SUMMARY OBJECTIVE: The objective of this study was to evaluate the impact of the implementation of a bundle of interventions through a "Program for Antibiotic Management and Nosocomial Infection Prevention" in the intensive care unit on antibiotic and devices use and healthcare-associated infections. METHODS: This was a quasi-experimental study of consecutive series of cases in periods before and after the establishment of protocols and checklists for the use of antibiotics as well as other measures to prevent healthcare-associated infection as part of a quality improvement program. Antimicrobial consumption was assessed by the defined daily dose. RESULTS: A total of 1,056 and 1,323 admissions in the pre-intervention and post-intervention phases, respectively, were evaluated. The defined daily dose per 100 patient-day decreased from 89±8 to 77±11 (p=0.100), with a decrease in carbapenems, glycopeptides, polymyxins, penicillins, and cephalosporins. The rates of ventilator and central venous catheter use decreased from 52.8 to 44.1% and from 76 to 70%, respectively. The rates of healthcare-associated infection decreased from 19.2 to 15.5%. CONCLUSION: Quality improvement actions focused primarily on antimicrobial management and prevention of healthcare-associated infection are feasible and have the potential to decrease antibiotic use and healthcare-associated infection rates. OBJECTIVE Program Prevention healthcareassociated healthcare associated infections METHODS quasiexperimental quasi experimental program RESULTS 1056 1 056 1,05 1323 323 1,32 preintervention pre intervention postintervention post phases respectively evaluated 10 patientday patient day 898 89 8 89± 7711 77 11 77±1 p=0.100, p0100 p p=0.100 , 0 (p=0.100) carbapenems glycopeptides polymyxins penicillins cephalosporins 528 52 52. 441 44 44.1 7 70 70% 192 19 2 19. 155 15 5 15.5% CONCLUSION 105 05 1,0 132 32 1,3 771 77± p010 p=0.10 (p=0.100 4 44. 15.5 1, 13 3 p01 p=0.1 (p=0.10 15. p0 p=0. (p=0.1 p=0 (p=0. p= (p=0 (p= (p

Abstract Perioperative Goal-Directed Therapy (PGDT) has significantly showed to decrease complications and risk of death in high-risk patients according to numerous meta-analyses. The main goal of PGDT is to individualize the therapy with fluids, inotropes, and vasopressors, during and after surgery, according to patients’ needs in order to prevent organic dysfunction development. In this opinion paper we aimed to focus a discussion on possible alternatives to invasive hemodynamic monitoring in low resource settings. GoalDirected Goal Directed (PGDT highrisk high metaanalyses. metaanalyses meta analyses. analyses meta-analyses fluids inotropes vasopressors surgery development settings

ABSTRACT Background: Critical illness is a major ongoing health care burden worldwide and is associated with high mortality rates. Sodium-glucose cotransporter-2 inhibitors have consistently shown benefits in cardiovascular and renal outcomes. The effects of sodium-glucose cotransporter-2 inhibitors in acute illness have not been properly investigated. Methods: DEFENDER is an investigator-initiated, multicenter, randomized, open-label trial designed to evaluate the efficacy and safety of dapagliflozin in 500 adult participants with acute organ dysfunction who are hospitalized in the intensive care unit. Eligible participants will be randomized 1:1 to receive dapagliflozin 10mg plus standard of care for up to 14 days or standard of care alone. The primary outcome is a hierarchical composite of hospital mortality, initiation of kidney replacement therapy, and intensive care unit length of stay, up to 28 days. Safety will be strictly monitored throughout the study. Conclusion: DEFENDER is the first study designed to investigate the use of a sodium-glucose cotransporter-2 inhibitor in general intensive care unit patients with acute organ dysfunction. It will provide relevant information on the use of drugs of this promising class in critically ill patients. ClinicalTrials.gov registry: NCT05558098 Background rates Sodiumglucose Sodium glucose cotransporter2 cotransporter 2 cotransporter- outcomes sodiumglucose sodium investigated Methods investigatorinitiated, investigatorinitiated investigator initiated, initiated investigator-initiated multicenter openlabel open label 50 11 1 1: mg alone therapy stay Conclusion ClinicalTrialsgov ClinicalTrials gov registry NCT NCT0555809 5 NCT055580 NCT05558 NCT0555 NCT055 NCT05 NCT0

