Abstract Introduction: The coronavirus disease 2019 (COVID-19) has negatively impacted healthcare services worldwide. We hypothesized that the pandemic would affect our case mix and mortality. Our objective was to study this impact. Methods: We retrospectively studied all patients who underwent congenital heart surgeries from March 21st to August 21st in 2019 and 2020 using the institutional electronic database. We compared demographic data, preoperative and postoperative length of stay (LOS), risk stratification using Risk Adjustment for Congenital Heart Surgery (RACHS) classification and outcomes in both periods. Results: We observed a 66.7% decrease in our surgical volume (285 × 95 patients). Patients operated in the pre-pandemic period were older (911.3 [174.8 - 5953.8] days-old) compared to the pandemic period (275 days-old; P<0.05). When the case mix was compared between periods, the percentage of neonatal surgery was increased in the pandemic era (8% × 21.1%; P<0.05), and the number of RACHS 1-2 surgeries decreased significantly (60.7 × 27.4%; P<0.05). Preoperative LOS was increased in the pandemic period (1.2 × 7 days; P=0.001). There was no significant increment in mortality (P=0.1). Two patients tested positive for COVID-19 in the postoperative period and both died. Conclusion: Our program observed a sudden decrease in surgical volume and a consequent increase in surgical complexity. There was a non-significant increment in mortality.

Human immunodeficiency virus (HIV) infection was considered a contraindication for solid organ transplantation (SOT) in the past. However, HIV management has improved since highly active antiretroviral therapy (HAART) became available in 1996, and the long-term survival of patients living with HIV has led many transplant programs to reevaluate their policies regarding the exclusion of patients with HIV infection. Based on the available data in the medical literature and the cumulative experience of transplantation in HIV-positive patients at our hospital, the aim of the present article is to outline the criteria for transplantation in HIV-positive patients as recommended by the Immunocompromised Host Committee of the Hospital das Clínicas of the University of São Paulo.

Cytomegalovirus infection is a frequent complication after transplantation. This infection occurs due to transmission from the transplanted organ, due to reactivation of latent infection, or after a primary infection in seronegative patients and can be defined as follows: latent infection, active infection, viral syndrome or invasive disease. This condition occurs mainly between 30 and 90 days after transplantation. In hematopoietic stem cell transplantation in particular, infection usually occurs within the first 30 days after transplantation and in the presence of graft-versus-host disease. The major risk factors are when the recipient is cytomegalovirus seronegative and the donor is seropositive as well as when lymphocyte-depleting antibodies are used. There are two methods for the diagnosis of cytomegalovirus infection: the pp65 antigenemia assay and polymerase chain reaction. Serology has no value for the diagnosis of active disease, whereas histology of the affected tissue and bronchoalveolar lavage analysis are useful in the diagnosis of invasive disease. Cytomegalovirus disease can be prevented by prophylaxis (the administration of antiviral drugs to all or to a subgroup of patients who are at higher risk of viral replication) or by preemptive therapy (the early diagnosis of viral replication before development of the disease and prescription of antiviral treatment to prevent the appearance of clinical disease). The drug used is intravenous or oral ganciclovir; oral valganciclovir; or, less frequently, valacyclovir. Prophylaxis should continue for 90 to 180 days. Treatment is always indicated in cytomegalovirus disease, and the gold-standard drug is intravenous ganciclovir. Treatment should be given for 2 to 3 weeks and should be continued for an additional 7 days after the first negative result for viremia.

JUSTIFICATIVA E OBJETIVOS: O paciente cirúrgico com infecção hospitalar, além de aumentar os custos hospitalares, pode não recuperar sua condição prévia e até morrer. Além dos riscos individuais bem estabelecidos, o desenvolvimento de infecção pósoperatória depende do procedimento a que será submetido, das condições hospitalares e do cirurgião. Apesar de haver muitos protocolos visando o controle da infecção, falta padronização de intervenções intraoperatórias visando a otimização desse paciente. Assim, esta revisão teve como objetivo discutir algumas dessas intervenções que são eficazes e necessárias, alertando o anestesiologista da sua importância na prevenção da infecção hospitalar. CONTEÚDO: Nesta revisão foram abordadas as causas de infecção no paciente cirúrgico e discutiu-se como a adequada administração de antibióticos, o controle térmico e glicêmico e as estratégias de ventilação mecânica, hidratação e transfusão podem reduzir as taxas de infecção no paciente cirúrgico. CONCLUSÕES: O anestesiologista é o profissional que deve intervir no intraoperatório com medidas simples para otimizar o atendimento do paciente cirúrgico e diminuir índices de infecção.

