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- Antibiotics and extracorporeal circulation – one size does not fit allPublication . Gonçalves-Pereira, J; Oliveira, B
- Artificial Intelligence to Close the Gap between Pharmacokinetic/Pharmacodynamic Targets and Clinical Outcomes in Critically Ill Patients: A Narrative Review on Beta LactamsPublication . Gonçalves Pereira, João; Fernandes, Joana; Mendes, Tânia; Gonzalez, Filipe André; Fernandes, Susana M.Abstract: Antimicrobial dosing can be a complex challenge. Although a solid rationale exists for a link between antibiotic exposure and outcome, conflicting data suggest a poor correlation between pharmacokinetic/pharmacodynamic targets and infection control. Different reasons may lead to this discrepancy: poor tissue penetration by β-lactams due to inflammation and inadequate tissue perfusion; different bacterial response to antibiotics and biofilms; heterogeneity of the host’s immune response and drug metabolism; bacterial tolerance and acquisition of resistance during therapy. Consequently, either a fixed dose of antibiotics or a fixed target concentration may be doomed to fail. The role of biomarkers in understanding and monitoring host response to infection is also incompletely defined. Nowadays, with the ever-growing stream of data collected in hospitals, utilizing the most efficient analytical tools may lead to better personalization of therapy. The rise of artificial intelligence and machine learning has allowed large amounts of data to be rapidly accessed and analyzed. These unsupervised learning models can apprehend the data structure and identify homogeneous subgroups, facilitating the individualization of medical interventions. This review aims to discuss the challenges of β-lactam dosing, focusing on its pharmacodynamics and the new challenges and opportunities arising from integrating machine learning algorithms to personalize patient treatment.
- Atrial Fibrillation in critically ill patients: incidence and outcomesPublication . Paula, Sofia B.; Oliveira, André; Melo e Silva, João; Simões, André F.; Gonçalves Pereira, JoãoAbstract Background: Atrial fibrillation (AF), either chronic or new onset, is common in critically ill patients. Its epidemiology and relationship with clinical outcomes are poorly known. Objective: To understand the burden of AF in patients admitted to ICU and its impact on patients’ outcomes. Methods: Single-center retrospective, cohort study, evaluating all patients with AF admitted to a non cardiac intensive care unit over the course of 54 months. Clinical outcomes were evaluated in the short (hospital discharge) and long-term (2-year follow-up). The hazard ratio (HR) with 95% CI was computed for the whole population as well as for propensity score-matched patients, with or without AF. Results: A total of 1357 patients were screened (59.1% male), with a mean age of 75±15.2 years, length of intensive care unit stay of 4.7±5.1 days, and hospital mortality of 26%. A diagnosis of AF was found in 215 patients (15.8%), 142 of which had chronic AF. The hospital all-cause mortality was similar in patients with chronic or new-onset AF (31% vs. 28.8%, p=0.779). Patients with AF had higher in-hospital, 1-year, and 2-year mortality (30.2%, 47.9%, and 52.6% vs. 22.9%, 35.3%, and 38.4%, respectively). However, after propensity score matching (N=213), this difference was no longer significant, neither in-hospital mortality (Odds Ratio 1.10; 95% CI 0.72-1.66), 1-year mortality (OR 1.16; 95% CI 0.79-1.70) or 2-years mortality, (Odds Ratio 1.16; 95% CI 0.79-1.70). Conclusions: In ICU patients AF was common, either chronic or new-onset, being diagnosed in 15.8%. Patients with AF had higher mortality but no significant differences were found in the short- and long-term mortality after adjustment for severity on admission.
- C-reactive Protein Variation and Its Usefulness in the Prognostication and Monitoring of Patients With Pneumococcal PneumoniaPublication . Gomes, André; Ribeiro, Rui; Froes, Filipe; Mergulhão, Paulo; Gonçalves Pereira, JoãoCommunity-acquired pneumonia (CAP) is a prevalent and life-threatening infection that causes significant morbidity and mortality. Biomarkers, such as C-reactive protein (CRP), can help to diagnose, monitor, and prognose patients with this condition. This study aimed to analyze the disease course, the CRP peak concentration, its relationship with prognosis, and its variation in hospitalized patients with pneumococcal CAP.
- A Case Report of Hemophagocytic SyndromePublication . Mendes, Tânia F.; Oliveira, Ana Isabel; Gomes, Carolina; Sousa, Nuno A.; Gonçalves Pereira, JoãoAbstract Hemophagocytic syndrome (HPS) represents a critical and often overlooked hyperinflammatory condition that can lead to rapid multi-organ failure and high mortality rates, particularly in adults. This article presents a compelling case study of a 45-year-old male with a complex clinical presentation, highlighting the diagnostic challenges posed by HPS, including its nonspecific symptoms and the necessity for a high index of suspicion. We underscore the paramount importance of early recognition, thorough differential diagnosis, and prompt initiation of treatment to improve patient outcomes. This case not only illustrates the intricacies of diagnosing HPS but also advocates for increased awareness among healthcare providers to mitigate the risks associated with this life-threatening syndrome.
