Revista Portuguesa de Medicina Intensiva

ENTERAL NUTRITION IN THE CRITICALLY ILL PATIENT: ADVANTAGES, MYTHS AND REALITY
Dr. Vitor Lopes (1), Dr. João Cunha (2)
(1) Unidade de Cuidados Intensivos Polivalente, Hospital Desterro, Lisboa
(2) Unidade de Cuidados Intensivos, Centro Hospitalar Conde S. Januário, Macau
ABSTRACT
Objective: to analyze the actual importance of enteral nutrition in ICU patients.
Source of data: Medline review of available bibliographic references.
Results: despite gastrointestinal motility dysfunction usually observed in the critically ill patients, namely gastroparesis, all strategies must be tried to feed these patients by enteral route. Complete digestive rest is associated with gut structure degeneration and possible translocation of organisms. Otherwise, exclusive total parenteral nutrition increase septic morbility and cost.
Conclusion: the advantages of enteral nutrition more than just supplying of energy and protein, includes modulation of the immune response, provision of nutrients to maintain gut integrity and possible prevention of bacterial translocation. Whenever possible the critically ill patients must be feed by enteral route. The enteral feeding should be an obsession. The use of feeding protocols allows to reach, in a majority of patients, the pretended caloric- proteic supply.
Keywords: Nutrition; Enteral Nutrition; Intensive Care; Critical Illness; Gastrointestinal motility; Enteral access; Enteral diets
(Integral text-nutenter.doc)

ENTERAL NUTRITION IN THE CRITICALLY ILL PATIENT: A NURSING PERSPECTIVE
Enfermeira Maria da Luz Bordalo, Enfermeira Cesaltina Anes, Enfermeiro Vítor Almeida; Enfermeira Isabel Simões
Unidade de Cuidados Intensivos Polivalente, Hospital de Santo António dos Capuchos
ABSTRACT
Nutritional support is essential for the success in the treatment of the critically ill patient. Enteral nutrition as first choice method for the feeding of the critically ill is not for long a controversial issue, due to its low cost, beneficial efects on intestinal mucosa and lower rate of complications.
This review pretends to focus attention on the increasing role of the nurse in this process.
They should know "who they should feed", "why to feed", "how to feed", "what are the desirable effects" and mainly "how to prevent complications", and, in the case they occur "how to treat them".
The implementation and use of a protocol for enteral nutrition is critical for the success of this process.
KEYWORDS: Nutrition; Enteral Nutrition; Intensive Care; Critical Illness.
(Integral text-AEntEnf.doc)

INFECCIOUS COMPLICATIONS OF THE CENTRAL VENOUS CATHETERISATION: PROSPECTIVE STUDY OF ONE YEAR
Dr. Pedro Póvoa, Dr. Antero Fernandes, Dr. Eduardo Almeida, Dr. Pedro Moreira, Dr. Rui Mealha, Dr. Henrique Sabino
Unidade de Cuidados Intensivos
Hospital Garcia de Orta
Almada
ABSTRACT
Introduction – Central venous catheter (CVC) related infections are the 2nd most common cause of nosocomial infections in Intensive Care Units.
Objectives – To study the incidence of, and risk factors associated with, CVC related infections.
Material and Methods – The insertion and nursing care of CVC's followed an established protocol. All CVC's inserted and removed, during a 1 year time period, were prospectively included. Catheter location (internal jugular, subclavian, femoral), type of CVC (multi-lumen, introducer, haemodyalisis, parenteral nutrition), insertion and type of CVC exchange (1st placement, "de novo" exchange, guidewire exchange) were all studied in relation to infection incidence.
Results – A total of 109 CVC's were studied. They remained in place for a median of 11 days (range: 1-49). The rate of CVC-related infections per 1,000 catheter-days was 7.5 (95% confidence interval: 2.9 a 12) and the rate of CVC-related bloodstream infections per 1000 catheter-days was 0.7. Only the CVC introducers and parenteral nutrition catheter's had an increased incidence of infection (P=0.02). Catheter duration >= 11 days was identified as an independent risk factor for infection (relative risk 6.07; 95% confidence interval: 1.07-34.52; P=0.042).
Conclusions – An increased incidence of infection was found when CVC introducers and parenteral nutrition catheters were used, in comparison to multi-lumen and haemodyalisis catheters. Duration of catheterization >= 11 days was identified as a significant independent risk factor for infection.
Keywords - central venous catheter, nosocomial infection, catheter exchange
(Integral text-complinf.doc)
CENTRAL VENOUS CATHETERS AND INFECTION: A PROPOSAL FOR A PROTOCOL
Dr. João Cunha(1), Dr. Pedro Póvoa(2)
(1) Unidade de Cuidados Intensivos; Centro Hospitalar Conde de S. Januário, Macau
(2) Unidade de Cuidados Intensivos, Hospital Garcia de Orta, Almada
ABSTRACT
The authors critically review the literature taking into account Central Venous Catheters (CVC) design and composition, insertion site selection and procedures, care with the CVC and its removal considering the impact of
these variables on CVC related-infection.
We conclude and recommend, in order to minimise infectious complications at a reasonable cost-benefit ratio that: 1) use a single lumen CVC unless exists a clear indication for multi-lumen CVC; 2) the subclavian vein via should be preferable if no contraindication exists (positive pressure ventilation, bleeding diathesis); 3) use of a sterile technique during the procedure; 4) use a dry sterile dressing and change it only every other day; 5) remove the CVC if there is pus on the insertion site; 6) proceed to a guidewire exchange if a CVC-related infection is suspected and culture the distal segment. If this culture is positive remove the replacement CVC.
KEY WORDS: Central venous catheterization; Infection; Catheter-related infection; Guidewire exchange; Intensive care
(Integral text-Cvcinfec.doc)