RESUMO Antecedentes: A doença crítica é um importante ônus permanente da assistência médica em todo o mundo e está associada a altas taxas de mortalidade. Os inibidores do cotransportador de sódio-glicose do tipo 2 têm demonstrado consistentemente benefícios nos desfechos cardiovasculares e renais. Os efeitos dos inibidores do cotransportador de sódio-glicose do tipo 2 em doenças agudas ainda não foram devidamente investigados. Métodos: O DEFENDER é um estudo de iniciativa do investigador, multicêntrico, randomizado, aberto, desenhado para avaliar a eficácia e a segurança da dapagliflozina em 500 participantes adultos com disfunção orgânica aguda hospitalizados na unidade de terapia intensiva. Os participantes aptos serão randomizados 1:1 para receber 10mg de dapagliflozina e o tratamento padrão por até 14 dias ou apenas o tratamento padrão. O desfecho primário é um composto hierárquico de mortalidade hospitalar, início de terapia renal substitutiva e tempo de internação na unidade de terapia intensiva, até 28 dias. O monitoramento da segurança será rigoroso durante todo o estudo. Conclusão: O DEFENDER é o primeiro estudo desenvolvido para investigar o uso de um inibidor do cotransportador de sódio-glicose do tipo 2 em pacientes de unidade de terapia intensiva geral com disfunção orgânica aguda. O estudo fornecerá informações relevantes sobre o uso de medicamentos dessa classe promissora em pacientes críticos. Registro ClincalTrials.gov: NCT05558098 Antecedentes sódioglicose sódio glicose renais investigados Métodos investigador multicêntrico randomizado aberto 50 11 1 1: mg hospitalar Conclusão críticos ClincalTrials.gov ClincalTrialsgov ClincalTrials gov NCT NCT0555809 5 NCT055580 NCT05558 NCT0555 NCT055 NCT05 NCT0

ABSTRACT Objective: To update the recommendations to support decisions regarding the pharmacological treatment of patients hospitalized with COVID-19 in Brazil. Methods: Experts, including representatives of the Ministry of Health and methodologists, created this guideline. The method used for the rapid development of guidelines was based on the adoption and/or adaptation of existing international guidelines (GRADE ADOLOPMENT) and supported by the e-COVID-19 RecMap platform. The quality of the evidence and the preparation of the recommendations followed the GRADE method. Results: Twenty-one recommendations were generated, including strong recommendations for the use of corticosteroids in patients using supplemental oxygen and conditional recommendations for the use of tocilizumab and baricitinib for patients on supplemental oxygen or on noninvasive ventilation and anticoagulants to prevent thromboembolism. Due to suspension of use authorization, it was not possible to make recommendations regarding the use of casirivimab + imdevimab. Strong recommendations against the use of azithromycin in patients without suspected bacterial infection, hydroxychloroquine, convalescent plasma, colchicine, and lopinavir + ritonavir and conditional recommendations against the use of ivermectin and remdesivir were made. Conclusion: New recommendations for the treatment of hospitalized patients with COVID-19 were generated, such as those for tocilizumab and baricitinib. Corticosteroids and prophylaxis for thromboembolism are still recommended, the latter with conditional recommendation. Several drugs were considered ineffective and should not be used to provide the best treatment according to the principles of evidence-based medicine and to promote resource economy. Objective COVID19 COVID 19 COVID-1 Brazil Methods Experts methodologists guideline andor ADOLOPMENT eCOVID19 eCOVID e e-COVID-1 platform Results Twentyone Twenty one generated authorization imdevimab infection hydroxychloroquine plasma colchicine made Conclusion recommended recommendation evidencebased economy COVID1 1 COVID- eCOVID1 e-COVID- e-COVID