BACKGROUND AND OBJECTIVES: Besides the increase in hospital costs, surgical patients with nosocomial infection may not recover their previous condition and their condition can even evolve to death. Besides well-established patient-related risks, postoperative infection is also dependent on the surgical procedure, the hospital conditions and the surgeon. Despite several protocols to prevent nosocomial infections, standardization of intraoperative interventions to optimize those patients does not exist. Thus, the objective of this review was to discuss some of those interventions that are effective and necessary, alerting anesthesiologists of their importance in preventing nosocomial infections. CONTENTS: In this review, the causes of infections in surgical patients as well as the adequate administration of antibiotics, temperature and blood glucose control, and strategies of mechanical ventilation, hydration, and transfusions that can reduce the incidence of infections in surgical patients are discussed. CONCLUSIONS: The anesthesiologist is the professional who should intervene in the intraoperative period with simple measures to optimize the care of surgical patients and to reduce the incidence of infections.

JUSTIFICATIVA Y OBJETIVOS: El paciente quirúrgico con infección hospitalaria, además de aumentar los costes hospitalarios, puede que no recupere su condición previa e incluso muera. Además de los riesgos individuales ya establecidos, el desarrollo de la infección postoperatoria depende del procedimiento a que será sometido, de las condiciones hospitalarias y del cirujano. A pesar de haber muchas medidas para controlar la infección, falta una estandarización de las intervenciones intraoperatorias para optimizar ese paciente. Esta revisión tuvo el objetivo de discutir algunas de esas intervenciones que son eficaces y necesarias, alertando al anestesiólogo sobre su importancia en la prevención de la infección hospitalaria. CONTENIDO: En esta revisión, fueron abordadas las causas de infección en el paciente quirúrgico, y se discutió también como una adecuada administración de antibióticos, el control térmico y glucémico y las estrategias de ventilación mecánica, hidratación y transfusión, pueden reducir los niveles de infección en el paciente quirúrgico. CONCLUSIONES: El anestesiólogo es el profesional que debe intervenir en el intraoperatorio con medidas sencillas para optimizar la atención del paciente quirúrgico y reducir sus indicadores de infección.

OBJETIVOS: Os procedimentos dialíticos para a correção da lesão renal têm a infecção como uma das principais complicações, com impacto significante na morbi-mortalidade em pacientes dialíticos crônicos e agudos críticos. O objetivo deste trabalho foi revisar a literatura sobre infecções em pacientes submetidos a procedimentos hemodialíticos. MÉTODOS: Foi realizado levantamento das publicações de 1990 a março de 2008 nas bases eletrônicas COCHRANE, PubMed/MEDLINE, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Banco de dados de Enfermagem. Foram utilizados os descritores em Ciências da Saúde (DeCS) e o Medical Subject Headings Section (MeSH) do PubMed/MEDLINE: infecção; infecção hospitalar; bacteremia; diálise renal; insuficiência renal crônica; insuficiência renal aguda; hemofiltração; hemodiafiltração; terapia de substituição renal. RESULTADOS: Foram selecionados 33 artigos. A maioria das publicações era americana, concentrou-se entre os anos 2001 e 2005 e a principal topografia foi infecção relacionada ao acesso vascular. Os estudos divergiram na definição de infecção e denominadores utilizados, comprometendo a comparação dos mesmos. Cinco artigos trabalharam com diferentes topografias de infecção, 16 estudaram infecção relacionada ao acesso vascular nos diferentes tipos de acessos vasculares, nove focaram especificamente nos cateteres centrais temporários para hemodiálise e apenas três estudaram infecções em pacientes de unidade de terapia intensiva. A realização de hemodiálise por cateteres centrais temporários foi o principal fator de risco identificado. CONCLUSÃO: Evidenciou-se a necessidade de estudos sobre a incidência de infecção no paciente crítico, que dialisa por cateter temporário devido à lesão renal aguda, na tentativa de estabelecer relação causal e fatores de risco, com a finalidade de direcionar medidas de prevenção e controle adequadas.

OBJECTIVE: Infection is one of the main complications of dialysis procedures to correct renal injury, with a significant impact on morbidity mortality in chronic and critically acute dialysis patients. The objective of this work was to review literature on infection in patients submitted to hemodyalisis. METHODS: A survey of publications from 1990 to March 2008 was carried out in the database COCHRANE, PubMed/MEDLINE, Latin-American and Caribbean literature on Health Sciences and Nursing database. In Health Science (DECS) and Medical Subject Headings Section (MeSH) from |PubMed/MEDLINE the following descriptors were used: infection; cross infection; bacteremia; renal dialysis; renal failure;acute renal failure; hemofiltation; hemodiafiltration; renal replacement therapy. RESULTS: Thirty three articles were selected. Most publications were American, from 2001 to 2005 and mainly about vascular access-related infection. Studies diverged on the definition of infection and nomenclature, hindering comparisons. Fiver articles covered different infection topographies, 16 studied vascular access-related infections in the different types of vascular accesses, nine specifically focused on temporary central catheters for hemodialysis and only three studied infections in intensive care unit patients. Temporary central catheters for hemodialysis were identified as the principal risk factor. CONCLUSION: There is a need for studies about infection incidence in critically ill, submitted to dialysis with temporary catheters, due to acute renal injury to define a causal relationship and risk factors to orient adequate prevention and control measures.

