Critical care science最新文献

Objective: To estimate the prevalence of burnout and low life satisfaction and identify associated factors among physicians working in intensive care units in Brazil.

Methods: We conducted a national, cross-sectional survey (March - October 2024) using probabilistic sampling stratified by specialist status. Eligible participants were physicians with ≥ 1 year of intensive care unit experience across Brazil's 27 federative units. Burnout was measured with the Maslach Burnout Inventory-Human Services Survey (overall burnout defined as ≥ 1 altered domain), and life satisfaction with the Satisfaction With Life Scale (low life satisfaction < 25 points). Because many physicians hold multiple intensive care unit jobs, the unit of analysis was the physician-employment link. Prevalence ratios and 95% confidence intervals were estimated using multivariable Poisson regression with robust variance under a Generalized Estimating Equations framework.

Results: Among 2,338 physicians (3,112 intensive care unit employment links), burnout prevalence was 68.9%, and low life satisfaction 54.2%. In adjusted analyses, burnout was less frequent among physicians aged > 50 years (prevalence ratio of 0.75; 95%CI 0.69 - 0.82) and those reporting frequent recovery behaviors, particularly good sleep quality ≥ 3 days/week (prevalence ratio of 0.81; 95%CI 0.77 - 0.86), while work schedule overload was positively associated with burnout (prevalence ratio of 1.25; 95%CI 1.15 - 1.36). Low life satisfaction was independently associated with working outside certified intensive care practice (prevalence ratio of 1.13; 95%CI 1.04 - 1.24), longer commuting distances (> 20km/week), and schedule overload, whereas leisure activity, adequate nutrition, and good sleep quality were inversely associated.

Conclusion: Burnout and low life satisfaction are highly prevalent among intensive care unit physicians in Brazil. Organizational load, particularly schedule burden and commuting distance, and recovery behaviors show independent associations with one or both outcomes. These findings highlight opportunities for organization-directed workload reforms and for promoting access to recovery resources as strategies to support clinician well-being and the sustainability of the intensive care unit workforce.

Although early mobilization is a cornerstone of modern critical care for reducing intensive care unit-acquired weakness, the duration of mechanical ventilation, and length of stay, its implementation remains highly variable due to the absence of standardized laboratory criteria to guide clinical decision-making. Therefore, this study aimed to generate safety recommendations regarding laboratory and blood count values to be considered prior to initiating early mobilization in critically ill adults, both with and without invasive supports, across different clinical conditions. To address this evidence gap, a modified Delphi process was conducted with 24 highly experienced intensive care unit staff, including physiotherapists, physicians, and nurses. All panelists met strict criteria related to clinical expertise, advanced training, and scientific productivity. Over eight iterative rounds, the panel achieved at least 85% agreement on 119 items across six clinical domains: respiratory, cardiovascular, renal, surgical, hematological/immunological, and neurological. Key laboratory parameters considered included hemoglobin, platelets, lactate, glucose, international normalized ratio, acid-base state (pH), and potassium in selected clinical contexts. The consensus also provides novel guidance in two previously underexplored areas: first, mobilization during blood product transfusions, recommending postponement of early mobilization until transfusion completion; and second, the importance of dynamic trends in routine laboratory tests, identifying clinically meaningful declines in hemoglobin: ≥ 2g/dL/24 hours and platelets: ≥ 20% within 24 hours as contraindications to mobilization. This consensus offers a pragmatic framework that has the potential to reduce interprofessional variability, enhance patient safety, and inform the development of local and national protocols, including in resource-limited settings. Nonetheless, prospective validation across different healthcare contexts is required to confirm its clinical impact and generalizability.

Objective: To compare the electromyographic activity of respiratory muscles during T-piece and pressure support ventilation trials.

Methods: This was a randomized crossover trial involving 16 patients weaning from mechanical ventilation. Each patient underwent two 30-minute spontaneous breathing trials (T-piece and pressure-support ventilation with 7cmH2O), separated by a 30-minute washout period, or until vital signs returned to baseline. Surface electromyography was used to assess muscle activation (percentage root mean square) and median frequency of the pectoralis major, rectus abdominis, and external intercostal muscles (nomenclature updated from diaphragm based on SENIAM and Phinyomark/De Troyer literature to account for crosstalk). Data were collected at baseline (T0), 15 (T15), and 30 minutes (T30). Intragroup comparisons were performed using two-way repeated-measures ANOVA, and intergroup differences in deltas (Δ) were analyzed using ANCOVA, adjusting for baseline values.

