Publications by authors named "José Augusto Santos Pellegrini"

13 Publications

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Rapid prognostic stratification using Point of Care ultrasound in critically ill COVID patients: The role of epicardial fat thickness, myocardial injury and age.

J Crit Care 2021 Oct 8;67:33-38. Epub 2021 Oct 8.

Postgraduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Cardiology Division - Hospital de Clínicas de Porto Alegre, Brazil.

Purpose: The burden of critical COVID-19 patients in intensive care units (ICU) demands new tools to stratify patient risk. We aimed to investigate the role of cardiac and lung ultrasound, together with clinical variables, to propose a simple score to help predict short-term mortality in these patients.

Material And Methods: We collected clinical and laboratorial data, and a point-of-care cardiac and lung ultrasound was performed in the first 36 h of admission in the ICU.

Results: Out of 78 patients (61 ± 12y-o, 55% male), 33 (42%) died during the hospitalization. Deceased patients were generally older, had worse values for SOFA score, baseline troponin levels, left ventricular ejection fraction (LVEF), LV diastolic function, and increased epicardial fat thickness (EFT), despite a similar prevalence of severe lung ultrasound scores. Based on the multivariable model, we created the POCOVID score, including age (>60 years), myocardial injury (LVEF<50% and/or usTnI>99til), and increased EFT (>0.8 cm). The presence of two out of these three criteria identified patients with almost twice the risk of death.

Conclusions: A higher POCOVID score at ICU admission can be helpful to stratify critical COVID-19 patients with increased in-hospital mortality and to optimize medical resources allocation in more strict-resource settings.
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http://dx.doi.org/10.1016/j.jcrc.2021.09.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8500966PMC
October 2021

Mechanism of a Flexible ICU Visiting Policy for Anxiety Symptoms Among Family Members in Brazil: A Path Mediation Analysis in a Cluster-Randomized Clinical Trial.

Crit Care Med 2021 09;49(9):1504-1512

Department of Critical Care, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil.

Objectives: To investigate whether the effect of a flexible ICU visiting policy that includes flexible visitation plus visitor education on anxiety symptoms of family members is mediated by satisfaction and involvement in patient care.

Design: We embedded a multivariable path mediation analysis within a cluster-randomized crossover trial as a secondary analysis of The ICU Visits Study (ClinicalTrials.gov number: NCT02932358).

Setting: Thirty-six medical-surgical ICUs in Brazil.

Patients: Closest relatives of adult ICU patients.

Interventions: Flexible visitation (12 hr/d) supported by family education or usual restricted visitation (median, 1.5 hr/d).

Measurements And Main Results: Overall, 863 family members were assessed (mean age, 44.7 yr; women, 70.1%). Compared with the restricted visitation (n = 436), flexible visitation (n = 427) resulted in better mean anxiety scores (6.1 vs 7.8; mean difference, -1.78 [95% CI, -2.31 to -1.22]), as well as higher standardized scores of satisfaction (67% [95% CI, 55-79]) and involvement in patient care (77% [95% CI, 64-89]). The mediated effect of flexible visitation on mean anxiety scores through each incremental sd of satisfaction and involvement in patient care were -0.47 (95% CI, -0.68 to -0.24) and 0.29 (95% CI, 0.04-0.54), respectively. Upon exploratory analyses, emotional support, helping the ICU staff to understand patient needs, helping the patient to interpret ICU staff instructions, and patient reorientation were the domains of involvement in patient care associated with increased anxiety.

Conclusions: A flexible ICU visiting policy reduces anxiety symptoms among family members and appears to work by increasing satisfaction. However, increased participation in some activities of patient care as a result of flexible visitation was associated with higher severity of anxiety symptoms.
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http://dx.doi.org/10.1097/CCM.0000000000005037DOI Listing
September 2021

All that glitters is not gold: an unusual presentation of S. aureus sepsis during ECMO.

