Brazilian recommendations of mechanical ventilation 2013. Part 2

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Brazilian recommendations of mechanical ventilation 2013. Part I

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumonia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Effect of intraperitoneally administered hydrolyzed whey protein on blood pressure and renal sodium handling in awake spontaneously hypertensive rats

The present study evaluated the acute effect of the intraperitoneal (ip) administration of a whey protein hydrolysate (WPH) on systolic arterial blood pressure (SBP) and renal sodium handling by conscious spontaneously hypertensive rats (SHR). The ip administration of WPH in a volume of 1 ml dose-dependently lowered the SBP in SHR 2 h after administration at doses of 0.5 g/kg (0.15 M NaCl: 188.5 +/- 9.3 mmHg vs WPH: 176.6 +/- 4.9 mmHg, N = 8, P = 0.001) and 1.0 g/kg (0.15 M NaCl: 188.5 +/- 9.3 mmHg vs WPH: 163.8 +/- 5.9 mmHg, N = 8, P = 0.0018). Creatinine clearance decreased significantly (P = 0.0084) in the WPH-treated group (326 +/- 67 microL min-1 100 g body weight-1) compared to 0.15 M NaCl-treated (890 +/- 26 microL min-1 100 g body weight-1) and captopril-treated (903 +/- 72 microL min-1 100 g body weight-1) rats. The ip administration of 1.0 g WPH/kg also decreased fractional sodium excretion to 0.021 +/- 0.019% compared to 0.126 +/- 0.041 and 0.66 +/- 0.015% in 0.15 M NaCl and captopril-treated rats, respectively (P = 0.033). Similarly, the fractional potassium excretion in WPH-treated rats (0.25 +/- 0.05%) was significantly lower (P = 0.0063) than in control (0.91 +/- 0.15%) and captopril-treated rats (1.24 +/- 0.30%), respectively. The present study shows a decreased SBP in SHR after the administration of WPH associated with a rise in tubule sodium reabsorption despite an angiotensin I-converting enzyme (ACE)-inhibiting in vitro activity (IC50 = 0.68 mg/mL). The present findings suggest a pathway involving ACE inhibition but measurements of plasma ACE activity and angiotensin II levels are needed to support this suggestion.

[Sublingual isosorbide-5 mononitrate during coronary arteriography. Comparison with sublingual nitroglycerin]

PURPOSE

To evaluate the effect of sublingual isosorbide-5 mononitrate (ISMN) and nitroglycerin (NTG) on luminal diameter of epicardial coronary arteries, mean arterial pressure and deleterious effects.

METHODS

Fifty patients were submitted to cardiac catheterization and coronary arteriography, at baseline, and 5 min after sublingual administration of ISMN, group A (GA) or NTG, group B (GB).

RESULTS

Reference vessel diameter increased in both groups, without statistical significance. In GA and GB, a decrease (1.66 mmHg) and an increase (0.79 mmHg) in mean arterial pressure, respectively, were demonstrated (p = 0.123). There were no deleterious effects with the use of these drugs.

CONCLUSION

Sublingual ISMN is an alternative to administration of NTG during coronary arteriography, and represents a therapeutic alternative to ischemic heart disease treatment.

Revascularization of the ischaemic hand using in situ veins

Chronic severe ischaemia of the upper limb is rare, due to the low incidence of arterial disease and to the presence of an adequate pre-existent collateral network. However, sometimes it occasionally occurs, dictating the need for revascularization. Since 1990, the authors have revascularized five upper extremities with severe ischaemic changes, employing the cephalic and/or basilic veins, used in situ. The aetiology of the arterial disease was autoimmune in one case and late sequelae of trauma in the others. Of the in situ venous bypasses performed, three were brachial-radial, and two sequential grafts (one axillary-radial-ulnar and one axillary-brachial-radial-ulnar). One concomitant sympathectomy was performed. All patients had excellent early and late results which leads the authors to recommend such revascularization of the forearm and hand, especially in the presence of severe ischaemia.

Duodenal ulcer and eradication of Helicobacter pylori in a developing country. An 18-month follow-up study

Forty-eight patients with endoscopically proven duodenal ulcer (DU) and Helicobacter pylori infection detected by 14C-urea breath test (BT) were assigned to 5 days of treatment with furazolidone, metronidazole, and amoxicillin in addition to eventual classical anti-ulcer agents if necessary. Clinical evaluation and BT were repeated at 2, 6, and 18 months after therapy to determine H. pylori eradication or reinfection. Endoscopy was also repeated at 6 and 18 months after treatment to detect DU relapse. In 29 (60%) patients H. pylori had been eradicated at 2 months after therapy, and in 19 (40%) infection persisted. After successful eradication, 6 of 29 (20.7%) were reinfected. All 24 patients who were negative at the 18-month evaluation were asymptomatic, free of anti-ulcer drugs, and with healed ulcers, whereas among the 19 positive patients followed up, 11 (57%) continued to be symptomatic and still using anti-ulcer agents (p less than 0.010), and 10 (53%) showed active ulcers at endoscopy (p less than 0.010). H. pylori eradication is clearly followed by long-term remission of DU. Reinfection may be an additional problem in treating DU patients in developing countries.