Results: Median frequency remained stable for all muscles (p > 0.05), indicating no electromyographic fatigue. In contrast, percentage root mean square activation differed significantly between methods. During the T-piece spontaneous breathing trial, a progressive increase in percentage root mean square was observed in the pectoralis major, rectus abdominis, and external intercostals (p < 0.05). Under pressure support ventilation, only the pectoralis major showed a modest increase (p < 0.05), while other muscles remained stable. Intergroup comparisons of pre-to-post variation confirmed greater activation during the T-piece spontaneous breathing trial for the pectoralis major (p = 0.048) and rectus abdominis (p = 0.009). No significant differences were observed between methods for the external intercostal muscles.

Conclusions: T-piece ventilation induces greater recruitment of thoracic and abdominal accessory respiratory muscles than pressure-support ventilation, reflecting a higher ventilatory demand. Stable median frequency values indicate preserved neuromuscular function and absence of clinically relevant respiratory muscle fatigue over 30 minutes. These findings suggest that pressure support ventilation partially unloads the respiratory system and may mask true ventilatory effort, whereas the T-piece more closely reproduces post-extubation conditions. Surface electromyography proved to be a feasible tool for physiological assessment during ventilatory weaning.

Objective: To evaluate the predictive validity of the White and Associação de Medicina Intensiva Brasileira (AMIB) criteria in predicting hospital mortality among critically ill COVID-19 patients in Brazil.

Methods: We conducted a retrospective cohort study using data from 992 mechanically ventilated COVID-19 patients admitted to a large Brazilian academic hospital, during the first pandemic wave. We applied White and AMIB triage models to this cohort and assessed their performance in predicting hospital mortality. We assessed discrimination AUROC, calibration and overall accuracy (Brier score). Decision curve analysis was used to evaluate clinical utility across varying risk thresholds.

Results: Out of 992 eligible patients, the hospital mortality was 58%. The White model demonstrated moderate discrimination (AUROC 0.73; 95%CI 0.70 - 0.76), fair overall accuracy (Brier = 0.205) and adequate calibration. The AMIB model had poor discrimination (AUROC 0.67; 95%CI 0.64 - 0.70) and overall accuracy (Brier = 0.222), with poor calibration. Neither model demonstrated significant net benefit for decision thresholds above 80% risk of death.

Conclusions: The White and AMIB triage models showed suboptimal performance in predicting hospital mortality in this cohort and were not effective standalone tools for intensive care unit triage, particularly for patients at the extremes of illness severity. These findings underscore the need for validation of triage tools before their implementation.

Objective: To evaluate the knowledge and clinical practices of pediatric intensivists in Brazil regarding the Pediatric Acute Lung Injury Consensus Conference 2 (PALICC-2) definitions and management of pediatric acute respiratory distress syndrome.

Methods: A nationwide online survey was conducted between February and August 2025 among pediatric intensive care unit physicians. The questionnaire assessed demographics, training, knowledge of the PALICC-2 diagnostic criteria, and preferred management strategies in response to a case vignette. Responses were analyzed descriptively.

Results: A total of 212 intensivists participated, of whom 158 completed the survey. Most respondents were female (67%), aged 31 - 40 years (50%), and had been out of school for 11 - 20 years (39%). The majority completed both general pediatrics and pediatric intensive care residency training (70%). For ventilatory management, 48.5% used a tidal volume of 4 - 6mL/kg, while 46.3% used 6 - 8mL/kg; 81% selected titration of optimal positive end-expiratory pressure; only 39% used a protective plateau pressure; 71.3% used a driving pressure limited to 15cmH2O. Analgesia strategies most frequently included neuromuscular blockade optimization (85%). In a case vignette, 88.8% correctly recognized severe pediatric acute respiratory distress syndrome according to PALICC-2 criteria, and nearly all (98.9%) classified the case as severe. In the event of deterioration despite optimized conventional therapies, 87% indicated extracorporeal membrane oxygenation as their rescue strategy.

Conclusion: Brazilian pediatric intensivists demonstrated fair knowledge of PALICC-2 definitions, though they had some concerns about recognizing pediatric acute respiratory distress syndrome. Variability in management strategies underscores the need for continued dissemination of standardized guidelines and training to improve adherence and optimize outcomes.