Intensive Care Med 2021 06 21;47(6):701. Epub 2021 Mar 21.

Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2400, Porto Alegre, RS, 90035-003, Brazil.

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http://dx.doi.org/10.1007/s00134-021-06366-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7981383PMC
June 2021

Incidence of venous thromboembolism among patients with severe COVID-19 requiring mechanical ventilation compared to other causes of respiratory failure: a prospective cohort study.

J Thromb Thrombolysis 2021 Feb 18. Epub 2021 Feb 18.

Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2400, Porto Alegre, RS, 90035-003, Brazil.

Previous studies have suggested that COVID-19 pneumonia is associated with an increased risk of venous thromboembolism (VTE). This study aimed to investigate the incidence of VTE among mechanically ventilated adults with COVID-19 pneumonia, compared to patients with respiratory failure related to other causes. Prospective study that enrolled critically ill adults with suspected COVID-19 pneumonia between June 2, 2020 and August 11, 2020. Critically ill adults with suspected COVID-19 pneumonia who required mechanical ventilation within 24 h after hospital admission were followed until death or hospital discharge. Sequential ultrasonography screening of the lower extremities and catheter insertion sites, as well as testing for plasma biochemical markers, were performed at the intensive care unit admission, day 3, day 7, and day 14. The primary outcome was a composite of deep venous thrombosis, pulmonary embolism, and thrombosis at the central catheter insertion sites. We enrolled 70 patients, including 57 patients with COVID-19 and 13 patients without COVID-19, and all patients completed follow-up. The incidence of the primary outcome was higher among patients with COVID-19 than among patients with respiratory failure related to other etiologies (36.8% vs. 0%, p = 0.023). Multivariate regression analysis revealed that VTE was independently associated with a COVID-19 diagnosis (odds ratio: 6.28, 95% confidence interval: 1.19-68.07) and D-dimer concentration (1-ng/mL increase, odds ratio: 1.15, 95% confidence interval: 1.05-1.30). The incidence of VTE was higher among critically ill mechanically ventilated patients, relative to among patients with respiratory failure related to other causes.
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http://dx.doi.org/10.1007/s11239-021-02395-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7890785PMC
February 2021

Effect of Flexible Family Visitation on Delirium Among Patients in the Intensive Care Unit: The ICU Visits Randomized Clinical Trial.

JAMA 2019 07;322(3):216-228

Intensive Care Unit, Hospital Regional Doutor Deoclécio Marques de Lucena, Parnamirim, Rio Grande do Norte, Brazil.

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.
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http://dx.doi.org/10.1001/jama.2019.8766DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635909PMC
July 2019

Statistical analysis plan for a cluster-randomized crossover trial comparing the effectiveness and safety of a flexible family visitation model for delirium prevention in adult intensive care units (the ICU Visits Study).

Trials 2018 Nov 19;19(1):636. Epub 2018 Nov 19.

Intensive Care Unit, HMV. Rua Ramiro Barcelos, 910, Moinhos de Vento, Porto Alegre, RS, 90035-001, Brazil.

Background: Most adult intensive care units (ICUs) worldwide adopt restrictive family visitation models (RFVMs). However, evidence, mostly from non-randomized studies, suggests that flexible adult ICU visiting hours are safe policies that can result in benefits such as prevention of delirium and increase in satisfaction with care. Accordingly, the ICU Visits Study was designed to compare the effectiveness and safety of a flexible family visitation model (FFVM) vs. an RFVM on delirium prevention among ICU patients, and also to analyze its potential effects on family members and ICU professionals.