RESUMO Objetivo: Atualizar as recomendações para embasar as decisões para o tratamento farmacológico de pacientes hospitalizados com COVID-19 no Brasil. Métodos: A elaboração desta diretriz foi feita por especialistas, incluindo representantes do Ministério da Saúde e metodologistas. O método utilizado para o desenvolvimento rápido de diretrizes baseou-se na adoção e/ou adaptação de diretrizes internacionais existentes (GRADE ADOLOPMENT) e contou com o apoio da plataforma e-COVID-19 RecMap. A qualidade das evidências e a elaboração das recomendações seguiram o método GRADE. Resultados: Chegaram-se a 21 recomendações, incluindo recomendações fortes quanto ao uso de corticosteroides em pacientes em uso de oxigênio suplementar e recomendações condicionais para o uso de tocilizumabe e baricitinibe, em pacientes com oxigênio suplementar ou ventilação não invasiva, e de anticoagulantes, para prevenção de tromboembolismo. Devido à suspensão da autorização de uso, não foi possível fazer recomendações para o tratamento com casirivimabe + imdevimabe. Foram feitas recomendações fortes contra o uso de azitromicina em pacientes sem suspeita de infecção bacteriana, hidroxicloroquina, plasma convalescente, colchicina e lopinavir + ritonavir, além de recomendações condicionais contra o uso de ivermectina e rendesivir. Conclusão: Foram criadas novas recomendações para o tratamento de pacientes hospitalizados com COVID-19, como as recomendações de tocilizumabe e baricitinibe. Ainda são recomendados corticosteroides e profilaxia contra tromboembolismo, esta em caráter condicional. Vários medicamentos foram considerados ineficazes e não devem ser usados, no intuito de proporcionar o melhor tratamento segundo os princípios da medicina baseada em evidências e promover a economia de recursos. Objetivo COVID19 COVID 19 COVID-1 Brasil Métodos especialistas metodologistas baseouse baseou se eou GRADE ADOLOPMENT eCOVID19 eCOVID e-COVID-1 RecMap Resultados Chegaramse Chegaram 2 baricitinibe invasiva anticoagulantes tromboembolismo imdevimabe bacteriana hidroxicloroquina convalescente ritonavir rendesivir Conclusão COVID19, 19, condicional usados recursos COVID1 1 COVID- eCOVID1 e-COVID- e-COVID

ABSTRACT Objective: To determine the prevalence, outcomes, and predictors of multidrug-resistant nosocomial lower respiratory tract infections (LRTI) in patients in an ICU. Methods: This was an observational cohort study involving patients with nosocomial LRTI (health care-associated pneumonia, hospital-acquired pneumonia, or ventilator-associated pneumonia). Data were prospectively collected between 2015 and 2019. The multidrug-resistant pathogens (MDRPs) identified in the isolates studied included resistant to extended-spectrum cephalosporin-resistant and carbapenem-resistant Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa, carbapenem-resistant Enterobacteriaceae, and methicillin-resistant Staphylococcus aureus at microbiological diagnosis. Results: During the study period, 267 patients in the ICU were diagnosed with LRTI, microbiological confirmation of LRTI having been obtained in 237. Of these, 146 (62%) had at least one MDRP isolate. Patients infected with MDRP were found to have poorer outcomes than patients infected with susceptible strains, such as prolonged mechanical ventilation (18.0 days vs. 12.0 days; p < 0.001), prolonged ICU length of stay (23.0 days vs.16.0 days; p < 0.001), and higher mortality (73% vs. 53%; p < 0.001) when compared with patients infected with susceptible strains. Hospital length of stay ≥ 5 days (OR = 3.20; 95% CI: 1.39-7.39; p = 0.005) and prolonged use vasoactive drugs (OR = 3.15; 95% CI: 1.42-7.01; p = 0.004) were independent predictors of LRTI caused by MDRPs (LRTI-MDRP). The presence of LRTI-MDRP was found to be an independent predictor of death (OR = 2.311; 95% CI: 1.091-4.894; p = 0.028). Conclusions: Prolonged use of vasoactive drugs and prolonged hospital length of stay were independent predictors of LRTI-MDRP in this population of critically ill patients with very poor outcomes. Objective prevalence multidrugresistant multidrug (LRTI Methods health careassociated care associated pneumonia hospitalacquired acquired ventilatorassociated ventilator pneumonia. . pneumonia) 201 2019 (MDRPs extendedspectrum extended spectrum cephalosporinresistant cephalosporin carbapenemresistant carbapenem baumannii pneumoniae aeruginosa Enterobacteriaceae methicillinresistant methicillin diagnosis Results period 26 237 these 14 62% 62 (62% isolate strains 18.0 180 18 0 (18. vs 120 12 12. 0.001, 0001 0.001 , 001 23.0 230 23 (23. vs160 16 vs.16. 73% 73 (73 53% 53 OR 3.20 320 3 20 95 CI 1.397.39 139739 1.39 7.39 1 39 7 1.39-7.39 0.005 0005 005 3.15 315 15 1.427.01 142701 1.42 7.01 42 01 1.42-7.01 0.004 0004 004 LRTIMDRP. LRTIMDRP (LRTI-MDRP) 2.311 2311 2 311 1.0914.894 10914894 1.091 4.894 091 4 894 1.091-4.894 0.028. 0028 0.028 028 0.028) Conclusions 6 (62 18. (18 000 0.00 00 23. (23 vs16 vs.16 (7 3.2 32 9 397 1.397.3 13973 139 1.3 739 7.3 1.39-7.3 3.1 31 427 1.427.0 14270 142 1.4 701 7.0 1.42-7.0 (LRTI-MDRP 2.31 231 0914 1.0914.89 1091489 1091 1.09 4894 4.89 09 89 1.091-4.89 002 0.02 02 (6 (1 0.0 (2 vs1 vs.1 ( 3. 1.397. 1397 13 1. 7. 1.39-7. 1.427. 1427 70 1.42-7. 2.3 1.0914.8 109148 109 1.0 489 4.8 8 1.091-4.8 0. 1.397 1.39-7 1.427 1.42-7 2. 1.0914. 10914 10 48 4. 1.091-4. 1.39- 1.42- 1.0914 1.091-4 1.091-

