes, two brands (Solidor and Ruschelit) and different diameter (8,0 mm and 8,5mm), inflated 20mL of air in the pilot balloon with plastic syringe and 20 mL, followed by pressure measurement device with industrial (cmH2 O) and handmade device (mmHg). After the conversion of cmH2O values for mmHg, the reliability and agreement of measurements were performed by intra-class correlation (ICC) and Bland-Altman tests, respectively, using SPSS (version 15.0) and adopting a significance level of 5% for all comparisons. Results: The data showed similarity between the different pressure equipment, brands and diameter, and demonstrated strong correlation and agreement between the methods. Tube Rus8,0mm industrial versus handmade (28.2±5.8 vs 28.4±6.2 mmHg: ICC=0.998; bias=0.20); Tube Solidor8.0mm industrial versus handmade (75.9±1.1 vs 76.4±1.2 mmHg: ICC=0.878; bias=0.40); Tube Rus8.5mm industrial versus handmade (17.1±8.8 vs 17.8±8.9 mmHg: ICC=0.999; bias=0.67); Tube Sol8.5mm industrial versus handmade (78.7±4.7 vs 78.6±4.6 mmHg: ICC=0.996; bias=-0.1). Conclusion: The high reliability and agreement presented in this study suggest that the cuff pressure gauge handmade can be used safely to evaluate the cuff pressure of the endotracheal tube.

Worldwide, the number of sepsis patients per year is estimated at 15 to 17 million, contributing to more than 5 million deaths annually.(1-3) In Brazil, recent publications have indicated an increase in the number of cases of this syndrome in late years.(4) Many factors have contributed to this trend, such as population growth and rising in life expectancy, which rose from 65.3 years in 1990 to 71.5 years in 2013, increasing the susceptible population to include elderly people, people with chronic diseases, and immunosuppressed people.(5) In addition, initiatives such as the Sepsis Survival Campaign (CSS) and the Global Sepsis Alliance (GSA) are some means used in better identifying septic patients and increasing disease reporting. The Brazilian ICUs project, created by Epimed Solutions®, together with the Associação de Medicina Intensiva Brasileira (AMIB) (http://www.utisbrasileiras. com.br/project/), is based on the National Registry of Intensive Therapy, with the objective of characterizing the epidemiological profile of Brazilian intensive care units (ICUs) and sharing epidemiological information that may be useful in guiding public health policies and developing research and treatment strategies to improve the outcomes of critically ill patients in Brazil.(2,4) The participation of ICUs in the Epimed Database is voluntary and governed by a commercial agreement with Epimed Solutions®, an information technology company responsible for the development, updating, security, and backup of all processes.(4) The participants in the Brazilian ICUs project have access to a free and simplified version of the system. The purpose of this review was to disclose the temporal trends of sepsis prevalence and mortality. We evaluated data from a large national registry, with participation of approximately 30% of the adult ICU beds in the country, with data from 190,999 hospitalized patients between 2010 and 2016 in 638 ICUs from 349 public and private hospitals that were part of the Brazilian ICUs project. All of the Brazilian regions are represented, namely, 58.2% in the Southeast, 14.6% in the Northeast, 13.3% in the Midwest, 9.6% in the South, and 4.5% in the North. These data demonstrate a progressive increase in the number of cases of sepsis in Brazilian ICUs, from 19.4% of total hospitalizations in 2010 to 25.2% in 2016 (Figure 1), in addition to a stable and constant decrease in mortality. Mortality rates fell from 39% in 2010 to 30% in 2016 (absolute risk reduction ARR: 9.1%, 95%CI 7.7 -10.4%, p < 0.001) (Figure 2) in patients with sepsis, while they remained unchanged for other medical hospitalizations. Standardized Mortality Rates (SMR), i.e., corrected for disease severity by Suzana Margareth Lobo1, Ederlon Rezende2, Ciro Leite Mendes3, Mirella Cristinne de Oliveira4, on behalf of the participants of the Brazilian ICUs project

Importance The effects of intensive care unit (ICU) visiting hours remain uncertain. Objective To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium. Design, Setting and Participants Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018. Interventions Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation. Main Outcomes and Measures Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory). Results Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation. Conclusions and Relevance Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium. Trial Registration ClinicalTrials.gov Identifier: NCT02932358.

The performance of severity-of-illness scores varies in different scenarios and must be validated prior of being used in a specific settings and geographic regions. Moreover, models’ calibration may deteriorate overtime and performance of such instruments should be reassessed regularly. Therefore, we aimed at to validate the SAPS 3 in a large contemporary cohort of patients admitted to Brazilian ICUs. In addition, we also compared the performance of the SAPS 3 with the MPM0-III.

A 26-year-old postpartum female presented with symptoms characteristic of dengue fever on the 16th day of puerperium. On the third day of the illness, the patient presented a clinical picture consistent with shock. Tests determined primary infection with dengue virus serotype 2. Cardiac tamponade was confirmed by echocardiography. This rare manifestation is described in a patient without any associated comorbidity.