THE ELDERLY PATIENT IN THE INTENSIVE CARE UNIT
Drª Rosalina Bairrada, Dr. Fernando Matos, Dr. Carlos Azevedo
Unidade de Cuidados Intensivos Polivalente / Reanimação
Hospital Geral - Centro Hospitalar de Coimbra
Presented as Free Comunication in "Encontros em Lisboa - Actualização em Cuidados Intensivos", March 1997
ABSTRACT
Objectives: Evaluate differences in procedures, as well as immediate and long-term out comes, in elderly (Group I) and young (Group J) patients admitted in the Intensive Care Unit (ICU).
Methods: Retrospective analysis of clinical records for patients admitted to the ICU in 1994 and follow - up visits during the 12 months after discharge. Results were compared between Group I and Group J.
Patients: During this period, 165 patients were admitted in ICU. Statistical analysis of demographics data, severity index (APACHE II) and distribution by nosological groups was made. We analysed data associated with admission in the ICU and General Hospital (length of stay, mortality rate, procedures) as well as results obtained one year after discharge (mortality rate, autonomy and quality of life).
Results: Of the studied population 28.5% belong to group I and 71.5% to group J. Data refered to hospitalisation showed no statistically significant differences in APACHE II (adjusted to age), duration of mechanical ventilation, mortality and procedures, between the two groups. The data obtained in the follow-up period (87 patients – 66.4%) show that mortality rate was significantly higher in group I (40% V.S. 10.8%; P<0.001) but no significant differences were found in autononomy and quality of life, duration of mechanical ventilation, APACHE II and previous disease were lower in the survivors.
Conclusions: Age was not determinant in short term results for patients admitted in the ICU, but must be considered in long-term prognosis. In our study different outcomes and specially the mortality rate were closely related to APACHE II scores, previous heath status and duration of mechanical ventilation.
Keywords: Intensive care unit, Elderly, Mortality, Quality of life
(Integral text-idoso.doc)

OXIGENATION DURING TRANSPORTATION OF THE VENTILATED PATIENT
Dr. Fernando Rua
Serviço de Cuidados Intensivos
Hospital Geral de Santo António
ABSTRACT:
Critically ill mechanically ventilated patients may need to be transported. It is well demonstrated that this transportation to a reference Hospital or to be submitted to diagnostic procedures may improve the patient prognosis.
It is also demonstrated that transportation of critically ill patients can be safe if well planed, with adequate equipment and performed by a properly trained team.
The objective of this review is to analyse the problems related to the oxygenation of the mechanically ventilated patient.
KEY WORDS: oxygenation, mechanical ventilation, transportation, intensive care, critical care
(Integral text-oxigtran.doc)