- Clinical nutrition issues in 2022: What is missing to trust supplemental parenteral nutrition (SPN) in ICU patients?Publication . Berger, Mette M.; Burgos, Rosa; Casaer, Michael P.; De Robertis, Edoardo; Delgado, Juan Carlos Lopez; Fraipont, Vincent; Gonçalves-Pereira, João; Pichard, Claude; Stoppe, ChristianA multidisciplinary group of international physicians involved in the medical nutrition therapy (MNT) of adult critically ill patients met to discuss the value, role, and open questions regarding supplemental parenteral nutrition (SPN) along with oral or enteral nutrition (EN), particularly in the intensive care unit (ICU) setting. This manuscript summarizes the discussions and results to highlight the importance of SPN as part of a comprehensive approach to MNT in critically ill adults and for researchers to generate new evidence based on well-powered randomized controlled trials (RCTs). The experts agreed on several key points: SPN has shown clinical benefts, resulting in this strategy being included in American and European guidelines. Nevertheless, its use is heterogeneous across European countries, due to the persistence of uncertainties, such as the optimal timing and the risk of overfeeding in absence of indirect calorimetry (IC), which results in divergent opinions and barriers to SPN implementation. Education is also insufcient. The experts agreed on actions needed to increase evidence quality on SPN use in specifc patients at a given time point during acute critical illness or recovery.
- COVID-19: A Possible Cause of Spontaneous PneumoperitoneumPublication . Ramos, Patrícia Varela; Oliveira, Ana Maria; Simas, Ângela; Rocha Vera Cruz, MargaridaIntroduction: Pneumoperitoneum is the presence of air within the peritoneal cavity and is mostly caused by organ rupture. Spontaneous pneumoperitoneum accounts 5% to 15% of the cases and occurs in the absence of organ damage. The pulmonary origin of pneumoperitoneum is unusual, and probably associated with mechanical ventilation and alveolar leak. In patients with coronavirus disease 2019 (COVID-19) there are some reports of air leak, like pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema. Case presentation: We present the case of a 70-year-old man with COVID-19 pneumonia admitted to the Intensive Care Unit (ICU). Since admission he was on Non-Invasive Ventilation (NIV), without improvement, needing Invasive Mechanical Ventilation (IMV) due to severe respiratory failure. Five days after IMV despite protective lung ventilation, massive spontaneous subcutaneous emphysema, pneumomediastinum and pneumoperitoneum were diagnosed. Besides initial conservative management 12 hours later, the patient developed abdominal compartment syndrome requiring percutaneous needle decompression. Conclusions: Pneumoperitoneum can be considered a rare complication of COVID-19 pneumonia and its management, resulting not only from the viral pulmonary but also from secondary causes. Conservative management should be usually enough. However, in the presence of abdominal compartment syndrome prompt recognition and treatment are crucial and eventually lifesaving.
- Critically ill patient mortality by age: long-term follow-up (CIMbA-LT)Publication . Gonçalves-Pereira, João; Oliveira, André; Vieira, Tatiana; Rodrigues, Ana Rita; Pinto, Maria João; Pipa, Sara; Martinho, Ana; Ribeiro, Sofia; Paiva, José-ArturBackground The past years have witnessed dramatic changes in the population admitted to the intensive care unit (ICU). Older and sicker patients are now commonly treated in this setting due to the newly available sophisticated life support. However, the short- and long-term benefit of this strategy is scarcely studied. Methods The Critically Ill patients’ mortality by age: Long-Term follow-up (CIMbA-LT) was a multicentric, nationwide, retrospective, observational study addressing short- and long-term prognosis of patients admitted to Portuguese multipurpose ICUs, during 4 years, according to their age and disease severity. Patients were followed for two years after ICU admission. The standardized hospital mortality ratio (SMR) was calculated according to the Simplified Acute Physiology Score (SAPS) II and the follow-up risk, for patients discharged alive from the hospital, according to official demographic national data for age and gender. Survival curves were plotted according to age group. Results We included 37.118 patients, including 15.8% over 80 years old. The mean SAPS II score was 42.8 ± 19.4. The ICU all-cause mortality was 16.1% and 76% of all patients survive until hospital discharge. The SAPS II score overestimated hospital mortality [SMR at hospital discharge 0.7; 95% confidence interval (CI) 0.63–0.76] but accurately predicted one-year all-cause mortality [1-year SMR 1.01; (95% CI 0.98–1.08)]. Survival curves showed a peak in mortality, during the first 30 days, followed by a much slower survival decline thereafter. Older patients had higher short- and long-term mortality and their hospital SMR was also slightly higher (0.76 vs. 0.69). Patients discharged alive from the hospital had a 1-year relative mortality risk of 6.3; [95% CI 5.8–6.7]. This increased risk was higher for younger patients [21.1; (95% CI 15.1–39.6) vs. 2.4; (95% CI 2.2–2.7) for older patients]. Conclusions Critically ill patients’ mortality peaked in the first 30 days after ICU admission. Older critically ill patients had higher all-cause mortality, including a higher hospital SMR. A long-term increased relative mortality risk was noted in patients discharged alive from the hospital, but this was more noticeable in younger patients.