RESUMO Objetivo: Determinar a prevalência, os desfechos e os preditores de infecções do trato respiratório inferior (ITRI) nosocomiais em pacientes em uma UTI. Métodos: Estudo observacional de coorte com pacientes com ITRI nosocomiais (pneumonia associada à assistência à saúde, pneumonia adquirida no hospital ou pneumonia associada à ventilação mecânica). Os dados foram coletados prospectivamente entre 2015 e 2019. Os patógenos multirresistentes (PMR) identificados nos isolados estudados incluíram Acinetobacter baumannii, Klebsiella pneumoniae e Pseudomonas aeruginosa resistentes a cefalosporinas de espectro estendido e carbapenêmicos, enterobactérias resistentes a carbapenêmicos e Staphylococcus aureus resistente à meticilina no diagnóstico microbiológico. Resultados: Durante o período do estudo, 267 pacientes internados na UTI foram diagnosticados com ITRI, 237 dos quais tiveram confirmação microbiológica de ITRI. Destes, 146 (62%) apresentaram pelo menos um isolado de PMR. Os pacientes infectados por PMR tiveram piores desfechos do que os infectados por cepas sensíveis, como ventilação mecânica prolongada (18,0 dias vs. 12,0 dias; p < 0,001), tempo prolongado de internação na UTI (23,0 dias vs. 16,0 dias; p < 0,001) e maior mortalidade (73% vs. 53%; p < 0,001). Tempo de internação hospitalar ≥ 5 dias (OR = 3,20; IC95%: 1,39-7,39; p = 0,005) e uso prolongado de drogas vasoativas (OR = 3,15; IC95%: 1,42-7,01; p = 0,004) foram preditores independentes de ITRI por PMR (ITRI-PMR). A presença de ITRI-PMR foi um preditor independente de óbito (OR = 2,311; IC95%: 1,091-4,894; p = 0,028). Conclusões: O uso prolongado de drogas vasoativas e o tempo prolongado de internação hospitalar foram preditores independentes de ITRI-PMR nesta população de pacientes críticos com desfechos muito ruins. Objetivo prevalência (ITRI Métodos saúde mecânica. . mecânica) 201 2019 (PMR baumannii microbiológico Resultados estudo 26 23 Destes 14 62% 62 (62% sensíveis 18,0 180 18 0 (18, vs 120 12 12, 0,001, 0001 0,001 , 001 23,0 230 (23, 160 16 16, 73% 73 (73 53% 53 0,001. OR 3,20 320 3 20 IC95% IC95 IC 1,397,39 139739 1,39 7,39 1 39 7 1,39-7,39 0,005 0005 005 3,15 315 15 1,427,01 142701 1,42 7,01 42 01 1,42-7,01 0,004 0004 004 ITRIPMR. ITRIPMR (ITRI-PMR) 2,311 2311 2 311 1,0914,894 10914894 1,091 4,894 091 4 894 1,091-4,894 0,028. 0028 0,028 028 0,028) Conclusões ruins 6 (62 18, (18 000 0,00 00 23, (23 (7 3,2 32 IC9 397 1,397,3 13973 139 1,3 739 7,3 1,39-7,3 3,1 31 427 1,427,0 14270 142 1,4 701 7,0 1,42-7,0 (ITRI-PMR 2,31 231 0914 1,0914,89 1091489 1091 1,09 4894 4,89 09 89 1,091-4,89 002 0,02 02 (6 (1 0,0 (2 ( 3, 1,397, 1397 13 1, 7, 1,39-7, 1,427, 1427 70 1,42-7, 2,3 1,0914,8 109148 109 1,0 489 4,8 8 1,091-4,8 0, 1,397 1,39-7 1,427 1,42-7 2, 1,0914, 10914 10 48 4, 1,091-4, 1,39- 1,42- 1,0914 1,091-4 1,091-

