Publications by authors named "Flavio E Nacul"

10 Publications

  • Page 1 of 1

Human factors and ergonomics to improve performance in intensive care units during the COVID-19 pandemic.

Anaesthesiol Intensive Ther 2021 ;53(3):265-270

International Fluid Academy, Lovenjoel, Belgium.

The COVID-19 pandemic has tested the very elements of human factors and ergonomics (HFE) to their maximum. HFE is an established scientific discipline that studies the interrelationship between humans, equipment, and the work environment. HFE includes situation awareness, decision making, communication, team working, leadership, managing stress, and coping with fatigue, empathy, and resilience. The main objective of HF is to optimise the interaction of humans with their work environment and technical equipment in order to maximise patient safety and efficiency of care. This paper reviews the importance of HFE in helping intensivists and all the multidisciplinary ICU teams to deliver high-quality care to patients in crisis situations.
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http://dx.doi.org/10.5114/ait.2021.105760DOI Listing
September 2021

Intra-abdominal hypertension, fluid balance, and adverse outcomes after orthotopic liver transplantation.

J Crit Care 2021 04 26;62:271-275. Epub 2020 Dec 26.

Intensive Care Division, FAMERP Medical School and Hospital de Base, São Jose do Rio Preto, SP, Brazil. Electronic address:

Background: Intra-abdominal hypertension (IAH) is frequently encountered in critically ill surgical patients. We aimed to evaluate the incidence of IAH after orthotopic liver transplant (OLT) and its impact on organ function, hospital length-of-stay (LOS), and death.

Methods: This prospective, observational, cohort study evaluated consecutive adult patients admitted in the ICU after undergoing OLT. Intra-abdominal pressure (IAP) was measured every 4-6 h for 3 days. Worsening IAP was defined as a gradual increase in IAP over a period of time. Daily fluid balance was the daily sum of all intakes minus the output.

Results: IAH was observed in 48% of the patients within the first 3 days after ICU admission, while ACS was diagnosed in 15%. Patients with IAH had a higher positive fluid balance at day 1 (1764 mL [812-2733 mL] vs. 1301 mL [241-1904 mL], p = 0.025). Worsening IAH was associated with fewer days free of organ dysfunction. IAH within 72 h after ICU admission was independently associated with a composite outcome of death or a longer ICU LOS (odds ratio 2.9; CI 95% 1.02-8.25, p = 0.043).

Conclusion: After OLT, nearly half of the patients presented IAH, that was associated with unfavorable outcomes.
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http://dx.doi.org/10.1016/j.jcrc.2020.12.021DOI Listing
April 2021

How Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Progresses: The Natural History of ME/CFS.

Front Neurol 2020 11;11:826. Epub 2020 Aug 11.

Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom.

We propose a framework for understanding and interpreting the pathophysiology of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) that considers wider determinants of health and long-term temporal variation in pathophysiological features and disease phenotype throughout the natural history of the disease. As in other chronic diseases, ME/CFS evolves through different stages, from asymptomatic predisposition, progressing to a prodromal stage, and then to symptomatic disease. Disease incidence depends on genetic makeup and environment factors, the exposure to singular or repeated insults, and the nature of the host response. In people who develop ME/CFS, normal homeostatic processes in response to adverse insults may be replaced by aberrant responses leading to dysfunctional states. Thus, the predominantly neuro-immune manifestations, underlined by a hyper-metabolic state, that characterize early disease, may be followed by various processes leading to multi-systemic abnormalities and related symptoms. This abnormal state and the effects of a range of mediators such as products of oxidative and nitrosamine stress, may lead to progressive cell and metabolic dysfunction culminating in a hypometabolic state with low energy production. These processes do not seem to happen uniformly; although a spiraling of progressive inter-related and self-sustaining abnormalities may ensue, reversion to states of milder abnormalities is possible if the host is able to restate responses to improve homeostatic equilibrium. With time variation in disease presentation, no single ME/CFS case description, set of diagnostic criteria, or molecular feature is currently representative of all patients at different disease stages. While acknowledging its limitations due to the incomplete research evidence, we suggest the proposed framework may support future research design and health care interventions for people with ME/CFS.
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http://dx.doi.org/10.3389/fneur.2020.00826DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7431524PMC
August 2020

Influence of Sedation Level and Ventilation Status on the Diagnostic Validity of Delirium Screening Tools in the ICU-An International, Prospective, Bi-Center Observational Study (IDeAS).

Medicina (Kaunas) 2020 Aug 13;56(8). Epub 2020 Aug 13.

Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany.