SYSTEMIC VARIABLES AS A PROGNOSTIC INDEX IN INTENSIVE CARE MEDICINE
Prof. Dr. Pedro Abecasis
Unidade de Cuidados Intensivos Geral
Hospital de Egas Moniz
ABSTRACT
The severity indices actually used in the Intensive Care Units are based on the measurement of multiple parameters, usually in the first 24 hours after admission. Some laboratory variables have been studied in the last years trying to find out if they could translate the systemic changes that occur in the organism in response to the aggression, relating themselves with the severity of the illness. In this article a review is made of the work done in this field. The variables that have been proposed are related to these systemic changes and translate the inflammatory, immunological and endocrine reactions to the illness. Some of the influences that these variables have on each other are also described trying to find out a better understanding of these complex phenomena.
(Integral text-systvari.doc)

LOOKING FOR A SEVERITY SCORE IN SEPSIS
Prof. Dr. Rui Moreno(1), Dr. Ricardo Matos(1), Drª. Teresa Fevereiro(2), Drª. Maria Ermelinda Pereira(2)
Unidade de Cuidados Intensivos Polivalente
Hospital de Santo António dos Capuchos
(1) Unidade de Cuidados Intensivos Polivalente, Hospital de Santo António dos Capuchos
(2) Serviço 3 Medicina, Hospital de Santo António dos Capuchos
ABSTRACT
Being responsible for most cases of Multiple Organ Failure Syndrome, sepsis represents nowadays one of the most common causes for morbidity and mortality in the Intensive Care Unit. (UCIs). The study of sepsis has been
hampered by the non existence of consensual definitions for diagnosis and by the absence of prognostic models for patient stratification.
The objective of this review is to analyse the models proposed for risk stratification in the septic patient, with special emphasis in the patient with Multiple Organ Failure Syndrome.
KEYWORDS: Sepsis; septic shock; Multiple organ Failure Syndrome; Prognosis.
(Integral text-IGsepsis.doc)

FORMATION IN INTENSIVE CARE
Enfª. Margarida Barão, Enfª.Eunice Henriques
Escola Superior de Enfermagem de Calouste Gulbenkian de Lisboa
(Integral text-Formacao.doc)

CRITICAL CARE/ NEW NURSES
Enfª. Maria Fernanda Tomáz Reino (1), Enfª. Maria João Alvellos Leitão (2)
(1) Hospital de Santa Marta
(2) Unidade de Cuidados Intensivos, Hospital Fernando Fonseca
(Integral text-novosenf.doc)

PSEUDOANEURYSM OF THE ASCENDING AORTA: A LATE COMPLICATION OF AORTO-CORONARY BY-PASS
Dr. F.J. Tejada Ruiz(1), Dr. M. Robles Marcos(1), Dr. A. Merchán Herrera(2), Dr. D. Pérez Civantos(1), Dr. V. Jerez G-C(1), Dr. J.A. Juliá Narváez(1)
Hospital Universitario Infanta Cristina, Badajoz
(1) Unidad de Cuidados Intensivos. Hospital Universitario Infanta Cristina, Badajoz
(2) Unidad de Hemodinamica. Hospital Universitario Infanta Cristina, Badajoz
(Integral text-Pseudoan.doc)

HOW I PERFORM DIALYSIS IN MY PATIENTS
Dr. Eduardo Almeida, Dr. Pedro Moreira
Unidade de Cuidados Intensivos
Hospital Garcia de Orta
(Integral text-Dialise.doc)

CONTINUOUS RENAL REPLACEMENT TECHNIQUES. WHERE WE ARE? WHERE WE WANT TO GO?
Dr. Aníbal Marinho
Serviço de Cuidados Intensivos
Hospital Geral de Santo António
Porto
(Integral text-Trenalco.doc)

THE ROLE OF THE NEPHROLOGIST IN THE ICU
Dr. Pedro Ponce
Serviço de Nefrologia Hospital Garcia de Orta
UCIP do Hospital da Cuf
(Integral text-nefrolog.doc)

Creation date: 21st May 1999
Last update: 16th September 1999

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