ABSTRACT Objective: To characterize myocardial injury and cardiovascular complications and their predictors in severe and critical COVID-19 patients admitted to the intensive care unit. Methods: This was an observational cohort study of severe and critical COVID-19 patients admitted to the intensive care unit. Myocardial injury was defined as blood levels of cardiac troponin above the 99th percentile upper reference limit. Cardiovascular events considered were the composite of deep vein thrombosis, pulmonary embolism, stroke, myocardial infarction, acute limb ischemia, mesenteric ischemia, heart failure and arrhythmia. Univariate and multivariate logistic regression or Cox proportional hazard models were used to determine predictors of myocardial injury. Results: Of 567 patients with severe and critical COVID-19 admitted to the intensive care unit, 273 (48.1%) had myocardial injury. Of the 374 patients with critical COVID-19, 86.1% had myocardial injury, and also showed more organ dysfunction and higher 28-day mortality (56.6% versus 27.1%, p < 0.001). Advanced age, arterial hypertension and immune modulator use were predictors of myocardial injury. Cardiovascular complications occurred in 19.9% of patients with severe and critical COVID-19 admitted to the intensive care unit, with most events occurring in patients with myocardial injury (28.2% versus 12.2%, p < 0.001). The occurrence of an early cardiovascular event during intensive care unit stay was associated with higher 28-day mortality compared with late or no events (57.1% versus 34% versus 41.8%, p = 0.01). Conclusion: Myocardial injury and cardiovascular complications were commonly found in patients with severe and critical forms of COVID-19 admitted to the intensive care unit, and both were associated with increased mortality in these patients. Objective COVID19 COVID 19 COVID-1 Methods th limit thrombosis embolism stroke infarction ischemia arrhythmia Results 56 27 48.1% 481 48 1 (48.1% 37 COVID19, 19, 861 86 86.1 28day day 28 56.6% 566 6 (56.6 271 27.1% 0.001. 0001 0.001 . 0 001 0.001) age 199 9 19.9 28.2% 282 2 (28.2 122 12 12.2% 57.1% 571 57 (57.1 34 418 41 8 41.8% 0.01. 0.01 01 0.01) Conclusion COVID1 COVID- 5 48.1 4 (48.1 3 86. 56.6 (56. 27.1 000 0.00 00 19. 28.2 (28. 12.2 57.1 (57. 41.8 0.0 48. (48. 56. (56 27. 28. (28 12. 57. (57 41. 0. (48 (5 (2 (4 (

RESUMO Objetivo: Caracterizar a lesão miocárdica e as complicações cardiovasculares e seus preditores em pacientes graves e críticos com COVID-19 admitidos à unidade de terapia intensiva. Métodos: Este foi um estudo de coorte observacional em pacientes graves e críticos com COVID-19 admitidos à unidade de terapia intensiva. A lesão miocárdica foi definida como níveis sanguíneos de troponina cardíaca acima do limite de referência superior ao percentil 99. Os eventos cardiovasculares considerados foram combinação de trombose venosa profunda, embolia pulmonar, acidente vascular cerebral, infarto do miocárdio, isquemia aguda de membros, isquemia mesentérica, insuficiência cardíaca e arritmia cardíaca. Regressão logística univariada e multivariada ou modelos de risco proporcional de Cox foram utilizados para determinar os preditores de lesão miocárdica. Resultados: Foram admitidos à unidade de terapia intensiva 567 pacientes graves e críticos com COVID-19, dos quais 273 (48,1%) apresentavam lesão miocárdica. Dos 374 pacientes críticos com COVID-19, 86,1% tinham lesão miocárdica, além de apresentarem mais disfunção orgânica e maior mortalidade aos 28 dias (56,6% versus 27,1%; p < 0,001). Foram preditores de lesão miocárdica idade avançada, hipertensão arterial e uso de imunomoduladores. Complicações cardiovasculares ocorreram em 19,9% dos pacientes graves e críticos com COVID-19 admitidos à unidade de terapia intensiva, e a maioria dos eventos deu-se em pacientes com lesão miocárdica (28,2% versus 12,2%; p < 0,001). A ocorrência de evento cardiovascular precoce durante internação em unidade de terapia intensiva estava associada à maior mortalidade aos 28 dias em comparação com eventos tardios ou inexistentes (57,1% versus 34,0% versus 41,8%; p = 0,01). Conclusão: Pacientes com formas graves e críticas de COVID-19 admitidos à unidade de terapia intensiva foram comumente diagnosticados com lesão miocárdica e complicações cardiovasculares, e ambas estavam associadas à maior mortalidade nesses pacientes. Objetivo COVID19 COVID 19 COVID-1 Métodos 99 profunda pulmonar cerebral miocárdio membros mesentérica Resultados 56 COVID19, 19, 27 48,1% 481 48 1 (48,1% 37 861 86 86,1 2 56,6% 566 6 (56,6 27,1% 271 0,001. 0001 0,001 . 0 001 0,001) avançada imunomoduladores 199 9 19,9 deuse deu se 28,2% 282 (28,2 12,2% 122 12 57,1% 571 57 (57,1 340 34 34,0 41,8% 418 41 8 0,01. 0,01 01 0,01) Conclusão COVID1 COVID- 5 48,1 4 (48,1 3 86, 56,6 (56, 27,1 000 0,00 00 28,2 (28, 12,2 57,1 (57, 34, 41,8 0,0 48, (48, 56, (56 27, 28, (28 12, 57, (57 41, 0, (48 (5 (2 (4 (