The use of delirium screening instruments (DSIs) is recommended in critical care practice for a timely detection of delirium. We hypothesize that the patient-related factors "level of sedation" and "mechanical ventilation" impact test validity of DSIs. This is a prospective, bi-center observational study (clinicaltrials.gov: NCT01720914). Critically ill patients were screened for delirium daily for up to seven days after enrollment using the Nursing Delirium Screening Scale (Nu-DESC), Intensive Care Delirium Screening Checklist (ICDSC), and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Reference standard for delirium diagnosis was the neuropsychiatric examination using the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Immediately before delirium assessment, ventilation status and sedation levels were documented. 160 patients were enrolled and 151 patients went into final analysis. Delirium incidence was 23.2%. Nu-DESC showed a sensitivity and specificity of 88.5%, a positive predictive value (PPV) of 71.9%, and a negative predictive value (NPV) of 95.8%. ICDSC had a sensitivity of 62.5%, a specificity of 92.4%, a PPV of 71.4%, and a NPV of 89.0%. CAM-ICU showed a sensitivity of 75.0%, a specificity of 94.7%, a PPV of 85.7%, and a NPV of 90.0%. For Nu-DESC and ICDSC, test validity was significantly better for non-sedated patients (Richmond Agitation Sedation Scale (RASS) 0/-1), whereas test validity for CAM-ICU in a severity scale version showed no significant differences for different sedation levels. No DSI showed a significant difference in test validity between noninvasively and invasively ventilated patients. Test validities of DSIs were comparable to previous studies. The observational scores ICDSC and Nu-DESC showed a significantly better performance in awake and drowsy patients (RASS 0/-1) when compared with other sedation levels. Physicians should refrain from sedation whenever possible to avoid suboptimal performance of DSIs.
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http://dx.doi.org/10.3390/medicina56080411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7466203PMC
August 2020

Fatal scorpion envenomation: a case report.

Anaesthesiol Intensive Ther 2019 ;51(2):163-165

Toxicology Center, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto - SP, Brazil.

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http://dx.doi.org/10.5114/ait.2019.85803DOI Listing
May 2020

Early determinants of death due to multiple organ failure after noncardiac surgery in high-risk patients.

Anesth Analg 2011 Apr 8;112(4):877-83. Epub 2010 Jun 8.

Faculdade de Medicina de São José do Rio Preto, Serviço de Terapia Intensiva do Hospital de Base e Laboratório de Sepse, Avenida Brigadeiro Faria Lima, 5544 CEP 15090-000 São Jose do Rio Preto, SP, Brazil.

Background: Prediction of perioperative cardiac complications is important in the medical management of patients undergoing noncardiac surgery. However, these patients frequently die as a consequence of primary or secondary multiple organ failure (MOF), often as a result of sepsis. We investigated the early perioperative risk factors for in-hospital death due to MOF in surgical patients.

Methods: This was a prospective, multicenter, observational cohort study performed in 21 Brazilian intensive care units (ICUs). Adult patients undergoing noncardiac surgery who were admitted to the ICU within 24 hours after operation were evaluated. MOF was characterized by the presence of at least 2 organ failures. To determine the relative risk (RR) of in-hospital death due to MOF, we performed a logistic regression multivariate analysis.

Results: A total of 587 patients were included (mean age, 62.4 ± 17 years). ICU and hospital mortality rates were 15% and 20.6%, respectively. The main cause of death was MOF (53%). Peritonitis (RR 4.17, 95% confidence interval [CI] 1.38-12.6), diabetes (RR 3.63, 95% CI 1.17-11.2), unplanned surgery (RR 3.62, 95% CI 1.18-11.0), age (RR 1.04, 95% CI 1 0.01-1.08), and elevated serum lactate concentrations (RR 1.52, 95% CI 1.14-2.02), a high central venous pressure (RR 1.12, 95% CI 1.04-1.22), a fast heart rate (RR 3.63, 95% CI 1.17-11.2) and pH (RR 0.04, 95% CI 0.0005-0.38) on the day of admission were independent predictors of death due to MOF.

Conclusions: MOF is the main cause of death after surgery in high-risk patients. Awareness of the risk factors for death due to MOF may be important in risk stratification and can suggest routes for therapy.
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http://dx.doi.org/10.1213/ANE.0b013e3181e2bf8eDOI Listing
April 2011

The effects of vasoactive drugs on intestinal functional capillary density in endotoxemic rats: intravital video-microscopy analysis.

Anesth Analg 2010 Feb;110(2):547-54

Laboratory of Cardiovascular Investigation, Oswaldo Cruz Institute, Fiocruz, Brazil.

Background: The use of vasoactive drugs to restore arterial blood pressure in patients with septic shock remains a cornerstone of intensive care medicine. However, vasopressors can accentuate the hypoperfusion of the gut during septic shock, allowing bacterial translocation and endotoxemia. In this study, we compared the effects of different vasoactive drugs on intestinal microcirculation and tissue oxygenation, independent of the effects of fluid therapy, in a rat model of endotoxemic shock.

Methods: Pentobarbital-anesthetized Wistar Kyoto rats were submitted to endotoxemic shock induced by Escherichia coli lipopolysaccharide (2 mg/kg IV). Arterial blood pressure was normalized by a continuous infusion of different vasoactive drugs, including epinephrine, norepinephrine, phenylephrine, dopamine, dobutamine, or a combination of dobutamine and norepinephrine. The functional capillary density (FCD) of the muscular layer of the small intestine was evaluated by intravital video-microscopy. Mesenteric venous blood gases and lactate concentrations were also analyzed.