Methods/design: The ICU Visits Study is a cluster-randomized crossover trial which compares an FFVM (12 consecutive ICU visiting hours per day) with an RFVM (< 4.5 ICU visiting hours per day) in 40 Brazilian adult ICUs. Participant ICUs are randomly assigned to either an FFVM or RFVM in a 1:1 ratio. After enrollment and follow-up of 25 patients, each ICU is crossed over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome is the cumulative incidence of delirium measured by the Confusion Assessment Method for the ICU. Secondary and tertiary outcomes include relevant measures of effectiveness and safety of ICU visiting policies among patients, family members, and ICU professionals. Herein, we describe all primary statistical procedures that will be used to evaluate the results and perform exploratory and sensitivity analyses of this study. This pre-specified statistical analysis plan was written and submitted without knowledge of the study data.

Discussion: This a priori statistical analysis plan aims to enhance the transparency of our study, facilitating unbiased analyses of ICU visit study data, and provide guidance for statistical analysis for groups conducting studies in the same field.

Trial Registration: ClinicalTrials.gov, NCT02932358 . Registered on 11 October 2016.
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http://dx.doi.org/10.1186/s13063-018-3006-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6245900PMC
November 2018

Pressure-support ventilation or T-piece spontaneous breathing trials for patients with chronic obstructive pulmonary disease - A randomized controlled trial.

PLoS One 2018 23;13(8):e0202404. Epub 2018 Aug 23.

Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.

Background: Little is known about the best strategy for weaning patients with chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Spontaneous breathing trials (SBT) using a T-piece or pressure-support ventilation (PSV) have a central role in this process. Our aim was to compare T-piece and PSV SBTs according to the duration of mechanical ventilation (MV) in patients with COPD.

Methods: Patients with COPD who had at least 48 hours of invasive MV support were randomized to 30 minutes of T-piece or PSV at 10 cm H2O after being considered able to undergo a SBT. All patients were preemptively connected to non-invasive ventilation after extubation. Tracheostomized patients were excluded. The primary outcome was total invasive MV duration. Time to liberation from MV was assessed as secondary outcome.

Results: Between 2012 and 2016, 190 patients were randomized to T-piece (99) or PSV (91) groups. Extubation at first SBT was achieved in 78% of patients. The mean total MV duration was 10.82 ± 9.1 days for the T-piece group and 7.31 ± 4.9 days for the PSV group (p < 0.001); however, the pre-SBT duration also differed (7.35 ± 3.9 and 5.84 ± 3.3, respectively; p = 0.002). The time to liberation was 8.36 ± 11.04 days for the T-piece group and 4.06 ± 4.94 for the PSV group (univariate mean ratio = 2.06 [1.29-3.27], p = 0.003) for the subgroup of patients with difficult or prolonged weaning. The study group was independently associated with the time to liberation in this subgroup.

Conclusions: The SBT technique did not influence MV duration for patients with COPD. For the difficult/prolonged weaning subgroup, the T-piece may be associated with a longer time to liberation, although this should be clarified by further studies.

Trial Registration: ClinicalTrials.gov NCT01464567, at November 3, 2011.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202404PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6107186PMC
February 2019

Point-of-care ultrasonography in Brazilian intensive care units: a national survey.

Ann Intensive Care 2018 Apr 20;8(1):50. Epub 2018 Apr 20.

Department of Critical Care Medicine, Hospital das Clínicas de São Paulo, FMUSP, São Paulo, Brazil.

Background: Point-of-care ultrasonography (POCUS) has recently become a useful tool that intensivists are incorporating into clinical practice. However, the incorporation of ultrasonography in critical care in developing countries is not straightforward.

Methods: Our objective was to investigate current practice and education regarding POCUS among Brazilian intensivists. A national survey was administered to Brazilian intensivists using an electronic questionnaire. Questions were selected by the Delphi method and assessed topics included organizational issues, POCUS technique and training patterns, machine availability, and main applications of POCUS in daily practice.