RESUMO Objetivos: Há diversas terapias sendo utilizadas ou propostas para a COVID-19, muitas carecendo de apropriada avaliação de efetividade e segurança. O propósito deste documento é elaborar recomendações para subsidiar decisões sobre o tratamento farmacológico de pacientes hospitalizados com COVID-19 no Brasil. Métodos: Um grupo de 27 membros, formado por especialistas, representantes do Ministério da Saúde e metodologistas, integra essa diretriz. Foi utilizado o método de elaboração de diretrizes rápidas, tomando por base a adoção e/ou a adaptação de recomendações a partir de diretrizes internacionais existentes (GRADE ADOLOPMENT), apoiadas pela plataforma e-COVID-19 RecMap. A qualidade das evidências e a elaboração das recomendações seguiram o método GRADE. Resultados: Foram geradas 16 recomendações. Entre elas, estão recomendações fortes para o uso de corticosteroides em pacientes em uso de oxigênio suplementar, para o uso de anticoagulantes em doses de profilaxia para tromboembolismo e para não uso de antibacterianos nos pacientes sem suspeita de infecção bacteriana. Não foi possível fazer uma recomendação quanto à utilização do tocilizumabe em pacientes hospitalizados com COVID-19 em uso de oxigênio, pelas incertezas na disponibilidade e de acesso ao medicamento. Foi feita recomendação para não usar azitromicina, casirivimabe + imdevimabe, cloroquina, colchicina, hidroxicloroquina, ivermectina, lopinavir/ ritonavir, plasma convalescente e rendesivir. Conclusão: Até o momento, poucas terapias se provaram efetivas no tratamento do paciente hospitalizado com COVID-19, sendo recomendados apenas corticosteroides e profilaxia para tromboembolismo. Diversos medicamentos foram considerados ineficazes, devendo ser descartados, de forma a oferecer o melhor tratamento pelos princípios da medicina baseada em evidências e promover economia de recursos não eficazes.

ABSTRACT Objective: Several therapies are being used or proposed for COVID-19, and many lack appropriate evaluations of their effectiveness and safety. The purpose of this document is to develop recommendations to support decisions regarding the pharmacological treatment of patients hospitalized with COVID-19 in Brazil. Methods: A group of 27 experts, including representatives of the Ministry of Health and methodologists, created this guideline. The method used for the rapid development of guidelines was based on the adoption and/or adaptation of existing international guidelines (GRADE ADOLOPMENT) and supported by the e-COVID-19 RecMap platform. The quality of the evidence and the preparation of the recommendations followed the GRADE method. Results: Sixteen recommendations were generated. They include strong recommendations for the use of corticosteroids in patients using supplemental oxygen, the use of anticoagulants at prophylactic doses to prevent thromboembolism and the nonuse of antibiotics in patients without suspected bacterial infection. It was not possible to make a recommendation regarding the use of tocilizumab in patients hospitalized with COVID-19 using oxygen due to uncertainties regarding the availability of and access to the drug. Strong recommendations against the use of hydroxychloroquine, convalescent plasma, colchicine, lopinavir + ritonavir and antibiotics in patients without suspected bacterial infection and also conditional recommendations against the use of casirivimab + imdevimab, ivermectin and rendesivir were made. Conclusion: To date, few therapies have proven effective in the treatment of hospitalized patients with COVID-19, and only corticosteroids and prophylaxis for thromboembolism are recommended. Several drugs were considered ineffective and should not be used to provide the best treatment according to the principles of evidence-based medicine and promote economical resource use.