- Critically ill patients with high predicted mortality: Incidence and outcomePublication . Oliveira, André; Vieira, Tatiana; Rodrigues, Ana; Jorge, Núria; Tavares, Luís; Costa, Laura; Paiva, José Artur; Gonçalves Pereira, JoãoAbstract Objective: As calculated by the severity scores, an unknown number of patients are admitted to the Intensive Care Unit (ICU) with a very high risk of death. Clinical studies have poorly addressed this population, and their prognosis is largely unknown. Design: Post hoc analysis of a multicenter, cohort, longitudinal, observational, retrospective study (CIMbA). Setting: Sixteen Portuguese multipurpose ICUs. Patients: Patients with a Simplified Acute Physiology Score II (SAPS II) predicted hospital mor tality above 80% on admission to the ICU (high-risk group); A comparison with the remaining patients was obtained. Interventions: None. Main Variables of Interest: Hospital, 30 days, 1 year mortality. Results: We identified 4546 patients (59.9% male), 12.2% of the whole population. Their SAPS II predicted hospital mortality was 89.0 ± 5.8%, whilst the observed mortality was lower, 61.0%. This group had higher mortality, both during the first 30 days (aHR 3.52 [95% CI 3.34---3.71]) and from day 31 to day 365 after ICU admission (aHR 1.14 [95%CI 1.04---1.26]), respectively. However, their hospital standardized mortality ratio was similar to the other patients (0.69 vs. 0.69, P = .92). At one year of follow-up, 30% of patients in the high-risk group were alive. Conclusions: Roughly 12% of patients admitted to the ICU for more than 24 h had a SAPS II score predicted mortality above 80%. Their hospital standardized mortality was similar to the less severe population and 30% were alive after one year of follow-up.
- Epidemiology and Burden of Ventilator-Associated Pneumonia among Adult Intensive Care Unit Patients: A Portuguese, Multicenter, Retrospective Study (eVAP-PT Study)Publication . Mergulhão, Paulo; Gonçalves Pereira, João; Fernandes, Antero Vale; Krystopchuk, Andriy; Ribeiro, João Miguel; Miranda, Daniel; Castro, Heloísa; Eira, Carla; Morais, Juvenal; Lameirão, Cristina; Gomes, Sara; Leal, Dina; Duarte, Joana; Pássaro, Leonor; Froes, Filipe; Martin-Loeches, IgnacioAbstract: Ventilator-associated pneumonia (VAP) is a prevailing nosocomial infection in critically ill patients requiring invasive mechanical ventilation (iMV). The impact of VAP is profound, adversely affecting patient outcomes and placing a significant burden on healthcare resources. This study assessed for the first time the contemporary VAP epidemiology in Portugal and its burden on the healthcare system and clinical outcomes. Additionally, resource consumption (duration of iMV, intensive care unit (ICU), hospital length of stay (LOS)) and empirical antimicrobial therapy were also evaluated. This multicenter, retrospective study included patients admitted to the hospital between July 2016 and December 2017 in a participating ICU, who underwent iMV for at least 48 h. Patients with a VAP diagnosis were segregated for further analysis (n = 197). Control patients, ventilated for >48 h but without a VAP diagnosis, were also included in a 1:1 ratio. Cumulative VAP incidence was computed. All-cause mortality was assessed at 28, 90, and 365 days after ICU admission. Cumulative VAP incidence was 9.2% (95% CI 8.0–10.5). The all-cause mortality rate in VAP patients was 24.9%, 34.0%, and 40.6%, respectively, and these values were similar to those observed in patients without VAP diagnosis. Further, patients with VAP had significantly longer ICU (27.5 vs. 11.0 days, p < 0.001) and hospital LOS (61 vs. 35.9 days, p < 0.001), more time under iMV (20.7 vs. 8.0 days, p < 0.001) and were more often subjected to tracheostomy (36.5 vs. 14.2%; p < 0.001). Patients with VAP who received inappropriate empirical antimicrobials had higher 28-day mortality, 34.3% vs. 19.5% (odds ratio 2.16, 95% CI 1.10–4.23), although the same was not independently associated with 1-year all-cause mortality (p = 0.107). This study described the VAP impact and burden on the Portuguese healthcare system, with approximately 9% of patients undergoing iMV for >48 h developing VAP, leading to increased resource consumption (longer ICU and hospital LOS). An unexpectedly high incidence of inappropriate, empirical antimicrobial therapy was also noted, being positively associated with a higher mortality risk of these patients. Knowledge of the Portuguese epidemiology characterization of VAP and its multidimensional impact is essential for efficient treatment and optimized long-term health outcomes of these patients.