Results: Of 1533 intensivists who received the questionnaire, 322 responded from all of Brazil's regions. Two hundred and five (63.8%) reported having access to an ultrasound machine dedicated to the intensive care unit (ICU); however, this was more likely in university hospitals than in non-university hospitals (80.6 vs. 59.6%; risk ratio [RR] = 1.35 [1.16-1.58], p = 0.002). The main applications of POCUS were ultrasound-guided central vein catheterization (49.4%) and bedside echocardiographic assessment (33.9%). Two hundred and fifty-eight (80.0%) reported having at least one POCUS-trained intensivist in their staff (trained units). Trained units were more likely to perform routine ultrasound-guided jugular vein catheterization than non-trained units (38.6 vs. 16.4%; RR = 2.35 [1.31-4.23], p = 0.001). The proportion of POCUS-trained intensivists and availability of a dedicated ultrasound machine were both independently associated with performing ultrasound-guided jugular vein catheterization (RR = 1.91 [1.32-2.77], p = 0.001) and (RR = 2.20 [1.26-3.29], p = 0.005), respectively.

Conclusions: A significant proportion of Brazilian ICUs had at least one intensivist with POCUS capability in their staff. Although ultrasound-guided central vein catheterization constitutes the main application of POCUS, adherence to guideline recommendations is still suboptimal.
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http://dx.doi.org/10.1186/s13613-018-0397-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5972134PMC
April 2018

Study protocol to assess the effectiveness and safety of a flexible family visitation model for delirium prevention in adult intensive care units: a cluster-randomised, crossover trial (The ICU Visits Study).

BMJ Open 2018 04 13;8(4):e021193. Epub 2018 Apr 13.

Intensive Care Unit, Hospital Tacchini, Bento Gonçalves, Brazil.

Introduction: Flexible intensive care unit (ICU) visiting hours have been proposed as a means to improve patient-centred and family-centred care. However, randomised trials evaluating the effects of flexible family visitation models (FFVMs) are scarce. This study aims to compare the effectiveness and safety of an FFVM versus a restrictive family visitation model (RFVM) on delirium prevention among ICU patients, as well as to analyse its potential effects on family members and ICU professionals.

Methods And Analysis: A cluster-randomised crossover trial involving adult ICU patients, family members and ICU professionals will be conducted. Forty medical-surgical Brazilian ICUs with RFVMs (<4.5 hours/day) will be randomly assigned to either an RFVM (visits according to local policies) or an FFVM (visitation during 12 consecutive hours per day) group at a 1:1 ratio. After enrolment and follow-up of 25 patients, each ICU will be switched over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome will be the cumulative incidence of delirium among ICU patients, measured twice a day using the Confusion Assessment Method for the ICU. Secondary outcome measures will include daily hazard of delirium, ventilator-free days, any ICU-acquired infections, ICU length of stay and hospital mortality among the patients; symptoms of anxiety and depression and satisfaction among the family members; and prevalence of burnout symptoms among the ICU professionals. Tertiary outcomes will include need for antipsychotic agents and/or mechanical restraints, coma-free days, unplanned loss of invasive devices and ICU-acquired pneumonia, urinary tract infection or bloodstream infection among the patients; self-perception of involvement in patient care among the family members; and satisfaction among the ICU professionals.

Ethics And Dissemination: The study protocol has been approved by the research ethics committee of all participant institutions. We aim to disseminate the findings through conferences and peer-reviewed journals.

Trial Registration: NCT02932358.
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http://dx.doi.org/10.1136/bmjopen-2017-021193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5905750PMC
April 2018

Elevated red blood cell distribution width at ICU discharge is associated with readmission to the intensive care unit.

Clin Biochem 2018 May 14;55:15-20. Epub 2018 Mar 14.

Department of Internal Medicine, School of Medicine, Universidade Federal do Rio Grande do Sul, 721 Jeronimo de Ornelas Ave, Porto Alegre 90040-341, RS, Brazil. Electronic address:

Background: Red blood cell distribution width (RDW) is a predictor of mortality in critically ill patients. Our objective was to investigate the association between the RDW at ICU discharge and the risk of ICU readmission or unexpected death in the ward.