FUNDAMENTO: Identificar os fatores de risco para complicações pós-operatórias do paciente cardiopata com indicação cirúrgica que podem influenciar na decisão sobre a conduta terapêutica. OBJETIVO: Descrever a experiência de um hospital de Cardiologia na validação e uso prático de um escore de risco pré-operatório. MÉTODOS: Para validação do escore escolhido (Tuman), avaliaram-se consecutiva e prospectivamente 300 pacientes adultos antes da cirurgia cardíaca eletiva com o uso de circulação extracorpórea (CEC). Pacientes com escore de 0 a 5 foram considerados de baixo risco; de 6 a 9 como risco moderado; e maior que 10, como alto risco para complicações cardíacas, infecciosas, neurológicas, pulmonares e renais, além de óbito. RESULTADOS: A classificação de Tuman mostrou relação estatisticamente significante com ocorrência de complicações infecciosas (p=0,010), com outras complicações pós-operatórias (p=0,034) e com evolução para óbito (p<0,001). Infecção pulmonar foi a mais freqüente dentre as complicações infecciosas (15,3%), Os pacientes infectados tiveram maior tempo de permanência na UTI (p=0,001) e internação mais prolongada (p=0,001). Após o uso rotineiro, uma nova avaliação de 154 pacientes operados em 2005 confirmou a validade desse escore na identificação daqueles com maior risco de infecções pós-operatórias. CONCLUSÃO: Escolheu-se o escore de Tuman por envolver variáveis de fácil obtenção, por classificar no mesmo sistema as cirurgias mais freqüentemente realizadas e prever risco de complicações pós-operatórias, além da mortalidade. Seu uso continuado nesse hospital permitiu identificar o grupo de pacientes com maior risco de complicações, especialmente as infecciosas, mas não foi preciso na predição do risco individual.

BACKGROUND: The identification of risk factors for postoperative complications in cardiac patients with surgical indication may influence the therapeutic decision. OBJECTIVE: To describe the experience of a Cardiology hospital in the validation and practical use of a preoperative risk score. METHODS:To validate TUMAN's score, chosen by considering morbidity and mortality, 300 adult patients were prospectively evaluated before elective cardiac surgery with the use of extracorporeal circulation (ECC). Patients with a score of zero to five were considered as being low risk; from six to nine, as moderate risk and a score higher than 10 as high risk for cardiac, infectious, neurological, pulmonary and renal complications, as well as death. RESULTS: The TUMAN classification showed a statistically significant association with the occurrence of infectious complications (p = 0.010), with the other postoperative complications (p = 0.034) and death (p <0.001). Pulmonary infection was the most frequent infectious complication (15.3%) and Infected patients had a longer ICU stay duration (p = 0.001) and more prolonged hospitalization (p = 0001). After routine use, a new review of 154 patients operated in 2005, confirmed the validity of this score in the identification of those with the highest risk of postoperative infections. CONCLUSION: TUMAN's score was chosen as it uses variables that can be promptly obtained, classifies in the same system the most frequently performed surgeries and predicts risk of postoperative complications, in addition to mortality. Its continued use in this hospital has been able to identify the group of patients with increased risk of complications, especially infectious ones, although it was not useful in the prediction of individual risk.

A febre Q é uma zoonose de distribuição mundial causada por Coxiella burnetii, sendo raros os registros da doença no Brasil. Estudos soroepidemiológicos mostraram uma freqüência relativamente elevada de anticorpos contra Coxiella burnetii em populações com exposição ocupacional. Em humanos, pode se manifestar clinicamente como doença aguda ou crônica, sendo que a endocardite é a forma crônica mais freqüente da febre Q e de maior morbi-mortalidade. Relatamos um caso grave de endocardite por Coxiella burnetii adquirida no Brasil com desfecho fatal, apesar de antibioticoterapia adequada e tratamento cirúrgico valvar.

Q fever is a zoonosis of worldwide distribution that is caused by Coxiella burnetii. However, reports of this disease in Brazil are rare. Seroepidemiological studies have shown relatively high frequencies of antibodies against Coxiella burnetii in populations with occupational exposure. In humans, it can be manifested clinically as acute or chronic disease. Endocarditis is the most frequent chronic form of Q fever and the form with the greatest morbidity and mortality. We report a severe case of endocarditis due to Coxiella burnetii acquired in Brazil that had a fatal outcome, despite specific antibiotic therapy and valve surgery treatment.