Results: FCD decreased by approximately 25% to 60% after the IV infusion of epinephrine, norepinephrine, and phenylephrine. Administration of dopamine, dobutamine, and the combination of dobutamine and norepinephrine did not induce significant alterations in gut FCD. In addition, the mesenteric venous lactate concentration increased in the presence of phenylephrine and showed a tendency to increase after the administration of epinephrine and norepinephrine, whereas there was no observable increase after the administration of dopamine, dobutamine, and the combination of dobutamine with norepinephrine.

Conclusion: This study confirms dissociation of the systemic hemodynamic and microvascular alterations in an experimental model of septic shock. Moreover, the results indicate that the use of dopamine, dobutamine, and dobutamine in combination with norepinephrine yields a protective effect on the microcirculation of the intestinal muscular layer in endotoxemic rats.
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http://dx.doi.org/10.1213/ANE.0b013e3181c88af1DOI Listing
February 2010

Lipopolysaccharide binding protein in a surgical intensive care unit: a marker of sepsis?

Crit Care Med 2008 Jul;36(7):2014-22

Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University Hospital, Jena, Germany.

Objectives: We investigated the time course of lipopolysaccharide binding protein (LBP) plasma concentrations in patients in the surgical intensive care unit (ICU), their value in discriminating sepsis from systemic inflammatory response syndrome, and their association with severity of sepsis and outcome in these patients compared with interleukin (IL)-6, C-reactive protein, and procalcitonin.

Design: Prospective, observational, cohort study.

Setting: Academic ICU.

Patients: All 327 consecutively admitted patients.

Measurements And Main Results: Serum LBP concentrations were higher in patients who had severe sepsis/septic shock on ICU admission than in patients who never had sepsis (20.5 [8.1-38.8] vs. 14.2 [7.7-22.2] microg/mL, p < .05) but were similar in patients with sepsis without organ failure and those who never had sepsis. After 3 days, LBP levels were similar in all groups. In a receiver operating characteristic curve analysis, LBP concentrations moderately discriminated sepsis from systemic inflammatory response syndrome (area under curve [AUC] = .66) and severe sepsis from sepsis without organ failure (AUC = .71). IL-6 had the highest AUC in discriminating sepsis from other conditions (AUC = .76) and procalcitonin had the highest AUC for discrimination of severe sepsis from sepsis (AUC = .86). LBP concentrations on admission and during the first week were similar in patients with gram-positive and those with gram-negative infections (15.9 [11-26.7] and 37.2 [25.1-62.4] vs. 16.3 [5.3-31.6] and 31.6 [13.4], microg/mL, p > .2). LBP concentrations on admission were similar in nonsurvivors and survivors and did not discriminate ICU mortality. However, the maximum LBP concentration during the first 3 days in the ICU discriminated moderately between survivors and nonsurvivors.

Conclusions: In the surgical ICU, LBP moderately discriminated patients without infection from patients with severe sepsis but not from patients with sepsis without organ dysfunction. LBP concentrations did not distinguish between gram-positive and gram-negative infections. The correlation of LBP concentrations with disease severity and outcome is weak compared with other markers and its use as a biomarker is not warranted in this patient population.
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http://dx.doi.org/10.1097/CCM.0b013e31817b86e3DOI Listing
July 2008

Massive nasal bleeding and hemodynamic instability associated with clopidogrel.

Pharm World Sci 2004 Feb;26(1):6-7

Clinical Research Center & Intensive Care Medicine, Clínica São Vicente, Rua João Borges 204, Rio de Janeiro, RJ 22451-100, Brazil.

A 58-year-old woman was brought to our emergency department with massive nasal bleeding and hemodynamic instability. The patient had been on clopidogrel treatment (75 mg/day) for 2 years, which was started after an episode of transitory ischemic attack. Blood pressure normalized following the administration of intravenous fluids, and the bleeding stopped after nasal tamponade and desmopressin therapy.
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http://dx.doi.org/10.1023/b:phar.0000013480.17165.6dDOI Listing
February 2004

Hemodynamic instability secondary to adrenal insufficiency in a major burn patient.

Burns 2002 May;28(3):270-2

Clínica São Vicente, Intensive Care Unit, RJ, Rio de Janeiro, Brazil.

A 39-year-old man presented with 80% body surface area burned following a thermal accident. The patient showed hemodynamic instability and low response to intravenous fluids or vasopressors for 20 days in the intensive care unit (ICU). The adrenocorticotropic hormone (ACTH) test was consistent with adrenal insufficiency. After a 3-day steroid treatment, the patient's blood pressure was normal without the administration of any vasopressor.
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http://dx.doi.org/10.1016/s0305-4179(01)00081-xDOI Listing
May 2002
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