Abstract Introduction and objective Due to the high cost and insufficient offer, the request for Intensive Care (ICU) beds for postoperative recovery needs adequate criteria. Therefore, we studied the characteristics of patients referred to postoperative care at an ICU from the perspective of anesthesiologists, surgeons, and intensive care physicians. Methods A questionnaire on referrals to postoperative intensive care was applied to physicians at congresses in Brazil. Anesthesiologists, surgeons, and intensive care physicians who agreed to fill out the questionnaire were included. The questionnaire consisted of hypothetical clinical scenarios and cases for participants to choose which would be the priority for referral to the ICU. Results 360 physicians participated in the study, with median time of 10 (5-18) years after graduation. Of the interviewees, 36.4% were anesthesiologists, 30.0% surgeons, and 33.6% intensive care physicians. We found that anesthesiologists were more conservative, and surgeons less conservative in ICU referrals. As to patients with risk of bleeding, 75.0% of the surgeons would refer them to the ICU, in contrast with 52.1% of the intensive care physicians, and 43.5% of the anesthesiologists (p< 0.001). As to elderly persons with limited reserve, 62.0% of the surgeons would refer them to the ICU, in contrast with 47.1% of the intensive care physicians, and 22.1% of the anesthesiologists (p< 0.001). As to patients with risk of respiratory complications, 64.5% of the surgeons would recommend the ICU, versus 43.0% of the intensive care physicians, and 32.1% of the anesthesiologists (p< 0.001). Intensive care physicians classified priorities better in indicating ICU, and the main risk indicator was the ASA physical status in all specialties (p< 0.001). There was no agreement among the specialties and surgeries on prioritizing post-operative intensive care. Conclusion Anesthesiologists, surgeons, and intensive care physicians presented different perspectives on postoperative referral to the ICU.

RESUMO Objetivo: Fornecer recomendações para nortear o manejo clínico do potencial doador em morte encefálica. Métodos: O presente documento foi formulado em dois painéis compostos por uma força tarefa integrada por 27 especialistas de diferentes áreas que responderam a questões dirigidas aos seguintes temas: ventilação mecânica, hemodinâmica, suporte endócrino-metabólico, infecção, temperatura corporal, transfusão sanguínea, e uso de checklists. Os desfechos considerados foram: parada cardíaca, número de órgãos retirados ou transplantados e função/sobrevida dos órgãos transplantados. A qualidade das evidências das recomendações foi avaliada pelo sistema Grading of Recommendations Assessment, Development, and Evaluation. Resultados: Foram geradas 19 recomendações a partir do painel de especialistas. Dessas, 7 foram classificadas como fortes, 11 fracas e uma foi considerada boa prática clínica. Conclusão: Apesar da concordância entre os membros do painel em relação à maior parte das recomendações, o grau de recomendação é fraco em sua maioria.

Abstract Objective: To contribute to updating the recommendations for brain-dead potential organ donor management. Methods: A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, answered questions related to the following topics were divided into mechanical ventilation, hemodynamics, endocrine-metabolic management, infection, body temperature, blood transfusion, and checklists use. The outcomes considered were cardiac arrests, number of organs removed or transplanted as well as function / survival of transplanted organs. The quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system to classify the recommendations. Results: A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong, 11 as weak and 1 was considered a good clinical practice. Conclusion: Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak.

