Mortalidade, sobrevida e fatores prognósticos de pessoas com AIDAS em Unidade de Terapia Intensiva

Abstract

This study aimed to analyze the prognostic factors, mortality and survival in people with AIDS admitted to the Intensive Care Unit (ICU). This is a retrospective cohort study, carried out with medical records of AIDS patients admitted to the ICU of São José Hospital for Infectious Diseases (HSJID). The calculated sample was 202 patients admitted in the period from 2015 to 2017. The inclusion criteria were: medical records of patients of both sexes, age equal to or greater than 18 years, with a stay of at least 24 hours in the ICU. The exclusion criteria were patients with no medical records available during the study period and pregnancy. Data collection took place from January to October 2018. After checking the names of the patients and the numbers of the medical records in the registry of the ICU, these were requested in the Service of Medical Archive and Statistics for analysis. Data were collected through a form with sociodemographic, clinical, epidemiological and hospitalization identification variables. After the data collection, the data were organized and analyzed in software R 3.2 (R Foundation for Statistical Computing, Vienna, Austria). Firstly, the descriptive analysis of the data was performed, considering the level of significance of 95% (p < 0.05). The magnitude of the association between exposure and death variables was estimated by the odds ratio (OR). A life table based on the Kaplan-Meier method was constructed to identify survival rates. Univariate Cox proportional hazards models were adjusted to identify prognostic factors for survival. A multivariate Cox proportional hazards model was adjusted to identify component variables of the prognostic index for survival. The adjustment of the Cox model was analyzed considering the explanatory power of the covariates in the time of occurrence of the deaths given by the coefficient R2, the Wald test for regression coefficients (null hypothesis  = 0), the likelihood ratio test to verify the global fit of the model, Log-Rank test to compare the occurrence distribution of deaths. Schoenfeld wastes were analyzed to verify the effect of covariates. The project was approved by the Research Ethics Committee of the Federal University of Ceará and HSJID, under reports, respectively, N ° 1,832,921 and N ° 1,684,646. Of the total sample, 73.8% were males, with a mean age of 38.25 years and 78.7% had less than eight years of schooling. 90.1% had already undergone sexual exposure, 54.9% had signs of vulnerability, such as the use of licit and illicit drugs, 5.0% were street moderators, 61.4% did not have regular follow-up in health services, 40.6% are not adherents to antiretroviral therapy (ART), 94% have low CD4 + T lymphocyte count and 44.6% have high viral load. The most common opportunistic diseases were pulmonary tuberculosis (30; 14.9%), neurotoxoplasmosis (26; 12.9%), esophageal candidiasis (41; 20.3%) and pneumonia for Pneumocystys jiroveci (23; 11.4%). The most comorbidities were arterial hypertension (28; 13.9%), dyslipidemia (51; 25.2%) and nephropathy (79; 39.1%). The main causes of ICU admission were respiratory insufficiency (96.0%), sepsis (59.9%), neurological alterations (54.5%) and renal insufficiency (32.2%). 41.5% of the patients were discharged to the ward 41.5% and 58.5% died in the ICU, with the overall survival rate being 41.6% and the median risk of death around the 15th to the 19th day in the ICU. The last mortality register occurred on the 45th day of hospitalization. The mean number of days at admission was 11.97 days (standard deviation: 10.5; median: 8.5; interquartile range: 14; p = 0.0001). The factors associated with death and with greater impact for poor prognosis were renal replacement therapy (p = 0.001) and sepsis (p = 0.0001). The presence of neurological disturbance (p = 0.043) and esophageal candidiasis (p = 0.003) on admission were associated with a reduction in the risk of death in the ICU. The time of ICU stay (p < 0.001), presence of sepsis on admission (p < 0.001), neurological disorders during ICU stay (p = 0.013), presence of pressure injury (p = 0.038) (p = 0.00001), use of efavirenz (p = 0.030) sexual exposure to HIV (p = 0.002) were associated with increased risk of death during ICU admission. It was concluded that patients with AIDS admitted to the ICU have vulnerabilities that influence hospitalization and discharge, with the overall survival rate being 41.6%. The factors most associated with death were renal replacement therapy and sepsis, whereas neurological disturbance and esophageal candidiasis on admission were factors associated with a lower mortality risk. The prognostic factors for death were hospitalization time, sepsis on admission, neurological disorders during hospitalization, presence of pressure lesions, increased viral load, use of efavirenz, and exposure.