Methods: A secondary analysis of prospectively collected data study was conducted including patients discharged alive from the ICU to the ward. The target variable was the RDW collected at ICU discharge. Elevated RDW was defined as an RDW > 16%. Outcomes of interest included readmission to the ICU, unexpected death in the ward and in-hospital death. Variables with a p-value <0.1 in the univariate analysis or with biological plausibility for the occurrence of the outcome were included in the Cox proportional hazards model for adjustment.

Results: We included 813 patients. A total of 138 readmissions to the ICU and 44 unexpected deaths in the ward occurred. Elevated RDW at ICU discharge was independently associated with readmission to the ICU or unexpected death in the ward after multivariable adjustment (HR: 1.901; 95% CI 1.357-2.662). Other variables associated with this outcome included age, tracheostomy and mean corpuscular volume (MCV) at ICU discharge. Similar results were obtained after the exclusion of unexpected deaths in the ward (HR 1.940; CI 1.312-2.871) and for in-hospital deaths (HR 1.716; 95% CI 1.141-2.580).

Conclusions: Elevated RDW at ICU discharge is independently associated with ICU readmission and in-hospital death.
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http://dx.doi.org/10.1016/j.clinbiochem.2018.03.010DOI Listing
May 2018

Mortality in chronically critically ill patients: Expanding the use of the ProVent score.

J Crit Care 2015 Oct 26;30(5):1039-42. Epub 2015 Jun 26.

Critical Care Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil. Electronic address:

Purpose: The purpose of the study is to look at the performance of the Prognosis for Prolonged Ventilation (ProVent) score with a short-term outcome as well as when used earlier during the course of prolonged mechanical ventilation (MV).

Materials And Methods: This retrospective study was performed in a tertiary public hospital from August 2011 to August 2012. All patients admitted to the intensive care unit (ICU) during this period were included in the study. Chronically critically ill (CCI) patients were defined as those with 21 days of MV. In a subsequent analysis, we considered CCI patients to be those with 14 days of MV. The data were collected in 2 ways: review of a prospectively elaborated database and review of electronic records.

Results: During the study period, 1360 patients were admitted to the ICU. Of these, 152 patients (11.2%) were considered CCI. Patients with high ProVent score presented higher ICU mortality. Mortality ranged from 25.0% for patients with a score of 0 to 84.0% for patients with a score of greater than or equal to 4. The analysis of the ProVent score performed earlier during the evolution (14 days of MV) was similar.

Conclusions: The ProVent score can be used for short-term prognosis (mortality in the ICU) and earlier in the evaluation of CCI patients.
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http://dx.doi.org/10.1016/j.jcrc.2015.06.022DOI Listing
October 2015

Inflammatory and perfusion markers as risk factors and predictors of critically ill patient readmission.

Rev Bras Ter Intensiva 2014 Apr-Jun;26(2):130-6

Departamento de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil.

Objective: To assess the performance of central venous oxygen saturation, lactate, base deficit, and C-reactive protein levels and SOFA and SWIFT scores on the day of discharge from the intensive care unit as predictors of patient readmission to the intensive care unit.

Methods: This prospective and observational study collected data from 1,360 patients who were admitted consecutively to a clinical-surgical intensive care unit from August 2011 to August 2012. The clinical characteristics and laboratory data of readmitted and non-readmitted patients after discharge from the intensive care unit were compared. Using a multivariate analysis, the risk factors independently associated with readmission were identified.

Results: The C-reactive protein, central venous oxygen saturation, base deficit, and lactate levels and the SWIFT and SOFA scores did not correlate with the readmission of critically ill patients. Increased age and contact isolation because of multidrug-resistant organisms were identified as risk factors that were independently associated with readmission in this study group.

Conclusion: Inflammatory and perfusion parameters were not associated with patient readmission. Increased age and contact isolation because of multidrug-resistant organisms were identified as predictors of readmission to the intensive care unit.
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http://dx.doi.org/10.5935/0103-507x.20140019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4103938PMC
August 2015
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