Abstract Introduction and objective Due to the high cost and insufficient offer, the request for Intensive Care (ICU) beds for postoperative recovery needs adequate criteria. Therefore, we studied the characteristics of patients referred to postoperative care at an ICU from the perspective of anesthesiologists, surgeons, and intensive care physicians. Methods A questionnaire on referrals to postoperative intensive care was applied to physicians at congresses in Brazil. Anesthesiologists, surgeons, and intensive care physicians who agreed to fill out the questionnaire were included. The questionnaire consisted of hypothetical clinical scenarios and cases for participants to choose which would be the priority for referral to the ICU. Results 360 physicians participated in the study, with median time of 10 (5-18) years after graduation. Of the interviewees, 36.4% were anesthesiologists, 30.0% surgeons, and 33.6% intensive care physicians. We found that anesthesiologists were more conservative, and surgeons less conservative in ICU referrals. As to patients with risk of bleeding, 75.0% of the surgeons would refer them to the ICU, in contrast with 52.1% of the intensive care physicians, and 43.5% of the anesthesiologists (p< 0.001). As to elderly persons with limited reserve, 62.0% of the surgeons would refer them to the ICU, in contrast with 47.1% of the intensive care physicians, and 22.1% of the anesthesiologists (p< 0.001). As to patients with risk of respiratory complications, 64.5% of the surgeons would recommend the ICU, versus 43.0% of the intensive care physicians, and 32.1% of the anesthesiologists (p< 0.001). Intensive care physicians classified priorities better in indicating ICU, and the main risk indicator was the ASA physical status in all specialties (p< 0.001). There was no agreement among the specialties and surgeries on prioritizing post-operative intensive care. Conclusion Anesthesiologists, surgeons, and intensive care physicians presented different perspectives on postoperative referral to the ICU.

RESUMO Objetivo: Verificar o impacto da transferência tardia do pronto-socorro para a unidade de terapia intensiva no tempo de permanência na unidade e na ocorrência de óbitos. Métodos: Este estudo de coorte prospectiva foi conduzido em um hospital acadêmico terciário, com obtenção dos dados de 1.913 pacientes admitidos ao pronto-socorro com solicitação documentada de admissão à unidade de terapia intensiva. Os pacientes admitidos diretamente para a unidade de terapia intensiva médico-cirúrgica (n = 209) foram categorizados em tercis segundo o tempo de espera para admissão à unidade de terapia intensiva (Grupo 1: menos de 637 minutos; Grupo 2: entre 637 e 1.602 minutos, e Grupo 3: acima de 1.602 minutos). Os pacientes que permaneceram na unidade de terapia intensiva por mais de 3,2 dias (tempo mediano de tempo de permanência na unidade de terapia intensiva para todos os pacientes) foram considerados como tempo prolongado de permanência na unidade de terapia intensiva. Resultados: Foram tratados no pronto-socorro durante o período do estudo 6.176 pacientes, dentre os quais 1.913 (31%) necessitaram de um leito na unidade de terapia intensiva. O tempo mediano de permanência no pronto-socorro foi de 17 horas (9 - 33 horas). Hospitalização por infecção/sepse foi preditor independente para tempo prolongado de permanência na unidade (RC: 2,75; IC95% 1,38 - 5,48, p = 0,004), porém o tempo de espera para admissão à unidade de terapia intensiva não. A taxa de mortalidade foi mais elevada no Grupo 3 (38%) do que no Grupo 1 (31%), porém a diferença não foi estatisticamente significante. Conclusão: A admissão tardia à unidade de terapia intensiva a partir do pronto-socorro não resultou em aumento do tempo de permanência ou da mortalidade na unidade de terapia intensiva.

ABSTRACT Objective: To examine the impact of delayed transfer from the emergency room into the intensive care unit on the length of intensive care unit stay and death. Methods: This prospective, cohort study performed in a tertiary academic hospital obtained data from 1913 patients admitted to the emergency room with a documented request for admission into the intensive care unit. The patients admitted directly into the medical-surgical intensive care unit (n = 209) were categorized into tertiles according to their waiting time for intensive care unit admission (Group 1: < 637 min, Group 2: 637 to 1602 min, and Group 3: > 1602 min). Patients who stayed in the intensive care unit for longer than 3.2 days (median time of intensive care unit length of stay of all patients) were considered as having a prolonged intensive care unit stay. Results: A total of 6,176 patients were treated in the emergency room during the study period, among whom 1,913 (31%) required a bed in the intensive care unit. The median length of stay in the emergency room was 17 hours [9 to 33 hours]. Hospitalization for infection/sepsis was an independent predictor of prolonged intensive care unit stay (OR 2.75 95%CI 1.38 - 5.48, p = 0.004), but waiting time for intensive care unit admission was not. The mortality rate was higher in Group 3 (38%) than in Group 1 (31%) but the difference was not statistically significant. Conclusion: Delayed admission into the intensive care unit from the emergency room did not result in an increased intensive care unit stay or mortality.