JUSTIFICATIVA E OBJETIVOS: As infecções fúngicas por Trichosporon Asahii têm sido cada vez mais freqüentes nas últimas duas décadas. Quadros graves com alta mortalidade são tradicionalmente descritos em pacientes neutropênicos com câncer. Recentemente, a infecção tem ocorrido também em outros grupos de pacientes. O objetivo deste estudo foi descrever a crescente prevalência de Trichosporon asahii em unidade de terapia intensiva cardiológica (UTIC), com perfil de pacientes habitualmente não susceptíveis a tal infecção fúngica, relatar um caso clínico e revisão da literatura. RELATO DO CASO: Paciente do sexo feminino, 85 anos, com antecedentes de hipertensão arterial sistêmica, insuficiência cardíaca (fração de ejeção = 30%) e embolia pulmonar, admitida na UTI depois de parada cardiorrespiratória em fibrilação ventricular durante consulta de rotina. Evoluiu sem seqüela neurológica. O ecocardiograma não revelou alterações em relação ao exame anterior. Não houve alteração dos indicadores de necrose miocárdica. A paciente apresentou falha na extubação traqueal e desmame difícil, necessitando ventilação mecânica prolongada mesmo após traqueostomia. Houve complicações por insuficiência renal aguda e infecções recorrentes (respiratória, urinária e sistêmica), com boa resposta ao tratamento com antibióticos de amplo espectro. Após sete meses de internação na UTI, evoluiu com choque séptico, associado à infecção urinária por Trichosporon asahii, com hemoculturas identificadas pelo mesmo fungo. Iniciado tratamento com anfotericina B lipossomal (5 mg/kg/dia). Apesar do uso associado de vancomicina e imipenem, houve piora clínica progressiva. Hemoculturas colhidas no sétimo dia de uso de antifúngico revelaram-se negativas, porém a urocultura ainda revelou o crescimento de T. asahii. Evoluiu com óbito após 18 dias de tratamento, por falência de múltiplos órgãos. CONCLUSÕES: O aumento da gravidade dos pacientes internados nas UTI e o uso disseminado de antibióticos de amplo espectro têm possibilitado o surgimento de infecções por fungos incomuns. As infecções graves por Trichosporon asahii, descritas como restritas a pacientes imunossuprimidos, oncológicos e hematológicos, têm sido freqüentemente encontradas em pacientes idosos, com insuficiência cardíaca grave e com alta mortalidade intra-hospitalar, internados em UTI. Deve-se estar atento à possibilidade da emergência de infecções por fungos não usuais em pacientes com este perfil clínico.

BACKGROUND AND OBJECTIVES: Infection with the non-Candida yeast species Trichosporon have been recognized with increasing frequency over the last two decades. Invasive disease due to trichosporonosis has been reported from neutropenic patients with cancer and the mortality is high. Recently, others groups of patients have become susceptible to this rare fungi. We report the emerging of infection with pathogenic Trichosporon asahii in severely ill heart failure patients in a tertiary cardiological intensive care unit (CICU). We describe our data, and report a fatal case of disseminated trichosporonosis in a patient with heart failure. We also review literature pertaining to T. asahii infections. CASE REPORT: An 85 year-old woman with a history of hypertension, heart failure (ejection fraction (EJ): 30%) and pulmonary embolism was admitted to a medical cardiological ICU after cardiac arrest (ventricular fibrillation) resuscitated during a routine consultation. There were no neurological sequelae and the echocardiogram revels no changes, neither the cardiac biomarkers. Ventricular fibrillation was considered secondary to heart failure. The patient had extubation failure and difficult weaning needing long term mechanical ventilation even after tracheostomy. Her hospital course was complicated by acute renal failure and recurrent respiratory, urinary and systemic bacterial infections, which responded to broad-spectrum antibiotics. After a temporary improvement she developed urinary infection and subsequent septic shock. Cultures of urine and blood specimens grew T. asahii. Treatment with liposome amphotericin B (5 mg/kg/day) was started. Despite receiving vancomycin and imipenem, the clinical condition of the patient deteriorates. Blood taken for culture on the seventh day of amphotericin B therapy were negative but urine specimen still grew T. asahii. On the eighteenth day of antifungal therapy, the patient died with multiorgan failure. CONCLUSIONS: The increasing of severely ill patients, and the use of broad spectrum antibiotics, has predisposed the emerging of invasive infections by rare and new opportunistic fungal pathogens. Severe infection related to T. asahii, until recently restricted to neutropenic patients with cancer, has been frequently identified in heart failure patients with advanced age. The mortality is high. These data highlights the importance of considering this group of patients as a risk group for T. asahii infection.